Intimate partner violence and depression (Literature review)

Intimate partner violence is a global public health problem. Prevalence of Intimate partner violence differs geographically and financially. In countries like Peru, Ethiopia, and Bangladesh, it was reported to be 60%, while in Japan, it was 15 percent (Garcia-Moreno et al., 2006). In a financial context, it is high in low- middle-income countries (Kabir, Nasreen, & Edhborg, 2014). A review by Tessera Bites also found intimate partner violence associated with depression (Bitew, 2014). Rural communities were found to have more prevalence than urban communities. (Erulkar, 2013) . After analyzing data from 19 countries, researchers noted the high occurrence of Intimate partner violence during pregnancy (Devries et al., 2010). However, statistics in those countries is underestimated, as many of women do not report it because of fear from husbands and male-dominant societies. Conflicts and being refugees/immigrant also enhances chances of IPV (Hyder, Noor, & Tsui, 2007) .Women who witnessed conflict violence is more likely to experience IPV than women who didn’t witness conflict (Falb, McCormick, Hemenway, Anfinson, & Silverman, 2013). In India, employed women experienced IPV more than unemployed owing to male dominant society (Chakraborty, Patted, Gan, Islam, & Revankar, 2014).

Intimate partner violence is associated with a myriad of health problems. The effect of IPV on mental health is well documented. My brief review focuses on depression, one of the major mental health outcomes. Study indicate that the percentage of women who report having symptoms of depression varies according to their exposure to intimate partner violence(Meekers, Pallin, & Hutchinson, 2013).Women who were abused both in childhood and adulthood were four to seven times more likely to suffer from depression than never-abused women. (Ouellet-Morin et al., 2015). In a Chinese study, research categorized into IT and SCV, and found IT associated more with depression (Tiwari et al., 2015). There have been studies to report an association between physical abuse and depression, but a prospective cohort study found emotional abuse as one of the risk factors for postnatal depression. (Ludermir, Lewis, Valongueiro, de Araujo, & Araya, 2010). In this study of 1045 women, of which 270 women reported depression, psychological torture was found to be an important cause. According to Yoshihama et al., the role of psychological abuse is understudied(Yoshihama, Horrocks, & Kamano, 2009). Injuries stemming from psychological abuse took more time to heal than physical abuse(Matheson et al., 2015). One Chinese study reported high-level of depression in migrants’ victims of intimate partner violence. Langdon et al. studied mental health outcomes of 58 studies and found depression as the most common outcome. (Lagdon, Armour, & Stringer, 2014). Golding et al. estimated the prevalence of depression at 48% among women victim of IPV.

Ludermir study makes policy makers to focus on even psychological abuse. So while planning for interventions, psychological torture should be taken into account. Interventions targeted at young men have shown positive results in Ethiopia. (Pulerwitz et al., 2015). So education young men of women right values could be positive step.(continued)

Bitew, T. (2014). Prevalence and risk factors of depression in Ethiopia: a review. Ethiop J Health Sci, 24(2), 161-169.

Chakraborty, H., Patted, S., Gan, A., Islam, F., & Revankar, A. (2014). Determinants of Intimate Partner Violence Among HIV-Positive and HIV-Negative Women in India. J Interpers Violence.

Devries, K. M., Kishor, S., Johnson, H., Stockl, H., Bacchus, L. J., Garcia-Moreno, C., & Watts, C. (2010). Intimate partner violence during pregnancy: analysis of prevalence data from 19 countries. Reprod Health Matters, 18(36), 158-170. Erulkar, A. (2013). Early marriage, marital relations and intimate partner violence in Ethiopia. Int Perspect Sex Reprod Health, 39(1), 6-13.

Falb, K. L., McCormick, M. C., Hemenway, D., Anfinson, K., & Silverman, J. G. (2013). Suicide ideation and victimization among refugee women along the Thai-Burma border. J Trauma Stress, 26(5), 631-635.

Garcia-Moreno, C., Jansen, H. A., Ellsberg, M., Heise, L., Watts, C. H., Health, W. H. O. M.-c. S. o. W. s., & Domestic Violence against Women Study, T. (2006). Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence. Lancet, 368(9543), 1260-1269.

Hyder, A. A., Noor, Z., & Tsui, E. (2007). Intimate partner violence among Afghan women living in refugee camps in Pakistan. Soc Sci Med, 64(7), 1536-1547. doi: 10.1016/j.socscimed.2006.11.029

Kabir, Z. N., Nasreen, H. E., & Edhborg, M. (2014). Intimate partner violence and its association with maternal depressive symptoms 6-8 months after childbirth in rural Bangladesh. Glob Health Action, 7, 24725.

Lagdon, S., Armour, C., & Stringer, M. (2014). Adult experience of mental health outcomes as a result of intimate partner violence victimisation: a systematic review. Eur J Psychotraumatol, 5.

Ludermir, A. B., Lewis, G., Valongueiro, S. A., de Araujo, T. V., & Araya, R. (2010). Violence against women by their intimate partner during pregnancy and postnatal depression: a prospective cohort study. Lancet, 376(9744), 903-910.

Matheson, F. I., Daoud, N., Hamilton-Wright, S., Borenstein, H., Pedersen, C., & O’Campo, P. (2015). Where Did She Go? The Transformation of Self-esteem, Self-Identity, and Mental Well-Being among Women Who Have Experienced Intimate Partner Violence. Womens Health Issues. Meekers, D., Pallin, S. C., & Hutchinson, P. (2013). Intimate partner violence and mental health in Bolivia. BMC Womens Health, 13, 28.

Ouellet-Morin, I., Fisher, H. L., York-Smith, M., Fincham-Campbell, S., Moffitt, T. E., & Arseneault, L. (2015). Intimate partner violence and new-onset depression: a longitudinal study of women’s childhood and adult histories of abuse. Depress Anxiety, 32(5), 316-324.

Pulerwitz, J., Hughes, L., Mehta, M., Kidanu, A., Verani, F., & Tewolde, S. (2015). Changing Gender Norms and Reducing Intimate Partner Violence: Results From a Quasi-Experimental Intervention Study With Young Men in Ethiopia. Am J Public Health, 105(1), 132-137.

Tiwari, A., Chan, K. L., Cheung, D. S., Fong, D. Y., Yan, E. C., & Tang, D. H. (2015). The differential effects of intimate terrorism and situational couple violence on mental health outcomes among abused Chinese women: a mixed-method study. BMC Public Health, 15, 314.

Yoshihama, M., Horrocks, J., & Kamano, S. (2009). The role of emotional abuse in intimate partner violence and health among women in Yokohama, Japan. Am J Public Health, 99(4), 647-653.

Recent judgment by Supreme Court to allow same sex marriages all over the country is one of the major landmarks in light of public health. There are numerous examples when policy changes have resulted in improved health such as tobacco policy, anti soda law to curb obesity, affordable care act, and civil right movements. This judgment is also not exceptional, and it has potential to reduce health disparities among LGB groups. In 1973, American Psychiatrist Association removed homosexuality from DSM. Being LGBT has nothing to do with mental health illness; it is our (heterosexuals) conservative nature makes them feel/experience mental health problems. To appreciate Supreme Court decision, this is my brief literature review on mental health aspect of LGBT groups. And I hope this revolutionary step would also motivate other part of the world to follow the same step.

According to various different rsources, we can estimate that United States is home to three to four percent LGBT population. Because of social, cultural, religious and political fabrics and taboos, real and clear number is not available globally. Health disparities among LGBT groups in United States are well known. Building on it, my paper focus on mental health disparities in LGBT population. Compared to heterosexuals, sexual minorities that comprise lesbians, gay men, bisexual individuals and trans genders are at an increased risk for mental health illness and psychiatric morbidities. According to Meyer’s conceptual framework in from of stress theory, stressors can elucidate disproportionate prevalance of mental health illness in sexual minority groups. When coupled with other minority statuses, additive effect increases probability of experiencing homophobia, discrimination and rejection (Meyer, 2003) . People living in a state with policies that did not provide safeguards to lesbian, gay, and bisexual individuals were four times likely to suffer a comorbid psychiatric condition compared to individuals living in a state with positive policies (Hatzenbuehler, Keyes, & Hasin, 2009). They are more prone to experience depression, anxiety, high distress, substance abuse, suicidal tendency, hopelessness, and disability.

Support from family is very crucial for LGB group; even support from sexual minority group can make a big difference in light of mental health. Ryan et al study proposed that family acceptance could help in reducing the stressors in this group. (Ryan, Russell, Huebner, Diaz, & Sanchez, 2010). Even few studies have reported that friends and family support helps in cessation of substance abuse. A longitudinal cohort study established inverse relationship between family support and smoking rated among sexual minority groups. (Newcomb, Heinz, Birkett, & Mustanski, 2014). Another longitudinal study concluded negative association between alcohols uses and perceived family support (Newcomb, Heinz, & Mustanski, 2012). While distinguishing between family support and non-kin support, Almeida et al study found family support is more useful for mental health compared to non-kin support (Almeida, Subramanian, Kawachi, & Molnar, 2011).

Discrimination stemming from racism also adds up already high anxiety level. According to Myer minority theory, many minority statuses augment experience of feeling homophobia and stress, which further aggravate outcome. Social stress is contributing factor for anxiety. A recent study reported two times anxiety and mood disorders among LGBT groups compared to heterosexuals. Previous studies have found differences in distress level of LGB and heterosexuals. Research implies relationship between emotional distress and perceived discrimination in sexual minority groups (Almeida, Johnson, Corliss, Molnar, & Azrael, 2009).

Several studies found higher chances of depression in LGB groups. Patel et al study determines that clinical depression is more widespread in sexual minority because of social rejection and stigma. (Patel, Mayer, & Makadon, 2012). According to research at UCLA Center for Health Policy Research, despite no differences in access to health care, older gays are reportedly to have higher rates of depression than heterosexual counterparts (Wallace, Cochran, Durazo, & Ford, 2011). Long time distress stemming from social environment can force patients to clinical depression (Safren & Heimberg, 1999). Stigma in union with stress put MSM to higher risk of Psychiatric morbidity in form of depression (Sandfort, Bos, Knox, & Reddy, 2015). Research conducted in Estonia, Northern European country, also reported high prevalance of anxiety and depression in sexual minority groups (Parker, Lohmus, Valk, Mangine, & Ruutel, 2015). A cross sectional study, using respondent driving sampling, conducted in Sub-Saharan Africa also reported high prevalance of depression among MSM attributed to social stigma (Stahlman et al., 2015). A longitudinal study exclusively conducted in sexual minority women found this sample had higher unadjusted odds of depressive symptoms compared to heterosexual women (Pyra et al., 2014). Lytle et al found this result consistent in across all racial groups in the United States (Lytle, De Luca, & Blosnich, 2014). Emails were sent to invite students from 30 osteopathic medical schools for cross-sectional questionnaire-based study , of which, only 6 schools responded. Results are in accordance with established association of sexual orientation and depression (Lapinski & Sexton, 2014). While evaluating distress among 9th-12^th LGBT grad students, researchers found higher rates of depression among students who percieved discrimination (Almeida et al., 2009).

A number of population based studies revealed higher rates of suicidal ideations in sexual minority groups. Prevalance of suicidal tendencies among trans-genders is more than general population. According to randomized trial study, people who experienced forced anal intercourse debut are more likely to have suicidal ideation (Defechereux et al., 2015). Adolescent group is the most vulnerable group for suicide attempts in MSM population. This is because gender awareness is developed in this period (Russell & Toomey, 2012).   Another study established association between parental rejection because of sexual orientation and suicidal tendency of gays (D’Augelli et al., 2005). A study designed in Denmark to investigate the suicide risk by sex and relationship status found that MSM have eight times more risk of suicide attempts compared to histories of heterosexual marriages (Mathy, Cochran, Olsen, & Mays, 2011).

Discrimination and stigma act as barrier to access to health services. Professional can also compound the problem for not having enough knowledge about community. Because of barrier and stigma, gay men in Spain are more likely to diagnose for HIV at advanced stage compared to heterosexuals (Hoyos et al., 2013). According to Hyoes et al, main barrier to HIV testing among MSMs includes: fear of HIV, legal implications of positive test and stigma/discrimination. In India, largely due to stigmatization by Indian medical community, MSM avoid routine health care (Patel et al., 2012). Sexual prejudice against MSM and transgender women is recognized as one of the impediments for access to anti retroviral therapy (Chakrapani, Newman, Shunmugam, & Dubrow, 2011). Chakrapani et al study implies barrier at three levels: family/social, health care system and at individual level. One Canadian study recommends that psychiatrists need to understand LGBT issue better.

Ryan et al study reported higher rates of smoking among sexual minorities. Bisexuals are more like to get indulged in Bing drinking and smoking. Stress resulting from stigma and discrimination contribute to higher risk of indulging in substance abuse. American College of Physicians documents the higher rates of smoking among MSMs than general population (Makadon). Alcohol misuse, a major health concern in lesbian and bisexual veterans, could be credited to higher prevalance of mental health symptoms (Lehavot, Browne, & Simpson, 2014). Revealed that gays rejected by family are more likely to indulge in alcohol and substance abuse. Gay neighborhood is not defined by more concentration of homosexuals in the neighborhood, but it is defined by higher concentration of gay bars, which highlight the magnitude and reflection of alcohol problem in sexual minorities (Midanik, Drabble, Trocki, & Sell, 2007). Lesbian bars were identified by several qualitative studies as a gathering place for lesbian women(Gruskin, Byrne, Kools, & Altschuler, 2006; Hequembourg & Brallier, 2009).

In nutshell, mental health of sexual minorities is preventable if certain policies are enacted which could help in reducing stigma and discrimination against them. Supreme court judgment is a big step in that direction and hopefully other countries in the world will follow the same suit.

Bibliography

Almeida, J., Johnson, R. M., Corliss, H. L., Molnar, B. E., & Azrael, D. (2009). Emotional distress among LGBT youth: the influence of perceived discrimination based on sexual orientation. J Youth Adolesc, 38(7), 1001-1014.

Almeida, J., Subramanian, S. V., Kawachi, I., & Molnar, B. E. (2011). Is blood thicker than water? Social support, depression and the modifying role of ethnicity/nativity status. J Epidemiol Community Health, 65(1), 51-56.

Bayer, Ronald. Bayer R. Homosexuality and American psychiatry: the politics of diagnosis. . New York, 1981.

Chakrapani, V., Newman, P. A., Shunmugam, M., & Dubrow, R. (2011). Barriers to free antiretroviral treatment access among kothi-identified men who have sex with men and aravanis (transgender women) in Chennai, India. AIDS Care, 23(12), 1687-1694.

D’Augelli, A. R., Grossman, A. H., Salter, N. P., Vasey, J. J., Starks, M. T., & Sinclair, K. O. (2005). Predicting the suicide attempts of lesbian, gay, and bisexual youth. Suicide Life Threat Behav, 35(6), 646-660.

Defechereux, P. A., Mehrotra, M., Liu, A. Y., McMahan, V. M., Glidden, D. V., Mayer, K. H., . . . Grant, R. M. (2015). Depression and Oral FTC/TDF Pre-exposure Prophylaxis (PrEP) Among Men and Transgender Women Who Have Sex With Men (MSM/TGW). AIDS Behav.

Gruskin, E., Byrne, K., Kools, S., & Altschuler, A. (2006). Consequences of frequenting the lesbian bar. Women Health, 44(2), 103-120.

Hatzenbuehler, M. L., Keyes, K. M., & Hasin, D. S. (2009). State-level policies and psychiatric morbidity in lesbian, gay, and bisexual populations. Am J Public Health, 99(12), 2275-2281.

Hequembourg, A. L., & Brallier, S. A. (2009). An exploration of sexual minority stress across the lines of gender and sexual identity. J Homosex, 56(3), 273-298.

Hoyos, J., Fernandez-Balbuena, S., de la Fuente, L., Sordo, L., Ruiz, M., Barrio, G., & Belza, M. J. (2013). Never tested for HIV in Latin-American migrants and Spaniards: prevalence and perceived barriers. J Int AIDS Soc, 16, 18560.

Lapinski, J., & Sexton, P. (2014). Still in the closet: the invisible minority in medical education. BMC Med Educ, 14, 171.

Lehavot, K., Browne, K. C., & Simpson, T. L. (2014). Examining sexual orientation disparities in alcohol misuse among women veterans. Am J Prev Med, 47(5), 554-562.

Lytle, M. C., De Luca, S. M., & Blosnich, J. R. (2014). The influence of intersecting identities on self-harm, suicidal behaviors, and depression among lesbian, gay, and bisexual individuals. Suicide Life Threat Behav, 44(4), 384-391.

Mathy, R. M., Cochran, S. D., Olsen, J., & Mays, V. M. (2011). The association between relationship markers of sexual orientation and suicide: Denmark, 1990-2001. Soc Psychiatry Psychiatr Epidemiol, 46(2), 111-117.

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Second. Philadelphia: merican College of Physicians, 2008.

Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull, 129(5), 674-697.

Midanik, L. T., Drabble, L., Trocki, K., & Sell, R. L. (2007). Sexual orientation and alcohol use: identity versus behavior measures. J LGBT Health Res, 3(1), 25-35.

Newcomb, M. E., Heinz, A. J., Birkett, M., & Mustanski, B. (2014). A longitudinal examination of risk and protective factors for cigarette smoking among lesbian, gay, bisexual, and transgender youth. J Adolesc Health, 54(5), 558-564.

Newcomb, M. E., Heinz, A. J., & Mustanski, B. (2012). Examining risk and protective factors for alcohol use in lesbian, gay, bisexual, and transgender youth: a longitudinal multilevel analysis. J Stud Alcohol Drugs, 73(5), 783-793.

Parker, R. D., Lohmus, L., Valk, A., Mangine, C., & Ruutel, K. (2015). Outcomes associated with anxiety and depression among men who have sex with men in Estonia. J Affect Disord, 183, 205-209. d

Patel, V. V., Mayer, K. H., & Makadon, H. J. (2012). Men who have sex with men in India: a diverse population in need of medical attention. Indian J Med Res, 136(4), 563-570.

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Ryan, C., Russell, S. T., Huebner, D., Diaz, R., & Sanchez, J. (2010). Family acceptance in adolescence and the health of LGBT young adults. J Child Adolesc Psychiatr Nurs, 23(4), 205-213.

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Sandfort, T., Bos, H., Knox, J., & Reddy, V. (2015). Gender Nonconformity, Discrimination, and Mental Health Among Black South African Men Who Have Sex with Men: A Further Exploration of Unexpected Findings. Arch Sex Behav.

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Wallace, S. P., Cochran, S. D., Durazo, E. M., & Ford, C. L. (2011). The health of aging lesbian, gay and bisexual adults in California. Policy Brief UCLA Cent Health Policy Res(PB2011-2), 1-8.

We are super-happy that Dr.Jim Sherry, global health leader, has joined CUNY SPH recently..Welcome!! I have been visiting Boston Global health series, Columbia and NYU! : now it was pleasure to travel from washington DC to New York to attend global health event in our own yard! Thanks Dean!!!

At one time, Rwanda had one of the weakest public health system in the world! Now it is example of good governance, economic growth, rationalized use of resources, equitable participation  of women in power and the effective use of outside financial assistance , which ultimately resulted in public health dividends  for once war torn country. In this article, I highlighted the achievement of Rwanda in light of public health, I also tried to find out the causes for its progress. And lastly, I mentioned the areas which need further improvement.. Rwanda emerged from the situation where security of life was first and foremost point on the agenda. Public health infrastructure was completely broken.

Even though Rwandas original inhabitants were Khosian speakers, their descendants now constitutes merely one percent of the total population of country. Hutu, Tutsi and Twa are the major ethnic groups. Hutu were traditionally concentrated in agriculture sector while Tutsi were cattle herder. Tutsi were powerful in military point of view. Rwanda had been witnessing ethnic conflict for almost 19th century, perhaps since the freedom from Belgium, but in 1994, it reached at zenith, which forced historian to term it as genocide. Rwanda genocide in which ten thousand people of Tutsi tribes were killed every day, and this massacre ran for 44 days., touching the number of deaths to one million. European medical staff were also executed who were treating victims. The most scary part of the killing was the people who participated in the massacre were between ages of 18 and 24 years, and from majority group of Hutu which left everlasting mark on all demographic, socioeconomic and health fabric Rwanda. Thousands became orphans and widows; and two million people became homeless. Even first woman Prime Minister  Madam Agathe and her husband  were not spared and were executed along with her Belgium security guards. One thing is sure, this carnage was the result of exclusion policies.

After genocide, Rwanda took eventful journey with optimism. Despite devastated completely by genocide, Rwanda did great comeback showing its resillience skills.  Its performance in public health is second best in Africa and only second to South Africa. It would be unfair to credit Rwandas success to just outside financial assistance. Nonetheless, it is worth to mention that of 49 Sub-Saharan countries, Rawanda is 22nd in getting financial assistance. Per capita income in getting financial assistance is little higher than other countries like Ethiopia and Uganda.  Almost 47% of budget of Ruwandian government comes from outside assistance.

Rwanda signed the declaration of achieving the Millennium Development Goals (MDGs) by 2015. It has scored high on at least two of  the eight goals. First, it achieved universal primary education, and second, it promoted equitable share of women in parliament. Child mortality rate has dramatically come down.  Even maternal heath has improved a lot. Infant mortality rate has come down from 92 in 1990 to 36 in 2012. Life expectancy at birth has also improved.  Rwanda is the country where number of women parliamentary members is higher than any other nation. This progress is credited to education, community health workers and governments insurance policies (muetelles de santé). 10percent of GDP is attributed to health sector.

It may be apparently debatable that Rwanda’s good result in light of public health is attributed to its business friendly environment policies and overall economic development.World Bank has ranked Rwanda at 28th in view of business friendly. According to Rwanda development Board (RDB), Rwanda is the most  competitive place for investment in the East Africa.Many of business initiatives were taken by present government since 2000. Construction permits, which used to takes years, are issued fast, perhaps in few days.  Foreign investment is encouraged. New business licenses are served in a day. Significant reduction in poverty by 11% was reported.   New Special Economiz Zones (SEZs) have been develed by the government. In addition. Labor in Rwanda is cheaper and efficient. According to Dr.Jim Sherry (CUNY SPH grand round lecture on 5/4/2015), success in public health goes hand in hand with economic prosperity and which seem largely applicable in case of Rwanda. Rwandas business and information technology initiatives are helping   to create job opportunities.

Malaria, HIV and tuberculosis yet account for estimated twenty percent of deaths. Rwanda has done well in view of fighting HIV/AIDS,  With funding from US presidents Emergecny Plan for the AIDS Relief , and Multisectoral AIDS program (mAP). Cancer as the cause of death is still far less than developing world, which stands at 3 percent. Since the life expectancy of Rwanda is less than 60 years, and large chuck of cause is attributed to infection and chronic diseases, low rate of cancer as cause of death is understandable.

One person who really deserves accolades for bringing Rwanda from death bed to the new hope of better life, for converting Rwanda from devastation to the new hope of edifice,  and for successfully meeting the herculean  challenge of changing Rwanda  from insecurity to the business friendly situation, is none other than sixth president of the nation, Dr.Paul Kagame . He has been head of Rwandan Government for last fifteen years. He once famously said that Rwanda is in hurry. What is the contribution of political part? Present government adopted inclusive growth, and tried not to widen the economic disparity across tribes. It also cancelled the identity of people on the basis of tribes. During our brief conversation, Dr.Jim Sherry, who did extensive public health work in Rwanda, also highlighted the enthusiasm and passion of President Kagame. The functioning of Rwanda government rely on 2020 vision-namely, human development, poverty reduction, economic growth, good governance. Population density of Rwanda is highest in the African continent.

Ethics and epidemiology were another pillars for the successful public health story in Rwanda. Performance was the criteria to provide benefits, allowances and rewards to health care workers. Data driven approach was taken into consideration before formulating policies. Evidence based public health practice as well as evidence based medical approach was emphasized while dealing with population and patients.

Good road network and market infrastructure helped to reduce food insecurity in some ways. Yet, according to 2012 report, 14% of Rwandan Households have to face hurdles to provide food to their families. Unequal distribution of food security is noted, especially in rural areas, Households with inadequate food consumption was especially high (42%). In addition, East and West of Congo Nile Crest also shows the seme results  because of soil erosions. Here, GIS can help in creating hotspots and assist in decision making process for policy makers.

No health is possible without mental health. Rwanda has been struggling to provide quality mental health care. Rwandan medical schools lack psychiatry clinical training. Its being almost 20 years passed, much of victims still suffers the effect of genocide. During hundred days genocide, HIV positive men were released from prison , and were asked to rape Tutsi women.  33% of genocide survivors experienced rape. Number of Psychiatrists per 1,00,000 population is 0.05 exact number in all country is 5. Nurses are the bulwark for the mental health care in Rwanda. . Rieder et al (2013) conducted mental health status study in conflict survivors. There are genocide survivors who were even raped and infected with HIV need extensive mental health therapy. Bolton et al 2002 reported that Bugesera had 15% prevalance of depression.   79% population was exposed to traumatic events. There is need of integration of mental health services. Mental health still carry stigma, it need cultural shift. It can be done through the channel of education and communication, where media can paly big role. Psychopharmacologic approach to deal with mental health patients, specially when drugs and quality mental health professionals are available, will work. In many condition, depression act as comorbidity. Though Rwanda is host to 0.13 percent population of world, it carries 5 percent burden of mental health illness. This magnitude speaks the quantum of the problem,

Though Rwanda has done dramatically well specially post-genocide, it has to go a long way to meet challenges such as unequal distribution of infrastructure between rural and urban areas, increasing population density, shortage of high-skilled physicians, shortage of tertiary centers, alarmingly high rates of chronic malnutrition for children under five, and high  burden of neuro-psychiatric disorder. Population control measures need to be in place. Rwanda had one the highest birth rates. If this issues is looked through the triad of environment, population and health,  it becomes obvious that increasing population will add burden on already limited resources. Despite, the journey of Rwanda is successful and can be labeled as template for other nations.

Rosa Park refused to vacate  the  seat in the colored section of the bus  for the white passenger when white-section was filled, for which she was arrested later(Bus is in Henry Ford museum).  We can imagine how much America has traveled since then and now it has Barack Obama who is the head of constitution.

Many sociopolitical scientists, researchers and human right activists might consider United States as template or reference for all these rights: Reproductive rights, immigration rights, civil rights, equal employment opportunity rights, marriage rights; but for such display on the actual screen, it had struggle, movements, sacrifices, lawsuits and politics behind the screen.Visit to this glorious place opened my *policy* eyes. National Archives Museum traveled me through sequence of shaping up of policies in the United States. Would you believe that United States was not different from any of conservative country  where women are still not even allowed to have driving license. Not so extreme, but till 1920,women didn’t have voting rights in this oldest democracy.
Immigration rights: United States is proud to be land of immigrants and land of opportunities. It is ,therefore,known for its diverse and dynamic society/community. One of pictures in museum  depicts how Irish workers as new immigrants  fought discrimination, long hours, and demand to work faster. It also have pages on display, collected  from the census schedule for Lowell , Massachusetts, 1860, which provides wealth of information for genealogists tracing family ties. It also helps in understanding the settling pattern of different immigrant groups. In my own observational research, I found people from Central America (especially Hondarus, Nicargua, Salvador and Guatamala) settled around Virginia and maryland. Recorded from immigrant case files,   a lady from HongKong was suspected as prostitute by immigrant officials,  and then she was kept under detention. After three appeals, she was granted entry.

Woman rights: Fight for suffrage escalated at the time of World War 1.  Women protesters were jailed in Virginia’s Occoquan workhouse (Fairfax county). Finally replying to women suffrage movement,  then President Woodrow Wilson endorsed  a federal woman suffrage amendment, and ultimately it became law in  August 1920.

Women didn’t have property right and she was subordinate to husbands. After marrying husband of different nationality, she was certain to lose her nationality. Museum mentions one case where a woman from Texas lost her citizenship after marrying the person from Czekoslovakia in 1941 (Continue)

Have you ever noticed Margaret Sanger Square in Manhattan? Yes, struggle of  Margaret Sanger is credited to the landmark judgement of  Griswold vs Connecticut when birth control in the United States was legalized. She is regarded as prominent figure in the fight for American woman’s right. It is also worth to write here that her mother was pregnant for 18 times in 22 years. I wish she was alive today , perhaps she would have provided useful guidance in Purvi Patel ‘s case.

Ariong Moses is my good friend from Uganda. He is global health leader and potential leader for Uganda who would like to change global health dimensions of Uganda in positive ways!! Here is his article which he shared with me last week.

The Ebola Epidemic has claimed over 4,500 deaths since it began around January 2014. Most of its victims are allegedly the women who have endured the suffering of their loved ones as they writhe and die painfully. Heroes are being made every day in the worst hit countries of Sierra Leone, Guinea and Liberia as medical workers – local and foreign, struggle to contain a ‘war’ that, if not well fought within the shortest time possible, might explode in to a 4^th World War of sorts. The spread however continues at alarming rates with WHO warning that over 10,000 new infections per week will be recorded if greater efforts are not put in place within the next 2 months.

Several reasons have been alluded to the failure to contain the virus by the affected countries. It is a known fact that health systems in Africa have a lot to be desired especially in countries like Liberia and Sierra Leone. It would be unwise to ask of them to handle a crisis of this nature to its logical conclusion knowing that any failures will be felt by the rest of the world.

Support has been obtained from USA, UK, China and many other nations to combat Ebola. We should however note that West Africa does not simply need some support, the people of West Africa and the rest of the world need Ebola to be dealt with to its logical conclusion. This Crisis has instilled fear among the people around the world as much as Terrorism has. Infact, a Student from sierra Leone was denied accommodation in Newcastle by three Landlords due to the fear of Ebola – I call it Ebophobia. Being black itself is now associated with Ebola in some parts of the world with the thinking that one might be coming from the hotspots of Ebola, Africa.

The mind boggling question though is that terrorism is being fought world over for a similar reason- to avoid deaths and fear that it brings to the innocent people around the world. A lot of resources are usually committed for this cause and countries are willing to unite and find the terrorists wherever they are. It is the reason my country Uganda contributed troops to fight in Somalia and recently South Sudan so as to stem any terrorist acts around the world. It is clear that Ebola is among these categories, claiming over 2000 lives within 06 months at an alarming death rate of 70%. Why is the world not doing enough to unite against Ebola? Several reports by WHO and other organisations on the ground indicate that the response has been slow as compared to the situation on the ground.

Well, one may be tempted to think that the world does not care much about those in this predicament. These are the sort of thoughts that run through a desperate mind. These are the thoughts that are running through thousands of people living in quarantined areas, faced with looming food shortages that could cost lives.

If the world is truly a Global Village, we should view the plight of the people of West Africa as our own. Let’s not give opportunity to those who need an excuse to humiliate black people around the world in the name of Ebola. Joyous will that day be when the mothers of West Africa stop crying for the loss of their children. I believe it is time to act and end Ebola!

Why Growing Old is admirable no more in many parts of the world.

The word ‘old’ used to be synonymous with the words; respect, wisdom, intelligence, experience, seniority, blessings, leadership as well as being a preserve of those blessed by God –  a belief among those who acknowledge presence of a supreme being.  Old persons (The elderly) were seen as a source of inspiration and were responsible for nurturing future generations based on their long life experiences with the notion “Experience is the best teacher” being widely accepted.

My father once told me of how his Grandfather handed over a special gift of his to his Son (My Grandfather), a gift that he had attained through several years of learning and practice. He took his Son to a place with many trees and shrubs and pointed at them. He asked, “Do you see all those Cattle and property all over this place?. There was obviously no wealth visible among this shrubs and bushes. My Great Grandfather was a medicine man just like many other persons at the time who had discovered medicinal properties of the elements of nature, the special gift that God had given to them. To him (The Great Grand), these were the ‘cattle’ and property that he was passing on to his Son, my Grandfather. Through practicing traditional medicine, he was able to raise his family and educate some of his children.

The African greats like Nelson Mandela (RIP), Desmond Tutu, Kenneth Kaunda of Zambia, Mzee Arap Moi of Kenya, Olusegun Obasanjo of Nigeria, Tata Awayo Mary of Uganda among others, have continued to inspire the current and the future generations in ways that I cannot explain due to the magnitude of its effect.

By now, I guess you (the reader) is asking yourself why you have not heard about the so called great Tata Awayo of Uganda. Awayo is a deaf and dumb neighbor of mind in the Town of Soroti, Eastern Uganda. She is about 75 years old and leaves alone in a grass thatched mud and wattle house. Awayo did not learn the sign language from any special needs training centre due to the challenges in Uganda’s education system that we ought to know by now.

With a smile on her face, Amojong Awayo waves me good bye almost every morning as I go to work but as well welcomes be back from the long day’s work. Awayo has been neglected by her own children and family members who fear to shoulder the burden of taking care of the now old and needy Awayo. Because the  world has turned its back on her, she has to wake up very early in the mornings to show her love to everyone passing around (especially me) as she begs for; a daily meal to keep her precious life going, support for medical care to mitigate the now chronic illnesses that she has, emergency roofing of her hut that leaks now and then when it rains heavily, for Love and companionship when she is lonely and needs to be heard just like any other human being and the list goes on and on.

On the day the Hybrid Solar Eclipse caught the attention of almost every individual in Awayos’ vicinity, she was left wondering why it was not shining as it was supposed to be – I learnt this through the crude sign language interactions that I held with her. I tried to explain to her that the moon was passing below the sun and covering its rays from reaching earth, it was a hard one to explain but I made my point by showing her the eclipse using a film strip. Awayo had a hearty laugh and pated me on the back as she was expressing her deep appreciation of my intervention to address the ‘mystery’.

Awayo Mary and several other old persons are being abandoned by us, the able and productive group in the society. I learnt that even in developed countries, the elderly are treated like Animals and are dumped in care centres. Why the hell would I dump my mother or my father or any of my close relatives that brought me up and natured me, to a care centre?  And to make it worse, some relatives never bother to check on them and give them the Love and company that every human being inherently deserves. I recently read an article where robots are being developed to care for the elderly, to feed them, to move them around and to “give them some Love”. This killed me internally and made me wonder where the human race is heading to.

As I blog about this, I am shedding invisible tears because of the old men and women that I have seen rotting away with Jiggers and several other treatable illnesses in my own home country, Uganda. They are given names like ‘the father of jiggers’, ‘a cursed old man or woman’, beggars among others.  The health service providers have as well focused their attention on mothers and children leaving the elderly to be ‘hosts’ to several diseases as they die and disappear slowly from the face of the earth.

Who will mentor us? Who will bridge the past and the present future for the good of the current generation and the future? Who will inspire us with those lovely old age stories and remind us of the struggle that our forefathers went through to achieve what we are enjoying today?

President Obama, while eulogizing Tata Madiba (Nelson Mandela), said that we will never see a person like Mandela again. It’s true that Madiba has passed on with all his brilliance and courage, but we still have a role to play to emulate his works, to fight for Justice for all, to respect and adore humanity and to preserve the unique brains that we have among our elderly persons. Let’s give ourselves a reason to live long and inspire the world without fear that our very own will abandon us in time to come.

By ARIONG MOSES

GLOBAL HEALTH CORPS FELLOW (2012-2013)

UGANDA

Authors: Wendy Huebner , Asif Patel,  Andrea Polk-Stephenson , Howell Sasser  and Erica E. Smith

From the Chair: Ebola—The New Normal
From the Secretary: Leading by Example—The Importance of Risk Communication
Fall 2014 Update in Epidemiology Education
Polio Eradication: Progress and Challenges
One of the Greats: A Tribute to Mervyn Susser

From the Chair: Ebola: The New Normal

The news today reports that a Liberian man who developed symptoms of Ebola fever after flying to Texas has died. Various other “mini-outbreaks” in the U.S. and Europe – as well as the still-growing index event in West Africa – continue to appear on front pages and TV screens around the world. And just this morning, my employer’s Employee Assistance Program sent me an email entitled, “Ebola: What You Need to Know to Protect Yourself.”

I will leave it to my readers to fill in appropriate thoughts about the case-to- coverage ratio, and about what might happen if similar attention were directed toward any of many public health problems that are much larger but which routinely go begging for prevention and treatment dollars, let alone face time on MSNBC AND Fox News. Instead, I will offer a few thoughts on what this and other high-profile communicable disease events mean for how we work and how we think.

Numerators and denominators are largely imaginary numbers. It is perhaps a bit ironic that this year’s APHA Annual Meeting theme is “Healthography” (subtitled, “How where you live affects your health and well-being”). Place nowadays seems to have less to do with the traditional combination of agent, host and environment, than with things like proximity to airports and interstate freeways. Ease – and rapidity – of movement puts a large but poorly defined portion of the population in

the (potential) hot zone. Counting cases and calculating rates becomes a vexed topic, and forecasting is little better than guessing.

Public health becomes a police issue (again). It has been announced again lately that airport security screens in various places would begin to include remote temperature measurement, presumably by infrared sensing, as a means of identifying carriers of communicable diseases. The impulse is understandable, and it is probably too much to expect that available technology not be used when disease may be prevented and perhaps lives saved. Still, the lack of specificity, the lack of professional training and discretion on the part of those doing the screening, and the coercive nature of the whole process seems at odds with the public health ethos. Can anyone imagine doing something similar for HIV, or HPV, or anything else not getting 24/7 coverage? Ask me again when we have remote scans for pre-diabetes or prostate cancer…

Prevention gets lost, and then found again. In the heat of the moment, the public health heroes are all wearing inflatable plastic suits. “What do we do now?” drowns out “What could we have done to prevent this?” When patients are already in the beds, a multi-thousand-dollar treatment sounds a lot more reasonable than it does when public health budgets are being discussed. But all of this passes. When the news cycle moves on, a return to a focus on prevention is the — reassuring — constant. May the present outbreak burn itself out rapidly and become less a parade of plastic suits and more a topic for education.

From the Secretary
Leading by Example: The Importance of Risk Communication

On Sept. 30, 2014, the Centers for Disease Control and Prevention, the Texas Department of State Health Services and the Dallas County Health & Human Services announced the first laboratory-confirmed Ebola case diagnosed in the United States (http://www.cdc.gov/media/releases/2014/s930-ebola-confirmed-case.html). The hours that followed exemplify the 24-hour news cycle in which we currently live. In some cases, media consultants and experts provided clear and accurate commentary on the situation at hand. In others, a variety of factors contributed to misinformation and speculation. In the new age of “viral” stories, sound bytes and social media, an “outbreak” of misinformation can be almost as dangerous as the true outbreak being described.

As epidemiologists, we are often in a unique position during public health emergencies — one that can become particularly relevant in the early hours of any outbreak investigation, when publicly available information may be limited, and fear and speculation can spread quickly. We understand public health and epidemiologic principles, as well as outbreak investigation and contact tracing. We frequently negotiate the delicate balance between agency transparency and patient confidentiality. This is where grassroots communication comes into play. Even in

our own social circles, we can lead by example to promulgate more accurate information and try to quell rumors and speculation.

Although many of us have no direct role in the current case follow-up and contact tracing in Texas, risk communication is key in any emergency situation. Staying informed is crucial, and an excellent source “related to emergency preparedness and response and emerging public health threats” is CDC’s Clinician Outreach and Communication Activity, or COCA) “COCA prepares clinicians to respond to emerging health threats and public health emergencies by communicating relevant, timely information related to disease outbreaks, disasters, terrorism events and other health alerts.” For more information and to subscribe,

visit http://www.bt.cdc.gov/coca/. Not all of us are specialists in risk communication, but CDC also provides some excellent resources on Crisis and Emergency Risk Communication (http://emergency.cdc.gov/cerc/index.asp) and Social Media Tools, Guidelines and Best Practices (http://www.cdc.gov/socialmedia/tools/guidelines/socialmediatoolkit.html).

As CDC DirectornTom Frieden, MD, MPH, stated in the CDC’s September 30 news release, “Ebola can be scary. But there’s all the difference in the world between the U.S. and parts of Africa where Ebola is spreading. The United States has a strong health care system and public health professionals who will make sure this case does not threaten our communities. While it is not impossible that there could be additional cases associated with this patient in the coming weeks, I have no doubt that we will contain this.”

Without clairvoyance we cannot predict the future of Ebola in the United States or the world, but an emphasis on good risk communication strategies can benefit all of us, whether we are talking about Ebola or any other situation.

Cheers,
Erica Smith,
Secretary, Epidemiology Section

Fall 2014 Update in Epidemiology Education

The Epidemiology Education Committee welcomes you to our corner. The Committee’s goal is to support efforts to increase and enhance epidemiology education for key target groups. These groups include the public health workforce, public health policymakers, the media, the general public, and our youth and their teachers. We will report activities and events that address one or more of these groups. Let us know if you have any such news to include in the EE Corner.

Using Smartphone Technologies in Undergraduate Epidemiology Classes

This article is written by Jeffrey Bethel, PhD, assistant professor of epidemiology at Oregon State University, College of Public Health and Human Sciences. As a member of the Epidemiology Education Committee, he is responding to the Committee’s desire to share information about using technology in the epidemiology classroom.

I was looking for a way to better engage the roughly 80 students in my undergraduate introduction to epidemiology course. Having heard of a few student engagement and response systems used by colleagues, I wanted to use one that utilized cell phones since cell phones had been a point of contention in the classroom. If you can’t get students off their phones, use the phones in class! I decided to use Top Hat (https://tophat.com/), which was touted as a way to transform students’ mobile devices into powerful classroom engagement tools. Students took their weekly quizzes on Top Hat rather than in paper form. This eliminated manual grading, saved paper, provided me with instant feedback, allowed students to view their scores in a timely manner, and stored all quizzes online for students to review at their leisure. No passing back quizzes that students may misplace. I also used Top Hat to assess student comprehension during lectures and used the instant feedback to review certain concepts in greater detail. Students also completed in-class exercises in groups and submitted their responses using Top Hat. These exercises were also available online for students to review in preparation for exams. After some difficulty getting students registered for Top Hat, the class quickly became adept at using the software that was available on smartphones, tablets, and laptops. Connectivity was rarely an issue. Student feedback was generally positive — they liked having access to quizzes and in-class exercises and really liked that it saved a large amount of paper. The consistent criticism was that they felt the added cost, while quite modest ($20), was unfair given they had already paid tuition and fees. Overall, my first experience using student engagement and response systems was positive. With a few tweaks, I believe I can more effectively use Top Hat to improve student learning in the future. Looking ahead, I am hoping to incorporate additional technology that could be used for data collection exercises in the epidemiology classroom to simulate real world experience in administering surveys. Contact: Jeff.Bethel@oregonstate.edu

High School Standards For Epidemiology — Update on Tennessee’s program

In the Spring 2013 and Summer 2014 newsletters, we reported that there were three states that have adopted high school standards focused on public health and epidemiology. Here is more about what is happening in Tennessee, written by Sheila Carlton, RN, MSN, who is at the Tennessee Department of Education’s Division of Career and Technical Education, and is working at the forefront of developing these standards as the Health Science, Law, Public Safety, Correction and Security, Government and Public Administration Career Cluster Consultant.

The Tennessee Department of Education’s Division of Career and Technical Education is excited to provide health science students and teachers the opportunity to expand the knowledge of public health across our state’s high schools. Our research found Americans’ overall health is on the decline in all areas, from very rural to dense metropolitan communities. To ensure that we were preparing our

students to meet the needs in this field, the Public Health program of study, or POS, was developed.

Within this POS, students will examine why and how the increase in chronic conditions impact and influence not only individuals, but also the health of their communities and the public. Course content includes: knowledge and skills to help communities prepare for and respond to disaster; public health problems and strategies for alleviating them; tools to evaluate the rise in mental health diseases and disorders; and the examination of how the health of the United States is related to larger global health issues. Upon completion of this POS, students will be prepared for advanced study at the postsecondary level in the areas of epidemiology, health policy and similar public health-related fields.

Currently, four schools will be offering the public health POS in the first year it is available. Three schools are located in small rural communities and one in a metropolitan area. “We are seeing unhealthily individuals in our community,” says one health science teacher, “If our students can become disease detectives in the Epidemiology course, possibly they can change their own community’s health.” The department is currently developing a resource toolkit to support teachers of these new courses. To share resources that will be valuable for these teachers, or learn more about the courses, please

visit http://www.state.tn.us/education/cte/HealthScience.shtml or email Sheila Carlton, Tennessee Career Cluster Consultant for Health Science Education,
at Sheila.Carlton@tn.gov.

Looking for epidemiology teaching materials for the Undergraduate and Graduate level? Here are a few URLs that link to epidemiology education resources suitable for post-secondary students. For a more extensive list of links to this and other target student groups, go to http://www.epiedmovement.org and click on “Links for Teaching Material.”

• Deadly Outbreaks — How medical detectives save lives threatened by killer pandemics, exotic viruses and drug-resistant parasites — A book by Alexandra M Levitt in conjunction with the Council of State and Territorial Epidemiologists. This book project is “intended to provide the next generation of young people attracted to the fields of math and science with an exciting and worthwhile career option…”
• North Carolina Center for Public Health Preparedness — University of North Carolina
• Tephinet — A professional alliance of field epidemiology training programs, or FETP, in 32 countries, Centers for Disease Control and Prevention
• Epidemiology Case Studies, Epidemiology Intelligence Sevice (EIS) — Centers for Disease Control and Prevention
• Understanding the Fundamentals of Epidemiology — an Evolving Text, Victor J. Schoenbach, Department of Epidemiology, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill (versión en

español: Comprendiendo los Fundamentos de la Epidemiología — un

Texto en Desarrollo)
• Epiville — Developed by the Mailman School of Public Health, Columbia

University

Polio Eradication: Progress and Challenges

As a consultant to the Centers for Disease Control and Prevention Center for Global Health, Global Immunization Division, I was privileged to be a part of a worldwide initiative to eradicate polio. I wanted to share some of what I learned so we can better understand polio epidemiology, prevention and the efforts to stop transmission of this cruel and preventable disease.

Polio is a viral infection that is usually recognized by the acute onset of flaccid paralysis caused by poliovirus types 1, 2 and 3.1 Less than 1 percent of cases result in flaccid paralysis, and the vast majority of cases go undetected.1 Poliovirus can be isolated from stool, cerebrospinal fluid, or CSF, and oropharyngeal samples, and from environmental (sewage) sampling. Transmission is generally through the fecal-oral route.1

Polio transmission has never been interrupted in Afghanistan, Nigeria and Pakistan. In 2013 and 2014, outbreaks occurred in the Horn of Africa, Cameroon, Equatorial Guinea, Syria and Iraq — all previously polio-free countries.2

Poliovirus can invade the brain and spinal cord of infected individuals and can result in permanent paralysis and, rarely, death. There is no cure, but safe and effective vaccines are available. Therefore, the strategy to eradicate polio is based on preventing infection by immunizing every child through routine immunization, supplemental immunization activities and/or “mop-up” vaccination campaigns in geographically-restricted areas following the identification of a case. Another cornerstone of the eradication effort is timely and sensitive clinical surveillance so that every case can be detected.2

There has been great progress since 1988 when the Global Polio Eradication Initiative was launched, and the number of annual polio cases has decreased by >99 percent. The World Health Organization, Rotary International, CDC, and the United Nations International Children’s Emergency Fund are spearheading GPEI partners.3 The Bill & Melinda Gates Foundation is also a critical partner in polio eradication activities. CDC activated its Emergency Operations Center in response to the 2012 World Health Assembly declaration that the completion of polio eradication was a programmatic emergency for public health.

In the United States, the CDC recommends the following:
The poliovirus vaccine used in the U.S. is inactivated poliovirus vaccine, or IPV. IPV is injected into the leg or arm and often given when other vaccines are administered.

It is routinely administered to children who get four doses at 2 months, 4 months, 6- 18 months, and a booster dose at 4-6 years.4

The polio program has made extraordinary progress, “The number of worldwide polio cases has fallen from an estimated 350,000 in 1988 to 407 in 2013 — a decline of more than 99 percent in reported cases.”5 Additionally, four regions of the world are certified polio free — the Americas, Europe, Southeast Asia and the Western Pacific. Within the remaining regions, only three polio-endemic countries (countries that have never interrupted the transmission of wild poliovirus) remain — Afghanistan, Nigeria and Pakistan.

However, there are challenges to the program in a number of countries. Difficulties persist in finding chronically missed children, obtaining parental consent to vaccinate children, and accessing children in areas of insecurity.

GPEI partners and other organizations continue to deploy staff, vaccine and other resources to countries around the world. As travel and trade have been globalized, we must be vigilant at home and abroad.

Further information on the Polio Eradication Initiative can be found at http://www.polioeradication.org/Home.aspx.

References:
1. Heyman, David L, Ed, Control of Communicable Diseases Manual, 19th ed.

APHA Press, 2008 p 484.
2. http://www.cdc.gov/polio/
3. http://www.polioeradication.org/AboutUs.aspx
4. http://www.cdc.gov/vaccines/vpd-vac/polio/dis-faqs.htm 5. http://www.cdc.gov/polio/progress/index.htm

One of the Greats: A Tribute to Mervyn Susser

One of the important chapters of epidemiology ended with the passing of Dr. Mervyn Susser on August 14, 2014. Dr. Susser’s work influenced a whole generation of epidemiologists and will no doubt inspire many generations in the future.

Dr. Susser’s contributions to public health began in the 1950s in South Africa, where he was a supporter of Nelson Mandela during the anti-Apartheid movement. Dr. Susser had many publications with his wife, Dr. Zena Stein; both were vocal opponents of Apartheid, and in 1955 they co-published “Medical Care in a South African Township,” which focused on community-oriented primary care in South Africa and was published in the Lancet.

Because of political pressure and his outspoken opposition to Apartheid, Dr. Susser moved from South Africa to England and then to the United States, where he joined Columbia University as the chair of the division of epidemiology in 1966. Dr. Susser’s most influential work, “Causal Thinking in the Health Sciences: Concepts and Strategies of Epidemiology,” was published in 1973 and focused on the emerging discipline-wide paradigm shift from infectious disease to chronic disease epidemiology. Later contributions of Dr. Susser and Dr. Stein during the 1980s focused on the then newly emerging disease HIV/AIDS and included the identification of women, not just men who have sex with men, as at-risk for HIV/AIDS. Dr. Susser was also the editor of the American Journal of Public Health between 1992 and 1998. Recognizing his numerous contributions to epidemiology, the APHA Epidemiology Section bestowed him with the John Snow Award. He will be long remembered for his many contributions to the fields of epidemiology and public health.

To read the entire New York Times obituary, please visit: http://www.nytimes.com/2014/08/27/us/mervyn-susser-92-dies-studied-illness- and-society.html?_r=0

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Various studies have found that community participation is vital for sustenance of public health programs. Recent rapid outbreak of Ebola have further highlighted the need of educating affected communities regarding basic prevention modalities as it timely prevention can reduce morbidities and mortalities. During the early outbreak of HIV it is was rumored among Indians that the disease was linked to H1 visa to the USA. Things have remarkably changed and due to successful public health interventions people are more awareness for prevention and transmission route of HIV. Imagine the global disease outcome if people were not aware/educated of HIV by now?

Moreover, these scenarios gives us more food for thought such as could participation by lay public help in disease investigation? Or vice versa if outbreak investigation underline community participation?

Ebola is already creating havoc in African countries like Liberia, Sierra Leone and Guinea and World Health Organization has declared public health emergency. In global arena, we need to prepare for any type of health emergencies stemming from travelers as any country can be exposed. In the absence of a vaccine, it is important to create awareness among people about the outbreak, lethality of virus, and more importantly preventive measures. As such barring travelers to or from the affected area does not offer solutions.

Ebola has quickly spread across the borders of 3 West African countries where people live across the shallow and narrow river that divides Guinea with Liberia and Sierra Leone. With community participation, it becomes easy to identify suspected case and again with community participation, treatment is made available fast to the diagnosed patients. It also helps to address attached myths and misconceptions about disease.

Another example of active community participation is of scabies treatment in the village of Galilli (Northern Israeli town). It was that time when computers and Internet were non-existent, Television was rare in villages and print media had supreme dominancy.

Physicians and nurses can play a great role in any public health emergency as they have contacts with multiple level of system. Physicians or nurses with community health background or epidemiology can influence investigation outcome, and community participation. Data collection needs involvement of community. Active participation of people would give large sample and accurate data. Even communicating findings needs the trust of the community if it needs to reach large population for creating awareness and healthy habits.

Educational interventions can be tailored as per the capacity of concerned country. In a resource limited setting, mode of education changes and materials used in education also vary to some extent. For example, People in Africa should be educated about the risks attached with burial of bodies or contact with forest animals helps transmission of disease. Objective of reducing human-to-human transmission should be on priority by educating people: contact with patients body fluid such as blood, saliva or pus should be avoided. Healthcare professional while dealing should wear gloves with patients; in addition, encourage hand washing. Lay people who come across such patients should notify health care agencies or health care professionals.

Three lethal facts about Ebola: 1) Case fatality rate is very high 2) There is no specific treatment available, only supportive measure available. 3) And no vaccine available. Only good news is that at least it is not air borne.

Ongoing ebola outbreak in West African countries has created public health emergency all over the world. What makes Ebola infection dreadful is that its case fatality rate is very high (50-90%), there is no specific treatment for it and vaccine for infection is still a distant dream. Fortunately, it doesn’t spread by air droplets. I am eagerly observing how Center for Disease Control and Prevention (CDC) responds to such public health emergency.

In 2002, because of short supply  of raw material required for the pharmaceutical company, Leiner Health product declared itself as bankrupted.  In 2006,  A flash fire resulted in loss of estimated one million dollar. Despite these shocks company maintained its spirit high.

Efficient dispensing and pricing of drugs is important in all pharmaceutical companies. Here is the role of drug distribution softwares.