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Comparing Health Systems

Permanent Link: http://ncf.sobek.ufl.edu/NCFE004183/00001

Material Information

Title: Comparing Health Systems HIV/AIDS in India and the United States
Physical Description: Book
Language: English
Creator: Tambay, Anita V.
Publisher: New College of Florida
Place of Publication: Sarasota, Fla.
Creation Date: 2009
Publication Date: 2009

Subjects

Subjects / Keywords: India
Public Health
HIV
AIDS
Health
Health Care
Genre: bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Public health systems function in ensuring the health needs of a population are met, focusing particularly on the prevention of ill health. Due to India�s enormous population, and the resultant strain on its resources, India�s public health system has proved inadequate. In the coming years, the Indian government should shift its focus towards addressing primary health care needs such as nutrition and prenatal care. In the US, though health standards are relatively high, disparities in health indicators can be seen across minority populations. These disparities indicate public health efforts are not reaching at-risk populations. Additionally, both India and the US must improve the standards of rural health care. HIV/AIDS affects every country and every population in the world. In comparing HIV/AIDS in India and the US, it is evident both nations have benefited from the global emphasis placed on containing the disease. India has received funding and support from international NGOs for behavioral modification programs targeting at-risk populations. In the US, funding has poured into research and education campaigns. Both countries have made gains, however neither has succeeded in halting HIV/AIDS incidence. India must address social prejudices and the US must work on racial disparities before further progress can be expected.
Statement of Responsibility: by Anita V. Tambay
Thesis: Thesis (B.A.) -- New College of Florida, 2009
Electronic Access: RESTRICTED TO NCF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE
Bibliography: Includes bibliographical references.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The New College of Florida, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Local: Faculty Sponsor: Gilchrist, Sandra

Record Information

Source Institution: New College of Florida
Holding Location: New College of Florida
Rights Management: Applicable rights reserved.
Classification: local - S.T. 2009 T1
System ID: NCFE004183:00001

Permanent Link: http://ncf.sobek.ufl.edu/NCFE004183/00001

Material Information

Title: Comparing Health Systems HIV/AIDS in India and the United States
Physical Description: Book
Language: English
Creator: Tambay, Anita V.
Publisher: New College of Florida
Place of Publication: Sarasota, Fla.
Creation Date: 2009
Publication Date: 2009

Subjects

Subjects / Keywords: India
Public Health
HIV
AIDS
Health
Health Care
Genre: bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Public health systems function in ensuring the health needs of a population are met, focusing particularly on the prevention of ill health. Due to India�s enormous population, and the resultant strain on its resources, India�s public health system has proved inadequate. In the coming years, the Indian government should shift its focus towards addressing primary health care needs such as nutrition and prenatal care. In the US, though health standards are relatively high, disparities in health indicators can be seen across minority populations. These disparities indicate public health efforts are not reaching at-risk populations. Additionally, both India and the US must improve the standards of rural health care. HIV/AIDS affects every country and every population in the world. In comparing HIV/AIDS in India and the US, it is evident both nations have benefited from the global emphasis placed on containing the disease. India has received funding and support from international NGOs for behavioral modification programs targeting at-risk populations. In the US, funding has poured into research and education campaigns. Both countries have made gains, however neither has succeeded in halting HIV/AIDS incidence. India must address social prejudices and the US must work on racial disparities before further progress can be expected.
Statement of Responsibility: by Anita V. Tambay
Thesis: Thesis (B.A.) -- New College of Florida, 2009
Electronic Access: RESTRICTED TO NCF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE
Bibliography: Includes bibliographical references.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The New College of Florida, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Local: Faculty Sponsor: Gilchrist, Sandra

Record Information

Source Institution: New College of Florida
Holding Location: New College of Florida
Rights Management: Applicable rights reserved.
Classification: local - S.T. 2009 T1
System ID: NCFE004183:00001


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COMPARING HEALTH SYSTEMS: HIV/AIDS IN INDIA A ND THE UNITED STATES BY ANITA V. TAMBAY A Thesis Submitted to the Division of Natural Sciences New College of Florida In partial fulfillment of the requirements for the degree Bachelor of Arts Under the sponsorship of Dr. Sandra Gilchrist Sarasota, Florida May, 2009

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Table of Contents List of Figures and Tables ................................................................................................ii Selected Acronyms ...........................................................................................................iii Abstract .............................................................................................................................iv Chapter 1: Introduction ...................................................................................................1 Chapter 2: The Indian context .......................................................................................12 Health care in India ....................................................................................................16 Chapter 3: Health care in America ...............................................................................26 Chapter 4: HIV/AIDS .....................................................................................................46 The AIDS Epidemic in India ......................................................................................53 HIV/AIDS in the United States ..................................................................................64 Chapter 5: Conclusion ....................................................................................................76 References ........................................................................................................................86

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ii List of Figures and Tables Figure 1: Public health pyramid 4 Table 1: U.S. government expenditures on health care, 2008 5 Figure 2.1: Map of India 15 Table 2.1: Differences between urban a nd rural, and high and low-performing Indian states on key health indicators 22 Figure 3.1: Declines in cigarette smoki ng in the United States (1965-2005) 28 Figure 3.2: DHHS Organizational Chart 30 Table 3.1: Total expenditure on health as percentage of GDP 32 Table 3.2: Total expenditure on health per capita 33 Figure 3.3: Personal health care expend itures in the United States, 2005 34 Figure 3.4: Did not receive need ed health services in the past year due to cost 35 Table 3.3: Life expectancy for total population at birth (in years) 37 Figure 3.5: Life expectancy in the US, by race and gender (1970-2004) 43 Figure 4.1: Overview of T cell me diated immune response 47 Figure 4.2: Overview of the HI V infection cycle 49 Figure 4.3: Prevalence of HIV/AIDS in India, by state 55 Figure 4.4: Incidence of HIV/AIDS in Indi a, by state 55 Figure 4.5: HIV prevalence among antenatal c linic attenders part icipating in HIV sentinel surveillance in Karnataka by age and year, 2003-2007 58 Figure 4.6: HIV prevalence in India in 2005 62 Figure 4.7 Estimated New HIV Infec tions, by race/ethnicity, extended back-calculation model, 50 US States and DC, 1977-2006 66 Figure 4.8: Transmission category for pers ons with a new HIV diagnosis in 2006 68 Figure 4.9: Geographic regions of the United States 73

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iii Selected Acronyms AIDSAcquired immune deficiency syndrome AMAAmerican Medical Association ANMAuxiliary nurse midwife APHAAmerican Public Health Association ARVAntiretroviral CDCCenters for Disease Control and Prevention DHHSDepartment of Hea lth and Human Services FSWFemale sex worker GDPGross domestic product HAARTHighly active antiretroviral therapy HIVHuman immunodeficiency virus IMRInfant mortality rate LBWLow birth weight MMRMorbidity and mortality rate MPWMultipurpose worker MSMMen who have sex with men NACONational AIDS Control Organization NFHSNational Family Health Survey NGONon-governmental organization NHPNational Health Policy NIHNational Institutes of Health OECDOrganization for Economic Cooperation and Development PHCPrimary health center TGTransgender WHOWorld Health Organization

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iv COMPARING HEALTH SYSTEMS: HIV/AIDS IN INDIA A ND THE UNITED STATES Anita V. Tambay New College of Florida, 2009 ABSTRACT Public health systems function in ensu ring the health need s of a population are met, focusing particularly on the preventi on of ill health. Due to India’s enormous population, and the resultant strain on its res ources, India’s public health system has proved inadequate. In the coming years, th e Indian government should shift its focus towards addressing primary health care needs su ch as nutrition and pr enatal care. In the US, though health standards are relatively high, disparities in health indicators can be seen across minority populations. These dispariti es indicate public health efforts are not reaching at-risk populations. Additionally, bo th India and the US must improve the standards of rural health care. HIV/AIDS affects every country and ever y population in the world. In comparing HIV/AIDS in India and the US, it is evident both nations have benefited from the global emphasis placed on containing the disease. In dia has received funding and support from international NGOs for behavioral modificati on programs targeting at -risk populations. In the US, funding has poured into research a nd education campaigns. Both countries have made gains, however neither has succeeded in halting HIV/AIDS incidence. India must

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v address social prejudices and the US must work on racial disparities before further progress can be expected. _______________________ Dr. Sandra Gilchrist Division of Natural Sciences

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1 Chapter 1: Introduction In the half of the century yet to come, the health officer must not be solely interested in syphilis, tuberculosis, or even heart disease and cancer. He must more and more concern himself with nutrition [and] housing…He should lead in the elimination of substandard dwelli ngs and participate actively in the planning for slum clearance, urban development and low-rent housing. He must concern himself with the living wage and the provision of a due measure of social security which is essential to both physiological and psychological health. In other words, public health which in its earliest days was an engineering science and has now also become a medical science must expand until it is, in addition, a social science. (C. E. A. Winslow (1923), as quoted in Mullan, 2000) Public health is a vast and expanding field whose legitimacy and importance is growing every day. In a nutshell, public hea lth is a field of study focused on preventing disease and illness and promo ting health and well-being. Th e most operational definition for health is given by the World Health Or ganization (WHO) whereby “health [is defined a]s a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (Evans and Stoddart 1990). The overarching goal of public health is to ensure that a society has adequate resour ces and facilities to maintain a holistic state of well-being for its citizens. The first public health programs came a bout when it was realized that polluted drinking water and improper waste disposal could adversely affect the health of populations. This understanding led to the promotion of cleanliness and hygienic

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2 practices. Along with the advocacy of healthy life practices, public health then moved on to ridding the population of some of the more wide-spread and pervasive diseases. Public health history counts the eradi cation of small pox as one of it most triumphant victories (Breman & Henderson 2002). In addition, thanks to an increasingly strengthening global public health infrastructure, more and more pe ople have access to vacc inations than ever before. While these efforts and many others ar ound the globe continue to triumph in their respective battles, one of the main goals of th e current global health agenda is to end the worldwide HIV/AIDS epidemic (UN 2001). Th e spread of HIV/AIDS has also made tuberculosis an issue that is at the forefront of the global he alth agenda (Kaufmann 2006). Public health efforts occur at the local, national, and global level. In general, global public health agencies fo cus on ridding the world of diseas es that are, or have the potential to be, pandemic. AI DS, malaria, and small-pox are a few examples of diseases on which transnational agents of change lik e the World Health Organization, etc. are focused. National public health programs are left to focus on the health problems that are specific to the national population. In America, educating the public of the detrimental effects of obesity, diabetes, and behaviors that augment the risk of cardiovascular disease have all been major causes of the health department (Olshansky et al. 2005). The term “public health” is associated with government-provided health care and is thus usually seen as health services provi ded to indigent populat ions. In reality, public health encompasses that and much more. Im provement of cleanline ss and quality of food and water supplies, control of communicable diseases, as well as promotion of park development are all functions of public health and all have significant impact on health. Working in tandem, national and global public health organizations function in filling the

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3 gaps left by the private h ealth care system. For those who cannot afford private practitioners, the public health agencies provide subsidized care; for those who live in remote and underserved locations, these agen cies provide medical personnel and access to care. Beyond ensuring the individual has a ccess to direct care, public health workers task themselves with assessing the health of communities through research into health problems and hazards. Armed with this info rmation, public health agencies are then supposed to educate the public on health hazar ds they may be facing or on the risks associated with specific behavior in which th ey may be engaged. Public health research is instrumental in formulation of health policy and in determining where funding is appropriated by the government. One way to think of how public and privat e agents interact in the health care industry is to envision a pyram id. The large base of the pyr amid pertains to services available to all segments of the population (Turnock 2004; Figure 1). These services encompass both health promotion and preventive efforts. Activities at this lowest level are often carried out by national, state, and c ity departments of health. Health promotion includes lobbying for the devel opment of more parks in a city, creating incentives for companies to provide on-site exercise fac ilities for employees, and providing counseling for at-risk youth (Smith et al. 2006).

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4 Fig 1: Public health pyramid (based on Turnock 2004) In the pyramid, the greater portion of the population is affected by public or population based health services. The next leve l up is the level of primary medical care. This is the point at which all medical pers onnel fit into the pict ure of overall health maintenance. Many people seek primary health care services so changes to this can also be viewed as a level at which a larg e portion of the population is affected. As the pyramid narrows, secondary medical services kick in. Secondary medical services are those in place for individuals suffering from chronic and long-term illnesses for which repeated and ongoing medical care is necessary. Though healthy individuals are the focus of population-base d health services at the bottom of the pyramid, people who are already sick are the fo cus of the third and fourth tie rs of the pyramid. The fourth tier, tertiary medical care, consists of highl y specialized care that only affects specific people. TERTIARY HEALTH CARE SECONDARY HEALTH CARE PRIMARY HEALTH CARE POPULATION-BASED PUBLIC HEALTH SERVICES

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5 Overall, the bottom two part s of the pyramid apply at the healthy population level, while the top two narrow the focus on specific populations that are already diseased. To date, much government funding has gone towards the secondary and tertiary levels of medical care, despite their impact on the fe west number of people. As Table 1 shows, approximately $2,105.50 was spent by the governme nt, per person, on health care in the United States in 2006. By combining the govern ment’s funding of public health activities ($58.70 per person) and investment into resear ch and infrastructure ($139.04 per person), it becomes evident that the US governme nt spent only $198.10 per person in 2006 on public health. The remainder was devoted to pe rsonal health care and insurance costs. In the future, funding should focus not only on im proving ill health, but also on maintaining and promoting good health. This would mark a sh ift from an allopathic to an osteopathic perspective, where prevention is more greatly emphasized. Table 1: U.S. government expenditures on he alth care per person, in terms of US$ (Taken from National Health Expenditures, Forecast summary and selected tables 2008) One of the foundations of public health is prevention. Preventive health programs are public health programs that focus on deterr ing behaviors that co uld later pose health

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6 risks. Universally, a major cause for concern in the field is the inequality in access to services for low-income and uni nsured populations. In Florida, the fact that the uninsured are less likely to initiate preventive health care (i.e. physician’s visi ts, prenatal care early in pregnancy) means the health care industry of ten has to bear a much higher price later in the individual’s life when these indivi duals seek care in an emergency room (Dorschiner 2009). In India, disp arities in access to health care between th ose living in urban versus rural settings mi rror disparities between the ur ban and rural populations in the US. In addition to working on prevention, public health is tasked with assessing the health of a population. Keeping in mind that the definition of health is so broad and encompasses so many different fields (psy chology, medicine, anth ropology, sociology, environmental sciences, etc.), defining para meters whereby a community’s health can be assessed is not simple. Data are obtained mainly from health surveys conducted in businesses, schools, and via census. Data ar e also obtained from hos pitals, managed-care organizations, health clinic s, and private physicians. At the most basic level, statistics that measure national morbidity and mortality patterns are used. Morbidity ra tes indicate the percentage of the population affected by a certain disease, whereas mortality rates indi cate the percentage of individuals who have passed away during a given time. These statis tics conform to an older vision of public health where health was viewed simply as th e absence of death or disease. However, as they are easy to measure, statis tics like life expectancy and in fant mortality rate are still pillars by which nations are compared. In underdeveloped nations like India, morbidity and mortality rates are often grossly underrepo rted due to poor data collection methods

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7 and a lack of proper identification of cause of death in hospitals and clinics (Jha et al. 2005). As knowledge and understanding of all the factors that contribute to health has improved, so has the sophisticat ion of statistics used to measure health. Beyond simply determining a nation’s morbidity rate, public health workers now attempt to determine what the causes of morbidity are. Using these st atistics, health offici als can gain a better understanding of the problems impacting a community. Often, this knowledge helps to shed light on specific risk factors that a ffect a population. Risk factors can include biological and environmental components, li festyle (e.g. diet, air quality index), and access to services. The job of pub lic health officials is to und erstand how all these factors are related, and to try to disseminate info rmation that makes the public aware of the factors that could put them at risk. Of all deaths in the United States, 27% are accounted for by heart disease (www.cdc.gov/heartdisease). Risk for heart disease has been shown to increase for smokers, individuals with high fat/low fiber di ets, high blood pressure, high cholesterol, diabetes, those who lead sede ntary lifestyles, are obese, or abuse alcohol (Turnock 2004). Public health officials use data from their own research, combine it with understanding of the body obtained from medicine, and create campaigns that inform Americans of the risks associated with their behaviors. Tobacco use has been implicated in an incr ease in the incidence of heart disease, lung cancer, and infant mortalit y rate. At first glance it woul d appear that tobacco use and infant mortality rate have no direct corre lation. However, mothers who are exposed to cigarette smoke while they are pregnant (whether by smoking or by inhaling smoke

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8 second-hand) put their unborn infants at risk (Jaddoe et al. 2008). Additionally, social factors that influence the rate of tobacco use may impact infant mortality rate. A person who smokes may be less inclin ed to visit a physician and ta ke care of their health, and thus may have fewer pre and postnatal vis its (Jacobs-van der Bruggen et al. 2007). The examples of heart disease and tobacco usage in the United States illustrate just a few ways in which public health draws on knowledge fr om a variety of fields to get a holistic picture of the health of the community. When comparing the health of nations worldwide, certain commonalities appear among countries with “favorable health status indicators”. In general they have 1) a welldeveloped health infrastructure 2) opportunity for educati on and training, 3) high status for women, and 4) economic development (Tur nock 2004). By contra st, nations suffering from poor overall health status can point to these threats to global health: the “3 P’s” which are pollution, population, and poverty. Ev idence of the interaction between these indicators is that the counties in the United States with the poores t tenth of the population have a life expectancy of 75 years, while those with the rich est tenth have a life expectancy of 80 years (Dorling 2006). This fact suggests that lif e expectancy may be influenced by the lifestyle produced by having a certain socioeconomic status. Many factors impact the delivery of health world-wide. Quality and availability of health services varies when examining an urba n versus a rural context, a rich area versus a poor community, and a developed nation comp ared to a developing nation. In addition to these demographic factors, the delivery of health care is greatly impacted by a society’s culture and values. These factors can influence who gets formal care, where they receive care, who provi des them with health serv ices, and how good or bad the

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9 services are. Acknowledging the impact of these factors, publ ic health polic y is shifting away from only creating programs that are specifically designed for prevention of a disease or identifying a multitude of risk fact ors to trying to address the socioeconomic reasons for health disparities (i.e. distribu tion of wealth, education, employment, etc.) (Berkman & Epstein 2008). Countries exhibiting poor h ealth outcomes are unable to achieve their full economic potential because th e productivity of an unhealt hy labor force is greatly diminished (Bennett et al. 2008). Funding lim itations are often the first barrier to providing adequate health serv ices. Particularly in deve loping nations, appropriating funding to improve health faci lities may mean neglecting f undamental needs in education and building of infrastructure. However, fo r these nations, country-level measures to improve health do nothing if a weak health syst em is in place. This fact is particularly important when it comes to controlling diseas es like tuberculosis, malaria, and AIDS. Bennett and colleagues (2004) define the greatest barriers to improving health outcomes as factors pertaining either to infras tructure or work-force. Less than adequate infrastructure results in a lack of facilities (i .e. hospitals, clinics, espe cially in rural areas), insufficient drugs and medicines, and a dear th of supervision a nd accountability at all levels of care. Problems of the work-force include a lack of staff, inability to provide training for staff, and low pay. When seeki ng to improve the delivery of a health care system, public health officials aim to target these deficiencies. Only when a sound system with adequate infrastructure and work-force is in place can a nation begin to build its health care services. Then the system must move on to addres s barriers in access to health

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10 care: physical inaccessibility due to distan ce, lack of affordab ility, and feeling of discontent between patient and caregiver. The world’s largest democracies, India a nd the United States, represent two very different ends of the health spectrum. T hough riddled with its own problems, America’s health care system is one of the best in the world, providing high quality and technologically advanced care to a large portion of its population. In India, only a select portion of the population enjoys comparable health care. For the vast majority of Indians, even basic health services are of low qualit y, it is difficult to find necessary medications, and any high quality care comes with a hyper inflated price tag. Although much its influence may be wa ning, America has long been a world power and the standard to which many nations aspire. In the last 15 years, the size of India’s economy has doubled (Bosworth & Co llins 2008). While it remains a third-world country in many ways, India is slowly estab lishing itself as a global power on par with America, China, Russia, and Great Britain. Though small portions of the population have experienced huge economic gains, evidence of ne w prosperity is scant in most of India. The challenge for India is to channel some of the prosperity towards the lower portion of its population. Since it gained independence from Britai n, India has largely i gnored the need to establish a comprehensive public health system. With well over 1 billion people and a looming health crisis, India is at an important juncture in it s history. India’s public health system is poorly equipped to handle the basic health needs of its people. This problem will not be remedied until the government initiates measures to divert misused resources towards actually providing health services for India’s booming population. The Indian

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11 government must act quickly to improve health outcomes or it risks curbing its current economic growth. Without a healthy workforce, there can be no hope of India fulfilling its economic potential (Bennett et al. 2008). In this thesis, I will assess India’s current system of public health, using America’s health system as a point of co mparison. I am going to take an allopathic approach to evaluating health care, though much health care, particularly in rural areas in India and in certain urban areas of the Unite d States, is accomplished with non-allopathic care (i.e. ayurveda, homeopathy, acupuncture, meditation, massage) (M ishra et al. 2001, Barnes et al. 2004). I will incl ude an evaluation of the effec tiveness of provided health services by exploring how the pub lic health infrastructure in India and the United States addresses what is currently a global public health problem: HIV/AIDS. I will conclude with recommendations for how both nations ca n improve their respective public health systems to better meet the n eeds of their populations.

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12 Chapter 2: The Indian context India is a vast nation en compassing so many ethnic gr oups, languages, religions, and customs, that it may be better understood as a collection of nati ons rather than an individual country. Though only the 7th larges t country in the worl d by area (CIA 2009), it is home to the 2nd largest popul ation in the world. By 2050, if current trends continue, India will surpass China and have the dubious distinction of being the most populous country in the world (Population Refere nce Bureau 2008). India’s population boom is due to a rapid decrease in the death rate (due to improved public health system and control of spread of epidemics) and a sl ow, but steady increase in the birth rate. India’s 22 official languages are barely representative of the hundreds of other languages and dialects spoken within its borde rs. Its 28 states house geographic diversity comparable with that of America’s. From some of the world’s most insurmountable peaks in the Indian Himalayas, to the most c oveted beaches in Goa, India has a little bit of everything. Though India is home to one of the world’s oldest civilizations, its history as an independent nation is a short one. In 1947, I ndia succeeded in rebuffing the British after over 150 years of rule. It was subsequently divided into a predominantly Hindu state (India) and a predominantly Muslim state (Pak istan). In 61 years, India has emerged from its colonial status to assume the role of emerging world power. However, the influence of the British from the colonial peri od still greatly impacts government. Part of India’s problem lies in the frag mentation of its society. Besides being home to peoples of a variety of customs and backgrounds, India must account for several religions, languages, and for an enormous gap between the rich and poor. Oftentimes,

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13 questions of health care quality and access ar e answered by the setting: urban or rural. India has many faces, but no two could be more different than rural and urban India. Urban cities in India have amenities that are comparable to those in developed nations: car-clogged highways and roads, modern shopping malls, American fast food, and young people with cell phones and pockets of expe ndable income. Rural areas in India are defined by a population density of less than 1,00 0 per square mile, where 75% or more of the working male population works in agriculture (Census of India 2007a). In rural India, there is rampant illiteracy, poverty, inaccessibi lity to mainstream India, and low quality of life for women. One set of factors contributing to the lack of national solidarity stems from the many differences evident in the different geographic regions of India. In traditionally matrilineal South India, females enjoy a higher literacy rate than the national average. Some experts laud this increased literacy as the primary reason for the low fertility rates witnessed in many south Indian states. On the other hand, experts have noted that illiterate women who practice birth control clamor for th e opportunity to send their children to school, believing it will improve th eir prospects for the future. By contrast, northern India remains strongly patrilineal, with girls still being married off before their teen years. Though illegal, this creates a situa tion in which girls are not given respect or value in their new surrounding until they have given birth to a male child. If there is any society in the world that is governed by social class, it is India's. Since its inception as a civilization, India has been a primarily Hindu society. Over 80% of India's 1.2 billion people are Hindu (Rothermund 2008). One of the unfortunate remnants of Hinduism in Indian society is the concept of the caste system. In India's caste

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14 system, individuals are born into one of se veral unchangeable categories. The caste an individual is born into determines how they are treated by others, what jobs they can obtain, and to what extent they can succeed in life. In the old India, a person's class was fixed and permanent, determined by birth. As India moves towards the 21st century, more and more individuals are pushing against the de facto caste system. However, upward social mobility is still nowhere near the nor m and many of the rigid rules that govern interaction between the classes remain in place. India’s emerging role on the internati onal scene has been fueled by, and has alternately created, a new middle class (Rothermund 2008). Not only can this emerging demographic afford to make day-to-day ends meet, this group has a substantial amount of expendable income. It is estimated that the new middle class is composed of 40 million people, and is growing rapidly. Many have them selves been educated in the U.S. or in Europe or are considering having their children educated abroad. Young families can afford to vacation all over India, and are increasingly traveling abroad. Though this new middle class is the face that India is currently portraying to the world, it is not at all representative of Indi a. Neither does this demographic live evenly distributed over India; rath er it is clustered around a few centers. Delhi, Mumbai, Bangalore, and Ahmadabad are ju st a few of the cities wh ere this group is clustered (Figure 2.1). India’s new middle class is marked by a variety of characteristics: a culture of consumption (of clothes, cars, and goods), assertiveness of women who are highly educated and earn on par with their male c ounterparts, and a cosmopolitan lifestyle of dining out and excess previously ne ver seen in India (Perry 2004).

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15 Fig 2.1 : Map of India (http://www.panasianbiz.com/wp-conten t/uploads/2009/01/map-of-India.jpg)

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16 Demographically speaking, India is somewhat of an anomaly. The male to female ratio is higher than most other countrie s in the world (1,000 males to 933 females) (Census of India 2007c). Female infanticide remains an issue in a nation where giving dowry is still common practice, and where th e consequences are pa rticularly burdensome to the lower class (Srinivasan 2004). In spit e of having had a female Prime Minister, India’s treatment of women leaves much to be desired. When married, Indian tradition dictates that the daughter-i n-law leaves her home and becomes part of her husband’s family. Because the daughter will eventually be leaving the family, parents are more reluctant to invest in her e ducation and future than they are for a son (Rothermund 2008). This is evidenced by the fact that nearly half of all Indian women are illiterate, while only a quarter of Indian males are ) (Census of India 2007b). In addition, families that are poor are more willing to spend money on medical costs if a son is ill, than if a daughter-in-law is ill, unless she has given bi rth to a son. Women in poor, rura l India are so marginalized that when the government was determin ing what population groups made up the “backwards” class for affirmative action purpos es, it was initially determined that all women would be included (The Ba ckward Classes Commission 1955). Health care in India In the year prior to Independence, th e Bhore Committee put out a report (1946) that measured the quality and availability of health services in India. The exhaustive and well-thought out report included a set of r ecommendations for the administration of health services in newly i ndependent India. Had those recommendations been followed in 1947, the status of India’s public health system would have been very different. As it

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17 stands, many of the results obtained by the Bhore Committee in 1946 apply to the India of today. After the 1946 Bhore Committee, a series of committees was created to periodically reevaluate hea lth care delivery in India. No t until 1983 was anything like a National Health Policy established. In the in terim, health care in India consisted of massive campaigns funded by international organizations like WHO, UNICEF, the Rockefeller Foundation, inter alia to eradicate diseases that were considered global threats. Primary and other health care needs were supposedly under the central government’s jurisdiction but budgets for the Indian Congress from the 1950’s and 1960’s demonstrate a callous and short-sighted disregard for India’s health care needs. Not until the 1970’s were the health care needs of the rural sector recognized in India’s Five Year Plan, but even then the needs we re not in the slightest adequately funded. India’s health system today is organized into three major levels of care: primary, secondary, and tertiary. The primary and s econdary levels are funded mainly by state governments (Sharma 2002). Targeted program s geared towards eradicating national health problems (i.e. HIV/AIDS, malaria, and tuberculosis), are f unded by the national government. The federal government is also in charge of funding and monitoring research and education, in addition to working with the states to gauge national problems (i.e. malnutrition, family planning, etc.) and to coordinate the prevention of diseases crossing states (Das Gupta a nd Rani 2004). Other than that health care services are considered to be the resp onsibility of the states. The primary tier of health care in India is responsible for maintaining standards in a variety of basic contributors to health (Fin ancing and delivery of health care services in

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18 India 2005). Chief among those ar e: 1) ensuring adequate nutr ition, access to clean water, and sanitation for citizenry, 2) maternal and child health care and access to family planning methods, 3) immunizations, and 4) co mmon injury treatment, mental health, and ensuring adequate supply of prescription medications. Primary health care occurs in primary health centers (PHC) located across the country. In rural areas, each block of 80,000-100,000 people is provided with one PHC (Maru 1983). Each PHC is supposed to be equipped with two physicians and 28 supplemental field workers. Per block of 6,000 to 7,000 people, each PHC is supposed to have a male multipurpose worker (MPW) and an auxiliary nurse midwife (ANM) (Gangolli et. al 2005). In order to provide even more direct local se rvices, the community health volunteer scheme was established, wh ereby for every 1,000 people, an individual was selected to undergo training to provide basic health education to his/her own community (Maru 1983). Though the structure and organization be hind PHCs is well-intentioned, in practice they have not met the needs they were designed to fulfill. Shortly after the creation of a number of new rural health clinics, officials came to the realization that some were being grossly underutilized despite th e fact that there was an undeniable need in the community (Maru 1983). It appears that locals did not fully comprehend the array of services provided in the clinic. At a mo re basic level, they had lived for so long without being cared for, they did not even know when it would be appropriate to seek medical help. However, a majority of PHCs today are unsuccessful because they have failed to inspire confidence in the people they are intended to serve. In separate studies done by

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19 the World Bank, MIT, and Princeton, 35-45% absenteeism was seen in clinics (Gangolli et al. 2005). In other words, patients would a rrive at clinics in need of medical services, only to find them closed or completely une quipped (Chatterjee 2006). These centers have proven so undependable that families turn to private “doctors” and traditional healers that are much more easily available. Ironicall y, locals have no auth ority over medical professionals in PHCs because they are pa id at the state and district levels. In Madhya Pradesh, one of India’s larg est states, by December 2002, all 51,000 of its villages were to have a midwife and health worker to serve basic needs of population (Sharma 2001). The idea behind this propos al was to attempt to decentralize the administration of health care by giving mo re control to locals. The push towards decentralization of health care is a sentimen t that was echoed in the National Health Policy (National Health Policy 2002). In Madhya Pradesh, surveys were used to document the health needs of each individua l village. Updated annually, local health monitors worked on implementation and oversig ht of health goals by creating timelines by which actual progress had to be demons trated. Though no recent evaluations of the initiative in Madhya Pradesh could be f ound, if successful, the program could have implications for the rest of India. Secondary health care needs are met mostly by publicly funded hospitals. Tertiary health services, designed to provi de specialized care for partic ular diseases are carried out mostly by private providers and NGOs (Pet ers & Muraleedharan 2008). As mentioned before, the primary and secondary levels of care are mostly funded by the government. This is considered to be the level at whic h “health” care is provided, where there is a focus on prevention and an awareness of the many factors that can influence health

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20 (Bagchi 2008). By contrast, the tertiary le vel focuses on curative approaches, largely ignoring prevention, and is thus classified more as “medi cal” care (Das Gupta & Rani 2004). Completing the picture of India’s health system are the numerous NGOs that are present. These NGOs tend to be funded by fo reign multinational f oundations or trusts (Sharma 2002). They are mostly diseasespecific, vertical programs that work independent of regulation by either the national or state governments. Though many NGOs provide much-needed service to Indi a’s population, in Ja nuary 2008, of five programs investigated by the World Bank, it wa s determined that serious corruption and fraud were occurring in all five World Bankfunded health organiza tions (dedicated to HIV/AIDS, tuberculosis, malari a) (Solberg 2008). This was not first time, by any means, that corruption has been identified in the Indi an health sector. Just in 2005, another World Bank-funded program was implicated in a corruption scandal and resulted in 2 pharmaceutical companies being blacklisted (Solberg 2008). Given the corruption of some officials and agencies involved, and th e absenteeism of medical professionals at clinics, is it any wonder the rural population is turning increasingly toward private medicine? Today, India’s health care system is a $34 billion industry. Of that $34 billion, 1% is accounted for by private insurance comp anies and roughly 15% is publicly funded (Bagchi 2008). That means a whopping 82% of all health care expenses in India are borne out-of-pocket by patients. Its low public investment and high expectations of patients make it one of the world’s most privatized health care systems (Sengupta & Nundy 2005).

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21 In 2002, India released the Na tional Health Policy (NHP), a document designed to give direction to health policy formati on that had not been updated since 1983. The Indian government promised to increase spe nding on public health from 0.9% of the GDP to 2% by 2010 (National Health Policy 2002) The government currently bears 15% of overall health care costs in India. The newe st NHP demonstrates India’s commitment to improvement by increasing the government’s share of health car e costs to 25%. The National Health Policy in 2002 also attempted to address the disadvantaged rural areas of India. In addition to th e already low funding generated from public financing, built-in inequalities in the system favor urban areas. Rural areas get half the resources that urban areas do (on a per capita basis), and most of these resources go to preventive programs, ignoring curative n eeds of rural populati on (Mukadam 2006b). In concrete terms, this has led to unfavorable outcomes in rural areas across the board. As seen in Table 2.1, even though the percent of the population living below the poverty line in rural and urban areas is fairly consistent, health indicators for the two regions produce vastly different results. Even more striki ng is disparity between the better-performing states and the lower performers (National Health Policy 2002). As a result of the clear lack of equitable health care, the National Health Policy attempted to augment its already increasi ng funding by requiring that all medical school graduates perform mandatory 2-year rotations in rural areas (Sharma 2002). Though this may help to partially address the shortage of physicians in rural areas, it will do nothing to solve the fundamental expense of health care. A recent study found that half of the poorest 20% of people who needed health care were forced to sell assets or had to take out loans to pay for their hospital stay (M ukadam 2006b). Without the ability to pay, and

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22 without trustworthy care within reach, it is no surprise the rural poor forsake health care early in their illnesses and end up havi ng to pay dearly for their decision. Table 2.1: Differences betw een urban and rural, and high and low-performing Indian states on key health indicato rs (National Health Policy 2002) (In the table below, IMR is defined as inf ant mortality rate and MMR is morbidity and mortality rate) Sector Population Below Poverty Line (%) IMR per 1000 live births (1999-SRS) Child mortality rate (under5) per 1000 (NFHS II) % of Children Under 3 years (<-2SD) MMR (in hundred thousands) (Annual Report 2000) Positive cases of Malaria, 2000 (in thousands) India 26.1 70 94.9 47 408 2200 Rural 27.09 75 103.7 49.6 Urban 23.62 44 63.1 38.4 Better Performing States Kerala 12.72 14 18.8 27 87 5.1 Maharashtra 25.02 48 58.1 50 135 138 Tamil Nadu 21.12 52 63.3 37 79 56 Low Performing States Orissa 47.15 97 104.4 54 498 483 Bihar 42.60 63 105.1 54 707 132 Rajasthan 15.28 81 114.9 51 607 53 Uttar Pradesh 31.15 84 122.5 52 707 99 Madhya Pradesh 37.43 90 137.6 55 498 528

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23 India suffers from a chronic shortage of doctors, beds, clinics, hospitals, and nurses (Gupta 2008). India averages 1.5 be ds per 1000 people, lagging behind other developing countries like Brazi l, China, and Thailand which average 3-4. The U.S., by comparison, has 4-8 beds per 1,000 people. India’s brain drain of doctors is partly due to the poor work conditions doctors can expect practicing in India. An estimated 20,000 doctors leave India every year, exacerbat ing an already dire need for doctors (Rothermund 2008). According to the WHO, India has 0.6 doctors and 0.08 nurses per 1000 people, far below the world aver age of 1.2 doctors and 2.6 nurses. At once, India is being slammed by health problems originating at both ends of the economic spectrum. India’s emerging middl e and upper classes suffer from diseases typically prevalent in developed societies. Ch ronic diseases like heart disease, cancer, and diabetes, are the leading cause of death a nd disability in the US (www.cdc.gov). Chronic diseases are also making an impact on health in India. It is estimated that India will lose $237 billion in the next 10 years due to chronic diseases (www.timesofIndia.org). While India’s well-to-do face diseases of excess, India’s poor suffer from their acute lack. Whether from malnut rition or from lack of access to even basic health care, the 30 million people that earn less than $1 a day are a huge public health concern. By comparison, the level of poverty in America wa s defined by a family of four earning less than $19,971 a year (www.gao.gov). By this standard, 37 million Americans were classified as poor. However, it is important to consider that while a small percentage does face destitution comparable with that seen in India, many classified as poor enjoy material conditions far superior to the Indi an poor. When it comes to health, although in very remote areas of America there is a s hortage of medical facilities and personnel,

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24 when compared to the quality and availabili ty for India’s poor, America’s poor enjoy excellent care. One of the barriers to access to health care in India is the disparity between resources available to urban dwellers compared to those who live in rural areas. Seventy percent of India’s 1.1 billion people live in rural areas (Population Reference Bureau 2008). Despite this fact, 75% of doctors are ba sed in cities, leaving only 25% to care for 70% of the population (Bagchi 2008). Many rura l areas are made geographically remote because of barriers like mountai ns and forests. Even those that do not face geographic barriers often lack adequate health services for rural populations. Patients report being forced to travel long distances to go to priv ate hospitals in urban areas, lose days of wages, and being treated rudely (Babu et al. 2008). Though there is a very different experience for urban and rural I ndians, not all of the population in either context can be gene ralized to operate under the same conditions. Urban upper and middle class Indians enjoy the best benefits. They have access to topnotch health care and can gene rally afford the cost of th eir needs without having to purchase insurance. For them, the difference in quality and availability of health services compared to America’s is negligible. Unfortunately, this is not telling of all ur ban Indians. Just like large cities across the world, cities in India are home to huge num bers of slum-dwellers. This population has often migrated from a rural part of India to the city in sear ch of jobs and a better future. These migrants tend to be uneducated, poor, a nd of weak physical h ealth. Many are also Muslim artisans who are marginalized by thei r lack of education, poverty, and religion (Rothermund 2008). Desperate slum conditions ar e ripe for the spread of communicable

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25 diseases, one of the reasons why HIV/AI DS and tuberculosis are so rampant (Sowmyanarayanan et al. 2008). Yet as rural, poor Indians are increasingl y being marginalized by the health care system, the urban well-to-do find the quality and availability of their health care increasing rapidly. Though the National Health Policy (Natio nal Health Policy 2002) did direct more funding towards public health, it also heavily emphasized policies that would only benefit high-tech hospitals that serve medical t ourists and the very rich. The government provides subsidies, land at throwa way prices, and removes tariffs on imports of technological equipment and drugs (Mukadam 2006a). Unfortunately, as the urban medical system becomes more technology-cente red, inefficiency and high cost of care become its hallmarks. The status of India’s health care syst em offers both a bleak and an exciting outlook on the future. It is true that currentl y, standards of health care for most Indians are very poor, and quality of life must be greatly improved. However, because of the overwhelming demands created by a huge popul ation, lack of resources, and poor infrastructure, there exists the possibility th at creative and revolutionary solutions could be developed (Kamdar 2007). India is plagued by both communicable and noncommunicable diseases and its problems exis t on a huge scale (both geographically and population-wise). If public health scientists, doctors, and politic ians can work together to find a way to stretch available resources to develop more efficient and effective methods for dealing with these diseas es, not only India, but the whole world would benefit.

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26 Chapter 3: Health care in America The earliest public health efforts in America came about during the 19th century as a result of the need for the proper dispos al of sewage and waste (Mullan 2000). In response to changing threats to public health, the field expa nded to include vaccination and maintenance of child health which led to th e establishment of standard testing of milk and water. During the early 1900’s, health de partments formed in the major cities and were found to be successful when they worked together with national medical and public health officials (Mullan 2000). In 1872, the American Public Hea lth Association was formed to support the creation of boards of h ealth and the educati on of leaders in the public health field (Turnock 2004). This orga nization has since spearheaded efforts to increase awareness of the importan ce of public health in America. Public health added to its early focu s by incorporating th e study of disease control, food testing and esta blishing licensing standards fo r medical professionals (Keck 2006). These efforts often manifested in campaigns aimed at containing threats by specific diseases to the entire population. As understanding of health improved, so too did the knowledge that beha viors and environment could put specific populations at greater health risk. This led to the identific ation of “high-risk” popul ations which became the target of preventative public health efforts (Awofeso 2004). Even as early as the 1940’s, public hea lth in America incl uded an understanding of the interplay between health and society so that public health was concerned not only with disease incidence and sanitation, but w ith urban development and wage and housing concerns (Mullan 2004). Given its history, it comes as no surpri se that the public health system in America today follows “a socioeco logical and social-determinants framework

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27 that assures key determ inants of poor health poverty, racism, unemployment, and a variety of conditions associated w ith unacceptable health disparities are addressed” (Walker 2008). This broad view of health is in keeping with a global trend to recognize the many disparate factors that can impact health outcomes. As in any country, the funding and attenti on given to pubic hea lth in America is greatly dependent upon the political environmen t at the time. The Progressive Era at the turn of the 20th century a llowed the public health moveme nt to flourish (Keck 2006). By the 1960’s, the spread of infectious diseases was being held under control (Mullan 2000); however the resurgence of HIV/AIDS has once ag ain made control of infectious diseases a prominent global public health topic. America is host to a variety of governme nt departments and agencies whose sole purpose is to achieve better public health ou tcomes. Decreasing tobacco use is one of the big successes in public health in Americ a (Eberhardt & Pamuk 2004). The landmark Surgeon General’s report of 1964 exposed carcin ogenic elements of cigarettes and led to a series of legislative measur es that have helped to cu rtail the incidence of smoking (Blum, Solberg, and Wolinsky 2004). The multifaceted approach employed to educate the public about the hazards of cigarettes se rves as a model for other public health initiatives (Figure 3.1).

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28 Fig 3.1: Declines in cigarette smok ing in the United States (1965-2005) The Department of Health and Human Services (DHHS) oversees the federal public health agencies. In addition to the Offi ce of the Surgeon General, divisions like the Centers for Disease Control and Prevention (CDC ), National Institutes of Health (NIH), and the Office of Global Health Affairs (OGHA) make the American national system one of the most well-esta blished in the world (Turnock 2004). Not only do these centers conduct cutting-edge medical a nd public health research, th ey are a component of the public health delivery system that is respons ible for surveillance of health indicators. Figure 3.2 shows the numerous agencies that are grouped in the DHHS.

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29 In addition to the American Public Hea lth Association (APHA), there are also a number of independent associ ations and foundations dedicate d to specific aspects of health care in America. The American Medical Association (AMA) is the hugely influential organization of physicians (Turnock 2004). Like the APHA, the AMA publishes a highly-respected journal that dissemi nates research on the state of health care. The AMA and APHA are not alone; there are hundreds of other organizations and associations that publish qualit y, peer-reviewed research on a variety of topics. Combined with the efforts of the federal agencies a nd research organizations it is evident that America has an impressive base from which to administer its public health schemes.

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30 Fig 3.2: DHHS Organizational Chart (US Department of Health and Human Services Organizational Chart 2008) Federally funded national organizations te nd to focus on research, surveillance and assessment, and educating the population on national health concerns. The notable exceptions to this are Medicare and Medicai d, federally administered health insurance programs (Keck 2006). For the most part, however, the states are in charge of the actual

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31 administration of public health services, including establishi ng local programs for disease prevention and health education. Additionally, county and municipal health de partments often administer clinics to make up for any health needs not met by th e medical sector in the area. Though it is evident that state public health agencies perform a number of important duties, the standards and methods of practic e differ widely from state to state (Beitsch et al. 2006). In general, state health agencies are seen as the main authorities on public health, but the specified duties of the agencies c ontinue to be highly variable. Despite the strong public health base in America, health outcomes are not as positive as expected, particularly when the cost of the overall health system is considered. These huge costs seem completely out of propor tion in light of the fact that the U.S. population is no healthier than that of nations that spend far less on health care (Schoen et al. 2008). As shown in Tables 3.1 & 3.2, in 2006 the US spent over $6,700 per person on health care, accounting for approximately 15.3% of the gross do mestic product (GDP) (OECD 2008). When compared to other wealthy, indus trialized nations like the United Kingdom and Germany, it is clear the US spends far mo re of its wealth on its health care system (OECD 2008). Unfortunately, this greater expense has not tran slated to supe rior health outcomes. Additionally, the US is the only major industrialized nation that does not guarantee basic health servi ces to all its citizens (Dav is 2007). The United Kingdom and Germany, in spite of spending far less per cap ita on health expenses, are able to provide universal health coverage to their populations.

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32 Table 3.1: Total expenditure on health as percentage of GDP (OECD 2008) (Emphasis placed by author on countries mentioned in text) Countries 1960 1970 1980 1990 2000 2002 2004 2006 Australia 3.8 6.3 6.9 8.3 8.6 8.8 8.7 Austria 4.3 5.2 7.5 8.4 9.9 10.1 10.3 10.1 Belgium 3.9 6.3 7.2 8.6 9.0 10.7 10.3 Canada 5.4 6.9 7.0 8.9 8.8 9.6 9.8 10.0 Czech Republic 4.7 6.5 7.1 7.2 6.8 Denmark 8.9 8.3 8.3 8.8 9.5 9.5 Finland 3.8 5.5 6.3 7.7 7.0 7.6 8.1 8.2 France 3.8 5.4 7.0 8.4 10.1 10.5 11.0 11.0 Germany 6.0 8.4 8.3 10.3 10.6 10.6 10.6 Greece 5.4 5.9 6.6 7.8 8.2 8.3 9.1 Hungary 6.9 7.6 8.2 8.3 Iceland 3.0 4.7 6.3 7.8 9.5 10.2 9.9 9.1 Ireland 3.7 5.1 8.3 6.1 6.3 7.1 7.5 7.5 Italy 7.7 8.1 8.3 8.7 9.0 Japan 3.0 4.6 6.5 6.0 7.7 8.0 8.0 8.1 Korea 3.4 4.0 4.5 5.1 5.4 6.4 Luxembourg 3.1 5.2 5.4 5.8 6.8 8.1 7.3 Mexico 4.8 5.6 6.2 6.5 6.6 Netherlands 7.4 8.0 8.0 8.9 9.5 New Zealand 5.2 5.9 6.9 7.7 8.2 Norway 2.9 4.4 7.0 7.6 8.4 9.8 9.7 8.7 Poland 4.8 5.5 6.3 6.2 6.2 Portugal 2.5 5.3 5.9 8.8 9.0 10.0 10.2 Slovak Republic 5.5 5.6 7.2 7.4 Spain 1.5 3.5 5.3 6.5 7.2 7.3 8.2 8.4 Sweden 6.8 8.9 8.2 8.2 9.3 9.2 9.2 Switzerland 4.9 5.4 7.3 8.2 10.3 11.0 11.4 11.3 Turkey 3.3 3.6 4.9 5.9 5.9 United Kingdom 3.9 4.5 5.6 6.0 7.2 7.6 8.0 8.4 United States 5.1 7.0 8.7 11.9 13.2 14.7 15.2 15.3

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33 Table 3.2: Total expenditure on health pe r capita, in terms of US$ (OECD 2008) (Emphasis placed by author on countries mentioned in text) Countries 1960 1970 1980 1990 2000 2002 2004 2006 Australia 90 643 1200 2265 2566 2885 3141 Austria 77 196 784 1631 2859 3068 3397 3606 Belgium 150 644 1358 2377 2685 3311 3462 Canada 125 301 780 1738 2513 2874 3218 3678 Czech Republic 560 980 1195 1388 1509 Denmark 897 1544 2379 2696 3057 3362 Finland 63 185 571 1367 1794 2089 2412 2668 France 69 194 669 1449 2542 2922 3117 3449 Germany 269 971 1769 2671 2937 3162 3371 Greece 161 491 853 1429 1792 1991 2483 Hungary 852 1114 1327 1504 Iceland 57 175 755 1667 2736 3156 3338 3340 Ireland 43 117 516 792 1801 2360 2724 3082 Italy 1359 2053 2223 2401 2614 Japan 30 151 585 1125 1967 2137 2337 2578 Korea 90 330 747 945 1110 1464 Luxembourg 2554 3081 4083 4303 Mexico 296 508 584 679 794 Netherlands 741 1416 2337 2833 3156 New Zealand 216 508 990 1604 1846 Norway 49 144 668 1370 3039 3629 4082 4520 Poland 290 583 733 808 910 Portugal 48 276 636 1509 1657 1913 2120 Slovak Republic 603 730 1058 1308 Spain 16 95 363 873 1536 1745 2128 2458 Sweden 312 944 1592 2284 2707 2964 3202 Switzerland 166 346 1017 2034 3256 3719 3990 4311 Turkey 70 156 432 483 576 United Kingdom 84 161 470 965 1847 2165 2509 2760 United States 147 351 1065 2738 4570 5305 6014 6714

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34 The US health care system is expensive for the government, as well as for the American population. Figure 3.3 shows a breakdo wn of who pays pers onal health care expenditures, and what fees are constituted in those expenditures (National Center for Health Statistics 2007). It is clear that the majority of expenses are borne by private health insurance and the federal government, and that most of these expenditures result from hospital and physician fees. Fig 3.3 Given the portion of health care expens es that are provided by private health insurance companies, it is no surprise that the 47 million Americans who are uninsured find it difficult to justify seeking adequate health care (Davis 2007). Even for Americans who have insurance, the costs of health care are high enough to dissuade people from getting care, even when it could lead to the early detection of seri ous and more expensive health problems down the road. More than 20% of 18-44 year olds in 2005 (Figure 3.4) did not seek health services because of cost (National Center for Health Statistics 2007). Dental services, in particular, are neglect ed when the patient is not able to pay.

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35 The exorbitant costs of the American h ealth care industry ar e only increasing as managed care means more elderly with ch ronic conditions live longer, stressing the system even more (Nuwer et al. 2008a). Ad ministrative overhead costs for physicians and insurance carriers in the US are double what they are in the much-maligned Canadian health care system (Woolhandl er 2003). Medicare makes use of electronic payments and spends only 3% on administrative costs, co mpared to 12-15% for insurance companies (Nuwer et al. 2008a). Moving towards main tenance of electronic records should be beneficial to doctors, patients, and public health in general, but it has not happened because it is expensive for doctors to make the switch. Fig 3.4:

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36 Establishing better primar y care services leads to better chronic care and decreased costs in the long term (Schoen 2008). Unfortunately, the current insurancedriven reimbursement system for physicia ns provides a disincentive for performing primary care procedures. Primary care procedures are listed only as “evaluation and management” codes and equate to much lo wer reimbursement levels than specialty procedures (Nuwer et al. 2008a). In th e Veteran’s Administ ration (VA) system, physicians are salaried and thus the system mi rrors that of a single-payer health system (Public Policy Committee of the American Colle ge of Physicians 2008). Physicians in the VA system have improved the way managed car e is coordinated, and are reportedly able to offer high quality comprehensive care for patients, particularly those with chronic diseases like diabetes (Asch et al 2004). Though the US health care system is th e most technologically advanced in the world, the overall health of its people is not as good as the hea lth of nations that spend far less on health care (OECD 2008). There are a vari ety of social, genetic, environmental, and cultural factors that come into play in each of the indicators used to measure health status, and the health care system alone is not responsible for the statistics from each nation. However, they are the commonly used indicators for drawing comparisons, so they will be used in this study. The first indicator that defines a nation’s health profile is life expectancy. In the US, life expectancy for the total population in 2004 wa s 77.8 years (OECD 2008; Table 3.3). This is lower than a number of the OECD nations, particularly Germany, France, and Canada, nations whose health care amount ed to only 8-11% of their GDP. However all the nations of the OECD appear to be doing phenomenally when compared to India.

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37 India’s life expectancy currently stands at 65 years, lower than the average for Asian nations (Population Reference Bureau 2008). S o, though it is evident the US is doing well when compared to developing nations, it does no t appear to be getti ng an adequate return on its health care investment when co mpared to other wealthy nations. Table 3.3: Life expectancy for total popul ation at birth (in years) (OECD 2008) (Emphasis placed by author on countries mentioned in text) Countries 1960 1970 1980 1990 2000 2002 2004 2006 Australia 70.9 70.8 74.6 77.0 79.3 80.0 80.6 81.1 Austria 68.7 70.0 72.6 75.5 78.1 78.8 79.3 79.9 Belgium 70.6 71.0 73.3 76.1 77.8 78.2 78.9 79.5 Canada 75.3 77.6 79.3 79.7 80.2 Czech Republic 70.7 69.6 70.5 71.6 75.1 75.4 75.9 76.7 Denmark 72.4 73.3 74.3 74.9 76.9 77.1 77.8 78.4 Finland 69.0 70.8 73.4 75.0 77.7 78.3 79.0 79.5 France 70.3 72.2 74.3 76.9 79.2 79.4 80.3 80.9 Germany 69.1 70.6 72.9 75.3 78.2 78.5 79.2 79.8 Greece 69.9 72.0 74.5 77.1 78.0 78.7 79.1 79.6 Hungary 68.0 69.2 69.1 69.4 71.7 72.6 72.8 73.2 Iceland 72.9 74.3 76.7 78.0 80.1 80.6 81.0 81.2 Ireland 70.0 71.2 72.9 74.9 76.6 77.9 78.9 79.7 Italy 74.0 77.2 80.0 80.3 80.9 Japan 67.8 72.0 76.1 78.9 81.2 81.8 82.1 82.4 Korea 52.4 62.2 65.9 71.4 76.0 77.0 78.0 79.1 Luxembourg 69.4 70.3 72.5 75.6 78.0 78.1 79.1 79.4 Mexico 57.5 60.9 67.2 71.2 74.1 74.6 75.2 75.7 Netherlands 73.5 73.7 75.9 77.0 78.0 78.4 79.2 79.8 New Zealand 71.5 73.2 75.5 78.4 79.0 79.6 80.2 Norway 73.8 74.4 75.9 76.7 78.8 79.0 80.1 80.6 Poland 67.8 70.0 70.2 70.7 73.9 74.6 75.0 75.3 Portugal 63.8 66.6 71.4 74.1 76.7 77.2 78.3 78.9 Slovak Republic 70.6 69.8 70.6 71.0 73.3 73.8 74.1 74.3 Spain 69.8 72.0 75.4 77.0 79.4 79.8 80.3 81.1 Sweden 73.1 74.7 75.8 77.6 79.7 79.9 80.6 80.8 Switzerland 71.4 73.1 75.7 77.5 79.9 80.6 81.2 81.7 Turkey 48.3 54.2 58.1 66.1 70.5 70.8 71.2 71.6 United Kingdom 70.8 71.9 73.2 75.7 77.9 78.3 78.9 United States 69.9 70.9 73.7 75.3 76.8 77.2 77.8

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38 Infant mortality rate is another figure that is relatively easy to measure and is thus commonly used in the field of public health to gauge a nation ’s progress. This indicator, even more so than life expectancy, is fra ught with controversy over the questionable data collection methods used in some countries (Save the Children 2006). The US improved its infant mortality rate dramatically through the early 1990’s because of improved understanding of sudden infant death syndr ome (SIDS) (Keck 2006), but since then infant mortality has stagnated at about 6.8 births per 1,000 (National Center for Health Statistics 2007). Critics often attack the hi gh infant mortality rate in the US as an indication of the inefficient use of American ’s health care dollars, citing the lower rates seen in countries like Cuba, Portugal, and some East Asian countries as proof that the US is in need of reform (Harris 2008). However, it is dangerous to view these statistics without further examination. Prematurity, a major cause of infant death, is underreported in the US because of the classification mechanisms currently being used (Callaghan 2006). However, premature birth is often implicated in cases of infant mortality. In fact, when infant mortality rose slightly between 2001 and 2002, a corresponding increase in the number of earliest preterm births was also recorded. Early preterm babies are so fragile that sometimes not even the most advanced techno logy can be expected to improve their life expectancy (Harris 2008). So, de spite the fact that the US health care system does have many weaknesses, dramatically reducing overa ll infant mortality may not be possible. Perhaps the best method to improving this key indicator woul d be to reduce the rate of infant mortality for African American mothers. According to the National Center for Health Statistics (2007), white mothers su ffer from an infant mortality rate of 5.7%,

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39 with Hispanic mothers slightly better at 5.5%. African American mothers, on the other hand, experience double the infant mortality ra te at 13.2%. In addition to delivering a disproportionately high number of preterm babies, African American mothers also deliver more low birth weight babies (Ha rris 2008; Keck 2006). Low birth weight for a baby is defined as weighing less than 5.5 pounds (2,500 grams) at birth (WHO 2004). Low birth weight (LBW) babies are at higher risk for infant mortality and are thus an important indicator of baby hea lth. It is important to recogn ize that income, environment, diet, culture, and genetics all play a role in the propensity for delivering premature or LBW babies, and these factors cannot be ignored in public health programs. The leading cause of infant mortality in the US is birth defects (Keck 2006). Birth defects include congenital heart, respiratory, and nervous system defects. Birth defects surveillance and educat ion programs and newborn screeni ng make use of genetic testing to serve a variety of public health goals (Wang & Watts 2007). However, with public health budgets so tight, genetics programs w ill have to evaluate the necessity of their services in order to justif y a need for funding over anothe r seemingly essential program. In addition, genetic testing has the potential to bring up a cont roversial issue. Parents who can screen for genetic disorders very early in the pregnancy may wish to terminate a baby that has the potential to be born unhealt hy (Shuster 2007). An abortion early enough in the pregnancy is completely legal, but is the use of genetic testing in this manner ethical? A number of pressing health care cha llenges face the US. Because the poor and most sick often cannot afford care, establishi ng a system of national health insurance has been a hotly contested subject for several years. The lack of affordability was a problem even in the 1940’s and resulted in 1965 in the formation of Medicare and Medicaid

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40 (Mullan 2004). Currently, federal Medicare, state Medicaid, and the VA system account for the needs of one third of the populat ion (Nuwer et al. 2008b). That leaves approximately half the population receivi ng insurance through employers and 5% purchasing individually. The first major challenge of health care in the US is providing for the approximately 47 million uninsured that remain (Davis 2007). The inherent cost of obtaining health care creates a disparity in access for the segment of the population that is uninsured. Beyond limiting access based on insurance, he alth care quality a nd availability is often impacted by location. In the past, the greater differences were seen between the urban and the rural health care systems. (Though many definitions exist, rural here will be loosely defined as a nonmetropolitan county that is home to approximately 10,000 residents; urban areas are highly congested, hi ghly populated areas at the heart of a large city; suburban areas are on th e border of cities and metr opolitan zones where residents must commute to reach their work (Eberh ardt & Pamuk 2004; Berkowitz 2004; Hartley 2004; Weeks et al. 2004)). In addition to the usual urban and rural classifications, different health resources are available at th e border of an urban locale when compared to the heart of an urban area (Eberhardt & Pam uk 2004). In studies that take into account the additional classification of suburban, the disadvantages seen in rural settings are mirrored by those seen in urban areas (Ros enblatt 2004). No longer is it a matter of simply studying the dichotomy of urban and rural health care; quality and access to suburban health care vastly differs from th e quality and access s een in the other two regions.

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41 Numerous studies have shown that the heal th care experience of patients is vastly different if sought in an urban versus a rural context (Hartley 2004). Compensating for the lack of private medical services offe red, rural health departments offer more immunization, lab services, personalized health services, community outreach and education, and assessment functions than do urban health departments (Berkowitz 2004). However, when health departments are co mpared based on the population size they service, those that serve le ss than 25,000 score lowest on n early all possible indicators (Suen & Magruder 2004). Veterans report hi gher incidences of depression, alcohol disorders, and chronic low back pain than other patient populations (Weeks et al. 2004). Rural veterans, in particular, have poorer health-related quality of life than do those living in urban and suburban settings. Poor health outcomes in rural areas could be blamed on the fact that rural health departments suffer from lower levels of f unding, must cover larger areas, and must compensate for a lack of physicians (Ber kowitz 2004). However, the rural populations that are reporting poorer hea lth also tend to be poor and uneducated (Hartley 2004). Experts find that there is al so a higher percentage of uni nsured in rural areas (NRHA 2004). Lower income and a lack of jobs that pr ovide health insurance are both factors that contribute to the rate of unins ured in rural areas. Given all these issues, it is difficult to distinguish the rural health care problem from the problems faced by those who lack insurance, those who lack access, and those who lack knowledge about the health system. It is easy to fall into the trap of clum ping together all rural regions and ignoring the great diversity that exists within these regions. Rural resident s in the Northeast, Midwest, South, and West have poor health outcomes when compared to non-rural

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42 residents; however, each region is particular ly lacking in areas where the others are providing adequate services (Hartley 2004). Specific cultural, environmental, and regional factors have an impact on the health outcomes of the area. Rural residents living in the South, for example, are more likely th an rural residents living anywhere else to be poor, inactive, and smoke as adults (Hartley 2004). For this reason, it is important to consider the specific cultural factors at play in determining health outcomes of a region. Just as understanding the concept of a regi onal rural culture is important to the field of public health, so t oo are the variety of sociologi cal factors that combine to influence the access and availabi lity of health resources to minority populations. To begin with, it must be acknowledged that basic diffe rences in health outcomes can be seen along racial/ethnic lines. The disproportionate ly high infant mortality rate for African American mothers was mentioned earlier. In ad dition, there is a consistent disparity in life expectancy for white males and females when compared to African American males and females (Figure 3.5; National Center fo r Health Statistics 2007). Though at 65 years life expectancy becomes somewhat equal, at birth there is a marked difference between the races. Females of both races have equal or longer life expectancies than males, but white females are expected to live more th an 5 years longer than African American females. The same gap persists between white males and African American males.

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43 Fig 3.5: Life expectancy in the US, by race and gender (1970-2004) Though current methods of assessing health have identified disparities between white and minority populations, there is some evidence that even more differences may be hidden behind inadequate methods of cat egorizing populations. There is evidently a substantial impact of race/ethnicity on birth outcomes. In the past, studies have used the term “white” to refer to babies with White mothers since it was believed that maternal race/ethnicity was most predictive of birth outcomes (Migone et al. 1991). (How mothers are classified as White is not made clear; it is likely based on light skin pigmentation and having European ancestry.) However, when broken down by paternal race/ethnicity, babies born to White mothers and White fath ers have significantly lower LBW rate and lower rates of 1-year morta lity than babies with a White mother and non-White father

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44 (Ma 2008). Therefore, there is great variati on in birth outcomes even among what would have been classified as “white” babies. This finding indicates that there may be genetic, socioeconomic, and cultural factors that need to be addressed before health outcomes among minority groups can be equalized. Studies in the past have demonstrated that higher minority concentrations in certain areas are positively correlated w ith lower health outcomes; however, when regional controls are included, minority concen tration has no correlati on to health status (Mellor & Milyo 2004). This suggests that region al cultural differenc es in lifestyle and diet are more at play than racial differen ces. These regional differences could include jobs with varying health risks, proximity to pollution, and a number of other factors that are more determined by geographic region and cultural milieu than by race. In a sense, minority concentration may indirectly result fr om factors that are actual determinants of health: income, socioeconomic status, level of education, access a nd quality of health care and environmental factors. Though America’s public health system is doing an adequate job of providing basic care for its population, ther e is clearly much that can be done to improve. The most glaring disparities between access and quality of health care services are seen based on race/ethnicity and geographic location. These disparities must be researched and better understood before they can be eliminated. In a country as rich and powerful as the United States, there is no reason why rural American s should face care of a lesser quality than their counterparts living in cities. Low-in come families should not have to choose between eating and paying for their medications. And minorities should not have less access to good health care simply because they are not a part of the majority population.

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45 However, given the infrastructure already in place in the United States, with the redirection of funds and efforts towards thes e populations, it can be argued that the disparities that exist could be quickly alleviated.

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46 Chapter 4: HIV/AIDS AIDS is currently on the forefront of th e global public health agenda. According to the 2008 UN Report on the Global AIDS Epidemic, 33 million people around the world are afflicted with AIDS The global percentage of pe ople living with HIV/AIDS has plateaued, indicating the epidemic seems to be stabilizing worldwide. As knowledge about the transmission and education about prevention of the disease has improved, the rate of new HIV infections has fallen in many countries. In India, recently revised numbers indicate the AIDS epidemic has reach ed the point where it can be managed and controlled (Steinbrook 2008). Unfo rtunately, positive signs in much of the world do not translate to all AIDS-afflicted areas. Sub-Saharan Africa continues to be disproportionately affected by HIV/AIDS and global improvements in access to treatment and prevention have not translat ed to improvements in this region (UNAIDS 2008c). The history of AIDS in America is a fair ly short one. In the early 1980’s, doctors were baffled by the presentation of rare di seases in immuno-comp romised patients who had previously been healthy (Fauci 2006) By 1983, scientists in an NIH lab and scientists in a French lab conc urrently discovered that at the root of these rare diseases was actually an entirely new disease: ac quired immune deficiency syndrome (AIDS) (Kallings 2008). Within two years it was di scovered that AIDS was caused by a virus called human immunodeficiency virus (HIV). Rapidly thereafter, a test for HIV was developed, and since then the scientific comm unity has worked tirelessly to elucidate the mechanism for the proliferation of this deadly disease.

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47 HIV virions contain single-s tranded RNA and are unable to replicate unless they have invaded a host cell. HIV reduces the effectiveness of the immune system by debilitating one of its most instrumental wea pons: T cells (Berg et al. 2007). In a healthy immune response, T-cell recognition of class specific proteins (class II major histocompatibility complexMHC) on an antigen presenting cell will le ad to a cascade of B-cells, macrophages, neutrophils, killer T-cells, and other agents (DHHS 2003, Figure 4.1). However, with AIDS, T-cells serv e as the primary host cells for HIV. Fig 4.1: Overview of T cell mediated immune response (http://arapaho.nsuok.edu/%7Ecastillo/N otesImages/Topic5NotesImage4.jpg)

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48 Viral cells are designed to attach to only specific target cells. CD4 is the class II MHC protein on the surface of helper T-cells that serves as a signal to HIV (Weeks & Alcamo 2006). Once the virion has attached to the host and the viral genome has entered the T cell, the enzyme reverse transcriptase uses the HIV RNA as a template to produce double-stranded DNA that is then incorporat ed into the host DNA (D olin et al. 2008). Because HIV uses reverse transcriptase to replicate, it does not have a proof-reading mechanism. In fact, almost ev ery time it replicates, HIV is mu tated even if by a change in a single base-pair (Phair 1999). The process of viral replicatio n continues until HIV protease, an aspartyl protease, cleaves specifi c parts of the virion that essentially activate the HIV (Weeks & Alcamo 2006). Scientists have attempted to create protease inhibitors as a way of preventing the activation of HI V. A brief overview of the process whereby HIV invades the host cell can be seen in Figure 4.2.

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49 Fig 4.2: Overview of the HIV Infe ction cycle (Raven & Johnson 2002) The HIV virion is found in blood, semen, va ginal fluids, breast milk, and other bodily fluids (www.aids.gov). Therefore, it can be transmitted anytime there is the exchange of these fluids. Exchange can o ccur during unprotected sexual intercourse with an infected individual, pre gnancy, sharing needles, and re ceiving blood transfusion from HIV+ blood (www.nlm.nih.gov). In addition, outside of the b ody it cannot replicate so it is not infectious. Though HIV+ patients often face discrimination as a result of their status, the reality is that the HIV virus cannot be transmitted simply by shaking hands, drinking from the same cup, kissing, food, or mosquitoes (www3.niaid.nih.gov). A month or two after a person has been infected with HIV, he or she often develops a flu-like illness th at presents no unusual symptoms (Dolin et al. 2008). Because of the unremarkable nature of the episode, th e infected individual has no real indication that they have been infected. During th e three-month window following infection, the

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50 individual is highly contagious particularly when compared to the level of infectiousness seen at later stages of HIV pr ogression. At this time, the virus then begins to replicate in the manner previously described, though it can c ontinue replicating for a number of years before the infected individual tr uly feels the effects. For years the HIV can remain in this “dormant” phase, replicating even though the individual is completely asymptomatic (www.aids.gov). In this way, the virus slowly debilitates the immune system, leaving it open to attack from opportunistic diseases li ke tuberculosis, pneumonia, shingles, and Kaposi’s sarcoma. Advanced HIV infection is accompanied by a variety of symptoms including: rapid weight loss, extreme fatigue, swollen gl ands or diarrhea for a long period of time, high fevers with night sweats, purple spots or a white coating on the skin surface or the body orifices, and even a lack of mental acuity and clarity ( www.cdc.gov/hiv). Since many of the signs of AIDS are symptoms of a variety of normal illnesses, a serum, saliva, or blood test is the only way to defin itively know if infection has occurred. Despite our greatly improved understanding of HIV, the scientific community is very far from finding a cure for AIDS (Fauci 2006). However, rather than face imminent death post-infection, individuals infected with HIV can now live long and normal lives. Current treatments for AIDS fall into a number of categories, each targeting HIV replication in different stages of its cycle: reverse transcriptase i nhibitors (RT), protease inhibitors, and fusion inhibitors (www.nlm .nih.gov). Because all act in opposition to a retrovirus, they are grouped under the classification of antir etroviral drugs. The objective in the use of antiretroviral drugs is not to cu re HIV/AIDS, but to slow the progress of the advancement of HIV and to prevent the progres sion of asymptomatic HIV+ patients to a

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51 stage where they have been become symptoma tic (Kartikeyan et al 2007). Each of the antiretroviral methods mentioned makes use of specific pathological characteristics of HIV to prevent progression of the vi rus in the infected individual. The prevailing approach to AIDS thera py is highly active antiretroviral therapy (HAART), whereby a cocktail of antiretrovi ral drugs are combined for the patient’s maximum benefit (Skowron & Ogden 2006). Though this initially meant that patients were taking dozens of pills in a single day, nowadays patients can take multiple drugs in the same tablet (Weeks & Alcamo 2006). Th ese advances in drug development have improved outcomes because viral resistance star ts to build up quickly if dosages are not taken exactly as described to the patient by the physician (Levy 2007). In addition to being used to treat HIV/AI DS, antiretroviral therapy can be applied to prevent the transmission of HIV from mo ther to child. Developed countries prevent mother-to-child transmission by employing a combination of HAART, a C-section as opposed to a regular birth, and the use of form ula instead of breast milk (Coovadia 2004). This therapy has caused the rate of mother-t o-child transmission to reduce from 25% to 1-2%. In spite of aid from the Gate s Foundation, PEPFAR, and the Global Fund, developing countries sometime s cannot provide HAART, so in stead they provide therapy in the form of a short course of zidovudine during pregnanc y and a singe peripartum dose of nevirapine. When accompanied by other standa rd care prevention practices, this course of therapy was found to reduce transmission in Thailand to 1.1% (Lalle mant et al. 2004). Unfortunately, cultural, societal, and economic factors mean breast-feeding cannot or has not been reduced in most developing countries, which means the transmission rate is still hovering at 15-25% (Coovadia 2004). Mother’s breast milk does

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52 provide immune support to the baby, and breast-feeding is a bonding process between mother and child; however, when HIV transmissi on is in question, at the very least, early weaning is recommended so as to minimize ne gative health consequences for the mother and the infant (Wilfert & Fowler 2007). When it comes to clinically preventing di seases caused by viruses, vaccines are the most commonly employed method. Vaccines function by provoking the body to produce antibodies to a specific antigen. Vaccines act as an infectious agent so that the body will remember it and mount an immune res ponse the next time it se es it. In the case of HIV, we know a variety of structures that could be used to induce response by antibodies. However, it has been 25 years sin ce the discovery that HIV is the cause of AIDS and still there is no vaccine. More th an $1 billion are sp ent annually on vaccine research, yet only two vaccines have even re ached human trials (Walker & Burton 2008). The most recent setback was Merck V520, a vaccine developed by a collaborative partnership between Merck and the National Institutes of Health (Steinbrook 2007b). The trial had to be suspended and preliminary resu lts were nothing short of disastrous: instead of acting as a prophylactic agent, the vacci ne was found to have actually increased susceptibility of patients to HIV infection. A much-criticized trial of a new vaccine is being conducted in Thailand, with results exp ected in late 2009 (J ohnston & Fauci 2008). Given this background on HIV/AIDS, it is now possible to examine the problem from a public health perspective in two pr ominent nations: India and the United States. HIV/AIDS is a global problem, but each of thes e nations has a prominent role to play in the future of the epidemic. India, with its emerging economy and booming population, must reconcile the strain on its resources with a need to se rve its people and support the

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53 global fight against AIDS. Si nce the discovery of AIDS, America has been at the forefront of research into the illness. Tha nks to the public health effort in the United States, knowledge and therapie s for HIV/AIDS are what they are today. Examining how both nations are dealing with HIV/AIDS will provide a starting point from which developed and developing nations can learn from each other to improve global outcomes of this deadly disease. The AIDS Epidemic in India India is home to the second largest population of peopl e with HIV/AIDS in the world (WHO 2005). Beating India in this dubio us category is South Africa, where over 18.3% of the adult population is afflic ted with AIDS (UNAIDS 2008b). In 2006, 2.5 million people in India were living wi th HIV/AIDS (UNAIDS 2008a). Though the numbers seem overwhelming, the truth is that behind the numbers there may actually be some reason for optimism. Despite being such a large number of people, those infected with HIV/AIDS represent only 0.36% of India’ s overall population (Pandey et al. 2009). India’s enormous population means even a sm all percentage yields a large number of people, but the problem is not one that has really penetrated mainstream society. As a result of a variety of soci al, cultural, politic al, and economic factors, HIV/AIDS has remained contained in India to very specific populations. Before the nature of the HIV/AIDS probl em can be understood, it is important to gauge the size and scope of the problem. In ot her words, how is the HIV prevalence rate in India determined? How accurate is this estimate? India has recently come under scrutiny for revising previously overestim ated HIV statistics (Steinbrook 2007a, 2007b, and 2008). Prior to 2006, India had been usi ng data collected in large public-sector

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54 hospitals to estimate HIV prevalence (D andona & Dandona 2007). Additional data on HIV came from clinics where pre-natal care was offered and from high-risk individuals receiving treatments at sexually transm itted disease clinics (Dandona et al. 2006). However, most clinics are in urban areas though two-thirds of the population is in rural areas. Not only that, but out of 600 districts in India, only 29 5 have at least one clinic where HIV surveillance is occurri ng (Chandrasekaran et al. 2006). Evidently the old method was sampling an unrepresentative p opulation and thus led to a gross overestimation of India’s HI V/AIDS problem. As a result, the method of calculating prevalence in India was revised and it was found that people needing HIV treatment is less than what had been e xpected (Dandona & Dandona 2007). As new data are reported, any national numbers showing a d ecline in the rate of HIV prevalence, new infections, etc. might actually be the result of better and more population-based data. The prevalence of HIV/AIDS in India varies greatly by state and region. The epidemic is concentrated in specific st ates: Andhra Pradesh, Tamil Nadu, Karnataka, Maharashtra, Nagaland, and Manipur (UNAI DS 2008a). The majority of at-risk populations in India can be found in the rural areas of these larger states (Figures 4.3 & 4.4). However, even then it is a problem that is found in high concentrations in certain rural or urban districts, whereas it is virtually un detectable in others.

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55 Fig 4.3: Prevalence of HIV/AIDS in India by State (Pandey et al. 2009) Fig 4.4: Incidence of HIV/AIDS in India by State (Pandey et al. 2009) (In the figure above, PLHIV is defi ned as people living with HIV)

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56 India’s high-risk population in cludes sex-workers and thei r clients, men who have sex with men (MSM), and injection-drug us ers (Steinbrook 2007a). This cohort receives the bulk of attention from India’s effort s at prevention and treatment (NACO 2008). Though these populations are most likely to be affected by AIDS, India’s general population does not remain entirely in the cl ear. HIV is moving from the most vulnerable population to bridge populations (i.e. clients of sex workers, particularly long-distance truck drivers), migrant workers, people with sexually transmitted infections, and partners of drug users) (NACO 2008, WHO 2005). This group forms the bridge group that has exposure to HIV/AIDS and is th erefore possibly at risk. As a linking group, individuals in this category have contact with both the at -risk and general populat ion and are therefore the means by which HIV/AIDS can integrate into mainstream society. The HIV epidemic in India is largely tr ansmitted sexually; an estimated 87.4% of AIDS cases in India were acquired by sexual means (NACO 2008). Therefore, understanding the nature of sexua l encounters in India is a criti cal step in being able to lower the rate of new infections and the prev alence of HIV overall. One of the most atrisk populations for infections are female sex workers (FSW) (Steinbrook 2007a). A large proportion of sex worker clients also have regular sex partners (Moses et al. 2008). However, a large proportion of people who pay for sex do not use condoms in their encounters with sex workers. When these sex worker clients (usually males) return to their regular sex partners (usually females), these women get infected by their regular sex partners who have acquired HIV from sex workers (Lancet 2006). Though this scenario does occur in India, earlier fears of an explos ion of HIV/AIDS in India have not come to

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57 fruition and the epidemic has been mostly c ontained to high-risk populations (Kumar et al. 2005). Several community-led HIV preventive intervention programs targeting FSWs are ongoing in India. A number of them are re porting preliminary results on the impact of these efforts on the rate of infection and continued presence of risky behavior among FSWs (Moses et al. 2008, Ramesh et al. 2008, Reza-Paul 2008). The findings demonstrate that a majority of sex workers ar e illiterate (over 75%), street-based (i.e. see clients at home or in a public place; almo st 95%), and have a regular partner (68%) (Reza-Paul 2008). Though the vast majority are street-based, it is more likely for sex workers to have HIV if they are brothel-based (Ramesh et al. 2008). An intervention conducted in Chandigarh increased AIDS awareness including improving understanding of met hods of transmission, condom usage, and risk associated with having multiple sex partners (Bhatia et al 2004). In Mysore, a decrease was seen in the number of new infections and a substantia l decrease was seen in the presence of other sexually transmitted infections (Reza-Paul 2008). Another study also saw a gradual decrease in new HIV infections and an increase in condom use from 2003-2007, particularly among younger FS W (under 25) (Moses et al., Figure 4.5). These studies demonstrate that intensive, focused preven tive intervention programs can be successful and should be implemented to target India’s other highrisk populations.

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58 Fig 4.5 (Moses et al. 2008) (In the figure below, the vertical axis repr esents HIV prevalence among women attending antenatal clinics in Karnataka from 2003-2007) Though there appear to be substantial be nefits from prevention programs, the mean cost for serving a sex worker was a litt le under $11 per year, a nd in sites that saw more sex workers, the cost per sex worker was even lower (Dandona et al. 2005). Despite the fact that poverty is ofte n linked to a life in sex wor k, many workers report hearing about AIDS information from the television or radio (Bhatia et al. 2004). To make up for a lack of education or access to mass media, community engagement is a tool that should be utilized (Pallikadavath et al. 2005). Ha nds-on prevention programs have been found to be quite successful, particularly when they make use of peer educators (former sex workers) (Dandona et al. 2005).

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59 Prevention of mother-to-child transmission of HIV/AIDS in India consists of a regimen much like that seen in other c ountries. Mothers are given ARV therapy, a cesarean delivery is recommended, and impr oved breast-feeding practices are adopted (Kapoor et al. 2004). Services for pregnant mothers are usually offered in large, government run hospitals that are actually more efficient than the small centers that are dedicated to providing one or two preventive se rvices (Dandona et al. 2008). As a result, the National AIDS Control Organization deve loped over 4,000 Integrated Counseling and Testing Centers that combine preventive serv ices for mother-to-child transmission, as well as testing and counseling of mothers and children (NACO 2007). Men who have sex with men (MSM) and tr ansgenders (TGs) are at high risk for acquiring HIV by sexual transmission. Howeve r, the MSM cohort is largely unexplored because it is such a taboo subject in India (Steward et al. 2008). Not only is it illegal under Section 377 of the Indian Penal Code of 1860 (Steinbrook 2007a), it is a very complex population to target (NACO 2008). Not all MSM and TGs have the same risk of acquiring HIV, a fact that is dependent upon whether the individuals engage in anal penetration or anal reception. Regardless, finding the target popul ation for statistical purposes and for intervention is made increasin gly difficult by the fact that much of the population does not identify as homosexual, transgender, etc. ( NACO 2008). A possible target population is emerging in the form of male sex workers (Shinde et al. 2009). This is another population that must be better unders tood before real gains can be made on the AIDS front in India. Individuals who use drugs vi a injection round out the most at-risk populations in India. Use of infected needles is not a pr oblem seen all over I ndia; it is prevalent

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60 predominantly in big cities in the north east (UNAIDS 2008). However, it is a major problem and is one that the National AIDS Control Organization of the Government of India has included as a top priority ( NACO 2008). Not only does intravenous drug use increase risk of HIV transmission, it is also implicated in transmi ssion of hepatitis B and hepatitis C (www.cdc.gov/hepatitis). With a prevalence rate of 6.92%, injected drug users are more likely than any other high-risk popul ation in India to have AIDS (NACO 2008). Still more alarming is the fact that injected drug use is strongly associated with risky sexual behavior (Mahanta et al. 2008). Given this information, it is evident that this too is a population that requires more in-depth study. Migrant populations in India are considered a bridge population for the transmission of HIV/AIDS. Migrant laborers are usually young (between the ages of 18 and 29), and though over half are married, one th ird have to live away from their wives (Census 2007b). Contract labore rs are paid minimum wage and are housed together in facilities that provide basi c health and sanitation need s (Ministry of Labor and Employment 2001). In such conditions, migr ant workers often feel isolated after spending long periods of time away from home and their families. The desperation created by the situat ion leads to behaviors not commonly condoned in Indian society. Relative to main stream India, migrant populations are more likely to pay for sex, engage in high-risk heterosexual sex, and abuse drugs and alcohol (Saggurti et al. 2008). Combined with the general lack of edu cation among migrant workers (Census 2007c), this creates an envi ronment primed for the spread of HIV. Similar to migrant workers, homeless men ar e emerging as a bridge population that will require more attention in the future (Tal ukdar et al. 2008). This population is currently

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61 ignored, but faces many of the same problem s that place migrant workers in such a perilous situation. Many of India’s goods are transported in tr ucks via one of the four major national highways (Steinbrook 2007a, Figure 4.6). The driver s of these trucks share similarities in terms of lifestyle with migrant laborers. Of ten far away from home and isolated from wives, truck drivers are a br idge population because they pay for sex with women that wait along the side of the highway and at truck stops (NACO 2007). In addition, their capacity to travel all over the country and im pact areas that were previously unaffected makes them an important population to target Not only do truck drivers not believe they are likely candidates for HIV/AIDS, they re port low condom usage with paid partners and with wives, and over 25% have never had contact with HIV prevention efforts (Pandey et al. 2008). Though most preventi ve efforts center on dissemination of information, an information-motivation-behavi oral skills (IMB) in tervention in Chennai did find that condom usage increased with ma rital partners (Cornman et al. 2007). Using this model, participants are not only educated on HIV/AIDS, they are taught that it is socially desirable for them to behave in a way that promotes safe sex.

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62 Fig 4.6 (Steinbrook 2007a) HIV/AIDS is transmitted sexually, via infected needle, through blood transfusions, and in mother-to-child transmission (www.nlm.nih.gov). Because all methods of transmission are prevalent in In dia, authorities have sought to reduce the numbers of people getting infected while simu ltaneously educating at-risk populations on

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63 the use of condoms and safer sex. In addition, In dia has sought to increa se the size of the population receiving antiretrovirals, both as treatment and as prophylaxis. In 2003, the government pledged to provide antiretr oviral (ARV) therapy to 100,000 people by 2007 (particularly to mothers to prevent in moth er-to-child transmission, children, and people who seek help in clinics) (WHO 2005). By December 2007, 158,000 people were receiving ARV treatment (Kaise r Family Foundation 2009). Despite patent laws preven ting the use of new drugs being developed in India (Havlir & Hammer 2005), the use of Indian generics has been beneficial not only to India but to sub-Saharan Africa as well. Though Indi a receives financial ai d from a variety of international organizations (Global Fund to Fight AIDS, Tuberculosis, and Malaria, the World Bank, UNDP, UNAIDS UNICEF, USAID, the Clinton Foundation, Gates Foundation, and the CDC, to name a few), at regular price, ARV therapy would have been unaffordable for the Indian government (WHO 2005). India’s booming pharmaceutical industry has greatly improved the access for Indian patients to ARV therapy consider ing the recommended treatment costs $146 US per person per year using Indian generics (WHO 2005). By compar ison, using American pharmaceuticals, the cost is roughly $2,738 pe r patient annually, only for one medication (www.worldbank.org). Though the development of generics has been useful, there is room for improvement. Diagnostic tests that measure CD4 cell count and viral load evaluations are done in labs which are expe nsive and often unaffordable (Kumarasamy et al. 2005). This is a potential area where the development of a new tool by the Indian scientific community could ha ve a global impact on how HIV is evaluated worldwide.

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64 HIV/AIDS in the United States Over 1million people in the United States are estimated to be currently living with HIV/AIDS (CDC 2008A). Though the ac tual number of known HIV/AIDS cases is about 600,000, the prevalence estimate account s for the infected population that is unaware they have HIV (about 25%) (Glynn & Rhodes 2005). For a population of just over 300 million (Census 2009), the overall preval ence rate calculates to approximately 0.3%. Though national prevalence is an important st atistic, public health agencies in the United States (i.e. CDC, HHS, NIH, etc.) are more concerned with incidence and prevalence in specific populations. While the prevalence of HIV gives an indicator of how many individuals have HI V/AIDS, incidence reports al l new cases, thereby allowing officials to view trends in HIV/AIDS (CDC 2007). Prevalen ce is still calculated, but thanks to new technologies that allow for more accurate inciden ce reporting, identifying the number of new HIV/AIDS cases is more emphasized. These st atistics allow public health officials to see whether programs and services in place are making a difference in targeted populations. Incidence testing has advan ced by leaps and bounds in th e past few years. One of the most useful new technologies developed is a serologic testing algorithm for recent HIV seroconversion (STARHS) (CDC 2007). In essence, STARHS uses an enzyme immunoassay to gauge the level of HIV anti body production in the body. If production is high, the body has obviously been battling HIV for a while. If antibody levels are low, it is assumed that HIV has recently entered the body and therefore the infection has occurred within the past 6 months (Withum et al. 2002). Though there is some debate as

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65 to whether the testing is truly dependable (Remis & Palmer 2009), it can be adjusted to be made unbiased and is thus wi dely accepted in the United States. Using new testing technology to back-calcu late time of infection is truly the future of HIV/AIDS in public health (Rutherf ord et al. 2000); it ensu res that incidence of new HIV infections can be determined. In a study that back-calculated using data from 2003 to 2007, blacks represented nearly 50% of all new infections and youngsters (13-29 years of age) accounted for 38% of all new infections (Hall et al. 2008). These findings are consistent with CDC data reported by 33 st ates in 2007. The data indicated that each year, black males have the highest rate of HIV diagnosis (119.1 per 100,000), followed by black females (56.2 per 100,000), Hispanic males (50.9 per 100,000), and white males (16.7 per 100,000) (CDC 2008A). HIV is at epidemic status in certain pa rts of the United States, particularly among certain populations (Chin & Bennet 2007). The full force of public health efforts are currently in place to make sure that the popul ation that does not know they are infected, finds out their HIV status ( HHS 2008). However, as indicated above, specific populations in America are being disproportionately a ffected by HIV/AIDS. Figure 4.7 shows the progression of HIV infection since discovery among the major race/ethnicity categories in the United States. As indicated by the figur e, at the outset of its discovery, HIV/AIDS was primarily a disease of the white ma n (HHS 2008). As time has passed, it has increasingly affected minor ities. Though African Ameri cans comprise 13% of the population, they account for 48% of HIV/AI DS cases (UNAIDS 2008b). Hispanics are 14% of the population, yet 18% of HIV/AIDS cases.

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66 Fig 4.7 (Hall et al. 2008)

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67 Truly understanding the characteristics of HIV infection among Hispanics is not an easy task given the diversity of the populat ion that is clumped under the umbrella term (Census 2008). The term include s many who were not born in the U.S. as well as those that identify with a multitude of different nations. Though it is particularly true of Hispanics born outside of the US, there is a general lack of ba sic understanding of the healthcare system among all Hispanics, possi bly due to the language and cultural barrier (Rev Panam Salud Publica 2002). However, this perceived barrier, a study that compared health related quality of lif e, no significant differences were found between groups that were born outside of the US and US-bor n Hispanics (van Servellen et al. 2002). Transmission of HIV among US-born Hisp anics parallels transmission trends seen in the US whereby HIV infection is passed along mostly by men who have sex with men, then by high-risk heterosexual contact, and finally by way of injection drug use (Espinoza et al. 2008). However, just looki ng at Hispanics as one broad, homogenous population is misleading. In Puerto Rico ther e is an extremely high per capita rate of HIV/AIDS via injected drug use (Loue 2006). For Puerto Rican populations living in the US and in PR, that is the primary me thod of transmission, followed by high-risk heterosexual sex. In general, the population in the United Stat es that has the highest risk of being infected with HIV are males (UNAIDS 2008b) Females only account for 25% of all HIV cases. It comes as no surprise then that the most rampant method of HIV transmission is by sex between men (CDC 2009; Figure 4.8). It is possible that the advent of HAART has made HIV/AIDS less scary to the populat ion that was once most affected by AIDS (Jaffe et al. 2007). In 2004, the number of ne w infections resulting from male to male

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68 sexual contact was 17,898, compared with 22,473 in 2007 (CDC 2008A). This rise is disturbing and signals better preventi on interventions must be created. Fig 4.8: Transmission category for pers ons with a new HIV diagnosis in 2006 (www.cdc.gov/hiv) Behavioral intervention programs have b een found to be successful in curbing high-risk sexual behavior, but their success ha s only been documented in majority white populations (Johnson et al. 2008). Interventi ons designed for Hispanic and African Americans are still necessary. Given the succ ess of recent trials in Africa, another consideration for prevention of HIV for me n is circumcision (Sullivan et al. 2007). Slowly the practice is being studied in America, and though no public health recommendations have been made, one study sh owed that male circumcision reduces the risk of HIV infection for men who engage in high-risk heterosexua l sex (Warner et al. 2009). As it becomes more accepted, some are calling for the establishment of

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69 circumcision programs and for research into the social effects of circumcision (i.e. increased risky behavior after ci rcumcision) (Brooks et al. 2009). Despite efforts at curbing high-risk hete rosexual sex (i.e. sex without a condom, anal sex, sex with numerous partners, et c.), the practice c ontinues. Among newly diagnosed women with HIV 2005, 80% contract ed it during unprotected sex, compared to 75% in 2001 (UNAIDS 2008c). Though these st atistics are not en couraging, there are some interventions that have potential. A br ief intervention on safe-sex practices was conducted on young African American males rece ntly diagnosed with an STD (Crosby et al. 2009). The program was found to increase likelihood of condom use in last sexual encounter and to reduce the number of sexual partners reported. Similarly, in programs that taught young African American and Hisp anic girls safer sex practices, STD rates after intervention were reduced (Jemmott et al. 2005; DiClem ente et al. 2004). As seen in the figure, injection drug use accounts for 13% of newly diagnosed HIV cases in the United States (CDC 2009). Because injection drug use is often found alongside risky sexual behavior prevention programs focus on reducing this behavior and discouraging the sharin g of needles (Santibanez et al 2006). Once they have been identified as HIV positive, injection drug users do tend to use less or share needle equipment with less frequency (Celentano et al. 1994). Additionally, injecting drug users who form social networks of non-users after being informed of thei r risky status were found to overwhelmingly decrease their nega tive behaviors (Coste nbader et al. 2006). This suggests that interventions that advocat e for the selection of a new social group do work and should be implemented more widely.

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70 Mother-to-child transmission and use of infected blood, though still found in developing countries, are extremely rare in the United States. Even in Washington D.C., where the prevalence of HIV is comparable to that of a sub-Saharan African country (3%), only 1 baby was born with HIV in 2006 and 2007 (Tanne 2009). The optimal preventive strategy for mother-to-child transmission combines prophylactic ARV therapy, a reduction in breast f eeding, and the performance of cesarean deliveries when possible (Cooper et al. 2002). As a result, incidence of mother-t o-child transmission accounts for 2% of all HIV cases, whereas wi thout the intervention it would account for 25-30% (CDC 2006). Though men are generally more affected th an women, African American males in particular are the hardest hit nationwid e (CDC 2009; DOH 2007). Not only do they account for more of the newly diagnosed cases of HIV, they also progress more quickly to AIDS after infection, have a lower chance of surviving past 3 years after diagnosis, and are more likely to suffer a poor outcome (Ha ll et al. 2007). These st atistics are true of all minorities affected by HIV, possibly due to late recognition of infection. In a study that examined health care uti lization of at-risk African Amer ican males, it was found that despite having pretty regular access to a prim ary care physician, the st udy participants did not fully use available services (Petroll et al. 2009). Most importantly, not enough males are getting tested though they c ontinue their risky behavior. For females, the primary method of infec tion is via high-risk heterosexual contact (CDC 2009). Though the US possesses a fairly comprehensive surveillance system, the HHS is lacking data on women, including the numbers of HIV+ pregnant women receiving prophylactic HAART tr eatment. What is known is that in 2007, the 35 states

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71 reporting indicated that 142 HI V+ women were pregnant, co mpared to 317 in 2001 (HHS 2008).To be included in CDC tabul ations, states must collect confidential, name-based HIV data (CDC 2008A). Most of the analyses currently in print use data that was collected when only a few states fit the CDC criteria. As of now, 48 states have confidential, name-based HIV surveillance ( HHS 2008), and the remaining states are well on their way. The same demographic differences that ar e evident in the ge neral population can be seen among newly infected women. Afri can American women and Hispanic women are disproportionately affected by HIV, desp ite decreases in the infection rates of both groups (McDavid et al. 2006). The African Amer ican community continues to be plagued by poverty, low accessibility to quality health care, and lack of preventive services despite the identification of these problems decades ago (Williams 2003). Similar problems plague the Hispanic community, thoug h Hispanics often face the addition of the language barrier as well (Espinoza et al. 2008). Because high-risk heterosexual sex is so prevalent in the United States, intervention programs attempt to address the issue by giving women a feeling of empowerment and comfort in telling men to use condoms during sex (Marin 2003). NonLatina white women report feeling more know ledgeable about HIV and more likely to demand condom use than Latina women. Othe r studies corroborate these findings, citing machismo typical of Latino culture as a factor co ntributing to a woman’ s lack of control in sexual situations (Or tiz-Torres et al. 2000). There is not very much current research that describes HIV/AIDS incidence in female sex workers in the United States. A study of inner-city sex workers in Miami

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72 found that they were exhibiting high-risk sexual behavior while being heavily involved with drugs and alcohol (Incia rdi et al. 2006). Also in Mi ami, Surratt and colleagues (2004) looked at sex workers who were homeless and found homelessness to be comorbid with more frequent drug use, pe rformance of riskier sex acts, and greater refusal by clients to use condoms. Migrants and laborers often engage in risky behavior and are thus another potential HIV/AIDS population. After Hurri cane Katrina, a large group of mostly undocumented Latino workers went to New Orleans to participate in the reconstruction of the city (Kissinger et al. 2008). The workers indicated they partook of much risky sexual behavior and many self-reported as HIV positive. Not only does the United States public he alth system have to deal with the incidence of HIV/AIDS among the population that currently lives here, it often is made to cope with immigrants who come already in fected with HIV. Immigrants from subSaharan Africa who are HIV positive have recently inundated the Minnesota public health system (Cartwright 2006). They introduc e viral diversity to the region, and add a host of problems including cultural and language difficulties in addressing this population through prevention programs. Because this problem is not unique to Minnesota, it is important to start to distinguish foreign-bor n blacks in AIDS surveillance instruments to determine the true extent to which HIV from Africa is proliferating in the United States (Kerani et al. 2008). These data are impor tant because the viral diversity these populations introduce can impact antiretroviral resistance in HIV strains in the United States (Cartwright 2006).

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73 Differences in HIV/AIDS prevalence and care can be found when comparing urban to rural settings. In general, the grea test proportion of HIV patients in the United States comes from metropolitan areas (t hose with populations greater than 500,000) (CDC 2008b). Due to decreased access to ARV therapy and inadequate care, AIDS patients who live in rural areas have higher mortality rate s compared to their urban counterparts (Lahey et al. 2007). The areas that are most affect ed are the rural areas in the south and north central region (McKinney 2002). In areas like the Deep South (Alabama, Georgia, Louisiana, Mississippi, North Carolina, and South Carolina), AIDS is concentrated in African Americans, wo men, and rural populations (Reif et al. 2006, Figure 4.9). As a result of the poor infrastructu re that is available in rural communities, some AIDS patients have to re sort to going to the nearest metropolitan area to seek care (McKinney 2002). Fig 4.9: Geographic regions of the United States, as defined by the CDC (CDC 2008b)

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74 The importance of testing for HIV/AIDS is undisputed; gettin g the population to comply, however, is a different matter. Hisp anics do not seek out HIV testing if they perceive themselves to be at low risk for HIV/AIDS ( Lopez-Quintero et al. 2005). Though this sounds logical, this can be dange rous given that a pe rson’s perception of their own risk may be completely unfounde d. However, once testing has occurred, individuals who find out they are positive fo r HIV have been found to dramatically reduce their high-risk sexual be havior (Marks et al. 2005). In 2006, frustrated by the continuing pr obability that a quar ter of infected individuals may not even know their HIV st atus, CDC officials recommended opt-out HIV testing for all Americans 13-64 years of age (Branson et al. 2006). In effect, this would make HIV testing a routine part of all health care settin gs. The idea, though not being implemented everywhere, would hopefully catch HIV infection at an earlier stage, enhancing the effectiveness of ARV thera py. It is important to note that this recommendation also includes the provision that newborn infants be tested for HIV, even in instances where mothers opted out of testing (Branson et al. 2006). This provision would help to reduce the rate of vertical transmission of HIV from mothers to their children to an even more negligible nu mber than where it currently stands. In order to care for HIV/AIDS patients in the United States, Congress instituted the Ryan White HIV/AIDS Program (HRS A 2008). The program ensures HIV/AIDS patients get quality care rega rdless of being uninsured, unde rinsured, or low-income (HHS 2008). The program is very compre hensive and provides case management, housing, nutritional, emergency financial a ssistance, client advocacy, psychosocial support, substance abuse treatment and ment al health treatment plus transportation

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75 services (HRSA 2008). In general, all this support has increased utilization of primary care services and has reduced disp arities while improving outcomes. In addition to providing care for HIV/ AIDS patients, the United States government supports research like no othe r nation in the world. In 2006 and 2007, the National Institutes of Health received more than $2.9 b illion to support a global, extensive, and comprehensive AIDS progr am that includes research on a possible vaccine, new medications or drugs, and como rbid infections (HHS 2008). Many of the U.S.’s resources are also being diverted by the US President’s Emergency Plan for AIDS Relief to aid in developing nations’ fights ag ainst HIV/AIDS (PEPFA R 2009). As can be seen, the US is actively trying to improve upon HIV/AIDS outcomes within its borders, but also around the world.

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76 Chapter 5: Conclusion A review of India’s public health system reveals a framework that is mightily struggling to serve the needs of its enormous population. T hough it is inadequately trying to provide basic needs for primary care, nutri tion, and health education services, India’s public health system is being challenged by a wide spectrum of chronic diseases found in both developing and developed nations. The In dian government has the difficult task of trying to provide services for populations f acing diseases that have been eradicated elsewhere, while simultaneously providing ca re to individuals with advanced, chronic illnesses, without the advantage of a strong network that delivers basic health care. To add to its multitude of problems, India’ s public health system is relatively new and very slow to adapt. Developed shortly af ter the British granted India independence in the 1950’s, the public health system is only now beginning to adapt to the diseases and areas of weakness of the Indian health care system. The United States, on the other hand, has a sophisticated, well-funded, and comprehens ive system to serve the public health needs of its population. This populat ion is barely one-third that of India’s, however it is to India’s benefit to learn whatever possible from nations with far more experience. For this reason, this thesis chose to examine how the Indian public health system could learn from the system in place in the United States However, the public health system in the United States is by no means perfect; it shar es many problems with India. By exploring both and comparing strong and weak points, both nations can learn and hopefully improve delivery of health care services. One of the biggest areas where both system s can improve is a fundamental aspect of a public health system: data collection fo r key health indicators. Better testing and

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77 surveillance methods are necessary all over the world, but particularly in developing countries. India has made strides in this aspect by recently implementing more decentralized, population-based methods of da ta collection. The United States for years has collected data on the basic indicato rs health systems are evaluated upon. When it comes to a fairly new disease like HIV/AIDS, both countries can better define the indicators they measure and the accuracy of their results. However, the difference in the maturity of India and Unite d States’ system is evident because India’s data are aiming to assess prevalence of HIV/AIDS accurately. India’s public health system is still trying to determine the true scope of the problem (i.e. who has HIV/AIDS, where is it concentrated, how it is transmitted, if prevention is working, etc.). The United States, on the other hand, is not trying to fi nd out who has it, but why that specific person took so long to find out they have HIV/ AIDS. Was it their race, geographic location, socioeconomic status, or gender that determ ined how and when they were infected? Because of new incidence testing, public he alth agencies in the United States can determine when the person was infected, thereby alerting the patient to the possibility that he/she could have been spr eading HIV to others unknowingly. India has improved its data collection method and th is has enabled a more representative estimate for the incidence of HIV/AIDS. Because this system was just recently implemented, only old data are availabl e to give a breakdown of the nature of the HIV/AIDS problem (i.e. where the problem is geographically concentrated, what populations suffer most, if interventions are truly making an impact). In the next few years, numbers will be coming in based on the new surveillance system, and this data will provide a much better picture of HIV/AI DS in India. Given this new method of

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78 surveillance, another potentia l area of improvement would be to increase the involvement of private physicians in the tabulation of health statistics. While the CDC in the United States relies heavily on physic ian reporting for monitoring he alth indicators, the Indian public health system and private physicians currently function independently of one another. With a coordinated effort, more accura te health surveillance can be achieved in India. Though the United States has pretty accu rate surveillance measurements in certain parts of the country, it is only now that all 50 stat es are providing confidential name-based HIV infection reporting (HHS 2008). This method of reporting has been implemented only recently, so all-inclusive data will be available in the next few years. In addition to getting more comprehensive numbe rs, both the United States and India should look to measuring more indicators that deal with the incidence of HIV/AIDS in women. In the United States, women are increasin gly being affected by HIV/AIDS and more knowledge is necessary regarding how they ar e infected, whether they are being given ARV therapy, whether they adhere to AR V therapy, and how much mother-to-child transmission currently exists. In addition to the way in which India and the United States measure the incidence of HIV/AIDS, both nations can improve upon preventive efforts and on the care they provide for those infected with HIV. One of the greatest tools of prevention, education, can be more effectively implemented in both India and the Unite d States, though with different population targets in mind. In India, the most at-risk populat ion is females living in rural areas that provide for themselves by conducting sex work. These women are poor and illiterate, based in a culture that suppor ts the notion that they have only minimal

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79 rights when the wishes of a man are involved. A number of studies have shown that peerdirected, community-driven in tervention programs do help to educate and empower the women (Moses et al. 2008, Ramesh et al. 2008, Reza-Paul 2008). Though they are not at risk for acquiri ng HIV through sex work, Hispanic women in the United States share some aspects of the HIV problem with Indian sex workers. Because Hispanic women are culturally less empowered than their male counterparts, they often have less say when it comes to condom usage during sex. Programs like the intervention for Indian sex workers are conduc ted for Hispanic women in that they are taught safer sex practices and given confidence to assert themselves (Jemmott et al. 2005). The success of both these sets of program s indicates they must continue to be implemented. Education in India cannot stop with fe male sex workers alone. India’s young urban population, increasingly be ing affected by HIV/AIDS, ha s demonstrated a general lack of knowledge of what HIV/AIDS is, how it manifests in sick individuals, and how it can be prevented by use of condoms (UNAIDS 2008). It would be worth educating this vulnerable population to prevent them from becoming a high-risk cohort. The US has been providing safe sex and HIV/AIDS educa tion in schools for many years. As it stands, 48.6 percent of School Districts require the teaching of HIV prevention in elementary schools, 79.0 percent in middle schools, a nd 89.3 percent in high schools (HHS 2008). India’s conservative society has resisted implementing AIDS education in schools, but the reality of the problem is causing an in creased emphasis on early education (McManus & Dhar 2008). Because at-risk girls have fa r less access to knowledge than boys in their situation, education programs at an early age would be most beneficial to them (Chhabra

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80 et al. 2008). As these students grow and b ecome sexually active adults, the hope is that their early education will enab le them to practice safe sex. In the United States, emba rrassingly high rates of HIV/ AIDS are found in certain cities and only among certain populations (Tanne 2009). Though traditionally a problem affecting gay, white men, HIV/AIDS has now evolved to an epidemic of young, African American males living in urban areas (Hall et al. 2008). This change is a reflection of the disparities being witnessed in the US public health system as a whole (Williams & Jackson 2005). African Americans and Hisp anics are bearing a higher burden of HIV/AIDS incidence than are White populat ions (CDC 2008A). Gi ven this changing dynamic, HIV/AIDS prevention programs must do a better job of targeting these populations for education, access to condoms, an d improvement of primary care services. Similar, but more pervasive, discrimi nation is seen against members of an untouchable caste or tribe in India. Nearly half of all sex workers in one survey identified as an untouchable caste/tribe, a fact that automatically limits their access to jobs and health care (Dandona et al. 2006). They are a population that is neither studied nor served in India, but they deserve equal access to prevention and treatment. Due to the risk of transmission from female sex workers to the general population, prevention programs in India need to address clients of female sex workers; they are an important bridge group that is currently somewhat ignored (Chandrasekaran 2006). It is a difficult population to study a nd identify because most are unwilling to be identified as having bought sex. However, in a cross-sectional survey of clients of female sex workers in three high-pre valence states some useful data were found. Older clients were reported as less likely to use condoms, clients tended to be frequent clients (paid

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81 multiple times for a variety of female sex workers), and a majority of clients also had a casual or a regular partner at home (Subramanian 2008). This information is something that future programs targeting se x worker clients can build upon. Though there is surprisingly little curren t research on sex workers in the United States, what little is availabl e points to high comorbidity of sex work with alcohol and drug abuse (Inciardi et al. 2006). The propensity of the clients of sex workers to refuse to use a condom is a particularly worrying finding (Surratt et al. 2004). Like sex workers in India, sex workers in the US have to be able to insist upon the use of protection for their own safety. Injection drug use is a major problem in both India and the United States. In India, the problem is localized to specific re gions, particularly the northeastern states of Nagaland and Manipur. Like the United States needle exchange programs and education about the dangers of sharing drug equipment are starting to make gains. In addition, facilitating the formation of new non-using pe er groups for injection drug users in India may prove as successful as it was in the United States (Costenbader et al. 2006). The rural/urban divide is pretty stark in India and the United States, though the definitions of rural in both countries are quite different. Neither country has established its rural health infrastructure to match the infrastructure seen in urban locations. Unfortunately for both rural populations, that means access to only th e most basic care, often at poorer quality than wh at urban counterparts receive. In addition to these built-in problems, India also has a few peculiaritie s that confound the difference even further. Some of India’s rural areas are truly unreachable and are ne arly impossible to maneuver. Additionally, the populations that live in these remote areas tend to speak a very specific

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82 dialect and identify with a minority culture As a result, programs designed for rural populations in India must be very specific in who they are pr ofessing to address. Likewise, the rural populations in America have their own particular culture, but it is not as different from urban America as rura l India is different from urban India. As established before, AIDS in India is primarily transmitted sexually and by injected drug use. Efforts are ongoing to prevent future spread by these methods; however they do not encompass all the wa ys in which HIV can be transmitted. Blood transfusions with infected blood and mothe r-to-child transmission still account for a portion of HIV cases. Of all HIV cases in India, 2% are accounted for by bad blood donation (Steinbrook 2007). This number is very small and only accounts for a handful of individuals, but even this number must be reduced. The United States, given its utilization of technology and stringent st andards for the use of blood, has virtually eliminated transmission of HIV via blood transfusion. If India truly hopes to make strides in its battle against HIV/AIDS, it must altogether eliminate mother-to-child tran smission. Given current drug technology and understanding, it is abso lutely possible to prevent tran smission of HIV by pregnant women. In the United States, even in hi gh-prevalence areas like Washington DC, only one case of mother-to-child transmission was found in 2007 (Tanne 2009). For India, this means access to prophylactic ARV therapy is necessary and more testing must occur among women. In the United States, 100-200 infants are infected by their mothers annually, with 80% of these infants being either black or Hispanic/Latino (www.cdc.gov/hiv). Though this relatively small number of mother-to-in fant transmissions would be desirable for

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83 India, for a country where access to HIV/AI DS education and ARV therapy are much more readily available, even this number is too high. In additi on, the disproportionate way mother-to-child transmission affects minority populations indicates a greater underlying problem is present. Evidently, despite the presence of such programs, they are lacking in effectiveness because they are not reaching the populations where they are most necessary. The final recommendation for improving India’s response to HIV/AIDS deals with a problem that is deeply imbedded in India’s social fabric. Though men who have sex with men (MSM) represent a high-ri sk population, they are also a largely unresearched population. Homosexuality is su ch a taboo subject in India that MSM do not find a supportive environment for seeking services and education. Only when these attitudes progress can a differen ce be made in this population. Male to male transmission of HIV is th e primary method of transmission in the United States. Despite initial gains in this community, men who have sex with men are becoming an increasingly vulnerable populatio n (CDC 2008A). The cavalier attitude of this population may have something to do with th e fact that the illne ss is no longer deadly and that the fear of AIDS that existed in th e 80’s and 90’s has given way to a feeling that AIDS can be handled. As a result of recent increases in transmission from males to males, public health efforts must be redoubled amongst this population before the prevalence of AIDS once again gets out of hand. The strength of the United St ates public health system lie s in its size and scope. It is heavily funded, research-foc used, and does not have to co mbat the social prejudices present in India. India’s problem is made fa r worse due to its size and the diversity of

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84 language, culture, and religion its borders contai n. This diversity leads to differences in methodology, questionnaires, and in the way re search is conducted. Because the Indian government lacks the resources to provide f unding and services on its own, public health initiatives are often done as co llaboration between a variety of organizations (Saidel et al. 2008). In this way, all organizations can pool th eir limited resources to better serve the public. However, that in itself brings about a host of problems. Additionally, geographic limitations are imposed upon the organizations, pa rticularly in the northern states where the mountainous region makes it very difficult to access area for educational, research, or surveillance purposes. It is evident India has many barriers to overcome in order to better understand and contain its HIV/AIDS problem. By learning fr om the success of certain aspects of the public health system in place in the United Stat es, India can definitely make strides. In such a short time, it has been able to establis h the framework for what can eventually be a fairly comprehensive health system. The bi ggest barrier to Indi a providing adequate services for its population is its lack of funding. India, how ever, has devoted a greater portion of its GDP to healthcare spending than ever before. Referring back to the public health pyramid mentioned in Ch apter 1, India’s public health system seems to be lacking its base. Plenty of funding has been applied to the top half of the pyramid for HIV/AIDS. Given the appalling state of ma lnutrition and primary care in certain parts of India, the extra funding for the bottom half is much needed. Thanks to the funding the Indian governmen t receives from outside sources, the needs of HIV/AIDS population are either being met or meas ured. In other words, their needs have been recognized and it is likely some international non-government

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85 organization will soon address them. Though I ndia was expected to host a booming HIVinfected population, its social conservativeness may have he lped to hold the prevalence rate of HIV in check. Combining directed f unds with India’s built -in resistance to HIV means that India truly has a chance to br ing down the incidence of the disease. Unfortunately, recent trends show possible in creases in HIV prevalence in states that used to have low AIDS incidence (Pandey et al. 2009). Quick and targeted work is essential to ensuring the epidem ic does not grow beyond control. There is obviously much the Indian government can do to improve and many of the problems it faces are unique to India. So me of these problems (lack of resources, severe strain on primary health care services general lack of e ducation, and socially accepted gender inequality) are shared with Af rican nations where HIV/AIDS is also a problem. Perhaps by blending solutions from the United States and Africa, India can create a public health response to HIV/AIDS that will truly make a difference. Either way, improvements in data collection met hods, an increased focus on prevention and education, and improvements in primary health care services all indicate India is moving in the right direction.

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