'Bring us the female condom': HIV intervention, gender and political empowerment in two South African communities

The quotation which heads this paper encapsulates two important issues in AIDS research in South Africa: the one is substantive, the other methodological. The link between them is the rapid spread of HIV/AIDS in the country and the indication not only that women are more at risk of infection than men, but that, as in many other parts of the world, much of their vulnerability is gender based. ‘Bring us the female condom’ sums up the response of one particular group of black South African women to AIDS education. Their demand was a reflection of their relative domestic and gender empowerment - and also a high degree of political mobilization. However, their position is not necessarily shared by other black women. But the call for the female condom went further: it was a challenge to rethink our position as researchers and particularly to face the implications of commitment to a participatory model of community based intervention research

Teaching and assessing consultation skills: an evaluation of a South African workshop on using the Leicester Assessment Package

BackgroundThe consultation is at the very centre of clinical practice. It is in the meeting between doctor and patient that the story is told (and in good practice properly heeded) and decisions are made about the cause and treatment of the patient's problem. Following one year of supervised internship, South African doctors are required to do a year of community service and these doctors mostly work in understaffed peripheral hospitals. A substantial component of this work is unsupervised consultations with patients suffering from new or complex continuing diseases. On graduation, these doctors therefore require a high level of consultation competence. They must be able to make accurate diagnoses and manage patients' problems reliably and efficiently.The Leicester Assessment Package (LAP) was originally developed to assess the consultation competence of general practitioners in the UK. It was subsequently adapted for use in undergraduate teaching. In 2002, the LAP was presented at a medical education conference in South Africa. As a result, the Department of Family Medicine at Pretoria University began using the LAP in the teaching and formative assessment of the consultation skills of senior students in outpatient clinics. In 2003, the University of the Witwatersrand introduced a four-year graduate entry medical curriculum. The Centre for Health Care Education was interested in assessing whether the LAP would be suitable for the summative assessment of the consultation performance of students during their third and four years of the new curriculum.A workshop course was organised to train senior clinicians from the Universities of Pretoria and the Witwatersrand in the use of the LAP as a means of teaching and assessing the consultation performance of South African medical students.MethodTwenty-two experienced South African medical educators participated in a three-day workshop. Their attitudes to the LAP and the forms of teaching that its use promotes were analysed by responses to pre- and post-workshop questionnaires with Likert-scale and free-text questions.ResultsThe participants were positive about the LAP at the end of the workshop. They all believed that it was a useful instrument, and a majority would apply this method in their own departments. There were continuing reservations about the feasibility of the method and some respondents felt it would require some adaptation, particularly to the criteria for awarding grades.ConclusionsThe workshop participants learnt to use an instrument developed in the United Kingdom that encourages an analytical approach to the assessment and teaching of consultation skills. They believed it would be useful in the contexts in which they worked.For full text, click here:SA Fam Pract 2006;48(3):14-14

The identification of markers of macrophage differentiation in PMA-stimulated THP-1 Cells and monocyte-derived macrophages

Differentiated macrophages are the resident tissue phagocytes and sentinel cells of the innate immune response. The phenotype of mature tissue macrophages represents the composite of environmental and differentiation-dependent imprinting. Phorbol-12-myristate-13-acetate (PMA) and 1,25-dihydroxyvitamin D3 (VD3) are stimuli commonly used to induce macrophage differentiation in monocytic cell lines but the extent of differentiation in comparison to primary tissue macrophages is unclear. We have compared the phenotype of the promonocytic THP-1 cell line after various protocols of differentiation utilising VD3 and PMA in comparison to primary human monocytes or monocyte-derived macrophages (MDM). Both stimuli induced changes in cell morphology indicative of differentiation but neither showed differentiation comparable to MDM. In contrast, PMA treatment followed by 5 days resting in culture without PMA (PMAr) increased cytoplasmic to nuclear ratio, increased mitochondrial and lysosomal numbers and altered differentiation-dependent cell surface markers in a pattern similar to MDM. Moreover, PMAr cells showed relative resistance to apoptotic stimuli and maintained levels of the differentiation-dependent anti-apoptotic protein Mcl-1 similar to MDM. PMAr cells retained a high phagocytic capacity for latex beads, and expressed a cytokine profile that resembled MDM in response to TLR ligands, in particular with marked TLR2 responses. Moreover, both MDM and PMAr retained marked plasticity to stimulus-directed polarization. These findings suggest a modified PMA differentiation protocol can enhance macrophage differentiation of THP-1 cells and identify increased numbers of mitochondria and lysosomes, resistance to apoptosis and the potency of TLR2 responses as important discriminators of the level of macrophage differentiation for transformed cells

The 'causes' of teenage pregnancy: review of South African research - Part 2

This article forms the second of a two-part series in which South African research on teenage pregnancy is reviewed. Part 1 of the series dealt with the consequences of teenage pregnancy; this paper reviews the 'causes' thereof. International literature is incorporated in the discussion by way of comparison. Contributory factors which have been investigated by South African researchers include: reproductive ignorance; the earlier occurrence of menarche; risktaking behaviour; psychological problems; peer influence; co-ercive sexual relations; dysfunctional family patterns; poor health services; socio-economic status; the breakdown of cultural traditions; and the cultural value placed on children. Preston-Whyte and colleagues present a revisionist argument, stating that early pregnancy may represent a rational life choice for certain adolescent women. The article is concluded with comments on methodological problems encountered in the South African research, and a discussion on the implications in terms of policy formulation

The effects of high HIV prevalence on orphanhood and living arrangements of children in Malawi, Tanzania, and South Africa

Using longitudinal data from three demographic surveillance systems (DSS) and a retrospective cohort study, we estimate levels and trends in the prevalence and incidence of orphanhood in South Africa, Tanzania, and Malawi in the period 1988–2004. The prevalence of maternal, paternal, and double orphans rose in all three populations. In South Africa—where the HIV epidemic started later, has been very severe, and has not yet stabilized—the incidence of orphanhood among children is double that of the other populations. The living arrangements of children vary considerably between the populations, particularly in relation to fathers. Patterns of marriage, migration, and adult mortality influence the living and care arrangements of orphans and non-orphans. DSS data provide new insights into the impact of adult mortality on children, challenging several widely held assumptions. For example, we find no evidence that the prevalence of child-headed households is significant or has increased in the three study areas

Pseudomonas expression of an oxygen sensing prolyl hydroxylase homologue regulates neutrophil host responses in vitro and in vivo

Background: Pseudomonas species are adapted to evade innate immune responses and can persist at sites of relative tissue hypoxia, including the mucus-plugged airways of patients with cystic fibrosis and bronchiectasis. The ability of these bacteria to directly sense and respond to changes in local oxygen availability is in part consequent upon expression of the 2-oxoglutarate oxygenase, Pseudomonas prolyl hydroxylase (PPHD), which acts on elongation factor Tu (EF-Tu), and is homologous with the human hypoxia inducible factor (HIF) prolyl hydroxylases. We report that PPHD expression regulates the neutrophil response to acute pseudomonal infection. Methods: In vitro co-culture experiments were performed with human neutrophils and PPHD-deficient and wild-type bacteria and supernatants, with viable neutrophil counts determined by flow cytometry. In vivo consequences of infection with PPHD deficient P. aeruginosa were determined in an acute pneumonia mouse model following intra-tracheal challenge. Results: Supernatants of PPHD-deficient bacterial cultures contained higher concentrations of the phenazine exotoxin pyocyanin and induced greater acceleration of neutrophil apoptosis than wild-type PAO1 supernatants in vitro. In vivo infection with PPHD mutants compared to wild-type PAO1 controls resulted in increased levels of neutrophil apoptosis and impaired control of infection, with higher numbers of P. aeruginosa recovered from the lungs of mice infected with the PPHD-deficient strain. This resulted in an overall increase in mortality in mice infected with the PPHD-deficient strain. Conclusions: Our data show that Pseudomonas expression of its prolyl hydroxylase influences the outcome of host-pathogen interactions in vitro and in vivo, demonstrating the importance of considering how both host and pathogen adaptations to hypoxia together define outcomes of infection. Given that inhibitors for the HIF prolyl hydroxylases are in late stage trials for the treatment of anaemia and that the active sites of PPHD and human HIF prolyl hydroxylases are closely related, the results are of current clinical interest

Cost-effectiveness of screening for ovarian cancer amongst postmenopausal women: a model-based economic evaluation

Background The United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) was the biggest ovarian cancer screening trial to date. A non-significant effect of screening on ovarian cancer was reported, but the authors noted a potential delayed effect of screening, and suggested the need for four years further follow-up. There are no UK-based cost-effectiveness analyses of ovarian cancer screening. Hence we assessed the lifetime outcomes associated with, and the cost-effectiveness of, screening for ovarian cancer in the UK, along with the value of further research. Methods We performed a model-based economic evaluation. Effectiveness data were taken from UKCTOCS, which considered strategies of multimodal screening (MMS), ultrasound screening (USS) and no screening. We conducted systematic reviews to identify the remaining model inputs, and performed a rigorous and transparent prospective evaluation of different methods for extrapolating the effect of screening on ovarian cancer mortality. We considered costs to the UK healthcare system and measured effectiveness using quality-adjusted life years (QALYs). We used value of information methods to estimate the value of further research. Results Over a lifetime, MMS and USS were estimated to be both more expensive and more effective than no screening. USS was dominated by MMS, being both more expensive and less effective. Compared with no screening, MMS cost on average £419 more (95% confidence interval £255 to £578), and generated 0.047 more QALYs (0.002 to 0.088). The incremental cost-effectiveness ratio (ICER) comparing MMS with no screening was £8864 per QALY (£2600 to £51,576). Alternative extrapolation methods increased the ICER, with the highest value being £36,769 (£13,888 to dominated by no screening). Using the UKCTOCS trial horizon, both MMS and USS were dominated by no screening, as they produced fewer QALYs at a greater cost. The value of research into eliminating all uncertainty in long-term effectiveness was estimated to be worth up to £20 million, or approximately £5 million for four years follow-up. Conclusions Screening for ovarian cancer with MMS is both more effective and more expensive than not screening. Compared to national willingness to pay thresholds, lifetime cost-effectiveness is promising, but there remains considerable uncertainty regarding extrapolated long-term effectiveness

Rat cities and beehive worlds: density and design in the modern city

Nestled among E. M. Forster's careful studies of Edwardian social mores is a short story called "The Machine Stops." Set many years in the future, it is a work of science fiction that imagines all humanity housed in giant high-density cities buried deep below a lifeless surface. With each citizen cocooned in an identical private chamber, all interaction is mediated through the workings of "the Machine," a totalizing social system that controls every aspect of human life. Cultural variety has ceded to rigorous organization: everywhere is the same, everyone lives the same life. So hopelessly reliant is humanity upon the efficient operation of the Machine, that when the system begins to fail there is little the people can do, and so tightly ordered is the system that the failure spreads. At the story's conclusion, the collapse is total, and Forster's closing image offers a condemnation of the world they had built, and a hopeful glimpse of the world that might, in their absence, return: "The whole city was broken like a honeycomb. [⋯] For a moment they saw the nations of the dead, and, before they joined them, scraps of the untainted sky" (2001: 123). In physically breaking apart the city, there is an extent to which Forster is literalizing the device of the broken society, but it is also the case that the infrastructure of the Machine is so inseparable from its social structure that the failure of one causes the failure of the other. The city has-in the vocabulary of present-day engineers-"failed badly.