On the Trail of Paediatric Liver Transplant in South Africa: Social Challenges to Equitable Distribution in Organ Transplantation

This paper tracks the journey of a family from a remote rural area in South Africa – a 2 year old child born with a life threatening liver disease, and his unemployed mother – who, by a series of contingencies, are sent on the trail of organ transplantation to land at the door of a private organ transplant centre. This case brings into focus the dilemmas that social factors present for equitable distribution of organ transplantation. The paper focuses on two interconnected issues: the link between socio-economic status and access to treatment, and existing practices of rationing. The uncritical conjunction of socio-economic status and organ transplantation disadvantages vulnerable sectors of the population. Yet, social circumstances impact the management of specialized medical treatment, which in itself imposes burdens on those with limited resources.  Similarly, although this paper poses questions about indiscriminate practices, it accepts the inevitable rationing of health care

War, gender and culture: Mozambican women refugees

Analyses of the psychological sequelae of war-related violence for women tend to rely on the concepts developed in research on male combatants. Post-traumatic stress disorder or varying combinations of its symptoms are identified as the principal outcomes of war-related events for women. By and large, the dominant literature does not examine possible outcomes which could be specified by gender. This paper refers to the war in Mozambique during the 1970s and 1980s as a typical illustration of how women are an integral part of the battlefield. It draws on research on African women and uses testimony of Mozambican women refugees who settled in South Africa to explore how gender is linked to psycho-social outcomes of massive social conflict. The paper argues that a richer understanding of the psycho-social outcomes of war and the needs of survivors is promoted by investigating gender in specific historical situations and how this frames the responses people have to experiences of violence and social destruction.Mozambique Women refugees Gender PTSD War South Africa

Violation and healing of the spirit : psycho-social responses to war of Mozambican women refugees

D.Litt et Phil.For over a decade, from the late 1970's to October 1992, a war raged in Mozambique that resulted in what has been described as, one of the "most terrible genocides in the history of Africa". Over 4 million people were displaced during this war. Conservative estimates put the number of Mozambicans who sought refuge in South Africa at 250 000. This study examines the trauma created by the war, and its psycho-social outcomes, from the perspective of women refugees who came to settle in villages in the Nkomazi region of Mpumalanga province, in South Africa. Posttraumatic stress disorder, the concept which dominates research in the field of trauma studies, was based on research with male war veterans in western industrial societies. Recently a body of work has emerged which questions the validity of applying posttraumatic stress disorder to contexts of massive social conflict, and its utility in cross cultural contexts. This body of work suggests that an understanding of extreme trauma and its outcomes requires careful consideration of the social and cultural dimensions of trauma. The inclusion of a cultural formulation in the latest edition of the Diagnostic and Statistical Manual for Mental Disorder, DSM-IV, reinforces a growing acknowledgement amongst mental health researchers of the influence of culture on mental health and disorder. The gaps in research on African women survivors of war and the lack of standardised assessment tools, makes this an exploratory study which uses qualitative research methods. Unstructured interviews were conducted with 30 Mozambican women refugees to explore their experiences and definitions of trauma, the psycho-social outcomes of the trauma, and coping and survival in the aftermath of the war. The magnitude of the trauma evident in the research findings called for a conceptual definition which reflects multiple risks and the interdependence of social and individual trauma. Thematic analysis and qualitative coding of the interview data revealed clinically well defined posttraumatic stress disorder symptoms and locally specific discourses of suffering framed by cultural beliefs, social practices and historical experiences. Their testimony and observations in the field, revealed that the survivors demonstrated a capacity to survive and reconstruct their lives. Their coping strategies and survival tactics were fundamentally shaped by socio-historical experiences and the limits and possibilities contained in the recovery environment. The results of this study suggest an approach to examining the complex relationship between trauma and its consequences, which abstracts neither trauma nor its victims from cultural and social-historical contexts

Cost-effectiveness of unselected multigene germline and somatic genetic testing for epithelial ovarian cancer

Background : Parallel panel germline and somatic genetic testing of all patients with ovarian cancer (OC) can identify more pathogenic variants (PVs) that would benefit from PARP inhibitor (PARPi) therapy, and allow for precision prevention in unaffected relatives with PVs. In this study, we estimate the cost-effectiveness and population impact of parallel panel germline and somatic BRCA testing of all patients with OC incorporating PARPi therapy in the United Kingdom and the United States compared with clinical criteria/family history (FH)–based germline BRCA testing. We also evaluate the cost-effectiveness of multigene panel germline testing alone. Methods: Microsimulation cost-effectiveness modeling using data from 2,391 (UK: n=1,483; US: n=908) unselected, population-based patients with OC was used to compare lifetime costs and effects of panel germline and somatic BRCA testing of all OC cases (with PARPi therapy) (strategy A) versus clinical criteria/FH-based germline BRCA testing (strategy B). Unaffected relatives with germline BRCA1/BRCA2/RAD51C/RAD51D/BRIP1 PVs identified through cascade testing underwent appropriate OC and breast cancer (BC) risk-reduction interventions. We also compared the cost-effectiveness of multigene panel germline testing alone (without PARPi therapy) versus strategy B. Unaffected relatives with PVs could undergo risk-reducing interventions. Lifetime horizon with payer/societal perspectives, along with probabilistic/one-way sensitivity analyses, are presented. Incremental cost-effectiveness ratio (ICER) and incremental cost per quality-adjusted life year (QALY) gained were compared with £30,000/QALY (UK) and $100,000/QALY (US) thresholds. OC incidence, BC incidence, and prevented deaths were estimated. Results: Compared with clinical criteria/FH-based BRCA testing, BRCA1/BRCA2/RAD51C/RAD51D/BRIP1 germline testing and BRCA1/BRCA2 somatic testing of all patients with OC incorporating PARPi therapy had a UK ICER of £51,175/QALY (payer perspective) and £50,202/QALY (societal perspective) and a US ICER of$175,232/QALY (payer perspective) and $174,667/QALY (societal perspective), above UK/NICE and US cost-effectiveness thresholds in the base case. However, strategy A becomes cost-effective if PARPi costs decrease by 45$68,808/QALY and societal-perspective ICERs of £6,923/QALY or $65,786/QALY. One year’s testing could prevent 209 UK BC/OC cases and 192 deaths, and 560 US BC/OC cases and 460 deaths. Conclusions: Unselected panel germline and somatic BRCA testing can become cost-effective, with a 45% to 46% reduction in PARPi costs. Regarding germline testing, unselected panel germline testing is highly cost-effective and should replace BRCA testing alone