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The development of the health and human rights framework coincided with the beginning of the rapid spread of HIV/AIDS. Since then, the international community has increasingly turned to human rights language and instruments to address the disease. Not only are human rights essential to addressing a disease that impacts marginalized groups most severely, but the spread of HIV/AIDS itself exacerbates inequality and impedes the realization of a range of human rights. Policy developments of the past decade include the United Nations (UN) Committee on Economic, Social and Cultural Rights’ General Comment on the ‘Right to Health’, the UN Declaration of Commitment on HIV/AIDS, and the UN’s International Guidelines on HIV/AIDS and Human Rights, among others. Rights-related setbacks include the failure of the Declaration and its 5-year follow-up specifically to address men who have sex with men, sex workers, and intravenous drug users, political restrictions placed on urgently needed US President’s Emergency Plan for AIDS Relief (PEPFAR) funds, and the failure of many countries to decriminalize same-sex sex and outlaw discrimination against people living with HIV/AIDS. Male circumcision as an HIV prevention measure is a topic around which important debate, touching on gender, informed consent and children’s rights, serves to illustrate the ongoing vitality of the health and human rights dialogue. Mechanisms to increase state accountability for addressing HIV/AIDS should be explored in greater depth. Such measures might include an increase in the use of treaty-based judicial mechanisms, the linking of human rights compliance with preferential trade agreements, and rights requirements tied to HIV/ AIDS funding.

Across the African continent, women’s rights have become integral to international declarations, regional treaties, national legislation, and grassroots activism. Yet there is little research on how African men have understood these shifts, and how African masculinities are implicated in such changes. Drawing on a year of ethnographic research in the Ugandan capital Kampala, this article investigates how ordinary men and women in Uganda understand women’s rights, and how their attitudes are tied to local conceptions of masculinity. I argue that a new configuration of gender relations is evident in urban Uganda—one that accommodates some aspects of women’s rights while retaining previous notions of innate male authority. This article, therefore, illustrates the complex and often contradictory engagements with human rights that occur in local contexts, and how such engagements are shaped by gender relations, including conceptions of masculinity.

Backgound

The concept of Human Rights has become the modern civilising standard to which all should aspire and indeed attain.

Discussion

In an era characterised by widening disparities in health and human rights across the world and spectacular advances in biotechnology it is necessary to reflect on the extent to which human rights considerations are selectively applied for the benefit of the most privileged people. Attention is drawn particularly to sub-Saharan Africa as a marginalised region at risk of further marginalisation if the power associated with the new biotechnology is not used more wisely than power has been used in the past. To rectify such deficiencies it is proposed that the moral agenda should be broadened and at the very least the concept of rights should be more closely integrated with duties

Summary

New forms of power being unleashed by biotechnology will have to be harnessed and used with greater wisdom than power has been used in the past. Widening disparities in the world are unlikely to be diminished merely by appealing to human rights. We recommend that a deeper understanding is required of the underlying causes of such disparities and that the moral discourse should be extended beyond human rights language.

Each year on the 25th April Africa and the rest of the world commemorate Africa Malaria Day as was agreed upon at the African Summit on Roll Back Malaria held in Abuja, Nigeria on 25th April 2000. The summit also called upon the United Nations to declare the period 2001–2010 a decade for malaria. The 1st Africa Malaria Day was commemorated with the theme "Communities Play a Central Role in Tackling Malaria". The 6th Africa Malaria Day was observed in 2006 with the theme "Get Your ACT Together" and the slogan "Universal Access to Effective Malaria Treatment is a Human Right". This article by the Secretariat of the Multilateral Initiative on Malaria (MIM) was also part of the commemorations for the day. MIM was founded in 1997 as an alliance of institutions and individuals concerned with the malaria problem, and aiming at maximizing the impact of scientific research on malaria through strengthening African research capacity and coordinated global collaboration. The MIM Secretariat has been hosted in rotation by the founding institutions, and is being hosted for the first time in Africa by the African Malaria Network Trust (AMANET) in Dar es Salaam, Tanzania. This article reviews the malaria situation in Africa six years after the Abuja Declaration, highlighting the disease burden trends, failures, achievements, challenges, and the way forward.

Background

Indigenous fermented food products play an essential role in the diet of millions of Africans. Lactic acid bacteria (LAB) are among the predominant microbial species in African indigenous fermented food products and are used for different applications in the food and biotechnology industries. Numerous studies have described antimicrobial susceptibility profiles of LAB from different parts of the world. However, there is limited information on antimicrobial resistance profiles of LAB from Africa. The aim of this study was to characterize 33 LAB previously isolated from three different African indigenous fermented food products using (GTG)5-based rep-PCR, sequencing of the 16S rRNA gene and species-specific PCR techniques for differentiation of closely related species and further evaluate their antibiotic resistance profiles by the broth microdilution method and their haemolytic activity on sheep blood agar plates as indicators of safety traits among these bacteria.

Results

Using molecular biology based methods and selected phenotypic tests such as catalase reaction, CO2 production from glucose, colonies and cells morphology, the isolates were identified as Lactobacillus delbrueckii, Lactobacillus fermentum, Lactobacillus ghanensis, Lactobacillus plantarum, Lactobacillus salivarius, Leuconostoc pseudomesenteroides, Pediococcus acidilactici, Pediococcus pentosaceus and Weissella confusa. The bacteria were susceptible to ampicillin, chloramphenicol, clindamycin and erythromycin but resistant to vancomycin, kanamycin and streptomycin. Variable sensitivity profiles to tetracycline and gentamicin was observed among the isolates with Lb. plantarum, Lb. salivarius, W. confusa (except strain SK9-5) and Lb. fermentum strains being susceptible to tetracycline whereas Pediococcus strains and Lb. ghanensis strains were resistant. For gentamicin, Leuc. pseudomesenteroides, Lb. ghanensis and Ped. acidilactici strains were resistant to 64 mg/L whereas some W. confusa and Lb. plantarum strains had a MIC value of 16 mg/L and 32 mg/L respectively. No β-haemolytic activity was observed, however, α-haemolytic activity was observed in 27% (9) of the strains comprising Lb. salivarius (6), W. confusa (2) and Lb. delbrueckii (1) isolates.

Conclusions

The resistance to kanamycin and vancomycin is probably an intrinsic feature since similar observations were reported in the literature for LAB. Low prevalence of pathogenicity indicator traits were observed among the isolates especially with the presence of poor haemolytic activities and they could therefore be considered as interesting candidates for selection of starter cultures or probiotics for different applications.

This study addresses the quest for rural-based health care services among women in urban Nigeria relying on a large qualitative database obtained from 63 Igbo women living in Aba, Nigeria. Results indicate that urban Igbo women of different socioeconomic and demographic characteristics utilize the services of different rural-based health care providers—indigenous healers, traditional birth attendants (TBAs), faith/spiritual, western-trained doctors and nurses as well as chemist shopkeepers—for conditions ranging from infertility, through child birthing and abortions, to swollen body, epilepsy, bone setting, and stubborn skin diseases. Major attractions to rural-based therapists were the failure of urban-based health services to provide cure, perceived mystical nature of conditions, need to conceal information on therapeutic progress and/or the nature of specific disease conditions, belief in rural-based therapists’ ability to cure condition, and affordability of the services of rural-based health care providers. Findings underscore the critical implications of service characteristics, cultural beliefs, and the symbolic content of place(s) for care seekers’ patterns of resort. We suggest that need exists for policies and programs aimed at making health care services in urban Nigeria more responsive to care seekers’ socioeconomic and cultural sensitivities, integrating informal health care providers into Nigeria’s health care system, and strengthening public health education in Nigeria.

Community stress associated with poverty is related to health risks and poor health outcomes. Perceived community stress is specifically related to HIV transmission risk behaviors in the United States, but research bas not examined these relationships in southern Africa, the region of the world with the highest rates of HIV infection and among the greatest poverty. Men (N=464) and women (N=531) living in impoverished adjacent communities distinguished by race (e.g., indigenous African and Coloured) completed anonymous surveys of perceptions of 10 poverty-related community stressors and measures of HIV risk-related behaviors. Indigenous African and Coloured communities differed in their perceptions of stressors, with Africans consistently viewing the 10 community stressors as more serious problems. In addition, perceived seriousness of lacking basic living resources was related to higher risk for HIV among Africans. Perceived community stress was also related to alcohol and drug use, but substance use did not mediate the association between perceived community stress and HIV risks. In the Coloured community, perceived community stressors were related to drug use, but percived community stressors were not associated with HIV risks. These findings extend the findings of previous research to show that povertyrelated stressors are associated with HIV transmission risks in some poverty-stricken communities and that these associations are not mediated by substance use.

Changes in sea ice, snow cover, lake and river ice, and permafrost will affect economy, infrastructure, health, and indigenous and non-indigenous livelihoods, culture, and identity. Local residents are resilient and highly adaptive, but the rate and magnitude of change challenges the current adaptive capacity. Cryospheric changes create both challenges and opportunities, and occur along local, regional, and international dimensions. Such changes will provide better access to the Arctic and its resources thereby increasing human activities such as shipping and tourism. Cryospheric changes pose a number of challenges for international governance, human rights, safety, and search and rescue efforts. In addition to the direct effects of a changing cryosphere, human society is affected by indirect factors, including industrial developments, globalization, and societal changes, which contribute to shaping vulnerability and adaptation options. Combined with non-cryospheric drivers of change, this will result in multifaceted and cascading effects within and beyond the Arctic.

Electronic supplementary material

The online version of this article (doi:10.1007/s13280-011-0219-4) contains supplementary material, which is available to authorized users.

Background

The continued poor sexual and reproductive health (SRH) outcomes in sub-Saharan Africa highlight the difficulties in reforming policies and laws, and implementing effective programmes. This paper uses one international and two national case studies to reflect on the challenges, dilemmas and strategies used in operationalising sexual and reproductive health and rights (SRHR) in different African contexts.

Methods

The international case study focuses on the progress made by African countries in implementing the African Union’s Maputo Plan of Action (for the Operationalisation of the Continental Policy Framework for Sexual and Reproductive Health and Rights) and the experiences of state and non-state stakeholders in this process. The case was developed from an evaluation report of the progress made by nine African countries in implementing the Plan of Action, qualitative interviews exploring stakeholders’ experiences and perceptions of the operationalisation of the plan (carried out as part of the evaluation) in Botswana and Nigeria, and authors’ reflections. The first national case study explores the processes involved in influencing Ghana’s Domestic Violence Act passed in 2007; developed from a review of scientific papers and organisational publications on the processes involved in influencing the Act, qualitative interview data and authors’ reflections. The second national case study examines the experiences with introducing the 2006 Sexual Offences Act in Kenya, and it is developed from organisational publications on the processes of enacting the Act and a review of media reports on the debates and passing of the Act.

Results

Based on the three cases, we argue that prohibitive laws and governments’ reluctance to institute and implement comprehensive rights approaches to SRH, lack of political leadership and commitment to funding SRHR policies and programmes, and dominant negative cultural framing of women’s issues present the major obstacles to operationalising SRH rights. Analysis of successes points to the strategies for tackling these challenges, which include forming and working through strategic coalitions, employing strategic framing of SRHR issues to counter opposition and gain support, collaborating with government, and employing strategic opportunism.

Conclusion

The strategies identified show future pathways through which challenges to the realisation of SRHR in Africa can be tackled.

The ancient cultural tradition in the middle belt region of northern Ghana, with its stone circle and house mounds, contains varied material culture. The unique contextual arrangements of the material culture within the stone circle mounds and the diverse ceramic art forms, as well as their ethnographic analogues in West Africa, indicate the mounds’ association with past shrines that have multiple functions, including curative purposes. The archaeology of the mounds and ethnographic associations related to past indigenous medical practices is reviewed and discussed. This paper will also consider how some of the figurines through which the Koma tradition has achieved ‘fame’ possibly functioned as physical representations of disease, perhaps underpinned by intentions of transference from afflicted to image. The notions of protection and healing are also examined with reference to the resorted and disarticulated human remains sometimes recovered from the sites.

We studied the diversity of bacteria and host in the H. pylori-human model. The human indigenous bacterium H. pylori diverged along with humans, into African, European, Asian and Amerindian groups. Of these, Amerindians have the least genetic diversity. Since niche diversity widens the sets of resources for colonizing species, we predicted that the Amerindian H. pylori strains would be the least diverse. We analyzed the multilocus sequence (7 housekeeping genes) of 131 strains: 19 cultured from Africans, 36 from Spanish, 11 from Koreans, 43 from Amerindians and 22 from South American Mestizos. We found that all strains that had been cultured from Africans were African strains (hpAfrica1), all from Spanish were European (hpEurope) and all from Koreans were hspEAsia but that Amerindians and Mestizos carried mixed strains: hspAmerind and hpEurope strains had been cultured from Amerindians and hpEurope and hpAfrica1 were cultured from Mestizos. The least genetically diverse H. pylori strains were hspAmerind. Strains hpEurope were the most diverse and showed remarkable multilocus sequence mosaicism (indicating recombination). The lower genetic structure in hpEurope strains is consistent with colonization of a diversity of hosts. If diversity is important for the success of H. pylori, then the low diversity of Amerindian strains might be linked to their apparent tendency to disappear. This suggests that Amerindian strains may lack the needed diversity to survive the diversity brought by non-Amerindian hosts.

Background

This paper broadly discusses the role of the State of Bangladesh in the context of the health system and human rights. The interrelation between human rights, health and development are well documented. The recognition of health as a fundamental right by WHO and subsequent approval of health as an instrument of welfare by the Universal Declaration of Human Rights (UDHR) and the International Covenant on Social, Economic and Cultural Rights (ICSECR) further enhances the idea. Moreover, human rights are also recognized as an expedient of human development. The state is entrusted to realize the rights enunciated in the ICSECR.

Discussion

In exploring the relationship of the human rights and health situation in Bangladesh, it is argued, in this paper, that the constitution and major policy documents of the Bangladesh government have recognized the health rights and development. Bangladesh has ratified most of the international treaties and covenants including ICCPR, ICESCR; and a signatory of international declarations including Alma-Ata, ICPD, Beijing declarations, and Millennium Development Goals. However the implementation of government policies and plans in the development of health institutions, human resources, accessibility and availability, resource distribution, rural-urban disparity, the male-female gap has put the health system in a dismal state. Neither the right to health nor the right to development has been established in the development of health system or in providing health care.

Summary

The development and service pattern of the health system have negative correlation with human rights and contributed to the underdevelopment of Bangladesh. The government should take comprehensive approach in prioritizing the health rights of the citizens and progressive realization of these rights.

The presence of Africans in Britain has been recorded since Roman times, but has left no apparent genetic trace among modern inhabitants. Y chromosomes belonging to the deepest-rooting clade of the Y phylogeny, haplogroup A, are regarded as African-specific, and no examples have been reported from Britain or elsewhere in western Europe. We describe the presence of a haplogroup A1 chromosome in an indigenous British male; comparison with African examples suggests a western African origin. Seven out of eighteen men carrying the same rare east-Yorkshire surname as the original male also carry haplogroup A1 chromosomes, and documentary research resolves them into two genealogies with most-recent-common-ancestors living in Yorkshire in the late eighteenth century. Analysis using 77 Y-STRs (short tandem repeats) is consistent with coalescence a few generations earlier. Our findings represent the first genetic evidence of Africans among ‘indigenous’ British, and emphasise the complexity of human migration history, as well as the pitfalls of assigning geographical origin from Y-chromosomal haplotypes.

The realities of doing field research with high-risk, minority, or indigenous populations may be quite different than the guidelines presented in research training. There are overlapping and competing demands created by cultural and research imperatives. A National Institute on Drug Abuse (NIDA)-funded study of American Indian youth illustrates competing pressures between research objectives and cultural sensitivity. This account of the problems that were confronted and the attempts made to resolve them will hopefully fill a needed gap in the research literature and serve as a throught-provoking example for other researchers. This study built cross-cultural bridges. Researchers worked as a team with stakeholders to modify the instruments and methods to achieve cultural appropriateness. The researchers agreed to the communities demands for increased service access and rights of refusal for all publications and presentations. Data indicate that these compromises did not substantially harm the first year of data collection completeness or the well-being of the youth. To the contrary, it enhanced the ability to disseminate results to those community leaders with the most vested interests. The conflicts between ideal research requirements and cultural demands confronted by the researchers and interviewers in the American Indian community were not necessarily different from issues faced by researchers in other communities. Of major import is the recognition that there are no easy answers to such issues within research.

Background

Systematic evidence on the patterns of health deprivation among indigenous peoples remains scant in developing countries. We investigate the inequalities in mortality and substance use between indigenous and non-indigenous, and within indigenous, groups in India, with an aim to establishing the relative contribution of socioeconomic status in generating health inequalities.

Methods and Findings

Cross-sectional population-based data were obtained from the 1998–1999 Indian National Family Health Survey. Mortality, smoking, chewing tobacco use, and alcohol use were four separate binary outcomes in our analysis. Indigenous status in the context of India was operationalized through the Indian government category of scheduled tribes, or Adivasis, which refers to people living in tribal communities characterized by distinctive social, cultural, historical, and geographical circumstances.

Indigenous groups experience excess mortality compared to non-indigenous groups, even after adjusting for economic standard of living (odds ratio 1.22; 95% confidence interval 1.13–1.30). They are also more likely to smoke and (especially) drink alcohol, but the prevalence of chewing tobacco is not substantially different between indigenous and non-indigenous groups. There are substantial health variations within indigenous groups, such that indigenous peoples in the bottom quintile of the indigenous-peoples-specific standard of living index have an odds ratio for mortality of 1.61 (95% confidence interval 1.33–1.95) compared to indigenous peoples in the top fifth of the wealth distribution. Smoking, drinking alcohol, and chewing tobacco also show graded associations with socioeconomic status within indigenous groups.

Conclusions

Socioeconomic status differentials substantially account for the health inequalities between indigenous and non-indigenous groups in India. However, a strong socioeconomic gradient in health is also evident within indigenous populations, reiterating the overall importance of socioeconomic status for reducing population-level health disparities, regardless of indigeneity.

Indigenous groups in India were found to have excess mortality rates compared with non-indigenous groups. A socioeconomic gradient within indigenous populations was also found.

Editors' Summary

Background.

In many parts of the world the majority of the population are the descendants of immigrants who arrived there within the last few hundred years. Living alongside of them, and in a minority, are the so-called indigenous (or aboriginal) people who are the descendants of people who lived there in more ancient times. It is estimated that there are 300 million indigenous people worldwide. They are frequently marginalized from the rest of the population, their human rights are often abused, and there are serious concerns about their health and welfare. The state of health of the indigenous people of developed countries such as the US and Australia has often been studied, and we have a fairly clear idea of the kinds of problems these people face. Most indigenous people, however, live in developing countries, and less is known about their health.

India is the second-most populous country in the world, with an estimated 1.1 billion inhabitants. An estimated 90 million indigenous people live in India, where they are often referred to as “scheduled tribes” or Adivasis. They live in many parts of the country but are much more numerous in some Indian states than in others.

Why Was This Study Done?

It has often been said that indigenous people in India have worse health than other Indians, though no figures have been compiled to confirm these claims. The researchers wanted to establish whether it is simply an issue of indigenous people being poorer than other Indians—poverty being well known as a cause of disease—or whether being indigenous is, in itself, a health risk. The researchers also wanted to establish whether there are health inequalities within indigenous groups, and if these differences also followed a socioeconomic patterning.

What Did the Researchers Do and Find?

They used figures collected in the 1998–1999 Indian National Family Health Survey. When this survey was conducted, it was noted whether people were considered to be members of scheduled tribes. The researchers also knew, from the survey, about the income of the families, their death rates, and whether they drank alcohol or smoked or chewed tobacco. They found that indigenous people had higher death rates than other Indians. They made statistical calculations to account for differences in standard of living, and this substantially reduced the difference in death rate among indigenous groups, but an indigenous person was still 1.2 times more likely to die than a non-indigenous person with the same standard of living. Indigenous people were also more likely to drink alcohol and smoke tobacco, and here again, differences in standard of living accounted for a substantial portion of the differences. Importantly, the researchers' analysis showed a strong socioeconomic patterning of health inequalities within the indigenous population groups: the health differences between the poorest and richest indigenous groups were similar in scale to the differences between the poorest and richest non-indigenous groups.

What Do These Findings Mean?

The authors consider their finding that there is a socioeconomic gradient in mortality and health behaviors among indigenous people to be an important result from the study. The socioeconomic marginalization of indigenous people from the rest of Indian society does seem to increase their health risks, and so does their use of alcohol and tobacco. However, if their standard of living can be improved there would be major benefits for their health and welfare.

Additional Information.

Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030421.

A useful discussion of the term “indigenous people” (with links to documents about international agreements intended to improve their human rights) may be found on Wikipedia. (Wikipedia is an internet encyclopedia that anyone can edit.)

Survival International is a human rights organization that campaigns for the rights of indigenous peoples, helping them preserve their land and culture.

The charity Health Unlimited also works with indigenous people and its Web site includes links to recent studies and conferences.

A news item from the BBC describes a recent investigation into the health of indigenous people worldwide.

The World Health Organization has produced a number of reports on the health of indigenous people

Africa is the source of all modern humans, but characterization of genetic variation and of relationships among populations across the continent has been enigmatic. We studied 121 African populations, four African American populations, and 60 non-African populations for patterns of variation at 1327 nuclear microsatellite and insertion/deletion markers. We identified 14 ancestral population clusters in Africa that correlate with self-described ethnicity and shared cultural and/or linguistic properties. We observed high levels of mixed ancestry in most populations, reflecting historical migration events across the continent. Our data also provide evidence for shared ancestry among geographically diverse hunter-gatherer populations (Khoesan speakers and Pygmies). The ancestry of African Americans is predominantly from Niger-Kordofanian (~71%), European (~13%), and other African (~8%) populations, although admixture levels varied considerably among individuals. This study helps tease apart the complex evolutionary history of Africans and African Americans, aiding both anthropological and genetic epidemiologic studies.

Africa is the birthplace of modern humans, and is the source of the geographic expansion of ancestral populations into other regions of the world. Indigenous Africans are characterized by high levels of genetic diversity within and between populations. The pattern of genetic variation in these populations has been shaped by demographic events occurring over the last 200,000 years. The dramatic variation in climate, diet, and exposure to infectious disease across the continent has also resulted in novel genetic and phenotypic adaptations in extant Africans. This review summarizes some recent advances in our understanding of the demographic history and selective pressures that have influenced levels and patterns of diversity in African populations.

Background

Africa contains the most genetically divergent group of continental populations and several studies have reported that African populations show a high degree of population stratification. In this regard, it is important to investigate the potential for population genetic structure or stratification in genetic epidemiology studies involving multiple African populations. The presences of genetic sub-structure, if not properly accounted for, have been reported to lead to spurious association between a putative risk allele and a disease. Within the context of the Africa America Diabetes Mellitus (AADM) Study (a genetic epidemiologic study of type 2 diabetes mellitus in West Africa), we have investigated population structure or stratification in four ethnic groups in two countries (Akan and Gaa-Adangbe from Ghana, Yoruba and Igbo from Nigeria) using data from 372 autosomal microsatellite loci typed in 493 unrelated persons (986 chromosomes).

Results

There was no significant population genetic structure in the overall sample. The smallest probability is associated with an inferred cluster of 1 and little of the posterior probability is associated with a higher number of inferred clusters. The distribution of members of the sample to inferred clusters is consistent with this finding; roughly the same proportion of individuals from each group is assigned to each cluster with little variation between the ethnic groups. Analysis of molecular variance (AMOVA) showed that the between-population component of genetic variance is less than 0.1% in contrast to 99.91% for the within population component. Pair-wise genetic distances between the four ethnic groups were also very similar. Nonetheless, the small between-population genetic variance was sufficient to distinguish the two Ghanaian groups from the two Nigerian groups.

Conclusion

There was little evidence for significant population substructure in the four major West African ethnic groups represented in the AADM study sample. Ethnicity apparently did not introduce differential allele frequencies that may affect analysis and interpretation of linkage and association studies. These findings, although not entirely surprising given the geographical proximity of these groups, provide important insights into the genetic relationships between the ethnic groups studied and confirm previous results that showed close genetic relationship between most studied West African groups.

Background: Among all racial and ethnic groups in the USA, African Americans bear the greatest burden from tobacco related disease. The tobacco industry has been highly influential in the African American community for decades, providing funding and other resources to community leaders and emphasising publicly its support for civil rights causes and groups, while ignoring the negative health effects of its products on those it claims to support. However, the industry's private business reasons for providing such support were unknown.

Objective: To understand how and for what purposes the tobacco industry sought to establish and maintain relationships with African American leaders.

Methods: Review and analysis of over 700 previously secret internal tobacco industry documents available on the internet.

Results: The tobacco industry established relationships with virtually every African American leadership organisation and built longstanding social connections with the community, for three specific business reasons: to increase African American tobacco use, to use African Americans as a frontline force to defend industry policy positions, and to defuse tobacco control efforts.

Conclusion: As the tobacco industry expands its global reach, public health advocates should anticipate similar industry efforts to exploit the vulnerabilities of marginalised groups. The apparent generosity, inclusion, and friendship proffered by the industry extract a price from groups in the health of their members. Helping groups anticipate such efforts, confront industry co-optation, and understand the hidden costs of accepting tobacco industry largesse should be part of worldwide tobacco control efforts.

Background

Street-based heroin injectors represent an especially vulnerable population group subject to negative health outcomes and social stigma. Effective clinical treatment and public health intervention for this population requires an understanding of their cultural environment and experiences. Social science theory and methods offer tools to understand the reasons for economic and ethnic disparities that cause individual suffering and stress at the institutional level.

Methods and Findings

We used a cross-methodological approach that incorporated quantitative, clinical, and ethnographic data collected by two contemporaneous long-term San Francisco studies, one epidemiological and one ethnographic, to explore the impact of ethnicity on street-based heroin-injecting men 45 years of age or older who were self-identified as either African American or white. We triangulated our ethnographic findings by statistically examining 14 relevant epidemiological variables stratified by median age and ethnicity. We observed significant differences in social practices between self-identified African Americans and whites in our ethnographic social network sample with respect to patterns of (1) drug consumption; (2) income generation; (3) social and institutional relationships; and (4) personal health and hygiene. African Americans and whites tended to experience different structural relationships to their shared condition of addiction and poverty. Specifically, this generation of San Francisco injectors grew up as the children of poor rural to urban immigrants in an era (the late 1960s through 1970s) when industrial jobs disappeared and heroin became fashionable. This was also when violent segregated inner city youth gangs proliferated and the federal government initiated its “War on Drugs.” African Americans had earlier and more negative contact with law enforcement but maintained long-term ties with their extended families. Most of the whites were expelled from their families when they began engaging in drug-related crime. These historical-structural conditions generated distinct presentations of self. Whites styled themselves as outcasts, defeated by addiction. They professed to be injecting heroin to stave off “dopesickness” rather than to seek pleasure. African Americans, in contrast, cast their physical addiction as an oppositional pursuit of autonomy and pleasure. They considered themselves to be professional outlaws and rejected any appearance of abjection. Many, but not all, of these ethnographic findings were corroborated by our epidemiological data, highlighting the variability of behaviors within ethnic categories.

Conclusions

Bringing quantitative and qualitative methodologies and perspectives into a collaborative dialog among cross-disciplinary researchers highlights the fact that clinical practice must go beyond simple racial or cultural categories. A clinical social science approach provides insights into how sociocultural processes are mediated by historically rooted and institutionally enforced power relations. Recognizing the logical underpinnings of ethnically specific behavioral patterns of street-based injectors is the foundation for cultural competence and for successful clinical relationships. It reduces the risk of suboptimal medical care for an exceptionally vulnerable and challenging patient population. Social science approaches can also help explain larger-scale patterns of health disparities; inform new approaches to structural and institutional-level public health initiatives; and enable clinicians to take more leadership in changing public policies that have negative health consequences.

Bourgois and colleagues found that the African American and white men in their study had a different pattern of drug use and risk behaviors, adopted different strategies for survival, and had different personal histories.

Editors' Summary

Background.

There are stark differences in the health of different ethnic groups in America. For example, the life expectancy for white men is 75.4 years, but it is only 69.2 years for African-American men. The reasons behind these disparities are unclear, though there are several possible explanations. Perhaps, for example, different ethnic groups are treated differently by health professionals (with some groups receiving poorer quality health care). Or maybe the health disparities are due to differences across ethnic groups in income level (we know that richer people are healthier). These disparities are likely to persist unless we gain a better understanding of how they arise.

Why Was This Study Done?

The researchers wanted to study the health of a very vulnerable community of people: heroin users living on the streets in the San Francisco Bay Area. The health status of this community is extremely poor, and its members are highly stigmatized—including by health professionals themselves. The researchers wanted to know whether African American men and white men who live on the streets have a different pattern of drug use, whether they adopt varying strategies for survival, and whether they have different personal histories. Knowledge of such differences would help the health community to provide more tailored and culturally appropriate interventions. Physicians, nurses, and social workers often treat street-based drug users, especially in emergency rooms and free clinics. These health professionals regularly report that their interactions with street-based drug users are frustrating and confrontational. The researchers hoped that their study would help these professionals to have a better understanding of the cultural backgrounds and motivations of their drug-using patients.

What Did the Researchers Do and Find?

Over the course of six years, the researchers directly observed about 70 men living on the streets who injected heroin as they went about their usual lives (this type of research is called “participant observation”). The researchers specifically looked to see whether there were differences between the white and African American men. All the men gave their consent to be studied in this way and to be photographed. The researchers also studied a database of interviews with almost 7,000 injection drug users conducted over five years, drawing out the data on differences between white and African men. The researchers found that the white men were more likely to supplement their heroin use with inexpensive fortified wine, while African American men were more likely to supplement heroin with crack. Most of the white men were expelled from their families when they began engaging in drug-related crime, and these men tended to consider themselves as destitute outcasts. African American men had earlier and more negative contact with law enforcement but maintained long-term ties with their extended families, and these men tended to consider themselves as professional outlaws. The white men persevered less in attempting to find a vein in which to inject heroin, and so were more likely to inject the drug directly under the skin—this meant that they were more likely to suffer from skin abscesses. The white men generated most of their income from panhandling (begging for money), while the African American men generated most of their income through petty crime and/or through offering services such as washing car windows at gas stations.

What Do These Findings Mean?

Among street-based heroin users, there are important differences between white men and African American men in the type of drugs used, the method of drug use, their social backgrounds, the way in which they identify themselves, and the health risks that they take. By understanding these differences, health professionals should be better placed to provide tailored and appropriate care when these men present to clinics and emergency rooms. As the researchers say, “understanding of different ethnic populations of drug injectors may reduce difficult clinical interactions and resultant physician frustration while improving patient access and adherence to care.” One limitation of this study is that the researchers studied one specific community in one particular area of the US—so we should not assume that their findings would apply to street-based heroin users elsewhere.

Additional Information.

Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030452.

The US Centers for Disease Control (CDC) has a web page on HIV prevention among injection drug users

The World Health Organization has collected documents on reducing the risk of HIV in injection drug users and on harm reduction approaches

The International Harm Reduction Association has information relevant to a global audience on reducing drug-related harm among individuals and communities

US-focused information on harm reduction is available via the websites of the Harm Reduction Coalition and the Chicago Recovery Alliance

Canada-focused information can be found at the Street Works Web site

The Harm Reduction Journal publishes open-access articles

The CDC has a web page on eliminating racial and ethnic health disparities

The Drug Policy Alliance has a web page on drug policy in the United States

Background

Individuals living with HIV/AIDS in sub-Saharan Africa generally take more than 90% of prescribed doses of antiretroviral therapy (ART). This number exceeds the levels of adherence observed in North America and dispels early scale-up concerns that adherence would be inadequate in settings of extreme poverty. This paper offers an explanation and theoretical model of ART adherence success based on the results of an ethnographic study in three sub-Saharan African countries.

Methods and Findings

Determinants of ART adherence for HIV-infected persons in sub-Saharan Africa were examined with ethnographic research methods. 414 in-person interviews were carried out with 252 persons taking ART, their treatment partners, and health care professionals at HIV treatment sites in Jos, Nigeria; Dar es Salaam, Tanzania; and Mbarara, Uganda. 136 field observations of clinic activities were also conducted. Data were examined using category construction and interpretive approaches to analysis. Findings indicate that individuals taking ART routinely overcome economic obstacles to ART adherence through a number of deliberate strategies aimed at prioritizing adherence: borrowing and “begging” transport funds, making “impossible choices” to allocate resources in favor of treatment, and “doing without.” Prioritization of adherence is accomplished through resources and help made available by treatment partners, other family members and friends, and health care providers. Helpers expect adherence and make their expectations known, creating a responsibility on the part of patients to adhere. Patients adhere to promote good will on the part of helpers, thereby ensuring help will be available when future needs arise.

Conclusion

Adherence success in sub-Saharan Africa can be explained as a means of fulfilling social responsibilities and thus preserving social capital in essential relationships.

Using ethnographic data from Nigeria, Tanzania, and Uganda, Norma Ware and colleagues examine why levels of adherence to HIV/AIDS drugs are so much higher in sub-Saharan Africa than in North America.

Editors' Summary

Background.

The acquired immunodeficiency syndrome (AIDS) epidemic has killed more than 25 million people since 1981, and about 30 million people (22 million in sub-Saharan Africa alone) are currently infected with the human immunodeficiency virus (HIV), which causes AIDS. HIV destroys immune system cells, leaving infected individuals susceptible to other infections. Early in the AIDS epidemic, most HIV-infected individuals died within ten years but in 1996, combination antiretroviral therapy (ART)—a mixture of powerful drugs—was developed. For HIV-infected people living in affluent, developed countries, HIV/AIDS became a chronic disease, but for the millions of infected people living in low- and middle-income countries, HIV/AIDS remained a death sentence—ART was simply too expensive. In 2003, this situation was declared a global health emergency. Today, through the concerted efforts of governments, international organizations, and funding bodies, nearly one-third of the people in developing and transitional countries who are in immediate need of life-saving ART receive free, reliable supplies of the drugs they need.

Why Was This Study Done?

For ART to work, it must be taken regularly. If drug doses are missed, the virus can rebound and resistance to ART is more likely to develop. In poor countries, even though free antiretroviral drugs are increasingly available, many obstacles to good adherence to ART remain. These include economic obstacles (for example, the cost of traveling to clinics and the loss of earning associated with clinic attendance), and social, cultural, and behavioral barriers. Some patients fear disclosure, for example. Others receive conflicting messages about the benefits of ART. However, despite worries that the scale-up of ART provision in developing countries would be dogged by inadequate adherence, people living with HIV/AIDS in sub-Saharan Africa generally take more than 90% of their prescribed doses of ART, a better level of adherence than in North America. In this study, the researchers investigate why ART adherence is so high in sub-Saharan Africa by analyzing qualitative data from an ethnographic study done in Nigeria, Tanzania, and Uganda. Qualitative data are often used to address “how” and “why” research questions: ethnography is a comprehensive qualitative approach to describing and explaining human behavior and culture.

What Did the Researchers Do and Find?

For their study, the researchers interviewed 158 patients, 45 treatment partners (lay-people who help HIV-positive people keep to their treatment), and 49 health care workers. Patients were asked about their experiences of ART and about the help they received from their treatment partners; partners were asked about the type of help they gave and about their feelings about this help; health care workers were asked to describe a typical clinic visit and to indicate how adherence was discussed. From these interviews and observations of clinic sessions, the researchers identified several strategies used by patients and their treatment partners to overcome economic obstacles to ART adherence. These included borrowing and “begging” funds to pay for travel to clinics and making “impossible choices” to prioritize adherence, and “doing without.” The researchers' analysis also indicates that the prioritization of adherence to ART reflects the importance of relationships as a resource for managing economic hardship. So, for example, they found that treatment partners and health care workers expected patients to adhere to ART (which, by improving patients' health, improves their ability to support themselves and their families) and made their expectations known, thereby creating a responsibility among patients to adhere. Patients, in turn, adhered to their treatment to promote good will from their helpers and thus ensure their continuing help.

What Do These Findings Mean?

The findings offer a possible explanation of adherence success in sub-Saharan Africa. The high level of adherence to ART can be explained as a means of fulfilling social responsibilities. Adherence, the researchers suggest, not only improves personal health (the main driver for ART adherence in resource-rich environments) but also preserves “social capital” in essential relationships. In other words, in sub-Saharan Africa, adherence to treatment may protect the relationships that individuals living in extreme poverty rely on to help them survive.

Additional Information.

Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000011.

This study is further discussed in a PLoS Medicine Perspective by Agnes Binagwaho and Niloo Ratnayake

Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS

HIV InSite has comprehensive information on all aspects of HIV/AIDS, including an article about to antiretroviral therapy

Information is available from Avert, an international AIDS charity, on HIV and AIDS in Africa (including detailed information on HIV/AIDS in Nigeria and Uganda) and on providing AIDS drug treatment for millions

The World Health Organization provides information about universal access to HIV treatment (in several languages)

The US Centers for Disease Control and Prevention also provides information on global efforts to deal with the HIV/AIDS pandemic

In 1929 the Julius Rosenwald Fund, in conjunction with the Public Health Service (PHS), sponsored a syphilis seroprevalence study in the South characterized as a humanitarian effort to benefit the health of rural African Americans. The study reported extraordinarily high rates of positive Wassermann tests, even among children. Despite the unreliability and nonspecificity of this test, modern authors continue to indict these subjects as syphilitic. However, there was no consistent relationship between syphilis and a positive Wassermann test. Additional treponemal pathogens that potentially caused false-positive tests could explain the results. After public outcry to the Tuskegee Syphilis Experiment, the Rosenwald study acquired new significance. It was used as evidence to bolster the argument that Tuskegee was a consequence of humanitarian motives that became captive to misguided methods of researchers at the Venereal Disease Division of the PHS. Humanitarianism implies the acknowledgement of a right invested in the recipient; health is an end in itself. However, African Americans were necessary as a source of cheap labor for competition in the world cotton markets and as a restraint on the market value of white labor in manufacturing. The administrative structure of the PHS, not zealous individuals, adopted utilitarianism as its paradigm for human research. Syphilis seroprevalence was a calculated use of public health as a means to economic development.

As a clinical entity, sickle cell anemia (SCA) is known to be relatively rarer in Africans than in the African-American population of the United States. Paradoxically, sickle cell trait (SCT), the non-anemic, heterozygous condition, is about three times more common among indigenous Africans than in African-Americans. The ratio of SCA to SCT is 1:50 for African-Americans, and less than 1:1,000 for tropical Africans. This etiological disparity is attributed to an anti-sickling agent, thiocyanate, (SCN-) found abundantly in staple African foods, such as the African yam (Dioscorea sp) and cassava (Manihot utilissima). Staple American foods have negligible SCN-concentrations. Nonstaple foods in the American diet, such as carrots, cabbage, and radishes, have SCN- levels far below the African yam and cassava. This finding explains the high incidence of SCA among African-Americans and its rarity in Africans.

The author concludes that SCA is a congenital deficiency anemia, ameliorable by prophylactic diets of foods with high SCN- contents. Thus, “thiocyanate deficiency anemia” is nutritionally a more correct clinical status for those born with the homozygous sickle hemoglobin genome. Just as any iron undernourished person can suffer from iron deficiency anemia, sickle hemoglobin homozygotes suffer from “thiocyanate deficiency anemia” when they subsist on SCN-deficient foods. This article reviews the role of dietary SCN- in SCA control.

Objectives:

Indigenous medicines are widely used throughout Africa, despite a lack of scientific evidence for their safety or efficacy. The aims of this study were: (a) to conduct a pilot study of the safety of a common indigenous South African phytotherapy, Lessertia frutescens (Sutherlandia), in healthy adults; and (b) to contribute to establishing procedures for ethical and scientifically rigorous clinical trials of African indigenous medicines.

Design:

A randomized, double-blind, placebo-controlled trial of Sutherlandia leaf powder in healthy adults.

Setting:

Tiervlei Trial Centre, Karl Bremer Hospital, Bellville, South Africa.

Participants:

25 adults who provided informed consent and had no known significant diseases or allergic conditions nor clinically abnormal laboratory blood profiles during screening.

Intervention:

12 participants randomized to a treatment arm consumed 400 mg capsules of Sutherlandia leaf powder twice daily (800 mg/d). 13 individuals randomized to the control arm consumed a placebo capsule. Each participant received 180 capsules for the trial duration of 3 mo.

Outcome Measures:

The primary endpoint was frequency of adverse events; secondary endpoints were changes in physical, vital, blood, and biomarker indices.

Results:

There were no significant differences in general adverse events or physical, vital, blood, and biomarker indices between the treatment and placebo groups (p > 0.05). However, participants consuming Sutherlandia reported improved appetite compared to those in the placebo group (p = 0.01). Although the treatment group exhibited a lower respiration rate (p < 0.04) and higher platelet count (p = 0.03), MCH (p = 0.01), MCHC (p = 0.02), total protein (p = 0.03), and albumin (p = 0.03), than the placebo group, these differences remained within the normal physiological range, and were not clinically relevant. The Sutherlandia biomarker canavanine was undetectable in participant plasma.

Conclusion:

Consumption of 800 mg/d Sutherlandia leaf powder capsules for 3 mo was tolerated by healthy adults.

Editorial Commentary

Background: In Africa, traditional herbal medicines are given for many illnesses. In particular, one herbal medicine, Sutherlandia (Lessertia frutescens) is commonly given in the belief that this herb will treat some of the symptoms associated with HIV/AIDS, such as nausea and lack of appetite, amongst others. However, there is very little evidence relating to the safety and none to the efficacy of this herb. Generally, when new drugs are developed, the first stage of human testing involves a Phase 1 trial. This type of trial would typically involve small numbers of healthy individuals, who would receive progressively increasing doses of the drug under study, and would be closely monitored for any sign of side effects. Phase 1 trials would typically also collect data from blood samples to find out how the drug is handled in the body and broken down and eliminated. Therefore, the researchers here carried out a preliminary study to assess just the safety of Sutherlandia. 25 healthy adults were randomized to receive either tablets containing a fixed dose of Sutherlandia leaf powder daily for three months, or matched placebo tablets containing lettuce leaf powder, for the same period of time. The main aim of the trial was to assess safety, so the primary outcomes were adverse events experienced by the participants. The researchers also measured standard outcomes such as blood pressure, heart rate, body weight, urine glucose, protein, and many others, at one-month intervals over the three-month period.

What the trial shows: Adverse events experienced by trial participants over the three months of this trial included those that might be expected in a group of otherwise healthy individuals, such as headaches, insomnia, allergies, malaise, palpitations, nosebleeds, and so on. The researchers did not see statistically significant differences between treatment and placebo groups in any of the major categories of these events. Most physical and laboratory measurements also showed no statistically significant differences between the study groups. However, there were statistically significant, but small, differences between groups in respiratory rate and in various basic blood tests. The researchers did not think these differences were clinically important. Overall, this trial suggested that Sutherlandia use was not associated with side effects at this dosage and over this time scale.

Strengths and limitations: Strengths of this study include the use of randomization to distribute individuals to either the Sutherlandia or control groups, and in the use of a placebo control group, which therefore allowed the researchers to compare the frequencies of adverse events in the Sutherlandia group with what might be expected among healthy individuals over the course of three months. An important limitation is the small sample size of the trial. This size limits the sensitivity of the trial to detect rare adverse events to the herb under study, and therefore one cannot say conclusively that the herb is safe, based on this data. Additionally, the study looked only at the participants' response to one dosage level of Sutherlandia. A strategy using progressively increasing doses would have allowed the researchers to see if there was a maximum tolerated dose to this herb. A further limitation in this study is the lack of data relating to how the herb is broken down in the body; these data are normally an important part of Phase 1 trials and, combined with safety data, are crucial to finding out whether a compound is safe when given at a dosage that allows it to be available to the appropriate tissues.

Contribution to the evidence: Data from previous studies in nonhuman primates have shown that Sutherlandia is not associated with toxic or other side effects at approximately equivalent or higher doses than that normally taken by people with HIV/AIDS. This study adds safety data relating to Sutherlandia consumption in healthy humans, which confirm the primate data. However, it is crucial to collect more data relating to how the probable active ingredients of Sutherlandia are absorbed and broken down, and to assess safety at different dosages, before studies are even considered for the next stage, which is to see whether Sutherlandia has any efficacy in people with HIV/AIDS.

What are human rights? In this article Enoch Powell, MP (a former Conservative Minister of Health), approaches this question through a critical discussion of Article 25 (I) of the United Nations Universal Declaration of Human Rights. Professor R S Downie in his accompanying commentary analyses Mr Powell's statements and takes up in particular Mr Powell's argument that claiming rights for one person entails compulsion on another person. In Professor Downie's view there is nothing in Article 25 (I) that cannot embody acceptable moral rights, the commonly accepted interpretation of that Article of the UN Universal Declaration of Human Rights which many people think is wholly acceptable.