Changes of heart: Debating the role of cardiology and cardiac surgery in India, 1948-1968.

In 1950, the leaders of independent India celebrated the contributions that surgeons could make to modernising India. Surgeons, however, faced a difficult choice. Some wanted to invest in generalist surgeons to make basic surgical care available to all Indians. Others wanted to invest in specialists to ensure that India participated in cutting-edge surgical research and care. These debates shaped the emergence of cardiac surgery at two centres: the Christian Medical College in Vellore and the King Edward Memorial Hospital in Bombay. CMC invested in thoracic surgery in the 1940s to offer new treatments for tuberculosis. This gave surgeons the opportunity to explore new techniques of cardiac surgery. Debate quickly emerged about whether investments in cardiology and cardiac surgery made sense. In the end, the specialities were supported in order to attract paying patients. A parallel controversy took place at KEM, where the dean debated the Bombay Municipal Corporation about the role of surgical research at a public hospital. The Rockefeller Foundation influenced both sites, offering financial support if they adopted an American model of full-time faculty clinician-researchers. The two case studies reveal how unusual dynamics could contribute to the establishment of new medical specialities in India.

Roles for community health workers in diabetes prevention and management in low- and middle-income countries.

Diabetes prevalence is increasing worldwide, especially in low- and middle-income countries (LMIC), posing the need for improved detection and management strategies. Chronic disease models and lifestyle medicine provide structures for action. Community health workers (CHWs) can significantly contribute to chronic disease care if they are trained and integrated into low-resource health systems. Although most current CHWs worldwide are performing maternal/child health and infectious disease-related tasks, other programs involving CHWs for noncommunicable disease prevention and management are increasing. In this article, we discuss the advantages, challenges, and questions regarding possible roles assigned to CHWs in the prevention and management of diabetes. These roles include performing simple screening tests, implementing lifestyle/behavioral interventions, and connecting patients with alternatives to biomedicine. Specifically, CHWs can aid diabetes epidemiological surveillance by conducting risk score-based screening or capillary glucose testing, and they can facilitate diabetes self-management by delivering interventions described in the transcultural diabetes nutrition algorithm. Furthermore, while this role has not formally been assigned, CHWs can leverage their intimate knowledge of local practices to provide decision-making support to patients in environments with pluralistic health systems. Ethnocultural differences in CHW functions and transcultural adaptations of their roles in diabetes care should also be considered. In summary, CHWs can improve diabetes care by screening high-risk individuals and implementing lifestyle interventions, especially in LMIC.

Roles for community health workers in diabetes prevention and management in low- and middle-income countries / O papel dos agentes comunitários de saúde na prevenção e manejo do diabetes em países de renda baixa e média / Roles de trabajadores comunitarios en salud para la prevención y gestión de la diabetes en países con medios y bajos ingresos

Diabetes prevalence is increasing worldwide, especially in low- and middle-income countries (LMIC), posing the need for improved detection and management strategies. Chronic disease models and lifestyle medicine provide structures for action. Community health workers (CHWs) can significantly contribute to chronic disease care if they are trained and integrated into low-resource health systems. Although most current CHWs worldwide are performing maternal/child health and infectious disease-related tasks, other programs involving CHWs for noncommunicable disease prevention and management are increasing. In this article, we discuss the advantages, challenges, and questions regarding possible roles assigned to CHWs in the prevention and management of diabetes. These roles include performing simple screening tests, implementing lifestyle/behavioral interventions, and connecting patients with alternatives to biomedicine. Specifically, CHWs can aid diabetes epidemiological surveillance by conducting risk score-based screening or capillary glucose testing, and they can facilitate diabetes self-management by delivering interventions described in the transcultural diabetes nutrition algorithm. Furthermore, while this role has not formally been assigned, CHWs can leverage their intimate knowledge of local practices to provide decision-making support to patients in environments with pluralistic health systems. Ethnocultural differences in CHW functions and transcultural adaptations of their roles in diabetes care should also be considered. In summary, CHWs can improve diabetes care by screening high-risk individuals and implementing lifestyle interventions, especially in LMIC.

A prevalência do diabetes está aumentando em nível global, sobretudo nos países de renda baixa e média, o que exige melhor detecção e manejo da doença. O modelo de doenças crônicas e a medicina de estilo de vida fornecem estruturas para a ação nesse sentido. Os agentes comunitários de saúde (ACS) podem contribuir de maneira significativa para a assistência às doenças crônicas, desde que sejam capacitados e integrados aos sistemas de saúde, que dispõem de recursos limitados. Embora a maioria dos ACS no mundo esteja desempenhando tarefas relacionadas à saúde materno-infantil e doenças infecciosas, estão crescendo outros programas que envolvem a prevenção e manejo das doenças não transmissíveis. O artigo discute as vantagens, desafios e questões relacionados aos possíveis papéis definidos para os ACS na prevenção e manejo do diabetes. Esses papéis incluem testes simples de triagem, implementação de intervenções comportamentais e de estilo de vida e recomendação de alternativas à biomedicina para os pacientes. Especificamente, os ACS podem auxiliar na vigilância epidemiológica do diabetes, realizando triagem baseada em pontuação de risco ou testagem de glicemia capilar, e podem facilitar o auto-manejo do diabetes através de intervenções baseadas no algoritmo nutricional transcultural do diabetes. Além disso, embora o papel não tenha sido definido formalmente, os ACS podem alavancar seu conhecimento íntimo das práticas locais para apoiar decisões pelos pacientes em contextos com sistemas de saúde pluralistas. Devem ser consideradas as diferenças etnoculturais nas funções dos ACS e nas adaptações transculturais de seus papéis durante a assistência ao diabetes. Em resumo, os ACS podem melhorar a assistência ao diabetes através da triagem e da implementação oportuna de intervenções de estilo de vida, principalmente nos países de renda baixa e média.

La prevalencia de diabetes está aumentando en todo el mundo, especialmente en los países de bajos y medios ingresos (LMIC por sus siglas en inglés), imponiendo la necesidad de una detección y gestión mejoradas. Un modelo de enfermedad crónica y la medicina del estilo de vida proporcionan estructuras para la acción. Los trabajadores comunitarios de salud (CHWs por sus siglas en inglés) pueden contribuir significativamente al cuidado de la enfermedad crónica, si son entrenados e integrados en sistemas con pocos recursos de salud. A pesar de que la mayoría de los actuales CHWs en todo el mundo están desarrollando tareas relacionadas con enfermedades infecciosas en la salud maternal/infantil, otros programas que implican a los CHWs para la prevención y gestión de enfermedades no comunicables están aumentando. En este artículo, discutimos las ventajas, desafíos, y preguntas respecto a los posibles roles asignados a los CHWs, en la prevención y gestión de la diabetes. Estos roles incluyen realizar simples pruebas de detección, implementando intervenciones de estilo de vida/comportamentales, y conectando pacientes con alternativas a la biomedicina. Específicamente, los CHWs pueden ayudar en la vigilancia epidemiológica de la diabetes, llevando a cabo pruebas de detección basadas en marcadores de riesgo o pruebas de glucosa capilares, y pueden facilitar el autocontrol de la diabetes proporcionando intervenciones descritas en el algoritmo transcultural de nutrición en diabetes. Asimismo, mientras este rol no se les haya asignado formalmente, los CHWs pueden potenciar su conocimiento profundo de prácticas locales para proporcionar apoyo en la toma de decisiones a pacientes en entornos con sistemas de salud plurales. Las diferencias etnoculturales en las funciones de los CHW y las adaptaciones transculturales de sus papeles en el cuidado de la diabetes deberían también ser consideradas. En resumen, los CHWs pueden mejorar el cuidado de la diabetes detectando e implementando oportunamente las intervenciones de estilo de vida, especialmente en LMIC.

Looking Sideways: Locating Epidemics and Erasures in South Asia.

While focused on the United States, Rosenberg's work on epidemics offers a nuanced framing that defines the stages and unfolding trajectories of epidemics. His writing is a good starting point to analyze the scope and challenges of epidemic historiography in South Asia. To redress its gaps, I have suggested an approach focused on writing histories of epidemics "sideways" and examined plague and influenza epidemics to situate the fluid politics of lived risks and marginality, moving away from dominant interpretations that have tried to characterize epidemics as finite and episodic.

Making heart-lung machines work in India: Imports, indigenous innovation and the challenge of replicating cardiac surgery in Bombay, 1952-1962.

In 1962, surgeons at two hospitals in Bombay used heart-lung machines to perform open-heart surgery. The devices that made this work possible had been developed in Minneapolis in 1955 and commercialized by 1957. However, restrictions on currency exchange and foreign imports made it difficult for surgeons in India to acquire this new technology. The two surgeons, Kersi Dastur and PK Sen, pursued different strategies to acquire the ideas, equipment, and tacit knowledge needed to make open-heart surgery work. While Dastur tapped Parsi networks that linked him to local manufacturing expertise, Sen took advantage of opportunities offered by the Rockefeller Foundation to access international training and medical device companies. Each experienced steep learning curves as they pursued the know-how needed to use the machines successfully in dogs and then patients. The establishment of open-heart surgery in India required the investment of substantial labor and resources. Specific local, national, and transnational interests motivated the efforts. Heart-lung machines, for instance, took on new meanings amid the nationalist politics of independent India: Even as surgeons sought imported machines, they and their allies assigned considerable value to 'indigenous' innovation. The confluence of the many interests that made Sen and Dastur's work possible facilitated the uneasy co-existence of conflicting judgments about the success or failure of this medical innovation.

Analysis of Social Science Research Into Cancer Care in Low- and Middle-Income Countries: Improving Global Cancer Control Through Greater Interdisciplinary Research.

This analysis lays a framework for greater collaboration between the cancer community and social scientists in both research and policy. We argue that the growing cancer burden that low- and middle-income countries face is raising social, political, and economic challenges of global cancer that require interdisciplinary research beyond the traditional biomedical-clinical nexus. First, we briefly review some of the most important existing social science studies that have addressed cancer in low- and middle-income countries, including the main methods, approaches, and findings of this research. Second, we give an overview of recent interdisciplinary collaborations between social scientists and oncologists and demonstrate how qualitative research can help us to understand the distinct challenges of cancer care in low- and middle-income settings. Finally, we identify key areas for future collaboration and suggest possible paths forward for cancer research and policy that involve social science.

Transplant Buccaneers: P.K. Sen and India's First Heart Transplant, February 1968.

On 17 February 1968, Bombay surgeon Prafulla Kumar Sen transplanted a human heart, becoming the fourth surgeon in the world to attempt the feat. Even though the patient survived just three hours, the feat won Sen worldwide acclaim. The ability of Sen's team to join the ranks of the world's surgical pioneers raises interesting questions. How was Sen able to transplant so quickly? He had to train a team of collaborators, import or reverse engineer technologies and techniques that had been developed largely in the United States, and begin conversations with Indian political authorities about the contested concept of brain death. The effort that this required raises questions of why. Sen, who worked at a city hospital in Bombay that could not provide basic care for all its citizens, sought a technology that epitomized high-risk high-cost, health care. To accomplish his feat, Sen navigated Cold War tensions and opportunities, situating his interests into those of his hospital, municipal authorities, Indian nationalism, Soviet and American authorities, the Rockefeller Foundation, and others. The many contexts and interests that made Sen's work possible created opportunities for many different judgments about the success or failure of medical innovation.

A Global View on the Effects of Work on Health in Later Life.

PURPOSE OF THE STUDY: Work is an important environment shaping the aging processes during the adult years. Therefore, the cumulative and acute effects of work characteristics on late-life health deserve great attention. Given that population aging has become a global trend with ensuing changes in labor markets around the world, increased attention is paid to investigating the effects of the timing of retirement around the world and the macroeconomic benefits often associated with delaying retirement. It will be essential for societies with aging populations to maintain productivity given an aging workforce and for individuals it will be crucial to add healthy and meaningful years rather than just years to their lives. DESIGN AND METHODS: We first describe the available evidence about participation of older workers (65+) in the labor force in high, middle, and low-income countries. Second, we discuss the individual-level and societal influences that might govern labor-force participation of older adults. Thirdly, we review evidence on the association between work on the one and physical, mental, and cognitive health in later life on the other. RESULTS AND IMPLICATIONS: Globally, both is true: work supports healthy aging and jeopordizes it. We draw implications for policymaking in terms of social protection, HR policies, and older employee employability.

Adolescent risk-taking, cancer risk, and life course approaches to prevention.

Adolescent risk-taking may have long-term consequences for adult cancer risk. Behaviors such as smoking and sexual activity, commonly initiated during adolescence, may result--decades later--in cancer. Life course epidemiology focuses on unique vulnerabilities at specific development periods and their importance to later development of disease. A life course epidemiological perspective that integrates social and biological risk processes can help frame our understanding how specific adult cancers develop. Moreover, life course perspectives augment traditional public health approaches to prevention by emphasizing the importance of unique windows of opportunity for prevention.

The United Nations High Level Meeting on the Prevention and Control of Noncommunicable Diseases: a missed opportunity?

The United Nations High Level Meeting on the Prevention and Control of Noncommunicable Diseases (September 19-20, 2011) provided an opportunity to recast the current global health agenda and offered a formidable platform to mobilize political will for concerted action. We argue that the opportunity was missed because the World Health Organization (WHO) neglected the politics of process that are key to mobilizing political support for global noncommunicable disease policies. Instead, it focused on the implementation process. The lessons to be drawn from the summit are critical because the WHO is the key agency that will be expected in the near future to steer further discussions and debate on the noncommunicable disease agenda.

Social support, volunteering and health around the world: cross-national evidence from 139 countries.

High levels of social capital and social integration are associated with self-rated health in many developed countries. However, it is not known whether this association extends to non-western and less economically advanced countries. We examine associations between social support, volunteering, and self-rated health in 139 low-, middle- and high-income countries. Data come from the Gallup World Poll, an internationally comparable survey conducted yearly from 2005 to 2009 for those 15 and over. Volunteering was measured by self-reports of volunteering to an organization in the past month. Social support was based on self-reports of access to support from relatives and friends. We started by estimating random coefficient (multi-level) models and then used multivariate logistic regression to model health as a function of social support and volunteering, controlling for age, gender, education, marital status, and religiosity. We found statistically significant evidence of cross-national variation in the association between social capital variables and self-rated health. In the multivariate logistic model, self-rated health were significantly associated with having social support from friends and relatives and volunteering. Results from stratified analyses indicate that these associations are strikingly consistent across countries. Our results indicate that the link between social capital and health is not restricted to high-income countries but extends across many geographical regions regardless of their national-income level.

The return of epidemics and the politics of global-local health.

With fears of global health epidemics (of reemerging infectious diseases) having escalated over the past few decades, we must ask how we understand the diverse responses to such outbreaks. I explore a single event that merits revisiting--the 1994 outbreak of plague in Surat, the commercial capital of the Indian state of Gujarat--in an attempt to answer this question. I trace responses at various intersecting levels of public health and political authority-global, national, and local-as they interacted with each other and expressed specific political concerns and social anxieties during this outbreak.