Intolerable Burden Research Articles

Efficacy and side-effects of two praziquantel treatments against Schistosoma haematobium infection, among schoolchildren from Côte d'Ivoire.

Praziquantel is the current drug of choice for the control of schistosome-attributable morbidity and is likely to remain so for several years. However, as there is concern that schistosomes might develop resistance to the drug, the monitoring of praziquantel's efficacy in different epidemiological settings is recommended. Here, the results of an innovative study of the drug's effectiveness, in an area in Côte d'Ivoire that is highly endemic for Schistosoma haematobium, are reported. Each of the subjects (354 schoolchildren aged 5-15 years) was given two oral doses of praziquantel (each of 40 mg/kg) 4 weeks apart. The numbers of schistosome eggs in urine samples collected over several consecutive days prior to the first and after the second treatment were then determined. High cure and egg reduction 'rates', of 93.0% and 96.6%, respectively, were found. Although mild and transient side-effects were frequently observed after the first treatments, no severe systemic complaints were recorded. When the 20 children who remained egg-positive after the second dose were each given a third dose of praziquantel, 16 (80%) of them responded and became egg-negative. Unfortunately, the schistosome strains infecting the remaining four children could not be investigated in detailed laboratory studies, because of the failure of eggs to hatch. There were therefore no unambiguous signs of resistance to praziquantel in this epidemiological setting. The benefits and disadvantages, compared with single-dose treatments, of administering praziquantel twice within a few weeks are discussed. It is anticipated that this approach might prove efficacious in areas of high infection intensity. The integration of such pharmaceutical measures with other readily available control tools is likely to mitigate the current, intolerable burden of schistosomiasis.

Shaun's Story: Troubling discourses of white working-class masculinities

This article tells the story of a hard-working, well-behaved, poor, white, working-class boy trying to achieve academically in a 'sink' inner-city boys' comprehensive school, whilst simultaneously trying to maintain his standing within the male peer group culture. In doing so, it raises questions about the possibilities of bringing together white working-class masculinities with educational success in inner-city working-class schooling. It is argued that to combine the two generates heavy psychic costs, involving young men not only in an enormous amount of academic labour but also an intolerable burden of psychic reparative work. Shaun's narrative also suggests that the problem of 'failing boys' cannot be solved through school-based initiatives. Until social processes of male gender socialisation move away from the imperative of privileging the masculine and allow boys to stay in touch with their feminine qualities, the problem of 'failing boys' will remain despite the best efforts of teachers and researchers.

Decline in rehabilitation services

Professor Grahame outlines the decline in rehabilitation services and its possible relation to the increase in disability benefits in the UK (March 2002 JRSM1). We agree that often the nearest a rheumatologist gets to rehabilitation is signing a benefits form and that patient care and the specialty may be the poorer for this. However, the phenomenon may have complex origins. The post-war period saw low unemployment levels and there was an expectation that the male of the family would be the breadwinner. With rising unemployment the job market has become more competitive and traditional gender roles have changed, perhaps ‘allowing’ more males to accept sickness roles. Litigation is more common and rising benefit claims may support Hadler's view that ‘if you have to prove you are ill, you can't get well’2. Rheumatology, like other specialties, is becoming more complex and many rheumatologists also have general medical responsibilities; rehabilitation may be an additional and intolerable burden. The expanding specialty of elderly care may be partly bridging the service gap; in our area the lower age limit for admission to rehabilitation under the elderly-care multidisciplinary team is 18 years, and rheumatology patients, among many others, have greatly benefited from the service. In addition, the National Service Framework for Older People makes specific recommendations regarding the enhancement of access to rehabilitation and makes an attempt to end ageism in the provision of services, which should benefit young and old patients in the future.

Utilization management: issues, effects, and future prospects.

Utilization management encompasses a diverse set of activities designed to influence the use of health care services and thereby constrain health care resource consumption. Utilization management, which has become one of the most widely used cost-containment approaches, has engendered debate and controversy. Physicians have been outspoken critics of utilization management because it has limited their clinical autonomy and has contributed to an intolerable administrative burden. Insurance carriers, managed care plans, and third-party payers have defended the use of utilization management as an imperfect-but necessary-practice that is needed to reduce consumption of unnecessary or inappropriate health care services. This review examines the operation and effects of three widely used utilization management procedures: prospective utilization review, case management, and physician gatekeeping programs. In addition, it explores the future role of utilization management in the health care system and outlines a set of principles that we believe should be used to guide the development of utilization management strategies in the future.

Profile. Dollars and cents vs. the AIDS epidemic.

PROFILEBOSTON-- Harvard economist Jeffrey Sachs has jumped into one of the biggest and most visible international public health issues of the day: the tragedy inflicted by HIV/AIDS on the developing world, especially sub-Saharan Africa. He's become one of the most vocal advocates for a multibillion-dollar international program to tackle not only AIDS but the intolerable disease burden that, he argues, is holding back the developing world. He's constantly cajoling rich governments to open up their coffers and drug companies to loosen their intellectual property claims on drugs desperately needed in poorer countries. (Also see Policy Forum by SchwartlA¤nder et al . on p. [2434][1].) [1]: http://www.sciencemag.org/cgi/content/short/292/5526/2434

The malaria burden and Africa.

The malaria burden and Africa.

The malaria burden and the need for research and capacity strengthening in Africa.

The Intolerable Burden of Malaria: A New Look at the Numbers supplement highlights the malaria scourge in subSaharan Africa, where the disease has recently attained unprecedented dimensions. The eleven articles included herein make it clear that the malaria burden on the African continent has been grossly underestimated across the board, whether considering rates of infection, causes of acute febrile and chronic illness, adverse outcomes of pregnancy, effects on early childhood, toll from anemia, impact of chloroquine resistance, long-term neurological and related sequelae, or economic consequences of infection. Economist gurus have concluded that malaria is a cause of poverty in sub-Saharan Africa and not vice-versa. Previous underestimates of the effects of malaria have undoubtedly hampered efforts to marshall greater resources for malaria research and disease reduction. Effective malaria control is essential for Africa’s renaissance. Crucial information on the burden of malaria in African communities has been widely dispersed and much of it is brought together in this supplement. This will greatly benefit malaria researchers, particularly epidemiologists, and those planning malaria control programs. This new compilation will also aid decision makers in both endemic and donor countries. The supplement provides crucial evidence to support increased investment in capacity strengthening in malaria research and operations and indicates why it is important for scientists and control specialists to work closely together. Emphasis in malaria epidemiology has undergone tremendous transformation in the recent past. The current emphasis on malaria chemotherapy and chemoprophylaxis during pregnancy has aroused great interest in malaria as a cause of morbidity and mortality. This emphasis is in stark contrast to the past, when malaria control and eradication strategies relied virtually entirely on vector control. Malaria epidemiology was then focused on entomological factors tied to transmission. At that time, Anopheles spp vectors of malaria were at center stage; humans now occupy that position and with good reason. However, if we forget the vector, it is at our peril. The recent neglect of research on malaria vectors, their role in transmission, and their control is apparent— there is not one article in this issue that covers malaria transmission, although it has a direct bearing on the malaria burden. Other important areas of malaria research that deserve increased attention are the impact of environmental changes, human behavior, and socioeconomic and demographic trends including urbanization, on transmission and disease patterns. It is true that considerable investment in capacity building for research and control of tropical diseases, especially malaria, has occurred over the past quarter-century. There is, however, greater need for increased investments in developing more African (and non-African) epidemiologists and other scientists interested in quantifying the malaria burden. The paucity of indigenous expertise is obvious from the authors’ analyses reported in this supplement. National experts are badly needed to enable each African country to understand its own health problems, to inform health policy and operational programs, to enhance the impact of limited funds and personnel, and to form a solid health research base. Moreover, there is a pressing need to develop expertise in institutional leadership so that findings from clinical and field research can influence policy and be deployed effectively in national health systems. I hope that the major legacy of this supplement will be the engagement of more Africans in malaria research, particularly that related to defining more precisely all of the factors bearing on the disease burden, including transmission dynamics. At the same time, it is to be expected that the institutions in which these scientists work will become true centers of excellence—focused on research, teaching, and service, in order to reduce the terrible impact of malaria and other tropical diseases.

The ears of the hippopotamus: manifestations, determinants, and estimates of the malaria burden.

Malarious patients experience asymptomatic parasitemia; acute febrile illness (with cerebral damage, anemia, respiratory distress, hypoglycemia); chronic debilitation (anemia, malnutrition, nervous system-related sequelae); and complications of pregnancy (anemia, low birth weight, increased infant mortality). These manifestations in patients, communities, and countries reflect intrinsic (human, parasite, mosquito) and extrinsic (environmental, social, behavioral, political, and economic conditions as well as disease-control efforts) determinants. At a minimum, between 700,000 and 2.7 million persons die yearly from malaria, over 75% of them African children. Between 400 and 900 million acute febrile episodes occur yearly in African children under 5 yr of age living in endemic areas. Although about half of these children are parasitemic, all merit consideration of malaria-specific therapy, which is becoming more problematic because of parasite resistance to drugs. These numbers will more than double over the next 20 yr without effective control. Fewer than 20% of these febrile episodes and deaths come to the attention of any formal health system. The relatively few ill patients who have any contact with the health services represent the "ears of the hippopotamus." Greatly intensified research activities and control of the intolerable burden of malaria are mandatory if economic development is to accelerate in Africa. In particular, support should be targeted to understanding and preventing malaria-induced anemia, hypoglycemia, effects on pregnancy, and neurologic and developmental impairment. To decrease and stop transmission of this intolerable scourge, there is an urgent need for malaria vaccines, newer drugs, and better vector control methods as well as the ability to improve current technologies and use them more efficiently.

Informal caregivers and the intention to hasten AIDS-related death.

To determine the extent to which homosexual men dying of the acquired immunodeficiency syndrome (AIDS) receive medication intended to hasten death. To assess the impact on caregivers of administering medications intended to hasten death. In a prospective study of caregiving partners of men with AIDS (n = 140), characteristics of the ill partner, the caregiver, and the relationship were assessed at baseline and 1 month before the ill partner's death. Three months after the death, caregivers were asked if they had increased their partner's narcotic and/or sedative-hypnotic medication dose and if so, what had been the objective of the increase, and their comfort with their medication decisions. Of 140 ill partners who died of AIDS, 17 (12.1%) received an increase in the use of medications immediately before death intended to hasten death. Diagnoses and care needs of ill partners who received increases in the use of medications to hasten death did not differ from those of ill partners receiving medication for symptoms. Fourteen increases (10%) in use of medications were administered by caregivers. These caregivers did not differ from those administering medication for symptom control in level of distress, caregiving burden, relationship characteristics, or comfort with the medication decision, but they reported more social support and positive meaning in caregiving. The decision to hasten death is not a rare event in this group of men. There is no evidence that it is the result of caregiver distress, poor relationship quality, or intolerable caregiving burden; and it does not cause excessive discomfort in the surviving partner. This study, although small, has implications for the policy debate on assisted suicide.

Refining treatment approaches in obsessive-compulsive disorder.

Obsessive-compulsive disorder (OCD) has emerged as a common but frequently hidden psychiatric disorder which inflicts an intolerable burden on sufferers and demands effective management. For many years, however, OCD was considered treatment resistant and it is only in the past 15 years that effective therapy has become available. The discovery that the symptoms of OCD could be controlled with clomipramine, but not with other tricyclic antidepressants, was a crucial step in the development of effective management of the condition. The ability of clomipramine to treat OCD derives from its potency as an inhibitor of serotonin reuptake. Serotonin reuptake inhibition has become the fundamental requirement for the pharmacological management of OCD. In the past decade selective serotonin reuptake inhibitors (SSRIs) have been shown to be effective in the management of OCD. Meta-analysis comparing the efficacy of clomipramine and SSRIs initially suggest that clomipramine is more effective than SSRIs, but changes in the clinical characteristics of trial populations over time indicate that the meta-analyses may be misleading. In the few direct comparisons of SSRIs and clomipramine, the two treatments have in fact proved equally effective. Attention is now shifting to the impact side effects on efficacy, a particularly important consideration for OCD patients who require long-term medication but are frequently reluctant to take drugs. The limited data available suggest that SSRIs are better tolerated than clomipramine and are therefore more likely to lead to a favourable treatment outcome.

The tithe rentcharge: a pioneer in income indexation

The Tithe Commutation Act 1836 converted church tithes in England and Wales from moduses, compositions and payments in kind to uniform rentcharges. It provided for indexation to reflect fluctuations in the prices of three grains. The object was to give the tithe-owners approximately the same money incomes as they would have expected under the old system, and tithepayers the same burden. This scheme was crippled by the collapse of agricultural prices after 1875. The First World War caused further disruption, and indexation was abandoned. The 1930s depression made tithes an intolerable burden on farmers, and after 1936 they were commuted to redemption annuities (abolished 1977) or the capital was redeemed.

The Extension of U.S. Tax Treaties to U.S. Territories, as Illustrated by the Example of Guam

THE EXTENSION OF U.S. TAX TREATIES TO U.S. TERRITORIES, AS ILLUSTRATED BY THE EXAMPLE OF GUAM Samuel J. Cohent In 1901, Justice Brown, writing for a majority of the U.S. Supreme Court in Downes v. Bidwell concluded that to apply the U.S. internal revenue system to U.S. territories' would prove an intolerable burden. ' 2 Nevertheless, in 1951, the U.S. Congress im- posed a mirror image of the Internal Revenue Code (the Code ) upon the territory of Guam. 3 Congress not only burdened Guam with a precise replicate of the Code, but it also excluded Guam from benefits of U.S. tax treaties with foreign nations. 4 Thus, while foreign investment within the U.S. receives favorable tax treatment, comparable investment in Guam faces a far greater tax burden. 5 Because Congress burdens territories such as Guam with tax sys- tems similar to the Code, it should alleviate this onus by allowing those territories to profit from U.S. tax treaties. This Article analyzes existing U.S. tax treaties with foreign na- tions and the application of those treaties to Guam. First, the legal status and the tax systems of U.S. territories are examined. Second, t J.D., University of Minnesota School of Law; LL.M. (Taxation), New York University School of Law; Senior Associate, Carlsmith Ball Wichman Murray Case Mukai & Ichiki, Agana, Guam. I wish to extend special thanks to Professor Kees Van Raad and Professor Law- rence Lokken for their guidance and insightful comments, and acknowledge that I alone am responsible for any errors the Article may contain. 1. See infra note 6 and accompanying text. 2. Downes v. Bidwell, 182 U.S. 244, 284 (1901). 3. See infra notes 25-28, 108 and accompanying text. According to history, Fer- dinand Magellan discovered Guam on March 6, 1521. PAUL CARANO & PEDRO C. SANCHEZ, COMPLETE HISTORY OF GUAM 41 (1964). However, doubt exists as to whether Magellan sighted Guam or the nearby island of Rota. Id. Guam, approxi- mately 225 square miles in area, is about 30 miles long and four to nine miles wide. Id. at 2. Guam lies 1,353 miles south of Yokohama, Japan; 1,506 miles east of Manila, Philippines; and 3,337 miles west of Honolulu, Hawaii. LAURA THOMPSON, GUAM AND ITS PEOPLE 20 (chart paraphrase) (3d ed. 1947). 4. See infra notes 72-100 and accompanying text. 5. See infra notes 62-133, 135 and accompanying text.

Informed consent in medicine: one physician's perspective

The American physician is today besieged by economic and societal forces which conspire to weaken whatever equanimity he or she could once bring to the practice of medicine. In the latter realm, the threat of malpractice actions is ever-present. In this regard, negligence has long been the theory whereupon plaintiffs' attorneys seek to recover damages for patients' misfortunes in the medical system. However, when no physician negligence can be shown to be the cause of bad medical outcomes, lack of informed consent has become an alternative theory for attorneys to use in pursuing legal action. This development in the law balances a laudable effort to protect patients' autonomy rights against an often intolerable burden for physicians. What to tell patients is thus a matter of paramount concern in the era of risk management. The issue of informed consent is a relatively recent development in the history of medicine. Traditionally the doctor-patient relationship has been paternalistic. In ancient Greece, Hippocrates advised physicians to

Resolving the Acquisitions Dilemma: Into the Electronic Information Environment

Editor's note: This article is the second part of a series on scholarly communications and serials prices. This paper analyzes the present serials acquisitions crisis as the latest manifestation of the instability of the economic system supporting scholarly communication, which places an increasingly intolerable burden on the research library. It reviews various solutions that have been proposed to solve this crisis, arguing that none is achievable as long as the present economic system continues. It proposes a resolution to this dilemma, drawing upon the capabilities of new electronic technology, through which the economic burden on the research library will be reduced or even eliminated, and the system of scholarly communication improved.

The Oppression of Caring: Women Caregivers of Relatives With Mental Illness

Caring is central to the experience of women. It is also a form of oppression for women, since this culture demands that women care for, as well as care about, others, yet does not acknowledge the value of caregiving tasks. Women who are caregivers to relatives with a severe and persistent mental illness carry an intolerable burden of care, with little support from the state. This article delineates these issues and proposes specific changes in social policy and actions by social workers that would alleviate the burden of care and the gender oppression on which it is based.

REFORMING PROPERTY RIGHTS IN LAND AND TENANCY

This article examines the nature and distribution of property rights in land and how they are changing under economic and demographic pressures. It also analyzes the practical chances of success of several alternative forms of policy intervention to redistribute property rights and regulate tenancy. This analysis begins with the political economy of land reform in the twentieth century. It draws a distinction between reforms precipitated by social upheaval (defeat in war, social revolution, or national liberation) and those that occur in 'normal' times, when the social and political order is more secure. It is argued that the former have been much more important and, drawing on examples, that the latter face formidable obstacles. In this connection, it is proposed that a tax reform which does away with the highly selective subsidies and exemptions that benefit the rich and inflate the price of land should be undertaken first. Then, when land prices have fallen, compulsory purchase of land for redistribution, at close to fair market value to ensure its political acceptability, will not entail an intolerable fiscal burden. Where tenancy is concerned, it is argued that this institution is commonly a socially useful market response, which provides opportunities for the fuller employment of family resources and, over the long run, for individual mobility. Thus interventions designed to inhibit tenancy directly or to transfer ownership-like rights to existing tenants may result in heavy costs, especially or future cohorts of will-be tenants

Forwarding of Medical Records

To the Editor.— In the Sept 21 issue ofThe Journal, there was a letter regarding the prompt forwarding of medical records. 1 This is a rather disturbing problem because with the increasing number of facilities, prepaid plans, and relocation of people, the demand for the forwarding of records is beginning to become an intolerable burden. I feel that the American Medical Association should recognize this and take appropriate action to try to establish some guidelines for the financial remuneration for this type of thing, since in many offices the amount of time and effort involved, photocopying and so on, runs into a substantial amount.

Opening address

It is an honour to have been invited to open this important conference. Every good physics conference has a few mathematicians hanging around on the outskirts, like scavenger fish, hoping to pick up an interesting problem. They are tolerated because occasionally they do something useful, although most of the time mathematicians modify the problems to make them more elegant or more tractable, and thereby accidentally destroy their relevance to the real world. But it is seldom that such a person is invited into the limelight. But in fact I am here in quite a different role. Today, when the headlines once again suggest that the Common Market is collapsing under the intolerable burden of the Common Agricultural Policy, it is right to remind you that the E E C. serves other and better purposes too. It needs the whole of Europe to provide a market large enough to allow high-technology industry to prosper. Just as national governments do within their own boundaries, the Commission subsidizes across Europe the strategic research from which the next generation of industries will spring. Its latest device for doing so is CODEST, the Committee for the Development of European Science and Technology, which was set up to encourage research across national boundaries. CODEST, of which I am a member, was set up last summer and given a pilot budget of 7 million European currency units for its first two years; if it proves itself successful, it can hope to get very much larger sums in the future. Most of that money will go on small grants, to help cooperative research between pairs of laboratories in different countries; but we were instructed to fund if possible one major project. In two months over the summer, Desmond Smith and Paul Mandel put together just such a project, with collaborators from all across Europe, in a key area of the technology of the future (see table 1). We were not merely happy to fund it, but amazed that such a team could be put together in so short a time. One of the side effects is this conference.

A Due Process Analysis of Judicially-Authorized Presumptions in Federal Aggravated Bank Robbery Cases

Within the past fifteen years several broadly-focused articles have identified general constitutional limits, under the due process clause, on presumptions and inferences created by statute or applied by courts in trying criminal cases.' Recently, in County Court of Ulster County, New York v. Allen,2 the Supreme Court affirmed the validity of the evidentiary devices of inferences and presumptions and labeled them staple of our adversary system of factfinding.3 This suggests that to unreasonably curtail the use of circumstantial evidence in the factfinding process would place an intolerable burden on prosecutors in their efforts to prove guilt beyond a reasonable doubt. Yet, notwithstanding the necessary evidentiary role for presumptions and inferences in the criminal justice process, the Court has acknowledged often-stated requirements of

‘The Omnipresent Bania:’ Rural Moneylenders in Nineteenth-Century Sind

After revisiting Sind in 1876, Sir Richard Burton wrote, ‘The Hindu's reed-pen is a rod of iron and abjectly the unhappy Sindi trembles before it.’ By ‘Hindu,’ Burton meant the Hindu bania, the trader and moneylender, and by ‘Sindi’ he meant the Sindhi Muslim zamindar (landholder), the perennial debtor. The creditor tyrannized over the debtor, imposing ever harsher and more inequitable terms on him. What is interesting is that Burton scarcely appeared to recognize the Hindu banias as Sindhis at all; he wrote as if they were interlopers on the Sindhi scene. It was a colourful summary of the average British official's attitude towards debt. Twenty years later, Evan James, the Commissioner in Sind, quoted Burton's remark to lend support to his own argument that debt was an intolerable burden on Sindhi Muslims in general and the great zamindars in particular.