Public Health Paradigm Research Articles

The implementation of isoniazid preventive therapy in HIV clinics: the experience from the TB/HIV in Rio (THRio) study.

The TB/HIV in Rio (THRio) study was launched in September 2005 to assess the impact of integrated tuberculosis (TB) and HIV treatment strategies in 29 HIV clinics in Rio de Janeiro, Brazil. THRio is a cluster-randomized trial (CRT) to determine whether routine screening for and treatment of latent TB in HIV clinic patients with access to antiretroviral therapy will reduce TB incidence at the clinic level. THRio is part of the Consortium to Respond Effectively to AIDS/TB Epidemic that is implementing research studies to assess the impact of bold, new public health paradigms for controlling the AIDS/TB epidemic. Twenty-nine public primary HIV clinics were randomly assigned a date to begin implementing TB screening procedures and provision of isoniazid preventive therapy (IPT) for TB/HIV coinfected patients. Final analysis of the CRT is expected in 2011. Starting at date of tuberculin skin test (TST)/IPT implementation at each clinic through August 2010, 1670 HIV-infected patients initiated IPT, of which 215 are still receiving treatment. Of the remaining 1455 patients, 1230 (85%) completed therapy and only 20 (1.2%) patients initiating IPT reported adverse reactions leading to discontinuation of therapy. IPT completion was higher among HIV-infected patients receiving HAART (87%) than those not yet receiving HAART (79%, P < 0.01). Times to TST and IPT have markedly decreased postintervention, but remain considerably long. The richness of the THRio database has resulted in several analyses of this expansive cohort of HIV-infected patients that are reviewed here. The national implementation of TST and IPT for HIV-positive patients in Brazil has been invigorated partly due to THRio's baseline results. Expanded use of IPT in HIV patients in Rio de Janeiro is achievable with high adherence and low adverse events, although this effort requires a package of activities including training, advocacy and reorganization of services.

How ideology shapes the evidence and the policy: what do we know about cannabis use and what should we do?

In the United Kingdom, as in many places, cannabis use is considered substantially within a criminal justice rather than a public health paradigm with prevention policy embodied in the Misuse of Drugs Act. In 2002 the maximum custodial sentence tariff for cannabis possession under the Act was reduced from 5 to 2 years. Vigorous and vociferous public debate followed this decision, centred principally on the question of whether cannabis use caused schizophrenia. It was suggested that new and compelling evidence supporting this hypothesis had emerged since the re-classification decision was made, meaning that the decision should be reconsidered. The re-classification decision was reversed in 2008. We consider whether the strength of evidence on the psychological harms of cannabis has changed substantially and discuss the factors that may have influenced recent public discourse and policy decisions. We also consider evidence for other harms of cannabis use and public health implications of preventing cannabis use. We conclude that the strongest evidence of a possible causal relation between cannabis use and schizophrenia emerged more than 20 years ago and that the strength of more recent evidence may have been overstated--for a number of possible reasons. We also conclude that cannabis use is almost certainly harmful, mainly because of its intimate relation to tobacco use. The most rational policy on cannabis from a public health perspective would seem to be one able to achieve the benefit of reduced use in the population while minimizing social and other costs of the policy itself. Prohibition, whatever the sentence tariff associated with it, seems unlikely to fulfil these criteria.

Solution focused nursing: A fitting model for mental health nurses working in a public health paradigm

The Australian Federal Government health agenda is advocating an extension of public health principles across all levels of the health sector. Since mental health nurses have long been proponents of public health and health promoting behaviours, an opportunity exists for this specialty of nursing to extend their influence and contribution within health. Solution focused nursing (SFN), a model that emerged from mental health practice, offers a framework to assist mental health nurses and leaders to more clearly practise public health principles within nursing and articulate that practice – for it is in the articulation of practice that nurses and nursing is made visible and valued. This paper aims to expand on and reiterate the SFN model, showing how it connects to public health principles and develops the mental health nurse’s role – particularly in those clinical areas that require more than medical management and illness stabilization.

Ecological public health and climate change policy

The fact that health and disease are products of a complex interaction of factors has long been recognized in public health circles. More recently, the term 'ecological public health' has been used to characterize an era underpinned by the paradigm that, when it comes to health and well-being, 'everything matters'. The challenge for policy makers is one of navigating this complexity to deliver better health and greater equality in health. Recent work in Scotland has been concerned to develop a strategic approach to environment and health. This seeks to embrace complexity within that agenda and recognize a more subtle relationship between health and place but remain practical and relevant to a more traditional hazard-focused environmental health approach. The Good Places, Better Health initiative is underpinned by a new problem-framing approach using a conceptual model developed for that purpose. This requires consideration of a wider social, behavioural etc, context. The approach is also used to configure the core systems of the strategy which gather relevant intelligence, subject it to a process of evaluation and direct its outputs to a broad policy constituency extending beyond health and environment. This paper highlights that an approach, conceived and developed to deliver better health and greater equality in health through action on physical environment, also speaks to a wider public health agenda. Specifically it offers a way to help bridge a gap between paradigm and policy in public health. The author considers that with development, a systems-based approach with close attention to problem-framing/situational modelling may prove useful in orchestrating what is a necessarily complex policy response to mitigate and adapt to climate change.

How can departments of community medicine shape the future of Public Health Education in India?

In order to effectively respond to a changing public health paradigm, it is imperative that the medical education and overall public health education (PHE) parallel the public health challenges faced by countries. Community medicine departments play a crucial role in PHE. This review analyzes the current situation of community medicine departments in the context of PHE, using a framework that outlines academic activities undertaken by these departments. This framework includes the syllabus of academic programs, internship, and infrastructure and faculty strength in the community medicine departments. The review also discusses how skill building of existing faculty members can help us in addressing emerging public health issues, and the role of partnerships and collaborative activities in advancing the PHE agenda, thereby continuing to shape the role played by these departments toward shaping the future of PHE in India.

Occupational Health, Mercury Exposure, and Environmental Justice: Learning From Experiences in Tanzania

Mercury is a potent neurotoxin that is used by poverty-driven miners to extract gold in more than 50 countries. This article examines efforts of the United Nations to address occupational health and environmental justice amid these challenges, focusing on a 3-year campaign in one of the fastest-growing mining communities in Tanzania. By providing an integrative analysis of environmental health risks, labor practices, public health policies, and drivers of social inequity and marginalization, this study highlights the need for interdisciplinary public health approaches that support community development by strengthening local capacities. It illustrates why, to ensure that the needs of vulnerable populations are met, environmental justice and public health paradigms have to expand beyond the conventionally narrow attention paid to toxic exposure and emissions issues.

Human ecology and public health

Understanding patterns of health and disease requires that the focus in public health is not only on personal behaviours, biologic traits and specific risks but also on characteristics of the social and physical environments that shape human experience. At the end of the 20th century a challenge of the dominance of biomedicine and the need to give greater emphasis to the ecological context in the study of human health and disease was growing.1,2,3 The emerging new paradigm of public health … Correspondence: Stanislaw Tarkowski, School of Public Health, Nofer Institute of Occupational Medicine, Sw. Teresy 8, 91-348 Lodz, Poland, e-mail: tarko{at}imp.lodz.pl

Editorial: The full spectrum of public health

Since the last decade of the twentieth century we have observed a global renaissance of public health as a major orientation for politicians, donors, activists and health professionals: a focus of debate in civil society. The doors opened with the declarations of Alma-Ata in 1978, the Ottawa Charter in 1986, and last but not least with the Millennium Development Goals in 2001 (http://www.un. org/documents/ga/docs/56/a56326.pdf). Recently two reports have been published underlining the social determination of the health of populations (http://www.who.int/ social_determinants/en/) and the central role of primary health care of high quality not only in developing countries but also in Europe (http://www.who.int/whr/2008/en/index. html). Analysing the broad range of public health issues and even more intervening at the population level requires a multidimensional scientific approach. That is why we should speak of the health sciences in the plural: There is no single truth. Especially the aged battle between medicine and the social sciences does not make sense anymore. We coined the term of the double paradigm of public health [Hurrelmann K, Laaser U (1993) Gesundheitswissenschaften als interdisziplinare Herausforderung. In: Hurrelmann K, Laaser U (eds) Gesundheitswissenschaften, Handbuch fur Lehre, Forschung und Praxis. Beltz, Weinheim, pp 3–25], but in fact today we have to accept a multiple paradigm. In conclusion we can speak of a two-dimensional extension of the new public health concept, across the globe and across the traditional disciplines. One step in this process is the 12th World Congress on Public Health: Making a Difference in Global Public Health: Education, Research, and Practice (27 April–1 May 2009 in Istanbul, http://www.wfpha.org). This issue of the Journal of Public Health covers quite a substantial part of the range of public health problems around the world. Communicable diseases especially viral infections are not at all out, on the contrary due to hunger, civil war and weak health systems we have to cope with a number of emerging and re-emerging diseases. As vaccines are still the most important preventive tool we face two restrictive factors: attitudes and costs. The paper by Allaert et al. deals with parents’ attitudes towards varicella vaccination and demonstrates by comparing the situation in France and Germany that appropriate information about the potential severity of the disease and the efficacy and safety of the vaccine can overcome any resistance. The paper by Hillemanns et al. analyses the cost-effectiveness of the tetravalent human papillomavirus (HPV) vaccination in the prevention of cervical cancer and genital warts associated with HPV types 6, 11, 16 and 18. The next five papers lead us to Burkina Faso in SubSaharan West Africa, to Iran, to the Gaza Strip and to Jordan. Marschall and Flessa investigate the cost-effectiveness or efficiency of rural health centres in Burkina Faso, one of the first economic evaluations of the primary health care sector in Africa. They conclude that instead of closing down inefficient centres transport facilities or accessibility as the main determinants of inefficiency have to be improved. Krieg and Gardemann report on the experience of international aid after the earthquake in Bam, Iran in 2003. Based on more than 16,000 cases they argue for a standardisation of morbidity records in emergency situations. Varasteh et al. report a cross-sectional representative survey on allergic symptoms in the industrial city of Mashdad, North-eastern Iran establishing an overall prevalence of 27.5%. Kanao et al. from the Al-Azhar University in Gaza point to dominant J Public Health (2009) 17:69–70 DOI 10.1007/s10389-008-0244-3

Chronic heart failure: β-blockers and pharmacogenetics

The European Society of Cardiology recommends that beta-blockers should be considered for treating all patients with stable, mild, moderate, or severe heart failure (HF) who are receiving standard treatment, unless there is a contraindication. Despite the significant benefit of the drug, there is widespread recognition of patient-to-patient variability in drug response. The genetic determinants of responses to drugs have important implications for the clinical course and management of HF. Pharmacogenetics (PGt) has drawn great attention for its potential to redirect personal care and public health paradigms. The aim of this review was to gather information on PGt of beta-blockers in HF treatment. We searched for articles related to PGt of beta-blockers in the PubMed database and attempted to cover all related articles. Several genetic polymorphisms affecting proteins in the beta-adrenergic receptor signaling pathway have been proposed as modifiers of HF risk. The most relevant of these to this review is the pharmacogenetic interactions between the genetic variants of catecholamine receptors or their effectors and beta-blockade for the treatment of HF. Interindividual variability of responsiveness to beta-blockers can be explained by PGt data of adrenaline-related genes. To demonstrate that pharmacogenetic intervention produces successful individualized beta-blocker treatment for HF patients, prospective, randomized, and pharmacogenomics (PGx)-based clinical trials are required. Our assessment is that we are already at a turning point in the history of clinical pharmacology.

A ‘vector of rights’ approach for public health: towards an intersectional human rights framework for considering the prevention and treatment of harms to girl child soldiers

The pervasive use of girls as soldiers for sexual and domestic purposes is a common global phenomenon. From a public health perspective, the impact of sexual violence on the mental and physical health and development of these girls is profoundly different from that experienced by boys and adult women in armed conflict. Human rights frameworks — restricted to either women or children — do not address this complex public health reality. This article seeks to develop a rights-based structure of analysis to address these intersecting gender- and age-specific harms.Through a case study of the civil war in Sierra Leone, the authors find that girl soldiers experience a cumulative vulnerability that is not merely additive in nature — girls do not simply face sexism in one context and age-related prejudice in another. Acknowledging this complex reality, this article advances an intersectional rights-based public health paradigm that would view these composite oppressions as interacting and mutually reinforcing under a ‘vector of rights’. Where there is no singular state apparatus to confront these overlapping harms and fulfil these human rights obligations together, the article concludes that international organisations, as representatives of the international community, have a heightened duty as non-state actors to protect girls from harm, proposing complementary international institutions to realise this vector of rights.

Ethnogenetic layering (EL): an alternative to the traditional race model in human variation and health disparity studies

Background: Traditionally, studies in human biodiversity, disease risk, and health disparities have defined populations in the context of typological racial models. However, such racial models are often imprecise generalizations that fail to capture important local patterns of human biodiversity.Aim: More explicit, detailed, and integrated information on relevant geographic, environmental, cultural, genetic, historical, and demographic variables are needed to understand local group expressions of disease inequities. This paper details the methods used in ethnogenetic layering (EL), a non-typological alternative to the current reliance of the biological racial paradigm in public health, epidemiology, and biomedicine.Subjects and methods: EL is focused on geographically identified microethnic groups or MEGs, a more nuanced and sensitive level of analysis than race. Using the MEG level of analysis, EL reveals clinical variations, details the causes of health disparities, and provides a foundation for bioculturally effective intervention strategies. EL relies on computational approaches by using GIS-facilitated maps to produce horizontally stratified geographical regional profiles which are then stacked and evaluated vertically. Each horizontal digital map details local geographic variation in the attributes of a particular database; usually this includes data on local historical demography, genetic diversity, cultural patterns, and specific chronic disease risks (e.g. dietary and toxicological exposures). Horizontal visual display of these layered maps permits vertical analysis at various geographic hot spots.Results and conclusions: From these analyses, geographical areas and their associated MEGs with highly correlated chronic disease risk factors can be identified and targeted for further study.

Pharmaceuticalization: AIDS Treatment and Global Health Politics

This article examines the political economy of pharmaceuticals that lies behind global AIDS treatment initiatives, revealing the possibilities and inequalities that come with a magic bullet approach to health care. It tells how Brazil, against all odds, became the first developing country to universalize access to antiretroviral drugs—a breakthrough made possible by an unexpected alliance of activists, government reformers, development agencies, and the pharmaceutical industry. The article moves between a social analysis of the institutional practices shaping the Brazilian response to AIDS and the stories and lives of people affected by it. It draws from interviews with activists, policy makers, and corporate actors and from longitudinal ethnographic work among grassroots AIDS care services. Pharmaceutical innovations allow unlikely coalitions that both expose the inadequacies of reigning public health paradigms and act to reform, if to a limited extent, global values and mechanisms (of drug pricing and of types of medical and philanthropic interventions, for example). Treatment rollouts are matters of intense negotiation; their local realizations are shaped by contingency and uncertainty. Such realizations encode diverse economic and political interests, as well as the needs and desires of citizens. These therapeutic coalitions also expose the deficiencies of national and local infrastructures and consolidate novel state-civil society relations. A pharmaceutically-centered model of public health has emerged as a byproduct of AIDS treatment scale-up and the sustainability of the Brazilian AIDS policy has to be constantly renegotiated in light of global drug markets. A multitude of networks and variations in AIDS care have emerged on-the-ground, and the article explores why AIDS treatment has been so difficult to put into practice among poor Brazilians, who are often stigmatized as noncompliant or untreatable, becoming invisible to the public. Poor AIDS patients live in a state of flux, simultaneously acknowledging and disguising their condition while they participate in local economies of salvation. At both the macro and micro levels, we see a state of triage and a politics of survival crystallizing.

Haben HIV-Positive eine besondere Verantwortung?

ZusammenfassungIn den 1980er-Jahren haben sich die meisten westlichen Länder für eine auf New Public Health basierte Lernstrategie für den Umgang mit HIV/AIDS entschieden. Jede sexuell aktive Person kann sich selbst schützen, lautet das Paradigma der Lernstrategie. Die Präventionslast müssen nicht die Betroffenen tragen wie bei Bekämpfungsstrategien nach Old Public Health. Es ist für den Autor offensichtlich, dass die New-Public-Health-Strategie gegen HIV unter gleichzeitigem Respekt von Bürger- und Menschenrechten erfolgreich war. Auf dem Hintergrund der Einschätzung, dass die Strategie auch angesichts der Erfolge von ART und steigender Infektionszahlen weiter hin richtig sei, wird die ethische Frage gestellt, wie weit die Mitverantwortung von HIV-Positiven bei der Prävention geht. Der Autor argumentiert für eine Präventionsmitverantwortung einer HIV-positiven Person in einer Liebesbeziehung. Im Gegensatz dazu sollte bei Begegnungen, bei denen es nur um Sex geht, kein Präventionsbeitrag der HIV-Positiven erwartet werden. Mit dieser ethischen Position können die Präventionsbotschaften expliziter und klarer formuliert werden. Eine Betrachtung des Zusammenhangs von Moral, Ethik und Recht rundet die Arbeit ab und fordert mehr Prävention von den Verantwortlichen für Verhältnisse, z. B. im Sexgewerbe.

Strategies for Academic and Clinician Engagement in Community-Participatory Partnered Research

THERE HAVE BEEN RECENT PRACTICE AND POLICY CONcerns over the “quality chasm,” or gap between the promise of evidence-based medicine and the realities of community practice with little variation by geographic and sociodemographic factors. Studies document disparities in access of care for particular conditions, and there is widespread concern about disparities in health status and health risk factors disadvantaging underserved ethnic minority and lower-socioeconomic status groups. Addressing quality gaps and health disparities will require implementation of programs to address social determinants of health and improve services delivery across diverse communities. Doing so for underserved communities may be especially challenging owing to resource constraints, underdevelopment of research, and historical distrust in research and health care in some groups. Experts recommend promoting public participation and engagement of diverse communities in research as a strategy to enhance its relevance and to address disparities more effectively Community-based participatory research (CBPR) is the prevailing paradigm to facilitate these goals by promoting mutual transfer of expertise and power sharing in decision making and data ownership across community and academic partners. A recent review identified relatively few English-language CBPR studies in health but wide variation in extent and type of participation. Community-based participatory research has been used more as a paradigm for public health than for clinical or health services research. Many features of CBPR—such as spending time in the community, power sharing, and action research methods—might challenge physicians, given their clinical training that often requires interactions under time pressure, the hierarchical structure of academic medicine, and the focus of medical research on controlled trials as the standard for evidence. However, opportunities (such as the recent National Institutes of Health announcement for CBPR research [http://grants.nih.gov/grants /guide/pa-files/PAR-07-004.html]) are emerging for conducting CBPR in substantive areas for which physician leadership could be helpful. It is timely to familiarize clinical investigators with principles of participatory research and to offer strategies to build effective research partnerships that facilitate clinician leadership in efforts to improve health for all communities. Over several years, we collaborated in exploring ways of blending concepts and approaches from clinical services research and CBPR in research initiatives, research training of physicians in the Robert Wood Johnson Clinical Scholars Program (http://www.hsrcenter.ucla.edu/csp), and a multicenter effort to develop infrastructure to support community-based research. This approach is based on community-partnered participatory research (CPPR), a form of CBPR developed by Healthy African American Families and Charles R. Drew Medical University with support from the Centers for Disease Control and Prevention (CDC), that emphasizes authentic community-academic partnerships as distinct from many collaborative research activities conducted at community sites without partnership in design, implementation, or product ownership. In collaboration with Keith Norris and Paul Koegel, we blended this model with methods from services research initiatives, such as Partners in Care, that addressed quality disparities. Communitypartnered participatory research promotes equal community and academic partnership and power sharing in all phases of research, grounded in evidence-based practice as defined from academic and community perspectives, a framing of CBPR that is suited to physician coleadership. This Commentary provides lessons learned from these applications. Recent examples are available at http://www .communitytrial.org. Many components of CPPR are partly based on CBPR models but are organized into a particular approach.

Rediscovery Of The ‘Public’ In Public Health

Rediscovery Of The ‘Public’ In Public Health

Finding Common Ground for Environmental Decisions: Public Health Principles as a Foundation for Better Choices

ABSTRACT The history of environmental decision-making in the United States is primarily one of antagonism, conflict, and litigation. Four sectors of American society are typically at odds over why and how to solve environmental problems—government regulators, businesses proponents, environmental advocates, and members of affected communities. Dissimilar worldviews are at the heart of most environmental disputes, and people in the four sectors tend to have diverse perspectives and philosophies that affect how they interpret and respond to environmental issues. To promote integrated, cost-effective decisions, the public health paradigm (prevention first, intervention second, treatment third), as embodied in the Precautionary Principle and the concept of Sustainable Development, should be mutually adopted as a joint framework for prioritizing solutions to pressing environmental problems. The core public health principle of prevention first is a simple yet powerful tenet that can help foster better environmental choices that are more effective, efficient, and equitable.

Time for an additional paradigm? The community-based catalyst approach to public health.

Introduction Governments, major foundations, and international organizations sometimes shift the focus on development initiatives in a fad-like manner, even changing in mid-course. They may also rely on single approaches for tackling complex problems rather than employing multiple strategies. An additional paradigm for public health could bridge the divide between building systems and focusing on a specific disease. A community-based catalyst approach appears to be useful in some situations; the approach presented here is based on ten essential elements and five criteria for using local volunteers in community-based initiatives. Fads and single-mindedness Governments, major foundations and other organizations tend to change focus roughly in unison, suggesting that they are vulnerable to fads, perhaps more so because of the often destructive tension that has existed since the 1800s between "horizontal" and "vertical" approaches (1). Also, they frequently select one principal approach to complex problems, although complexity generally demands multiple strategies. In the middle of the twentieth century, large projects were in Favour among those seeking to facilitate development, but in the 1970s, bad press about "white elephant" projects (e.g. big hospitals in poor countries) helped to drive a dramatic switch to low-technology infrastructure in peripheral localities. In 1970 "traditional birth attendants" (who assist with normal births after limited training) became a focus of the United Nations Population Fund (UNFPA) and of the United Nations Children's Fund (UNICEF), with little back-up for obstetric complications. The Declaration of Alma-Ata in 1978 reinforced the heavy focus on local (under-supported) health workers. Subsequently, education and the goal of developing "civil society" (enhancing social structures outside government) gained favour, as bilateral donors, and especially the major foundations, largely abandoned support for health. Now, with the exception of Japan and the USA, the favoured avenue for bilateral assistance is budget support via ministries of finance for health and other "soft" development areas, though not for airports, harbours and similar "hard" development areas. Massive shifts from one primary strategy, to another have numerous disadvantages. For instance, successful activities being carried out under an approach no longer favoured may be terminated. At The World Bank, most loans for distinct health projects have been cancelled following a shift to budgetary support through "poverty reduction support credits" (PRSCs), a "sector-wide approach". AbouZahr showed how "cautious champions", including well-intentioned international agencies, had even changed their approach several times during a single initiative as they tried to reduce the persistent and scandalously high rates of maternal mortality (2)--equivalent to the number of people who would be killed if one jumbo jet crashed every 4 hours. Contrasting realities Considerable funding for health infrastructures since the Declaration of Alma-Ata has arguably brought relatively little improvement in the provision of adequate health care to poor populations in some contexts. "For a decade, the figure of 500 000 maternal deaths a year has been part of the statistical liturgy" (3). Meanwhile, several disease eradication efforts have been singularly successful in the face of severe corruption, poverty, weak health infrastructures, political chaos and war, using limited resources. The eradication of dracunculiasis (guinea-worm disease) has received less funding since its inception than the poliomyelitis campaign uses each year. Yet the incidence of dracunculiasis has been reduced by more than 99.5%, from an estimated 3.5 million cases in 1989 to 15 522 cases, of which only 1479 were outside Ghana and Sudan, provisionally reported in 2004. The Onchocerciasis Control Programme (which was not an eradication programme) enjoyed similar success for 28 years (1974-2002). …

Aging and the environment: a research framework.

The rapid growth in the number of older Americans has many implications for public health, including the need to better understand the risks posed to older adults by environmental exposures. Biologic capacity declines with normal aging; this may be exacerbated in individuals with pre-existing health conditions. This decline can result in compromised pharmacokinetic and pharmacodynamic responses to environmental exposures encountered in daily activities. In recognition of this issue, the U.S. Environmental Protection Agency (EPA) is developing a research agenda on the environment and older adults. The U.S. EPA proposes to apply an environmental public health paradigm to better understand the relationships between external pollution sources → human exposures → internal dose → early biologic effect → adverse health effects for older adults. The initial challenge will be using information about aging-related changes in exposure, pharmacokinetic, and pharmacodynamic factors to identify susceptible subgroups within the diverse population of older adults. These changes may interact with specific diseases of aging or medications used to treat these conditions. Constructs such as “frailty” may help to capture some of the diversity in the older adult population. Data are needed regarding a) behavior/activity patterns and exposure to the pollutants in the microenvironments of older adults; b) changes in absorption, distribution, metabolism, and excretion with aging; c) alterations in reserve capacity that alter the body’s ability to compensate for the effects of environmental exposures; and d) strategies for effective communication of risk and risk reduction methods to older individuals and communities. This article summarizes the U.S. EPA’s development of a framework to address and prioritize the exposure, health effects, and risk communications concerns for the U.S. EPA’s evolving research program on older adults as a susceptible subpopulation.

The Global Alliance for Vaccines and Immunization: Is It a New Model for Effective Public–Private Cooperation in International Public Health?

The Global Alliance for Vaccines and Immunization (GAVI) has in many ways been remarkably successful in revitalizing the international coalition of institutions and organizations concerned with getting vaccines to the children of the poorest countries. Many have seen this high-profile venture in public-private cooperation as a model for other groups concerned with more effectively helping to solve health problems in the developing world. We examined major flaws in the GAVI and argue that in fact the alliance does not represent a new paradigm for international public health. However, the experience of the GAVI may suggest an alternative, and more effective, way to conceptualize future global initiatives.

A public health perspective for youth gambling

The recent emergence of gambling problems among youth around the world is alarming. For those most vulnerable in our society, children and adolescents, problem gambling presents a serious public health concern. Our current knowledge and understanding of the magnitude of the problem and its considerable impact upon the well-being of youth compels us to respond in a timely and effective manner. A general public health paradigm to gambling, originally articulated by Wynne (1997) and Korn and Shaffer (1999), highlights the importance of such an approach. However, a conceptual model and framework to understand and specifically address youth problem gambling within a public health framework is needed. This article articulates a theoretical framework and model that will help facilitate the development, implementation and evaluation of a comprehensive, multi-level health promotion and prevention strategy for youth problem gambling.