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Jeffrey A Brinker, M.D.

Jeffrey A Brinker, M.D.

  • Professor of Medicine
  • Joint Appointment in Radiology and Radiological Science


One enthusiastic physician established a busy vasectomy facility at the main Bombay railway station purchase ziana online from canada. In addition to 15g ziana with mastercard those undergoing ster ilization buy ziana on line, candidates were brought to the camps by promoters, and medical person nel performing the services were all rewarded with monetary incentives of varying amounts. Government officials participated in many of these camps, lending a coer cive element to the process. In 1970, the most spectacular vasectomy camp was organized in the Ernaculum district of Kerala. Krishnakumar, the district collector (chief government adminis trator), launched a massive publicity campaign prior to a one-month vasectomy camp. He organized a march by thousands of men carrying family planning banners to the town hall, where the vasectomies were performed. During the period of aggressive vasectomy campaigns, India led the world in the number of sterilizations performed, both vasectomies and tubectomies. During his assignment as Home Secretary (1971?73), Narain estimated this number as exceeding 4. Coercion and The Emergency? In 1975, Prime Minister Indira Gandhi declared an emergency because of an eco nomic crisis brought on by crop failure and doubled oil prices. She proposed a 20-point program to deal with the crisis that, surprisingly, failed to mention control of population growth. Sanjay Gandhi, her son and heir apparent, however, promoted his own four-point program, which gave top priority to population control. Accord ingly, he set about persuading politicians throughout the country to adopt harsh measures to bring down the birthrate. Sterilization was the method of choice, inspired by the success of the vasectomy camps with their packages of incentives and active involvement by local government officials. Consequences of the Emergency States raised their sterilization targets and introduced coercive measures to meet these targets. For example, in Bihar, public food rations were to be withdrawn from cou ples with more than three children. A law was passed in Maharashtra requiring sterilization for couples with more than three children. While such coercive measures were adopted to curry favor with Sanjay Gandhi, few were actually implemented (Gwatkin 1979). The number of sterilizations conducted during the 12 months beginning in April 1975 escalated to 8. Fresh Start at Democratic Approach to Family Planning A revised population policy was inaugurated in 1977. Family planning was renamed as family welfare and sterilization targets were reduced significantly. The new policy was designed to promote education and motivation and was directed primarily at spacing births rather than lowering fertility. The govern ment acted on this information by raising the official minimum age of marriage to 18 for girls and 21 for boys. Politicians and policy makers had also learned the hard lesson that couples opted for sterilization so late in their reproductive lives that the procedure barely made a dent in population growth. Howard Taylor, professor of obstetrics at the Columbia College of Physicians and Surgeons, and Bernard Berelson, president of the Population Council. As Taylor and Berelson recognized, women who have recently delivered or aborted are partic ularly willing to accept a birth control method (Ross and Mauldin 1988). According to follow-up data, another 5 percent accepted a method within three months of their discharge (Visaria and Jain 1976). Although hospital-based programs had appealing features, their scope was lim ited, as an extremely small percentage of births took place in hospitals in India, even in the cities; such facilities were not available in most rural areas. Hospital-based pro grams could at best reach urban elites, who generally did not need incentives for practicing family planning. Bold Experiment By its nature, such an audacious experiment in an untraversed field as family plan ning as part of the economic development process was bound to face many setbacks, even in the midst of successes. Early in his term, Prime Minister Nehru and his Planning Commission recognized the urgent need to control population growth and to permit the use of artificial meth ods of birth control, a drastic diversion from the Gandhian legacy that had guided the path to an independent India. Without experience from other countries to draw on, policy makers were prepared to take decisions and to change course and seek advice and assistance when necessary. Although by no means an unmitigated success, the Indian program left an indeli ble mark on the history of early family planning efforts in the 20th century. Calculations based on the number of births averted concluded that the annual birthrate fell from about 42 live births per 1,000 population in 1960?61 to about 38 in 1970?71 and about 35 in 1974?75. Incom plete vital statistics make these birthrate calculations approximate at best. Furthermore, It is quite difficult to isolate the effect of the family planning pro gram on the birthrate of a country or to establish a causal relationship between program efforts and a decline in the birthrate even when adequate data on the many interrelated factors affecting the birthrate are available? (Visaria and Jain 1976, p. Social Setting From the earliest days of family planning until the present, the acceptance of family planning between the south and north of India has diverged sharply. The so-called four poor-performance states of Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh in the northern Hindi belt? are notable for their poverty and for their slow progress in relation to all elements of development, not just family planning. In 1971, for example, the literacy rate in such states as Bihar and Rajasthan was about 18 to 20 percent, in con trast to some 60 percent in Kerala, a high-performance state in the southwest. For example, the number of illiterate people increased by about 16 percent during 1961 to 1971 (Visaria and Jain 1976). As of 1974?75, the proportion of married couples with three or more children adopting birth control methods ranged between 5 and 10 percent in such states as Bihar, Rajasthan, and Uttar Pradesh, compared with 20 to 49 percent in such rela tively literate states as Gujarat, Karnataka, and Maharashtra. The Indian experience offers a clear demonstration of an analysis by Freedman and Berelson (1976) of the joint effects of the strength of a family planning program and the social setting. The major components of the social setting are literacy and education, especially of women; the level of families? economic well-being; the acces sibility of health facilities, including family planning facilities; and child survival lev els.


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Others from within and outside Guatemala tried to order ziana uk defend the benefits of such programs buy 15g ziana with visa. A major factor in the hostility toward los norteamericanos? or gringos? (that is discount ziana 15g with visa, the United States) was the military invasion in 1954, in which the United States had supported a coup led by Colonel Carlos Castillo Armas that unseated President Jacobo Arbenz Guzman, who the United States viewed as a communist for having expropriated the banana farms of the United Fruit Company. The overbearing power and influence of the United States throughout the Western hemisphere was a thorn in the side of many Latin American countries during this period, and revolutionary fervor often found its voice on university campuses. The anti-American climate at San Carlos was so intense that it caused the univer sity to make decisions that actually went against its own self-interests. In another case, the University of San Carlos declined the offer by Ferdinand Rath of the Latin American Demographic Center to establish its Central American branch for demographic research in Guatemala. Instead, the regional center was established in Costa Rica, subsequently produced some of the best demographic research in Latin America, and trained a number of Central American demographers. The opposition of the University of San Carlos to family planning has had nega tive repercussions that are still felt to this day. First, the university authorities prohibited research in the area of human reproduction: it blocked research by Dr. Sec ond, the university did not train or permit training of its medical students in family planning, contraception, and other aspects of human reproduction. When medical students in their final year or recent graduates were sent to practice in rural areas, they did not have even the most fundamental training in contraception. Similarly, the National School of Nursing, which was run by Catholic nuns, denied this type of training to its students. Thus, the doctors and nurses graduating from these programs did not have the necessary knowledge and competencies to deliver family planning services. Moreover, they tended to have negative attitudes to family planning, which combined with the weak to nonexistent support of family planning in government facilities to further doom family planning in the public sector. Despite being a majority, the indigenous population has endured for decades social and economic oppression at the hands of the Spanish speaking ladinos (the white and mestizo population that has controlled economic resources since the time of the conquistadores). The vast majority of Mayans live in poverty in rural areas, experience high rates of maternal and infant mortality, and have low rates of education and literacy. In addition, their unique view of the world (cosmovision) conflicts with some aspects of planned fertility control. The marked differences between ladinos and Mayans in political power, educational levels, access to the media and Western ideas, and cultural values explain the dramatic differences in contraceptive use between the Spanish-speaking ladinos (52. However, this was not a major issue in the 1960s, as the early programs sought to increase demand and provide services to low-income, primarily ladino, populations in urban areas. Yet, at the same time, the socioeconomic characteristics and cultural values of the predominant group in the country certainly did not help the introduction of family planning in the country. The Internal Civil Conflict the 1960s witnessed the beginning of an internal armed conflict that would expand into civil war in the 1970s, peaking in the 1980s, and lasting until the signing of the peace agreements in 1996. This conflict first developed in the eastern highlands, where the Guatemalan army allegedly repeatedly attacked guerilla forces. Soon after, the conflict shifted to the mountainous northwestern region, home to large segments of the indigenous population. Mayans who assumed any type of leadership position during la violencia in the 1980s took huge risks, as many disappeared,? while oth ers managed to flee the country. In the midst of this violent and chaotic situation, the government and nongovernmental organizations, already challenged to provide health services to rural populations, found the job next to impossible. Although this situation had tremendous implications for the expansion of family planning service delivery into rural areas in the 1980s and 1990s, it did not have a major influence during the early years of family planning, when programs targeted urban areas. Lessons Learned the lessons learned from the Guatemala experience may be of limited value for pro grams in other countries with a different sociocultural context and at a different historical point in relation to family planning. The experience of Guatemala illustrates the difficulty of firmly establishing family planning in a country where the Catholic Church and the government join forces in their opposition to family planning. The strong opposition from the leading university in the coun try had strongly negative repercussions that stymied contraceptive research, training of health workers, and provision of contraceptive services. The large indigenous pop ulation in Guatemala and the incipient civil unrest were other factors that hindered the introduction of family planning, especially in the 1980s and 1990s. Against this backdrop of obstacles, several factors kept family planning alive in the early days. Second, even though the ruling elite opposed family planning, the demand for contraception was strong and people responded to the offer of services. Fourth, key figures in the media kept the topic of population and family planning in the public view and periodically challenged the position of the Catholic Church. As concerns what might have been done differently, with hindsight, more effort should have been invested in understanding the sociopolitical context and in design ing and implementing programs tailored to local needs. Certainly the Ministry of Health should have disseminated the legislative agreement that established family planning more widely within the min istry, and it could have avoided the antagonism toward the program that was created by the financial incentives given to family planning service providers. For other countries struggling to introduce family planning under unfavorable conditions, the following recommendations may be pertinent: Conclusions the difficulties that the pioneers in family planning confronted during the 1960s foreshadowed problems that have continued to hinder progress ever since. Yet the lack of political support, the incessant attacks by the Catholic Church, and the periodic civil unrest all took their toll, as reflected in the still low level of contraceptive prevalence in Guatemala. This training took place at the National Cancer Institute, then subsequently in the Central American School for Cytology, which was based at the Roosevelt Hospital in Guatemala City. When, eventually, population control became national policy, the relation ship between the initial private programs and the national effort did not always evolve smoothly, as the Jamaican experience shows (see box 10. A related question was whether the family planning program should be a vertical one, that is, with a staff directed toward a sole objective, or whether it should be integrated within the public health service.

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Family Planning under the Current Health Service Structure In 1993 ziana 15g, the 1987 changes were largely reversed buy discount ziana on-line. The subhealth post is the first contact point for basic health care and referral services cheap ziana amex, and in practice, it is also the referral center for traditional birth attendants, female community health volunteers, and community-based activi ties such as immunizations and primary health care. Each level above the subhealth post is a referral point in a hierarchical network designed to ensure the availability of basic health services and to make minor treatment accessible and affordable. Logistical, financial, supervisory, and technical support is provided to each lower level from the one above. The institutions involved in the delivery of basic health services during 2001 to 2002 included 78 hospitals, 188 primary health centers or health centers, 608 health posts, and 3,129 subhealth posts. At the community level, Nepal had 48,307 female community health volunteers, 15,553 traditional birth attendants, and 14,769 pri mary health care outreach clinics. All these are to some extent involved in providing family planning information, services, or both to clients. It has also conducted various studies and has gathered extensive data through such means as national fertility and family planning surveys. Subsequently, surveys of this type have taken place every five years, namely, the contraceptive prevalence survey (1981); the Nepal fer tility and family planning survey (1986); and the demographic and health survey (1991, 1996, 2001, 2006). This figure increased remarkably to more than 50 percent by 1981 and to 99 percent by 2001. This suggests that informa tion, education, and communication activities were more intense and effective dur ing that period. Among the modern methods, sterilization (male and female), fol lowed by injectables, the pill, and condoms, are now the best known. Current Use During 1976 to 2001, the percentage of currently married women using modern con traceptives increased from 2. Sterilization Regret and Quality of Care Sterilization has been, and continues to be, the major thrust of the family planning program. Mobile sterilization camps are organized around the country each year and those who are sterilized receive some financial compensation. Almost two-thirds of contraceptive users (60 percent) are using sterilization (male or female). The extent of regret about opting for sterilization may serve as an indicator of the quality of care (informed choice, choice of method, counseling, and provision of good quality serv ices) offered by the program. Overall sterilization regret among currently married women who are sterilized or whose husbands are sterilized is about 8 percent accord ing to the 2001 survey. The declines in sterilization regret and in regret because of side effects between 1996 and 2001, while small, suggest that the quality of care might have improved slightly during the period. Family planning users are largely dependent on the public sector for services and supplies (table 21. Availability and Accessibility Access to contraception has improved over time because of the expansion of health institutions and the increased number of female community health volunteers, who distribute contraceptives, especially condoms and pills. According to available infor mation, in 1976, half of married women said that it took more than a day to reach a service delivery point. This improved to 2 hours or more in 1991 and then to 30 minutes in 2001 (Thapa and Pandey 1994). Unmet Need the demand for family planning is quite high based on the level of current use plus the level of unmet need. Unmet need is defined as those who say that they do not want any more children or that they want to wait two or more years before having another child, but are not using contraception. In the 2001 survey, unmet need for family planning was approximately 28 percent, 11 percent for spacing, and 16 per cent for those not wanting more children. At the same time, the survey revealed a substantial gap between the total wanted fertility rate (2. This implies that Nepalese women want fewer children than they are currently having. More unwanted pregnancies could be avoided by having a more aggressive family planning program. The focus has been on marital fertility and contraceptive use, as distinct from changes in the age of marriage or the use of induced abortion. Nevertheless, demand and unmet need are still high, and services need to be expanded and made more effec tive to further reduce unwanted pregnancies. The early program decision to focus on developing basic infrastructure, such as physical facilities and human resources, helped accelerate the implementation of services during the ensuing years. During most of the period under discussion, Nepal was divided geographically into more than 4,000 panchayats, each consisting of nine wards, with each ward made up of one or more villages. The panchayat system was also partly political, and thus the term resists translation. Basic health services, which were offered through district hospitals and rural health posts, were defined as immunizations; assistance to mothers during pregnancy and delivery; postnatal care and health services for children; contraceptive advice and services; adequate, safe, and accessible water supplies; sanitation and vector control; health and nutrition education; diagnosis and treatment of simple diseases; first aid and emergency treatment; and referral facilities (Justice 1989). Kathmandu: Family Health Division of Department of Health Services, Ministry of Health. Policies, Plans and People?Foreign Aid and Health Development: Comparative Studies of Health Systems and Medical Care. Indeed, foundations and governments, and accordingly technical aid programs, doubted the value of introducing population programs to the region in the 1960s, as the countries were poor, attitudes were mostly pro-natalist, and independence was recent. The early Population Council program in Ghana happened largely by accident, but Ghana turned out to be a fortunate setting.

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Use of peptide protects the skin from invasive bacterial human reconstructed epidermis to buy ziana 15g low price analyze the regula infection purchase cheap ziana on line. Human beta lowing bacterial infection: role in cutaneous host defensin-2 production in keratinocytes is regulated by defense best buy ziana. Cutaneous injury induces the release of catheli antimicrobial peptides and proin? Granulysin: a novel host express functional cathelicidin antimicrobial peptides defense molecule. Endogenous anti Granulysin-derived peptides demonstrate antimi microbial peptides and skin infections in atopic der crobial and anti-in? A new microbial activity of cytolytic T cells mediated by concept for acne therapy: a pilot study with zileuton, granulysin. For a long time hyper seborrhea has been considered as a major etio pathogenetic factor for the development of acne. However, current research provides evidence that sebum quantity per se cannot be the only respon sible factor, as demonstrated by the success of treatment with agents with no primary effect on sebum excretion rate [3]. Indeed, additional func tions of the gland are associated with the develop ment of acne (Table 23. Zouboulis Keratinocytes and sebocytes, as major compo Departments of Dermatology, Venereology, Allergology and Immunology, nents of the pilosebaceous unit, may act as Dessau Medical Center, Dessau, Germany immune-active cells capable of microbial C. Acting that way, keratinocytes and alterations of fatty acid composition [32, 33 ] sebocytes may be activated by P. Lower essential fatty acid levels were addition, antimicrobial peptides, such as defensin found in wax esters in twins with acne rather than 1, defensin-2, and cathelicidin, are expressed and in twins without acne [34]. It is a mixture of follicular keratinization leading to comedogene relatively nonpolar lipids [22, 23], most of which sis in rabbit skin but to minor irritation in human are synthesized de novo by the sebaceous gland skin [36]. Overall, free fatty acids were detected of the mammals to coat the fur as a hydrophobic to express proin? The composition of sebum is Altered ratio between saturated and unsatu remarkably species speci? The human skin as a hormone target play an important role in the progression of com and an endocrine gland. Enzymes involved in the biosynthe composition and the oxidant/antioxidant ratio sis of leukotriene B4 and prostaglandin E2 are active in of the skin surface lipids are major concurrent sebaceous glands. Evidence for events associated with the development of acne expression of melanocortin-1 receptor in human sebo [1]. Moreover, several lipid fractions, tericidal oleic acid effective against skin infection of especially sebaceous lipid fractions, also methicillin-resistant staphylococcus aureus: a therapy express antibacterial activity, possibly protect concordant with evolutionary medicine. Human beta defensin-1 and -2 expression in human pilosebaceous units: upregulation in acne vulgaris lesions. New develop innate immune defense of human sebocytes by upreg ments in our understanding of acne pathogenesis and ulating? Neonatal receptor 2-responsive lipid effector pathway protects skin: structure and function. Testosterone synthesized in cultured human stearoyl-CoA desaturase and fatty acid desaturase 2 23 Acne and Antimicrobial Lipids 183 expression by linoleic acid and arachidonic acid in 37. Picardo M, Ottaviani M, Camera E, Mastrofrancesco and apoptosis in human immortalized sebocytes. Essential of lipid peroxide in the content of comedones may be fatty acids and acne. Further insight into the pathomechanism classes in sebum by rapid resolution high-performance of acne by considering the 5-alpha-reductase inhibi liquid chromatography and electrospray mass spec tory effect of linoleic acid. Chiba K, Yoshizawa K, Makino I, Kawakami K, composition of human skin surface lipids from birth Onoue M. On the biogenesis of the free composition during therapy for severe acne vulgaris fatty acids in human skin surface fat. Thielitz Dermatologisches Zentrum/iDerm, Berufsgenossenschaftliches Unfallkrankenhaus Hamburg, Hamburg, Germany 24. Gollnick (*) Acne is a frequent reason to use sunbeds and has Department of Dermatology, Otto von Guericke Universitaet Magdeburg, Magdeburg, Germany been identi? Gollnick psoriasis, eczema, and acne use sunbeds more because the results were inferior to other avail often than unaffected individuals [2]. One observational studies dating from 1978 to 1987 major methodological drawback of the available and no controlled clinical studies exist. No therapeutic suntanning? should be Benzoyl peroxide Mild photosensitivity recommended. An investigation of appearance motives for tanning: the development and evaluation must be taken into account especially when topi of the Physical Appearance Reasons For Tanning cal or systemic anti acne drugs are prescribed. Boldeman C, Beitner H, Jansson B, Nilsson B, Ullen corneum thickness (topical and systemic retinoids) H. A questionnaire sur phototoxic reactions (tetracyclines), as well as on vey among Swedish adolescents. Agents that the interactions of topical and systemic acne drugs cause enlargement of sebaceous glands in hairless with sun/light exposure [16?21 ]. Novel aspects in cutane ous biology of acetylcholine synthesis and acetylcho 24. Enhanced comedo formation in rabbit racyclines, and sunscreens are recommended ear skin by squalene and oleic acid peroxides. Ultraviolet phototherapy and mouse skin benign tumors by free-radical-generating photochemotherapy of acne vulgaris.


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