Poverty,Housing, and the Rural Slum: Policies and the Production of Inequities,Past and Present

We studied historical materials to examine the conditions that gave rise to California''s rural slums, the consequences of their emergence, and how interpretations of housing, health, and welfare policies by government officials, and public health officials in particular, produced health inequities for residents of these communities. For more than a century, successive groups of immigrants and domestic migrant laborers have worked on California''s farms and faced numerous challenges, among them a lack of safe and affordable housing, poor working conditions, and denial of public services. Although these experiences are not new, nor are they unique to agricultural workers, they illustrate a longer history in which inequities and injustices have been rooted in the exploitation and disposability of labor. Ameliorating or even redressing inequities will require understanding the social determinants of health through ecological approaches that can overcome the historical, social, and political causes of inequity.FOR MORE THAN A CENTURY, waves of immigrants, predominantly non-White, have composed the agricultural workforce in California.1 By the early twentieth century, public health played a significant role in reinforcing constructions of race and class, particularly regarding immigrant populations.2 Nativist rhetoric often intertwined diseases with immigrants and reinforced the idea that immigrants threatened the health of the United States. In some cases, immigrants were excluded or were denied access to general assistance and health care services. In other cases, immigrants refused these services for fear of being deemed a public charge and running the risk of deportation.Although the 1937 California Welfare and Institutions Code formalized an obligation for local counties to provide access for general assistance and medical care for the indigent, regardless of an individual''s migration status, use of these services required proof of residency, which was at times an insurmountable burden for immigrants and domestic migrant agricultural workers who followed the crops.3 These requirements affected and depended on the ability to establish formal residency as well as where such residency was established.Rather than focusing on the history of immigration and public health in urban communities, we examined the impact of health and housing policies on populations in rural California.4 By documenting this history, particularly regarding housing and formal residency for agricultural laborers in rural areas in the post–World War II period, we sought to address an important gap at the intersection of labor and public health history and illustrate how the inequities agricultural workers experienced were embedded in differential treatment toward immigrants and the disposability of labor. Government officials and public health officials, in particular, participated in worsening the inequities through their application and interpretation of health and welfare policies.     

Healthcare Needs of and Access Barriers for Brazilian Transgender and Gender Diverse People

Transgender and gender diverse people (TGD) have specific healthcare needs and struggles with access barriers that should be addressed by public health systems. Our study aimed to address this topic in the Brazilian context. A hospital and web-based cross-sectional survey built with input from the medical and transgender communities was developed to assess TGD healthcare needs of and access barriers in two Brazilian states. Although services that assist this population have existed in Brazil since the 1990s, TGD have difficulty accessing these services due to discrimination, lack of information and a policy design that does not meet the needs of TGD. A history of discrimination was associated with a 6.72-fold increase in the frequency of health service avoidance [95% CI (4.5, 10.1)]. This article discusses the urgent necessity for adequate health policies and for the training of professionals regarding the needs of Brazilian TGD.     

Medical care reform: lessons from around the world

Once again the United States is in a ferment of health policy reform. Proposals abound but sage observers remark that national health insurance has been "just around the corner" more than once in the last forty years. This time may be different, however. Proposals from all across the ideological spectrum are converging on the notion of "managed care" which is perhaps best known in its guise as a health maintenance organization (HMO). Other forms of managed care exist but they have neither the history nor the incentives found in traditional HMOs. The discussion on national health insurance (NHI) proposals has focused on financing issues to the virtual exclusion of public health concerns. In this article, the author addresses rural health and public hospitals in the United States; two problems that have been with us for a long time. Then articles examining the Canadian and English medical care systems are reviewed, illustrating some of the weaknesses of these approaches to national medical care. Research studies relating to Europe and the developing nations are next. Once again, these are intended to highlight public health problems found in differing medical care systems. Finally, the author examines utopian views of the United States medical care system of the future: the reform proposal offered by the National Association for Public Health Policy, the experimental policy in Washington State, and a vision of a planned system. The review is intended to draw together the lessons offered by public health policy research in other countries and the United States and apply them to the issue at hand: reforming the United States medical care system.     

NAVIGATING the Future Through the Past The Enduring Historical Legacy of Federal Children's Health Programs in the United States

The United States excels at treating the most complex medical conditions, but our low-ranking health statistics (relative to other countries) do not match our high-end health care spending. One way to understand this paradox is to examine the history of federal children''s health programs. In the 1800s, children''s health advocates confronted social determinants of health to reduce infant mortality. Over the past 100 years, however, physicians have increasingly focused on individual doctor–patient encounters; public health professionals, meanwhile, have maintained a population health perspective but struggled with the politics of addressing root causes of disease. Political history and historical demography help explain some salient differences with European nations that date to the founding of federal children''s health programs in the early 20th century. More recently, federal programs for children with intellectual disability illustrate technical advances in medicine, shifting children''s health epidemiology, and the politics of public health policy.HOW DID CHILDREN''S HEALTH in the United States get to where it is today? In some community hospitals in Miami, Florida, my hometown, every birth is attended by a board-certified obstetrician and a board-certified neonatologist. Prenatal care for expectant mothers is widely available, and children are screened and treated for a host of medical conditions from infancy through their school years. If serious illness occurs, vast resources go to medical specialists and hospitals to address the needs of affected children and their mothers. Yet in some neighborhoods, 48% of children aged 3 years are overweight or obese, and asthma rates are double the national average.1 My community is not unique: throughout the United States, we excel at treating the most complex medical conditions, yet we rank poorly relative to other nations on population health measures. In a 2006 international comparison, the United States was first in health care spending and 39th in infant mortality rate (IMR).2 Despite a century of dramatic progress in infant and child mortality, significant disparities that correlate with income, race, and ethnicity persist.3Uneven access to health care is one explanation for our relatively poor health outcomes: millions of US children are uninsured or underinsured, with negative consequences for their health.4 A related factor is that advances in medical care may improve overall health but exacerbate health care disparities, because some populations with better access benefit first from new treatments and health advice.5 A different set of explanations focuses on the social determinants of health.6 Because health is determined by a complex array of genetic, behavioral, social, and environmental factors, access to health care is only one contributing influence on population health. Long-standing differences in housing, nutrition, life experiences, and built environment affect health across the life span and contribute to disparities among populations in the United States.7 The US health care system rarely addresses these underlying causes with the intensity or resources that are devoted to medical care.8 For example, a 2010 study estimated that local, state, and federal investment in public health programs amounts to less than $100 per person in the United States; overall health care spending, by contrast, is more than $6000 per capita.9The neglect of public health in the United States is a vitally important phenomenon that first took shape and then accelerated during the 20th century. In the 19th century, medical practitioners were deeply concerned with each patient''s environment, and they were frequently involved in local public health issues. In larger cities, public health professionals viewed social and political reform as critical to improving population health.10 Over the past century, physicians and public health professionals followed diverging professional trajectories, and tensions arose over the best way to improve the health of US citizens.11 Physicians have increasingly focused on providing technologically sophisticated care to patients in acute care settings; public health professionals, meanwhile, have become responsible for collecting vital statistics, monitoring epidemics, testing for specific diseases, providing health education, addressing maternal and children''s health, and investigating environmental health hazards.12 Both have increasingly relied on the impartial mantle of science while reducing alliances with overtly political groups that address issues such as income, housing, and civil rights.13The 75th anniversary of Title V of the Social Security Act provides an auspicious opportunity to explore how these broader historical trends have affected children''s health. Federal health agencies such as the Maternal and Child Health Bureau (MCHB) have their origins in this landmark legislation,14 and exploring the history of federal programs is one sampling device for understanding the US approach to children''s health. To that end, I reviewed the history of medical care for children in the United States over the past 200 years, explored the origins of federal children''s health programs in the United States in the early 20th century and how those programs differed from those of our European counterparts, and examined how federal intellectual disability programs serve as an example of how Title V leaders (members of the federal government who implemented Title V and distributed funding) crafted strategies to improve children''s health since the 1940s. Decisions made over the past 100 years continue to affect children''s health today.     

Divorce between theory and practice: the system of public health training in the United States

Many analysts have complained about the severe disconnect between public health as it is taught in schools of public health and public health as it is practiced in health departments. At least in the United States, few faculty members teaching in schools of public health have ever worked in public health departments. By the same token, few of those working in public health departments have degrees from schools of public health; most receive on-the-job training. This history traces the roots of this disconnect or "divorce between theory and practice." It finds that the 1930s were the prime years of community-based public health education, when the pressure of the Depression and the funding newly made available from the federal government by New Deal legislation encouraged practical training programs linked to local communities and health departments. The "divorce" began in the post-war period as an unintended consequence of the system for funding medical education and research at a time of general unpopularity of public health during the McCarthy era. Schools of public health were generally ignored in the 1950s and they began to adapt the strategy that continues today, of using research grants, primarily from the National Institutes of Health, to grow their faculty and facilities.     

Fagerstrom test for nicotine dependence vs heavy smoking index in a general population survey

Background

Linkage to care after HIV diagnosis is associated with both clinical and public health benefits. However, ensuring and monitoring linkage to care by public health departments has proved to be a difficult task. Here, we report the usefulness of routine monitoring of CD4 T cell counts and plasma HIV viral load as measures of entry into care after HIV diagnosis.

Methods

Since July 1, 2006, the San Francisco Department of Public Health (SFDPH) incorporated monitoring initial primary care visit into standard HIV public health investigation for newly diagnosed HIV-infected patients in select clinics. Entry into care was defined as having at least one visit to a primary HIV care provider after the initial diagnosis of HIV infection. Investigators collected reports from patients, medical providers, laboratories and reviewed medical records to determine the date of the initial health care visit after HIV diagnosis. We identified factors associated with increased likelihood of entering care after HIV diagnosis.

Results

One -hundred and sixty new HIV-infected cases were diagnosed between July 1, 2006 and June 30, 2007. Routine surveillance methods found that 101 of those cases entered HIV medical care and monitoring of CD4 T cell counts and plasma HIV viral load confirmed entry to care of 25 more cases, representing a 25% increase over routine data collection methods. We found that being interviewed by a public health investigator was associated with higher odds of entry into care after HIV diagnosis (OR 18.86 [1.83–194.80], p =.001) compared to cases not interviewed. Also, HIV diagnosis at the San Francisco county hospital versus diagnosis at the county municipal STD clinic was associated with higher odds of entry into care (OR 101.71 [5.29–1952.05], p <.001).

Conclusion

The time from HIV diagnosis to initial CD4 T cell count, CD4 T cell value and HIV viral load testing may be appropriate surveillance measures for evaluating entry into care, as well as performance outcomes for local public health departments' HIV testing programs. Case investigation performed by the public health department or case management by clinic staff was associated with increased and shorter time to entry into HIV medical care.     

Teaching public health to medical students in the United Kingdom--are the General Medical Council's recommendations being implemented?

BACKGROUND: Despite frequent calls to improve undergraduate medical public health teaching, little is known about whether curricula have changed. We report a survey of undergraduate public health teaching in UK medical schools in 1996. The survey aimed to assess whether the General Medical Council's 1993 recommendations to strengthen undergraduate medical education in public health have been implemented. METHODS: We asked heads of academic departments of public health at all 26 UK medical schools to complete a questionnaire and provide supporting documentation for each undergraduate public health course or module. We compared results from the 1996 survey with those from a similar survey in 1992. RESULTS: Twenty-one out of 26 (81 per cent) medical schools responded. All responding medical schools included public health teaching within their curriculum. The median number of public health courses per medical school was unchanged since 1992. A wide variety of topics were taught. Core public health subjects were taught at most schools, though over a quarter of medical schools did not cover some core topics. Between 1992 and 1996 the proportion of time devoted to teaching by lectures decreased, whereas the following all increased: teaching by small group methods; the proportion of courses using methods of assessment encouraging active learning; and the contribution of public health courses to the final degree assessment. CONCLUSION: The findings suggest that many of the General Medical Council's recommendations for improving the delivery of undergraduate education are being addressed by public health teaching in UK medical schools. However, addressing the gaps in undergraduate public health teaching revealed in this survey is a continuing challenge for academic public health departments. Medical schools should review the content of their undergraduate public health teaching to ensure that tomorrow's doctors are adequately equipped with public health knowledge and skills.     

Struggles for maintenance: Patient activism and dialysis dilemmas amidst a global diabetes epidemic

ABSTRACT

Diabetes has become a leading cause of death in Belize, making this Central American country emblematic of challenges amplified by a growing global diabetes epidemic. The struggles people face as they seek care for chronic conditions like diabetes (and its complications such as kidney failure) are bringing citizens and institutions alike to revisit longstanding norms about the terms through which healthcare is accessed. Ethnographically tracing Belize’s first patient-driven healthcare protests and activism – an ad hoc movement for public dialysis that began over a decade ago – this paper examines patients’ and caregivers’ struggles to probe and shape a legacy of social justice health activism, drawing on perspectives from an often-overlooked part of Central America where basic healthcare access has not historically been framed as a right of citizens. It considers these dilemmas in relation to much larger chronic struggles ‘to maintain’ and repair bodies, medical technologies, and health systems in the aftermath of colonial legacies – with special attention to the challenges posed for small countries now facing rising issues of diabetes injuries and chronic complications – and the role of civic media and citizen activism in this context.     

Public Health in the Vilna Ghetto as a Form of Jewish Resistance

We describe the system of public health that evolved in the Vilna Ghetto as an illustrative example of Jewish innovation and achievement during the Holocaust. Furthermore, we argue that by cultivating a sophisticated system of public health, the ghetto inmates enacted a powerful form of Jewish resistance, directly thwarting the intention of the Nazis to eliminate the inhabitants by starvation, epidemic, and exposure. In doing so, we aim to highlight applicable lessons for the broader public health literature. We hope that this unique story may gain its rightful place in the history of public health as an insightful case study of creative and progressive solutions to universal health problems in one of the most challenging environments imaginable.During World War II (WWII), food, water, medical supplies, and other necessities were withheld by the Nazis, and sanitary living was made virtually impossible in ghettos throughout Eastern Europe.Thus although ghettos preceded the more mechanized extermination camps, which had as their sole purpose the murder of Jews, the result of living in ghettos, which included segregation, humiliation, and death, was similar.1 In response, Jewish public health evolved as a form of resistance to policies that were explicitly designed to ruin human life, health, and dignity.2–5 Using the Vilna Ghetto as an illustrative example of the state of public health achieved in extremis, we hope to demonstrate applicable lessons for the broader public health literature. Furthermore, as scholarship illustrating dilemmas and triumphs of Jewish medicine in the Holocaust continues to prompt reflection in the field of medicine, we aimed to inspire similar discussion with respect to the historical importance of Jewish public health resistance.Although virtually all ghettos had organized departments designed to manage sanitation and public health, hitherto there has been no systematic study of the public health policies of the Jewish leadership in the Nazi-imposed ghettos during WWII. Overall, the Warsaw Ghetto has received the greatest attention, partly because of the particular adversity it faced, as discussed by Charles G. Roland,1 S. M. Shasha,2 and Myron Winick.3 Other important and applicable works have been published by Sara Bender4 and George Weisz et al.5 Mark Dworzecki’s memoirs from the Vilna Ghetto6 and a new work edited by M. A. Grodin add to this literature.7 For this article, we relied on these and other important historical works, including Solon Beinfeld’s Health Care in the Vilna Ghetto.8Vilna is of particular importance because, whereas other ghettos (such as Warsaw’s) have received special attention for their profound challenges—including immense size and less systemic planning—Vilna stands out as an example of what could be accomplished. Jewish leaders in the Vilna Ghetto created a public health system designed to stymy the Nazis’ genocidal mission for as long as possible and vigilantly maintained this organization under increasingly dire circumstances. Because of this, public health measures not only directly benefited the residents but were also a form of political resistance; by their very nature, they were designed to thwart the Nazi genocidal program via organized health policy and practice. Thus we present the Vilna Ghetto as a case study of creative and progressive solutions to universal health problems in one of the most challenging environments imaginable.     

妊娠高血压综合征的影响因素研究

目的:探讨多病因因素对妊娠高血压综合征(妊高征)的影响。方法:2001年2月～2004年10月,观察在本院治疗并分娩的70例妊高征患者,分为两组,本地产妇组24例,外地产妇组46例,对年龄、职业、籍贯、文化程度、就医行为、家庭关系、经济状况以及家族史、体重指数、季节变化等妊高征的多病因因素及相关因素进行分析比较。结果:外地产妇组文化程度低,经济收入少,两组家庭经济收入比较,χ2=5.59,P<0.05,差异有显著性;外地产妇组就医行为差,两组就医行为比较,χ2=32.66,P<0.005,差异有极显著性。结论:妊高征是一种身心疾病,与环境因素、行为生活方式、医疗卫生服务相关。对妊高征的防治应该是全方位的,为提高整个民族的生活质量,社会要关心外来民工这一弱势群体,提高他们的自我保健意识。对于妊高征,重要的是预防,而不仅仅是药物治疗。     

Health promotion: a global perspective

The first part of this paper reviews the work of the World Health Organization's Regional Office for Europe undertaken to clarify the relevance of health promotion for all member states and regions. This work led to a definition of "health" as the ability to realize aspirations and satisfy needs and to change or cope with the environment. Health promotion was considered to 1) involve the population as a whole in the context of everyday lives, 2) be directed towards action on the determinants of health, 3) combine diverse but complementary methods or approaches, 4) aim for effective and concrete public participation, and 5) involve health professionals. Areas covered by health promotion activities include 1) access to health, 2) development of an environment conductive to health, 3) strengthening of social networks and social supports, 4) promoting positive health behavior and appropriate coping strategies, and 5) increasing knowledge and disseminating information. The next section of the paper traces the development of the concept of health promotion from its roots in health education, and the third section presents a brief history of public health to contextualize this development. The differences between the old and new approaches to public health are presented (the new role of the health sector is to ensure access to health, create advocacy for health, and move beyond health care through intersectoral action and public participation), and the new "forcefield" of public health that emerges from a conceptualization of health promotion is described. This forcefield, illustrated as a triangle linking healthy public policy, health promotion, and community action, works at all levels and is the framework for the development of appropriate strategies. It is concluded that in many cases public health will have to be reorganized as will the health care system as a whole. Health must be viewed as a social project linked to political responsibilities not as a medical enterprise.     

The role of epidemiology in the committee on the costs of medical care

Among the most important 20th century documents of American public health is the 1932 report of the Committee on the Costs of Medical Care (CCMC). In May 1927, leaders of medicine, public health, and the social sciences, met at the annual meeting of the AMA, to consider that, despite advances in medical sciences, a vast amount of preventable disease and unnecessary death existed. A committee of 50 men and women, the CCMC, was formed to investigate. Of the six public health members, three were epidemiologists. A spectrum of governmental and private organizations supported the CCMC and eight foundations provided funding. A staff of 51 conducted 26 studies, many epidemiological, to support its five categorical recommendations. Briefly these were: 1) Medical services, preventive and therapeutic, should be provided by interdisciplinary groups; 2) Basic public health services should be available to all without cost; 3) The costs of medical care should be placed on a group basis (insurance, taxation, or a combination thereof); 4) Study, evaluation, and coordination of medical and public health services should be important functions for local and state governments; and 5) Professional education for a wide variety of medical and public health personnel should be greatly expanded with emphasis on prevention and social considerations.Perhaps the most interesting of the CCMC's epidemiological studies was, "The Incidence of Illness and the Receipt and Costs of Medical Care Among Representative Families: Experiences in Twelve Consecutive Months During 1928-1931." This study included 8,639 families comprising 38,668 persons and described the then current status of medical care and public health practice in the U.S.A.The final report of the CCMC contained minority reports ranging from claims that the recommendations were too radical to assertions that they didn't go far enough! Nevertheless, they have been the focus for medical and public health concern and controversy for almost three-quarters of a century. Their roots in epidemiology should not be forgotten!     

Risk factors for hysterectomy among Brazilian women

A case-control study was conducted to investigate risk factors for hysterectomy among women using the public health system in Northeast Brazil. The cases were 373 women aged 30-54 years that had undergone elective hysterectomy for benign pelvic conditions. Controls were 742 women with preserved uterus selected from public health clinics. Data were collected through a review of medical records and a personal interview using a structured, pre-tested questionnaire. Unconditional multiple logistic regression was applied in the analysis. Women at greater risk for hysterectomy were those with a higher per capita family income, zero to three children, a history of medical consultation for menstrual problems, hospitalization for gynecological problems, or tubal ligation before age 30 years. Menopause and a history of stillbirth appeared as protective factors in the statistical analysis.     

An evidence-based review of current guidelines for the public health control of typhoid in Australia: a case for simplification and resource savings

BACKGROUND: Although an uncommon disease in Australia, public health control measures for typhoid remain important to prevent further cases, however, they are labour intensive. METHODS: We reviewed current guidelines from all Australian states and territories, England and the United States to ascertain whether recommended control measures for typhoid are supported by evidence from the medical literature or data from Victorian typhoid notifications. RESULTS: Guidelines lacked consistency and were overly complex, particularly with reference to the frequency and timing of faecal specimens required to demonstrate eradication of typhoid from cases and contacts. Data from the medical literature are limited and do not support the superiority of any one approach, or multiple approaches based on risk groups of cases or contacts. Victorian data suggest that a general approach, with a reduction in the number of specimens collected and duration of follow-up is reasonable. CONCLUSIONS: Potential exists for simplification and improved consistency between guidelines for the public health control of typhoid, with associated resource savings.     

Factors promoting follow-up services after medical examinations by municipal governments

OBJECTIVE: All Japanese municipal governments have a responsibility to conduct a medical examination for their residents aged 40 or more under the Health Services for the Elderly Act since 1984. According to the results of the medical examination, municipal governments should give appropriate follow up services to all users. The objective of this study was to find the factors promoting follow up services after medical examinations conducted by municipal governments. SUBJECTS AND METHODS: Mailed questionnaire surveys on follow up services after medical examination were sent out to all 3,255 municipal governments in Japan. The 2,447 municipal governments that answered all items on the questionnaire were enrolled in this study. Follow-up services by municipal government for persons with abnormal findings at medical examinations included "Suggestion to have a more detailed examination", "Confirmation of having had a detailed examination", "Individual health consultation", and "Home visit for medical guidance". These follow-up services were analysed in terms of the number of public health nurses per population and whether a continuous data set was maintained for medical examinations. RESULTS: Follow-up services were conducted more frequently in municipalities that maintained continuous data sets of medical examination than those that did not. They were also carried out more frequently in municipalities with higher numbers of health visitors per population than in those with lower numbers. The percentage of municipal governments that maintained continuous data of medical examinations was higher among those that conducted group medical examinations than those that conducted individual medical examinations at local medical facilities. CONCLUSION: Follow-up services after medical examinations by municipal governments showed a significant relationship with maintenance of a continuous data set of medical examinations and the number of public health nurses.     

Chronic disease, prevention policy, and the future of public health and primary care

Globally, chronic disease and conditions such as diabetes, cardiovascular disease, depression and cancer are the leading causes of morbidity and mortality. Why, then, are public health efforts and programs aimed at preventing chronic disease so difficult to implement and maintain? Also, why is primary care—the key medical specialty for helping persons with chronic disease manage their illnesses—in decline? Public health suffers from its often being socially controversial, personally intrusive, irritating to many powerful corporate interests, and structurally designed to be largely invisible and, as a result, taken for granted. Primary care struggles from low reimbursements, relative to specialists, excessive paperwork and time demands that are unattractive to medical students. Our paper concludes with a discussion of why the need for more aggressive public health and redesigned primary care is great, will grow substantially in the near future, and yet will continue to struggle with funding and public popularity.     

Evaluating the treatment of sexually transmitted diseases at an urban public hospital outpatient clinic.

Sexually transmitted diseases occur disproportionately among the poor, are often treated in public hospitals and clinics, and have not been subjected to quality-of-care evaluation. We designed a medical record abstraction system using well-established, specific process-of-care criteria drawn from the medical literature and experts and grouped into three levels of quality: excellent, adequate, and minimal. One hundred seventy-six consecutive patients were identified from the clinic logbook and their medical records abstracted. Deficiencies in history taking, physical examination, laboratory testing, treatment, and public health reporting were identified.     

AIDS in historical perspective: four lessons from the history of sexually transmitted diseases.

Four lessons from the social history of sexually transmitted disease in the U.S. are assessed for their relevance to the current AIDS epidemic: fear of disease will powerfully influence medical approaches and public health policy, education will not control the AIDS epidemic, compulsory public health measures will not control the epidemic, and the development of effective treatment and vaccines will not immediately or easily end the AIDS epidemic. Diseases are complex bio-ecological problems that may be mitigated only by addressing a range of scientific, social, and political considerations; no single intervention will address the complexities of the AIDS epidemic.     

Can abuse deterrent formulations make a difference? Expectation and speculation

Background

Five cases of severe neutropenia (neutrophil counts < 0.5 per 10⁹ cells/L) associated with exposure to cocaine and levamisole, an antihelimithic agent no longer available in Canada, were identified in Alberta in 2008. Alberta and British Columbia (BC) public health officials issued an advisory and urged health care professionals to report cases to public health. This paper presents the findings of the public health investigations.

Methods

Cases were identified prospectively through reporting by clinicians and a retrospective review of laboratory and medical examiners data from January 1, 2006 to March 31, 2009. Cases were categorized as confirmed, probable or suspect. Only the confirmed and probable cases are included in this paper.

Results

We compare cases of severe neutropenia associated with tainted cocaine (NATC) identified in Alberta and BC between January 1, 2008 to March 31, 2009. Of the 42 NATC cases: 23(55%) were from Alberta; 19(45%) were from British Columbia; 57% of these cases reported crack cocaine use (93% of those who identified type of cocaine used); 7% reported using cocaine powder; and the main route of cocaine administration was from smoking (72%). Fifty percent of the NATC cases had multiple episodes of neutropenia associated with cocaine use. Cases typically presented with bacterial/fungal infections and fever. One Alberta NATC case produced anti-neutrophil antibodies, and four were positive for anti-neutrophil cytoplasmic antibody (ANCA). Analysis of two crack pipes and one drug sample obtained from NATC cases confirmed the presence of both cocaine and levamisole. A further 18 cases were identified through the retrospective review of laboratory and medical examiner data in Alberta

Interpretation

Our findings support a link between neutropenia and levamisole tainted cocaine; particularly from smoking the crack form of cocaine. Some patients may be genetically predisposed to develop levamisole-related neutropenia. Awareness of the differential diagnosis will assist clinicians with case timely detection and appropriate management.