Program in Infectious Disease and Social Change
Salmaan Keshavjee MD, PhD, ScM, Program Director
More than 50 years after the development of effective antibiotics, infectious diseases remain the leading cause of mortality in most of the world: one-third of all deaths are attributable to bacterial, viral, or parasitic infections. Complex, sometimes chronic, infectious diseases pose major challenges to improving the health of populations and have a profound impact on social and economic development. Because these diseases are fundamentally both biological and social in nature—existing at the nexus of political, economic, religious, and social structures—understanding them and intervening effectively in their control require an analytic lens that draws from multiple social and biological disciplines.
The Program in Infectious Disease and Social Change brings together clinicians, anthropologists, epidemiologists, and public health specialists, who approach the study of infectious diseases from the vantage point of multiple and complementary disciplines. Investigators apply ethnographic and other social science methods to understand these diseases and the responses to them at the local and global levels—from the experience of patients and families confronting illness and inadequate health care to the construction of national and global health policies. Program faculty also apply epidemiologic methods to understand the factors affecting treatment outcomes and to improve treatment through observational studies and clinical trials of existing and new regimens.
The Program in Infectious Disease and Social Change addresses gaps in knowledge concerning the emergence and persistence of infectious diseases and applies this knowledge to improving and expanding access to effective therapies. Educational objectives include:
- Educating undergraduate and graduate students, postgraduate trainees, and health care professionals in research and practice methods appropriate to the biosocial complexity of infectious diseases.
Research objectives include:
- Conducting research on infectious disease to increase access to care (including preventive services), improve treatment outcomes, and strengthen health systems.
Service and policy objectives include:
- Using research findings to improve local health care delivery approaches.
- Using research findings to guide development and implementation of social, health, and economic policies—locally, nationally, and globally—that will reduce the disproportionate burden of infectious diseases among the world’s poor.
- Ensuring that linked service efforts reflect and inform the Program’s research, education, and policy objectives.
Featured InitiativesMultidrug-Resistant Tuberculosis Treatment and Policy
Faculty on this project are involved in the following research, teaching, and service areas:
- Design, implementation, and evaluation of programs that provide treatment for multidrug-resistant tuberculosis (MDR-TB)
- Treatment outcomes research
- Transmission dynamics of drug-resistant tuberculosis
- Clinical trials to optimize existing tuberculosis drugs and new antituberculosis therapies, including novel drug-delivery mechanisms and leadership of the RESIST-TB clinical trials network
- Tuberculosis infection- and transmission-control research
- Development of local and international guidelines and policy for drug-resistant tuberculosis
- Provision of technical assistance for international agencies to more than 50 countries
- Training of health workers at all levels in Africa, Asia, Eastern Europe, and the Americas
- International course for engineers and architects to build capacity for scaling up global efforts to address MDR-TB
This active program of research on the social, behavioral, and psychosocial dimensions of HIV treatment and prevention in sub-Saharan Africa and Haiti involves extensive collaborations between project faculty and clinicians, program directors, and policymakers in Haiti and sub-Saharan Africa. These efforts include:
- Basic and operational research projects in Nigeria, Tanzania, and Uganda addressing key questions of health care delivery in a number of domains; for example, adherence to antiretroviral treatment for HIV/AIDS, retention in care, decentralization of health care, and health systems integration and strengthening.
- Training in social science concepts and methods for HIV research in low-income countries.
- The implementation of a family-centered psychosocial support group model in Haiti with HIV-affected youth and their caregivers; this effort includes research into the effectiveness of such a support group model.
- Development of monitoring and evaluation systems, including HIV/TB monitoring, for programmatic efforts, such as the Village Health Works initiative in Burundi.
- Clinical trial research aimed at identifying effective prevention of HIV infection in Tanzania.
- Mentorship of Harvard Medical School students and contribution to Harvard classes.
Project faculty have been integral to establishing the Latin American and Caribbean Initiative for the Integration of Prenatal Care with the Testing and Treatment of HIV and Syphilis (ILAP, acronym in Spanish). The project’s goal is to conduct operational research designed to contribute to the integration of prenatal care with the diagnosis and management of HIV and syphilis. An additional goal is to improve efforts to prevent mother-to-child transmission of HIV in participating Latin American and Caribbean countries.
- The Perinatal and Neonatal Clinical History Form (PANC) Project. Characterizing the current use of the form most commonly used in Latin America to record a prenatal clinical history, facilitating its development as an instrument to record and report data about HIV and syphilis in prenatal and neonatal care, and improving clinical follow-up, epidemiologic monitoring, and planning by the ministries of health. Research conducted in the Dominican Republic, Colombia, and Peru.
- The Laboratory Turnaround Time (TAT) Project. Understanding the flow of syphilis and HIV tests performed during pregnancy, measuring laboratory turnaround time for both tests in various settings within an ILAP country, and identifying actions that would shorten TAT. Research conducted in Nicaragua and the Dominican Republic.
- Prevention of Maternal Mortality and Severe Maternal Morbidity (MM) Project. Conducting assessments of the direct and indirect causes of maternal mortality and severe maternal morbidity, paying particular attention to both the socioeconomic context in which these conditions occur and the organization of health services that prevent better quality of care. Research conducted in the Dominican Republic, Haiti, and Peru.
Since 2000, project faculty have been collaborating with the medical informatics team from the nonprofit Partners In Health (PIH) to develop Web-based electronic-medical-record (EMR) systems to support the management of MDR-TB and other diseases. Beginning in Lima, Peru, the team built the first Web-based EMR system to support the treatment of MDR-TB in a resource-poor environment. This system is used to manage the clinical data on all MDR-TB patients treated by the Peruvian National TB program, including clinical history, drug regimens, laboratory data, and outcomes. It includes tools to forecast drug requirements based on a model of the typical patient’s treatment time and regimens.
- Laboratory data management. The PIH-EMR was extended to add a module for laboratory data collection and reporting. The team also implemented a laboratory data collection system for small labs without internet access using personal digital assistants.
- OpenMRS-TB. Development of a new EMR system for MDR-TB clinical management and reporting based on the open source model. It is now in used in Haiti, Pakistan, and Rwanda, with ongoing efforts to implement it in additional countries.
- Pharmacy and drug forecasting. Development of a pharmacy and supply-chain management system in Haiti to manage TB and MDR-TB drugs as well as the full range of other products used in the clinics. A similar tool for MDR-TB has been created and implemented in Peru.
- New initiatives with Indus Hospital in Pakistan. Development of community-based data-transfer systems using cellular phones.
The Program is closely affiliated with the Division of Global Health Equity in the Department of Medicine at Brigham and Women’s Hospital and with Partners In Health, a Boston-based nonprofit that provides free medical care to poor patients in several countries. Program faculty collaborate with the United Nations and its agencies, as well as governments, multilateral and bilateral organizations, and nongovernmental organizations in Eastern Europe, Latin America and the Caribbean, Central Asia, South Asia, and Africa. Participating agencies include:
- Center for Human Rights and Global Justice, NYU School of Law
- François-Xavier Bagnoud (FXB) Center for Health and Human Rights, Harvard School of Public Health
- Federal University of Espirito Santo, Brazil
- Indus Hospital, Pakistan
- Institute of Tropical Medicine Pedro Kourí, Cuba
- Interactive Research & Development, Pakistan
- Médecins Sans Frontières
- Ministry of Public Health, Dominican Republic
- Ministry of Health, Peru
- National Institute of Maternal and Perinatal Health, Peru
- Ministry of Health, Nicaragua
- Muhimbili University of Health and Allied Sciences (MUHAS) and the Harvard School of Public Health (HSPH) HIV treatment program funded through the U.S. President’s Emergency Plan for AIDS Relief
- National Center for Research on Maternal and Child Health (CENISMI) of the Dominican Republic
- Pan American Health Organization
- Partners In Health and its sister organizations in Haiti, Peru, Russia, Lesotho, Rwanda, Malawi, and Kazakhstan, as well as the governments of these countries
- Presidential Council on AIDS (COPRESIDA) of the Dominican Republic
- Regional Office of UNICEF for Latin America and the Caribbean
- Regional Support Team of UNAIDS for Latin America
- Robert F. Kennedy Center for Justice and Human Rights
- The Global Fund to Fight AIDS, Tuberculosis, and Malaria
- Treatment Action Group
- University of Liverpool, United Kingdom