Few illnesses lay bare the inequities of the modern global health system like tuberculosis. 仅在2021年，该疾病就导致1人死亡.6 million people worldwide, more than any other infectious illness besides COVID-19.
这些结核病死亡, 然而, 集中在贫困率高的国家，因为大多数感染都可以用抗生素治疗——而在富裕国家呢, 它们已经存在了好几代. 这意味着，未能在全球范围内降低这种疾病的死亡率不是一个科学问题:这是一个政策问题.
布兰妮·范德沃特, assistant professor at the 康奈尔护理学院, hopes to better understand and address this inequity. 她正在电子游戏正规平台实施结核病护理实践的方法，以便发现哪些策略真正有效. “我希望通过实施科学的视角来看待这个问题，以便在追求全球卫生公平方面尽可能有效,范德沃特说.
Out of a population of about 60 million, 450,000 South Africans develop TB each year. 这些, 270,000人同时感染艾滋病毒, 大约89人,每年有000人死亡, making the need for more effective care a critical matter of life and death. She explained that “almost every low-income country has a high incidence of TB, but in South Africa about 60 percent of tuberculosis cases are in people co-infected with HIV. That makes it a totally different and dangerous epidemic, and one that needs to be urgently addressed at a systems level.”
的障碍
Rural South Africa is a challenging place in which to promote public health. Due in large part to the legacy of racial apartheid, many parts of the country had little to no access to schooling, 基础设施, 或者直到20世纪90年代中期才有干净的水. 从那以后的几年里, 发展仍然缓慢而不平衡, with many areas not receiving electricity until last year. 意料之中的是, 然后, 结核病治疗仍然严重不足:目前感染结核病的南非人中只有80%得到诊断, and just 53 percent successfully complete 治疗.
图片:Christine Hunt
贫困和疾病的流行也不可避免地改变了临床医生照顾病人的方式. 范德沃特说，她的南非同事教会了她他们在医院遇到病人时会问的两个基本问题:“你从哪里来?到这里花了多长时间?? 这些问题的答案既揭示了一个人的病情有多严重，也揭示了贫困社区交通状况的惊人现实.”
例如, if someone took a long time to cover a short distance, that tells the clinician something important about the patient’s current condition. 这一信息也有助于预测后续访问的可能性——甚至当降雨将土路变成泥路时是否有可能返回.
But once a patient arrives at a hospital, the clinicians’ challenges have just begun. 即使在医院，也在贫困农村地区面临的其他主要挑战——艾滋病毒——方面取得了稳步改善的成果, 孕产妇健康, infant health—tuberculosis has been difficult to get under control. Sometimes this is because people with tuberculosis show up with symptoms for something else, 这样他们就不会接受结核病筛查. 有时，得到正确诊断的患者由于食物不稳定或无法获得其他基本资源而无法遵循治疗过程.
Van de Water的主题不是结核病本身，而是结核病治疗:患者在治疗过程的哪个阶段失败了, and what barriers keep them from getting the care they need?
简而言之, 范德沃特解释道, TB mortality rates remain stubbornly high—according to the WHO, 未经治疗的结核病死亡率约为50%，因为全球卫生界还没有弄清楚如何始终如一地向那些最需要的人提供我们所知道的有效治疗. “Instead, people are unnecessarily dying every day,”她说。.
不幸的是, 仅仅知道诊所不能满足结核病患者的需求并不意味着知道如何解决这个问题. 在过去, well-intentioned outsiders have offered advice to clinicians on how to improve TB care, but these practices made sense in a different context. In rural South Africa, this counsel has yet to meaningfully improve outcomes for patients.
该方法
To address South Africa’s unique challenges, 范德沃特对卫生保健系统的分析借鉴了实施科学的技术, 她将这一领域描述为“在日常卫生保健中采用循证实践”的电子游戏正规平台.
“This kind of research doesn’t take place in a highly controlled lab, 但在现实世界中,她解释道. “It’s about understanding what makes it harder for something to be implemented, 是什么让它更容易.”
换句话说, 她的主题不是结核病本身，而是结核病的治疗:患者在治疗过程的哪个阶段失败了, and what barriers keep them from getting the care they need?
关于南非结核病(TB)
450,000
# of South Africans who develop TB annually
89,000
# of South Africans who die from TB annually
53
% of South Africans who successfully complete TB 治疗
为了找出答案, van de Water和她的团队正在使用一种称为系统分析和改进方法(SAIA)的策略。, 在病人无法进入下一步的治疗过程中，是哪一种方法利用数据来绘制阶段图. 她将与南非东开普省Sarah Baartman区的16家机构合作，确定这些瓶颈. “那, using micro-interventions or quality improvement projects, we help each clinic feel empowered to make improvements that they identify,”她说。.
Van de Water and her team have identified six steps in the optimal “TB care cascade”: screening, 评价, 诊断, 关怀联动, 治疗, 以及无结核生存. 每一步都代表着治疗过程中病人可能无法取得进展的关键时刻，也是重新思考每个诊所如何运作的机会. 例如, one clinic may decide to screen all patients for TB, 不管症状如何, while another may work to alleviate local food insecurity.
连同所有16个诊所, van de Water will implement what’s called a stepped wedge cluster randomized control trial. “四诊所, 或者是一个集群, 从实施项目开始, 他们会执行18个月,范德沃特解释道. “The next cluster of four clinics starts three months after the first, 以及之后的三个月.“这种设计有助于电子游戏正规平台人员在不可能进行对照实验的情况下将变量归零，并允许干预具有最广泛的影响。.
关怀级联
电子游戏正规平台
在电子游戏正规平台的早期，van de Water还不知道哪种干预措施会被证明是最成功的. For her, that uncertainty is part of the appeal because it rewards openness to diverse ideas. “I think this work requires a lot of buy-in from district health officials and clinic staff,”她说。. “We’re not coming in and taking over to run TB care for five years. Instead, each clinic can come up with micro-interventions that work for them.”
布兰妮·范德沃特 照片:Sophie Smith
这种利用这么多人的集体专业知识和创造力的机会是最让范德沃特兴奋的部分. Her role, as she sees it, is to support them in what they do by providing necessary analytics. 她说:“俗话说，如果一件事没有得到衡量，就没有得到管理。. “这就是我们在这里的原因:执教, 指南, and measure with people who are seeing firsthand what really works.”
认识到改善全球结核病治疗的重要性和她卓越的电子游戏正规平台成果, 范德沃特最近收到了一封 胡德基金会资助 for her ongoing work on TB and post-TB care for kids. 本电子游戏正规平台, 也将在南非举行, 这是她帮助改变让弱势群体失望的全球卫生系统的更广泛努力的一部分吗. 最终, 她认为有必要改变富裕国家对全球健康的看法，让更多的人认识到结核病等可预防和可治疗疾病的重要性.
他说:“我认为，很多美国人都是这样认为的.S. think TB either doesn’t exist anymore or that we’ve fixed it or have a great vaccine for it,范德沃特说. “我们没有，我们也不会. 但是，如果我们选择做这项工作并了解真正有效的方法，我们可以为最需要它的人提供循证护理. If we want to see a just system that offers universal access to care, it means starting with these fundamental basics of health care.”
学生的合作者
Undergraduate research fellow Anna Laytham ’24 with 助理教授布兰妮·范德沃特 照片:Sophie Smith
Key to van de Water’s research is the support of CSON students such as Anna Laytham ’24, 他是一名本科电子游戏正规平台员，今年夏天在南非工作，支持电子游戏正规平台团队. “I was monitoring whether contacts were screened and, 如果检测结果呈阳性, 接受治疗,莱瑟姆说. “It was amazing to see what research really looks like on the ground, and the realities of the barriers that people—both patients and researchers—really face. It’s just so important to understand the local context.”