In epidemic preparedness and response, it is now commonly accepted that insights from social scie... more In epidemic preparedness and response, it is now commonly accepted that insights from social science disciplines are important in shaping action. Unfortunately, the role of social science is often confined to risk communication and community engagement (RCCE) efforts. In this article, we propose an analytical framework that would allow researchers and practitioners from different disciplines to employ social science insights to enrich their understanding of epidemics and formulate more effective and sustainable responses. The framework goes beyond simply unpacking social, political, economic and cultural dimensions of context; it situates disease itself – as it is shaped by the contexts in which it circulates – and views it in dynamic relation to response. It also explores how different individuals, social groups and institutions shift their knowledge and practices during an epidemic through power-laden processes of dialogue and learning, or even through silencing and side-lining. I...
Veterinary public health (VPH) is ideally suited to promote convergence between human, animal and... more Veterinary public health (VPH) is ideally suited to promote convergence between human, animal and environmental sectors. Recent zoonotic and emerging infectious disease events have given rise to increasing calls for efforts to build global VPH capacities. However, even with their greater vulnerability to such events, including their economic and livelihood impacts, the response from low-and middle-income countries such as India has been suboptimal, thereby elevating global health risks. Addressing risks effectively at the human-animal interface in these countries will require a clear vision, consistent policies, strategic approach and sustained political commitment to reform and refine the current VPH capacity-building efforts. Only then can the discipline serve its goal of disease prevention, poverty alleviation and support for sustainable livelihoods through improvements in human and animal health.
Despite emerging consensus that the One Health concept involves multiple stakeholders, the human ... more Despite emerging consensus that the One Health concept involves multiple stakeholders, the human health sector has continued to view it from a predominantly human health security perspective. It has often ignored the concerns of other sectors, e.g. concerns that relate to trade, commerce, livelihoods and sustainable development, all of which are important contributors to societal well-being. In the absence of a culture of collaboration, clear One Health goals, conceptual clarity and operating frameworks, this disconnect between human health and One Health efforts has often impeded the translation of One Health from concept to reality, other than during emergency situations. If there are to be effective and sustainable One Health partnerships we must identify clear operating principles that allow flexible approaches to intersectoral collaborations. To convince technical experts and political leaders in the human health sector of the importance of intersectoral cooperation, and to make the necessary structural adjustments, we need examples of best practice models and trans-sectoral methods for measuring the risks, burden and costs across sectors. Informal collaborations between researchers and technical experts will play a decisive role in developing these methods and models and instilling societal wellbeing into the human health sector's view of One Health.
Japanese Encephalitis (JE) has caused repeated outbreaks in endemic pockets of India. This study ... more Japanese Encephalitis (JE) has caused repeated outbreaks in endemic pockets of India. This study was conducted in Kushinagar, a highly endemic district, to understand the human-animal-ecosystem interactions, and the drivers that influence disease transmission. Utilizing the ecosystems approach, a cross-sectional, descriptive study, employing mixed methods design was employed. Four villages (two with pig-rearing and two without) were randomly selected from a high, a medium and a low burden (based on case counts) block of Kushinagar. Children, pigs and vectors were sampled from these villages. A qualitative arm was incorporated to explain the findings from the quantitative surveys. All human serum samples were screened for JE-specific IgM using MAC ELISA and negative samples for JE RNA by rRT-PCR in peripheral blood mononuclear cells. In pigs, IgG ELISA and rRT-PCR for viral RNA were used. Of the 242 children tested, 24 tested positive by either rRT-PCR or MAC ELISA; in pigs, 38 out o...
Proceedings of the National Academy of Sciences of the United States of America, Dec 20, 2016
Over 20,000 rabies deaths occur annually in India, representing one-third of global human rabies.... more Over 20,000 rabies deaths occur annually in India, representing one-third of global human rabies. The Indian state of Tamil Nadu has pioneered a "One Health" committee to address the challenge of rabies in dogs and humans. Currently, rabies control in Tamil Nadu involves postexposure vaccination of humans after dog bites, whereas potential supplemental approaches include canine vaccination and sterilization. We developed a data-driven rabies transmission model fit to human rabies autopsy data and human rabies surveillance data from Tamil Nadu. Integrating local estimates for canine demography and costs, we predicted the impact of canine vaccination and sterilization on human health outcomes and evaluated cost-effectiveness according to the WHO criteria for India, which correspond to thresholds of $1,582 and $4,746 per disability-adjusted life-years (DALYs) for very cost-effective and cost-effective strategies, respectively. We found that highly feasible strategies focused ...
Research papers on New Delhi metallo-β-lactamase (NDM-1) provoked considerable but very different... more Research papers on New Delhi metallo-β-lactamase (NDM-1) provoked considerable but very different media coverage in the United Kingdom (UK) and India. We describe how the media represented this research using qualitative thematic analysis of contemporary coverage by daily newspapers in the UK and India. Fifty-four UK and 187 Indian articles mentioned NDM-1, describing it as the 'new super superbug' resistant to most antibiotics. They emphasised the role of medical tourism to the Indian subcontinent. In both countries, blame was framed abstractly as arising from the general misuse of antibiotics. In India, controversy about using New Delhi to name the organism dominated coverage, with officials seeking to discredit the two studies and media coverage characterised by denial and outrage, developing into theories of conspiracies to undermine tourism. Researchers must seek to anticipate the way that their work may be reported and proactively engage with the media to maximise the public health impact of their findings.
Objective-To estimate the potential health impact and cost-effectiveness of nationwide Haemophilu... more Objective-To estimate the potential health impact and cost-effectiveness of nationwide Haemophilus influenzae type b (Hib) vaccination in India. Study design-A decision support model was used, bringing together estimates of demography, epidemiology, Hib vaccine effectiveness, Hib vaccine costs, and health care costs. Scenarios favorable and unfavorable to the vaccine were evaluated. State-level analyses indicate where the vaccine might have the greatest impact and value. Results-Between 2012 and 2031, Hib conjugate vaccination is estimated to prevent over 200 000 child deaths (~1% of deaths in children <5 years of age) in India at an incremental cost of US $127 million per year. From a government perspective, state-level cost-effectiveness ranged from US$192 to US$1033 per discounted disability adjusted life years averted. With the inclusion of household health care costs, cost-effectiveness ranged from US$155-US$939 per discounted disability adjusted life year averted. These values are below the World Health Organization thresholds for cost effectiveness of public health interventions. Conclusions-Hib conjugate vaccination is a cost-effective intervention in all States of India. This conclusion does not alter with plausible changes in key parameters. Although investment in Hib conjugate vaccination would significantly increase the cost of the Universal Immunization Program, about 15% of the incremental cost would be offset by health care cost savings. Efforts should be made to expedite the nationwide introduction of Hib conjugate vaccination in India.
Complex health policy challenges such as antimicrobial resistance and other emerging infections a... more Complex health policy challenges such as antimicrobial resistance and other emerging infections are driven by activities in multiple sectors. Therefore, addressing these also requires joint efforts from multiple sectors as exemplified in the One Health approach. We undertake a critical review to examine the different ways in which multisector partnerships have been conceptualized across multiple disciplines and thematic areas. We started with a set of six articles from the disciplines of health, nutrition and public administration that reviewed conceptual frameworks within their respective fields. We conducted backward citation tracing using the bibliography of the six articles to identify other articles in the same and related fields that conceptualized multisector partnerships. We identified 58 articles published from 1967 to 2018 from the fields of global health, infectious diseases, management, nutrition and sustainability sciences indicating that multisector partnerships have b...
The study aimed to determine costs to the state government of implementing different intervention... more The study aimed to determine costs to the state government of implementing different interventions for controlling rabies among the entire human and animal populations of Tamil Nadu. This built upon an earlier assessment of Tamil Nadu's efforts to control rabies. Anti-rabies vaccines were made available at all health facilities. Costs were estimated for five different combinations of animal and human interventions using an activity-based costing approach from the provider perspective. Disease and population data were sourced from the state surveillance data, human census and livestock census. Program costs were extrapolated from official documents. All capital costs were depreciated to estimate annualized costs. All costs were inflated to 2012 Rupees. Sensitivity analysis was conducted across all major cost centres to assess their relative impact on program costs. It was found that the annual costs of providing Anti-rabies vaccine alone and in combination with Immunoglobulins was $0.7 million (Rs 36 million) and $2.2 million (Rs 119 million), respectively. For animal sector interventions, the annualised costs of rolling out surgical sterilisation-immunization, injectable immunization and oral immunizations were estimated to be $ 44 million (Rs 2,350 million), $23 million (Rs 1,230 million) and $ 11 million (Rs 590 million), respectively. Dog bite incidence, health systems coverage and cost of rabies biologicals were found to be important drivers of costs for human interventions. For the animal sector interventions, the size of dog catching team, dog population and vaccine costs were found to be driving the costs. Rabies control in Tamil Nadu seems a costly proposition the way it is currently structured. Policy makers in Tamil Nadu and other similar settings should consider the long-term financial sustainability before embarking upon a state or nation-wide rabies control programme.
In India, quality surveillance for acute encephalitis syndrome (AES), including laboratory testin... more In India, quality surveillance for acute encephalitis syndrome (AES), including laboratory testing, is necessary for understanding the epidemiology and etiology of AES, planning interventions, and developing policy. We reviewed AES surveillance data for January 2011-June 2012 from Kushinagar District, Uttar Pradesh, India. Data were cleaned, incidence was determined, and demographic characteristics of cases and data quality were analyzed. A total of 812 AES case records were identified, of which 23% had illogical entries. AES incidence was highest among boys <6 years of age, and cases peaked during monsoon season. Records for laboratory results (available for Japanese encephalitis but not AES) and vaccination history were largely incomplete, so inferences about the epidemiology and etiology of AES could not be made. The low-quality AES/Japanese encephalitis surveillance data in this area provide little evidence to support development of prevention and control measures, estimate the effect of interventions, and avoid the waste of public health resources.
Objective To estimate the potential health impact and cost-effectiveness of nationwide Haemophilu... more Objective To estimate the potential health impact and cost-effectiveness of nationwide Haemophilus influenzae type b (Hib) vaccination in India.
Review the research output on rabies from India and examine its alignment with national policy pr... more Review the research output on rabies from India and examine its alignment with national policy priorities Themes Infectious disease; Health Systems and Governance, Policy and Financing
Background: Despite the availability of effective interventions and public recognition of the sev... more Background: Despite the availability of effective interventions and public recognition of the severity of the problem, rabies continues to suffer neglect by programme planners in India and other low and middle income countries. We investigate whether this state of 'policy impasse' is due to, at least in part, the research community not catering to the information needs of the policy makers.
Background: Zoonotic infections pose a significant public health challenge for low-and middle-inc... more Background: Zoonotic infections pose a significant public health challenge for low-and middle-income countries and have traditionally been a neglected area of research. The Roadmap to Combat Zoonoses in India (RCZI) initiative conducted an exercise to systematically identify and prioritize research options needed to control zoonoses in India.
Although India accounts for nearly 50% of the global rabies mortality, there is no organised nati... more Although India accounts for nearly 50% of the global rabies mortality, there is no organised national rabies control programme. Rabies control is generally confined to small urban pockets, with minimal intersectoral co-ordination. Tamil Nadu is the first state in India to implement a state-wide, multisectoral rabies control initiative. The CDC Program Evaluation Framework guided the current assessment of this rabies prevention and control initiative in Tamil Nadu. Principle stakeholders were engaged through a series of interviews in order to document policy initiatives, to describe the programme and to understand their various roles. Surveillance data on dog bites were triangulated with vaccine consumption and dog population data to identify trends at the district level in the state. Findings and recommendations were shared at different levels. Rabies control activities in Tamil Nadu were conducted by separate departments linked by similar objectives. In addition to public health surveillance, animal census and implementation of dog licensing rules, other targeted interventions included waste management, animal birth control and anti-rabies vaccination, awareness campaigns, and widespread availability of anti-rabies vaccine at all public health facilities. In conclusion, this assessment suggests that it is possible to implement a successful 'One Health' programme in an environment of strong political will, evidence-based policy innovations, clearly defined roles and responsibilities of agencies, co-ordination mechanisms at all levels, and a culture of open information exchange. (M. Kakkar). due to rabies in India. Domestic dogs are the main vector, causing 94% of human cases. Two-thirds of India's population lives in villages. They are more vulnerable to zoonotic infection and disease, with nearly 76% of rabies cases reported from this segment. 1,2 Recent community surveys also revealed that the majority of dog-bite victims do not receive any rabies vaccine, demonstrating gross negligence on the part of both the bite victim as well as the healthcare system. 2
In epidemic preparedness and response, it is now commonly accepted that insights from social scie... more In epidemic preparedness and response, it is now commonly accepted that insights from social science disciplines are important in shaping action. Unfortunately, the role of social science is often confined to risk communication and community engagement (RCCE) efforts. In this article, we propose an analytical framework that would allow researchers and practitioners from different disciplines to employ social science insights to enrich their understanding of epidemics and formulate more effective and sustainable responses. The framework goes beyond simply unpacking social, political, economic and cultural dimensions of context; it situates disease itself – as it is shaped by the contexts in which it circulates – and views it in dynamic relation to response. It also explores how different individuals, social groups and institutions shift their knowledge and practices during an epidemic through power-laden processes of dialogue and learning, or even through silencing and side-lining. I...
Veterinary public health (VPH) is ideally suited to promote convergence between human, animal and... more Veterinary public health (VPH) is ideally suited to promote convergence between human, animal and environmental sectors. Recent zoonotic and emerging infectious disease events have given rise to increasing calls for efforts to build global VPH capacities. However, even with their greater vulnerability to such events, including their economic and livelihood impacts, the response from low-and middle-income countries such as India has been suboptimal, thereby elevating global health risks. Addressing risks effectively at the human-animal interface in these countries will require a clear vision, consistent policies, strategic approach and sustained political commitment to reform and refine the current VPH capacity-building efforts. Only then can the discipline serve its goal of disease prevention, poverty alleviation and support for sustainable livelihoods through improvements in human and animal health.
Despite emerging consensus that the One Health concept involves multiple stakeholders, the human ... more Despite emerging consensus that the One Health concept involves multiple stakeholders, the human health sector has continued to view it from a predominantly human health security perspective. It has often ignored the concerns of other sectors, e.g. concerns that relate to trade, commerce, livelihoods and sustainable development, all of which are important contributors to societal well-being. In the absence of a culture of collaboration, clear One Health goals, conceptual clarity and operating frameworks, this disconnect between human health and One Health efforts has often impeded the translation of One Health from concept to reality, other than during emergency situations. If there are to be effective and sustainable One Health partnerships we must identify clear operating principles that allow flexible approaches to intersectoral collaborations. To convince technical experts and political leaders in the human health sector of the importance of intersectoral cooperation, and to make the necessary structural adjustments, we need examples of best practice models and trans-sectoral methods for measuring the risks, burden and costs across sectors. Informal collaborations between researchers and technical experts will play a decisive role in developing these methods and models and instilling societal wellbeing into the human health sector's view of One Health.
Japanese Encephalitis (JE) has caused repeated outbreaks in endemic pockets of India. This study ... more Japanese Encephalitis (JE) has caused repeated outbreaks in endemic pockets of India. This study was conducted in Kushinagar, a highly endemic district, to understand the human-animal-ecosystem interactions, and the drivers that influence disease transmission. Utilizing the ecosystems approach, a cross-sectional, descriptive study, employing mixed methods design was employed. Four villages (two with pig-rearing and two without) were randomly selected from a high, a medium and a low burden (based on case counts) block of Kushinagar. Children, pigs and vectors were sampled from these villages. A qualitative arm was incorporated to explain the findings from the quantitative surveys. All human serum samples were screened for JE-specific IgM using MAC ELISA and negative samples for JE RNA by rRT-PCR in peripheral blood mononuclear cells. In pigs, IgG ELISA and rRT-PCR for viral RNA were used. Of the 242 children tested, 24 tested positive by either rRT-PCR or MAC ELISA; in pigs, 38 out o...
Proceedings of the National Academy of Sciences of the United States of America, Dec 20, 2016
Over 20,000 rabies deaths occur annually in India, representing one-third of global human rabies.... more Over 20,000 rabies deaths occur annually in India, representing one-third of global human rabies. The Indian state of Tamil Nadu has pioneered a "One Health" committee to address the challenge of rabies in dogs and humans. Currently, rabies control in Tamil Nadu involves postexposure vaccination of humans after dog bites, whereas potential supplemental approaches include canine vaccination and sterilization. We developed a data-driven rabies transmission model fit to human rabies autopsy data and human rabies surveillance data from Tamil Nadu. Integrating local estimates for canine demography and costs, we predicted the impact of canine vaccination and sterilization on human health outcomes and evaluated cost-effectiveness according to the WHO criteria for India, which correspond to thresholds of $1,582 and $4,746 per disability-adjusted life-years (DALYs) for very cost-effective and cost-effective strategies, respectively. We found that highly feasible strategies focused ...
Research papers on New Delhi metallo-β-lactamase (NDM-1) provoked considerable but very different... more Research papers on New Delhi metallo-β-lactamase (NDM-1) provoked considerable but very different media coverage in the United Kingdom (UK) and India. We describe how the media represented this research using qualitative thematic analysis of contemporary coverage by daily newspapers in the UK and India. Fifty-four UK and 187 Indian articles mentioned NDM-1, describing it as the 'new super superbug' resistant to most antibiotics. They emphasised the role of medical tourism to the Indian subcontinent. In both countries, blame was framed abstractly as arising from the general misuse of antibiotics. In India, controversy about using New Delhi to name the organism dominated coverage, with officials seeking to discredit the two studies and media coverage characterised by denial and outrage, developing into theories of conspiracies to undermine tourism. Researchers must seek to anticipate the way that their work may be reported and proactively engage with the media to maximise the public health impact of their findings.
Objective-To estimate the potential health impact and cost-effectiveness of nationwide Haemophilu... more Objective-To estimate the potential health impact and cost-effectiveness of nationwide Haemophilus influenzae type b (Hib) vaccination in India. Study design-A decision support model was used, bringing together estimates of demography, epidemiology, Hib vaccine effectiveness, Hib vaccine costs, and health care costs. Scenarios favorable and unfavorable to the vaccine were evaluated. State-level analyses indicate where the vaccine might have the greatest impact and value. Results-Between 2012 and 2031, Hib conjugate vaccination is estimated to prevent over 200 000 child deaths (~1% of deaths in children <5 years of age) in India at an incremental cost of US $127 million per year. From a government perspective, state-level cost-effectiveness ranged from US$192 to US$1033 per discounted disability adjusted life years averted. With the inclusion of household health care costs, cost-effectiveness ranged from US$155-US$939 per discounted disability adjusted life year averted. These values are below the World Health Organization thresholds for cost effectiveness of public health interventions. Conclusions-Hib conjugate vaccination is a cost-effective intervention in all States of India. This conclusion does not alter with plausible changes in key parameters. Although investment in Hib conjugate vaccination would significantly increase the cost of the Universal Immunization Program, about 15% of the incremental cost would be offset by health care cost savings. Efforts should be made to expedite the nationwide introduction of Hib conjugate vaccination in India.
Complex health policy challenges such as antimicrobial resistance and other emerging infections a... more Complex health policy challenges such as antimicrobial resistance and other emerging infections are driven by activities in multiple sectors. Therefore, addressing these also requires joint efforts from multiple sectors as exemplified in the One Health approach. We undertake a critical review to examine the different ways in which multisector partnerships have been conceptualized across multiple disciplines and thematic areas. We started with a set of six articles from the disciplines of health, nutrition and public administration that reviewed conceptual frameworks within their respective fields. We conducted backward citation tracing using the bibliography of the six articles to identify other articles in the same and related fields that conceptualized multisector partnerships. We identified 58 articles published from 1967 to 2018 from the fields of global health, infectious diseases, management, nutrition and sustainability sciences indicating that multisector partnerships have b...
The study aimed to determine costs to the state government of implementing different intervention... more The study aimed to determine costs to the state government of implementing different interventions for controlling rabies among the entire human and animal populations of Tamil Nadu. This built upon an earlier assessment of Tamil Nadu's efforts to control rabies. Anti-rabies vaccines were made available at all health facilities. Costs were estimated for five different combinations of animal and human interventions using an activity-based costing approach from the provider perspective. Disease and population data were sourced from the state surveillance data, human census and livestock census. Program costs were extrapolated from official documents. All capital costs were depreciated to estimate annualized costs. All costs were inflated to 2012 Rupees. Sensitivity analysis was conducted across all major cost centres to assess their relative impact on program costs. It was found that the annual costs of providing Anti-rabies vaccine alone and in combination with Immunoglobulins was $0.7 million (Rs 36 million) and $2.2 million (Rs 119 million), respectively. For animal sector interventions, the annualised costs of rolling out surgical sterilisation-immunization, injectable immunization and oral immunizations were estimated to be $ 44 million (Rs 2,350 million), $23 million (Rs 1,230 million) and $ 11 million (Rs 590 million), respectively. Dog bite incidence, health systems coverage and cost of rabies biologicals were found to be important drivers of costs for human interventions. For the animal sector interventions, the size of dog catching team, dog population and vaccine costs were found to be driving the costs. Rabies control in Tamil Nadu seems a costly proposition the way it is currently structured. Policy makers in Tamil Nadu and other similar settings should consider the long-term financial sustainability before embarking upon a state or nation-wide rabies control programme.
In India, quality surveillance for acute encephalitis syndrome (AES), including laboratory testin... more In India, quality surveillance for acute encephalitis syndrome (AES), including laboratory testing, is necessary for understanding the epidemiology and etiology of AES, planning interventions, and developing policy. We reviewed AES surveillance data for January 2011-June 2012 from Kushinagar District, Uttar Pradesh, India. Data were cleaned, incidence was determined, and demographic characteristics of cases and data quality were analyzed. A total of 812 AES case records were identified, of which 23% had illogical entries. AES incidence was highest among boys <6 years of age, and cases peaked during monsoon season. Records for laboratory results (available for Japanese encephalitis but not AES) and vaccination history were largely incomplete, so inferences about the epidemiology and etiology of AES could not be made. The low-quality AES/Japanese encephalitis surveillance data in this area provide little evidence to support development of prevention and control measures, estimate the effect of interventions, and avoid the waste of public health resources.
Objective To estimate the potential health impact and cost-effectiveness of nationwide Haemophilu... more Objective To estimate the potential health impact and cost-effectiveness of nationwide Haemophilus influenzae type b (Hib) vaccination in India.
Review the research output on rabies from India and examine its alignment with national policy pr... more Review the research output on rabies from India and examine its alignment with national policy priorities Themes Infectious disease; Health Systems and Governance, Policy and Financing
Background: Despite the availability of effective interventions and public recognition of the sev... more Background: Despite the availability of effective interventions and public recognition of the severity of the problem, rabies continues to suffer neglect by programme planners in India and other low and middle income countries. We investigate whether this state of 'policy impasse' is due to, at least in part, the research community not catering to the information needs of the policy makers.
Background: Zoonotic infections pose a significant public health challenge for low-and middle-inc... more Background: Zoonotic infections pose a significant public health challenge for low-and middle-income countries and have traditionally been a neglected area of research. The Roadmap to Combat Zoonoses in India (RCZI) initiative conducted an exercise to systematically identify and prioritize research options needed to control zoonoses in India.
Although India accounts for nearly 50% of the global rabies mortality, there is no organised nati... more Although India accounts for nearly 50% of the global rabies mortality, there is no organised national rabies control programme. Rabies control is generally confined to small urban pockets, with minimal intersectoral co-ordination. Tamil Nadu is the first state in India to implement a state-wide, multisectoral rabies control initiative. The CDC Program Evaluation Framework guided the current assessment of this rabies prevention and control initiative in Tamil Nadu. Principle stakeholders were engaged through a series of interviews in order to document policy initiatives, to describe the programme and to understand their various roles. Surveillance data on dog bites were triangulated with vaccine consumption and dog population data to identify trends at the district level in the state. Findings and recommendations were shared at different levels. Rabies control activities in Tamil Nadu were conducted by separate departments linked by similar objectives. In addition to public health surveillance, animal census and implementation of dog licensing rules, other targeted interventions included waste management, animal birth control and anti-rabies vaccination, awareness campaigns, and widespread availability of anti-rabies vaccine at all public health facilities. In conclusion, this assessment suggests that it is possible to implement a successful 'One Health' programme in an environment of strong political will, evidence-based policy innovations, clearly defined roles and responsibilities of agencies, co-ordination mechanisms at all levels, and a culture of open information exchange. (M. Kakkar). due to rabies in India. Domestic dogs are the main vector, causing 94% of human cases. Two-thirds of India's population lives in villages. They are more vulnerable to zoonotic infection and disease, with nearly 76% of rabies cases reported from this segment. 1,2 Recent community surveys also revealed that the majority of dog-bite victims do not receive any rabies vaccine, demonstrating gross negligence on the part of both the bite victim as well as the healthcare system. 2
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Papers by Syed Abbas