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McDowell, Andrew

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McDowell

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McDowell, Andrew
Author's Publications: search.filters.isAuthorOfPublication.112cdb77-7210-49ee-b8da-02a846160b32

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    Troubling Breath: Tuberculosis, care and subjectivity at the margins of Rajasthan.
    (2014-06-06) McDowell, Andrew; Kleinman, Arthur Michael; Good, Byron; Pinto, Sarah; Keshavjee, Salmaan
    "Troubling Breath," the product of fourteen months of fieldwork, examines the experience of tuberculosis sufferers in rural Rajasthan, India. In it, I engage the Indian national tuberculosis control program, local health institutions, informal biomedical providers, non-biomedical healers and sufferers to consider how global tuberculosis control initiatives interact with social life and subjectivity among the rural poor. I ask how tuberculosis affliction and healing builds and reveals the diversity and limit of relationships between state and citizen, individual and kin, body and social, global and local, and formal and informal healthcare.
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    “Before Xpert I only had my expertise”: A qualitative study on the utilization and effects of Xpert technology among pediatricians in 4 Indian cities
    (Public Library of Science, 2018) McDowell, Andrew; Raizada, Neeraj; Khaparde, Sunil D.; Rao, Raghuram; Sarin, Sanjay; Kalra, Aakshi; Salhotra, Virender Singh; Nair, Sreenivas Achuthan; Boehme, Catharina; Denkinger, Claudia M.
    Background: Diagnosing tuberculosis (TB) in children presents considerable challenges. Upfront testing on Xpert® MTB/RIF (‘Xpert’)—a rapid molecular assay with high sensitivity and specificity—for pediatric presumptive TB patients, as recommended by India’s Revised National Tuberculosis Control Program (RNTCP), can pave the way for early TB diagnosis. As part of an ongoing project implemented by Foundation for Innovative New Diagnostics (FIND) dedicated to providing upfront free-of-cost (FOC) Xpert testing to children seeking care in the public and private sectors, a qualitative assessment was designed to understand how national guidelines on TB diagnosis and Xpert technology have been integrated into the pediatric TB care practices of different health providers. Methods: We conducted semi-structured interviews with a sample of health providers from public and private sectors engaged in the ongoing pediatric project in 4 major cities of India. Providers were sampled from intervention data based on sector of practice, number of Xpert referrals, and TB detection rates amongst referrals. A total of 55 providers were interviewed with different levels of FOC Xpert testing uptake. Data were transcribed and analyzed inductively by a medical anthropologist using thematic content analysis and narrative analysis. Results: It was observed that despite guidance from RNTCP on the use of Xpert and significant efforts by FIND and state authorities to disseminate these guidelines, there was notable diversity in their implementation by different health care providers. Xpert, apart from being utilized as intended, i.e. as a first diagnostic test for children, was utilized variably–as an initial screening test (to rule out TB), confirmatory test (once TB diagnosis is established based on antibiotic trial or clinically) and/or only for drug susceptibility testing after TB diagnosis was confirmed. Most providers who used Xpert frequently reported that Xpert was an important tool for managing pediatric TB cases, by reducing the proportion of cases diagnosed only on clinical suspicion and by providing upfront information on drug resistance, which is seldom suspected in children. Despite non-standard use, these results showed that Xpert access helped raise awareness, aided in antibiotic stewardship, and reduced dependence on clinical diagnosis among those who diagnose and treat TB in children. Conclusion: Access to free and rapid Xpert testing for all presumptive pediatric TB patients has had multiple positive effects on pediatricians’ diagnosis and treatment of TB. It has important effects on speed of diagnosis, empirical treatment, and awareness of drug resistance among TB treatment naive children. In addition, our study shows that access to public sector Xpert machines may be an important way to encourage Public-Private integration and facilitate the movement of patients from the private to public sector for anti-TB treatment. Despite availability of rapid and free Xpert testing, our study showed an alarming diversity of Xpert utilization strategies across different providers who may be moving toward suggested practice over time. The degree of diversity in TB diagnostic approaches in children reported here highlights the urgent need for concerted efforts to place Xpert early in diagnostic algorithms to positively impact the pediatric TB care pathway. A positive change in diagnostic algorithms may be possible with continued advocacy, time, and increased access.