Artistic Authenticity in Annie Dillard’s The Writing Life

by Herman Bailey | Feb 25, 2023 | Essays | 0 comments

Dillard wrote her last book, The Writing Life. Inherent and conspicuous in all Dillard’s works are her focus on self−sacrifice and her try to get in touch with life’s beauty with its known horrors. Although she is known as a writer of nature, she can be described neither as an expert, nor as an appreciator of nature. Rather, she is a student of the person ideas and is passionate about how people perceive their surroundings and world. Actually, her idea of nature and art can be identified as the two factors of the same coin. This is especially apparent in The Writing Life. This material will discuss and evaluate the theme artistic authenticity and how it has been developed in the book (Dillard 24). In her previous works, Dillard (54) have a perception of the the world through her natural creatures analysis, but in The Writing Life, she decides the way of lifestyle and actions of other artists to come to understand the suffering life.

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In this book, she made a huge step from what she did in her previous works, and provides with, what is gradually, a wrong feeling of comfort from a group, as if to say artists are usually different from the public. It is apparent that Dillard seems left out from society and seriously desires to find others with whom she be identified with. She looks out for the neighbors’ views and at some aspect accepts that however fashionable her job might be, writing is just a job in the end.

The Writing Life main theme is the Dillard’s wish of authenticity in art. On an insignificant learning, one might neglect the grotesqueness of anecdotes and value of the metaphors. Clearly, Dillard wanted to make an exploration on the human conditions as an extension of the kinds she used in her formerly works. Those who belittled her work as disjointed also did not see it in the light of her formerly works. Dillard never wrote actions, which were truly complete in themselves but effective the growth of her designs through her actions to add our understanding of each of her actions.

One of the most amazing anecdotes in The Writing Life is the story of Dillard about the stunt pilot called Dave Rahm. Through the story, she explains her world vision. Dave Rahm was a climber of the mountain who became a mountain exert and explored many mountains from every view point for the desire to find out more about the mountains from every perspective. He furthermore studies geography and later became a professor of geology, yet both geology and geography seemed to be “too pedestrian” for Dave Rahm, and so he decided to pursue piloting (Dillard 76).

The narrator makes a parallel between the stunt pilot’s life and the writer’s life. She parallels the writing sensation to spinning, which brings out how seriously Dillard takes the writing of a book challenge, and how self absorbed she became in the process of realizing her goals as a writer. “The writing sensation of a book is the spinning sensation, blinded by daring and love. It is the sensation of peering and rearing from the bent tip of a grass blade, looking for a route.” (Dillard, 86)

While the narrator watches Dave Rahm passionately, she ponders over her own craft. It comes out clearly in the language applied to give a description her sensation as a writer that she gives it a consideration much like the show that Dave Rahm creates on his airplane (Dillard 85).

The first similarity pointed out by the narrator is that she neither sees them while they are performing. Neither is aware of their work developments, their art while they are in the process of doing out their task. “He could not see them himself. If he did not see it on a film, he never saw them at all, as if Beethoven could not hear his last symphonies because he was inside the paper he was writing and no9t that he was deaf” (Dillard, 62).

At the end of The Writing Life, the narrator make identification of herself with Dave Rahm and sees the world through the eyes of Dave Rahm, which makes her to have a perception  all forms of art including the writing act, as a vocation, a life honorable worthy of the ultimate sacrifice.

Dillard (19) uses Icarus and Dedalus to exemplify her art and invention understanding, which at time s demands sacrifice totally. Dillard respects people who give up themselves completely to their art and make a risk on everything for them to achieve perfection, just like what the stunt pilot and Icarus did in The Writing Life. She believes clearly that at least she should be esteemed for the sacrifices she had all along made. However, she also brings out the “not seeing” danger. She also critically examines herself as transcendentalist who concentrates much on seeing what her eyes are sometimes dimmed because of their self-importance. Now, she seems to have to have gotten over the set limits of the artists who were there before her (Dillard, 14).

In The Writing Life, she chooses different mediums through which she was able to see the world. The other artists descriptions which tell the readers more about writing or about herself than about the described artists: the stunt pilots analogy which seriously shows how she take her work, the Dedalus and Icarus myths  which tells the reader how significant is her ambition, sacrifice and achievement as a writer (Dillard, 64). Through these mediums, Dillard brigs out the basic question, how do we see the world around us? This is a question about the person who has the right to give interpretation and how best it should be accomplished. Moreover, what is the understanding behind per consistent pursuit of art in this The Writing Life book? Self-sacrifice in her art chosen is work frame and can be understood as her life ethics. Without understanding way of looking art, we cannot understand her way of getting to understand the nature. Because of she gives much respect to self-sacrifice in art and the life, she seeks worldly sacrifice and beauty in the natural world grotesqueness. Before examining and understanding her way of looking at nature, it is important to recognize her way of perceiving the world (Dillard, 72).

If we give definitions to nature and art in the broader sense, as Dillard did in The Writing Life, then we can see that she tends to ask fundamental questions about how we perceive and interpret the printed art forms. Arts such writing, but also how deeper understanding of these forms of art leads to a deeper understanding of life (Dillard 53).

Work cited

Dillard, Annie. The Writing Life. New York: Harper & Row, 1989. Print.

Herman Bailey

With a student-centered approach, I create engaging and informative blog posts that tackle relevant topics for students. My content aims to equip students with the knowledge and tools they need to succeed academically and beyond.

Gender Roles in the 18th Century through “The Rover” by Aphra Behn

by Herman Bailey | Feb 25, 2023 | Essays | 0 comments

Outline

During the eighteenth century, women’s roles in society were categorized as domestic. The roles of women were strictly defined in areas such as “work, family, and society according to ideas of what is appropriate for the sex” (Easton 389).  These roles gave women fewer career choices, loveless marriages with few rights and many, many domestic duties (Hawthorne et al. 34). Many women writers, who lived during the 18th century, wrote about the experiences that women were faced with during that time.  Chief among those voices was Aphra Behn, who attempted to come to grips with the role of women during this period in society. One of Behn’s most famous plays, “The Rover”, depicted her views on how women were portrayed in society during the 18th century.  This paper will present the roles women were forced to carry out during the 19th century. This paper will relate the roles of the women characters in the play “The Rover” to the roles of women during the 18th century.  This novel will be used like a reference to depict how Aphra Behn used her artistic and literary skills to express her feelings about the gender roles of women during the 18th century.

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Introduction

Aphra Behn, a controversial and female author, is one of the notable literary critics throughout the centuries (Canfield et al, 221). The literary plays she documented during the period of restoration were very popular on the stage. Similarly, her poetry and fiction were successful. Gallagher (97) asserted “the feminine interest now giving importance to Behn as a pioneer in professionalism, in women, began to emerge.” Moreover, she used her literary work to address politics, social commentary, money, sex, power, relationships, ideal and virtue. However, her major writing focus was on gender roles.

The essay will examine the of gender roles through the through the work of Behn of “the rover”. According to Hutner (198), the play of “the rover” criticized the arranged marriages through the inclusion of societal criticism. To understand the play of “The Rover” better, it is of great importance to understand the relationship of her life to her writing, her society she lived and perception of the women’s roles. The rover provides an oral criticism of the expectations of the society, denounces ideas of forced marriages and lastly the accompanying authority of the parents.

The rover is about of sisters’ Florinda, and Hellena who are making an attempt  of an escape from the fates of their male members of their family have decided for them, in addition to a band of, English cavaliers in Naples who are burnished at the carnival time. Link (109) observed that men are promiscuous and gay; there is the loyal Belvile, Wilmore, the rover, blunt and the negative Fredrick, the low comedian squire of the country. Belvile met and rescued the Florinda from being attacked by Naples previously, and eventually fell in love with her. Forinda, on the other hand, is destined for a pre arranged marriage. However, Hellena is destined for a convent. The escape of the sisters to the carnival is where they meet the cavaliers. Furthermore, Florinda loves Belivele and Hellena and Wilmore fall in love. However, Angelina Bance, the gorgeous courtesan complicates things. She is also in love with Wilmore although she has Pedro, the brother to Hellena and Florinda and Antonio, one of the potential future husbands of Florinda fighting to get her attention.

The plot of the play has complicated series masking, intrigues, and overall character confusion. There is love, rape, sex, anger, betrayal, jealousy, despair and joy. The play finally ends with marriages of Wilmore and Hellena and Belvile and Wilmore.

According to Markley (68), the main conflict in the play of the rover originates from the arranged marriage idea. This is attributed to the own experience of Behn and her marriage which was arranged and unhappy. Despite the fact that Behn was successful in the contemporary literature realm, her life clearly shows struggles which the women of the restoration faced in forging their identities in a large society dominated by the control of patriarchs. Even as Aphra Behn created new grounds for women by writing and publishing her literary plays in the public stage, the society she went against and raged bound her both by social ideals and financial dependence (Canfield and Sneidern, 109).

“The Rover” shows how Behn challenged the patriarchy hegemony as she applied male play writers texts, Thomas Killinger and later manipulated it  propose subtle social commentary on the women’s roles. Moreover, Behn, like other women in the restoration period applied tools such as improvisation, wit, madness, disguise and sexuality as ways in their endeavor to strive for theatre equality. The culture of restoration Behn confronted was a typical in which women held very little respect or independence (Gallagher, 61).

According to Hutner (395), rape was considered to be culture endemic by many people as the authority of men over women was total and supreme. Hutner (395) further pointed out that the crime of rape in 17th and 18th centuries was not prosecuted the same way it is done today. It was not even considered a crime, but it was a man exhibiting and expressing his power and sexuality over a woman. The violence of rape which was heinous did not transcend the social classes or even advertised; rather it reinforced the variation between the non privileged and the privileged. Behn, one of the feminist writers, disagreed with this rape representation and she later incorporated these wrongs into her work.

Similarly, the restoration society did not see the difference between the realms of dueling and courtship. This reflects the inherent violence in the female-male relations. Behn allowed her audience to see through the Rovers lens the representation of the courting and dueling. This is intrinsically the similar scenario in which there is a struggle by men to possess women as objects. Women according to Quinsey (284) are belittled to the commodity status, and airs of love just becomes the marketable transactions.

The representation of Angelica Bianca shows the real illustration of an empowered woman by her sex and matter to its consequences as exchange object. She is courtesan and thereby sells her sex and body to a man. Todd (117) observed that not only did men physically possess her, but also possess her as power or status symbol. While Angelica is portrayed as able to control her situation, the rejection by Wilmore of her love shows that she is in mercy of the patronage of men. Women according to Woodcock (42), had to negotiate between their sex, physical power, their intellect and mental capacity, which men believed, they did not have. On the theatre stage, they were able to use their wit and body sexuality together with one another to subvert the power of male.

According to Canfield (97), the female legibility was heavy and pressing concern and Behn bring out this through Angelica the hypocrisy of denouncing the poetess for subverting the sex of female. Even the women who were most contentious were bound socially and financially to men, their livelihoods and hearts resting in the men’s whims.

The play of “The Rover” of the 17th century portrays the problematic nature of the independence of female. Despite the fact that Behn has become an icon for equality among the feminine, she was snared by patriarchy dependence that she opposed. Explicit sexuality as asserted by Behn makes an ideal power that contrasts the dangerous vulnerability reality for women (Behn, 34-97).

The role of women is expressed in the three characters, in the play of “The Rover”; Angelica Biance, Hellena and Florinda. The stage was one of the only arenas and spaces where social experimentation could be done. Therefore, it served the purpose of questioning the gender roles and even the feminism precursors. In reality women had little power but the stage was one of places to subvert the reality.

The roles of women brought out from the play of “The Rover” were diverse. There were expectations from the society on women and the society defined their roles. Behn, who was a female writer does not encourage complete overthrow of the expectations of the society on women despite being distain. Even when Hellena and Florinda rebelled against the wishes of their father, they firmly keep themselves within the confines of their gender roles. Similarly, Hellena escapes a convent so as to play the traditional women role by becoming the wife of the philandering libertine who targets her fortune (Behn, 61).

According to Gallagher (72), in the play of “The Rover,” two types of women are seen. The first woman is the one which represent the societal woman which had no roles to express her desire, and the second woman which depicts the real life of Behn. This is a woman who becomes the desiring subject by adopting positions of power, distance and coldness.

According to Hutner (240), the society placed the value on women by virtue of possessing particular features. Florinda also applies these traits to make a judgment of her own self worth. She tells her sister “I understand better what is due to my fortune, birth and beauty, and more to my soul, than to obey those commands which are unjust” (Behn, 26-28). Similarly, she goes on to argue against her brother and make her point: “let him consider my fortune, beauty and youth” (Behn, 93-95). This brings out the social issues women underwent that time and also explains the reason of Florinda’s rebellion. The same traits she believes should give her freedom to choose her own husband are the very same traits the male members of the family exploit to sell her off to the wealthiest bidder. The women are valued like property to be sold off, and this was one of the social issues.

Another social issue in the play of “The Rover” is the exploitation experienced in the forced marriages. “The Rover” is a perfect example of a discussion that Behn was not a revolutionary, by making an attempt to overthrow the gender roles that were prevailing. For instance, the disdainful idea of forced marriages which Behn seems, to oppose not just the way it applies to women but to men too. The forced marriages are characterized by exploitation and unhappiness. The play acknowledges the expectations of the arranged marriages that were harmful to the forced women and men who did not have a say on them (Quinsey, 183)

In the play, it is evident that there were many major ways the men in the society nurtured and maintained their gender roles. Todd (112) pointed out that one of them was rape, and this was a major social issue of the time. Rape was used for many different reasons. For Blunt, rape was a means in which men exerted revenge on women in general just for the action of one particular woman. However, for Wilmore, rape was like a seduction or a diversion. The reason the heroes of Behn violate the conservative standards of sexual morality in the play of “The Rover” is to legitimize aristocratic worth and birth notions (Woodcock, 53).

Behn’s view of marriage seems to be consistent with the view of Wilmore in the play. When Hellena first suggest about marriage, his first response is “Hold Hold…no no, we will have vows now but not love, child, nor witnesses but the lover…marriage is a kind of a nuisance to love, as lending money is same as to friendship”(Behn, 124)

According to Canfield and Sneidern (319), Hellena is characterized by emotional strength and masculine wit and appears to have huge success for a woman in the play. He has both charm and wit to seduce her lover, in addition to self interest to, persuade him for marriage. Gallagher (102) pointed out that Hellena fits the image of a new heroine genre. Hellena suggested that, through a women’s wit, they has the manipulative power to the social hierarchy and gain equal footing with the male counterparts. She mirrors the real image of Behn, who through the writing creates a degree of sexual and financial independence. Similar to the way Hellena manipulates and uses sex to get her honor, Hutner (119) suggested that the play writing of Behn shoulders her vulnerability and broaden her sexual power.

Conclusion

Surrounded by social reprimand, Behn fought to have equal footing in the stage. Using the space of the public as a platform to air her thoughts, she challenged the society by her authorship and the content of her plays. Behn did not consider or believed herself to be an exception of the rules but a spokesperson on behalf of her gender. The play of the rover exposes double blind feminism and frustrations of the restoration women. The social issues and the role of women in the restoration period have been elaborated. Women were defined.

Work Cited

Behn, Aphra. The Rover. Lincoln: University of Nebraska Press, 1967. Print.

Canfield, J D, and Sneidern M.-L. Von. The Broadview Anthology of Restoration & Early Eighteenth-Century English Drama. Peterborough, Ont: Broadview Press, 2001. Print.

Gallagher, Catherine. Nobody’s Story: The Vanishing Acts of Women Writers in the Marketplace, 1670-1820. Berkeley: University of California Press, 1995. Internet resource.

Hutner, Heidi. Rereading Aphra Behn: History, Theory, and Criticism. Charlottesville: University Press of Virginia, 1993. Print.

Quinsey, Katherine M. Broken Boundaries: Women & Feminism in Restoration Drama. Lexington, KY: The University Press of Kentucky, 1996. Print.

Todd, Janet M. Aphra Behn. New York: St. Martin’s Press, 1999. Print.

Woodcock, George. Aphra Behn: The English Sappho. Montréal: Black Rose Books, 1989. Print.

Herman Bailey

With a student-centered approach, I create engaging and informative blog posts that tackle relevant topics for students. My content aims to equip students with the knowledge and tools they need to succeed academically and beyond.

Overcoming Community Barriers in Online Education

by Herman Bailey | Feb 25, 2023 | Essays | 0 comments

Chapter One: Introduction

Education conducted through the internet is a typical choice for many learners. The versatility of the studying procedure is particularly the reason learners prefer to research on the internet. Learning institutions are applying various factors of on the online education in their program. Online education is a program that allows individuals from different parts all over the globe to fulfill up with and interact culturally. The comprehensive development in technical innovation has provided significantly towards the online education intensity. It has offered an opportunity for people working on the internet on the long distance education to achieve out beyond their limitations and cultural limitations.

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Gauvain (1995) recognized three techniques in which a society impresses upon the developing a kid what studying and educating “mean”:

(1) Any learning and teaching scenario rests upon a foundation–sometimes only designed, sometimes made clearly explicitly–about what kinds of goals and actions a culture values;

(2) The culture provides the trainer and student with tools and materials to fulfill up with the goals and make a support to those values;

(3) There are available “high-level community structures” (e.g., programs, workouts, and rituals) that are considered suitable and useful to apply the goals and ideas in culturally outstanding and building up ways.

These three subsystems, Gauvain claims, assist and limit the intelligent development of the student, demonstrate what it “means” to educate and learn, and route her thinking in techniques suitable to and valuable of her culture. Gauvain (2001) has also demonstrated how culture-specific messages shape the child who is developing as she:

1) Understands “problem solving skills” (techniques to apply and the base of knowledge to develop to be able to identify and approach and settle a problem);

2) Constructs “memory” (which requires taking in ideas revealed as remembrances of “exemplary situations” as well as studying particular techniques for remembering);

3) Understands of the guidelines for “planning” (learning how to organize someone’s own actions to be able to achieve goals as well as the suggestions for how to organize programs with the programs of others).

When learners from cultures structured with the teacher’s normative culture are more effective it does not actually mean that they are less large than other learners. It generally indicates that they are better ready for that scenario with a community worldview is more effective with the worldview of the trainer and university than is the community worldview of learners from society cultures. This problem is the same, only perhaps raised in some techniques, in the internet perspective.

Cultural comprehensive variety represents different individuals in a society or company whereby different ideas techniques and terminology limitations are available. It is experienced in on the online education in three different factors. They include:

a) Communication barriers

b) Educational policies

c) Public divides

Technological developments and the rapid development in online use have provided significantly towards global on the internet information. Public comprehensive variety problems have come up which range from terminology limitations. For instance, most of the online education techniques usually indicate on the English-speaking world’s perspective in accordance with the style of the online education program. It sides out the non-English sound system. Public and terminology variations usually do not be incorporated in the planning and style of the internet information. Nevertheless, cross-cultural on the online education is growing as well.

In addition, community gaps are available among on the online education users. Contribution rates vary in accordance with the various community groups. Some learners may face problems with the position of the interface and techniques of on the internet information. It is mainly because of the community variations. Public variations are available and they cause to community conditions in on the internet information.

Cross-cultural problems associated with online education mostly impact the studying and educating procedure. Learning is very reliant on someone’s actions. Students are expected to apply the found ideas in their lifestyle. The importance to someone’s culture mostly relies on your business presentation and is culturally affected. The ideas found are considered to be real if they are culturally relevant. At this point, an outstanding student attracts comparison depending on his or her community concepts. The challenge rests in because of the different cultures among the learners utilizing on the internet information. Different learners have different understanding and understanding of the ideas found depending on their cultures. The method of business presentation varies from one personal to the other. On the internet programs are becoming extreme. It is necessary to come up on the internet studying techniques that take into consideration the community comprehensive variety among the learners.

Objectives of the Study

This research is designed at introducing the different community conditions faced by learners in on the internet information. By the end of the research, the specialist is designed at creating few techniques, which can be valuable in reducing community limitations for learners.

Research Questions

I. How to get over community problem in on the internet education?

Subsidiary Questions

I. Does community distinction also are available in variety education?

II. Do disputes as a result of community variations transfer from the conventional class room to the distance-learning environment?

III. How do instructors and learners get around different cultures of studying in these environments?

IV. What role are instructors playing in conquering community conditions in on the internet education?

V. What should possibly be done to deal with community limitations in on the internet education?

Chapter 2: Literature Review

There are several problems to on the internet information. One of the first great problems in cross-cultural e-mails, also obvious in on the internet studying, is that many of our goals are designed, below our stage of awareness and unseen to us. It is typically only when we are in through contact with another way of doing factors, and when that way of doing factors does not fulfill our designed goals that we can start to locate what our original goals were and how they might vary from different techniques of understanding and being.

For an example, Spindler (1963) claims that there is a normative national The the united states culture which might be invisible to most People the united states because they assume everyone on the globe stocks the same reasoning. He suggested that the conventional ideas that create up the primary of the Anglo-American design involve the following five characteristics:

a) A Puritan concepts, particularly regarding the company of a family and sexual reliability of partners,

b) A idea that effort will cause to success,

c) A top quality placed on personal image,

d) An position of someone’s initiatives towards culturally and economically fulfilling success.

e) A future-time orientation–that is, seeing someone’s present actions and conditions in terms of their upcoming generate, almost as if the present were an continuous investment later on (pp. 134-136).

It is in deep and significant e-mails with others that People the United States start to realize not all hold the same initial reasoning. Many of the world’s individuals have social-psychological features that usually vary from these to one degree or another. Nisbett (2003) categorizes cultures as relatively separate and independent relatively, which are totally dissimilar in the following ways:

1. Insistence on independence of personal activity vs. a choice for combined action

2. Desire for personal distinctiveness vs. choice for combining harmoniously with the group

3. A choice for egalitarianism and obtained position vs. acceptance of structure and connected status

4. A understanding that the suggestions managing proper actions should be globally vs. a choice for particularistic techniques that take into account the perspective and you will of the connection involved.

Cultural comprehensive variety in on the online education results in community conditions. It is due to several factors of community comprehensive variety.

i. Communication Barriers

Culture and Learning

Teaching is an significantly community act. Knowledge is essential in most cultures. Moreover, studying and educating extremely relies on what is culturally approved subject to community ideas and specifications. The community specifications and techniques figure out the content that is suitable for educating. On the online education is no exemption to the community goals. Pai and Adler (2001) declare that culture and information are so related that they figure out each other.

The processes of studying and educating are affected by the primary ideas, concepts, and actions, as well as the frequent intelligent and connections styles and terminology styles, of a culture. Further, the educative procedure, whether formal or casual, is equally affected by the socioeconomic position of the student, professional requirements, you will of the connection between popular and society groups, and the result of technology in the society. Regardless of how information is determined, from a community perspective it can be considered as the filled with meaning indicates by which each society initiatives to deliver and perpetuate its idea of the outstanding culture, which is based on the society’s essential concepts concerning you will all over the globe, information, and ideas (p. 4).

Although the influence of socio-culture on mental development was mentioned significantly by Vygotsky in the 1920s-1930s, and recognized by Dewey in the Thirties, other following movements (behaviorism, intelligent, etc.) seemed to give less focus to these matters, until recently with the reemergence of socio-cultural ideas of studying (e.g. Brown, Collins, & Duguid, 1989; Lave & Wenger, 1991; Siemens, 2004).

Online information is a program that allows for the connections of learners from different cultures. Developing these cultures proves to be challenging because of the different goals. For example, France learners and the United States learners have different goals.

i. Difference in the training and studying systems

The United States information program evaluates clients’ performance through participation in class room conversations and getting them while trainer is lecturing. In the France information program, this act is considered disrespectful to the trainer.

ii. Fear of incapable is typical between France students

French learners are seen to be shy. The stage of participation in the class room is relatively low. They are scared of giving the wrong answers in the class room. The trainer in charge must help learners get over this worry.

iii. Differences in the position system

In the United States program, a C+ grade is considered a pass while in the France System it is considered incapable. The learners are likely to get confused about the position.

Differences in culture impact studying. Teachers and learners need to accept these variations especially in an on the online education environment. Joan Vienna said,

“The only way we will matter is through information.”We should perspective these variations as opportunities to create our intercultural connections and share our best techniques for a better globe. Consequently, it would be easier to live and understand each other in this reducing world”

When learners from cultures structured with the teacher’s normative culture are more effective it does not actually mean that they are less large than other learners. It generally indicates that they are better ready for that scenario with a community worldview is more effective with the worldview of the trainer and university than is the community worldview of learners from society cultures. This problem is the same, only perhaps raised in some techniques, in the internet perspective.

Herman Bailey

With a student-centered approach, I create engaging and informative blog posts that tackle relevant topics for students. My content aims to equip students with the knowledge and tools they need to succeed academically and beyond.

A Review of Brenda Niskala’s Of All the Ways to Die

by Herman Bailey | Feb 25, 2023 | Essays | 0 comments

Outline

“Of All the Ways to die” is a book authored by Brenda Niskala, as a little ghost story that is offbeat, sweet and short. The story weaves the ordinary people’s lives together, teetering on the edges of hope with historical figures that are fascinating. The plot of the story shows how the author narrates her story. The author of the “Of All the Ways to Die” book takes readers into the long journeys of the underworld, the real living world of the Saskatchewan and the land of the dead. Urma in the book of “Of All the Ways to Die” holds for people the pot luck. These are the people she has lost in her entire life. Every individual brings their favorite recipes, a dish and their life stories and how they used to live, and how they died. Death comes to all people, and it does not matter the lifestyle, fame and fortune that one possessed in the true life.

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Human compassion gets portrayed in the book, compounded by marvelous character collection and a marvelous prose of the analogy. The invitation from Urma attracts attention from acquaintances, loved ones and a few faces that are famous including that of the bog mummy, a Cree grandmother, St. Antony and the prairie ship builder who is eccentric (Niskala, 24). Is there a possibility that these people can help Urma in finding Eleen, the teenager who is missing?

Critical analysis

Niskala (44) attempts to show that the journey into the afterlife or death is not as easy and straightforward as people may imagine. Not only are important aspects of the dead lost along the way, there are cases where people are completely lost and unable to trace their journey into the after-life. Despite the fact that a new life awaits them, people could end up desperately lost, with the living and the dead completely unaware. This is signified through Eleen the young teenager being rescued in the novel.

Death comes to all people, and it does not matter the lifestyle, fame and fortune that one possessed in the true life, when death comes knocking all people are equalized. The characters in the novel, famous, rich and average, all together lived different lives. Lives in which they all admit, perhaps, they would never have willingly crossed paths. However, upon death they all become equalized, journeying together into the unknown (Niskala, 88).

The reader gets drawn into the lives of the characters both past and present, often finding villains and heroes mixed in the group. Those who are willing to help trace and find Eleene and those who desire to remain as they are.

Unlike the many novels of death and the journey into the death, Niskala finds a way to add satire, humor and mystery into a book educating people on life after death. Conflicts between the characters, inspiring stories of their lives and Urma the girl who brings it all together manage to make the book not drab, and dull as many books on death are, but more lively and exciting.

According to Niskala (7), the book of “Of All the Ways to Die” is a novella about a pot luck dinner, where the entire guests who have been invited are all dead. The book leaves the readers in suspense wondering whether the book is for zombies. The interplay at the pot luck dinner is wonderful witty and charming. Death is portrayed as meaningless as the characters laments on their unachieved dreams during their lifetimes.

The story has been narrated casually, fascinating and in a friendly manner. Moreover, the amazing thing in “Of All the Ways to Die “is that the author has packed hell in the meaning of death. The afterlife is not portrayed as pleasant to the readers in about a hundred pages of the book. The story is also sorrowful that can make a reader cry a bunch of times.

Niskala (42) indicated “Of All the Ways to Die” can also make the reader smile until the face hurts. The recipes elaborated in the book may tempt an individual to go and try them. Niskala (52) pointed out the characters contained within the book. They include stores of drug addicts, sex trade workers, pow-wows, acquired brain damage, love family, war dreams, royalty, hope, death, life, mystery and food. The book is entirely a mystery, a historical and a speculative fiction, and a fantasy. Furthermore, “Of All the Ways to Die” is also a recipe book and a brilliant tribute to people who are inspirational.

The novel provides a way for people to relive and find what they lost in their real lives. It provides an insight into what the characters of the novel found to be important during their lifetime. Whether it is a recipe or a piece of attire, it is one thing that these characters would have wanted to have before and after their death. It is also a story of denial, despite being the living dead, these people have desires and wants which have been denied them. They seek ways to have the desires restored, small things that may not be considered important, and perhaps they did not consider important until their demise. Urma gives the characters a chance to find happiness through finding for them the small things they lost in their journey between the worlds.

Work cited

Niskala, Brenda. Of All the Ways to Die. Thornhill, ON: Quattro Books, 2009. Print.

Herman Bailey

With a student-centered approach, I create engaging and informative blog posts that tackle relevant topics for students. My content aims to equip students with the knowledge and tools they need to succeed academically and beyond.

Efficiency Challenges in Public and Private Healthcare Systems

by Herman Bailey | Feb 25, 2023 | Essays | 0 comments

The terms private and public are descriptive words used in healthcare systems. The private in healthcare means the process where the business, individuals and charitable organizations gets involved in while the public refers to the involvement of the government (Grover, 2007).

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The current healthcare system does not operate efficiently and this calls for improvement in the system to increase efficiency of the system. However, the efficiency of the system cannot be improved if there is no standard mechanism of measuring the efficiency and the probable actions that should be taken or put in place to improve it.

Measuring of the efficiency in the healthcare system is also challenging because of lack of standard framework to measure the efficiency, technical issues which have not been resolved and notable differences to data access (Long, 1998).

According to (Grover, 2007), for the healthcare to perform highly, efficiency is one the factors that need to be employed. Inefficiency in the healthcare system is manifested in different dimensions. For example, the spending in the healthcare has little impact on the outcome of the beneficiaries. Furthermore, high cost for healthcare is also evidenced in some places and satisfaction of the patient or health improvement is minimal nowadays.

Moreover, it is evidenced in many hospitals that some costly physicians produce low quality services and the low priced physicians produce the highest quality of services (Long, 1998). This calls for ways to measure the efficiency of the healthcare system. However, it is challenging to measure the efficiency of the healthcare because there is limited scientific evidence on the authenticity and validity of the measuring criteria. In addition, the implication of the reporting the efficiency measures to the public can be detrimental. According to United States, & United States. (2002) it is challenging to define the healthcare efficiency because of the following reasons:

• The relative nature of the term efficiency. There is a great influence on the perspective of the healthcare delivery elements .Furthermore; definition of the efficiency is different by payers, purchasers, consumers, plans and consumers.
• All these category of people have different perspective on what forms and constitutes appropriate cost and quality.
• Efficiency also comes in different types. These include productive, technical and social efficiency. Productive and technical efficiency cannot be described alongside social efficiency. Moreover, some efficiency types are viewed as contradicting the healthcare practitioner’s values. For instance, the perception of the physicians of their obligation as a priority over the needs of the individuals in the society.
• Lack of a true definition of efficiency. There is lack of evidence to certainly assert how many and what healthcare services input will produce the best efficiency with what kind of benefits and risks.
• The rewards such as financial are often not associated with the actual outcome of the healthcare. For example, the patients pay for the healthcare which can be measured in monetary terms or visits to the hospital. However, the outcome of the healthcare is not factor in the purchasing equation.

In comparison of the healthcare of the United States with other industrialized countries we find some similarities and differences. For example united states spend highest on the healthcare in relation to her gross domestic product (GDP) than any other country. For instance, in the year 2010 alone united states spent 17.9% of her GDP on healthcare. This translated to $8402 per person (Grover, 2007).

According to United States, & United States. (2002), the most trusted organization to source data for comparison of healthcare among the industrialized nations is the Organization for Economic Co-operation and Development (OECD). This organization’s journal documents the inefficiency of the US healthcare system in relation to other countries. These inefficiencies are evidenced by the way US conducts its operations for example the manner in which they counts the number of live births. Although the efficiency of the healthcare cannot be measured, OECD derives the statistics from the observable measures as health status proxies to provide comparative analyzed results. However, the reality which is depressing is that the observable realities are just mortality derivatives. Three statistics of the OECD in which they use to base their analysis in its report includes the life expectancy, infant mortality and the premature death.

There has been growing discontent among the populations in United States over their expenditures on healthcare and access to necessary services which is inverse. This is in sharp contrast with other industrialized nation which has a universal decent medical care access at a cheap cost compared to United States (Long, 1998). The US escalating healthcare cost which is  lined to exclusively the healthcare organization system, delivery and funding which has gone through a process of evolution in United states.

Furthermore, in comparing the healthcare systems of many industrialized nations, there is no common feature amongst them. Every system is unique .However; According to Oandasan, I., & Canadian Health Services Research Foundation. (2005), the systems of the healthcare in many nations are struggling with the intense pressure of the aging persons, exponential increase in medical costs and over reliance on high tech procedures and solutions which are extremely expensive. Similarly, all the industrialized nations battle with the way to balance the three common and shared problems in the modern health care. These include cost, quality and access.

As discussed above, industrialized nations have made the decisions to employ different approaches to address their healthcare concerns. The paper will examine the systems of heath care in United States and Canada and try to make comparisons. In United States, the health care system is offered majorly through the private sectors while in Canada the system in place for administration of the health care is through provincial government system.

Canada

Canada employs the capitals economy which is similar to the economy of United States. Moreover, her healthcare system uses a system of free-for-service which is administered by the entities of the government (Oandasan, I., & Canadian Health Services Research Foundation, 2005). In this system, the coverage for the healthcare services is universal. Moreover, all the citizens of Canada are covered. The ten provinces of Canada administer and manage themselves but the differences are very few. The costs for the plan are mostly paid by the provincial government through premiums subscription and payment of taxes. Moreover, the government of Canada further funds the system by provision of additional funds to each provinces of Canada by grant systems and funds transfer generated and gotten through corporate income taxes and personal revenues. However, as much as the healthcare system in Canada is social and universal, the plan does not cater for drugs taken at homes, cosmetic surgery and the dental care (National Pharmaceuticals Policy, 2011).

About the hospital expenditures, those are regulated and determined by the central government. The doctors’ salaries are surrendered by the government according to the determination through negotiation between the doctor’s associations and the provincial governments (Grover, 2007).

The social healthcare system of Canada which is universal which ensures every Canadian citizen have access to healthcare also has its advantages and disadvantages. The main advantage which is conspicuous is that it ensures that healthcare coverage is universal. Moreover, despite the fact the health care cost is also rising in Canada, the cost of administration is appreciably lower because of the use of one payment source in each province (Long, 1998).

According to United States, & United States. (2002), the disadvantage of the system is that hospital expenditures control by the system has created a scenario whereby some forms of the latest technology such as the cardiac surgery have led to overflowing waiting lists and the patients face delays. Moreover, the physical conditions of some facilities in the hospitals have deteriorated because of insufficient funding to maintain them.

In comparing the health system of Canada, there are many differences which come out. According to Oandasan, I., & Canadian Health Services Research Foundation (2005), the data of 1989 stipulates that the healthcare expenditure per capita of united states was $2354 compared to Canada which had $1683.Moreover, the healthcare in united states took a budget of 11.8% of the gross domestic product of the country compared to Canada where it was 8.7% of the gross domestic product. It is important to note that the GDP of united stets is far much higher than that of Canada. Therefore, this shows that their expenditure was higher.

It is very difficult or close to impossible to compare how the health cares in a certain country in relation to the other. However, the simplest way to bring out the differences is by analyzing the statistics of the nation such as the infant mortality which are the deaths which occur in the first year of life, life expectancy and the prenatal mortality which are the deaths that occur within the seven days of birth (Grover, 2007). From the statistics, Canada has the highest life expectancy and the lowest percentage of infant mortality (Oandasan, I., & Canadian Health Services Research Foundation, 2005). This brings the conclusion that higher expenditure does not result to a better healthcare.

Obamacare

The Obamacare is a common term used to refer to The patient protection and Affordable Act (PPACA) which was signed by president Obama in 2010. The healthcare law has since received criticism and support alike since it was enacted, passed and signed into law (Tate, 2012)

The law has does the following things to the citizens of United States as discussed below. The main purpose which was stated since the formulation of the law was to increase the number of citizens of America covered by health insurance and reduce the healthcare cost. However, the most parts which people usually talks about in the Obamacare is that there will be no exclusion of anyone from getting insurance and everybody will have to obtain the insurance (Tate, 2012).

According to Tate, (2012), the companies of insurance cannot refuse to cover the citizens of America like they used to do before and furthermore they cannot revoke the insurance cover they had on the citizens of the America. Moreover, there will be no forcing of people to pay extra for the coverage because of the conditions which are pre existing. However, there will be a set limit on the amount the insurance companies can get profit legally and eventually they will have to cover all forms of preventive care. All these changes the Obamacare is introducing among others have the main aim of containing the health care spending of the United States which is skyrocketing (Tate, 2012).

Since the law was passed almost three years ago, from the outward analysis, it seems that that no significant change has taken place due to the introduction of the law. However, the law promises that most significant changes will be realized after the first ten years. However, some of the noticeable changes which have affected the insurance companies in the united states and the slowing down of the health care spending for the last three years (Tate, 2012).

However, the bone of contention in the law which has led to many disputes was the mandate of every individual that required most citizens of America to get a health insurance cover which is essential at least at minimal. Moreover, this is the part of the law that prompted ACA to file a case at the Supreme Court (Tate, 2012).

From the discussion of the Obamacare law, the pros has been identified and discussed clearly. However, the cons to the law are also discussed below. More than forty five million Americans do not have the health insurance. However, the law requires every citizen t have a minimal health cover by the year 2014 when the law will go into effect (Tate, 2012). What is the projected number that will have taken the health insurance by the year 2014?

The government of the states and the federal government have put in place exchanges that are expected to start in October. Exchanges are simply open markets where business which are medium or small and the people can shop for the insurance and also compare the benefits and prices. This will be done online on the web sites (Tate, 2012).

However, the big question is the affordability of the insurance covers. The government has subsidized it for the people with moderate source of income where they can get the money or discounts to help them in payment. However, the low income earners will get the Medicaid care.

According to Tate (2012), the conservatives have been upbeat because of the radical nature of the Obamacare law in transforming the health sector. Furthermore, they claim the system is costly to the many citizens of America in terms of the required minimal health insurance cover. In addition, the conservatives have opposed the law out of political reasons. It is political game of supremacy between the Republicans and the Democrats.

References

Grover, J. (2007). Healthcare. Detroit: Greenhaven Press.

Long, M. J. (1998). Health and healthcare in the United States. Chicago, Ill: Health Administration Press.

United States., & United States. (2002). Help Efficient, Accessible, Low Cost, Timely Healthcare (HEALTH) Act of 2002: Report together with dissenting views (to accompany H.R. 4600) (including cost estimate of the Congressional Budget Office). Washington, D.C: U.S. G.P.O.

Oandasan, I., & Canadian Health Services Research Foundation. (2005). Teamwork in healthcare: Promoting effective teamwork in healthcare in Canada : policy synthesis and recommendations. Ottawa, Ont: Canadian Health Services Research Foundation.

Healthcare reform, including: health care reform, medical cannabis, publicly funded health care, comparison of the health care systems in Canada and the United States, single-payer health care, the citadel (novel), national pharmaceuticals policy. (2011). S. l: Hephaestus Books.

Tate, N. (2012). ObamaCare survival guide.

Herman Bailey

With a student-centered approach, I create engaging and informative blog posts that tackle relevant topics for students. My content aims to equip students with the knowledge and tools they need to succeed academically and beyond.

Outbreak Report: Investigating the Typhoid Epidemic in Tajikistan

by Herman Bailey | Feb 25, 2023 | Essays | 0 comments

Please follow the below guideline for the outbreak report of Typhoid in Tajikistan

OUTBREAK INVESTIGATION REPORT WRITING GUIDELINE

1. Introduction

[A brief summary of the outbreak/setting the scene (this report is about…will discuss this and that and finally summarise key findings….outline some public health interventions to control outbreak]

1. Background

[Briefly describe- when outbreak occurred; how the outbreak was discovered; where or what sources (e.g. foods) were implicated; important facts to be drawn out; total number; summary of the case investigated and anything else that may be of relevance e.g. previous outbreaks]

1. Investigation of the outbreak

[Highlight some epidemiological, environmental and microbiological aspects]

1. Confirm that this is really an outbreak

[What sort of data was collected, what you know about the usual prevalence of these microorganisms e.g. surveillance systems].Describe the data you have so far [You are required to mention setting up an outbreak control committee and talk about control measures].

2. put together a case definition (person, place, time symptoms)

3. Describe how other cases were found e.g. GP alerts or use ofquestionnaires to collect information on cases.

4. Describe cases, what sort of outbreak is this? Any informationabout incubation period, age and gender of cases?

5. Put together a hypothesis on the likely source and vehicle associated with outbreak

6. Test hypothesis usually case/control study including Odds ratio. How are the controls recruited? (If needed or given)

7. What other information might be used to confirm the hypothesis? E.g. sampling of environment and/or food.

8. Recommendations to prevent future outbreaks (control measures)

[Infection control, policy changes, public information]

1. Discussion and conclusion
2. Lessons learned and recommendations
3. References (Harvard – APA style]

Note

Assessment Component: 1 (2000 words, +/-10%) Weighting: 40%

Outbreak investigation report must be submitted and electronically (using Turnitin)!

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Typhoid in Tajikistan

PART I. OUTBREAK DETECTION

Tajikistan is one of five Central Asian countries that were formerly part of the Soviet Union (Figure 1). Tajikistan is one of the poorest of these countries, with less than 7% of its land available for cultivation.

Figure 1.Location of Tajikistan including the country’s capital and largest city, Dushanbe.

Tajikistan became an independent nation in 1991 as the result of the dissolution of the former Soviet Union. The shift in its status from being a member of a totalitarian republic to an independent nation brought with it certain challenges. Basic public services (e.g., health care, water supply, and sewer systems), previously guaranteed for even the poorest nations in the Soviet Union, were no longer supported through the Soviet cost-sharing system. Financial hardships and inadequate tariffs in Tajikistan severely limited provision of services and maintenance of equipment. Faulty design and installation of equipment while Tajikistan was still part of the Soviet Union added to these problems.

To make matters worse, shortly after becoming an independent nation, Tajikistan experienced a civil war that continued until a cease-fire occurred in 1996. During the civil war, an estimated 50,000 lives were lost and 1.2 million persons were internally displaced.3 In addition, a substantial number of trained technical and professional workers left the country.

By 1997, the country’s economy and much of its infrastructure had collapsed. Consequently, the health of the people of Tajikistan suffered. Diseases rarely seen before the dissolution of the Soviet Union reappeared in increasing numbers.

Residents of Tajikistan received primary health care at designated polyclinics on the basis of their place of residence. The polyclinics provided ambulatory care and certain acute care services but lacked surgical and post-operative care facilities. Limited hospital beds at nationally run hospitals were available for patients needing in-patient services. Cases of notifiable disease were reported each week from the polyclinics and hospitals to the Sanitary Epidemiologic Service (SES), the public health unit that monitored infectious diseases.

In February 1997, an increase in typhoid fever cases was reported in Dushanbe, the capital of Tajikistan (population approximately 600,000). Although typhoid fever was endemic in this area, more than 2,000 cases had been reported during January 29−February 11 (i.e., a 2-week period), compared with approximately 75 cases each week during the previous month. During the same 2-week period in 1996, only 23 cases had been reported.

All typhoid fever patients were hospitalized at one of six full-service hospitals in the city, as required by a central government edict. SES staff studied the situation to determine the likelihood of an outbreak.

As a first step in exploring the increase in typhoid fever cases in Tajikistan, SES investigators confirmed the diagnosis of typhoid fever in a sample of patients admitted to one of the Dushanbe hospitals. They also examined laboratory testing procedures and reagents at all six hospitals. No evidence of laboratory error or contamination of cultures was identified.

SES investigators were unable to identify recent events that might have led to an increase in the completeness of case reporting. Notifiable disease reporting procedures had not changed since the early 1980s. Typhoid in Tajikistan Page 3

SES investigators noted that the civil war had resulted in the displacement of substantial numbers of Tajikistan citizens and an increase in the Dushanbe population. However, movement of the displaced persons was spread over a lengthy period and seemed an unlikely explanation for the sudden increase in typhoid fever cases during January−February of 1997.

SES staff concluded that the increase in typhoid fever cases was real and likely represented an outbreak. Because previous typhoid fever outbreaks had been associated with foods and beverages sold by street vendors, the city government prohibited such sales. However, considerable debate remained about the source of the outbreak and appropriate control measures.

PART II. HYPOTHESIS GENERATION

SES investigators pursued different lines of investigation to gain clues about the typhoid fever outbreak in Dushanbe. The first step was to review known information about the disease and risk factors on the basis of its epidemiology and previous outbreaks.

SES staff then reviewed the typhoid fever cases reported through the notifiable disease surveillance system and characterized the cases by person, place, and time (i.e., performed the descriptive epidemiology).

To characterize the typhoid fever cases associated with the Dushanbe outbreak, SES investigators defined a case of typhoid fever as a physician diagnosis of typhoid fever or isolation of Salmonella Typhi from the stool, blood, or urine of a Dushanbe resident (i.e., a relatively sensitive case definition). Investigators analyzed typhoid fever cases reported to SES with onset of illness since January 1.

A total of 3,822 patients meeting the typhoid fever case definition had onset of illness since January 1. Of these cases, 127 had onset of illness from January 1−14 (median of 64 cases each week) and 3,695 had onset of illness from January 15 to February 18 (median of 724 cases each week) (Figure 2).

Among the cases reported during January 15−February 18, the following signs and symptoms were reported: sustained fever (91% of cases), headache (81%), weakness (76%), chills (73%), loss of appetite (67%), abdominal pain (51%), vomiting (39%), diarrhea (30%), and rose-colored spots (6%). Blood, stool, or urine cultures confirmed 1,145 (31%) of the cases.

The median age of patients was 16 years (range: <1−80 years); 51% were male. Cases were spread across the city with varying rates of infection by polyclinic catchment area (Figure 3).

Forty-eight (1.3%) of the 3,695 patients had died. Mortality rates were lowest among patients aged <10 years (0.3%) and highest among those aged >39 years (1.4%). Typhoid in Tajikistan Page 4

Figure 2. Cases of typhoid fever by week of onset of illness, Dushanbe, Tajikistan, June 1996−February

Source: Dushanbe SES Notifiable Disease Surveillance System.

Figure 3.Incidence rate of typhoid fever by registered polyclinic, Dushanbe, Tajikistan, January 15–February 18, 1997.

Source: Dushanbe SES Notifiable Disease Surveillance System.

Detailed hypothesis-generating interviews were conducted to detect common and suspicious exposures among a sample of the typhoid fever patients. Interviews were undertaken with 10 patients who had culture-confirmed illness. These patients lived in the catchment areas of five different polyclinics and ranged in age from 5 to 69 years. Six of the patients were female. All of the patients had had onset of symptoms during the first 2 weeks of February.

Hypothesis-generating interviews revealed that all of the patients had purchased groceries from state-approved markets. However, four of the patients had also purchased food from local street vendors, with fruits and vegetables being the most commonly purchased items. No market, street vendor, restaurant, or social event was identified in common among the patients.

The households of all patients included in hypothesis-generating interviews were supplied with public water. All but one patient reported that the water was often cloudy and occasionally had a foul smell.

Only one patient had travelled outside the city during the previous 6 weeks; seven patients had had visitors who normally resided outside Dushanbe staying in their home because of Ramadan (i.e., a month-long Muslim observance involving a fast from food and water from sunrise to sunset that began on January 10). None of the patients knew each other. Two patients knew someone else who had been similarly ill.

SES investigators suspected the public water supply as the source of the Dushanbe typhoid fever outbreak. The widespread occurrence of cases throughout the city, affecting both sexes and all age groups, was indicative of a waterborne outbreak. Complaints during the hypothesis-generating interviews about the quality of the public water further heightened their suspicions.

Investigators initiated both epidemiologic and environmental health studies to confirm their hypothesis.

PART III. AN EPIDEMIOLOGIC STUDY TO TEST THE HYPOTHESIS

SES investigators conducted a case-control study to test the hypothesis that the public water system was the source of the typhoid fever outbreak in Dushanbe.

Beginning March 24, patients hospitalized with typhoid fever in Dushanbe were recruited to participate in the case-control study. For the study, a case was defined as an illness in a person that included the following:

Clinical criteria

– sustained fever (i.e., oral temperature ≥ 101.5 F [38.5C] for ≥7 days), and

– one or more other signs and symptoms indicative of typhoid fever (e.g., weakness, stomach pains, headache, loss of appetite, or rose-colored rash), and

– culture of stool or blood positive for Salmonella Typhi.

Restrictions on time, place, and person

– onset of symptoms after February 1,

– resident of Dushanbe, and

– person with earliest onset of symptoms in household.

Case-patients were interviewed within 5 days of hospital admission by a trained SES interviewer, using a standardized questionnaire. Questions focused on exposures during the 30 days before onset of illness.

Within 5 days of interviewing each case-patient, investigators selected neighbourhood control

subjects from households in which no one had experienced fever for ≥3 consecutive days during the Typhoid in Tajikistan Page 6

previous 90 days. Control subjects were recruited by going systematically from door-to-door, starting at the case-patient’s house; control subjects were then matched with case-patients by age group.

Two to three control subjects were identified for each case-patient.

Control subjects were interviewed by using the same standardized questionnaire as case-patients, except that exposure information was requested for the 30 days before the interview.

During March 24−April 7, a total of 45 case-patients and 123 healthy control subjects were enrolled in the case-control study. SES investigators tabulated the results and set a P value of 0.05 as the cut-off for statistical significance.

On the basis of these analyses, case-patients were similar to control subjects with respect to age, sex, and nationality (Table 1). Exposure to potential risk factors for infection with S. Typhi, however, differed between case-patients and control subjects (Table 2).

Tables 1.Characteristics of case-patients and control subjects, case-control study, Dushanbe, Tajikistan, 1997.

Table 2. Exposures to selected risk factors for infection with Salmonella Typhi, case-control study, Dushanbe, Tajikistan, 1997

*Exposure during the 30 days before becoming ill (case-patients) and during the 30 days before the interview (control subjects)

†Denominator does not always total to 45 (case-patients) or 123 (control subjects) because certain subjects could not remember if they had had the exposure.

On the basis of the matched case-control study, infection with S. Typhi in Dushanbe was associated with drinking water that had not been boiled during the 30 days before onset of symptoms. The odds ratio increased with the amount of water consumed each day (Figure 4). Drinking at least 1 glass of water that had not been boiled had a matched odds ratio of 3; drinking 2 glasses had a matched odds ratio of 12; and drinking > 2 glasses had a matched odds ratio of 40.

Obtaining water from a tap outside the home and eating food obtained from street vendors were also associated with illness. Using boiled water in the home and eating butter, apples, or onions were determined to be protective factors.

Factors not associated with illness (data not shown) included type of toilet facilities; drinking beverages with ice; eating or drinking at restaurants or a friend’s or relative’s home; travelling outside Dushanbe or receiving visitors who usually reside outside Dushanbe; and consuming raw fruits and vegetables (other than apples and onions), dairy products (other than butter), and medicines.

Figure 4. Odds ratios by amount of water consumed per day that had not been boiled, case-control study, Dushanbe,Tajikistan, 1997.

Investigators undertook a multivariate logistic regression analysis that included all exposures identified as significantly associated with infection in the univariate analysis (Table 3).

Table 3. Multivariate analysis of reported exposures to risk factors for infection with Salmonella Typhi, case-control study, Dushanbe, Tajikistan, 1997

PART IV. ENVIRONMENTAL STUDIES AND WATER SUPPLY INVESTIGATION

Concurrent with the case-control study, SES investigators evaluated the Dushanbe public water supply to identify factors that might have allowed introduction of pathogenic organisms into the drinking water or the survival of such organisms.

To evaluate the Dushanbe public water supply, SES investigators first talked with the superintendent of public water and viewed maps of the watersheds for the water treatment plants. They then toured all of the water treatment plants (and associated wells) and spoke with water treatment plant operators and maintenance technicians. Investigators observed procedures used to treat the water at each plant and inspected equipment used in water treatment.

SES investigators learned that the city of Dushanbe had four water treatment plants that used surface and groundwater. The two treatment plants in the northern part of the city (i.e., the Napornaya and Samotechnaya Stations) used surface water from the Varzob River. The two treatment plants in the southern part of the city (i.e., the Kafernigan and South-West Stations) used groundwater.

The Varzob River’s source is in the Hissar Mountain range, 72 km north of Dushanbe, and is fed by the Siyoma, Ojuk, Kondara, Maikhura and Tagob Rivers. Heavy rains in the winter and spring and snowmelt result in periodic flash floods along the watershed. Lack of wastewater purification facilities or storage in villages and factories along the river resulted in the discharge of communal wastes directly into the river. Within the Dushanbe city limits, water was drawn from the Varzob River through a system of canals into the surface water treatment plants (i.e., Napornaya and Samotechnaya Stations).

Typically, the water was strained and held in open sedimentation basins where particulates were allowed to settle out naturally. Chlorine was added directly to the sedimentation basins before the water was passed through sand filters to allow for adequate contact time. From the filters, water was pumped into the distribution system without further storage.

The water for the two groundwater treatment plants (i.e., Kafernigan and South-West Stations) was pumped directly from the wells into holding tanks and from the holding tanks into the public water distribution system without treatment.

On inspection of the surface water treatment stations, investigators noted that the sedimentation basins were filled with silt and algae. Dredging machines used to remove the silt were broken. Sand filters had formed mud balls (i.e., conglomerations of filter material that form if a filter is not cleaned adequately) and displayed substantial fouling with iron-oxide that can compromise the filtration process. Water at the surface water treatment stations had not been chlorinated regularly since December. The chlorine -producing facility in Yavan, Tajikistan, which once supplied chlorine to the entire country, had closed in 1996.

Inspections of the groundwater treatment stations were unrevealing. The wells were in good condition and wellhead seals were functioning correctly. However, approximately half of the pumps at these stations were not operational, limiting the ability to provide the city with adequate water pressure. Plant workers had scavenged spare parts to maintain the functionality of the remaining pumps. Typhoid in Tajikistan Page 10

SES investigators tested treated water samples from each of the water treatment plants for turbidity and fecal coliforms. The turbidity of treated water from the Napornaya Station was 150 nephelometric turbidity units (NTUs). Fecal coliforms were 132 colony forming units (CFU)/100 mL. Treated water from the Samotechnaya Station had a turbidity of 70 NTUs; fecal coliforms were 118 CFU/100 mL. Both groundwater plants pumped fecal-coliform-free water with a turbidity of 0 NTUs.

Water leaving all four water treatment plants entered an interconnected distribution system where surface and groundwater blended. To distinguish the source of water supplied to different parts of the city, SES investigators measured water hardness at the treatment plants and at a sample of consumer taps. They determined that the northern part of the city received water primarily from the surface water treatment plants. The southern part of the city received water primarily from the groundwater treatment plants. The central part of the city received water from both the surface and the ground water treatment plants (Figure 5).

Figure 5. Water source by polyclinic, Dushanbe, Tajikistan, 1997

The water distribution system in Dushanbe was approximately 690 km in total length and consisted mainly of steel and cast-iron pipelines. Approximately 5% of pipes were asbestos or plastic. Distribution pipes had corroded over the years, and breaks occurred intermittently throughout the city.

SES investigators undertook a community survey to assess domestic water quality and use in Dushanbe. Households were selected from each polyclinic catchment area by using a stratified random-sampling scheme. At each house or apartment, investigators recorded the number of residents, frequency of water outages and other problems, and attitudes toward water use. They also collected water from the tap for fecal coliform testing and quantified water usage.

SES investigators learned that low and intermittent water pressure was common across the city, resulting in water outages on a daily basis. Apartment buildings often had supplemental water pumps that were activated at times of low water pressure. Residents in households and apartment buildings without supplemental water pumps were forced to obtain water from outside taps. In addition, nonstandard connections to waterlines were commonly used to supply homes. Investigators also observed that water pipes ran inside storm drains along roadsides.

Water usage at the surveyed households was substantial. On average, 1,000 L of water were used/person/day, the majority of which was wasted. A total of 300 L/person/day were lost because of open taps within the households, and another 300 L/person/day were lost because of broken pipes or faucets within the house. An additional 400 L/person/day were wasted because of open or broken taps or pipes in public areas. (Note: For comparison, according to a 2006 United

Nations Development Programme report,4water usage was approximately 575 L/person/day in the United States and 200−300 L/person/day in Europe.)

Surveyed residents considered the water supply a free commodity. Approximately 2% of domestic users paid the tariff charged by the public water utility, which by the majority of standards was quite low (i.e., US$0.004/1,000 L equivalent for domestic consumers). Residents did not consider running taps to be wasteful or as a contributing factor to the typhoid fever epidemic.

Based on the water samples collected during the survey, 97% of household and community taps throughout the city had water contaminated with fecal coliforms. The average fecal coliform concentration in water samples was 175 CFU/100 mL.

PART V. PREVENTION AND CONTROL MEASURES

Prevention and control of typhoid fever and other waterborne diseases in Dushanbe required many actions, including improved protection of the watershed of the Varzob River, repair or replacement of equipment at the water treatment plants (e.g., dredging machinery, sand filters, and pumps), thorough training of water treatment plant staff, changes to the water treatment processes, procurement of adequate amounts of chlorine and coagulant, and repair and replacement of the aging water distribution system. In addition, public education on water conservation was needed to decrease water wastage across the city.

Officials estimated that these efforts might cost at least US$150 million and require yearstocomplete. Public health officials considered implementing point-of -use water treatment to protect the public’s health while more costly improvements were being made to the water system.

SES investigators worked with the Tajikistan Ministry of Health in developing a citywide public education campaign about point-of-use water treatment. A health educator from the Ministry of Health was designated to lead and coordinate campaign efforts.

EPILOGUE

Use of multiple barriers to keep water contaminants from entering the water supply and surviving is the best approach to achieving a healthy public water supply. Development of multiple barriers to protect the water means that the system will continue to perform adequately despite the failure of part of the system.

The Dushanbe typhoid fever outbreak resulted from failures at multiple points in the water treatment and distribution process. The factors contributing to the state of water services in Dushanbe included

• Chronically contaminated surface waters caused by discharge of untreated sewage into the river and heavy flooding each spring;

• inadequate treatment processes (e.g., lack of chlorination because of inadequate supplies, improperly maintained sand filters, and lack of residual chlorine levels in water leaving the water treatment stations);

• disrepair of the water treatment plants resulting from inadequate initial design, unavailable or low-quality of materials and equipment, limited financial resources, and departure of trained staff;

• frequent low and intermittent water pressure because of nonoperational water pumps at treatment facilities, breakages in the water distribution lines, and water wastage in the community; and

• Inadequate monitoring of the water system to identify and correct problems.

In 2002, the World Bank began funding the Dushanbe Water Supply Project. Loans were approved to address the most critical deficiencies of the water supply, including replacement of pumps and other equipment at the treatment plants and repair of major sections of the distribution system. Despite improvements, many Dushanbe residents still had inadequate water service and outbreaks of typhoid fever reoccurred on an annual basis. In 2006, the World Bank approved additional funds to continue work on the water system. Renovations and repairs are ongoing.5

Although the investigation of the typhoid fever outbreak in Dushanbe presents a dramatic third world image, similar problems occur elsewhere. In 2007, the U.S. Environmental Protection Agency estimated that 240,000 water mains in the United States break each year, resulting in a loss of 1.7 trillion gallons of water.6 These problems are attributed to factors that are reminiscent of the Dushanbe situation and include reductions in resources devoted to water treatment system maintenance, a growing backlog of needed repairs, aging treatment equipment and distribution pipes, and loss of trained personnel to maintain the systems.

In the majority of U.S. cities, water supplies have not yet been adversely affected. However, a growing number of localities have had serious problems resulting in at least a temporary loss of

Although the investigation of the typhoid fever outbreak in Dushanbe presents a dramatic third world image, similar problems occur elsewhere. In 2007, the U.S. Environmental Protection Agency estimated that 240,000 water mains in the United States break each year, resulting in a loss of 1.7 trillion gallons of water.6 These problems are attributed to factors that are reminiscent of the Dushanbe situation and include reductions in resources devoted to water treatment system maintenance, a growing backlog of needed repairs, aging treatment equipment and distribution pipes, and loss of trained personnel to maintain the systems.

In the majority of U.S. cities, water supplies have not yet been adversely affected. However, a growing number of localities have had serious problems resulting in at least a temporary loss of potable water and substantial commitment of resources to correct the problem. If steps are not taken to understand and address these growing problems, a widespread decline in drinking water quality and reliability, even in the United States, is possible.

REFERENCES

1. Mermin JH, Villar R, Carpenter J, et al. Massive epidemic of multidrug-resistant typhoid fever in Tajikistan associated with consumption of municipal water. J Infect Dis 1999;179:1416–22.

2. Centers for Disease Control and Prevention (CDC). Epidemic typhoid fever—Dushanbe, Tajikistan, 1997. MMWR Morb Mortal Wkly Rep 1998;47:752–6. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00054823.htm. Accessed September 20, 2010.

3. United Nations. Tajikistan: rising from the ashes of civil war. Available at: http://www.un.org/events/tenstories_2006/story.asp?storyID=600. Accessed September 20, 2010.

4. United Nations Development Programme. Human Development Report 2006. Beyond Scarcity: Power, Poverty and the Global Water Crisis. New York: Palgrave Macmillan; 2006. Available at: http://hdr.undp.org/en/media/HDR06-complete.pdf. Accessed September 20, 2010.

5. World Bank. Project paper on a proposed additional financing grant for a Dushanbe water supply project.. Report No. 38085-TJ. Available at: http://waterwiki.net/images/3/32/WB_Project_Paper_Dushanbe_Financing_WS.pdf. Accessed September 20, 2010.

6. US Environmental Protection Agency (EPA). Aging water infrastructure research program: addressing the challenge through innovation. Washington, DC: EPA; 2007. Available at: http://www.epa.gov/nrmrl/pubs/600f07015/600f07015.pdf. Accessed September 20, 2010.

ADDITIONAL RESOURCES

Arnold BF, Colford JM. Treating water with chlorine at point-of-use to improve water quality and reduce childhood diarrhea in developing countries: a systematic review and meta-analysis. Am J Trop Med Hyg 2007;76:354–64.

Australian Cooperative Research Centre (CRC) for Water Quality and Treatment. Drinking water facts.Drinking water treatment. Adelaide, South Australia: CRC; 2008. Available at: http://www.wqra.com.au/crc_ archive/dwfacts/DWF_Drinking_Water_Treatment_Nov08.pdf. Accessed on September 20, 2010.

Clasen T, Schmidt W-P, Rabie T, Roberts I, Cairncross S. Interventions to improve water quality for preventing diarrhoea: systematic review and meta-analysis. BrMed J 2007;334:782−792. Available at: http://www.bmj.com/content/early/2006/12/31/bmj.39118.489931.BE.full.pdf+html?maxtoshow=&HIT S=10&hits=10&RESULTFORMAT=&fulltext=clasen&searchid=1&FIRSTINDEX=0&resourcetype=H WCIT. Accessed on September 20, 2010.

Centers for Disease Control and Prevention (CDC). Preventing diarrheal disease in developing countries: proven household water treatment options. USAID-sponsored activity. Atlanta, GA: US Department of Health and Human Services, CDC; 2008. Available at: http://www.ehproject.org/PDF/ehkm/cdc-proven.pdf. Accessed September 20, 2010.

Centers for Disease Control and Prevention (CDC). Safe Water Systems for the Developing World: A Handbook for Implementing Household-Based Water Treatment and Safe Storage Projects. Atlanta, GA: US Department of Health and Human Services, CDC; [undated]. Available at: http://www.cdc.gov/safewater/manual/sws_manual.pdf. Accessed September 20, 2010.Typhoid in Tajikistan Page 14

Committee on Communicable Diseases Affecting Man, Food Subcommittee. Procedures to Investigate Waterborne Illness, 2nd ed. Ames, Iowa: International Association of Milk, Food, and Environmental Sanitarians, Inc (IAMFES); 1996.

U.S. Environmental Protection Agency (EPA). Drinking water glossary: a dictionary of technical and legal terms related to drinking water. Washington, DC: EPA; 2009. Available at: http://www.epa.gov/safewater/pubs/gloss2.html. Accessed September 20, 2010.

Hrudey WE, Huck PM, Payment P, Gillham RW, and Hrudey EJ. Walkerton: lessons learned in comparison with waterborne outbreaks in the developed world. J Environ SciEng 2002;1:397–407.

Lantagne DS, Quick R, and Mintz ED. Household water treatment and safe storage options in developing countries: a review of current implementation practices. Washington, DC: Woodrow Wilson International Center for Scholars; 2007. Available at: http://www.wilsoncenter.org/topics/pubs/WaterStoriesHousehold.pdf. Accessed September 20, 2010.

LeChevallier MW, Au K-K. Water Treatment and Pathogen Control: Process Efficiency in Achieving Safe Drinking Water. Geneva, Switzerland: World Health Organization and IWA Publishing; 2004. Available at: http://www.who.int/water_sanitation_health/dwq/watreatment/en/index.html. Accessed September 20, 2010.

National Environmental Services Center.National drinking water clearinghouse [Homepage on the Internet]. Morgantown, WV: University of West Virginia; 2010. Available at: http://www.nesc.wvu.edu/drinkingwater.cfm. Accessed September 20, 2010.

World Health Organization (WHO).Guidelines for Drinking Water Quality.2nd ed. Volume I. Recommendations. Geneva, Switzerland: WHO; 1993. Available at: http://www.who.int/water_sanitation_health/dwq/2edvol1b.pdf. Accessed September 20, 2010.Typhoid in Tajikistan Page 15

APPENDIX

APPENDIX A: Typhoid and Paratyphoid Fever (by Eric Mintz)

Infectious Agent

Typhoid fever is an acute, life-threatening febrile illness caused by the bacterium Salmonella entericaserotype Typhi. Paratyphoid fever is a similar illness caused by S. Paratyphi A, B, or C.

Mode of Transmission

• Humans are the only source. No animal or environmental reservoirs have been identified.

• Typhoid and paratyphoid fever are most often acquired through consumption of water or food that have been contaminated by feces of an acutely infected or convalescent individual or a chronic asymptomatic carrier.

• Transmission through sexual contact, especially among men who have sex with men, has rarely been documented.

Occurrence

• An estimated 22 million cases of typhoid fever and 200,000 related deaths occur worldwide each year; an additional 6 million cases of paratyphoid fever are estimated to occur annually.

• Approximately 400 cases of typhoid fever and 150 cases of paratyphoid fever are reported to CDC each year among persons with onset of illness in the United States, most of whom are recent travelers.

Risk for Travelers

• Risk is greatest for travelers to South Asia (6 to 30 times higher than all other destinations). Other areas of risk include East and Southeast Asia, Africa, the Caribbean, and Central and South America.

• Travelers to South Asia are at highest risk for infections that are nalidixic acid-resistant or multidrug-resistant (i.e., resistant to ampicillin, chloramphenicol, and trimethoprim– sulfamethoxazole).

• Travelers who are visiting friends or relatives are at increased risk.

• Although the risk of acquiring typhoid or paratyphoid fever increases with the duration of stay, travelers have acquired typhoid fever even during visits of less than 1 week to countries where the disease is endemic.

Clinical Presentation

• The incubation period of typhoid and paratyphoid infections is 6–30 days. The onset of illness is insidious, with gradually increasing fatigue and a fever that increases daily from low-grade to as high as 102° F–104° F (38.5° C–40° C) by the third to fourth day of illness. Headache, malaise, and anorexia are nearly universal. Hepatosplenomegaly can often be detected. A transient, macular rash of rose-colored spots can occasionally be seen on the trunk.

• Fever is commonly lowest in the morning, reaching a peak in late afternoon or evening. Untreated, the disease can last for a month. The serious complications of typhoid fever generally occur only after 2–3 weeks of illness, mainly intestinal haemorrhage or perforation, which can be life threatening.

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Diagnosis

• Infection with typhoid or paratyphoid fever results in a very low-grade septicemia. Blood culture is usually positive in only half the cases. Stool culture is not usually positive during the acute phase of the disease. Bone-marrow culture increases the diagnostic yield to about 80% of cases.

• The Widal test is an old serologic assay for detecting IgM and IgG antibodies to the O and H antigens of Salmonella. The test is unreliable, but is widely used in developing countries because of its low cost. Newer serologic assays are somewhat more sensitive and specific than the Widal test, but are infrequently available.

• Because there is no definitive test for typhoid or paratyphoid fever, the diagnosis often has to be made clinically. The combination of a history of being at risk for infection and a gradual onset of fever that increases in severity over several days should raise suspicion of typhoid or paratyphoid fever.

Treatment

• Specific antimicrobial therapy shortens the clinical course of typhoid fever and reduces the risk for death.

• Empiric treatment of typhoid or paratyphoid fever in most parts of the world would utilize a fluoroquinolone, most often ciprofloxacin. However, resistance to fluoroquinolones is highest in the Indian subcontinent and increasing in other areas. Injectable third-generation cephalosporins are often the empiric drug of choice when the possibility of fluoroquinolone resistance is high.

• Patients treated with an appropriate antibiotic still require 3–5 days to defervesce completely, although the height of the fever decreases each day. Patients may actually feel worse during the time that the fever is starting to go away. If fever does not subside within 5 days, alternative antimicrobial agents or other foci of infection should be considered.

Preventive Measures for Travelers

Vaccine

• CDC recommends typhoid vaccine for travelers to areas where there is a recognized increased risk of exposure to S. Typhi.

• The typhoid vaccines currently available do not offer protection against S. Paratyphi infection.

• Travelers should be reminded that typhoid immunization is not 100% effective, and typhoid fever could still occur.

• Two typhoid vaccines are currently available in the United States.

o Oral live, attenuated vaccine (Vivotif vaccine, manufactured from the Ty21a strain of S. Typhi by Crucell/Berna)

o Vi capsular polysaccharide vaccine (ViCPS) (Typhim Vi, manufactured by sanofipasteur) for intramuscular use

• Both vaccines protect 50%–80% of recipients.

• Table 2-10 provides information on vaccine dosage, administration, and revaccination. The time required for primary vaccination differs for the two vaccines, as do the lower age limits.

• Primary vaccination with oral Ty21a vaccine consists of four capsules, one taken every other day. The capsules should be kept refrigerated (not frozen), and all four doses must be taken to achieve maximum efficacy. Each capsule should be taken with cool liquid no warmer than 37° C (98.6° F), approximately 1 hour before a meal. This regimen should be completed 1 week before potential exposure. The vaccine manufacturer recommends that Ty21a not be administered to infants or children<6 years of age.

• Primary vaccination with ViCPS consists of one 0.5-mL (25-μg) dose administered intramuscularly.

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One dose of this vaccine should be given at least 2 weeks before expected exposure. The manufacturer does not recommend the vaccine for infants and children <2 years of age.

Vaccine Safety and Adverse Reactions

Information on adverse reactions is presented in Table 2-11. Information is not available on the safety of these vaccines in pregnancy; it is prudent on theoretical grounds to avoid vaccinating pregnant women. Live, attenuated Ty21a vaccine should not be given to immunocompromisedtravelers, including those infected with HIV. The intramuscular vaccine presents a theoretically safer alternative for this group. The only contraindication to vaccination with ViCPS vaccine is a history of severe local or systemic reactions after a previous dose. Neither of the available vaccines should be given to persons with an acute febrile illness.

Precautions and Contraindications

Theoretical concerns have been raised about the immunogenicity of live, attenuated Ty21a vaccine in persons concurrently receiving antimicrobials (including antimalarial chemoprophylaxis), IG, or viral vaccines. The growth of the live Ty21a strain is inhibited in vitro by various antibacterial agents. Vaccination with Ty21a should be delayed for >72 hours after the administration of any antibacterial agent. Available data do not suggest that simultaneous administration of oral polio or yellow fever vaccine decreases the immunogenicity of Ty21a. If typhoid vaccination is warranted, it should not be delayed because of administration of viral vaccines. Simultaneous administration of Ty21a and IG does not appear to pose a problem.

Herman Bailey

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