Ronald E Pust

Interests

Research

Child Nutrition, Hansen Disease, Tuberculosis

Teaching

Global Health

Courses

Scholarly Contributions

Chapters

• Pust, R. E. (2015). Working clinically in resource-limited settings. In Essential Global Health Medicine. Wiley-Blackwell.
• Pust, R. E. (2013). Global Health Distinction Track at University of Arizona. In Developing Global Health Programming: a Guidebook for Medical and Professional School..
• Pust, R. E. (2010). Symphisiotomy. In Global ALSO. American Academy of Family Physicians.
• Pust, R. E. (2002). Travel Medicine. In Textbook of Family Practice. W. B. Saunders Co.
• Pust, R. E. (2000). Leprosy. In Saunders Manual of Medical Practice. W. B. Saunders Co.

Journals/Publications

• Carrillo, J. M., Pust, R. E., & Borbon, J. (2016). Dar a Luz: a perinatal care program for Hispanic women on the U.S.-Mexico border. American journal of preventive medicine, 2(1), 26-9.
  More info

  In Arizona, undocumented pregnant Hispanic women without private care have no recourse but to enter an emergency room after labor begins. A survey we conducted showed over 150 such "emergency" births annually in Tucson. As a result, a prenatal care program, "Dar a Luz," specifically targeted at this population, was developed. It includes prenatal obstetrical care and anticipatory birthing education that is sensitive to Mexican-American traditions, community consciousness-raising, and a cooperative obstetrical agreement with Tucson hospitals. Bilingual community volunteers act as patient advocates, following these patients through pregnancy and accompanying them to emergency rooms for hospital deliveries. Based in an Hispanic neighborhood community center, professional and lay volunteers provide health care coordinated by medical students in the paracurricular Commitment to Underserved People Program at the University of Arizona College of Medicine.
• Pust, R. E. (2016). Balance of trade: export-import in family medicine. Family medicine, 39(10), 746-8.
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  North American family physicians leaving for less-developed countries (LDCs) may not be aware of internationally validated diagnostic and treatment technologies originating in LDCs. Thus they may bring with them inappropriate models and methods of medical care. More useful "exports" are based in sharing our collaborative vocational perspective with dedicated indigenous generalist clinicians who serve their communities. More specifically, Western doctors abroad can promote local reanalyses of international evidence-based medicine (EBM) studies, efficient deployment of scarce clinical resources, and a family medicine/generalist career ladder, ultimately reversing the "brain drain" from LDCs. Balancing these exports, we should import the growing number of EBM best practices originated in World Health Organization and other LDCs research that are applicable in developed nations. Many generalist colleagues, expatriate and indigenous, with long-term LDC experience stand ready to help us import these practices and perspectives.
• Pust, R. E. (2016). Indication. Annals of family medicine, 10(1), 75-8.
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  Should the indications for therapies differ from one nation to the next? What are the reasons behind controversial therapeutic variations? What roles do cultural history and authoritarian conflict among clinicians play in the adoption of therapies? When I worked at a rural hospital in Kenya, a woman experiencing obstructed labor made me ponder many questions-but only after our emergency ended in the death of her newborn son. In recounting and learning from this episode, I listened to the disparate Kenyan voices of the patient, the hospital's director, the consultant obstetrician, and to the even more controversial voices of evidence-based medicine. In reflecting on this process, I have learned at least 3 lessons-about the transmissibility of arrogance, the role of guests in other countries, and the nature of science.
• Pust, R. E. (2016). Re: promotion of family-centered birth with gentle cesarean delivery. Journal of the American Board of Family Medicine : JABFM, 28(1), 160-1.
• Pust, R. E. (2006). Teaching chest radiology. Family medicine, 38(8), 538.
• Pust, R. E. (2004). Trapped head after fetal demise. Tropical doctor, 34(2), 127.
• Pust, R. E. (1999). A piece of my mind. Underlying cause. JAMA, 281(3), 215-6.
• Pust, R. E. (1995). Numbness of the arm and hand as a manifestation of leprosy. American family physician, 51(8), 1830.
• Pust, R. E., & Moher, S. P. (1995). Medical education for international health. The Arizona experience. Infectious disease clinics of North America, 9(2), 445-51.
  More info

  At the University of Arizona we have learned that a systematic approach to educating North Americans for international health roles makes sense. We have focused on an intensive problem-based orientation course for senior medical students and residents about to embark on a field experience. We have shared with and greatly benefited from the International Health Medical Education Consortium (IHMEC). The lessons learned at Arizona focus on the importance of long-term commitment and mentoring and on the direct relationship between health care careers internationally and among our own domestic underserved populations.
• Ball, T. M., & Pust, R. E. (1993). Arm circumference v. arm circumference/head circumference ratio in the assessment of malnutrition in rural Malawian children. Journal of tropical pediatrics, 39(5), 298-303.
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  The arm circumference/head circumference ratio (AC/HC) was compared with arm circumference (AC) alone in the diagnosis of protein-energy malnutrition (PEM) in 685 Malawian children between the ages of 3 and 48 months. The AC/HC ratio correlates well, r = 0.6863 (P < 0.001), with weight-for-age (WA). The sensitivity and specificity were calculated for both indicators compared to the NCHS reference standard of WA. Compared to 80 per cent WA, the 0.310 AC/HC cut-off was 92 per cent sensitive and 41 per cent specific, while the 0.290 AC/HC cut-off was 75 per cent sensitive and 74 per cent specific. AC alone in the 6-12-month-old children was 75 per cent sensitive and 89 per cent specific at a cut-off of 12.5 cm. In the children from 12 to 48 months with a cut-off of 13.5 cm the AC was 82 per cent sensitive and 70 per cent specific. The AC alone was more sensitive than AC/HC at all levels of specificity. Adding the HC to AC offered no advantage in screening for PEM in these children. In fact, if one were to use the standard 0.310 cut-off for AC/HC, the resulting low (41 per cent) specificity would identify such a large proportion of false positives as to make this ratio impractical for field use where it is most needed--in primary health care programmes with low resources which serve populations with high prevalences of PEM.
• Pust, R. E. (1992). Portable stature device for child anthropometry. Journal of tropical pediatrics, 38(6), 276-7.
• Pust, R. E. (1992). Tuberculosis in the 1990's: resurgence, regimens, and resources. Southern medical journal, 85(6), 584-93.
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  Physicians in the United States must maintain vigilance for the 25,000 annual new cases of tuberculosis, concentrated in the elderly, in immigrants, in migrant and minority populations, and in immunosuppressed patients. Tuberculosis rates in the South remain above the national average. Physicians diagnosing tuberculosis may also treat the disease, working with health departments, which can assist with drugs, follow-up tests, and contact investigation. Powerful short-course regimens have been standard treatments since 1986. The preferred combination is isoniazid, rifampin, and pyrazinamide daily for 2 months, followed by isoniazid and rifampin for 4 more months. A 9-month regimen of isoniazid and rifampin is equally effective. Supplementation or extension of these regimens is mandatory when drug resistance or immunosuppression, respectively, is likely. Isoniazid prophylaxis for 6 to 12 months continues to be a vital but often neglected preventive measure for those infected with Mycobacterium tuberculosis, but without active disease.
• Pust, R. E., & Moher, S. P. (1992). A core curriculum for international health: evaluating ten years' experience at the University of Arizona. Academic medicine : journal of the Association of American Medical Colleges, 67(2), 90-4.
• Pust, R. E., Hirschler, R. A., & Lennox, C. E. (1992). Emergency symphysiotomy for the trapped head in breech delivery: indications, limitations and method. Tropical doctor, 22(2), 71-5.
  More info

  Careful case selection can avoid most obstetrical emergencies. However, even with optimum management of breech labour, the fetal head may become trapped. Since doctors in developing nations must be prepared for this dire situation, this article reviews breech case selection and outlines the steps in breech delivery, illustrating symphysiotomy for the entrapped head. The limitations and precautions associated with symphysiotomy are stressed.
• Mathews, D. S., Pust, R. E., & Cordes, D. H. (1991). Prevention and treatment of travel-related illness. American family physician, 44(4), 1343-58.
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  Traveler's diarrhea, malaria, acquired immunodeficiency syndrome and jet lag are among the issues for the traveler preparing for a trip to or returning from developing countries. With appropriate measures, most travel-related diseases can be prevented. Diarrheal diseases, schistosomiasis, sexually transmitted diseases and AIDS can be prevented with proper avoidance behavior. Diseases such as hepatitis, rabies, yellow fever and meningitis can be prevented with immunization. Chemoprophylaxis can prevent malaria, altitude sickness and sinus barotrauma. Diagnosing an illness in a returning traveler requires a high index of suspicion regarding diseases that might have been acquired during travel. Resources for accessing up-to-date information concerning prophylaxis, diagnosis and treatment of travel-related illnesses are available.
• Pust, R. E., Campos-Outcalt, D., & Cordes, D. H. (1991). Parasitic diseases. International travel. Preparing your patient. Primary care, 18(1), 213-40.
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  Patients who travel to developing nations are those most likely to encounter parasitic diseases. Using a risk assessment approach and the resources introduced in this article, the primary care physician can prepare them for travel and continue their care on return. Immunizations and patient education are the major modes of prevention, coupled with chemoprophylaxis for malaria and traveler's diarrhea. Traveling pregnant women and young children need special precautions. A large body of preventive and therapeutic knowledge, including parasitology, is at the core of emporiatrics, the science of travel medicine.
• Rogers, S., Paija, S., Embiap, J., & Pust, R. E. (1991). Management of common potentially serious paediatric illnesses by aid post orderlies at Tari, Southern Highlands Province. Papua and New Guinea medical journal, 34(2), 122-8.
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  Systematic observations were made of a small number of aid post orderlies (APOs) managing children with the common but potentially serious symptoms of cough, fever and diarrhoea. On-site performance was evaluated against recommended management guidelines set out in Dr Keith Edwards' Diagnosis and Treatment of Common Childhood Illnesses for APOs. History taking at the aid post was brief and usually non-exploratory; examination of patients was often neglected. Drug prescription was generally appropriate for the diagnosis made, but drug dosages were often incorrect and treatment principles were rarely explained to guardians. Preventive health issues were rarely tackled. Our study reaffirms the need for on-site assessment of the performance of paramedical workers, sets priority demands for continuing education of health workers, and provides a framework for competency-based problem-solving activities within this context.
• Weiss, B. D., Hart, G., & Pust, R. E. (1991). The relationship between literacy and health. Journal of health care for the poor and underserved, 1(4), 351-63.
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  In non-industrialized countries, populations with the lowest literacy rates have the poorest health status. In the United States, however, there is no published research on whether illiteracy, independently of other sociodemographic factors, is related to health status. There are numerous plausible mechanisms by which such a relationship could occur. For example, published reports indicate that most information handouts, consent forms, and other materials for patients are written at reading levels too difficult for most American adults. These and other findings may have important implications in the health care of underserved populations. Research is needed to determine the health effects of impaired literacy skills among Americans, and to develop non-literacy-dependent methods for providing patient education, obtaining informed consent, and administering diagnostic tests.
• Yost, D. A., & Pust, R. E. (1988). Arm circumference as an index of protein-energy malnutrition in six- to eleven-month old rural Tanzanian children. Journal of tropical pediatrics, 34(6), 275-81.
• Pust, R. E. (1987). International exchange of physicians. JAMA, 258(11), 1478-9.
• Pust, R. E., & Burrell, J. M. (1986). Paramedicals' clinical accuracy in 102 cases referred to a provincial hospital. Tropical doctor, 16(1), 38-43.
• Pust, R. E., Peate, W. F., & Cordes, D. H. (1986). Comprehensive care of travelers. The Journal of family practice, 23(6), 572-9.
  More info

  Travel, especially if it is international, often means major changes for the family. Family physicians should assess the epidemiologic risk and psychosocial significance of travel or relocation in light of the family's life-cycle stage and antecedent health. Using core references, which are kept current in partnership with public health agencies, family physicians are able to provide comprehensive immunization, medications, and patient education for all travel risks. Families are given medical record summaries and recommended sources of care at their destination. Eight weeks after their return patients are reassessed for newly acquired illness and helped to integrate the perspectives gained during the travel into the family's future dynamics. Taking advantage of growing travel medicine opportunities, family medicine educators should base the care of travelers and teaching of residents on defined competence priorities. Travelers' health provides a mutually rewarding model of shared care with public health consultants in the community medicine curriculum.
• Peate, W. F., & Pust, R. E. (1985). Health precautions for travelers to Mexico. Southern medical journal, 78(3), 335-9.
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  After Canada, Mexico is the most popular destination for Americans traveling outside the United States. As a developing country, Mexico presents numerous health hazards to American visitors, including the prevalent travelers' diarrhea (turista), from which 40% will suffer, and the less common typhoid, dengue, rabies, malaria, taeniasis, cysticercosis, and trichinosis. Environmental hazards, including sun, heat, high altitude, motion sickness, and accidents, also threaten the unwary traveler. In the event of illness or injury, Americans may find medical facilities unfamiliar and less well equipped than those in the United States. Utilizing both an individualized risk assessment for each traveler and readily available references, physicians, in partnership with local public health agencies, can develop comprehensive preventive health plans for their patients traveling to Mexico.
• Pust, R. E. (1985). Analysing referral patterns to rural provincial hospitals. Tropical doctor, 15(2), 95-7.
• Pust, R. E. (1985). Family tuberculosis contacts: resource-contingent management. Family practice, 2(1), 30-4.
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  Recent findings in tuberculosis research have questioned the efficacy of bacille Calmette-Guérin (BCG) vaccination and demonstrated the effectiveness of combined-drug chemotherapy and isoniazid (INH) chemoprophylaxis, both in regimens of under 12 months duration. Because of the renewed emphasis on drug treatment in tuberculosis control, family physicians and the health personnel they supervise need to be involved in this effort. Despite differences in health care resources in different regions, rational and effective management of active cases and their contacts in the family can be devised. While the priority remains treatment of the active index case, family physicians have a unique opportunity to utilize family relationships to find and to treat other active cases and to reinforce compliance with INH chemoprophylaxis by high-risk family contacts.
• Pust, R. E. (1985). Society, medicine, and the rural poor. "What shall we do about the Selways?". Minnesota medicine, 68(5), 384-6.
• Pust, R. E., & Campos-Outcalt, D. (1985). Leprosy in the United States. Risks, recognition, regimens, resources. Postgraduate medicine, 77(5), 151-5, 159.
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  Although leprosy is increasing in incidence in the United States, it is confined almost entirely to immigrants from developing countries and their close contacts. While the clinical disease has not changed, leprosy has diffused more widely throughout the United States as a result of migration. Primary care physicians should maintain a high index of suspicion in foreign-born individuals with skin or peripheral nerve problems. Punch biopsy of skin lesions is the most practical diagnostic method for both the multibacillary and paucibacillary types of leprosy. Because of resistance to dapsone, multi-drug treatment is now the rule; most patients are referred to or managed in consultation with a regional Hansen's disease clinic for long-term treatment. Consultation is available to any physician through the National Hansen's Disease Center in Carville, Louisiana.
• Pust, R. E., Binns, C. W., Weinhold, D. W., & Martin, J. R. (1985). Palm oil and pyrantel as child nutrition mass interventions in Papua New Guinea. Tropical and geographical medicine, 37(1), 1-10.
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  Two mass interventions in the local low energy-density diet were evaluated for safety, acceptability and nutritional efficacy in a four-group matched study of 896 Papua New Guinea children aged 12-54 months. A single dose of 125 mg of pyrantel pamoate and an 800 mg supply of red palm oil were given monthly at the regular child health clinics. Both were safe and highly accepted. Children given palm oil gained more weight than controls (P less than .05) in the first three study months, confirming a pilot study. However, weight gain after one year was 94% of standard, with no differences in anthropometry, morbidity or mortality between groups. The lack of demonstrable differences at one year is attributed to secular improvement in control group nutrition and to diffusion of palm oil supplies within the family. While pyrantel was an effective antihelminthic, further study is needed to define the nutritional role of mass worm treatment. Palm oil was economical and culturally popular; thus it should be an ideal import substitution. It is clinically useful where diets are of low energy-density. However, any simultaneous demonstration of its nutritional safety, acceptability as a sustained mass intervention must be carried out in an area where major child growth deficits remain and expropriation of the oil by other household members can be controlled.
• Pust, R. E., Newman, J. S., Senf, J., & Stotik, E. (1985). Factors affecting desired family size among preliterate New Guinea mothers. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics, 23(5), 413-20.
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  A random sample of 331 Enga mothers in Papua New Guinea perceived that an average of 5.96 live births (S.D. = 1.88) were needed to achieve their mean desired completed family size (DFS) of 4.65 children (S.D. = 1.32). The mean of the personal child mortality rates projected by the individual mothers. 194/1000, is very close to the rate of 198/1000 (224 deaths among 1134 live births) experienced by the women as a group and the 177/1000 documented in a 1972 prospective study in the area. This suggests that as a group preliterate women may possess an accurate estimate of prevailing child mortality rates. Considerable interest in family planning was shown. However for cultural or linguistic reasons, the majority (except in the case of the pill and tubal ligation) expressed no opinions about their readiness to use specific modern methods. The mean parity of 43 women seeking tubal ligation was 5.98 (S.D. = 1.81). An integrated maternal health and family planning program focusing on the health benefits to mother and child of the current 3-4-year birth interval seems indicated.
• Binns, C. W., Pust, R. E., & Weinhold, D. W. (1984). Palm oil: a pilot study of its use in a nutrition intervention programme. Journal of tropical pediatrics, 30(5), 272-4.
• Boyer, G., & Pust, R. E. (1984). Public perceptions of AHCCCS and estimates of eligibility for enrollment in publicly-funded health care programs: results of telephone surveys in Metropolitan Tucson. Arizona medicine, 41(7), 459-63.
• Campos-Outcalt, D., & Pust, R. E. (1984). Hansen's disease in Arizona. Arizona medicine, 41(10), 658-60.
• Pust, R. E. (1984). Clinical practice roles for the doctor in developing countries. Arizona medicine, 41(5), 327-32.
• Pust, R. E. (1984). US abundance of physicians and international health. JAMA, 252(3), 385-8.
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  American clinicians with careers encompassing both Third World and underserved American populations would benefit both regions and bring new perspectives to foreign policy and domestic health care problems. Application of the parallel concepts of Community-Oriented Primary Care and Health for All should help contain costs and extend access to appropriate clinical care both in the United States and abroad. As American physicians weigh their short- or long-term career options in the post-Graduate Medical Education National Advisory Council era, there is an urgent need both for a specific US policy on international health and for new partnerships to facilitate careers spanning domestic and Third World areas of need.
• Pust, R. E., & Erickson, P. (1984). Determining Mycobacterium tuberculosis infection in high prevalence groups: a comparative study among Nigerian adults. Tubercle, 65(4), 263-78.
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  In populations where both tuberculosis and strong sensitization to nontuberculous mycobacteria are common, determining the proportion infected with M. tuberculosis is difficult. We skin tested 488 unvaccinated young Nigerian workers, typical of tropical populations having high prevalences of tuberculosis, with 4 low-dose Mantoux tests (PPD-RT-23, PPD-Tuberculin, PPD-Battey, and PPD-Gause) and with concentrated (2 mg/ml) PPD by the Heaf multiple-puncture method. Reactions (greater than or equal to 2 mm) to all 4 Mantoux sensitins (elicitins) unexpectedly were normal in distribution; however, the midpoint values (13 mm) of the RT-23 and PPD-T distributions were lower than the midpoints typically seen in groups of tuberculosis patients. Established methods for estimating the proportion tuberculous-infected (cutting point, dual-test, and curve-reconstruction) yielded a wide range, 32%-62%. Combining the 3 methods provided consistent estimates near 50%, despite interference due to strong sensitivity to PPD-B and especially to PPD-G in 80%-90%. PPD-T correlated well with RT-23 (r = .84), yet more closely resembled published PPD-S reaction distributions than did RT-23. All diagnostic-accuracy measures for the Heaf test, considering only grades 3 and 4 positive, exceeded 80%.
• Pust, R. E., & Moher, L. M. (1984). Students' opinions on the 1980 GMENAC Report. JAMA, 251(18), 2349.
• Pust, R. E., Edwards, L. M., & Ortiz, A. (1984). Private voluntary care for the "Notch Group:" the St. Elizabeth's Clinic experience. Arizona medicine, 41(9), 609-12.
• Pust, R. E., Moher, S. P., Moher, L. M., & Newman, J. (1984). International health: a problem-based core curriculum. Journal of medical education, 59(6), 522-3.
• Pust, R. E. (1983). Clinical epidemiology of tuberculosis in the Papua New Guinea Highlands. Papua and New Guinea medical journal, 26(2), 131-5.
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  In the Papua New Guinea Highlands, tuberculosis has an epidemiological setting unique in the developing world. Mycobacterium tuberculosis is slowly infiltrating a susceptible, formerly isolated population. Because of this unique situation, commonly-recommended standard programmes must be rationally, sometimes radically, altered if case finding is to be epidemiologically efficient.
• Pust, R. E. (1983). The BCG controversy. JAMA, 250(21), 2928-9.
• Pust, R. E., & Moher, L. M. (1983). Promoting medical careers in underserved areas: the C.U.P. Program at the University of Arizona. Arizona medicine, 40(6), 397-401.
• Lennox, C. E., & Pust, R. E. (1979). Surgical experience of tribal warfare in Papua New Guinea. Tropical doctor, 9(4), 184-8.
• Pust, R. E., Onejeme, S. E., & Okafor, S. N. (1974). Tuberculosis survey in East Central State, Nigeria: implications for tuberculosis programme development. Tropical and geographical medicine, 26(1), 51-7.
• Pust, R. E., Onubogu, H. O., Egornu, L. I., & Smithwick, R. (1973). Pulmonary disease due to Mycobacterium fortuitum in a Nigerian. The American review of respiratory disease, 108(6), 1416-20.
• Pust, R. E. (1970). BCG vaccination for American Indians. Annals of internal medicine, 73(6), 1043-4.

Presentations

• Pust, R. E. (2016, June). Heartbeat for Africa's Community Health Programs in West Africa. CCIH 2016 annual meeting. JH University, Baltimore MD: CCIH.
• Moran, E. A., Koleski, J. F., & Pust, R. E. (2014, September). Does duration make a difference? The long and the short of global service.. AAFP Global Health Workshop. San Diego, CA.