Thursday, 26 September 2013

Global Report on health and access to care by minorities and indigenous people

Find the original website here.

Minorities and indigenous peoples suffer more ill-health and poorer quality of care, new global report launched as UN meets to follow up on MDGs

25 September 2013

Minorities and indigenous peoples suffer more ill-health and receive poorer quality of care, says an international rights organization in a new global report.
Minority Rights Group International's (MRG) flagship report, State of the World's Minorities and Indigenous Peoples 2013, presents a global picture of the health inequalities experienced by minorities and indigenous communities.
The report is launched to coincide with a United Nations General Assembly meeting to follow up on efforts made towards achieving the Millennium Development Goals (MDGs), and says that ill-health and poor healthcare are often consequences of discrimination.
‘Indigenous peoples and minorities are often marginalized in all aspects of life, such as access to water and sanitation, education and employment. But the marginalization and inequalities experienced by these groups in relation to health outcomes are particularly stark,' says Carl Soderbergh, MRG's Director of Policy and Communications.
‘MRG believes that everyone - regardless of their ethnic, religious, linguistic or cultural background - should have the right to access appropriate care and to lead healthy lives. After all, the right to health is the most fundamental right - the right to survive,' he adds.
In Africa, Asia and the Americas the report says that the maternal mortality rate - a key area of concern for the MDGs - is generally much higher among indigenous and minority communities, particularly those in remote areas.
For instance, in Pakistan, the maternal mortality ratio for Baluchistan - largely inhabited by the Baluch minority - stands at nearly three times the national average. Women and girls from marginalized communities in Kenya and across East Africa, who are subjected to harmful cultural practices such as female genital mutilation and early marriage, are at high risk from obstetric fistula, a hole in the birth canal caused by prolonged or obstructed pregnancy.
Other key MDGs include reducing child mortality and combating HIV/AIDS, malaria and other diseases.
The report finds that in Guatemala, indigenous children experience 20 per cent higher malnutrition than their Ladino counterparts, whilst in Europe Roma children have less access to vaccines and have higher infant mortality rates.
Meanwhile in Tanzania, national HIV/AIDS prevention campaigns were issued only in the dominant language of Swahili. Anti-retrovirals, although free, were not easily accessible in districts where pastoralists predominantly live.
The report makes key recommendations for ensuring that minorities and indigenous people have access to life-saving healthcare, such as the training of minority or indigenous staff and increased community involvement in local healthcare initiatives.
The UN General Assembly must take into consideration the perspectives of minorities and indigenous communities, the factors that they identify as priorities for delivery of healthcare, and the problems and structural barriers that exist, in the formulation of a new generation of development goals after 2015, says MRG.
A case study in the report shows that involving Adivasi women in the planning and evaluating of health care has significantly reduced deaths and empowered women among Adivasi communities in Jharkhand and Odisha. Over 84 million Adivasis (original inhabitants) from more than 500 tribal groups live in western, central, eastern and north-eastern India.
‘The report, with its focus on health inequalities, clearly shows that any post-MDGs framework is doomed to fail unless discrimination towards minorities and indigenous peoples is urgently addressed,' says Carl Soderbergh. ‘Critical to this is the involvement of community representatives in the UN discussions.'
According to UN estimates, there are some 370 million individuals belonging to indigenous peoples in the world, and a much greater number of persons belonging to ethnic, religious and linguistic minorities. Over 900 million people, or, some one in seven of the world's population, belong to groups that experience disadvantage as a result of their identity.

Our Man in New York - tweets from Richard Horton

I thought these tweets from Richard Horton, Editor of the Lancet were so fantastic that I am collecting them and putting them here. If you do not know, this week is UN week in New York City where the General Assembly, Social Good Summit, and Clinton Global Initiative among other meetings are all happening. It is where the powerful, wealth, and famous are all converging to talk about how to improve global health. Richard has an insider view.

10 lessons from the UNGA. 1. The voice of civil society is shut out of serious discussion, and when present is only lip gloss. 2. Nobody here takes equity seriously. 3. The scientific community has made a massive, and largely unrecognised, contribution to global health policymaking. 4. Innovation, innovation, innovation, innovation, innovation...the most meaningless word in the lexicon of global health. 5. Nobody wants to talk about the 22 million women who have to endure an unsafe abortion every year. 6. Too many people on panels want to flirt with fame or superficially amuse rather than offer serious proposals for advancing health. 7. When people talk about greater private sector engagement they are warmly applauded, but nobody really knows what they mean. 8. You will never hear these two words: sexual rights. 9. Everybody wants "quick wins" and "low-hanging fruit": which shows how short-term thinking will never solve the deep inequities that kill. 10. Global health is paralysed by its silos: NCDs, RMNCH, HIV, NTDs, TB, malaria—they live in serene and deliberate ignorance of one another Two favourite UNGA quotes. 1. Joy Phumaphi: "The biggest gaps in global health are those between intent and action, and action and results." 2. Michel SidibĂ©: "The global health architecture is obsolete."

Wednesday, 25 September 2013

India's Women: The mixed truth. - Amartya Sen

Originally posted by New York Review of Books.  Find the original here.

India’s Women: The Mixed Truth

“I am not a boy, I am a girl,” wrote a twenty-one-year-old woman in Delhi, called Jyoti, who was studying at a medical college to be a physiotherapist. This was in a text message sent in December 2010 to a twenty-six-year-old man who worked in information technology and who had initially taken Jyoti to be a man. They met, and what began as a casual communication became a close friendship.
Two years later, on December 16, 2012, after they had seen a film, The Life of Pi, Jyoti was gang-raped with extreme brutality, and the man was severely beaten as he tried to protect her. They had been tricked into boarding a bus that seemed to be going their way and that had offered them a ride. It was a closed bus with darkened windows in which five determined rapists were waiting for their prey, with their impatience heightened, it is alleged, by the drugs they had taken. The battered bodies of the abused pair were dropped off on a lonely street, and by the time Jyoti received medical attention, she was on her way to death from the injuries, despite specialized medical care in Delhi, and later in Singapore.
The gang rape, including the violence accompanying it, not only got headlines in every serious Indian newspaper, it received continuous coverage around the clock on radio, television, and cable channels. It also led to large-scale public protests and demonstrations that continued for many days in Delhi as well as in other Indian cities, with agitated crowds—men and women—much larger than any seen before in protests of this kind. The insecurity of women, including their vulnerability to rape and abuse, became overnight a national issue in a way it had never been.
Public anger at gender inequality in India must be seen as an important—and long-overdue—social development, and it can certainly help in remedying the persistent inequalities from which Indian women suffer. It is, however, very important to understand the nature of female disadvantage in India, which can take many different forms. If the lack of safety of women is one aspect of it, the old phenomenon of “boy preference” in family decisions is surely another. Boy preference relates closely to the deep-rooted problem of what has been called “missing women,” which refers to the shortfall of the actual number of women from the number we would expect to see, given the size of the male population, and the female–male ratios that could be expected if there were symmetry in the treatment of women and men. There is, moreover, strong evidence that the economic and social options open to women are significantly fewer than those available to men; and going beyond women’s well-being, we have reason to ask also about women’s limited role in society and their ability to act independently, and how their initiatives and actions influence the lives of men as well as women, and boys as well as girls.

Numbers and Insecurity

One of the positive consequences of the agitation following the barbaric incident of December 16 has been to draw attention both to the prevalence of sexual brutality and rape in India, and to the failure of the media to report on it seriously, thereby limiting public discussion and the likelihood of social change. Even though Indians buy more newspapers every day than any other nation, the reporting of sexual assaults and sexual harassment had been quite rare in the widely circulated papers. It is, therefore, impressive and encouraging that newspapers in India, smarting from intense criticism of the negligence in their coverage, rapidly reinvented themselves as rape-reporting journals, and many of them have been devoting several pages every day to reports of rapes gathered together from all the different parts of India. This dramatic change is certainly a welcome development, but it can be asked whether the ongoing news reporting is well aimed and as helpful for public discussion as it could be.
How frequent is rape in India? If there are pages and pages of reports of rapes from across the country in the newspapers, the incidence must be high. There are, in fact, good reasons to believe that the majority of rapes go unreported in India, and the actual incidence of rape may be much higher (some estimates suggest that it is larger by a factor of five or more) than what gets recorded by the police. Based on the news coverage of rape across India, it has been argued, with some plausibility, that India has an extraordinarily high frequency of rape. To what extent is this the right way of thinking about India’s problem? Rape and brutality against women are not exactly unknown around the world. One question is whether rape is relatively more common in India than elsewhere, despite the increased attention it is now getting in Indian news reports.
In fact, if we go by the comparative statistics of reported rape, India has one of the lowest levels of rape in the world. The United Nations Office on Drugs and Crime found the incidence of rape in India for 2010 to be 1.8 per 100,000 people, compared with, for example, 27.3 in the US, 28.8 in the UK, 63.5 in Sweden, and 120.0 in South Africa. The number of recorded rapes in India is certainly a substantial underestimate, but even if we take five times—or ten times—that figure, the corrected and enlarged estimates of rapes would still be substantially lower in India than in the US, the UK, Sweden, or South Africa (even with the assumption that there is no underreporting in these other countries).
High frequency of rape may not be the real issue in India, but all the evidence suggests that India has a huge problem in seriously monitoring rape and taking steps to reduce it. The failure of the police to help rape victims and to ensure the safety of women is particularly lamentable. Following the December incident there were large clashes with the police by protesting crowds, not only because of the attempts by the police to break them up, but also because the demonstrators frequently confronted the police for their very poor record in dealing with this problem.
Even though the alleged rapists in the particular case on December 16 were picked up by the police quite quickly and promptly charged in court, the police were criticized for acting too slowly in giving emergency care when the raped victim and her beaten male friend were found lying on the street. Even in dealing with another terrible aspect of the December incident, the failure of people in passing cars to stop to help the victims (even though some of them did call the police), it was claimed that many passersby are afraid to get involved in a scene of criminal activity because of the fear that the police can—and often do—harass the good Samaritans who are found near the victims of crime, rather than searching diligently for the criminals who have fled the scene.
There was discussion also of the large number of cases in which the police seemed to doubt the credibility of a rape victim on the ground that the suspected rapist told a different story that seemed “equally credible” to the authorities. The Indian judicial system is itself extremely slow, and has not typically been able to rise to the challenge of bringing about speedy convictions of rapists and assaulters on the basis of the information provided by the victims. But the courts are certainly not well served by the unclear information provided by police reports on what exactly happened. From what we know, India’s problem may well lie not so much in a particularly high incidence of rapes, but in its inefficient policing, bad security arrangements, slow-moving judicial system, and, ultimately, the callousness of the society.

Legal Reform and Social Change

One of the salutary effects of the public agitation about women’s insecurity and the inadequacy of the law and policing was the appointment—within a week of the December 16 incident—of a Committee on Amendments to Criminal Law, chaired by a former chief justice of the Supreme Court of India, J.S. Verma, with two other leading jurists, Leila Seth and Gopal Subramanium, as members. Their report, which was thoroughly researched yet delivered in less than a month, led to a new law, enacted in Parliament by the end of March, aimed at providing more adequate, and quicker, legal remedy to violated or threatened women.
Some of the proposals of the Verma Committee were diluted in Parliament, and many human rights activists have plausibly criticized this weakening, including the continued failure to include among sexual offenses what is sometimes called “marital rape”—forced sexual activity with an unwilling partner. There are other gaps too in the parliamentary act; but taking everything into account, the new act is a substantial, though partial, step forward in dealing with gender injustice in India.
Four new provisions are important. First, the act has a broader and more inclusive definition of the crime of “sexual assault”: it includes, but goes beyond, what counts technically as rape. Second, there is a prima facie presumption of nonconsensual sex when the affected woman affirms (even if unilaterally) that there was no consent. Third, “sexual harassment”—common on the streets of some cities in India—is included among the list of criminal acts. Finally, there is a new emphasis on the criminality of the sexual trafficking of young women, mainly for the purpose of forced prostitution.
Such trafficking—sometimes even of very young girls—remains disturbingly common in India, although few serious statistics have been collected about it. There is, however, considerable evidence that the sex trade is indeed big business in India. And yet the newspapers are still shockingly negligent in their failure to investigate this area of darkness (unlike what has happened in the case of rape). Most cases of sexual trafficking involve young women from very poor families, and here the difficulty in getting authorities and journalists, among others, to cross class barriers in their care and concern—a distressingly general phenomenon in India—affects the zeal with which information is sought. There is a clear need for the new activism of newspapers to go well beyond the reporting and discussion of only rapes.
To some extent, the class barrier preventing information from being collected is a problem even in dealing with rapes, not just sex trafficking. Even though Jyoti came from a family of modest means (her father is a baggage loader at the airport), her family was upwardly mobile. It was easier for the Indian middle classes, including the educated middle classes, to take an immediate interest in the predicament of a young medical student than it would have been in the case of a rape of a poor and socially distant Dalit woman. There is a broad and urgent need to supplement the new provisions of the recently enacted law with ways to obtain and disseminate information about the treatment of women from the poorer classes.
There is also a regional dimension to the problem of women’s insecurity in India. It is clear that Delhi, where Jyoti’s rape occurred, has a very special problem that may not apply, in quite that form, to the other megacities in India. The rate of recorded rape per 100,000 people was 2.8 for Delhi in 2011, compared with 1.2 in Mumbai, 1.1 in Bangalore, 0.9 in Chennai, and 0.3 in Calcutta. Since there is nothing to indicate that keeping track of rape is much more efficient in Delhi than in the other cities, it is indeed remarkable that Delhi has a record that is more than nine times worse than Calcutta’s. No matter how unfriendly to women Indian society may be, huge differences exist between different regions of India, which apply to other kinds of gender inequality as well. In many ways India can be seen as a collection of distinct countries with diverse records, experiences, and problems.

Missing Women and Boy Preference

A distressing aspect of gender bias in India that shows little sign of going away is the preference for boys over girls. One of the most pernicious manifestations of this pro-male bias is the relatively higher mortality rates of girls compared with boys, not because girls are killed, but mainly because of the quiet violence of the neglect of their health and illness in comparison with the attention that male children receive. Studies have shown that male priority in care continues for adults as well as children, raising the mortality rates of adult women above those of men.
A distinct bias of “boy preference” can be found in countries extending from North Africa and West Asia to South Asia, including India, and East Asia, including China. That such discrimination has a place in a large part of the modern world is distressing: the number of “missing women” can be quite large. When I wrote on “missing women” in these pages in December 1990,* and also in the British Medical Journal, I based my conclusion on data available up to the 1980s. The missing women could be identified then as the result of the differences in mortality rates between men and women. These in turn reflected discrimination, mainly in health care, against girls and women.
Over the last couple of decades those kinds of discrimination have substantially declined in most of the countries I wrote about. Even though female mortality is still higher than male mortality for children in many Indian states, and the gap is even higher for infants in China, nevertheless in both China and India, and indeed in many of the other countries in the region, women now have a substantially higher life expectancy at birth than men.
However, since the 1980s, the wide use of new techniques such as sonograms for determining the sex of fetuses has led to huge—and growing—numbers of selective abortions of female fetuses, offsetting the gains in declining difference in mortality rates (as I discussed in the British Medical Journal in December 2003). Selective abortion of female fetuses—what can be called “natality discrimination”—is a kind of high-tech manifestation of preference for boys. Because of this counteracting influence, the proportion of missing women in the total population has not declined in many countries, including China and India. Women’s education, which has been a powerful force in reducing mortality discrimination against women and also in achieving other important social objectives such as the reduction of fertility rates, has not been able to eliminate—at least not yet—natality discrimination.
Still, we must not underestimate the effects of women’s education. There is definitive empirical evidence that women’s literacy and schooling cut down child mortality and work against the selective neglect of the health of girls. They are also the strongest influence, among all relevant causal factors, in cutting down fertility rates. The reduction of fertility that has taken place throughout India (and more sharply in Bangladesh) is clearly connected with the expansion of women’s literacy, which empowers women to have a stronger voice in family decisions. The lives that are most battered by excessive bearing and rearing of children are those of young women; any change that increases the force and impact of their voice, such as girls’ education and women’s ability to earn an independent income, has the effect of sharply reducing childbearing.
Bangladesh’s steep fall in total fertility rate from nearly seven children not long ago to 2.2 now (quite close to the replacement rate of 2.1) is strongly connected with the power of women to gain more control of their lives, and both girls’ education and women’s outside employment have done much to yield that result. I should also note here that even China’s shift from high fertility to below-replacement fertility can in many cases be more easily explained by women’s having more say, and more power, in family life—helped by education and greater economic independence—than by the draconian compulsions of its punitive “one-child policy.”
In India too, expansion of women’s schooling has contributed to its significant reduction in fertility rates. While the average of 2.4 children per family for the entire country is still above the replacement level of 2.1, this reflects a big fall from earlier rates, and nine of the twenty largest states of India have fertility rates now that are below the replacement level, which seems to reflect mainly the impact of the increased power of women to influence decisions about bearing children. Women’s education does not seem to be adequately effective in reducing discrimination against giving birth to girls; but it would be a mistake not to appreciate what female education clearly does achieve.
It is important to ask why women’s education and the corresponding enhancement of women’s voice and influence in family decisions have not done much to eliminate selective abortion of female fetuses. Educated mothers seem clearly less inclined to neglect girls compared with boys once they have been born; but they seem almost as keen on having boys rather than girls as uneducated mothers are. Here larger questions of enlightened understanding and scrutiny of traditional values become central and go beyond women’s role and influence in family decisions. There seems to be a lack of adequate awareness of the oddity of seeing girls as inferior to boys, and a lack of knowledge about what happens in other places where such discrimination against girls is not present.
An analogy can be drawn here with Adam Smith’s discussion, in The Theory of Moral Sentiments, of the willing acceptance of the alleged necessity of infanticide by intellectuals in ancient Greece. Smith quoted Plato and Aristotle in defense of infanticide. He thought that the hold of parochial values can be broken primarily by knowledge of what happens elsewhere and how other people think about the same problems. It was with respect to such parochialism that Smith emphasized the importance of considering how a local custom would look to people at “a certain distance from us,” which is a part of his thought experiment of invoking an “impartial spectator.” What is crucial here is not just freedom of action but also freedom of thought and the ability to overcome parochial boundaries of thinking.
In China and South Korea, the standard routes to women’s empowerment, such as female literacy and economic independence, have resulted in major achievements. But with the new techniques of sex determination of fetuses, discrimination through selective abortion of female fetuses became surprisingly common in both countries. This has led to organized public initiatives to make women aware of the value of having daughters and not just sons. Such efforts have had much more success in Korea than in China, where the female–male ratio at birth remains lower even than in India.

Contrasts Within India

While female education does not serve as a silver bullet to prevent discrimination against girls, other factors make the experience of the different regions within India quite diverse. In fact, there is a sharp regional divide. In the northern and western states, there is clear evidence of extensive use of selective abortion of female fetuses. In the states in the south and east of India, we do not typically find evidence of its widespread use.
Everywhere in the world more boys are born than girls, and the female–male ratio at conception is even more sharply biased in the direction of males (the standard ratio is often taken to be 910 conceptions of female fetuses compared with 1,000 male conceptions). But females do better than males in survival, if they have equal care, which they tend to get in the uterus. By the time births take place, the female–male ratio is around 940 to 950 females per 1,000 males in European countries. Between 2005 and 2010, the average ratio of females to males at birth for Europe as a whole was 943 females per 1,000 males.
There are variations within the European countries that cannot be plausibly attributed to the effects of presumed practices of sex-selective abortion; and so we have to accept a range of values for “normal” sex ratio at birth. Among the larger European countries, the female–male ratio at birth is 941 in Italy, 940 in Spain, 939 in Greece, and 935 in Ireland. If we take the ratio of 935 per 1,000 (the ratio for Ireland) as a standard against which to measure selective abortion of female fetuses, what can be said about the Indian states?
Since birth registration is incomplete in India, the ratios of girls to boys at birth are calculated by first looking at the actual numbers of girls and boys in the age group between zero and six (counted by the census), and then working backward to the female–male birth ratio by adjusting the zero to six figures for differences in mortality rates at specific ages between birth and age six. Using this method with the data provided by the 2011 census, it appears that all the states in the north and west of India, without exception, show absolutely clear evidence that sex-selective abortion is practiced to a much greater degree than is generally the case in the states in the east and south. Though many of the states even in the south and east have had some fall in female–male ratio among children between the censuses of 2001 and 2011, even in 2011 the female–male ratio at birth in the south and east of India remains not only substantially higher than in the north and the west, but also within the European range for such ratios.
Estimated female-male ratio at birth, per 1,000 males
In fact, we can draw a dividing line to cut India into two halves (see the map above), with the states in the west and north (including Maharashtra, Gujarat, Madhya Pradesh, Uttar Pradesh, Rajasthan, Himachal Pradesh, Punjab, Haryana, Uttarkhand, and Jammu and Kashmir) showing clear evidence of widespread sex-selective abortion, with female–male ratios well below the cut-off line of 935 per 1,000 males. In fact, in all western and northern states this ratio actually is even below 920, and in many of these states well below 900.
This contrasts sharply with the figures for states in the east and south—Kerala, Karnataka, Tamil Nadu, Andhra Pradesh, Chhattisgarh, Jharkhand, Bihar, West Bengal, and Assam—all of which have ratios above 935 (with Odisha marginally so). In those states the use of sex-selective abortion, when present, is not on a scale to pull the female–male ratio below the cut-off line based on Irish figures. Incidentally, the data from Bangladesh, where the female–male ratio for the age-group zero to four years is 972, conform strongly to the pattern of eastern India, which it adjoins.
Why is there such a regional difference? I do not know of any convincing clear-cut answer to this question, even though the correspondence of these gender-specific differences with language groups and cultural practices offers fruitful lines of research. Any serious explanation will demand a much fuller understanding of the diversities between India’s different traditional cultures, as well differences in economic, political, and social influences.
While that important research must be done, there are many necessary actions that need not await the results of that research. There is a need for better policing and for greater media attention to neglected issues, including sexual trafficking and marital rape. There is an extremely powerful case for paying much more attention to schooling for girls, for more political and social discussion of the peculiarity—and the moral strangeness and inequity—of “boy preference,” and for more commitment by India’s mainstream political parties to address the issues central to gender inequality. There is a lot to do on the basis of what we do know, even as we remain engaged in finding out more about regional cultures and divergent behavior within India.
  1. *
    See my “ More Than 100 Million Women Are Missing,” The New York Review, December 20, 1990. 

Saturday, 21 September 2013

The meaning of death: the rise in excessive death rates of the elderly since 2008 great recession.

The original source of this is the Financial Times and can be found here.

September 20, 2013 12:06 am

The meaning of death

mortality depictions. Illustration by Tom Duxbury©Tom Duxbury
In July, Public Health England, the public health oversight body, distributed a report that revealed that about 23,400 more elderly people died between June 2012 and June 2013, than over the same period a year before.
In addition, week on week, more people were reported to have died in 2012 than at the same time in 2011. And so far in 2013, the excess death rates are reported to be higher than in any of the previous five years. The death rates were higher for women than men, especially in the most deprived areas of England. The causes were not immediately obvious – something the report itself admitted.
However, in a letter attached to a report on a related topic released a month later, John Newton, chief knowledge officer of PHE, provided some explanation. The July report, he wrote, had been written by an analyst who used a novel statistical approach that was consequently found to have potential methodological weaknesses.
There had been excess deaths in 2012-13, Newton continued, but they could be explained by higher-than-expected circulation of influenza and a bout of cold weather. Also, the rise in death rates did not look exceptional, he wrote, when compared with the past 12 years rather than with data from more recent years.




Newton observed that many of the deaths were preventable and that the data showed the need to work harder to protect the vulnerable from both flu and extreme weather. Nevertheless, questions have been raised over a possible link between the rising mortality rates and a drop in the UK’s overall wealth, as measured by its gross domestic product.
About 20 years ago, Amartya Sen, the Nobel Prize-winning economist, wrote an article in the journal Scientific American about the importance of mortality data. Death statistics can be an important supplement to traditional economic indicators, he wrote, as they reveal very clearly what is actually happening in society, namely, if people are dying prematurely. Equally importantly, Sen argued that mortality data also show the efficacy of social institutions. In contrast, the most commonly used indicator of how well a society is doing is often the size of its economy or GDP, as the popular argument among economists and social scientists holds that wealth leads to wellbeing and, therefore, the wealthier the country the better off are its people.
Sen’s advocacy for the importance of mortality data is part of his broader work spanning decades on moving economics beyond just wealth, and measuring social progress beyond traditional economic indicators such as GDP.
Rather than focus on the means, he would see us focus on the quality of people’s daily lives.
Sen’s arguments have influenced development economics greatly and aided wellbeing indices such as the Human Development Index. During economic booms such as in the years preceding the economic crisis of 2008, there was growing interest among wealthy nations in moving beyond using GDP data or simply focusing on wealth as an indicator of people’s lives.
In early 2008, the then French President Nicolas Sarkozy set up the Commission on Economic Performance and Social Progress with Sen as one of its three chairmen.
In late 2010, UK Prime Minister David Cameron instructed the Office of National Statistics to begin measuring national ­wellbeing using a broader set of measures than just GDP.
Since the recession, however, GDP has come back firmly to centre stage. Changes in the latest set of data make headlines, and the justification for any policy is often linked to its effect on the underlying rate of growth. The ­re-entrenchment of GDP as an indicator might lead us to conclude that wealth is in fact the most important basis of how people live their lives.
But while many people around the world are indeed concerned about GDP data, particularly on how it affects their personal wealth, they are starting to recognise that other factors are just as important. Healthcare, for example, is on the political agenda of many countries.
mortality depictions. Illustration by Tom Duxbury©Tom Duxbury
England is not alone in reporting rising excess mortality rates among the elderly. In April 2012, a group of researchers published a study in the journal Eurosurveillance that detailed increases in excess mortality rates of the elderly across 12 European countries. And in the US, the Centers for Disease Control and Prevention reported a sharp increase of excess mortality due to influenza during the winter of 2012-13. Yet death from influenza or a harsher winter is not inevitable.
What role should the state play in preventing these early deaths – and, further, is the harsh economic climate taking its toll?
People’s health and mortality rates are due to a combination of factors – biological, behavioural and environmental. Economic growth is undoubtedly important for maintaining and improving people’s health and life expectancy. But it is unclear what the link between the two actually is. The range of life expectancies across countries with the largest economies, as well as health inequalities within countries, show that there is no automatic connection between health and wealth.
Morbid though they may be, Sen was right to argue that mortality rates are an important social indicator of the state of people’s lives and the efficacy of social institutions.
Looking deeper into the causes of deaths, or their inequalities within different social groups could reveal much not only about healthcare but also about a country’s social and economic development.
With the number of preventable deaths of the elderly in many industrialised countries on the rise, now is surely the time for the relationship between health and wealth to come under greater scrutiny.

Sunday, 8 September 2013

article: Corruption in healthcare and medicine: Why should physicians and bioethicists care and what should they do?

This is an open access article published in the Indian Journal f Medical Ethics.  Original source can be found Here.

Corruption in healthcare and medicine: Why should physicians and bioethicists care and what should they do?
Corruption, an undeniable reality in the health sector, is arguably the most serious ethical crisis in medicine today. However, it remains poorly addressed in scholarly journals and by professional associations of physicians and bioethicists. This article provides an overview of the forms and dynamics of corruption in healthcare as well as its,implications in health and medicine. Corruption traps millions of people in poverty, perpetuates the existing inequalities in income and health, drains the available resources undermines people's access to healthcare, increases the costs of patient care and, by setting up a vicious cycle, contributes to ill health and suffering. No public health programme can succeed in a setting in which scarce resources are siphoned off, depriving the disadvantaged and poor of essential healthcare. Quality care cannot be provided by a healthcare delivery system in which kickbacks and bribery are a part of life. The medical profession, historically considered a noble one, and the bioethics community cannot evade their moral responsibility in the face of this sordid reality. There is a need to engage in public discussions and take a stand - against unethical and corrupt practices in healthcare and medicine - for the sake of the individual's well-being as well as for social good.

Corruption is, to say the least, a complex phenomenon and a difficult problem. It is complex because of its deep roots in the social, cultural, economic, political, legal, and ethical value systems of individuals, communities, cultures, and countries. It is a difficult problem because it defies easy answers and resists any single-track, copy-book model of solutions.

There was a period in the not-so-distant past when corruption was considered, at best, merely an issue of development and, at worst, a socioeconomic issue beyond the world of scientific medicine. In the recent past, however, corruption in the health sector has raised serious concern and received global attention among researchers and policy-makers (1-4). In October 2003, the UN General Assembly adopted the United Nations Convention against Corruption, which came into force in 2005. Other UN agencies have also undertaken anti-corruption measures in health. For example, the Good Governance for Medicines programme, launched as part of the World Health Organisation Medicines Strategy, 2004-2007, incorporated corruption as a priority issue. Further, having recognised the relationship between child mortality and corruption, the United Nations Children's Fund linked its promotion of child rights to good governance (5).
Undermining the moral vision-and nobility-of the art of healing, corruption is arguably the most serious ethical crisis in medicine today. Thus, understanding corruption, its varied nature and its adverse effects on health outcomes is absolutely necessary for healthcare professionals in the 21st century, not only to steer clear of fraud, but also to devise effective strategies to tackle the menace and safeguard the moral vision of medicine (6, 7).

What is corruption?
Corruption has been defined as "the abuse of public office for private gain" (8). This definition appears to be narrow as it does not cover areas other than "public office." Transparency International, a global anti-corruption watchdog, defines corruption as "the abuse of entrusted power for private gain" (3). Questions may arise about how terms such as "private" (or "public") are defined and whether it would be ethically justifiable to abuse entrusted power for shared collective gain. Private gain may also be either actual (or immediately available) or potential (to be realised in the future), and financial or even political. It is thus extremely difficult, if not impossible, to provide a definition of corruption which is applicable to all its forms, types and degrees across various cultures to the satisfaction of all stakeholders. In the absence of such an allinclusive and precise definition, "the abuse of entrusted power for private gain" may serve as a 'working definition' as it could cover, in general, most of the unethical and corrupt practices in the health sector.

Corruption is pervasive across cultures and endemic in countries, be they small or large, poor or rich, capitalist or socialist or in the North or South (3). Newspapers generally capture only startling instances of large-scale corruption. Petty corruption, however, has long been a part of, or rather a way of, 'normal' life in many parts of the globe. Furthermore, those who take or give bribes in a particular setting (eg an office or the residence of an official) may claim in another setting (e.g. a court) that these were 'gifts'. Thus, cultural interpretations and legal implications of what is perceived of as corruption may also vary from one context to another.

What are the forms of corruption in healthcare and medicine?
The problem of corruption in healthcare is of a multidimensional nature. Corruption may be involved, for example, in construction of health centres/hospitals, purchase of instruments, supply of medicines and goods, overbilling in insurance claims and even appointment of healthcare professionals. Another aspect of the problem is the involvement of multiple parties, e.g. policy-makers, ministers, economists, engineers, contractors, suppliers, and doctors. All this may give rise to innumerable clandestine transactions of a corrupt nature among various stakeholders.

Forms of corruption in healthcare and medicine may include, but not be limited to, the following (1,3,5):

Bribes and kickbacks
Characterised as hallmarks of corruption, bribes and kickbacks can be paid by individuals and firms to (i) procure government contracts, leases or licences for the construction of healthcare facilities, and for the supply of medicines, goods and services, as well as ensure the terms of their contracts; (ii) prefix and 'rig' the bidding process; (iii) manipulate and falsify records, and modify 'evidence' to give the appearance of its being in compliance with the norms of regulatory agencies; (iv) speed up the procedure of permission to carry out legal activities, eg obtaining institutional affiliation, company registration or construction permits; and (v) influence or change legal outcomes so as to avoid punishment for wrong-doing (3,5).

Theft and embezzlement
This may occur as theft of public assets and goods, such as instruments and medicines, by individuals for sale, personal use or use in for-profit private clinics. The theft of government revenues, such as patient registration fees, and the payment of salary to deceased or "ghost" workers are other forms of corruption (3, 5).
Intentional damage to public goods for private gain1
Public assets and instruments in government hospitals may also be intentionally damaged so as to make them unavailable to patients, with the ultimate aim of ordering the services from private clinics in return for financial incentives or "commission."

Perceived somewhat less often as a form of corruption, absenteeism (not attending work but claiming salary) in the health sector has been a major concern in some developing countries (5).

Informal payments
In some countries, patients commonly make informal payments to healthcare professionals for better services. The imposition of such a "tax" on "free" healthcare services has a negative impact on access to health services (5).
Use of human subjects for financial gain
Clinical researchers get paid by the biomedical industry for the recruitment of poor and illiterate, ie vulnerable, human subjects for clinical trials (9). Another way in which hospitals and physicians use patients is by charging uninsured patients and patients with other health plans far more than the actual costs involved and what the health insurers pay.

Institutionalised potential corruption
In some for-profit hospitals, physicians have contractual obligations to admit a fixed number of patients to allotted beds and prescribe a number of laboratory investigations (even if unnecessary) to generate revenues.
Whatever the form, corruption has far-reaching consequences on patient care, clinical research and medical education, as outlined in Table 1.

Case studies: windows into how corruption affects health sector
Published reports on the exploitation of human subjects in clinical trials and the scam in the National Rural Health Mission (NRHM) in Uttar Pradesh (UP), India, give us a window into how unethical and corrupt practices can mar clinical research and public health programmes, turning them, quite literally, into "killing fields".

1. Clinical trials
    Illiterate persons not to be used for clinical trials (9)
    Hyderabad: Reeling under allegations of using poor and illiterate people as guinea pigs for clinical trials [emphasis added], five of the 12 registered clinical research organisations in the state...claimed to have even decided against using illiterate volunteers for trials (emphasis added).
    The Times of India, Hyderabad, September 7, 2011
    Only 45 of 2868 clinical trial deaths [in India] compensated since 2005 (10)
    Business Standard, New Delhi, March 5, 2013
Few would disagree that clinical trials hold the promise of making a positive difference in the lives of people. However, there is no room for such a pleasant illusion in the face of the unethical and corrupt practices in health research. Nearly 2900 people died in India during clinical trials of drugs conducted by various pharmaceutical companies from 2005-12, and compensation was paid in only 45 cases (10). This news came after an earlier news report that victims of the 1984 Bhopal gas tragedy were also enrolled, without their knowledge or consent, in clinical trials sponsored by certain pharmaceutical companies (11). Further, as revealed in 2008, 49 babies had died during clinical trials for new drugs at the All India Institute of Medical Sciences, India's premier medical institution, over a period of two-and-a-half years (12).

Table 1
Primary areasSpecific aspects under primary areasTypes of unethical and corrupt practicesImplications
Patient careConstruction of healthcare facilitiesBribes and kickbacks for procuring contracts, speeding up procedureHigh cost, low-quality construction work and facilities that do not fulfil needs, resulting in inequity in access
Purchase and supply of medicines, goods and servicesBribes, kickbacks to fix winner of bids in advance

Unethical marketing and sales of medicines

Suppliers not held accountable for failing to deliver
High-cost, sub-standard or inappropriate drugs and goods and equipment

Health inequity
Distribution and use of medicinesSale of "free" drugs or supplies

Theft of drugs/supplies at storage and distribution points_
Undue "tax" on free drugs and supplies

Lack of access to essential medicines for poor patients

Interruption of or incomplete treatment of patients
Access to healthcare, admission into hospitalBribes and informal paymentsLack of access to basic healthcare for poor patients

Health inequity
Monitoring and regulation of quality in products, servicesBribes for approval of registration and quality of drugs

Bribes or political considerations influencing results of inspections or
suppressing findings
Circulation of counterfeit or fake drugs in market

Spread of infectious and communicable diseases

Death of patients from improper treatment or inadequate services
Biomedical researchClinical trialsRecruitment of human subjects for drug research for financial incentives

Absence of adequate compensation policy for participants in trials in case of
injury or death
Exploitation of "guinea pigs in human form" in unethical trials

Death of trial participants without compensation
Students' researchBribes or informal payments for "supervising" students' research projectsFraud and misconduct in research and publication
Medical education*AdmissionBribes to gain entry into medical education

Political influence, nepotism in selection of students
Entry of incompetent healthcare professionals into medicine

Loss of faith, cynicism and frustration with an unfair system

Ethically compromised professionals who perpetuate the vicious cycle of unethical and corrupt practices
ExaminationBribes to pass qualifying examinations or top merit list
Appointment of physicians and medical teachersNepotism, favouritism, political influence in selection of healthcare professionals
*The head of the Medical Council of India, removed from his post for allegedly taking bribes to grant permission for the establishment of private medical colleges, was
president-elect of the World Medical Association (WMA).

Perhaps this is the price for putting economics before ethics. In 2005, as a policy pursuant to economic liberalisation, the Government of India amended Schedule Y of the Drugs and Cosmetics Act to permit concurrent phase II and phase III trials in India (13). A myriad of factors, such as substantial reduction in time and cost in conducting clinical trials, diverse population, English-speaking healthcare professionals and less stringent regulatory mechanisms, made India one of the most attractive locations of clinical trials. Not surprisingly, there was a substantial growth in the number of clinical trials held in India from 2005. In 2000, the Indian Council of Medical Research (ICMR) had issued ethical guidelines for biomedical research on human subjects (modified in 2006) and the registration of clinical trials was made mandatory by the Drugs Controller General of India (DGCI) in 2009. However, the ICMR guidelines are not legally binding, while the DCGI is understaffed and illequipped to monitor and regulate research effectively. Thus, blatant unethical practices, such as providing lucrative financial incentives for the recruitment of human subjects, obtaining "informed-but-not-understood-consent" from poor illiterate "volunteers," and failing to provide compensation for the death of participants in trials, have become a part of the booming industry of clinical trials in India (14-17).

Part of the threat that the industry of clinical trials poses to India stems from the fact that these trials, conducted mostly by the contract research organisations (CROs) hired by pharmaceutical companies, are essentially commercial ventures in the garb of benevolent medical research. The question arises as to whether the drugs tested in India will actually benefit or be affordable for needy patients. The crisis is further compounded by the dampening "ethical climate" of the Indian institutions that are related to the conduct of clinical drug trials. India ranks 94th in the list of 178 countries in the corruption perception index (18). In a country where corruption is undeniably an all-pervasive part of life, including healthcare and medicine, it is hard to imagine that if at some point, provisions are made for ethical oversight of all clinical research, such oversight will be of the highest standards and that "guinea pigs in human form" will get high-quality care in keeping with ethical standards. Questions thus arise whether it is ethically justifiable to allow the conduct of clinical trials to begin with, in the absence of ethical oversight, effective regulatory mechanisms and an appropriate compensation policy for the participants, especially in countries plagued by corruption.

2. National Rural Health Mission, Uttar Pradesh
    Half a dozen babies are born in the clinic daily, but the water tank is broken, so deliveries are performed without running water. The centre has an ambulance, but it, too, is broken. Repairs would cost only about $30, but there is no cash to pay for it. Crucial medical supplies, like oral rehydration salts for children with diarrhoea, have been out of stock for months. Mr Tiwari [centre's vaccination officer] said that the money to fuel the generator ran out, leaving workers scrambling to keep vaccines cold (19).
In 2005, India launched a centrally-funded country-wide health programme, the NRHM, in order to revamp rural health. The Government of India allocated the state of Uttar Pradesh (UP), which can rival sub-Saharan Africa in terms of infant mortality and child malnutrition, "the largest sum of money of all states" to improve the abysmal status of its health services (19--22).
What went wrong with the NRHM in this state?
  • According to the report of India's Comptroller and Auditor General (CAG), the UP State Health Mission failed to fulfil its mandate and was responsible for an unaccounted loss of Rs 5754 crore out of the total amount of Rs 8657 crore (20).
  • "[I]n the case of NRHM in Uttar Pradesh, it was organised looting of government funds." (21)
  • According to the Central Bureau of Investigation (CBI), "Large-scale bungling took place in the implementation of NRHM. The modus operandi for siphoning off state wealth included overpricing, fake supply of medicines and hospital equipment by fictitious firms as well as huge kickbacks in construction activity to improve health services in government-run primary health centres in rural areas. The CBI also discovered how some persons acted as middlemen between contractors and influential bureaucrats and ministers to supply medicines and equipment under the programme" (20).
How did people suffer when the NRHM was beset by corruption?
    Subhadra Chaurasia developed cataract in her right eye four years ago. In the past one year, visibility in her left eye has also faded. If the 75-year-old doesn't receive medical attention soon, she will go completely blind. She has two sons, both married, who barely make a living from the 2.5 bighas [of land] they own in Raipur village, 10 km away from Lucknow. The yield from this landholding is just enough to save the family from starvation. With no money to buy even basic necessities of everyday life, Subhadra can't dream of having an eye operation, something that would cost more than Rs 15,000. But if you go by official records, Subhadra has already been operated upon and cured (22).
    NGOs, private nursing homes and doctors have siphoned off crores of taxpayers' money intended for eye operations for the rural poor in the state over the past five years (22).
    Tehelka [investigative journalists' team] visited more than half a dozen villages in and around Lucknow and found that the women, children and men who should have been the beneficiaries of the NRHM funds are living without the most basic health services. The funds meant for them have been siphoned off by the politician-bureaucrat-private contractor nexus (22).
    NRHM's Mothers Protection Scheme, known as Janani Suraksha Yojana, was launched in 2005 to provide conditional cash transfers to pregnant women for facilities like transportation to encourage them to give birth in health facilities. But civil society organisations find pregnant rural women didn't receive quality maternal health services, especially if they were from lower income groups... (23).
    Quality of care in UP is poor, according to nongovernmental organisations, and may have worsened due to the corruption (23).
Crores of rupees were thus spent on the construction of nonexistent healthcare facilities, and on the acquisition of goods and services which never reached the intended beneficiaries. This scam not only perpetuated ill health and suffering among the rural poor, but also cost six lives. Among the six persons who died are top-ranking medical officers, murdered presumably as part of a cover-up operation to hush up the wrongdoing.
What is fearsome is that it is only the tip of the iceberg which is visible; the bottom of the "iceberg" of corruption is almost untraceable. Sadly, the art of healing has turned into a science of stealing and the conspiracy to cover up has introduced criminality into medicine. What is scandalous is that doctors are not only among the victims of corruption; they are also beneficiaries and perpetrators, together with the others involved in the larger nexus that is threatening to undermine the very foundation of medicine. The question arises as to what physicians and bioethicists should do to tackle the menace of corruption and to answer this, one must be clear on why they should do something in the first place.

Medical corruption: why should physicians and bioethicists care?
There are a number of good reasons why physicians and bioethicists should care about corruption, discuss the problems that corruption creates and perpetuates in healthcare and medicine, explore possible remedial measures to tackle the menace, and take a stand against unethical and corrupt practices in the health sector.

The first is, to put it simply, corruption kills. The difference between life and death, good health and suffering is often determined by corruption. Not surprisingly, the poor suffer the most. Three of the UN's eight Millennium Development Goals, which are intended to reduce poverty by half by 2015, relate directly to health: reducing child mortality, improving maternal health, and combating HIV/AIDS, malaria and other diseases.
Corruption in the healthcare system has been revealed as one of the factors responsible for the failure to fulfil these goals by the target date (3). Corruption also exacerbates the harm caused by natural disasters. For example, the death toll in the earthquake in Haiti was directly related to corruption. Buildings certified as earthquake-resistant had not been constructed properly because the system was plagued by corruption and thus, there was a lack of oversight (24). If physicians are really opposed to serving the machinery of death, oiled by corrupt practices in medicine, they need to address the issue, discuss it and take a stand against it.

The second is that corruption fosters ill health and prolongs suffering. On the other hand, good governance (reduced corruption) is associated with better health outcomes. A transnational study found that the quality of governance was positively associated with higher life expectancy, lower mortality rates for children and mothers, and higher levels of subjective feelings of health (25). By taking a stand against corruption and in favour of appropriate anti-corruption measures, healthcare professionals may create opportunities for good governance and consequently, better health outcomes for the population.

Thirdly, corruption undermines the patient's trust in the physician and healthcare delivery system. Trust lies at the core of the doctor-patient relationship in medicine. "Trust is critical to patients' willingness to seek care, reveal sensitive information, submit to treatment, and follow physicians' recommendations." (26). Patients would not like to see a doctor they do not trust and would be loath to accept such a doctor's advice. By taking a stand on corruption, physicians and bioethicists can start rebuilding the trust of patients and the people at large.

The fourth is that corruption destroys the moral vision of medicine. Ethics lies at the heart of medicine-it is difficult to imagine a good but corrupt physician. Few would disagree that medicine sans morality turns this praxis into one of stealing, killing and criminality. Those who have embraced a noble profession like medicine cannot afford the luxury of "doing nothing" when its ethical foundation is being endangered by unethical and corrupt practices (27).

Towards a new beginning: what should physicians and bioethicists do to tackle the menace of corruption?
Corruption in the health sector is not just an issue of development, or a legal issue pertaining to fraud and abuse, but also an issue concerning ethics. As darkness is characterised by lack of light, corruption is characterised by a lack of moral values. Regrettably, the word "corruption" is conspicuous by its near absence in the agenda and vocabulary of academic medicine. At most, mention is made of "professional misconduct." Worse still is the deafening silence of the medical profession when the cause of ethics in medicine is at stake. Furthermore, bioethicists, who are the modern-day custodians of morality in medicine, have little, if any, interest in addressing this "dull" social problem. Unlike esoteric ethical puzzles such as determining the moral status of a part-human part-animal embryo, this problem does not trigger enough hair-splitting debates to satisfy their philosophical minds. The initiation of proactive measures to counter corruption in all its manifestations is long overdue. A number of anti-corruption measures that could provide a starting point are outlined below.

1. Zero tolerance for unethical and corrupt practices in health
Physicians, professional medical associations of diverse disciplines and the bioethics community should discuss possible anti-corruption measures and implement a publicly declared policy of zero tolerance for unethical and corrupt practices in the care of patients, clinical research and medical education. This entails, among other things, taking appropriate measures to counter unnecessary investigations and overbilling, censuring members with questionable integrity, developing mechanisms to handle allegations of misconduct, and promoting transparency and accountability in diverse aspects of medicine.

2. Whole-hearted support for anti-corruption measures
Physicians and bioethicists should support, whole-heartedly and without reservation, the anti-corruption initiatives undertaken by the other sections of society and state, such as civil society, patient rights groups, voluntary health associations, nongovernmental organisations (NGOs), the judiciary, and the media. This would help build good governance and a just society.

3. Protection of whistle-blowers
Physicians and bioethicists should provide moral support and legal help to members of their profession or discipline who have dared to expose serious wrong doing in any aspect of healthcare and medicine. This is necessary because whistleblowers run the risk of facing harassment, if not harm, by vested interests. (27)

4. Legislation
Physicians and bioethicists should play a more proactive role in pressing for the enactment and implementation of legislation and regulations for good governance, transparency and accountability in healthcare and medicine. Anti-corruption laws are frequently breached because of inadequate regulation and monitoring, or the absence of effective penalties. One solution could be to set up an office of ombudsman to deal with corruption (eg Lokpal) in every district, province and state capital. The ombudsman should be equipped with adequate resources, infrastructure and real powers.

5. Education
The importance of (continuing) education can hardly be overemphasised. It is hard to believe that all young men and women join medicine only to make money out of people's illness. Education in ethics through the use of positive role models may reinforce moral values. It would help present and future healthcare professionals not only to steer clear of fraud and abuse, but also to create a favourable ethical climate within the profession (27).

It is time to acknowledge that corruption in healthcare entails crimes against humanity. There is no room for complacency- history will not forgive physicians and bioethicists if they fail in their moral duty to safeguard the cause of ethics in medicine when it is necessary.

1Note: This author witnessed an incident in which a delegation of doctors were complaining that intentional damage had been done to the only laparoscope in the department of surgery in a government medical college in India. The laparoscopic surgeon kept the instrument out of order intentionally, and then referred the patients to the nursing home where he had a private practice.

This paper is dedicated to Sri Ramakrishna and Sri Sri Thakur Anukulachandra for their teachings against unethical and corrupt practices in medicine.
*Disclaimer: This author works as Head of the Department of Physiology at the College of Medicine and JNM Hospital, West Bengal University of Health Sciences, India. The views and opinions expressed here are those of the author and do not reflect the view of the College or University or any of its offices.

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Professor, Department of Physiology, College of Medicine and JNM Hospital, West Bengal University of Health Sciences*, Kalyani, Nadia 741 235, West Bengal, INDIA email:,