Routledge offers open access to curated articles on health inequalities http://bit.ly/Health_Inequalities

Routledge are pleased to offer a broad look into the complex and controversial issue of Health Inequalities.

In order to gain a full perspective on the subject we have brought research together on the following elements, all of which are impacted in some way by health inequalities in their various forms:

• Children
• Communities
• Ethnicity
• Families
• Gender
• HIV/AIDS and sexuality

Access the research here for free. 

Have you enjoyed this collection? Let us know!
@Routledge_PHSC, use #HealthInequalities.
Share the collection with your followers: http://bit.ly/Health_Inequalities

PhD funding in Justice, Health & Quality of Life indicators

This is a fantastic PhD opportunity for anyone interested in combining philosophy and epidemiology/ health inequalities empirical research.

The supervisor is Prof. Marcel Verweij, Editor of Public Health Ethics journal.  At Wageningen University in the Netherlands.

Find the direct link to job posting here:

Vacancy

PhD Justice, Health and Quality of Life

Published on

March 28, 2014

We are looking for

People in lower socio-economic classes on average have shorter lives and are less healthy than people in higher socio-economic classes and this raises concerns about justice. Indeed, health policies often aspire to improve the health of worse-off groups, or otherwise reduce (socio-economic) health disparities. But if we are interested in reducing health inequalities for reasons of justice, what indicators of health and/or health-related quality of life should we use? In the Netherlands, the average life-expectancy for people in lowest socio-economic groups is 7 years less than for those in the highest class, but health disparities appear much higher (up to 20 years) if more subjective measures of health or quality of life are included.
The core elements of the philosophical PhD study are (a) to clarify the links between various theories of health and quality of life, and (b) to assess the ethical relevance of concepts and measures of health and quality of life from the perspective of theories of health justice. This work interacts with empirical studies that aim to clarify how people in different socio-economic classes conceptualise health. The research program will result in proposals how health and quality of life should be conceptualised and measured in policies that aim to reduce health inequalities. The PhD study is supervised by prof Marcel Verweij.
The PhD student will write a PhD thesis that includes 4 philosophical articles for international peer reviewed journals; collaborate in an interdisciplinary research group and, in that capacity, give input to the empirical substudies in the program; participate in regular activities of the philosophy chair group in Wageningen; and participate in relevant PhD courses of the Netherlands Research School in Philosophy and Wageningen School of Social Sciences.

We ask

You have a master’s degree in philosophy with excellent study results, and you are familiar with normative theories of justice and health. Furthermore, you have the cognitive, communicative and social skills that facilitate interdisciplinary cooperation. For this project, fluency in English is necessary; mastery of Dutch language is desirable but not necessary.

We offer

We offer you fulltime employment (38 hours a week) for 18 months with a possible extension of 30 months after positive evaluation. The gross salary is € 2.083,- per month in the first year and increases to € 2.664,- per month in the fourth year. (based on fulltime employment). In addition, we offer a holiday bonus of 8% and an end-of-the-year bonus of 8.3% of your annual salary.

Starting date: 1st July, 2014

You will be appointed at the Philosophy Group, part of CPT (Communication, Philosophy and Technology) within Department of Social Sciences at Wageningen University. The group’s work focuses on public health ethics, philosophy of life science and technology, and animal ethics. We cooperate with a variety of groups in the Netherlands and abroad.

More information

Additional information can be obtained from:
prof. dr. Marcel Verweij (tel.: +31(0)317484310)
email: marcel.verweij@wur.nl

How to apply
You can apply till 20 april 2014. Please don't email directly to the person mentioned above, but use the website to apply and upload your CV, references and short motivation letter.


We are
Wageningen University and Research Centre
Delivering a substantial contribution to the quality of life. That's our focus – each and every day. Within our domain, healthy food and living environment, we search for answers to issues affecting society – such as sustainable food production, climate change and alternative energy. Of course, we don’t do this alone. Every day, 6,500 people work on ‘the quality of life’, turning ideas into reality, on a global scale.

Could you be one of these people? We give you the space you need.
 

We are

The Philosophy group offers a position for a PhD student. This PhD project is part of an interdisciplinary research program “Socio-economic inequalities in health and quality of life” that combines philosophical and epidemiological studies. The program involves close cooperation between Wageningen University and the Academic Medical Centre in Amsterdam (Karien Stronks, professor of Public Health).

Oxford - Ethox Centre Visiting Fellowship 2014

CAROLINE MILES VISITING SCHOLARSHIP

THE ETHOX CENTRE

UNIVERSITY OF OXFORD

The Caroline Miles Visiting Scholarship is funded by the Ethox Foundation and is awarded annually to a post-doctoral or early career researcher to visit the Ethox Centre, University of Oxford.

The value of the scholarship is up to £2000.

Visiting Scholars will spend up to a month working at the Ethox Centre in Oxford, pursuing a research project on a topic relating to one of the Ethox Centre’s four main research programmes: global health ethics; clinical ethics; public health ethics; research ethics. Scholars will be expected to make a presentation on their research toward the end of their stay.

Deadline: 14th April 2014

For more information on how to apply visit: www.ethox.org.uk

Contact:

Dr Angeliki Kerasidou

Director of Caroline Miles Scholarship Scheme angeliki.kerasidou@ethox.ox.ac.uk

The most important infographic in global health

Find the original source on wired.com here

This is the most important infographic and image in global health right now.

I usually do not write commentary on this blog, preferring to just reblog.  However, this image is hugely important.  Other people have found this image, including Bill Gates's twitter feed.  Which is unlikely to have been sent by him, and largely misses the importance of this image.

The value of DALYs, which this infographic is based on, is that it seeks to measure the loss of life years across all human beings (humanity) due to premature death and morbidity.  It has many controversial aspects that are still open for debate, and it is often used in cost-effective analysis which is also questionable.  However, the really exciting thing about DALYs, and the important aspect of the work of the Institute of Health Metrics at the University of Washington, is that they make concrete the amorphous notion of suffering of the global poor/third world/ global health.  If want to know the GDP of a country, there are measurements that all feed into one number.  If you want to know a nation's debt, there is a number.  But if you wanted to know what a country's health looks like, or the health of all human beings in the world, there was no number, no picture.

This is the first image that I have seen that truly makes concrete how much of human lives are lost because of premature mortality and morbidity.  It also identifies the causes.  And, now, we can start a more informed global public discussion about what are the causes, how much will healthcare solve this problem, and how much do we have to go beyond healthcare and health systems to reduce this loss of human life years.  Once you understand that a preventable loss of a year of life is the preventable loss of one human being's ability to live a life they would like, the question of justice comes to the forefront.

Other people just see a list of diseases and lack of healthcare.  That is a real shame.

Want to Save Lives? You Need a Map of What’s Doing Us In

• BY LEE SIMMONS
• 11.15.13
• 9:30 AM

If sorrow were a landscape, here’s how it would look from a cruising altitude of 30,000 feet. This graphic maps the global cost of early mortality—some 1.7 billionyears of human life forfeited annually—sorted by cause of death. That’s 1.7 billion years of harvests and weddings, of factory work and music lessons and novels and new ideas that were supposed to happen and now won’t.

Infographic by Thomas Porostocky  |  Source: Institute for Health Metrics and Evaluation

And get this: Worldwide, about 40 percent of that toll results from disorders (shown in yellow above) that could be avoided with basic medications, clean water, and neonatal care. As you read this, 3,000 young kids are dying from diarrhea that a few zinc tablets might have stopped. Cost: 38 cents per life.

You might wish you hadn’t read that. But it’s the kind of insight that policymakers and NGOs need in order to focus health resources where they can do the most good. That’s why the Institute for Health Metrics and Evaluation at the Univer­sity of Washington created the massive database on which this graphic is based. Known as the Global Burden of Disease, it quantifies the incidence and impact of every conceiv­able illness and injury. Want to see your own odds of dying from gunshot or animal attack? You can go to the GBD Compare website and find out.

But IHME doesn’t just tally up death rates, it estimates the years of life lost (YLLs) from all those deaths: A fatal pneumonia infection at age 3 erases many more future birthdays than a heart attack at 80. Adding in years lived with disability, the database provides the most comprehensive measure we have of the burden of disease, in terms of lost human potential. It’s not a pretty picture.

Luckily, policymakers are paying attention. Well-targeted campaigns are reducing mortality from infectious diseases and birth complications throughout the world (as shown by the light shading in the picture above). While more than a million people still die of malaria each year, mostly children in sub-Saharan Africa, that number is down more than 20 percent since 2005.

These are just a few of the insights offered by GBD Compare. The interactive
visualization tool lets you drill down on that global map to compare regions and countries, spot trends, or slice the data by demographic groups. And because the data is structured hierarchically, you can set the resolution to zoom in for more detail or zoom out for big-picture comparisons. The basic inter­face is easy to use, but there’s a helpful video tutorial if you want to dig deeper into the toolbox.

Here are are few screenshots from the website itself. Don’t be thrown by the different color scheme; the “tree map” layout is basically the same as in the artist’s rendering above. The labels are a bit cryptic here, but if you visit the site you can run your cursor over the map to see full descriptive info for every tile.

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.

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? SUBRATA CHATTOPADHYAY1 PDF Abstract 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. Introduction 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." Absenteeism 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 areas Specific aspects under primary areas Types of unethical and corrupt practices Implications Patient care Construction of healthcare facilities Bribes and kickbacks for procuring contracts, speeding up procedure High cost, low-quality construction work and facilities that do not fulfil needs, resulting in inequity in access Purchase and supply of medicines, goods and services Bribes, 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 medicines Sale 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 hospital Bribes and informal payments Lack of access to basic healthcare for poor patients Health inequity Monitoring and regulation of quality in products, services Bribes 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 research Clinical trials Recruitment 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' research Bribes or informal payments for "supervising" students' research projects Fraud and misconduct in research and publication Medical education* Admission Bribes 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 Examination Bribes to pass qualifying examinations or top merit list Appointment of physicians and medical teachers Nepotism, favouritism, political influence in selection of healthcare professionals Note: *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). Conclusion 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. Acknowledgements 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. References Vian T. Review of corruption in the health sector: theory, methods and interventions. Health Policy Plan. 2008 Mar;23(2):83-94. doi: 10.1093/ heapol/czm048. Epub 2008 Feb 14. Sankaranarayanan R, Budukh AM, Rajkumar R. Effective screening programmes for cervical cancer in low- and middle-income developing countries. Bull World Health Organ. 2001; 79(10): 954-62. Shastri SS, Mittra I, Mishra G, Gupta S, Dikshit R, Badwe RA; Tata Memorial Centre, Mumbai, India. Effect of visual inspection with acetic acid (VIA) screening by primary health workers on cervical cancer mortality: A cluster randomized controlled trial in Mumbai, India. [Internet]. Presentation, American Society for Clinical Oncology annual meeting 2013[cited 2013 Jun 15]. Available from: http://meetinglibrary.asco.org/content/112133-132 Ortega R. Ethics of 2 cancer studies questioned. The Arizona Republic [Internet]. 2013 Feb 15 [cited 2013 Jun 3]. Available from: www.azcentral.com/ news/articles/20130313ethics-cancer-studies-india-questioned.html Lurie P, Wolfe SM. Unethical trials to reduce perinatal transmission of the human immunodeficiency virus in developing countries. N Engl J Med. 1997 Sep 18; 337(12): 853-6. World Medical Association. Declaration of Helsinki. Ethical principles for medical research involving human subjects. Last revised 2008 Oct. [cited 2013 Jul 4]. Available from: http://www.wma.net/en/30publications/10policies/b3/17c.pdf Indian Council of Medical Research. Ethical guidelines for biomedical research on human participants. New Delhi: ICMR; 2006. Sankaranarayanan R, Nene BM, Shastri SS, Jayant K, Muwonge R, Budukh AM, Hingmire S, Malvi SG, Thorat R, Kothari A, Chinoy R, Kelkar R, Kane S, Desai S, Keskar VR, Rajeshwarkar R, Panse N, Dinshaw KA. HPV screening for cervical cancer in rural India. N Engl J Med. 2009 Apr 2;360(14):1385-94. Sankaranarayanan R, Esmy PO, Rajkumar R, Muwonge R, Swaminathan R, Shanthakumari S, Fayette R, Cherian J. Effect of visual screening on cervical cancer incidence and mortality in Tamil Nadu, India: a cluster-randomised trial. Lancet. 2007 Aug 4;370(9585):398-406. Rathod SD. Commentary on HPV screening for cervical cancer in rural India. Indian J Med Ethics. 2011Jul-Sep;8(3):180-2. discussion 182-3. Mudur G. Indian study of women with cervical lesions called unethical. BMJ. 1997 Apr 12; 314(7087):1065. Srinivasan S. Research on public health interventions in poor countries. Issues Med Ethics. 2001 Oct-Dec;9(4):118-9. Srinivasan S, Loff B. Medical research in India. Lancet. 2006 Jun 17;367(9527):1962-4. Sengupta A. Fatal trials: clinical trials are killing people. Indian J Med Ethics. 2009 Jul-Sep;6(3):118-9. Nundy S, Gulhati CM. A new colonialism?--Conducting clinical trials in India. N Engl J Med. 2005 Apr 21;352(16):1633-6. Yee A. Regulation failing to keep up with India's trials boom. Lancet. 2012 Feb 4;379(9814):397-8. Chattopadhyay S. Guinea pigs in human form: clinical trials in unethical settings. Lancet. 2012 May 26;379(9830):e53. Transparency International India. New Delhi: Transparency International India; c2013[cited 2013 Jul 4]. Available from: http://www.transparency. org/country#IND Polgreen L. Health officials at risk as India's graft thrives. Gainesville.com[Internet]. 2011 Sep 17[cited 2013 Jun 4]. Available from: http://www. gainesville.com/article/20110917/ZNYT04/109173020 Bhalla A. How they made the NRHM sick. Tehelka.com [Internet]. 2012 Mar 17[cited 2013 Jun 4];9(11). Available from: http://archive.tehelka. com/story_main52.asp?filename=Ne170312HOW.asp Chatterjee P. How free healthcare became mired in corruption and murder in a key Indian state. BMJ. 2012 Feb 6;344:e453 doi: 10.1136/ bmj.e453 Khetan A. Where did Rs 8,500 cr of UP's health funds go? Tehelka.com [Internet]. 2011 Aug 20[cited 2013 Jun 4];8(33). Available from: http:// new.tehelka.com/story_main50.asp?filename=Ne200811COVERSTORY. asp Shukla S. India probes corruption in flagship health programme. Lancet. 2012 Feb 25;379(9817):698. Ambraseys N, Bilham R. Corruption kills. Nature. 2011Jan13;469(7329):153-5. Holmberg S, Rothstein B. Dying of corruption. Health Econ Policy Law. 2011 Oct;6(4):529-47. Hall MA, Camacho F, Dugan E, Balkrishnan R. Trust in the medical profession: conceptual and measurement issues. Health Serv Res. 2002 Oct; 37(5):1419-39. Campbell AV. Can virtue prevail? Safeguarding integrity in medicine and science Indian J Med Ethics. 2013 Jan-Mar;10(1):11-13. Professor, Department of Physiology, College of Medicine and JNM Hospital, West Bengal University of Health Sciences*, Kalyani, Nadia 741 235, West Bengal, INDIA email: linkdrsc@yahoo.com, linkdrsc@gmail.com

New book: Health Inequalities and Global Justice.

warning! self-promotion.....a really good, new book is now out on global justice and health

Health Inequalities and Global Justice (Studies in Global Justice and Human Rights) [Hardcover]
Patti Tamara Lenard and Christine Straehle (eds.)
Aug 2012
Binding: Hardback
ISBN: 9780748646920
Price: £65.00

Edinburg University Press / Columbia University Press
On Amazon.com


Introduction: Health inequality as a concern for global redistributive justice, Patti Tamara Lenard and Christine Straehle;

Part 1: A right to equal health?;

1. Is there a human right to health?, Adina Preda;
2. What’s Wrong with Global Health Inequalities?, Daniel M. Hausman;
3. Ecological Subjects, ‘Ethical Place-making’, and Global Health Equity, Lisa Eckenwiler;
4. Health inequalities, capabilities, and global justice, Sridhar Venkatapuram;

Part 2: Who is responsible for remedying global health inequality?;

5. Reexamining the Ethical Foundations: Behind the Distribution of Global Health, Garrett Wallace Brown;
6. Global Health and Responsibility, Gillian Brock;
7. Outlining the global duties of justice owed to women living with HIV/AIDS in sub-Saharan Africa, Angela Kaida and Patti Lenard;

Part 3: Measuring heath or health outcomes;

8. Measuring Global Health, Kristin Voigt;
9. Exploring a Sufficiency View of Health Equity, Yukiko Asada;
10. Rating Efforts to Extend Access on Essential Medicines: Increasing Global Health Impact, Nicole Hassoun;

Part 4: Borders and health;

11. Justice and Health Inequalities in Humanitarian Crises: Structured Health Vulnerabilities and Natural Disasters, Matthew R. Hunt and Ryoa Chung;
12. ‘Illegal’ Migrants and Access to Public Health: A Human Rights Approach, Phillip Cole;
13. Medical Migration between the Human Right to Health and Freedom of Movement, Eszter Kollar;
14. Health Care Migration, Vulnerability and Individual Autonomy – The case of Malawi, Christine Straehle.

World Conference: Case studies on social determinants of health

World Conference on Social Determinants of Health, Rio Oct 19 -21, 2011

http://www.who.int/sdhconference/en/

Case studies on social determinants of health   

The following case studies were commissioned by WHO Regional Offices for the World Conference on Social Determinants of Health. The case studies present successful examples of policy action aiming to reduce health inequities, covering a wide range of issues, including conditional cash transfers, gender-based violence, tuberculosis programmes and maternal and child health.

The case studies were written by individual experts and are being circulated as draft background papers to inform discussions at the conference. They represent the views of the authors and do not necessarily represent the views, policies, or decisions of WHO or the governments of the countries where the case studies are set.

• Brazil
  pdf, 978kb
  The Brazilian experience with conditional cash transfers: a successful way to reduce inequity and to improve health
• United States of America
  pdf, 1.05Mb
  How can we get the 'social determinants of health' message on the public policy and public health agenda?
• Solomon Islands
  pdf, 836kb
  Gender-based violence in Solomon Islands: Translating research into action on the social determinants of health
• Republic of Kiribati
  pdf, 831kb
  Measuring and responding to gender-based violence in the Pacific: Action on gender inequality as a social determinant of health
• Viet Nam
  pdf, 937kb
  Gender-based violence in Viet Nam: Strengthening the response by measuring and acting on social determinants of health
• Australia
  pdf, 1.23Mb
  Health in All Policies: South Australia's country case study on action on the social determinants of health
• WHO Western Pacific region
  pdf, 891kb
  Addressing social determinants of health through tuberculosis control programmes in Western Pacific Region
• Malaysia
  pdf, 1.47Mb
  Health in All Policies: The Primary Health Care Approach in Malaysia. 50 years experience in addressing social determinants of health through Intersectoral Action for Health
• India
  pdf, 888kb
  India's country experience in addressing social exclusion in maternal and child health
• India
  pdf, 771kb
  Effective social determinants of health approach in India through community mobilization
• Thailand
  pdf, 915kb
  Health systems, public health programmes and social determinants of health
• Egypt
  pdf, 819kb
  Social participation in Egypt: Civil society's former experience and new opportunities
• Morocco
  pdf, 761kb
  Social determinants and health equity in Morocco
• United States of America
  pdf, 764kb
  A national partnership for action to end health disparities in the United States of America
• Australia
  pdf, 732kb
  Supporting public policy and action on the social determinants of health by providing evidence through the Social Health Atlases of Australia
• Cambodia
  pdf, 776kb
  Gender as a social determinant of health: Gender analysis of the health sector in Cambodia
• WHO Western Pacific region
  pdf, 1.11Mb
  Gender mainstreaming in emerging disease surveillance and response
• Iran
  pdf, 845kb
  School Pupil Policy Officer (Hamyare Police) - A national initiative based on social participation to improve road safety
• Jordan
  pdf, 666kb
  National commitment to action on social determinants of health in Jordan: Addressing obesity
• Namibia
  pdf, 2.46Mb
  Report on country experience: A multi-sectoral response to combat the polio outbreak in Namibia
• Rwanda
  pdf, 1.75Mb
  Community performance-based financing in health: Incentivizing mothers and community health workers to improve maternal health outcomes in Rwanda
• Uganda
  pdf, 718kb
  Social determinants of health: Food fortification to reduce micronutrient deficiency in Uganda - Strengthening the National Food Fortification Programm
• Kenya
  pdf, 2.01Mb
  The national deworming programme: Kenya's experience
• Zimbabwe
  pdf, 857kb
  Intersectoral actions in response to cholera in Zimbabwe: From emergency response to institution building
• Brazil
  pdf, 2.01Mb
  The Green Area of Morro da Policia: Health practitioners working with communities to tackle the social determinants of health
• Chile
  pdf, 1.74Mb
  Steps towards the health equity agenda in Chile
• Pakistan
  pdf, 1.03Mb
  Heartfile Health Financing: Striving to achieve health equity in Pakistan
• Costa Rica
  pdf, 766kb
  Impact of long term policies based on social determinants of health: The Costa Rican experience