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

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It is possible to address social determinants of illness/health in the USA - Rebecca Onie of Health Leads

Rebecca Onie is the founder of Health Leads, a program that connects patients to basic care and resources, such as food and housing, that are the root cause of many health problems.


In 1996, as a sophomore in college, Rebecca Onie had a realization: The health care system in the United States was not set up to diagnose nor treat the socioeconomic issues that lead to poor health, and that health care providers are not given tools to address basic problems like nutrition and housing.

So, while still a sophomore, she co-founded Health Leads, a program that assists low-income patients and their families to access food, heat, and other basic resources they need to be healthy. With the additional insight that college volunteers could be recruited and trained into an elite group just like a college sport team, she found the people and skills needed to produce such an audacious idea. Since then it has grown tremendously, and now operates in Baltimore, Boston, Chicago, New York, Providence, and Washington, DC, and in the last year assisted over 8,800 patients.

In 2009, Rebecca was awarded a MacArthur “Genius” Fellowship.

Globalization, Global Governance and the Social Determinants of Health: A review of the linkages and agenda for action

This is an old report of a knowledge network part of the WHO commission.  However, in light of the recent report of the Oslo-Lancet Commission on Global Governance for Health, I think it is still a very good resource on the whole concept of global governance.

Globalization, Global Governance and the Social Determinants of Health:
A review of the linkages and agenda for action

WHO Commission on Social Determinants of Health

As processes of globalization have accelerated in recent decades, there have been widespread ef- forts to develop appropriate forms of governance to deal effectively with emerging worldwide challenges. This paper reviews the existing evidence concerning the impacts of global governance on the social deter- minants of health (SDH). First, it documents the tran- sition taking place towards global governance related to the SDH in terms of institutional actors, and their relative roles, power and authority. Second, it assesses how emerging forms of global governance may be in- fluencing the SDH. How might various institutions, and the distribution and use of power and authority among them, affect the SDH? Third, this paper assess- es the quality of emerging forms of global governance against recognized “good governance” criteria. Fourth, it identifies how global governance can play a transfor- mational role in addressing the SDH.

A Dream Deferred: The Right to Food in America

Original link to Huffington post can be found here

A Dream Deferred: The Right to Food in America

Posted: 10/30/2013 5:03 pm

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Hunger, Poverty , Farm Bill, Martin Luther King Jr., Food For Thought, Food Insecurity,Food Stamps, Hunger In America, Right To Food, Snap, Politics News

This year our nation commemorated the fiftieth anniversary of the March on Washington and Dr. Martin Luther King Jr.'s "I Have a Dream" speech, giving us all occasion to reflect on his civil rights aspirations and the extent to which they have been fulfilled. But the persistence of hunger in America today brings to mind Dr. King's other dream -- that of ending poverty and realizing the full spectrum of human rights, including the right to food.

Dr. King understood that social justice cannot be achieved without economic justice. In March 1965 he declared: "Let us march on poverty until no American parent has to skip a meal so that their children may eat." In the months before his assassination, Dr. King spearheaded nationwide efforts to launch a multiracial Poor People's Campaign. "We are coming to Washington," he said. "We are coming to demand that the government address itself to the problem of poverty."

Although he did not live to see the Campaign, those of us who believed in his dream carried it forward. In May 1968 thousands of people occupied the National Mall and demanded economic justice in the form of fair wages, decent housing, quality health care and education, and access to adequate food. Nearly fifty years later, this dream remains deferred for far too many Americans. Most starkly, we continue to treat access to food as a privilege, instead of as a fundamental human right.

The world over, freedom from hunger and access to sufficient, nutritious food are recognized as human rights. These ideas are not foreign to the United States; they were inspired by our government's commitment to ensuring "freedom from want" in the wake of the Great Depression. Now, more than ever, we must reclaim these values and ensure the right to food for all Americans.

Last month, the USDA reported that 49 million Americans live in "food insecure" households, meaning they cannot afford adequate food for themselves or their families. In other words, nearly one in six individuals in the richest country in the world is struggling to put food on the table. Hunger in the United States is not the result of a shortage of food or resources -- it is the direct result of poverty perpetuated through policies that fail to prioritize Americans' fundamental needs.

On the heels of the USDA report, the House voted to cut $40 billion over the next ten years from the Supplemental Nutrition Assistance Program (SNAP) -- the nation's largest anti-poverty program. Under the House version of the farm bill, 3.8 million individuals would lose their SNAP benefits in 2014 alone, and an estimated 210,000 children would be kicked off of free school lunch programs. On November 1, SNAP recipients will see an automatic decline in their benefits when a temporary boost to the program (voted in as part of the 2009 Recovery Act) ends.

The impact of these assaults on our nutrition assistance programs will be felt over a generation and possibly beyond. Children who do not receive adequate nutrition -- including prenatally -- are at risk of serious health and developmental problems. Hungry children struggle to learn in school and, according to a report by Feeding America, are far more likely to experience behavioral problems, increasing the chance that they will drop out of school and decreasing their lifetime earning potential. By failing to adequately feed our children, we are setting them up to fail.

This is a moral failing. It is also a violation of human rights.

As the House and Senate enter negotiations over the farm bill, we must call upon them to strengthen -- not undermine -- our food safety net. A recent study by the International Human Rights Clinic at NYU School of Law found that many food insecure households do not receive SNAP benefits because the program's eligibility requirements are drawn too narrowly. For households that do qualify, the benefits are simply insufficient to meet their food-related needs. On average, families on SNAP receive under $1.50 per person per meal.

We need to fortify SNAP, ensuring that it reaches all food insecure households and enables families to afford sufficient, nutritious food. In addition, we need to adopt and implement a national strategy to tackle the root causes of hunger in America today. At minimum, we must ensure a living wage so that individuals and families can provide for themselves.

Five years from now, when we commemorate the fiftieth anniversary of the Poor People's Campaign, we will inevitably ask ourselves: How far have we come in fulfilling Dr. King's other dream?

Let us act now to end hunger and ensure the right to food for all.

Rev. Jesse L. Jackson Sr., a former aide to the Rev. Dr. Martin Luther King Jr., is the president and founder of the RainbowPUSH Coalition.

Smita Narula is a human rights lawyer and professor and co-author of the studyNourishing Change: Fulfilling the Right to Food in the United States.

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

Health and philosophy post-docs at McGill Univ.

2013 Call for Applications

The MHERC Postdoctoral Fellowship in Causal Inference, Population Health, and Health Equity

The Montreal Health Equity Research Consortium (MHERC) is seeking to appoint one or two post-doctoral fellows doing research related to the role of causal inference in population health and health equity research and policy. Applications regarding any dimension of this general theme will be considered, but the following areas are of particular interest:

·         The role of causal inference in the generation of population health and health inequalities information.

·         The use of epidemiologic evidence in the development of population health and health equity policies and priorities. 

·         Causal models and their use in research on social determinants of health and health equity.

The duration of the award is 12 months, renewable for a second year, commencing on September 1, 2013. The value of each award will be CA$42,000. In addition, Fellows will be provided with a $2000 research allowance. Fellows will be in residence at McGill University in Montreal.

Applicants should have at the time of award completed a PhD in a relevant discipline including, but not restricted to, epidemiology, economics, philosophy, cognitive psychology, and sociology. Applicants may not have received their PhDs more than 5 years before the beginning of the fellowship.

Successful applicants will be provided with office space in one of the two participating research centers associated with the project, and will be expected to participate in all of MHERC’s activities. For more information on MHERC, please see our website at http:www.mherc.net

Applications should be written in English, and include a cover letter describing the candidate’s background, qualifications, and research interests; a complete Curriculum Vitae; a writing sample; and the names of three referees. Applications should be sent to Nicholas B. King at nicholas.king@mcgill.ca

Recessions can hurt, but austerity kills - new book by David Stuckler and Sanjay Basu

From the Guardian 15 May 2013

'Recessions can hurt, but austerity kills'

In the US, more than five million people have lost access to health care. In Greece, there's a 200% increase in HIV cases. And in some of the worst-hit countries, suicide rates are up. David Stuckler, author of an explosive new book, says the facts speak for themselves

• 
• • Jon Henley
  • The Guardian, Wednesday 15 May 2013 17.40 BST

A man begging on a street in Athens as an anti-austerity demonstration passes by. Greece used to have one of the lowest suicide rates in Europe, but have gone up by 60%. Photograph: Reuters

The austerity programmes administered by western governments in the wake of the 2008 global financial crisis were, of course, intended as a remedy, a tough but necessary course of treatment to relieve the symptoms of debts and deficits and to cure recession. But if, David Stuckler says, austerity had been run like a clinical trial, "It would have been discontinued. The evidence of its deadly side-effects – of the profound effects of economic choices on health – is overwhelming."

1. The Body Economic: Why Austerity Kills
2. by David Stuckler, Sanjay Basu
3. 

1. Tell us what you think: Star-rate and review this book

Stuckler speaks softly, in the measured tones and carefully weighed terms of the academic, which is what he is: a leading expert on the economics of health, masters in public health degree from Yale, PhD from Cambridge, senior research leader at Oxford, 100-odd peer-reviewed papers to his name. But his message – especially here, as even the IMF starts to question chancellor George Osborne's enthusiasm for ever-deeper budget cuts – is explosive, backed by a decade of research, and based on reams of publicly available data: "Recessions," Stuckler says bluntly, "can hurt. But austerity kills."

In a powerful new book, The Body Economic, Stuckler and his colleague Sanjay Basu, an assistant professor of medicine and epidemiologist at Stanford University, show that austerity is now having a "devastating effect" on public health in Europe and North America.

The mass of data they have mined reveals that more than 10,000 additional suicides and up to a million extra cases of depression have been recorded across the two continents since governments started introducing austerity programmes in the aftermath of the crisis.

In the United States, more than five million Americans have lost access to healthcare since the recession began, essentially because when they lost their jobs, they also lost their health insurance. And in the UK, the authors say, 10,000 families have been pushed into homelessness following housing benefit cuts.

The most extreme case, says Stuckler, reeling off numbers he knows now by heart, isGreece. "There, austerity to meet targets set by the troika is leading to a public-health disaster," he says. "Greece has cut its health system by more than 40%. As the health minister said: 'These aren't cuts with a scalpel, they're cuts with a butcher's knife.'"

Worse, those cuts have been decided "not by doctors and healthcare professionals, but by economists and financial managers. The plan was simply to get health spending down to 6% of GDP. Where did that number come from? It's less than the UK, less than Germany, way less than the US."

The consequences have been dramatic. Cuts in HIV-prevention budgets have coincided with a 200% increase in the virus in Greece, driven by a sharp rise in intravenous drug use against the background of a youth unemployment rate now running at more than 50% and a spike in homelessness of around a quarter. The World Health Organisation, Stuckler says, recommends a supply of 200 clean needles a year for each intravenous drug user; groups that work with users in Athens estimate the current number available is about three.

In terms of "economic" suicides, "Greece has gone from one extreme to the other. It used to have one of Europe's lowest suicide rates; it has seen a more than 60% rise."

In general, each suicide corresponds to around 10 suicide attempts and – it varies from country to country – between 100 and 1,000 new cases of depression. In Greece, says Stuckler, "that's reflected in surveys that show a doubling in cases of depression; in psychiatry services saying they're overwhelmed; in charity helplines reporting huge increases in calls".

The country's healthcare system itself has also "signally failed to manage or cope with the threats it's facing", Stuckler notes. "There have been heavy cuts to many hospital sectors. Places lack surgical gloves, the most basic equipment. More than 200 medicines have been destocked by pharmacies who can't pay for them. When you cut with the butcher's knife, you cut both fat and lean. Ultimately, it's the patient who loses out."

Such phenomena, he says, "are just a few of many effects we're seeing. And with all this accumulation of across-the-board, eye-watering statistics, there's a cause-and-effect relationship with austerity measures. These issues became apparent not when the recession hit Greece, but with austerity."

But public health disasters such as Greece's are not inevitable, even in the very worst economic downturns. Stuckler and Basu began to look at this before the crisis hit, studying how large personal economic shocks – unemployment, loss of your home, unpayable debt – "literally could get under people's skin, and cause serious health problems".

 Civil servants in Spain demonstrating against cuts in 2012. 'There was little investment in labour programmes,' says Stuckler, 'and we saw a spike in suicides.' Photograph: Andrea Comas/Reuters

The pair examined data from major economic upsets in the past: the Great Depression in the US; post-communist Russia's brutal transition to a market economy; Sweden's banking crisis in the early 1990s; the East-Asian debacle later that decade; Germany's painful labour market reforms early this century. "We were looking," Stuckler says, "at how rises in unemployment, which is one indicator of recession, affected people's health. We found that suicides tended to rise. We wanted to see if there was a way these suicides could be prevented."

It rapidly became clear "there was enormous variation across countries", he says. "In some countries, politicians managed the consequences of recession well, preventing rising suicides and depression. In others, there was a very close relationship between ups and downs in the economy and peaks and valleys in suicides."

Investment in intensive programmes to help people return to work – so-called Active Labour Market Programmes, well developed in Sweden (where suicides actually fell during the banking crisis) but also effective in Germany – were a factor that seemed to make a big difference.

Maintaining spending on broader social protection and welfare programmes helped, too: analysis of data from the 1930s Great Depression in the US showed that every extra $100 of relief in states that adopted the American New Deal led to about 20 fewer deaths per 1,000 births, four fewer suicides per 100,000 people and 18 fewer pneumonia deaths per 100,000 people.

"When this recession started, we began to see history repeat itself," says Stuckler. "InSpain, for example, where there was little investment in labour programmes, we saw a spike in suicides. In Finland, Iceland, countries that took steps to protect their people in hard times, there was no noticeable impact on suicide rates or other health problems.

"So I think we really noticed these harms aren't inevitable back in 2008 or 2009, early in the recession. We realised that what ultimately happens in recessions depends, essentially, on how politicians respond to them."

Poorer public health, in other words, is not an inevitable consequence of economic downturns, it amounts to a political choice – by the government of the country concerned or, in the case of the southern part of the eurozone, by the EU, European Central Bank and IMF troika.

Stuckler seizes on Iceland as an example of "an alternative. It suffered the worst banking crisis in history; all three of its biggest banks failed, its total debt jumped to 800% of GDP – far worse than what any European country faces today, relative to the size of its economy. And under pressure from public protests, its president put how to deal with the crisis to a vote. Some 93% of the population voted against paying for the bankers' recklessness with large cuts to their health and social-protection systems."

And what happened? Under Iceland's universal healthcare system, "no one lost access to care. In fact more money went into the system. We saw no rise in suicides or depressive disorders – and we looked very hard. People consumed more locally sourced fish, so diets have improved. And by 2011, Iceland, which was previously ranked the happiest society in the world, was top of that list again."

What also bugs Stuckler – an economist as well as a public-health expert – is that neither Iceland nor any other country that "protected its people when they needed it most" did so at the cost of economic recovery. "It didn't break them to invest in programmes to help people get back to work," he says, "or to save people from homelessness. Iceland now is booming; unemployment fell back to below 5% and GDP growth is above 4% – far exceeding any of other European countries that suffered major recessions."

Countries such as those in Scandinavia that took what Stuckler terms "wise, cost-effective and affordable steps that can make a difference" have seen the impact reflected not just in improved health statistics, but also in their economies. Which is why, occasionally, the austerity argument angers him.

"If there actually was a fundamental trade-off between the health of the economy and public health, maybe there would be a real debate to be had," he says. "But there isn't. Investing in programmes that protect the nation's health is not only the right thing to do, it can help spur economic recovery. We show that. The data shows that."

Drilling into the data shows the fiscal multiplier – the economic bang, if you like, per government buck spent, or cost per buck cut – for spending on healthcare, education and social protection is many times greater than that for money ploughed into, for example, bank bailouts or defence spending.

"That," says Stuckler, "seems to me essential knowledge if you want to minimise the economic damage, to understand which cuts will be the least harmful to the economy. But if you look at the pattern of the cuts that have happened, it's been the exact opposite."

So in this current economic crisis, there are countries – Iceland, Sweden, Finland – that are showing positive health trends, and there are countries that are not: Greece, Spain, now maybe Italy. Teetering between the two extremes, Stuckler reckons, is Britain.

The UK, he says, is "one of the clearest expressions of how austerity kills". Suicides were falling in this country before the recession, he notes. Then, coinciding with a surge in unemployment, they spiked in 2008 and 2009. As unemployment dipped again in 2009 and 2010, so too did suicides. But since the election and the coalition government's introduction of austerity measures – and particularly cuts in public sector jobs across the country – suicides are back.

 'In Britain, we haven't yet seen what can happen when people are denied access to healthcare, but the US system gives us a pretty clear warning,' says Stuckler. Photograph: London News Pictures/Rex Features

Ministers seem unwilling to address the increase in suicides, arguing it is too early to conclude anything from the data. Stuckler points out that this is because the Department of Health prefers to use three-year rolling averages that even out annual fluctuations. But based on the actual data, he is in no doubt. "We've seen a second wave – of austerity suicides," he says. "And they've been concentrated in the north and north-east, places like Yorkshire and Humber, with large rises in unemployment. Whereas London … We're now seeing polarisation across the UK in mental-health issues."

He cites, also, the dire impact on homelessness – falling in Britain until 2010 – of government cuts to social housing budgets, and the human tragedies triggered by the fitness-for-work evaluations, designed to weed out disability benefit fraud.

"What's so particularly tragic about those," he says, "is that the government's own estimates of fraud by persons with disabilities is less than the sum of the contract awarded to the company carrying out the tests."

At least, though, no one in the UK has been denied access to healthcare – yet. Stuckler confesses to being "heartbroken" as what he sees happening to the NHS. "Britain stood out as the great protector of its people's health in this recession," he says. "By all measures – public satisfaction, quality, access – the UK was at or near the top, and at very low relative cost."

But that, he says, is now changing. "I don't know if people quite realise how fundamental this government's transformation of the NHS is," he says. "And once it's in place, it will be difficult, if not impossible, to reverse. We haven't yet seen here what can happen when people are denied access to healthcare, but the US system gives us a pretty clear warning."

He finds this all in stark and depressing contrast to the post-second world war period, when Britain's debt was more than 200% of GDP (far higher than any European country's today, bar Iceland) and the country's leaders responded not by cutting spending but by founding the welfare state – "paving the way, incidentally, for decades of prosperity. And within 10 years, debt had halved."

The Body Economic should come as a broadside, morally armour-plated and data-reinforced. The austerity debate, Stuckler says, is "a public discussion that needs to be held. Politicians talk endlessly about debts and deficits, but without regard to the human cost of their decisions."

What its authors hope is that politicians will take the message they have uncovered in the data seriously, and start basing policy on evidence rather than ideology. (Some already do. When Stuckler and Basu presented some of their findings in the Swedish parliament, the MPs' response was: "Why are you telling us this? We know it. It's why we set up these programmes." Others, notably in Greece, have sought to divert responsibility.)

"Our book," says Stuckler, "shows that the cost of austerity can be calculated in human lives. It articulates how austerity kills. It shows austerity and health is always a false economy – no matter how positively some people view it, because for them it shrinks the role of the state, or reduces payments into a system they never use anyway."

When times are hard, governments need to invest more – or, at the very least, cut where it does least harm. It is dangerous and economically damaging to cut vital supports at a time when people need them most.

"So there is an opportunity here," Stuckler concludes, "to make a lasting difference. To set our economies on track for a happier, healthier future, as we did in the postwar period. To get our priorities as a society right. It's not yet too late. Almost, but not quite."

The Body Economic: Why Austerity Kills by David Stuckler and Sanjay Basu is published by Allen Lane on May 21 (rrp £20).