Saturday, 21 September 2013

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

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

September 20, 2013 12:06 am

The meaning of death

By Sridhar Venkatapuram

©Tom Duxbury

In July, Public Health England, the public health oversight body, distributed a report that revealed that about 23,400 more elderly people died between June 2012 and June 2013, than over the same period a year before.

In addition, week on week, more people were reported to have died in 2012 than at the same time in 2011. And so far in 2013, the excess death rates are reported to be higher than in any of the previous five years. The death rates were higher for women than men, especially in the most deprived areas of England. The causes were not immediately obvious – something the report itself admitted.

However, in a letter attached to a report on a related topic released a month later, John Newton, chief knowledge officer of PHE, provided some explanation. The July report, he wrote, had been written by an analyst who used a novel statistical approach that was consequently found to have potential methodological weaknesses.

There had been excess deaths in 2012-13, Newton continued, but they could be explained by higher-than-expected circulation of influenza and a bout of cold weather. Also, the rise in death rates did not look exceptional, he wrote, when compared with the past 12 years rather than with data from more recent years.

ON THIS STORY

IN FT WEALTH

Newton observed that many of the deaths were preventable and that the data showed the need to work harder to protect the vulnerable from both flu and extreme weather. Nevertheless, questions have been raised over a possible link between the rising mortality rates and a drop in the UK’s overall wealth, as measured by its gross domestic product.

About 20 years ago, Amartya Sen, the Nobel Prize-winning economist, wrote an article in the journal Scientific American about the importance of mortality data. Death statistics can be an important supplement to traditional economic indicators, he wrote, as they reveal very clearly what is actually happening in society, namely, if people are dying prematurely. Equally importantly, Sen argued that mortality data also show the efficacy of social institutions. In contrast, the most commonly used indicator of how well a society is doing is often the size of its economy or GDP, as the popular argument among economists and social scientists holds that wealth leads to wellbeing and, therefore, the wealthier the country the better off are its people.

Sen’s advocacy for the importance of mortality data is part of his broader work spanning decades on moving economics beyond just wealth, and measuring social progress beyond traditional economic indicators such as GDP.

Rather than focus on the means, he would see us focus on the quality of people’s daily lives.

Sen’s arguments have influenced development economics greatly and aided wellbeing indices such as the Human Development Index. During economic booms such as in the years preceding the economic crisis of 2008, there was growing interest among wealthy nations in moving beyond using GDP data or simply focusing on wealth as an indicator of people’s lives.

In early 2008, the then French President Nicolas Sarkozy set up the Commission on Economic Performance and Social Progress with Sen as one of its three chairmen.

In late 2010, UK Prime Minister David Cameron instructed the Office of National Statistics to begin measuring national wellbeing using a broader set of measures than just GDP.

Since the recession, however, GDP has come back firmly to centre stage. Changes in the latest set of data make headlines, and the justification for any policy is often linked to its effect on the underlying rate of growth. The re-entrenchment of GDP as an indicator might lead us to conclude that wealth is in fact the most important basis of how people live their lives.

But while many people around the world are indeed concerned about GDP data, particularly on how it affects their personal wealth, they are starting to recognise that other factors are just as important. Healthcare, for example, is on the political agenda of many countries.

©Tom Duxbury

England is not alone in reporting rising excess mortality rates among the elderly. In April 2012, a group of researchers published a study in the journal Eurosurveillance that detailed increases in excess mortality rates of the elderly across 12 European countries. And in the US, the Centers for Disease Control and Prevention reported a sharp increase of excess mortality due to influenza during the winter of 2012-13. Yet death from influenza or a harsher winter is not inevitable.

What role should the state play in preventing these early deaths – and, further, is the harsh economic climate taking its toll?

People’s health and mortality rates are due to a combination of factors – biological, behavioural and environmental. Economic growth is undoubtedly important for maintaining and improving people’s health and life expectancy. But it is unclear what the link between the two actually is. The range of life expectancies across countries with the largest economies, as well as health inequalities within countries, show that there is no automatic connection between health and wealth.

Morbid though they may be, Sen was right to argue that mortality rates are an important social indicator of the state of people’s lives and the efficacy of social institutions.

Looking deeper into the causes of deaths, or their inequalities within different social groups could reveal much not only about healthcare but also about a country’s social and economic development.

With the number of preventable deaths of the elderly in many industrialised countries on the rise, now is surely the time for the relationship between health and wealth to come under greater scrutiny.

Sunday, 8 September 2013

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

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

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

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
Biomedical research	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
Medical education*	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

Thursday, 5 September 2013

Coca-Cola investment in India on track

The original source of this article can be found here. LIVEMINT(India) Wall Street Journal

Coca-Cola investment in India on track

World’s largest beverage maker to spend $5 billion in India over eight years, setting aside concerns that a slowing economy will affect its investments

Suneera Tandon

First Published: Fri, Aug 23 2013. 12 18 AM IST

The company could, after evaluating demand and volume growth, even increase investments if required, Ahmet C. Bozer, executive vice-president of Coca-Cola, said. Photo: Bloomberg

Most frequent global health authors.

Global health authors. A search on Scopus for 'global health' in article title comes up with 4,437 articles. The earliest being in 1958. The authors ranked according to how many of their article titles included global health are below. Interesting.

Monday, 5 August 2013

Latin American countries crack down on junk food

The Lancet, Volume 382, Issue 9890, Pages 385 - 386, 3 August 2013

doi:10.1016/S0140-6736(13)61657-8 (click here for original posting)

Latin American countries crack down on junk food

Barbara Fraser

While several Latin American nations have introduced healthy food laws to try to combat childhood obesity, implementation has proved trickier. Barbara Fraser reports from Lima, Peru.

Sergio Escalante got a shock at lunchtime on the first day of school this year. His school's food kiosk no longer offered the usual fare—potato crisps, cookies, sweets, soft drinks, and sandwiches dripping with creamy sauces.

“He came home and said there was nothing to eat”, his mother, Miriam González, a nurse, recalled with a chuckle. “They were selling fruit and chicken sandwiches without mayonnaise—to him, that meant ‘nothing to eat’.”

The food concession was lining up with Peru's new healthy food law, which aims to tackle the country's rising obesity rate by getting children onto a healthier diet.

Peru's law is the latest in a series of efforts by Latin American countries to tackle a public health problem that has accompanied the economic boom of the past two decades—more overweight kids and an increase in non-communicable diseases such as diabetes and cardiovascular problems.

But although several countries have passed laws, implementing regulations have lagged, and some public health experts are calling for international measures—such as the ones used to tackle cigarette sales—to counter what they say is powerful lobbying by the food and advertising industries.

Peru's law immediately drew criticism from legislators, advertisers, and even the Catholic archbishop of Lima, who said that shaping children's dietary habits was a job for parents, not the government.

But the entire country will benefit if the government can head off future health problems by reducing children's consumption of salty, sugary, and high-fat processed foods, according to Luis Fernando Leanes, who heads the Pan American Health Organization (PAHO) office in Peru.

“Being able to decrease children's exposure to these foods will mean more hospital beds free in the future to care for people with other illnesses”, he said on July 9 at a conference in Lima on public policy for promoting healthy foods.

Peru, Chile, Colombia, Costa Rica, and Brazil are among the Latin American countries with healthy food legislation. Uruguay's Senate recently approved a law and Ecuador is considering one. The Latin American Parliament, an inter-governmental group, is drafting non-binding recommendations for countries that are considering legislation.

In Latin America, efforts to redirect children's food choices have taken several approaches. Most have focused on controlling the food offered and advertised in schools. Some countries have added labelling regulations, while others have tried limiting advertising, especially on television.

In 2011, PAHO issued a series of recommendations on the regulation of marketing of food to children, in the wake of a series of studies showing that television channels in some countries bombarded children with more than a dozen ads per hour for foods high in salt, fat, and sugar.

The Peruvian law, signed by the president in May, calls for nutrition education in schools; information campaigns by the education and health ministries; a system for monitoring nutrition, overweight, and obesity among children and adolescents; healthy food in school kiosks or cafeterias; more physical activity; and controls on advertising aimed at children and adolescents younger than 16 years.

The law prohibits advertising that encourages “immoderate consumption” of food and non-alcoholic beverages that contain trans fats or high levels of sugar, salt, and saturated fat; shows “inappropriate portions”; appeals to children's naiveté or emotions; claims products are natural when they really are not; or uses testimony from real people or fictitious characters whom the children might admire. It also forbids adverts that suggest that a parent is “more intelligent or more generous” if he or she purchases a particular product.

Studies have shown the power of advertising. In São Paulo, Brazil, 85% of parents said advertising influenced their children's demands, and three-quarters said prizes or free food were strong incentives, according to a 2010 study commissioned by the Alana Institute, a Brazilian non-profit organisation that advocates for children's rights.

Full-size image (49K) Jenny Matthews/Panos Pictures

The Peruvian law will not take effect until implementing regulations, being drafted by a multi-agency commission, are approved. Those regulations will flesh out the details and ultimately determine how strong the law will be.

Chile passed a healthy foods law after a 5-year effort by consumer organisations, academics, and some sympathetic legislators, but the deadline for publishing the implementation regulations passed on July 6, said Cecilia Castillo, a paediatrician who works with a consumer group. “We're afraid the law may just die”, she says. “The regulations have been difficult because of pressure from large companies.”

Industry lobbying led Congress to remove some provisions before the law was approved in 2012, including a “traffic light” symbol on packages, indicating how healthy a food item is; banning the sale of junk food within a certain radius of schools, like a rule that applies to cigarettes; and a prohibition on the distribution of infant formula.

The law does require nutrition labelling and ingredient lists on packages of prepared food and calls for the Health Ministry to identify foods that are high in calories or salt and set per-portion limits on fats, sugars, and salt. Those foods cannot be advertised to children younger than 14 years, and advertisers cannot use toys, stickers, or other enticements.

Castillo called the law “the best legislation possible” but said there was little public participation in the drafting of the regulations, and the law's supporters do not know how strong they will be.

In Chile, as in Peru, food and advertising industry representatives argued that the industry could regulate itself with codes of conduct. The problem with such codes, which exist worldwide, is that “none of them is particularly strong”, says Corinna Hawkes, head of policy and public affairs for the London-based World Cancer Research Fund International. “What works are clear objectives and clear criteria” for substantially reducing children's exposure to advertising.

Countries should begin by gathering their own data about advertising that targets children and set clear standards for types of food, age groups, communication channels, marketing techniques, and labelling requirements, she says. They must also devise ways to monitor the rules they put in place.

Industry representatives must also play a part, not in drafting the rules, but in negotiations about how they will be implemented, said Ekaterine Karageorgiadis, a lawyer with the Alana Institute in Brazil. The institute, which also raises awareness about nutrition, has taken some food companies to court under consumer defence laws.

In Costa Rica, industry lawyers appealed to the country's Constitutional Court to overturn a law promoted by the Education Ministry, which limited the kinds of food available in schools. “People told us not to take on the big food industry” because of its political and economic clout, says Education Minister Leonardo Garnier. “And the pressure was strong, but both the public and the media played a role in support of the regulations.”

That backing, he said, stemmed from a growing realisation of the seriousness of obesity-related public health problems. When colleagues in Mexico warned Garnier that industry representatives would lobby for setting maximum levels of sugar and fats in a way that would allow them to sell the same product in a smaller package, Costa Rican officials based their calculations on energy density instead. “We were insistent that it wasn't a matter of package size”, Garnier said.

The court upheld the law and manufacturers began to adapt. A few months after the law took effect, one company invited Garnier to a press conference, which he attended with some trepidation. To his surprise, the company—which had had only five acceptable products when the law took effect—was launching 20 more products that complied with the new standards.

To ensure that the law is implemented properly, Education Ministry staff members are training school principals and food vendors, he said. Controlling advertising to children, which is not addressed in Costa Rica's law, may be a task for the future.

Brazil took a different approach to promoting healthy food in schools, not only setting nutrition standards, but also requiring that schools purchase locally grown or manufactured products, supporting small farmers and stimulating the local economy, according to Fabio Gomes, a nutritionist at the Health Ministry's National Cancer Institute.

Unlike Europe or the USA, where processed foods make up more than half the diet, about two-thirds of the average Brazilian diet still consists of traditional, unprocessed foods, he said. The Brazilian law reinforces that, requiring that 70% of the food served to children in school meal programmes be unprocessed—rice, beans, meat, fish, fruits, or vegetables—and 30% be locally sourced.

Health experts and children's rights advocates in Brazil have tried to win controls on advertising, but so far the efforts have been unsuccessful. “As neighbouring countries approve [regulation of advertising], it gives us hope that one day one of those measures will be approved here”, says Gomes.

For the complete Lancet Series on Maternal and Child Nutrition see http://www.thelancet.com/series/maternal-and-child-nutrition

Health and global social justice

TABS

Saturday, 21 September 2013