HEALTH AS FREEDOM: ADDRESSING SOCIAL DETERMINANTS OF GLOBAL HEALTH INEQUITIES THROUGH THE HUMAN RIGHT TO DEVELOPMENT

In spite of vast global improvements in living standards, health, and well-being, the persistence of absolute poverty and its attendant maladies remains an unsettling fact of life for billions around the world and constitutes the primary cause for the failure of developing states to improve the health of their peoples. While economic development in developing countries is necessary to provide for underlying determinants of health – most prominently, poverty reduction and the building of comprehensive primary health systems – inequalities in power within the international economic order and the spread of neoliberal development policy limit the ability of developing states to develop economically and realize public goods for health. With neoliberal development policies impacting entire societies, the collective right to development, as compared with an individual rights-based approach to development, offers a framework by which to restructure this system to realize social determinants of health. The right to development, working through a vector of rights, can address social determinants of health, obligating states and the international community to support public health systems while reducing inequities in health through poverty-reducing economic growth. At an international level, where the ability of states to develop economically and to realize public goods through public health systems is constrained by international financial institutions, the implementation of the right to development enables a restructuring of international institutions and foreign-aid programs, allowing states to enter development debates with a right to cooperation from other states, not simply a cry for charity.     

REPRODUCTIVE TOURISM IN ARGENTINA: CLINIC ACCREDITATION AND ITS IMPLICATIONS FOR CONSUMERS,HEALTH PROFESSIONALS AND POLICY MAKERS

A subcategory of medical tourism, reproductive tourism has been the subject of much public and policy debate in recent years. Specific concerns include: the exploitation of individuals and communities, access to needed health care services, fair allocation of limited resources, and the quality and safety of services provided by private clinics. To date, the focus of attention has been on the thriving medical and reproductive tourism sectors in Asia and Eastern Europe; there has been much less consideration given to more recent ‘players’ in Latin America, notably fertility clinics in Chile, Brazil, Mexico and Argentina. In this paper, we examine the context‐specific ethical and policy implications of private Argentinean fertility clinics that market reproductive services via the internet. Whether or not one agrees that reproductive services should be made available as consumer goods, the fact is that they are provided as such by private clinics around the world. We argue that basic national regulatory mechanisms are required in countries such as Argentina that are marketing fertility services to local and international publics. Specifically, regular oversight of all fertility clinics is essential to ensure that consumer information is accurate and that marketed services are safe and effective. It is in the best interests of consumers, health professionals and policy makers that the reproductive tourism industry adopts safe and responsible medical practices.     

Comforting the (exile) afflicted in Croatia--around and beyond the analytical approaches of critical medical anthropology

Recently, there has been a growing recognition that any research conducted with those that suffer should definitely be critical of the continuing policy of group equalizing, either in relation to ones ethnicity or any other salient parameter. However, it is seldom that this critical knowledge is applied from "outsiders" when a negation and re-evaluation of history, especially concerning the medical systems and their historical development within nations and populations, is used. The propositions within this paper are given on the basis of knowledge gained in the course of a long-term study dedicated to the exiled in Croatia, and are tightly linked to theoretical perspectives of critical medical anthropology, yet exceed its limits. Critical medical anthropologists deeply engage in ongoing debates that stress how there needs to be more understanding of the necessity to study the wider social context of any population we approach and analyze. However, the knowledge about wider social contexts is unachievable without the new grounds of dialogue being created between professionals and researchers of all disciplines and equally--regardless whether they are "insiders" or "outsiders" to the problem in focus. The knowledge about developments in developing countries, and especially of countries in post-war transition cannot be solely built on strategies of globality and theoretical explorations disconnected from people and their experiences on ground, especially when they concern the delicate issues of social and health care. Hopingly, the given examples in this paper will add to dialogues of corrective kind that should be raised more often.     

生态旅游发展的成功要素分析--对国内外25个生态旅游发展案例的定量研究

生态旅游发展的5个成功要素包括：1)一体化发展;2)规划与循序渐进的发展;3)教育与培训;4)当地利益最大化;5)评价与反馈等。遴选国内外较为成功的25个生态旅游发展案例,定量分析这些案例的5个成功要素及24个发展战略,帮助认清目前生态旅游发展中存在的问题,如生态旅游发展未与当地的社会、经济、文化及环境发展一体化;缺乏较为完善的生态旅游规划与管理方案;缺乏有效的与生态旅游成功发展相关的教育与培训机制、方案、纲要;没有充分重视当地居民的利益;缺乏有效的生态旅游效应评价与信息反馈机制。     

A ROBUST,PARTICULARIST ETHICAL ASSESSMENT OF MEDICAL TOURISM

Recently, in increasing numbers, citizens of wealthy nations are heading to poorer countries for medical care. They are traveling to the global South as medical tourists because in their home nations either they cannot get timely medical care or they cannot afford needed treatments. This essay offers a robust, particularist ethical assessment of the practice of citizens of richer nations traveling to poorer countries for healthcare.     

Systemic Negligence: Why It Is Morally Important for Developing World Bioethics

In the context of clinical and non‐clinical biomedical practices, negligence is usually understood as a lapse of a specific professional duty by a healthcare worker or by a medical facility. This paper tries to delineate systemic negligence as another kind of negligence in the context of health systems, particularly in developing countries, that needs to be recognized and addressed. Systemic negligence is not just a mere collection of stray incidences of medical errors and system failures in a health system, but is proposed in this paper as a more pervasive kind of neglect. Several non‐medical factors, such as lack of social and political will, also contribute to it and hence is more difficult to address in a health system. This paper argues that recognizing systemic negligence and including it research agenda have special moral importance for researchers in developing world bioethics, public health ethics and for health activists in the developing world. For, it can be a potent health system barrier, and can seriously impair efforts to ensure patient safety, particularly in the weaker health systems. As it erodes accountability in a health system, addressing it is also important for the twin goals of ensuring patient safety and improving health system performance. Above all, it needs to be addressed because the tolerance of its persistence in a health system seems to undervalue health as a social good.     

Psychotic symptoms are associated with physical health problems independently of a mental disorder diagnosis: results from the WHO World Health Survey

This study explored whether physical health problems are related to psychotic symptoms independently of a mental disorder diagnosis. A total of 224,254 subjects recruited for the World Health Organization World Health Survey were subdivided into those with both a lifetime diagnosis of psychosis and at least one psychotic symptom in the 12 months prior to the evaluation, those with at least one psychotic symptom in the past 12 months but no lifetime diagnosis of psychosis, and those without psychotic symptoms in the past 12 months and without a lifetime diagnosis of psychosis. The three groups were compared for the presence of medical conditions, health problems, and access to health care. Medical conditions and health problems (angina, asthma, arthritis, tuberculosis, vision or hearing problems, mouth/teeth problems, alcohol consumption, smoking, and accidents), medication consumption, and hospital admissions (but not regular health care visits) were more frequent in individuals with psychotic symptoms but no psychosis diagnosis, compared to those with no symptoms and no diagnosis. The number of medical conditions increased with the number of psychotic symptoms. Given the sample analyzed, this trend seems to be independent from the socio‐economic development of the country or the specific health care system.     

IMPROVING GLOBAL HEALTH: COUNTING REASONS WHY

This paper examines cumulative ethical and self-interested reasons why wealthy developed nations should be motivated to do more to improve health care in developing countries. Egalitarian and human rights reasons why wealthy nations should do more to improve global health are that doing so would (1) promote equality of opportunity, (2) improve the situation of the worst-off, (3) promote respect of the human right to have one's most basic needs met, and (4) reduce undeserved inequalities in well-being. Utilitarian reasons for improving global health are that this would (5) promote the greater good of humankind, and (6) achieve enormous benefits while requiring only small sacrifices. Libertarian reasons are that this would (7) amend historical injustices and (8) meet the obligation to amend injustices that developed world countries have contributed to. Self-interested reasons why wealthy nations should do more to improve global health are that doing so would (9) reduce the threat of infectious diseases to developed countries, (10) promote developed countries' economic interests, and (11) promote global security. All of these reasons count, and together they add up to make an overwhelmingly powerful case for change. Those opposed to wealthy government funding of developing world health improvement would most likely appeal, implicitly or explicitly, to the idea that coercive taxation for redistributive purposes would violate the right of an individual to keep his hard-earned income. The idea that this reason not to improve global health should outweigh the combination of rights and values embodied in the eleven reasons enumerated above, however, is implausibly extreme, morally repugnant and perhaps imprudent.     

Stem cell tourism and future stem cell tourists: policy and ethical implications

Stem cell tourism is a small but growing part of the thriving global medical tourism marketplace. Much stem cell research remains at the experimental stage, with clinical trials still uncommon. However, there are over 700 clinics estimated to be operating in mostly developing countries--from Costa Rica and Argentina to China, India and Russia--that have lured many patients, mostly from industrialized countries, driven by desperation and hope, which in turn continue to fuel the growth of such tourism. While much research has focused on such dimensions as the promotions that allow such businesses to make their services known, media coverage, some patient research, and regulatory conditions for developing country clinics, little attention has been paid to the non-affected members of the general population, the future potential users of such services. This empirical study based on five focus group discussions with a diverse group of healthy adults in a Canadian city, explored participant views of patients who use stem cell tourism services, the likelihood they would avail themselves of such services if they were to suffer similar illnesses, and the conditions under which they might do so, and the impact that admonitions and advice from international expert bodies might have on their decisions. Our findings suggest that these healthy adults are sympathetic to the drivers of hope and desperation, and, despite cautions about research limitations, may seek such treatments themselves under similar conditions. These findings are discussed in the context of the policy and ethical issues raised by this form of medical tourism.     

我国现行医疗卫生政策的相关问题分析

医疗卫生是构建和谐社会的重要因素之一,也是关乎百姓切身利益的重大问题之一,近年来,医疗体制的不断改革,医疗卫生的相关政策的不断出台,已经大大地改善了我国广大人民群众的“看病难,看病贵”等问题,增加了医保的覆盖人群,减轻了城市低收入人群及农村的医疗负担,但是,我们仍面临着巨大的挑战,新的问题也不断涌现,医疗卫生政策不适应现在的医疗需求发展、经济发展不均衡、不同层次群众的医疗需求有差异等,都是医疗卫生改革中面临的问题,医疗改革的不断推进势在必行。我国的医疗保障制度覆盖率已经达到95％,但是,现行的医疗保障制度的还不能从根本上解决人民群众的“就医难,治病贵”的问题,其他医疗保险不能与现行的医疗保障制度相适应,从而,影响了我国整体的医疗水平的提高。     

Water flowing north of the border: export agriculture and water politics in a rural community in Baja California

Favored by neoliberal agrarian policies, the production of fresh crops for international markets has become a common strategy for economic development in Mexico and other Latin American countries. But as some scholars have argued, the global fresh produce industry in developing countries in which fresh crops are produced for consumer markets in affluent nations implies “virtual water flows,” the transfer of high volumes of water embedded in these crops across international borders. This article examines the local effects of the production of fresh produce in the San Quintín Valley in northwestern Mexico for markets in the United States. Although export agriculture has fostered economic growth and employment opportunities for indigenous farm laborers, it has also led to the overexploitation of underground finite water resources, and an alarming decline of the quantity and quality of water available for residents’ domestic use. I discuss how neoliberal water policies have further contributed to water inequalities along class and ethnic lines, the hardships settlers endure to secure access to water for their basic needs, and the political protests and social tensions water scarcity has triggered in the region. Although the production of fresh crops for international markets is promoted by organizations such as the World Bank and Inter-American Development Bank as a model for economic development, I argue that it often produces water insecurity for the poorest, threatening the UN goal of ensuring access to clean water as a universal human right.     

Actions to alleviate the mental health impact of the economic crisis

The current global economic crisis is expected to produce adverse mental health effects that may increase suicide and alcohol-related death rates in affected countries. In nations with greater social safety nets, the health impacts of the economic downturn may be less pronounced. Research indicates that the mental health impact of the economic crisis can be offset by various policy measures. This paper aims to outline how countries can safeguard and support mental health in times of economic downturn. It indicates that good mental health cannot be achieved by the health sector alone. The determinants of mental health often lie outside of the remits of the health system, and all sectors of society have to be involved in the promotion of mental health. Accessible and responsive primary care services support people at risk and can prevent mental health consequences. Any austerity measures imposed on mental health services need to be geared to support the modernization of mental health care provision. Social welfare supports and active labour market programmes aiming at helping people retain or re-gain jobs can counteract the mental health effects of the economic crisis. Family support programmes can also make a difference. Alcohol pricing and restrictions of alcohol availability reduce alcohol harms and save lives. Support to tackle unmanageable debt will also help to reduce the mental health impact of the crisis. While the current economic crisis may have a major impact on mental health and increase mortality due to suicides and alcohol-related disorders, it is also a window of opportunity to reform mental health care and promote a mentally healthy lifestyle.     

Personalised Medicine: A Critique on the Future of Health Care

In recent years we have seen the emergence of “personalised medicine.” This development can be seen as the logical product of reductionism in medical science in which disease is increasingly understood in molecular terms. Personalised medicine has flourished as a consequence of the application of neoliberal principles to health care, whereby a commercial and social need for personalised medicine has been created. More specifically, personalised medicine benefits from the ongoing commercialisation of the body and of genetic knowledge, the idea that health is defined by genetics, and the emphasis the state places on individual citizens as being “responsible for” their own health. In this paper I critique the emergence of personalised medicine by examining the ways in which it has already impacted upon health and health care delivery.     

Development of health biotechnology in developing countries: Can private-sector players be the prime movers?

Health biotechnology has rapidly become vital in helping healthcare systems meet the needs of the poor in developing countries. This key industry also generates revenue and creates employment opportunities in these countries. To successfully develop biotechnology industries in developing nations, it is critical to understand and improve the system of health innovation, as well as the role of each innovative sector and the linkages between the sectors. Countries' science and technology capacities can be strengthened only if there are non-linear linkages and strong interrelations among players throughout the innovation process; these relationships generate and transfer knowledge related to commercialization of the innovative health products. The private sector is one of the main actors in healthcare innovation, contributing significantly to the development of health biotechnology via knowledge, expertise, resources and relationships to translate basic research and development into new commercial products and innovative processes. The role of the private sector has been increasingly recognized and emphasized by governments, agencies and international organizations. Many partnerships between the public and private sector have been established to leverage the potential of the private sector to produce more affordable healthcare products. Several developing countries that have been actively involved in health biotechnology are becoming the main players in this industry. The aim of this paper is to discuss the role of the private sector in health biotechnology development and to study its impact on health and economic growth through case studies in South Korea, India and Brazil. The paper also discussed the approaches by which the private sector can improve the health and economic status of the poor.     

Linking bioprospecting with sustainable development and conservation: the Panama case

The limited international resources for economic aid and conservation can only mitigate poverty and losses of biodiversity. Hence, developing nations must establish the capacity to resolve their problems. Additionally, policy-makers and donors need to obtain scientific input on issues such as global change and ecosystem services. We propose that for nations rich in biodiversity, ecosystem services derived from bioprospecting, or drug discovery, could contribute to economic development. In the case where unstudied samples are shipped abroad for research, the chances of obtaining royalties are infinitesimally small. Therefore developing nations will only realize benefits from bioprospecting through in-country research on their own biodiversity. Policy-makers and donors have failed to appreciate the value of this approach. In order to provide an example of the inherent links between conservation and sustainable economic development, we initiated a drug discovery effort in Panama that emphasizes local benefit. As much of the drug discovery process as possible is conducted in Panamanian laboratories, providing jobs dependent on intact biodiversity and enhancing local research and training. In short, research, plus the spin-offs from research, provide immediate and long-lasting benefits to Panama. The connection between conservation and development has been highlighted in publicity about the project in Panama’s urban media. This provides a constructive alternative to the perception the among the urban populace that economic development inevitably competes with conservation. In summary, our program uses biodiversity to promote human health as well as to support research capacity, economic development and conservation within Panama. The program provides an example of the widely recognized but little developed concept of bioprospecting research as an ecosystem service.     

Recycled Sandalistas: From Revolution to Resorts in the New Nicaragua

In the post-Sandinista period, Nicaragua has adjusted to the new terms of a neoliberal economy by turning to tourism development as a leading industry. As the nation is refashioned as a safe and desirable tourist destination, efforts have been made to conceal evidence of the recent revolutionary past that might discourage visitors from traveling to the country. Nevertheless, there are indications that selected images and memories of revolution are making a reappearance and may prove marketable for tourism. This article argues that the twin projects of neoliberalism and nationalism may be served by this seemingly contradictory process. The Nicaraguan case offers an example of how the past figures in the remaking of postrevolutionary nations for tourism in the era of globalization.     

Confronting utilization review in New Mexico's Medicaid mental health system: the critical role of "medical necessity"

The insertion of managed care into Medicaid services for the mentally ill has created contention about clinical decision making. At the center of this debate is the matter of what constitutes a medical necessity. Employing ethnographic methodology, this study examines utilization review (UR), the context in which decisions concerning the authorization of mental health care services are made. Interviews carried out in the study contrast ideological underpinnings of providers and advocates of the mentally ill, on the one hand, with employees and administrators of managed care institutions, on the other. The result is an exploration into the ways discourses surrounding the mental health care needs of New Mexico's Medicaid population are being constructed and are determining the actual care they receive.     

Issues and Challenges in Research on the Ethics of Medical Tourism: Reflections from a Conference

The authors co-organized (Snyder and Crooks) and gave a keynote presentation at (Turner) a conference on ethical issues in medical tourism. Medical tourism involves travel across international borders with the intention of receiving medical care. This care is typically paid for out-of-pocket and is motivated by an interest in cost savings and/or avoiding wait times for care in the patient’s home country. This practice raises numerous ethical concerns, including potentially exacerbating health inequities in destination and source countries and disrupting continuity of care for patients. In this report, we synthesize conference presentations and present three lessons from the conference: 1) Medical tourism research has the potential for cross- or inter-disciplinarity but must bridge the gap between researchers trained in ethical theory and scholars unfamiliar with normative frameworks; 2) Medical tourism research must engage with empirical research from a variety of disciplines; and 3) Ethical analyses of medical tourism must incorporate both individual and population-level perspectives. While these lessons are presented in the context of research on medical tourism, we argue that they are applicable in other areas of research where global practices, such as human subject research and health worker migration, are occurring in the face of limited regulatory oversight.     

Is 2020 the year when primatologists should cancel fieldwork? A reply

The aim of this article is to explore the impact of coronavirus disease (COVID-19) pandemic on primate-related conservation work. The withdrawal of primatologists and conservation staff from field research can lead to a number of detrimental effects not just on conservation but also on local communities in low- and middle-income countries. Inequalities in access to health and financial insecurities may be drivers for the illegal wildlife trade and the lack of tourism and research activity may allow poachers to work with greater ease. The paper also looks at how conservation organizations and research bodies should modify their field protocols by developing robust occupational health policies that will not only make field work safer but also support local staff as they are likely to face the greatest threats to their physical health, psychological health, and economic loss from COVID-19. By adopting a One Health approach that considers the complex interactions between human and primate health, researchers will be able to find new ways of working not only to protect primates but understand how they adapt to the COVID-19 pandemic.     

The Poverty of Tourism under Mobilizational Developmentalism in China

ABSTRACT

In China tourism has been promoted not only as a passport to development in general, but also as an effective instrument to help the poor, and to regulate the serious regional disparity between the coastal and inland areas. In practice, tourism has been adopted popularly by local state elites as an important local economic development strategy, especially in poverty-stricken areas. This article studies the pattern of tourism development in China through the historically specific institutional dynamics of mobilizational developmentalism, which is generated from a blending of mobilizational bureaucracy with developmentalism. With the analytical framework of mobilization developmentalism, this article studies a case of “industrialization of tourism” in which the Miao New Year was promoted by a nationally designated poor county as a tourism-led development project. On one hand, this article analyzes how local bureaucrats at various levels of the government responded to the political mobilization of a tourism-led development project. On the other hand, this study explores how local communities respond to tourism projects mobilized from above. This article argues that mobilizational developmentalism shapes a specific set of political, economic and cultural processes among local state elites, tourist operators, and local communities in developing tourism in China.