The benefits of privatization.

The promise of a universal, comprehensive, publicly funded system of medical care that was the foundation of the Medical Care Act passed in 1966 is no longer possible. Massive government debt, increasing health care costs, a growing and aging population and advances in technology have challenged the system, which can no longer meet the expectations of the public or of the health care professions. A parallel, private system, funded by a not-for-profit, regulated system of insurance coverage affordable for all wage-earners, would relieve the overstressed public system without decreasing the quality of care in that system. Critics of a parallel, private system, who base their arguments on the politics of fear and envy, charge that such a private system would "Americanize" Canadian health care and that the wealthy would be able to buy better, faster care than the rest of the population. But this has not happened in the parallel public and private health care systems in other Western countries or in the public and private education system in Canada. Wealthy Canadians can already buy medical care in the United States, where they spend $1 billion each year, an amount that represents a loss to Canada of 10,000 health care jobs. Parallel-system schemes in other countries have proven that people are driven to a private system by dissatisfaction with the quality of service, which is already suffering in Canada. Denial of choice is unacceptable to many people, particularly since the terms and conditions under which Canadians originally decided to forgo choice in medical care no longer apply.     

The Influence of Health Systems on Hypertension Awareness,Treatment, and Control: A Systematic Literature Review

Background

Hypertension (HT) affects an estimated one billion people worldwide, nearly three-quarters of whom live in low- or middle-income countries (LMICs). In both developed and developing countries, only a minority of individuals with HT are adequately treated. The reasons are many but, as with other chronic diseases, they include weaknesses in health systems. We conducted a systematic review of the influence of national or regional health systems on HT awareness, treatment, and control.

Methods and Findings

Eligible studies were those that analyzed the impact of health systems arrangements at the regional or national level on HT awareness, treatment, control, or antihypertensive medication adherence. The following databases were searched on 13th May 2013: Medline, Embase, Global Health, LILACS, Africa-Wide Information, IMSEAR, IMEMR, and WPRIM. There were no date or language restrictions. Two authors independently assessed papers for inclusion, extracted data, and assessed risk of bias. A narrative synthesis of the findings was conducted. Meta-analysis was not conducted due to substantial methodological heterogeneity in included studies. 53 studies were included, 11 of which were carried out in LMICs. Most studies evaluated health system financing and only four evaluated the effect of either human, physical, social, or intellectual resources on HT outcomes. Reduced medication co-payments were associated with improved HT control and treatment adherence, mainly evaluated in US settings. On balance, health insurance coverage was associated with improved outcomes of HT care in US settings. Having a routine place of care or physician was associated with improved HT care.

Conclusions

This review supports the minimization of medication co-payments in health insurance plans, and although studies were largely conducted in the US, the principle is likely to apply more generally. Studies that identify and analyze complexities and links between health systems arrangements and their effects on HT management are required, particularly in LMICs. Please see later in the article for the Editors'' Summary     

Measuring the health of nations: analysis of mortality amenable to health care

Objective To assess whether and how the rankings of the world''s health systems based on disability adjusted life expectancy as done in the 2000 World Health Report change when using the narrower concept of mortality amenable to health care, an outcome more closely linked to health system performance.Design Analysis of mortality amenable to health care (including and excluding ischaemic heart disease).Main outcome measure Age standardised mortality from causes amenable to health careSetting 19 countries belonging to the Organisation for Economic Cooperation and Development.Results Rankings based on mortality amenable to health care (excluding ischaemic heart disease) differed substantially from rankings of health attainment given in the 2000 World Health Report. No country retained the same position. Rankings for southern European countries and Japan, which had performed well in the report, fell sharply, whereas those of the Nordic countries improved. Some middle ranking countries (United Kingdom, Netherlands) also fell considerably; New Zealand improved its position. Rankings changed when ischaemic heart disease was included as amenable to health care.Conclusion The 2000 World Health Report has been cited widely to support claims for the merits of otherwise different health systems. High levels of health attainment in well performing countries may be a consequence of good fortune in geography, and thus dietary habits, and success in the health effects of policies in other sectors. When assessed in terms of achievements that are more explicitly linked to health care, their performance may not be as good.     

Prospective study of clinical,laboratory, and ancillary staff with accidental exposures to blood or body fluids from patients infected with HIV.

In a prospective study of 150 health care workers in the United Kingdom who had been accidentally exposed to the human immunodeficiency virus no evidence of transmission was found. Larger studies in the United States and anecdotal accounts in publications from other countries confirm that the risk of occupational infection is very low. Health care workers must adopt safe procedures at all times, however, to avoid exposure to infection.     

Complementary medicine in Europe.

Complementary or unconventional treatments are used by many doctors and other therapists throughout Europe. The major forms are acupuncture, homoeopathy, manual therapy or manipulation, and phytotherapy or herbal medicine. The relative popularity of therapies differs between countries, but public demand is strong and growing. Regulation of practitioners varies widely: in most countries only registered health professionals may practice, but in the United Kingdom practice is virtually unregulated. Germany and some Scandinavian countries have intermediate systems. Legal reforms are in progress in the Netherlands and the United Kingdom. European institutions are starting to influence the development of complementary medicine. Harmonisation of training and regulation of practitioners is the challenge for the future.     

Is Private Health Care the Answer to the Health Problems of the World's Poor?

Background to the debate: The global burden of disease falls disproportionately upon the world''s low-income countries, which are often struggling with weak health systems. Both the public and private sector deliver health care in these countries, but the appropriate role for each of these sectors in health system strengthening remains controversial. This debate examines whether the private sector should step up its involvement in the health systems of low-income countries.     

Managing future Gulf War Syndromes: international lessons and new models of care

After the 1991 Gulf War, veterans of the conflict from the United States, United Kingdom, Canada, Australia and other nations described chronic idiopathic symptoms that became popularly known as 'Gulf War Syndrome'. Nearly 15 years later, some 250 million dollars in United States medical research has failed to confirm a novel war-related syndrome and controversy over the existence and causes of idiopathic physical symptoms has persisted. Wartime exposures implicated as possible causes of subsequent symptoms include oil well fire smoke, infectious diseases, vaccines, chemical and biological warfare agents, depleted uranium munitions and post-traumatic stress disorder. Recent historical analyses have identified controversial idiopathic symptom syndromes associated with nearly every modern war, suggesting that war typically sets into motion interrelated physical, emotional and fiscal consequences for veterans and for society. We anticipate future controversial war syndromes and maintain that a population-based approach to care can mitigate their impact. This paper delineates essential features of the model, describes its public health and scientific underpinnings and details how several countries are trying to implement it. With troops returning from combat in Afghanistan, Iraq and elsewhere, the model is already getting put to the test.     

Is the United States country zero for the First-World AIDS epidemic?

The incidence for AIDS per hundred thousand is several times higher in the United States than in the rest of the First World. Earlier work by Thompson (1984, 1989a, b, 1990, 1998) indicated that a relatively small proportion of gay males frequenting the bathhouses in the United States, drove AIDS over the epidemiological threshold in the U.S. It is shown that the rate of growth of AIDS is essentially the same for the United States and other First-World countries. An argument is advanced, based on WHO AIDS data, to the effect that it is contact with the pool of infectives in the United States that drives the epidemic in other First-World Countries.     

The practice of health risk assessment in the united states (1975–1995): How the U.S. and other countries can benefit from that experience

The process of quantitatively predicting the likelihood of an adverse response in humans or wildlife due to exposure to one or more chemicals is collectively known as environmental risk assessment. Quantitative risk assessment has been practiced in the United States and Canada for nearly 20 years and is the basis for most environmental and many occupational health regulations in North America. However, only since 1990 has it begun to receive serious consideration in Europe, Australia, Asia, and other regions. This paper reviews the historical evolution of health risk assessment in the United States and the scientific shortcomings in the process that have been introduced due to various regulatory policies. Despite these limitations and the reluctance of some countries to implement risk‐based policies, risk assessment will undoubtedly grow in importance within the international arena as other countries search for an ideal balance between cost and risk reduction. With the emergence of risk analysis as an international tool for understanding environmental issues, several improvements to the risk assessment process are recommended here that the United States and other countries could immediately incorporate into hazard identification, dose‐response and exposure assessments, and risk characterization. Examples of these improvements include use of a weight‐of‐evidence approach, physiologically‐based pharmacokinetic (PB‐PK) modelling, Monte Carlo techniques, and uncertainty analyses. These recommendations could, if coupled with an understanding of the historical experience in the United States, lead to superior environmental risk assessment policies for all countries as they enter the 21st century.     

Solving multicomponent chiral separation challenges using a new SFC tandem column screening tool

A tool for improved tandem column chiral supercritical fluid chromatography (SFC) method development screening was prepared by modification of a commercial analytical SFC instrument with two different software-controllable, six position high-pressure column selection valves, each controlling a bank of five different columns and a pass through line. The resulting instrument, which has the ability to screen 10 different individual columns and 25 different tandem column arrangements, is a useful tool for facilitating the screening of tandem column SFC arrangements for separation of complex mixtures of stereoisomers or other multicomponent mixtures. Strategies for optimal use of the instrument are discussed, and several examples of the use of the instrument in developing tandem SFC methods for resolution of multicomponent mixtures are presented.     

Inversion polymorphism in Drosophila obscura

The inversion polymorphism of Drosophila obscura Fallen, a European species of the obscura group of the subgenus Sophophora, is described. A total of 21 inversions have been recorded; they are located in the five large chromosomes of the species (a dot chromosome is also present) and form 25 gene arrangements present in the species' natural populations. Strains from five different countries were studied. Two of these inversions were found to be pericentric, and the remaining were paracentric. The presence of "hot" points (multibreaks) was noticed. The distribution of the relative lengths of inversions conformed to the Van Valen-Levins distribution, contrary to what happens in D. subobscura. Observations also showed that there is no crossover inhibition between nonoverlapping inversions. The phylogeny of chromosome C was reconstructed; the existence of several arrangements not found was postulated; and the primitive gene arrangement, linking D. obscura to its closely related species was identified, as well as the primitive gene arrangements of the other chromosomes. Photographic maps of the chromosomes of D. obscura are provided here.     

In search of self‐reliance: Problems of marine technology transfer to the developing countries: The case of West Africa

Abstract

This study presents some of the main features of the marine technology transfer process and identifies the key factors determining the particular transfer arrangements available for developing countries of West Africa under different circumstances. Emphasis is made on the fisheries sector because of its economic importance in that region. It examines the principal characteristics of suppliers and recipients of fisheries technology and their prevailing attitudes with regard to transfers. It draws on empirical research covering several international cooperative fisheries arrangements in Mauritania, Guinea‐Bissau, and Guinea‐Conakry that have high potential to function as a technology transfer mechanism from developed to developing coastal countries.     

Resident Assessment Instrument (RAI): a review of international research on the psychometric qualities and effects of implementation in nursing homes

This article is a review of the available literature on psychometric qualities and effects of implementation of the Resident Assessment Instrument (RAI) on quality of care and health of nursing homes residents. The RAI was developed in the USA to assess the needs of nursing home residents. It consists of a comprehensive assessment of the resident (the Minimum Data Set) and 18 protocols (Resident Assessment Protocols) for further analysis of major problem areas. RAI is implemented in nursing homes in the United States, Canada, Japan and several European countries. The interrater reliability was adequate for clinical use in several studies. The validity is good for the appraisal of ADL- and cognitive functions, but moderate for mood and behaviour. In Japan and the United States positive effects were found after implementation of the RAI, especially on the care process. Implementation of RAI has shown to have positive effects on the physical and cognitive function of the resident, but there were negative effects on a number of psychosocial domains. Fourteen Dutch nursing homes have recently implemented the RAI. Studies concerning reliability, validity and effects on quality of care and quality of life are underway.     

Characteristics and Quality of Child Care for Toddlers and Preschoolers

In this article, we use data from the National Institute of Child Health and Human Development (NICHD) Study of Early Child Care (NICHD Early Child Care Research Network, 1996, 1997, 1998, 1999) to answer 3 questions. The first question is: What structural features and caregiver characteristics predict more positive caregiver behavior in child care for 1- to 3-year-old children? Positive caregiving was assessed in 5 types of care (centers, child-care homes, and care provided by in-home sitters, grandparents, and fathers) when children in the NICHD study were 15, 24, and 36 months of age (Ns = 612, 630, and 674). Across ages and types of care, positive caregiving was more likely when child-adult ratios and group sizes were smaller, caregivers were more educated, held more child-centered beliefs about childrearing, and had more experience in child care, and environments were safer and more stimulating. The second question is: What differences in caregiving are associated with the type of child care and the child's age? The highest level of positive caregiving was provided by in-home caregivers, including fathers and grandparents, caring for only 1 child, closely followed by home-based arrangements with relatively few children per adult. The least positive caregiving was found in center-based care with higher ratios of children to adults. By 36 months of age, the significance of child-adult ratio decreased, and in-home arrangements became less positive. The third question is: What is the overall quality of child care for 1- to 3-year-olds in the United States? Observed positive caregiving was determined to be "very uncharacteristic" for 6% of the children in the NICHD sample, "somewhat uncharacteristic" for 51%, "somewhat characteristic" for 32%, and "highly characteristic" for 12%. An extrapolation to the quality of care in the United States was derived by applying NICHD observational parameters, stratified by maternal education, child age, and care type, to the distribution of American families documented in the National Household Education Survey (Hofferth, Shauman, Henke, & West, 1998). Positive caregiving was extrapolated to be "very uncharacteristic" for 8% of children in the United States ages 1 to 3 years, "somewhat uncharacteristic" for 53%, "somewhat characteristic" for 30%, and "highly characteristic" for 9%.     

Late Diagnosis and Entry to Care after Diagnosis of Human Immunodeficiency Virus Infection: A Country Comparison

Background

Testing for HIV infection and entry to care are the first steps in the continuum of care that benefit individual health and may reduce onward transmission of HIV. We determined the percentage of people with HIV who were diagnosed late and the percentage linked into care overall and by demographic and risk characteristics by country.

Methods

Data were analyzed from national HIV surveillance systems. Six countries, where available, provided data on two late diagnosis indicators (AIDS diagnosis within 3 months of HIV diagnosis, and AIDS diagnosis within 12 months before HIV diagnosis) and linkage to care (≥1 CD4 or viral load test result within 3 months of HIV diagnosis) for people diagnosed with HIV in 2009 or 2010 (most recent year data were available).

Principal Findings

The percentage of people presenting with late stage disease at HIV diagnosis varied by country, overall with a range from 28.7% (United States) to 8.8% (Canada), and by transmission categories. The percentage of people diagnosed with AIDS who had their initial HIV diagnosis within 12 months before AIDS diagnosis varied little among countries, except the percentages were somewhat lower in Spain and the United States. Overall, the majority of people diagnosed with HIV were linked to HIV care within 3 months of diagnosis (more than 70%), but varied by age and transmission category.

Conclusions

Differences in patterns of late presentation at HIV diagnosis among countries may reflect differences in screening practices by providers, public health agencies, and people with HIV. The percentage of people who received assessments of immune status and viral load within 3 months of diagnosis was generally high.     

Provision of facilities for secondary transport of seriously ill patients in the United Kingdom

A survey by questionnaire of 280 hospitals with general intensive care units was carried out to find out what facilities were provided for secondary transport of seriously ill patients in the United Kingdom. Replies were received from 181 units. Extrapolating from the survey data showed that about 10 000 patients were transported each year, although many units transferred only a few patients. An appreciable minority of units reported that facilities for secondary transport were inadequate and many were obliged to send inexperienced medical staff with patients. Almost half of the respondents thought that arrangements for transfer were unsatisfactory, but only a tenth said that they delayed or refused transfer for this reason. This undoubtedly reflects a policy of “making do” despite inadequate resources.We believe that these results support the concept of regional transport services, where each major unit would be adequately equipped and staffed and unnecessary duplication of resources avoided.     

US IRBs confronting research in the developing world

Increasingly, US‐sponsored research is carried out in developing countries, but how US Institutional Review Boards (IRBs) approach the challenges they then face is unclear. METHODS: I conducted in‐depth interviews of about 2 hours each, with 46 IRB chairs, directors, administrators and members. I contacted the leadership of 60 IRBs in the United States (US) (every fourth one in the list of the top 240 institutions by National Institutes of Health (NIH) funding), and interviewed IRB leaders from 34 (55%). RESULTS: US IRBs face ethical and logistical challenges in interpreting and applying principles and regulations in developing countries, given economic and health disparities, and limited contextual knowledge. These IRBs perceive wide variations in developing world IRBs/RECs' quality, resources and training; and health systems in some countries may have long‐standing practices of corruption. These US IRBs often know little of local contexts, regulations and standards of care, and struggle with understandings of other cultures' differing views of autonomy, and risks and benefits of daily life. US IRBs thus face difficult decisions, including how to interpret principles, how much to pay subjects and how much sustainability to require from researchers. IRB responses and solutions include trying to maintain higher standards for developing world research, obtain cultural expertise, build IRB infrastructure abroad, communicate with foreign IRBs, and ‘negotiate’ for maximum benefits for participants and fearing ‘worst‐case scenarios’. CONCLUSIONS: US and foreign IRBs confront a series of tensions and dilemmas in reviewing developing world research. These data have important implications for increased education of IRBs/RECs and researchers in the US and abroad, and for research and practice.     

Key issues in managed competition.

All managed competition proposals for health system reform must confront several key issues. The premiums paid to health care purchasing cooperatives will need to be subsidized for those who cannot pay full fare; the amount and sources of the subsidies are controversial political issues. The payments passed on by purchasing cooperatives to health plans must be risk adjusted to account for differences in the health care needs of their enrolled populations. This is essential to create a level playing field for competition and to eliminate incentives for plans to use risk assessment for attracting enrollees. The data and methods needed for risk adjustment, however, are not adequate at present. The Clinton Administration''s plan to limit expenditure increases raises a host of thorny issues. Maintaining quality of care will require health plan quality report cards to be supplemented by external quality assurance systems. Assuring quality will be particularly problematic for traditional indemnity plans. The structure and governance of the system, administration simplification, and other issues need to be addressed. The size and voluntariness of the purchasing cooperatives greatly influence all of these considerations. Physicians should inform their political representatives on how these issues should be resolved as compromise bills are drafted by the United States Congress this year.     

Structural diversity and isomorphism of hydrogen-bonded base interactions in nucleic acids

The wide structural diversity of RNA results in part from the diversity of non-Watson-Crick interactions between bases. To examine the repertoire of possible hydrogen bond interactions among bases, we computed databases of base-pairs and base-triples by systematically matching all possible hydrogen-bond donors and acceptors between bases and evaluating the geometries of each planar configuration. For base-pairs, we find 53 arrangements having at least two hydrogen bonds, including 23 pairs with protonated bases that have not previously been modeled. A comparison with experimentally observed base-pairs reveals an unexpected G:U pair recently observed in the ribosome. For base-triples, we find 840 arrangements in which the three bases are constrained by a total of at least three hydrogen bonds. Base-triples in particular exhibit a wide range of structural diversity, suggesting how compact or elongated nucleic acid structures may be constructed using different hydrogen-bonding patterns. Base-pair and base-triple conformations were systematically compared to identify structurally isomorphic combinations, and the experimentally observed arrangements within double and triple helices are among the most isomorphic. Unexpectedly, however, other combinations in the database are even more isomorphic, including several in which all-purine arrangements overlap with all-pyrimidine arrangements. These studies highlight some of the combinatoric and geometric versatility of base interactions and help provide a framework for analyzing and modeling isomorphic interactions and potentially for designing novel nucleic acid structures.     

The evolution of female sexuality and mate selection in humans

Understanding female sexuality and mate choice is central to evolutionary scenarios of human social systems. Studies of female sexuality conducted by sex researchers in the United States since 1938 indicate that human females in general are concerned with their sexual well-being and are capable of sexual response parallel to that of males. Across cultures in general and in western societies in particular, females engage in extramarital affairs regularly, regardless of punishment by males or social disapproval. Families are usually concerned with marriage arrangements only insofar as those arrangements are economically or politically advantageous, but females most often have a voice in arranged marriages. Extended families also concentrate on a couple’s future reproduction rather than on sexual exclusivity. Although marriage for females is often compromised by male or family reproductive interests (which may not in fact differ from female interests), females appear to exercise their sexuality with more freedom than has previously been suggested. Notions of human females as pawns in the male reproductive game, or as traders of sex for male services, should be dispelled.