The Ethics of Medical Practitioner Migration From Low-Resourced Countries to the Developed World: A Call for Action by Health Systems and Individual Doctors

Medical migration appears to be an increasing global phenomenon, with complex contributing factors. Although it is acknowledged that such movements are inevitable, given the current globalized economy, the movement of health professionals from their country of training raises questions about equity of access and quality of care. Concerns arise if migration occurs from low- and middle-income countries (LMICs) to high-income countries (HICs). The actions of HICs receiving medical practitioners from LMICs are examined through the global justice theories of John Rawls and Immanuel Kant. These theories were initially proposed by Pogge (1988) and Tan (1997) and, in this work, are extended to the issue of medical migration. Global justice theories propose that instead of looking at health needs and workforce issues within their national boundaries, HICs should be guided by principles of justice relevant to the needs of health systems on a global scale. Issues of individual justice are also considered within the framework of rights and social responsibilities of individual medical practitioners. Local and international policy changes are suggested based on both global justice theories and the ideals of individual justice.     

Mode of effective connectivity within a putative neural network differentiates moral cognitions related to care and justice ethics

Background

Moral sensitivity refers to the interpretive awareness of moral conflict and can be justice or care oriented. Justice ethics is associated primarily with human rights and the application of moral rules, whereas care ethics is related to human needs and a situational approach involving social emotions. Among the core brain regions involved in moral issue processing are: medial prefrontal cortex, anterior (ACC) and posterior (PCC) cingulate cortex, posterior superior temporal sulcus (pSTS), insula and amygdala. This study sought to inform the long standing debate of whether care and justice moral ethics represent one or two different forms of cognition.

Methodology/Principal Findings

Model-free and model-based connectivity analysis were used to identify functional neural networks underlying care and justice ethics for a moral sensitivity task. In addition to modest differences in patterns of associated neural activity, distinct modes of functional and effective connectivity were observed for moral sensitivity for care and justice issues that were modulated by individual variation in moral ability.

Conclusions/Significance

These results support a neurobiological differentiation between care and justice ethics and suggest that human moral behavior reflects the outcome of integrating opposing rule-based, self-other perspectives, and emotional responses.     

A systematic classification of Plasmodium falciparum P-loop NTPases: structural and functional correlation

Background

Angola's malaria case-management policy recommends treatment with artemether-lumefantrine (AL). In 2006, AL implementation began in Huambo Province, which involved training health workers (HWs), supervision, delivering AL to health facilities, and improving malaria testing with microscopy and rapid diagnostic tests (RDTs). Implementation was complicated by a policy that was sometimes ambiguous.

Methods

Fourteen months after implementation began, a cross-sectional survey was conducted in 33 outpatient facilities in Huambo Province to assess their readiness to manage malaria and the quality of malaria case-management for patients of all ages. Consultations were observed, patients were interviewed and re-examined, and HWs were interviewed.

Results

Ninety-three HWs and 177 consultations were evaluated, although many sampled consultations were missed. All facilities had AL in-stock and at least one HW trained to use AL and RDTs. However, anti-malarial stock-outs in the previous three months were common, clinical supervision was infrequent, and HWs had important knowledge gaps. Except for fever history, clinical assessments were often incomplete. Although testing was recommended for all patients with suspected malaria, only 30.7% of such patients were tested. Correct testing was significantly associated with caseloads < 25 patients/day (odds ratio: 18.4; p < 0.0001) and elevated patient temperature (odds ratio: 2.5 per 1°C increase; p = 0.007). Testing was more common among AL-trained HWs, but the association was borderline significant (p = 0.072). When the malaria test was negative, HWs often diagnosed patients with malaria (57.8%) and prescribed anti-malarials (60.0%). Sixty-six percent of malaria-related diagnoses were correct, 20.1% were minor errors, and 13.9% were major (potentially life-threatening) errors. Only 49.0% of malaria treatments were correct, 5.4% were minor errors, and 45.6% were major errors. HWs almost always dosed AL correctly and gave accurate dosing instructions to patients; however, other aspects of counseling needed improvement.

Conclusion

By late-2007, substantial progress had been made to implement the malaria case-management policy in a setting with weak infrastructure. However, policy ambiguities, under-use of malaria testing, and distrust of negative test results led to many incorrect malaria diagnoses and treatments. In 2009, Angola published a policy that clarified many issues. As problems identified in this survey are not unique to Angola, better strategies for improving HW performance are urgently needed.     

Prospects, achievements, challenges and opportunities for scaling-up malaria chemoprevention in pregnancy in Tanzania: the perspective of national level officers

Objectives

To describe the prospects, achievements, challenges and opportunities for implementing intermittent preventive treatment for malaria in pregnancy (IPTp) in Tanzania in light of national antenatal care (ANC) guidelines and ability of service providers to comply with them.

Methods

In-depth interviews were made with national level malaria control officers in 2006 and 2007. Data was analysed manually using a qualitative content analysis approach.

Results

IPTp has been under implementation countrywide since 2001 and the 2005 evaluation report showed increased coverage of women taking two doses of IPTp from 29% to 65% between 2001 and 2007. This achievement was acknowledged, however, several challenges were noted including (i) the national antenatal care (ANC) guidelines emphasizing two IPTp doses during a woman's pregnancy, while other agencies operating at district level were recommending three doses, this confuses frontline health workers (HWs); (ii) focused ANC guidelines have been revised, but printing and distribution to districts has often been delayed; (iii) reports from district management teams demonstrate constraints related to women's late booking, understaffing, inadequate skills of most HWs and their poor motivation. Other problems were unreliable supply of free SP at private clinics, clean and safe water shortage at many government ANC clinics limiting direct observation treatment and occasionally pregnant women asked to pay for ANC services. Finally, supervision of peripheral health facilities has been inadequate and national guidelines on district budgeting for health services have been inflexible. IPTp coverage is generally low partly because IPTp is not systematically enforced like programmes on immunization, tuberculosis, leprosy and other infectious diseases. Necessary concerted efforts towards fostering uptake and coverage of two IPTp doses were emphasized by the national level officers, who called for further action including operational health systems research to understand challenges and suggest ways forward for effective implementation and high coverage of IPTp.

Conclusion

The benefit of IPTp is appreciated by national level officers who are encouraged by trends in the coverage of IPTp doses. However, their appeal for concerted efforts towards IPTp scaling-up through rectifying the systemic constraints and operational research is important and supported by suggestions by other authors.     

Social justice now for an equitable tomorrow: Reflections from the Consortium of Universities for Global Health Conference 2022

PLOS Medicine editors Beryne Odeny and Callam Davidson report from the Consortium of Universities for Global Health conference.

“Healthy People, Healthy Planet & Social Justice,” was the theme of the second virtual Consortium of Universities for Global Health (CUGH) 2022 conference, held from March 28 to April 1, 2022. In the face of escalating global health and security challenges, this bold theme and the associated agenda (https://cugh.confex.com/cugh/2022/meetingapp.cgi) were welcomed with great anticipation by thousands of stakeholders from 135 countries across the globe. As adeptly put by Dr. Peter A Singer, Special Advisor to the Director General of WHO, the fundamental question at the heart of social justice is simple: “Do we value every human life equally?”. In answering this question, we must acknowledge that what we now consider to be the discipline of global health is in fact anchored by deep and tortuous colonialist roots that continue to bear the fruits of injustice to this day. Over the course of the conference, speakers conceptualized a human rights framework for rethinking global health. This perspective piece presents a curated synopsis of the main CUGH conference and preceding satellite sessions.The conference commenced with a call from Thuli N. Madonsela, Former Public Protector of South Africa, to uphold the sacrosanct respect for human life given the interconnectedness of humanity’s existence on our shared planet. Her insights on social justice as interpreted within the framework of Ubuntu philosophy brought a breath of fresh air to the debate on neo-colonialism. Thuli’s keynote concluded with an optimistic outlook: “Investing in justice today is like throwing a javelin into the future, one that will become the guardrail for sustainable development.”Globalization has brought tremendous advances in industry, commerce and trade, and eye-watering financial gains for some in both high income countries (HICs) and low- and middle-income countries (LMICs). Alongside these gains, global openness has contributed to the swift spread of the most formidable maladies of the present day, not least of which are the dual epidemics of COVID-19 and non-communicable diseases (NCDs), climate change and global warming, global corruption, conflict and wars, and ensuing humanitarian crises [1,2]. Pervasive health inequities which compound the toll of these calamities are a stark reminder of how global health has failed the most vulnerable. The COVID-19 pandemic continues to be the litmus test against which our truest values are tested. “If we can’t handle COVID-19, what does it mean about our approach to tackling climate change?”–this was a germane question from a speaker reflecting on inequitable vaccine distribution [3,4].Comparable to other health sectors awash with global funding, the global COVID-19 vaccine delivery effort has created fertile ground for corruption, due to a toxic combination of high commodity demand, unprecedented resource allocation, and perennially weak health systems with fragmented supply chains [5,6]. It has been shown that corruption can fuel vaccine hesitancy by creating suspicion and mistrust in science and government. This has been witnessed in some countries in Asia, despite commendable levels of vaccine coverage. In contrast, the long-standing National Immunization Program in Brazil created a culture of vaccination and helped minimize hesitancy (despite the influence of the country’s present leadership) [7]. Other factors beyond vaccine-specific factors include contextual, individual, and group influences that can inform hesitancy; these additional factors can be exploited to undergird vaccine efforts–barbers delivering vaccines, and outreach efforts by Buddhist monks, for example.Beyond the COVID-19 pandemic is the rise of Commercial Determinants of Health (CDoH). CDoH refer to approaches used by corporate sectors to promote products that are detrimental to health [8]. These products include processed foods and drinks, alcohol, and tobacco–factors that are fueling the rising burden of NCDs–more so in LMICs and among the socially disadvantaged in HICs, who bear the largest brunt of related mortality [9]. Unrestrained access to and use of harmful products such as heavy metals and asbestos, pose a threat to poor and vulnerable communities in proximity to mines and industries. These injustices are propagated by powerful corporates that stealthily evade restrictive public health policies to protect their profit margins [10]. A downstream impact of the surge of NCDs in LMICs, is the intense suffering among those dying from terminal illnesses due to the unethical lack of access to palliative care. There is a dearth of palliative resources, including trained health providers, particularly in low resource contexts such as fragile and conflict settings, and among ethnically diverse groups in HICs [11].The COVID-19 and NCDs conundrums are accompanied by another global health woe–namely the paternalist nature of HIC support for LMICs. Paternalistic support presents in the form of tied aid and technical support which have been used to determine the seat of power, with regard to who holds the money, who generates knowledge, who practices, who publishes, and, ultimately, who thrives in the global health ecosystem. This is demonstrated by institutionalized power asymmetries across funding, academic research, and global health priority setting, which disproportionately favor researchers from HICs at the expense of those from LMICs. To date, less priority has been accorded to health issues of concern, beyond infectious diseases, in the poorest parts of the world such as cancer among other NCDs. Conditionality and increased vertical funding have been shown to limit LMICs’ autonomy to finance their primary health challenges and are linked to reduced government health expenditure with commensurate increases in out-of-pocket/ household expenditure. The health sector is known to be highly corrupt as well as it is well-resourced (accounting of 10% of overall GDP spending) [12]. The lethal mixture of politics, power, and corruption in LMICs is a brewing pot for injustice as it perpetuates a vicious cycle of poverty and disease among the most vulnerable.Tackling corruption at international and national levels requires multisectoral attention to wider issues of global security, giving people a voice and providing the backing of legal frameworks, to demand accountability and transparency without fear of retaliation. Empowering global health stakeholders and civil societies to engage corporate and political sectors in planetary and global health discourse is an essential tool for fostering health equity, environmental justice, and social justice in business paradigms [2,8]. In this way, leaders can be enlightened and held accountable for performance of equity-based indicators e.g., proportion of specific global goods going to LMICs. Within the global health fraternity, decolonizing global health through inclusive partnerships is necessary to remove longstanding hierarchies in decisional spaces, and shift the balance of power so that more indigenous community actors can define their problems and find relevant solutions [13]. Inspirational stories of the national COVID-19 taskforce in Uganda demonstrate how active communities can promote vaccine uptake [14]. Scaling up community-led integrated health care efforts can extend beyond the pandemic and may even accelerate realization of the UN Sustainable Development Goals. Sustainable funding streams, training, and capacity development to create a robust workforce and enabling environments to host research in LMICs should be at the center of the global health agenda. Other considerations would include leveraging integrated digital and information systems that foster inclusion of marginalized populations in program planning and service delivery, and in so doing uphold equity and inclusion in health system strengthening globally.Decolonizing global health and upholding social justice will be crucial to containing the impending NCD tsunami, pandemics beyond COVID-19, and climate change. However, throwing off the pernicious colonial legacy presents one of the biggest challenges in global health. No one is exempt from the experience of neo-colonialism regardless of location; thus, all hands are needed on deck to disrupt and resist its existence. Dr. Madhukar Pai of McGill University in Montreal, Canada, and colleagues emphasized that allyship is invaluable to this end–it seeks to identify what the most privileged can do to elevate the voices of those suffocating under the weight of injustice [15]. Beyond speaking up against inequities, meaningful allyship needs disruptive change, sometimes as far as ceding positions of power. The global health community is at a crossroads, a defining moment since its existence, and needs to decide which way to proceed–whether to remain passive to entrenched notions of polarization or to embrace a disruptive paradigm shift that defends social justice and secures sustainable development for all. The question remains–are we ready to shift?     

The Politics and Regulation of Anger in Urban China

Negative emotions such as anger, and community responses to their expression are culturally and politically conditioned, including by dominant medical discourse on anger’s somatic and psychic effects. In this article I examine local genres of anger expression in Beijing, China, particularly among marginalized workers, and address culturally specific responses to them. Through majie (rant), xiangpi ren (silenced rage), and nande hutu (muddledness as a more difficult kind of smartness), workers strategically employ anger to seek redress for injustices and legitimate their moral indignation while challenging official psychotherapeutic interventions. Those who seek to regulate anger, mostly psychosocial workers acting as arm’s-length agents of the state, use mixed methods that draw on Western psychotherapy and indigenous psychological resources to frame, medicalize or appease workers’ anger in the name of health and social stability. I demonstrate how the two processes—anger expression and responses to it—create tensions and result in an ambiguous and multivalent social terrain which Chinese subjects must negotiate and which the state attempts to govern. I argue that the ambivalence and multi-valence of anger expressions and state-sponsored reactions to them render this emotion both subversive vis-à-vis power and subject to manipulations that maintain social order.     

GENETIC TIES: ARE THEY MORALLY BINDING?

Does genetic relatedness define who is a mother or father and who incurs obligations towards or entitlements over children? While once the answer to this question may have been obvious, advances in reproductive technologies have complicated our understanding of what makes a parent. In a recent publication Bayne and Kolers argue for a pluralistic account of parenthood on the basis that genetic derivation, gestation, extended custody and sometimes intention to parent are sufficient (but not necessary) grounds for parenthood. ¹ 1 Bayne, T. & Kolers, A. . Toward A Pluralist Account of Parenthood . Bioethics 2003 ; 17 : 221 – 242 .
Bayne and Kolers further suggest that definitions of parenthood are underpinned by the assumption that ‘being causally implicated in the creation of a child is the key basis for being its parent’. ² 2 Ibid. p. 241.
This paper examines the claim that genetic relatedness is sufficient grounds for parenthood based on a causal connection between genetic parents and their offspring. I argue that parental obligations are about moral responsibility and not causal responsibility because we are not morally accountable for every consequence to which we causally contribute. My account includes the conditions generally held to apply to moral responsibility, i.e. freedom and foreseeability. I argue that parental responsibilities are generated whenever the birth of a child is a reasonably foreseeable consequence of voluntary actions. I consider the implications of this account for third parties involved in reproductive technologies. I argue that under some conditions the obligations generated by freely and foreseeably causing a child to exist can be justifiably transferred to others.     

Female sex worker social networks and STI/HIV prevention in South China

Background

Reducing harm associated with selling and purchasing sex is an important public health priority in China, yet there are few examples of sustainable, successful programs to promote sexual health among female sex workers. The limited civil society and scope of nongovernmental organizations circumscribe the local capacity of female sex workers to collectively organize, advocate for their rights, and implement STI/HIV prevention programs. The purpose of this study was to examine social networks among low-income female sex workers in South China to determine their potential for sexual health promotion.

Methods/Principal Findings

Semi-structured interviews with 34 low-income female sex workers and 28 health outreach members were used to examine how social relationships affected condom use and negotiation, STI/HIV testing and health-seeking behaviors, and dealing with violent clients. These data suggested that sex worker''s laoxiang (hometown social connections) were more powerful than relationships between women selling sex at the same venue in establishing the terms and risk of commercial sex. Female sex workers from the same hometown often migrated to the city with their laoxiang and these social connections fulfilled many of the functions of nongovernmental organizations, including collective mobilization, condom promotion, violence mitigation, and promotion of health-seeking behaviors. Outreach members observed that sex workers accompanied by their laoxiang were often more willing to accept STI/HIV testing and trust local sexual health services.

Conclusions/Significance

Organizing STI/HIV prevention services around an explicitly defined laoxiang social network may provide a strong foundation for sex worker health programs. Further research on dyadic interpersonal relationships between female sex workers, group dynamics and norm establishment, and the social network characteristics are needed.     

Next-generation sequencing analyses of the emergence and maintenance of mutations in CTL epitopes in HIV controllers with differential viremia control

Background

Despite the low level of viral replication in HIV controllers (HICs), studies have reported viral mutations related to escape from cytotoxic T-lymphocyte (CTL) response in HIV-1 plasma sequences. Thus, evaluating the dynamics of the emergence of CTL-escape mutants in HICs reservoirs is important for understanding viremia control. To analyze the HIV-1 mutational profile and dynamics of CTL-escape mutants in HICs, we selected 11 long-term non-progressor individuals and divided them into the following groups: (1) viremic controllers (VCs; n?=?5) and (2) elite controllers (ECs; n?=?6). For each individual, we used HIV-1 proviral DNA from PBMCs related to earliest (V_E) and latest (V_L) visits to obtain gag and nef sequences using the Illumina HiSeq system. The consensus of each mapped gene was used to assess viral divergence, and next-generation sequencing data were employed to identify SNPs and variations within and flanking CTL epitopes.

Results

Divergence analysis showed higher values for nef compared to gag among the HICs. EC and VC groups showed similar divergence rates for both genes. Analysis of the number of SNPs showed that VCs present more variability in both genes. Synonymous/non-synonymous mutation ratios were?<?1 for gag among ECs and for nef among ECs and VCs, exhibiting a predominance of non-synonymous mutations. Such mutations were observed in regions encoding CTL-restricted epitopes in all individuals. All ECs presented non-synonymous mutations in CTL epitopes but generally at low frequency (<?1%); all VCs showed a high number of mutations, with significant frequency changes between V_E and V_L visits. A higher frequency of internal mutations was observed for gag epitopes, with significant changes across visits compared to Nef epitopes, indicating a pattern associated with differential genetic pressure.

Conclusions

The high genetic conservation of HIV-1 gag and nef among ECs indicates that the higher level of viremia control restricts the evolution of both genes. Although viral replication levels in HICs are low or undetectable, all individuals exhibited CTL epitope mutations in proviral gag and nef variants, indicating that potential CTL escape mutants are present in HIC reservoirs and that situations leading to a disequilibrium of the host-virus relationship can result in the spread of CTL-escape variants.

     

Seasonal Influenza Vaccination amongst Medical Students: A Social Network Analysis Based on a Cross-Sectional Study

Introduction

The Chief Medical Officer for England recommends that healthcare workers have a seasonal influenza vaccination in an attempt to protect both patients and NHS staff. Despite this, many healthcare workers do not have a seasonal influenza vaccination. Social network analysis is a well-established research approach that looks at individuals in the context of their social connections. We examine the effects of social networks on influenza vaccination decision and disease dynamics.

Methods

We used a social network analysis approach to look at vaccination distribution within the network of the Lancaster Medical School students and combined these data with the students’ beliefs about vaccination behaviours. We then developed a model which simulated influenza outbreaks to study the effects of preferentially vaccinating individuals within this network.

Results

Of the 253 eligible students, 217 (86%) provided relational data, and 65% of responders had received a seasonal influenza vaccination. Students who were vaccinated were more likely to think other medical students were vaccinated. However, there was no clustering of vaccinated individuals within the medical student social network. The influenza simulation model demonstrated that vaccination of well-connected individuals may have a disproportional effect on disease dynamics.

Conclusions

This medical student population exhibited vaccination coverage levels similar to those seen in other healthcare groups but below recommendations. However, in this population, a lack of vaccination clustering might provide natural protection from influenza outbreaks. An individual student’s perception of the vaccination coverage amongst their peers appears to correlate with their own decision to vaccinate, but the directionality of this relationship is not clear. When looking at the spread of disease within a population it is important to include social structures alongside vaccination data. Social networks influence disease epidemiology and vaccination campaigns designed with information from social networks could be a future target for policy makers.     

Interrelation of Sport Participation,Physical Activity,Social Capital and Mental Health in Disadvantaged Communities: A SEM-Analysis

Background

The Health through Sport conceptual model links sport participation with physical, social and psychological outcomes and stresses the need for more understanding between these outcomes. The present study aims to uncover how sport participation, physical activity, social capital and mental health are interrelated by examining these outcomes in one model.

Methods

A cross-sectional survey was conducted in nine disadvantaged communities in Antwerp (Belgium). Two hundred adults (aged 18–56) per community were randomly selected and visited at home to fill out a questionnaire on socio-demographics, sport participation, physical activity, social capital and mental health. A sample of 414 adults participated in the study.

Results

Structural Equation Modeling analysis showed that sport participation (β = .095) and not total physical activity (β = .027) was associated with better mental health. No association was found between sport participation and community social capital (β = .009) or individual social capital (β = .045). Furthermore, only community social capital was linked with physical activity (β = .114), individual social capital was not (β = -.013). In contrast, only individual social capital was directly associated with mental health (β = .152), community social capital was not (β = .070).

Conclusion

This study emphasizes the importance of sport participation and individual social capital to improve mental health in disadvantaged communities. It further gives a unique insight into the functionalities of how sport participation, physical activity, social capital and mental health are interrelated. Implications for policy are that cross-sector initiatives between the sport, social and health sector need to be supported as their outcomes are directly linked to one another.     

Social life cycle assessment of first and second-generation ethanol production technologies in Brazil

Purpose

The main goal of this study is to suggest quantitative social metrics to evaluate different sugarcane biorefinery systems in Brazil by exploring a novel hybrid approach integrating social life cycle assessment and input-output analysis.

Methods

Social life cycle assessment is the main methodology for evaluating social aspects based on a life-cycle approach. Using this framework, a hybrid model integrating social life cycle assessment and input-output analysis was introduced to evaluate different social effects of biorefinery scenarios considering workers as the stakeholder category. Job creation, occupational accidents, wage profile, education profile, and gender profile were selected as the main inventory indicators. A case study of three scenarios considering variations in agricultural and industrial technologies (including sugarcane straw recovery and second-generation ethanol production, for instance) was carried out for evaluating present first-generation (1G-basic, 1G-optimized) and future first- and second-generation ethanol production (1G2G).

Results and discussion

The 1G-basic scenario leads to higher job creation levels over the supply chain mainly because of the influence of agricultural stage whose workers are mostly employed in sugarcane manual operations. On the other hand, 1G-optimized and 1G2G present supply chains are more reliant on the manufacturing, trade, and services sectors whose workers are associated with a lower level of occupational accidents, higher average wages, higher education level, and more participation of women in the work force.

Conclusions

The use of a novel hybrid approach integrating social life cycle assessment (SLCA) and input-output analysis (IOA) was useful to quantitatively distinguish the social effects over different present and future sugarcane biorefinery supply chains. As a consequence, this approach is very useful to support decision-making processes aiming to improve the sustainability of sugarcane biorefineries taking social aspects into account.

     

Pandemic management and developing world bioethics: bird flu in West Bengal

This paper examines the case of a recent H5N1virus (avian influenza) outbreak in West Bengal, an eastern state of India, and argues that poorly executed pandemic management may be viewed as a moral lapse. It further argues that pandemic management initiatives are intimately related to the concept of health as a social 'good' and to the moral responsibility of protection from foreseeable social harm from an infectious disease. The initiatives, therefore, have to be guided by special moral obligations towards biorisk reduction, obligations which remain unfulfilled when a public body entrusted with the responsibility fails to manage satisfactorily the prevention and control of the infection. The overall conclusion is that pandemic management has a moral dimension. The gravity of the threat that fatal infectious diseases pose for public health creates special moral obligations for public bodies in pandemic situations. However, the paper views the West Bengal case as a learning opportunity, and considers the lapses cited as challenges that better, more effectively conducted pandemic management can prepare for. It is hoped that this paper will provoke constructive bioethical deliberations, particularly pertinent to the developing world, on how to ensure that the obligations towards health are fulfilled ethically and more effectively.     

政府补偿与监管机制改革对公立医疗机构公共卫生及公益性服务的影响分析

目的 分析上海市闵行区政府补偿与监管机制改革对公立医疗卫生机构的公共卫生和公益性服务状况的影响。方法 收集2008—2012年闵行区12家社区卫生服务中心的公共卫生服务和公益性服务,以及3家综合性医院的公益性服务的指标数据,并将部分指标与上海市同期的平均水平进行比较分析。结果 改革后,闵行区社区卫生服务中心公共卫生服务能力显著提升,服务质量保持在较高水平,服务效率也有所改进,公共卫生服务数量明显优于上海市平均水平。结论 闵行区政府补偿与监管机制改革对公立医疗卫生机构的公共卫生和公益性服务的提供有积极的影响,但未来需要关注对公益性服务的激励和补偿,尤其是补偿机制和标准更为明确和细化。     

Rights and Responsibilities of Tuberculosis Patients,and the Global Fund: A Qualitative Study

Background

Implementation of the Charter to protect patients’ rights is an important criterion to achieve patient-centered approach and receive financial support from the Global Fund. Our study aims to explore the knowledge of tuberculosis (TB) patients about their rights and responsibilities at the Chest Disease Unit of the Bahawal Victoria Hospital, Bahawalpur, Pakistan.

Methods

This was a qualitative study. The data from purposefully selected TB patients was collected by in-depth interviews. Eligibility criteria included confirmed diagnosis of TB and enrollment in the TB program. A pilot tested interview protocol was based upon the objectives of the study, and was used uniformly in each interview to maintain the consistency. The sample size was limited by applying the saturation criteria. All interviews were audiotaped and transcribed verbatim. Inductive thematic content analysis was applied to analyze the data and draw conclusions.

Results

Out of the total 16 patients, four were female, and seven were illiterate. Eight patients were known cases of multi-drug resistant TB. Analysis of the data yielded seven themes; tuberculosis care services, moral support and stigmatization, dignity and privacy, complaints, fear of losing job, information sharing and compliance to the treatment plan, and contribution to eradicate TB. First five represented the rights section while latter two were related to the responsibilities section of the Charter.

Conclusion

Discriminatory access to TB care services and the right to privacy were two major concerns identified in this study. However, the respondents recognized their responsibilities as a TB patient. To ensure uninterrupted investment from the Global Fund, there is a need to implement fair TB care policies which support human rights-based approach.     

Persons With AIDS in prison: A critical and phenomenological approach to suffering

Conclusions There are many structural implications which help illuminate the bureaucratic and coercive nature of the contemporary criminal justice system, especially as it deals with IV drug users who may also be infected with the AIDS virus. The link between criminal justice and achieving social order is clear, and the current war on drugs is reminiscent of earlier criticisms of social control. Foucault, for instance, argued that formal control of the mad can be interpreted as a governmental response to the growing demands for order, responsibility and restraint.⁵¹ The nation's ongoing law enforcement campaign, as is the case with other moral and political crusades, focuses primarily on those who are unpopular and unable adequately to defend themselves, especially the poverty-stricken, urban IV drug users. The war on drugs further represents an ideological campaign that utilizes law enforcement to attack many forms of social conduct which are perhaps better addressed as health issues (i.e., substance abuse and AIDS). Considering this, the criminal justice system functions, therefore as the main vehicle by which the demands for order, responsibility and restraint are reinforced.The emergence of AIDS in prison, which has been complicated by inadequate health care, demonstrates an ironic twist in the history of corrections and the demand for social order. In his analysis of the development of prisons and the early notions of rehabilitation, Rothman pointed out that traditional assumptions about criminality and punishment were couched in strict medical reasoning. That is, human improvement was possible if a criminal's unfortunate upbringing could be overcome in an antiseptic and healthy setting; prisons soon were constructed to serve as these healthy environments.⁵² However, considering the numerous problems in delivering adequate health care to PWAs, the so-called liberal and humane approach to incarceration is undermined by a bureaucratized prison system which has difficulty attending to inmates with special needs.The prison system, as a formal organization, is guided by a rational, and seemingly detached, plan to deal with the huge number of inmates. Yet, in processing thousands of inmates through state and federal prisons, the ideals and principles of corrections are overshadowed by the organizational needs of the system. These bureaucratic priorities, which emphasize processing and warehousing inmates instead of attending to those with special needs, have created several unintentional consequences. Because over-bureaucratized prison systems are generally self-defeating (in terms of the failure to apply corrective principles), prisons have become unreasonably painful for most inmates, especially those suffering from AIDS.My purpose in this essay was to explore the form of suffering endured by PWAs in prison by way of phenomenological assumptions and critical insights. However, at this point it is important to broaden the relevance of this discussion to include all inmates inflicted with terminal disease. The central idea of this analysis was based on the perspective that time is fundamentally altered for prisoners because their incarceration is marked by a temporary state of futurelessness. Prison life, in general, is often meaningless because the inmates experience emotional strains which emerge from the perception of not having a future. Moreover, the form of suffering sustained by PWAs and other inmates with terminal diseases is clearly more pronounced because they are forced to face a permanent state of futurelessness. The drastic shift in the temporal field also contributes to a heightened sense of self-consciousness insofar as they become alarmingly aware of their physical deterioration. In sum, their suffering involves a complex arrangement of emotional, psychosocial and physical problems which are exacerbated by inadequate health care in prisons.As mentioned, compassionate release should be considered for PWAs, but this type of parole should also be extended to other inmates with terminal diseases. Such a proposal, however, requires a more detailed discussion of current social functions of prisons. That is, should prisons exist as institutions in which everyone convicted of a felony is incarcerated? Or should prisons be reserved only for the violent and dangerous? It is my opinion that prisons should serve the function of protecting society, and that the other strategies of retribution and restitution be made more available as alternatives to incarceration.By way of decades of research, criminologists have identified many sources and forms of criminality, as well as the various degrees of severity. This accumulation of knowledge, now often regarded as common sense by criminal justice practitioners, does, in fact, influence decisions regarding prosecution and sentencing. Judges, often informally, take into consideration the severity of the crime (as well as other circumstances) in sentencing the offender to a particular length of time (whether the sentence involves incarceration, probation or both). These same circumstances, therefore, should be formalized to determine who is actually to be punished by incarceration, and who should be diverted from prison to such alternatives as house incarceration, treatment facilities, community service, etc.. Again, taking into consideration the many forms of criminality (and its range of severity) as they relate to sentencing, it is important to extend this concern to inmates suffering from terminal illnesses. Furthermore, it should be noted that compassionate release can be established. For example, dying inmates who do not pose a serious or imminent threat to society should be immediately eligible for either home incarceration or a suitable medical setting (depending on their current medical condition and level of recommended security).These alternatives also must be examined in light of other pressing issues. Given the state of inadequate health care in prisons, it is unlikely that swift reforms will take place in time to properly treat terminally ill inmates currently incarcerated. To compound matters, it should be mentioned that one of the primary sources for inadequate health care is the prison's limited budget, and it is further unlikely that budgetary reforms for prisons will take place any time soon. Therefore, not only is it humane to release nonviolent and low-risk inmates suffering from terminal diseases, but it may also be cost-effective (due to soaring health care costs); especially considering the numerous class-action suits challenging the existing prison conditions involving health care.To conclude, criminal justice agencies are currently at a juncture in which decision-makers need to include additional characteristics and circumstances (i.e., medical conditions of offenders and lack of adequate health care in prisons) in determining how offenders are to be punished. Criminal justice agencies also need to address the realities of punishment-for instance, whether society is best served by having terminally ill offenders incarcerated. Is it, perhaps, more practical and humane to utilize existing alternatives to incarceration? I suggest that difficult sentencing and parole decisions regarding the terminally ill should now benefit from social science models which further conceptualize, among other things, those who are both marginal and dying.Michael Welch teaches Sociology at St. John's University, New York.     

Social capital and mental health in Japan: a multilevel analysis

Background

A national cross-sectional survey was conducted in Japan. This is because the growing recognition of the social determinants of health has stimulated research on social capital and mental health. In recent years, systematic reviews have found that social capital may be a useful factor in the prevention of mental illness. Despite these studies, evidence on the association between social capital and mental health is limited as there have been few empirical discussions that adopt a multilevel framework to assess whether social capital at the ecological level is associated with individual mental health. The aim of this study was to use the multilevel approach to investigate the association between neighborhood social capital and mental health after taking into account potential individual confounders.

Methodology/Principal Findings

We conducted a multilevel analysis on 5,956 individuals nested within 199 neighborhoods. The outcome variable of self-reported mental health was measured by the one dimension of SF-36 and was summed to calculate a score ranging from 0 to 100. This study showed that high levels of cognitive social capital, measured by trust (regression coefficient = 9.56), and high levels of structural social capital, measured by membership in sports, recreation, hobby, or cultural groups (regression coefficient = 8.72), were associated with better mental health after adjusting for age, sex, household income, and educational attainment. Furthermore, after adjusting for social capital perceptions at the individual level, we found that the association between social capital and mental health also remained.

Conclusions/Significance

Our findings suggest that both cognitive and structural social capital at the ecological level may influence mental health, even after adjusting for individual potential confounders including social capital perceptions. Promoting social capital may contribute to enhancing the mental health of the Japanese.     

Taking the ‘Error’ Out of Ruse‘s Error Theory

Michael Ruses Darwinian metaethics has come under just criticism from Peter Woolcock (1993). But with modification it remains defensible. Ruse (1986) holds that people ordinarily have a false belief that there are objective moral obligations. He argues that the evolutionary story should be taken as an error theory, i.e., as a theory which explains the belief that there are obligations as arising from non-rational causes, rather than from inference or evidential reasons. Woolcock quite rightly objects that this position entails moral nihilism. However, I argue here that people generally have justified true beliefs about which acts promote their most coherent set of moral values, and hence, by definition, about which acts are right. What the evolutionary story explains is the existence of these values, but it is not an error theory for moral beliefs. Ordinary beliefs correspond to real moral properties, though these are not objective or absolute properties independent of anyones subjective states. On its best footing, therefore, a Darwinian metaethics of the type Ruse offers is not an error theory and does not entail moral nihilism.     

Workplace Social Capital and Mental Health among Chinese Employees: A Multi-Level,Cross-Sectional Study

Background

Whereas the majority of previous research on social capital and health has been on residential neighborhoods and communities, the evidence remains sparse on workplace social capital. To address this gap in the literature, we examined the association between workplace social capital and health status among Chinese employees in a large, multi-level, cross-sectional study.

Methods

By employing a two-stage stratified random sampling procedure, 2,796 employees were identified from 35 workplaces in Shanghai during March to November 2012. Workplace social capital was assessed using a validated and psychometrically tested eight-item measure, and the Chinese language version of the WHO-Five Well-Being Index (WHO-5) was used to assess mental health. Control variables included sex, age, marital status, education level, occupation status, smoking status, physical activity, and job stress. Multilevel logistic regression analysis was conducted to explore whether individual- and workplace-level social capital was associated with mental health status.

Results

In total, 34.9% of workers reported poor mental health (WHO-5<13). After controlling for individual-level socio-demographic and lifestyle variables, compared to workers with the highest quartile of personal social capital, workers with the third, second, and lowest quartiles exhibited 1.39 to 3.54 times greater odds of poor mental health, 1.39 (95% CI: 1.10–1.75), 1.85 (95% CI: 1.38–2.46) and 3.54 (95% CI: 2.73–4.59), respectively. Corresponding odds ratios for workplace-level social capital were 0.95 (95% CI: 0.61–1.49), 1.14 (95% CI: 0.72–1.81) and 1.63 (95% CI: 1.05–2.53) for the third, second, and lowest quartiles, respectively.

Conclusions

Higher workplace social capital is associated with lower odds of poor mental health among Chinese employees. Promoting social capital at the workplace may contribute to enhancing employees’ mental health in China.     

Evaluating health workers' potential resistance to new interventions: a role for discrete choice experiments

Background

The currently recommended approach for preventing malaria in pregnancy (MiP), intermittent preventive treatment with sulphadoxine-pyrimethamine (SP-IPT), has been questioned due to the spread of resistance to SP. Whilst trials are underway to test the efficacy of future alternative approaches, it is important to start exploring the feasibility of their implementation.

Methods and Findings

This study uses a discrete choice experiment (DCE) method to assess the potential resistance of health workers to changing strategies for control of MiP. In Ashanti region in Ghana, 133 antenatal clinic health workers were presented with 16 choice sets of two alternative policy options, each consisting of a bundle of six attributes representing certain clinical guidelines for controlling MiP (type of approach and drug used), possible associated maternal and neo-natal outcomes, workload and financial incentives. The data were analysed using a random effects logit model. Overall, staff showed a preference for a curative approach with pregnant women tested for malaria parasites and treated only if positive, compared to a preventive approach (OR 1.6; p = 0.001). Increasing the incidence of low birth weight or severe anaemia by 1% would reduce the odds of preferring an approach by 18% and 10% respectively. Midwives were more resistant to potential changes to current guidelines than lower-level cadres.

Conclusions

In Ashanti Region, resistance to change by antenatal clinic workers from a policy of SP-IPT to IST would generally be low, and it would disappear amongst midwives if health outcomes for the mother and baby were improved by the new strategy. DCEs are a promising approach to identifying factors that will increase the likelihood of effective implementation of new interventions immediately after their efficacy has been proven.