Rethinking equal access: agency, quality, and norms.

In 2005 the Global Health Council convened healthcare providers, community organizers, policymakers and researchers at Health Systems: Putting Pieces Together to discuss health from a systems perspective. Its report and others have established healthcare access and quality as two of the most important issues in health policy today. Still, there is little agreement about what equal access and quality mean for health system development. At the philosophical level, few have sought to understand why differences in healthcare quality are morally so troubling. While there has been considerable work in medical ethics on equal access, these efforts have neglected health agency (individuals' ability to work toward health goals they value) and health norms, both of which influence individuals' ability to be healthy. This paper argues for rethinking equal access in terms of an alternative ethical aim: to ensure the social conditions in which all individuals have the capability to be healthy. This perspective requires that we examine injustices not just by the level of healthcare resources, but by the: (1) quality of those resources and their capacity to enable effective health functioning; (2) extent to which society supports health agency so that individuals can convert healthcare resources into health functioning; and (3) nature of health norms, which affect individuals' efforts to achieve functioning.

Global health inequalities: an international comparison.

OBJECTIVE: To study cross-national inequalities in mortality of adults and of children aged <5 years using a novel approach, with clustering techniques to stratify countries into mortality groups (better-off, worse-off, mid-level) and to examine risk factors associated with inequality. DESIGN, SETTING AND PARTICIPANTS: Analysis of data from the World Development Indicators 2003 database, compiled by the World Bank. MAIN OUTCOME MEASURES: Adult and child mortality among countries placed into distinct mortality categories by cluster analysis. RESULTS: 29 countries had a high adult mortality (mean 584/1000; range 460/1000 to 725/1000) and 23 had a high child mortality (mean 207/1000, range 160/1000 to 316/1000). All these countries were in western and sub-Saharan Africa and Afghanistan. Bivariate analyses showed that relative to countries with low child mortality, those with high child mortality had significantly higher rates of extreme poverty (p<0.001), populations living in rural areas (p<0.001) and female illiteracy (p<0.001), significantly lower per capita expenditure on healthcare (p<0.001), outpatient visits, hospital beds and doctors, and lower rates of access to improved water (p<0.001), sanitation (p<0.001) and immunisations. In multivariate analyses, countries with high adult mortality had a higher prevalence of HIV infection (odds ratio per 1% increase 18.6; 95% CI 0.3 to 1135.5). Between 1960 and 2000, adult male mortality in countries with high mortality increased at >4 times the rate in countries with low mortality. For child mortality, the worse-off group made slower progress in reducing <5 mortality than the better-off group. CONCLUSIONS: Inequalities in child and adult mortality are large, are growing, and are related to several economic, social and health sector variables. Global efforts to deal with this problem require attention to the worse-off countries, geographic concentrations, and adopt a multidimensional approach [corrected] to development.

Ethics and governance of global health inequalities.

BACKGROUND: A world divided by health inequalities poses ethical challenges for global health. International and national responses to health disparities must be rooted in ethical values about health and its distribution; this is because ethical claims have the power to motivate, delineate principles, duties and responsibilities, and hold global and national actors morally responsible for achieving common goals. Theories of justice are necessary to define duties and obligations of institutions and actors in reducing inequalities. The problem is the lack of a moral framework for solving problems of global health justice. AIM: To study why global health inequalities are morally troubling, why efforts to reduce them are morally justified, how they should be measured and evaluated; how much priority disadvantaged groups should receive; and to delineate roles and responsibilities of national and international actors and institutions. DISCUSSION AND CONCLUSIONS: Duties and obligations of international and state actors in reducing global health inequalities are outlined. The ethical principles endorsed include the intrinsic value of health to well-being and equal respect for all human life, the importance of health for individual and collective agency, the concept of a shortfall from the health status of a reference group, and the need for a disproportionate effort to help disadvantaged groups. This approach does not seek to find ways in which global and national actors address global health inequalities by virtue of their self-interest, national interest, collective security or humanitarian assistance. It endorses the more robust concept of "human flourishing" and the desire to live in a world where all people have the capability to be healthy. Unlike cosmopolitan theory, this approach places the role of the nation-state in the forefront with primary, though not sole, moral responsibility. Rather shared health governance is essential for delivering health equity on a global scale.

Smokers over age 35 continue to receive oral contraceptives. Survey of patients in a family practice residency practice.

OBJECTIVE: To assess the frequency with which women over age 35 report both current oral contraceptive use and current cigarette smoking. DESIGN: Cross-sectional survey of women in a single practice setting. SETTING: Primary care teaching practice in a mid-sized US city. PATIENTS: 142 women aged 35-55 who had not reached menopause and had not had hysterectomy. MAIN OUTCOME MEASURES: Smoking status in current oral contraceptive users. RESULTS: 19 women (13%) were current oral contraceptive users and 46 (32%) were current smokers. Four of the oral contraceptive users (21%) reported current smoking. CONCLUSIONS: Despite reported cardiovascular risk, women who smoke continue to receive prescriptions for oral contraceptives. Physicians should redouble efforts to record smoking status and offer smoking cessation treatment to women over age 35 who smoke and wish to take oral contraceptives.

Alloresponses in vitro and in vivo show restricted T-cell receptor V beta gene usage.

Our studies of V beta restriction in alloresponses have demonstrated that V beta restriction in H-2 + Mls-1a, class I and class II responses in MLC and in H-2 + Mls-1a disparate sponge matrix allografts, supporting the hypothesis that certain alloresponses in vitro and in vivo have more restricted V beta gene usage than previously thought.

Age-sensitive T cell phenotypes covary in genetically heterogeneous mice and predict early death from lymphoma.

We have assessed several age-sensitive indicators of immune status in young (i.e., 6 to 11-month-old) mice of a genetically heterogeneous population to see if these varied in parallel and to determine if one or more of the status indices predicted life span or cancer incidence. We report that the number of memory (i.e., CD44hi) T cells within the CD8 subset is correlated with number of memory cells in the CD4 population, and inversely correlated with the number of naive (i.e., CD45RBhi) CD4 cells at both 6 and 11 months of age, suggesting that the conversion of naive to memory cells may occur at similar rates in both T cell subsets. Mice that ranked high in the proportion of memory T cells (within the CD4 and CD8 pools) at 6 months of age tended to retain their ranking at 11 months, suggesting that the pace or extent of memory cell formation may be a consistent trait that distinguishes mice at least within a genetically heterogeneous population. Mice that at 6 months of age exhibited high levels of CD4 or CD8 memory T cells, low levels of naive CD4 cells, or low levels of T cells able to proliferate in response to Con A and IL-2 were found to be significantly more likely than their littermates to die within the first 18 months of life. Cases of follicular cell lymphoma, lymphocytic and lymphoblastic lymphoma, and hepatic hemangiosarcoma were seen within the group of mice dying at early ages.(ABSTRACT TRUNCATED AT 250 WORDS)

Age-associated changes in human T cell phenotype and function.

We used a limiting dilution method to estimate the proportion of T lymphocytes that could respond to PHA by producing IL-2, in peripheral blood mononuclear cells from healthy adult donors ranging in age from 18 to 81 years. The donors were selected using the guidelines of the SENIEUR protocol to exclude samples from donors not in optimal health. The frequency of PHA responsive, IL-2 producing T cells was found to decline with age, even though there was no corresponding change in the proportions of cells expressing the CD3 or CD4 determinants. There was, however, a statistically significant increase in the proportion of CD4 and CD8 cells expressing the CD45R0 determinant, thought to be a marker for memory T cells, and a corresponding decline in cells expressing the CD45RA marker found on naive peripheral T cells. The decline in the proportion of mitogen-reactive T cells in older donors, although statistically significant, was smaller than that seen in studies of aging mice, probably because the assay conditions for human T cell function are preferentially stimulatory for memory T cells, which accumulate in old age.

Preoperative sodium appetite experience and hypothalamic lesions in rats.

When a sodium deficit is induced in rats without lesions, they increase their saline intake regardless of prior experience. By contrast, this experiment found that rats with lateral hypothalamic lesions increased their saline intake only when they had had preoperative experience ingesting saline in response to a sodium deficit. Rats were given natriuretic and mineralocorticoid treatments to induce sodium appetite. The role of preoperative experience in neural function are discussed.

Effect of total amygdalectomy upon regulation of salt intake in rats.

Sodium appetite was studied in rats with lesions destroying the entire amygdaloid nuclear complex. The rats were totally aphagic and adipsic for several days following lesioning but regained nearly normal levels of food and water intake about 2 to 3 weeks postoperatively. Intake of 3% saline was observed after induction of sodium appetite by treatment with a mineralocorticoid and a natriuretic agent. Rats with amygdaloid lesions generally manifested severe but not total loss of sodium appetite. Regulation of water intake was also moderately to severely impaired. Suggestive evidence was obtained that recovery of sodium appetite in amygdalectomized rats can be enhanced by postoperative experience with sodium appetite and saline reinforcement.

Drug information: an overview and prospect for the future.

The need and demand for improved adverse drug reaction reporting; literature access, control and dissemination; and student-literature exposure has been evident for many years. Drug information attempts to manage these perplexities by performing specific functions (i.e., by the communication of information, designing improved retrieval systems and offering individualized services). The drug information specialist is clinically-oriented and endeavors to surmount long-existing barriers to information transmission (e.g., the "invisible college" or colleague consultation). As a documentalist he is concerned with bibliographic control and systems improvement and design. Both functions require specialized education which is obtainable in schools of graduate pharmacy and in schools of library and information science. The properties of such programs are presented.

[Accidents and lethality in ocular surgery (author's transl)]. / Zwischenfälle and Letalität bei Augenoperationen

The mortality and morbidity rates in eye surgery are low as compared to other surgical specialities. The lethality rate is not, however, as low as one might suppose if one follows the fate of patients which require postoperative transfer into other (non ophthalmologic) clinics. The morbidity rate differs markedly, depending on whether a local or general anesthetic is used. Following local anesthetics, the incidence of pulmonary emboli was 2.4 times greater, and thrombophlebitis twice as common as with general anesthetics, whereas cardiac complications occurred more frequently with general anesthetics. Pre- and postoperative measures are presented which have proven useful in the reduction and prevention of such mishaps.