Archive for September, 2008

Agent Orange and the Vietnamese Community In the Bronx

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Nestled amidst the McDonalds, Duncan Donuts and various Latin eateries of Jerome Avenue in the Bronx, sits the World of Taste Deli/Restaurant (formerly the Phung Hung Market), a cheery Vietnamese restaurant serving authentic sandwiches and various noodle soups.  It is one of many signs of our local Vietnamese community.

One of the health concerns of the Vietnamese patients who visit our clinic has been the possible health sequelae of the use of Agent Orange by US forces during the Vietnam War.  On Friday, September 19, 2008 we had the pleasure of meeting Mr. Ngô Thanh Nhàn, a Vietnamese activist in the Agent Orange campaign.  He spoke at a forum organized by the South East Asian community in the Bronx entitled “Justice is Healing.”  [We will be discussing this forum in a future post.].  Mr. Nhàn’s presentation follows that of Dr. Nguyen Thi Ngoc Phuong, one of the leading Vietnamese obstetrician-gynecologists, who spoke at our Social Medicine Rounds in November of 2007.  Both are members of the Vietnam Agent Orange Relief & Responsibility Campaign. This campaign is a joint initiative by US veterans and Vietnamese living in the US.

Agent Orange was one of several defoliants sprayed by the US Army during the Vietnam War. Defoliants kill plants and were intended to deprive guerilla fighters of hiding places and destroy crops that might feed them.  In addition, the Army sought to make entire regions “uninhabitable” forcing their population into controlled villages (called strategic hamlets).

These defoliants were contaminated with dioxin, considered one of the most toxic substances known to man.  The health impacts of dioxin were succinctly summarized in a 2007 American Public Health Association statement on Agent Orange:

“Dioxins are known to be risk factors for cancer, immune deficiency, reproductive and developmental disorders, and central nervous system and peripheral nervous system effects.

Studies conducted by the international scientific community have shown the association between exposure to the herbicides and health outcomes, including cancer, reproductive illnesses, immune deficiency, endocrine deficiencies, nervous system damage, and other ill effects and possible developmental disabilities and emotional problems in children.

Those negatively affected may include children born to parents who were sprayed directly. Current conditions recognized by the US Veterans Administration as service connected to Agent Orange exposure include the following: soft tissue sarcoma, chloracne, Hodgkins Disease, multiple myeloma, non-Hodgkin’s lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers, chronic lymphocytic leukemia, diabetes (type 2), and spina bifida in the children of veterans.”

About 1/10th of Vietnam is estimated to have been sprayed with some 20 million gallons of Agent Orange.  Dioxin hot spots remain today around US air bases.   Upwards of 2.1 million people may have been exposed to Agent Orange.

There is a strong case that the use of Agent Orange and other herbicides is illegal under various international agreements.  In addition, there is evidence that the US military knew that Agent Orange was contaminated with dioxin.

In September of 2004 a group of Vietnamese filed a law suit in New York Federal Court against 36 chemical companies. The suit sought to hold the companies “accountable for their actions when they knew they were providing a poison in orangebanded barrels to the United States government which was to be sprayed on millions of people and vast areas of land in South Viet Nam.” The suit was thrown out of court by Judge Jack Weinstein.  The judge’s decision stated in part: Defendants moved in those cases for summary judgment based on the government contractor defense-in essence, the claim that the government told us to do it and knew at least as much as we did about the dangers. The court granted defendants’ motion to dismiss those tort-based claims on the grounds that the contractor defense applied.” This lawsuit has been appealed.

There is a need to clean up the dioxin that remains in Vietnam and to care for and compensate the victims of this toxin.  There is also an interest in doing a comprehensive survey of the effects of Agent Orange in the Vietnamese community in the US.  Agent Orange-related damage is also an ongoing problem for US Veterans. The Veterans’ Administration has lots of information on Agent Orange, sprayed “to remove unwanted plant life and leaves which otherwise provided cover for enemy forces during the Vietnam Conflict.”

Sadly, we are likely witnessing a replay of this story today in Iraq.  Please see our September 12, 2008 posting on the impact of the war on health conditions in Fallujah.

Posted by Matt Anderson,  MD

The Business of Being Born: You Cannot Have Bliss Without Pain

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 	 	Cara Muhlhahn, Certified Nurse Midwife (left) with Mayra and David Radzinski in the documentary THE BUSINESS OF BEING BORN, directed by Abby Epstein.

Cara Muhlhahn, Certified Nurse Midwife (left) with Mayra and David Radzinski. Photo Credit: Paulo Netto

Social Medicine Rounds on 9/23/08 was devoted to a showing of the film The Business of Being Born, produced by Ricki Lane and directed by Abby Epstein.

The film, which traces several pregnancies and births, offers an extended contrast between the highly medicalized world of US obstetrics and the world of homebirths and midwifery.  It argues that American medicine has so lost touch with the basic needs of women in labor that most obstetricians have never seen a home birth and only rarely witness a ‘normal’ birth.

In 1900, 95% of birth in the US occurred in homes.  Fifty-five years later less than 1% did.  During this time, physicians asserted control over pregnancy and birth, progressively marginalizing midwifery.  With the introduction of fetal monitors in 1970, Cesarean Section rates in the US climbed from 4% of births to 23% in the space of a decade.  This dramatic change in medical practice occurred without evidence to support the benefit of fetal monitoring.  The film argues that hospitals and physicians, anxious to keep the assembly line of the obstetrics floor moving smoothly, simply don’t have time for normal labor.  Women are started on epidurals for pain, their labors slow, they are given pitocin to augment contractions, they get more pain, more pain medicine, more pitocin, and so on in a cycle of ever increasing medical intervention.  “Her labor is taking longer than it should,” is the comment of the obstetrician.  Finally when the monitor shows fetal distress, the doctor intervenes “for the sake of the baby.” The woman ends up with a Cesarean, the safest solution, we are told, for the doctor concerned about malpractice.

Woven into this story is the counter tale of how home birth was revived by the hippies during the 1960’s. Ina Mae Gaskin, the “mother of authentic midwifery” is interviewed and we see scenes of her working at the Farm Birthing Center.  She proudly recounts that they did not do their first Cesarean until after over 180 births.  The film also follows a contemporary certified nurse midwife (seen in the photo above) as she rounds in New York City. We witness several home births – including that of Ricki Lane.  These are clearly the most striking moments of the movie. The women labor in a variety of positions – squatting down, lying in a tub, squatting in a tub, lying propped on a couch.  In an amusing moment a Brazilian doctor describes how the lithotomy position (lying flat on your back with your feet up) is the worst possible one for a woman delivering a baby.  Finally, after the intense pain of labor, there is a moment of silent release and the baby is born. “Reach down and take your baby,” the midwife says to the new mother.  As a physician who has experienced only hospital births these scenes were revelatory.

Running throughout the film is a concern over the safety of homebirth and the competence of midwives.  And not all of the home births shown are successful.  But if one can question homebirths and midwifery, is it not also legitimate to question hospital births and the competence of physicians?  Clearly, 1/3 of all births don’t have to be done by Cesarean Section.  The question really is how to design a health care system that can find the right place for each type of practice. But academic medicine seems largely unable to even pose that question.

Our thanks to the filmmakers for posing it so movingly. And for allowing us to share in the births of their children.

The film’s website has links to a variety of resources on midwifery and a short trailer.

Posted by Matt Anderson, MD

International Week of Resistance to Tobacco Transnationals

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One of our readers passed along to us the following press release (dated 9/17/08) from Corporate Accountability International.  It concerns a week of actions to stop interference by the tobacco industry in efforts to control smoking.  The WHO website has information on the tobacco treaty, its history, and the Working Group which monitors its implementation. The United States signed the agreement in 2004, but has yet to ratify it. A 2006 NPR report discusses some of the politics behind the Bush Administration’s failure to present ‘the first global public health treaty” to Congress.

BOSTON– Next week, Corporate Accountability International and its allies are launching a series of actions in 25 countries demanding tobacco transnationals stop interfering in the implementation of the global tobacco treaty (formally known as the World Health Organization Framework Convention on Tobacco Control).

The 9th Annual International Week of Resistance to Tobacco Transnationals is a precursor to the third enforcement meeting on the treaty this November in Durban, South Africa. Countries will be considering specific guidelines on how to implement Article 5.3, including recommendations to:
• keep the tobacco industry out of tobacco control bodies such as treaty delegations;
• prohibit government partnership or collaboration with the tobacco industry; and
• require the tobacco industry to be transparent about its activities and operations.

Action organizers are alerting governments to expected efforts by Big Tobacco to block or water down such provisions.

“The tobacco industry poses the single greatest threat to people getting the health protections they need under the treaty,” says Kathy Mulvey, international policy director for Corporate Accountability International. “It is plain nonsensical-and contrary to the treaty itself-to allow these corporations that are damaging our health to sit at the table when our health policies are developed.”

At next week’s events around the world, Corporate Accountability International and the Network for Accountability of Tobacco Transnationals (NATT) will be releasing a report  called Protecting Against Tobacco Industry Interference: The 2008 Global Tobacco Treaty Action Guide. The report provides a snapshot of tobacco industry interference in a range of countries from Nigeria to Mexico and provides activists and policy makers with tools and tactics to counter industry interference.

The following is a short list of in-country actions:

  • In Sri Lanka, to illustrate the close ties between Ceylon Tobacco Company (CTC, a subsidiary of British American Tobacco) and many government sectors, the Swarna Hansa Foundation will be holding a press conference at Buddhist Ladies College, which is just meters from a shop refurbished by CTC, the national hospital, the capitol city town hall and the main tobacco dealer.
    The Zambia Consumers Association (ZACA) is planning a training workshop for Provincial Health Inspectors to improve implementation of a new smoking ban and to highlight BAT attempts to weaken the ban.
    In Costa Rica, which just ratified the FCTC on August 21, the National Anti-Tobacco Network is planning a delivery of the Action Guide to government officials.

“Corporations like Philip Morris International have a fundamental conflict of interest with public health,” says Akinbode Oluwafemi of Environmental Rights Action/Friends of the Earth-Nigeria. “While millions of people are getting sick and dying from their deadly products, these giant corporations are pulling out all the stops to undermine effective policies.”

The global tobacco treaty has now been ratified by 160 countries, protecting nearly 85 percent of the world’s people. Tobacco kills 5.4 million people around the world each year. The death toll is projected to rise to eight million a year by 2030, with 80 percent of those deaths occurring in developing countries. The WHO estimates that broad implementation of the treaty could save 200 million lives by 2050.

For a full schedule, news and photos of the International Week of Resistance to Tobacco Transnationals, or to download the 3rd edition of the Global Tobacco Treaty Action Guide, available in English, French and Spanish, visit: www.StopCorporateAbuse.org.

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Corporate Accountability International is a membership organization that protects people by waging and winning campaigns challenging irresponsible and dangerous corporate actions around the world. The Network for Accountability of Tobacco Transnationals (NATT) includes over 100 NGOs from more than 50 countries working for a strong, enforceable FCTC. For more information visit www.StopCorporateAbuse.org.

Global Tobacco Treaty Toolkit
This toolkit includes all you need to take action to help us build public pressure, such as submitting letters to the editor and writing to your senators to ask them to call on the Bush administration to submit the treaty to the Senate for consideration.  Download the toolkit now to take action!

Global Tobacco Treaty Action Guide:
Challenging Tobacco Industry Interference – Second Edition
This Action Guide is a tool to help public health advocates, non-governmental organizations, government officials and concerned citizens stop the tobacco industry’s attempts to use its money and influence to undermine ratification and implementation of the global tobacco treaty. It is a collection of first-hand stories about how tobacco transnationals, like British American Tobacco, Philip Morris/Altria and Japan Tobacco, are attempting to interfere with health policy and what government officials and NGOs are doing to expose and challenge this interference.
September 2006
Download PDF (English) | Download PDF (Français) | Download PDF (Español)

Report on Tobacco Industry Interference in  Heath Policy and Measures in the Global Tobacco Treaty to Prevent it
The purpose of this document is to expose tobacco industry interference in countries that have ratified the FCTC, to highlight measures currently being taken to prevent this interference, and to call for coordinated action by Parties to safeguard treaty implementation against commercial and other vested interests of the tobacco industry.
Download PDF (English) | Download PDF (Français) | Download PDF (Español)

The International Code of Marketing of Breast-milk Substitutes & Its Violators

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Nestlé-Free small

In August of this year, we reported on an American Academy of Pediatrics endorsement of a Babys ‘R Us pamphlet in which advertisements for baby formula were featured.  One of our readers sent us links to several documents discussing the International Code of Marketing of Breast-milk Substitutes.

In 1981 WHO published an International Code of Marketing of Breast-milk Substitutes.  The Code was developed starting in late 1979 under joint WHO and UNICEF auspices and involved multiple stakeholders. After several revisions, the code was adopted by the Executive Committee of the WHO in January 1981 and by the World Health Assembly in May of 1981.

The Code runs some 10 pages long and is quite technical in parts.  Yet in its preamble it reflects the bold, social vision that animated WHO at the time:

Recognizing that infant malnutrition is part of the wider problems of lack of education, poverty, and social injustice;

Recognizing that the health of infants and young children cannot be isolated from the health and nutrition of women, their socioeconomic status and their roles as mothers…”

And similarly the strictures put on marketing of breast-milk substitutes are also bold:

5.1 There should be no advertising or other form of promotion to the general public of products within the scope of this Code.


5.2 Manufacturers and distributors should not provide, directly or indirectly, to pregnant women, mothers or members of their families, samples of products within the scope of this Code.

5.3 In conformity with paragraphs 1 and 2 of this Article, there should be no point-of-sale advertising, giving of samples, or any other promotion device to induce sales directly to the consumer at the retail level, such as special displays, discount coupons, premiums, special sales, loss-leaders and tie-in sales, for products within the scope of this Code. This provision should not restrict the establishment of pricing policies and practices intended to provide products at lower prices on a long-term basis.

5.4 Manufacturers and distributors should not distribute to pregnant women or mothers or infants and young children any gifts of articles or utensils which may promote the use of breast-milk substitutes or bottle-feeding.


5.5 Marketing personnel, in their business capacity, should not seek direct or indirect contact of any kind with pregnant women or with mothers of infants and young children.

A brief pamphlet from the International Baby Food Action Network discusses the main points of the code and its subsequent revisions.  IBFAN produces a regular report called Breaking the Rules which documents violations of the Code.  Various pages of this report are available online and contain pictures of advertisements violating the code.  For the page about Abbott, click here.

The Nestle Boycott

Based on their studies IBFAN considers Nestle Corporation to be the biggest violator of the Code and has organized an ongoing international boycott of Nestle Products.  Baby Food Action, the British affiliate of IBFAN has an excellent page on the Nestle boycott which might serve a resource for other activists interested in boycotts.  Nestle had pledged in 1984 to observe the Code in exchange for a seven year suspension of the boycott; this agreement broke down in 1988.  The IBFAN website has a history of the boycott. Nestle has published its own version of the story.

In 2007 the Guardian published an expose written by Joanna Moorhead entitled “Milking It” about how Nestle violates the Code in Bangladesh.  To quote from the article:

“Here’s how: on [Hospital Pediatrician Dr Khaliq] Zaman’s desk, lots of small pads lie scattered: each contains sheets with information about formula milk, plus pictures of the relevant tin. The idea, he says, is that when a mother comes to him to ask for help with feeding, he will tear a page out of the pad and give it to her. The mother – who may be illiterate – will then take the piece of paper (which seems to all intents and purposes a flyer for the product concerned) to her local shop or pharmacy, and ask for that particular product either by pointing the picture out to the pharmacist or shopkeeper, or by simply searching the shelves for a tin identical to the one in the picture on their piece of paper. “I’d never give these pieces of paper out – when I’ve got a big enough bundle, I take them home and burn them,” says Zaman. But that does not mean every other health worker would do the same.

At least three types of Nestlé formula are among the brands whose tear-off pads are on Zaman’s desk.”

The WTO & the Code

According to the SpeakEasy.org website, a 1983 Guatemalan law implementing the Code was cited by the US as a violation of Gerber’s patent law.  The complaint was filed in 1993 and after several years of discussion “in 1995, under threat of a WTO challenge by the U.S. State Department, Guatemala changed its law to allow labelling of imported baby food products that violates WHO/UNICEF guidelines.

Posted by Matt Anderson

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National Physicians Alliance "Unbranded Doctor" Campaign

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In our last posting we discussed the visit of Dr. Jean Silver-Isenstadt of the National Physicians Alliance.  In this posting we will focus more closely on the NPA “Unbranded Doctor Campaign” part of an attempt to protect integrity and trust in medicine. This campaign asks doctors to stop accepting gifts, however small, from pharmaceutical companies.

The campaign offers resources on how to become an unbranded doctor. Among these is a slideshow from the Madras Medical Group documenting their transition from accepting visits and gifts from pharm reps to becoming “Pharm-free.”  Not as easy as it sounds, particularly since not everyone felt this was a good thing initially.  There are links to videos, including the Frontline Expose A Bitter Pill which discusses the problems with the FDA’s role as watchdog of medication safety in the US.  There is a reading room of both books and articles.  And finally there is a listing of “sources of independent medical information and industry-free CME.

The campaign is being conducted in association with the American Medical Student Association, No Free Lunch, and Pharmed Out.  The website links to several blogs: PostScript, The Carlat Psychiatry Blog, Hooked: Ethics, Medicine, and Pharma, GoozNews, and Pharmalot.

This initiative is also associated with the Prescription Project, an effort “led by Community Catalyst in partnership with the Institute on Medicine as a Profession.  Funded by the Pew Charitable Trusts, the Project seeks to eliminate conflicts of interest created by industry marketing by promoting policy change among academic medical centers, professional medical societies and public and private payers.” The specific platform supported by the Prescription Project are the recommendations published in the January 2006 JAMA.

The Unbranded Doctor campaign is closely associated with several other NPA initiatives.  The Protecting Prescription Privacy Campaign seeks to bar pharmaceutical companies from purchasing prescribing information about individual doctors. This information is used to target Pharma advertising.  They are also supporting S. 2029 The Physician Payments Sunshine Act which seeks to force reporting of pharmaceutical gifts to doctors.

Last, but not least, you can actually buy “Unbranded Doctor” paraphernalia including mugs, T-shirts and wall clocks.  Who would have thought?

Commentary

It is heartening to see the range and depth of activism around this issue, which even involves important elements within “mainstream” academic medicine.  However, it is worth remembering that according to a 2008 article by  Marc-André Gagnon and Joel Lexchin in PLOS: Pharmaceutical promotion in the United States in 2004 is as high as $57.5 billion compared to the figure of $27.7 billion given by IMS. Excluding direct-to-consumers advertising and promotion towards pharmacists, the industry spent around $61,000 in promotion per practicing physician.”

$61K per doctor! This is truly a Goliath.

Posted by Matt Anderson

Dr. Jean Silver Isenstadt of the National Physicians Alliance

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Dr. Jean Silver-Isenstadt

Dr. Jean Silver-Isenstadt

On Tuesday, September 11, Dr. Jean-Silver Isenstadt, the founding Executive Director of the National Physicians Alliance spoke at Social Medicine Rounds about the work of the NPA since its formation in 2005.

She began her presentation with Broken Covenant, a short film which captures the issues and events surrounding the birth of the NPA; it is available on the NPA website.  The Alliance developed from a core group of AMSA (American Medical Student Association) ex-presidents who wanted to create an “AMSA beyond AMSA,” i.e. a physician’s organization that could better express the values animating AMSA.  These core values, as identified by NPA’s founders, were: service, integrity and advocacy.

Core Issues

The core issues identified by the new organization were:

Integrity & Trust in Medicine

Equitable, Affordable Health Care for All, Without Health Disparities

Prevention and Wellness

NPA Campaigns

These core issues have translated into three major NPA campaigns:

1. The Unbranded Doctor (which will be the subject of our next posting).

2. Rx: Vote, a voter registration campaign (see our posting of June 20, 2008)

3. Secure Health Care for All

The Secure Health Care for All campaign has chosen not to endorse a specific plan, but rather endorses the Institute of Medicine’s general principles for health care reform:

1.      Health care coverage should be universal.

2.      Health care coverage should be continuous.

3.      Health care coverage should be affordable to individuals and families.

4.      The health insurance strategy should be affordable and sustainable for society.

5.      Health insurance should enhance health and well-being by promoting access to high-quality care that is effective, efficient, safe, timely, patient-centered, and equitable.

This campaign has been undertaken in alliance with a number of groups including HCAN, Health Care for America Now.  HCAN calls for a plan which guarantees affordable coverage and allows people to: “keep your current private insurance plan, pick a new private insurance plan, or join a public health insurance plan.”  It appears this plan has been controversial within the NPA, some seeing it as too left, others as not left enough.  (For a recent critique of HCAN from Physicians for a Naitonal Health Plan, see the PNHP blog).  The campaign also offers NPA’s report card on the health plans of the current presidential candidates.

In addition to these three large campaigns, the NPA website has information on campaigns to address malpractice, safety, and the global health worker shortage.

The NPA lays great importance on the role of physicians as advocates.  Dr. Silver-Isenstadt stated: “Patient advocacy is a responsibility of the profession.”  And their website offers many opportunities for physicians to work as advocates.  In addition, NPA has a blog and a facebook page.

From the NPA website: “Jean Silver-Isenstadt holds a doctorate in the history and sociology of medicine from the University of Pennsylvania, a medical degree from the University of Maryland, and a master’s degree in nonfiction and science writing from the Johns Hopkins University. Her doctoral work focused on 19th-century American health reform.  She is the author of Shameless: The Visionary Life of Mary Gove Nichols (Baltimore: Johns Hopkins University Press, 2002), a biography of the infamous and influential health advocate and social reformer best known for her leadership of the water-cure movement and for her scandalous public lectures to women on anatomy and physiology.”

After her talk, Dr. Silver-Isenstadt reminded me that the Social Medicine Portal was one of the first sites to give publicity to the NPA in 2005.

Posted by Matt Anderson

Reports from Iraq on the Health Impact of the War

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Dr. Dahlia Wasfi has passed on to us several Iraqi reports about the dramatic health problems caused by the US invasion and occupation of their country.  The materials sent by Dr. Wasfi are important because they provide an Iraqi perspective.

Two concern the use of chemical weapons in Fallujah.  Fallujah, once known as the City of Mosques, was the subject of two major U.S. assaults in April 2004 and November 2004.  Fallujah had also been subject to bombings during the first Gulf War.  Italian RAI News has produced a documentary entitled Fallujah: The Hidden Massacre which shows scenes from the November 2004 attacks.

  • A 9 minute video, Iraq Deformities, produced by Journeyman Pictures reports an increase in birth defects among children born since the assault. The local population attributes these defects to the use of white phosphorus by the US Army.
  • Dr. Dr. Muhamad T. A. Al-Darraji is an embryologist who is President of the Conservation Center of Environmental and Reserves in Fallujah (CCERF) and Director of Monitoring Net of Human Rights in Iraq (MHRI net). In March of 2008 he prepared a report for the High Commissioner for human Rights of United Nations entitled Prohibited weapons Crisis: The effects of pollution on the public health in Fallujah. He notes in his report that the medical records of Fallujah General Hospital were destroyed in the assaults, making it difficult to establish a comparison before and after 2004. This problem is compounded because the population in Fallujah has been greatly decreased. His document points to increased numbers of pediatric illnesses:

The main civilian victims of most illnesses were the children, and the rate of them represents 72% of total illness cases of 2006, most of them between the ages of 1 month and 12 years. While in 2007 was not very difference because many illnesses accounted the children with another ages.

Many new types and terrible amounts of illnesses started to appear since 2006 until now, such as Congenital Spinal cord abnormalities, Congenital Renal Abnormalities, Septicemia, Meningitis, Thalassemia, as well as a significant number of undiagnosed cases at different ages.

He also reports an increased incidence of cancer.

MPT [Muslim Peacekeeper Teams]  report refer Starting in 2004 when the political situation and devastation of the health care infrastructure were at their worst, there were 251 reported cases of cancer. By 2006, when the numbers more accurately reflected the real situation, that figure had risen to 688. Already in 2007, 801 cancer cases have been reported. Those figures portray an incidence rate of 28.21 by 2006, even after screening out cases that came into the Najaf Hospital from outside the governate, a number which contrasts with the normal rate of 8-12 cases of cancer per 100,000 people.

Dr. Wasfi also sent us a report from Dr. Souad N. Al‐Azzawi, an Associate Professor in Environmental Engineering, Iraq which focuses on the use of depleted uranium (DU) during the war.  She concludes:

“Continuous use of Depleted Uranium weapons since 1991 against the population and the environment of Iraq is an act of crime. The occupation’s total denial of the problem and refusing to allow international agencies to conduct any exploration programs to define the risk associated with this contamination, has resulted in more exposure to these radioactive pollutants, and more health damages.

Ignoring DU related health damages and the ongoing occupation of Iraq have proved to the world how desperate the American Administration is to control oil resources of the Middle East. Occupation of Iraq is a catastrophic criminal act that resulted in the death of over two million people and forced about five million of the population to leave their living areas inside and outside Iraq.

The occupying forces intentionally created a state of chaos during the invasion in 2003 to facilitate committing genocide against the Arab majority who refused the occupation of Iraq, ultimately changing Iraq’s demography and national identity in favor of the occupation’s new constitution and the minorities who helped them during the invasion and occupation of Iraq.

The occupation forces and allies failed to comply with Article 2 of the four Geneva Conventions of 1949, and articles (42-56) of the Hague Regulations that addresses obligations imposed on occupying powers towards occupied people. The occupation forces and its assigned governments failed to ensure basic human needs like potable water, food, medical care, education, sanitation, and security. The excessive use of power, besieging whole cities, illegal imprisonment of civilians and even children, and occupation induced poverty have all turned Iraq into a death camp.

The international community is urged to help Iraqis gain back their independence and sovernity through getting the occupation forces out of Iraq and through refusing any shape of colonial, long term security treaties that would facilitate taking over the country and control the oil of Iraq through permanent foreign army bases.”

Commentary

This situation is not a new story.  There is an active campaign in the US to address the long-term health consequences (particularly in terms of congenital abnormalities) amongst Vietnamese exposed to dioxin during the Vietnam War. This campaign resulted from years of collaborative work between Vietnamese and international researchers.

It would seem fitting that US health personnel build relationships with our Iraqi colleagues to take their concerns seriously, to work collaboratively to document the health impact of the invasion/occupation, and to repair the damage caused by the war.

Posted  by Matt Anderson

Urgent appeal for Cuban Medical School hit by Hurricane Gustav

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The Medical School on the Isle of Youth in Cuba was destroyed by last week’s Hurricane Gustav. We have received the following appeal from our friends at MEDICC.

ATLANTA, GA, September 5, 2008 — The Isle of Youth was one of two Cuban regions hardest hit by Gustav, the worst hurricane to ravage Cuba in the last 50 years. The small island south of the mainland is well-named: it is home to over 5,000 students of medicine, about half Cuban and half students from low-income families in Latin America and the Caribbean who have pledged to serve in poor communities when they graduate.

While all the students and faculty are safe, their Faculty of Medicine was totally destroyed by the winds – blasts so fierce they riveted pieces of roofing into tree trunks and chair legs into door frames.

Picking up the pieces, the most urgent tasks for the Isle are restoring sources of food, electricity and water. Next, rebuilding their homes: of 25,000 houses, 20,000 were at least partially affected, 10,000 roofs blown away. But the bigger task ahead is to restore the Isle’s institutions, the livelihoods of its 85,000 residents-and its schools.

The Faculty of Medicine, even in temporary facilities, desperately needs to replenish stocks of reference textbooks lost when its buildings were destroyed.

MEDICC (Medical Education Cooperation with Cuba) already has one shipment of books on the way: help us send at least five more.

Thanks to the Free Trade in Ideas Act, medical literature is exempt from the otherwise draconian US embargo on Cuba, so these books can be airlifted directly to Cuba as soon as they can be purchased.

Send your tax-deductible donation to MEDICC, Hurricane Fund, 1902 Clairmont Road, Suite 250, Decatur, GA 30033. Make your check payable to ‘MEDICC’. Or donate online at https://secure.groundspring.org/dn/index.php?aid=18349.  Check the “Textbooks & Journals to Cuban Medical Schools” program, which will be dedicated exclusively to the Isle of Youth Medical School through the end of 2008.

The future physicians of Cuba, Latin America and the Caribbean will surely join your dollars with their good works to make a difference in the communities they’ll serve.

ABOUT MEDICC

Medical Education Cooperation with Cuba (MEDICC) is a US non-profit organization based in Atlanta, Georgia and Oakland, California working to enhance cooperation among the US, Cuban and global health communities aimed at better health outcomes. Founded in 1997, MEDICC supports education and development of human resources in health committed to equitable access and quality care, providing the Cuban experience to inform global debate, practice, policies and cooperation in health.

MEDICC’s Textbooks & Journals Program for Cuban Medical Schools has shipped multiple copies of over 100 latest-edition books to Cuba’s 23 medical schools over the last five years.

For a look at MEDICC programs, visit:  www.medicc.org. See also: MEDICC Review‘s current issue, which we have made available FREE online, outlining Cuba’s Strategies for Disaster Management, at www.medicc.org/mediccreview.

Unofficial Synopsis of the Social Determinants of Health Report

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A number of people have requested a brief synopsis of the final report by the WHO Commission on the Social Determinants of Health (discussed in our posting of 9/1/2008). David Woodward (formerly with the New Economics Foundation) has prepared an unofficial synopsis that is shorter and, he promises us, more interesting that the Executive Summary (we agree). We reproduce his synopsis in this posting.

We also note that the report has been the subject of editorials in the British Medical Journal and the Lancet. It was not mentioned in 8/27 and 9/3/08 editions of JAMA or in the 8/28 and 9/4/08 editions of the New England Journal of Medicine.

From: “David Woodward” <David.Woodward@neweconomics.org>
Subject: Commission on Social Determinants of Health – a Golden Opportunity!

As is well known by now, the Commission on Social Determinants of Health has finally published its report, which can be downloaded at http://www.who.int/social_determinants/final_report/csdh_finalreport_2008.pdf. There is a great deal of very valuable material in it not only on health systems and policies, but also on economic policies, globalisation and global governance. Unfortunately, this is played down in the Executive Summary, limited in the recommendations it makes, and virtually absent from the official WHO press release – and consequently from all of the media coverage we’ve seen so far.

To redress the balance, we are attaching a (wholly unofficial) “synopsis”, drawing together and summarising what the main text of the report says in a number of key areas. (Take it from us, it is much more interesting than the Executive Summary!) Anything anyone can do to highlight these aspects of the report would be invaluable – it has some of the best ammunition we’ve had for years!

Part 1: What the Report of the Commission on Social Determinants of Health says about:

Health Care

Other Health-Related Services

Economic Models of Development

Markets and the Corporate Sector

Employment and Livelihoods

Social Protection

While the Commission makes a number of specific recommendations, these are constrained by its mandate, and as a result do not include many suggestions and proposals included in the body of the report, or address specific issues which are clearly identified as necessary if the Commission’s objective of “closing the gap in a generation” is to be fulfilled. At the same time, because of the very complex and inter-connected nature of influences on the social determinants of health, material relevant to a number of key issues is spread across several sections of the report. The following is an attempt to draw the material in the report together, in summary form, under a number of thematic headings, highlighting the Commission’s suggestions and proposals, and the specific needs it identifies, as well as its formal recommendations.

It should be emphasized that this synopsis has no official status, that it has been compiled entirely independently of the Commission and its secretariat, and that it should in no way be attributed to them. While the contents are intended to reflect what the report says on each subject, some selectivity has been inevitable, and the emphasis undoubtedly reflects the priorities of the writer.

Health Care

The Commission is strongly critical of recent health-sector reforms, which it sees as a product of broader economic influences and driven by international agencies, commercial actors, and medical groups. These reforms have resulted in health care becoming increasingly commodified, commercialised and fragmented, and promoted a narrow technical/medical focus. This has undermined the development of comprehensive primary health care, and generated a stark and growing divide between over- and under-consumption of health-care services between the rich and the poor worldwide.

Health-care systems should be designed and financed to ensure equitable, universal coverage and access, allowing everyone who needs health services to use quality services, with adequate human resources. Health systems should be based on the primary health-care model, combining locally organised action on the social determinants of health with strengthened primary care, and should focus at least as much on prevention and health promotion as on treatment. Where universal services cannot be achieved immediately, services disproportionately benefiting disadvantaged groups may be prioritised in the short term. User charges for health services are unacceptable, and health care should be financed from general taxation or mandatory insurance, minimising out-of pocket spending. Intended beneficiary groups should be included in all aspects of policy and programme development, implementation, and evaluation.

The report also criticises the IMF’s Medium-Term Expenditure Framework (MTEF) as prioritising very low inflation and conservative fiscal policy over poverty and health needs, leading to underinvestment in the human capacity critical for health-care systems; and it warns that global health initiatives may skew priorities and exacerbate human resource scarcity. Investment in medical and health personnel should be increased, and efforts made to balance health-worker density in rural and urban areas, for example, through use of community health workers.

Other Health-Related Services

Education, quality housing, clean water and sanitation, as well as health and health-care, are human rights. The report condemns commercialisation of health services and education, which should be governed by the public sector. The state also has a clear responsibility to ensure access to water and sanitation, which is essential to life, and wholesesale privatisation of water should be discouraged. Access to clean water should not be limited by ability to pay, and cross-subsidies should be used where cost recovery is necessary.

Economic Models of Development

The development model pursued since the 1980s has been the target of a great deal of deserved criticism. Structural adjustment had a severe adverse impact on key social determinants of health across most participating countries; and market-oriented economic policies have contributed to the dispersion of regional performances in life expectancy. It is not clear that such policies produced the anticipated benefits, or that the health and social costs were justified. The over-reliance of these programmes on markets to solve social problems has proved damaging; and they have limited investment in infrastructure and human resources, reducing state capacity. There is growing demand for a new approach to social development, moving beyond an overriding focus on economic growth to look at building well-being through a combination of growth and empowerment.

The Commission finds that the relationships among globalisation, growth, and poverty reduction are deeply problematic, noting widespread challenges to he view that economic growth alone can provide a solution to global poverty, and the decline in the income share of the poorest 20% of the population in many countries over the last 15 years. Without appropriate social policies, economic growth brings little benefit to health or health equity. Progress towards health equity requires addressing economic inequality, including inequity in public financing, and the evidence suggests that income redistribution is a more efficient means of reducing poverty. Systems should be built to ensure that no-one’s income falls below a minimum healthy level.

The role of governments through public sector action is fundamental to health equity, and the State has a responsibility to guarantee a comprehensive set of rights and ensure fair distribution among population groups. An empowered public sector, based on principles of justice, participation and inter-sectoral collaboration, is needed to underpin action on the social determinants of health and health equity. This requires strengthening the core functions of government and public institutions, nationally and sub-nationally.

Policy coherence and inter-sectoral action for health – “health in all policies” – are essential, and renewed government leadership is urgently needed to balance public and private sector interests.

Markets and the Corporate Sector

While recognising the potential benefits of markets to health, the Commission also highlights their adverse effects, including economic inequality, resource depletion, pollution, unhealthy working conditions, and increased consumption of dangerous and unhealthy goods. Even where goods and services can be efficiently and equitably provided through the private sector, government regulation is vital, and efforts are needed to ensure that private sector activities and services (eg production and patenting of medicines, and health insurance) contribute to health equity rather than undermining it.

The impact of voluntary initiatives on corporate behaviour is inevitably limited, and “corporate responsibility” is often little more than cosmetic, lacks enforcement, and entails little evaluation. Corporate *accountability*may provide a better means of ensuring positive effects of business activities. The Commission suggests disclosure standards for companies on where products have been produced and with what employment standards. Consideration could also be given to internationally coordinated changes to company law, to require publicly quoted companies to pursue a broader set of social and environmental objectives rather than maximising shareholder value.

Employment and Livelihoods

The Commission condemns inequitable, exploitative, unhealthy and dangerous working conditions, and calls for employment conditions conducive to well-being, including safe, secure and fairly paid work, year-round work opportunities, and healthy work-life balance for all, with effective worker protection and measures to reduce stress and exposure to material hazards.

Fair employment and decent work should be a central focus of development strategies, and economic and social policies should provide secure work and a living wage, taking in line with the cost of health needs. Full employment requires integrated economic and social policies, including employment generation, eg through public works, local procurement policies, income-generation and support to small, medium and micro enterprises.

The Commission calls for progressive fulfillment of global labour standards. While standards should be graduated, recognising the lower standards developing countries are able to achieve, there should be progressive upward convergence of standards over time. The starting point should be the four core principles – freedom of association and the right to collective bargaining; freedom from forced labour; the effective abolition of child labour; and non-discrimination in employment. Child labour can be reduced by increasing poor households’ income and ensuring quality schooling. The state should guarantee the right to collective action among formal and informal workers.

The Commission supports progressive development and implementation of binding codes of practice in relation to labour and occupational health and safety (OHS). Mechanisms should also be explored to create cross-country wage agreements, initially at a regional level.

Government policy and legislative support are required to rebalance work and private life, providing parents the right to time to look after children, access to childcare regardless of ability to pay, flexible working hours, paid holidays, parental leave, job share, and long-service leave. Encouragement could be given to shorter working hours in high-income countries. Government policy and legislation are also needed to create more security in different working arrangements.

Efforts should be made to improve working conditions in the informal sector as part of a coherent economic and social policy including social protection, education, and public sector strengthening. OHS policy and programmes should be applied to all workers, and should be extended to include work-related stress and harmful behaviours. OHS components should be included in employment creation programmes, and in regulation of subcontracting and outsourcing.

The Commission emphasises that changes in the operation of the global economy are necessary for its recommendations on employment to be implemented. (See *Globalisation* in part 2.)

Social Protection

Social protection should be provided to all people across the lifecourse, and should include unemployment, sickness, and disability benefits and social pensions. Universal (rather than targeted) approaches are important for dignity and self-respect, can enhance social cohesion and social inclusion, and may be more politically acceptable. Governments should build towards universal social protection systems, increasing the generosity of benefits over time towards a level that is sufficient for healthy living, and gradually protecting against a more comprehensive set of risks. Targeting should be used only as a back-up for those who slip through the net of universal systems.

A concerted effort is needed to develop realistic solutions to social protection of migrants, asylum seekers and refugees. Attention should also be given to the needs of people with disabilities, including fighting discrimination by employers

In developing countries, social protection should be embedded in Poverty Reduction Strategies. Social protection systems can be developed gradually through pilot projects, successful pilots being rolled out nationally, starting with the most deprived regions. Donors and international organisations have an important role to play in building capacity for social protection.

As for employment, the Commission emphasises that changes in the operation of the global economy are necessary for its recommendations on social protection to be implemented. (See Globalisation in part 2.)

Part 2: What the Report of the Commission on Social Determinants of Health says
about:

Financing
Globalisation
Global Governance

While the Commission makes a number of specific recommendations, these are constrained by its mandate, and as a result do not include many suggestions and proposals included in the body of the report, or address specific issues which are clearly identified as necessary if the Commission’s objective of “closing the gap in a generation” is to be fulfilled. At the same time, because of the very complex and inter-connected nature of influences on the social determinants of health, material relevant to a number of key issues is spread across several sections of the report. The following is an attempt to draw the material in the report together, in summary form, under a number of thematic headings, highlighting the Commission’s suggestions and proposals, and the specific needs it identifies, as well as its formal recommendations.

It should be emphasized that this synopsis has no official status, that it has been compiled entirely independently of the Commission and its secretariat, and that it should in no way be attributed to them. While the contents are intended to reflect what the report says on each subject, some selectivity has been inevitable, and the emphasis undoubtedly reflects the priorities of the writer.

Financing

The Commission calls for increased public finance for programmes and policies to support the social determinants of health, including child development, education, improved living and working conditions and health care, recognising the failure of markets to supply vital goods and services equitably. It also calls for a fair allocation of the costs of action on the social determinants of health, both geographically and across social groups, through progressive taxation at the national level, a major increase in aid, improved aid quality and greater debt cancellation.

Tax systems should be progressive, and focus on direct rather than indirect taxation; and mechanisms should be established to ensure that available tax funding is allocated between populations and areas according to need. This requires strengthening tax systems and capacities in many developing countries.

The Commission finds current levels of aid “grossly inadequate”, and the net financial outflow from many developing countries to richer countries “alarming”. It identifies a “trust deficit” between donors and recipients, leading to multiple and onerous conditions which increase transaction costs, strain recipient countries’ often weak administrative capacity, and constrain their freedom to determine their own developmental and financing priorities. It also highlights problems arising from the volatility and unpredictability of aid flows.

It calls on donor countries to honour existing commitments by increasing aid to 0.7% of GDP, to establish predictable long-term funding mechanisms, to increase aid quality, to reduce tied aid, to increase budgetary support, to align aid with recipient countries’ own development plans, to increase aid for health (particularly the social determinants of health), and to coordinate aid use through a social determinants of health framework

The Commission identifies a need for new multilateral institutions for an expanded, reliable and more coherent system of global aid. Greater emphasis should be placed on globally pooled funds, multilaterally managed and transparently governed, multi-year stability of donor inputs, and the determination of recipients’ eligibility and allocations according to agreed needs and developmental objectives.

The PRSP process has been “something of a missed opportunity”, and appears to have had an adverse impact on national policy space and public spending on education and health care. The PRSP process should emphasise more explicitly that it is a process of national cross-sectoral coherence in decision-making. Donors and national governments should provide more funding for cross-sectoral work on the social determinants of health; more support should be provided to Health Ministries in their engagement with Ministries of Finance; and Medium-Term Expenditure Frameworks should be more flexible, to allow key recurrent costs to be met.

An urgent need exists for more debt relief, deployed more effectively in support of social determinants of health, as the considerable weight of remaining debt continues to draw public resources away from developmental investments. The Multilateral Debt Relief Initiative should be strengthened and extended; and there have been calls for a more balanced approach to debt cancellation and independent arbitration. Consideration of indebtedness should expand the focus from narrow indicators of economic sustainability towards a broader concept of ‘debt responsibility’, including broader measures of economic vulnerability, and legislative scrutiny of government borrowing and lending.

Efforts should be made to ensure that increases in aid and debt relief support coherent policy-making and action by recipient governments on the social determinants of health, and performance indicators of health equity and social determinants of health should be core conditions of recipient accountability.

Globalisation

While the Commission sees potential benefits in globalisation, the process has been inherently disequalising, concentrating benefits among the better off and negative effects among the poor. It criticises various aspects of the recent process of globalisation, market integration and liberalization throughout the report as increasing inequity in health between and within countries; increasing the cost of life-saving drugs; damaging food security; undermining the ability of governments to collect taxes though tariff reduction and tax competition; adversely affecting labour and working conditions and increasing job insecurity; contributing to the double burden on women of paid and domestic work; increasing the frequency of financial crises; intensifying the commodification and commercialisation of water, health care, and electrical power; severely diminishing the role of the public sector in regulation for health; increasing the availability and consumption of health-damaging products; and encouraging unhealthy diets.

The Commission emphasises the necessity of changes in the operation of the global economy and international institutions, including WTO, IMF and World Bank, for its recommendations on employment and social protection to be implemented. While it notes that the the design of a new international economic order is beyond its mandate, it stresses the need for urgency and innovation to integrate health, development and environmental concerns.

The Commission sees an urgent need for a global economic system which supports renewed government leadership to balance public and private sector interests, and identifies quantifying the impact of supra-national political, economic, and social systems on health and health inequities within and between countries as an important research need. It also proposes that international legislative standards for rich country business relations with low- and middle-income trading partners should be increased.

The Commission notes that the global financial architecture may have more influence on health than international assistance for health care, contributing to large net outflows of resources from poor to rich countries and increasingly frequent financial crises.

It calls for better international coordination of tax policy and the establishment of an International Tax Organisation, and highlights the need for a globally enforceable framework to reduce international tax avoidance and capital flight, calling for measures to combat the use of offshore financial centres and curb tax avoidance. It also stressses the need for effective taxation of transnational corporations, including the avoidance of tax incentives for export-processing zones. It proposes requirements for disclosure by companies of all tax, royalty and other payments to governments and other public entities. It calls on all governments to ratify and implement the UN Convention against Corruption rapidly.

The Commission also calls for the development of new national and global public finance mechanisms, ensuring that the resources generated are genuinely additional to development assistance. It sees a strong argument in favour of the development of a system of global taxation, possibly including a tax or solidarity levy on currency transactions.

Health impact assessments are required before international agreements or policy commitments on trade and investment are finalised. Countries considering such commitments should exercise due caution. WHO should re-affirm its global health leadership by initiating a review of trade and investment agreements, in collaboration with other multilateral agencies, with a view to institutionalising health equity impact assessment as a standard part of all future agreements. The flexibility of trade agreements should be increased to allow signatory countries, after signing, to mitigate unforeseen negative impacts on health and health equity, possibly including opt-out provisions where domestic conditions suggest this is necessary.

Implementation of the Commission’s recommendations on empoyment requires improved terms in WTO Agreements, more development-friendly trade policies in developed countries, reduced dependence on external capital and export markets in developing countries, and more intra-regional trade. High- and middle-income countries should not demand further tariff reductions in bilateral, regional, and world trade negotiations with low-income countries which still depend on tariffs for public revenue; and low-income countries should be extremely cautious in agreeing to reduce tariffs before creating alternative revenue streams to replace them. The report also indicates support for the development of preferential trade agreements offering protection to countries attempting to build the capacity to engage viably in the global marketplace.

While it supports the inclusion of occupational health and safety provisions in trade agreements, the Commission highlights the need for caution in seeking to use ‘social clauses’ in trade agreements to enforce international labour standards, which may have counterproductive effects, urging instead the strengthening of the International Labour Organisation, the UN Environment Programme, the Food and Agriculture Organisation and WHO.

Countries should avoid making any commitments in binding trade treaties (eg the WTO’s General Agreement on Trade in Services) which affect their ability to regulate health services effectively until they have demonstrated that they can regulate private health services in ways that increase health equity. It is not clear that any country has yet done so.

Food-related trade agreements should concentrate on the three key aspects of nutrition and health equity – availability, accessibility and acceptability. Trade policy that actively encourages the production and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy. It is important to ensure that local agriculture is not threatened by international trade agreements and agriculture protection in rich countries. National and local government policies and programmes should focus on agricultural development and fairness in international trade arrangements, and protect the livelihoods of farming communities exposed to cost and competition pressures through agricultural trade agreements.

The Commission calls on international agencies, donors and national governments to address the “brain drain” of health human resources, focusing on investment in increasing health human resources, and bilateral agreements to regulate gains and losses. It also calls for more effective policy and financing mechanisms to support refugees and internally displaced populations; and greater global cooperation on the establishment of ‘portable rights’ accruing to all cross-border migrants, to be honoured by all host countries.

Global Governance

The nature of global systems and the requirements of good global governance have changed considerably since the current multilateral system was established some 60 years ago. Poor democratic function and inequality of influence are widely prevalent. The institutional processes and democratic credentials of the World Bank and IMF are questionable; trade and investment agreements have often been characterised by asymmetrical participation and inequalities in bargaining power among signatory countries; and participation and representation on the Codex Alimentarius Commission are inequitable and biased, resulting in an imbalance between the goals of trade and consumer protection. Agreements are often entered into without adequate assessment of the full scale of the social risks; and the profound disempowerment of some countries through their lack of resources and unequal capacity leads to treaties and agreements that do not necessarily serve their best interests.

The Commission argues for stronger global management of integrated economic activity and social development as a more coherent way to ensure fairer distribution of globalisation’s costs and benefits. It sees the entrenched interests of some social groups and countries as “barriers to common global flourishing”, and expresses concern about the increasing influence of transnational companies, which it argues should be accountable to the public good as well as to private profit.

The Commission highlights the need for new, strengthened and more democratic forms of global governance, considering it imperative that the international community recommit to a multilateral system in which all countries have an equitable voice. A system of global governance which places fairness in health at the heart of the development agenda and genuine equity of influence in the centre of its decision-making is indispensable to the realisation of the right to health. The Commission calls for reform of Security Council, for example through strengthened regional representation; and for support to governments and other stakeholders to allow their equitable participation in global policy-making fora.

Multilateral agencies should work more coherently to a common set of overarching objectives, underpinned by a common vision of issues to be addressed, and shared indicators by which to measure the impact of their actions. Representation of public health in domestic and international economic policy negotiations should be ensured and strengthened; and the public sector should take a leadership role in national and international regulation to protect health and reduce health inequities.

The ‘thick’ global governance on economic, trade, finance and investment relations, is in marked contrast with ‘thin’ governance on health and social equity, and global roles relating to social determinants of health are fragmented between numerous competing actors. The Commission proposes revising existing global development frameworks to incorporate health equity and social determinants of health indicators more coherently, and the adopting health equity as a core global development goal, with appropriate indicators to monitor progress both within and between countries. The MDGs should be reconsidered, advancing equity as a core marker of achievement,

The Commission strongly supports WHO in renewing its leadership in global health and its stewardship role across the multilateral system, and urges an increase in WHO’s capacity, and its institutional renewal through the establishment of a social determinants of health approach across its programmes and departments. It also proposes the creation of inter-agency thematic working groups on different aspects of the social determinants of health, the appointment of a Special Envoy for Global Health Equity, and a Permanent Special Rapporteur on the Right to Health.

David Woodward

A Brief History of the Residency Program in Social Medicine & the DFSM

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A Brief History of the Residency Program in Social Medicine (RPSM) & the Department of Family and Social Medicine:

Montefiore Medical Center / Albert Einstein College of Medicine

The Residency Program in Social Medicine (RPSM) of the Montefiore Medical Center (MMC) was founded in 1970 by Drs. Harold Wise and David Kindig, who sought to develop residency training in pediatrics and internal medicine that emphasized primary care for the underserved. In 1973 family practice was added as a third track. Residents worked in partnerships and maintained their continuity practices at the Dr. Martin Luther King, Jr. Health Center (MLK), which Dr. Wise had begun in 1968. The RSPM was their response to the difficulty of recruiting physicians to MLK who could work effectively with the community and other members of the health care team. At the time MLK was the flagship of the neighborhood health center movement of the Office of Economic Opportunity.

In 1973 Dr. Jo Ivey Boufford, one of the RPSM’s first pediatric graduates, became the director of the RPSM and began developing the social medicine curriculum which all three disciplines shared. This included health systems skills, such as medical care organization and economics; community and organizational skills, such as medical anthropology, Spanish and community-based projects; research and evaluation skills, such as epidemiology, biostatistics, and health services research; and educational and teaching skills, including patient education and curriculum development.

In 1977 the family practice track moved its continuity practice from MLK to North Central Bronx Hospital and in 1978 Dr. Robert Massad, already a national leader in his discipline, became chairman of Montefiore’s Department of Family Medicine. Under his leadership in 1980 the Montefiore Family Health Center (FHC) was opened and became the primary site for residency training and faculty practice in family medicine.

In 1982 Dr. Boufford left the RPSM to become a Vice President of New York City’s Health and Hospitals Corporation and Dr. Massad assumed her responsibilities. That year the RPSM offered its first month-long “Core Curriculum” rotations in Medical Spanish; Understanding the Health System; and Epidemiology and Community Assessment. Because of MLK’s fiscal problems, the pediatrics and internal medicine tracks moved to St. Barnabus Hospital in 1986. In 1990 several independent community health centers affiliated with MMC were organized into the Montefiore Ambulatory Care Network (MACN) under Dr. Massad. In 1991 pediatrics and internal medicine moved to MACN, now divided between the Comprehensive Health Care Center (CHCC) in the South Bronx and the Comprehensive Family Care Center (CFCC) near the Albert Einstein College of Medicine (AECOM) campus in the East Bronx. In 1997, when CHCC moved into a newly constructed facility, the social internal medicine and pediatrics tracks were again consolidated there. CHCC, CFCC, and FHC are all federally-funded community health centers (Section 330).

In 1992 the Department of Family Medicine at Montefiore, which administers the RPSM, became a full academic department at AECOM with a Division of Research, a required third year clerkship for medical students, and its first geographic inpatient ward on Rosenthal D. Dr. Massad became the first Unified Chairman of Family Medicine at AECOM with affiliated residencies at Bronx-Lebanon Hospital Center. In 1993 Dr. Massad received national recognition awards from both the National Association of Community Health Centers and the Society of Teachers of Family Medicine. In 1995 the RPSM itself became the first organization to receive the National Primary Care Achievement Award in Education from the Pew Charitable Trust (in collaboration with the U.S. Public Health Service, the Pew Health Professions Commission, and the Primary Care Organizations Network). The award cited RPSM’s success in having more than two-thirds of its graduates enter practice in underserved communities.

In 1996 MACN was merged with the older Montefiore Medical Group and a former RPSM graduate, Dr. Kathryn Anastos, was recruited as its first Medical Director. Family practice residents began work at Castle Hill and Valentine Lane Family Practices, where medical students had been rotating since 1993.

In 1998 Dr. Massad announced his retirement, and in 1999 he was succeeded by another RPSM graduate, Dr. Peter Selwyn, as Chair of the Department of Family Medicine and Community Health. Dr. Selwyn extended the Research Division and initiated a Palliative Care Service, including hospice beds on Rosenthal D.

In 2000 the Valentine Lane Family Practice was transferred to the St. John’s Riverside Hospital System in Yonkers, and half of the family practice residency moved to the Williamsbridge Family Practice. In 2001 member of the department established the first Hispanic Center of Excellence in New York State at the medical school. In 2003 the department established the Bronx Center to Reduce and Eliminate Ethnic and Racial Health Disparities, the first and only such NIH Center of Excellence in a department of family medicine. After the AECOM Department of Epidemiology and Social Medicine became the Department of Epidemiology and Population Health in 2004, we became the Department of Family and Social Medicine in 2005.

This brief history was written by Dr. Hal Strelnick for the 2005 RPSM Alumni Reunion. Posted by Matt Anderson, MD




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