On another important matter that I’ve given little attention to recently, Revere reminds us that we are woefully unprepared for a flu pandemic, and the “free market,” even with massive government subsidies, isn’t doing anything about it. As Revere suggests, only governments are capable of pursuing the public interest in cases like this where private companies don’t see a profit. But this will only occur if we exert pressure. Otherwise the free market fundamentalists will endanger our health in yet another way. after all, whether Avian flu, or another strain, an influenza epidemic is as certain as death and taxes:
Red Flag on the Flu Vaccine Front
A story in CIDRAP News by the always excellent science journalist Maryn McKenna provides food for thought:.
A flu vaccine manufacturer’s decision not to build a US facility has highlighted the perpetual mismatch between flu-shot supply and demand–and the reality that the mismatch may undermine plans for pandemic flu vaccines.On Tuesday, Solvay Pharmaceuticals Inc. of Marietta, Ga., announced that it was canceling plans to build a US flu-vaccine manufacturing plant, a $386 million project that Birmingham, Ala., and Athens, Ga., have been competing for. The plant would have made both seasonal and pandemic flu vaccines–but at just about the moment when a final site selection was expected, the company announced that the economics of the two-year-old deal no longer make sense. (Maryn McKenna, CIDRAP News)
The US Government sunk almost $300 million into Solvay for design and development of the new plant but didn’t provide enough for capitalizing it. Apparently to make economic sense some companies require that someone else pay all the upfront costs. I’m sure this is true for Solvay, a chemical, plastics and pharmaceutical conglomerate based in Belgium. Why invest a dollar (or a Euro) in flu vaccine, even though it will make you a tidy profit, when you can invest in some other product that can make you a big profit. That makes business sense. So the losers in this one are US taxpayers (so what else is new?). But the problem, as McKenna points out, is probably deeper than a bad investment of tax dollars:
Nevertheless, the Solvay decision deprives the United States of a domestic source for pandemic flu vaccine if or when a global outbreak begins. And by refusing to offer supply into an uncertain market, the company is challenging the central assumption behind US and global planning for pandemic-vaccine capacity: that demand for seasonal vaccine will provide companies with a rationale for making more vaccine than they now do.Federal health officials have asserted many times that demand will boost manufacturing capacity to the level needed for a pandemic. To reach that level, the World Health Organization’s 2006 “Global Pandemic Influenza Action Plan” calls for countries to boost their flu-shot usage to 75% of their populations, including countries where seasonal vaccine has never been used.
Here’s how I would say this: the market doesn’t work for flu vaccine. It is like saying that a war is like the market and will call up a demand for an army. so between wars we can disband the military. I might like that, but if you believe there are real threats out there requiring a military this would be nonsense to you. Since most scientists think there is a pandemic threat out there, why should we let “the market” govern if we have the resources if and when we need them? Because the US government, especially this administration but not only this administration, worships the market (except when they don’t) and kowtows to drug companies (almost always).
If the market doesn’t work for flu vaccine I see no reason to throw up our hands and give up. We construct another mechanism. In this case it could be a global network of regional vaccine laboratories (maybe ten or a dozen, with some large regions, like the US, having several) that have adequate reserve capacity to ramp up production quickly in the case of need. In the absence of demand this produces unused and redundant capacity and is inefficient. As do standing armies in times of peace. The cost would be borne by the global community as a whole.
The alternative is to do as we are dong now, leave it to the private sector which has no incentive to meet the need, and should a pandemic arise will be able to respond too little, too late and at great cost, both because the demand will exceed supply and the loss in pain in suffering from the missed opportunity will be enormous.
The Solvay decision is another warning flag. Of course, we have shown a prodigious capacity to ignore warning flags
October 6th, 2008
Physicians for Human Rights has released the following statement on today’s dramatic letter from APA President Kazdin to President Bush, calling for removing psychologists from the illegal detention centers:
PHR Salutes APA’s Ban on Psychologists at Illegal US Interrogations
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Media Contacts:
Nathaniel Raymond
nraymond [at] phrusa [dot] org
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Physicians for Human Rights (PHR) CEO Frank Donaghue congratulates American Psychological Association (APA) President Alan E. Kazdan, PhD, who wrote to President George W. Bush on October 2 to inform him of a significant change in APA policy that limits the roles of psychologists at illegal U.S. detention facilities, such as Guantanamo Bay, Cuba, and CIA black sites overseas, where systematic torture has occurred.
Cambridge, MA. (PRWEB) October 2, 2008 - “APA’s announcement today is a historic victory for medical ethics and human rights,” said Physicians for Human Rights CEO Frank Donaghue. “PHR salutes the APA for telling President Bush that psychologists can no longer serve at illegal US facilities that violate the Constitution and international human rights standards. This dramatic policy reversal represents a massive transformation by an organization that has until now encouraged members to assist interrogations of detainees at Guantanamo Bay, Cuba, and CIA black sites overseas.”
The Association’s policy reversal was driven by a first-of-its-kind referendum, pushed by a reform movement among its members, with PHR’s active support. PHR has been campaigning since 2005 for the APA to end psychologists’ participation in U.S. national security interrogations. Government and press reports have confirmed that military and intelligence psychologists were central to the design, implementation, and supervision of the Bush administration’s regime of psychological and physical torture.
“The Pentagon and the CIA must now abide by the APA’s new policy and immediately cease employing psychologists as part of detainee interrogations,” stated Donaghue. “The Bush Administration’s interrogation policies have inflicted grievous damage to the core principles of medical ethics and the rule of law. The APA’s statement today is a watershed moment in the fight to stop psychologists from being used to cause harm and return them to their appropriate role as healers.”
The Department of Defense is expected this month to review the operational guidance for BSCTs (Behavioral Science Consultation Teams), which use mental health professionals in detainee interrogations—an application which violates international standards of health professional ethics. PHR has led the public and behind-the-scenes effort to shut down the BSCT program.
“While today is a proud day for the APA and its membership, the APA must now act to permanently prohibit direct participation by psychologists in interrogations and to ensure those psychologists who engaged in abuse and torture are held to account,” said Donaghue. “The APA has taken a tremendous step forward but has not yet reached the ethical standards of the American Medical Association and the American Psychiatric Association, organizations which have banned direct participation by physicians in all interrogations. Also, the APA has not yet specified what rights abuses would render a detention facility illegal under its new policy.”
October 2nd, 2008
Revere at Effect Measure explains what’s going on at the National Institutes of Health [NIH] as the Director resigns, and the implications for U.S. science:
Like a lot of other research scientists supported by NIH I got an email yesterday from NIH Director Elias Zerhouni announcing his intention to leave his position “to devote much of my attention to writing.” At least it wasn’t the hackneyed “to spend more time with my family.” While Zerhouni won’t actually leave until the end of next month, the federal health research establishment is essentially leaderless, awaiting the next administration. The main public health institute within the NIH system, the National Institute for Environmental Health Sciences (NIEHS) has been under “Acting” (although quite capable) for many months after its previous Director resigned under fire (see here, here, here, here and here). That scandal reached all the way to Director Zerhouni’s office, although Zerhouni himself left no fingerprints. In any event, his departure is not a surprise. It was widely predicted he would resign over the summer in time to take an academic job. His plans to “devote time to writing” and the timing of the announcement after the start of the academic year suggest he wasn’t able to secure a top level academic position.
Zerhouni presided over tumultuous years at NIH. The doubling of the NIH budget in the five years prior to 2003 created a pig in a python effect when the budget flatlined and all the new post docs, graduate students, laboratories and research projects stimulated by the doubling were left high and dry. Now the budget is at about what it was in real dollars before the doubling but there are many more mouths to feed and lab benches to maintain. Basic health research is facing its own financial meltdown as existing grants aren’t being renewed and the hands that do the work — the post docs and graduate students — are leaving the field and the research programs they were a part of are withering. This is creating a crisis in leadership in academic science in the US, as the post docs leave for other work and the mid level academics coming up for tenure can’t get their grants renewed and have to leave their institutions to look for other positions and start over or leave research altogether.
The result will be continued erosion of US leadership in the basic sciences. The current financial crisis and wasteful and atrocious war in Iraq have squandered enormous quantities of federal resources, a small fraction of which could have strengthened the kind of science that would benefit everyone. Instead we will see the basic science foundation of the country weakened.
Zerhouni is getting out while the getting is good.
September 26th, 2008
Just when you think you’ve heard it all in contemporary America. In this bizarre tale, Scott Horton alerts us to what our federal resources — both VA and Justice Department — are being used for. In order to prosecute a woman for refusing to pay $3.80 for a cup of soda, they violate medical record considentiality and expend scare Justice Department resources:
Unexpected Consequences from a Mug of Soda
By Scott Horton
The Bush Justice Department continuously tells us it is beleaguered, under-resourced, and having a hard time battling crime. But sometimes its enthusiasm for a prosecution is just effervescent. The latest episode showing the Justice Department’s more than curious notions of justice can be found this week in the pages of the Idaho Statesman. Natalie Walters is now facing prosecution that could put her in prison for six months. Her crime? She poured a cup of Diet Coke on a counter in a Veteran’s Administration cafeteria.
The 39-year-old North Idaho resident periodically drives her father, a disabled Vietnam veteran, to Boise’s VA Medical Center for doctor visits. She brings her own mug and fills it with soda in the hospital’s cafeteria. The cafeteria does not have a posted price for refills and typically the cashier charges her $1 or $1.50, Walters said.
But on Aug 20, when Walters filled her mug with Diet Coke, the clerk charged $3.80. “I told her that cannot be right and asked to talk to the manager,” Walters said. The manager told Walters the price is correct. Walters decided she didn’t want to pay that much and offered to return the soda, she said. But the manager told her there was no way to accept the returned soda, so Walters had to pay. Walters refused, and she said she was angry by this point, and she poured the soda onto the counter. The manager banned Walters from the cafeteria. Walters left but remained in the hospital for a couple of hours waiting for her father to finish his appointments. No one came to talk to her, so she assumed the soda ordeal was over.
Evidently not. VA bureaucrats used surveillance cameras to monitor her movements in the hospital and then, in what was possibly a criminal act, and certainly an unethical one, accessed the medical records of her father to demand that he be in touch with his daughter and pressure her to turn herself in over the spat.
The VA turned the matter over to Idaho U.S. attorney, Thomas E. Moss, who prides himself on having been picked as an adviser to Alberto Gonzales. Moss literally decided to make a federal case of it by bringing a prosecution. Remember, this is the same Bush Justice Department which has advised Congress that it “lacks the resources” to investigate or prosecute more than 30 rape cases involving contractors in Iraq, and which recently decided that senior Republican appointees caught in a massive corruption, cocaine and illicit sex scandal at the Interior Department weren’t worth going after. The Justice Department knows, however, just where its priorities lie.
And that $3.80 cup of Diet Coke? A former Coca-Cola bottling executive told me that the cost to a vendor in syrup and carbonated water of a Diet Coke dispensed in an 8-ounce container would be approximately 8 cents ($0.08). The profit margin that the VA was seeking on the sale was therefore staggering–price gouging directed at visitors and patients at a Veteran’s facility. (I didn’t factor in the ice, but still.) It’s good to know the Justice Department’s priorities, but unfortunate that justice is not one of them.
September 20th, 2008
Bioethicist steven Miles sends this request:
I am interested in collecting names, clippings, websites, citations or other information on cases involving physicians who have been tried in criminal courts, appeared before licensing boards, been censured by professional societies, or sued in civil cases for participation in torture, government directed kidnappings of political opponents, falsifying medical records or death certificates to conceal torture, oversight of genocide and other related human rights violations.
I am not interested in material related to World War II experiences.
Please circulate this request broadly.
Thank you.
Steven Miles, MD
Center for Bioethics
Dept of Medicine
University of Minnesota
miles001@umn.edu
September 16th, 2008
A new study described in Science Daily reports intriguing findings linking childhood abuse to asthma rates in urban Puerto Rican children. Neighborhood violence, in contrast, was not associated with an elevated asthma rate, suggesting a specificity of mechanism. The differential effect of types of violence suggests that the negative effects have to do with the social context and/or personal meanings associated with the violence.
Physical And Sexual Abuse Linked To Asthma In Puerto Rican Kids
Children who are physically or sexually abused are more than twice as likely to have asthma as their peers, according to a recent study of urban children in Puerto Rico. In fact, physical and sexual abuse was second only to maternal asthma in all the risk factors tested, including paternal asthma and indicators of socioeconomic status.
“To our knowledge, this is the first report of a direct association between childhood abuse and asthma and asthma-related outcomes,” wrote Robyn T. Cohen, M.D., M.P.H., lead author of the paper of the Channing Laboratory of Brigham and Women’s Hospital in Boston.
“We wanted to explore whether exposure to stress and violence is associated with an increased risk of asthma in urban children living in Puerto Rico,” said principal investigator, Juan C. Celedón, M.D., Dr.P.H. “We already know that there is a high prevalence of asthma in Puerto Rican children, and many studies have linked stress and exposure to violence to health problems in childhood, including asthma.”
The researchers interviewed 1,353 parent-child pairs in between 2001 and 2003, and re-interviewed nearly 90 percent of the same pairs two years after their initial interviews. They used validated questionnaires to elicit information about stress and violence in the children’s lives (whenever possible, without the parent present), and used doctor-diagnosed asthma, allergic rhinitis, use of prescription medication for asthma and physician visits for asthma and/or allergic rhinitis within the previous year to assess the children’s asthma/allergy status.
“Children with a history of abuse had higher frequencies of all outcomes of interest than those without a history of abuse,” wrote Dr. Cohen. “After adjusting for relevant covariates, history of abuse was associated with an approximate doubling of the odds of current asthma, healthcare use for asthma, and allergic rhinitis.” For example, whereas 15 (20 percent) of the 75 children with a history of abuse had current asthma, 128 (11.5 percent) of 1,117 children without history of abuse had current asthma.
The study did not, however, find a link between neighborhood violence and asthma, as other studies have done in the past. The researchers suggest that the discrepancy may be the result of the fact that “it is not simply the exposure to a particular stressor but the physiological response to that stressor that predicts physical health outcomes.”
Individual responses to stressors such as community violence will vary, and according to some data, Puerto Rican culture itself may have protective features. “Latino culture places an emphasis on certain values and social supports that may buffer the effects of poverty and community violence experienced by children in Puerto Rico,” said Dr. Cohen. Direct physical or sexual abuse, however, could cause a break-down of those buffering systems.
The investigators postulate that abuse may alter the hypothalamic-pituitary-adrenal (HPA) axis, which in turn may depress the glucocorticoid response, resulting in decreased suppression of airway inflammatory responses. Other studies have supported this possibility, especially among patients with post-traumatic stress disorder.
But while the exact pathway remains unclear, and beyond the scope of a cross-sectional study has yet to be ascertained, there is immediate relevance of the findings for social workers and physicians: “Our findings highlight the importance of both screening for illnesses such as asthma in children who are abused and of being aware of the possibility of abuse in children with asthma,” wrote Dr. Cohen.
The article was published in the first issue for September of the American Journal of Respiratory and Critical Care Medicine, a publication of the American Thoracic Society.
August 31st, 2008
Steven Miles has a new editorial in the British Medical Journal on medical complicity with torture and the spotty record of accountability:
Doctors’ complicity with torture: It is time for sanctions
By Steven H. Miles
It is an arresting thought. More doctors abet torture than treat the millions of victims. More than 100 countries condone the use of torture. A third to a half of torture survivors report that a doctor oversaw the abuse.1 Many prisoners never see the doctors who refined the techniques to minimise evidential scars, prolong pain, or cause psychological destruction.2 Estimates of the numbers of torture victims do not include people whose murders disappear when a doctor writes “natural causes” on a death certificate.
The medical profession ought to dissociate itself from torture-a practice that destroys institutions of civil society; that is used against colleagues of conscience, and that has far reaching adverse mental, physical, and social consequences. Instead, medical societies and licensing boards offer lofty condemnation, which is most ardently aimed at offenders abroad rather than accomplices at home.
Doctors who abet torture rarely face professional risks. Governments will not punish a doctor for helping them carry out their crimes. Few medical societies or licensing boards have the courage and constancy of vision to investigate or censure colleagues who carry out the law of the land. In principle, medical societies support ethics codes like the World Medical Association’s Declaration of Tokyo, which bars doctors from complying with torture. In practice, they sustain the policy of impunity.3
The exceptions are instructive. The Nuremberg trial of Nazi doctors for war crimes was the birth of bioethics. That admirable court was convened by victors over defendants from a vanquished nation. But it is the wrong place to look for solutions to the common problem of doctors complying with torture. The problem today is holding doctors accountable for abetting torture and cruel, inhuman, or degrading treatment of their own citizens. Such cases have occurred after a torturing regime loses power. Brazilian medical licensing boards began investigating doctors for collaborating with torture during the last years of military rule. Initially, the government blocked sanctions against doctors; within a decade of civilian government sanctions against doctors took hold.4
In Greece, Dimitrios Kofas, a doctor stationed at the persecution section of a prison in Athens, was sentenced to prison within a year of the military junta being deposed.5 The Chilean Medical Society actively investigated complaints against doctors and expelled six doctors for overseeing torture during Pinochet’s rule.6 Three years after Argentina’s junta fell, Dr Jorge Berges was sentenced to prison for carrying out torture.7 A South African medical board tabled complaints against police doctors who failed to report or treat the fatal head injury inflicted by police on civil rights leader Steven Biko; two doctors were punished eight years after his death.8
A more secure foundation for this kind of accountability can and should be laid. The World Medical Association’s Declaration of Hamburg states that licensing boards should deny licences to doctors who are guilty of war crimes, including torture.9 Unfortunately, that declaration only applies to immigrating doctors who are accused of crimes in another country. For example, there was a successful campaign to deny a Belgian licence to an immigrant doctor who had been active in Rwanda’s genocide.10 The BMA is one of a few medical societies that support sanctions against doctors who torture, but it has not established a means to implement such sanctions.11
Countries wax and wane in their practice of torture. Foundations for making doctors accountable for this crime must be laid during periods of civil society. At such times, each national medical society and licensing agency should assert that medical complicity with torture and cruel inhuman or degrading treatment is a punishable breach of medical ethics that cannot be excused by law and for which there is no term limit. In the United States, California is considering a law that would ask its licensing agencies to inform health professionals that participating in coercive interrogation, torture, or other forms of cruel, inhuman, or degrading treatment or punishment may subject them to prosecution.12
The recruitment of the medical community in support of torture has far reaching effects. It harms prisoners. It deprives all prisoners of hope in the humanity of the medical staff. A civilian medical community that acquiesces to torture by its military members cannot credibly protest against foreign doctors who carry out torture. Such a community can hardly support doctors who are endangered for their resistance against torture. The prestige and values of medicine make it a crucial part of the campaign to abolish torture.
“I will guard my art and my life.” That pivotal promise of vigilance in the Hippocratic oath acknowledges that medical professionalism is not an easy virtue. Diverse enticements lure doctors from the core of medicine: “I will use regimens for the benefit of the ill but from what is to their harm or injustice, I will protect them.” Governments that practice torture need doctors. The medical accomplices of torture must not rest in the confidence that they can violate civil society and the ethics of medicine with impunity.
Cite this as: BMJ 2008;337:a1088
Steven H Miles, professor of medicine and bioethics
1 Center for Bioethics, N504 Boynton, Minneapolis, MN 55414, USA
miles001@umn.edu
Competing interests: None declared. Provenance and peer review: Commissioned; not externally peer reviewed.
From the archive: Two recent news stories have dealt with torture. Doctors protest against surgeon held for six years at Guantanomo (news story; doi: 10.1136/bmj.a1071); Medical evidence exposes US use of torture-includes embedded video clip (news story; doi: 10.1136/bmj.a490)
References
- Rasmussen OV. Medical aspects of torture. Dan Med Bull 1990;37(suppl 1):1-88.[ISI][Medline]
- Stover E, Nightingale E. The breaking of bodies and minds. Washington DC: American Association for the Advancement of Science, 1985.
- World Medical Association. Guidelines for medical doctors concerning torture and other cruel, inhuman or degrading treatment or punishment in relation to detention and imprisonment (Declaration of Tokyo). 2006. www.wma.net/e/policy/c18.htm.
- Amnesty International. Brazil. Human rights violations and the health professions. 1996. http://asiapacific.amnesty.org/library/Index/ENGAMR190251996?open&of=ENG-346.
- Amnesty International. Torture in Greece: the first torturers’ trial 1975. London: Amnesty International, 1977.
- BMA. Medicine betrayed. London: BMA, 1992.
- Human Rights Watch. Argentina. 2006. www.hrw.org/reports/2001/argentina/argen1201-02.htm.
- McLean GR, Jenkins T. The Steve Biko affair: a case study in medical ethics. Dev World Bioethics 2003;3:77-95.[CrossRef]
- World Medical Association. Statement on the licensing of physicians fleeing prosecution for serious criminal offences (Declaration of Hamburg). 1997. www.wma.net/e/policy/c16.htm.
- Hall P. Doctors and the war on terrorism. BMJ 2004;329:66.[Free Full Text]
- British Medical Association. The medical profession and human rights: handbook for a changing agenda. Torture. 2001. www.bma.org.uk/ap.nsf/Content/MedProfhumanRightsRecommendations#Torture.
- California Senate 19. Health professionals: torture. 2008. www.leginfo.ca.gov/cgi-bin/postquery?bill_number=sjr_19&sess=CUR&house=B&author=ridley-thomas.
Steven Miles, MD
N504 Boynton, 410 Church St SE
Minneapolis, MN 55455-0346
612-624-9440
July 31st, 2008
The New York Times reported yesterday on a new study concluding that receipt of loans from the International Monetary Fund is associated with increased tuberculosis cases. The bottom line, from the Editors’ Summary (posted below the article):
“[T]hese results challenge the proposition that the forms of economic development promoted by the IMF necessarily improve public health”
Here is the Times article:
Rise in TB Is Linked to Loans From I.M.F.
By Nicholas Bakalar
The rapid rise in tuberculosis cases in Eastern Europe and the former Soviet Union is strongly associated with the receipt of loans from the International Monetary Fund, a new study has found.
Critics of the fund have suggested that its financial requirements lead governments to reduce spending on health care to qualify for loans. This, the authors say, helps explain the connection.
The fund strongly disputes the finding, saying the former communist countries would be much worse off without the loans.
“Tuberculosis is a disease that takes time to develop,” said William Murray, a spokesman for the fund, “so presumably the increase in mortality rates must be linked to something that happened earlier than I.M.F. funding. This is just phony science.”
The researchers studied health records in 21 countries and found that obtaining an I.M.F. loan was associated with a 13.9 percent increase in new cases of tuberculosis each year, a 13.3 percent increase in the number of people living with the disease and a 16.6 percent increase in the number of tuberculosis deaths.
The study, being published online Tuesday in the journal PLoS Medicine, statistically controlled for numerous other factors that affect tuberculosis rates, including the prevalence of AIDS, inflation rates, urbanization, unemployment rates, the age of the population and improved surveillance.
The lead author, David Stuckler, a research associate at Cambridge University, defended the study against the fund’s criticisms, noting that the researchers considered whether increased mortality might have led to more loans rather than the other way around.
Instead, they found that the increase in tuberculosis mortality followed the lending; each 1 percent increase in credit was associated with a 0.9 percent increase in mortality. And when a country left an I.M.F. loan program, mortality rates dropped by an average of 31 percent.
“When you have one correlation, you raise an eyebrow,” Mr. Stuckler said. “But when you have more than 20 correlations pointing in the same direction, you start building a strong case for causality.”
The study can be read here. Here is the Editors’ Summary for the article:
Editors’ Summary
Background.
Tuberculosis—a contagious, bacterial infection—has killed large numbers of people throughout human history. Over the last century improvements in public health began to reduce the incidence (the number of new cases in the population in a given time), prevalence (the number of infected people), and mortality rate (number of people dying each year) of tuberculosis in several countries. Many authorities thought that tuberculosis had become a disease of the past. It has become increasingly clear, however, that regions impacted by health and economic changes since the 1980s have continued to face a high and sometimes increasing burden of tuberculosis. In order to boost funding and resources for combating the global tuberculosis problem, the United Nations has set a target of halting and reversing increases in global tuberculosis incidence by 2015 as one of its Millennium Development Goals. Yet one region of the world—Eastern Europe and the former Soviet Union—is not on track to achieve this goal.
Why Was This Study Done?
To achieve these targets, the World Health Organization (WHO) and tuberculosis physicians’ groups promote the expansion of detection and treatment efforts against tuberculosis. But these efforts depend on the maintenance of good health infrastructure to fund and support health-care workers, clinics, and hospitals. In countries with significant financial limitations, the development and maintenance of these health system resources are often dependent upon international donations and financial lending. The International Monetary Fund (IMF) is a major source of capital for resource-deprived countries, but it is unclear whether its economic reform programs have positive or negative effects on health and health infrastructures in recipient countries. There are indications, for example, that recipient countries sometimes reduce their public-health spending to meet the economic targets set by the IMF as conditions for its loans. In this study, the researchers examine the relationship between participating in IMF lending programs of varying sizes and durations by 21 post-communist Central and Eastern European and former Soviet Union countries and changes in tuberculosis incidence, prevalence, and mortality in these countries during the past two decades.
What Did the Researchers Do and Find?
To examine how participation in IMF lending programs affected tuberculosis control in these countries, the researchers developed a series of statistical models that take into account other variables (for example, directly observed therapy programs, HIV rates, military conflict, and urbanization) that might have affected tuberculosis control. Participation in an IMF program, they report, was associated with increases in tuberculosis incidence, prevalence, and mortality rate of about 15%, which corresponds to hundreds of thousands of new cases and deaths in this region. Each additional year of participation increased tuberculosis mortality rates by 4.1%; increases in the size of the IMF loan also corresponded to greater tuberculosis mortality rates. Conversely, when countries left IMF programs, tuberculosis mortality rates dropped by roughly one-third. The authors’ further statistical tests indicated that IMF lending was not a positive response to worsened tuberculosis control but precipitated this adverse outcome and that lending from non-IMF sources of funding was associated with decreases in tuberculosis mortality rates. Consistent with these results, IMF (but not non-IMF) programs were associated with reductions in government expenditures, tuberculosis program coverage, and the number of doctors per capita in each country. These findings associated with mortality were also found when analyzing tuberculosis incidence and prevalence data.
What Do These Findings Mean?
These findings indicate that IMF economic programs are associated with significantly worsened tuberculosis control in post-communist Central and Eastern European and former Soviet Union countries, independent of other political, health, and economic changes in these countries. Further research is needed to discover exactly which aspects of the IMF programs were associated with the adverse effects on tuberculosis control reported here and to see whether IMF loans have similar effects on tuberculosis control in other countries or on other non–tuberculosis-related health outcomes. For now, these results challenge the proposition that the forms of economic development promoted by the IMF necessarily improve public health. In particular, they put the onus on the IMF to critically evaluate the direct and indirect effects of its economic programs on public health.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050143.
July 23rd, 2008
Bob Herbert writes in the New York Times of the recently releases Physicians for Human Rights report, Broken Laws, Broken Lives: Medical Evidence of Torture by the US:
All Too Human
By Bob Herbert
Thursday was the 21st anniversary of the United Nations Convention Against Torture.
It was also the same day that two Bush administration lawyers appeared before a House subcommittee to answer questions about their roles in providing the legal framework for harsh interrogation techniques that inevitably rose to the level of torture and shamed the U.S. before the rest of the world.
The lawyers, both former Justice Department officials, were David Addington, who is now Dick Cheney’s chief of staff, and John Yoo, now a law professor at the University of California, Berkeley. There is no danger of either being enshrined as heroes in the history books of the future.
For most Americans, torture is something remote, abstract, reprehensible, but in the eyes of some, perhaps necessary - when the bomb is ticking, for example, or when interrogators are trying to get information from terrorists willing to kill Americans in huge numbers.
Reality offers something much different. We saw the hideous photos from Abu Ghraib. And now the Nobel Prize-winning organization Physicians for Human Rights has released a report, called “Broken Laws, Broken Lives,” that puts an appropriately horrifying face on a practice that is so fundamentally evil that it cannot co-exist with the idea of a just and humane society.
The report profiles 11 detainees who were tortured while in U.S. custody and then released - their lives ruined - without ever having been charged with a crime or told why they were detained. All of the prisoners were men, and all were badly beaten. One was sodomized with a broomstick, the report said, and forced by his interrogators to howl like a dog while a soldier urinated on him.
He fainted, the report said, “after a soldier stepped on his genitals.”
Officials at Physicians for Human Rights said extensive medical and psychological examinations were conducted - and in two cases prior medical records were consulted - to help corroborate the testimony of the detainees. The organization has a long and credible history of documenting such abuses.
Leonard Rubenstein, president of Physicians for Human Rights, said: “In doing the evaluations, we used international standards, medical assessments of torture and ill treatment, and meticulously assessed physical and psychological evidence of torture and ill treatment, and the long-term physical and mental health consequences.”
The most effective element of the report is the way in which it takes torture out of the realm of the abstract to show not just the horror and cruelty of the torture itself, but the way in which it absolutely devastates the body, soul and psyche of its victims.
The detainees profiled in the report were abused at facilities in Afghanistan, Iraq and Guantánamo Bay, Cuba. Three said they had been subjected to electric shocks. One said he was stabbed in the cheek with a screwdriver and hit in the head and in the jaw with a rifle.
In an example of how medical evidence was used to back up a detainee’s account, the report said scarring on one of the prisoner’s thumbs “was highly consistent with the scarring caused by electric shock.”
In addition to the physical mistreatment, the detainees reported that various gruesome forms of humiliation, including sexual humiliation, were pervasive. They said men were paraded nude in front of female soldiers, forced to watch pornography, and forced to disrobe before female interrogators.
The sheer number of different ways in which detainees were reported to have been abused was mind-boggling. They were deprived of sleep, forced to endure extremes of heat and cold, chained in crouching positions for 18 to 20 hours at a time, told that their female relatives would be raped, that they themselves would be killed, and on and on. All to no good end.
The ostensible purpose of mistreating prisoners is to inflict pain and induce disorientation and despair, creating so much agony that the prisoners give up valuable intelligence in order to end the suffering. But torture is not an interrogation technique; it’s a criminal attack on a human being.
What the report makes clear is that once the green light is given to torture, the guaranteed result is an ever-widening landscape of broken bodies, ruined lives and profound shame to all involved.
Nearly all of the detainees profiled in the report have experienced excruciating psychological difficulties since being released. Several said that they had contemplated suicide. As one put it: “No sorrow can be compared to my torture experience in jail. That is the reason for my sadness.”
Congress and the public do not know nearly enough about the nation’s post-Sept. 11 interrogation practices. When something as foul as torture is on the table, there is a tendency to avert one’s eyes from the most painful truths.
It’s a tendency we should resist.
July 1st, 2008
Are we to have accountability for torture at last? two new developments give hope that an accountability moment may yet occur.
Rendition Investigation Reopened
In the first development, the Homeland Security Inspector General told Congress he is reopening an investigation into the “extraordinary rendition” of Canadian Maher Arar. Arar, as you may recall, was arrested as he was switching planes en route home from vacation in Switzerland and sent to be tortured in Syria. For the first time a US official admitted that there is evidence that Arar was sent to Syria because it was expected that he would be tortured there.
Skinner’s testimony said officials “concluded that Arar was entitled to protection from torture and that returning him to Syria would more likely than not result in his torture.”
The Canadian government acknowledged error, apologized to Arar, and issued reparations. The US government refused to allow him to enter the country to give Congressional testimony.
More information on the Arar case and the IG investigation can be obtained from Scott Horton’s posting, which includes his testimony to Congress this week. As Horton summed up his view of the hearings:
The hearing revealed some remarkable facts. First, that Deputy Attorney General Larry Thompson made a key finding that facilitated Arar’s shipment to Syria (a determination that it was against U.S. interests for him to be returned to Canada). Second, that the INS had determined that Arar would more likely than not be tortured if he was returned to Syria. Third, that his shipment to Syria, overriding normal procedures, occurred after tremendous pressure had been brought to bear from the office of the Deputy Attorney General.
The hearing was remarkable in that, although pretty harsh criticism was doled out by Committee members and myself, IGs Skinner and Ervin largely agreed that the criticism was well-founded, that the conduct involved was inexplicable or inexcusable, and that a further investigation was necessary.
Even more amazingly, the entire panel of speakers (including the two IGs) agreed that it would be appropriate for a criminal investigation to be commenced looking into violations of the anti-torture statute by those involved in the case, particularly figures in the Deputy Attorney General’s office.
Congress Members Urge Special Counsel
In the other development, nearly 60 members of Congress have written the Attorney General (aka, Director of Torture Cover-up), requesting that a Special Counsel be appointed to investigate Bush administration involvement in torture. [The letter to Mukasey can be read here.]
In a letter to Attorney General Michael B. Mukasey, the lawmakers cited what they said is “mounting evidence” that senior officials personally sanctioned the use of waterboarding and other aggressive tactics against detainees in U.S.-run prisons overseas. An independent investigation is needed to determine whether such actions violated U.S or international law, the letter stated.
Apparently referring to a recent ABC News report that US torture was micromanaged out of the White House by the so-called Principals Committee — which included Vice President Richard Cheney, Condoleezza Rice, Donald Rumsfeld, Colin Powell, George Tenet, and Attorney General John Ashcroft – with President Bush’s knowledge and approval:
[W]ithin the last month additional information has surfaced that suggests the fact that not only did top Administration officials meet in the White House and approve the use of enhanced techniques including waterboarding against detainees, but that President Bush was aware of, and approved of the meetings taking place.
They go on to summarize the implications of the revelations of White house micromanaging of torture:
“This information indicates that the Bush administration may have systematically implemented, from the top down, detainee interrogation policies that constitute torture or otherwise violate the law,” it said. The letter was signed by 56 House Democrats, including House Judiciary Committee Chairman John Conyers Jr. (D-Mich.) and House Intelligence Committee members Jan Schakowsky (D-Ill.) and Jerrold Nadler (D-N.Y).
As Rep. John Conyers explained:
“We need an impartial criminal investigation,” said Conyers, who called the detainee controversy “a truly shameful episode” in U.S. history. “Because these apparent ‘enhanced interrogation techniques’ were used under cover of Justice Department legal opinions, the need for an outside special prosecutor is obvious.”
Fiven the determination of Attorney general Mukasey to carry out his primary duty of protecting the torturers, there is little chance the recommendation in this letter will be acted upon during this administration. When a new administration takes power on January 20, there will be great pressure to forget the wrongs committed by the Bush administration. We are likely to be told by the opinion makers to “let bygones be bygones” and to look ahead. It is up to us concerned citizens to keep the pressure on for accountability for Bush administration crimes, among the foremost of which is the open legalized use of torture. Only truth and accountability can inhibit a recurrence when the next crisis hits our country.
Health Professions’ Accountability
While the lawyers and others who made possible the Bush regime abuses are starting to receive the scrutiny they deserve, we should not forget the need for psychologists and other health professions to establish accountability for our professions’ aiding and abetting Bush’s torture regime. It is well known that the American Psychological Association worked hard to provide cover for Bush administration actions. But the other health professions, while taking stronger positions regarding their members’ participation in detainee interrogations, have not acted to discipline or condemn the actions of their members aiding the torture regime.
It is openly acknowledged by both the Defense Department and the CIA that their “harsh interrogations” (aka “torture”) are conducted under medical supervision. Yet neither the AMA nor ANA have acted to investigate nor discipline members performing these functions. And official and unofficial reports have consistently pointed to the failure of medical professionals, in most cases, to stop or report abuse of detainees, even as they stitched up the wounds and medicated the damaged souls.
None of the health professions should be proud of how it responded to this crisis of human rights and of human decency. We need a Health Professionals Truth Commission to investigate and produce a definitive account of the collaboration of members of our professions in detainee abuses. We further need an analysis of the policy errors and institutional pressures that inhibited our professions from doing the right thing and putting “do no harm” at the top of our agenda.
June 8th, 2008