Secretary of State Hillary Clinton on the Global Health Initiative

This C-SPAN report is worth considering: “Secretary of State Hillary Clinton spoke at Johns Hopkins University’s School of Advanced International Studies on the Obama Administration’s Global Health Initiative. She discussed the six-year, $63 billion investment that focuses on improving the health of women, children and newborns throughout the world.”

You can see the video (or the transcript) by clicking on the picture.

Recommended Reading: Recent Legal Scholarship on Issues in Global Public Health

Redressing the Unconscionable Health Gap: A Global Plan for Justice (published in the Harvard Law & Policy Review). In this article Lawrence Gostin brings a big picture issue — the vast global health gap between rich and poor — into perfect focus. Professor Gostin reminds us of an “uncomfortable truth” — “that closing the health gap is well within the means of the international community” — and he proposes a simple (in concept if not execution) plan to do just that.  No international treaty would be required; Professor Gostin’s Global Plan for Justice would take the form of a World Health Assembly resolution.  No new organization or governance structure would be required either; rather, the World Health Organization would “assume its place as the global health leader.”  States would be asked to contribute a small percentage — Professor Gostin suggests 0.25% — of their Gross National Income each year to a Global Health Fund.  The WHO would then allocate the Fund’s resources based on “the health needs of developing countries measured by poverty, morbidity, and premature mortality.”  Professor Gostin suggests that the mission of the Fund be threefold: “(1) ensure the fair allocation of essential vaccines and medicines, with particular attention to low- and middle-income countries in a public health emergency; (2) meet basic survival needs [e.g. food, water, sanitation, and vector controls] and create the conditions in which people can be healthy; and (3) help countries that will suffer most to adapt to the health impacts of climate change.”  Existing efforts, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, demonstrate the power of voluntary collective action; unlike the proposed Global Health Fund, however, they are too narrowly-targeted and inconsistent to close the global health gap.  Professor Gostin’s article is short (it’s based on the text of a speech), straightforward, and provocative in the best sense of the word.  I highly recommend it.

I also highly recommend Kevin Outterson’s The Legal Ecology of Resistance: The Role of Antibiotic Resistance in Pharmaceutical Innovation (published in the Cardozo Law Review) in which he uses proprietary sales and volume data for the important hospital antibiotic vancomycin to test a number of widely-propounded theories about the interplay between antibiotic resistance and intellectual property law.  The vancomycin case study fails to support the hypothesis that a patent holder is likely to zealously market an antibiotic with an eye to the drug’s dwindling patent term, without regard for the risk that increased uptake could accelerate the evolution of antibiotic-resistant bacteria.  It also fails to support the hypothesis that if patent terms for antibiotics were extended, patent holders would better manage the sales and use of their drugs to forestall the development of resistance.  By contrast, the story of vancomycin is consistent with the hypothesis that antibiotic resistance stimulates innovation — as bacteria evolve that are resistant to an existing antibiotic a market for a new antibiotic arises.  All of this suggests that “tinker[ing] with the patent system” is unnecessary and could even backfire.  Professor Outterson concludes that a more direct and potentially more effective approach to preserving the antibacterial effectiveness of our antibiotics would be to fix our broken health care reimbursement system, under which infection control is an unreimbursed cost and “hospitals and doctors have generally gained revenues from additional infections[.]“

Developments In Domestic and Global HIV/AIDS Strategies

The White House recently released its HIV/AIDS strategy to reduce the number of new infections in the United States by 25% over the next five years.  During a press conference, President Obama observed that “[t]he question is not whether we know what to do, but whether we will do it.  Whether we will fulfill those obligations… to prevent a tragedy.”  Those obligations primarily concern reducing the number of new infections through HIV prevention programs, increasing access to and quality of care for those living with HIV, and decreasing HIV-related health disparities.  Right now there are 56,000 new infections in the United States every year.  Approximately 1.1 million Americans are living with HIV, but 1 in 5 don’t know it.

Advocates have criticized both the administration and Congress for failing to adequately fund HIV/AIDS efforts at home and abroad.  A recent AIDS Healthcare Foundation (AHF) “Who’s Better on AIDS?” advocacy advertisement unfavorably compared President Obama’s track record to that of President Bush.  (In 2003, the Bush administration implemented the President’s Emergency Plan for AIDS Relief (PEPFAR), a multibillion dollar initiative which has proved successful in lowering the AIDS death rate in Africa, though not the rate of HIV infection).   Michael Weinstein, President of AHF, told CNN that:

“when you see what this administration has done on AIDS, you have to give them very low grades.”

Obama has “consistently underfunded AIDS” programs, Weinstein said.  The president “did not mention the word AIDS for the first five months of his administration.  This national AIDS strategy has been worked on for 15 months, [and] I think it could have been done in 15 minutes.  There’s nothing new in it.”

Weinstein [also] criticized the administration’s intention to redirect money to those groups at greatest risk of contracting HIV/AIDS.  “It’s not good to pit one group against another and it’s unnecessary,” he said.  “The bottom line is that we should be seeking to get all sexually active people to get an HIV test.”

Some recent Canadian research also suggests another bottom line: treating people with HIV reduces the number of new infections.  And there the treatment is free.

The Center for Disease Control (CDC) recently presented its findings that heterosexuals living below the poverty line ($10,000 or less) in American cities were twice as likely to be infected with HIV as their higher-income neighbors.  The statistics translate to 1 in 42 people (the national average is 1 in 222 people).  Most studies focus on sexual orientation, race, and/or intravenous drug use.  None of those factors were included here though.  Kevin Fenton, a CDC HIV/AIDS expert, said that “HIV clearly strikes the economically disadvantaged in a devastating way.”  Researchers found that the risk of spreading HIV came from a lack of access to medical care and unawareness of infection.  Dr. Carlos del Rio, Chair of Global Health at Emory University’s Rollins School of Public Health, frames the issue differently as “[y]ou can talk about ‘Can we decrease the HIV burden in the United States?’  I would say, ‘What can we do to decrease poverty in the United States?’”

The 18th International AIDS Conference took place last week in Vienna, Austria.  Policymakers, researchers, advocates, and persons living with HIV met to draw attention to the epidemic and assess the global response to it.  According to the Associated Press, Julio Montaner, President of the International AIDS Society and Chairman of the Conference, opened the event by pointing to how:

the G-8 group of rich nations has failed to deliver on a commitment to guarantee so-called universal access and warned this could have dire consequences.

“This is a very serious deficit,” Montaner said.  “Let’s rejoice in the fact that today we have treatments that work … what we need is the political will to go the extra mile to deliver universal access.”

With the global economic crisis in full swing, AIDS activists are concerned about developed countries reducing their foreign aid, including funding for AIDS assistance.

In its annual report released last week, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the Kaiser Family Foundation found that global AIDS spending has “flattened.”  Although public and private sources contributed $15.9 billion in 2009, the amount was $7.7 billion short of the estimated $23.6 billion needed to combat AIDS in low and middle-income countries.  Contributing governments included the U.S. (58%), United Kingdom (10.2%), Germany (5.2%), the Netherlands (5%), France (4.4%), and Denmark (2.5%).  The report noted that “without U.S. funding, international AIDS assistance from donor governments would have significantly declined between 2008 and 2009.”

Global Inequality & Access to Health Care

According to a recent study in The Lancet, “The world’s wealthiest two billion people get 75 percent of all the surgery done each year, while the poorest two billion get only 4 percent and often die or live in misery as a result.” It’s a striking fact; how are we to interpret it?

There are two metanarrative accounts of the relationship between inequality and health care. On a Whiggish, optimistic view, vast inequality can generate the capital necessary to fund investment in innovative health care technologies. Scholars like Richard Epstein have celebrated both general economic inequality and unequal access to health care particularly because, they claim, buying power at the top promotes investment in medical advances. On this view, innovations in the wealthy world can diffuse throughout lesser developed regions. Moreover, the rich can also subsidize the poor locally, paying for infrastructure that serves a broader community.

Interpreted less charitably, inequality enables the well-off to bid away resources and opportunities from the poor. Richer nations and persons may snap up limited resources; for instance, in 2009, Jeanne Whalen at the Wall Street Journal wrote an article entitled “Rich Nations Lock In Flu Vaccine as Poor Ones Fret:”

A scramble among wealthy nations to guard against a swine-flu pandemic is raising concerns that billions of people in poorer countries could be left without adequate supplies of vaccine. . . . The emerging battle between the haves and have-nots underscores a major weakness in the global health system: Pharmaceutical companies have severely limited capacity to produce flu vaccines in emergencies.

Inequalities can be even more stark at the R&D phase. If an anti-baldness cure can generate billions of dollars in revenue while a new therapy for tuberculosis only generates hundreds of millions, for-profit pharmaceutical companies may well have a fiduciary duty to invest scarce research dollars in the unhirsute rather than the truly unhealthy.

Lawrence Gostin’s recent article “Redressing the Unconscionable Global Health Gap” offers some practical ways of addressing these disparities:

The international community is deeply resistant to taking bold remedial action — more concerned with their geostrategic interests than the health of the poor. The scale of foreign aid is both insufficient and unsustainable and fails to address the key determinants of health. As a result, the world’s distribution of the “good” of human health remains fundamentally unfair, causing enormous physical and mental suffering by those who experience the compounding disadvantages of poverty and ill health.

Lest we dismiss such inequalities as “not our problem,” Thomas Pogge’s sobering new book elaborates on his earlier argument that wealthier nations are responsible for the plight of the poorest:

[P]olitical and economic inequalities are rising dramatically both intra-nationally and globally. The affluent states and the international organizations they control knowingly contribute greatly to these evils — selfishly promoting rules and policies harmful to the poor while hypocritically pretending to set and promote ambitious development goals.

Both Pogge and Gostin’s work should guide policy responses to the extraordinary disparities exemplified in the Lancet story. As I continue to study fractal inequality in access to medicine, I will be sure to consult their proposals for a more just world. I also hope to see proposals for taxation of “medical tourism” that would redirect at least some of the funds from overseas patients to infrastructure that would support underserved patients in the regions they visit.

Mirror, Mirror on the Wall–Who Has the Most Free Market Health Care System of them All?

At least since legal realist Robert Hale published his Freedom through Law, the question of what constitutes state “intervention” in the market has been complex. For example: at what point does licensing of doctors move from being a natural aspect of any competent health system to being termed a suspect “intervention”? If there is to be free trade in services, don’t we at least need some information about what constitutes genuine medical care? “Perfect information” is a cornerstone of idealized markets—isn’t some baseline of information necessary to any actual market?

In health policy circles, the United States health care system is often seen as the most “free market” system internationally. But even the US would appear to be more interventionist than China, on a cursory reading of Blumenthal and Hsiao’s 2005 article in the NEJM:,

in the early 1980s, China virtually dismantled its apparently successful health care and public health system overnight, putting nothing in its place. In retrospect, this startling and almost inexplicable event seems to have been collateral damage from a much more carefully planned and successful policy strike: the privatization of China’s economy and a general effort to reduce the role of Beijing’s central government in China’s regional and local affairs. Only recently have Chinese authorities recognized the pain and the massive disruption in health care that they have caused.

By contrast, by some calculations, “the current tax-financed share of health spending is . . . 59.8 percent.” Very recent Chinese stimulus spending may be reversing prior privatizations there. But it’s clear that Chinese savings rates are still high, largely because so many citizens are scared of being sick and broke in a market-driven health care system.

Of course, it’s hard to develop any clear metric of private/public here; Blumenthal & Hsiao’s piece may only speak to financing and not other practices. Nevertheless, if Americare fails, the US and Chinese health care systems may be en route to superfusion.

Ethical Marketing Measures in Access to Medicines Index: An Important First Step

Earlier this week, the Access to Medicine Foundation released its 2010 Access to Medicine Index, “a ranking of the world´s largest pharmaceutical companies on their efforts to increase access to medicine for societies in need.”

In a change from the 2008 Index, which was the first to be issued, the 2010 Index includes measures designed to assess companies’ commitment to, and practice of, ethical marketing behavior.  Per the report accompanying the Index, “[t]he marketing and promotion of drugs can have a significant influence on the type of medicines that patients receive.  Particularly in Index Countries [88 countries with low or medium levels of development] with less robust regulatory enforcement and consumer protection, the marketing behavior of pharmaceutical companies can shape access to both appropriate and affordable medicines.  Unethical marketing can lead to suboptimal clinical decisions, prescription of more expensive drugs and irrational use of medicines by consumers, which can result in reduced treatment efficacy and other complications, such as adverse drug reaction and drug resistance.”

The Index ranks pharmaceutical companies’ marketing behavior along three axes: (1) commitments, (2) transparency, and (3) performance.  In the commitments category, companies are assigned points for the marketing codes and standards they have adopted and that they require their local third party sales agents to adopt.  For example, “originators,” i.e., research-based pharmaceutical companies, receive 5 points on a scale of 1-5 for committing to the International Federation of Pharmaceutical Manufacturers & Associations (IFPMA) Code of Pharmaceutical Marketing Practices, the WHO Ethical Criteria for Medicinal Drug Promotion, “or an equivalent industry code.”  Originators that have not committed to any external codes but that have an internal code which covers the same core principles receive 2.5 points.  (The scoring is different for generics on this measure because they do not have a “viable up to date and auditable external code.”)  With regard to third party sales agents, both originator and generic companies can receive all 5 points if they make “specific ethical marketing demands” of their sales agents and then audit the agents’ practices to ensure compliance.

For transparency, the Index gives points to companies that “publicly disclose[] detailed information regarding [their] marketing and promotional programs in the Index Countries, such as payments to physicians or other key opinion leaders and also its promotional activities for other healthcare providers, distributors, etc.”  None of the companies earned any points in this category.  While some have started to disclose payments made in the United States, no company has disclosed payments made in any of the Index Countries.  According to the report, three companies — GlaxoSmithKline, Merck, and Roche — have pledged to disclose payments made in the Index Countries soon.  Companies can also earn disclosure points for revealing breaches of marketing codes and marketing-related litigation in the Index Countries.

For the third category, performance, companies lose points if they breach the IFPMA Code or if they are sued or subjected to fines for marketing behavior.  Companies can earn points for including binding ethical marketing requirements in their agreements with their sales agents and by establishing employee codes of conduct in the Index Countries equivalent to the codes they have in place in other markets.  Despite the fact that issues have been raised “about pharmaceutical marketing practices in the Index Countries, especially regarding clear mention of … adverse side effects,” none of the companies studied lost any points in this category.

As the title of this post suggests, I think that the Index’s attempt to rank companies’ commitment to and practice of ethical marketing practices is important.  Anyone who works in a law school knows how influential rankings can be — for better or for worse.  It is easy to imagine the Access to Medicine rankings providing an additional nudge to companies to begin disclosing payments to healthcare providers around the world not just here in the United States.  At the same time, there is ample room for refinement.  In the performance category, for example, measures, in addition to breaching the IFPMA Code/being sued/ being fined, are needed to expose differences that surely exist in companies’ approaches to marketing in the Index Countries.

Medical Care for Haitians: US Announces Funding

This past Sunday, the White House resumed military airlift of injured Haitians into the United States.  The halt on incoming Haitian patients had happened just days earlier, springing from the economic and logistic fears of many state officials of Florida, where the majority of patients from Haiti were being sent for care.  After finding a solution to the hospital capacity issue in Florida,  and fully knowing that they could not keep certain patients in the medically hazardous environment which is Haiti, White House officials reopened U.S. hospital doors to  badly injured patients.  Yet, the resounding question “who is going to pay for this emergency care?” remains.

The costs are not insignificant.  One Florida hospital executive estimates costs to her hospital alone to be in the millions, and while she hopes some of this cost will be lessened through federal government assistance, other hospitals have already started to initiate reimbursement for the costs themselves through private donations.  In addition, many doctors and nurses are volunteering their services to help reduce the high cost of the care.

The U.S. Department of Health and Human Services announced on Monday that they would supply funding for the emergency care through the National Disaster Medical System, which is usually accessed only in times of domestic emergencies. As described in the announcement, “activation will allow U.S. hospitals that treat Haitian patients evacuated with life-threatening injuries due to the earthquake, to receive federal reimbursement for the costs they incur.”  The reimbursement for the care to Haitians is equal to 110% of Medicare rates.

Since the announcement of aid through the National Disaster Medical System, hospitals in other areas, such as Atlanta, are agreeing to treat patients.  Hospitals in the Atlanta and Florida area are able to provide assistance due to their proximity to Haiti and their “extensive medical resources.”  Other hospitals in the New York, New Jersey, Philadelphia, and Boston areas have been notified that their medical centers may also be tapped  for help in treating the Haitian patients.

Because some of the patients that are being treated at American hospitals are American citizens who were in Haiti when the earthquake hit, some of the medical care can be reimbursed through the insurance coverage that those patients may already have or be eligible to receive.  Interestingly, Haitians who are not legal residents of the United States might also qualify for insurance through Medicaid, but to qualify, the patients would have to be granted “Humanitarian Parole” by U.S. Citizenship and Immigration Services.  Up until this point, Humanitarian Parole visas, which last for a year, have mostly been granted to orphans who were already in the process of being adopted before January 12^th.  Only 50 Humanitarian Parole visas have been granted to those who were sent to the United States for health care; due to the difficulty in tracking patients after their care is complete, the Immigration Services is hesitant to grant more such visas.

While the federal government appears to have systems in place to aid Haitians who are in dire need of medical care for now, questions about long term help still linger.  International aid experts want to see systems of sustainability put into place so that Haiti can once again stand on its own after the foreign aid ends.  Maybe our nation’s leaders will be able to give to Haiti the health care reform it needs, even if they can’t give it to America itself.

Medical Experts Say Haitians Will Need Health Care Help for Years to Come

The BBC recently reported that medical organizations with members serving the Haitian communities affected by the earthquake on January 12^th warn that one of the larger issues for Haitians will likely be the need for increased medical supplies, such as prosthetic devices and rehabilitation services.

Concerned about infection, doctors in Haiti have had to amputate the limbs of a great many injured patients.  In addition to the need for such resources as medical devices and prosthetic equipment, doctors are also still in need of simple medications.  Antibiotics are needed to prevent the spread of infections and painkillers to help damaged patients simply make it through the day.

Because many of the country’s hospitals were also destroyed by the earthquake, doctors in Haiti are performing most care in makeshift open areas.  And in such environments, infection spreads fast.  Though the few hospitals that are running are reported to be in relatively well-organized condition, many of the patients in those hospitals are not leaving as they have nowhere else to go, except perhaps the streets– where infections await their open wounds. So they stay,  Doctors are left with fewer and fewer areas to treat, and the number of patients increases. To remedy the situation, there are plans at present to quickly build a convalescent center.

The present medical needs are only the beginning.  The concerns of some medical experts extend to the years after the media eye has turned away from Haiti, after the NGOs have left the country, and after foreign doctors have returned to their home-countries.  These experts worry about how the Haitians that are being treated today will be able to continue with one less leg or one less arm in the future.  Without proper rehabilitation services or necessary follow-up medical care, many Haitians will lack the physical capabilities to rebuild their lives.  Mark Hyman, a doctor and volunteer with Partners In Health, calls these future medical needs of the injured Haitian community the “third wave,” and he finds that such aid is not yet realized:

Soon, very soon, there is the need for rehabilitation, helping the thousands with lost or broken limbs get back on their feet or foot again. There are no physical therapists, no facilities, and no place for them to go for care. As the immediate surgical needs are slowly addressed, the psychological needs explode magnified by each minor aftershock.

Some medical device companies have already donated supplies to aid the doctors’ efforts as well as money to support the other necessary aid efforts in Haiti.  While such donations are helping address an urgent need, they are being outpaced by the number of amputations being performed.  Hope lies in the idea that health care systems will be put in place before the external help exits; that prosthetic devices will ultimately be made available to the patients that need them; and that Haitian medical workers are trained to be able to properly care for those who cannot care for themselves.

The needs of the Haitian people are great, and the impact of this disaster will be felt for years to come.  Please give to help those who are working hard towards rebuilding Haiti.  Click here to find a list of the different organizations through which you can donate. And if you happen to be a part of a prosthetic device company which wants to do something amazing, we’d love to write the story.

Market Competition in Health Care: The EU’s Parallel Struggle

Last week, I took a break from U.S. health reform and attended a fascinating conference on Health Care and EU Law at Radboud University in the Netherlands.  It gave me the chance to step back and revisit a struggle common to most health care systems — the appropriate role for market competition.  Without drawing too many parallels here, the view from 30,000 feet confirms that like the United States, European health care systems (varied as they are) must decide the extent to which health care is an economic, commercial product versus a non-economic, public good.

In Europe, this tension is generated by the European Union’s internal common market of 27 member states.  European law — enunciated through treaties, directives, regulations, and decisions by the European Court of Justice — prohibits states from restricting the free movement of goods, persons, and services within the EU, and bans anti-competitive or protectionist arrangements.

But is health care a commercial product subject to these market rules?  Or can member states control their health care systems without worrying whether it restricts free movement or is anti-competitive?  Although EU law says that states shall retain responsibility for managing services of general interest like health care and social security, case law has bounded this authority in several high-profile free movement and competition cases.  For example, a series of court opinions has held that member states have limited authority to prevent their residents from traveling to other member states for health care, or even to require prior authorization before reimbursing for that care back in the home state. Read more

Immigrants, Health Reform, and “Lies”

In a much-anticipated prime time address to Congress, President Obama made the case for health care reform.  One ostensible goal of the speech was to correct misinformation about the bills proposed by Congress.  As a scholar who studies both health care and immigration (and sometimes the intersection between the two), I’ve grown increasingly frustrated with the misconceptions surrounding this issue — and I very much hoped the President would deflate the myth that health reform would provide federal benefits to undocumented immigrants.

Of course, when President Obama made this very point (”The reforms I’m proposing would not apply to those who are here illegally”), he was greeted with a heckle from South Carolina Representative Joe Wilson, who shouted “You lie!”  Although Rep. Wilson later apologized for his “lack of civility,” he didn’t recant the basic factual assertion, making clear that he still disagreed with the President’s statement that health reform doesn’t cover undocumented immigrants.  Of course, the media has jumped on this story, but perhaps unsurprisingly, few bothered to clarify the underlying factual dispute.

Neither bill published by the House or Senate covers undocumented immigrants.  In fact, both bills state in pretty plain terms that they don’t do it.  The House bill, titled America’s Affordable Health Choices Act of 2009, states in Section 242 that those not lawfully present in the United States are not eligible for insurance subsidies or tax credits.  To make it even more clear, Section 246 is titled “No Federal Payment for Undocumented Aliens,” and states “Nothing in this subtitle shall allow Federal payments for affordability credits on behalf of individuals who are not lawfully present in the United States.”

Likewise, the Senate Health, Education, Labor, and Pension Committee’s bill, titled the Affordable Health Choices Act, states in Section 3111(h) that “Nothing in this Act shall allow Federal payments for individuals who are not lawfully present in the United States.”  The Senate Finance Committee has yet to release its bill, but it’s a good bet that undocumented immigrants similarly will be excluded.

Although nothing in the bills apparently would prohibit undocumented immigrants from purchasing health insurance in the new national marketplace (called an “exchange” and a “gateway” in the House and Senate bills), it’s not clear why anyone would take issue with immigrants purchasing insurance on their own, without federal subsidies.  Moreover, although nothing in the bills seems to alter federal funding for emergency care provided to immigrants, nothing creates such a benefit either — thus undercutting Rep. Wilson’s contention with the President.

This controversy should remind us that immigrants remain in a sort of health care purgatory, caught in our two most dysfunctional systems — immigration and health care.  In the mid-1990s, Congress severely limited immigrant access to programs like Medicaid as part of welfare reform, making it difficult for even lawful immigrants to enroll.  In fact, even lawful immigrants aren’t eligible for Medicaid for five years after entering the United States — and various peculiarities of immigration law often push this waiting period to ten years.  At the same time, immigrants do receive indirect federal funding for health care through the Emergency Medical Treatment and Active Labor Act (EMTALA), which requires hospitals with emergency departments to screen and at least stabilize patients presenting with emergent conditions.  Thus, hospitals must provide emergency care regardless of the patient’s immigration status.

Unfortunately, most immigrants are ineligible for means-tested public insurance programs like Medicaid.  This regulatory framework has led to “medical repatriation,” in which hospitals effectively deport immigrant patients to unload expensive long-term care burdens.  Of course, hospitals — most of which are run by state and local governments — complain about unfunded federal mandates like EMTALA.  Hospitals can be “stuck” treating immigrants whose medical needs have shifted from acute to long-term (as with the car accident victim who needs neurological rehabilitation and nursing care).  As Prof. Boozang discussed, a growing number have begun “repatriating” immigrant patients by sending them back to their country of origin — without consulting immigration officials — sometimes by purchasing commercial plane tickets or even hiring air ambulances.

Certainly, there are more humane ways to handle health care for immigrants.  California, for example, legalized cross-border health insurance, thus allowing immigrants living in the state to purchase insurance with lower premiums and deductibles that covers care provided in Mexico.  Arizona and Texas have considered similar legislation, to no avail.  Recently, UCLA researchers estimated that over 950,000 people travel from California to Mexico for medical care every year.  For a population being left out of health care reform, traveling to Mexico for care may be the future — whether voluntary or not.

Kidney Sales, a Free-Market Approach

Recent events in New Jersey have served to highlight deficiencies in the Kidney Market.

The impoverished of the world, at present, freely considering their options in a market economy, have taken to selling their kidneys, valued at roughly $160,000 on the less than open market, to kidney brokers for the approximate sum of, give or take, $10,000.

At present one may sell a body part legally only in Iran. Thus, as anyone steeped in the strict virtues of Chicago School economics would tell you, the Market in Kidneys suffers at present from “distortions.” The problem, of course, is two fold: the almost universal illegality has added risk to the cost; and limited access to the market has allowed the brokers, through government interference and lack of open competition, to exclude others from their fair share of the profit.

The Kidney Exchange

Patterned after the stock exchange (or perhaps the commodity exchange is a more apt analog), I propose we create, as part of a market driven health reform initiative, a Kidney Exchange. Value maximization will ensure the free flow of kidneys into the most appropriate markets and the most appropriate recipients.

In the interest of fairness and transparency, full reports on each putative “donor” will be submitted to the exchange by medical clinicians who (as is the current practice among medical device researchers) will be paid in stock options in the subjects of their examinations. This stake in the endeavor will ensure commitment to the process. These reports will function as the basis for prospectus and, in the case of those not yet ready for immediate harvest, ongoing quarterly reports.

We would not, of course, limit the purchase of kidneys to those who “need” the actual kidneys, as that too would tend to skew the market. “Need” must be determined through the time-tested criteria of the market: availability of, and a willingness to use, investment capital.

Because, however, even with the most thorough information that money can buy, things can on occasion go awry, we will need a market instrument to ensure protection in the event of failure. Kidney Default Swaps (KDS), an insurance of sorts keyed to whether or not the putative “donor” ultimately tenders a viable kidney. Further, KDS could be patterned after the Credit Default Swap–in that we can allow investors with no connection or insurable interest in the transaction to wager freely on the ultimate outcome–thus creating another lucrative market.

Of course, to combat inefficiencies, a wholesale market will ultimately develop, procurement and development syndicates will be set up, and branded groups of similar subjects will be packaged together for large investors like collateralized mortgage securities.

This investor/market driven approach will further ensure the development of a “Pipeline” to enhance quality and dismiss with the vagaries of procurement.

And lest we forget the benefit to the “donor,” the market too will provide for it. Obviously, anyone who has invested a handsome sum in 4 year old boys from Pakistan (”Pak-Neph B4, b. type O+, trading at…”) will have great interest in safeguarding his investment–nourishing well those kidneys until they are ready for harvest upon demand.

Considering the environmental risks involved for the “free range” donor in many prime but impoverished areas, “harvest banks” to house homegrown investments will, of course, be built. Within the sterile confines of such banks, subjects will grow, watered and fed and exercised to ensure sufficient blood flow and proper kidney function. Subjects kept thus would of course demand a premium on the open market.

Furthermore, upon harvest and release into world, such harvest bank subjects can also readily be expected to breed. Uneducated and untrained in any vocation (market contraindicated) one can reasonably expect them to turn over for modest profit the products of their breeding to the market for eventual harvesting–thus ensuring a steady supply of prime kidneys for generations to come. Naturally, the best genetic lines of kidneys will be identified–arrangements can be made (”Pak-Neph B14/Braz-NephG16, b. type AB+, trading at…), profits in accord.

The addition to one’s portfolio of such financial instruments as “Kidney Futures” or “Kidney Options,” will, I believe, prove a handsome reward to savvy holders. And a thriving business in Kidneys could well be just the market innovation that this economy needs to pull it out of its current doldrums. A Kidney Exchange will provide a swift feast of employment and real wealth.  And of course, we need not be limited to kidneys, there are many other organs that the poor do not, and cannot, use to best advantage.

Conclusion

280 years have passed since Jonathan Swift offered his “Modest Proposal” for solving the pangs of poverty in Catholic Ireland through the sale and eating of Irish babies.[1] Consider this an update of sorts.

There is, however, one distinction between the Swift model that is worth noting: considering the high market value of Irish babies, Swift proposes a preference in procurement for ravenous English Landlords:

I grant this food will be somewhat dear, and therefore very proper for landlords, who as they have already devoured most of the parents, seem to have best title to the children.

A Kidney Exchange, less sentimental but more modern, would, of course, put the preference where the invisible hand of the market deems it best (though under Swift’s criteria the  IMF, and World Bank would seem to be the  sentimental favorites). In this way it would allow, as we do now with private health insurance, that most efficient of instruments, the market, to decide who lives or dies.

---

[1] Swift notes that before the age of 12, Irish children were  not particularly saleable or employable, and that “They can very seldom pick up a livelihood by stealing till they arrive at six years old.” His solution stems from the following:  “I have been assured by a very knowing American of my aquaintance in London that a young healthy child well nursed is at a year old a most delicious, nourishing, and wholesome food, whether stewed, roasted, baked, or boiled; and I make no doubt that it will equally serve in a fricassee or a ragout.” His modest proposal: “I do therefore humbly offer it to public consideration that of the hundred and twenty thousand children, already computed, twenty thousand may be reserved for breed…. That the remaining hundred thousand may at a year old be offered in sale to persons of quality and fortune through the kingdom, always advising the mother to let them suck plentifully in the last month, so as to render them plump and fat for a good table.”

The full title of the piece is “A Modest Proposal For Preventing The Children of Poor People In Ireland From Being A Burden To Their Parents Or Country, And For Making Them Beneficial To The Public.” Though most noted for his relatively benign Gulliver’s Travels, Swift’s Modest Proposal helped make him a hero among the Irish.

The Less You Change, The More It Costs

Today, on his Washington Post blog, Ezra Klein described how the estimated price tag of health reform is giving Congress sticker shock, and how Congress seems to be responding with less reform, not more. However, as widely-respected Princeton health economist Uwe Reinhardt explains, the status quo of our current system is too expensive to maintain. Thus, Klein notes perceptively that, “In health care, the less you change, the more it costs.”

With Congressional Budget Office estimates sinking in, Congress might be drifting towards compromises that could scale back proposed government involvement in offering health insurance. But as Tim Jost explained in a previous post, public plan alternatives like cooperatives probably won’t solve our problems without concerted and long-lasting support from the federal government anyway. In search of a viable alternative, conservatives have struck a familiar pose, decrying rationing and more government intervention, instead proposing market-based solutions like tax rebates and consumer-directed incentives.

However, conservative proposals would take the United States health care system further out of the mainstream and make us even more of an international outlier (relying primarily, as we do, on private, voluntary health insurance). These proposals don’t seem to hold water at a time when international experience suggests we should be moving in the opposite direction. As Timothy Noah explains (and as Tim Jost has argued persuasively elsewhere), American exceptionalism isn’t necessarily a good thing in health care. We spend nearly twice as much per capita as any other country, and we account for roughly half of all worldwide health care spending each year (roughly $2 trillion out of $4 trillion). Meanwhile, we leave around 47 million people uninsured, and another 25 million don’t have adequate insurance. Finally, we don’t rank particularly well compared to our peer countries on many quality measures. If we don’t start seriously revamping the way we provide and pay for health care, we’ll continue our dubious exceptionalism.

So as we deal with sticker shock, let’s remind ourselves where we stand in the health care world. Taiwan, given the chance, avoided our model like the plague. As one observer notes, “Taking lessons in health care policy from the United States is like receiving lessons in seamanship from the crew of the Titanic.” Why should we accept going down with the ship?

New Jersey-based group digs wells to fight disease and malnutrition in Malawi

Today’s post comes from Seton Hall Law LL.M candidate and former long time Newark Star Ledger reporter, Robert Schwaneberg, J.D.

Health Reform Watch is truly pleased to welcome a reporter of such great renown to our blog.

By ROBERT SCHWANEBERG

The road to Euthini in northern Malawi is a narrow dirt path through fields of gourds, maize and peanuts, known locally as groundnuts. The delegation from WorldHope Corps arrives, by four-wheel-drive vehicle, to find the village leaders waiting under a tree. They are sitting in straight-backed wooden chairs with velveteen cushions that seem strangely elegant in this poor African community that lacks electricity, modern sanitation and any source of clean water.

According to the World Health Organization, 38 percent of rural Malawi lacks access to improved water sources.[i] Along with high rates of HIV infection, lack of clean water is a leading reason “Malawi’s health indicators are among the worst in the world.”[ii] Water-borne diseases such as diarrhea and cholera are “common in Malawi”[iii] and are among the top three killers of children under five.[iv] A survey done in 2000 found 18% of children under five had experienced diarrhea in the preceding two weeks.[v]

WorldHope Corps is trying to change that. Working with other non-governmental organizations, churches and private donors, it has arranged the installation of six hand-pumped wells in Malawi in the past two years and has plans for more.

“Wells are the water of life,” said the Rev. Michael Christensen, who teaches at Drew University in Madison, N.J., and founded WorldHope Corps in 2007. “If we can provide clean water to villages without water, we can save hundreds of lives because one out of five children dies under the age of five of water-borne diseases like cholera, dysentery and malaria.”

Drilling wells in northern Malawi is expensive. Holes have to be bored deep — 50 to 100 meters — to get below the groundwater contamination that pollutes shallow wells. Heavy rigs must be brought in from the southern part of the country, where the only drilling companies are located, and transported over primitive “roads” like the dirt path to Euthini. There are additional costs for having a government official inspect the work and certify the well is deep enough to provide safe water.

“All in all, it’s about $10,000, give or take $500,” Christensen said. He hopes to cut the cost by helping one of WorldHope Corp’s partners, CitiHope International, form a well-drilling business in northern Malawi.

“The prospects are very good,” Christensen said. “I think by this time next year we’ll have the beginnings of a well business that will cut the cost of a well in half.”

Last month, Christensen led a team of 10 volunteers on a 12-day mission to inspect existing well sites in Malawi and scout locations for new ones. Michael Bond of Basking Ridge, N.J., did not go with the idea of funding a well. He decided to do so after observing the stark differences between Euthini, where women haul water from a stream about a kilometer away, and Zowe, which got a deep well through WorldHope Corps in 2007.

“The life of a village, the life of a people changes dramatically once they get fresh, clean water,” Bond said. At Zowe, which also has a part-time medical clinic, Bond learned from the health surveillance officer that a remarkable thing happened after it got its well: No child died during 2008.

“The ah-hah moment for me was the difference a 20-minute drive down that trail (from Zowe to Euthini) made,” Bond said. “The difference was night and day. The kids were in dirty clothes; they were dirty because they weren’t bathed. Some showed signs of malnutrition.”

Malnutrition results not just from poor agricultural yields, but also from dirty water. About half the cases of underweight children are due to repeated bouts of diarrhea and intestinal infections from unsafe water and substandard sanitation and hygiene, according to W.H.O.’s 2008 report, “Safer Water, Better Health.”[vi] Globally, W.H.O. estimates that each year 860,000 children under five die from malnutrition induced by unsafe water, inadequate sanitation and insufficient hygiene.[vii]

The visit to Euthini ended with Christensen calling for a village youngster to fetch a shovel to break ground for its new well. But first, as he does with all his projects, Christensen enlisted the villagers in a partnership. He asked what they would contribute; they replied they would supply bricks, rocks and labor to construct the spillway and sinks for washing clothes. He asked how they would use overflow water; they said they would divert it to a community garden. He asked how they would pay for spare parts and repairs; they promised to take up a collection from all the villages drawing water from the new well.

“It’s not just about a bore hole,” Christensen said. “It’s about promotion of human rights, gender equality, community action, power of the people to make change.”

More information about WorldHope Corps is online at http://www.worldhopecorps.com/index.htm

---

[i] World Health Organization, Country System Fact Sheet 2006 - Malawi. Online at http://www.afro.who.int/home/countries/fact_sheets/malawi.pdf

[ii] WHO Country Cooperation Strategy, Malawi, 2005-2009 at page15. Online at

http://www.who.int/countryfocus/cooperation_strategy/ccs_mwi_en.pdf

[iii] Id. at page 12.

[iv] The others are pneumonia and all neonatal causes, including diarrhea. World Health Organization, Country System Fact Sheet 2006 - Malawi.

[v] WHO Country Cooperation Strategy, Malawi, 2005-2009 at page 12.

[vi] World Health Organization, “Safer Water, Better Health: Costs, benefits and sustainability of interventions to protect and promote health,” at page 7. Available online at http://www.who.int/water_sanitation_health/publications/safer_water/en/print.html

[vii] Id.

Health Care, “Common Sense” and a Global Health Blogging Experiment

Today, Health Reform Watch is participating in a “Global Health Blogging experiment” coordinated by Christine Gorman of Global Health Report. Health Bloggers from around the world will all be converging to discuss a topic: for today, “prevention v. treatment,” and, to some extent-the underlying realities in which this experiment in synchronized dissemination is being conducted as they relate to global health concerns. I thought I’d take a look at the “to some extent.”

Ms. Gorman proposed this idea as a means of assembling something of a critical mass to explore issues regarding “Global Health” and as a means of gauging the mass of that mass. In addition to organizing the assemblage, Ms. Gorman also asked some prescient questions about the nature of the medium and the endeavor itself. It is here that I will focus.

She asks,

Is a social network around global health news starting to emerge organically on the web? What can we do to nurture it? Do economic realities dictate that this will have to be a volunteer led endeavor, at least for a while?

Or, another way of putting that last question: Is news about global health subject to the same market failures that afflict products for global health (e.g. free-market forces alone will not lead to new tuberculosis medications and other drugs that affect mostly the poorest people in the world)?

These are good questions. And as I think about the economic forces and the affect of such upon the dissemination of information, I find myself thinking that even with the emergence of a somewhat new journalistic paradigm–the blog– the dissemination of information is still largely governed by the older rule: zero sum. And this goes for time and money–as well as focus.

In many ways the blog is merely the modern progeny of its paper ancestor-the pamphlet, a time honored medium purveyed by amateur and psuedo-professional journalists and would be statesmen with some design on shaping policy and the contours of their fellow citizens’ minds. But it is perhaps important to remember that Thomas Paine’s revolutionary Common Sense, perhaps the most famous and influential American pamphlet of all time, was sold for a price-and it sold very well (it should be noted though that Paine donated his royalties to George Washington’s Continental Army for the procurement of mittens). It did not hurt sales that the first printing appeared at a time when King George had just denounced the Colonies to Parliament. Common Sense was of the moment; “Global Health” is not. Read more

The Glasses Half Full

This story is not about health policy, but maybe in the end, in a way, it is. Maybe it’s about the essence of what health policy should be. What international policy should be. What academia, and even patent law, look like in their finest hours.

For the most part, I will just allow this Washington Post story to speak for itself.

Joshua Silver, an Oxford atomic physicist who also teaches optics, designed a set of self-adjusting eyeglasses. He has spent the last two decades perfecting the “ugly” eyewear. The glasses are manufactured in China, and he is now in the process of distributing them to those who are unable to afford to partake in “the current business model for the industry that involves optometrists, opticians and labs making custom lenses and frames.” Thus far Mr. Silver has distributed his glasses with the help of the U.S. Dept. of Defense, the World Bank, and the British Government.

Though offered “a substantial amount of money” by a vision company for his patented technology, the inventor “declined because he had no assurance that it would be used to bring low-cost glasses to the poor.”

The Washington Post reports that Mr. Silver, “has attached plastic syringes filled with silicone oil on each bow of the glasses; the wearer adds or subtracts the clear liquid with a little dial on the pump until the focus is right. After that adjustment, the syringes are removed and the ‘adaptive glasses’ are ready to go…. The more liquid pumped into a thin sac in the plastic lenses, the stronger the correction.”

Currently, Silver said, a pair costs about $19, but his hope is to cut that to a few dollars.

Silver said he wants to provide eyeglasses to more than a billion people with poor eyesight. For starters, he hopes to distribute a million pairs in India over the next year or so.

He has distributed about 30,000 spectacles. The U.S. Department of Defense bought 20,000 pairs to give away to poor people in Africa and Eastern Europe. Those glasses have a small U.S. flag and “From the American People” engraved in small print on one side of the frames. The World Bank and the British government have also helped fund his work.

In the United States, Britain and other wealthy nations, 60 to 70 percent of people wear corrective glasses, Silver said. But in many developing countries, only about 5 percent have glasses because so many people, especially those in rural areas, have little or no access to eye-care professionals.

Even if they could visit an eye doctor, the cost of glasses can be more than a month’s wages. This means that many schoolchildren cannot see the blackboard, bus drivers can’t see clearly and others can no longer fish, teach or do other jobs because of failing vision.
“It’s about education, economics and quality of life,” Silver said.

One could certainly say the same thing about health and health care; and at a basic level, the health and health care proposition in human terms is simply sine qua non–”without which, not.”

Having said that, one might hope that the Nobel Committee can see its way clear to Oxford.

Next Page »