Wielding the implement of law: Distilling new rights and responsibilities in the age of the ‘new genetics’

The law has, to date, been slow to respond to advances in genetics, but in many ways this may be propitious. History teaches us that there is an ever-present risk that the law will be used merely to embody knee-jerk reactions to new developments in medicine and science, frequently to the detriment of all interested parties. Adequate and appropriate legal responses to genetic research can only come once a full debate on the problems to be addressed has taken place, and when society as a whole is appraised of the options at hand. This article offers an overview of the problems which are thrown up for the law by 'new genetics', including the problem of reconciling competing claims to genetic information from family members, insurers and employers, as well as the dilemma of determining how to regulate the potential range of uses of new genetic knowledge. The article offers some views on how we might use the law to proceed sensibly and productively in the future.     

Carpal tunnel syndrome. A new feature in the natural history of TOS?

Objective: To ascertain whether carpal tunnel syndrome (CTS) in patients affected with toxic oil syndrome (TOS) is associated with conditions and diseases considered risk factors for CTS in the general population and/or with certain clinical manifestations of TOS. Methods: We conducted a case–control study to compare 89 TOS patients residing in Madrid diagnosed with CTS from 1981 through July 2001 (cases) against 638 TOS patients not affected with CTS (controls). Risk factors for CTS and clinical manifestations of TOS were analyzed. Results: Multivariate logistic regression analysis yielded the following odds ratios (95% confidence interval): 3.32 (1.47–7.50) for TOS-related neuropathy; 2.85 (1.14–7.13) for TOS-related thromboembolic events; 2.63 (1.36–5.06) for female gender; 0.43 (0.24–0.80) for TOS-related scleroderma; 0.26 (0.12–0.59) for smoking; and, in women, 2.53 (1.06–5.70) for fibrositis and 1.84 (1.04–3.20) for miscarriages. Conclusion: Our study findings support the hypothesis that CTS in TOS patients is more linked to certain clinical manifestations of TOS, mainly neuropathy, than to conditions and diseases considered risk factors for CTS in the general population.     

A new crisis for the med mal market?

Medical malpractice insurance loss costs are surging, insurers are quitting the business, and doctors are threatening to leave their practices. Is med mal on the verge of a major new crisis? This article explores the genesis of the current crisis and attempts to provide some perspective that may be helpful inviewing the situation.     

Philanthropy and the nation-state in global health: The Gates Foundation in India

In recent years, philanthropic actors such as the Gates Foundation have been understood as commanding sweeping influence in global health. They have been associated with the outsourcing of public health services, shifting of policy priorities, and the eventual sidelining of national governments. This article makes a different argument about the impact of global philanthropic actors. It focuses on the work of the Gates Foundation in India over the last decade and a half, tracing how the foundation initially circumvented the national government but then moved on to a discourse of partnership. Ironically, after an early discounting of the role of the government, the foundation later sought to transition its programmes to the state. The foundation's evolving trajectory reflects its experiences on the ground and also the difficulties of realising its original ambitions. While the foundation's work in India is marked by ebbs and flows, the state's institutions remain constant. The article argues that there is not always a straightforward marginalisation of the government vis-à-vis global philanthropic actors. Actors such as the Gates Foundation, perceived as enormously powerful in global health institutions in Geneva and New York, may have a far more qualified impact in large developing countries such as India.     

The role of state and non-state actors in the policy process: the contribution of policy networks to the scale-up of antiretroviral therapy in Thailand

Antiretroviral therapy (ART) is difficult in poor settings. In 2001, the Thai government adopted the policy to scale-up its treatment initiative to meet the needs of all its people. Employing qualitative approaches, including in-depth interviews, document review and direct observation, this study examines the processes by which the universal ART policy developed between 2001 and 2007, with the focus on the connections between actors who shared common interests--so-called policy networks. Research findings illustrate the crucial contributions of non-state networks in the policy process. The supportive roles of public-civic networks could be observed at every policy stage, and at different levels of the health sector. Although this particular health policy may be unique in case and setting, it does suggest clearly that while the state dominated the policy process initially, non-state actors played extremely important roles. Their contribution was not simply at agenda-setting stages--for example by lobbying government--but in the actual development and implementation of health policy. Further it illustrates that these processes were dynamic, took place over long periods and were not limited to national borders, but extended beyond, to include global actors and processes.     

The role of non-governmental organizations in global health diplomacy: negotiating the Framework Convention on Tobacco Control

The Framework Convention on Tobacco Control (FCTC) is an exemplar result of global health diplomacy, based on its global reach (binding on all World Health Organization member nations) and its negotiation process. The FCTC negotiations are one of the first examples of various states and non-state entities coming together to create a legally binding tool to govern global health. They have demonstrated that diplomacy, once consigned to interactions among state officials, has witnessed the dilution of its state-centric origins with the inclusion of non-governmental organizations (NGOs) in the diplomacy process. To engage in the discourse of global health diplomacy, NGO diplomats are immediately presented with two challenges: to convey the interests of larger publics and to contribute to inter-state negotiations in a predominantly state-centric system of governance that are often diluted by pressures from private interests or mercantilist self-interest on the part of the state itself. How do NGOs manage these challenges within the process of global health diplomacy itself? What roles do, and can, they play in achieving new forms of global health diplomacy? This paper addresses these questions through presentation of findings from a study of the roles assumed by one group of non-governmental actors (the Canadian NGOs) in the FCTC negotiations. The findings presented are drawn from a larger grounded theory study. Qualitative data were collected from 34 public documents and 18 in-depth interviews with participants from the Canadian government and Canadian NGOs. This analysis yielded five key activities or roles of the Canadian NGOs during the negotiation of the FCTC: monitoring, lobbying, brokering knowledge, offering technical expertise and fostering inclusion. This discussion begins to address one of the key goals of global health diplomacy, namely 'the challenges facing health diplomacy and how they have been addressed by different groups and at different levels of governance' (Kickbusch et al. 2007a: 972).     

Framing health and foreign policy: lessons for global health diplomacy

Global health financing has increased dramatically in recent years, indicative of a rise in health as a foreign policy issue. Several governments have issued specific foreign policy statements on global health and a new term, global health diplomacy, has been coined to describe the processes by which state and non-state actors engage to position health issues more prominently in foreign policy decision-making. Their ability to do so is important to advancing international cooperation in health. In this paper we review the arguments for health in foreign policy that inform global health diplomacy. These are organized into six policy frames: security, development, global public goods, trade, human rights and ethical/moral reasoning. Each of these frames has implications for how global health as a foreign policy issue is conceptualized. Differing arguments within and between these policy frames, while overlapping, can also be contradictory. This raises an important question about which arguments prevail in actual state decision-making. This question is addressed through an analysis of policy or policy-related documents and academic literature pertinent to each policy framing with some assessment of policy practice. The reference point for this analysis is the explicit goal of improving global health equity. This goal has increasing national traction within national public health discourse and decision-making and, through the Millennium Development Goals and other multilateral reports and declarations, is entering global health policy discussion. Initial findings support conventional international relations theory that most states, even when committed to health as a foreign policy goal, still make decisions primarily on the basis of the 'high politics' of national security and economic material interests. Development, human rights and ethical/moral arguments for global health assistance, the traditional 'low politics' of foreign policy, are present in discourse but do not appear to dominate practice. While political momentum for health as a foreign policy goal persists, the framing of this goal remains a contested issue. The analysis offered in this article may prove helpful to those engaged in global health diplomacy or in efforts to have global governance across a range of sectoral interests pay more attention to health equity impacts.     

Backstage: the relationship between the Rockefeller Foundation and the World Health Organization,Part I: 1940s–1960s

In recent years, there has been a growing debate about what role foundations should play in global health governance generally, and particularly vis-à-vis the World Health Organization (WHO). Much of this discussion revolves around today's gargantuan philanthropy, the Bill and Melinda Gates Foundation, and its sway over the agenda and modus operandi of global health. Yet such pre-occupations are not new. The Rockefeller Foundation (RF), the unparalleled 20th century health philanthropy heavyweight, both profoundly shaped WHO and maintained long and complex relations with it, even as both institutions changed over time. This article examines the WHO–RF relationship from the 1940s to the 1960s, tracing its ebbs and flows, key moments, challenges, and quandaries, concluding with a reflection on the role of the Cold War in both fully institutionalizing the RF's dominant disease-control approach and limiting its smaller social medicine efforts, even as the RF's quotidian influence at WHO diminished.     

The access to medicine index: How ranking pharmaceutical companies encourages polycentric health governance

The field of access to medicines is becoming a complex governance system. Along with formal international organizations, non-state actors have created various new institutional arrangements, such as funds, initiatives, programs, and partnerships. This study focuses on the role and power of non-governmental organizations (NGOs) who have introduced a new dynamism regarding the problem of access to medicines, by analyzing the “Access to Medicine Index” (hereinafter, AtM Index) case.This study examines how the AtM Index interacts with other initiatives led by various actors. In particular, we focus on several recent initiatives concerning the AtM Index, by actors including the World Health Organization (WHO), the World Intellectual Property Organization (WIPO), and other partnerships. This study examines the linkages between these initiatives and the AtM Index, and explores whether interconnections among multiple initiatives lead to the overall effectiveness of global health governance. We argue that the field of access to medicines is now evolving into a “polycentric” governance system; however, there may be some limitations to such a system.     

Chile’s role in global health diplomacy: a narrative literature review

Background

Global health diplomacy (GHD) has become an important field of investigation due to health concerns increasingly entering the foreign policy domain. Much of the existing academic writing focuses on North-South cooperation in global health, and emphasizes the role of security and economic interests by Northern countries as drivers of GHD. Chile presents a favourable environment for an expanded involvement in future GHD activities. However, there is little knowledge about what has been driving Chile’s integration of health into foreign policy, and little effort to appropriate knowledge from international relations theories to better theoretically grasp the emergence of GHD.

Methods

To fill this knowledge gap, we conducted a narrative literature review of the driving forces behind Chile’s integration of health into foreign policy. Drawing on a popular analytical framework used in international relations scholarship, we identified driving forces of the integration of health into Chile foreign policy at three levels of analysis.

Results

At the international/global level of analysis, the main driving forces were related to national security concerns and compliance with regulations of international organizations. At the regional level, GHD was driven by a commitment to regional solidarity through mutually beneficial cooperation in response to neoliberal reforms; health coordination in emergencies; and protection of indigenous peoples. Finally, at the domestic level, drivers identified include economic interests of various productive sectors and how health regulations might impact those; the high degree of social inequity which impacts on access to healthcare; and management of natural disasters.

Conclusion

Health actions in the context of international relations in Chile are still mainly motivated by more traditional foreign policy interests rather than by a desire to satisfy health needs per se. This seems to conform with findings of existing GHD scholarship that emphasize the importance of security and economic interests as driving forces of GHD, and how health is often appropriated instrumentally within foreign policy settings to achieve other goals. But the review also reveals that in the context of South-South cooperation (and regional health diplomacy), solidarity and normative considerations can be important driving forces as well. Finally, the review demonstrates that there has been an evolution from chiefly domestically focused health policies (e.g. maternal and child nutrition treatment) towards internationally inspired integrated policies (e.g. maternal and child nutrition promotion aligned with international guidelines).

     

Geneva–Seattle collaboration in support of developing country vaccine manufacturing

Vaccines were once produced almost exclusively by state-supported entities. While they remain essential tools for public health protection, the majority of the world’s governments have allowed industry to assume responsibility for this function. This is significant because while the international harmonisation of quality assurance standards have effectively increased vaccine safety, they have also reduced the number of developing country vaccine producers, and Northern multinational pharmaceutical companies have shown little interest in offering the range of low-priced products needed in low and middle-income-country contexts. This article examines how public–private collaboration is relevant to contemporary efforts aimed at strengthening developing country manufacturers’ capacity to produce high-quality, low-priced vaccines. Specifically, it casts light on the important and largely complimentary roles of the World Health Organization, The Bill and Melinda Gates Foundation, and the Seattle-based non-profit PATH, in this process. The take away message is that external support remains critical to ensuring that developing country vaccine manufacturers have the tools needed to produce for both domestic and global markets, and the United Nations supply chain, and collaboration at the public–private interface is driving organisational innovation focused on meeting these goals.     

The Global Fund and the re-configuration and re-emergence of 'civil society': widening or closing the democratic deficit?

The past decade has witnessed a tremendous growth in the scale and policy influence of civil society in global health governance. The AIDS 'industry' in particular opens up spaces for active mobilisation and participation of non-state actors, which further crystallise with an ever-increasing dominance of global health initiatives. While country evaluations of global initiatives call for a greater participation of 'civil society', the evidence base examining the organisation, nature and operation of 'civil society' and its claims to legitimacy is very thin. Drawing on the case of one of the most visible players in the global response to HIV epidemic, the Global Fund to Fight AIDS, Tuberculosis and Malaria, this article seeks to highlight the complex micropolitics of its interactions with civil society. It examines the nature of civil society actors involved in the Fund projects and the processes through which they gain credibility. We argue that the imposition of global structures and principles facilitates a reconfiguration of actors around newer forms of expertise and power centres. In this context, the notion of 'civil society' underplays differences and power dynamics between various institutions and conceals the agency of outsiders under the guise of autonomy of the state and people.