Health sector reform in the Occupied Palestinian Territories (OPT): targeting the forest or the trees?

Since the signing of the Oslo Peace Accords and the establishment of the Palestinian Authority in 1994, reform activities have targeted various spheres, including the health sector. Several international aid and UN organizations have been involved, as well as local and international non-governmental organizations, with considerable financial and technical investments. Although important achievements have been made, it is not evident that the quality of care has improved or that the most pressing health needs have been addressed, even before the second Palestinian Uprising that began in September 2000. The crisis of the Israeli re-invasion of Palestinian-controlled towns and villages since April 2002 and the attendant collapse of state structures and services have raised the problems to critical levels. This paper attempts to analyze some of the obstacles that have faced reform efforts. In our assessment, those include: ongoing conflict, frail Palestinian quasi-state structures and institutions, multiple and at times inappropriate donor policies and practices in the health sector, and a policy vacuum characterized by the absence of internal Palestinian debate on the type and direction of reform the country needs to take. In the face of all these considerations, it is important that reform efforts be flexible and consider realistically the political and economic contexts of the health system, rather than focus on mere narrow technical, managerial and financial solutions imported from the outside.     

What is suicide? Classifying self-killings

Medicine, Health Care and Philosophy - Although the most common understanding of suicide is intentional self-killing, this conception either rules out someone who lacks mental capacity being...     

Familial hypercholesterolemia: the lipids or the genes?

Familial Hypercholesterolemia (FH) is a common cause of premature cardiovascular disease and is often undiagnosed in young people. Although the disease is diagnosed clinically by high LDL cholesterol levels and family history, to date there are no single internationally accepted criteria for the diagnosis of FH. Several genes have been shown to be involved in FH; yet determining the implications of the different mutations on the phenotype remains a hard task. The polygenetic nature of FH is being enhanced by the discovery of new genes that serve as modifiers. Nevertheless, the picture is still unclear and many unknown genes contributing to the phenotype are most likely involved. Because of this evolving polygenetic nature, the diagnosis of FH by genetic testing is hampered by its cost and effectiveness.In this review, we reconsider the clinical versus genetic nomenclature of FH in the literature. After we describe each of the genetic causes of FH, we summarize the known correlation with phenotypic measures so far for each genetic defect. We then discuss studies from different populations on the genetic and clinical diagnoses of FH to draw helpful conclusions on cost-effectiveness and suggestions for diagnosis.     

Artificial Christmas trees: how real are the lead exposure risks?

Exposure to lead has long been recognized as a major public health issue in the United States and other industrialized nations. The health risks associated with low lead levels mean that consumer products (such as those made from polyvinyl chloride [PVC] plastic, which often incorporates lead as a stabilizer) with even moderate lead exposure risks could be dangerous. The purpose of the experiments reported in this article was to test for lead exposure from artificial Christmas trees made of PVC, which are now present in an estimated 50 million U.S. households. The first phase of experimentation tested artificial Christmas trees in the laboratory for lead content in branches, lead transfer from hand contact, and lead dust levels under the tree. The second phase was based on a field-testing survey of households with artificial Christmas trees. Results from these experiments show that, while the average artificial Christmas tree does not present a significant exposure risk, in the worst-case scenarios a substantial health risk to young children is quite possible.     

Market forces or force the market?

States think they have some answers to the healthcare cost spiral. But the answers can be as different as the states themselves. Some advocate rigorous regulation to contain costs, while at the other end are those who believe good old competition is the best weapon against healthcare inflation. An increasing number of experts say both camps are partially right. So who's having the most success?     

Fresh or frozen? Classifying ‘spare’ embryos for donation to human embryonic stem cell research

United Kingdom (UK) funding to build human embryonic stem cell (hESC) derivation labs within assisted conception units (ACU) was intended to facilitate the 'In-vitro fertilisation (IVF)-stem cell interface', including the flow of fresh 'spare' embryos to stem cell labs. However, in the three sites reported on here, which received this funding, most of the embryos used for hESC research came from long term cryopreservation storage and/or outside clinics. In this paper we explore some of the clinical, technical, social and ethical factors that might help to explain this situation. We report from our qualitative study of the ethical frameworks for approaching women/couples for donation of embryos to stem cell research. Members of staff took part in 44 interviews and six ethics discussion groups held at our study sites between February 2008 and October 2009. We focus here on their articulations of social and ethical, as well as scientific, dimensions in the contingent classification of 'spare' embryos, entailing uncertainty, fluidity and naturalisation in classifying work. Social and ethical factors include acknowledging and responding to uncertainty in classifying embryos; retaining 'fluidity' in the grading system to give embryos 'every chance'; tensions between standardisation and variation in enacting a 'fair' grading system; enhancement of patient choice and control, and prevention of regret; and incorporation of patients' values in construction of ethically acceptable embryo 'spareness' ('frozen' embryos, and embryos determined through preimplantation genetic diagnosis (PGD) to be genetically 'affected'). We argue that the success of the 'built moral environment' of ACU with adjoining stem cell laboratories building projects intended to facilitate the 'IVF-stem cell interface' may depend not only on architecture, but also on the part such social and ethical factors play in configuration of embryos as particular kinds of moral work objects.     

Will CHINs hit the jackpot or break the bank?

Before providers, payers and others sign up to share data through community health information networks, they're asking for proof that savings will far exceed the cost. The fate of the CHIN movement may hinge on the evidence.     

Chaperones: protecting the patient or protecting the doctor?

The routine use of chaperones during medical examinations, including intimate examinations, is variable. Practice varies between countries and also within them. Use of a chaperone may protect patients from sexual abuse by medical or nursing practitioners. An appropriate chaperone may also protect healthcare practitioners from false accusations. This article considers issues surrounding the use of chaperones and suggests a chaperoning policy for sexual health clinics, while acknowledging that it may not be appropriate or acceptable to all patients or medical staff, or for different parts of the world.     

Caring: the neglected health outcome? or input?

In most forms of evaluation of health care--and it is certainly true of economic evaluation--and is considering the outcomes of such care, caring tends to be omitted, or simply forgotten. It is often the case that little more than lip service is paid to the inclusion of caring as an input. This paper takes a closer look at caring, the neglected outcome of health care. The perspective starts from that of economics but other disciplines are examined briefly along the way to determine whether they deal better with caring than does the dismal science of economics. It is concluded that there is a need for greater consideration of caring as both an outcome and an input in evaluation of health care and that in the specific context of economic evaluation, when considering caring, economists might usefully look to other disciplines to broaden and deepen their conceptualisation of both benefits and costs in their economic evaluation studies.