Ethics, ideology, and reproductive health policy in the United States

The 1994 International Conference on Population and Development held in Cairo recognized the centrality of reproductive health to human rights and development. Progress on the Cairo agenda has slowed for numerous reasons, however. The United States, once an enthusiastic promoter of this agenda and still the world's leading reproductive health donor, has revised its reproductive health policies radically since the 2000 presidential election of George W. Bush. This study examines how policies have been reconfigured in five key reproductive health areas, sparking controversy both in the United States and internationally. These categories are the content of sex education, access to emergency contraception and to abortion services, condom effectiveness, and HIV/AIDS prevention. The analysis presented here elucidates how ideological considerations have superseded public health and ethical concerns and reflects on health and ethical consequences.     

Decolonizing health policy and practice: Vaccine hesitancy in the United States

Using 2021 data and information related to COVID-19, this paper discusses the contribution of colonization, medical mistrust and racism to vaccine hesitancy. Vaccine hesitancy is defined as ‘delay in acceptance or refusal of vaccines despite availability’. Colonization is described as the ‘way the extractive economic system of capitalism came to the United States, supported by systems of supremacy and domination, which are a necessary part of keeping the wealth and power accumulated in the hands of the colonizers and ultimately their financiers’. The system of colonization results in policies and practices, including those related to health, that continue to create oppression and support racism. Persons experience trauma as the byproduct of colonization. Chronic stress and trauma create chronic inflammation and all diseases, whether genetic or lifestyle, have a common pathogenesis that is a component of inflammation. Medical mistrust is the absence of trust that healthcare providers and organizations genuinely care for patients' interests, are honest, practice confidentiality and have the competence to produce the best possible results. Finally, racism is described as everyday racism and perceived racism in healthcare.     

Future directions in national health policy for the United States

Unlike other countries which have established some form of national health insurance, the United States is debating this profound social program in facing all problems of financing and managing personal health services simultaneously: elimination of cost at time of service, sharing this cost equitably through the tax system, distributing the services equitably goegraphically, controlling rapidly rising costs and managing the organizational structure of services. Originally in other countries the primary objectives were to free citizens of the burden of costly illnesses, improve access across income groups, and share the costs more or less equally. Now other countries are expressing the problems found simultaneously by the United States. It is argued that universal and comprehensive national health insurance spreads money and resources so thinly that specific and important problems such as pockets of high infant mortality or curable diseases are obscured and ignored. The United States sould set up a health program which targets specific problems and mitigates high cost episodes rather than indulge itself in a comprehensive and universal national health insurance. This proposal is not politically feasible, however, and predictions are made as to what will happen in the United States within the politically and culturally determined range of debatable options.     

Shaping public policy and population health in the United States: why is the public health community missing in action?

Renewed international interest in the structural determinants of health manifests itself in a focus on the social determinants of health and the public policy antecedents that shape their quality. This increased international interest in public policy in support of the structural determinants of health has had little traction in the United States. This should be surprising since the United States presents one of the worst population health profiles and public policy environments in support of health among wealthy developed nations. The U.S. position as a health status and policy outlier results from long-term institutional changes that are shaped by political, economic, and social forces. U.S. public health researchers' and workers' neglect of these structural and public policy issues conforms to the dominant ideological discourses that serve to justify these changes. The author presents some means by which public health researchers and workers can challenge these dominant discourses.     

Recurrent cost and public health care delivery: the other war in El Salvador

This study analyzes the causes and effects of the persistent underfinancing of recurrent costs in the Ministry of Health (MOH) of El Salvador over the past decade. Causative factors identified and discussed include (1) a functionally unintegrated MOH structure--consisting of (a) the autonomous hospitals and (b) the remainder of the Ministry; (2) the functional isolation of the Ministry's planning department from its budgetary department; (3) the use of historical-budget based decision-making--in lieu of more explicitly goal oriented resource allocation and planning criteria; (4) donor agencies' funding of infrastructure construction projects, coupled with their unwillingness to financially support the recurrent costs such projects ultimately give rise to; and finally, (5) the civil war and its associated economic dislocation, altered central government funding priorities and general state of disarray. The effects of persistent underfinancing of recurrent costs in El Salvador are the growing proportion of the MOH budget being consumed by outlays for personnel at the expense of virtually all other budgetary categories; the shortages of drugs and general medical supplies in public health facilities; and reduced levels of utilization of those facilities from what would otherwise be expected; all of which together imply a reduced level of both productivity and effectiveness of the public health care system. Policy implications and recommendations are briefly noted.     

The fruits of empire rot on the vine: United States health policy in the austerity era

Since 1970--with the decline in the hegemonic empire--the U.S. economy has entered a period of lower profitability, producing a major shift in the economic behavior of corporate capital. In contrast to the demand stimulation (New Deal) programs of the earlier period of prosperity capitalism, capital has moved toward a profit stimulation strategy in the current era of austerity capitalism. Fundamental to this austerity strategy is the drive to reduce costs of production. Both governmental and employee health benefits represent a cost of production. Thus in the health field, austerity strategy signifies a reduction in the provision of health benefits to employees and cuts in governmental health programs. An effect of austerity capitalism may be that health patterns now mainly confined to the underdeveloped world will become more prominent among the low-wage and unemployed sectors of the working class in the United States.     

Mental health systems in El Salvador, Guatemala, and Nicaragua: results of a WHO-AIMS evaluation]

The authors evaluated the mental health systems of El Salvador, Guatemala, and Nicaragua, using a group of select indicators. The World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS) was used to collect data from the nations. The national mental health systems of Nicaragua, Guatemala, and El Salvador have serious limitations, especially in primary care, and a marked lack of qualified human resources. Budget allocations for mental health care are barely 1% of the total health care budgets; and the psychiatric hospitals located in the national capitals consume at least 90% of those funds. The limited human and material resources available are concentrated in the respective country capital cities. National mental health policies and legislation have not been adopted; however, all three countries do have national plans in progress. Furthermore, all three have designed and implemented programs for mental health care in case of disaster. Agreements must be reached with offices for the defense of human rights to raise awareness and protection of rights for the mentally ill. In recent years, new experiences have been gained and these should be distributed more widely. The Pan American Health Organization (PAHO/WHO) and the WHO-AIMS project have contributed toward developing community models for mental health services. Lastly, priorities have been identified and action items recommended.     

Evaluation of a programme to train village health workers in El Salvador

The civil war in El Salvador has had devastating effects onthe country's health care system, especially in rural areas.The Catholic Archdiocese of San Salvador undertook a programmeto train village health promoters, in an effort to alleviatethe serious shortage of primary health care in some of the affectedareas. The objectives of the programme included not merely anattempt to take medical care to the most needy, but rather thepromotion of health education and community development. Thevolunteer promoters received a four-week training course. A private non-profit international organization, AesculapiusInternational Medicine, took over the follow-up and supervisionof a group of promoters in 1984. One part of the programme evaluationwas a survey designed to assess the work patterns and attitudesof the promoters. It was found that most of them spent a greatdeal of time treating illnesses and very little on communityhealth education. As a result, a one-week course devoted tocommunity education was added to the curriculum and emphasiswas placed on increasing teaching skills and confidence.     

Children's public health policy in the United States: how the past can inform the future

As we struggle to respond to child public health problems in the twenty-first century, the past provides many core lessons. This paper explores three of them: the need to focus on the environment that makes children sick rather than on sick children; the need to attack the biggest problems, not the most scientifically interesting ones; and the need to provide services where children are most likely to be. To illuminate these lessons, we discuss important child public health efforts in the nineteenth and twentieth centuries.     

National practice guidelines for mental health care: a comparative policy analysis of the United kingdom and the United States

Mental disorders are the leading cause of disability worldwide, according to the World Health Organization (WHO, 1996). In a report on health indicators of premature death and disability, the World Bank concluded that mental health problems account for 8.1% of the global burden of disease (GBD). Industrialized nations have taken different approaches in applying innovations to mental health care and mental health care policy. This paper uses the K. McInnis-Dittrich model of policy analysis (Ginsberg, 1994) to analyze the approaches of the United Kingdom (U.K.) and the United States (U.S.) to mental health treatment, specifically examining the effects of the U.K.'s national practice guidelines and the U.S.'s lack of similar guidelines. Recommendations for changes in current U.S. mental health policy are presented.