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Southern Sudan hit by epidemic of sleeping sickness
THE LANCET
POLICY AND PEOPLE
Southern Sudan hit by epidemic of sleeping sickness According to Charles Paquet, a he outbreak of sleeping sickness researcher on sleeping sickness in in southern Sudan is threatening southern Sudan, the problem lies over 10 million people in the vast with the increasing war-torn provinces of density of tsetse flies. Equatoria, Upper Nile, Last year, Paquet preand Bahr-el-Ghazal. dicted the outbreak of The epidemic is one of disease after he saw the worst to occur there people with symptoms this century. In certain at Chukudum, Labone, areas 20% of the popuand Nimule. lation is affected and A spokesman of the the extent of the disease SPLA office in Nairobi is still unknown. said: “People are Western aid workers dying from many disattribute the new epieases, though sleeping demic to social and sickness is the leading political disruptions. Victims of displacement killer in the villages.” For over 15 years now, “Movements and displacement of rebels of the Sudan Peoples population and limited health faciliLiberation Army (SPLA), have been ties have complicated the situation”, fighting the Khartoum government said James D Mwaura, a Norwegian for greater autonomy for non-Islamic People’s Aid doctor at Chukudum southern Sudan. Panos Pictures
T
Hospital in eastern Equatoria. “Southern Sudan has been cut off from the outside world apart from aid workers who are operating under difficult situations in a war zone, where people fled towns and villages to the bush to escape fighting”, says Timothy Wachira of the African Medical and Research Foundation. There is fear that the disease might spread to neighbouring countries. As an emergency control action, the European Union has allocated Ecu 5 million for combating tsetse flies in Ethiopia, Kenya, and Uganda. However, so long as the density of tsetse flies is high in southern Sudan and other endemic areas in tropical Africa, sleeping sickness will always be a threat in sub-Saharan Africa, says Paquet. Anderson Wachira Kigotho
US budget deal introduces Medicaid changes hile Medicare captured most of the headlines in discussion of the health portions of the huge budget bill signed by President Clinton on Aug 5, the measure also made large changes to the Medicaid programme for the poor. And while most of the changes were lauded by state governors, they could have a far-reaching impact for physicians. In addition to trimming some US$12 billion over the next 5 years in special payments to hospitals that serve many poor and uninsured patients, the bill also repealed the “Boren amendment” that required states to pay “reasonable and adequate” rates to hospitals and nursing homes. Those industries had successfully used the amendment to
W
sue states to force them to raise payments. The bill will also make it easier for states to put patients in managed care, since it lifts requirements for explicit federal permission, and for managed-care plans to serve a certain proportion of private patients. Advocates for the poor expressed fears that such changes could lead to substandard care for Medicaid patients forced into plans that they do not understand. Advocates are also expressing concern about a provision in the bill that allows states to pay lower rates for patients who are eligible for both Medicare and Medicaid. The change “opens the prospect of a two-tier system, leading to different levels of care for the better and less well-off”,
said American Medical Association president Percy Wooton. Concern about the Medicaid language notwithstanding, the AMA did get much of what it wanted in the budget bill. Language passed by the House to cap malpractice damage awards was dropped but the bill does foster development of “provider service organisations”, groups of hospitals and doctors who can join together to provide managed care to Medicare patients, bypassing insurance companies. AMA also won a delay, and a probable rewrite, of a controversial change to Medicare’s fee system that would have greatly reduced fees for many specialists. Julie Rovner
Prospect of further restrictions on abortion in USA looms ince 1977, the annual spending bill for the US Department of Health and Human Services has carried language banning the use of federal funds for abortion in Medicaid. But now, as more states are enrolling more and their Medicaid patients in managed care, the man after whom the abortion ban is named, Representative Henry Hyde, says his amendment needs an update. Hyde and abortion opponents want to include new language this year saying that federal funds should
S
502
not used to pay premiums of plans that include abortion as a covered benefit. But abortion rights supporters, led by Representative Nita Lowey, insist that the language could prompt managed-care plans, more than two-thirds of which now include abortion as a benefit, according to the National Abortion and Reproductive Rights Action League, to drop abortion for all patients, not just for Medicaid enrollees. Hyde and Lowey reached a compromise of sorts on July 31, which
will add the new language to the spending bill for the next fiscal year, but will also include language stipulating that the ban will not affect the ability of managed-care plans to offer elective abortions to private patients or to Medicaid patients if the state chooses to use its money and contract separately for the services. The bill is expected to come to the House floor for debate after Congress returns from its break in September. Julie Rovner
Vol 350 • August 16, 1997
POLICY AND PEOPLE
Southern Sudan hit by epidemic of sleeping sickness According to Charles Paquet, a he outbreak of sleeping sickness researcher on sleeping sickness in in southern Sudan is threatening southern Sudan, the problem lies over 10 million people in the vast with the increasing war-torn provinces of density of tsetse flies. Equatoria, Upper Nile, Last year, Paquet preand Bahr-el-Ghazal. dicted the outbreak of The epidemic is one of disease after he saw the worst to occur there people with symptoms this century. In certain at Chukudum, Labone, areas 20% of the popuand Nimule. lation is affected and A spokesman of the the extent of the disease SPLA office in Nairobi is still unknown. said: “People are Western aid workers dying from many disattribute the new epieases, though sleeping demic to social and sickness is the leading political disruptions. Victims of displacement killer in the villages.” For over 15 years now, “Movements and displacement of rebels of the Sudan Peoples population and limited health faciliLiberation Army (SPLA), have been ties have complicated the situation”, fighting the Khartoum government said James D Mwaura, a Norwegian for greater autonomy for non-Islamic People’s Aid doctor at Chukudum southern Sudan. Panos Pictures
T
Hospital in eastern Equatoria. “Southern Sudan has been cut off from the outside world apart from aid workers who are operating under difficult situations in a war zone, where people fled towns and villages to the bush to escape fighting”, says Timothy Wachira of the African Medical and Research Foundation. There is fear that the disease might spread to neighbouring countries. As an emergency control action, the European Union has allocated Ecu 5 million for combating tsetse flies in Ethiopia, Kenya, and Uganda. However, so long as the density of tsetse flies is high in southern Sudan and other endemic areas in tropical Africa, sleeping sickness will always be a threat in sub-Saharan Africa, says Paquet. Anderson Wachira Kigotho
US budget deal introduces Medicaid changes hile Medicare captured most of the headlines in discussion of the health portions of the huge budget bill signed by President Clinton on Aug 5, the measure also made large changes to the Medicaid programme for the poor. And while most of the changes were lauded by state governors, they could have a far-reaching impact for physicians. In addition to trimming some US$12 billion over the next 5 years in special payments to hospitals that serve many poor and uninsured patients, the bill also repealed the “Boren amendment” that required states to pay “reasonable and adequate” rates to hospitals and nursing homes. Those industries had successfully used the amendment to
W
sue states to force them to raise payments. The bill will also make it easier for states to put patients in managed care, since it lifts requirements for explicit federal permission, and for managed-care plans to serve a certain proportion of private patients. Advocates for the poor expressed fears that such changes could lead to substandard care for Medicaid patients forced into plans that they do not understand. Advocates are also expressing concern about a provision in the bill that allows states to pay lower rates for patients who are eligible for both Medicare and Medicaid. The change “opens the prospect of a two-tier system, leading to different levels of care for the better and less well-off”,
said American Medical Association president Percy Wooton. Concern about the Medicaid language notwithstanding, the AMA did get much of what it wanted in the budget bill. Language passed by the House to cap malpractice damage awards was dropped but the bill does foster development of “provider service organisations”, groups of hospitals and doctors who can join together to provide managed care to Medicare patients, bypassing insurance companies. AMA also won a delay, and a probable rewrite, of a controversial change to Medicare’s fee system that would have greatly reduced fees for many specialists. Julie Rovner
Prospect of further restrictions on abortion in USA looms ince 1977, the annual spending bill for the US Department of Health and Human Services has carried language banning the use of federal funds for abortion in Medicaid. But now, as more states are enrolling more and their Medicaid patients in managed care, the man after whom the abortion ban is named, Representative Henry Hyde, says his amendment needs an update. Hyde and abortion opponents want to include new language this year saying that federal funds should
S
502
not used to pay premiums of plans that include abortion as a covered benefit. But abortion rights supporters, led by Representative Nita Lowey, insist that the language could prompt managed-care plans, more than two-thirds of which now include abortion as a benefit, according to the National Abortion and Reproductive Rights Action League, to drop abortion for all patients, not just for Medicaid enrollees. Hyde and Lowey reached a compromise of sorts on July 31, which
will add the new language to the spending bill for the next fiscal year, but will also include language stipulating that the ban will not affect the ability of managed-care plans to offer elective abortions to private patients or to Medicaid patients if the state chooses to use its money and contract separately for the services. The bill is expected to come to the House floor for debate after Congress returns from its break in September. Julie Rovner
Vol 350 • August 16, 1997