- Email: [email protected]
WHO confronts the ethical challenge
NEWS merely recommended a study. In this fashion, politically unspeakable matters have worked their way into pub-
WASHINGTON PERSPECTIVE
Clinton at the one-year mark What’s the difference in health affairs after a year of Bill Clinton in the White House? In tangible terms, very little. A broader immunisation programme for poor children is a promi-
exception. Otherwise, neither public health nor many patients better off even though the candiare date championing health-care reform won the election. But in matters of governmental attitude and mustering of public attention and political forces in pursuit of extraordinary changes, Clinton has achieved a great deal in a relatively short time. Year two is when the preparations should either bear fruit or signal a political impotence that could sink the presinent
the
dent’s re-election chances. : Health insurance for all is on the political agenda only because Clinton put it there after 12 years of wary avoidance of the issue by his two Republican predecessors. The president can be faulted for protracted delays in formulating a health plan, and further delays in pushing it after it was completed. As a result, critics of all political stripes have been handed ample time to fire away while promoting their own particular schemes. Of increasing importance, some of these alternatives now ride on the assertion that, with medical inflation in decline, the so-called health-care crisis is evaporating, leaving only isolated problem spots to be addressed by specially focused legislation. Nonetheless, for the first time the United States is talking seriously about the failings of its health-care system. Though remedies differ, no
lic discourse.
tion-always
a
sensitive
matter
first year has seen a restoration of effective working relations, even congeniality, between the National Institutes of Health and its cabinet-level parent, the Department of Health and Human Services. During the Bush era, relations between the two iced up on a variety of issues. The politicos at the Department considered NIH less than loyal in supporting the ban on fetal-tissue research. They also felt, with justification, that NIH was indifferent to White House demands for frugality, and was surreptitiously agitating on Capitol Hill for bigger budgets. Toward the end of her two-year reign under Bush, NIH director Bernadine Healy gingerly endorsed a secession movement to get her agency out from under the Department’s control. Her successor at NIH, Harold Varmus, is reported to get on well with the new regime at the Department, where a former colleague from the University of California at San Francisco, Philip Lee, is Assistant Secretary for Health-the top political post for health-related matters. Clinton’s performance in health affairs, as in all other matters, has so far merited the grace period that is summed up by "too early to tell". That won’t do for the second year.
Finally, Clinton’s
in
politics-the
American administration has restored funding for population-control assistance in US foreign aid programmes (see p 227). The AIDS lobby has made it clear that no amount of federal concern and money can be sufficient for confronting the disease and the it causes. But Clinton promised a great deal in this area, and after a slow start, has made deliveries. An impresario, if not a czar, for AIDS has been installed in the White House. Produced with government money, candid advertisements promoting condoms as protection against HIV have recently appeared on television for the first time. In his choice for Surgeon General,
suffering
Joycelyn Elders, a physician from Arkansas, the president seems to have enlisted a stalking horse for controversial public-health testing notions that many suspect he himself may quietly harbour. Elder’s latest . foray into thinking the unthinkable aloud in public concerns legalisation of drugs, which she cautiously said
should be "studied". When the predictable demands for her resignation were showered on the White House, the president guardedly pointed out that his Surgeon General, was, one, speaking for herself, and two, hadDaniel S
WHO confronts the ethical
challenge
counselling at federally financed v health clinics. The president also lifted the ban on fetal-tissue research and on the use of federal funds for abortions in cases of rape or incest. In:
Instead of watching more or less silently from the sidelines, the World Health : Organization now proposes to face up to "the ethical challenges, emerging from dramatic advances in biomedical technology". These challenges, Dr Hiroshi Nakajima, WHO Director General, underlined in his opening address to the 31-member Executive Board, meeting at headquarters in Geneva, Jan 17-26, "touch upon the: definition of the human being, its biological integrity, and its status and relationships within the family structure and society at large". With the public now perceiving the whole field as a major social issue, the time had come for its being given full scrutiny. : In this, the intention is that WHO’s role should be pivotal, in cooperation with the Council for International Organisations of Medical Sciences (CIOMS). This body, : whose offices are conveniently within the
another
WHO
politician dares revert to the Reagan-Bush tactic of piously calling for more study while otherwise ignoring the issue. Clinton’s impact on health affairs has been particularly strong in policies concerning abortion, a topic on which Reagan and Bush invariably
national
deferred
their fundamentalist supporters on the political right. One of ’. Clinton’s first steps in office was to cancel the "gag rule" on abortion to
change concerning reproduc-
complex
of
buildings,
was
Greenberg
lished in 1949 as a non-governmental organisation, with financial assistance from WHO and LTNESCO. Although initially providing research grants to young scientists, it has been obliged by shortage of funds in recent years to concentrate on meetings concerned with the sociological implications of health policy and biomedical science, including ethics. In referring to such matters as cloning of cells of human embryos and post-
menopausal pregnancies, organ transplants, and experimentation on human subjects, Nakajima’s speech emphasised that these issues could not be regarded as
countries alone. countries and, as in developed countries as well, there are few ethical safeguards to guarantee that, in such health-related issues, the safety and rights of both individuals and communities are estab-adequately protected", he said. WHO, limited
to
"Today in
affluent
developing documented recently, most
225
would push for its "intensive their opinion, than WHO, for formulating involvement in the fields of both human rules of conduct and overseeing their : application. : rights and biomedical ethics". The outcome of the Board’s deliberaAccording to WHO officials, this readiness to shoulder additional tions will be put before the World Health is regarded as an inevitable development, Assembly in May. Although that body given the heightened attention now directproduced a resolution on transplants in . ed to the whole subject of ethics, includ- : 1987, followed two years later by a set of . ing discussions in the Council of guiding principles, WHO until now has Europe-a body much less qualified, inbeen marking time on anything that could
accordingly,
responsibilities
ANC health
policy for South
With the first one-person-one-vote elections in South Africa scheduled for April 27, the contesting parties are beginning to . unveil their manifestoes. The African National Congress (ANC), widely expected to be the senior party in the government of national unity, published its health plan this week. The party has previously indicated that its key priorities are the economy, foreign affairs, home affairs, and defence. If the pro-ANC vote is not sufficiently large, the position of the Minister of Health may have to be offered to another party. : The ANC is under pressure to deliver substantial gains to the hitherto disenfranchised and disempowered majority of ’. the country. Resources are limited, however, and gains will need to be shown not just in health, but also in housing, education, employment, and water and sanitation if the party is to consolidate the present support into the longer term. The ANC needs to pragmatically promise only what it can deliver; it also needs to woo political support from as wide a base as possible, and compromises from previous, more radical, proposals have already been made. : The challenges in the health sector are numerous and awesome. Equity must be promoted as a major objective. Deep divisions between a wide range of providers must be overcome. Linkages between primary, secondary, and tertiary levels need streamlining. Resources need to be allo-
historically deprived communities The massive budgets of the tertiary hospitals will need to be assessed for their effectiveness and efficiency. : The ANC has the disadvantage of having been prevented, with few exceptions, from learning from the inside of the syscated and
to
process
226
its mission, in line with the new challenges, including biomedical ethics, global change is creating". Media attention has accelerated the process. restate
Alan
McGregor
and to areas of greatest need be investigated and a commission will be established to examine the crisis in the medical aid sector and to recommend the most appropriate means of financing health. User charges are not to be levied on specific vulnerable groups: exactly which these are still need to be clarified. Within the context of a mixed economy, the private sector is there to stay, but providing incentives for more appropriate activities and regulating its less desirable attributes are to be attempted. The ANC is sensibly not rushing into constructing new facilities, a measure that has created problems in other countries after change of government and the cessation of conflict elsewhere, in part because of the lack of attention to the recurrent costs associated with running the system, and because of the lack of attention to functional rather than infrastructural issues. A more rational plan to construct primary care facilities according to national standards and norms (yet to be developed; targeted for the next few years) is envisaged. The policy statement aims to stimulate debate; refinements will take place over the quarter year before the elections and in the initial years of post-apartheid governance that will follow. The process of seeking broad acceptance, compromising on the most radical proposals, being pragmatic and not promising the unachievable, augurs well for the health sector. But, the changes envisaged need to be carefully promoted (where’s the acknowledgement of the role of public health?) and carefully instituted (where are the managers with vision?). Efforts will also need to be made to keep control of health policy at a time when the multilateral and bilateral donors, whose funds are necessary for achieving gains, are more aggressive than ever before in imposing their view of the health sector; their vision is likely to include the promotion of the private sector, establishing a more limited role for the state, promoting competition and giving priority to a limited range of health care "packages". Offers of foreign assistance, often directed at buildings (visible symbols of achievement) and highly vertical programmes, will need to be carefully scrutinised by the new government, to ensure their coherence with more fundamental policy objectives. health
Africa
care
are to
term. The objectives are impressive in most cases, realistic, although the and, time scale for many of the targets are highly ambitious. South Africa needs to catch up with reasonably well-established policies elsewhere, such as developing an essential drugs list and promoting generic substitution, regulating advertising and sponsorships by the alcohol and tobacco industries, improving immunisation services and promoting improved obstetric services. Equitable access to health care is to be promoted; but "being within reach of a primary care service" needs more explicit definition. Some of the stated targets will, however, be difficult to achieve-for example, significant annual . reductions in incidence of diarrhoea, : acute respiratory infection and tuberculosis, which depend on improvements in other sectors. There is a welcome commitment to promoting intersectoral activities and promoting health public policy. Others are perhaps over-ambitious, v although well worth targeting-for example, establishing rehabilitation services in half of all community health centres by the end of next year. Still other priorities are put very cautiously, identifying important areas, such as improving mental health care, but without promising significant measurable improvements in the near future. : The thorniest questions, such as those concerning the financing of the health system, remain unresolved. Mechanisms for reallocating resources towards primary
short
areas.
tem-about the balance of power between the provinces and the centre, the of policy-making, the writing of legislation, and day-to-day management of health services. But it has forged links with its natural allies and supporters and members within the progressive health movement, and began seriously to address national policy issues after the ban on the party was lifted in 1990. : So, what has the ANC seen fit to offer the electorate? A nationalised health service free for all at the point of use has been recognised as unobtainable in the
properly be regarded as a "structured response" on the question of ethics. The Board’s working group had suggested that WHO "update its health targets and
Health
priorities
. Maternal and child health Safeguarding women’s and children’s rights; improving, and providing free, maternal care; eradicating polio and neonatal tetanus, and greatly reducing incidence of measles; and promoting breastfeeding. of communicable diseases Reducing incidence of tuberculosis, hepatitis B, and common diseases of childhood; promoting sex education in schools. Other health priorities Programmes to cover main health problems of vulnerable groups; legal protection for women and children against violence; enforcement of health and safety legislation.
:
:
* Control
: : : :
Anthony Zwi
WASHINGTON PERSPECTIVE
Clinton at the one-year mark What’s the difference in health affairs after a year of Bill Clinton in the White House? In tangible terms, very little. A broader immunisation programme for poor children is a promi-
exception. Otherwise, neither public health nor many patients better off even though the candiare date championing health-care reform won the election. But in matters of governmental attitude and mustering of public attention and political forces in pursuit of extraordinary changes, Clinton has achieved a great deal in a relatively short time. Year two is when the preparations should either bear fruit or signal a political impotence that could sink the presinent
the
dent’s re-election chances. : Health insurance for all is on the political agenda only because Clinton put it there after 12 years of wary avoidance of the issue by his two Republican predecessors. The president can be faulted for protracted delays in formulating a health plan, and further delays in pushing it after it was completed. As a result, critics of all political stripes have been handed ample time to fire away while promoting their own particular schemes. Of increasing importance, some of these alternatives now ride on the assertion that, with medical inflation in decline, the so-called health-care crisis is evaporating, leaving only isolated problem spots to be addressed by specially focused legislation. Nonetheless, for the first time the United States is talking seriously about the failings of its health-care system. Though remedies differ, no
lic discourse.
tion-always
a
sensitive
matter
first year has seen a restoration of effective working relations, even congeniality, between the National Institutes of Health and its cabinet-level parent, the Department of Health and Human Services. During the Bush era, relations between the two iced up on a variety of issues. The politicos at the Department considered NIH less than loyal in supporting the ban on fetal-tissue research. They also felt, with justification, that NIH was indifferent to White House demands for frugality, and was surreptitiously agitating on Capitol Hill for bigger budgets. Toward the end of her two-year reign under Bush, NIH director Bernadine Healy gingerly endorsed a secession movement to get her agency out from under the Department’s control. Her successor at NIH, Harold Varmus, is reported to get on well with the new regime at the Department, where a former colleague from the University of California at San Francisco, Philip Lee, is Assistant Secretary for Health-the top political post for health-related matters. Clinton’s performance in health affairs, as in all other matters, has so far merited the grace period that is summed up by "too early to tell". That won’t do for the second year.
Finally, Clinton’s
in
politics-the
American administration has restored funding for population-control assistance in US foreign aid programmes (see p 227). The AIDS lobby has made it clear that no amount of federal concern and money can be sufficient for confronting the disease and the it causes. But Clinton promised a great deal in this area, and after a slow start, has made deliveries. An impresario, if not a czar, for AIDS has been installed in the White House. Produced with government money, candid advertisements promoting condoms as protection against HIV have recently appeared on television for the first time. In his choice for Surgeon General,
suffering
Joycelyn Elders, a physician from Arkansas, the president seems to have enlisted a stalking horse for controversial public-health testing notions that many suspect he himself may quietly harbour. Elder’s latest . foray into thinking the unthinkable aloud in public concerns legalisation of drugs, which she cautiously said
should be "studied". When the predictable demands for her resignation were showered on the White House, the president guardedly pointed out that his Surgeon General, was, one, speaking for herself, and two, hadDaniel S
WHO confronts the ethical
challenge
counselling at federally financed v health clinics. The president also lifted the ban on fetal-tissue research and on the use of federal funds for abortions in cases of rape or incest. In:
Instead of watching more or less silently from the sidelines, the World Health : Organization now proposes to face up to "the ethical challenges, emerging from dramatic advances in biomedical technology". These challenges, Dr Hiroshi Nakajima, WHO Director General, underlined in his opening address to the 31-member Executive Board, meeting at headquarters in Geneva, Jan 17-26, "touch upon the: definition of the human being, its biological integrity, and its status and relationships within the family structure and society at large". With the public now perceiving the whole field as a major social issue, the time had come for its being given full scrutiny. : In this, the intention is that WHO’s role should be pivotal, in cooperation with the Council for International Organisations of Medical Sciences (CIOMS). This body, : whose offices are conveniently within the
another
WHO
politician dares revert to the Reagan-Bush tactic of piously calling for more study while otherwise ignoring the issue. Clinton’s impact on health affairs has been particularly strong in policies concerning abortion, a topic on which Reagan and Bush invariably
national
deferred
their fundamentalist supporters on the political right. One of ’. Clinton’s first steps in office was to cancel the "gag rule" on abortion to
change concerning reproduc-
complex
of
buildings,
was
Greenberg
lished in 1949 as a non-governmental organisation, with financial assistance from WHO and LTNESCO. Although initially providing research grants to young scientists, it has been obliged by shortage of funds in recent years to concentrate on meetings concerned with the sociological implications of health policy and biomedical science, including ethics. In referring to such matters as cloning of cells of human embryos and post-
menopausal pregnancies, organ transplants, and experimentation on human subjects, Nakajima’s speech emphasised that these issues could not be regarded as
countries alone. countries and, as in developed countries as well, there are few ethical safeguards to guarantee that, in such health-related issues, the safety and rights of both individuals and communities are estab-adequately protected", he said. WHO, limited
to
"Today in
affluent
developing documented recently, most
225
would push for its "intensive their opinion, than WHO, for formulating involvement in the fields of both human rules of conduct and overseeing their : application. : rights and biomedical ethics". The outcome of the Board’s deliberaAccording to WHO officials, this readiness to shoulder additional tions will be put before the World Health is regarded as an inevitable development, Assembly in May. Although that body given the heightened attention now directproduced a resolution on transplants in . ed to the whole subject of ethics, includ- : 1987, followed two years later by a set of . ing discussions in the Council of guiding principles, WHO until now has Europe-a body much less qualified, inbeen marking time on anything that could
accordingly,
responsibilities
ANC health
policy for South
With the first one-person-one-vote elections in South Africa scheduled for April 27, the contesting parties are beginning to . unveil their manifestoes. The African National Congress (ANC), widely expected to be the senior party in the government of national unity, published its health plan this week. The party has previously indicated that its key priorities are the economy, foreign affairs, home affairs, and defence. If the pro-ANC vote is not sufficiently large, the position of the Minister of Health may have to be offered to another party. : The ANC is under pressure to deliver substantial gains to the hitherto disenfranchised and disempowered majority of ’. the country. Resources are limited, however, and gains will need to be shown not just in health, but also in housing, education, employment, and water and sanitation if the party is to consolidate the present support into the longer term. The ANC needs to pragmatically promise only what it can deliver; it also needs to woo political support from as wide a base as possible, and compromises from previous, more radical, proposals have already been made. : The challenges in the health sector are numerous and awesome. Equity must be promoted as a major objective. Deep divisions between a wide range of providers must be overcome. Linkages between primary, secondary, and tertiary levels need streamlining. Resources need to be allo-
historically deprived communities The massive budgets of the tertiary hospitals will need to be assessed for their effectiveness and efficiency. : The ANC has the disadvantage of having been prevented, with few exceptions, from learning from the inside of the syscated and
to
process
226
its mission, in line with the new challenges, including biomedical ethics, global change is creating". Media attention has accelerated the process. restate
Alan
McGregor
and to areas of greatest need be investigated and a commission will be established to examine the crisis in the medical aid sector and to recommend the most appropriate means of financing health. User charges are not to be levied on specific vulnerable groups: exactly which these are still need to be clarified. Within the context of a mixed economy, the private sector is there to stay, but providing incentives for more appropriate activities and regulating its less desirable attributes are to be attempted. The ANC is sensibly not rushing into constructing new facilities, a measure that has created problems in other countries after change of government and the cessation of conflict elsewhere, in part because of the lack of attention to the recurrent costs associated with running the system, and because of the lack of attention to functional rather than infrastructural issues. A more rational plan to construct primary care facilities according to national standards and norms (yet to be developed; targeted for the next few years) is envisaged. The policy statement aims to stimulate debate; refinements will take place over the quarter year before the elections and in the initial years of post-apartheid governance that will follow. The process of seeking broad acceptance, compromising on the most radical proposals, being pragmatic and not promising the unachievable, augurs well for the health sector. But, the changes envisaged need to be carefully promoted (where’s the acknowledgement of the role of public health?) and carefully instituted (where are the managers with vision?). Efforts will also need to be made to keep control of health policy at a time when the multilateral and bilateral donors, whose funds are necessary for achieving gains, are more aggressive than ever before in imposing their view of the health sector; their vision is likely to include the promotion of the private sector, establishing a more limited role for the state, promoting competition and giving priority to a limited range of health care "packages". Offers of foreign assistance, often directed at buildings (visible symbols of achievement) and highly vertical programmes, will need to be carefully scrutinised by the new government, to ensure their coherence with more fundamental policy objectives. health
Africa
care
are to
term. The objectives are impressive in most cases, realistic, although the and, time scale for many of the targets are highly ambitious. South Africa needs to catch up with reasonably well-established policies elsewhere, such as developing an essential drugs list and promoting generic substitution, regulating advertising and sponsorships by the alcohol and tobacco industries, improving immunisation services and promoting improved obstetric services. Equitable access to health care is to be promoted; but "being within reach of a primary care service" needs more explicit definition. Some of the stated targets will, however, be difficult to achieve-for example, significant annual . reductions in incidence of diarrhoea, : acute respiratory infection and tuberculosis, which depend on improvements in other sectors. There is a welcome commitment to promoting intersectoral activities and promoting health public policy. Others are perhaps over-ambitious, v although well worth targeting-for example, establishing rehabilitation services in half of all community health centres by the end of next year. Still other priorities are put very cautiously, identifying important areas, such as improving mental health care, but without promising significant measurable improvements in the near future. : The thorniest questions, such as those concerning the financing of the health system, remain unresolved. Mechanisms for reallocating resources towards primary
short
areas.
tem-about the balance of power between the provinces and the centre, the of policy-making, the writing of legislation, and day-to-day management of health services. But it has forged links with its natural allies and supporters and members within the progressive health movement, and began seriously to address national policy issues after the ban on the party was lifted in 1990. : So, what has the ANC seen fit to offer the electorate? A nationalised health service free for all at the point of use has been recognised as unobtainable in the
properly be regarded as a "structured response" on the question of ethics. The Board’s working group had suggested that WHO "update its health targets and
Health
priorities
. Maternal and child health Safeguarding women’s and children’s rights; improving, and providing free, maternal care; eradicating polio and neonatal tetanus, and greatly reducing incidence of measles; and promoting breastfeeding. of communicable diseases Reducing incidence of tuberculosis, hepatitis B, and common diseases of childhood; promoting sex education in schools. Other health priorities Programmes to cover main health problems of vulnerable groups; legal protection for women and children against violence; enforcement of health and safety legislation.
:
:
* Control
: : : :
Anthony Zwi