A DECADE OF SOCIAL ENTERPRISE Celebrating the 10th Anniversary of Pacific Health & Development Sciences Inc. (PacificSci)

PREAMBLE: The term “Social Enterprise” is not yet a fully mature concept, and its various forms are continually evolving. In 2008, on our 5^th Anniversary, Pacific Health & Development Sciences Inc. (“PacificSci”) applied (in this blog) other terms to describe our company and its modus operandi: as “a hybrid organization”,[1,2] falling within the domain of “fourth sector” or “for benefit” enterprises. Such entities represent a new paradigm in organizational design, aiming to link two concepts often falsely held as dichotomous: private interest and public benefit.  Since 2008, the term “social enterprise”, perhaps being more intuitive in its meaning, seems to be gaining ascendancy.

Definitions for “social enterprise” vary globally.  The definition used by the Social Enterprise Council of Canada (SECC): … “businesses owned by nonprofit organizations,… directly involved in the production and/or selling of goods and services for the blended purpose of generating income and achieving social, cultural, and/or environmental aims.”[3]. Although based in Canada, PacificSci does not meet this restrictive definition as we are not “founded by” a non-profit entity.  However, we do fit the more inclusive definition of the Social Enterprise Alliance USA,[4] namely: “Social enterprises are businesses whose primary purpose is the common good. They use the methods and disciplines of business and the power of the marketplace to advance their social, environmental and human justice agendas.”  Perhaps the most neutral definition is that of Wikipedia: “…an organization that applies commercial strategies to maximize improvements in human and environmental well-being, rather than maximizing profits for external shareholders. Social enterprises can be structured as a for-profit or non-profit, and may take the form of a co-operative, mutual organization, a disregarded entity, a social business, or a charity organization.”[5]

Now, on our 10^th anniversary (December 8, 2013), the scope of PacificSci is mostly in international and global health and development - we know who we are and what we do, and label ourselves accordingly.  And as a legally constituted corporation in Canada, we fit most definitions of social enterprise, even if not the dominant one used in Canada.

Background Analysis

Before reviewing the story of PacificSci, we ask readers to revisit the observations below (first shared in our December 2008 blog) regarding conflicts confronting traditional organizations:

• Private companies have always had to balance between achieving the largest possible profits for their shareholders and retaining trust and contact with their other stakeholders: the local community, consumers, sub-contractors, pressure groups, etc.

• The public sector for years now has faced enormous political pressure in favour of privatization of a wide range of functions - and then being forced to 'repurchase' the very same functions and institutions when private companies no longer find them profitable.

• Voluntary organizations: fierce competition among voluntary organizations along with tight state financing has led to organizations experimenting with their independent income - the sale of services and new products. (For examples of this, visit the Social Enterprise Council of Canada website, already referenced below). However, pitfalls exist as certain activities and financial priorities can be at variance with an organization's main goals and mission.

Regarding the private sector, the recent and ongoing world financial crisis amply demonstrates that some firms are perceived as “too big to fail”, despite incompetent and unethical leadership e.g., the US bailing out its once mighty banking industry. Clearly, western industrialized nations are capitalist when going up, and socialist going down!

Equally, it is increasingly clear that neither public nor voluntary sector organizations truly operate in the “pure” manner traditionally implied. Increasingly public enterprises compete with the private sector, while the voluntary sector has become more commercially oriented.

For example, many voluntary not-for-profit organizations today operate with a fully funded core staff, supplemented by contract income, thus building handsome “working capital funds”, while remaining eligible for government grants.  In effect, such non-governmental organizations or NGOs (once mostly charitable organizations) have actually become a good “business model” with a competitive advantage over other types of organization.

In the meantime, many public sector (government) entities have become so hollowed out that they must hire private contractors to deliver the expertise that actually belongs with their public mandate. In addition to consulting firms, much of that expertise (sometimes hidden) is obtained from universities, themselves having become “hybrid” organizations. Even publicly funded universities now engage in industry partnerships while receiving government financing, and simultaneously contracting out services to government. See Menard, cited below.

In this complex scenario, where the traditional rules separating organizational forms are increasingly less applicable (if not broken), the emergence of hybrid/fourth sector/social enterprises is virtually inevitable, breaking with earlier concepts of relationships between the state, private and voluntary sectors.

Operating outside the world of grants, yet within the economic boundaries of surviving as a business, the bottom line for our company is nonetheless one of social purpose: in many ways we are participating in a modern renaissance of motivation to improve the human condition.

Note: A further development of this discussion can be found presented in our recent book Global Public Health-Ecological Foundations, published by Oxford University Press.[6]

With this backdrop we now update the short story of PacificSci as a fourth sector organization.

Feature Story – TENTH ANNIVERSARY OF PacificSci

Pacific Health & Development Sciences Inc. (PacificSci), was incorporated ten years ago, on December 8th, 2003, as a health systems consulting firm, with the mission of “seeking solutions to health and social impacts of economic development”.

As a joint venture of principals Franklin White (FW) and Debra Nanan (DN), currently President and Vice-President respectively, PacificSci was conceived primarily as a vehicle for our continued involvement in the field of public health, within which we had accumulated some 50 (now 70) years of combined professional expertise and experience. With FW having worked outside Canada for the previous 15 years, and DN then a new resident of Canada, it was clear that one way to promote and sustain involvement at appropriate levels of philosophy and responsibility was to establish our own entity.

The act of incorporation was carried out without professional legal assistance, using a simple “how to” guide. Within the first year, we were listed on various public sector registries in Canada, and launched our first website, subsequently upgraded in 2007 using SiteCube.com. In 2006, "PacificSci" was approved as our registered trademark. See http://www.pacificsci.org/

Since incorporation, PacificSci has engaged in a blend of contractual and pro bono activities, mostly with an international focus, and with an expanding domestic portfolio. Without attempting to be fully comprehensive, the following is a selection from our portfolio.

International Development-related Contracts

Contractual work is the primary source of corporate income. We have been successful in attracting both international and domestic assignments which reflect our social mission, while committing to the same level of rigour and professionalism as previously applied to our former substantive careers in both academia and government service.

Currently(2013-14),  PacificSci serves as the designated health systems expert with Universalia Management Group (Ottawa, Montreal) in an evaluation of research grant influence on external policy decisions, on behalf of the International Development Research Centre (IDRC Ottawa).

In 2010 and again in 2013, PacificSci accepted subcontracts from Universalia as Internal Advisor for quality control in consecutive management evaluations of the World Health Organization (WHO) on behalf of the Multilateral Organisation Performance Assessment Network (MOPAN), comprising 17 donor countries with the common interest of assessing the effectiveness of organizations they fund (Australia, Austria, Belgium, Canada, Denmark, Finland, France, Germany, Ireland, the Netherlands, Norway, South Korea, Spain, Sweden, Switzerland, UK and USA).

In 2009, PacificSci performed a Performance Review for the ICDDR,B (International Centre for Diarrhoeal Disease Research, Bangladesh) for 6 donor nations (Australia, Canada, Netherlands, Sweden, Switzerland, and the UK). 

From 2005 through to 2010, PacificSci engaged in Health Project Monitoring in Pakistan: In 2004 PacificSci had participated with Universalia Management Group to bid for this Canadian International Development Agency (CIDA) role. During this period we conducted M&E tasks in relation to four CIDA-supported initiatives:

- Family Planning Association of Pakistan (FPAP)
- HIV/AIDS Surveillance Project (HASP)
- Systems-Oriented Health Investment Programme (SOHIP)
- Lady Health Workers Programme (LHWP)

Notes:

PacificSci’s task in relation to the LHWP was to provide external review service to Oxford Policy Management (OPM), which had a lead role in this evaluation. In 2006, we reviewed a World Bank (WB) evaluation of a primary health care initiative in Pakistan.  Both efforts were acknowledged by these partners: OPM and the WB respectively.

In 2005, we were contracted by Sweden’s International Development Cooperation Agency (SIDA) to represent them in a joint donor evaluation of the African Medical Research Foundation (AMREF). From October 2005 this entailed site visits to headquarters and field operations in Kenya, Uganda and Tanzania; the assignment was completed in March 2006.

NOTE: Links to several of these projects are supplied on our website: http://www.pacificsci.org/

Domestic Contracts

Domestic contracts have also been a source of revenue compatible with our mission, the most significant of which have been:

. University of Victoria, School of Public Health and Social Policy: In late 2012, the firm contracted to develop a new on-line course entitled Foundations of International and Global health and Human Development, for delivery at both senior undergraduate and graduate levels.  In Spring of 2013, we then accepted a contract to deliver the course. 

. Royal Roads University, Centre for Health Leadership & Research (CHLR): From April – September 2008 Nanan, PacificSci, contracted to support CHLR research. In July 2007, both principals delivered a review of process evaluation for population health initiatives. In Sept 2006, White co-developed with Graham Dickson, CHLR a concept paper to support the ActNow-BC initiative, Ministry of Tourism, Sports & the Arts.

. EDS Canada: From December 2005 to February 2006, PacificSci was retained for technical expertise to assist EDS in a response to a federal-provincial Request for Proposals to develop a Pan-Canadian system disease surveillance and management system. Out of 10 bidders, EDS ranked second to IBM Canada, and ruled eligible if IBM did not fulfil contract requirements.

. British Columbia Ministry of Health: in 2004 PacificSci developed the Provincial Health Officer's (PHO) 2003 report. "Every Breath You Take..." This cites ~200 references, original analyses of air quality and morbidity data, and includes the first health impact analysis of 2003 forest fires. It was presented by the PHO to the BC Legislature.

Pro Bono and Academically-Linked Activities

PacificSci has been active in various (mostly honorary and voluntary) roles with: the University of Victoria (UVIC, where both principals are adjunct faculty), Kuwait University (KU), the Aga Khan University (AKU), Dalhousie University (Dal, where one principal (FW) also has an adjunct appointment), Royal Roads University (RRU), the University of Wisconsin (UWisc), Michigan State University (MSU) and others. The roles have included serving as: Advisory Board member (UVIC); advisor, external examiner and reviewer (KU); visiting speaker (UWisc); thesis supervisor and consulting researcher (Dal); co-grantee and collaborative researcher (AKU); and co-author (UMich and others).  Again, more details are accessible from our website:  www.pacificsci.org

Both principals serve on the board of the on-line publication Global Journal of Medicine and Public Health, and FW, since its launching in 2012, also serves as its (founding) Executive Editor. This journal, based in Kashmir India, is included in the List of Open Access Journals and other indexes, and attracts an international array of contributors.

PacificSci’s activities in this category have also included many hundreds of pro-bono hours in mentoring individuals and groups abroad and in Canada, participating in e-communities and in health policy groups, and peer reviews for scientific journals.

Regarding interactions and connections, we are currently active in Linked-In groups, most actively “The Economist” and “Global Public Health” groups. In 2006 the firm launched this particular blog (PacificSci Global Perspectives) presenting on a monthly basis an independent view on current affairs, emphasizing the determinants of health and social well-being. We were also a Communications Partner for the World Urban Forum (WUF) 2006, Vancouver.

On January 10, 2006, we launched PacificSci GLOBAL HEALTH DATA LINKS [7], a free subsidiary website developed primarily for students of international and global health providing annotated links to the following sources:

. UNDP Human Development Statistical Reports

. WHO Statistical Information Systems

. US Census Bureau International Database

. Population Reference Bureau Data-Finder

. WHO's Global Health Atlas.

Since incorporation, PacificSci principals have reviewed various scientific and professional articles for the following leading international journals:

Anthropology & Medicine; Archives Medical Sciences; Bulletin of the World Health Organization; Canadian Medical Association Journal; Diabetes/Metabolism Research and Reviews; Evidence-based Complementary and Alternative Medicine (eCAM); Global Journal of Medicine and Public Health; Globalization & Health; International Journal of Medicine and Public Health; International Journal for Quality in Health Care; Journal of Global Infectious Diseases; Journal of Public Health; Medical Science Monitor; Preventing Chronic Disease (US Centers for Disease Control and Prevention); Qualitative Health Research.

Also: We are utilized as a book proposal reviewer for Oxford University Press (New York).

Since incorporation, as an expression of ongoing commitment to the population health sciences, PacificSci principals (in addition to numerous contracted technical reports) have themselves authored or co-authored 34 articles in peer-reviewed journals, 1 book, 2 book contributions, 4 conference abstracts and 1 on-line video. Franklin White is the senior author of a new Oxford textbook: White F, Stallones L, Last JHM.  Global Public Health – Ecological Foundations.  Oxford University Press. New York. 2013 (see URL with citation below, which provides more information about this book). He also served as an Associate Editor and Debra Nanan as a contributor in: Dictionary of Public Health. JM Last (ed) Oxford University Press 2007. [Oxford Reference Online Series.]  White is also a contributor to Porta M. Editor. Dictionary of Epidemiology. 5^th edition. International Epidemiological Association. Oxford University Press. 2008. New York.  Together, both principals also completed a major book chapter: White F, Nanan D. International and Global Health. Chap 76. In: Maxcy-Rosenau-Last, Public Health & Preventive Medicine. 15th Ed. McGraw Hill 2008.

Unlike most other university and government colleagues, who are compensated for similar efforts as part of their job descriptions/academic or service expectations, these contributions are of a pro bono nature. Thus, we are in touch with and maintaing leadership in our field, while developing PacificSci as a fourth sector organization.

NOTE: Links for many of the items noted above are on our website: http://www.pacificsci.org/

Discussion
The most significant discovery in growing our enterprise is the unique and valued contribution to the public good our company delivers, despite working outside the formal system. While much less personally remunerative than a public sector or academic post, this is offset by more “intellectual freedom” along with more control over professional time than persons working for an institution or a health service. Our third party independence, especially in monitoring and evaluation roles, and our ability to “think outside the box”, allows us to speak out and comment on issues as we perceive and understand them, according to our best judgment.


A significant disadvantage however is that, not being part of collective agreements, we must either fund ourselves or be invited as a resource (e.g., to conferences) to access professional development and networking opportunities. Thus, the fourth sector approach demands we deliver on our skills, or go out of business. Happily, as we enter our 11^th year, this has not happened.

Conclusion
This has been a brief and candid account of the experience of Pacific Health & Development Sciences Inc., during its first 10 years of operation. During this period, PacificSci, as a “business venture with a social purpose” has succeeded in delivering on its mission:  “seeking solutions to health and social impacts of economic development”.

Our “fourth sector” model of social enterprise has facilitated flexibility, so that we, as principals, can make choices we are comfortable with and motivated by professionally. As a cautionary note, this model comes at a relatively late stage in our careers, where financial and family responsibilities have receded. For those seeking professional freedom of choice and who are prepared to weather lean inter-contract periods, we can recommend this approach.

Envoi

We close this special 10th Anniversary issue of PacificSci Global Perspectives with the eternal words of Nelson Mandela, a giant of a human being who taught the world so much by example, and left it a better place. 

“…to be free is not merely to cast off one's chains, but

to live in a way that respects and enhances the freedom of others." 

So, with these thoughts and memories, we wish our readers near and far a joyous Holiday Season, and a happy, safe and healthy New Year!

Franklin White & Debra Nanan, Co-Principals,

Pacific Health & Development Sciences Inc.

www.pacificsci.org

REFERENCES:

1. Lamb R. Hybrid Organization. University of Hawaii, Manoa. June 17, 2004. Accessed Dec 15, 2013. http://www.vfh.fh-brandenburg.de/vfh/gastvorlesungen/gastvortrag_05.pdf

2. Ménard, Claude (2004), ‘The Economics of Hybrid Organizations’, Journal of Institutional and Theoretical Economics 160 (3), 345-376. http://www.econ.kobe-u.ac.jp/~yanagawa/Economics_of_Hybrids--JITE-2004.pdf

3. Social Enterprise Council of Canada website.  Accessed December 15, 2013. http://www.socialenterprisecanada.ca/en/learn/nav/whatisasocialenterprise.html

4. Social Enterprise (USA) website. Accessed December 16, 2013. https://www.se-alliance.org/

5. Social enterprise.  Wikipedia.  Accessed December 15, 2013. http://en.wikipedia.org/wiki/Social_enterprise#Canada

6. New Trends in Organizational Forms and Functions – Shifting Sands. Chapter 4, pages 81-82 In: White F, Stallones L, Last JM. Global Public Health – Ecological Foundations. Oxford University Press. New York 2013. For more information about this book, including its contents, visit Oxford University Press at:

http://global.oup.com/academic/product/global-public-health-9780199751907;jsessionid=1629DD204A7E2D4B5EADCD281AB187F4?cc=ca&lang=en&

7. PacificSci GLOBAL HEALTH DATA LINKS website. Accessed December 16, 2013. http://globalhealthdata.webspawner.com/

  ANNOUNCEMENT:  With priority for this issue having been given to the 10^th Anniversary of PacificSci, our Year in Review for 2012 will be the selected topic for the first issue of 2014.

CANADA' CONSERVATIVE GOVERNMENT MUZZLES SCIENTISTS

PREAMBLE:  In this issue we report on the findings of a survey of federally employed scientists commissioned by the Professional Institute of the Public Service of Canada. 

By way of political background for the majority of our readership, which is mostly (85%) international in distribution, it is now virtually common knowledge in Canada that the evidence-based views of scientists have been both generally and selectively suppressed by the ruling Conservative government of Stephen Harper on a wide range of issues, such as: fisheries management, crime prevention, food safety standards, public health, and environmental protection among many others, not to overlook the barely concealed denial of climate change and the need for Canada to step up and play a more constructive role in its alleviation.

 

All this is not so surprising, given that the so-called “Conservative Party“ is actually a cobbling of the Canadian Alliance Party (which had its roots in the right wing fundamentalist former Reform Party of Canada), with the once powerful Progressive Conservatives. The outcome ushered into federal politics numerous political actors who did/do not comprehend the role of science, favouring a biblical interpretation of issues bearing on the body politic.  As an example, this rose to a ridiculous level in the appointments of Stockwell Day as (consecutively) Minister for Public Safety, Minister of International Trade, then President of the Treasury Board, despite having voiced the belief that dinosaurs and man walked the Earth simultaneously, and who held that people with AIDS deserve no sympathy, among other retrograde views. Although he dropped out of federal politics in 2011, he was not simply an isolated case: an undercurrent of science denial still swirls disturbingly just below the surface of the so-called Conservative Party.

Ironically, in light of early commitments to transparency, the Harper government has also revealed itself to have suffered increasingly from major corruption ranging from tampering with local elections (deliberately misleading “robocalls”) to major expense fraud committed by several Senators personally appointed by Prime Minister Harper himself.

 

To understand how this mess came about, it is important to recognize that the ascendancy of the so called Conservative Party of Canada capitalized on the fact that, while a majority of Canadians have never supported its ideology, their political support is split between two other major parties: the New Democratic Party (now official opposition) and the Liberal Party of Canada (former government). And even though the Green Party accounts for ~7% of voter support, lacking proportional representation, it enjoys only one representative in parliament.  Parenthetically, there is a movement to address the need for proportional representation.

In this preamble, we have used the term “so-called” advisedly, as we are aware that many mainstream conservatives do not align themselves with the Conservative Party of Canada as they now see it under the Harper regime, and that many are embarrassed by it and would like to restore a balance with proper respect for science (especially in relation to the environment and public health) as well as more transparent and accountable government. This sentiment includes streams of political rationality and global values (as distinct from fundamentalism); but these face an uphill battle.

With this thumbnail sketch of contemporary Canadian politics, written mostly for our international readers, we now present (verbatim), a release from the Professional Institute of the Public Service of Canada. Readers wishing greater detail, will also find below the URLs for linking to the full report, and the technical report from Environs, the firm which conducted this survey under contract.

Release: PROFESSIONAL INSTITUTE OF THE PUBLIC SERVICE OF CANADA

“Most Federal Scientists Feel They Can’t Speak Out, Even If Public Health and Safety at Risk, Says New Survey”

A major survey of federal government scientists commissioned by the Professional Institute of the Public Service of Canada (PIPSC), has found that 90% feel they are not allowed to speak freely to the media about the work they do and that, faced with (making) a departmental decision that could harm public health, safety or the environment, nearly as many (86%) would face censure or retaliation for doing so.

The survey, the findings of which are included in a new report titled The Big Chill, is the first extensive effort to gauge the scale and impact of “muzzling” and political interference among federal scientists since the Harper government introduced communications policies requiring them to seek approval before being interviewed by journalists. Information Commissioner Suzanne Legault is currently conducting her own investigation of the policies, which have been widely criticized for silencing scientists, suppressing information critical or contradictory of government policy, and delaying timely, vital information to the media and public.

In particular, the survey also found that nearly one-quarter (24%) of respondents had been directly asked to exclude or alter information for non-scientific reasons and that over one-third (37%) had been prevented in the past five years from responding to questions from the public and media.

In addition, the survey found that nearly three out of every four federal scientists (74%) believe the sharing of scientific findings has become too restricted in the past five years and that nearly the same number (71%) believe political interference has compromised Canada’s ability to develop policy, law and programs based on scientific evidence. According to the survey, nearly half (48%) are aware of actual cases in which their department or agency suppressed information, leading to incomplete, inaccurate, or misleading impressions by the public, industry and/or other government officials.

“Federal scientists are facing a climate of fear,” says PIPSC president Gary Corbett, “– a chill brought on by government policies that serve no one’s interests, least of all those of the Canadian public. The safety of our food, air, water, of hundreds of consumer and industrial products, and our environment depends on the ability of federal scientists to provide complete, unbiased, timely and accurate information to Canadians. Current policies must change to ensure these objectives are met.”

“Documenting the problem is the essential first step toward solving it,” added Francesca Grifo, Senior Scientist with the Union of Concerned Scientists in the United States where, under the Bush administration, federal scientists faced many similar problems. “You can’t hope to solve the issues until you fully understand them.”

Invitations to participate in the online survey, hosted by Environics Research, were sent to 15,398 PIPSC members – scientists, researchers and engineers – engaged in scientific work in over 40 federal departments and agencies. Of these, 4,069 (26%) responded between June 5 and 19, 2013. The survey is considered accurate + or – 1.6%, 19 times out of 20

Source: Statement from the Professional Institute of the Public Service of Canada.

http://www.pipsc.ca/portal/page/portal/website/issues/science/bigchill

 

The ENVIRONICS REPORT:  http://www.pipsc.ca/portal/page/portal/website/issues/science/pdfs/environics.en.pdf

The FULL REPORT IS AVAILABLE AT: http://www.pipsc.ca/portal/page/portal/website/issues/science/pdfs/bigchill.en.pdf

LAUNCHING UNIVERSAL HEALTH CARE IN THE UNITED STATES - Global Perspective

PREAMBLE:  We delayed this month’s issue due to the uncertain outcome of a political confrontation in the United States of America over raising its debt ceiling, which would have resulted in a US default on its budgetary commitments. The confrontation was resolved meekly at the “eleventh hour”, late on October 16, when a majority of elected officials came off their soapboxes and voted for sanity.

The standoff came about, as anyone who watches the news knows, due to an abortive attempt by an ultra-right wing Republican faction to block the US from finally aligning itself with other developed countries in providing universal health care.  This faction was lead by Senator Ted Cruz from Texas, the state with the greatest proportion of persons not covered by health insurance: about 1 person in four – an underclass of people that it seems this faction would like to keep that way on a permanent basis.

Many Americans see their country as ”exceptional”, and exceptional this certainly was: a startling display of grand-standing as the world watched in dismay as the United States was pushed to the precipice of a default that would certainly cause irreparable damage to its own and the global economy.

During this crisis, many individuals from a political lunatic fringe (dubbed the Tea Party) made deliberately false statements about the new health care provisions, using the opportunity to sow confusion in the minds of Americans at large.  Despite all this, the new health system was launched ahead of time on October 1^st, 2013. Core provisions are supposed to be in place by 2014. Although with its early launching, and perhaps largely because of this, operational glitches were widespread e.g., registration webpages not fully functional, but no major amendments were made as a result of the simultaneous carnival of political opportunists.

Watching on, it was difficult to accept that the USA – a nation often projected as the leader of the free world – was being subjected to what can only be viewed as a form of sedition by self-proclaimed defenders of political freedom, all the while attempting an end-run to deny Americans a measure of universal health protection that citizens of all other developed countries have enjoyed for decades.

It is with this background in mind, including the importance of US global leadership, that we devote this issue to the core elements of the Patient Protection and Affordable Care Act, so that readers may appreciate what it was that the Tea Party sought to overturn by using the threat of default as political blackmail.

UNIVERSAL HEALTH CARE AS THE EVENTUAL OUTCOME OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT – As viewed by a Non-American

In the United States, the private sector has long dominated the health care system, yet has failed to meet the health care needs of some 50 million non-insured people, about 20% of the population. The Patient Protection and Affordable Care Act (modeled after a system now in place in Massachusetts, brought in under a state Republican administration under former Governor George Romney, but dubbed “Obamacare” by political opponents of the federal Democratic administration which designed the legislation), intends that everyone has access.

Dramatic changes are now taking place: under this new legislation (to be fully phased in by 2020), the US will begin to close the gap on universality and other deficiencies will be addressed. The legislation was upheld by the Supreme Court on June 28, 2012, against challenges by numerous states and individuals and the National Federation of Independent Businesses. Nonetheless, even with this policy shift, the US will remain the only developed nation that depends predominantly on a private insurer, private provider entrepreneurial model.This acknowledged, the US system also contains substantial public sector elements that will continue to grow: Medicare for the elderly (a universal single payer system where providers are not directly employed by government); a program called Medicaid to address essential health care for low-income families based on eligibility criteria, financed jointly by state and federal governments; Veteran’s Affairs health care (a single payer system whose providers are employed by the Department of Veterans Affairs, although not applied to persons in active service who are covered by private insurers under “Tricare” - an employer based insurance scheme).

The Patient Protection and Affordable Care Act (passed in 2010) is too complex to address in its entirety in this blog. People of developed countries with more equitable systems will find the barriers to health care access and/or affordability in the US to be instructive, e.g., the ability of insurance companies to deny coverage for pre-existing conditions – this practice is to cease in 2014.

Obamacare will take many years to fully implement, but does have the prospect of bringing the US into line with the principle of universal coverage that has been in observed for decades in all other developed countries, and increasing numbers of developing ones.  Access to essential health care is also addressed under the Universal Declaration on Human Rights (Article 25:  http://www.un.org/en/documents/udhr/ )

Readers interested in further information on the Patient Protection and Affordable Care Act in the U.S., as upheld by their Supreme Court, a summary of its key features is available at the following site:  Senate Democrats  http://dpc.senate.gov/healthreformbill/healthbill04.pdf

Wikipedia has also been updated on this topic although their full article is much longer and history more detailed   http://en.wikipedia.org/wiki/Patient_Protection_and_Affordable_Care_Act

Our Opinion:

"Obamacare" is a major step forward to a more equitable health system in the USA. Issues of effectiveness and efficiency will be tested, studied and addressed as it attempts to provide quality care for all citizens under the new legislation. This process should not be treated as a political football by Republican extremists although no doubt there will be legitimate policy challenges as it makes its way forward to the goal of universality.  If the Tea Party continues to engage in obstructionist antics, primarily for local constituency gains, and risk default once again, the reputation of the US for sober global leadership will only be further damaged.  


Background References

American College of Physicians. Position Paper: Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries. Ann Intern Med 2008;148:55-75. http://www.annals.org/content/148/1/55.full#T1  Accessed October 17, 2013.

White F, Nanan D. A Conversation on Health in Canada: revisiting universality and the centrality of primary health care. J Ambul Care Manage 2009; 32,2:141-9. http://journals.lww.com/ambulatorycaremanagement/Abstract/2009/04000/A_Conversation_on_Health_in_Canada__Revisiting.9.aspx Accessed October 17, 2013.

Guyatt GH, Devereaux PJ, Lexchin J, et al. A systematic review of studies comparing health outcomes in Canada and the United States. Open Medicine 2007;1,1:E27-36. http://www.pnhp.org/PDF_files/ReviewUSCanadaOpenMedicine.pdf  Accessed September 15, 2012.

The World Health Report 2000 – Health systems: improving performance. Geneva, 2000 http://www.who.int/whr/2000/en/whr00_en.pdf  Accessed October 17, 2013.

Supreme Court of the United States. National Federation of Independent Business et al vs Sebelius, Secretary. Health and Human Services et al. Certiorari to the United States Court of Appeals to the Eleventh Circuit. No 11-393. Decided June 28, 2012. As cited in the Washington Post: Full text of the Supreme Court health-care decision. June 28, 2012. http://www.washingtonpost.com/wp-srv/politics/documents/supreme-court-health-care-decision-text.html  Accessed October 17, 2013.

New Publication: A GLOBAL REVIEW OF PUBLIC HEALTH EDUCATION & CAPACITY BUILDING

PREAMBLE: This month we bring to your attention a comprehensive review by Franklin White, on the topic of “The Imperative of Public Health Education: A Global Perspective.”  

Published in the peer reviewed journal Medical Principles and Practice, this full text article is available on-line free of charge at http://www.karger.com/Article/FullText/354198

The abstract as published on PubMed (US National Library of Medicine), now follows:

ABSTRACT:  White F. The Imperative of Public Health Education: A Global Perspective. Med Princ Pract 2013 August 21 [Epub ahead of print] 

This review positions public health as an endeavour that requires a high order of professionalism in addressing the health of populations; this requires investment in an educational capacity that is designed to meet this need. In the global context, the field has evolved enormously over the past half century, supported by institutions such as the World Bank, the World Health Organization and the Institute of Medicine. Operational structures are formulated by strategic principles, with educational and career pathways guided by competency frameworks, all requiring modulation according to local, national and global realities. Talented and well-motivated individuals are attracted by its multidisciplinary and transdisciplinary environment, and the opportunity to achieve interventions that make real differences to people's lives. The field is globally competitive and open to many professional backgrounds based on merit. Its competencies correspond with assessments of population needs, and the ways in which strategies and services are formulated. Thus, its educational planning is needs-based and evidence-driven. This review explores four public health education levels: graduate, undergraduate, continuing professional education and promotion of health literacy for general populations. The emergence of accreditation schemes is examined, focusing on their relative merits and legitimate international variations. The role of relevant research policies is recognized, along with the need to foster professional and institutional networks in all regions of the world. It is critically important for the health of populations that nations assess their public health human resource needs and develop their ability to deliver this capacity, and not depend on other countries to supply it. © 2013 S. Karger AG, Basel.

Full Reference and Link to article: White F. The Imperative of Public Health Education: A Global Perspective. Med Princ Pract 2013 August 21 DOI: 10.1159/000354198 [Epub ahead of print] http://www.karger.com/Article/FullText/354198

Note: One of the most comprehensive reviews of its type (15 journal pages), its observations should be of relevance to institutional capacity building for public health education in all global regions. Citing over 70 references, the work is a by-product of reviews carried out in support of public health educational development at Kuwait University; it also draws insights from an extensive international career in public health (see Wikipedia entry for Franklin White: http://en.wikipedia.org/wiki/Franklin_White).

REFUGEES, ASYLUM SEEKERS, DISPLACED AND STATELESS PERSONS – A Primer

PREAMBLE: For this issue, we lay out the mainstream terms used in this increasingly complex field of humanitarian concern, and offer a selection of statistics on the dimensions of the refugee movement globally. Our sources include Refugees International (RI), a US based organization started in 1979 as a citizens’ movement to protect Indochinese refugees. Since then, RI has expanded to become a leading advocacy organization that provokes action from global leaders to resolve refugee crises. RI does not accept government or UN funding. We select global trends (2012) from the United Nations High Commissioner for Refugees (UNHCR) publication on Displacement the New 21st Century Challenge, and we develop a brief statement on “environmental refugees” from a National Geographic sources (references cited below).


REFUGEES, ASYLUM SEEKERS, DISPLACED AND STATELESS PERSONS

The following terms have been extracted verbatim from Refugees International website:

Who is a Refugee?
A refugee is legally defined as a person who is outside his or her country of nationality and is unable to return due to a well-founded fear of persecution because of his or her race, religion, nationality, political opinion, or membership in a particular social group. By receiving refugee status, individuals are guaranteed protection of their basic human rights, and cannot be forced to return to a country where they fear persecution.

In 2012, there were 15.4 million refugees around the world, including 4.8 million Palestinian refugees. According to the UN Refugee Agency, the leading countries of origin for refugees in 2012 were:

· Afghanistan: 2.6 million
· Somalia:1.1 million
· Iraq: 746,000
· Syria: 728,500
· Sudan: 569,200
· DRC: 509,400

Who is an Internally Displaced Person (IDP)?
Internally displaced people (IDPs) have been forced to leave their homes as a result of armed conflict, generalized violence, or human rights violations, but unlike refugees they have not crossed an international border. Although internally displaced people outnumber refugees by more than two to one, no single UN or other international agency has responsibility for responding to internal displacement. As a result, the global response to the needs of IDPs is often ineffective.

In 2011, there were an estimated 28.8 million people displaced internally by conflict. The largest populations of internally displaced people are found in:

· Colombia: 4.9 - 5.5 million
· Sudan/South Sudan: About 3 million
· DR Congo: 2.6 million
· Iraq: Up to 2.1 million
· Somalia: 1.1 million

Who is a Stateless Person?
Stateless people are individuals who do not have a legal bond of nationality with any state, including people who have never acquired citizenship of their birth country or who have lost their citizenship and have no claim to citizenship of another state. Children of stateless people often are born into statelessness and few manage to escape that status. According to the 1954 Convention relating to the Status of Stateless Persons, a de jure stateless person is someone “not considered as a national by any State under the operation of its law.” Persons are considered de facto stateless if they have an ineffective nationality, cannot prove they are legally stateless, or if one or more countries dispute their citizenship. The Office of the UN High Commissioner for Refugees (UNHCR) has the international mandate for responding to the needs of stateless people and leading the global effort to reduce statelessness. Historically, however, the agency has devoted few resources to this aspect of its mandate.

There are an estimated ten million stateless people around the world. Refugees International focuses its efforts on reducing statelessness, particularly for the following populations:

· Syria: more than 300,000 denationalized Kurds
· Kuwait: 93,000 Bidoon
· Dominican Republic: an estimated 900,000 to 1.2 million undocumented individuals of Haitian origin, many of who are stateless or at risk of statelessness.

What is an Asylum Seeker?
An asylum seeker is a person who is seeking to be recognized as a refugee, but has not yet received formal refugee status. During 2012, some 893,700 individual applications for asylum or refugee status were submitted to governments and UNHCR offices in 166 countries. 2012 saw a significant number of people seeking asylum or refugee status from countries experiencing recent or ongoing conflict or security concerns. This includes asylum-seekers originating from Afghanistan, Somalia, the Syrian Arab Republic, and DR Congo.

Can a country refuse to admit refugees?
Under international law, refugees must not be forced back to the countries they have fled. This principle of non-refoulement is the key provision of the 1951 UN Refugee Convention, which defines international law and guidelines to protect refugees. Host governments are primarily responsible for protecting refugees and most states fulfill their obligations to do so. Others, however, avoid their responsibility by pointing to a lack of resources, threats to national security, fears of domestic political destabilization, or the arrival of even greater numbers of refugees. This is a violation of international law that is binding on all states.

What are the solutions to refugee and displacement crises?
The UN Refugee Agency (UNHCR) speaks of three “durable solutions” to refugee crises: return; local integration; and third country resettlement.

The most desirable way to end forced displacement is for people to return home when conflict ends. To return in safety and dignity, families need help with transportation and require basic goods for restarting their lives, including a provisional supply of food, seeds and tools, and building materials for home repair or construction. In addition, support for the reconstruction of schools and health clinics is also critical.

If instability persists or if the individual will face persecution when they return, then integrating into the country of asylum is another option. Most countries hosting refugees, however, are reluctant to allow refugees to integrate and become citizens, fearing competition for scarce resources between the refugees and residents of a particular locale.

Resettlement to a third country can also be a solution for refugees who cannot return home, cannot establish a new life in their country of asylum, or are considered to be particularly vulnerable. Resettlement can never be an option for more than a tiny minority of the world’s refugee population, but still benefits tens of thousands of refugees who have made new lives in countries such as the United States, Canada, Sweden, and Norway


SELECTED GLOBAL STATISTICS FROM THE 2012 REFUGEE SITUATION
An estimated 7.6 million people were newly displaced due to conflict or persecution, including 1.1 million new refugees - the highest number of new arrivals in one year since 1999. Another 6.5 million people were newly displaced within the borders of their countries – the second highest figure of the past ten years.

During the year, conflict and persecution forced an average of 23,000 persons per day to leave their homes and seek protection elsewhere, either within the borders of their countries or in other countries.

Some 35.8 million persons were of concern to UNHCR by end 2012, the second highest number on record. Of this figure, 17.7 million were IDPs and 10.5 million were refugees - 2.3 million people more than in 2011. The refugee figure was close to that of 2011 (10.4 million) and the number of IDPs had increased by 2.2 million since end 2011.

Statelessness is estimated to have affected at least 10 million people in 2012; however, data captured by governments and communicated to UNHCR were limited to 3.3 million stateless individuals in 72 countries.

Developing countries hosted over 80 per cent of the world’s refugees, compared to 70 per cent ten years ago. The 49 Least Developed Countries were providing asylum to 2.4 million refugees by year-end.

Pakistan was host to the largest number of refugees worldwide (1.6 million), followed by the Islamic Republic of Iran (868,200), Germany (589,700) and Kenya (565,000).

More than half of the refugees under UNHCR’s mandate resided in countries where the GDP per capita was below USD 5,000. Pakistan hosted the largest number of refugees in relation to its economic capacity with 552 refugees per 1 USD GDP (PPP) per capita. Ethiopia (303) and Kenya (301) ranked second and third, respectively.

More than half (55%) of all refugees worldwide came from five countries: Afghanistan, Somalia, Iraq, the Syrian Arab Republic, and Sudan.

Over the course of 2012, 526,000 refugees repatriated voluntarily, half of them either to Afghanistan, Iraq or Côte d’Ivoire. This figure was similar to that of 2011 (532,000), and while an improvement on the figures of 2009 and 2010, it was still lower than those of all other years in the past decade.

During the year UNHCR submitted over 74,800 refugees to States for resettlement, and more than 71,000 departed with UNHCR’s assistance. According to governmental statistics, 22 countries admitted 88,600 refugees for resettlement during 2012 (with or without UNHCR’s assistance). The United States of America received the highest number (66,300).

More than 893,700 people submitted individual applications for asylum or refugee status in 2012. UNHCR offices registered 13 per cent of these claims. With an estimated 70,400 asylum claims, the United States of America was the world’s largest recipient of new individual applications, followed by Germany (64,500), South Africa (61,500), and France (55,100).

Some 21,300 asylum applications were lodged by unaccompanied or separated children in 72 countries in 2012, mostly by Afghan and Somali children. It was the highest number on record since UNHCR started collecting such data in 2006.

Refugee women and girls accounted for 48 per cent of the refugee population in 2012, a proportion that has remained constant over the past decade.

Children below 18 years constituted 46 per cent of the refugee population in 2012. This was in line with 2011 but higher than a few years ago.

Sources:
· Refugees International website http://www.refintl.org/get-involved/helpful-facts-%2526-figures Accessed August 17, 2013
· UNHCR’s publication on Displacement the New 21st Century Challenge http://unhcr.org/globaltrendsjune2013/UNHCR%20GLOBAL%20TRENDS%202012_V05.pdf

ADDITIONAL CONSIDERATIONS
Refugee streams from Smaller Countries: Absolute numbers are most relevant to the magnitude and management of this global issue. However, refugee movements from relatively small countries, may also contribute disproportionately from their populations as a whole.

Case Study: The Lhotshampa, people of Nepali origin, began settling in southern Bhutan in the late 19th century. In the 1980s Lhotshampas, being seen as a threat to the political order, were subjected to measures that discriminated against them. When they organised demonstrations, several thousands were imprisoned, and more than 2000 tortured, according to Amnesty International, although few were formally charged. Thousands fled to India and Nepal. In the 1990s, Bhutan (current population approx. 750,000) expelled nearly one-fifth of its population in the name of preserving its culture and identity, claiming that those expelled were illegal residents. By 1992, there were more than 80,000 living in UNHCR camps in south eastern Nepal. By 1996, camp populations had increased to 100,000 <http://en.wikipedia.org/wiki/Bhutanese_refugees>. Since 2008, the International Organization for Migration (IOM) and UNHCR jointly commenced resettlement programs to many countries e.g., USA, Australia, Canada and others. More than 50,000 refugees have already been settled in those countries.

Reference: Hutt M, School of Oriental and African Studies, University of London, at: http://www.photovoice.org/bhutan/index.php?id=3 Accessed August 17, 2013

Environmental and Climate Refugees: Environmental refugees include immigrants forced to flee because of natural disasters, such as volcanoes and tsunamis. Climate refugees are a subgroup within this, and considered to be an increasing phenomenon due to the impact of climate change both in terms of displacement due to climate related inundation and desertification, and related human conflict surrounding increasingly scarce resources in such settings. The International Red Cross estimates that there are more environmental refugees than political refugees fleeing from wars and other conflicts. The UNHCR states 36 million people were displaced by natural disasters in 2009, the last year such a report was taken. Scientists predict this number will rise to at least 50 million by 2050. Some say it could be as high as 200 million.

Reference: National Geographic Education website. Accessed August 17, 2013. http://education.nationalgeographic.com/education/encyclopedia/climate-refugee/?ar_a=1

EQUAL PROTECTION BEFORE THE LAW - Does it really exist in the United States?

PREAMBLE: Florida: July 13, 2013: Neighborhood-watch captain George Zimmerman was acquitted of all charges in the shooting of Trayvon Martin, the unarmed black teenager whose killing unleashed furious debate across the U.S. (and around the world).  

This debate concerns the practice of racial profiling (which was clearly evident throughout this case, even though denied by officials of the justice system), the (mutual) right of self-defence, equal justice, and (must we say it again?) capricious gun violence.

We will not debate the pros and cons of this court outcome, which seems to be an example of extreme injustice even as it is deemed to be legally correct under Florida state law. 

However, in this month’s blog, we wish to bring the attention of readers to a consistent international finding that the US Justice System is performing poorly with regard to equal protection before the law, especially for racial minorities and the poor.

THE US LEGAL SYSTEM RANKS POORLY COMPARED WITH OTHER WEALTHY NATIONS.

The following material is extracted and paraphrased from two sources: a piece by Dan Froomkin. Huffington Post 11/12/2012, and the website of the European Commission: Joint Research Centre.   Complete citations are given below. 

Access to justice is said to be a core American value. And even the lead prosecutor for the state of Florida stated following the verdict, stated that theirs was “the best justice system in the world.”

But a 2012 world survey of the rule of law (third in a series which began in 2010, following the formation of the World Justice Project which was initiated with the active support of the American Bar Association), continues to find that the U.S. ranks surprisingly low relative to its peers (other wealthy industrialized countries) in terms of equal protection under criminal law.

The "Rule of Law Index," released by the independent World Justice Project, found that in some categories the U.S. even ranks below some developing nations, such as Botswana and Georgia.

In an interview with The Huffington Post, the survey's authors said the problems in the U.S. are primarily due to unequal access to justice based on race and class.  "In the U.S., socioeconomic level matters," said Alejandro Ponce, chief research officer for the World Justice Project. "Poor people are at a disadvantage in all these situations, as are ethnic minorities."

In the category of criminal justice, the U.S. ranked 26th among 97 countries, and in the bottom 20% of wealthy nations - dragged down by low scores in the subcategory of equal protection.

In the civil justice category, the U.S. lags behind in providing access to disadvantaged groups, the survey found. "Legal assistance is frequently expensive or unavailable, and the gap between rich and poor individuals in terms of both actual use of and satisfaction with the civil court system is significant. In addition, there is a perception that ethnic minorities and foreigners receive unequal treatment."

The U.S.'s highest ranking, in the category of open government, still placed it only 13th out of 97 countries worldwide. "The U.S. lags behind most of the Western European countries in all dimensions," Ponce said.

This is the third annual index by the World Justice Project, and since the first survey in 2010, the U.S. rankings have remained weak.

"It remains very significant and the problem is that we do not see that government efforts or private efforts are making any dent in the problem," said Juan Botero, the project's executive director. "We were very hopeful when the Obama administration launched the Access to Justice Initiative  - but we do not see any improvement yet," he said.

Source: Adapted from: Rule of Law index: U.S. Ranks Low In Access To Justice Compared To Other Wealthy Nations.  Dan Froomkin. Huffington Post 11/12/2012  http://www.huffingtonpost.com/2012/11/28/rule-of-law-index-2012_n_2200765.html

Some Aspects of Methodology 

We at PacificSci tried to access the World Justice Project site today to learn more about the methodology, but it appeared to be blocked, or at least inaccessible perhaps due to heavy traffic on the heels of the Zimmerman acquittal.  

However, relevant information on methods for the previous year's survey was accessible through the European Commission Joint Research Centre site The approach documented there is likely to be germane to the most recent survey, in that it states that the earlier survey was “audited by the JRC's Institute for the Protection and the Security of the Citizen (IPSC). JRC researchers also acted as academic advisers to the report.  

To make a comprehensive evaluation of each country, the authors of the (2011) report looked not only at the written laws, but also at how they are implemented in practice and how they are perceived and experienced by the citizens. The WJP Rule of Law Index™ examines four hundred variables arranged in nine factors and 52 sub-factors corresponding to goals that societies seek to achieve.

The outcome elaborates the input of 2,000 academics and practitioners along with an opinion pool that involved 66,000 individuals. JRC carried out a sensitivity analysis of the data sets produced and confirmed the statistical reliability of the results.

Readers may wish to verify these and other aspects of methodology independently.

Source: European Commission: Joint Research Centre. The World Justice Project.  28/06/11 http://ec.europa.eu/dgs/jrc/index.cfm?id=1410&obj_id=13600&dt_code=NWS&lang=en

Our Conclusion 
Leaders of the U.S. Legal System should curtail their tedious habit of proclaiming their system to be “the best in the world”.  Clearly to make such a claim in the face of global evidence to the contrary is merely political propaganda.  To get your house in order requires a higher level of moral courage than has been demonstrated lately by the US Congress, and equally so in relevant state legislatures (especially those which are Republican controlled, such as Florida), which are evidently hostage to the gun lobby in proclaiming such archaic legislation such as "stand your ground”, while tacitly maintaining, if not actively promoting, a racial divide on equal protection before the law. 

It seems the U.S. justice system could learn a lot by studying the experience of other developed countries, many of which may in practice be more reasonable and just societies than the U.S.. While we live in hope that Americans will eventually pull themselves out of this self-destructive morass of gun violence, racially motivated or otherwise, in the meantime - a warning to visitors to the U.S.: this is a dangerous place where self-appointed vigilantes carry concealed weapons and may take the law into their own hands, even if your only misstep is to fit a preconceived stereotype (in their preconditioned brains, over which you have no control). This vigilante "right" is protected under legislation: do take care!