FROM a Great Canadian and World Statesman

"A great gulf... has... opened between man's material advance and his social and moral progress, a gulf in which he may one day be lost if it is not closed or narrowed..." Lester B Pearson http://nobelprize.org/nobel_prizes/peace/laureates/1957/pearson-lecture.html
Showing posts with label health care. Show all posts
Showing posts with label health care. Show all posts

Wednesday, 12 November 2008

CAN OBAMA RESTORE THE WORLD’S TRUST IN AMERICA'S IDEALS?

PREAMBLE: The past 8 years have been devastating for the world, due to the cavalier attitude of US leadership: an ignorant and arrogant approach to global issues from the environment to the “war on terror”, negligence in economic stewardship, and not least sweeping aside ethical and legal principles as if these are unconnected to core democratic principles.

Equally, due to the skewed priorities of now discredited neo-conservative ideology, the USA failed to make progress on its domestic front, especially in health and education: areas in which it does not compare favourably to other developed countries.

Responsibility for the catastrophic damage to the reputation of the USA can be laid at the feet of the “Bush 2” administration: so much damage done, so much opportunity lost.

Reprieve? We attribute the following statement to Ken Gude of the Guardian.
“All across the globe, people awoke Wednesday morning November 5, 2008 to a dramatically different world. Americans shook off the 400-year legacy of racism and elected an African-American named Barack Hussein Obama to the nation's highest office. That an experienced and admired war hero was defeated underscores the real significance of the electorate's hunger for change and the promise of an Obama presidency.

But the world that President-elect Obama awoke to on Wednesday morning had already changed. America's military deterrent, its economic power and its standing as a global leader have all nearly collapsed and old and new powers are seeking to fill the void.”

Note: The balance of Ken Gude’s article is paraphrased below as the third item in this issue.

We dedicate this issue of PacificSci Global Perspectives to Senator Obama’s political victory, and wish him whatever success is achievable in his efforts to turn around the abysmal situation described in our opening paragraph. He deserves wide support.

Reference: Ken Gude. The Guardian Newspaper on-line Friday, November 7, 2008 14.00 GMT.

President-Elect OBAMA – An Historic Breakthrough
The proposition that Barack Hussein Obama would become the 44th President of the United States seemed somehow remote. He was an unlikely candidate - he seemed inexperienced and had spent much of his childhood abroad. But mainly because he is black. It says much about the virtues of US democracy that Mr Obama could even have been nominated. But it says much more about perceptions of American democracy abroad that so many doubts prevailed for so long about the final outcome.

Opinion polls consistently gave Mr Obama an unassailable lead. The incumbent Republican President's personal ratings were at record lows. But the world would not believe until it saw it. Contrary to many predictions, race did not dominate the campaign. But it filled the gap between what Americans said they intended to do and what the rest of the world feared they would do. That anxiety played also on the minds of many US citizens. The joy expressed in the US and around the world at the result represents a moment of global realignment with America's best sense of national purpose. For most of its history, the US has perceived itself as a beacon of opportunity and an example to the world. Anti-Americanism, meanwhile, has always drawn strength from the assertion that those ideals are debased by the way the US projects its power abroad and by the raw facts of its unequal society.

A single election will not heal American social divisions, nor will it stop America pursuing its interests overseas, with military power if it so chooses. But by electing as their leader a man whose grandfather was a Kenyan goat-herder and who shares a middle name with the grandson of the Prophet Mohammed, Americans have made it harder for their enemies to portray them as a military nation and one of bigots.

Many challenges lie ahead but these should not detract from the optimism that is felt not only in America but around the world at the result of last week's election. Mr Obama has already proved his skill as a diplomat and politician. The young senator from Illinois once looked like an unconventional candidate. But a majority of US voters decided their choice would not be dictated by conventional thinking, choosing a President first and foremost to defend their own interests.

Source: Adapted from the Editorial: "America has restored the world's faith in its ideals". The Guardian Newspaper on-line Sunday November 9, 2008 00.01 GMT http://www.guardian.co.uk/commentisfree/2008/nov/09/barack-hussein-obama-american-dream#history-byline#history-byline

THE IN-TRAY – Key Issues for the Obama Presidency
In researching this issue, we looked at a number of sources, and settled on the Guardian’s coverage. Here we highlight that newspaper’s selection of key issues that must be tackled by President Obama and his team.

Health Care: Obama's plan (to include treating America's 46 million uninsured) entails using tax credits to coax more businesses into insuring their workers, while setting up a separate new healthcare system at a cost of more than $1 trillion. Can he do that while making good on a vow to reduce insurance fees by $2,500 per household?

Environment: for global climate talks to proceed smoothly next winter, Congress must be coaxed into approving US carbon emissions caps. Liberals will not hesitate to criticize him if he veers too far towards concessions to fossil-fuel producers. If Obama cannot bring Congress around, his advisers suggest he would use the president's regulatory powers to implement his plan for an 80% emissions reduction by 2050.

Energy: Americans pay $700 billion a year to oil-exporting nations. Obama wants to reduce that, and aims to put 1million plug-in hybrid cars into circulation by 2015, a formidable task while US car sales are tumbling. His goal to impose a windfall profits tax on oil companies is sure to draw intense opposition from the business lobby, while his promise to expand untested "clean coal" technology will anger the green movement.

Education: A quarter of US teenagers drop out before graduation, underscoring the need for an education overhaul when George Bush's No Child Left Behind policy expires next year. Obama has called for adding more funding to NCLB and shedding its emphasis on standardized tests. But with at least five states joining legal challenges to NCLB, he may be forced to focus on his less controversial goals, such as expanding early childhood education and community service tuition credits for university students.

Homeland security: Bush cut grants to police and firefighters by hundreds of millions of dollars, leaving a gaping hole in security for urban public transport as well as suburban street corners. Fixing that problem forces Obama to find extra cash during the economic crisis. But the real minefield is domestic surveillance, which alienated Obama from his Democratic base after he supported Bush's grab for new wiretapping powers.

Supreme Court: As many as three US supreme court justices are likely to retire in the next four years, giving Obama an opportunity to nominate justices that share his views on abortion, constitutional rights of terrorism suspects, separation of church and state, and other contentious social and legal issues. But legal analysts say the court's ideological make-up is unlikely to change much in Obama's first four-year term, because the justices likely to retire are firmly in the liberal wing.

Source: The In Tray: Key Issues. The Guardian Newspaper on-line Thursday November 6, 2008. http://www.guardian.co.uk/world/2008/nov/06/uselections2008-barackobama2#history-byline#history-byline

EDITORIAL NOTE: We note the curious omission of the economic collapse in this list, and refer readers to our last issue where this was addressed under title “the Brown Doctrine” http://pacificsci.blogspot.com/2008/10/global-economic-crisis-brown-doctrine.html

CLOSE GUANTANAMO, END TORTURE
According to the opinion expressed by Ken Gude of the Guardian, in contrast to the Bush administration's failed policies, Barack Obama will fight terrorism legally, competently. The following is paraphrased from his article referenced below, leaving in the active links to sources that he utilized in his original article.

President Bush will bequeath Obama numerous ongoing crises in Iraq, Afghanistan, Pakistan, Iran and Israel-Palestine that will demand urgent and sustained attention, constraining his ability to define his own agenda.

This makes it all the more important for President Obama to take US policy in a demonstrably different direction in the areas he can control, starting with the fight against al-Qaida. President Obama must follow through on his pledges to close Guantánamo Bay and renounce torture, and carry forward these changes by also shutting down the secret CIA prisons, ceasing extraordinary rendition and ensuring that all electronic surveillance is within the law and with necessary safeguards to protect against eavesdropping on innocent Americans. Obama will close Guantánamo Bay as one of his first actions as president. He will not be able to simply wave his hand and empty the prison, however, as any responsible policy will take time to implement.

Two early and relatively easy decisions will signal to the US and the world that Obama will chart a very different course than Bush: President Obama should order the release of Salim Hamdan and the remaining Guantánamo Uighurs. Hamdan was the first detainee convicted in a military commission trial, but the Bush administration will not release him even after his sentence expires at the end of the year. The 17 Guantánamo Uighurs are among the greatest tragedies of this sad saga, the Bush administration is fighting a US court decision ordering their release even though it has already determined that they are not enemy combatants.

Announcing the closure of Guantánamo Bay and releasing Hamdan and the Uighurs would change the dynamic surrounding the detention camp and enable the international cooperation required to ultimately empty the prison of the remaining 225 detainees. Obama should stop the military commissions process and begin preparing cases for trial in US courts against those detainees who should face criminal charges. He should institute at Guantánamo reintegration and de-radicalisation programmes that have been used successfully by the US military in Iraq and the Saudi government. And he should establish an international working group to find new homes for detainees that cannot be sent back to their home countries while accelerating transfers for those that can.

Thanks to President Bush, it is no longer adequate to assert that the US does not torture detainees in its custody and President Obama must go beyond simply returning to the pre-Bush status quo. The first step is to admit complicity in the torture of detainees in custody. President Obama should make public the legal opinions and policy guidelines that the Bush administration relied upon to craft its interrogation programmes. He should further pledge that all legal opinions developed by his administration related to interrogation and detention will be promptly and freely submitted to the relevant committees and leadership in Congress. Finally, President Obama should clearly and unequivocally publicly renounce torture and put all US government employees and contractors on notice that the torture and abuse of detainees will not be tolerated on his watch. President Obama should take the additional step of ensuring that the US is not complicit through the back door and end the outsourcing of torture by stopping extraordinary renditions and shutting down secret CIA prisons.

Many of Obama's supporters were disappointed in his decision this summer to support the compromise legislation on the National Security Agency's wiretapping programme. Some even worry that this move signals his intention to continue President Bush's warrantless wiretapping scheme, but that interpretation badly misreads both the political circumstances and the bill itself. A presidential campaign is a terrible place for tough policy decisions, and this latest amendment to the Foreign Intelligence Surveillance Act was far from perfect but importantly brought the entire surveillance programme under the jurisdiction of the FISA court. President Obama will now have pre-existing legislative sanction to conduct electronic surveillance with meaningful judicial oversight, which he clearly intends to do, and a strengthened progressive majority in both houses to pursue any additional steps necessary to preserve the liberties of the American people and prevent abuse.

Perhaps no area of US policy was more widely condemned than President Bush's war on terror and Obama must take immediate steps to reverse course or risk saddling all of America with the legacy of George W Bush. Under President Obama, America may come back, but there is no going back to the old order. Those countries who spent the Bush administration railing against American unilateralism must now accept the responsibilities that come with a seat at the table. The challenges we face are immense, and if we are to meet them we must work together in a spirit of cooperation that has not existed for many years, if it ever did. In the US and across the world, this is our time, this is our moment. Are we ready?

Source: Ken Gude. Close Guantanamo, end torture. The Guardian Newspaper on-line Friday, November 7, 2008 14.00 GMT.

Sunday, 15 June 2008

HEALTH CARE IN CANADA – An Essay

Preamble: A public consultation on health care, called the Conversation on Health, took place during 2007 in the Canadian province of British Columbia.[1] Our firm made a written submission [2], and now we take the opportunity to transform the core of this into an overview of Canada’s health care, on the premise that this may be of global interest.

NOTE: The essay is written for the Canadian context, so we caution that Canada’s model is NOT readily translatable to most other countries. However, it may be a viable option for economically developed ones that still lack universal coverage.

We reserve the right to change our views on any aspect of this essay as new analysis may emerge to justify revision, and in this sense it may be viewed as a work in progress.

NEW NOTE January 25, 2013: Due to the popularity of this posting (based on our web traffic statistics) we wish to alert readers to a related article: 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):141-149.  Full FREE access to that article has been arranged at the following site: http://www.phabc.org/modules.php?name=Contentpub&pa=showpage&pid=173

CANADIAN HEALTH CARE – An Overview
Canada’s health system enjoys wide public support. Its most valued features are: universality, portability and no direct fees for insured services, financed by government in accordance with the Canada Health Act (1984). The objective under the Act is "to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers."

While the Canada Health Act resonates politically, not all health modalities are equally recognized. Nor are they equal in terms of need, quality of supporting evidence, nor necessarily affordable. Choices have always have been made. Thus, even though “comprehensiveness” is one of the stated principles, in practice this particular attribute has never been a reality as it refers historically to services deemed “medically necessary” in the context of 3-4 decades ago when the provincial acts supporting universal health care were promulgated. Elements still not adequately recognized include: home care, long term care, dental care, physiotherapy and pharmaceuticals, and others. A relevant question: will universality be applied in future to services not fully financed today?
To the extent that the system delivers on equity therefore, it approaches this only for fully insured medical and hospital-based services; but where coverage is not universal, ability to pay is critical. This contrast reflects how society views health as a public good, what it considers essential, the extent of equity it seeks, and the resources it is prepared to allocate. While the Canadian experience overall has been positive, the commitment and sustainability are remain functions of social values and political will. Canada’s health care system is justifiably a source of pride, but there is still much room for improvement

Health therefore is both a complex social goal and a major enterprise in Canada, mostly now based in the public sector. While compassion and human rights lie at its base, it is also seen in terms of the social and economic benefits it provides to the entire population.

INTER & INTRA JURISDICTIONAL COMPARISONS
A systematic review of 38 studies recently confirmed that Canada’s system leads to health outcomes that are favourable overall when compared with the US private for-profit system, at less than 50% of the cost [3]. However, perhaps more relevant is WHO’s landmark study in 2000 of health systems performance in almost 200 countries, ranking the UK in 18th place, Canada at 31st, and the US (most expensive health care in the world) at 37th. Most European countries performed better than Canada, while Australia’s performance (similar socio-demographics) at 32nd place was virtually tied with Canada [4]. Several other countries also scored better than Canada eg., Singapore, Japan. In our view, rather than dismiss such comparisons (which is unfortunately a defensive reaction in some circles) Canada should study and learn from those systems which appear to be doing better, and (while staying consistent with the core principles of the Canada Health Act) be more prepared to innovate, test and evaluate new approaches. We should also show more interest in the internal comparisons being revealed from within our health and social sectors [5], specifically: why are health conditions so different for different groups within the country, and what can be done about this? The key premise here is to be guided by evidence within the social contract represented by the Canada Health Act.

When one examines overall health status of populations using objective measures, it is tempting to conclude that the health systems of countries with similar socio-economic conditions appear to vary more with regard to cost than performance, irrespective of the public-private mix. However, the type of system does appear to have a strong influence on the indicators of equity. Beyond observing the principle of universality, this is reflected in steadily improving outcomes. A new Canadian study [6] reveals that – over a 25 year period – differences between the richest and poorest quintiles in expected years of life lost amenable to medical care decreased 60% in men and 78% in women. Reductions in rates of death amenable to medical care made the largest contribution to narrowing the socioeconomic mortality disparities. Continuing disparities in mortality in causes amenable to public health suggest that public health initiatives have a potentially important but yet unrealized role in further reducing mortality disparities in Canada.

If we make the political decision that there is probably already enough money in the system, the challenge in achieving better performance necessarily must lie in improving leadership, priority-setting, decision-making and management at all levels: in particular, we must do better on health promotion, public health and preventive medicine. On the other hand, there are many in society and among the ranks of the health professions who believe that the system we have is already doing very well, and – while its underlying principles seem secure – we would adjust its design and the way it is working at our peril. Nonetheless, the existing budget is by definition aligned with the status quo, mostly a legacy of thinking of the early 1970s (when most Canadian provinces launched their particular version of “medicare”). Does it necessarily follow that this is the only formulation we are capable of, or has the time come to expand the scope of health services to more within currently underfinanced sub-sectors eg., pharmacare, dentistry?
LOOKING WHERE THE OBJECT IS LOST, NOT WHERE THE LIGHT IS BEST
When engaged in public debate about health care, as a society Canada tends to focus on the high cost items that preoccupy institutional administrators, while overlooking the powerful forces that preserve our health: healthy living environments and workplaces, primary prevention (eg., nutrition education, childhood immunization, ante-natal care, physical activity, smoking prevention), and social policies (affecting literacy, employment, crime, housing quality and community wellbeing). These are the “upstream factors”. We also become so preoccupied with acute care issues, which are crisis-prone and sometimes glamorized, forgetting not only the upstream factors, but even downstream ones (eg., long-term care, home care) whose availability determines the speed with which acute care patients may move on to more appropriate levels of care.

To the extent that health systems fail, especially with regard to addressing priority needs and the ethic of equity (universality, access, affordability), this most often results from failing to deliver on basic needs, especially for groups that lack power or recognition.

OUR SUGGESTIONS FOR THE CONTINUED STEWARDSHIP OF CANADIAN HEALTH CARE

o That federal and provincial governments continue to recognize health as a public good, recommit to the principles of universality and equity in health services delivery, and curtail private for-profit entities as an alternative in any area of core or essential services. Clearly our governments must continue to ensure that how it puts together services must be in compliance with the Canada Health Act (1984).

o The Government of Canada should be kept under scrutiny regarding the decline in its financial contributions to provincial health services, thereby contravening the Canada Health Act. The “new” federal government must be held accountable for reneging on the Kelowna Accord (investment in aboriginal peoples) and Child Care. These failures to honour prior commitments that enjoyed public support reveal a short-sighted federal political agenda that undermines important determinants of health and social equity.

o Also in the spirit of the Canada Health Act, we urge government to re-examine now what services should be core or essential, and to consider expansion of the scope of publicly financed provisions, with emphasis on the more vulnerable eg., dental provisions for children and the elderly; provisions for new parents eg., maternity leave and child care, and expand the eligibility and/or scope of pharmacare for elderly. This is particularly timely given record governmental budget surpluses in recent years.

o Health care quality and outcomes for Canadian jurisdictions generally compare favorably with those of the US. Nonetheless, the tendency of Canadians to refer to the US performance in health care and outcomes as if this is a desirable norm is misplaced. It makes more sense to learn from the experience of systems elsewhere in the world eg., western Europe, Japan, Singapore, that are better performers than the failing US model. To the extent that Canada looks to the US for systems design support or medical records contracting, this must not threaten privacy; under the current US administration even its own citizens are losing trust regarding the invasion of privacy in the name of security.

o The most critical elements of any health system needs to be public health (ie., population health provisions, including health promotion) and primary health care: to the extent that systems fail, this is often due to failure to support these components. Effort is needed to attract talented individuals to engage in these fields. The responsibility for this lies with professional education institutions, specialty bodies and professional associations, with support from relevant ministries to ensure that effective action is taken.

o There is a need for Canada to strengthen its response to the surging chronic disease burden. The international literature indicates that about half of this burden is potentially preventable through attention to modifiable behaviours eg., smoking, fitness, weight control; and about half of those who do develop these conditions can be prevented from progressing to more complicated forms through attention to secondary prevention eg., blood pressure screening; active glucose monitoring for persons with diabetes.

o When one looks at Canada’s population health internally, it is obvious that there is still a substantial amount of inequity, both regionally eg., northern regions, inner city areas, and by population group eg., First Nations. We therefore recommend that, equity must be given more prominence in the public debate and in government decision making.

References1. Conversation on Health. Government of British Columbia, Canada (2007): http://www.bcconversationonhealth.ca/EN/401/
2. Pacific Health & Development Sciences. Shaping health in BC – observations and suggestions. Submission to the B.C. Conversation on Health. http://www.bcconversationonhealth.ca/media/PacificSci_COH_Submission.pdf
3. Guyatt GH, Devereaux PJ, Lexchin J, et al. A systematic review of studies comparing health outcomes in Canada and the United States. Open Med 2007;1(1):e27–36.
4. The World Health Report 2000. June 21, 2000. Geneva. http://www.who.int/whr/2000/en/index.html
5. Hertzman C, Irwin LG. It takes a child to raise a community: population-based measurement of early child development. Human Early Learning Partnership. No 1: July 2007. http://www.earlylearning.ubc.ca/
6. James PD, Wilkins R, Detsky, Tugwell, Manuel DG. Avoidable mortality by neighbourhood income in Canada: 25 years after the establishment of universal health insurance. J Epidemiol Community Health 2007; 61:287-296. http://jech.bmj.com/cgi/content/abstract/61/4/287

INSPIRATIONAL WELCOME ............................... from T.S.Eliot's "Little Gidding"

If you came this way From the place you would come from... It would be the same at the end of the journey... If you came, not knowing what you came for, It would be the same... And what you thought you came for Is only a shell, a husk of meaning... From which the purpose breaks only when it is fulfilled If at all.