Vol7 Issue2 PDF

Editor-in-Chief Abraar Karan LETTER FROM THE EDITOR
S
Managing Editors Yifan Chen, Jaymin Patel ystematizing how a population receives health is extremely complicated. We no longer live
Swati Yanamadala
in a world in which treatment is the responsibility of doctors paying home visits to indi-
Senior Editor Rebecca Linfield
vidual patients. The role of globalization has made the notion of health as an interconnected
Content Editors Lara Fourman, Tobias Kuehne global system much more important. Healthcare delivery is largely a process in which govern-
Ben Liu, Alison Pease
ments, NGOs, large private donors, and individuals navigate law, culture, business, and politics
Layout Director Cynthia Jin to provide as many citizens with the highest quality of care possible.
Graphics Director Lucia Tang In this issue of the YJML, we explore the global healthcare system in snapshots. We cover
Research Director Varoon Bashyakarla KRZGLIIHUHQWFRXQWULHVDQGRUJDQL]DWLRQVKDYHGHDOWZLWKVSHFLÀFKHDOWKLVVXHV)RUH[DPSOH
Business Directors Byron Edwards, Yuning Liu
the response to the HIV epidemic has been quite different in Brazil and in Russia largely due
to how treatment of the disease was incorporated into the larger healthcare infrastructure. The
Distribution Director Parker Collins issue of culture and healthcare has also shaped delivery in many places and we examine the
Development Director Courtney Rubin situation in the Middle East where gender norms play a large part in health.
Online Media Directors Aubrey Alleman, Julia Goldberg Law and medicine intertwine very relevantly in terms of health systems. This is seen in
Staff Writers Connie Cho
PDQ\FDVHV³WKHVWULFWOHJDOUHTXLUHPHQWVIRUDVVLVWHGUHSURGXFWLRQLQ)UDQFHWKHYDULHW\RI
Paulo Coelho Filho medical malpractice lawsuits around the world, and the response by the Women on Waves
Jenny Mei, Ben VanGelder organization to sidestep abortion laws in certain countries are but a few instances that we
Annie Wang, Vincent Yu
touch on. Moreover, health systems are driven by business and markets. The international
Board of Robert A. Burt, JD, MA
Advisors Alexander M. Bickel pharmaceutical companies that are slowly creeping into the markets of the developing world
Professor of Law are a prime example of how healthcare is changing quickly in resource-poor nations. We look
Yale Law School
at the lack of essential medicines and the way that pharmaceutical expansion may abet access
Thomas Pogge, PhD. to higher quality health for millions.
Professor of Philosophy
and International Affairs ,WLVXOWLPDWHO\GLIÀFXOWWRGHFODUHZKLFKKHDOWKFDUHV\VWHPLVWKHÉHVWµDQGWKHUHLVVRPH
Yale University truth to the idea that no one system will be best for any individual. We take the opportunity to
Carl Zimmer, look in depth at the WHO’s attempt to rank the healthcare systems of the world and identify
Author, Journalist
ÁDZVLQLWVÀQGLQJV/DVWO\ZHDUHGHOLJKWHGDQGKRQRUHGWRSUHVHQWWR\RXRXUFRYHULQWHUYLHZ
Howard P. Forman, MD, ZLWK'U)UDQFLV&ROOLQVWKH'LUHFWRURI WKH1DWLRQDO,QVWLWXWHRI +HDOWK7KHLQWHUYLHZZLWK
MBA
Professor of Diagnostic 'U&ROOLQVLVZKROO\UHOHYDQWWRQDWLRQDODQGLQWHUQDWLRQDOKHDOWKFDUHDVWKH1,+·VUHVHDUFKLV
Radiology and pioneering the global health landscape. We end this issue with two entertaining anecdotes that
Healthcare Economics
elucidate health, sickness, and the globe.
Sharon Terry, MA
President, CEO of As always, the YJML dedicates itself to accurate, compelling, and informative journalism
Genetic Alliance that will facilitate and encourage a dialect of health politics and policy within the larger Yale
Founder
Theodore Long community. The writing, editorial, research, layout/design, and business staffs have put in
many hours to make this issue possible and I would like to thank them for their work.
This journal is published by Yale University students. Yale University is

not responsible for its contents. The opinions expressed by the contrib-‐
uters to the Yale Journal of Medicine and LawĚŽŶŽƚŶĞĐĞƐƐĂƌŝůǇƌĞŇĞĐƚ
ƚŚŽƐĞŽĨŝƚƐƐƚĂīŽƌŝƚƐĂĚǀĞƌƟƐĞƌƐ͘dŚĞĚĞƐŝŐŶĂŶĚĐŽŶƚĞŶƚŽĨƚŚŝƐƉƵďůŝ-‐
ĐĂƟŽŶĂƌĞĐŽƉǇƌŝŐŚƚŽĨYJML and may not be reprinted without express
Abraar Karan, ‘11
ǁƌŝƩĞŶĐŽŶƐĞŶƚĨƌŽŵƚŚĞĚŝƚŽƌͲŝŶͲŚŝĞĨ͘ Editor-in-Chief
writing. editing. business. research. design.

Join the Yale Journal of Medicine and Law
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2 Spring 2011 Vol. VII Issue II Yale Journal of Medicine and Law http://www.yalemedlaw.com
Landmarks in
International
Health Care
WHO declared World AIDS Day SARS
1945
1988
2003
1979
1948
United Nations World Health
formed under Organization was that human established to pro- outbreak
President Harry founded under the smallpox had mote research and declared.
Truman in April United Nations. been eradicated. to reduce stigma.
04. A Right to Care: TABLE OF

International Healthcare in
Developing Countries
18. Defining Parenthood:
Assisted Reproduction in France
CONTENTS
Molly Patterson Connie Cho
32. Gender in Middle Eastern
06. The Growth of 20. When Government Health Care Health Care
International Pharmaceuticals: Meets Citizen Involvement: Vincent Yu
The Promises and Challenges of Lessons from the Brazilian Approach
Pharmaceutical Start-ups in to the HIV Epidemic
Developing Economies 34. Women on Waves:
Anjali Balakrishna The Abortion Rights Movement
Mitchell Murdock
Sets Sail
22. The Gates Foundation Alexa Sassin
09. Methodology of Connie Cho
WHO Healthcare Rankings
37. The Individual Mandate in Rwanda:
Gianna Fote 24. Interview with Dr. Francis Collins, Mutuelles and the Push for Universal
Director of the Coverage
12. Essential Medicines: National Institutes of Health Aditya Mahalingam-Dhingra
The Crisis in Developing Countries Courtney Rubin
Anne Bozik 40. Flu in the Mountains of Costa Rica
28. The HIV/AIDS Crisis in Russia: Patrick Toth
14. International Organ What Has Been Done and
Transplantation What is Still Left to be Done
Ben VanGelder 42. Doubled Over in Paradise
Ronit Abramson Nicole Negbenebor
16. Medical Malpractice: 30. One Child, No Healthcare:

How Medical Lawsuits are Won Population Control and
Around the World Its Impact on Health Care in China
Catherine Chen Martin D. Weaver, Jr.
41.9 years 33.3 million 9.4 million 894 million

Life expectancy in Afghanistan Infected with HIV/AIDS globally, New cases of Tuberculosis in 2008 People globally who lack access to
including 2.5 million children globally clean water
78.3 years
1.8 million 30% Every 20 seconds
Life expectancy in USA
AIDS-related deaths in 2009 Percentage of obese Americans A child dies due to poor sanitation
82.9 years 7.6 million 220 million 2015
Life expectancy in Japan Cancer-caused deaths in 2008 Cases of diabetes around the world U.N. Millennium Goal target to halt
the spread of AIDS
http://www.yalemedlaw.com Yale Journal of Medicine and Law Spring 2011 Vol. VII Issue II 3
A Right to Care International Health Care in Developing Countries
BY MOLLY PATTERSON
Exploring the relationships between

NGO’s and government healthcare
services in South Africa.
T he structure of health care around
the globe varies as widely as the
health issues facing the citizens of every
African heads of state met in Abuja in
2001 and all pledged to commit at least
RI QDWLRQDOEXGJHWVWRKHDOWK>EXW@
FRXQWU\)XQGLQJIRUKHDOWKFDUHV\VWHPV that is not happening yet. South Africa
Interview with Dr. Thembi Xulu, is equally variant, and largely dictated by is spending 9.1% of its budget on health
Medical Director of Right to Care. both the economic and developmental but it’s still not enough to meet the
status of each country. Developed na- country’s needs because we cannot even
tions are generally able to offer a wider start implementing the much needed na-
scope of services at higher subsidized WLRQDO KHDOWK LQVXUDQFHµ ,Q WKH FDVH RI
rates many developing nations – South Africa
Because of the lack of healthcare in- LQFOXGHG²WKLVGHÀFLWLVUHGXFHGZLWKWKH
frastructure, developing countries suffer help of non-governmental organizations
disproportionately from diseases and (NGOs) and foreign government aid.
other public health problems. South 2QHVXFK1*2LV;XOX·V5LJKWWR&DUH
Africa, for instance, is home to over one of the largest NGOs to provide
5.7 million people living with HIV6, healthcare to South Africans affected
and was ranked 175 out of 191 in the with HIV/AIDS, tuberculosis (TB), and
2000 WHO healthcare survey. The re- other poverty-related diseases.
cent global economic crisis limits the While the South African government
depth of resources allocated by South has established a larger healthcare bud-
Africa to any one government sector, get than some of its sub-Saharan Africa
and health care is no exception. As Dr. counterparts, that funding is widely dis-
Thembi Xulu, Medical Director of Right persed and therefore largely diluted by
WR &DUH H[SODLQV ´>PRVW@ $IULFDQ JRY- the time it reaches the country’s 49 mil-
ernments have not been putting enough OLRQSHRSOH)LUVWWKHKHDOWKFDUHEXGJHW
>IXQGLQJ@ WRZDUGV WKHLU KHDOWK EXGJHWV is divided amongst the nine provinces of
government contributes the majority of
the funding for these NGOs, the NGO
services are incorporated into the gov-
ernment’s health infrastructure rather
than existing as alternative health care
SURYLGHUV )RU LQVWDQFH 5LJKW WR &DUH
doesn’t own any clinics – employees
work within the South African Depart-
ment of Health clinics.
)XQGLQJIRU1*2VLVQ·WWKHRQO\ZD\
in which South Africa relies on foreign
aid to support its healthcare system. The
South African government actively re-
FUXLWV GRFWRUV IURP 7XQLVLD &XED DQG
Iran to supplement the doctor shortage
that persists.3,4 The approach is very
practical, and is also used by the NGOs.
$V ;XOX H[SODLQV ´ZKHQ GRFWRUV IURP
ABOVE The French government assumes 100% of all diabetes-related costs. 7XQLVLDRU&XED>RU,UDQ@FRPHLQRQFH
WKH\·YH PHW WKH FHUWLÀFDWLRQ UHTXLUH-
the country. Prior to 2004, the healthcare about 60% of hospital admissions are re-
ments from the government’s perspec-
allocation amongst the provinces was lated to these diseases. Similar trends are
tive and are registered on the health pro-
HTXDOUHVXOWLQJLQDQHPSKDVL]HGÀQDQ- seen in other developing nations around
IHVVLRQVFRXQFLOQRWKLQJVWRSV>5LJKWWR
cial divide between the rural and urban the world. These NGOs operate inde-
&DUH@IURPHPSOR\LQJWKHPµ
areas of the country. Starting in 2004, pendently, but the national government
When asked what she would empha-
the government allocates resources on a often provides partial funding. In 2006,
size if given the opportunity to develop
sliding scale based on province need. As the South African government allocated
the South African healthcare system
DUHVXOW´SURYLQFHVWKDWKDYHKLJKHFR- over $8 million in grants to such NGOs.
from scratch, Xulu sees access to ser-
QRPLF DFWLYLW\ DQG >DYDLODEOH@ MREV WHQG Developed nations also aid the NGO ef-
vices and quality of care as most im-
to be overpopulated and end up getting forts. Under President George W. Bush,
portant. Remaining loyal to her cause,
TXLWHDVLJQLÀFDQWVKDUHRI WKHEXGJHWµ the United States President’s Emergency
VKH VD\V VKH ZRXOG DGYRFDWH ´LQWHJUDW-
according to Xulu. However, the situa- 3ODQIRU$,'65HOLHI 3(3)$5ZDVHV-
ing HIV care into all health systems…
WLRQDULVHVWKDW´RQFHWKHPRQH\LVLQVLGH WDEOLVKHGVSHFLÀFDOO\WRDVVLVWGHYHORSLQJ
Many units within the healthcare system
the provinces, the provinces have au- nations in combating HIV, AIDS and
IXQFWLRQV LQ VLORV >:H QHHG WR@ LQWH-
WRQRP\WRGHFLGHµZKLFKSURYLQFHVSH- TB by partially funding NGOs focused
JUDWH KHDOWKFDUH VR WKDW LW·V >XQGHU@ RQH
FLÀF KHDOWK SURJUDPV DUH IXQGHG >DQG@ on these diseases. In the case of South
provider - under one roof - making it
LQ ZKDW SURSRUWLRQµ VD\V ;XOX 3URY- Africa, the government pays 83% of the
FRQYHQLHQW IRU RXU SDWLHQWVµ ,I PRQH\
inces also individually decide how they costs associated with running programs
were not an issue, Xulu’s healthcare sys-
monitor standards of disease treatment OLNH5LJKWWR&DUHDQGIXQGVIURP3(3-
tem suggestions stem from a saying she
and patient quality of care since there is )$5FRYHUWKHUHPDLQLQJ;XOXVD\V
recalls from her graduate school days:
no countrywide health monitoring and ´LW·VTXLWHDQLFHEDODQFHLQWHUPVRI VXV-
´MXVWEHIRUHWKH+,9HSLGHPLFZDVDWLWV
evaluation system established by the na- WDLQDELOLW\ EH\RQG WKH GRQRU IXQGLQJµ
peak, we used to say ‘poor people are so
tional government. This autonomy cre- EXWDGGVWKDW3(3)$5GRHVQRWH[WHQG
poor, they can’t even afford to get sick,’
ates a problem of migration between the to all countries, so South Africa’s situa-
because even when they were sick they
provinces since sick individuals seek the tion is somewhat unique.
had to go to work because they were
best care, overpopulating and straining 5LJKW WR &DUH LV RQH RI WKH +,9
poor. But now the poorest of the poor
the resources of hospitals that provide AIDS, and TB-focused NGOs Xulu
have HIV. They’re dying, so now they
such care. UHIHUV WR DV WKH ÉLJ ÀYH SOD\HUVµ ZKR
are the sickest of the sick and they can’t
To alleviate some of this strain, JHW WRS IXQGLQJ E\ 3(3)$5 WR VHUYLFH
work because they are sick… The only
NGOs aid in the operation of govern- citizens across South Africa. The other
way to change that is to bring services to
ment-funded clinics and hospitals. A IRXU DUH WKH )RXQGDWLRQ IRU 3URIHV-
the people, so national health insurance
VLJQLÀFDQW QXPEHU RI 6RXWK $IULFDQ VLRQDO 'HYHORSPHQW )3' WKH 5HSUR-
ZRXOGEHELJRQP\DJHQGDµ
healthcare NGOs focus on providing ductive Health and HIV Research Unit
care to patients with HIV, AIDS, TB, (RHRU), BroadReach, and the Perinatal
Molly Patterson is a sophomore in Trumbull College.
and other poverty-related diseases, since HIV Research Unit (PHRU). Since the
Marketing Services (IMS), an organiza-
tion that monitors the pharmaceutical
industry, the global pharmaceutical mar-
ket will grow 5-7% in 2011 to $880 bil-
lion, largely because of pharmaceutical
companies based in emerging markets.
However, unless changes are made to
international patent laws and countries’
RZQHFRQRPLFLQHIÀFLHQFLHVWKHVHFRP-
panies are unlikely to meet their full po-
tential.
%HFDXVHWKRVHDIÁLFWHGE\WKHZRUOG·V
BY MITCHELL MURDOCK most devastating diseases almost always
ODFN VLJQLÀFDQW SXUFKDVLQJ SRZHU PRVW
pharmaceutical companies believe drugs
A new drug to treat HIV is set to be

manufactured in Uganda early next
year. Previously, HIV/AIDS patients
IRU WKHVH GLVHDVHV RIIHU LQVXIÀFLHQW UH-
turns on investment. As Scottish jour-
nalist Isabel Hilton put it, it is more prof-
relied primarily on charitable donations itable for multinational pharmaceutical
from developed countries, and the lim- FRPSDQLHVWRFXUH´GLVHDVHVRI DIÁXHQFH
ited drugs available were exorbitantly and longevity—heart disease, cancer, Al-
expensive. However, Uganda now joins ]KHLPHUVµ )RU WKLV UHDVRQ GLVHDVHV DI-
a host of other countries that have de- fecting much of the world’s population
veloped homegrown efforts to respond aren’t well addressed by the majority
to pressing health needs.
The pharmaceutical business is a
rapidly growing industry in developing
economies. Like all entrepreneurs who
ÀOO D QHHG OHDGHUV RI SKDUPDFHXWLFDO
companies based in emerging economies
DUH ÀQGLQJ FXUHV WR SUHYLRXVO\ LJQRUHG
diseases. According to Intercontinental
The Growth of
International
Pharmaceuticals
The promises and challenges of pharmaceutical
start-ups in developing economies
RI PHGLFDO UHVHDUFK )RU H[DPSOH DF- on the market. This potential to create panies in emerging markets spend rela-
cording to a paper published in Health solutions to global health through sus- tively little on marketing, their drugs are
Affairs, of 1,556 new drugs approved tainable entrepreneurship provides a VLJQLÀFDQWO\ FKHDSHU WKDQ WKRVH RIIHUHG
between 1975-2004, only 21 (1.3%) tar- much-needed response to previously ig- by most multinational pharmaceutical
geted tropical diseases that affect 15% nored diseases. companies. However, emerging phar-
of the world. This contributes to what By developing new, affordable medi- PDFHXWLFDOFRPSDQLHVDUHVWLOOIRUSURÀW
WKH *OREDO )RUXP IRU +HDOWK 5HVHDUFK cines for diseases largely ignored by mul- Peter Singer, director of the McLaugh-
calls the 10/90 gap, the uncomfortable tinational pharmaceutical corporations, OLQ5RWPDQ&HQWUHIRU*OREDO+HDOWKDW
observation that only 10% of medical these companies offer hope for change the University of Toronto, explains in a
research addresses 90% of the world’s to millions of people. Their business paper published in Nature Biotech last
problems. PRGHOLVVWUXFWXUHGVRWKDWSURÀWVIURP \HDU´7KHVHORFDOFRPSDQLHVEDVHWKHLU
However, this global health disparity cheap, generic drugs are reinvested in business model on affordable innovation
is due to change with the advent of phar- QRYHOUHVHDUFK)RUWKLVUHDVRQPDQ\RI WRPHHWORFDOQHHGV·µ
maceutical companies based in emerging these companies are described as tran- Singer, who describes his research in-
markets. These companies have the sci- VLWLRQLQJ IURP ´LPLWDWRUVµ WR ´LQQRYD- WHUHVWVDV´KRZWHFKQRORJLHVPRYHIURP
HQWLÀFDQGPDUNHWLQJFDSDFLW\WRDGGUHVV WRUVµ ODEWRYLOODJHµHPSKDVL]HG´2QHWKLQJ
the health needs of local populations; The remarkable promise of these is clear: when you think of biotechnol-
some even say they have the potential companies is their ability to meet a mar- RJ\ LW·V QR ORQJHU MXVW 6DQ )UDQFLVFR
to become major global competitors. In ket niche. Part of why multinational Boston, London and Tokyo. It’s also Hy-
the same study from Health Affairs, of pharmaceutical corporations’ drugs are derabad, Shanghai, and Sao Paulo. While
SURÀOHG ELRWHFKQRORJ\ FRPSDQLHV prohibitively expensive is the compa- in the emerging economies it is still in
KRPHJURZQLQ%UD]LO&KLQD,QGLDDQG nies’ marketing costs; these companies its adolescence, biotechnology is no lon-
South Africa, 123 new products have are criticized for spending as much on ger the sole hegemony of the rich world.
been produced, 69 of which are already marketing as on research. Since com- Biotechnology innovation is becoming >>
Countries in GREEN, designated

as “permanent” developing
nations, are witnessing a boom
in pharmaceutical markets.
search—is the abrasive system of inter-
national patent law that often inhibits
their success. By excessively patenting
resources, multinational pharmaceutical
companies prevent new companies from
creating new products. The World Trade
Organization’s agreement on Trade-Re-
lated Aspects of Intellectual Property
Rights (TRIPs) attempts to remedy this
GLVSDULW\ E\ FUHDWLQJ D ÉDODQFHµ EH-
tween innovation and social progress.
However, critics argue that TRIPs hasn’t
actually improved global health. Joseph
Stiglitz, 2001 Nobel laureate in econom-
ics, wrote an article in the British Medical
-RXUQDO FDOOHG ´6FURRJH DQG LQWHOOHFWXDO
SURSHUW\ULJKWVµLQZKLFKKHDUJXHGWKDW
intellectual property rights reduce access
to generic medicines. This has direct rel-
ABOVE An x-ray from a patient with advanced bilateral pulmonary tuberculosis; the disease affects 13.7 million people world- evance to pharmaceutical companies in
emerging markets because it makes it
> JOREDOL]HGµ HPHUJLQJPDUNHWVRIWHQODFNVXIÀFLHQWO\ XQOLNHO\WKHVHÀUPVFDQFRQWLQXHWRFUH-
´:KDW \RX FDOO D QHJOHFWHG GLVHDVH trained personnel. Without specialized ate the new generic drugs that help drive
,FDOODEXVLQHVVRSSRUWXQLW\µVD\V)HU- WUDLQLQJ SURJUDPV DQG ´DFDGHPLF PRG- WKHLU SURÀWV 3DUDGR[LFDOO\ SDWHQW ODZ
nando Kreutz, president of Brazilian HOVµ RI XQLYHUVLW\ SUHSDUDWLRQ PDQ\ which intends to encourage innovation
ELRWHFKQRORJ\FRPSDQ\).%LRWHFQROR- ÀUPVDUHQRWDGHTXDWHO\VWDIIHGZLWKDS- and growth, inhibits development. MIT
gia. One company, for instance, hopes to propriately trained scientists. OLQJXLVW 1RDP &KRPVN\ ZULWHV ´7KH
develop a $25 tuberculosis test to replace Promising steps have been taken to World Trade Organization regime insists
the existing $150 version. combat these multifaceted problems. Dr. on product patents…it’s intended to cut
Because these companies meet a mar- 6LQJHUSURSRVHVD´*OREDO+HDOWK$FFHO- back innovation, growth, and develop-
ket need with products that are both HUDWRUµWRSURYLGHD VWUXFWXUHIRU FRP- ment and to maintain extremely high
effective and affordable, many predict munication that would improve links be- SURÀWVµ
these companies will become global tween the international community and Others suggest that it is too early
FRPSHWLWRUV $FFRUGLQJ WR 6DUDK )UHZ pharmaceutical companies, including to determine the impact of TRIPS on
RI WKH 0F/DXJKOLQ5RWPDQ &HQWUH public-private partnerships and business emerging pharmaceutical industries.
´&RXQWULHV VXFK DV &KLQD DQG ,QGLD support services. The plan even includes According to one paper published by
are emerging as major global players in DQDQQXDOSUL]HWKH´*OREDO+HDOWK(Q- &RQFHSW )RXQGDWLRQ DQ RUJDQL]DWLRQ
health biotechnology, with the expertise WHU3UL]HµWRHQFRXUDJHUHVHDUFKZLWKDQ WKDW´VXSSRUWVWKHLQWURGXFWLRQDQGSUR-
and resources to produce new drugs and impact on global health. motion of essential healthcare products
vaccines at a fraction of the costs of the DURXQG WKH ZRUOG IRFXVLQJ VSHFLÀFDOO\
ELJSKDUPDFHXWLFDOFRPSDQLHVµ on under-served markets in low-income
FRXQWULHVµ VRPH GHYHORSLQJ ELRWHFK
Despite these companies’ promise What you call a neglected
of bringing new opportunities to the companies may choose to focus their ef-
world’s sickest, their progress is impeded disease, I call a business forts globally rather than on local health
by stringent patent laws and structural needs, a shift precipitated by the struc-
opportunity.
economic problems. Partly this is domes- ture of patent law.
WLFLQHIÀFLHQF\LWFDQWDNHWKH%UD]LOLDQ Fernando Kreutz
It is refreshing to see companies in
SDWHQWRIÀFHRYHUVHYHQ\HDUVWRSURFHVV FK Biotecnologia (Brazil) developing markets identify a potentially
patent applications for drug candidates. OXFUDWLYHPDUNHWWKDWEHQHÀWVWKHZRUOG·V
5HJXODWRUV LQ WKH SDWHQW RIÀFH RIWHQ VLFNHVWSHRSOH+RSHIXOO\SURÀWPDUJLQV
lack practical experience, which com- Perhaps more disconcerting than will continue to enable these companies
pounds the problem. Equally pernicious, these companies’ internal problems— to work on their behalf.
however, is the lack of a high number which most analysts call relatively minor
RI WUDLQHG VFLHQWLVWV %LRWHFK ÀUPV LQ JLYHQWKHSURPLVHRI WKHLUVFLHQWLÀFUH- Mitchell Murdock is a freshman in Morse College.
Methodology of
WHO Healthcare Rankings
BY GIANNA FOTE
An analysis and commentary about the WHO’s Healthcare Systems rankings.
I n 2000, the World Health Report’s

(WHR) Health System rankings un-
settled the international health com-
health care systems to policymakers and
relevant organizations so they can make
appropriate decisions about policy and
PRUWDOLW\ 7KH :+5 VWDWHV WKDW ´KRZ
the system responds to health needs…
VKRZVXSLQKHDOWKRXWFRPHVµEXWWKHUH
PXQLW\ ZLWK FRQIXVLRQ DQG FRQÁLFW funding. The explanations for such un- is little evidence that mortality rates
)RUW\ SHUFHQW RI WKH ,WDOLDQ SRSXODWLRQ expected results can only be found in correspond with health care quality. In
thought there was so much wrong with an examination of the criteria that were fact, there is copious evidence that so-
their health care system that it should be used to determine healthcare systems cial, political, and economic factors, not
completely redone. However, the WHR WKDW UDQNHG KLJKHVW LQ ´SHUIRUPDQFHµ medical advances, are responsible for
had ranked Italy second in the world. The WHR used three main indicators: changes in mortality rates. The WHR at-
The report ranked the United States not effectiveness, fairness, and responsive- tributes the drastic declines in mortality
ÀUVWQRWHYHQWRSÀYHEXWWKLUW\VHYHQWK ness. rates that occurred in the 20th century
for overall health system performance. ´(IIHFWLYHQHVVµ ZDV VXSSRVHG WR entirely to medical advances, but many
In the US and around the world, the fu- measure the health care system’s medi- of these changes occurred long before
ture of healthcare policy was on the line. cal competence. However, the WHR’s medical techniques were effective. Medi-
Moreover, the message policymakers PHWKRG RI PHDVXULQJ ´HIIHFWLYHQHVVµ WHUUDQHDQQDWLRQVOLNH6SDLQDQG)UDQFH
could take from these results, assuming ZDV EDVHG RQ IDXOW\ DVVXPSWLRQV ´(I- ranked disproportionately highly in this
the results were reliable enough to take IHFWLYHQHVVµ ZDV PHDVXUHG LQ UHVSHFW category because their life expectancies
any message from them at all, was mired to the rate of reduction of a nation’s are so high, despite extremely low satis-
in controversy. mortality and morbidity rates, assum- faction from patients. The WHR states,
The purpose of the WHR is to pro- ing that a nation’s health care system is ´,I 6ZHGHQ HQMR\V EHWWHU KHDOWK WKDQ
vide information about health care and primarily responsible for reductions in Uganda—life expectancy is almost ex- >>
> actly twice as long—it is in large part be-
cause it spends exactly 35 times as much
SHUFDSLWDLQLWVKHDOWKV\VWHPVµLQGLFDW-
ing that the WHR assumes that medical
resources correspond directly with bet-
ter health and life expectancy. However,
in addition to medical resources, a na-
tion’s birth rate, cultural factors, sanita-
tion, eating habits, and general standard
of living contribute to its mortality rate
as well. The true causes are rooted in
economic prosperity and overall increase
in quality of life, outside of any medical
lifesaving techniques.
Even if one accepts the WHR’s as-
sumption that death rate is an accurate
indicator of medical effectiveness, the
statistical methods used to describe a na-
tion’s mortality are controversial and sel-
dom used outside the WHR. The WHR
used the Disability Adjusted Life Expec-
tancy (DALE) rate of a country to de-
termine the mortality rate. The DALE
ranks disabilities, and has often been ac-
cused of undervaluing the lives of dis-
abled people. The WHR assumed that
mortality rates correspond with health
care quality, and based their mortality
statistics on a controversial model.
7KHVHFRQGLQGLFDWRUZDVÍDLUQHVVµ
)DLUQHVVUHIHUVWRWKHHTXDOLW\RI DFFHVV
to health care resources. The measure
of how fair a system was based on the
controversial assumption that the pro-
portion of money a person spends on
their health care to non-food expen-
ditures should be equal for all citizens ABOVE Critics of the World Health Rankings argue that other social and economic factors aside from medical resources greatly
of a nation. This system assumes that influence mortality rates. 1.1 billion people lack proper access to water, and 2.6 billion lack sufficient sanitation. The 2006 United
the rich will spend more and make up Nations Human Development Report estimates that 1.8 million children die annually as a result of diarrhea due to poor water.
for the poor spending less. In this case,
the poor would spend very little because The third indicator the WHR used given in the report and the fear is that
they can’t afford medical expenses, and ZDV ÚHVSRQVLYHQHVVµ RU D KHDOWK FDUH they may have had a disproportional in-
the rich spend exorbitant amounts of system’s ability to protect a person’s dig- ÁXHQFHRQWKHUDQNLQJV7KHNH\LQIRU-
money on luxury procedures. Since the nity, providing prompt care and a choice mants were pulled from only 35 out of
proportions would be equal, this system of provider. This indicator deals most the 191 nations, and over half of them
ZRXOG EH GHHPHG ÍDLUµ E\ WKH :+5 directly with customer satisfaction, and were WHO staff.
Where and on what sort of health care it seems safe to assume that the best in- 7KH :+2·V ´SHUIRUPDQFHµ UDQNLQJ
one’s money is spent is an essential is- dication of how well patients are treated is the sum of three weighted indicators,
sue that is not addressed in this ranking. by the system would come from patients. the effectiveness of the system, the de-
Also, this system does not differentiate However, the WHO calculated their JUHH RI ÀQDQFLDO IDLUQHVV DQG WKH UH-
between racial, ethnic, gender, age, or UDQNLQJV E\ KDQG SLFNLQJ ŃH\ LQIRU- sponsiveness of the system to the user.
social status divisions, so while the over- PDQWVµZKRGHWHUPLQHGWKHYDOXHVDQG These indicators are unconventional and
DOO ÍDLUQHVVµ RI D SRSXODWLRQ FRXOG EH weights of the indicators that made up vague to begin with, and weighing and
ranked highly, a small subgroup could be ÚHVSRQVLYHQHVVµ /LWWOH LQIRUPDWLRQ RQ synthesizing them into a single measure-
grievously mistreated. WKHLGHQWLW\RI WKHVHŃH\LQIRUPDQWVµLV ment further obfuscates the meaning of
ABOVE G-7 countries, shown here in dark orange, heavily fund and influence the World Health Organization.
the results. Ranking healthcare sys- the limitations of their rankings, and ZLOOEHQHÀWWKHULFKDQGVHYHUHO\UHVWULFW
tems on only one all-encompassing mea- inform the reader of the fact that these the poor’s access to health care.
VXUHPHQW JURVVO\ RYHUVLPSOLÀHV WKHLU values and assumptions are not univer- In the decade since the WHR’s pub-
true complexities. sally held. The WHR could guide policy- lication, it has both helped and harmed
In addition to the issues with the in- making in nations where promotion of a WKH LQWHUQDWLRQDO FRPPXQLW\ &LWLQJ WKH
dicators used, the WHR’s data is incom- private provider system could be disas- rankings without careful analysis of how
plete. This forced the WHO to make they were developed has proven ex-
estimates for much of their data. Usu- tremely misleading, but several big pic-
ally, when estimates are made, old data While there may not be a ture ideas from the report have contrib-
is taken into account, and the statistics uted to health care in a positive way. The
are thoroughly peer-reviewed by statisti- ‘perfect’ way to rank health rankings themselves have generated in-
cians. Since the indicators and data used care systems, the WHO terest in comparing health care systems,
here is either seldom used or new alto- and the debate over the credibility of the
gether, there was no old data to compare. needs to at least explicitly WHR’s statistics has stimulated new re-
2I WKHDUWLFOHVWKDWZHUHFLWHGDIÀUP- acknowledge the limita- search and analysis projects to clarify and
ing the methodologies in the report, 26 LPSURYHWKHGDWD)RUH[DPSOHWKHLVVXH
were non-peer reviewed internal WHO tions of their rankings, and of mortality rates not corresponding to
documents by the authors of the WHR. inform the reader of the health care quality has been addressed by
Since the nations ranked in this report beginning to collect data on deaths from
are from all different cultural and eco- fact that these values and causes that are preventable with timely
nomic histories and situations, it should assumptions are not univer- and effective medical care. The WHR
be necessary to examine improvement has created a discussion of the relation-
RYHU WLPH WR DVVHVV WKH ´SHUIRUPDQFHµ sally held. ship between the government and health
of a health care system. However, the care, and the concept that the govern-
:+5 VWDWHV WKDW ´GHWHUPLQLQJ KRZ ment is responsible not only for provid-
to evaluate progress rather than only a WURXV%\UDQNLQJ&RORPELD·VSULYDWHLQ- ing resources, but managing those re-
health system’s current performance is surance system (modeled after the U.S.) sources and ensuring results. The WHR
one of many challenges for future ef- highly, the WHR suggests that other Lat- continues to inspire discussion about
IRUWµ DQG LW LV QRW UHDOO\ WDNHQ LQWR DF- LQ$PHULFDQQDWLRQVVKRXOGWDNH&RORP- how to improve health care in the U.S.
count in the rankings. bia as an example. However, in nations and abroad, despite the limitations of
While there may not be a ‘perfect’ way where there is a large gap between the the report itself.
to rank health care systems, the WHO upper and lower classes and no robust
needs to at least explicitly acknowledge middle class, a private health care system Gianna Fote is a freshman in Pierson College.
RIGHT Polio, which had
once been eradicated from
Western Africa, has recently
returned. Here, a young girl
receives an oral polio vaccine
by a few, simple drops to the
mouth. Julian Harneis/Flickr.
Essential Medicines The Crisis in Developing Countries BY ANNE BOZIK
Developing nations struggle to provide its citizens with the World Health Organization’s “Model List” of
essential medicines like ibuprofen and penicillin, especially in light of the recent economic crisis.
O n June 29, 1999, four Guatemalans

learned that they had won the lot-
tery. Their prize: anti-retroviral therapy
cause no medication was available.
Unfortunately, over a decade later,
this lack of essential medicines persists,
tion, and inadequate supplies result in a
lower quality of life and often death for
many patients in impoverished nations.
for AIDS. The other eighty-six patients both in Guatemala and elsewhere in the Developing nations face the greatest
were not so lucky that day—they did not GHYHORSLQJ ZRUOG )URP LEXSURIHQ WR GLIÀFXOW\ LQ REWDLQLQJ WKHVH PHGLFLQHV
receive any treatment from the Luis An- penicillin, essential medicines address low availability and high prices prevent
JHO*DUFLD&OLQLFLQ6DQ-XDQVLPSO\EH- the most pressing needs of a popula- the world’s poorest and most in need
from obtaining adequate health care. Al- tion of essential medicines are even ÀQDQFLQJ VWUDWHJLHV WR VLJQLÀFDQWO\ GH-
though both public and private groups more pronounced in the availability of crease the price of essential medicines in
KDYH LQYHVWHG VLJQLÀFDQW UHVRXUFHV WR- treatments for chronic diseases than developing nations. Alternatively, local
ward the alleviation of these inequalities, for acute diseases. In Africa, countries production of these drugs is seen as a
much work remains to be done. have, on average, nine times the amount potential path toward achieving adequate
Essential medicines vary in nature. of resources for acute diseases than for availability.
They can include vaccines, treatments chronic diseases, yet chronic disease ac- This latter system has already encoun-
for chronic and acute diseases, and items counts for 25% of the mortality in the WHUHGVHYHUDOGLIÀFXOWLHVLQUHJLRQVZKHUH
for emergency preparedness. Popula- FRQWLQHQW )DLOXUH WR WUHDW WKHVH FRQGL- it has been implemented. In Africa, local
tion health needs are not homogenous, WLRQV LQWURGXFHV VLJQLÀFDQW ORQJWHUP drug producers face challenges in receiv-
however, and thus each nation’s gov- economic strains on individual house- LQJ RIÀFLDO UHFRJQLWLRQ IURP RUJDQL]D-
ernment ultimately must be responsible holds and on the economy at large. By tions such as the WHO and the United
for the construction of its own list of impairing the ability of individuals to 6WDWHV )RRG DQG 'UXJ $GPLQLVWUDWLRQ
essential medicines. The World Health sustain jobs for extended periods of )'$:LWKRXWWKLVUHFRJQLWLRQWKHVH
Organization (WHO) assists nations in time, chronic disease shatters the eco- companies are cut off from major sourc-
the production of their lists by compil- nomic stability of individual households, HV RI ÀQDQFLQJ UHFHLYHG WKURXJK WKH
LQJD´0RGHO/LVWµRI PHGLFDWLRQV7KH which cumulatively serves to weaken the :+2 DQG )'$ DVVRFLDWHG JURXSV OLNH
power behind the WHO’s list lies in entire economy of developing nations. WKH*OREDO)XQG)XUWKHUPRUHWKHSUR-
three major areas: the comprehensive- )XUWKHUPRUHWKHULVHRI PXOWLGUXJUH- FHVVHVWRFRQÀUPWKHDGHTXDF\RI ORFDO
ness, the inclusion of only cost-effective sistant strains of acute diseases, such drug products and active ingredient sup-
treatments, and the up-to-date content. DV 0'57XEHUFXORVLV KDV VLJQLÀFDQWO\ plies are often too expensive for these
This list provides important guidance, decreased the impact of the more avail- local groups. These roadblocks prevent
oversight, and standardization for many able acute treatments, thereby rendering ORFDO GUXJ SURGXFWLRQ IURP EHLQJ D À-
countries in terms of which medicines the difference in treatment availability nancially superior alternative to produc-
should be prioritized. for acute and chronic drugs even more tion elsewhere.
Even with a list of essential medi- strenuous to developing nations. Increased research and development
cines, developing nations are consistent- DQG D ´SRROHG UHVRXUFHVµ DSSURDFK WR
ly unable to provide for the needs of its drug acquisition have also been proposed
patients. High prices and low availability In Africa, countries have, as possible solutions to this essential
in both the public and private sectors medicines crisis. Encouraging research
on average, nine times
combine to make these drugs largely and development on diseases primar-
inaccessible to the lowest income popu- the amount of resources LO\ DIÁLFWLQJ WKHVH ORZLQFRPH QDWLRQV
lations. The WHO calculated shocking could potentially result in more cost-ef-
for acute diseases than
reference prices that showed the cost IHFWLYH GLVHDVH WUHDWPHQW 7KH ´SRROHG
that individual nations must pay relative for chronic diseases, yet UHVRXUFHVµ DSSURDFK SURSRVHV WKDW QD-
to this standardized value. Public health tions collaborate to purchase drugs in
chronic disease accounts
facilities in poor nations face prices at cases where they otherwise might not
around 270% of the international refer- for 25% of the mortality in qualify for discounts of purchasing these
ence price and on average have access to drugs en masse. In fact, members of
only 42% of essential medicines. While
the continent. WKH2UJDQL]DWLRQ RI (DVWHUQ&DULEEHDQ
the private health sector has increased States, including nine island nations,
access to essential medicines by 64%, The global economic crisis resulted have already adopted this procedure with
private providers’ 630% markup of the in funding cuts to basic healthcare. Yet much success, seeing prices reduced by
international reference price prevents from 2008 to 2009, pharmaceutical as much as 44%. This offers much hope
this increased availability from being of prices rose 5% in high-income countries for its adoption by other groups of na-
DQ\ EHQHÀW WR WKH SRRU 5DWKHU KLJK and 11% in low-income countries. In the tions throughout the world.
costs force developing nations to devote face of such bleak circumstances, how- With both individual health and gen-
most of their resources simply to the at- ever, both public and private organiza- eral economic viability at stake, immedi-
tainment of medicine, money which in tions are striving to reverse the growing ate attention must be devoted to pro-
developed nations is employed toward disparities in access to essential medi- viding adequate essential medicines to
better technology and more advanced cines between rich and poor nations. developing nations. We can no longer
treatment options. This further aggra- Several economic strategies are being allow situations such as the Guatemalan
vates the vicious cycle of high prices and employed to this end. Groups such as ÓRWWHU\µIRU$,'6PHGLFDWLRQWRSHUVLVW
low availability in the developing world. WKH*OREDO)XQGWR)LJKW$,'67%DQG
These inadequacies in the distribu- Malaria are working to create alternative Anna Bozik is a sophomore in Trumbull College.
International
Organ TransplaBY RONIT ABRAMSON
Policymakers around the world struggle to hem in the black market of organ donation.
T he black market for organs has long

been a last-resort option for patients
in dire need of organ transplants, but
curring in upscale hospitals throughout
the world, from Tel Aviv to Los Angeles.
In many cases, the hospitals are naively
70,000 kidneys transplanted in the world
each year, the World Health Organiza-
tion (WHO) estimates that approximate-
patients are increasingly looking abroad complicit in the illegal organ market. A ly 20% are from the black market. The
for transplants and are willing to pay top third-party organ broker arranges a pre- WHO further asserts that international
dollar for the new organ that could save matched donor pair to arrive at the hos- WUDIÀFNLQJ RI NLGQH\V WKH PRVW ZLGHO\
their life. Sometimes the donor may even pital with the donor providing the organ WUDIÀFNHGRUJDQDORQJZLWKOLYHUVH\HV
travel to the recipient’s home for the ´DOWUXLVWLFDOO\µ WR KLV ÍDPLO\ IULHQGµ RU VNLQDQGEORRGLVÁRXULVKLQJ
transaction. ´FORVHQHLJKERUµ$VORQJDVWKHKRVSLWDO
7KHH[FKDQJHRI RUJDQVIRUÀQDQFLDO doesn’t look too closely and each of the
compensation is illegal in every country cast of characters plays his or her part to
in the world besides Iran. Nevertheless, the evaluating pre-transplant psycholo-
the international black market for organs gist, the scheme is usually successful.
is booming, fueled by a growing demand The rise in illegal organ donation and
by patients all over the world, especially WUDIÀFNLQJ RFFXUUHG ODUJHO\ LQ UHVSRQVH
those struggling through harsh econom- to the growing worldwide shortage of
ic times. Although it is nearly impossible organs. As of October 2010, there were
to collect reliable data on organ traf- 109,186 people on the United States’
ÀFNLQJWKHJRLQJSULFHIRUDWUDQVSODQW waitlist for organs, but only 8,477 peo-
through a black-market broker appears ple donated an organ between January To combat the tremendous shortage
to range from $100,000 to $200,000, and July 2010, according the United of donated organs, many countries have
depending on the organ and destination Network for Organ Sharing (UNOS), a DGRSWHG DQ ´RSWRXWµ V\VWHP RI RUJDQ
country. Of those princely sums, the do- SULYDWH QRQSURÀW RUJDQL]DWLRQ WKDW LV transplantation, where the default is to
nors may receive as little as $1,000 for a under contract by the American govern- assume consent for donation. The alter-
NLGQH\ZLWKWKHWUDIÀFNHUVDQGWKHLUDF- ment to manage the nation’s organ trans- QDWLYHWRRSWRXWLVWKH´RSWLQµV\VWHP
complices pocketing the lion’s share. plant system. The number of people on practiced in the US, where the default is
Transplant tourism is just one as- the waitlist has nearly tripled in the last no donation. However, even a shift from
pect of the international organ trade. decade, and despite media campaigns RSWLQWRRSWRXWGRHVQRWDOZD\VVLJQLÀ-
Not all black market deals are done in urging people to sign up as donors, the cantly increase the availability of organs.
shady hospital basements in Third World number of registered donors has re- )RUH[DPSOHZKHQ%UD]LOFKDQJHGIURP
countries, although the most active or- mained steady between 5,000 and 8,000 opt-in to opt-out, there was an initial dip
gan-exporting markets include Paki- for the past two decades. Waitlists are in organ donations, since the govern-
VWDQ ,QGLD &KLQD 7XUNH\ DQG %UD]LO RIWHQNQRZQDV´'HDWK·V:DLWLQJ/LVWVµ mental policy change stirred controversy
Research by Nancy Scherper-Hughes, since patients who need a heart, lung, or because it was interpreted as an invasion
DQDQWKURSRORJLVWDW8QLYHUVLW\RI &DOL- liver usually cannot wait long and often into personal privacy.
fornia Berkeley and an expert in inter- die before a donor is found. More than Although opt-out countries gener-
QDWLRQDO RUJDQ WUDIÀFNLQJ DQG VWXGLHV 100 people die every week waiting for an ally have higher rates of donation, high
by the World Health Organization show organ. organ procurement rates cannot be at-
WZR VXUSULVLQJ ÀQGLQJV $PHULFDQV DUH It is therefore not surprising that the WULEXWHGWRDQ\VSHFLÀFOHJDOFRQFHSWLRQ
both buyers and sellers of organs inter- RUJDQ WUDGH KDV JURZQ VR VLJQLÀFDQWO\ of consent or method of managing the
nationally, and illegal transplants are oc- in recent years. Of the approximately donation process. Spain (opt-out) and
antation
Austria (opt-out) both have high rates of
donation, while Germany (opt-in) and
Sweden (opt-out) both have low rates.
The policies in other countries serve
as a salient reminder of the value of
individual self-determination. In many
FDVHV LW LV PRUH HIÀFLHQWWR RUFKHVWUDWH
massive public education and awareness
campaigns about organ donation instead
RI ÀJKWLQJ WKH OHJDO EDWWOHV DVVRFLDWHG
with a policy change.
International policy varies from coun-
try to country, but ultimately the shortage
is universal, and hundreds of thousands
of people around the world are waiting
for an organ. Thus, there is a need for
changing cultural norms regarding organ
donations: By simply reminding people
that they have the individual power to
save a life by signing up as an organ do-
nor, we may save many lives while cur-
tailing the activity on the black market
for organs.
Ronit Abramson is a sophomore in Ezra Stiles Col-

lege.
RIGHT The annual UAB/

Alabama Organ Center
Celebration of Life
Picnic links together organ
donors and recipients.
MGShelton/Flickr
LEFT You have the power

to Donate Life. Be an
organ, eye and tissue
donor. Register today at
donatelife.net. Logo Used
with permission.
Medical
Malpractice
How Medical Lawsuits are Won Around the World BY CATHERINE CHEN
An analysis of the relationship between malpractice law and medicine in the US, Canada, and Germany.
T he intersection between the practice

of law and the practice of medicine
can often be frustrating, complex, and
ties come into the picture when theory
is put into practice. Although these is-
sues are found in countries all across the
WKH OHJDO VWUXFWXUH LQ &DQDGD UHVXOW LQ
unfairly low reimbursements to patients.
,Q &DQDGD LW LV D UHTXLUHPHQW WKDW
fraught with seemingly insurmountable globe—albeit in different social and cul- physicians obtain medical liability insur-
tensions. One of the most obvious situ- tural contexts—there are both profound DQFH DYDLODEOH WKURXJK WKH &DQDGLDQ
ations in which legal and medical pro- differences and similarities in their mani- 0HGLFDO3URWHFWLYH$VVRFLDWLRQ&03$
fessionals combine is that of medical festations and consequences. 7KH&03$WKXVQRWRQO\SD\VWKHPHGL-
malpractice. The theory behind medical &DQDGD LV RQH FRXQWU\ LQ ZKLFK WKH cal malpractice settlements but also de-
PDOSUDFWLFH VWLSXODWHV WKDW ÀQDQFLDO UH- debate is particular visible. Often used as fends the physicians during the lawsuit.
percussions for causing harm to patients a standard of comparison for the United The organization has frequently been
through clinical mistakes will be a pow- 6WDWHV &DQDGD UHFHLYHV DERXW DV PXFK criticized for being too aggressive in its
erful source of accountability. In other criticism for its medical malpractice sys- defense, however, often rejecting fair,
words, if physicians are required to pay tem as the United States does. However, reasonable settlements, drawing out the
for their errors and negligence, they will the reasons for such criticism are quite process in an attempt to discourage fur-
work harder to prevent errors from hap- different, though. While it is common ther lawsuits.
pening and the patients will get better to hear the assertion that medical mal- There are legal barriers to claiming
treatment. As is the case with most as- practice lawsuits have unduly high costs PDOSUDFWLFH VHWWOHPHQWV LQ &DQDGD DV
SHFWVRI OLIHKRZHYHULQÀQLWHFRPSOH[L- in the United States, many believe that ZHOO )RU H[DPSOH &DQDGD·V JHQHUDO OH-
Though such a structure might suggest
otherwise, India does not see exorbitant
numbers of settlements regarding medi-
cal malpractice according to the 2005
study conducted by Anderson and Wa-
ters.
While it is important to look at mal-
practice law in terms of its large-scale
public health and economic consequenc-
es, it is extremely dangerous to ignore its
implications on an individual-level. The
threat of legal repercussions has the
potential to force physicians to refocus
their decision-making efforts from the
needs of the patient to their own. This
results in the widespread practice of de-
fensive medicine—actions that will likely
QRWEHQHÀWWKHSDWLHQWEXWDUHVWLOOLPSOH-
© CHAD CROWE, USED WITH PERMISSION
mented solely because they will promote
the impression that the physician has
gal system requires the losing party of a tively little incentive to engage in a suit. been attentive and thorough from a legal
court case to pay two-thirds of the other )RUWKRVHZKRGRVHHNVHWWOHPHQWV point of view. This undercuts the theory
VLGH·V OHJDO IHHV 7KLV SUHVHQWV D VLJQLÀ- choose to do so outside of the formal behind medical malpractice. Patients are
cant risk, especially for the populations court systems, with medical associations not necessarily getting better services;
RI &DQDGD·VORZHUHFRQRPLFVWUDWD7KH and insurer consultants acting as media- they are simply getting more services.
6XSUHPH &RXUW RI &DQDGD LQ WKH FDVH tors according to a study conducted by The threat of litigation has made a large
of Koukounakis v. Stainrod (1995), also Ziegler and Ehl 2009. Settlements tend impact on certain clinical decisions: one
established a punitive damage award cap to be relatively low. of the major results is a clear increase in
RI &DQDGLDQ GROODUV ZLWK RQO\ The implications of Germany’s medi- WKH GHFLVLRQ WR XVH WHVWV OLNH 05,&7
extremely extraordinary circumstances cal malpractice systems are similar to VFDQV UDGLRLVRWRSHV DQG ÁXRURVFRS\
as exceptions. Whiten v. Pilot (2002) also WKRVHRI &DQDGD·V,QDGGLWLRQWRDORVV DVIRXQGE\DVWXG\E\)HQQ*UD\
limits the types of cases in which puni- in the accountability factor, however, and Rickman. What is debatable is to
tive damages may be awarded. the unwillingness of patients to sue for what extent those increases are helpful
In the end, these procedures allow for malpractice claims means that social se- and to what extent they are useless and
a safety net for physicians. They are also curity is shouldering much of a burden even harmful.
quite effective in discouraging patients of medical malpractice. This creates eco- What, then, is the solution for medical
IURPÀOLQJODZVXLWV$FFRUGLQJWRD QRPLFLQHIÀFLHQFLHVWKDWFDQEHDVGDP- malpractice laws? Is it possible to protect
study conducted by Anderson and Wa- aging to a country’s economy as exces- both the patients and the practitioners?
ters found that the United States has sive malpractice lawsuits. How can we ensure that those with few-
PRUHVXLWVÀOHGHDFK\HDUSHUSHU- The situation in India is quite differ- HUÀQDQFLDOUHVRXUFHVDUHQRWEHLQJPDU-
VRQFRPSDUHGWR&DQDGD2QRQHKDQG HQW ,Q WKH &RQVXPHU 3URWHFWLRQ ginalized in this system? The junction
the abuses of the system are prevented, Act was passed, and in 1995, the court between law and medicine remains in-
UHVXOWLQJLQHFRQRPLFHIÀFLHQF\2QWKH ruled in Indian Medical Association v. HYLWDEO\GLIÀFXOWDSODFHRI EXUHDXFUDWLF
other hand, the protection that medical V.P. Shantha, A.I.R. that the patients UHGWDSHDQGFRQÁLFWLQJLQWHUHVWVLQWHQVL-
malpractice laws offer patients becomes would be counted as consumers under ÀHGDVWKHVWDNHVRI OLIHDQGGHDWKORRP
undermined. this law. What this means practically is large in the background. Each country’s
)RU *HUPDQ\ WKH QXPEHU RI PDO- that patients can recover damages more V\VWHPIHDWXUHVLWVRZQÁDZVDVZHOODV
practice lawsuits also under-represent quickly than if they had to go through its own qualities, but the relationship
the actual number of malpractice cases traditional means of tort law. Tort laws, EHWZHHQWKRVHÁDZVDQGTXDOLWLHVVHHPV
experienced in the country. The main civil violations toward other individuals, to be a frustrating game of give-and-
reason is the extensive social security sys- and criminal laws are still available ven- take. So what is the correct balance that
tem offered by the German government. ues through which medical malpractice should be achieved? The answers are as
Because of this safety net, patients suffer can be brought to court, but the added GLIÀFXOWDVWKH\DUHLPSRUWDQW
very few out-of-pocket losses related to option of consumer laws facilitates the
medical malpractice and have compara- pursuit of settlements in the courts. Catherine Chen is a sophomore in Pierson College.
Defining Parenthood Assisted Reproduction in France BY CONNIE CHO
A ccording to the latest World Health

2UJDQL]DWLRQUDQNLQJ)UDQFHKROGV
the title for the best healthcare system
ability to conceive a child would there-
fore not be a sign of a medical condi-
tion, so homosexual couples could not
lished registered domestic partnerships
in 1999 and banned LGBT-targeted
hate speech in 1995. But these restric-
in the world. Sécurité Sociale, WKH )UHQFK be deemed in need of a therapeutic WLRQV RQ $57 DFFHVV FOHDUO\ UHÁHFW D
national health insurance system, even treatment. In addition, gay male cou- more conservative stance on the value
FRPSUHKHQVLYHO\ÀQDQFHVDVVLVWHGUHSUR- ples using ARTs would require surro- of the traditional family structure.
ductive technologies (ARTs). To date, gate mothers. However, surrogacy is )UDQFH·V KHWHURVH[XDOLW\ UHTXLUH-
more than 200,000 children have been LOOHJDOLQ)UDQFHDVSDUWRI DV\VWHPWKDW ment has remained even after reviews
ERUQ IURP )UHQFK $57 VHUYLFHV DQG is averse to bodily commoditization in of its bioethics laws in 2004 and 2009.
)UDQFHKDVWKHPRVWIHUWLOLW\FOLQLFVLQWKH general. This decision was supported by popular
world. However, government legislation RSLQLRQH[SUHVVHGWRWKH)UHQFKJHQHUDO
tightly controls access to ARTs—only assembly as well as a 2005 L’Encephale
heterosexual, young, medically infertile Government legislation study that found a consensus in physi-
couples that have been married or have cian opinion that homosexual parentage
tightly controls access to might result in children with develop-
cohabitated for at least two years are eli-
gible. ARTs—only heterosexual, mental problems. However, there have
7KLV QDUURZO\ GHÀQHG DFFHVV WR been some voices of dissent from the
$57V FDPH DERXW DV SDUW RI D ÁXUU\ young, medically infertile Socialist Party, notably in the 2007 pres-
of bioethics legislation passed in 1994. couples that have been idential race between Segolene Royal
Beyond simply direct legislation, how- and Nicholas Sarkozy. Royal supported
ever, Dr. Melanie Latham attributes the married or have cohabi- gay marriage and full rights to adoption
root of restrictive ART regulation to DQG$57VVWDWLQJVLPSO\WKDW´WKHIXQ-
tated for at least two years
WKH)UHQFKFLYLOODZFRGHLQJHQHUDO,Q damental question is that of discrimi-
Regulating Reproduction: A Century of Con- are eligible. QDWLRQµ LQ D LQWHUYLHZ ZLWK 7HWX
ÁLFW%HWZHHQ%ULWDLQDQG)UDQFH, Dr. Latham Magazine.
ZULWHV WKDW WKH )UHQFK JRYHUQPHQW LV The heterosexuality requirement on
much more reliant on preemptive, all- the basis of projet parental is an example
inclusive legislation than the govern- 7KH )UHQFK SULPDULO\ MXVWLI\ WKLV of how an ART policy that manages
ments of the United States or United controversial restriction based on the to transcend socioeconomic class has
Kingdom. The U.S. government, for guiding principle of projet parentalÚH- nevertheless led to the marginaliza-
instance, has practically no supervisory VSRQVLEOH SDUHQWKRRGµ ZKLFK QHFHV- tion and devaluation of a minority in
role in the ART market, meaning that VLWDWHV VFUHHQLQJ IRU ´JRRGµ SDUHQWV )UHQFK VRFLHW\ 8OWLPDWHO\ WKH )UHQFK
ART access for homosexual couples, 7KHDUWLFOHÁMP: L’assistance médicale à government’s decision-making author-
single women, and older women is lim- la procréation en pratique,µZULWWHQE\'U ity on questions of ART access is de-
ited only by their ability to pay. -DFTXHV /DQVDF WKH &KDLUPDQ RI WKH ULYHGIURPWKHÀQDQFLDOFRQWURORI WKH
Perhaps the most contentious point )UHQFK1DWLRQDO&ROOHJHRI *\QDHFROR- Sécurité Sociale and executed through
of debate is the explicit requirement JLVWVDQG2EVWHWULFLDQVDQG'U)DEULFH the regulatory authority of the national
that ART treatment be given only to Guerif, further explains projet parental )UHQFK %LRPHGLFLQH $JHQF\ ,I WKHVH
heterosexual couples. The exclusion of as the valuation of the potential child’s institutions choose to invoke principles
homosexuals is sometimes defended right to adequate parents over the po- of social conservatism, it becomes law.
under the idea that homosexual couples tential parents’ right to have a child. We can only hope that these governing
cannot naturally have children. The in- 7KH)UHQFKJRYHUQPHQWKDVXVHGprojet ERGLHV ZLOO UHHYDOXDWH WKHLU GHÀQLWLRQV
parental WROLPLWWKHWHUP´RSWLPDOSDU- of parenthood in the next round of
HQWKRRGµWRKHWHURVH[XDOFRXSOHV bioethical legislation review.
LEFT France’s national healthcare system, Sécurité Sociale, $W ÀUVW WKLV UHTXLUHPHQW VHHPV LQ-
carefully limits access to its assisted reproductive technolo-
gies, which have contributed to over 200,000 births. consistent with the liberal and secular Connie Cho is a sophomore in Silliman College
LPDJHRI WKH)UHQFKVWDWHZKLFKHVWDE- and a staff writer for the YJML.
When Government Health Care Meets Citizen Involvement: I n September of 2000, all 192 mem-
ber nations of the United Nations
Lessons from the embarked upon a weighty mission at

WKH´0LOOHQQLXP6XPPLWµKHOGLQ1HZ
<RUN &LW\ 7KHVH QDWLRQV FUHDWHG DQG
promised to achieve eight Millennium
Brazilian Approach to the Development Goals, which included: an

end to poverty and hunger, the provi-
sion of universal education, the promise
HIV Epidemic
of gender equality, the right to universal
child health care and universal maternal
health care, the combat of HIV/AIDS,
the achievement of environmental sus-
tainability, and the development of last-
BY ANJALI BALAKRISHNA ing foundations for global partnerships.
LEFT Brazilian President Luiz Inácio Lula da Silva was and medical resources for Brazilian citi-
presented with the UNAIDS leadership award by Mr Michel ]HQV )XUWKHUPRUH ZKHQ DQWLUHWURYLUDO
Sidibé, UNAIDS Executive Director on World AIDS Day, 1
drugs (ARVs) began to show promise
December 2010. Brasilia, Brazil. Photo from UNAIDS
in the treatment of HIV/AIDS in 1996,
the Brazilian Ministry of Health prom-
While these goals were generally broad ised free provision of ARVs to any citi-
in scope, one stands out as strikingly zen living with HIV.
VSHFLÀF³WKHQHHGWRFRPEDWWKHGLVHDVH In 2003, the government also launched
HIV/AIDS. an extensive awareness and advertising
The United Nations estimates that campaign encouraging HIV testing. The
about 36 million people worldwide are FDPSDLJQZLWKWKHVORJDQRI ´)LTXH6D-
infected with HIV. The causes of the vi- EHQGRµÉHLQWKHNQRZµIHDWXUHGFH-
rus’s transmission are varied, from sexual lebrities imploring citizens to determine
contact to intravenous drug use. Treat- their HIV status. In the end, by bring-
ment options exist, but are often expen- ing together grassroots programs and
VLYH DQG GLIÀFXOW WR DGPLQLVWHU WR WKH government resources, citizens of every ABOVE The “Fique Sabendo”, or “Be in the Know” campaign
masses of infected people in under de- socio-economic status were made aware featured celebrities requesting that citizens determine their
veloped nations. However, one nation— of the disease and were provided with HIV positive or negative status.
Brazil—has managed to tackle its HIV health care if needed.
epidemic with a combination of pre- In addition to establishing a powerful EDVLFGLVHDVHÀJKWLQJWHQHWVDVWKH+,9
vention and treatment. The promise of model for high-quality prevention and program—education and treatment.
Brazil’s HIV program can serve not only care in low-income settings, Brazil pro- With the government’s emphasis on the
as inspiration for other nations, but also vided technical assistance and support to disease, the number of Brazilians able to
as a model for treating other epidemics, HIV treatment and prevention efforts in get treatment for TB increased from 34
such as tuberculosis (TB), within Brazil. Mozambique, Angola and other African percent to 75 percent, according to the
As in many nations, the HIV epidemic countries. As a result, Brazil was recog- WHO.
PDGHLWVÀUVWDSSHDUDQFHLQ%UD]LOLQWKH nized globally for its successful, innova- In March 2009, Brazil’s Minister of
early 1980s, when Brazil was in a state of tive response to AIDS. In 2003, the Bra- Health, José Gomes Temporão, an-
SROLWLFDOÁX[+RZHYHUDIWHUWKHSDVVDJH zilian Ministry of Health was awarded nounced new plans for TB control and
of time and a great deal of partnership the Gates Award for Global Health by Multi Drug Resistant TB (MDR-TB)
between the government and grassroots WKH%LOO 0HOLQGD*DWHV)RXQGDWLRQ SUHYHQWLRQDWWKH6WRS7%3DUWQHUV·)R-
organizations, Brazil’s decreased HIV Having brought its HIV epidemic un- rum in Rio de Janeiro. At the conference,
rate is now considered one of the great- der control, Brazil has since turned to Temporão pledged to reduce the inci-
est success stories of HIV containment. tackle another of its greatest health con- dence of TB until Brazil was removed
2QFH WKH ÀUVW %UD]LOLDQV ZHUH GLDJ- cerns – tuberculosis. USAID notes that from the WHO’s high-burden list. These
nosed with the disease in 1982, social Brazil has the 14th highest incidence of new commitments will focus on improv-
activist groups soon appeared, offering TB in the world, with an estimated inci- ing TB control, scaling up services, and
places of solidarity as well as guidance dence of 48 cases per 100,000 residents. creating and adopting innovative preven-
for HIV positive citizens. Organizations As with HIV, the government’s uni- tion and treatment strategies.
VXFKDV*UXSR3HOD9LGGD´*URXS)RU versal health care program theoretically The success story of HIV treatment
/LIHµ RIIHUHG %UD]LOLDQV ZLWK +,9 D covered tuberculosis treatment. How- in Brazil offers guidance to other, less
place to interact with other HIV-positive ever, as tuberculosis became an epi- developed nations that are battling this
members of society. Government in- demic in Brazil, the resources, political disease. Moreover, the experience with
volvement followed closely afterward. commitment, and coordination were HIV currently informs Brazil’s own ef-
When democracy was restored to the na- outmatched by the need for treatment. forts to combat a high incidence of tu-
tion in 1985, a new focus on civil rights, Since 2003, the government of Brazil berculosis. To be sure, the Brazilian HIV
DQG VSHFLÀFDOO\ KHDOWKFDUH ULJKWV ZDV has worked to ameliorate the country’s movement has demonstrated that a dis-
FRGLÀHG LQ WKH FRXQWU\·V QHZ FRQVWLWX- TB epidemic using a similar strategy to HDVHÀJKWLQJ SDUWQHUVKLS EHWZHHQ JRY-
tion. This revamped Brazilian consti- that employed against HIV, and as a re- ernment programs and citizen groups
WXWLRQ ÀQDOL]HG LQ JXDUDQWHHV DOO VXOW WKH 1DWLRQDO 7XEHUFXORVLV &RQWURO can have life-saving results, and it would
FLWL]HQVKHDOWKFDUHFDOOLQJLW´DULJKWRI 3URJUDP 17&3 KDV JUHDWO\ H[SDQGHG be wise for other nations to consider
DOODQGDGXW\RI WKHVWDWHµ,QRUGHUWR not only its resources but also its sup- similar strategies.
act on this constitutional promise, the SRUWLYH DELOLW\ LQ WKH ÀJKW DJDLQVW WKH
government launched a nationwide cam- disease. The program was constructed Anjali Balakrishna is a freshman in Jonathan Ed-
paign to inform and provide HIV testing to deal with TB by focusing on the same wards College.
BY CONNIE CHO
The Gates Foundation’s role in

shaping global health.
,W LV GLIÀFXOW WR FULWLFL]H WKH %LOO DQG
0HOLQGD *DWHV )RXQGDWLRQ ZKHQ LWV
annual contributions to global pub-
lic health programs and initiatives total
$800 million dollars, an amount compa-
rable to the funds invested by the United
Nation’s World Health Organization
(WHO). Since its inception in 1994, the
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and technology to save lives in poor
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al Health Program not only funds groups
dedicated to the research and preven-
tion of diseases such as diseases, HIV/
AIDS, malaria, pneumonia, tuberculosis,
and neglected infectious diseases, but
also work on integrated health solutions
for family planning, nutrition, maternal,
neonatal and child health, tobacco con-
trol, and vaccine preventable diseases.
In the face of the recession, the Gates
)RXQGDWLRQEROGO\LQFUHDVHGLWVÀQDQFLDO
commitment to global health and devel-
opment, setting an example for the rest
of the world’s governments and NGOs.
7KH*DWHV)RXQGDWLRQKDVEHHQLQWHU-
HVWHGLQÀOOLQJDYHU\SDUWLFXODUQLFKHLQ
global health intervention. At the 2010
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The Gates F
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over 10 years and called for dedication
WRD´GHFDGHRI YDFFLQHVµIURPJRYHUQ-
ments and the private sector institutions
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health, supporting efforts to target spe- GLVHDVHV 7KHVH LQYHVWPHQWV UHÁHFW D upon them. Many argue that the founda-
FLÀF GLVHDVHV 7KLV DSSURDFK SHUKDSV ÝHUWLFDOµ DSSURDFK IRFXVLQJ DOO HQHUJ\ tion ignores larger environmental chal-
UHÁHFWV%LOO*DWHV·VSULRULWLHVDQGYLVLRQ into eradicating particular diseases rather lenges that do not fall under the scope
for his foundation. In his 2010 Annual than attempting to make systemic health of the approved global health grants. A
)RXQGDWLRQ /HWWHU %LOO *DWHV H[SODLQV care changes. 2007 investigation series on the Gates
´0HOLQGD DQG , VHH RXU IRXQGDWLRQ·V &ULWLFVRI WKHYHUWLFDODSSURDFKSRLQW )RXQGDWLRQ E\ WKH /RV $QJHOHV 7LPHV
key role as investing in innovations that out that the outcomes of the Gates DOVR KLJKOLJKWV WKH ÀQDQFLDOO\ GULYHQ
ZRXOG QRW RWKHUZLVH EH IXQGHGµ $V )RXQGDWLRQ·V IDLWK LQ ´PDJLF EXOOHWµ ÉUDLQGUDLQµWKDWVKLIWVFOLQLFLDQVIURP
such, the foundation has invested sub- vaccines as the answer to global health basic care to specialty care. Targeting
stantially in high-impact technology like problems are counteracted by founda- diseases like AIDS and malaria when
vaccines that target and prevent certain tionally weak health care systems that basic hunger and poverty needs remain
cannot sustain the progress that is thrust unaddressed has shown to be futile. The
Melinda and I see our
foundation’s key role as
investing in innovations
that would not otherwise
be funded.
struction on hygiene and sanitation must

be added to the traditional vertical in-
vestments in vaccine delivery. Bill Gates’
2010 Annual Letter also recognizes and
DGGLWLRQDOO\FRPPLWVWRWKH´LQWHJUDWHG
DSSURDFKµ SLORW SURJUDPV ZKLFK HGX-
cated mothers and nurses in addition to
providing much-needed antibiotics.
Global health and development is
more in the hands of non-governmental
organizations and private sector insti-
WXWLRQV OLNH WKH *DWHV )RXQGDWLRQ WKDQ
ever before. A 2009 Institute for Health
Metrics and Evaluation Report shows
that private spending in global health
has grown from 19% in 1998 to 26.7%
LQDQGFLWHVWKH*DWHV)RXQGDWLRQ
as a major contributor to the growth in
FRQWULEXWLRQV 7KHLU JURZLQJ LQÁXHQFH
challenges governmental institutions like
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This systemic check that should ben-
HÀWVRFLHW\EXWVRPHWLPHVGHYROYHVLQWR
clashing egos as exhibited in public dis-
Foundation
putes between the WHO and the Gates
)RXQGDWLRQ DERXW PDODULD UHVHDUFK LQ
2009. The New York Times reports
´VRPHVFLHQWLVWVKDYHVDLGSULYDWHO\WKDW
>WKH *DWHV )RXQGDWLRQ@ LV ¶FUHDWLQJ LWV
RZQ:+2·µ<HWWKHIDFWUHPDLQVWKDW
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*DWHV )RXQGDWLRQ·V ODFN RI LQYHVWPHQW developing nation. and handles itself as the benefactor of
in systemic health care structures ren- 7KH *DWHV )RXQGDWLRQ LV QRW LQÁH[- innovation and technology-driven de-
GHUVLWVVSHFLÀFGLVHDVHWDUJHWHGLQYHVW- ible. After spending $700 million dollars liverables. The rest of the global public
ments less than effective. The LA Times on the effort to eradicate polio, almost a KHDOWKÀHOGPXVWÀQGDZD\WRÀOOLQWKH
investigative series exposed international ÀIWKRI WKHJOREDOLQYHVWPHQWDQGVHH- rest of the gaps and make sure that it is
concerns over disrupting currently de- ing undeniable evidence of an escalating covering the holistic and systemic needs
veloping health care structures. As the outbreak of polio from contaminated WKDWWKH*DWHV)RXQGDWLRQGRHVQRWSUR-
*DWHV)RXQGDWLRQLVVXFKDPDMRUSOD\HU water in Nigeria, Bill Gates made a trek vide.
in shaping how global health problems to Nigeria. As reported by Rob Guth’s
are solved, it must balance its priority for 2010 Wall Street Journal article, Gates Connie Cho is a sophomore in Silliman College
risk-taking innovation with responsible FRPPLWWHGWRDGGLWLRQDO´KRUL]RQWDODS- and a staff writer for the YJML.
investments for the holistic needs of a SURDFKµPHDVXUHVVXFKDVVXSSRUWRI LQ-
Interview with
Dr. Francis Collins Director of the National Institutes of Health
BY COURTNEY RUBIN
1. You were the director of the Na- family planning and infectious dis- genome sequencing and use this in-
tional Human Genome Research eases like AIDS/HIV and malaria. formation to create personalized dis-
Institute and oversaw the Human What programs and projects do you ease therapies?
Genome Project. How has your hope for the NIH to implement in
background as a geneticist affected order to address the growing concern Today, one of our biggest goals is to
the way you approach managing the over global health disparities, and cut the cost of sequencing an entire hu-
NIH and developing strategies to what do you foresee as the most chal- man genome to $1,000 or less. This ad-
address national (and global) health lenging issues you will have to face? vance will pave the way for each person’s
concerns? genome to be sequenced as part of the
In recent decades, much of global standard of care, leading to a revolution
Genetics underlies nearly every dis- KHDOWK UHVHDUFK KDV MXVWLÀDEO\ EHHQ IR- in the practice of medicine.
ease, from rare diseases, such as cystic FXVHGRQWKHÉLJWKUHHµGLVHDVHV$,'6 In this new era, the current one-size-
ÀEURVLV DQG VLFNOH FHOO DQHPLD WR PRUH TB, and malaria. However, biomedical ÀWVDOO DSSURDFK WR KHDOWKFDUH ZLOO JLYH
common, chronic conditions, such as research must now set its sights on other way to personalization. Healthcare pro-
cancer, heart disease, and diabetes. In more-neglected causes of death and dis- viders will use a person’s genomic pro-
fact, as we learn more about the human ability in low-income nations. That in- ÀOHDORQJZLWKLQIRUPDWLRQDERXWKLVRU
genome and how its 3 billion letters vary cludes non-communicable diseases like her lifestyle and environment, to develop
ever so slightly among individuals, we cancer, heart disease, and diabetes, which individualized strategies for preventing,
DUHOHDUQLQJWKDWJHQHWLFVHYHQLQÁXHQFHV are the fastest growing causes of mor- detecting, and treating disease. Genomic
susceptibility to many infectious diseases, bidity and mortality in the developing information will also enable doctors to
such as tuberculosis (TB) and acquired world. In collaboration with other fund- prescribe medications in safer and more
LPPXQHGHÀFLHQF\V\QGURPH$,'6 ing sources, such as the Bill and Melinda effective ways, selecting for each patient
&RQVHTXHQWO\,WKLQNP\EDFNJURXQG *DWHV)RXQGDWLRQ1,+FDQSOD\DPDMRU the right drug at the right dose at the
serves as a strong foundation for leading role in ramping up the discovery of nov- right time.
the efforts of the National Institutes of el targets that may facilitate the develop- Granted, there will be great chal-
+HDOWK1,+WRWXUQVFLHQWLÀFGLVFRYHU\ ment of new ways to prevent, diagnose, lenges in interpreting anyone’s complete
into health for all peoples of the world. and treat these neglected diseases. genome sequence, so it will likely take a
The study of the genome also fos- It is also critical to build biomedical while before all of these advances show
ters a broad view of human biology. As research capacity and training opportu- up in local hospitals and clinics. But I
leader of the National Human Genome QLWLHV LQ WKH GHYHORSLQJ ZRUOG )RU H[- expect that within the next decade or
Research Institute, I encouraged applica- ample, NIH and the Wellcome Trust, a so, most people living in developed na-
tion of genomic knowledge, tools, and global charity based in London, recently tions will have their genomes sequenced
technologies to a wide range of human formed a partnership to support popula- as part of their medical record -- and I
disorders. So, unlike scientists who have tion-based studies in Africa of common, hope it will come even sooner.
devoted their entire careers to studying a chronic disorders, as well as infectious
VSHFLÀFGLVRUGHURUELRORJLFDOSDWKZD\, GLVHDVHV &DOOHG WKH +XPDQ +HUHGLW\ 4. The passage of GINA (the Ge-
owe no allegiance to any particular group and Health in Africa (H3Africa) project, nomics Information Nondiscrimi-
of diseases. the effort will enable African researchers nation Act) was a major victory for
,QVFLHQWLÀFUHVHDUFKLWLVYHU\WHPSW- to take advantage of new research ap- proponents of secure genetic testing.
ing to stay within your comfort zone. proaches to understand both the genetic What are your thoughts on the priva-
But the Human Genome Project, which and non-genetic factors that contribute cy concerns of genetic testing? What
ZDV VXFFHVVIXOO\ ÀQLVKHG XQGHU EXGJHW to the risk of illness. We anticipate that genetic testing infrastructure still
and ahead of schedule, is proof of the what is learned in Africa about genetic needs to be improved before privacy
extraordinary progress that can be made variation and disease will have an impact is no longer an issue?
when researchers set bold goals and around the globe.
work together to achieve them. My hope The passage of The Genetic Infor-
is that, as director of NIH, I can encour- 3. As the development of new tech- mation Nondiscrimination Act of 2008
age the entire research community to nology makes whole genome se- (GINA) represented a major victory
pursue endeavors that push us beyond quencing faster, cheaper and more for all Americans. In fact, the late Sen.
RXU FRPIRUW ]RQHV LQ ZD\V WKDW EHQHÀW feasible for the average person, how Edward Kennedy (D-MA), who co-
humankind. do you see genetic data like this be- sponsored the legislation in the Senate
ing integrated into mainstream with Sen. Olympia Snow (R-ME), called
2. The Obama Administration has healthcare? Do you think we have *,1$ ´WKH ÀUVW QHZ PDMRU FLYLO ULJKWV
announced a Global Health Initiative amassed enough knowledge to cor- ELOORI WKHQHZFHQWXU\µ >>
focused on maternal and child health, rectly interpret the results of whole
> This federal law protects consumers preventive measures. However, despite clinical trials to see if the drugs work,
from discrimination by health insurers our best efforts at prevention, people are NIH has a 240-bed clinical research cen-
and employers on the basis of genetic still going to get sick. So, we also want ter on its Bethesda, Md., campus, along
information. One reason this nationwide to come up with better treatments than with a network of about 60 clinical cen-
level of protection was needed was to what we have now. In the past, the de- ters scattered all over the country. In ad-
reduce Americans’ growing concern that velopment of drugs has largely been left dition, the NIH has established a much
results of genetic testing could be used to the private sector, which used rather VWURQJHUUHODWLRQVKLSZLWKWKH)RRGDQG
against them by health insurers and in broad-brush, empirical approaches to Drug Administration, trying to ensure
the workplace. Another motivating force identify compounds that would have the that there is a synergism there between
was that patients’ fears of potential dis- right properties to improve the situation. the development of new drug com-
crimination were threatening our ability Today, informed by a better under- pounds and their oversight.
to conduct the very research we need to standing of what is going on inside a I’m optimistic that, working in part-
understand, treat, and prevent disease. cell and how a disease affects that, re- nership with the private sector, we can
Despite the protections provided by searchers in both the private and public create a new paradigm that will provide
GINA, the law is not perfect. GINA sectors have developed more rational the public with new and more effective
does not address life insurance, disabil- strategies for screening very large librar- treatments far faster than we do now. We
ity insurance, or long-term care insur- ies of chemical compounds in a system- simply cannot sit around and wait for
ance. So, we need to thoughtfully evalu- DWLFKLJKWKURXJKSXWPDQQHUWRÀQGWKH the next blockbuster drug. In fact, there
ate these and other areas of our society one that has the right properties. NIH are not going to be very many block-
in which it may be tempting to use – or recently has gotten much more involved busters. As we increase our molecular
misuse -- genetic information. in such efforts, helping many academic understanding, diseases are actually be-
investigators who are interested in taking ing divided into smaller and smaller
5. Many people believe translational their basic discoveries and move it in the subsets, which means that the odds of
research to be a better funding in- direction of therapeutics. ÀQGLQJRQHEORFNEXVWHUGUXJWKDWZRUNV
vestment, as it is more directly rel- Still, it is one thing to have a com- against all subtypes are growing smaller
evant to clinical medicine than basic pound that works in a Petri dish, and and smaller. Instead, we likely will need
science research. How do you see quite another to give it to a patient. There to develop a wide array of drugs, each
the balance between basic science is much work that needs to be done in H[TXLVLWHO\ WDUJHWHG WR VSHFLÀF VXEW\SH
and translational research evolving in terms of testing the compound’s toxicity So, if we want to see true progress in the
the future? in an animal, as well as assessing its abil- rational design of therapeutics, NIH-
ity to be metabolized and absorbed. All supported science has to play a larger
In the past, critics have complained of these steps are long, expensive, and role – and that will be one of my highest
that NIH is too slow to translate basic time-consuming processes. It is in this priorities during my time as NIH Direc-
discoveries into new advances in the gap between target discovery and human tor.
clinic. Some of that criticism may be jus- clinical trials where a lot of drug devel- None of this should be taken as an
WLÀHG EXW RIWHQ WKH SDWKZD\ IURP PR- opment projects die – a gap that many erosion of NIH support for basic sci-
OHFXODULQVLJKWWRWKHUDSHXWLFEHQHÀWZDV LQWKHLQGXVWU\UHIHUWRDVWKH´9DOOH\RI ence, however. Basic science is the foun-
just not discernible. Death. dation of all translation, and must con-
)RU PDQ\ GLVRUGHUV WKDW LV QRZ NIH is now pushing very hard to tinue to be a major component of our
changing. We are experiencing a remark- bridge that Valley of Death for care- research agenda.
able deluge of discovery in terms of the fully chosen projects. Make no mistake,
causes of disease, much of it coming we are not trying to compete with the 6. Judge Royce Lambert recently
out of genomics, the ability to pinpoint private sector. Instead, we are develop- ruled that the Obama administra-
at the molecular level what pathway has ing new partnership models, especially tion’s policy on embryonic stem cell
gone awry in causing a particular medical for unexplored drug targets or diseases research violated the Dickey-Wicker
condition. Such information is exciting that are relatively less common, and for amendment. How has this ruling af-
in itself because it provides new insights which there exists little economic infected the NIH? How do you hope to
into human biology. However, what we FHQWLYHWRGHYHORSWKHUDSHXWLFV)RUH[- resolve this issue?
really want to do is to take such infor- DPSOH 1,+·V QHZ &XUHV $FFHOHUDWLRQ
mation and push it forward into clinical Network, which was established by the The preliminary injunction issued on
EHQHÀW 3DWLHQW 3URWHFWLRQ DQG $IIRUGDEOH &DUH Aug. 23, 2010 has cast a cloud of uncer-
6RPH RI WKH EHQHÀWV FRXOG FRPH LQ Act, will make it possible for academic WDLQW\LQWKHÀHOGRI KXPDQHPEU\RQLF
the form of prevention, that is, identi- investigators to move their discoveries stem cell research. Young scientists,
fying people at highest risk and making much further down that pipeline towards once excited about careers in stem cell
sure be sure they are taking the right a therapeutic. Also, to carry out initial research, are now worried about the fu-
ABOVE Advances in sequencing technology have enabled shotgun DNA sequencing analyzers at The National Institute for Genomic Research to sequence the entire human genome in a matter of
ture. logic of physical chemistry and into the ity to unravel nature’s biggest mysteries
If this research is slowed or halted, ZLOGDQG´PHVV\µZRUOGRI ELRORJ\DQG and solve medicine’s toughest puzzles
the greatest loss will be suffered by the medicine. will hinge upon assembling complex re-
millions of Americans with conditions I enrolled in medical school at the search teams that meld biological know-
that might be helped by research involv- 8QLYHUVLW\RI 1RUWK&DUROLQDLQ&KDSHO how with expertise in computer science,
ing human embryonic stem cells. Such Hill, where I earned an M.D. in 1977. physics, math, clinical research, bioeth-
people include those suffering from After a residency and chief residency ics, and many other disciplines.
heart disease, diabetes, liver disease, and in internal medicine, I returned to New Also, bear in mind that the power of
vision problems, along with those af- Haven for a postdoctoral fellowship in discovery comes with a very serious re-
ÁLFWHGE\VSLQDOFRUGLQMXULHVDQGQHXUR- human genetics at Yale Medical School. sponsibility -- the responsibility of sci-
degenerative conditions, such as amyo- )RUWXQDWH HQRXJK WR EH PHQWRUHG E\ entists to weigh the ethical, legal, and so-
trophic lateral sclerosis and Parkinson’s Sherman Weissman, a wonderful advi- cial implications of their research before
disease. While we continue through the sor who encouraged creativity, I used the embarking upon a project or advocating
legal process, we must keep patients and opportunity to develop an innovative ap- DQHZWHFKQRORJ\&OHDUO\ZHGRQRW\HW
their families foremost in our thoughts. proach, called chromosome jumping, to have the answers to many of these daunt-
cross large strands of DNA to identify ing questions. It likely will take years of
7. You earned your PhD in physical genes responsible for inherited disor- thoughtful research and vigorous debate
chemistry from Yale in 1974. What is ders. among scientists, ethicists, legal scholars,
your favorite memory of Yale? and ordinary citizens to chart the wisest
8. What advice do you have for peo- course. And that is where you come in.
While at Yale in 1972, a course in bio- SOH LQWHUHVWHG LQ VFLHQWLÀF UHVHDUFK Whether your journey of discovery takes
chemistry changed the course of my life. healthcare and medicine? you to a high-tech laboratory, an inner-
Taught by Peter Lengyel and Bill Sum- city clinic, the courtroom, or some other
mers, this course sparked my interest in &KRRVHLPSRUWDQWSUREOHPVWRZRUN equally challenging setting, the future de-
the molecules that hold the blueprint for on. Identify great mentors. Persevere. pends on you.
life: DNA and RNA. It became clear to Our world urgently needs bright, cre-
me that a revolution was coming in mo- ative minds if we are to turn discovery Courney Rubin is a Junior in Trumbull College
lecular biology and genetics. So, I shifted into health. Equally important, we need and, Development Editor for the YJML.
gears and moved away from the orderly such minds to work together. Our abil-
The
HIV/AIDS
Crisis in
Russia
What Has Been Done and
What is Still Left to Be Done
BY BEN VANGELDER
A poster for a governmental anonymous hotline for HIV/AIDS information. Marinal/Flickr
HIV stigmatization and high

I n spite of encouraging global statis-
tics, the spread of HIV/AIDS re-
mains a very serious problem in certain
in transmission from more vulnerable
populations to a larger segment of the
general public. In areas with high preva-
prevalence of injecting drug parts of the world, particularly in Rus- lence of HIV among injecting drug us-
users pose as challenges for sia. According to the USAID HIV/ ers (IDUs), HIV is commonly but often
the Russian government to $,'6 +HDOWK 3URÀOH 5XVVLD WRGD\ KDV unknowingly being spread from IDUs to
successfully reduce HIV the second highest HIV prevalence in all their sexual partners. In St. Petersburg,
transmission. of Eastern Europe and Eurasia - about for example, the majority of whose IDU
1.1 percent of its population was esti- population is estimated to have the vi-
mated to be living with the virus at the rus, 6.5 percent of previously untested
end of 2007. Transmission through in- pregnant women who were admitted to
travenous drug use remains the primary maternity hospitals in 2008 were found
cause of new HIV infection in Russia, to be infected with the virus. The stigma
followed by heterosexual transmission, directed toward high risk populations,
ZKLFK KDV FDXVHG D VLJQLÀFDQW LQFUHDVH including IDUs, people living with HIV/
AIDS (PLWHA), and men who have sex has shown opiate-substitution therapy
with men (MSMs), is one of the main to dramatically reduce the prevalence
GLIÀFXOWLHV LQ PDNLQJ +,9$,'6 VHU- Russia today has the sec- of HIV and rates of HIV transmission,
vices and treatments accessible. ond highest HIV prevalence but the legal barriers present for such
In response to this rapidly escalating WUHDWPHQW PHWKRGV PDNH LW GLIÀFXOW WR
problem, the Russian Government has in all of Eastern Europe and combat the problem of drug addiction,
made several efforts to combat the grow- especially in urban areas. Since needle-
Eurasia - about 1.1 percent
ing prevalence of HIV/AIDS among its based transmission of HIV, by far the
citizens, particularly since 2005. Several of its population was esti- most common cause of transmission
government-sponsored entities, such as at this point in time, is largely the prod-
mated to be living with the
WKH*RYHUQPHQW&RPPLVVLRQRQ+,9 uct of addiction among injection drug
AIDS, which was established in 2006, virus at the end of 2007. users, addressing the problem of HIV
have been working to develop HIV/ transmission by IDUs via needle sharing
AIDS programs and review existing and intercourse goes hand-in-hand with
legislation and regulations pertaining to RUSKDQV²JHWWKHFDUHWKH\QHHGµ addressing the already large problem of
treatment of the disease. These pro- Despite the success of these collab- opiate addiction within Russia.
grams and others have had some mea- orative efforts, the spread of new HIV/ The ability of the Russian health
surable success in acting to make treat- AIDS infections from more vulnerable, system to handle the HIV/AIDS crisis
ment for HIV/AIDS more available and ´KLJKULVNµ SRSXODWLRQV WR WKH JHQHUDO
depends upon their willingness to reach
widespread. According to a statistic public remains a very serious problem. out to high-risk populations throughout
offered by the World Health Organiza- Government-sponsored HIV/AIDS the country. Although the availability of
tion (WHO), the Joint United Nations programs have realized success, as pre- treatments such as antiretroviral treat-
Program on HIV/AIDS (UNAIDS), viously noted, but this effort has been ment (ART) has increased over the past
DQGWKH8QLWHG1DWLRQ&KLOGUHQ·V)XQG directed more toward the treatment of few years, many IDUs continue to have
81,&()SHUFHQWRI +,9SRVLWLYH AIDS rather than towards awareness and inequitable access to such treatments,
women were receiving assistance from prevention, which is most essential in as indicated by the fact that fewer than
programs to help prevent mother-to- VROYLQJWKHFXUUHQWFULVLV)RUH[DPSOH10 percent of those receiving ART are
child transmission of HIV. Accord- while a lot of effort has been devoted IDUs, a statistic cited by the WHO, UN-
ing to the same source, the number of WRÀJKWLQJWKHHSLGHPLFVSHFLÀFDOO\ZLWK $,'6 DQG 81,&() 7KH KHDOWKFDUH
HIV-positive individuals on antiretrovi- the IDU population, WHO estimates system must overcome cu to promote
ral treatment (one of the most effective that only 5 percent of this demographic knowledge about HIV prevention to
treatments available today) increased by is reached at least once a month by sy- DOOLQGLYLGXDOVDQGSDUWLFXODUO\WR´KLJK
around 77 percent between 2007 and ringe and needle exchange programs, ULVNµ GHPRJUDSKLFV 3URYHQ ORQJWHUP
2008. which allow individuals to exchange, at addiction treatments (including OST),
Russia has also received substantial no cost, used syringes for sterile ones. which currently remain unavailable in
international aid from the HIV/AIDS 0RUH HIIRUW PXVW EH WDNHQ ÀUVW DQG
many regions of Russia, must be made
relief programs launched by the U.S. foremost, to combat the problem of legal and more readily accessible. The
Agency for International Development addiction and HIV transmission within problem at hand continues to pose a
(USAID), as part of the U.S. President’s the IDU population. While short-term serious risk to Russia’s general popula-
Emergency Plan for AIDS Relief (PEP- WUHDWPHQWV VXFK DV GHWR[LÀFDWLRQ DUH
tion. A general decline in the number
)$5 ,Q WKHVH SURJUDPV· +,9 widely available throughout Russia, of new HIV transmissions can be real-
prevention efforts reached over 86,000 these do not serve as effective, long- ized, however, if Russia’s health care
people in Russia, and over 10,000 were term methods for combating addiction. system can effectively combat intrave-
provided with HIV testing and counsel- &RQYHUVHO\ PDQ\ ORQJWHUP DGGLWLRQ nous drug abuse, overcome the stigma
ing. President Obama promised at the treatments, such as needle exchange pro- DVVRFLDWHGZLWKPDQ\RI WKH´KLJKULVNµ
,QWHUQDWLRQDO $,'6 &RQIHUHQFH grams and addictive counseling, are not groups, and extend HIV prevention and
to provide for more outreach and treat- readily accessible. According to The Ep- treatment options to previously alien-
PHQW WKURXJK 3(3)$5·V HIIRUWV ZLWKLQ och Times, a media organization based ated segments of the population. While
the Global Health Initiative. Accord- in New York, the Russian government WKHVHJRDOVPD\EHGLIÀFXOWWRDWWDLQWKLV
ing to Medical News Today, Obama said has outlawed opiate-substitution therapy life-threatening situation requires the im-
WKDWWKH\KRSHGWR´GRXEOHWKHQXPEHU (OST), one of the most effective forms mediate attention of Russia’s healthcare
RI EDELHV ERUQ +,9IUHHµ ´ZRUN WR of addiction treatment. In OST, pa- system.
prevent more than 12 million new infec- tients replace injection-based drug use
WLRQVµ DQG ´KHOS PRUH WKDQ PLOOLRQ with oral dosing of drugs such as metha- Ben VanGelder is a Sophomore in Jonathan
people – including 5 million children and done. Repeated research by the WHO Edwards College.
One Child
No Health Care
Population Control and Its Impact
on Health Care in China
ALL THREE Photos from

a countryside clinic in
Guizhou, China
Photos by Heilongjiang
University Chaoyang Love
Volunteer Team
ban and rural population and a majority and responsibly demand and seek out
BY MARTIN D. WEAVER JR. is already uninsured. While healthcare higher quality health services.
expenditures and actual government The government has already begun to
China’s rapid economic growth did funding have been steadily increasing provide more funds and employ new ini-
not entail a proper expansion of its over the past twenty years, according to tiatives to improve public health, evalu-
healthcare system. China’s aging the IBM report, as a percentage of GDP, ate hospitals through the solicitation of
SRSXODWLRQRQO\DGGVIXHOWRWKHÀUH these expenditures have actually been patient feedback, and begin the develop-
decreasing. ment of a national health infrastructure.
)XUWKHUPRUH KHDOWKFDUH IXQGLQJ The future of the healthcare system will
A recent report by IBM titled Health-

FDUH LQ &KLQD 7RZDUG JUHDWHU DFFHVV
HIÀFLHQF\ DQG TXDOLW\, outlines three ma-
limited as it is, is allocated dispropor-
tionately, which exacerbates the dispar-
UHDSWKHEHQHÀWVRI JRYHUQPHQWIXQGHG
initiatives to funnel medical graduates
ity between urban and rural healthcare. to rural hospitals, performance-based
MRU SUREOHPV LQ WKH &KLQHVH KHDOWKFDUH )RUH[DPSOHLQZKLOHRI WKH salaries, and clear guidelines for the im-
system: a lack of access to affordable XUEDQ SRSXODWLRQ VHOIÀQDQFHG PHGLFDO plementation of up-to-date techniques
KHDOWKFDUH LQHIÀFLHQW XVH RI KHDOWKFDUH services, an even higher percentage of including referral systems, electronic
resources, and a lack of high-quality the rural population—79%—fell victim UHFRUGV HWF )XUWKHUPRUH WKH JRYHUQ-
patient care. These challenges are com- to uninsured services. This disparity is ment’s support of the growth of the pri-
SRXQGHGE\WKHLPPHQVHVL]HRI &KLQD·V evident in the rapid expansion of larger vate health sector will surely increase the
population. urban hospitals, which leaves smaller ru- quality of care by introducing new ideas
&KLQD·V SRSXODWLRQ RI ELOOLRQ ral community hospitals and health cen- and competition.
people represents 20% of the world. WHUVZLWKRSHQEHGVDQGVXSHUÁXRXVSHU- The IBM report suggests that the
7KLVSRSXODWLRQÀJXUHKDVLQVWLJDWHGWKH VRQQHO )XUWKHUPRUH WKHVH SHUVRQQHO role of the service providers will be to
LQIDPRXV 2QH &KLOG 3ROLF\ LQ &KLQD D are, in fact, not always capable, as there adopt a three-tier system. At the primary
SROLF\&KLQDLQWHQGVWRFRQWLQXHDWOHDVW DUHQRVWDQGDUGGHÀQLWLRQVWRGRFXPHQW level of this system, patients would visit
WKURXJK WKH ÀYH \HDU SODQ- WKHUHTXLUHGTXDOLÀFDWLRQVRI KHDOWKFDUH a community hospital for minor illness-
ning period. This policy, despite reduc- personnel. These three challenges must es, and be referred up to the secondary
ing population growth by 300 million, be taken into consideration in the com- level if the condition worsens. Similar-
has resulted in a troubling imbalance ing years as the byproducts of the one ly, at the tertiary level, major hospitals
between younger adults and the elderly. child policy begin to take form. ZRXOG EH UHVHUYHG IRU WUHDWLQJ GLIÀFXOW
7KHUHDUHPXFKIHZHU\RXQJDGXOWV&LW- While there is no simple solution to cases, referring the patient down as they
ies are currently heavily populated by QDUURZLQJWKHJDSEHWZHHQ&KLQD·VHFR- recover. This proposition would more
older, retired, and disabled people who nomic development and its healthcare effectively distribute resources and pa-
are more prone to sickness and unable development, the comprehensive study tients and ameliorate the current situa-
to support themselves. The implications RI &KLQD·V KHDOWKFDUH V\VWHP SURYLGHG tion in which tertiary establishments are
RQ&KLQD·VKHDOWKFDUHV\VWHPDUHWUHPHQ- by the IBM has highlighted some key overcrowded and primary services are
dous. factors that have the potential to pro- underutilized. In addition to the redistri-
$OWKRXJK&KLQDKDVH[SHULHQFHGWUH- GXFHWKHÀUVWVWHSVWRZDUGUHIRUP bution mentioned before, hospitals will
mendous economic growth in the past According to IBM, by 2020, 11.8% of need to increase their quality of care.
WZHQW\ÀYH \HDUV WKLV JURZWK KDV QRW &KLQD·V SRSXODWLRQ ZLOO EH RYHU WKH DJH IBM proposes that this would be pos-
created a corresponding improvement RI SODFLQJVLJQLÀFDQWVRFLDODQGHFR- sible through the introduction of gover-
RI KHDOWKDQGKHDOWKFDUH:KLOH&KLQD·V nomic pressure on healthcare services. nance. The report claims that a Board of
healthcare expenditures have been in- As a result of the one-child policy, an Directors, adept managerial efforts and
creasing, they remain low when com- older population is bound to incite an government transparency are all neces-
pared to other countries. The report by increased demand for medical services, sary to produce higher-quality care at
,%0RQKHDOWKFDUHLQ&KLQDVWDWHVWKDW especially for treatment of chronic ill- lower costs.
&KLQD VSHQW RQO\ RI LWV *'3 RQ nesses. By the same year, the rapid ur- However, the government’s role
healthcare in 2002, while comparable de- EDQL]DWLRQRI &KLQDLVH[SHFWHGWRUHDFK must not stop here. It must provide ba-
veloping countries such as South Africa, 55%-60% urbanization. This shift in sic medical services that are universally
Brazil and India managed more; 8.7%, lifestyle will no doubt contribute to an affordable and available in addition to
7.9%, and 6.1% of GDP, respectively. increase in non-communicable diseases, EOXUULQJWKHFXUUHQWO\ZHOOGHÀQHGOLQHV
In comparison to countries experiencing which as of 2003 already account for between rural and urban insurance.
WKHVDPHUDSLGLQFUHDVHRI *'3&KLQD RI DOOGHDWKVLQ&KLQD7KHUHIRUHLW
commits the least to its healthcare sys- is imperative that patients begin to take Martin D. Weaver, Jr. is a junior in Jonathan
tem. Medical expenses are far too costly more interest in their health, become Edwards College.
IRU D VLJQLÀFDQW SRUWLRQ RI &KLQD·V XU- more knowledgeable of their conditions,
Gender in
Middle Eastern
BY VINCENT YU
Health Care
A survey of progressive and traditional trends in gender within the Middle East.
T he Middle East is popularly con-

ceived as a cluster of closely related,
culturally uniform states with similar
ian culture, women are under continu-
ous pressure to bear children until they
have a son. Abortions are strictly illegal.
patient will always take priority over
same-gender inspections.
In terms of education, Dr. Hakim
forms of governance and levels of in- In recent years, though, the Ministry of says that a recent trend over the past 10
frastructure. This picture could not be Health has provided free family planning years is leading to more females in medi-
more different. The region known as services and contraceptives to women. cal schools than males. At the same time,
WKH´0LGGOH(DVWµFRQVLVWVRI DKHWHUR- he notes that hospitals are still quicker
geneous mixture of countries with large to hire male doctors. This trend can best
disparities in wealth, standard of living, Each nation struggles to be explained by a lingering perception
and sophistication of healthcare sys- balance shifts toward WKDW IHPDOHV DUH QRW DV ÀW IRU KDQGOLQJ
tems. Yet, the entire region shares one a career as a physician as males. The tra-
common thread: each nation struggles modernity with traditions ditional role of females as caretakers at
to balance shifts toward modernity with home perpetuates the notion that the
YVV[LKÄYTS`PU[OLWHZ[
WUDGLWLRQVURRWHGÀUPO\LQWKHSDVW7KLV female doctor is dealing with a juggling
effort is particularly evident in gender act and would not be able to dedicate
disparities in healthcare, and its equilib- VXIÀFLHQWWLPHDQGUHVRXUFHVWRKHUSUR-
rium largely varies from nation to nation. &DUHHUV LQ KHDOWKFDUH DOVR KLJKOLJKW fession.
Traditional gender roles and percep- undertones of gender inequality. Dr. Most Middle Eastern countries have
WLRQVVWLOOWLJKWO\LQÁXHQFHWKHGHJUHHRI Shoushtariali Hakim, a recent immigrant developed or are developing a more in-
healthcare freedom offered to men and who received his medical education in FOXVLYHDQGHIÀFLHQWKHDOWKFDUHV\VWHPWR
women in many Middle Eastern coun- Iran, notes that males in Iran are legally counteract these problems and provide
tries. A prevailing trend, though, is a restricted from specializing in gynecol- equal treatment opportunities for all citi-
modernizing effort by governments to ogy; similarly, females are not allowed to zens, male and female. In the country of
increase awareness of healthy repro- go into urology. During routine check- Qatar, for example, the healthcare system
ductive health practices and to create ups and physicals, female doctors are covers a wide variety of issues, including
resources for family planning. In Syria, greatly preferred to examine female pa- a complete maternity program. Women
for example, males are generally more tients, and likewise for males and male are given much freedom to make inde-
active in the social sphere while women SDWLHQWV1RQHWKHOHVV+DNLPQRWHV´,I pendent decisions about their health,
DUHFRQÀQHGWRWKHGRPHVWLFVSKHUH)RU LW LV HVVHQWLDO WR EH H[SRVHG >D SDWLHQW@ independently of their husbands and
this reason, women, especially those in FDQEHH[SRVHGµWRDGRFWRURI WKHRS- their families. In some instances, though,
rural areas, are considered socially infe- posite sex. In situations in which there employers of these women, especially if
rior and lack the freedom to make inde- will be legitimate detrimental harm to they are domestic workers, will impede
pendent decisions regarding their health. the patient’s health if the check-up does their access to healthcare by restricting
As sons are generally preferred in Syr- not occur quickly, the well-being of the their freedom of movement.
there is little information that is avail-
able to the public, and it is a taboo topic.
Although every citizen in Libya is given
free healthcare, the poorly equipped clin-
ics and hospitals are often inadequate.
Those who can afford it will often travel
abroad. Yet, Libyan law dictates that a
male relative must accompany females
during travel; this creates more expense
and might deter the female from trav-
eling. The forced presence of the male
relative might also take away from her
independence in making healthcare deci-
sions.
In Tunisia, as well, women have the le-
gal right to make independent decisions
about their health, but social constraints,
especially in rural areas, still hamstring
their true freedom. In these areas, tra-
ditional gender roles place women in an
inferior social status to men and make
equal access to healthcare facilities dif-
ÀFXOW <HW WKH JRYHUQPHQW KDV ZRUNHG
over the past twenty years to increase
literacy and education, as well as imple-
menting a successful family planning
In the small island country of Bah- but research done indicates that repro- program. Social policies enacted include
rain, primary health and maternity ser- ductive information and contraceptive the legalization of the import and sale of
vices are provided free of charge in needs are all met to an adequate extent. contraceptives, limitation of families to
public hospitals and health clinics. As a Egypt, among several other coun- only three children, and legalization of
result, the maternal mortality rate is ex- tries, though, suffer from a common regulated abortion.
ceedingly low: 0.22 per 1000 live births, DQG GHYDVWDWLQJ KXUGOH $ VLJQLÀFDQW The Middle East is truly an interesting
compared to the 2000 world average of disparity in services offered to the rich region for the future of healthcare. Gen-
0.44 per 1000. Girls are given the same metropolitan areas, and poor rural areas. GHULQHTXDOLWLHVLQÁXHQFHGE\WUDGLWLRQDO
access as boys to childhood healthcare. Although government hospitals provide cultural norms are being combated by
Guidelines for maternity care and in- free healthcare services, their facilities efforts to modernize health care by mak-
formation on contraceptives, as well as are woefully underequipped. This leads ing it equal and free for all. Although the
other health services are given, free of more traditional views of women to road towards modernization and com-
charge, to all women. Although it is un- VWLÁHDQ\PRGHUQL]LQJDWWHPSWWRHTXDO- plete gender equality seems long and
common for a woman to make the de- ize their healthcare. Additionally, the daunting, we can be optimistic that the
cision without the permission of her lack of adequate resources for women in future will only bring better things. As
spouse, women in Bahrain are given ac- rural areas of Middle Eastern countries technology advances, the gap in wealth
cess to family planning services indepen- greatly increases the risk of serious ill- between rural areas and metropolitan ar-
dently. ness from relatively common, harmless eas is likely to decrease as their modes of
The extensive welfare system in Ku- SURFHGXUHV )RU H[DPSOH VXUYH\V DQG contact increase. A trend towards stron-
wait allows the government to offer health demographics released in 2000 ger infrastructure will create improved
health services to all citizens at a minimal show that maternal mortality rates in transportation routes. As our medical
cost. Women in Kuwait can make inde- rural sections of Egypt are twice those knowledge continuously improves, sim-
pendent decisions about their health and of morality rates in metropolitan areas, pler and more effective treatment meth-
reproduction, and are given full and equal despite a two-decade long campaign to ods might be able to more easily trickle
access to health care services at govern- improve health facilities nationwide. from metropolitan areas to rural ones.
ment run clinics and hospitals, often at In Libya, a woman’s reproductive
little or no cost. Kuwait does not have a health is considered to be a family af- Vincent Yu is a sophomore in Jonathan Edwards
government sponsored family program, fair. While contraception is available, College.
Women
on Waves The Abortion Rights Movement Sets Sail
BY ALEXA SASSIN
´ Every eight minutes a woman dies

needlessly as a result of an unsafe il-
OHJDO DERUWLRQµ UHDGV WKH IDFWV SDJH RI Gomperts’s strategy is to
no means of obtaining abortion ser-
vices. She developed a mobile abortion
clinic that can be easily transported onto
the Women on Waves website. Women stir up controversy with her a ship. Aboard the ship, WoW also pro-
on Waves (WoW) is a Dutch pro-choice vides contraceptives, information, train-
QRQSURÀWRUJDQL]DWLRQRQDPLVVLRQWR visit and to ignite debate ing, and workshops in addition to safe
´HPSRZHU ZRPHQ SUHYHQW XQZDQWHG that may eventually lead to and legal abortions. When the ship is in
pregnancy, reduce suffering, and liberal- international waters, at least 12 miles off
L]HWKHODZµE\SURYLGLQJIDPLO\SODQQLQJ a reversal in the legislation the coast, the local anti-abortion laws
information and abortion services to against abortion. do not apply. Gomperts’s strategy is to
women living in countries where abor- stir up controversy with her visit and to
tion is illegal. What distinguishes WoW ignite debate that may eventually lead to
from other family planning centers like a reversal in the legislation against abor-
Planned Parenthood is the fact that the restrictive abortion laws. The majority tion.
early medical abortions and counsel- of these countries are located in Latin In October of 2008, Gomperts and
ing sessions take place not on land but $PHULFD$IULFDDQG$VLD,Q&KLOHIRU her onboard doctors sailed to Spain to
rather on a boat in open waters. To cir- example, an illegal abortion is a criminal provide medical abortions using a cock-
cumvent the laws that prohibit women offense punishable by jail time. These tail of two drugs—mifepristone and
from obtaining abortion procedures in anti-abortion laws are rooted in Pope misoprostol. Mifepristone terminates
their places of residence, WoW sails to Pius IX’s decree in 1869 that ensoule- the pregnancy and misoprostol helps ex-
the countries where abortion is illegal. ment occurs at conception. Thus, laws pel the unborn fetus. Spain’s pro-life ap-
Aboard the ship, the organization as- in the 19th century prohibited the termi- proach to abortion stems from its deeply
VHUWV WKDW ´HDUO\ PHGLFDO DERUWLRQV FDQ nation of pregnancy. These laws from URRWHG KLVWRU\ RI &DWKROLFLVP ZKLFK
be provided safely, professionally, and two centuries ago form the basis of the holds abortion to be a grave evil. It
OHJDOO\µ :R: KRSHV WR DYHUW XQVDIH legislation against abortion that still ex- wasn’t until 1985 that abortions in cases
DERUWLRQVDQGLQFLWHZRPHQ´WRH[HUFLVH ists in numerous developing countries of rape, deformity of the fetus, or men-
their human rights to physical and men- today. While many developed countries WDOXQÀWQHVVRI WKHZRPDQZHUHGHFULP-
tal autonomy by combining free health- relaxed their abortion laws in the 50s, inalized in Spain. Gomperts teamed up
care services and sexual education with 60s, 70s, and 80s with the rise of hu- with 33 different Spanish activist groups
DGYRFDF\µ man rights movements, the countries to create a hotline for women seeking
Approximately 25% of the world’s in which abortion is still illegal retained abortion and transported the women 17
population lives in countries with very their colonial era laws. miles off the coast of Spain. Her efforts
Rebecca Gomperts founded Women garnered the media’s attention and ignit-
LEFT Dr. Rebecca Gomperts, founder of Women on Waves on Waves in 1999 to ease the suffering ed the push to liberalize Spain’s abortion
of women in these countries who had laws. In 2009, the Socialist government >>
from having an abortion are still termi-
nating their pregnancies through illegal
means. These illegal abortions have
caused upwards of 67, 000 deaths and
5 million hospitalizations worldwide
every year.
To me, the fact that they

want to limit other people’s
ability to make their own
decisions will always be
unacceptable.
Dr. Rebecca Gomberts,

Women on Waves
However, recent changes to Dutch

abortion laws have prompted WoW to
cancel all upcoming trips. Until May
18, 2009, WoW was allowed to provide
pills for early abortions based on written
permission from the then Dutch health
PLQLVWHU(OV%RUVW&XUUHQWO\KRZHYHU
the Dutch government is limiting the
distribution of abortion pills to spe-
cially approved clinics only. Gomperts
has refocused her energy on founding
Women on Web, a company registered
LQ&DQDGD7KLVZHEVLWHDOORZVZRPHQ
to order the abortion pill online after
answering questions from a doctor, who
also checks for contraindications before
ABOVE A Chilean abortion hotline advertisement established by Women on Waves.
writing the prescription. The pills are
> began working on a law that would al- 2007, Gomperts’s efforts paid off when mailed in a discrete envelope.
low abortion for pregnancies through Portugal’s parliament was given the Even though Gomperts is striving to
WKHIRXUWHHQWKZHHN7KHODZZRQÀQDO green light to make the country’s strict make abortion safer for women every-
DSSURYDORQ)HEUXDU\DQGWRRN DQWLDERUWLRQ ODZV PRUH ÁH[LEOH 7ZR where, she is doubtful that rapproche-
effect on July 5, 2010. \HDUVODWHULQWKH(XURSHDQ&RXUW ment between proponents and oppo-
Gomperts’s WoW ship has also taken of Human Rights ruled that Portugal nents of abortion will ever occur. Says
her and her team to Ecuador, Portugal, had violated WoW’s right to freedom of *RPSHUWV´,WKLQNLWLVLPSRVVLEOHIRU
Ireland, and Poland. In 2004, the Por- expression with the naval blockade. proponents and opponents of abortion
tuguese government used two military Research completed by the World to ever come together. We’re talking
warships to block WoW from entering Health Organization makes it clear that about two entirely different philoso-
Portuguese ports. Gomperts responded efforts to make abortion safer, such as phies here. There is no room for dis-
by establishing an informational hotline those of WoW, are in desperate need. cussion. To me, the fact that they want
that helped women obtain medical abor- Abortion rates have been found to be to limit other people’s ability to make
WLRQV7KHPHGLDÀUHVWRUPWKDWHQVXHG consistent across the globe regardless their own decisions will always be unac-
over her campaign and the subsequent of whether or not there is a prohibi- FHSWDEOHµ
blockade helped prompt Portugal to re- tive law against abortion in place. This
examine the country’s abortion laws. In indicates that women who are barred Alexa Sassin is a sophomore in Davenport College.
The Individual Mandate in Rwanda:
Mutuelles and the

push for universal
coverage
BY ADITYA MAHALINGAM-DHINGRA
As Rwanda zeroes in on universal healthcare coverage for its citizens, it hits the ceiling of having to develop its infrastructure.
A V WKH JOREDO ÀQDQFLDO FULVLV EULQJV

rising healthcare costs into sharp
focus in many well-developed countries,
prevent its complete dissolution, one of
WKH ÀUVW DFWV RI WKH QHZ SRVWJHQRFLGH
regime was to implement patient cost-
DQGWKH\DUHDGPLQLVWHUHGE\QRQSURÀW
local authorities. The mutuelles use an in-
novative tier system of risk-sharing, with
more and more leaders are asking the sharing to Rwanda’s health plan. As a local risk-pools for primary care, district-
question of how to provide low-cost result of the marginal increase in costs, wide pools for secondary care, and a
health insurance to an entire population. primary care utilization dropped to 23% nationwide all-encompassing insurance
Answers may come from some surpris- by 2001, and HIV/AIDS as well as other pool for tertiary care. This system theo-
ing places; Rwanda has been on a two- infectious diseases were spreading. retically allows government administra-
and-a-half decade journey to achieve In 2001, the Rwandan government tors to target their primary and preven-
universal, nationally-subsidized health- drafted a new plan for community-based tative interventions locally.
care. Despite the massive setback of one health insurance. Preventative services The plans are subsidized by the Rwan-
of the worst genocides in recent history, would be provided for all Rwandans at dan government as well as a variety of
it has achieved some surprising success- no cost, and curative medical treatment DLGDQGÀQDQFLDOLQVWLWXWLRQVVRWKDWVXE-
es, although complicated by some last- would be made affordable through vol- scribers’ premium contributions amount
mile cost issues. untary community health insurance to only 50% of the program’s funding.
plans. While forms of health insurance Annual premiums are thus relatively
Introduction for curative services had existed prior modest, even by Rwandan standards –
to the formation of community-based 2007 estimates are US $1.81 per person,
Prior to the Rwandan genocide, the plans, they were restricted to civil em- RU DERXW 5ZDQGDQ )UDQFV $V D
1988 Bamako Initiative set the country ployees, excluding the majority of Rwan- comparison, medical bills for neonatal
on a path towards a decentralized and dans from any kind of coverage until the FDUHRI DSUHPDWXUHFKLOG´FDQFOLPEWR
locally-based health infrastructure that new health plan was introduced. 5ZDQGDQ )UDQFVµ DV UHSRUWHG
could provide free health care to all by IntraHealth International. Amazingly,
Rwandans. The 1994 genocide, however, Mutuelles less than 1% of the mutuelles program’s
set an end to the peacetime prosperity funding comes from foreign develop-
that had fueled the rise of the nascent The new insurance plans are known ment partners, with the rest contrib-
national health system. In an effort to as mutuelles de santé, or simply mutuelles, uted by various organs of the Rwandan >>
PHOTO Mutuelles, Rwandan
insurance plans, are subsidized
by the Rwandan government
and have effectively pooled
health risks across a large
population to maintain costs.
> government and transfers from the civil The Copayment Debate
service-based insurance programs.
The mutuelles program has met with Some other thoughts were put for- The mutuelles use an inno-
notable success; perhaps because of its ward by the Norwegian People’s Aid vative tier system of risk-
community-based, grassroots forma- (NPA) in a 2005 evaluation of its ongo-
tion and its affordability, the plans have ing aid commitments in Rwanda’s Gise- sharing.
seen high rates of uptake. Out-of-pocket nyi district. While on the one hand, the
spending has decreased, and primary NPA recognized the importance of a In the same article, Dr. Ruxin brings
care utilization has increased as a result KLJK PHPEHUVKLS EDVH WR WKH ÀQDQFLDO up another crucial consideration. Be-
of the program, which has enjoyed con- stability of the program at large and cause access is somewhat limited in
tinued and increasing support from the therefore encouraged mutuelles authori- Rwanda, care-seeking typically involves
Rwandan government and involved aid ties to cover premium costs for poorer long trips with high opportunity costs
organizations. Rwandans’ widespread subscribers, they also worried about the in missed work time. Overcoming these
participation in the mutual insurance SRVVLELOLW\RI PRUDOKD]DUG&RSD\PHQWV EDUULHUVLVGLIÀFXOWHQRXJKZKLFKPDNHV
schemes is unique in the region; accord- the principal tool for ensuring that sub- LW GLIÀFXOW WR LPDJLQH WKDW DGGLWLRQDO
ing to Laurent Musango of the World scribers do not abuse their subsidized PRQHWDU\ FRSD\V DUH UHTXLUHG WR ÀJKW
+HDOWK 2UJDQL]DWLRQ ´5ZDQGD LV WKH KHDOWKLQVXUDQFHSRVHWKHODUJHVWÀQDQ- VXSSRVHG ´RYHUXVHµ E\ 5ZDQGD·V SRRU
only country in sub-Saharan Africa in cial barrier to participating in the mutu- subscribers.
which 85% of the population partici- elles scheme for many Rwandans. The
pates in mutual insurance programmes NPA worried that, without coinsurance Conclusion
IRUWKHLUKHDOWKFRYHUDJHµ of any kind, poor subscribers might en-
JDJHLQÁDJUDQWDEXVHRI WKHLUIUHHFRY- Despite its shortcomings, Rwanda’s
Financial Barriers to Uptake erage. The report therefore argued that, mutuelles program has provided consid-
HYHQIRUWKHSRRUHVWVXEVFULEHUV´VPDOO HUDEOH EHQHÀWV WR SXEOLF KHDOWK LQ WKH
Despite the program’s successes, it co-payments must be applied to avoid country. According to a study published
continues to struggle with serious cost- H[FHVVLYHXVHRI WKHKHDOWKVHUYLFHVµ in the 2008 WHO Bulletin, members of
related last-mile complications. In an These changes may counter the com- WKH FRPPXQLW\ LQVXUDQFH SODQV ´ZHUH
effort to push the remaining uninsured plaints of some critics that the mutuelles 1.7 times more likely to get treated for
into mutuelles plans, Rwanda established program is more like an additional health fevers in modern facilities; three times
an individual mandate requiring resi- tax than an insurance system due to its more likely to take children with diarrhea
dents to have some form of health in- ÁDWIHH FRPSXOVRU\ FRQWULEXWLRQ DQG to a health facility and/or treat them
surance in April of 2008. However, the its management which is directly con- with oral rehydration salts at home; twice
poorest segments of the population trolled by the Ministry of Health. as likely to make four or more prenatal
DUH IDFLQJ FRQVLGHUDEOH ÀQDQFLDO EDUUL- Others suggest going in the opposite visits; and twice as likely, if pregnant or
ers, and currently there is no system of direction, proposing even more progres- younger than 5 years, to sleep under an
subsidies or premium-waiving for these sive measures. Dr. Josh Ruxin of The LQVHFWLFLGHWUHDWHGQHWµ
LQGLYLGXDOV ´,Q WKH SRRUHVW UHJLRQV RI Access Project, writing for the New $FFRUGLQJ WR WKH VDPH VWXG\ ´GLV-
5ZDQGD WKHUH DUH SHRSOH ZKR DUH ÀQG- York Times, noted that: WDQFH ZDV DOVR D VLJQLÀFDQW QHJDWLYH
LQJ LW GLIÀFXOW WR SD\ IRU WKH mutuelles,µ predictor for the utilization of many
Partners in Health’s community health The Millennium Villages project VHUYLFHVSDUWLFXODUO\DVVLVWHGGHOLYHULHVµ
GLUHFWRU 'LGL %HUWUDQG )DUPHU QRWHG supports a Rwandan-managed health It is thus important to place the success
Several solutions have been proposed, center in Mayange where – due to of Rwanda’s coverage expansion in the
but among the most obvious ones would extreme poverty – co-pays are not context of its serious access and deliv-
be to make payments to the program required and the health mutuelle pre- ery shortages. Rwandans’ distance from
scalable based on ability to pay. Adélio PLXPLVVXEVLGL]HG3DXO)DUPHUDQG their nearest providers, a function of
)HUQDQGHV$QWXQHVDQDQDO\VWZLWKWKH Partners in Health have recently ad- the country’s acute provider shortage,
WHO’s Department of Health Sys- opted a similar approach . . .). The is a further barrier to care that mutuelles
WHPV )LQDQFLQJ KDV QRWHG WKDW ´HYHQ results have been impressive: nearly cannot solve. The wonder of universal
LQDFRXQWU\OLNH5ZDQGDµZLGHLQFRPH 100 percent of community mem- coverage in Rwanda cannot come about
GLVSDULWLHV H[LVW DQG ´RQH PD\ ZDQW WR bers have health mutuelle and consider before the much greater miracle of lift-
search for opportunities to increase the health care their right. Utilization ing the country out of poverty has been
contribution of better-off households rates have increased dramatically but achieved.
and to support the access of the poor staff report that they have not seen a
ZLWKWKRVHPRQLHVµ single case of abuse. Aditya Mahalingam-Dhingra is a junior in Ezra
Stiles College.
Flu in the Mountains of Co
O n a sixty-degree day, I felt like it
was at least one hundred. To be
precise, like it was 102.5. In the middle
the United States. The local doctor came
to my hostel room, something increas-
ingly rare here at home. Moreover, the
of an eight-week sojourn to the cloud care that I received was incredibly inex-
forests of Monteverde, high in the cen- pensive, at least by American standards.
WUDOPRXQWDLQVRI &RVWD5LFD,KDGIDOOHQ In total, I paid exactly $10 out of pocket,
LOOZLWKDEDGÁXWKDWNHSWPHEHGULGGHQ about the equivalent of a nice dinner at a
for three days in the summer of 2008. local restaurant.
Surprisingly, my experience was com- &RVWD5LFDEOHVVHGZLWKUHODWLYHSURV-
parable to times when I was sick back SHULW\ ZKHQ FRPSDUHG WR LWV &HQWUDO
KRPH LQ 1HZ <RUN &LW\ ,Q DQ LVRODWHG American neighbors, provides universal
town with a population of only about healthcare to its citizens. As a tourist, I
6500, there was a fully functional doc- clearly did not qualify for taxpayer-sub-
WRU·VRIÀFHDQGDZHOOVWRFNHGSKDUPDF\ sidized healthcare. Nevertheless, I found
A doctor, competent and professional, that my insurance, UnitedHealthcare,
quickly diagnosed my condition and pre- was readily accepted.
scribed the requisite drugs, which the As anybody who has read the classic
pharmacy delivered directly to my room Spanish short story Vuelva Usted Mana-
in a local hostel. ña will tell you, bureaucracy in the Span-
I recovered quickly, thanks to the two- ish-speaking world is notorious for its
pronged attack of acetaminophen and LQHIÀFLHQFLHV (YHU\WKLQJ VWHUHRW\SLFDO
WKH &RVWD 5LFDQ HTXLYDOHQW RI FKLFNHQ about paper-pushing is present: there are
soup—fresh fruit consumed in large IRUPVWREHÀOOHGRXWLQWULSOLFDWHZDLW-
quantities. With generalizations about ing in long lines to get the appropriate
poor healthcare in developing countries, VWDPSVDQGRIÀFLDOVZKROHDYHIRUORQJ
especially in rural areas, I was pleasantly siestas in the middle of the afternoon.
VXUSULVHG WR ÀQG P\ WUHDWPHQW DQG UH- However, I found quite the opposite to
FRYHU\ WR EH HIÀFLHQW DQG SDLQOHVV MXVW EHWUXHWKHUHZDVOHVVUHGWDSHLQ&RVWD
like it would have been at home. Rica than back home. That being said,
In many respects, the care that I re- however, I did not require a visit to a
FHLYHG LQ &RVWD 5LFD ZDV HYHQ VXSHULRU hospital, which my local friends told me
to the care that I could have received in would involve a very long wait. In fact,
ABOVE Monteverde, Costa Rica. Photo: Oliver Neumann
osta Rica BY PATRICK TOTH
the manager of my hostel told me that
he once had to wait for an entire day in
order to get a broken leg set in a cast!
This is, according to most of my lo-
cal friends, the main problem with the
&RVWD 5LFDQ KHDOWKFDUH V\VWHP %\ WKH
vast majority of their stories, its quality is
H[FHOOHQW/LIHH[SHFWDQF\LQ&RVWD5LFD
is actually a bit greater than life expec-
tancy in the United States by a narrow
margin of 0.1 years. However, several re-
porters have revealed long waiting times
for simple surgeries, including upwards
RI WKLUW\ÀYHGD\VIRUDKLSUHSODFHPHQW
In contrast, if one breaks their hip in the
United States and requires a hip replace-
ment, it would generally be performed
within two to three days at most.
&RVWD 5LFDQ KHDOWKFDUH PD\ QRW EH
without its problems. However, it shines
LQ PDQ\ UHVSHFWV &RVWD 5LFDQV RI DQ\
income are covered under the country’s
universal healthcare plan, and the coun-
try spends only 7% of GDP on health-
care per year, as opposed to the United
States’ 15%! My experience of being sick
LQ&RVWD5LFDZLWKWKHH[FHSWLRQRI WKH
sickness itself, was completely positive,
DQG UHÁHFWV WKH VWUHQJWK DQG UHOLDELOLW\
RI WKH&RVWD5LFDQKHDOWKFDUHV\VWHP
Patrick Toth is a freshman in Morse College.
Doubled Over
in Paradise
BY NICOLE NEGBENEBOR
Negbenebor shares about suffering from food poisoning during a trip to egypt.
I swallowed a monster. Tearing at the

inner lining of my stomach walls, the
lamb and eggplant dish sent me into a
sine a beautiful nightmare (no Beyoncé).
Natives warned me about the richness
of the food and how I would probably
two-day downward spiral brimming with get food poisoning at least once some-
tablespoons of Pepto-Bismol, nausea, and time during my trip. I laughed at the
sprints to the nearest bathroom. Do not warnings. Since my stomach had been
get me wrong. My trip to Egypt was one through everything from spoiled milk
RI WKH PRVW PDJQLÀFHQW OLIHFKDQJLQJ to the spiciest food in New Orleans, I
HYHQWV , KDYH H[SHULHQFHG &OLPELQJ WKH knew that Egyptian food would be just
pyramids, walking barefoot on white san- another thread in my dinner napkin. If
dy beaches, and riding two-humped cam- only I had known that on the third day
els were just a few activities that created of the trip, an upscale restaurant would
paradise in this African country. I walked serve me my kryptonite. Juicy, succu-
pass the gorgeous people on the streets lent, and gleaming in a sweet glaze—the
and attempted to formulate a plan for lamb on the plate before me became the
how I could stay there forever. Yes, Egypt immediate object of my culinary desire.
was a sweet dream but, unfortunately, the I ignored the neighboring fried bataatis
food poisoning I contracted made its cui- and vegetables to take full advantage of
Joel Abroad/Flickr
the sautéed mound of meat. so I turned a stall into my own private cu- within the four walls of my hotel room
One bite and I was in Heaven; one bicle and began reading all the words on and stuck to ordering food from room
minute later and I was in Hell. The nau- the back of the Pepto-Bismol bottle—es- service. The worst thing about being sick
sea crept up on me so that by the sixth pecially the recommended dosage for a overseas was not the pervasive nausea or
bite I gave up on attempting friendly ta- twenty-four hour period. My rendezvous diarrhea, but the fear that I would not
ble conversation for fear that more than in Egypt was put on hold until symptoms JHWZHOOLQWLPHWRÀQLVKWKHWULS,WZDV
just words would spill out of my mouth. began to desist with the help of plenty of not until the third day that the light at
I looked down the length of the table bottled water and prayer. Although the the end of my food poisoned tunnel
and noticed a few of my fellow travelers healthcare system in Egypt is excellent in freed me from perpetual bathroom runs.
also slow down in their eating pace, but its ability to offer quality clinical service, Thankfully, by that afternoon, I was back
when it feels like your internal organs are the tour leader suggested that I hold off to my sightseeing ways with only a few
at war, what’s going on around you is the on seeing a doctor since my condition was lingering signs of what happened days
last of your concerns. considered typical for travelers with mild before. Renewed, weary of any dish with
After three sequential trips to the bath- food poisoning. Only if my symptoms lamb, and excited for the rest of the trip,
room, a bottle of Pepto-Bismol from were to persist for several more days did I was ready to continue exploring my
someone’s suitcase was chugged without he suggest that I should seek the refuge paradise.
avail. Soon there came a time when leav- of a hospital.
ing the bathroom was an ill-advised move, )RU WZR GD\V , H[SORUHG WKH VLJKWV Nicole Negbenebor is a junior in Saybrook College.
yalemedlaw.com

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Editor-in-Chief Abraar Karan LETTER FROM THE EDITOR

This journal is published by Yale University students. Yale University is

writing. editing. business. research. design.

04. A Right to Care: TABLE OF

16. Medical Malpractice: 30. One Child, No Healthcare:

41.9 years 33.3 million 9.4 million 894 million

Exploring the relationships between

A new drug to treat HIV is set to be

Countries in GREEN, designated

An analysis and commentary about the WHO’s Healthcare Systems rankings.

I n 2000, the World Health Report’s

Essential Medicines The Crisis in Developing Countries BY ANNE BOZIK

O n June 29, 1999, four Guatemalans

T he black market for organs has long

 Ronit Abramson is a sophomore in Ezra Stiles Col-

RIGHT The annual UAB/

LEFT You have the power

T he intersection between the practice

A ccording to the latest World Health

Lessons from the embarked upon a weighty mission at

Brazilian Approach to the Development Goals, which included: an

The Gates Foundation’s role in

struction on hygiene and sanitation must

HIV stigmatization and high

ALL THREE Photos from

A recent report by IBM titled Health-

T he Middle East is popularly con-

´ Every eight minutes a woman dies

To me, the fact that they

Dr. Rebecca Gomberts,

However, recent changes to Dutch

Mutuelles and the

A V WKH JOREDO ÀQDQFLDO FULVLV EULQJV

ABOVE Monteverde, Costa Rica. Photo: Oliver Neumann

 Patrick Toth is a freshman in Morse College.

I swallowed a monster. Tearing at the

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Ronit Abramson is a sophomore in Ezra Stiles Col-

Patrick Toth is a freshman in Morse College.