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EDITOR'S CHOICE: Trish Groves Make health inequality history BMJ 2007; 335: 0 [Full text]

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Poor pay for their poverty with their lives!

BM Hegde   (29 October 2007)

Who can alleviate poverty?

Sridhar Srinivasan   (31 October 2007)

'SICKO'

Rini Paul   (31 October 2007)

Note on the cover image for this theme issue on poverty and health

Trish Groves   (1 November 2007)

Health Inequalities - a personal view of the Rwandan healthcare system.

Sheo B Tibrewal   (20 November 2007)

Secrets of health

Dr Sumithra Josepha   (10 March 2008)

Poor pay for their poverty with their lives! 29 October 2007
BM Hegde, Retd. Vice Chancellor Mangalore-575004. India. Send response to journal: Re: Poor pay for their poverty with their lives!	Dear Editor, As in any calamity, it is the poorest of the poor that are hit the hardest. The cyclones in Bangla Desh in 1970 and in 1991 killed nearly 300,000 and 139,000 people respectively whereas the Hurricane Andrew in the US in 1992, which was equally ferocious, killed a meager 55 people. The poor have less coping capacity. The estimated number of hungry people in the twenty-first century, if the climatic change is not controlled forthwith, is estimated to be around 80-90 million, mostly in the poorer countries. Health Care expenditures in the US have reached 14% of the Gross National Product and a staggering $1.6 trillion in 2003. No wonder, one might be tempted to think that with such an appalling record of efficacy and such an unbelievable death rate for the treatments routinely administered, the current medical system can only be said to be in great need of deep reform. Health needs of humankind, rich or poor, are very few: clean drinking water, three square healthy meals uncontaminated, clean surroundings for dwelling, tranquility of mind, and moderate exercise on a regular basis. None of these is the concern of modern medicine. Health is our birthright. Our inbuilt immune system will keep us going as long as it could. In the unlikely event of it failing only should doctors intervene to “cure rarely, comfort mostly, but console always.” Modern medicine’s biggest curse has been “not letting the well alone.” Screening the healthy for early diseases and intervening has been the bane of modern medicine although it has been a boon to the industry-the medi-business. One should see his/her doctor at the first sign of anything going astray with one’s body or mind, but not when one hundred per cent fit. The greatest discovery of science in this century has been the discovery of man’s ignorance. After independence Indian leaders paid scant respect for the indigenous systems of medical care that existed and evolved successfully over Centuries through observational research. They opted, instead, for the western model of medical care. Consequently, today India has one of the most privatized medical care systems in the world. Although we need robust public health infrastructure to eradicate illnesses and poverty, we are going in the opposite direction. India uses a meager 0.9% of its GDP for public health while the share of the corporate and private hospitals in India is one of the highest in the world at 78.4%. Only Azerbaijan, Myanmar, and Burundi spend less than we do. Cambodia, Togo, Sudan and Guinea, in addition to the above three countries, spend slightly more than we for private medical care do. While poverty is the womb of all illnesses, most of which could be prevented by better standards of living, we seem to depend on our corporate “five star” hospitals for medical care after the illnesses hit- inverse care law. Even the poor opt for private care out of sheer compulsion. A recent World Bank publication notes that only 0.02% patients use public hospitals in Bihar, India whilst the highest 2.8% use them in Kerala. Many of these giant corporate hospitals get billions of rupees in benefit to provide 30% of free beds for poor. Alas, that does not happen in practice. The poor end up having private hospital bills as an important debt trap. Many of the suicides by poor people result from this. Bihar and some of its neighbouring states still harbor the deadly visceral leishmaniasis-Kala-Azar. While this could easily be eradicated by a neat house without crevices to prevent the carrier sand fly from breeding during the rains and better nutrition, those with the disease end up today mostly in private hospitals for terminal care spending thousands. Since we have given up our national economic strategy in favour of making India a “magnet for attracting foreign investments through privatization, social spending cuts and deregulation”, public spending on health care fell sharply to less than 1% of the GDP! Before 1991 it was 6%. We pride ourselves as the best country for “health” tourism. It is, in fact, medical tourism. The US today has the worst medical care scenario among the 14 industrialised countries. The new movie by Michael Moore, SICKO, released in London on the 26th October will give graphic details of the sorry state of affairs in the US. Let us not replicate the US medical care system in other parts of the world. Poor countries’ health care needs are clean drinking water, three square meals a day uncontaminated by animal and/or human excreta, toilets and other sanitary facilities, economic empowerment of village women, smoke free clean houses, better education and late marriage of the girl child. The following data will give the reader the relative importance of poverty. While World Trade Centre bombing killed 2,863 people and AIDS affects 40 million in the world, 824 million are hungry in this world on a given day and 630 million are very poor! The present Indian medical education is geared to produce doctors fit to work either in our corporate hospitals or in foreign countries. They are not trained to work in our villages. We need urgent correction to the medical curriculum to incorporate the wealth of the best in the local systems, like Ayurveda, Siddha, Unani, Homeopathy, Yoga and Naturopathy in an integrated system for future graduates after authenticating such methods with modern scientific research methodologies. Many of our tribals have such effective remedies for many illnesses that need to be harnessed and studied in detail. Here, of course, we have to scientifically pick the wheat from the chaff. The poor, all over the world, pay for their poverty with their lives even in the 21st Century! Yours ever, bmhegde Competing interests: None declared
Who can alleviate poverty? 31 October 2007
Sridhar Srinivasan, Speciality Registrar Portsmouth Hospitals NHS Trust, Southwick Hill Road, Portsmouth PO6 3LY Send response to journal: Re: Who can alleviate poverty?	One trillion dollars, the money we have spent in 2005 on defence with USA responsible for 48% of the world's total distantly followed by UK, China, France and Japan. Although China and India, the world's two emerging economic powers have demonstrated an increase in military expenditure of 26% and 7% respectively between 1996-2005 their current spending is only a fraction of the USA's in actual terms. USA in the corresponding 10 year period has increased it's defence expenditure by a whooping 165%. [1] The United Nations and all its agencies and funds spend about $20 billion each year, or about $3 for each of the world’s inhabitants. This is a very small sum compared to most government budgets and it is just a tiny fraction of the world’s military spending. Yet for nearly two decades, the UN has faced a financial difficulties and it has been forced to cut back on important programs in all areas. Many member states have not paid their full dues and have cut their donations to the UN’s voluntary funds. As of October 31, 2006, members’ arrears to the Regular Budget topped $661 million, of which the United States alone owed $526 million (80% of the regular budget arrears). [1] UN Financial Crisis, Global Policy Forum http://www.globalpolicy.org/finance/ and http://www.globalissues.org/Geopolitics/ArmsTrade/Spending.asp (accessed February 25, 2007 Competing interests: None declared
'SICKO' 31 October 2007
Rini Paul, Salaried GP and Assistant to Year Leads 3 and 5 at Kings College Medical School E7 0QH Send response to journal: Re: 'SICKO'	This themed episode of the BMJ struck a chord with me. Recent events have made me focus on inequalities in the health service. Michael Moore's film 'Sicko' about the American health system reveals shocking facts, 1/6 of the population (50million) denied healthcare, the poor and middle classes unable to afford healthcare when necessary. His view of the NHS and other 'socialised' medical systems (such as in France and Cuba) were one sided. He highlighted the principles which i strongly believe in-free,good quality and equitable medical care but none of the daily difficulties we face. After 5 years working as a full time GP the inequities are more apparent to me. Young GPs struggle to get partnerships, female GPs still face prejudice in male dominated systems,how GPs run practices and are paid are manipulated to win elections, threats of private healthcare loom and alternate providers have started to present themselves. As Iona Heath and Tumwine suggest in articles in this issue money is so tied into targets and payments that sometimes this detracts from the other issues at hand. GPs (recent surveys reveal) feel similarly to their collegues in developing countries, over worked, under valued and demotivated with constant threats and uncertainties. Many of us would no longer recommend medicine or general practice as a career. Concrete action is required. Let us show that we still care and believe in the core values and founding principles of the NHS. We will not be paid for attending the mass rally this Saturday 3rd November in London- but that's not what we're all about anyway. Let us strive towards preserving the NHS we have created and work within and move away from a two tiered private system as exists in the States. I love the NHS...hope to see you there. Competing interests: None declared
Note on the cover image for this theme issue on poverty and health 1 November 2007
Trish Groves, deputy editor BMJ Send response to journal: Re: Note on the cover image for this theme issue on poverty and health	We intended, but failed, to explain the map shown on this cover. With apologies to Worldmapper and to readers frustrated by the lack of explanation. Here's the missing information: Cover note: Health in an unequal world. The map shows the world shaped with area in proportion to the deaths of children between the ages of 1 and 4 inclusive (2002 data) (http://www.worldmapper.org/display.php?selected=263). Some 3.2 million children of these ages die a year, every year. Competing interests: I was the editor of this theme issue
Health Inequalities - a personal view of the Rwandan healthcare system. 20 November 2007
Sheo B Tibrewal, Consultant Orthopaedic Surgeon Queen Elizabeth Hospital NHS Trust, Stadium Road, Woolwich, London SE18 4QH Send response to journal: Re: Health Inequalities - a personal view of the Rwandan healthcare system.	Having been involved in Project Umubano, I was able to gain a personal insight into the healthcare system in Rwanda. Rwanda remains one of the poorest countries in the world. More than 60% of the total population are below the poverty line and 42% of the population live in extreme poverty. The genocide of 1994 has left a horrific legacy with a significant reduction in the number of adult men, a large number of orphans and many households without permanent shelter, a reduction in small scale family farming and an increase in the prevalence of AIDS, loss of human resources and infrastructure. Although there has been steady economic growth of over 10% on an average annually, the real GDP per capita is 230 US dollars. The healthcare is provided by a mixture of public, private and traditional healthcare systems which are supported by the government, development partners, non governmental organisations and the civil society. AIDS and malaria place the greatest burden on the health system and economy of the country. The prevalence of HIV/AIDS amongst the adult population is estimated at 13.2% in the capital town of Kigali, 6.3% in other urban areas and 3.1% in rural zones. Malaria accounts for at least 40% of all consultations in health centres with a fatality rate of 10.12% in district hospitals and 2.7% in health centres (data collected by the Government of Rwanda in 1991). Diseases associated with childbirth are responsible for high rates of maternal mortalities. The contributory factors include low rate of female literacy and underutilisation of family planning services as well as prenatal and delivery services. The combination of neonatal causes, pneumonia, malaria, diarrhoea, HIV/AIDS and malnutrition accounts for a large part of the levels of infant and child mortality in the country. The numbers of tuberculosis cases increase year by year partly as a result of an outbreak of the disease linked to the spread of HIV/AIDS but also because of improvements in the identification of the cases. The health system has a pyramidal structure, consisting of 3 levels; central, intermediary and peripheral. There are 3 national referral hospitals including Butari Hospital, which has approximately 500 beds, and Kigali Hospital, Central Hospital Kigali, which has 511 beds, and together they make up the University Hospital (CHU) and Ndera Mental Health Hospital. The King Faisal Hospital, which has 141 beds, was created to provide a higher level of technical expertise than that available in the national referral hospitals to both the private and public sector; its role is also to ensure that there is a reduction in the number of transfers abroad. At each district there is a district hospital which is connected with a network of peripheral health centres that are either public, government assisted, non-profit or private. I understand that there are approximately 40 such facilities in the country. At each district hospital there are approximately 4 medically qualified doctors (but no specialists) and some nurses. Each district hospital serves a population between 200,000 to 400,000. In a district general hospital there are usually 150 in-patient beds, some facilities for operative treatment. The facilities vary from one hospital to another. These district hospitals act as the first referral centres for the peripheral health clinics in the rural areas. At the present time, there is approximately one primary healthcare centre per 50,000 population. These healthcare centres are located in remote rural areas where the local population have to walk 6 to 8 miles to attend these healthcare centres. Approximately 50% of these centres are run by missionaries and 50% by the government of Rwanda. The majors issues facing the healthcare system include: Lack of human resources - There is a severe lack of well qualified professionals throughout the country particularly in rural areas (doctors, nurses, healthcare workers, etc). The available healthcare workforce (medical and paramedical and in-service training staff), are mainly deployed in the township areas. There is a need to improve in both the quantity and quality of such staff. Furthermore, the available workforce is poorly motivated because they are poorly paid. Access to treatment/facilities - The poor population are not able to travel as they are unable to pay for their transportation to the nearest healthcare facilities. This is also compounded by the poor infrastructures such as roads, etc, and for a large proportion of the patients the health centres are not close enough for them to walk barefoot to receive the treatment that they need. It is further compounded by the fact that they have no finance to pay for any treatment. Finance - As described above, the population is poor and not able to pay for their services. There is a limited government subsidy for some treatment but currently the government is looking at a number of prepayment insurance schemes to break even with the treatment costs of the health services within the country. It is important to once again record that 75% of the population live in the primary care setting, ie, rural areas, 25% of the population live in the secondary or tertiary care setting, ie, district hospital areas and tertiary care centres, ie, Kigali (approximately 10% of the population live here). The healthcare workers do not want to go and work in the primary care setting because there is not enough incentive for them to be motivated to go to these far remote places and to retain them. A breakdown of problems in finance is as follows: 85% of the population cannot pay for their treatment - 15% cannot pay at all - 35% can pay a little, ie, $1 per year per person - 35% can pay a variable amount between $2 to $10 per year per person and; 15% can pay full costs. Poor infrastructure (roads, electricity, etc) - Although the government has a strategy and policy, there is minimal links between strategy policy, its implementation and monitoring. Costing data - The data on costing of prevention of diseases, diagnosis and treatment and future developments are unclear and insufficient. My suggestions and reflections on the situation are as follows: Finance - The Government of Rwanda needs to prepare accurate data on estimated costs for pump priming funding to tackle the following at the earliest possible opportunity (within 5 years): Prevention of diseases - ie, malaria, AIDS, tuberculosis, respiratory diseases and others. The cost of these would include staffing, drugs and vaccines, fumigation, equipment, infrastructure, maintenance and monitoring. Future development - for the development of human resources at all grades, continuing education, development of further health posts, health centres and district hospitals as planned, equipment, etc. Costing would be required. Once an approximate cost is available, then a pump priming funding should be sought from the international community as well as from the country’s own budget to implement their plans on the basis of immediate need over the next 5 years rather than a longer period, to be able to see the fruits in 12 or 14 years. The difficulty in obtaining pump priming monies from the international community is not underestimated, nonetheless worth trying. The development of human resources - In order for Rwanda to become self-sustainable, there is a clear need for increasing their own capacity by training healthcare workers at all levels locally. At the preset time, there is one medical/nursing school in Butari with limited training opportunities. There would clearly be the need for at least one extra such facility in Kigali or increase the training opportunities in its existing facility at Butari University. Work force - A pump priming exercise maybe used to import doctors, nurses and other paramedics to develop their local workforce and provide a service until their own work force is available to take over. In addition another innovative idea would be to develop visiting professorships and travel fellowships at Rwandan university level attracting individual professionals from the Western as well as Asian worlds to teach and train the local workforce. I would urge that the current medical workforce in Rwanda should enforce the culture of self audit, departmental meetings and CMEs (Continuing Medical Education) on a weekly basis for each hospital/health centre as a self learning tool. The efficacy of such self learning may be regulated by Government agencies, universities or other such agencies as appropriate. The Development of Healthcare Facilities (ie, hospitals, health centres) Primary healthcare posts - these are a good idea and should be cost effective once implemented monitoring will be required. Primary healthcare centres - increased numbers would go a long way in improving the services District General Hospitals - an increase in numbers would help and the major speciality services should be provided including Accident & Emergency, general medicine, urology, orthopaedics, general surgery, gynaecology, paediatrics, eye and ENT. Tertiary centres - increase the quality of services in each speciality; establish cardiac services including paediatric cardiology, catheter laboratories, etc, particularly at King Faisal and Central Hospitals in Kigali and if possible in Butari; establish an oncology service particularly at Kigali; increase the number of beds in all hospitals; cross referral of trauma and other emergencies from the Central Hospital to King Faisal Hospital to be made easier (ie, to make it financially viable for poor people) It would be essential to concentrate on primary care via enhanced nurse training, ie, post secondary school qualification for the prevention and treatment of common, killing diseases. Conclusions In order to develop a self-sustainable healthcare system, it would be essential to obtain and build on the present system both in terms of facilities, ie, healthcare posts/healthcare centres, equipment, capacity and retention as well as development of human resources. An urgent need for reform in the training system to support the programme is required to deliver quality care. Monitoring of this quality care would be essential. Some of the elements of their needs can be met with international collaborations and help, particularly in terms of workforce development and hopefully, financially. This will help Rwanda achieve its mission by the year 2020. Time is of the essence to comprehensively tackle this complex and vast medical unmet need. Urgent help from the international community to help the Rwandan government’s efforts is desperately required on humanitarian grounds. Competing interests: None declared
Secrets of health 10 March 2008
Dr Sumithra Josepha, Doctor,Kundubella,Near Cheranmarey Colony,Bellala,India Bellala,670541 Send response to journal: Re: Secrets of health	The secret of being healthy does not lie in a sophisticated health system but in a sound life and preventive measures.I belong to remote village in kerala called Manimoola where the tribal people live normally up to the age of 90-100.Their secrets of good health I personally feel lie in hard work,simple food and regular prayers to God.Most of them havent even visited a Doctor once in their life time.Even when they die they have a very peaceful death.They usally have a sudden death somewhere in their 90s.I wish some one could look into he lives of these tribal people and take a lesson for all. Competing interests: None declared