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PubMed1993

The evolution of medicine as a profession. A 75-year perspective.

The profession of medicine has changed dramatically in 75 years. Despite the commitment of individual practitioners to the highest ideals of professionalism, the profession itself has lost privilege, power, and public reputation. It has been toppled from the high moral ground of professionalism. This has happened not so much because individual clinicians have abandoned that ground, but largely because others have occupied it--primarily complex organizations that have developed public mandates to regulate and oversee health care. The issue is not one of unfeeling physicians--it is one of a health care system that has evolved so as to limit medicine's autonomy. This changing system places new constraints and pressures on the physician-patient relationship. The question we are left with is whether medicine can regain its professionalism. How do we reform a system that, by its complexity, has become amoral? The only way is for physicians to re-assume a stout position of advocacy--advocacy for individual patients in a complex and frightening system of care, advocacy for patients as a class of people in a political system that seeks to restrict care, advocacy for patients in a world of environmental and epidemic threats. Such advocacy requires an equally strong moral commitment to the principles of service. Acting in the patient's best interest is not enough. It requires that the profession avoid the appearance of blatant self-interest at every turn. It requires a revised commitment to political activism in the interest of service to patients as a community. The costs are extremely high--but the alternative, physicians-as-technicians and medicine as a slave to corporate and government interests, is hardly acceptable.

History, 20th Century↗
PubMed2002

Patterns of violence in Karachi, Pakistan.

OBJECTIVES: Government reports on violence in developing countries are almost universally based upon police data, which are typically incomplete and unreliable. Violence in Karachi was evaluated using ambulance service, not police, records. SETTING: Karachi, Pakistan. METHODOLOGY: The study was based on a case series of persons suffering from intentional injuries and transported by Edhi, the largest emergency service in Karachi, between October 1993 and January 1996. Main outcome variables were injury and death rates. RESULTS: Edhi Ambulance Service transported 4,091 intentionally injured persons during the 29 month period from October 1993 to January 1996. Ninety five per cent (n=3,864) were males; 74% (n=2,823) were 20 to 40 years of age, and 2,400 (58%) died before reaching the hospital. Firearms were the most common mode of injury (n=3,396, 83%). Forty six per cent (n= 1,828) of violent injuries occurred in four neighborhoods of Karachi--22% in Korangi (n= 884) and 8% each in Orangi (n=337), Malir Colony (n=307), and Nazimabad (n=300). On the 32 days when a political strike was called, more people were injured (mean = 10.4 v 5.0 persons, p=0.01) and killed (mean 6.6 v 3.9 persons, p<0.01) compared with days without a political strike. CONCLUSION: Violence is a major public health problem in Karachi, affecting predominantly wage earners. At least some of the violence is rooted within the political system. Detailed study of the causes of violence that explains the role that political and ethnic tensions play, may suggest strategies to lessen the toll of violence.

Adult↗
PubMed1978

Organizational complexity in family practice: a sociological model of a family practice group.

The growth of a family practice goup is presented as a case study. Enlarging size and increasing functions require organizational change--from solo to collegial to bureaucratic to political systems. Organizational theory distinguishes between the characteristics and functions of individual, collegial, bureaucratic, and political organizations. Different styles and strategies are appropriate at different stages.

Decision Making↗
PubMed2000

What happens to the state in conflict?: political analysis as a tool for planning humanitarian assistance.

It is now part of received wisdom that humanitarian assistance in conflict and post-conflict situations may be ineffective or even counterproductive in the absence of an informed understanding of the broader political context in which so-called 'complex political emergencies' (CPEs) occur. Though recognising that specific cases have to be understood in their own terms, this article offers a framework for incorporating political analysis in policy design. It is based on a programme of research on a number of countries in Africa and Asia over the last four years. It argues that the starting-point should be an analysis of crises of authority within contemporary nation-states which convert conflict (a feature of all political systems) into violent conflict; of how such conflict may in turn generate more problems for, or even destroy, the state; of the deep-rooted political, institutional and developmental legacies of political violence; and of the difficulties that complicate the restoration of legitimate and effective systems of governance after the 'termination' of conflict. It then lists a series of questions which such an analysis would need to ask--less in order to provide a comprehensive check-list than to uncover underlying political processes and links. It is hoped these may be used not only to understand the political dynamics of emergencies, but also to identify what kinds of policy action should and should not be given priority by practitioners.

Africa↗
PubMed1995

It's the institutions, stupid! Why comprehensive national health insurance always fails in America.

We argue that the United States does not have comprehensive national health insurance (NHI) because American political institutions are biased against this type of reform. The original design of a fragmented and federated national political system serving an increasingly large and diverse polity has been further fragmented by a series of political reforms beginning with the Progressive era and culminating with the congressional reforms of the mid-1970s. This institutional structure yields enormous power to intransigent interest groups and thus makes efforts by progressive reformers such as President Clinton (and previous reform-minded presidents before him) to mount a successful NHI campaign impossible. We show how this institutional structure has shaped political strategies and political outcomes related to NHI since Franklin D. Roosevelt. Finally, we argue that this institutional structure contributes to the antigovernment attitudes so often observed among Americans.

Attitude to Health↗
PubMed1989

Developing wellness programs: a nurse-managed Stay Well Center for senior citizens.

This article describes the process from conception to implementation of developing a nurse-managed wellness center for senior citizens. The center was established in a federally subsidized high rise residential complex in midtown Manhattan. The unique senior population living in this New York City community includes a large proportion of performing artists. These individuals are struggling to maintain ties to their community at a time when their most productive performing years have passed. A health needs assessment was designed to evaluate whether or not these seniors were interested and would participate in a nurse-managed wellness center. The strategies needed to propose and move the project forward through all systems are explored. Two clinical nurse specialists assessed the need, proposed the center, and guided it through several political systems while maintaining leadership to establish a viable and innovative hospital-based health center based on prevention.

Aged↗
PubMed1980

Conference report. Patient re-entry into the community.

The National Assoication of Private Psychiatric Hospitals, in cooperation with 19 other national health-related associations, held a conference last June in Washington, D.C., on the issues involved in patient re-entry into the community. Representatives of the legal and medical professions, the insurance industry, allied health and mental health organizations, and federal, state, and local officials discussed the complex legal, social, and treatment problems that have resulted from the national movement of deinstitutionalization. As a start toward solving those problems, most of the speakers mentioned the need for partnerships among state, local, federal, and private providers, between the hospitals and community-based facilties, and among all mental health professionals. Several speakers emphasized the need for an effective advocacy system for the mentally ill and the need for mental health professionals to learn to use the political system in order to secure benefits for patients re-entering the community.

Chronic Disease↗
PubMedDate not supplied

Vaccine policies across the pond: looking at the U.K. and U.S. systems.

Major differences exist in the immunization programs of the United Kingdom and the United States. If one believes that most health policy decisions in Western industrialized democracies are political, then many of the differences may seem to reflect the variance in the nature of political systems. However, each program has unique components that appear paradoxical, and what works in one society will not necessarily work in another. Those who seek to substitute portions of one vaccine system with those of another must appreciate the context within which each functions.

Culture↗
PubMed1980

The problem of monopoly power in federal health policy.

Federal programs to regulate health care providers appear to have contradictory objectives, indicating ambivalence toward group power in American political philosophy. The conflict between monopoly-creating monopoly-destroying strategies is demonstrated through three attempts to integrate professional power into a democratic political system.

Democracy↗
PubMed2003

Policy without politics: the limits of social engineering.

The extent of coverage provided by a country's health services is directly related to the level of development of that country's democratic process (and its power relations). The United States is the only developed country whose government does not guarantee access to health care for its citizens. It is also the developed country with the least representative and most insufficient democratic institutions, owing to the constitutional framework of the political system, the privatization of the electoral process, and the enormous power of corporate interests in both the media and the political process. As international experience shows, without a strong labor-based movement willing to be radical in its protests, a universal health care program will never be accepted by the US establishment.

Capitalism↗
PubMed1996

Dimensions of accountability for not-for-profit hospitals and health systems.

This article examines four dimensions of accountability as they apply to not-for-profit hospitals and health systems: political accountability, particularly relating to the retention of tax-exempt status; commercial accountability associated with the nonprofit hospital's role of selling low cost and high value health services to a variety of commercial payers; community accountability in terms of addressing community health and other social needs, and clinical/patient accountability in terms of access and quality outcomes.

Community-Institutional Relations↗
PubMed2006

Interests, relationships, identities: three central issues for individuals and groups in negotiating their social environment.

This chapter begins with a summary of a model, developed half a century ago, that distinguishes three qualitatively different processes of social influence: compliance, identification, and internalization. The model, originally geared to and experimentally tested in the context of persuasive communication, was subsequently applied to influence in the context of long-term relationships, including psychotherapy, international exchanges, and the socialization of national/ethnic identity. It has been extended to analysis of the relationship of individuals to social systems. Individuals' rule, role, and value orientations to a system--conceptually linked to compliance, identification, and internalization--predict different reactions to their own violations of societal standards, different patterns of personal involvement in the political system, and differences in attitude toward authorities and readiness to obey. In a further extension of the model, three approaches to peacemaking in international or intergroup conflicts are identified--conflict settlement, conflict resolution, and reconciliation--which, respectively, focus on the accommodation of interests, relationships, and identities, and are conducive to changes at the level of compliance, identification, and internalization.

Attitude↗
PubMed1992

Teaching health policy and politics in U.S. schools of public health.

Because most public health endeavors in the United States are funded by the public sector, public health practitioners need to be adept at working within the political system. However, the 1988 Institute of Medicine report, The Future of Public Health, found that many public health professionals are ignorant or disdainful of political processes and will not participate in activities that they perceive to be political. Our study examined the health policy and politics curricula of the 24 accredited schools of public health in the U.S., finding that most public health students are not exposed to these areas during their graduate coursework. Moreover, those students who do take health policy and politics courses study these areas within the context of health care delivery; the politics of public health and prevention are ignored by most schools of public health. Recommendations for improving public health curricula in health policy and politics are presented, including linkages with prevention activities.

Curriculum↗
PubMed1995

HIS priorities in developing countries.

Looking for a solution to fulfill the requirements that the new global economical system demands, developing countries face a reality of poor communications infrastructure, a delay in applying information technology to the organizations, and a semi-closed political system avoiding the necessary reforms. HIS technology has been developed more for transactional purposes on mini and mainframe platforms. Administrative modules are the most frequently observed and physicians are now requiring more support for their activities. The second information systems generation will take advantage of PC technology, client-server models and telecommunications to achieve integration. International organizations, academic and industrial, public and private, will play a major role to transfer technology and to develop this area.

Costs and Cost Analysis↗
PubMed2005

Re-emergence of trichinellosis in southeastern Europe due to political and economic changes.

The countries of southeastern Europe including the Balkan region and bordering countries - Albania, Bulgaria, Bosnia and Herzegovina, Croatia, Greece, Hungary, Macedonia, Romania, Serbia and Montenegro, Slovenia, and the European part of Turkey - occupy a very important strategic position and represent a land bridge between Europe and Asia. In the majority of southeastern European countries, cases of trichinellosis among the human and animal populations were described in the late 19th or early 20th centuries. Trichinella infections among wildlife were also described in the aforementioned countries. Today, the prevalence of trichinellosis is different between the Balkans and bordering countries. A high prevalence of trichinellosis in domestic animals and humans has been reported in Bulgaria, Serbia and Montenegro, Romania and Croatia. A moderate prevalence was found in Bosnia and Herzegovina. In Hungary, human trichinellosis has not been present for a long period of time. However, sporadic cases were recorded in swine over the last 2 years. Trichinellosis has not been found among domestic animals and humans in Greece and Macedonia in recent years while in Turkey and Slovenia human trichinellosis is sporadic. The re-emergence of trichinellosis is connected with the changes in the social and political systems in Bulgaria and Romania. In Serbia and Montenegro as well in Croatia, however, a re-emergence of trichinellosis was due not only to political and social changes but also to wars that took place in these countries during the last years of the 20th century. Social, economic and political factors responsible for the re-emergence of trichinellosis in southeast European countries are discussed in this communication.

Animals↗
PubMed2005

State health policy making determinants, theory, and methods: a synthesis.

The American states exhibit considerable differences in health policy and market characteristics. Not only do they display substantial variation in spending, but they also display substantial variation in the strategies chosen to control costs, improve access, and ensure quality care. This article synthesizes studies that use 50-state statistical techniques to model policy adoption in the health sector. The purpose is to assess the strengths and weaknesses of this literature, to place it in the context of comparative state policy research generally, and to identify factors that best predict 17 health policy outcomes at the state level. A database was assembled containing 245 equations abstracted from 63 studies published between 1975 and 2002. Some predictors (such as income, aged population, public opinion, and nursing home beds) were studied much more frequently than others (e.g., education, divided government, federal Medicaid mandates, other states' adoptions). Results show that 43 of the 87 policy making determinants examined consistently predict two or more state-level outcomes, including four that predict five outcomes (non-white, urban, income, unemployment), two that predict six (tax capacity/effort, hospital beds), and two that predict seven (nursing home beds, liberal public opinion). Gaps are shown to exist in our understanding of the policy making effects of political system and intergovernmental characteristics.

Financing, Government↗
PubMed2005

Modernizing UK health services: 'short-sharp-shock' reform, the NHS subsistence economy, and the spectre of health care famine.

Modernization is the trend for societies to grow functionally more complex, efficient and productive. Modernization usually occurs by increased specialization of function (e.g. division of labour, such as the proliferation of specialists in medicine), combined with increased organization in order to co-ordinate the numerous specialized functions (e.g. the increased size of hospitals and specialist teams, including the management of these large groups). There have been many attempts to modernize the National Health Service (NHS) over recent decades, but it seems that none have significantly enhanced either the efficiency or output of the health care system. The reason may be that reforms have been applied as a 'drip-drip' of central regulation, with the consequence that health care has become increasingly dominated by the political system. In contrast, a 'short-sharp-shock' of radical and rapid modernization seems to be a more successful strategy for reforming social systems - in-between waves of structural change the system is left to re-orientate towards its client group. An example was the Flexner-initiated reform of US medical education which resulted in the closure of nearly half the medical colleges, an immediate enhancement in quality and efficiency of the system and future growth based on best institutional practices. However, short-sharp-shock reforms would probably initiate an NHS 'health care famine' with acute shortages and a health care crisis, because the NHS constitutes a 'subsistence economy' without any significant surplus of health services. The UK health care system must grow to generate a surplus before it can adequately be modernized. Efficient and rapid growth in health services could most easily be generated by stimulating provision outside the NHS, using mainly staff trained abroad and needs-subsidized 'item-of-service'-type payment schemes. Once there is a surplus of critically vital health services (e.g. acute and emergency provision), then radical modernization should rapidly improve the health service by a cull of low-quality and inefficient health care providers.

Efficiency, Organizational↗