Improving antibiotic prescribing for children in the resource-poor setting.

Antibiotics are a critically important part of paediatric medical care in low- and middle-income countries (LMICs), where infectious diseases are the leading cause of child mortality. The World Health Organization estimates that >50% of all medicines are prescribed, dispensed or sold inappropriately and that half of all patients do not take their medicines correctly. Given the rising prevalence of antimicrobial resistance globally, inappropriate antibiotic use is of international concern, and countries struggle to implement basic policies promoting rational antibiotic use. Many barriers to rational paediatric prescribing in LMICs persist. The World Health Organization initiatives, such as 'Make medicines child size', the Model List of Essential Medicines for Children and the Model Formulary for Children, have been significant steps forward. Continued strategies to improve access to appropriate drugs and formulations, in conjunction with improved evidence-based clinical guidelines and dosing recommendations, are essential to the success of such initiatives on both a national and an international level. This paper provides an overview of these issues and considers future developments that may improve LMIC antibiotic prescribing

Maritime security and nuclear cargoes

Civilian nuclear operations entail the transportation of sometimes substantial quantities of radioactive material. These can range from large quantities of weakly radioactive fresh fuel for power reactors, with the corresponding removal of highly radioactive spent fuel and operational wastes, to the shipment of small quantities of radioactive isotopes (“sources”) for medical, industrial or research purposes and their subsequent disposal. In relation to the civilian nuclear fuel cycle, there may also be relatively large quantities of radioactive material produced by “back-end” activities, such as the reprocessing of spent fuel to recover plutonium and then create mixed oxide, or MOX, fuel.1 In between these extremes, there are occasional consignments of fresh and spent fuel to and from research reactors, together with the associated wastes. In many of these cases, circumstances will dictate that consignments are dispatched overland, or by air, but there are some cases where a substantial maritime component is entailed and where there will be particular security and safety concerns that arise from that. Traditionally, the focus of this concern has been on the possibility of accidents, which might result in environmental contamination or human harm, but more recently, and certainly since 11 September 2001, the locus of concern has somewhat shifted to risks that might arise from the activities of non-state armed groups, or terrorists (or even pirates). This is the focus of the present review

Biological Terrorism, Emerging Diseases, and National Security

Examines the extent to which bioterrorist attacks have proven or may prove difficult to distinguish from outbreaks of emerging diseases. Makes recommendations for how the U.S. could better prepare to meet the threat of biological terrorism

Pandemic Influenza: Ethics, Law, and the Public\u27s Health

Highly pathogenic Influenza (HPAI) has captured the close attention of policy makers who regard pandemic influenza as a national security threat. Although the prevalence is currently very low, recent evidence that the 1918 pandemic was caused by an avian influenza virus lends credence to the theory that current outbreaks could have pandemic potential. If the threat becomes a reality, massive loss of life and economic disruption would ensue. Therapeutic countermeasures (e.g., vaccines and antiviral medications) and public health interventions (e.g., infection control, social separation, and quarantine) form the two principal strategies for prevention and response, both of which present formidable legal and ethical challenges that have yet to receive sufficient attention. In part II, we examine the major medical countermeasures being being considered as an intervention for an influenza pandemic. In this section, we will evaluate the known effectiveness of these interventions and analyze the ethical claims relating to distributive justice in the allocation of scarce resources. In part III, we will discuss public health interventions, exploring the hard tradeoffs between population health on the one hand and personal (e.g., autonomy, privacy, and liberty) and economic (e.g., trade, tourism, and business) interests on the other. This section will focus on the ethical and human rights issues inherent in population-based interventions. Pandemics can be deeply socially divisive, and the political response to these issues not only impacts public health preparedness, but also reflects profoundly on the kind of society we aspire to be

Trust and Betrayal in the Medical Marketplace

The author argues in this Comment that disingenuity as first resort is an unwise approach to the conflict between our ex ante and our later, illness-endangered selves. Not only does rationing by tacit deceit raise a host of moral problems, it will not work, over the long haul, because markets reward deceit\u27s unmasking. The honesty about clinical limit-setting that some bioethicists urge may not be fully within our reach. But more candor is possible than we now achieve, and the more conscious we are about decisions to impose limits, the more inclined we will be to accept them without experiencing betrayal

Rehabilitating antisocial personalities: treatment through self-governance strategies

Offenders with antisocial personality disorder (ASPD) are widely assumed to reject psychotherapeutic intervention. Some commentators, therefore, argue that those with the disorder are better managed in the criminal justice system, where, following the introduction of indeterminate sentences, engagement with psychological treatment is coercively linked to the achievement of parole. By comparison, National Institute of Clinical Excellence guidelines on the management and treatment of ASPD recommend that those who are treatment seeking should be considered for admission to specialist psychiatric hospitals. The rationale is that prison-based interventions are underresourced, and the treatment of ASPD is underprioritised. The justification is that offenders with ASPD can be rehabilitated, if they are motivated. One problem, however, is that little is known about why offenders with ASPD seek treatment or what effect subsequent treatment has on their self-understanding. The aim of this paper is to address these unresolved issues. It draws on the findings of Economic and Social Research Council (ESRC) funded qualitative study examining the experiences of sentenced male offenders admitted to a specialist personality disorder ward within the medium secure estate and the medical practitioners who treat them. The data are analysed with reference to Michel Foucault’s work on governmentality and strategy in power relations. Two arguments are advanced: first, offenders with ASPD are motivated by legal coercive pressures to implement a variety of Foucauldian-type strategies to give the false impression of treatment progress. Second, and related, treatment does not result in changes in self-understanding in the resistive client with ASPD. This presupposes that, in respect of this group at least, Foucault was mistaken in his claim that resistive behaviours merely mask the effectiveness of treatment norms over time. Nevertheless, the paper concludes that specialist treatment in the hospital setting can effect changes in the resistive offender’s self-understanding, but not if the completion of treatment results, as is commonplace, in his prison readmission