Global health ethics: critical reflections on the contours of an emerging field, 1977–2015

Abstract Background The field of bioethics has evolved over the past half-century, incorporating new domains of inquiry that signal developments in health research, clinical practice, public health in its broadest sense and more recently sensitivity to the interdependence of global health and the environment. These extensions of the reach of bioethics are a welcome response to the growth of global health as a field of vital interest and activity. Methods This paper provides a critical interpretive review of how the term “global health ethics” has been used and defined in the literature to date to identify ethical issues that arise and need to be addressed when deliberating on and working to improve the discourse on ethical issues in health globally. Results Selected publications were analyzed by year of publication and geographical distribution, journal and field, level of engagement, and ethical framework. Of the literature selected, 151 articles (88%) were written by authors in high-income countries (HIC), as defined by the World Bank country classifications, 8 articles (5%) were written by authors in low- or middle-income countries (LMIC), and 13 articles (7%) were collaborations between authors in HIC and LMIC. All of the articles selected except one from 1977 were published after 1998. Literature on global health ethics spiked considerably from the early 2000s, with the highest number in 2011. One hundred twenty-seven articles identified were published in academic journals, 1 document was an official training document, and 44 were chapters in published books. The dominant journals were the American Journal of Bioethics (n = 10), Developing World Bioethics (n = 9), and Bioethics (n = 7). We coded the articles by level of engagement within the ethical domain at different levels: (1) interpersonal, (2) institutional, (3) international, and (4) structural. The ethical frameworks at use corresponded to four functional categories: those examining practical or narrowly applied ethical questions; those concerned with normative ethics; those examining an issue through a single philosophical tradition; and those comparing and contrasting insights from multiple ethical frameworks. Conclusions This critical interpretive review is intended to delineate the current contours and revitalize the conversation around the future charge of global health ethics scholarship

Access to care for childhood cancers in India: perspectives of health care providers and the implications for universal health coverage.

BACKGROUND: There are multiple barriers impeding access to childhood cancer care in the Indian health system. Understanding what the barriers are, how various stakeholders perceive these barriers and what influences their perceptions are essential in improving access to care, thereby contributing towards achieving Universal Health Coverage (UHC). This study aims to explore the challenges for accessing childhood cancer care through health care provider perspectives in India. METHODS: This study was conducted in 7 tertiary cancer hospitals (3 public, 3 private and 1 charitable trust hospital) across Delhi and Hyderabad. We recruited 27 healthcare providers involved in childhood cancer care. Semi-structured interviews were audio recorded after obtaining informed consent. A thematic and inductive approach to content analysis was conducted and organised using NVivo 11 software. RESULTS: Participants described a constellation of interconnected barriers to accessing care such as insufficient infrastructure and supportive care, patient knowledge and awareness, sociocultural beliefs, and weak referral pathways. However, these barriers were reflected upon differently based on participant perception through three key influences: 1) the type of hospital setting: public hospitals constituted more barriers such as patient navigation issues and inadequate health workforce, whereas charitable trust and private hospitals were better equipped to provide services. 2) the participant's cadre: the nature of the participant's role meant a different degree of exposure to the challenges families faced, where for example, social workers provided more in-depth accounts of barriers from their day-to-day interactions with families, compared to oncologists. 3) individual perceptions within cadres: regardless of the hospital setting or cadre, participants expressed individual varied opinions of barriers such as acceptance of delay and recognition of stakeholder accountabilities, where governance was a major issue. These influences alluded to not only tangible and structural barriers but also intangible barriers which are part of service provision and stakeholder relationships. CONCLUSION: Although participants acknowledged that accessing childhood cancer care in India is limited by several barriers, perceptions of these barriers varied. Our findings illustrate that health care provider perceptions are shaped by their experiences, interests and standpoints, which are useful towards informing policy for childhood cancers within UHC

Sustainable care for children with cancer: a Lancet Oncology Commission.

We estimate that there will be 13·7 million new cases of childhood cancer globally between 2020 and 2050. At current levels of health system performance (including access and referral), 6·1 million (44·9%) of these children will be undiagnosed. Between 2020 and 2050, 11·1 million children will die from cancer if no additional investments are made to improve access to health-care services or childhood cancer treatment. Of this total, 9·3 million children (84·1%) will be in low-income and lower-middle-income countries. This burden could be vastly reduced with new funding to scale up cost-effective interventions. Simultaneous comprehensive scale-up of interventions could avert 6·2 million deaths in children with cancer in this period, more than half (56·1%) of the total number of deaths otherwise projected. Taking excess mortality risk into consideration, this reduction in the number of deaths is projected to produce a gain of 318 million life-years. In addition, the global lifetime productivity gains of US$2580 billion in 2020-50 would be four times greater than the cumulative treatment costs of$594 billion, producing a net benefit of $1986 billion on the global investment: a net return of$3 for every $1 invested. In sum, the burden of childhood cancer, which has been grossly underestimated in the past, can be effectively diminished to realise massive health and economic benefits and to avert millions of needless deaths

Is IL-5 suppression sufficient to control eosinophilic airway allery?: studies of experimental allergic rhinitis in IL-5 deficient mice

No abstract available

The Moral Foundations of Child Health and Social Policies: A Critical Interpretive Synthesis

Background: Allusions to the uniqueness and value of childhood abound in academic, lay, and policy discourse. However, little clarity exists on the values that guide child health and social policy-making. We review extant academic literature on the normative dimensions of child health and social policy to provide foundations for the development of child-focused public policies. Methods: We conducted a critical interpretive synthesis of academic literature on the normative dimensions of child health and social policy-making. We employed a social constructivist lens to interpret emergent themes. Political theory on the social construction of target populations served as a bridge between sociologies of childhood and public policy analysis. Results: Our database searches returned 14,658 unique articles; full text review yielded 72 relevant articles. Purposive sampling of relevant literature complemented our electronic searches, adding 51 original articles, for a total of 123 articles. Our analysis of the literature reveals three central themes: potential, rights, and risk. These themes retain relevance in diverse policy domains. A core set of foundational concepts also cuts across disciplines: well-being, participation, and best interests of the child inform debate on the moral and legal dimensions of a gamut of child social policies. Finally, a meta-theme of embedding encompasses the pervasive issue of a child’s place, in the family and in society, which is at the heart of much social theory and applied analysis on children and childhood. Conclusions: Foundational understanding of the moral language and dominant policy frames applied to children can enrich analyses of social policies for children. Most societies paint children as potent, vulnerable, entitled, and embedded. It is the admixture of these elements in particular policy spheres, across distinct places and times, that often determines the form of a given policy and societal reactions to it. Subsequent work in this area will need to detail the degree and impact of variance in the values mix attached to children across sociocultural contexts and investigate tensions between what are and what ought to be the values that guide social policy development for children

‘The problem is small enough, the problem is big enough’: a qualitative study of health technology assessment and public policy on drug funding decisions for children

Abstract Background Public policy approaches to funding paediatric medicines in developed public health systems remain understudied. Current approaches to HTA present a variety of conceptual, methodological and practical problems in the context of child health. This study explores the technical and sociopolitical determinants of public funding decisions on paediatric drugs, through the analysis of interviews with stakeholders involved in or impacted by HTA for child health technologies at the provincial and national levels in Canada. Methods We undertook in-depth interviews with a purposive sample (n = 22) of stakeholders involved with or affected by drug funding decisions for children at the provincial (Ontario) and national levels in Canada. Grounded theory methods were employed to guide data collection and analysis. Theory on ‘technology-as-policy’ and the sociopolitics of health technologies served as sensitizing concepts for inductive data coding and analysis. Emergent themes informed the development of conceptual and practical insights on social values and system dynamics related to child HTA, of relevance to public policymaking on the coverage of health technologies for children in Canada. Results Participant reflection on the normative and systems dimensions of drug funding for children formed two broad categories: HTA paradigms and sociopolitical context. Our analysis revealed notable differences of context and substance related to child health technology production, evaluation and use. These differences spanned the major phases of HTA (from assembly to assessment to integration) and the surrounding sociopolitical milieu (from markets to governance to politics). Careful analysis of these differences sets in relief a number of substantive and procedural shortcomings of current HTA paradigms in respect of child health. Our findings suggest a need to rethink how HTA is structured and operationalized for child health technologies. Conclusions Current approaches to health technology assessment are not well calibrated to the realities of child health and illness. Our study presents a nuanced and contextually grounded analysis of concepts instrumental to drug funding decisions for children. The insights generated are directly applicable to the Canadian and Ontario contexts, but also yield fundamental knowledge about HTA for children that are germane to drug policy in other health systems

Trends in investigations of abuse or neglect referred by hospital personnel in Ontario

Background; There is a dearth of literature surrounding mandated reporters to child welfare services in the Canadian context. This paper examines 20 years of reporting patterns from hospitals, which represent 5% of all referrals to child welfare services in Ontario. Methods: The Ontario Incidence Study of Reported Child Abuse and Neglect (OIS) is a representative study that has taken place every 5 years since 1993. The OIS is a multistage cluster sample design, intended to produce an estimate of reported child abuse and neglect in the year the study takes place. Results: There have been significant changes in referral patterns over time. Hospital referrals in 2013 are more likely to involve a concern of neglect, risk of maltreatment or exposure to intimate partner violence. In 1993, children were more likely to be referred from a hospital for a concern of physical abuse. Between 1993 and 1998, there was a significant drop in the number of sexual abuse investigations referred from a hospital. Hospitals have low rates of substantiation across all of the OIS cycles. Conclusion: This is the first study to examine hospital based referral patterns in Canada. The relatively low percentage of hospital referrals across the cycles of the OIS is consistent with the extant literature. The findings warrant further discussion and research. This study is foundational for future research that can assist in identifying and developing responses across sectors that meet the complex needs of vulnerable families and that ultimately promote children’s safety and well-being.Funding for the Ontario Incidence Study was provided by the Ontario Ministry of Children and Youth Services, Government of Ontario, and support for this secondary analysis was provided through a Social Sciences and Humanities Research Council Connections Grant (no: 611-2015-0137)

Pathogenesis of Murine Experimental Allergic Rhinitis: A Study of Local and Systemic Consequences of IL-5 Deficiency

Recent studies have demonstrated an important role for IL-5-dependent bone marrow eosinophil progenitors in allergic inflammation. However, studies using anti-IL-5 mAbs in human asthmatics have failed to suppress lower airway hyperresponsiveness despite suppression of eosinophilia; therefore, it is critical to examine the role of IL-5 and bone marrow responses in the pathogenesis of allergic airway disease. To do this, we studied the effects of IL-5 deficiency (IL-5-/-) on bone marrow function as well as clinical and local events, using an established experimental murine model of allergic rhinitis. Age-matched IL-5+/+ and IL-5-/- BALB/c mice were sensitized to OVA followed by 2 wk of daily OVA intranasal challenge. IL-5-/- OVA-sensitized mice had significantly higher nasal mucosal CD4+ cells and basophilic cell counts as well as nasal symptoms and histamine hyperresponsiveness than the nonsensitized group; however, there was no eosinophilia in either nasal mucosa or bone marrow; significantly lower numbers of eosinophil/basophil CFU and maturing CFU eosinophils in the presence of recombinant mouse IL-5 in vitro; and significantly lower expression of IL-5Rα on bone marrow CD34+CD45+ progenitor cells in IL-5-/- mice. These findings suggest that IL-5 is required for normal bone marrow eosinophilopoiesis, in response to specific Ag sensitization, during the development of experimental allergic rhinitis. However, the results also suggest that suppression of the IL-5-eosinophil pathway in this model of allergic rhinitis may not completely suppress clinical symptoms or nasal histamine hyperresponsiveness, because of the existence of other cytokine-progenitor pathways that may induce and maintain the presence of other inflammatory cell populations