Tag Archives: healthcare

Who lives, who dies, who cares?

By Izabela Delabre, University of Reading

Advances in healthcare technologies and pharmaceutical breakthroughs politicise and manipulate our lives.  An article in The Guardian last week describes how French doctors are challenging the patent of a new and highly expensive drug for hepatitis C in an attempt to bring down the price (the drug, Sofosbuvir, made by the pharmaceutical multinational Gilead Sciences, costs $1,000 (£650) a pill for a 10-week course).  It is a cure for the viral infection that can lead to liver cirrhosis, cancer and death.  The struggle against health inequality persists, with large numbers of people lacking access to healthcare.

A new biopolitical regime judges an individual’s ‘worth’ through their economic productivity

A new biopolitical regime judges an individual’s ‘worth’ through their economic productivity. Image credit: Elvert Xavier Barnes Photography via Wikimedia Commons.

Writing in Transactions of the Institute of British Geographers, Emma Whyte Laurie’s article entitled, “Who lives, who dies, who cares? Valuing life through the disability-adjusted life year measurement” provides a critique of the disability-adjusted life year (DALY) measurement. The World Health Organization defines a DALY as one lost year of “healthy” life. It is a measure of overall disease burden, expressed as the number of years lost due to ill-health, disability or early death.  Emma Whyte Laurie argues that DALYs have ‘become normative because many health policy makers and their funding partners use the DALY as their only measure of disease impact in programmatic analysis’ (King and Bertino 2008, 2). DALYs have supported the emergence of an epoch in global health governance whereby resource allocation is justified on the premise of ‘cost-effectiveness’, ‘value for money’ and ‘good return for investment,’ and this is compounded with the global financial climate which has negatively impacted the available budget for health interventions.

DALYs are established on the conceptualisation of individuals as exclusively economic beings, but individuals may fail to live up to the economically productive ‘ideal.’  DALYs may be partly responsible for the devaluation of the lives of certain individuals, by asserting the values of individualism in relation to wider economic gain where, individuals lose humanness when they become poor, and also unproductive.  Emma Whyte Laurie states that the problem may be less associated with DALYs as a measurement in itself, but rather with the faith that has been placed in them by mainstream institutions.

The question of who benefits from health interventions is heavily value-laden. Priority-setting is essentially a political and social process (rather than a scientific one), involving deliberation and public accountability. Through the exact numbers provided by the DALY measurement, important questions of ethics and politics are omitted, potentially hindering important and difficult discussions of setting priorities in the health sector.

Emma Whyte Laurie considers the question posed by Farmer: ‘[if health is a human right, who is considered human enough to have that right?’ (2005, 206). According to Agamben (1998), throughout history, the humanity of living man has been judged by each society, which has decided whose lives have value. Today, these judgements are increasingly based on economic productivity or the pursuit of capital accumulation where certain (wealthier) lives are considered more valuable than others. DALYs reflect this, capturing the ‘disease burden’ through economic loss, but also addressing Farmer’s question as to who is valuable, or who is human enough, to be afforded the right to health.

References

books_icon   Agamben G. (1998). Homo sacer: sovereign power and bare life. Stanford University Press, Stanford CA

60-world2   Boseley S. (2015). Doctors challenge hepatitis C drug patent in price protest. The Guardian, 10 February

books_icon   Farmer P. (2005). Pathologies of power: health, human rights and the new war on the poor. University of California Press, Berkeley CA

books_icon   King C. H. and Bertino A-M. (2008). Asymmetries of poverty: why global burden of disease valuations underestimate the burden of neglected tropical diseases. PLoS Neglected Tropical Diseases 2 e209

books_icon   Laurie E.W. (2015). Who lives, who dies, who cares? Valuing life through the disability-adjusted life year measurement. Transactions of the Institute of British Geographers, 40:1 pp. 75–87.

60-world2   World Health Organization (WHO). Metrics: Disability-Adjusted Life Year (DALY).

Reorganising the NHS: lessons from the past

Norfolk and Norwich University Hospital NHS Trust

In July 2010 the new UK government published a white paper on the National Health Service, Equity and excellence: liberating the NHS, laying out plans for a radical re-organization of the NHS. A key element in the plans is closing the 150 existing PCTs (Primary Care Trusts) and 10 Strategic Health Authorities, and transferring their £80bn healthcare commissioning budget to perhaps 600 consortia of local GPs. The plans aim to save 45% of NHS management costs. Polly Toynbee, writing in The Guardian, notes various criticisms made of the plans, including their transitional cost, the loss of strategic planning, and the likelihood of large healthcare companies moving in to what will become effectively a fully free market in healthcare provision. “GPs favouring local providers can be challenged in court if their consortium rejects a cheaper offer from a loss-leading large company: cue extreme disruption for local hospitals losing out to private bidders.” The plans also risk a radical revision of the relationship between patients and GPs – potentially undermining patient trust: “Once patients suspect GPs’ pay depends on keeping bills low, it spells the end of trust.”

A 2003 paper by John Mohan looked at  the geography of hospital provision in pre-NHS Britain. Whilst most acute hospital treatment was provided by voluntary hospitals, the 1929 Local Government Act had given local authorities the power to provide general hospital services, in addition to duties in relation to the treatment of infectious diseases and care for the chronically sick. There was no national or regional planning (some voluntary cooperation aside), and the timing, location, quality and quantity of both voluntary and municipal provision varied. Continue reading