THE HEALTH CARE FINANCIAL CRISIS: REORGANIZATION AND EVIDENCE-BASED MEDICINE AS A RESPONSE TO AN "UNHOLY TRINITY"

The key issues of the health care system are often conceptualized as involving three basic dimensions: 1) the quality of health care provided, 2) access to the health care system, and 3) the cost of health care. Following two decades of rapidly escalating health costs throughout advanced industrial societies, the relationships among these three dimensions now constitute what has been called an “unholy trinity” in that improvements along one dimension will almost inevitably provoke problems in terms of one or both of the others. This symposium examines two distinct types of reform that have been developed in response to the crisis in health care costs. The first focuses upon attempts to reorganize existing institutions in order to make them more effective and cost‐efficient. The second considers the move toward “evidence‐based medicine,” that is, more critically evaluating health care outcomes to make sure that treatments are effective and cost‐efficient.     

Politicians Using History

The political potency of national history has been understood for generations. Yet there has been an unquestionable surge in history's political influence over the last twenty or thirty years, as the various history wars that have broken out around the world attest. Australia has been no exception: disputes over its national story continue to generate considerable controversy in the media, in politics and in public debate. But how has this politicisation of the past affected Australian political history in the present? This paper examines how history is practised in contemporary Australian politics — and notices an increasingly strategic use of the past by politicians in recent years.     

National unity and reconciliation in Rwanda: A flawed approach?

This article examines the Rwandan government's national unity and reconciliation policy and one of its key elements, the National Unity and Reconciliation Commission (NURC). It contends that while the NURC potentially represents an innovative model that other post-conflict societies could adapt and use, the central premise on which both the commission and the government's broader national unity and reconciliation policy are based is critically flawed. The unity that they are endeavouring to achieve, as a vehicle for reconciliation, relies upon a negation of ethnicity – a core component of the 1994 genocide – and hence does not allow for an open and honest engagement with the past. The problem is further compounded by the government's attitude towards the prosecution of crimes committed by the Rwandan Patriotic Front (RPF), which not only demonstrates that ethnicity remains highly significant but also underscores the incomplete and partial way in which the past is being addressed.     

Using law to fight a silent epidemic: the role of health literacy in health care access, quality, & cost

The dominant rhetoric in the health care policy debate about cost has assumed an inherent tension between access and quality on the one hand, and cost effectiveness on the other; but an emerging discourse has challenged this narrative by presenting a more nuanced relationship between access, quality, and cost. This is reflected in the discourse surrounding health literacy, which is viewed as an important tool for achieving all three goals. Health literacy refers to one's ability to obtain, understand and use health information to make appropriate health decisions. Research shows that improving patients' health literacy can help overcome access barriers and empower patients to be better health care partners, which should lead to better health outcomes. Promoting health literacy can also reduce expenditures for unnecessary or inappropriate treatment. This explains why, as a policy matter, improving health literacy is an objective that has been embraced by almost every sector of the health care system. As a legal matter, however, the role of health literacy in ensuring quality and access is not as prominent. Although the health literacy movement is relatively young, it has roots in longstanding bioethical principles of patient autonomy, beneficence, and justice as well as the corresponding legal principles of informed consent, the right to quality care, and antidiscrimination. Assumptions and concerns about health literacy seem to do important, yet subtle work in these legal doctrines--influencing conclusions about patient understanding in informed consent cases, animating decisions about patient responsibility in malpractice cases, and underlying regulatory guidance concerning the quality of language assistance services that are necessary for meaningful access to care. Nonetheless, health literacy is not explicitly treated as a legally relevant factor in these doctrines. Moreover, there is no coherent legal framework for incorporating health literacy research that challenges traditional assumptions about patient comprehension and decision-making, and that emphasizes the need for providers to improve communication and take affirmative steps to assess patient understanding. The absence of a clear and robust consideration of health literacy in these doctrines undermines core access and quality aims, and it means that such laws are of limited efficacy in promoting health literacy. Returning to the theme that the health literacy problem reflects a complementary view of access, quality and cost, it is likely that the cost implications of this problem (and not concerns about quality and access) will motivate the kind of health literacy reform that may ultimately strengthen existing quality and access standards. One recent example of this can be seen in reforms linked to government, insurer and provider attempts to reduce costly medication errors.     

Grizzly Bear conservation in the Foothills Model Forest: appraisal of a collaborative ecosystem management effort

In west-central Alberta, Canada, an ambitious collaborative conservation program for grizzly bears began in 1999, after extensive controversy over the Cheviot coal mine project and successful negotiation of a unique federal–provincial strategic framework for grizzly bear conservation. Unfortunately that program was effectively terminated without any substantive implementation of its research findings. The regional ecosystem approach for conserving grizzlies in the Foothills Model Forest originated in federal and provincial legislative processes but proved vulnerable to shifting goals and containment by a single powerful participant. This case study’s results demonstrate vulnerabilities of the ecosystem management approach to conserving large carnivores. To enable other such conservation efforts to achieve their goals, we recommend supporting emergent small-scale initiatives and designing collaborative institutions that limit the potential for containment of decision processes.     

The Mental Health of 13–17 Year-Olds in Australia: Findings from the National Survey of Mental Health and Well-Being

The prevalence of 3 mental disorders (Depressive Disorder, Conduct Disorder and Attention-Deficit/Hyperactivity Disorder), the prevalence of mental health problems, and rates of health-risk behaviours among those with problems, along with patterns of service utilisation, are reported for 1490 adolescents aged 13–17 years in Australia. Mental disorders were assessed using the Diagnostic Interview Schedule for Children Version IV completed by parents. Parents and adolescents also completed standard questionnaires designed to assess mental health problems, health-risk behaviours and service use. On the basis of parent reports, 13% of adolescents were identified as having mental health problems, while 19% were identified as having problems on the basis of adolescent reports. Many of the adolescents with mental health problems also had problems in other areas of their lives. Only 31% of those identified by parents as having mental health problems and 20% of adolescents who identified themselves as having problems, had attended a professional service during the 6 months prior to the survey. School counselling was the service most frequently attended. Clinical and population health interventions must take into account the presence of co-morbid problems and low rates of health service usage reported amongst adolescents with mental health problems.

GC-IRD studies on regioisomeric ring substituted methoxy methyl phenylacetones related to 3,4-methylenedioxyphenylacetone

The methoxy methyl phenylacetones share an isobaric relationship (equivalent mass but different elemental composition) to the controlled precursor substance 3,4-methylenedioxyphenylacetone (3,4-methylenedioxyphenyl-2-propanone; 3,4-MDP-2-P). The ten ring substituted methoxy methyl phenylacetones are resolved by capillary gas chromatography on a modified cyclodextrin stationary phase. All ten regioisomeric ketones eluted before the controlled precursor substance 3,4-methylenedioxyphenylacetone. The vapor phase infrared spectra generated from the capillary column effluent clearly differentiated 3,4-MDP-2-P from the various methoxy methyl phenylacetones. Additionally the methoxy methyl phenylacetones provide unique individual infrared spectra. Infrared absorption frequencies and patterns confirmed the relative position of the methoxy-group and the acetone side-chain for the regioisomeric ketones.