Mortality between for profit & not-for profit centres

P. J. Devereaux, MD; Holger J. Sch?nemann, MD, PhD; Nikila Ravindran, BSc; Mohit Bhandari, MD, MSc; Amit X. Garg, MD; Peter T.-L. Choi, MD, MSc; Brydon J. B. Grant, MD; Ted Haines, MD; Christina Lacchetti, MHSc; Bruce Weaver, MSc; John N. Lavis, MD, PhD; Deborah J. Cook, MD, MSc; David R. S. Haslam, MD, MSc; Terrence Sullivan, PhD; Gordon H. Guyatt, MD, MSc

Comparison of Mortality Between Private For-Profit and Private Not-For-Profit Hemodialysis Centers. A Systematic Review and Meta-analysis
JAMA. 2002;288:2449-2457

Context Private for-profit and private not-for-profit dialysis facilities provide the majority of hemodialysis care in the United States. There has been extensive debate about whether the profit status of these facilities influences patient mortality.

Objective To determine whether a difference in adjusted mortality rates exists between hemodialysis patients receiving care in private for-profit vs private not-for-profit dialysis centers.

Data Sources We searched 11 bibliographic databases, reviewed our own files, and contacted experts in June 2001�January 2002. In June 2002, we also searched PubMed using the “related articles” feature, SciSearch, and the reference lists of all studies that fulfilled our eligibility criteria.

Study Selection We included published and unpublished observational studies that directly compared the mortality rates of hemodialysis patients in private for-profit and private not-for-profit dialysis centers and provided adjusted mortality rates. We masked the study results prior to determining study eligibility, and teams of 2 reviewers independently evaluated the eligibility of all studies. Eight observational studies that included more than 500 000 patient-years of data fulfilled our eligibility criteria.

Data Extraction Teams of 2 reviewers independently abstracted data on study characteristics, sampling method, data sources, and factors controlled for in the analyses. Reviewers resolved disagreements by consensus.

Data Synthesis The studies reported data from January 1, 1973, through December 31, 1997, and included a median of 1342 facilities per study. Six of the 8 studies showed a statistically significant increase in adjusted mortality in for-profit facilities, 1 showed a nonsignificant trend toward increased mortality in for-profit facilities, and 1 showed a nonsignificant trend toward decreased mortality in for-profit facilities. The pooled estimate, using a random-effects model, demonstrated that private for-profit dialysis centers were associated with an increased risk of death (relative risk, 1.08; 95% confidence interval, 1.04-1.13; P

Conclusions Hemodialysis care in private not-for-profit centers is associated with a lower risk of mortality compared with care in private for-profit centers.

Palestinian Urgent Appeal – July 16, 2002

THIS IS AN URGENT CALL FOR ALL HUMANITARIAN ORGANIZATIONS WORLWIDE TO INTERVENE IMMEDIATELY

The Union of Palestinian Medical Relief Committees
Urgent Appeal- July 16, 2002

Continuing Curfew Creates Humanitarian Disaster

For nearly a month, two million residents of the West Bank have been under almost constant curfew. This deliberate policy by the Israeli government has created a humanitarian disaster throughout the West Bank. Hospitals, schools, universities as well as civil and governmental institutions have been completely paralyzed. Furthermore, the Israeli-imposed curfew has decimated the economy leaving a considerable percentage of Palestinians under the poverty line and nearing levels of starvation.

The Israeli government’s curfews are intended to, and have succeeded in destroying the socio-economic infrastructure of Palestine. Its collective punishment measures represent a severe violation of international law, and have no justification as security measures.

As such, we are astounded and deeply concerned by the weak response of the international community in denouncing Israel’s creation of this ever-increasing humanitarian crisis.

For more information, please contact Dr. Mustafa Barghouthi at: Medical
Relief – 00972-59-254-218 or consult our new website

Private finance & “value for money”, by A. Pollock et al.

Pollock AM, Shaoul J, Vickers N.

Private finance and “value for money” in NHS hospitals: a policy in search of a rationale?

British Medical Journal, 2002; 324: 1205-1209

Summary points:

The private finance initiative (PFI) brings no new capital investment into public services and is a debt which has to be serviced by future generations.

The government’s case for using PFI rests on a value for money assessment skewed in favour of private finance

The higher costs of PFI are due to financing costs which would not be incurred under public financing

Many hospital PFI schemes show value for money only after risk transfer, but the large risks said to be transferred are not justified

PFI more than doubles the cost of capital as a percentage of trusts’ annual operating income

2002 IAHP/FADSP Mallorca Conference papers

…other papers will be gradually added

13 women flogged in Qom Iran

The state-run daily, Seday-e Edalat, reported yesterday that 13 women were flogged in the city of Qom. Among them were three pairs of sisters. They were each sentenced to 180 lashes.

Flogging women for “prostitution” and “drinking alcohol” and issuing these kinds of barbaric sentences against women come from mullahs who themselves run prostitution and drug trafficking rings and are involved in smuggling women and girls to neighboring countries. The Iranian Resistance has revealed the names of some of these mullahs.

The Women’s Committee of the National Council of Resistance of Iran calls on international human rights and women’s rights organizations to urge the United Nations High Commissioner for Human Rights and the coming session of the General Assembly of the United Nations and other relevant international forums and organizations to take  effective measures and adopt resolutions condemning evil crimes of the mullahs against Iranian women.

Women’s Committee of the National Council of Resistance of Iran.

Legal boost for Dutch abortion ship

The Dutch Government has given the go-ahead to the Women on Waves group to offer the abortion pill to pregnant women on board their boat, Aurora. The Aurora is due to set sail again for countries where abortion is forbidden.

It will dock in international waters and members of Women on Waves will offer advice and treatment to women who come on board.

The group sparked a storm of protest from pro-life activists last year when they docked off the coast of Ireland, where the practice of abortion is illegal. The first stop for the Aurora – sometimes known as the Sea of Change – will probably be back to Ireland, from where 6,000 women travel to England for abortions each year. The Dutch Health Minister, Els Borst, said the decision to allow Women on Waves to give out the abortion pill was in line with government policy regarding the sexual independence of women. Women on Waves are allowed to offer the drug to terminate pregnancies of up to six weeks, provided a gynaecologist is present. However the group say they will appeal against the decision in the hope of being able to offer clinical abortions to women who are up to three months pregnant. The World Health Organization estimates that 100,000 women die each year from illegal back-street abortions.

UPMRC International Voluntary Work Camp in Palestine

UPMRC International Voluntary Work Camp in Palestine

During the current Intifada, the Israeli government’s policies have led to devastation and destruction in all areas of Palestinian life. From September 29, 2000- June 12, 2002, 1,588 Palestinians have been killed, and more than 20,000 injured. In conjunction with its excessive use of force against civilians, the Israeli government has imposed various collective punishment measures that have served to choke the physical, economic, social and political life of Palestinians. These measures include invasions, curfews, strict internal and external closure and the destruction of houses, agriculture and industry. The current crisis emphasizes the need for international support of and solidarity with the Palestinian people. There is much that international volunteers can do to help Palestine. Thus, the Union of Palestinian Medical Relief Committees is sponsoring a weeklong summer work camp for international and local volunteers.

The purpose of the camp is to improve community resources in Palestine and provide an opportunity for internationals to show solidarity with the Palestinian people, while learning about and experiencing life in Palestine under occupation. UPMRC is a grassroots, community-based Palestinian health organization. It is non-profit, voluntary, and one of the largest health NGOs in Palestine. UPMRC’s national health programs emphasize prevention, education, community participation, and empowerment of the Palestinian people.
We are seeking 200 internationals interested in:

a.. Showing solidarity with Palestinians

b.. Participating in voluntary projects that support public institutions in different Palestinian cities, villages and refugee camps

c.. Supporting the Palestinian cause and participating in advocacy for Palestinian rights


The work camp will also have 300 local Palestinian youth volunteers,
as well as 150 Palestinian youth living in Israel.
Through this camp, you will:
a.. Work in solidarity with the Palestinian People
b.. Participate in the restoration of public institutions, schools
and other buildings destroyed during recent Israeli military incursions
c.. Participate in voluntary work in refugee camps such as clearing
rubble and aiding in reconstruction
d.. Help provide access to villages and cities isolated by the
Israeli closure
e.. Meet and work closely with Palestinian youth
f.. At the end of your visit, we hope that you will be able to
educate people in your communities about Palestine and promote international solidarity for the Palestinian people

Location
The camp will primarily be based in El Bireh, which is a suburb of
Ramallah, and volunteers will work both in Ramallah and El Bireh. There will also be options to volunteer for short periods in Nablus and Jenin, as well as in rural areas isolated by Israeli closure.

Duration: August 3-10, 2002

Activities:
Voluntary work
a.. Reconstruction, repair and maintenance in public schools and
public parks, including mural painting, gardening and light construction
b.. Voluntary days in Jenin Refugee camp and Nablus Old City (two
of the areas hit the hardest during the latest Israeli invasion) clearing
rubble and helping to rebuild
Cultural and informative activities
a.. Documentaries
b.. Lectures on political situation
c.. Field visits
d.. Social activities

Entertainment
a.. Musical evenings
b.. Films
c.. Sports
d.. Photo/art exhibit
Transportation:
Participants should fly into Ben Gurion Airport in Tel Aviv.
Expenses:
Work camp fees: $50
Approximate Airfare: US: $800-$1,200
Europe: $500-$800
Requirements:
Participants must be at least 18 years old.

Please fill out the Registration form “Summer Work Camp” and submit it by July 20.

If you have any questions, please contact Ghadeer

More information on UPMRC

For more information on Palestine, please visit

Defending freedom of health services research

Defending independence and freedom of health services research

The work of Prof Allyson Pollock and her team is well known internationally. Her scientifically sound and politically sharp work especially analysing and unmasking the privatisation tactics used by the british government (Private Finance Initiative & Public Private Partnership) produced an unbelievable assault against her by the Commons Health Select Committee.

A debate is ongoing these days with written reactions against the Commons Health Select Committee’s assault on Prof Allyson Pollock’s credibility and on the integrity of her research and findings.

Baleares Declaration for the Defense of Health Care (english / spanish)

THE BALEARES DECLARATION FOR THE DEFENSE OF HEALTH CARE

The participants of XIV Meeting on Health Care Delivery Systems held in Palma de Mallorca (Spain) from the 21 to 24 of May 2002 declare:

Health is a fundamental human right.

  1. Health care is a right that must be established in the constitutions and laws of every country. Necessary preconditions for health are peace and health promoting socioeconomic and environmental conditions. Health care should be organized to guarantee democratic, universal access, quality, equity and efficiency.
  2. Health care systems around the world are threatened pro-market and pro-corporate policies that reduce public accountability and increase the private delivery of public services. The process of globalization spreads the view that health care is a commodity to be organized and controlled by market forces, a view encouraged at an international level by the World Trade Organization, the World Bank and the International Monetary Fund. Their policy is to reduce or eliminate the role of government as a provider of basic health and social services. Their aim is to increase the profits of multinational corporations, such as insurance companies, HMOs, pharmaceutical firms, health care management businesses, and biotechnology corporations, at the expense of patient care. Commercialization of health care reduces equity and access to care, especially for the poor, the sick and the aged.
  3. The model of health care as a business paradoxically increases the costs of health care as money is shifted from the care of patients to the business of medicine, which requires increasing funds for administration, marketing, and profits.
  4. All countries must guarantee health care with sufficient public funding to provide care to all residents without discrimination by race, class, income, employment, gender, age, ethnicity, geography, disease, or costs of illness.
  5. Public health, disease prevention, medical treatment, rehabilitation and relief of suffering are essential health services, and must be distributed equitably in relation to the health and medical needs of the population. Public funding safeguards equitable distribution and enhances solidarity.
  6. Aging populations, work and traffic accidents, violence and wars, environmental pollution, poor nutritition, societally-induced ills, the deterioration of living conditions, infectious diseases, hunger, and poverty are producing increases in the numbers of patients with chronic illnesses and long term care needs. Equitable, compassionate and ethical health systems must include the care of vulnerable individuals, communities and populations.
  7. Globalization and corporatization punish developing countries through destruction of natural resources and exploitation of human labor. The levels of poverty and malnutrition, among the majority persons in the world, are unacceptable when there are enough resources to feed and care for the entire world. The weakest members of these global communities � women and children � are the most vulnerable targets of discrimination in market-based and male-dominated health systems. Vulnerable individuals suffer infectious diseases, chronic illnesses and other medical conditions that could be prevented by vaccination and by universal access to a free health care system. Instead of assisting women, children and other individuals with medical care, these countries face the paradox of losing any of their economic gains to support the rising costs of health care needs that are often induced by the very countries which should support them.
  8. The dismantling and privatization of national health systems is promoted through hidden and undemocratic strategies, such as �neutral� policies like separation of the financing and provision of health care. Such strategies transform health care into a private business, whose goal is to give private control over public needs. This strategy, promoted as a �public-private partnership,� results inherently in inequality in health care services. This is particularly evident in Latin America, where governments weakened by structural adjustment policies are unable to even minimally regulate the corporate involvement and control of health care.
  9. The strategy of the World Health Organization to achieve �health for all based on primary health care, health promotion and the participation of the population� is being obstructed by the interests of the health care-industrial complex, which includes the multinational pharmaceutical and biotechnology industries, large financial groups, banks and insurance companies. These groups promote treatment-centered systems, as opposed to preventive care, with intensive use of high technology, producing a situation in which, to the extent that health care is provided, individuals only receive care that is profitable to provide.
  10. The World Trade Organization, by enforcing patent policies designed to maximize the profits of the pharmaceutical industry, deprives millions of people of affordable drugs and the means to meet rising and unconscionable drug costs. Limits on the production of generics have been expanded at the expense of the health of largely abandoned patients, including patients in both poor and wealthy countries.

IN ORDER TO ADDRESS THE ABOVE SITUATIONS, WE PROPOSE:

1. The end to all war of all types, and the production and sale of weapons of destruction.
2. Ongoing research and policy development to:
a. Investigation, analysis and disclosure of practices and policies that undercut the achievement of the above principles.
b. Adoption of reforms in national health and social services that reaffirm the need for public accountability and public control of health and social services, such as health care, education, housing, food, jobs, etc
c. Organization and coordination of the struggle of unions and citizen groups against the privatization and destruction of national health systems.
d. Promotion, as proposed in Porto Alegre, of the development of a massive public-political campaign and outreach to grassroots organizations, NGOs, governments, and national and international organizations, such as the World Health Organization.
3. Creation of a Coordinating Committee for the Defense of National Health Care that is open to all grassroots and professional organizations, the goals of which are the development, coordination and support for an international movement against market-based health care.

***

Los asistentes a las XIV Jornadas de debate sobre Sanidad pública llevadas a cabo en Palma de Mallorca durante los días 21 a 24 de mayo de 2002 quieren poner de manifiesto los siguientes puntos:

  1. La Salud es un derecho fundamental de la persona que debe estar contemplado en las constituciones y leyes de todos los Estados y naciones. Hacerlo efectivo exige, en primer lugar, que impere la paz, pero también necesita de unas condiciones socioeconómicas y medioambientales saludables y dignas y de unos sistemas sanitarios públicos capaces de garantizar la asistencia universal, equitativa, solidaria, constante, eficaz y participativa.
  2. La sanidad pública se encuentra amenazada en todo el mundo por las políticas neoliberales que promueven el desmantelamiento y privatización de los servicios públicos. El proceso de globalización y mundialización de la economía capitalista pretende convertir la salud en una mercancía más sometida a las leyes de la oferta y demanda. Esta política, impulsada internacionalmente por la Organización Mundial del Comercio, el Banco Mundial y el Fondo Monetario Internacional, pretende acabar con el papel del Estado como garante de los servicios sociales básicos. La finalidad de ese intento de retirar la responsabilidad de la asistencia sanitaria de los sistemas de salud públicos no es otra que la de conseguir que los grandes grupos financieros, las compañías aseguradoras, las empresas multinacionales de servicios, los laboratorios farmacéuticos y la industria de electromedicina incrementen sus enormes beneficios. Como consecuencia directa, la mercantilización de la sanidad incrementa las desigualdades sanitarias, deja sin asistencia a los sectores que más la precisan y aumenta, paradójicamente, los gastos sanitarios.
  3. Los Estados deben garantizar la atención de la salud a todas sus ciudadanos, mujeres y hombres, con unos presupuestos publicos suficientes, en condiciones de igualdad y sin discriminaciones por razones de etnia, género, edad, situación económica o social, residencia o procedencia.
  4. La promoción, prevención y recuperación de la salud precisan de un Sistema Sanitario Público, universal y gratuito, dotado de recursos propios que estén distribuidos equitativamente en función de las necesidades de salud de la población. Un sistema sanitario público así debe contar con gestión pública directa, control social y financiación mediante fondos públicos como forma mejor, si no única, de garantizar su carácter redistributivo y solidario a escala nacional e internacional.
  5. En los países desarrollados el envejecimiento de la población, los accidentes laborales y de tráfico, la contaminación ambiental, el aumento del paro y la precariedad laboral están produciendo un incremento en las enfermedades crónicas, en las discapacidades y en las minusvalías. En consecuencia, las personas afectadas precisan de asistencia continuada en sus domicilios particulares o en los centros sanitarios. La atención a estas personas debe realizarse desde los sistemas sanitarios públicos con el apoyo de los sistemas sociales públicos.
  6. La globalización neoliberal ha castigado en mayor medida a los países en desarrollo que se tienen que enfrentar a unos recursos naturales sumamente deteriorados por el efecto de las guerras y la violencia. Los niveles de pobreza y malnutrición de esos países son inaceptables cuando el mundo desarrollado produce bienes más que suficientes para alimentar a toda la humanidad. Por añadidura, los miembros más débiles de los países en vías de desarrollo, las mujeres y los niños de uno u otro sexo, son a menudo víctimas de las discriminaciones debidas a los sistemas de patriarcado y, así, sufren en gran medida enfermedades infecciosas y crónicas que serían muchas de ellas prevenibles por medio de la vacunación y la atención sanitaria si se contase con servicios adecuados de salud universales, gratuitos y accesibles. Pero con gran frecuencia las inversiones en estos países no han ido en la dirección de instaurar Sistemas Sanitarios Públicos, por lo que se da la paradoja de que son los más pobres los que tienen que contribuir con sus recursos propios cuando necesitan de la atención sanitaria.
  7. El desmantelamiento y privatización de los sistemas sanitarios públicos están siendo aplicados mediante una estrategia que se disfraza de propuestas aparentemente neutrales, como son, entre otras, las de separar la financiación de la provisión de la asistencia, transformar los centros sanitarios en empresas, diversificar el aseguramiento o aumentar la participación del sector privado. La finalidad de todas ellas es el fragmentar y privatizar las partes más rentables de los sistemas sanitarios públicos. Esta estrategia, conocida como Mix Público/ Privado, ha demostrado en todos los países en que ha tenido lugar un aumento de la desigualdad, pero más aún en los de Latinoamérica, continente en el que los Estados Nacionales, muy debilitados por el modelo neoliberal, son incapaces de regular mínimamente el Mix Público/ Privado.
  8. La estrategia de la Organización Mundial de la Salud de alcanzar la salud para todos, basada en la potenciación de la Atención Primaria, la Promoción de Salud y la Participación de la Población, está siendo arrinconada por los intereses de la multinacionales farmacéuticas y de la tecnología médica, de los grupos financieros y de las compañías aseguradoras cuyos intereses requieren que se opere en sistemas basados en el hospitalocentrismo y en el uso intensivo de la tecnología sanitaria. Por añadidura, en América Latina la sanidad pública cubre sólo un mínimo de los costos de las acciones médicas de todo tipo, cargando a los pacientes con unas deudas que no pueden pagar.
  9. La Organización Mundial del Comercio pretende con su política de patentes multiplicar sus enormes beneficios, dejando desatendidos a millones de personas de países pobres que no pueden pagar los altos precios de los cada vez más costosos productos farmacéuticos. Se prolongan los períodos de prohibición de la producción y comercialización de los medicamentos genéricos a costa de la salud de poblaciones cada vez más marginadas.

Para hacer frente a esta situación, consideramos necesario:

En primer lugar, poner fin a las guerras que asolan el Planeta. Seguir el proceso de debate y de actuaciones a escala internacional para:

  • Desenmascarar las políticas neoliberales, y su repercusión sobre la salud y la calidad de vida de las poblaciones.
  • Realizar propuestas de reforma de los sistema sanitarios y sociales públicos que mejoren su nivel de eficacia, eficiencia y calidad en lugar de su destrucción
  • Organizar y coordinar los esfuerzos y la lucha de profesionales y ciudadanos contra las políticas privatizadoras y de destrucción de los sistemas sanitarios públicos

En segundo lugar, creemos necesario seguir en la línea de las propuestas del Foro Social Mundial de Porto Alegre en Defensa de la salud de los Pueblos para promover de manera democrática, colectiva y participativa:

  • Una Agenda Política en Defensa de la Salud Pública que sea presentada las organizaciones sociales, las Organizaciones no gubernamentales, los gobiernos, los parlamentos y las organizaciones internacionales como la Organización Mundial de la Salud y la Organización Panamericana de la Salud.
  • Un Observatorio Internacional destinado a estudiar, vigilar y combatir las políticas y actuaciones contra los sistemas sanitarios públicos.

En tercer lugar, sugerimos constituir un Organismo Coordinador en Defensa de la Sanidad Pública de naturaleza estable, democrática, abierta y participativa. Un organismo así estaría abierto a todas las organizaciones sociales y profesionales y destinado a coordinar esfuerzos logrando alianzas a nivel mundial en contra de la versión neoliberal de la globalización que pretende convertir la salud en una mercancía.

Palma de Mallorca, Mayo de 2002

Health care under globalisation, by H.U.Deppe

H.U. Deppe

Re-thinking the basic conditions of health care under the impact of globalisation
addressed to the 12th IAHP and XIV FADSP Conference, Palma de MAllorca 23 May 2002

1. Globalisation is an amorphus concept. The process of capital accumulation got a relevant push by the collapse of the socialist states and the development of the productive forces, triggered off by the micro-electronic technology. Public property becomes more and more privatised, market and competition shall self-regulate more social relations and the thinking in categories of business management penetrates and subsumes all social niches. That concerns too health care, a social sector which is controled by the state in the European welfare states. In this context we speek from a process of economisation.

Health care systems are not isolated social constructions. They are rooted deeply in the structure, culture and history of their societies. They are the result of social and political struggles. And they are a pre-condition for social peace in contradictionary societies. In opposite to the increasing globalisation of the capital health care systems are strongly connected with the national states.

On the backgrund of such developments it makes sense to re-think the fundamental principles of the social dealing with sickness and health.

2. Health or sickness as a whole cannot get the character of a commodity. Worldwide we cannot see a health care system which is regulated only by the market. That depends on serveral special items:

  • Health is an existential good. It is a use value, which is in our societies collective and public � similar like the air we breath, drinking water, education or trafic and juridical security.
  • It is not possible to decide being without sickness � like with commodities for consumtion.
  • The patient do not know when and why he will become sick, by which sickness he will suffer in the future. Sickness is an event which cannot be regulated individually. It is a general life risk.
  • The demand of a patient for medical aid is primarily not specific. At first the competence of an expert defines and specifies it. There is a relevant difference between the competence and information of a physician and a patient. And the physician has a big discretionary power for diagnostic and therapeutical decisions.
  • Over this the patient is in a position of unsecurity, weakness, dependency, need in combination with anxiety and shame.

This short description of the relation between market and patient shows that social protection is necessary. The rules of supply and demand are in this field inadequat. Therefore the health care system is an exemple for the theory of market failure. The distributing forces of the market are insufficient here. The market is a blind power without orientation. And the social aims must be formulated by the state, the democratic community.

3. Over this we have to differentiate inside the economy between a rationality of the business management and a rationality which is orientated to the national economy. Problems and questions which are interesting for a single enterprise must not support the economy for the whole. Not seldom these two dimensions contradict each other. We know this especially from environmental protection or more obviously from the atomic industry. The expansion of the business rationality is not seldom an enormous wasting of social ressources. The social costs can be neglected until the society or the state intervenes under national economic and social aspects. This phenomenon we have too in health care. The transfere of costs from the outpatient to the hospital sector or vice versa can be a financial advantage for the prevailing institution. But under a general perspective it is more expensive. And under a microeconomic view � under the rationality of business management – ineffective or even dangerous health services can make the same profit like effective and useful one.

4. The patient-physician- relationship (or better: patient-healthworker-relationship), the basic relationship of medical care, is not in the public sphere of the bourgeois society. To speek about sickness � its causes, its special symptoms or its unusual care � sometimes is even not possible in the family or a partnership. There are the phenomenons of shame and fault. Speeking about sickness and looking for help is in the intimacy, the protected part of the private sphere. And the characteristics of the intimate sphere contradict the conditions of the market constitutively.

The patient-physician-relationship is structural asymmetric. The unequal division of knowledge and instrumental abilities, the one dimensional professional and social competence until the application of sanctions provide the social position of a physician with power. And how this professional power is used, depends considerably on external impacts. In this relation it is important to know how the professional power can influence the personal income of physicians, what are the criterions for the transfers from one to another medical institution, what are the criterions for applications or prescriptions and what are the spoken and unspoken guidelines for indications.

5. The question is: Why physicians are able to be so fexible? A relevant cause therefore seems to be obviously the scientific character of the applied or practical medicine and their necessary orientation to the so-called �single case� of a patient. And the single or special cases of the same sickness can be very different. Another cause is the obligation for practice. Often we have in medical practice a demand for immediate help. Therefore we have a big space of decision, a discretionary power, in medical practice. It follows sometimes the parole �anything goes�. This favours a different � occasionally contradicitionary � behaviour: It can be done to much � or it can be done not enough. We speek about overuse and underuse. We know exemples where we have both in one situation. It determinates not only the clinical indication but also different diagnostic methods of medical interventions.

This person-orientated, unsecure, sensitive and complex field is susceptible to external impacts. Money, competition, juridical security, professional carreers or deep rooted anxiety to loose the workingplace have a light game to influence clinical decisions � consciously or unconsciously. The neoliberal economic pressure with its instruments of market, competition and profit increased the struggle for market shares. The market produces winners and loosers. And the loosers are the economically weakest. At this time in our countries many physicians and health workers see in the relation between the pressure of the market and individual health care a constitutive contradiction. In general until now the utilitarist modell of cost-benefit thinking has a low acceptance. The power of definiton – what means “medical necessary” – is assigned to the medical profession. But we can registrate slow and calm changes. External impacts are penetrating medical decisions and selections. In a research study made in Germany we can read: �In the background of clinical decisions more and more indicators like age, privat or public insured, the profession, education and social status of a patient become a criterion. But with the words of an interviewt physician: Nobody would say this publicly. None of these criterions is legitimised by a moral codex, by law or by medical norms.� I think this is not a new knowledge � but the situation is increasing. All of us, who are working in medical institutions, can confirm this from their own experience.

The discretionary power of the medical profession, its space of decision, and that what we call �medical necessity� build the core of the discussion about unnecessary operations, unnecessary cardiac catheterization and PTCAs, the prescription of ineffective drugs or avoidable stays in hospitals. Meanwhile the problem is recognised: Guidelines, proofed standards and evidence based medicine shall replace or complete the pragmatical medical experience by scientific controled research results, which can be generalised.

6. On the background of these soft character of the medical science the medical institutions are confronted with the hard consequences of neoliberal economic modell. The expansion of market, competition and profit in health care will change the patient-physician-relationship fundamentally. The relation which is actually still based on confidence will change to a commercial relationship which is based on a contract. And to make an official contract is not even the result of good confidence, but more the result of misstrust. A contract shall controle a risky relation between more or less strange people with common interests. Confidence implicates a close relation which makes the patient possible to give intimate informations, which are essential for medical care. Therefore this relation is protected by the medical secrecy. The patient-physician-relationship is based on an asymmetric relation. From the expert is expected that he cares and cures a layman to the best of his (the experts) knowledge and belief. The layman can count on the competence of the expert, he can expect his good intentions, he can believe his statements and he can trust him. Confidence assumes responsible acting. Benefits which are offered on the basis of confidence are going in the direction of a credible promis. It is based on reliability and well-meaning.

On the orther hand let´s look at the meaning of contracts. They are a part of the system of laws. Contracts confirm common intentions with fixed mutual obligations of more or less strange persons. Especially the development of the market and the privat property determined the character of contracts. At the market equal propriators exchange their commodities for a negotiated price. � Of course the buyers and sellers are interested in their personal advantage!

The increasing commercialisation of the patient-physician-relationship demands from the physician more and more a special measurable service for a fixed price. This service becomes more and more the charakter of a commodity, which will be produced and distributed under the conditions of economic competition. The patient comes increasingly into the role of a customer or purchaser, with whom a seller of a commodity will earn money. And the best customer is normally one, with whom can be made the most money. Under such conditions patients perhaps will get the good service of a customer but not the necessary medical care of a sick human being. As much as the economic competition will increase, as much the demand for good purchasing power of the patient is asked. This provoces a merkantil incentive that more benefits will be done, which patients want instead of such, which they need. Patients as medical laymen define more and more what is to understand by medical quality. In the most cases it reduces the question of medical quality on the niveau of a short-term satisfaction. And satisfaction shall tie customers.

By the increasing commercialisation of health care even well informed patients will come into a difficult and confused situation. What mean medical recommendations and informations during the treatment � like:
This is medically not necessary. The risk of this intervention is in your case to high. Or: This therapeutical intervention is in your case not effective. Means this � it is not compatible with the knowledge and experience of medicine, or means it only, it is too expensive. How do the patient know, why the doctor gives him this recommmendation? Is it indeed the best therapy, which is necessary for his sickness? Will alternative treatments not be told to him? Do from such recommendations or prescriptions depend the carreer and the workingplace of the physician or even the creditworthyness of a private hospital, which determin the share price and the dividend. Or: Did the physician just got the information that he is beyond his budget? Here we can suspect the limits of the rationality of business management in health care. In such a case the rationality of business mangement is perhaps profitable but it contradicts deeply the social contract of our civilisation. The pressure of economic competition and capital accumulation in health care leads to a cultural change in medicine.

The increasing commercialisation seems to be not only a problem of practical health care but also a problem of medical researches and experiments with men. Many researchers are loosing the necessary care and responsiblitiy in their researches. The patients´ rights are not enough protected. The cause therefore is to see in the advanced commercialisation of medical researches. Results of researches must be achieved in short times. But exact and fair enlightment of the people or patients need time. Over this many scientists take part commercially at the products of their researches in clinical studies. And a German pharmacologist formulated: The quality of health care is threatened by an increasing uncritical submissivness of researchers under the interests of industrial sponsors. This is the consequence of the retreat of the state from the promotion of clinical researches.

7. What is my message? I am deeply convinced that we have relevant sectors in our societies which should not be privatised and commercialised, because it will counteract and destroy the humane and social values of our societies. We have to respect and to keep on areas in our societies, in which the communication and co-operation is de-commodified, where services have not the character of a commodity. Such sectors must be socially defined and protected. Such sectors are dealing with vulnerable social groups, vulnerable social aims like solidarity and equity or vulnerable structures of communication like the physician-patient-relationship. They build the core of our European welfare model. And I think, it is worthful and necessary to struggle for its efficient public and non-profit structure.

Of course this is not easy! But I think there is hope. The popular masses in Europe with their traditional experience of welfare resisted the naked neoliberalism and elected some years ago parties of the so-called “third way”. But meanwhile they had to recognice that the parties of the third way are following too the mainstream of neoliberalism in different clothes – and that they can take influence only by pressure. On this background we have to see the worldwide emergence of new social mass-movements from Goeteborg over Genova to Porto Allegre. In Germany we have in September federal elections. The election campagne has started already. One point – beside the main point of unemployment – is the health reform. Especially the main trade unions resist its neoliberal change. And they are since some weeks in a direct alliance with the new mass-movement of ATTAC coming from France- which is very popular among young German people. And the main political parole of ATTAC in Germany is at this time : Health is no commodity! That let´s hope!

Hans-Ulrich Deppe, M.D.
Professor for Medical Sociology and Social Medicine
Univeristätsklinikum der J.W. Goethe-University
Theodor-Stern-Kai 7
60590 Frankfurt