Public Health and Preventive Services

International agencies play a critical role in health policy, first by setting public health and health-status goals, and then by monitoring an individual country's progress toward these goals. For example, over the past twenty years the World Health Organization (WHO) has established goals and specific targets for the Health-for-All initiative. Two fundamental objectives of this initiative are: (1) making health central to human development and (2) building sustainable health systems (Antezana, et al.). In order to monitor these objectives, Health-for-All in the 21st Century has identified global health targets that each country should meet, such as eliminating certain infectious diseases through childhood immunization and improving access to water, sanitation, food and shelter (Visschedijk and Simeant). In 2000 the WHO began ranking and assessing health sys-tems's performance in 191 countries based on five composite indicators. The WHO hopes to make this assessment a regular activity, which will help policy-makers to monitor their performance in comparison to other countries (WHO, 2000a).

In most countries, public health agencies have the primary responsibility for creating programs that will achieve specific health objectives. International agencies like the World Bank and the United Nations and some affluent countries have programs to assist developing countries. The U.S. Agency for International Development (USAID), for example, operates programs that help developing countries to establish and operate a variety of public health activities.

While there is generally a consensus that government agencies should finance and provide public health and disease-prevention services, policy differences and financial commitments affect the success of specific programs. For example, the childhood immunization rates for six major infectious diseases (diphtheria, pertussis, tetanus, measles, poliomyelitis, and tuberculosis) vary greatly from country to country. In 2000 the immunization rates for diphtheria, pertussis, measles, and poliomyelitis ranged from 55 percent of infants in Africa to over 90 percent of infants in Europe (WHO, 2001). In most countries the WHO's target rate of 90 percent coverage for the year 2000 was not achieved (WHO, 2001).

Another public health activity, the testing and approval of drugs, highlights conflicting ethical values. Beneficence, in terms of concern for public welfare, is reflected when nations employ comprehensive but time-consuming approval processes in order to ensure a safe and efficacious drug supply. The U.S. Food and Drug Administration, for example, has adopted strict regulatory standards that prevent the domestic adoption of new drugs and devices until their safety and efficacy are established beyond reasonable doubt (Sheinin and Williams). In contrast, a respect for autonomy, in terms of individual access to healthcare, is obstructed when the length of the drug approval process delays access to potentially lifesaving treatments—particularly for patients who have exhausted current treatment options and are willing to take experimental drugs.

Since the early 1990s, people with acquired immunodeficiency syndrome (AIDS) have been the most vocal proponents of allowing individuals unrestricted access to unproven medical treatments. Advocates of placing greater weight on beneficence, on the other hand, point to the approval of thalidomide by the United Kingdom in the 1960s, while it was still in testing stages in other countries. The drug was never approved in other countries and was pulled from the British market after it became apparent that severe congenital deformations resulted from maternal use of the drug (Burger).

The principle of justice can be jeopardized when drug trials are carried out in developing countries by investigators and sponsored by agencies from developed countries (Beyrer and Kass; Council for International Organization of Medical Sciences [CIOMS]). Some developing nations have used drugs not approved in industrialized countries. Lower costs of unapproved drugs make them a relatively affordable medical treatment option for poorer nations. In some cases, individuals in low-income nations benefit from access to various drugs, while in other cases individuals are harmed by access to unsafe or inefficacious therapies. For example, HIV/AIDS accounts for about 20 percent of all deaths in Africa, which creates urgent need for new drugs and effective vaccines for HIV infection (Creese, et al.). This urgency is being used to lower the ethical standards of international research and result in ethically controversial actions (e.g., not providing drugs after the conclusion of the clinical trial or make the drugs available at unaffordable prices) (Greco,

Stolberg, Okie). In order to assist the efficient purchase of safe and efficacious drugs by developing nations, the WHO and other international agencies have established essential drug lists that identify drugs satisfying the healthcare needs of the majority of the population, and are revised every two years (WHO, 2000b).

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