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Health care in the United States is far costlier than in any other country, yet its outcomes, while improving, are worsening relative to other countries in the Organisation for Economic Co-operation and Development (OECD). 1 Perhaps the de facto organizing principle for US health care—approaching each patient strictly as an individual—is obsolete. The population health approach is an alternative. It aims to improve and maintain health across a defined population. 2,3 A “defined population” can mean a clinician’s patients or a health plan’s enrollees, but the defined population for the population health approach includes everyone in the community. This Viewpoint addresses 3 related questions. First, can the population health approach improve the outcomes of US health care? Second, for the population health approach to succeed, must it reconcile the needs of the individual and the community? Third, how might

HOSPITAL READMISSIONS ARE UNDER SCRUTINY BY policy makers but are hardly a new problem. For more than 30 years, researchers have studied factors associated with readmission and tested care models to address these admissions, yet rates of readmissions have not declined appreciably during this time. The renewed focus on readmissions has been stimulated by several converging forces rather than by a strong evidence base for how improvements can be reliably achieved. US federal financial penalties for high rates of readmissions focus on hospitals as the locus of accountability for the problem, but such penalties are a weak incentive since the investment required to improve may exceed the potential loss of inpatient revenue. In this Viewpoint, we suggest that it may be more advantageous to view readmissions within a broader systems and community context that effectively engages all stakeholders to cooperatively improve outcomes.

ALTHOUGH NOT QUITE A HOUSEHOLD NAME, DURing the late 19th and early 20th centuries Hermann M. Biggs (1859-1923) commanded enormous power and influence. Throughout his career at the helm of the Health Department of the City of New York and later as Commissioner of the New York State Department of Health, Biggs was world-renowned for developing innovative and effective policies that both protected the public’s health and respected the needs of the ill. While still a young man in the early 1880s, Biggs’ intellectual life was indelibly shaped by the exciting discoveries being made about bacteria and the then-novel germ theory of disease. Indeed, a signal event that occurred during Biggs’ medical student days at New York City’s Bellevue Medical College superbly illustrates the cultural and intellectual wedge then being driven between antiquated medical practices and the scientific revolution in healing that continues to the present. One of Biggs’ favorite medical school professors at Bellevue was William Henry Welch, a brilliant young pathologist and bacteriologist just beginning his meteoric rise to becoming one of the founders of the Johns Hopkins Hospital and Medical School and the leading medical statesman of his generation. One spring afternoon in 1882, Welch lectured to his pathology class, of which Biggs was a promising member, about Robert Koch’s monumental discovery of the tubercle bacillus as the cause of the white plague of tuberculosis. So inspired was Biggs by this pedagogic moment that he ran to Bellevue’s senior professor of medicine, the redoubtable and bespectacled Alfred L. Loomis, to tell him about the remarkable information. A few days later, the aging Loomis, author of scores of textbooks that made him famous among medical students and practitioners alike, ascended the lecture platform of the Bellevue Hospital amphitheater, looked merrily about the vast room, and boldly declared: “People say there are bacteria in the air, but I cannot see them.” Many of the medical students laughed uproariously at Loomis’ witty denunciation, as they are wont to do whenever their professor makes the slightest attempt at humor. Yet when Biggs later told Welch about the episode, the pathologist shook his head with an equal mixture of sadness and whimsy. “That’s too bad,” Welch quipped, “Loomis is such a nice man”; in other words, time had passed Loomis by, and his old notions about disease causation and prevention had been, or were about to be, superseded by new ones. And by refusing to accept

MEDICAL CARE REFORM IS A CRITICAL PIECE IN achieving a healthy society but needs to be complemented by changes in community programs and policies. While the body of evidence-based clinical and population interventions is increasing, the challenge is to identify and implement those interventions that provide the greatest health benefits and value. A critical first step is to construct a sound, common framework for identifying and organizing the universe of evidence-based interventions. That framework can then be used to assess society’s investments in health. In this Commentary, we describe how 3 concepts—the ecologic model, the life course perspective, and evidence-based intervention strategies—contribute to a common goal and how they need to be viewed as integrated and complementary. A brief synopsis of each concept is provided, followed by a description of its fit within a broader conceptual framework.

UNITED STATES HEALTH CARE, OFTEN HAILED AS “THE best health care system in the world,” is also faulted for being too costly, leaving many millions of individuals uninsured, and having avoidable lapses in quality. Criticism often draws on comparisons with other countries of the Organization for Economic Co-operation and Development (OECD). This Viewpoint also makes such comparisons, over a broad range of variables, and reaches one inescapable conclusion—US health care is very different from health care in other countries. Potential reasons for the differences are discussed, leading to the conclusion that future efforts to control cost, provide universal coverage, and improve health outcomes will have to consider the United States’ particular history, values, and political system.

Several investigators are preparing to conduct efficacy trials of human immunodeficiency virus (HIV) vaccines in the developing world. Failure to adequately address the unique ethical, behavioral, and social issues that surround vaccine testing in that setting will jeopardize the success of these trials and future acquired immunodeficiency syndrome (AIDS) research in the host nation.Twelve investigators from Africa, Asia, North America, and South America reviewed previous experience with HIV trials in developing countries and explored potential solutions to these issues.Host country scientists, government officials, and media must be actively involved in all aspects of the trials. Minimum prerequisites for conducting the trial include the following: (1) researching vaccines active against developing world HIV isolates; (2) establishing and maintaining an adequate technological infrastructure; (3) assessing the feasibility of recruitment in countries where the existence of HIV may be denied; (4) designing methods to obtain informed consent from each individual subject, rather than exclusively from family members or community elders; (5) creating locally appropriate instruments to measure risk behavior; (6) identifying a behavioral intervention for placebo and treatment groups; (7) making available laboratory methods to distinguish between natural HIV infection and vaccine-induced seropositivity; and (8) guaranteeing that an effective vaccine is available free of charge to the placebo group and at affordable prices to other host country residents.

ContextThe psychological rehabilitation of former child soldiers and their successful reintegration into postconflict society present challenges. Despite high rates of impairment, there have been no randomized controlled trials examining the feasibility and efficacy of mental health interventions for former child soldiers.ObjectiveTo assess the efficacy of a community-based intervention targeting symptoms of posttraumatic stress disorder (PTSD) in formerly abducted individuals.Design, Setting, and ParticipantsRandomized controlled trial recruiting 85 former child soldiers with PTSD from a population-based survey of 1113 Northern Ugandans aged 12 to 25 years, conducted between November 2007 and October 2009 in camps for internally displaced persons. Participants were randomized to 1 of 3 groups: narrative exposure therapy (n = 29), an academic catch-up program with elements of supportive counseling (n = 28), or a waiting list (n = 28). Symptoms of PTSD and trauma-related feelings of guilt were measured using the Clinician-Administered PTSD Scale. The respective sections of the Mini International Neuropsychiatric Interview were used to assess depression and suicide risk, and a locally adapted scale was used to measure perceived stigmatization. Symptoms of PTSD, depression, and related impairment were assessed before treatment and at 3 months, 6 months, and 12 months postintervention.InterventionTreatments were carried out in 8 sessions by trained local lay therapists, directly in the communities.Main Outcome MeasuresChange in PTSD severity, assessed over a 1-year period after treatment. Secondary outcome measures were depression symptoms, severity of suicidal ideation, feelings of guilt, and perceived stigmatization.ResultsPTSD symptom severity (range, 0-148) was significantly more improved in the narrative exposure therapy group than in the academic catch-up (mean change difference, −14.06 [95% confidence interval, −27.19 to −0.92]) and waiting-list (mean change difference, −13.04 [95% confidence interval, −26.79 to 0.72]) groups. Contrast analyses of the time × treatment interaction of the mixed-effects model on PTSD symptom change over time revealed a superiority of narrative exposure therapy compared with academic catch-up (F1,234.1 = 5.21, P = .02) and wait-listing (F1,228.3 = 5.28, P = .02). Narrative exposure therapy produced a larger within-treatment effect size (Cohen d = 1.80) than academic catch-up (d = 0.83) and wait-listing (d = 0.81).ConclusionAmong former Ugandan child soldiers, short-term trauma-focused treatment compared either with an academic catch-up program including supportive counseling or with wait-listing resulted in greater reduction of PTSD symptoms.Trial Registrationclinicaltrials.gov Identifier: NCT00552006

MORAL PLURALISM IS A VALUABLE ASPECT OF A free society but sometimes creates conflicts in medical care when individual physicians object to providing certain legal but morally controversial services, such as abortion, physician-assisted suicide (where it is legal), and palliative sedation to unconsciousness. Genuine conscience-based refusals (CBRs) are refusals in which a physician believes that providing the requested service would violate his or her core moral beliefs (religious or secular), thereby causing personal moral harm. Conscience-based refusals should be a “shield” to protect individual physicians from being compelled to violate their core moral beliefs rather than a “sword” to force their beliefs onto patients. This partially explains why many physicians who invoke CBRs refer their patients to physicians willing to provide the requested care. Savulescu has characterized CBRs as self-serving acts accomplished at the expense of patients. Others accept CBRs as legitimate acts to protect moral integrity despite the potential negative consequences for patients. Both characterizations neglect a complexity: society may obtain higherquality medical care in aggregate by accommodating some CBRs. In this Commentary, CBRs are addressed from this societal perspective.

To assess the long-term impact of trauma and confinement on the functional health and mental health status of Cambodian displaced persons living on the Thailand-Cambodia border.Household survey of 993 adults randomly selected from household rosters. Household sample selection by multistage area probability sample.Site 2, the largest Cambodian displaced-persons camp on the Thailand-Cambodia border.Adults 18 years of age and older selected at random within households; 98% of eligible persons selected agreed to participate.From 1975 through 1979 (Khmer Rouge regime), more than 85% reported lack of food, water, shelter, and medical care, brainwashing, and forced labor; 54% reported murder of a family member or friend; 36% reported torture; 18% reported head injury; and 17% reported rape or sexual abuse. During the refugee period between 1980 and 1990, 56% reported lack of food or water, 44% reported lack of shelter, 28% reported lack of medical care, 24% reported brainwashing, and 8% reported torture. Since 1980, reports of murder of a family member, head injury, and rape/sexual abuse have decreased to 5%. Reports of experiencing combat situations and shelling attacks have remained consistent between the two time periods, approximately 44% and 30%, respectively. From 1989 to 1990, 25% reported experiencing lack of food or water, and 5% to 10% reported serious injury, combat, and shelling conditions. More than 80% said they were in fair or poor health, felt depressed, and had a number of somatic complaints despite good access to medical services. Fifty-five percent and 15% had symptom scores that correlate with Western criteria for depression and posttraumatic stress disorder, respectively. Fifteen percent to 20% reported health impairments limiting activity, and moderate or severe bodily pain. Despite reported high levels of trauma and symptoms, social and work functioning were well preserved in the majority of respondents.Reports of extensive trauma, poor health status, and depressive symptoms of this population are of concern in predicting future morbidity and mortality. The health and mental health needs of Cambodian displaced persons and their impact on social and economic behavior should be addressed now that the Cambodians have been repatriated.

GREECE IS GOING BANKRUPT. THE EURO IS SHAKY. The oil inundating the Gulf Coast may eliminate one-third of the US seafood catch. In the midst of this chaos, the nightly news focuses on a medical breakthrough. At a cost of about $100 000, a man with metastatic prostate cancer can be treated with an infusion of his own cells and live, on average, a few months longer. The commentator questions whether insurance companies will pay for this therapy and wonders whether men who do not have metastatic cancer will demand access to the therapy, even if they have to pay for it themselves. Perhaps Yeats was right—“Things fall apart; the centre cannot hold.” The United States spends more money per person on medical care than any other developed country in the world. But Americans are not the healthier for it. Life expectancy in the United States is lower than in virtually any other developed country, and variation in life expectancy, as a function of where a person lives or grows up, is high. In the context of this dismal reality, consider the assertion in the Declaration of Independence that every citizen has the right to life, liberty, and the pursuit of happiness. What should be expected from a physician leader in this complex world? Physicians are found in leadership positions throughout US society but are rarely at the top. Physicians have been elected to both houses of Congress, but no physician has been elected president. Medical leaders are found in the executive branch of the Department of Health and Human Services, but virtually never at its highest levels. But physicians have extraordinary influence. They run the programs that spend large amounts of money to treat the elderly and the poor, at both state and national levels. They provide a moral compass when they serve as surgeon general. And most frequently, they are responsible for running large health care delivery systems and for training the future health workforce of the United States. Indeed, the teaching role has expanded from being a dean of a medical school to overseeing the entire health enterprise of an academic campus, including teaching hospitals and schools of medicine, nursing, pharmacy, and public health. Physicians also control all of the organizations that set professional standards in medicine, from individual specialty societies to organizations cutting across the entire medical establishment. What defines a successful leader of such organizations? That’s more than a rhetorical question. Medicine now makes up 17% of the US gross domestic product; thus, a large part of the country’s ability to ensure life, liberty, and the pursuit of happiness is in the hands of medical leaders. There are several possible definitions of successful leadership. Is it an indication of success if the leader of an academic medical center keeps the institution financially solvent, constructs new buildings—especially those for basic science research—moves the institution higher on the National Institutes of Health grant list, and trains physicians to concentrate on the patient by using all tools at their disposal? Are leaders of professional societies successful when they persuade Congress that the society’s members provide great scientific value and thus merit higher salaries; or if those leaders convince philanthropies to donate a disproportionate amount of money to that specialty? Is the leader of a major program, such as Medicare, successful when bills are paid promptly, adequate reimbursement is made for services rendered, and services are provided with high quality and little waste? Is the medical leader of a pharmaceutical company successful when the company develops a product that increases life expectancy by 3 months at a price of $100 000 and then convinces the public and insurers that patients must have the product and that it must be paid for with public money? Many would answer yes in all of these cases. Who wants a leader of an academic medical center who builds nothing, does not attract research grants, and fails to maintain financial stability? Certainly not the center’s board of governance. But in this complex world, are these sufficiently inclusive definitions of a successful physician leader? There are 3 competing models for improving health in a population. The first, for which virtually all of the resources are used, is the medical model, in which an individual patient visits a physician who uses his or her clinical training to diagnose and treat the patient. The second is the

The Aids Litigation Project, which monitors the legal repercussions of the AIDS epidemic in the United States, is operated by the American Society of Law and Medicine and the Department of Health Policy and Management, Harvard School of Public Health, and supported by the National AIDS Program Office of the U.S. Public Health Service. Gostin's article is the first in a two-part series reviewing case law and human rights commission rulings tracked by the Project since 1981. The series covers 469 AIDS cases decided, settled, pending, or filed at local, state, and federal levels. Part I discusses civil and criminal cases involving issues ranging from AIDS education to AIDS and the prison system. Accompanying the article are tables of cases broken down by court system and by subject matter, and a subject compilation of 320 case citations.