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Fig 1 Edith Irby Jones graduated from University of Arkansas for Medical Sciences in 1952 Edith Irby Jones, who devoted her life to treating poor patients and is widely believed to have been the first black student enrolled in any all white medical school in the American South, has died at the age of 91. Edith Mae Irby was born in Mayflower, Arkansas, to Mattie, a domestic worker, and Robert, a sharecropper. The family lived on a farm. When Edith was around 3 years old, her father was fatally injured after his horse was stung by a bee and kicked him in the chest. The fatherless family were evicted from their home by the owner, owing to a small debt. Further tragedy followed four years later, in the early 1930s, when Edith’s older siblings contracted typhoid fever. Her brother Robert recovered, but her sister, Juanita, died. Seven year old Edith was haunted by the thought that Juanita had received inadequate care because they were poor. She recalled that a doctor had visited Juanita just once while she was sick, lavishing more time on his affluent patients. It was then that Edith determined to become a doctor who would care for neglected poor people. “I was going to particularly see those who did not have money and those who were less fortunate, who would get the kind of care that …

The man most likely to be the UK’s next prime minister has called for a review of what he calls “stealth sin taxes” (doi:10.1136/bmj.l4557). Boris Johnson says he is concerned about their disproportionate effect on poor people. He also wants to base the UK’s tax policy “on clear evidence.” If so, all of us who want to improve the public’s health can rest easy: the accumulating evidence in favour of such taxes is becoming hard to counter. First comes the evidence of the damage caused by excessive intake of sugar and of sugary drinks in particular. To the long and evidence …

Experts in public health have condemned comments by the Tory leadership candidate Boris Johnson that he may halt the government’s sugar levy if he becomes the next prime minister. The comments were made at a leadership campaign event where Johnson pledged to review taxes on sugar, salt, and fat that he argued unfairly punished poor people. Johnson said, “The recent proposal for a tax on milkshakes seems to me to clobber those who can least afford it. If we want people to lose weight and live healthier lifestyles, we should encourage people to walk, cycle, and generally do more exercise. Rather than just taxing people more, we should look at how effective the so called sin taxes really are …

GSK, Novartis, Johnson and Johnson, and Merck KGaA have retained their 2016 positions as the leading drug companies in terms of making their products available to patients in low and middle income countries, an independent ranking shows. The Access to Medicines (AtM) Index, published every two years, ranks 20 of the world’s largest pharmaceutical companies according to their work in this area.1 The bottom five companies are named as Bayer, Abbvie, Daiichi Sankyo, Astellas, and Eli Lilly. Of these five, only Bayer and Eli Lilly have strategies in place for improving access to drugs. The index found that five companies were carrying out 63% of the most urgently needed research and development projects: GSK, Johnson and Johnson, Merck KGaA, Novartis, and Sanofi (fig 1). Fig 1 Ranking of 20 drug companies by numbers of priority R&D projects The index has …

Infectious and parasitic diseases cause massive health problems in the developing world. Research and development of drugs for diseases that mainly affect poor people in developing countries is limited. The advance market commitment (AMC) idea is an incentivising mechanism for research and development of drugs for neglected diseases. Discussion of the AMC idea is of renewed interest given the launch in June 2009 of the first AMC. This pilot AMC is designed to, among other things, test the idea for potential future applications. This paper is a critique of the AMC idea. It seeks to show that the idea has a hitherto unrecognised theoretical flaw that should make policy-makers and donors hesitant to embrace future applications of the idea.

US citizens experience “relatively low levels of moral discomfort” over the gap in access to healthcare between rich and poor people, a study has found.1 The international study, which analyzed people’s perception of their health in relation to their income, found that Americans were less concerned about differences in access to healthcare related to income than people in other countries. In general, Americans were less likely to consider disparities resulting from income differences to be unfair. Although 67% of US respondents said that “many” people in the country did not have access to …

It’s hiding in plain sight. Poor people live less long than those who are rich,1 and people with a learning disability are more likely to die sooner than people without.2 GPs have been urged to respond to this in the way the contract knows best: by offering health checks and a checklist of items to be ticked. In Scotland the Keep Well programme, aimed at people in deprived areas, has demonstrated only minimal or marginal benefits but is still used in some areas.3 Health checks for people with learning disabilities often detect symptomatic conditions. This is itself …

Tobacco control benefits economies as well as public health, a major report from the World Health Organization has found.1 The report, published in conjunction with the National Cancer Institute of the United States, found that tobacco use costs the global economy $1 trillion (€0.94trn; £0.82trn) a year in terms of healthcare expenditure and lost productivity from ill health. The world currently has 1.1 billion smokers aged 15 or over, around 80% of whom live in low or middle income countries. Smoking rates have fallen in most regions of the world over the past 15 years, and smoking rates among adults in Europe have fallen from 59.2% in 2000 to 47.2% in 2015. …

Ruth Levine argues that WHO needs to concentrate on confronting global health risks, improving the health of poor people, and marshalling technical expertise

New indicators show that primary care clinical commissioning groups (CCGs) in England vary widely in their ability to deliver healthcare equitably to rich and poor people. Some inner city areas, such as Tower Hamlets in east London, have done well on the new measure, while others, such as central Manchester, did poorly. A large gap could also be seen in affluent areas, with south Cheshire performing relatively badly while east Surrey did well. The Centre for Health Economics at York University devised the measure, which has now been adopted by the NHS in England as one of the tools it uses to assess and improve the performance of CCGs. To make the comparison the York team needed a marker that enabled CCGs to be compared on how well they delivered healthcare to their populations, regardless of how large the underlying discrepancies in overall health were. This was …

Health experts in India have welcomed a move by the prime minister, Narendra Modi, to increase the retirement of age of doctors employed by the central government from 60-62 to 65 years to meet the shortfall of doctors in the country. Figures for 2015 show that India has one government doctor for every 11 528 people.1 The shortage of doctors especially affects poor people, who depend …

The gap between the life expectancy of rich and poor people in England and Wales has increased for the first time in almost 150 years, a report from the Cass Business School and the International Longevity Centre-UK (ILC-UK) has found.1 Using data from the Human Mortality Database, the report’s authors measured the differences in age between the earliest 10% of adult deaths in England and Wales and the latest 5%. They found that while …

Nearly two thirds of families enrolled in a scheme that entitled them to free health services in Maharashtra paid substantial out-of-pocket expenses when they needed hospital treatment, a study has found. The state of Maharashtra launched a health insurance scheme called Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) in 2012 to improve access to medical care for poor people in the state. It entitles people with an annual income of up to Rs100

One in 10 women in England reported taking antidepressants in one week in 2013, double the rate among men, a survey has found. The annual Health Survey for England 1 found that 11% of women took antidepressants, compared with 5.5% of men. Their use was most common among middle aged women, as 16% of women aged 45 to 64 reported taking them. The figures also showed a significant gap between rich and poor people: 17% of the nation’s poorest women reported taking antidepressants, compared …

Half of all people in poverty in the United Kingdom are in a family with someone in paid work, says the annual report written by the New Policy Institute for the social policy research charity the Joseph Rowntree Foundation.1 The report says that the UK labour market has changed significantly in the past 10 years, with a big increase in insecure work such as jobs on zero hours contracts, part time work, and low paid self employment. Getting a job does not necessarily mean getting out of poverty, the report says. The UK today has 13 million people in …

A change in a guidance document concerning payment for participating in research undermines protection for human participants, a US consumer advocacy group has said.1 At issue is how much study participants can be paid without causing them to accept risks that they wouldn’t otherwise have accepted. Under current US policy, payment is allowed to remunerate participants for their time, inconvenience, and discomfort, for example, but should not be so large that it induces them to accept risks they wouldn’t accept if it were not for the money. The concern is that such payments could be used to exploit poor people who might agree to participate in high risk studies because of their need for money. The changes that sparked the controversy appear in a document of frequently asked questions about informed consent, issued by the US Office for Human Research Protections (OHRP). …

Removing financial barriers is only the first step towards better access to care for poor people

Many urban poor people prefer going to hospital for care rather than a doctor’s office because they perceive hospital care as less expensive, more accessible, and of higher quality, and because hospitals provide social and emotional support that many of these patients lack in the community, says a study in the current issue of the journal Health Affairs.1 Researchers interviewed 40 low income hospital patients from poor neighborhoods in Philadelphia, Pennsylvania. The participants were also selected to create two patient profiles: those who reported five or more acute care episodes in the previous six months, Profile A; and those who had one to four episodes, Profile B. The study’s lead author was Shreya Kangovi, a Robert Wood Johnson Foundation Clinical Scholar in the department of medicine at the Philadelphia Veterans Affairs Medical Center. Twelve men and 28 women participated in the study. Their average age was 42.2, standard deviation 14.5, and 90% were African American. The researchers said, “Most participants perceived two main benefits of hospital care relative to ambulatory care: better overall access across a variety of domains and higher levels of trust in the technical quality of hospital providers and services.” Just making appointments with a …

> “There’s nobody in Mississippi who does not have access to health care.” > > Haley Barbour, former governor of Mississippi Governor Barbour made this remark to the Boston Globe in April 2011,1 insisting that people without health insurance in Mississippi can get charitable care from hospitals and doctors whenever they need it, and poor people can rely on Medicare, a national insurance programme run by the United States government. I was recently in Mississippi to experience the US healthcare system myself. Early one morning at 7 am, I sat slumped on a sofa, bleary eyed, waiting for surgery to start. A doctor sat down on the sofa next to me. “Did you hear what our president is doing?” he asked me. …

The High Court in Delhi has written to 10 leading private hospitals asking them to explain why they have not complied with an order passed a decade ago that they must treat a proportion of poor patients free of charge. On 15 November 2002 the government of the National Capital Territory gave some 43 hospitals in Delhi land at minimal costs with the proviso that at least 10% of beds be reserved for poor people, who would be given free treatment when admitted as inpatients, and that 25% of patients would get free drugs …

Many of the 16 million extra US citizens who will become eligible for health insurance under the Medicaid programme from January 2014 are expected to have trouble finding a doctor. Many US doctors are reluctant to take patients with Medicaid insurance because of the scheme’s low proportion of reimbursement paid to doctors, and a study published in the August issue of Health Affairs has found that 31% of doctors would not be prepared to accept any new patients under Medicaid.1 Medicaid currently covers about 60 million people, including many poor people, disabled people, pregnant women, and people in long term care. President Barack Obama’s Affordable Care Act, passed in March 2010, expanded eligibility to at least 16 million more people, predominantly those on low incomes but above the …

Governors of at least five US states have said that they will resist the expansion of healthcare insurance coverage to more poor people. The health reform law, the Affordable Care Act, was intended to cover about 17 million uninsured poor people aged under 65 by extending the Medicaid health insurance programme. Medicaid usually covers only pregnant women and poor parents and their children, not poor childless adults. About 57% of Medicaid costs are paid for by the federal government and the rest by the states. However, each state sets its own eligibility requirements for Medicaid, and some states are more generous than others. The Affordable Care Act called for the expansion of Medicaid to cover about 17 million people on low or middle incomes but who were above the poverty level. The federal government promised to pay 100% of the cost for the first …

Several thousand people took to the streets in Germany on Saturday 9 June to protest against proposed new anticounterfeiting controls, which they say will harm the production of generic drugs across the world and consequently reduce poor people’s access to them. The day of action, which was organised to stop the implementation of the Anti-Counterfeiting Trade Agreement (ACTA), also produced demonstrations in London, Brussels, Vienna, the Netherlands, and Sweden. Protestors said that the “undemocratic” agreement would harm fundamental rights and curb access to essential, affordable drugs in Europe and in developing countries that have not participated in negotiations. Tessel Mellema, a …

After more than a decade of wrangling, the Filipino parliament has moved a step closer to approving a bill that would provide free access to contraception to poor people. By a vote of 113 for and 104 against, with three abstentions, the House of Representatives passed the bill, which as well as providing free contraception would make sex education available to children and teenagers. The bill would also require the Department of Health to improve obstetric care. It says that for every 500 000 people there should be at least one hospital with …

Epidemiology is a scientific discipline dating back about 150 years. During this period it has contributed enormously to our understanding of the causes of disease and to the identification of strategies for their prevention. Unfortunately, epidemiologists have been less successful in ensuring that the epidemiological information so exquisitely gathered is translated into effective policies and programmes. Epidemiologists have failed to actively contribute to improving the health of populations we serve, especially poor and disadvantaged populations. The case of non-communicable diseases (NCD) is instructive. Two in every 3 of the 57 million deaths worldwide each year are due to NCD, principally cardiovascular diseases, cancers, diabetes and chronic respiratory diseases; NCD death rates are now higher in poor than in wealthy countries and among poor people in all countries. The UN High-Level Meeting on NCD in September 2011 stems from the global NCD crisis and the need for a coordinated and effective response. If this meeting results in a positive outcome, it will be in part because of the contribution by epidemiologists in mapping the NCD pandemic and identifying its causes. However, a successful outcome will result only if we engage with the political dimensions of disease prevention and treatment. The steps required in translating the epidemiology of NCD into simple, focused and politically acceptable messages have not been easy and have taken epidemiologists into areas for which we are remarkably unskilled, but which provide important lessons for the future of epidemiology.

Antimalaria advocacy groups have renewed calls for an end to taxes and tariffs on vital products used to fight the disease, including drugs, insecticide treated bed nets, and rapid diagnostic tests. Awa Marie Coll-Seck, executive director of the Roll Back Malaria Partnership, welcomed all initiatives to make these products affordable and accessible. Eliminating the tariffs—which in some countries add 40% to 50% to the price of antimalarial products, would help slash costs and make them affordable and accessible to poor people, experts say. Data collected by the Malaria Taxes and Tariffs Advocacy Project (M-TAP), a two …

The proliferation of substandard drugs in poor countries is being used as an excuse to tighten rules on intellectual property, boosting the profits of large drug companies while making it harder for poor people to get access to the treatments they need, the charity Oxfam says in a new report. The report, launched in Paris this week in association with Interpol and the World Intellectual Property Organization, says that more than two billion people “lack regular access to affordable and quality medicine.” The World Health Organization estimates that 30% of countries have no functioning drug regulatory authorities. In the absence of effective regulation, says the report, …

The world’s healthcare systems are estimated to be wasting between 20% and 40% of their resources, but smarter spending and tackling leakages could increase healthcare coverage of their populations by similar amounts, says a new World Health Organization report. The study also says that more than a billion poor people, mostly in poor nations, don’t have access to the health services they need because they can’t afford to pay for them. “In ethical terms, no one in need of healthcare, whether curative or preventive, should risk financial ruin as a result of paying for this care,” said Margaret Chan, WHO’s director general, at the launch of the report in Berlin this week. The report says, “Worldwide, about 150 million people a year face catastrophic health costs …

The president of the British Medical Association has hit out at the coalition government’s spending cuts last week, claiming that its continued insistence that its proposals would create a fairer society were a “grotesque parody of the word fairness.” Speaking to the World Medical Association’s general assembly in Vancouver on 14 October, Michael Marmot criticised the government’s proposed benefit cuts, which he said would hit poor people the hardest. “They raise value added tax, which is regressive, and they say we are doing this in the interests of fairness. They cut benefits to the poor, and they say they are …

Current approaches taken by governments and international agencies to cut poverty by targeting only poor people or adopting measures separate from broader aspects of economic development fail to tackle the underlying causes, a United Nations report warns. Such failure could leave about one billion people destitute by 2015, it says. The report analyses the causes and persistence of poverty and looks at what works and what doesn’t in current policy planning and practice. “The evidence shows that poverty is reduced when economic and social policies, institutions and political arrangements are mutually supportive,” the report says. “Simple prescriptions may …

Chokshi and Kesselheim make a strong case for developing countries to invest in an evidence base for developing and appropriately using newer vaccines.1 However, an infrastructure of the required research and information systems is entirely absent in …

British doctors should consider volunteering their time to work abroad to help improve the health of poor people overseas, a new BMA report says. The report on the health of the world's poor, which was published this week, says that the NHS should actively support health improvements in poor countries. The United Kingdom, which has recruited many thousands of health workers from poor countries in the past decade without incurring training costs (Observations, doi: 10.1136/bmj.39206.640903.94), has a duty to assist financially poor countries to rebuild their …

Global spending on health research is rising by about $10bn (£5bn, €8bn) a year, but too little is spent on researching diseases that affect the poor and marginalised people in developing countries, a new report from the Global Forum for Health Research says. The total spending for 2003, the most recent year for which statistics are available, was almost $129bn. Stephen Matlin, the forum's executive director, told the BMJ that no one knew how much of the total went into researching diseases that most affect poor people. “But we do know that it's not nearly enough,” he added. Almost 93% of the global spending on health …

The era of big health information campaigns is over because the public no longer trusts messages sent out by the government, advertising experts told public health workers this week. At a conference to discuss how eating habits differ in the United Kingdom between rich and poor people and the resulting inequalities in health, delegates were told that to educate people about nutrition they must adopt the same marketing practices as commercial giants such as Philip Morris or Coca Cola. Jeff French, project director of the national social marketing strategy for health at the National Consumer Council, said people didn't want to be preached to. He said, “Government led, top-down information aimed at a generalist audience …

A global appeal to focus research on developing new drugs, diagnostic tests, and vaccines for tropical diseases affecting poor people in developing countries has been launched by a group of scientists and non-governmental organisations. Led by an independent foundation, Drugs for Neglected Diseases Initiative (DNDi), the appeal was launched simultaneously in London, New Delhi, Nairobi, and Rio de Janeiro and was supported by Medecins Sans Frontieres (MSF) and Oxfam. The appeal asks governments to make neglected diseases a research priority, ensure sustained financial support, and reduce patent and regulatory barriers in order to increase research and development activities for neglected diseases. “The current system needs a fundamental overhaul to address …

Rich countries should increase aid and make it work better for poor people, cancel world debt, and change the rules of world trade so that they favour the interests of the poor. That was the new year's message to Britain's prime minister, Tony Blair, from a coalition of more than 100 UK charities, trades unions, and campaigners, including rock and pop stars. Their Make …

I worked for the first time on a development project in 1978—a multistate agricultural project in India. After travelling around rural India for two months I came to realise how much poor people were able to do with very little. But the project also raised the question of what it was that kept people so poor. A shortage of resources was part of the problem—but only part.

Medical errors in hospital are responsible for the deaths of nearly 4500 children in the United States every year, says a study examining the effect of lapses in patient safety on children in hospitals throughout the nation ( Pediatrics 2004;113:1741-6). “The bottom line is that none of these events should have happened,” said Dr Marlene R Miller, the study's lead author and director of quality and safety initiatives at the Johns Hopkins Children's Center in Baltimore. Children less than 1 year old and those covered by Medicaid, the government's insurance programme for poor people, were most likely to experience medical errors, Dr Miller and Dr Chunliu Zhan …

Few randomised controlled trials published in leading general medical journals address the major health problems that affect most of the world's poor people. An analysis of trials published in six leading general medical journals in 1999 shows that only 14 of 90 trials (16%) that looked at at least one of the top 10 causes of the global burden of disease were highly relevant to international health, as assessed by World Health Organization criteria ( CMAJ 2004;170:1673-7). Seven of the 35 most deadly and debilitating diseases were not studied in …

A substantial increase in global spending on health research over the last decade has boosted funds available for neglected diseases that mainly affect poor, developing countries, the Global Fund for Health Research said in its annual report. The report, published this month, found that spending on health research worldwide has increased by about 50% since 1998, helped by large donations from governments and charitable foundations for diseases that affect poor people, such as malaria, tuberculosis, and dengue fever. Stephen Matlin, head of the Geneva based organisation, …

Former physician New Delhi (b 1906; q Durham 1930; MD, MRCP, DTM), d 21 May 2003. Major general Baij Nath Bhandari had an illustrious career with the Indian Army Medical Corps, from which he retired as a deputy director of medical services. He was one time principal of Maulana Azad Medical College and medical director of Irwin Hospital, New Delhi. In the second part of his life he dedicated himself to the poorest of the poor in the bastis (slums) of New Delhi, providing free primary health care services. He became closely involved with the Arpana charity, which works to empower poor people in the villages of India. His translation of the Bhagavad Gita from Hindi into English is a reflection of his good understanding of Hindi and Sanskrit and was well received. He leaves a wife, Kamla, and two daughters.

It's Carnival time in Brazil; a time of year when practical realities such as the country's health policies take a backseat to the sun, samba, and sensationalism of the Mardi Gras festival. The thousands of tourists descending on the country, flocking to the tourist capital, Rio de Janeiro, will embrace the intoxicating hedonism of the spectacle. The few who actually encounter the Brazilian health service will probably do so as a result of excess Cachaca--an unbeleivably potent rum. Unfortunately, postcards depicting the Cidade Maravilhosa of Rio are unrecognisable to most of the population. In stark contrast to its opulent carnival, …

Alternative and “additive free” cigarettes, which are increasingly popular with North American adolescents, deliver substantial amounts of nicotine and other toxic components of tobacco smoke, contrary to common perceptions. That is the finding of a study published in the December issue of Nicotine and Tobacco Research (2002;4:485-90). Lead researcher Wallace Pickworth, of the US National Institute of Drug Abuse, said that adolescents' use of alternative cigarettes, such as clove cigarettes, additive free cigarettes, and “bidis”—a type of leaf wrapped, unfiltered cigarette popular among poor people in India but increasingly fashionable among US teenagers—has increased. The report says, …

Ninety per cent of the world is at risk from infectious diseases, but only 10% of the world9s research and pharmaceutical resources are spent on them. Drug development for diseases that affect poor people has come to a virtual standstill. Nathan Ford explains how Medecins Sans Frontieres is trying to redress the balance with its ‘Access to Medicines’ campaign(also see the review of Secret Agents on p298)

Walking and non-motorised vehicles are the major means of transport for most poor people in Asian cities. They provide access to economic opportunities, health services, and other social services essential for survival. For many people, walking is the only way of getting to work, even over long distances. Even subsidised public transport and low cost bicycles are out of reach. These people are “captive pedestrians.” Those who use public transport systems also become pedestrians at least four times a day when they access those systems. These two groups form the largest group of road users. Yet their needs for a safe and convenient infrastructure are ignored as cities continue to invest in an infrastructure that makes the environment even more hostile for pedestrians. State authorities plan for the …

EDITOR—Wiltshire et al have added to the tobacco control debate by documenting that smokers in deprived areas perceive a lack of support for cessation.1 Their findings need to be interpreted in the totality of the evidence. Firstly, the study did not pose or answer the key question: “If the government were to subsidise nicotine replacement or other cessation programmes, would they take advantage of the subsidy and try to quit?” A “yes” answer would deserve respect and a public response, …

Editor—The Rome Declaration on World Food Security , adopted on 13 November 1996, affirms the “right of everyone to have access to safe and nutritious food, consistent with the right to adequate food and the fundamental right of everyone to be free from hunger.”1 Hunger and inadequate food intakes are not confined to developing countries; poor people in Britain have also experienced a decline in food security over the past decade. The report Low Income, Food, Nutrition and Health: Strategies for Improvement …

Ed Cedric Pugh Earthscan, £16.95, pp 250 ISBN 1 85383 357 6 Cities in many developing countries have been growing since the 1960s at a remarkable rate, and now over 430 million poor people live in them. The impact on the environment is immense. A city of 100 000 people consumes 200 tonnes of food and generates 385 tonnes of garbage and human waste a day, so it is not surprising that city planners and inhabitants alike are concerned with services and meeting basic living requirements. Ironically, city growth is part of industrial development. Cities are huge economic machines, …

Privatisation is sweeping across the American public hospital system. Last month New York City's huge city run health system for poor people was threatened with the prospect of becoming the latest--and largest--system to be privatised under a plan suppported by the Republican mayor, Rudolph Giuliani. The city has been a leader in providing care for …