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In the 12 years since publication of the previous issue of this volume, the world has changed significantly. In addition to further widening of many of the disparities in health previously described, the impact and implications of the still evolving global economic crisis and of climate change have led to increasing recognition of how the ‘development’ agenda has failed, and that global health is one of the major challenges for the twenty-first century (Benatar and Brock, 2011). World population has increased to 7 billion people, half of whom continue to live in severe poverty (on less than US$2–3 a day), most in constant hunger and under squalid conditions, with little prospect of significant improvement unless new solutions are envisaged. This article discusses the health of citizens of very poor countries and the global interdependence of the health of all peoples, including the privileged.

In this paper, we propose a new model for development, one that transcends the North-South dichotomy and goes beyond a narrow conception of development as an economic process. This model requires a paradigm shift toward a new metaphor that develops sustainability, rather than sustains development. We conclude by defending a 'report card on development' as a means for evaluating how countries perform within this new paradigm.

Although the application of major biomedical advances has yielded spectacular results for individual health, there has been little improvement in the health of whole populations. There is a "back to the future" irony in the fact that at the inception of the 21st century, the eruption and spread of a multitude of "old" and "new" infectious diseases has become the most serious global threat to the health of humankind. At this historical juncture, the United States is the country with the most potential for favorably influencing global health and health care. Although there are historical, cultural, economic, and political factors that impede the United States from rising to this challenge, there is both a moral imperative and a rational long-term self-interest basis for the U.S. medical profession and government to exercise leadership in facing the health challenges of tragic and genocidal proportions that threaten everyone in an increasingly interdependent world.

Interest in the ethics of research on human subjects, stimulated by atrocious human experimentation during WWII and the resultant Nuremberg Code, has been sustained by examples of unethical research in many countries and by proliferation of codes and guidelines. Such interest has intensified in recent years in association with expanding international collaborative research endeavors. The ongoing controversy in international research ethics takes place at two levels. At the practical level it is about the competing concerns of those predominantly interested in doing research to advance knowledge and those who, while supporting the need for research, are more acutely aware of the potential to exploit vulnerable participants, especially in developing countries. At the level of theory the controversy pits ethical universalism against moral relativism.In her recent review of agreements and controversies in international research ethics, Ruth Macklin has concluded that, despite seeming agreement on several issues, many different viewpoints persist. In her view it is unlikely that these will be resolved easily.

A major focus within the modern bioethics debate has been on reshaping power relationships within the doctor-patient relationship. Empowerment of the vulnerable has been achieved through an emphasis on human rights and respect for individual dignity. However, power imbalances remain pervasive within healthcare. To a considerable extent this relates to insufficient attention to social injustice. Such power imbalances together with the development of new forms of power, for example through new genetic biotechnology, raise the spectre of increasing social injustice. Attention will be drawn to the need to extend the bioethics debate to include ethical considerations regarding public health. Changes in political philosophy will also be required to reshape international power relations and improve population health.

Spectacular achievements in the health of individuals have not been matched by equivalent improvement in the health of whole populations. Indeed it is against the background of deterioration in levels of population health in some parts of the world and the emergence and re-emergence of infectious diseases in association with powerful globalizing forces that there has been a recrudescence of interest in 'Public Health'. Here attention is drawn to the dominant values that have shaped our world, to the differences between broad and narrow definitions of public health, to some values that need to be promoted, and to an ethic of public health that considers both human rights and human needsLos espectaculares logros alcanzados por la salud de los individuos no han sido equiparados por una mejoría equivalente de la salud de las poblaciones en su conjunto. Justamente, ha habido un aumento del interés por la "Salud Pública" debido al deterioro del nivel de la salud de la población en algunas partes del mundo y a la emergencia y re-emergencia de enfermedades infecciosas asociadas con poderosas fuerzas globalizadoras. Aquí se llama la atención hacia los valores dominantes que han moldeado nuestro mundo, hacia las diferencias entre definiciones amplias y/o restrictivas de la salud pública, hacia algunos valores que deben ser promovidos y hacia una ética de la salud pública que considere tanto los derechos como las necesidades humanasOs avanços espetaculares alcançados pela saúde pública individual não foram acompanhados por uma melhoria equivalente da saúde das populações. Em algumas partes do mundo aumentou o interesse pela "saúde pública" devido ao deterioração do nível de saúde da população e a emergência e re-emergência das enfermidades infeciosas com poderosas forças globalizantes. Chama-se atenção para os valores dominantes que moldaram nossos mundo, em relação às diferenças entre definições amplas ou restritivas de saúde pública, para alguns valores que devem ser promovidos e para uma ética de saúde pública que leve em conta tanto os direitos como as necessidades humanas

Despite spectacular twentieth century scientific and technological progress, the world is more inequitable than it was fifty years ago. This is evident both in terms of access to health care for individuals, and in relation to the health of whole populations. Disparities in wealth and health within and between nations are widening inexorably and the rapidly expanding global economy has failed to reduce poverty among those with little if any access to health care. In this context the Universal Declaration of Human Rights remains an unrealized aspiration for the majority of the world's people. Given these realities, no single discipline, or body of knowledge is likely to make much difference. For example, approaches based only on neo–liberal economics, as exemplified by the structural adjustment programmes of the World Bank, have not been successful in promoting health equity. The authors believe that an interdisciplinary approach is required, and that bioethics, an interdisciplinary field, can make a contribution towards improving health globally. To do this, the scope of bioethics should be expanded towards a results–oriented global health ethics, based upon widely shared and foundational values that could be carried forward through five transformational approaches.

Intense scientific work on HIV/AIDS has led to the development of effective combination drug therapies and there is hope that effective vaccines will soon be produced. However, the majority of people with HIV/AIDS in the world are not benefiting from such advances because of extreme poverty. This article focuses on the pandemic as a reflection of a complex trajectory of social and economic forces that create widening global disparities in wealth and health and concomitant ecological niches for the emergence of new infectious diseases. While the biomedical approach to HIV/AIDS is necessary, has prolonged the lives of many individuals and could offer much at the level of population health, it cannot, in isolation, improve the health of populations. To achieve the latter will require understanding and addressing the deeper social causes of pandemics. Broadening the discourse on ethics to include public health ethics and the ethics of international relations could contribute to reducing the impact of the pandemic and to preventing the emergence of new infectious diseases in the future.

The debate on the ethics of international clinical research involving collaboration with developing countries has achieved a high profile in recent years. Informed consent and universal standards have been most intensively debated. Exploitation and lack of adequate attention to justice in the distribution of risks/harm and benefits to individuals and communities have to a lesser extent been addressed. The global context in which these debates are taking place, and some of the less obvious implications for research ethics and for health are discussed here to broaden understanding of the complexity of the debate. A wider role is proposed for research ethics committees, one that includes an educational component and some responsibility for audit. It is proposed that new ways of thinking are needed about the role of research ethics in promoting moral progress in the research endeavour and improving global health.

1 Lawn JE. The child survival revolution: what next? Lancet 2014; 384: 931–33. 2 Barros AJ, Ronsmans C, Axelson H, et al. Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries. Lancet 2012; 379: 1225–33. 3 Wang H, Liddell CA, Coates MM, et al. Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 957–79. 4 South Centre. Capital fl ows from South to North: A new dynamic in global economic relations. Geneva: South Centre; 2008. 5 Klein N. This changes everything: capitalism vs the climate. New York: Simon & Shuster; 2014. 6 Bensimon CM, Benatar SR. Developing sustainability: a new metaphor for progress. Theor Med Bioeth 2006; 27: 59–79. 7 Horton R. Offl ine: Why the Sustainable Development Goals will fail. Lancet 2014; 383: 2196. issues in the next 15 years—namely inequity and climate change. Reduction of the neonatal mortality rate, for example, from 70 to 30 might be achievable through biomedical interventions, technological changes coupled with health systems change, female education, and nutritional interventions. Decreasing it further however, is going to depend less on these factors and issues of governance than it does on paradigm shifts in global political and economic thinking. The global system is driven by inequity, by capital outflows from low-income countries that dwarf infl ows by more than six to one, and a global system with increasing numbers of what Klein calls “sacrifi ce zones” (poor out of the way places that are being destroyed by the consequences of global warming). Biomedical and health system change will not aff ect these “sacrifi ce zones” and as such, are likely to hinder further improvements in child survival in the coming decades. This has particular resonance in view of the imminent release of the Sustainable Development Goals for the post-2015 era. The very phrase ”sustainable development” has been criticised as unachieveable when development is defined in economic terms (in the context of hyper consumption and depletion of the earth’s resources), and there is a need to think about ”developing sustainably”. If we link this to the six dimensions of sustainability outlined by Horton (wellbeing, capability, intergenerational equity, externalities, resilience, and strength of our civilisations) and, more specifi cally, the last one, we have to then situate ourselves firmly in the realm of the political. Location of future gains in child survival squarely within what has gone before, largely biomedical and for the most part apolitical, runs the risk of simply doing business as usual and masking the real social and societal changes that are needed to achieve ambitious goals.

Twenty years after the fall of apartheid, social and economic disparities persist in South Africa and have a profound effect on the health of the population. HIV infection and tuberculosis remain major health problems, and there are not enough health care workers.

In the third decade of a new South Africa (SA), major challenges are being faced in almost every aspect of life, ranging from meeting minimum daily subsistence requirements, through providing education and primary healthcare, to the functioning of our legal system and governance at local and national levels. While in this context levels of crime and corruption are reaching new heights, we should not lose sight of the need for humane and accountable approaches to crime and imprisonment. The 37th anniversary on 12 September of Steve Biko’s death under inhumane conditions and without adequate medical care in prison provides an opportunity to remember past failings and to reconsider the lessons these hold for our society.

To develop explicit criteria for patient admission in order to optimize utilization of PICU facilities in the face of increasing demand outstripping resources.Multidisciplinary PICU in a university-affiliated referral hospital in Cape Town, South Africa.Retrospective description of policy development and implementationAll patients referred to the Paediatric Intensive Care Unit of the Red Cross War Memorial Children's Hospital.Development and application of admission policy.In consultation with clinicians at the hospital, principles for utilization of PICU resources were established and then translated into specific policies for prioritization of admission of particular groups of patients. The hospital team developed and implemented: criteria for intensive care admission; prioritization for certain categories of patients (including those scheduled for elective surgery); processes for refusing intensive care admission to other categories of patients; and processes to review implementation. These criteria and procedures were made explicit to clinicians, administrators, and managers and eventually agreed to by them. It was challenging to obtain "buy-in" from all potential stakeholders in the process and also to implement such policies under conditions of high stress.Development and implementation of explicit policies for utilization of PICU resources provide a "reasonable" process for fair and equitable utilization of scarce resources. The factors that have to be considered while developing these policies may extend beyond the priorities of individual patients. Implementation is still fraught with problems. Development of explicit admission policies that consider the needs of individual patients and also the longer term development of healthcare services may enable the retention of small but essential services.

INTRODUCTIONDuring the 20th century, developments in science and technology and their application in medical practice have transformed the nature of health care and improved the lives of many people. In the 21st century, advances in genetics have the potential to transform medical practices even further through a revolution in applied genomics and molecular medicine. Some examples of what could be achieved include the ability to determine genetic susceptibility to disease and to prevent disease by linking environmental control measures to those at particular risk; the use of gene therapy to correct genetic defects; and the use of new molecular biology techniques to design new, more specific therapeutic agents. New functional imaging diagnostic techniques, less invasive surgical methods, and specifically designed target drugs could contribute to more efficient treatment of many disorders. The global reach of communications technology, which can bring appropriate health care knowledge to health care workers worldwide, also offers the possibility of enhancing health and well being globally. This is an exciting and challenging time for medicine and health care professionals.Changes in the world economy, especially in the past 50 years, have generated great wealth, which has also enhanced the lives of many people. Some believe that continued economic growth is the primary factor in improving human life. However, current economic trends are both widening the gap between rich and poor and exacerbating the extent of absolute poverty. Because health care systems are shaped by both societal values and the distribution of wealth and power, the result is striking disparities in health care expenditure and health research priorities, neither of which mirrors disease burdens. Lack of access to modern communication facilities, unwise use of new biological power, and a failure to make basic health care widely accessible are widening rather than narrowing the gap between rich and poor - as vividly illustrated by the lack of access of millions of people to modern treatment for HIV/AIDS.At the end of a century in which spectacular scientific and technological progress greatly enhanced the lives of about one-fifth of the world's population but available knowledge and resources were not used wisely the warning signs of an impending catastrophe in international health were increasingly apparent. Intense poverty, widespread hunger, and preventable diseases, the emergence of many new infectious diseases, environmental degradation, profound human suffering, and internecine conflict on a large scale (adversely affecting the lives of up to 80 per cent all people in the world) can be interpreted as malaise and instability within a complex global system. These features are late manifestations of humanly determined processes that have been under way for many years. They warn us of the potential for a phase in human history characterized by malnutrition and rampant infectious disease pandemics as a result of multidrug resistant organisms on the one hand and a growing burden of morbidity and mortality from obesity, diabetes, vascular disease, and malignancies on the other.(1)Economic growth, progress in science and technology, and the unprecedented potential power of gene-based health care should not blind us to the fact that threats to the health status of billions of the planet's citizens could today be greatly attenuated by improving access to essential drugs and vaccines and through well recognized public health measures. Today, more than ever, it is necessary to acknowledge that equitable access to health care is a morally required basic need for humans to grow to maturity and achieve their potential. Advances in knowledge and the application of technology alone are not sufficient to achieve such goals.We will have to make major shifts in the way we think about the health of individuals and populations, present and future, to encourage the policy changes necessary to achieve more widespread human well being. …

Economic globalization has profound implications for health. The scale of injustice at a global level, reflected in inexorably widening disparities in wealth and health, also has critical implications for health related research ‐ in particular when the opportunities for exploiting research subjects are carefully considered. The challenge of developing universal guidelines for international clinical research is addressed against the background of a polarizing, yet interdependent, world in which all are ultimately threatened by lack of social justice. It is proposed that in such a world there is a need for new ways of thinking about research and its relevance to health at a global level. Responsibility to use knowledge and power wisely requires more radical changes to guidelines for research ethics than are currently under consideration.

South Africa's peaceful transition is evolving during a period in which spectacular twentieth-century achievements have greatly improved life for one-fifth of the world's population. These are being gradually eclipsed, however, by the impact of social and economic forces that relegate four-fifths of the world's population to increasingly insecure, miserable and impoverished lives. South Africa's negotiated revolution, which has allowed it to move from the pariah status of apartheid to that of a fledgling democracy, exemplifies the paradigm shift required for global progress towards a more just and peaceful world. The HIV/AIDS pandemic, a major threat to South Africa, the African continent and many others around the world, is used in this article as a window through which to view the prospects for the long-term social success of South Africa's transition. It is also used as a mirror to reflect the world in which such a disease could emerge and spread pervasively. The explanatory links between exploitative global economic forces and the emergence of threats to lives are considered, in order to illuminate new pathways towards global progress in which respect for human rights will be further consolidated through promotion of solidarity, interdependence and social justice.

to design new, more specific therapeutic agents. New functional imaging diagnostic techniques, less invasive surgical methods, and specifically designed target drugs could contribute to more efficient treatment of many disorders. Advances in information technology could enable home monitoring of patients with asthma and chronic obstructive pulmonary disease (COPD) and further empower patients, especially those who can afford it, to care for themselves. Distance diagnosis and teaching (e.g., through Internet transmission of radiological and video images) and more widespread access to electronic literature sources could facilitate the spread of knowledge and expertise. While it is the hope of many that such advances will improve respiratory health globally, the risk that such advances will be available only to those with resources should not be underestimated ( see below ).

Clinical research has become a burgeoning activity in recent years, largely stimulated by the pharmaceutical industry's interest in new drugs with high marketing profiles. Several other forces fuel this thrust: the increasing dependence of academic medical institutions on research funding from industry; the need for large, efficient multicenter trials to obtain reliable and statistically significant results in the shortest possible time for drug registration purposes; and access to research subjects in “developing” countries. The intense interest in HIV/AIDS research and recent controversies about revisions to the Helsinki Declaration, which have been seen by some to be motivated by the desire to facilitate exploitative research in “developing” countries, have stimulated renewed interest in the ethics of clinical research.

A major strength of this capacity building programme is that it encourages cross-cultural considerations in the application of research ethics principles to research in developing countries.

Widening disparities in health and human rights at a global level represent the dark side of progress associated with escalation of economic and military exploitation and exponential population growth in the 20th century. Even the most basic universal human rights cannot be achieved for all under these circumstances. The goal of improved population health will be similarly elusive while medical care is commodified and exploited for commercial gain in the marketplace. Recognition of the powerful forces that polarize our world and commitment to reversing them are essential for the achievement of human rights for all, for the improvement of public health, and for the peaceful progress required to protect the "rational self-interest" of the most privileged people on earth against the escalation of war, disease, and other destructive forces arising from widespread poverty and ecological degradation.

South Africa's peaceful political transition from apartheid to democracy will have to be followed by a profound social transformation process if inequities are to be reduced and sustainable progres...

A shift in mind‐set is required to appreciate the extent of change demanded at a global level to begin to reverse ideological and exploitative processes that by continuing to polarize the world into a small and shrinking rich core and a large and growing poor periphery threaten the lives of all in an interdependent world. Proposals for reversing such adverse processes include (i) acquiring a deeper understanding of the ‘Third World’ or ‘periphery’ as a problem in which all nations are deeply implicated, (ii) fostering greater support for peace movements, and (iii) propagating new ways of thinking about progress. The dramatic political transition in South Africa illustrates how war can be avoided through peaceful negotiations. Successful ongoing social transformation in South Africa will depend, at least in part, on other countries emulating South Africa's example in different, but analogous, contexts.

The escalating expenditure on patients with HIV/AIDS within an inadequately funded public health system is tending towards crowding out care for patients with non-HIV illnesses. Priority-setting decisions are thus required and should increasingly be based on an explicit, transparent and accountable process to facilitate sustainability. South Africa's public health system is eroding, even though the government has received extensive donor financing for specific conditions, such as HIV/AIDS. The South African government's 2007 HIV plan anticipated costs exceeding 20% of the annual health budget with a strong focus on treatment interventions, while the recently announced 2012-2016 National Strategic HIV plan could cost up to US$16 billion. Conversely, the total non-HIV health budget has remained static in recent years, effectively reducing the supply of health care for other diseases. While the South African government cannot meet all demands for health care simultaneously, health funders should attempt to allocate health resources in a fair, efficient, transparent and accountable manner, in order to ensure that publicly funded health care is delivered in a reasonable and non-discriminatory fashion. We recommend a process for resource allocation that includes ethical, economic, legal and policy considerations. This process, adapted for use by South Africa's policy-makers, could bring health, political, economic and ethical gains, whilst allaying a social crisis as mounting treatment commitments generated by HIV have the potential to overwhelm the health system.

The proposal for national health insurance (NHI) is part of a welcome resurgence in public discourse about poverty, health and access to health services in South Africa. Despite certain areas of progress in the country since 1994, disparities in wealth and health are among the widest in the world. In 2008, for example, 54% of South Africans had an income below $3/day. The top 10% of South Africans account for 58% of annual national personal income, while the balance of 70% received a mere 16.9%. The Gini co-efficient, a measure of income inequality, increased from 0.6 in 1995 to 0.679 in 2009.

Objectives To examine the frequency of limiting (withdrawing and withholding) therapy in the intensive care unit (ICU), the grounds for limiting therapy, the people involved in the decisions, the way the decisions are implemented and the patient outcome.

Universal access to renal replacement therapy is beyond the economic capability of most low and middle-income countries due to large patient numbers and the high recurrent cost of treating end stage kidney disease. In countries where limited access is available, no systems exist that allow for optimal use of the scarce dialysis facilities. We previously reported that using national guidelines to select patients for renal replacement therapy resulted in biased allocation. We reengineered selection guidelines using the 'Accountability for Reasonableness' (procedural fairness) framework in collaboration with relevant stakeholders, applying these in a novel way to categorize and prioritize patients in a unique hierarchical fashion. The guidelines were primarily premised on patients being transplantable. We examined whether the revised guidelines enhanced fairness of dialysis resource allocation. This is a descriptive study of 1101 end stage kidney failure patients presenting to a tertiary renal unit in a middle-income country, evaluated for dialysis treatment over a seven-year period. The Assessment Committee used the accountability for reasonableness-based guidelines to allocate patients to one of three assessment groups. Category 1 patients were guaranteed renal replacement therapy, Category 3 patients were palliated, and Category 2 were offered treatment if resources allowed. Only 25.2% of all end stage kidney disease patients assessed were accepted for renal replacement treatment. The majority of patients (48%) were allocated to Category 2. Of 134 Category 1 patients, 98% were accepted for treatment while 438 (99.5%) Category 3 patients were excluded. Compared with those palliated, patients accepted for dialysis treatment were almost 10 years younger, employed, married with children and not diabetic. Compared with our previous selection process our current method of priority setting based on procedural fairness arguably resulted in more equitable allocation of treatment but, more importantly, it is a model that is morally, legally and ethically more defensible.

The SARS epidemic showed how easy it is for infectious diseases to spread round the world. Ethical as well as clinical issues need to be resolved to improve the response to the next epidemic The outbreak of severe acute respiratory syndrome (SARS) in the Toronto area earlier this year forced medical and government workers to make hard choices, often with limited information and short deadlines. Healthcare providers were on the firing line, and were the people most affected by the disease.1 Decision makers had to balance individual freedoms against the common good, fear for personal safety against the duty to treat sick people, and economic losses against the need to contain the spread of a deadly disease. Such decisions have to be guided by both scientific knowledge and ethical considerations. The SARS outbreak showed that Canadian society was not fully prepared to deal with the ethical issues. We formed a working group to identify the key ethical issues and values most important for an analysis of ethical dimensions of the SARS epidemic. The final list of issues and values was agreed by a consensus process and found to have face validity and credibility. We then developed a framework for looking at the ethical implications of the SARS outbreak, identifying 10 key ethical values relevant to SARS (box), and five major ethical issues faced by decision makers. We examined the underlying ethical values for the five major issues and drew lessons from how each was tackled. The following case studies illustrate the issues and are an amalgam of our experiences. A medical clerk is asked by public health officials to remain at home in quarantine for 10 days because of possible exposure to SARS. She wants to comply but fears this could cost both her job and her apartment. Five …

The history of bioethics in the Faculty of Health Sciences of the University of Cape Town (UCT) follows a similar pattern to elsewhere. At first, bioethics received little formal attention, but there has been a flowering of interest over the last few decades. There has also been a shift from a professionally insular view of bioethics to one informed by non-medical disciplines. While this pattern is to be found in many parts of the world, there are some distinctive, but not unique, features of bioethics at South Africa’s oldest medical school.

This chapter focuses on South African bioethics, which originated as the “spillover” from British and European academic institutions as a result of its colonial past. South African bioethics are linked to indigenous concerns and takes on social functions that advance on local social, political, and humanitarian concerns. It highlights the apartheid state as a repressive, authoritarian society under which public and professional debates on ethics are limited, and the death of Steve Biko as a significant turning point to the indigenization of South African bioethics.

Introduction: severe poverty persists on a massive scale and could be greatly reduced at low cost Many more people – some 360 million – have died from hunger and remediable diseases in peacetime in the 20 years since the end of the cold war than have perished from wars, civil wars, and government repression over the entire twentieth century. And poverty continues unabated, as the official statistics amply confirm: 1020 million human beings are chronically undernourished (FAO, 2009), 884 million lack access to safe water (WHO & UNICEF, 2008, p. 30), and 2500 million lack access to improved sanitation (WHO & UNICEF, 2008, p. 7), while 2000 million lack access to essential medicines (Fogarty Center for Advanced Study in the Health Sciences, n.d.), 924 million lack adequate shelter (UN-Habitat, 2003, p. vi) and 1600 million lack electricity (UN-Habitat, n.d.). About 774 million adults are illiterate (UNESCO, 2008) and 218 million children are child laborers (ILO, 2006, p. 6). Roughly one-third of all human deaths, 18 million annually, are due to poverty-related causes, straightforwardly preventable through better nutrition, safe drinking water, cheap rehydration packs, vaccines, antibiotics and other medicines. People of color, females and the very young are heavily over-represented among the global poor, and hence also among those suffering the staggering effects of severe poverty. Children under 5 account for half, or 8.8 million, of the annual death toll from poverty-related causes (UNICEF, 2009). The over-representation of females is clearly documented (UNDP, 2003, pp. 310–330).

This contribution analyses and systematiscs apartheid as a phenomenon and as a problem in South African health and health care. It is assumed that apartheid is one of the most decisive forces moulding the South African health care system as well as the health of the people, resulting in grave race-related disparities, inequalities, fragmentation and discrimination on the one hand, and divergent, race-related health outcomes in the health indices and health statuses of the different ‘colour’ groups. The material presented. is systematised within a fourfold framework, differentiating between a structural/institutional component and a consequential/outcome component of apartheid, The former refers to both the racially segregated supply system and the racially divided clientele; the latter applies to both structural outcomes in the form of race-related deformities in the organisation and allocation of health care supply and racerelated inequalities and disparities in the health and health status of t...

The military might of the modern era poses devastating threats to humankind. Wars result from struggles for material or ideological power. In this context the probability of flouting agreements made during peaceful times is great. The rights of victims and the rights of medical personnel are vulnerable to State and military momentum in the quest for sovereignty. Scholars, scientists and physicians enjoy little enough influence during times of peace and we should be sanguine about their influence during war. But we also must avoid becoming co-opted by partisan political forces. The universal ideals for which we strive, need to be cherished and kept central in our field of vision if we are to rise above man's basest instincts and if we are to preserve professional integrity, individuality and humanitarian concern for the sanctity of life — even the lives of our foes who are engaged in battle against us. Such compassion also recognizes the coercion implicit in recruiting persons into wars they detest and which pits them against their own image. Man's inhumanity to man, most evident during war, must not be allowed to pervade the sanctuary of medical care. Health professionals must constantly be encouraged to serve humankind with empathy and compassion and great social effort needs to be expended to facilitate this role globally and under all conditions.

Following promulgation of the Nuremberg code in 1947, the ethics of research on human subjects has been a challenging and often contentious topic of debate. Escalation in the use of research participants in low-income countries over recent decades (stimulated by the HIV pandemic and the need to carry out clinical trials expeditiously on large numbers of patients), has intensified the debate on the ethics of international research and led to increasing attention both to exploitation of vulnerable subjects and to considerations of how the 10:90 gap in health and medical research (ie, 90% of resources being spent on 10% of the problems) could be narrowed. In 2000, prompted by the discussions over several years that led to the US NIH launching a capacity building programme on research ethics for members of research ethics committees in developing countries, we advanced a ‘new look’ for the ethics of international research.1 Since then progress has been made on several fronts. First, our ideas—considered somewhat radical and impractical at the time—have been provocatively addressed by scholars who have either contested them or advanced similar conceptions of what obligations international researchers have to research participants and communities in low income countries before, during and after clinical trials. Second, those researchers who have been sympathetic to our ideas have either endeavoured to put these into practice or have investigated the feasibility of doing so. Third, the intractability of the 10/90 gap and the escalation of interest in global health have sensitised many to the need to amplify the uptake of these ideas in practice. Here, we briefly review the conceptual and practical developments in international research ethics. While much conceptual progress has been made (and the concepts are now appearing …

In the 60 years since the Universal Declaration of Human Rights was promulgated, the promise of achieving respect for the human rights, health and well being of all is becoming an ever more distant prospect. We have not even remotely met the challenge of improving health for a large proportion of the world's population, and the prospects for improving global health seem to be receding in the current deteriorating economic and political climate. As global health remains one of the most pressing problems of our time, we must question the values that direct our actions and current approaches, which proclaim 'human rights to health' but which subsume these rights to a broader paradigm of unregulated global market economics and national politics, rather than working to make these oft-contradictory goals mutually compatible through justifiable and accountable global governance processes. We suggest that a new balance of values and new ways of thinking and acting are needed. These must transcend national and institutional boundaries and recognise that health in the most privileged nations is closely linked to health and disease in impoverished countries. Sustainable development of health and well-being is a necessity for all, and values for health should permeate every area of social and economic activity.

There are two perspectives on the problem of human rights abuses: the perpetrator perspective and the system perspective. The perpetrator perspective focuses on the shortcomings of persons, blaming them for neglect, cruelty, or moral weakness, and it attempts correction through education, activism, and judicial intervention. The system perspective acknowledges that the social circumstances within which individuals live can surreptitiously co-opt otherwise good people into participating in human rights abuses. Here, the corrective approach needs to focus on the complex task of altering structures and functions of systems in order to overcome structurally propelled abuses of human rights, while at the same time recognizing the moral and legal importance of allocating individual blame for the violation of such rights.

The prevalence of HIV infection in South Africa is approaching 20% of young adults. In severely mentally ill people it is probably higher. Testing for infection is subject to stringent ethical principles. Undiagnosed HIV infection in people with severe mental illness increases costs and morbidity. Since effective treatments are available, it is imperative to diagnose HIV infection early in this high-risk population.A literature review established the prevalence of HIV infection in inpatient populations with HIV infection. The pattern of testing for HIV over 3 years at a major psychiatric hospital was investigated. We surveyed public sector psychiatrists in the Western Cape to establish their attitudes to HIV in their patients.The reported HIV seroprevalence in psychiatric inpatients ranges from 0 to 59.3%, with a mean of 10%. Data show a clear trend towards an increase in prevalence: before 1996 the mean HIV seroprevalence was 7.4%, while after 1996 the mean was 15%. State psychiatrists in the Western Cape do not test routinely for HIV infection, mainly owing to ethical constraints: 14.6% of patients at Lentegeur Hospital were tested in 2006.The high prevalence of HIV infection in South Africa, which is probably higher in patients with severe mental illness (most of whom are not competent to provide informed consent), and the availability of effective treatment require debate and a clear policy regarding testing for HIV infection to be implemented. We recommend a new approach to HIV testing in these patients.