When Doctors strike: Making Sense of Professional Organizing in Kenya.

Little is known about how the health professions organize in low- and middle-income countries (LMICs). This is particularly troubling as health worker strikes in LMICs appear to be growing more frequent and severe. While some research has been conducted on the impact of strikes, little has explored their social etiology. This article draws on theory from organization and management studies to situate strike behavior in a historical process of sensemaking in Kenya. In this way, doctors seek to expand pragmatic, moral, and cognitive forms of legitimacy in response to sociopolitical change. During the first period (1963-2000), the legacy of colonial biomedicine shaped medical professionalism and tensions with a changing state following independence. The next period (2000-2010) was marked by the rise of corporate medicine as an organized form of resistance to state control. The most recent period (2010-2015) saw a new constitution and devolution of health services cause a fractured medical community to strike as a form of symbolic resistance in its quest for legitimacy. In this way, strike behavior is positioned as a form of legitimation among doctors competing over the identity of medicine in Kenya and is complicating the path to universal health coverage.

Hospital markets in the United States, 2007-2017.

BACKGROUND: U.S. hospital markets have undergone consolidation in recent decades with the growth of large "health systems," but little is known about the characteristics of systems, and whether certain geographic areas or service types (e.g. intensive care, obstetrics) have been differentially impacted by consolidation. METHODS: Using 2007-2017 American Hospital Association data, we characterized health systems and their growth, and determined how changes in hospital market structure have differentially affected specific service types and geographic areas. RESULTS: Despite a national trend of reduced hospital utilization, health systems grew larger during our study period. Hospital markets were already highly concentrated in 2007 and became even more concentrated between 2007 and 2017, across all service types that we measured. The least concentrated service was emergency department care, while intensive care and obstetrics were the most concentrated. As of 2017, 19.0% of markets - representing 11.2 million Americans - are served by only one hospital system. Concentrated markets are less populous, poorer areas and have lower physician supply than less concentrated markets. CONCLUSIONS: Hospital markets were highly concentrated in 2007 and have since become more concentrated in the subsequent decade. Hospital consolidation is a nationwide phenomenon, and is occurring across hospital service types. IMPLICATIONS: Antitrust alone may be insufficient to address high and increasing hospital market power. Decreasing barriers to entry may allow for more competition.

Developing Medical Affairs Leaders Who Create the Future.

Medical affairs has evolved over recent years from a support, to a partner, to a strategic leadership function. In the future, there will be significant changes in healthcare and pharmaceutical industries, and many of these will be due to technological advances and digitalisation. Medical affairs will be largely influenced by these developments in terms of partnerships with key stakeholders, embracing innovation and patient-centric healthcare, and demonstrating value for novel treatment options. In order to secure future success within their roles, medical affairs professionals will have to demonstrate specific capabilities founded on communications and behavioural change, business leadership acumen, knowledge acquisition and self-development, and the ability to generate real-world evidence from insights and expertise within data science and analytics. It will be our responsibility as medical affairs leaders to create this foundation for the leaders of tomorrow.

[From "culprits" to "victims:" the expansion and professionalization of the healthcare system in the province of Mendoza in the late nineteenth and early twentieth century]. / De "culpables" a "víctimas": expansión y profesionalización del sistema de salud en la provincia Mendoza a fines del siglo XIX y principios del XX.

From the late 19th century to the beginning of the 20th, the province of Mendoza presented problematic sanitary conditions due to rapid demographic and urban growth, the scarcity of public services, and the poor state of the old colonial city (destroyed by the 1861 earthquake), which facilitated the spread of various infectious diseases. The objective of this article is to inquire into the ways in which the healthcare system in the province of Mendoza both expanded and became increasingly professionalized from the late 19th to early 20th century. We explore how these factors, along with the predominant social representations of disease that permeated the discourses of governing elites, influenced public policy aimed at combating the diseases of the time. To that end, we consulted a wide range of written documents and photographic material that allowed us to analyze changes in discourse as well as public policy.

Entre fines del siglo XIX y comienzos del XX, la provincia de Mendoza presentaba un estado sanitario marcado por el crecimiento demográfico y urbanístico, la escasez de los servicios públicos y la destrucción de la antigua ciudad colonial como consecuencia del terremoto de 1861, lo que propiciaba un ambiente favorable para el desarrollo de diversas enfermedades infectocontagiosas. El objetivo de este artículo es indagar cómo se fue profesionalizando y expandiendo el sistema de salud en la provincia de Mendoza a fines del siglo XIX e inicios del XX, y cómo esos factores, junto con las representaciones sobre la enfermedad que predominaban en el discurso de la elite gobernante, incidieron en las políticas públicas para combatir las dolencias de la época. Para ello se consultaron diversos documentos escritos y fotográficos que permitieron analizar las modificaciones del discurso y las políticas públicas implementadas.

What Historians of Medicine Can Learn from Historians of Capitalism.

After briefly surveying the New History of Capitalism and its objectives, this article explores ways that the history of medicine and the history of capitalism can productively interact. The article argues that historians of medicine should adopt a broad definition of "capitalism" to accommodate the distinctive nature of medical and health care markets. Across millennia and diverse cultures, medical markets have demonstrated extensive commodification, with spiritual or religious goods and services composing a significant portion of commercial trade. Moreover, health care markets, at least since the ancient era, have been susceptible to third-party interventions by both the state and voluntary organizations. Accordingly, historians of medicine should look for pockets of capitalist exchange in otherwise noncapitalist economies and also assess how the logic of capitalism has influenced government programming and other types of third-party involvement in the health care market. To illustrate that insights from the history of capitalism can be applied to many topics within the history of medicine, this article presents three case studies. It examines medical markets in ancient Egypt; in Medieval Europe as managed by the Catholic Church; and in Germany, England, and the United States at the end of the nineteenth century and into the twentieth.

De "culpables" a "víctimas": expansión y profesionalización del sistema de salud en la provincia Mendoza a fines del siglo XIX y principios del XX / From "culprits" to "victims": the expansion and professionalization of the healthcare system in the province of Mendoza in the late nineteenth and early twentieth century

RESUMEN Entre fines del siglo XIX y comienzos del XX, la provincia de Mendoza presentaba un estado sanitario marcado por el crecimiento demográfico y urbanístico, la escasez de los servicios públicos y la destrucción de la antigua ciudad colonial como consecuencia del terremoto de 1861, lo que propiciaba un ambiente favorable para el desarrollo de diversas enfermedades infectocontagiosas. El objetivo de este artículo es indagar cómo se fue profesionalizando y expandiendo el sistema de salud en la provincia de Mendoza a fines del siglo XIX e inicios del XX, y cómo esos factores, junto con las representaciones sobre la enfermedad que predominaban en el discurso de la elite gobernante, incidieron en las políticas públicas para combatir las dolencias de la época. Para ello se consultaron diversos documentos escritos y fotográficos que permitieron analizar las modificaciones del discurso y las políticas públicas implementadas.

ABSTRACT From the late 19th century to the beginning of the 20th, the province of Mendoza presented problematic sanitary conditions due to rapid demographic and urban growth, the scarcity of public services, and the poor state of the old colonial city (destroyed by the 1861 earthquake), which facilitated the spread of various infectious diseases. The objective of this article is to inquire into the ways in which the healthcare system in the province of Mendoza both expanded and became increasingly professionalized from the late 19th to early 20th century. We explore how these factors, along with the predominant social representations of disease that permeated the discourses of governing elites, influenced public policy aimed at combating the diseases of the time. To that end, we consulted a wide range of written documents and photographic material that allowed us to analyze changes in discourse as well as public policy.

Transformation of the Health Care Industry: Curb Your Enthusiasm?

Policy Points: Policymakers seek to transform the US health care system along two dimensions simultaneously: alternative payment models and new models of provider organization. This transformation is supposed to transfer risk to providers and make them more accountable for health care costs and quality. The transformation in payment and provider organization is neither happening quickly nor shifting risk to providers. The impact on health care cost and quality is also weak or nonexistent. In the longer run, decision makers should be prepared to accept the limits on transformation and carefully consider whether to advocate solutions not yet supported by evidence. CONTEXT: There is a widespread belief that the US health care system needs to move "from volume to value." This transformation to value (eg, quality divided by cost) is conceptualized as a two-fold movement: (1) from fee-for-service to alternative payment models; and (2) from solo practice and freestanding hospitals to medical homes, accountable care organizations, large hospital systems, and organized clinics like Kaiser Permanente. METHODS: We evaluate whether this transformation is happening quickly, shifting risk to providers, lowering costs, and improving quality. We draw on recent evidence on provider payment and organization and their effects on cost and quality. FINDINGS: Data suggest a low prevalence of provider risk payment models and slow movement toward new payment and organizational models. Evidence suggests the impact of both on cost and quality is weak. CONCLUSIONS: We need to be patient in expecting system improvements from ongoing changes in provider payment and organization. We also may need to look for improvements in other areas of the economy or to accept and accommodate prospects of modest improvements over time.

Nonegalitarian Social Responsibility for Health: A Confucian Perspective on Article 14 of the UNESCO: Declaration on Bioethics and Human Rights.

This essay offers a Confucian evaluation of Article 14 of the UNESCO Declaration on Bioethics and Human Rights, with a focus given to its statement that "the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being." It indicates that "a right to health" contained in the statement is open to two different interpretations, one radically egalitarian, another a decent minimum. It shows that Confucianism has strong moral considerations to reject the radical egalitarian interpretation, and argues that a Confucian nonegalitarian health distribution ethics of differentiated and graded love and obligation can reasonably be supported with a right to the decent minimum of health at the international level.

Policy commercializing nonprofits in health: the history of a paradox from the 19th century to the ACA.

UNLABELLED: POLICY POINTS: Health policy in the United States has, for more than a century, simultaneously and paradoxically incentivized the growth as well as the commercialization of nonprofit organizations in the health sector. This policy paradox persists during the implementation of the Affordable Care Act of 2010. CONTEXT: For more than a century, policy in the United States has incentivized both expansion in the number and size of tax-exempt nonprofit organizations in the health sector and their commercialization. The implementation of the Affordable Care Act of 2010 (ACA) began yet another chapter in the history of this policy paradox. METHODS: This article explores the origin and persistence of the paradox using what many scholars call "interpretive social science." This methodology prioritizes history and contingency over formal theory and methods in order to present coherent and plausible narratives of events and explanations for them. These narratives are grounded in documents generated by participants in particular events, as well as conversations with them, observing them in action, and analysis of pertinent secondary sources. The methodology achieves validity and reliability by gathering information from multiple sources and making disciplined judgments about its coherence and correspondence with reality. FINDINGS: A paradox with deep historical roots persists as a result of consensus about its value for both population health and the revenue of individuals and organizations in the health sector. Participants in this consensus include leaders of governance who have disagreed about many other issues. The paradox persists because of assumptions about the burden of disease and how to address it, as well as about the effects of biomedical science that is translated into professional education, practice, and the organization of services for the prevention, diagnosis, treatment, and management of illness. CONCLUSIONS: The policy paradox that has incentivized the growth and commercialization of nonprofits in the health sector since the late 19th century remains influential in health policy, especially for the allocation of resources. However, aspects of the implementation of the ACA may constrain some of the effects of the paradox.

"When pirates feast who pays?" condoms, advertising, and the visibility paradox, 1920s and 1930s.

For most of the 20th century, the condom in the United States was a cheap, useful, but largely unmentionable product. Federal and state statutes prohibited the advertising and open display of condoms, their distribution by mail and across state lines, and their sale for the purpose of birth control; in some states, even owning or using condoms was illegal. By the end of World War I, condoms were increasingly acceptable for the prevention of sexually transmitted disease, but their unique dual function--for disease prevention and contraception--created ongoing ambiguities for sellers, consumers, and distributors as well as for legal, political, health, and moral leaders. Not until the 1970s did condoms emerge from the shadows and join other personal hygiene products on open drugstore and supermarket shelves and in national advertisements. Then came the 1980s and AIDS when, despite the rise of Ronald Reagan, the radical right's demonization of condoms, and the initial reluctance of condom merchants to market to gay constituencies, the HIV/AIDS epidemic slowly but inexorably propelled the condom to the top of the prevention agenda. The condom's journey from lewd device to global superstar was fitful, but colorful. The Comstock Act of 1873, prohibiting birth control information and devices, created a vast underground operation--periodically illuminated, however, by arrests, protests, legal proceedings, and media coverage. This essay chronicles one such moment of illumination: the legal battle in the 1920s and 1930s over the legitimacy and legality of the Trojan Brand condom trademark and the unusual series of advertisements produced by the Youngs Rubber Corporation, makers of Trojans, to dramatize the ethical and economic issues of the trademark battle. Culminating in Youngs Rubber Corporation v. C.I. Lee & Co., Inc. (45 F, U.S. Court of Appeals for the Second Circuit 103 [1930]), this landmark case in trademark law established the right of the Trojan Brand condom, despite its ambiguous dual function, to the protection of a federal trademark. I seek to show how the Youngs antipiracy ad series illuminates the paradox of visibility by illuminating the paradox of any binary division: to establish the one depends inevitably on invoking or making visible--even if to suppress--the other. This essay is a case study in the negotiation of such a dialectic.

The master hearing aid.

As early as the 1930s the term Master Hearing Aid (MHA) described a device used in the fitting of hearing aids. In their original form, the MHA was a desktop system that allowed for simulated or actual adjustment of hearing aid components that resulted in a changed hearing aid response. Over the years the MHA saw many embodiments and contributed to a number of rationales for the fitting of hearing aids. During these same years, the MHA was viewed by many as an inappropriate means of demonstrating hearing aids; the audio quality of the desktop systems was often superior to the hearing aids themselves. These opinions and the evolution of the MHA have molded the modern perception of hearing aids and the techniques used in the fitting of hearing aids. This article reports on a history of the MHA and its influence on the fitting of hearing aids.

[Medical certificates on the healthcare market: professionalised testimony and the burgeoning administrative apparatus in the early nineteenth century]. / Arztliche Zeugnisse auf dem medizinischen Markt. Professionalisierte Zeugenschaft im wachsenden Verwaltungsapparat des frühen 19. Jahrhunderts.

This article deals with medical certificates issued by the physician Cäsar Adolf Bloesch (1804-1863) from Biel/Bienne. It aims at examining this service as a part of the medical market in the early nineteenth century. Firstly, it focuses on four administrative procedures which show how the standardized medical certificate was established at the time. Secondly, it examines how expert testimony in general and medical testimony in particular depended on public and private demand. Finally, this study argues that by attesting health or illness, physicians could gain their patients' confidence and increase their own social capital. For patients a medical certificate could imply release from moral judgement.