"Post"-pandemic Capitalism: Reform or Transform? Comment on "Ensuring Global Health Equity in a Post-pandemic Economy".

This commentary expresses appreciation for Professor Labonté's work, along with some hopefully constructive suggestions. Professor Labonté's editorial shows ambivalence about reforms within capitalism. Such reforms remain contradictory and unlikely to prevail. Transformation to post-capitalist political economies is an exciting focus of moving beyond the hurtful effects of capitalism. Can "the state… mitigate capitalism's inherent inegalitarianism"? Problematically, government resides in the capitalist state, whose main purpose is to protect the capitalist economic system. The state's contradictory characteristics manifest in inadequate measures to protect health, as during the COVID-19 pandemic. "Social determination," referring to illness-generating structures of power and finance, is replacing "social determinants," referring mainly to demographic variables. Problems warranting attention include: capitalist industrial agriculture causing pandemics through destruction of protective natural habitat, structural racism, sexism and social reproduction, social class structure linked to inequality, and expropriation of nature to accumulate capital. Transformation to post-capitalism involves creative construction of new solidarity economies, while creative destructions block smooth functioning of the capitalist system.

How missing evidence-based medicine indicators can inform COVID-19 vaccine distribution policies: a scoping review and calculation of indicators from data in randomised controlled trials.

OBJECTIVE: Reports of efficacy, effectiveness and harms of COVID-19 vaccines have not used key indicators from evidence-based medicine (EBM) that can inform policies about vaccine distribution. This study aims to clarify EBM indicators that consider baseline risks when assessing vaccines' benefits versus harms: absolute risk reduction (ARR) and number needed to be vaccinated (NNV), versus absolute risk of the intervention (ARI) and number needed to harm (NNH). METHODS: We used a multimethod approach, including a scoping review of the literature; calculation of risk reductions and harms from data concerning five major vaccines; analysis of risk reductions in population subgroups with varying baseline risks; and comparisons with prior vaccines. FINDINGS: The scoping review showed few reports regarding ARR, NNV, ARI and NNH; comparisons of benefits versus harms using these EBM methods; or analyses of varying baseline risks. Calculated ARRs for symptomatic infection and hospitalisation were approximately 1% and 0.1%, respectively, as compared with relative risk reduction of 50%-95% and 58%-100%. NNV to prevent one symptomatic infection and one hospitalisation was in the range of 80-500 and 500-4000. Based on available data, ARI and NNH as measures of harm were difficult to calculate, and the balance between benefits and harms using EBM measures remained uncertain. The effectiveness of COVID-19 vaccines as measured by ARR and NNV was substantially higher in population subgroups with high versus low baseline risks. CONCLUSIONS: Priorities for vaccine distribution should target subpopulations with higher baseline risks. Similar analyses using ARR/NNV and ARI/NNH would strengthen evaluations of vaccines' benefits versus harms. An EBM perspective on vaccine distribution that emphasises baseline risks becomes especially important as the world's population continues to face major barriers to vaccine access-sometimes termed 'vaccine apartheid'.

Universal health coverage as hegemonic health policy in low- and middle-income countries: A mixed-methods analysis.

Universal health coverage (UHC) has become an influential global health policy. This study asked whether and to what extent UHC became a "hegemonic" health policy. The article consists of three parts: a historical timeline of UHC's rise, a bibliometric analysis of UHC in the literature, and a qualitative thematic analysis of how UHC is defined and the thematic content of those definitions. The roots of UHC can be traced to policies enacted by international financial institutions (IFIs) such as the World Bank and International Monetary Fund (IMF) during the latter half of the twentieth century. These policies caused the debt of low- and middle-income countries (LMICs) to rise precipitously and led the same IFIs and other institutions like the World Health Organization to become involved in the development and restructuring of health systems. UHC was presented as the leading method for financing development of health systems. As the bibliometric analysis shows, UHC has come to predominate in the literature around health system reforms. The thematic analysis based on a random selection of papers obtained in the bibliometric component of the study shows that often the term is not defined or only poorly defined. There is wide variation in the definitions, with many papers mentioning concepts such as quality, access, and equity without further clarification. Usually, papers define UHC to include tiering of benefits, with discussions of financing that focus on preventing "catastrophic [individual] expenditures" rather than discussing universal budgeting of a national health care system or national health insurance. We conclude that UHC has become hegemonic within global health policy, to the exclusion of discussions about other approaches to the transformation of health systems that are not predominately based on insurance coverage such as Health Care for All system, a system which provides equal services for the entire population.

Confronting the Upstream Causes of COVID-19 and Other Epidemics to Follow.

The upstream causes of the COVID-19 pandemic have received little attention so far in public health and clinical medicine, as opposed to the downstream effects of mass morbidity and mortality. To resolve this pandemic and to prevent even more severe future pandemics, a focus on upstream causation is essential. Convincing evidence shows that this and every other important viral epidemic emerging in the recent past and predictably into the future comes from the same upstream causes: capitalist agriculture, its destruction of natural habitat, and the industrial production of meat. International and national health organizations have obscured the upstream causes of emerging viral epidemics. These organizations have suffered cutbacks in public funding but have received increased support from international financial institutions and private philanthropies that emphasize the downstream effects rather than upstream causes of infectious diseases. Conflicts of interest also have impacted public health policies. A worldwide shift has begun toward peasant agricultural practices: Research so far has shown that peasant agriculture is safer and more efficient than capitalist industrial agricultural practices. Without such a transformation of agriculture, even more devastating pandemics will result from the same upstream causes.

COVID-19 as Cause versus Trigger for the Collapse of Capitalism.

According to the official narrative of COVID-19, the pandemic has caused the global capitalist economy to collapse, or at least to enter a deep recession and possibly a great depression. Assigning blame to a virus takes attention away from the structural contradictions and instabilities of capitalism that would have led to a crash in any case. This narrative also helps justify non-evidence-based public health policies, including lockdowns, travel bans, closed schools and factories, and forced quarantines of large populations rather than individuals and clustered groups who harbor the infection. Advantages of such drastic measures happen primarily in countries that did not prepare adequately, that did not respond quickly enough with more focused measures to test and isolate people infected with the virus, and that have health care systems either organized by capitalist principles or suffering cutbacks and privatization as a result of capitalist economic ideologies, such as austerity. Authoritarian tactics purportedly intended to protect public health pave the way to antidemocratic rule, militarism, and fascism. These harsh policies also exert their most adverse effects on poor, minority, incarcerated, immigrant, and otherwise marginalized populations, who already suffer from the worsening economic inequality that global, financialized capitalism has fostered.

Moving Beyond Capitalism for Our Health.

Deepening crises now affect not only the capitalist health system in the United States, but also the national health programs of countries that have achieved universal access to services. In our recent collaborative book, Health Care Under the Knife: Moving Beyond Capitalism for Our Health, we analyze these changing structural conditions and argue that the struggle toward viable national health programs now must become part of a struggle to move beyond capitalism. Privatization, cutbacks in public-sector services and institutions, and public subsidization of private profit-making through transfer of tax revenues into private insurance corporations have worsened under neoliberal policies. Financialization of capitalist economies includes the increasingly oligopolistic and financialized character of health insurance, both public and private. Those struggling for just and accessible health systems now need to confront the shifting social class position of health professionals. Due to loss of control over the work process and a reduced ability to generate high incomes compared to other professional workers, the medical profession has become proletarianized. To achieve national health programs that will remain viable over a long term, a much more fundamental transformation needs to reshape not just health care, but also the capitalist state and capitalist society.

Military Personnel Who Seek Health and Mental Health Services Outside the Military.

Background: Although research conducted within the military has assessed the health and mental health problems of military personnel, little information exists about personnel who seek care outside the military. The purpose of this study is to clarify the personal characteristics, mental health diagnoses, and experiences of active duty U.S. military personnel who sought civilian sector services due to unmet needs for care. Materials and Methods: This prospective, multi-method study included 233 clients, based in the United States, Afghanistan, South Korea, and Germany, who obtained care between 2013 and 2016 from a nationwide network of volunteer civilian practitioners. A hotline organized by faith-based and peace organizations received calls from clients and referred them to the network when the clients described unmet needs for physical or mental health services. Intake and follow-up interviews at 2 wk and 2 mo after intake captured demographic characteristics, mental health diagnoses, and reasons for seeking civilian rather than military care. Non-parametric bootstrap regression analyses identified predictors of psychiatric disorders, suicidality, and absence without leave (AWOL). Qualitative analyses of clients' narratives clarified their experiences and reasons for seeking care. The research protocol has been reviewed and approved annually by the Institutional Review Board at the University of New Mexico. Results: Depression (72%), post-traumatic stress disorder (62%), alcohol use disorder (27%), and panic disorder (25%) were the most common diagnoses. Forty-eight percent of clients reported suicidal ideation. Twenty percent were absence without leave. Combat trauma predicted post-traumatic stress disorder (odds ratio [OR] = 8.84, 95% confidence interval [CI] 1.66, 47.12, p = 0.01) and absence without leave (OR = x3.85, 95% CI 1.14, 12.94, p = 0.03). Non-combat trauma predicted panic disorder (OR = 3.64, 95% CI 1.29, 10.23, p = 0.01). Geographical region was associated with generalized anxiety disorder (OR 0.70, 95% CI 0.49, 0.99, p = 0.05). Significant predictors were not found for major depression, alcohol use disorder, or suicidal ideation. Clients' narrative themes included fear of reprisal for seeking services, mistrust of command, insufficient and unresponsive services, cost as a barrier to care, deception in recruitment, voluntary enlistment remorse, guilt about actual or potential killing of combatants or non-combatant civilians, preexisting mental health disorders, family and household challenges that contributed to distress, and military sexual trauma. Conclusions: Our work clarified substantial unmet needs for services among active duty military personnel, the limitations of programs based in the military sector, and the potential value of civilian sector services that are not linked to military goals. We and our institutional review board opted against using a control group that would create ethical problems stemming from the denial of needed services. For future research, an evaluative strategy that can assess the impact of civilian services and that reconciles ethical concerns with study design remains a challenge. Due to inherent contradictions in the roles of military professionals, especially the double agency that makes professionals responsible to both clients and the military command, the policy alternative of providing services for military personnel in the civilian sector warrants serious consideration, as do preventive strategies such as non-military alternatives to conflict resolution.

The History and Future of Neoliberal Health Reform: Obamacare and Its Predecessors.

The Colombian reform of 1994, through a strange historical sequence, became a model for health reform in Latin America, Europe, and the United States. Officially, the reform aimed to improve access for the uninsured and underinsured, in collaboration with the private, for-profit insurance industry. After several historical attempts at health reform adhering to the neoliberal pattern, favored by international financial institutions and multinational insurance corporations, the Affordable Care Act (ACA) similarly enhanced access by corporations to public-sector trust funds. An ideology favoring for-profit corporations in the marketplace justified these reforms through unproven claims about the efficiency of the private sector and enhanced quality of care under principles of competition and business management. The ACA maintains this historical continuity by dealing with health care as a commodity bought and sold in a marketplace, rather than a fundamental human right to be guaranteed according to principles of social solidarity. As the ACA heads toward probable failure, a space finally will open for a U.S. national health program that does not follow same historical patterns of the neoliberal model.

Place as a predictor of health insurance coverage: A multivariate analysis of counties in the United States.

This study assessed the importance of county characteristics in explaining county-level variations in health insurance coverage. Using public databases from 2008 to 2012, we studied 3112 counties in the United States. Rates of uninsurance ranged widely from 3% to 53%. Multivariate analysis suggested that poverty, unemployment, Republican voting, and percentages of Hispanic and American Indian/Alaskan Native residents in a county were significant predictors of uninsurance rates. The associations between uninsurance rates and both race/ethnicity and poverty varied significantly between metropolitan and non-metropolitan counties. Collaborative actions by the federal, tribal, state, and county governments are needed to promote coverage and access to care.

Erratum to "Place as a predictor of health insurance coverage: A multivariate analysis of counties in the United States" [Health Place 34 (2015) 207-214].

[This corrects the article PMC6528484.].

The effects of behavioral health reform on safety-net institutions: a mixed-method assessment in a rural state.

In July 2005, New Mexico initiated a major reform of publicly-funded behavioral healthcare to reduce cost and bureaucracy. We used a mixed-method approach to examine how this reform impacted the workplaces and employees of service agencies that care for low-income adults in rural and urban areas. Information technology problems and cumbersome processes to enroll patients, procure authorizations, and submit claims led to payment delays that affected the financial status of the agencies, their ability to deliver care, and employee morale. Rural employees experienced lower levels of job satisfaction and organizational commitment and higher levels of turnover intentions under the reform when compared to their urban counterparts.

Medicina y salud pública al final del imperio / Medicine and publich health in the end of the empire

Las conexiones entre imperio, salud pública, y servicios médicos han actuado con distintas instituciones de mediación. Durante la subida del imperio, las organizaciones filantrópicas intentaron dirigir con iniciativas de la salud pública varios desafíos que las empresas capitalistas enfrentaban: productividad de trabajo, seguridad para los inversores y los gerentes, y los costos de atención. De orígenes modestos, las instituciones financieras internacionales y los acuerdos internacionales de comercio cambiaban eventualmente hacia una estructura masiva de las reglas comerciales que ejercerían efectos profundos sobre la salud pública y servicios de salud mundialmente. Las organizaciones internacionales de salud manifestaban una colaboración de continuidad con las instituciones que intentaban proteger comercio y negocios.

The connections between empire, public health and medical services have worked with various institutions in mediation. During the rise of the empire, philanthropic organizations attempted to steer with public health initiatives several challenges faced by capitalist firms: labor productivity, security for investors and managers, and care costs. With modest origins, international financial institutions and international trade agreements eventually changed into a massive structure of trade rules that exert profound effects on public health and health services worldwide. International health organizations manifested a continued collaboration with institutions trying to protect trade and business.

Economic crisis, restrictive policies, and the population's health and health care: the Greek case.

The global economic crisis has affected the Greek economy with unprecedented severity, making Greece an important test of the relationship between socioeconomic determinants and a population's well-being. Suicide and homicide mortality rates among men increased by 22.7% and 27.6%, respectively, between 2007 and 2009, and mental disorders, substance abuse, and infectious disease morbidity showed deteriorating trends during 2010 and 2011. Utilization of public inpatient and primary care services rose by 6.2% and 21.9%, respectively, between 2010 and 2011, while the Ministry of Health's total expenditures fell by 23.7% between 2009 and 2011. In a time of economic turmoil, rising health care needs and increasing demand for public services collide with austerity and privatization policies, exposing Greece's population health to further risks.