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Offers focal point fires with a product or service that delivers valor fires and baxi fires. Key Scientific Information on Housing and Health * Research Studies Risk Factors for Pediatric Asthma: Contribution of Poverty, Race, and Urban Residence September 2000, American Journal of Respiratory and Critical Care Medicine C. Andrew Aligne, Peggy Auinger, Robert S. Byrd, and Michael Weitzman Using data from the Child Health Supplement to the 1988 National Health Interview Survey, researchers demonstrated that although black children had higher rates of asthma than white children, when adjusted for multiple factors including poverty status and urban residence, there was no significant correlation of asthma by race. Further analyses showed that regardless of race or poverty level, urban children were at significantly increased risk of asthma when compared to non-urban children. These results suggest that "the higher prevalence of asthma among black children is not due to race or to low income per se, and that all children living in an urban setting are at increased risk for asthma." Symptoms of Wheeze and Persistent Cough in the First Year of Life: Associations with Indoor Allergens, Air Contaminants, and Maternal History of Asthma August 1, 2003, American Journal of Epidemiology Kathleen Belanger, William Beckett, Elizabeth Triche, et al. This study, conducted in Connecticut and southern Massachusetts, examined a wide range of factors that can impact indoor air quality, including allergens, tobacco smoke, wood smoke, and mold. It found that while common allergens did not significantly impact the respiratory health of the infants in the study, mold did trigger greater rates of wheezing and persistent coughing in babies. The study also demonstrated that infants whose mothers have asthma are at a greater risk of adverse health effects from exposure to mold than infants whose mothers do not have asthma, suggesting that mold sensitivity may be genetic. The study's authors recommend further inquiries to explore the interaction between possible genetic factors and mold exposure in infants. Exposure to Indoor Pesticides during Pregnancy in a Multiethnic, Urban Cohort January 2003, Environmental Health Perspectives Gertrude S. Berkowitz, Josephine Obel, Elena Deych, et al. As pesticide use in the U.S. and in urban area in particular grows, these researchers have identified the exposure of pregnant women, and their growing fetuses, to these pesticides as a growing concern requiring additional assessment and evaluation. The study concludes that there is a great need to assess the "potentially adverse effects of pesticide exposure on fetuses and infants" and stresses the "importance of finding alternative methods for pest management to reduce pesticide exposures." Association of Housing Disrepair Indicators with Cockroach and Rodent Infestations in a Cohort of Pregnant Latina Women and Their Children July 2005, Environmental Health Perspectives Asa Bradman, Jonathan Chevrier, Ira Tager, et al. Health burdens associated with poor quality housing and indoor pest infestations are likely to particularly affect young children, who spend most of their time indoors at home. In the homes assessed by this study, located in a region experiencing a high rate of rural poverty, high residential densities and housing disrepair were common, and evidence of cockroaches and rodents was also common. Compared to representative national survey data from the Department of Housing and Urban Development, homes in the study were more likely to have rodents, peeling paint, leaks under sinks, and cockroach infestations. Rodent and cockroaches infestations were more likely in homes with several indicators of housing disrepair such as water damage, peeling paint, and indoor mold growth. The study concludes that adverse housing conditions are common in rural areas with high rates of poverty, and those poor conditions increase the likelihood of pest infestations and home pesticide use. Interventions to improve housing and promote children's health and safety among the rural poor are needed, according to the study. The Influence of Exterior Dust and Soil Lead on Interior Dust Lead Levels in Housing That Had Undergone Lead-Based Paint Hazard Control May 2004, Journal of Occupational and Environmental Hygiene Scott Clark, William Menrath, Mei Chen, et al. Using information from the HUD Lead-Based Paint Hazard Control Grant Program Evaluation, this study examined the impacts of exterior lead dust and lead in exterior soil on interior dust lead levels in housing in which lead hazard control work had been conducted. The study analyzed data from 12 state and local governments and concluded that high dust lead levels immediately outside dwellings can increase dust lead loading on interior surfaces of homes. Modest soil lead control measures were found to reduce exterior dust lead levels, indirectly but significantly lowering the impact on interior levels. National Prevlance and Exposure Risk for Cockroach Allergen in US Households November 2005, Environmental Health Perspectives Richard D. Cohn, Samuel J. Arbes, Jr., Renee Jamamillo, Laura H. Reid, and Darryl C. Zeldin This study used data from the National Survey of Lead and Allergens in Housing to characterize the prevalence of cockroach allergen exposure in U.S. households. The study found that cockroach allergen is common in U.S. households and is present at levels that can cause problems for asthmatics in ten percent of American homes. The study also found that elevated concentrations of cockroach allergen were found in high-rise apartments, urban settings, homes built before 1940, and households with incomes less than $20,000 per year. Home and Allergic Characteristics of Children with Asthma in Seven U.S. Urban Communities and Design of an Environmental Intervention: The Inner-City Asthma Study September 2002, Environmental Health Perspectives Ellen F. Crain, Michelle Walter, George T. O'Connor, et al. This study was designed to address the unique characteristics of the homes and therefore asthma experiences of inner-city children with moderate to severe asthma. It concluded that these children "tend to be sensitized to multiple allergens and to live in homes with many conditions associated with allergen and [environmental tobacco smoke] ETS exposure." Further identified conclusions include the need for remediation methods that are flexible and easily tailored to meet the varying needs of individual children based on the nature of their multiple exposures. Asthma in Children: Environmental Factors June 1994, British Medical Journal P. Cullinan and A.J. Taylor (editorial) This editorial was written to support the publication of two separate studies examining the causes for an observed increase in asthma prevalence over a 10-15 year study period. The editorial uses findings from these and various additional studies to support the assertion that although genetic factors do have a role, "the short period during which the increases in asthma and other allergic diseases have occurred suggests that environmental influences have been mainly responsible." The Environment and Asthma in U.S. Inner Cities June 1999, Environmental Health Perspectives Peyton A. Eggleston, Timothy J. Buckley, Patrick N. Breysse, et al. This paper presents an overview of environmental, immunologic, and genetic factors associated with asthma and provides a potential framework for designing an interdisciplinary asthma research program. The "strongest epidemiologic association has been found between asthma morbidity and the exposure of immunologically sensitive asthmatic patients to airborne allergens." Therefore, study researchers further assert that "indoor exposures are more important than ambient pollutants and that bioaerosols containing allergenic proteins are especially important" in understanding asthma. How Environmental Exposures Influence the Development and Exacerbation of Asthma July 2003, Pediatrics Ruth A. Etzel This article asserts that indoor air exposures are more strongly linked to the increase in asthma prevalence than either outdoor air exposures or violence. Specifically, dust mite and tobacco smoke exposure are identified as both risk factors for the development of asthma, as well as factors that may exacerbate existing asthma. Housing Quality and Children's Socioemotional Health February 2003 Robert Gifford, Canadian Mortgage and Housing Corporation Conducted to explore the relationship between the quality of a child's housing and neighborhood with apparent childhood behavior problems (socioemotional health), this study demonstrates significant relationships between the number of children's behavioral problems and two housing quality indices: the general condition of the residence's interior and the general physical condition of the neighborhood. Further, the more problems noted in these residences and neighborhoods, the more behavior problems were reported. Both of these relationships remained independent of other factors such as income and education levels. Obesity and the Risk of Newly Diagnosed Asthma in School-age Children 2003, American Journal of Epidemiology Frank D. Gilliland, Kiros Berhane, Talat Islam, et. al. Theorizing that obesity may play a role in the development of childhood asthma, the authors of this study analyzed data from over 3,000 participants in the Children's Health Study in southern California. The authors examined data related to later physician-diagnosed asthma, height, weight, and known risk factors of asthma in order to determine the relationship between childhood obesity and asthma development. The authors concluded that obesity is associated with an increased risk of asthma in boys and non-allergic children. Childhood Asthma and Indoor Environmental Risk Factors 1993, American Journal of Epidemiology Claire Infante-Rivard This study examined indoor environmental factors in relation to the incidence of asthma in newly diagnosed 3-4 year old asthmatic children and non-asthmatic children. The results of this study include the conclusion that indoor environmental factors - such as maternal smoking, use of a humidifier in a child's bedroom, and the presence of an electrical heating system in the home - contribute to the incidence of asthma in children. Indoor Air Pollutants: Limited-Resource Households and Child Care Facilities March 2005, Journal of Environmental Health J. Laquatra, LF Maxwell, and M. Pierce This paper reports on a study of indoor air quality in homes and child care facilities in non-metropolitan counties of New York State. Specific pollutants examined were lead, radon, carbon monoxide, asbestos, and mold. Some homes had high levels of pollutants, and certain pollutants were significantly and negatively correlated with household income. High levels of pollutants also were observed in many child care facilities, which raises questions about constant exposure of children to pollutants. Recommendations are made for lowering pollutant levels in low-income households and child care facilities. Clearing the Air: Asthma and Indoor Air Exposures 2000, National Academy Press Institute of Medicine, Committee on the Assessment of Asthma and Indoor Air Recognizing that the indoor environment plays a role in worldwide increases in asthma prevalence and therefore "interventions to limit or eliminate indoor exposures have the potential to help asthmatics and perhaps result in the primary prevention of the illness," the results of this EPA-commissioned NAS assessment provide scientific and technical information accessible to the public on the health impacts of indoor pollutants related to asthma and mitigation and prevention strategies to reduce exposures, and identify related existing and future research needs. Significant findings of the study include: 1) "there is sufficient evidence of a causal relationship between exposure to house dust mite allergen and the development of asthma in susceptible children;" and 2) sufficient evidence of a "causal relationship between exposure to the allergens produced by cats, cockroaches, and house dust mites, and exacerbations of asthma in sensitized individuals." Indoor Allergens: Assessing and Controlling Adverse Health Effects 1993, National Academy Press Institute of Medicine, Committee on the Health Effects of Indoor Allergens Andrew M. Pope, Roy Patterson, and Harriet Burge, Editors This book focuses on various aspects of the relationship between allergens and the indoor environment - diseases caused; sources; medical responses and testing; and exposure and risk assessment. It further discuses the role of available control strategies and education methods. Conclusions focus on the need for improved education of patients and medical personnel, appropriate building development and operation, and expanded research activities. Asthma and the Home Environment 2000, Journal of Asthma A. P. Jones This review article discusses the modifications to the home environment that have occurred over the years, their coincidence with a global increase in asthma prevalence, the existence of indoor allergens and other indoor air quality concerns, and the existing information on the links between asthma and indoor air pollution. It further addresses the need for patient education beyond the provision of information and briefly discusses asthma research funding, legislative, and regulatory needs. Pesticides and Inner-City Children: Exposures, Risks, and Prevention June 1999, Environmental Health Perspectives Philip J. Landrigan, Luz Claudio, Steven B. Markowitz, et al. This article outlines the excessive exposures to pesticides suffered by inner-city children due to the age and poor maintenance of the urban housing stock, and the developmental vulnerabilities of children that place them at "seriously increased risk for neurological, endocrine, and other developmental disabilities," to develop several prevention recommendations for a comprehensive strategy to protect inner-city children against the hazards of pesticides. Further, the article specifically states that integrated pest management (IPM) must be utilized in conjunction with risk assessment to prevent exposures, as reliance on risk assessment has been demonstrated to be unsuccessful in limiting the pesticide exposures of urban children. Residential Exposures Associated with Asthma in US Children March 2001, Pediatrics Bruce Lanphear, C. Andrew Aligne, Peggy Auinger, et al. In this study, researchers conducted a cross-sectional survey of over 8,000 children less than 6 years of age who participated in the Third National Health and Nutrition Examination Survey to reach their objective of identifying residential exposure risk factors and estimating the population attributable risk of these exposures for doctor-diagnosed asthma. Their results indicate that approximately 39% of the doctor-diagnosed cases of asthma in US children under 6 years old "could be prevented by eliminating exposures to indoor pollutants and allergens in housing." Is There a Dose-Response Relationship between Exposure to Indoor Allergens and Symptoms of Asthma? October 1995, Journal of Allergy and Clinical Immunology Thomas A. E. Platts-Mills, Richard B. Sporik, Lisa M. Wheatly, and Peter W. Heymann As evidence, reports, and studies exist which both support and question whether there is an association and/or causal relationship between indoor allergen exposure and asthma, this review article examines and discusses the findings of several other studies to conclude that although there is "clear evidence for a dose-response relationship such that the higher the levels of allergen in the homes of a community, the larger the percent of children who will become sensitized … the evidence for a dose-response relationship between exposure and symptoms of asthma among sensitized individuals is indirect." The Role of Intervention in Established Allergy: Avoidance of Indoor Allergens in the Treatment of Chronic Allergic Disease November 2000, Journal of Allergy and Clinical Immunology Thomas A. E. Platts-Mills, John W. Vaughan, Melody C. Carter, and Judith A. Woodfolk This study concludes that controlling exposure to allergens in houses the not only an effective treatment for allergic patients, but is preferable to other treatments such as immunotherapy and drug treatments. Further, decreasing exposure to allergens through avoidance allows immunotherapy and drug treatments to become more effective if used. According to these researchers, the key to successful avoidance is extensive education of patients on the biology of the allergen source, intervention methods, and potential regional and structural influences on home dust characteristics. Deteriorated Housing Contributes to High Cockroach Allergen Levels in Inner-City Households April 2002, Environmental Health Perspectives Virginia A. Rauh, Ginger L. Chew, Robin S. Garfinkel This study investigated levels of cockroach allergens in a sample of low-income, Dominican or African-American, New York City households with young children to determine whether allergen distribution is a function of housing deterioration. Results indicated that "indoor household allergen levels are related to degree of household disrepair, after adjusting for individual family attributes" such as income and sociocultural factors, and pest control methods. Pesticides in Children October 2001, Pediatric Clinics of North America J. Routt Reigart and James R. Roberts First, this article discusses pesticide use in the United States, exposures routes among children, diagnosis and treatment of acute poisonings, and the toxic effects of exposure. Second, it outlines some of the legislative and regulatory progresses achieved to reduce the risks of pesticides to children. Finally, it provides a list of recommendations that pediatricians can relay to parents to limit pesticide exposure. The Role of Cockroach Allergy and Exposure to Cockroach Allergen in Causing Morbidity among Inner-City Children with Asthma May 1997, New England Journal of Medicine David L. Rosenstreich, Peyton Eggleston, Meyer Kattan, et al. The results of this study showed that as compared to other children, inner-city children from around the United States who were both allergic to cockroach allergen and exposed to high levels of cockroach allergen had significantly more: hospitalizations and unscheduled medical visits related to asthma per year; days of wheezing; missed school days; nights with lost sleep; and caregivers whose nighttime sleep patterns and daytime plans were disrupted due to the child's asthma. Early Life Environmental Risk Factors for Asthma: Findings from the Children's Health Study December 2003, Environmental Health Perspectives Muhammad Towhid Salam, Yu-Fen Li, Bryan Langholz, and Frank Davis Gilliland This study out of southern California concluded that chemical exposures during the first year of life can substantially increase a child's risk of developing asthma. The study of nearly 700 children in 12 communities found that children exposed to household pesticides in their first year of life were more than twice as likely to develop asthma. Infants exposed to wood smoke, cockroaches, and farm animals also suffered higher rates of asthma. While noting that an array of factors contribute to asthma, the study indicates that both indoor and outdoor contaminants have especially strong effects on infants and that respiratory health may be determined by exposure during the child's first year. Exposure to House-Dust Mites Allergen (Der P I) and the Development of Asthma in Childhood: A Prospective Study August 1990, New England Journal of Medicine Richard Sporik, Stephen T. Holgate, Thomas A.E. Platts-Mills, and Jeremy J. Cogswell This investigation into the relationship between the development of sensitization and asthma and exposure to house-dust mite allergen concluded that "in addition to genetic factors, exposure in early childhood to house-dust mite allergens in an important determinant of the subsequent development of asthma." The researchers further states that comprehensive evaluation of both this and other similar studies seems to provide "sufficient evidence to suggest a causal relation between exposure to house-dust mites and asthma." Health Effects of Housing Improvement: Systematic Review of Intervention Studies July 2001, British Medical Journal Hilary Thomson, Mark Petticrew, and David Morrison This study was undertaken to examine the existing evidence on the effects on health of housing improvement interventions by systematically reviewing historical housing intervention studies that measured quantitative health outcomes. Researchers determined that overall "good research evidence is lacking on the health gains that result from investment in housing" quite possibly because of the "intuitive relation" between poor housing and poor health. The researchers go on to illustrate the need for a holistic approach that recognizes the "multifactorial and complex nature of poor housing and deprivation" through "large scale studies that investigate the wider social context of housing interventions." Effects of Physical Interventions on House Dust Mite Allergen Levels in Carpet, Bed, and Upholstery Dust in Low-Income, Urban Homes August 2001, Environmental Health Perspectives Patrick J. Vojta, Sandra P. Randels, James Stout, et al. To assess the feasibility and effectiveness of physical interventions to mitigate house dust mite allergens in low-income, urban homes, this study: enrolled homes with high level of house dust mite allergen in the bed, bedroom carpet, or upholstered furniture; employed various interventions; and collected samples for comparison. Results concluded that physical interventions such as mattress and pillow encasement, proper laundering techniques, and intensive vacuuming offer practical means of reducing house dust mite allergen levels in these environments. Sensitisation to Airborne Moulds and Severity of Asthma: Cross Sectional Study from European Community Respiratory Health Survey August 2002, British Medical Journal Mahmoud Zureik, Catherine Neukirch, Bénédicte Leynaert, et al. Researchers of this study followed over 1,000 asthmatic adults to assess whether asthma severity is associated with sensitization to airborne molds rather than to other seasonal or perennial allergens. Study results demonstrated that sensitization to airborne molds increased significantly with increasing asthma severity; no increase in asthma severity was observed with sensitization to pollens or cats. Therefore, the researchers concluded that "sensitization to moulds is a powerful risk factor for severe asthma in adults." Reports, Articles, and Statements Toxic Effects of Indoor Molds April 1998, Pediatrics American Academy of Pediatrics Committee on Environmental Health This policy statement from the AAP describes the toxic properties of molds and their potential for causing respiratory problems in infants. The AAP concludes that infants should not be "exposed to chronically moldy, water-damaged environments" and further identifies a list of recommendations for pediatrician-to-patient action and advice. Home is Where the Harm Is: Inadequate Housing as a Public Health Crisis May 2002, American Journal of Public Health Samiya A. Bashir This article explores the increasing indoor isolation that characterizes urban households and discusses some of the "ill effects on family health" this seemingly "safe" environment actually inflicts upon its inhabitants due to the dangers it harbors. It looks at primary prevention, community advocacy, the need for multi-issue approaches, and the availability of tools to assist in the prevention of hazards as possible ways to effect positive changes in both individual and community health. The Asthma Epidemic: Prospects for Controlling an Escalating Public Health Crisis September 2000, National Health Policy Forum, Background Paper Richard E. Hegner, The George Washington University This paper reports not only on asthma prevalence data, mechanics, vulnerabilities, diagnosing challenges, and causes, but moves ahead to discuss asthma treatment issues such as medical management, patient information availability, existing treatment barriers, and economic implications. The paper concludes with a policy discussion of asthma and public health in the U.S., current federal government weaknesses in dealing with asthma, and future plans of various related federal government agencies. Damp Indoor Spaces and Health May 2004, National Academies Press Institute of Medicine of the National Academies In 2003, the Centers for Disease Control and Prevention asked the National Academy of Sciences' Institute of Medicine to review the scientific literature regarding the relationship between moisture and mold in the indoor environment and adverse health effects. On May 25, 2004, the Institute issued its long-awaited final report, Damp Indoor Spaces and Health. The report presents a number of significant conclusions about the health impacts of moisture in homes and other buildings and makes key recommendations on how to minimize those impacts. Housing and Health: Time Again for Public Action May 2002, American Journal of Public Health James Krieger and Donna L. Higgins This article discusses the background, history, and indicators of "housing quality as a determinant of health" and makes the case for increased public health involvement in housing issues. Examples of existing public health efforts to improve housing condition are identified, however the priorities of expanding capacity and securing adequate resources are the main needs recognized to reach significant impact levels. The article concludes by suggesting several opportunities available to public health programs to become more involved in housing issues, such as housing code development and enforcement, healthy homes program implementation, and affordable, healthy housing advocacy. Housing and Health - Current Issues and Implications for Research and Programs March 2000, Journal of Urban Health Thomas D. Matte and David E. Jacobs This article presents a synopsis of the ways in which human health can be affected by the home environment and explains the relationships of specific health hazards in housing (including: unintentional injuries, lead, asthma allergens, moisture, mold, rodent and insect pests, pesticide residue, and indoor air pollution) to then discuss the implications of these concerns for addressing the health-housing connection in future prevention programs and research. Specific recommendations include the need for integrated efforts to address multiple housing problems simultaneously, as well as the need for stronger ties between housing and public health programs. Healthy Housing: A Structured Review of Published Evaluations of US Interventions to Improve Health by Modifying Housing in the United States, 1990-2001 September 2003, American Journal of Public Health Susan C. Saegert, Susan Klitzman, Nicholas Freudenberg, Jana Cooperman-Mroczek, and Salwa Nassar This literature review analyzed 72 studies selected from 12 electronic databases of U.S. healthy homes interventions, which occurred between 1990 and 2001. The authors find that 92 percent of the interventions addressed a single condition, most often lead poisoning, injury, or asthma. Most of the interventions significantly improved the condition they targeted, but only 14 percent were deemed to be extremely successful. The authors conclude that the analyzed interventions show strong links between housing conditions and health and that interventions can and do improve health. However, the authors also state that in order to be more effective, healthy homes interventions must be "ecological" or holistic in nature, encompassing entire housing complexes, neighborhoods, and communities. How Substandard Housing Affects Children's Health October 2000, Contemporary Pediatrics Megan Sandel and Jean Zotter Connecting conditions such as lead poisoning, asthma, and injury with the underlying problem of inadequate housing environment as the cause of the condition is a necessary first step to improving children's health. This article explains the existing housing crisis and the direct and indirect effects of inadequate housing on health both independently and through the use of case study examples to explore the available opportunities for pediatricians to improve their patient's housing and health through advocacy, awareness, and partnerships. There's No Place Like Home: How America's Housing Crisis Threatens Our Children March 1999, Doc4Kids Project Megan Sandel, Joshua Sharfstein, and Randy Shaw This publication "pulls together for the first time the most up-to-date research from the Centers for Disease Control, leading medical and public health journals, and firsthand observations by pediatricians across the country on the link between affordable housing and children's health." As background, the report discusses the growing housing crisis in the U.S.; it's contribution to the increase in children suffering from health problems such as asthma, viral infections, anemia, and stunted growth; and it's impact on childhood death, hunger, and education failure rates. The report culminates in a list of recommendations aimed at addressing the federal government's "failure to provide affordable housing opportunities" to a growing number of American families. Housing and Public Health 2004, Annual Review of Public Health Mary Shaw This review from the United Kingdom considers the broad area of housing and public health and takes into account the range of factors through which housing affects health. The review finds that housing affects health in a myriad of ways, in sum forming one of the key social determinants of health. The author states that the investment in affordable, healthy housing is more than just an investment in "bricks and mortar;" such an investment can form the foundation of the future health and well being of an entire population and can also work to combat poverty. The author further notes that addressing poor-quality and blighted housing is a task that must be seriously undertaken by all those who work to advance public health. Making the Right to Health a Reality : Legal Strategies for Effective Implementation Commonwealth Law Conference London September 2005 Iain Byrne Commonwealth Law Officer, Interights Visiting Fellow, Human Rights Centre, Essex University The right to health, similar to other economic and social rights, is not always codified in domestic law. However, as this paper seeks to demonstrate, this does not mean that health rights are incapable of adjudication and enforcement by courts. Analysing the jurisprudence of commonwealth and other courts on issues such as AIDS/HIV the paper will assess the approaches of a number of jurisdictions to protecting health rights and suggest legal strategies for effective implementation. Introduction This paper seeks to examine how non-codification of the right to health in domestic law is not necessarily a bar to both consideration and enforcement by the courts of healthcare and treatment issues through innovative approaches taken by jurists. It demonstrates some of the major challenges faced by courts - whatever the domestic legal framework - in considering health issues and the some of the strategies that can be employed to ensure effective implementation. The UN Committee on Economic, Social and Cultural Rights in its General Comment 9 has emphasised that it is up to states how they give effect to the rights contained in the International Covenant on Economic, Social and Cultural Rights (ICESCR), including the right to health, but whatever arrangements they choose they must be effective : "..[T]he central obligation in relation to the Covenant is for States parties to give effect to the rights recognized therein. By requiring Governments to do so "by all appropriate means," the Covenant adopts a broad and flexible approach which enables the par-ticularities of the legal and administrative systems of each State, as well as other relevant considerations, to be taken into account. But this flexibility coexists with the obligation upon each State party to use all the means at its disposal to give effect to the rights recognized in the Covenant. In this respect, the fundamental requirements of international human rights law must be borne in mind. Thus the Covenant norms must be recognized in appropriate ways within the domestic legal order, appropriate means of redress, or remedies, must be available to any aggrieved individual or group, and appropriate means of ensuring governmental accountability must be put in place." [Paras 1 and 2] Given that the majority of Commonwealth states have ratified the ICESCR (with some notable exceptions such as South Africa which has its own progressive constitution - see further below) these entreaties should carry some force not the least in those countries such as the UK, Canada, Australia and New Zealand which have no constitutionally entrenched esrs. Hence the role of the courts is vital in ensuring that liberal and purposive interpretations are given to those fundamental guarantees that are codified in order to offer the prospect of indirect protection for esrs such as the right to health. Both states and the international community have tended to pay lip service to the principle that all rights are of equal status, indivisible and interdependent, as elaborated in instruments such as the Universal Declaration of Human Rights and the Vienna Declaration and Programme of Action , with economic, social and cultural rights often regarded (at least in the developed world) as the poor cousin of their civil and political counterparts . Yet it is self-evident that the right to health has clear links to many other rights, both civil and political - e.g. rights to life, not to be subjected to torture or cruel, inhuman or degrading treatment and to information - or economic and social - e.g. rights to food, environment, housing, work and education. This can be seen both in the impact the denial or enjoyment of other rights can have on a person's ability to achieve the highest attainable standard of physical and mental health and, conversely, the role health plays in our enjoyment of other rights - an unhealthy citizen is not able to play a full and active part in society either economically or politically. Traditionally, health issues when they reach the courts (particularly in those jurisdictions where there is no explicit guarantee to the right to health) have tended to be dealt with from a negative civil liberties perspective rather than consideration of the positive state obligations to provide adequate resources or access to treatment for effective enjoyment. This is particularly the case in relation to mental health where judgments have tended to focus on the restrictions placed on patients rather than their right to adequate treatment. There have been some rare forays by tribunals into examining positive aspects but often the analysis is limited . How far judges should be prepared to go in deciding questions with resource implications - something which does not just effect the right to health but clearly all economic and social rights (esrs) - is a crucial question whether rights are codified or not. Certainly, violations of esrs are easier to identify and remedy when state obligations relate to respecting and protecting rights - the lower end of the typology framework used by the UN Economic, Social and Cultural Rights Committee and other experts - rather than at the more contentious provision or fulfilment stage . Where claims are sought in relation to the latter, one leading commentator on the right to health has noted that they will be most likely to be successful where the obligations relate to clearly defined rights of access to health-related services . Codification of the right to health in domestic law - enhanced protection but still problematic Chile provided the first constitutional recognition of the right to health as far back as 1925. Subsequent constitutional provisions have taken various forms with clauses elaborating amongst others (i) a right to general well-being (e.g. South Africa where the guarantee is part of a provision requiring access to health care services, food and water and social security (see further below) and similarly in Finland ); (ii) a right to free medical services (e.g. Guyana ) (iii) a right to a healthy environment (e.g. Hungary ) (iv) a right to enjoy the highest possible level of physical and mental health (e.g. Hungary ); (v) a direct relationship to right to the life (e.g. Haiti ) ; (vi) specific state obligations (e.g. Netherlands and Haiti ) and (vii) Directive Principles of State Policy (DPSP) (e.g. India , Philippines , Malawi , Uganda and Ghana ). In terms of the Commonwealth, a non exhaustive survey reveals that the developed economies (e.g. UK, Australia, Canada, New Zealand) and Caribbean jurisdictions (with the exception of Guyana) do not provide for any explicit recognition of health rights whilst African and South Asian countries do (albeit often by way of DPSP although, as will be shown below, this is not a bar to judicial recognition and enforcement). This divide reflects the geo-political context of the post World War II world where Western and Western influenced states tended to favour civil and political rights over esrs whilst those states more closely allied to the Soviet bloc, or non-aligned in the case of India, and engaged in colonial independence struggles took an opposite view point. The end of the Cold War and increasing recognition, not least amongst jurists, that both sets of rights are interconnected and of equal value have provided new avenues of legal protection, particularly in the case of esrs such as the right to health. The remainder of this paper seeks to explore some of these developments and what lessons can be learned for future litigation strategies. The South African Experience Of those countries that do provide constitutional recognition of a right to health and other esrs, arguably one of the best known and most widely celebrated in the Commonwealth (if not beyond) is South Africa reflecting the values of the pluralist, egalitarian and democratic state that replaced apartheid in 1994. However, it should be noted that although esrs are a prominent feature of the Constitution these were not included without a struggle and significant cases to date amount to no more than half a dozen. Esrs are divided into three broad categories : (a) basic rights with no qualification on implementation covering children's rights, basic education for everyone including adults and rights of detainees; (b) access rights covering the main guarantees to adequate housing, food, water, social security, and health care based on progressive realization according to available resources (a similar formulation to Article 2(1) of the International Covenant on Economic, Social and Cultural Rights (ICESCR) although South Africa has yet to ratify it) and (c) prohibition on certain negative actions by the state including forced evictions and refusal of emergency medical treatment. The specific provision protecting health rights is Article 27 which provides (as part of a general well being provision similar in formulation to Article 25 of the Universal Declaration of Human Rights and s 19 of the Finnish Constitution) that : "(1) Everyone has the right to have access to (a) health care services, including reproductive health care; (b) sufficient food and water; and (c) social security, including, if they are unable to support themselves and their dependants, appropriate social assistance. (2) The state must take reasonable legislative and other measures, within its available resources, to achieve the progressive realisation of each of these rights. (3) No one may be refused emergency medical treatment.' Health rights, together with housing rights, have provided the most significant constitutional esrs cases considered by the South African courts to date and this paper considers three of them. In Soobramoney v Minister of Health KwaZulu Natal 1997 (12) BCLR 1696 the Constitutional Court was faced with not merely one of its first esrs cases but potentially difficult moral questions to consider. S had chronic kidney failure which was terminal. However, costly dialysis treatment would have prolonged his life for a short period, but the local health authority refused it on the grounds of lack of resources. In his claim S relied on s 27(3) protecting the right to emergency medical treatment construed with the right to life as guaranteeing him a right to cost free medical treatment. Distinguishing the Indian case of Paschim Banga Khet Mazdoor Samity & Ors v State of West Bengal 1996 AIR SC 2426 (see further below) the Court held there was no need to infer a right to medical treatment from the right to life since it was directly protected by s 27. However, it went on to rule that a request for ongoing treatment could not come under emergency medical care and therefore the case fell to be decided under the access to medical services provisions. On this point the Court found no breach since, within the context of the limited resources available, the health authority had acted reasonably and applied its guidelines rationally and fairly in the case of S given (a) the expensive nature of the treatment and (b) the fact that it would only have prolonged S's life for a short period. For the Court this has been the crucial test in considering all esrs claims - has the State done all it could reasonably do in the circumstances ? By adopting this approach the Court has recognized that it is not in a position to assume the role of the state in making decisions about resource allocation but is instead there to act as an impartial arbiter. This process is similar in format to judicial review although will often extend beyond the decision-making process to examine all the actions taken by the state. Indeed in Soobramoney the Court was very explicit about the large margin of discretion it would give to the state to set budgetary priorities stating that the court "will be slow to interfere with rational decisions taken in good faith by the political organs and medical authorities" [para 29]. Sachs J went further stating that : "In open and democratic societies based upon dignity, freedom and equality, the rationing of access to life-prolonging resources is regarded as integral to, rather than incompatible with, a human rights approach to health care" [para 52]. To admit S's case would have been to open the floodgates to other claimants in a similar position placing an unbearable strain on medical resources . The second significant health case considered by the Constitutional Court and one of the most widely known due to the issues involved is Minister of Health v Treatment Action Campaign (TAC) (2002) 5 SA 721 (CC) or the TAC case. The Court was required to determine whether the state's failure to provide comprehensive anti-retroviral drugs to prevent mother-child HIV transmission constituted a breach of Article 27(1). The state argued that the drugs could only be distributed through a few centres designated for research which were able to provide the necessary complementary services such as counselling, new obstetric practices and education of mothers in alternative to breast feeding. The Court held that whilst research was important this was not a sufficiently good reason for delay in rolling out the programme to other centres : "This does not mean….that until the best programme has been formulated and the necessary funds and infrastructure provided for the implementation…the drug must be withheld from mothers and children who do not have access to the research and training sites. Nor can it reasonably be withheld until medical research has been completed" [para 68]. An important factor for the Court was the fact the drug (unlike the treatment in Soobramoney) was costless to the government and therefore arguments centred on lack of resources did not carry any weight. However, by requiring that the programme should include reasonable measures for counselling and testing, the Court did make orders with some (albeit limited) financial implications. Beyond this and unlike the approach often taken by the Indian Supreme Court and the Inter-American Court of Human Rights, the Court refrained from discussing detailed modes of implementation. Arguably, this created subsequent problems regarding the implementation of the judgment since it took several months of campaigning and lobbying by TAC and others to force the authorities to act and start supplying the drugs. The lessons from the TAC case demonstrate that obtaining a positive judgment, particularly in relation to esrs is only half the story, and that ensuring effective implementation is often a greater challenge. The third case, B & Ors v Minister of Correctional Services [1997] ICHRL 37, considered by the High Court, also concerned the supply of anti-retroviral drugs and whether they should be provided to HIV prisoners at the state's expense. The Court, in finding a breach of a prisoner's right to adequate medical care under s 35(2) of the Constitution, held that given this guarantee is not a right provided to people outside prison, the latter should not be an absolute standard for what is adequate for prisoners. The Court recognised that unlike free persons, prisoners have no access to other resources to gain medical treatment and that HIV positive prisoners are more exposed to opportunistic viruses because of overcrowded accommodation. In these circumstances the extension of life expectancy and enhanced quality of life provided by anti-viral therapy required the treatment to be provided to sufferers of HIV if at all affordable. In particular, the Court held that where anti-viral therapy has been prescribed to a prisoner on medical grounds then it should be provided at the state's expense and failure to do so amounted to an infringement of Article 35(2). However, the Court also continued to proscribe the limits of the judiciary's role in health cases by stating that whether the applicants and other HIV patients who fell within certain grounds were entitled to a prescription of a particular combination of anti-viral treatments was a medical question and it was not the court's function to make an order dictating to doctors when they must prescribe anti-viral treatment without discretion. Moreover, it recognised that in deciding what 'adequate medical treatment' constituted in terms of s 35(2) the court could and should be aware of budgetary constraints. The cautious approach of the South African courts in relation to esrs contrasts with the more assertive stance of their Indian brethren who over a much longer period have frequently been willing to actively intervene in policy and administrative areas usually viewed as the preserve of the executive, handing down detailed orders often with significant resource implications (see further below) . Critics of the Indian approach have pointed to the lack of cooperation it has apparently engendered in state officials requiring, on occasion, contempt of court proceedings to be initiated. However, the TAC case illustrates that the South African Constitutional Court cannot rely on the goodwill of officials to implement its decisions and may also have to be more proactive in monitoring and enforcement whilst continuing to walk a fine line in preserving the separation of powers. Other examples from beyond the Commonwealth The universality of human rights law can blur the distinction between different legal systems allowing us to draw on examples not just from the common law but also from other systems, whether, for example, the civil law in Latin America or post Soviet system in Eastern Europe. This is particularly important in relation to esrs, given the relative underdevelopment of caselaw, both in terms of interpreting the content of the right and the nature of state obligations. Three cases from Latin America deal with similar problems explored in the TAC case concerning inadequate state responses to pandemic diseases. One of the leading decisions is Mariela Viceconte v Ministry of Health and Social Welfare Case No 31.777/96 (1998) from Argentina in 1998 . The claim was brought by a number of community groups to ensure that the state would manufacture a vaccine against Argentine hemorrhagic fever, threatening the lives of 3.5 million people, most of whom did not adequate access to preventive medical services, in certain affected areas. Whilst the state had been able to obtain 200,000 doses of a vaccine from the United States and vaccinate 140,000 people between 1991 to 1995 it was unable to carry out a massive immunisation campaign due to the lack of an adequate quantity. A judicial writ of amparo (a constitutional remedy providing individual relief) was filed requiring the health ministry to manufacture and distribute further supplies of the vaccine to persons living in the affected areas. Following initial rejection the Court of Appeals ruled favourably establishing the state's obligation to manufacture the vaccine. Significantly (and unlike in South Africa) the court also set a legally binding deadline for the obligation to be met. In reaching its judgment the court drew on regional and international human rights standards, including the American Declaration on the Rights and Duties of Man, the UDHR, but particularly the right to health under Article 12 of ICESCR, all of the instruments having been incorporated into the domestic law in Argentina and considered to form part of the Constitution. This was in direct response to the petitioners' assertion that where a state is facing a major health problem threatening significant numbers of lives the legal obligation under Article 12 of the ICESCR is particularly strong. As in the TAC case, it required further action by the groups, including litigation, to secure enforcement. Nevertheless, the case is seen as important for a number of reasons. It reaffirmed the judicial process as a method for enabling ordinary citizens to challenge state agencies regarding the merit of health policies, saw the direct application by a domestic court of international standards on the right to health thereby expanding the scope for further realization of esrs; imposed personal responsibility on two ministers for the manufacture of the vaccine with a specific deadline thereby demonstrating that the obligations arising from esrs are legal in nature and entail legal liabilities and affirmed the role of the state as guarantor of the right to health in the event that the private sector is unable or (more likely) unwilling to provide the necessary services. Ultimately cases such as Mariela Viceconte can have a political as well as legal impact far beyond that perhaps envisaged when the original petition was submitted. Within five years Argentina had developed a social plan to deliver basic medicines the roots of which can be directly traced to the Viceconte case. A case concerning HIV is Mendoza & Ors v Ministry of Public Health Resn No 0749-2003-RA (28 Jan 2004) from Ecuador where the Constitutional Court held that Ministry of Health had failed in its obligation under Article 42 of the Constitution to protect the right to health by suspending a HIV treatment programme. Again, in upholding the right to health, references were made to relevant international standards including Article 11 of the American Declaration on the Rights and Duties of Man and Article 10 of the San Salvador Protocol. The Court also held that although right to health is an autonomous right it also forms part of the right to life echoing the approach of the Indian Supreme Court (see the West Bengal case below). In so doing it envisaged that a right to health entitled citizens not only to take legal action for the adoption of policies and plans related to general health protection but also to demand that appropriate laws be enacted and that the Government provide the necessary resources. Whilst such a judgment might be seen as having enormous implications for the executive it provides the measure of accountability necessary to achieve effective implementation of the right to health. In Central and Eastern Europe the legacy of the Soviet system where priority was given to economic and social rights over civil and political freedoms has not only resulted in a number of constitutions expressly recognising the right to health, but also Constitutional Courts adopting a more collective approach, e.g. in both Hungary and Poland the courts have interpreted right to health (or free health care) as non-individual rights satisfied by the provision of public services by the state. The Hungarian Constitutional Court has been particularly vigorous, adopting a 'ratchet' approach which recognises a state duty to maintain the level of services (e.g. welfare benefits, number of patient beds) even during economic austerity. The result is that once a certain level of protection is provided under statute it cannot be repealed or diminished by a subsequent law . Compare this approach to the UK where economic and social rights have tended to be subject to the vagaries of the government of the day unless the courts are prepared to indirectly protect healthcare rights through innovative application of the European Convention on Human Rights standards (see further below). The Hungarian approach is more in line with the 'progressive realisation' of the ICESCR, although this was not explicitly mentioned by the Constitutional Court which based its argument instead on the principle of legal certainty which respected vested rights and recognised legitimate expectations . Non-codification - the need to adopt innovate approaches The lack of express constitutional protection for health rights provides courts, lawyers and activist with significant but not insurmountable challenges for enforcement. Much will depend upon how far courts will be prepared to go in offering creative but legitimate approaches which do not exceed the scope of judicial powers. Techniques include : (a) adopting expansive definitions of civil rights some of which tend to be widely if not universally guaranteed under domestic law, e.g. rights to life or not be subjected to cruel, inhuman or degrading treatment. This approach has been sanctioned to differing degrees by both the UN Human Rights Committee and the European Court of Human Rights . The former in its General Comment Number 6 para 5 on the right to life stated : "the right to life has been too often narrowly interpreted. The expression "inherent right to life" cannot properly be understood in a restrictive manner, and the protection of this right requires that States adopt positive measures. In this connection, the Committee considers that it would be desirable for States parties to take all possible measures to reduce infant mortality and to increase life expectancy, especially in adopting measures to eliminate malnutrition and epidemics." Indeed, as the previous comment makes clear that the Committee was explicitly considering health issues in adopting a more liberal interpretation of the right to life; (b) considering the due process issues by exercising some form of judicial review. This has tended to be the approach adopted by the British courts in the absence of any express constitutional protection but suffers from the fact that only the reasonableness of the decision-making process itself is considered rather than the substance of the right although it may still allow for some indirect protection of esrs (c) use of cross-cutting provisions such as equality and non-discrimination which, again, may not allow for consideration of the substantial economic or social right but at least afford some measure of indirect protection. The Indian story : activism and innovation Although South Africa has tended to attract much of the attention amongst Commonwealth jurisdictions for its protection of economic and social rights Indian courts have been at the forefront of esrs litigation for over three decades. The Indian Constitution, promulgated in 1947, is a creature of its age and on its face far less progressive than its South African counterpart from the mid 1990s. Economic and social rights, including the right to health contained in Article 47 (as in a number of other Constitutions such as the Philippines, Ghana and Uganda) are consigned to the Directive Principles of State Policy (DPSP) section. According to Article 37 of the Constitution DPSP "shall not be enforceable by any court, but the principles therein laid down are nevertheless fundamental in the governance of the country and it shall be the duty of the state to apply these principles in making laws." Therefore on its face the Supreme Court is barred from considering and enforcing individual health rights claims but rather is concerned with offering non-binding guidelines on how health policies should be implemented whilst leaving the final decision to the state. However, the early 1970s witnessed a watershed in Indian human rights litigation with the Fundamental Rights Case ushering in an unprecedented period of progressive jurisprudence following the recognition by the Court that DPSP should enjoy the same status as 'traditional' fundamental rights. At the same time standing rules were relaxed in order to promote public interest litigation and access to justice. Suddenly writ petitions could be submitted on a postcard . The main means by which the Supreme Court has achieved equivalence between civil rights and their economic and social counterparts has been through the application of an expansive definition of the right to life. Unsurprisingly the right to health was one of the guarantees to first benefit from this approach . To date one of the most significant right to health decisions has been the public interest litigation case of Paschim Banag Khet Samity v State of West Bengal (1996) 4 SCC 37 where the Supreme Court used the right to life to secure the right to emergency medical care concluding that such an essential obligation could not be avoided by pleading financial constraints. The petitioner had been taken to a succession of eight state medical institutions ranging from a local health centre to two medical colleges and was refused treatment at each either due to lack of beds or lack of technical capacity. Eventually he was admitted to a private hospital where he was treated at a cost of Rs. 17,000. The Court, in holding that there had been a violation of the right to life under Article 21 and awarding compensation, stated that the right to emergency medical care formed a core component of the right to health which in turn was recognised as forming an integral part of the right to life. It did this by reconceptualizing the right to life as imposing a positive obligation on the state to safeguard the life of every person stating that "preservation of human life was of utmost importance" and that : "The Constitution envisages the establishment of a welfare state…Providing adequate medical facilities for the people is an essential part of the obligations undertaken by the government in this respect and discharges this obligation by running hospitals and health centres.." In line with its general approach of frequently offering comprehensive remedies that go beyond merely providing redress for the victim but also lay down the necessary policy and administrative steps to be taken by the state in the wider public interest, the Court not only ordered compensation, but also directed the type of facilities that the state government had to provide. This included hospitals and emergency provision (ambulances and communications) by formulating a blueprint for primary health care with particular reference to treatment of patients under an emergency as part of the state's public health obligation under Article 47. Furthermore, the Court ruled that its orders should apply to other states, together with the national government, and that they should be sent a copy of the judgment. However, in Consumer Education and Research Centre v. Union of India (1995) 3 SCC 42 the Court recognised that state resources are not limited and that no breach of the Constitution was incurred by reducing some employees' entitlements to medical benefits : "No State or country can have unlimited resources to spend on any of its projects. That is why it only approves its projects to the extent it is feasible. The same holds good for providing medical facilities to its citizens including its employees. Provision on facilities cannot be unlimited. It has to be to the extent finances permit. If no scale or rate is fixed then in case private clinics or hospitals increase their rate to exorbitant scales, the State would be bound to reimburse the same. " During the last two decades the Court has considered many public interest litigation cases involving protection of the environment, many of them brought by lawyer and activist, M C Mehta. These cases not only demonstrate the links between environmental rights and rights to health and to life, but also demonstrate how active the Supreme Court is prepared to be on occasion to secure protection of esrs. In Mehta v Union of India (1999) 6 SCC 9 the Supreme Court, after appointing an expert committee to formulate a detailed policy on conversion from petrol to cleaner fuels for vehicles in heavily polluted Delhi and incorporating its recommendations, issued several time-bound directions for conversion. However, the Court had to contend with the charge that these orders were inconsistent with existing statutes and that it was illegitimately extending its jurisdiction into an area of competence normally reserved for the executive. The Court responded that the directions were necessary to safeguard people's right to health and therefore should trump statutory provisions. Hence in exercising its mandate as the guardian of constitutional rights, the Court made clear that the public health considerations were clearly significant enough to justify taking a major policy decision rather than a stricter adherence to separation of powers This activist approach has had an impact beyond India's own borders to other countries in the South Asian region who have also framed esrs under DPSP. In Dr Mohiuddin Farooque v Bangladesh & Ors (No 1) 48 DLR (1996) HCD 438 the Bangladeshi Supreme Court, upon finding that a consignment of powdered milk imported by a company exhibited a radiation level above the acceptable limit in some (but not all) of the examinations conducted by various government testing bodies, upheld the claim that the actions of government officers in not compelling the importer to send the consignment back to the exporter had violated the constitutional right to life of people who were potential consumers. The Court noted that the right to life is not limited to the protection of life and limb necessary for the full enjoyment of life but also includes, amongst other things, the protection of the health and normal longevity of an ordinary human being and that if this was threatened by a man made hazard then the state could be compelled by the court to remove the threat (unless justified by law) even where its primary DPSP obligation under Art 18 to raise the level of nutrition and improve public health could not be enforced. Hence, as in the Indian cases, the Court was recognizing that artificial divisions between 'Fundamental Rights' and DPSP provisions should not prevent it acting to safeguard public health. Creative approaches from other Commonwealth jurisdictions Canada has no express provision protecting the right to health in its Charter of Rights and Fundamental Freedoms. Yet this has not prevented the Supreme Court from indirectly offering protection to the right by using other provisions. In particular, the equality provision under Article 15 has been used to protect esrs on the basis that similar treatment may not always guarantee substantive equality in order in the words of former Supreme Court Justice L'Heureux Dube to achieve a "contextual and empathetic approach to ensuring each person's human dignity" . In this context the Court has ruled that whilst s 15 does not impose upon governments the obligation to take positive actions to remedy the symptoms of systematic inequality, it does require that the government should not be a further source of inequality. The main health care case to date is Eldridge v British Columbia [1997] 3 SCR 624 which involved deaf individuals challenging the failure of a provincial government to provide sign-language interpreters as part of its publicly funded healthcare system. The Court held that this constituted discrimination on the basis that government should ensure that in providing general benefits to the population they should guarantee that disadvantaged members of society have the resources to take full advantage of these benefits and, in this context, effective communication was an indispensable component of the delivery of medical services. To hold otherwise was, for the Supreme Court, a "thin and impoverished view… of equality" [para 73] New Zealand has a very limited Bill of Rights centred on the protection of basic civil liberties. However, in the case of Shortland v Northland Health Ltd [1998] 1 NZLR 433 this did not prevent the Court of Appeal, through a generous interpretation of the right to life as protected by Article 8 of the Bill of Rights, and drawing on the equivalent international provision - Article 6 of the International Covenant on Civil and Political Rights (ICCPR) - from assessing a clinical decision to withdraw dialysis treatment according to human rights principles. In so doing the Court recognized that s 151 of the Crimes Act 1961 placed a legal duty on the local health authority to supply the patient with 'the necessaries of life' and that a failure to perform that duty 'without lawful excuse' could lead to criminal responsibility. The Court noted that this positive duty was related to the right to life as guaranteed by Article 6(1) of the ICCPR and the understanding of that provision as elaborated by the United Nations Human Rights Committee in its General Comment 6. The Court held that extent of the duty to provide the necessaries of life must be assessed in the context of the intensive appraisal of the patient's condition by the clinical team which had knowledge of his condition and his ability to benefit from dialysis. In so doing it recognized that judges were concerned with the lawfulness of the decision to discontinue dialysis and not with the likelihood of the effectiveness of the treatment . Hence, the Court found that, in light of the careful assessment of the patient by the clinical team, who had come to a bona fide decision that the cessation of treatment was in his best interests, Northland Health could not be said to be in breach of its duty to provide the necessaries if life and that therefore the decision to withdraw dialysis was not objectionable and would not deprive the patient of his right to life. The Court of Appeal's approach clearly mirrors that of the South African Constitutional Court in Soobramoney (see above) with judges recognizing that in right to health issues there are clear boundaries which they should not cross. Their main task is to assess whether those responsible for providing treatment had done all they could reasonably could do in the circumstances either in terms of making clinical decisions or how to manage limited resources. The UK courts, in the absence of the right to health or any esr guarantees incorporated into our domestic law, have again needed to adopt a creative approach using the limited set of fundamental civil guarantees contained in the European Convention on Human Rights that have been incorporated through the Human Rights Act 1998, in particular those safeguarding against cruel and inhuman treatment and respecting family life. However, it is important to recognise that in the UK, as in other jurisdictions where health rights are not entrenched, this is still very much an emerging area of law and that the record is mixed at best, as illustrated by a number of recent cases. In Watts, R (on the application of) v Bedford Primary Care Trust & Ors [2003] EWHC 2228 the High Court considered the extent of the state's positive obligations to provide healthcare regarding a claim for reimbursement of costs following treatment abroad. The applicant relied on both Articles 3 and 8 of the ECHR . The Court recognized the wide reach of both provisions and that "the Strasbourg jurisprudence demonstrates that Articles 3 and 8 do not only impose on the State merely negative obligations not to act in such a way as to interfere with the rights protected by those Articles. They also in certain circumstances impose positive obligations to take measures designed to ensure that those rights are effectively protected." [para 45]. However, Munby J went on to hold that in the light of the Court of Appeal decision R v North West Lancashire Health Authority ex p A [2000] 1 WLR 977, Article 8 imposes no positive obligations to provide medical treatment and that the pain and suffering endured by the applicant in not receiving treatment was not sufficiently serious to engage Article 3. Although the applicant was not able to succeed using human rights law he was able to on the basis of European Community law. Nevertheless, it appears unlikely until R v North West Lancashire Health Authority ex p A is overruled that claims for meeting medical treatment costs based solely on human rights arguments will succeed. However, this does not mean that positive healthcare issues cannot engage the Human Rights Act. In Goldsmith, R (on the application of) v London Borough of Wandsworth [2004] EWCA Civ 1170 the Court of Appeal addressed the failure of a local authority to sufficiently consider a patient's right to private life under Article 8 of the ECHR when deciding to transfer her to a nursing home. The Court concluded inter alia that the decision-making process had not acted in the best interests of patient in securing her health, together with a complete failure to take into account her Article 8 rights, thereby recognizing that a patient's right to respect for her private life does not cease upon her entering a healthcare institution. A number of recent decisions could have a significant impact - both positive and negative - on the health of asylum seekers, a particularly vulnerable segment of the British population. On the positive side the courts have recognised that asylum seekers should not be thrown into destitution by denying them access to welfare benefits. This was affirmed by the Court of Appeal in Secretary of State for the Home Department v Limbuela & Ors [2004] EWCA Civ 540 when it held that the state has a duty under Article 3 of the ECHR to prevent homeless asylum-seekers from suffering destitution even where they had failed to make an asylum claim as soon as reasonably practicable under s 55(1) of the Nationality, Immigration and Asylum Act. Applying R (Q) v Secretary of State for the Home Department [2004] QB 36 the Court held it was not necessary for the claimant to show the actual onset of severe illness or suffering for a claim to be established. If the evidence established clearly that charitable support in practice was not available, and that he had no other means of fending for himself the presumption would be that severe suffering would imminently follow. The majority of the Court recognised that the correct approach was one of prevention rather than 'wait and see' which could result in the victim having to endure unnecessary suffering before upholding a claim. An appeal was heard by the House of Lords in October 2004 and at the time of writing a judgment is yet to be handed down. The consequences of the decision being overturned for the health of many asylum seekers would be dire. Limbuela, involving as it did the positive obligation of the state to provide basic sustenance for the individual, irrespective of status, in order to prevent them suffering cruel and inhuman treatment did not require recourse to arguments based on the right to health or any other relevant economic and social rights guarantees, such as right to housing. However, two other recent decisions illustrate the dangers for claimants of not being able to argue esrs which have either been incorporated into domestic law or constitutionally entrenched. Both cases concerned the right of access of failed asylum seekers to medical treatment in the UK. In Dbeis and Ors v Secretary of State for the Home Department [2005] EWCA Civ 584 the Court of Appeal ruled that it was reasonable to return a failed asylum seeker and her son suffering from cerebral palsy to her country of origin where there were adequate medical and education facilities. The applicant had to argue her claim under Article 8 of the ECHR, but in the absence of any express entitlements to healthcare the Court ruled that the case did not satisfy the exceptional test laid down in a previous case and that therefore both her and her son could be deported back to the Lebanon. The case affirms a high threshold for those seeking to argue that health or other social needs should act as a bar to deportation. An even more disturbing decision was made by the House of Lords in N v Secretary of State for the Home Department [2005] UKHL31 when it found that that the UK had not breached Article 3 of the ECHR by deporting a failed asylum seeker with terminal HIV/AIDS back to her country of origin despite the fact that Uganda's medical facilities were clearly significantly less advanced than the UK. The Court distinguished D v UK (1997) 24 EHRR 423, the European Court of Human Rights decision relied on by the appellant, on the grounds that the situation in the receiving state were not as extreme as that faced by a terminally ill patient in that case where there was no prospect of any medical care or family support. For their Lordships a claim would only succeed where "the applicant's medical condition has reached such a critical state, that there are compelling humanitarian grounds for not removing him or her to a place which lacks the medical and social services which he or she would need to prevent acute suffering." [para 94]. Therefore Article 3 did not require contracting states to undertake the obligation of providing aliens with indefinite medical treatment lacking in their home countries. To hold otherwise they maintained would be to open the floodgates to a myriad of claims placing an unreasonable burden on the state. Whilst expressing sympathy for the appellant's plight and reminding the Home Secretary that he was not bound to deport her but could exercise his discretion, their Lordships concluded that she should not be allowed " to remain in the host state to enjoy decades of healthy life at the expense of [the] state" [para 92]. Yet their Lordships admitted themselves that without the necessary medication she had been receiving in the UK the appellant's life expectancy could be two years at best and the chances of receiving such treatment in Uganda was problematic. One is left with the conclusion that if N could not qualify for Article 3 protection then who will in the future ? It is clear that the House of Lords, as they themselves recognised, faced difficult moral choices in the case. Yet, whilst acknowledging that a line must be drawn somewhere to prevent the state (even one as wealthy as the UK) becoming overburdened, it is submitted that the scope of the protection offered to desperately ill people in the wake of N v Secretary of State for the Home Department is too narrow. It is also worth considering how the decision might have differed if N could have argued that she had a right to receive treatment as part of an explicit right to health under domestic law and that, given her serious condition, it was unreasonable to deport her. This is not a Soobramoney case where the patient, whatever the nature of the treatment she received, would only have a short period to live. A recent decision from the Australian Federal Court of Appeal, albeit one without the resource considerations of the House of Lords case, offers a more positive example of how the situation in other countries can and should be taken into account as part of the state's decision making process. The Court in De Bruyn v Minister of Justice and Customs [2004] FCAFC 334 was required to consider whether it would be unjust, oppressive or incompatible with humanitarian considerations to extradite a detainee to South Africa due to the risk of his contracting HIV/AIDS in prison. The Court, in holding that the prison conditions in the requesting country must be taken into consideration, ruled that the Minister had failed to address the question whether, in the circumstances of the case, it would be oppressive or incompatible with humanitarian considerations to surrender the subject to a country when there was a risk of contracting HIV/AIDS considerably greater than if he was not surrendered. Conclusions This limited survey of right to health jurisprudence from across the Commonwealth and beyond has demonstrated that express codification is not a bar to consideration of health issues by other courts. However, it will often require a creative approach and generous interpretation of existing guarantees by both lawyers and judges in order to give true meaning to the principle of indivisibility and interdependence of rights. Courts, whether assessing constitutionally entrenched rights, incorporated guarantees or conducting a more limited form of review, will need to be mindful of how far they can go in determining claims with often significant resource and policy implications as well as difficult moral choices. They will naturally be reluctant to supplant clinical decisions by health professionals but may be prepared to intervene if the state is considered to have acted unreasonably in denying services or medication to patients. Even where positive judgments are handed down the challenge of enforcement frequently remains, requiring both an active judiciary and committed health rights activists. Above all, reference to comparative and international law from a range of jurisdictions and fora should contribute to a greater understanding and appreciation of the right to health and other economic and social rights and, ultimately, to improved protection. 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Biography Resource Center + Complete Marquis Who's Who (Thomson Gale) For all age groups Comprehensive source for biographical information " More than 335,000 biographies of people from around the world and throughout history " Quick reference information on nearly one million people from Who's Who sources " Full-text articles from hundreds of magazines and links to selected biography Web sites Business & Company Resource Center (Thomson Gale) (1980 - present) For college-level and adult researchers and advanced high school students NOTE: Compare to General BusinessFile ASAP Comprehensive periodical and reference resource for business, management and investment topics, with Newsletters ASAP and Predicast's PROMT databases " Articles from academic and general business, industry and management periodicals, newsletters, newspapers and newswires (4,000+ indexed titles; 2,900+ full-text) " Investment and broker research reports " Company and association directory listings from a number of sources " Additional content from reference sources covering industries, company histories, associations, brands, market share and more Custom Newspapers (Thomson Gale) For all age groups Full-text articles from more than 100 U.S. and international newspapers " New York Times (2000-); Christian Science Monitor (1996-); Post & Courier (Charleston, SC; 2000-); Atlanta Journal-Constitution (1998-); and 40+ other domestic papers " Times (London; 1996-) and 60+ other international papers " Complete lists of newspapers included, with beginning dates of coverage: - Alphabetical List www.gale.com/tlist/sb5100.html - List by State & Country www.gale.com/tlist/online/CUSN_by_state.html " Updated 1 to 3 days after publication of the print newspapers Encyclopedia Americana (Grolier) For grades 8 and up In-depth information, current events and news archive for student researchers " More than 45,000 encyclopedia articles on all subjects " More than 100,000 related full-text periodical articles " Links to more than 150,000 selected Web sites " Weekly news feature, teacher resources and links to U.S. and international news sites " Interactive atlas, dictionary; 4,500 black-and-white and color images Expanded Academic ASAP (Thomson Gale) (1980 - present) For college-level and adult researchers and advanced high school students Comprehensive periodical database covering all academic disciplines " Millions of full-text articles from 2,000+ scholarly, refereed and professional journals and selected general interest magazines " Indexing of additional professional and general periodicals Gale Virtual Reference Library (Thomson Gale) For middle school students and above A selection of 24 cross-searchable reference e-books covering a variety of subject areas, including health and medicine, language and literature, history, social studies, science and more " Full-text articles " Photos and other illustrations General BusinessFile ASAP (Thomson Gale) (1980 - present) For college-level and adult researchers and advanced high school students NOTE: Compare to Business & Company Resource Center Comprehensive periodical resource for business, management and investment topics " Articles from academic and general business, industry and management periodicals, newspapers and newswires (3,300+ indexed titles; 2,600+ full-text) " Investment and broker research reports " Company directory listings " InfoTrac interface General Reference Center (Thomson Gale) (1980 - present) For high school students through adults Magazine, newspaper and reference articles on a variety of topics of general interest " Millions of full-text articles from more than 900 general magazine titles " Reference information from encyclopedias, dictionaries and almanacs " Coverage of school subjects, current events and consumer interest topics Grolier Multimedia Encyclopedia (Grolier) For grades 5 and up Reference information and news on all subjects with learning tools and multimedia " More than 40,000 encyclopedia articles with associated pictures, flags, maps and media, including video, sound, animations, panoramas and cutaways " Links to thousands of related periodical articles and Web sites " Weekly news articles with news quiz and related Web links " Monthly Brain Jam e-zine with teacher resources and student activities Health & Wellness Resource Center (Thomson Gale) (1980 - present) For advanced middle school students through adults Portal to health information from a variety of sources for general users; includes "Alternative Health Module" content NOTE: Compare to Health Reference Center-Academic " Full-text articles from 400 health, nursing, allied health and medical journals, including 30+ alternative health periodicals " More than 700 health-related videos from Healthology Inc. " Health-related articles from 2,200 general interest magazines " Medical encyclopedia articles, pamphlets, drug information and hospital directory, including alternative health reference titles and herbal medicine information " Access to health news and key health Web sites Health Reference Center-Academic (Thomson Gale) (1980 - present) For college-level and other adult researchers Health and medical periodicals and reference information for academic researchers NOTE: Compare to Health & Wellness Resource Center " Full-text articles from 600+ health, nursing, allied health and medical journals " Health-related articles from 1,500 general interest magazines " Articles from medical reference titles and pamphlets " InfoTrac interface InfoTrac OneFile (Thomson Gale) (1980 - present) For college-level and adult researchers and advanced high school students Comprehensive periodical database covering all subjects and all types of periodicals " Periodicals from nearly all InfoTrac collections merged into a single database " More than 25 million full-text articles on all subjects from more than 5,000 periodical titles " Articles from newswires and general, professional, scholarly and children's periodicals " Indexing of the New York Times, other major newspapers and 8,000+ periodicals Junior Edition (Thomson Gale) (Latest four years) For middle school students, their teachers and parents Magazine, newspaper and reference sources on all subjects " Full-text articles from 130+ magazines, with full image for 60+ titles " Maps, articles from reference books and newswire articles " Includes short stories, poems, quizzes, experiments and activities " Toolbox to help students learn research and writing skills Kids InfoBits (Thomson Gale) (1990s - present) For K-5 students, their teachers and parents Articles, pictures and reference information on all subjects " Full-text articles from 120+ children's magazines, reference sources and newspapers " 2,500 searchable images and maps " Reading levels assigned to most articles " Includes activities, recipes, experiments, poetry and stories by children " Teacher Toolbox to help teach research and writing skills LegalTrac (Thomson Gale) (1980 - present) For college-level and adult researchers and advanced high school students Index to law and legal periodicals with selected full-text articles " Indexing of more than 1,400 titles; full-text articles from 100+ titles " Major law reviews, legal newsletters, bar association journals and international titles " Law-related articles from more than 1,000 additional business and general interest titles Literature Resource Center (LRC) (Thomson Gale) For high school students and above Comprehensive periodical and reference resource for literature, featuring the online versions of these Gale print series: Contemporary Authors, Dictionary of Literary Biography, Contemporary Literary Criticism, Twayne's Authors Series and Scribner Writers Series. Also includes: " More than 415,000 full-text journal articles from more than 250 literary journals " Nearly 44,000 critical essays " Nearly 6,000 links to authoritative related Web sites Literature Resource Center (LRC) (Thomson Gale) continued For high school students and above " Nearly 5,000 work overviews, plot summaries and explications " More than 122,000 author biographies " Nearly 3,000 author portraits " Merriam-Webster's® Encyclopedia of Literature, featuring 10,000 definitions of literary terms New Book of Knowledge (Grolier) For grades 3 and up Reference information on all subjects with current events and educational features " More than 9,000 encyclopedia articles on all subjects, with pictures and maps " Related articles from children's magazines; related Web sites appropriate for children " Weekly news articles and pictures with lesson plans " Links to student activities, educational games and teacher resources SC Newspapers: Columbia and Greenville (NewsBank) For all age groups Archive of full-text articles from The State (Columbia, SC; December 1987-) and The Greenville News (Greenville, SC; January 1999-) " Locally written articles, including news, editorials, sports, business, arts and features " Letters to the editor and major newswire articles " Includes obituaries and death notices (although this coverage is incomplete prior to 1999) " Added features from NewsBank: Special Reports, Maps and News Headlines/Activities " Updated 1 to 2 days after publication of the print newspaper (Note: See thestate.com and greenvilleonline.com for free access to the most recent 1 to 2 days of coverage) Scribner Writers Series (Thomson Gale) For high school through college level Essays on the lives and works of 1,600+ important authors from around the world " In-depth coverage of noted novelists, playwrights, poets, short story writers, essayists, journalists, critics, philosophers and writers for children and young adults " Includes 40+ essays on special topics in literature, including gothic novels, nature poetry, etc. SIRS Discoverer (SIRS) For students in grades 1 through 9, their teachers and parents Articles, pictures, reference information and Web sites on all subjects " Age-appropriate, full-text articles and images selected from 1,600+ U.S. and international magazines, newspapers, government publications and reference sources " Reading levels assigned to all articles " Maps, pictures, photo essays, activities, biographies, country facts and current events " Links to age-appropriate Web sites with reading level indicators SIRS Knowledge Source (SIRS) For advanced middle school students through adults Articles, images, reference information, Web sites and more on all subjects " Articles selected from 2,500+ U.S. and international magazines, newspapers, government publications and reference sources " News, current events and organized links to evaluated Web sites " Includes special features on literature, terrorism and other topics " Interactive textbook on citizenship with teacher resources " Images, maps, country profiles, primary sources and Supreme Court decisions Student Edition (Thomson Gale) (1985 - present) For high school students, their teachers and parents Articles and reference information on topics most-often researched in high schools " Over 3 million full-text articles from 400+ periodical titles " Newswire articles and articles from reference sources " Selection of maps and historical images What Do I Read Next? (Thomson Gale) For librarians and teachers and readers of all ages Readers' advisory resource for recommended fiction and nonfiction " Recommendations on 100,000+ book titles for children, young adults and adults " Includes plot summaries, author information and award lists " Find recommended books by series, subje November 16, 2004 Elias Zerhouni, M.D. Director National Institutes of Health 9000 Rockville Pike Bethesda, MD 20892 Re: Comments from Health Affairs on the Proposal of the National Institutes of Health for Enhanced Public Access to NIH Research Information (NOT-OD-04-64), issued September 3, 2004 Dear Dr. Zerhouni: We are pleased to have this opportunity to comment on the proposal of the National Institutes of Health (NIH) put forth on September 3, 2004, to enhance public access to NIH-funded research. Agree with goal; concerns with proposal Health Affairs, as the leading journal of health policy, sees its primary mission as one and the same with that proposed by the NIH: that is, to increase the visibility and usefulness of top-quality research so that it may inform efforts to improve health care systems both in the United States and around the world. Health Affairs has been published since 1981 by the not-for-profit organization, Project HOPE, a leader in international health education. I have served as its Founding Editor since the journal's inception, and my goal has been to provide a nonpartisan forum for rigorous and timely policy research and debate on the nation's most pressing health care concerns. Health Affairs is now the number-one-ranked journal in the field, based on our "impact factor" as measured by the Institute for Scientific Information. While we share the goal of enhanced public access, we have concerns about aspects of the NIH proposal's concepts and implementation, which we discuss in detail here. Our primary concern is whether the proposal may disproportionately affect the small, nonprofit journals that play a large role in disseminating some of the nation's top research for its most effective use. We would be very supportive of nonpartisan research into this question. Overall, we ask that the NIH consider building more flexibility into its proposal to allow for the vast diversity among journals. The size of journal, frequency of publication, percentage of NIH-funded research published, and nonprofit status all have bearing on the ability of a journal to recoup its publication expenses if asked to make NIH-funded research papers free after six months. We know from our experience at Health Affairs that most of the expense of a journal is in its labor. Our labor costs include: (1) seeking out new papers on the most timely issues of the day; (2) encouraging health care leaders to write Perspectives on the effects of new research or policy proposals, or interviewing such leaders, including yourself, as a means of getting these important views into the broader research and policy community; (3) reviewing papers internally; (4) managing the external peer review process; (5) working closely with authors to revise papers (something we spend a great deal of effort on to help researchers from a multitude of disciplines write for a policymaking audience); (6) careful, detailed editing for content, errors, and readability (so strongly do we believe in the "translational" role of our journal that we have been cited numerous times for our readability and have become the "most-read" health care journal on Capitol Hill); (7) formatting the content for both print and Web; (8) maintaining highly searchable and research-friendly Web site and archives in perpetuity, including continual technology upgrades; and (9) promoting the research widely to interested health professional and policy-making audiences, as well as to the lay reader via extensive media promotion. All of these efforts are costly but are critical components of getting the research read and used by as wide an audience as possible. As a nonprofit journal, we have developed a business model that combines foundation grants and subscription revenues to support a break-even operation with a large amount of free access to journal content. However, our timetable and model for free access publishing does not match that proposed by the NIH. Our concern is what effect moving to the NIH model would have on our ability to earn subscription revenue to support the wide range of activities involved in publishing a journal such as Health Affairs. We believe that it is important for all stakeholders to reach a better understanding of this proposal's effects-both in reaching the NIH's goals and in avoiding unintended consequences that may have a deleterious impact on the future of scholarly research peer review and dissemination. Our specific concerns are as follows: Potential for unintended negative effects on free-access publishing. Health Affairs has a hybrid publishing model that already supports a great deal of free access to content. We strongly believe in making research content widely available and have joined with fifty-nine publishers as an original signatory to the DC Principles for Free Access to Science. " About 25% of our most timely papers are published online-only as "Web Exclusives" and are free to all upon publication. " Our entire archive of articles are available in full text online. Subscribers have access to the entire archive. Any nonsubscriber may access any article free after thirty-six months and may view individual articles that are not yet free access at a rate of $12.95 per article. We have waived this fee in cases of demonstrated need. " Since November 2003 we have offered free online access to the journal to researchers in more than 100 low-income nations. " We offer free access subscriptions to those who truly cannot afford to pay. We also provide complimentary copies of specific issues to thousands of key stakeholders on particular health care topics in an effort to contribute to the development of sound health policymaking. " With our new subscription site license model, students and faculty at universities have site-wide online access to the journal under one low-cost subscription. This model has been so successful in opening up journal access on campuses that we now see single universities downloading thousands of articles a month from the journal-something that was never possible in the days of print. " We offer free electronic interlibrary loan to aid those institutions that have not subscribed to the journal. " As part of our move to HighWire Press in November 2003, we now offer free full-text reference linking to Health Affairs articles that are cited in any of the more than 700 journals hosted by HighWire. This feature greatly aids the researcher in following a trail of journal articles. " All abstracts of Health Affairs articles are available free to all online and are indexed in MEDLINE, which is accessible via the NIH's PubMed Web site. " Over the past year our online access has increased so dramatically that Web usage has more than quadrupled in one year. While only 11% of Health Affairs papers are NIH-funded, fully one-third of the research we publish has funding from the U.S. Department of Health and Human Services. And virtually all of the research has funding from either a private foundation or public agency. Our concern, and that of many journals, is that the NIH, as the leading funder of health care research, is setting a closely watched precedent that will be emulated not only by other government funders but by private-sector funders as well. Indeed, the Wellcome Trust has announced its intention to implement a similar plan. If a large percentage of the papers we published were required to be available free after six months, this in combination with our current extensive free-access policies would almost certainly affect our ability to support the journal with subscription revenue. We would need to rethink our current free-access model at potential detriment to the policy-making community. We would like to see the NIH encourage publishers' efforts that are already under way to increase access to research, instead of pushing all journals into a "one-size-fits-all" model. We believe that a quadrupling of Web usage in one year shows success in making research highly accessible and usable. Risk of six-month access window for smaller journals. As the NIH, and potentially other funders, request free public access to their funded research, journals such as Health Affairs may find subscription funding erode as readers decide to wait six months to read articles when they are free. This may not be a problem for weekly or monthly publications; however, it is a greater concern for quarterly and bimonthly journals such as Health Affairs. While the open-access "author-pays" model of raising publication revenue bears monitoring and evaluating, for Health Affairs, we believe that a key strength of our long-standing subscription model is that it spreads the cost of research dissemination not only among the research community that created and funded the research, but also to those organizations that may monetarily benefit from the research and can afford to pay for it. We have an extremely diverse audience of health care industry leaders, consultants, lobbyists, lawyers, investment analysts, and health benefits advisers who we believe should share in the cost of research dissemination, in addition to the more traditional academic research audience and government health policy-making audience. In addition, our current subscription model is actually less expensive for universities and other research funders than the author-pays model. A university-wide subscription to Health Affairs is less than one-quarter the cost to publish one paper in a PLoS journal. We would rather see the NIH focus its effort in a more targeted way on helping the particular audiences that cannot afford to pay for access to the research, instead of taking a blanket approach of a six-month free-access window for all NIH-funded research. The subscription model has the economic benefit of distributing costs widely. We believe that it is a viable financing mechanism for research dissemination, and it is in the best interest of the taxpayer and research community to share this dissemination expense with all those who benefit from and can afford to pay for access to the research. To this end, we ask that the NIH allow some flexibility on the six-month free-access window, especially to assist less frequently published journals in maintaining their subscription models. Other ways to harness the power of the Web for NIH goals. The NIH has stated three objectives for its proposal: 1. Facilitate public access to NIH-related health research information. 2. Establish a fully searchable digital archive of NIH-funded research findings. 3. Improve the NIH's ability to manage its research portfolio. To this end, the NIH proposal requests that its research grantees deposit in PubMedCentral an electronic copy of the author's final version of a manuscript accepted for publication in peer-reviewed journals (not the edited and corrected article as ultimately published). This "submission of the electronic versions of final manuscripts will be monitored as part of the annual grant progress review and close-out process," according to the notices posted in the Federal Register and the NIH Guide to Grants and Contracts. The manuscript would become publicly available after six months. Under the proposal, PubMedCentral, which was established as an open-access repository in 2000, would need to receive and prepare for posting some 60,000 - 65,000 manuscripts per year from individual researchers. Cost estimates for scaling PMC to handle such an endeavor and to improve its searching and retrieving functionality vary widely. To fulfill the NIH's laudable goals of access, searchability, and portfolio management, we believe that there are less costly, less centralized ways of harnessing the power of the Web. We ask that the NIH consider using a distributive model of archiving that builds on the linking power of the Web rather than building up PubMedCentral as a centralized archive. Under such a model, journals would continue to provide abstracts of all articles published to PubMed at publication, along with links to the final version of the article on the publisher's site (as part of a program called "LinkOuts"). The advantages of such a model include: " Referring the public to the final published version of a research article, complete with extensive edits and corrections. This would minimize the confusion of having several versions of the research publicly available. And in the case of the clinical literature, this would minimize the potential public health problems of dosing errors or inaccuracies. " Providing searchable access to the full range of research, not just that funded by the NIH. Currently MEDLINE/PubMed indexes abstracts of about 5,000 journals; about two-thirds of those participate in the LinkOut program. All research articles from these journals are indexed in MEDLINE, not just the 10% that are NIH-funded. " Providing the public with links to additional supplemental material related to the published research. Such supplemental material may include additional data tables, further explanation of methodology, published corrections to the literature, and public comment on the research in the form of e-Letters. " Leveraging the sizeable investment publishers have already spent and are continuing to spend on improving the searchability and stability of online content. If there are concerns about longevity of publishers' Web sites, there could be a designated set of "approved" archives such as the one we use at Stanford University (HighWire Press, which was established in 1995 and is currently the largest free-access biomedical archive in existence). This would help avoid duplication of effort and taxpayer expense in creating highly searchable, interlinked archives to best serve the needs of the research community at large. Summary In sum, we believe that the NIH proposal, while well-intentioned, raises a number of concerns that bear closer evaluation before implementation. (1) Will the proposal truly increase access for those most in need of free access to health care research, without jeopardizing scientific publishing and visibility of the research - especially for research currently published in smaller, nonprofit journals? We would support closer examination of this question by a nonpartisan research group, such as the GAO, prior to implementation of the proposal. (2) Would the NIH consider allowing flexibility on the six-month access window to reduce the potential harm for smaller, less frequently published journals? (3) Would the NIH consider using a distributive model of archiving that builds on the linking power of the Web rather than building up PubMedCentral as a centralized archive? We greatly appreciate the opportunity to provide comments on the NIH proposal. We stand ready to answer any questions you may have about our suggestions for adding flexibility to the proposal and to build on the sizeable investment in research dissemination already under way in the publishing sphere. Ultimately, we wish to fulfill our mission of continuing to disseminate and increase access to the nation's health policy research. Sincerely, John K. Iglehart Founding Editor Health Affairs Member, Institute of Medicine, The National Academies Fitzhugh Mullan, MD Contributing Editor, Health Affairs Assistant Surgeon General, (Ret.) Member, Institute of Medicine, The National Academies Gail R. Wilensky, Ph.D. Senior Fellow, Project HOPE Former Administrator, Health Care Financing Administration Member, Institute of Medicine, The National Academies Enclosed is this month's Health for the Whole Family article, entitled, "OMT Is Good for More Than Just Back Pain." * DOs and other members of the profession have found that the Health for the Whole Family articles are a great way to promote the profession and educate patients about a variety of health topics. To use the article, simply insert your information in the appropriate areas and submit the article for publication in your newsletters or local newspapers. You can even leave the articles in your office waiting room. You can help us gauge the usage of the Health for the Whole Family articles by letting us know when and where you have been successful in getting these articles published. You can contact me by e-mail at kblackburn@osteopathic.org. You can also mail or fax copies of clips that have been published to me at: American Osteopathic Association Kelletta Blackburn, Marketing Communications Coordinator 142 E. Ontario St. Chicago, IL 60611 (fax) 312.202.8345 Thank you. Enc. *The contributing physician to this article was Melicien Tettambel, DO. Health for the Whole Family OMT Benefits for Mom and Baby OMT is Good for More Than Just Back Pain Form of treatment found to benefit mothers and babies Public awareness about Osteopathic Manipulative Treatment (OMT) is on the rise as medical studies prove the benefits of using OMT to treat back pain and health conditions like asthma. However, osteopathic physicians (DOs) will be quick to tell you that OMT has many other benefits, such as aiding in the treatment of pregnant mothers and their babies. "As a DO, I try to educate my patients about OMT by letting them know that it is one of the most unique and distinctive tools of osteopathic medicine," says insert full name, DO, an osteopathic insert specialty area from insert practice in insert town. "I also let them know how the use of OMT might benefit their individual health care needs." OMT requires a hands-on, whole body approach to diagnose health problems; treat dysfunctions; preserve good health; and prevent the spread of disease. In addition, OMT can enable DOs to treat and diagnose injuries or illnesses and has been found to be an effective treatment for individuals suffering from conditions ranging from carpal tunnel syndrome, menstrual pain, sinus disorders, and migraines. Dr. insert last name, states that OMT can benefit women during pregnancy by helping their bodies adjust to a growing uterus and displaced organs. OMT also can be used to help pregnant women with their posture by adjusting the body mechanics to work more efficiently. "The ways that OMT can benefit a pregnant woman even extends to the delivery room," says Dr. insert last name. "For example, OMT used during labor can help a woman reduce the number of times she needs to push," says Dr. insert last name. Infants can also benefit from OMT in a number of ways. Dr. insert last name notes that OMT can help prevent abnormal physical development caused by how the infant reshaped his or her body to pass through the birth canal. And, recent findings show that infants and toddlers who suffer from repeat ear infections can find relief from OMT. The treatment requires the physician to put their fingers on the bony prominence behind the ear and applying a gentle rocking motion. This enables fluid to flow more freely through the ear. "Best of all, children who received this treatment used less antibiotics and had fewer surgeries," says Dr. insert last name. As complete physicians, DOs are able to prescribe medication, perform surgery and can be found practicing in all areas of medicine. DOs can also use their hands to help diagnose and treat injury and illness and to encourage the body's natural tendency toward good health through the use of Osteopathic Manipulative Treatment (OMT). The Right to Health in International Legislative Texts Article 25 (1) of the Universal Declaration of Human Rights (UDHR) Article 25 Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR) Article 12 1. The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. 2. The steps to be taken by the States Parties to the present Covenant to achieve the full realization of this right shall include those necessary for: (a) The provision for the reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child; (b) The improvement of all aspects of environmental and industrial hygiene; (c) The prevention, treatment and control of epidemic, endemic, occupational and other diseases; (d) The creation of conditions which would assure to all medical service and medical attention in the event of sickness. Article 24 of the Convention on the Rights of the Child (CRC) Article 24 1. States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services. 2. States Parties shall pursue full implementation of this right and, in particular, shall take appropriate measures: (a) To diminish infant and child mortality; (b) To ensure the provision of necessary medical assistance and health care to all children with emphasis on the development of primary health care; (c) To combat disease and malnutrition, including within the framework of primary health care, through, inter alia, the application of readily available technology and through the provision of adequate nutritious foods and clean drinking-water, taking into consideration the dangers and risks of environmental pollution; (d) To ensure appropriate pre-natal and post-natal health care for mothers; (e) To ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of child health and nutrition, the advantages of breastfeeding, hygiene and environmental sanitation and the prevention of accidents; (f) To develop preventive health care, guidance for parents and family planning education and services. 3. States Parties shall take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children. 4. States Parties undertake to promote and encourage international co-operation with a view to achieving progressively the full realization of the right recognized in the present article. In this regard, particular account shall be taken of the needs of developing countries. Article 12 of the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), Article 12 1. States Parties shall take all appropriate measures to eliminate discrimination against women in the field of health care in order to ensure, on a basis of equality of men and women, access to health care services, including those related to family planning. 2. Notwithstanding the provisions of paragraph I of this article, States Parties shall ensure to women appropriate services in connection with pregnancy, confinement and the post-natal period, granting free services where necessary, as well as adequate nutrition during pregnancy and lactation. The right to non-discrimination as reflected in article 5 (e) (iv) of the International Convention on the Elimination of All Forms of Racial Discrimination (ICERD). Article 5 In compliance with the fundamental obligations laid down in article 2 of this Convention, States Parties undertake to prohibit and to eliminate racial discrimination in all its forms and to guarantee the right of everyone, without distinction as to race, colour, or national or ethnic origin, to equality before the law, notably in the enjoyment of the following rights: (e) iv: (iv) The right to public health, medical care, social security and social services; European Conventions and Charters European Social Charter, aim 11, articles (2), (11) and (13) Aim (11): Everyone has the right to benefit from any measures enabling him to enjoy the highest possible standard of health attainable. Article 2 - The right to just conditions of work With a view to ensuring the effective exercise of the right to just conditions of work, the Contracting Parties undertake: (1): to provide for reasonable daily and weekly working hours, the working week to be progressively reduced to the extent that the increase of productivity and other relevant factors permit; (2): to provide for public holidays with pay; (3): to provide for a minimum of two weeks annual holiday with pay; (4): To provide for additional paid holidays or reduced working hours for workers engaged in dangerous or unhealthy occupations as prescribed; (5): to ensure a weekly rest period which shall, as far as possible, coincide with the day recognised by tradition or custom in the country or region concerned as a day of rest. Article 11 - The right to protection of health With a view to ensuring the effective exercise of the right to protection of health, the Contracting Parties undertake, either directly or in co-operation with public or private organisations, to take appropriate measures designed inter alia: (1): to remove as far as possible the causes of ill-health; (2): to provide advisory and educational facilities for the promotion of health and the encouragement of individual responsibility in matters of health; (3): to prevent as far as possible epidemic, endemic and other diseases. Article 13 - The right to social and medical assistance With a view to ensuring the effective exercise of the right to social and medical assistance, the Contracting Parties undertake: (1): to ensure that any person who is without adequate resources and who is unable to secure such resources either by his own efforts or from other sources, in particular by benefits under a social security scheme, be granted adequate assistance, and, in case of sickness, the care necessitated by his condition; (2): to ensure that persons receiving such assistance shall not, for that reason, suffer from a diminution of their political or social rights; (3): to provide that everyone may receive by appropriate public or private services such advice and personal help as may be required to prevent, to remove, or to alleviate personal or family want; (4): to apply the provisions referred to in paragraphs 1, 2 and 3 of this article on an equal footing with their nationals to nationals of other Contracting Parties lawfully within their territories, in accordance with their obligations under the European Convention on Social and Medical Assistance, signed at Paris on 11th December 1953. Articles 34 and 35 of The Charter of the Fundamental Rights of the European Union Article 34 - Social security and social assistance 1. The Union recognises and respects the entitlement to social security benefits and social services providing protection in cases such as maternity, illness, industrial accidents, dependency or old age, and in the case of loss of employment, in accordance with the rules laid down by Community law and national laws and practices. 2. Everyone residing and moving legally within the European Union is entitled to social security benefits and social advantages in accordance with Community law and national laws and practices. 3. In order to combat social exclusion and poverty, the Union recognises and respects the right to social and housing assistance so as to ensure a decent existence for all those who lack sufficient resources, in accordance with the rules laid down by Community law and national laws and practices. Article 35 - Health care Everyone has the right of access to preventive health care and the right to benefit from medical treatment under the conditions established by national laws and practices. A high level of human health protection shall be ensured in the definition and implementation of all Union policies and Offers focal point fires with a product or service that delivers valor fires and baxi fires. You will want to find out more information.