Category - Healthcare

By Patrice Woeppel, Ed.D.
Author of Depraved Indifference: the Workers’ Compensation System

March 16, 2009

The Bureau of Labor Statistics (BLS) records 5,488 worker fatalities for 2007, the most recent year for which their data is completed. But the number of worker fatalities recorded by BLS is grossly under-reported.

Worker deaths from toxic exposures, other work illnesses are conservatively estimated by NIOSH and other researchers at 50,00 to 60,000 deaths each year, or ten times the number of fatalities from work injuries.[fn1] [fn2] [fn3] It is a disaster of monumental proportions that goes largely unrecorded. The United States has no comprehensive occupational health data collection system.

As we have lagged behind other nations in our lack of a national comprehensive medical and statistical database on occupational illnesses, occupational injuries; we have lagged behind in the research into the causes and consequences of occupational illnesses that would lead to improved diagnosis, treatment, prognosis, and ultimately prevention, of occupational toxic exposures and resultant diseases.

While the United States has set permissible exposure limits on less than 500 of the hundreds of thousands of chemicals in use in workplaces throughout our country, the EU regulates 30,000 chemicals utilized in their workplaces, and many that we allow here have been banned for years in the EU.[fn4] Even the small number of chemicals, upon which exposure limits have been set in the US, are grossly out of date based on more recent scientific data.

It is a major and costly health issue – costly in lives, and costly in dollars. The economic burden for occupational illness, injury and death in our country is an estimated $170 billion annually. It is an economic burden that falls mainly on families (44%) and on taxpayers (18%); with only 27%, on average, being paid by workers’ compensation.[fn5]

There has been very little general public awareness of this system that maims and kills with impunity. The time is long overdue to re-evaluate a structure that evolved over one hundred years ago; and which clearly doesn’t meet the needs of seriously injured, ill, or toxic chemical-exposed workers, or the families of workers who died from their work – a system that has fostered devastating and lasting damage to families, to communities, to our environment.

Increasingly as a nation, we have been all too willing to push corporate costs onto workers and taxpayers; and all too willing to cut protections for workers, communities.

Occupational illness deaths are now the eighth leading cause of death in the US, more than many of the diseases that receive far more government, public, and media attention.[fn6] We need to right this terrible, continuing American tragedy.

References:

1. Leigh, J. Paul; Markowitz, Steven; Fahs, Marianne; Landrigan, Philip. Costs of Occupational Injuries and Illnesses. University of Michigan Press, 2000.

2 U.S. House of Representatives. Hidden Tragedy: Underreporting of Workplace Injuries and Illnesses. A Majority Staff Report by the Committee on Education and Labor. Honorable George Miller, Chairman, June 2008.

3.Steenland, Kyle; Burnett, Carol; Lalich, Nina; et al.Dying for Work: The Magnitude of US Mortality From Selected Causes of Death Associated With Occupation, American Journal of Industrial Medicine, Vol 43, pp 461-482, 2003.

4. Regulation EC 1907/2006 of the European Parliament and of the Council of 18 December 2006 concerning the Registration, Evaluation, Authorization and Restriction of Chemicals (REACH), http://eur-lex.europa.eu.

5. op. cit. Leigh, et al, 2000.

6. LaDou, J., M.D. Occupational and Environmental Medicine in the United State: A Proposal to Abolish Workers’ Compensation and Reestablish the Public Health Model, International Journal of Occupational and Environmental Medicine in the United States. 2006; 12 (2) 154-168; and US Department of Health and Human Services, National Center for Health Statistics, Centers for Disease Control and Prevention, National Vital Statistics System, National Vital Statistics Reports, Vol 53, Number 5. Deaths: Final Data for 2002, Table 10 and Worktable I, pp. 1585, 1634, 1662, 1703, 2220-2224, at cdc.gov/hchs/data/dvs/mortfinal2002_workipt2.pdf.

Paul Krugman’s latest column asserts that Senator Clinton should be the clear favorite for those in favor of universal health care.

The principal policy division between Hillary Clinton and Barack Obama involves health care. It’s a division that can seem technical and obscure — and I’ve read many assertions that only the most wonkish care about the fine print of their proposals.

But as I’ve tried to explain in previous columns, there really is a big difference between the candidates’ approaches. And new research, just released, confirms what I’ve been saying: the difference between the plans could well be the difference between achieving universal health coverage — a key progressive goal — and falling far short.

Specifically, new estimates say that a plan resembling Mrs. Clinton’s would cover almost twice as many of those now uninsured as a plan resembling Mr. Obama’s — at only slightly higher cost.

[cont’d]

On the other hand, and mucking up the analysis of what’ll happen if Clinton is elected versus Obama (assuming one of them is indeed elected over the Republican candidate), is the idea I’ve seen advocated that Obama on the November ballot will better help in the election of lots more Democrats to the US House and Senate. The idea being that Clinton is more divisive, so even if she wins, there will be fewer middle-ground and moderate-Republican voters who will feel enthusiastic about the Dems in general, and so less likely to vote for other Dems on the ticket. But Obama is seemingly more unifying and uplifting of a character, and so good vibes for him will rub off on other Dems on the ticket. And if that’s true, then ironically Obama would have a Congress to work with that would be more amenable to a strong health care initiative, whereas Clinton would have a harder fight on her hand because the Congress she faced wouldn’t be as friendly to progressive causes. (Examples of this sort of analysis from The Nation and DailyKos.)

And is Krugman right that those opposed to universal health care will actually and successfully be able to kill an attempt by Obama to expand his policy vision by turning his primary campaign words against him? It seems plausible that he could change his vision and that, if this occurs during a honeymoon first 100 days following a landslide victory, brush aside those sorts of attacks without too much trouble. Maybe I’m being too optimistic. It’s just that I find myself reasonably convinced by the “Obama brings with him a stronger Congress than Clinton” arguments and so have been finding myself moving towards supporting him for that reason. (I’m in Vermont and our primary isn’t until March 6.)

Onward!

[Update] It’s all pretty frustrating, this not being able to predict the future. I say that because I agree with something else that Krugman has said (though I can’t recall where to link to it at the moment) that establishing a viable universal health care system is enormously important, both for the wellbeing of the country in general, and for a left/progressive movement as well. It’d be like a new New Deal–it would provide a kind of shared benefit that tens-, hundreds of millions of people would feel and appreciate. They’d not only be better off, they’d know that it was the left that got them better off. Large numbers of people who felt that there was no useful difference between the Republicans and the Democrats would learn that in fact there is. (And even if you think there isn’t currently, the establishment of universal health care would in itself be the fact of difference.) Large numbers of people who think government is just a big joke would learn that government can indeed do some things–some very, very important things–right, do them better than the alternatives. A decent universal health care system, alongside a carbon cap-and-dividend system, would breathe vibrant new life into a progressive political movement. We’d gain a generation or more of new loyalty and energy.

And we need that loyalty and energy. There’s lots to be done, from avoiding the worst of global warming to eliminating poverty, from ending the Iraq war to rebuilding crumbling schools and other infrastructure. These things are big jobs and expensive. To do them right means having the backing of the majority of the people. To get that backing, the people have to feel–to know–that “we’re all in it together” is more than empty rhetoric. Universal health care is the achievable reality that makes that rhetoric tangible. It’s a policy of solidarity that makes each next step a little easier to achieve. It’s why I’ve been quipping (mostly to myself) for a while now that “universal health care is an environmental issue.” If we can provide universal health care that makes it one heck of a lot easier to convince people that we all have to face restrictions on energy consumption (and so consumption in general). We have to face both the restrictions and the benefits (of health care, of a healthy environment, etc.) together.

And so if in fact that’s all true, then boy oh boy will it be disappointing if Obama (or Clinton) is elected president–especially if he (or she) is backed by a newly enlarged Democratic majority in Congress–and yet fails to seize the opportunity. Boy oh boy, very disappointing.

Bruce E. Levine has an interesting article over at Alternet on the use of psychiatric medication to tame defiant youth. Some tantalizing excerpts:

For a generation now, disruptive young Americans who rebel against authority figures have been increasingly diagnosed with mental illnesses and medicated with psychiatric (psychotropic) drugs.

Disruptive young people who are medicated with Ritalin, Adderall and other amphetamines routinely report that these drugs make them “care less” about their boredom, resentments and other negative emotions, thus making them more compliant and manageable. And so-called atypical antipsychotics such as Risperdal and Zyprexa — powerful tranquilizing drugs — are increasingly prescribed to disruptive young Americans, even though in most cases they are not displaying any psychotic symptoms.

Many talk show hosts think I’m kidding when I mention oppositional defiant disorder (ODD). After I assure them that ODD is in fact an official mental illness — an increasingly popular diagnosis for children and teenagers — they often guess that ODD is simply a new term for juvenile delinquency. But that is not the case.

Young people diagnosed with ODD, by definition, are doing nothing illegal (illegal behaviors are a symptom of another mental illness called conduct disorder). In 1980, the American Psychiatric Association (APA) created oppositional defiant disorder, defining it as “a pattern of negativistic, hostile and defiant behavior.” The official symptoms of ODD include “often actively defies or refuses to comply with adult requests or rules” and “often argues with adults.” While ODD-diagnosed young people are obnoxious with adults they don’t respect, these kids can be a delight with adults they do respect; yet many of them are medicated with psychotropic drugs.

…

Throughout American history, both direct and indirect resistance to authority has been diseased. In an 1851 article in the New Orleans Medical and Surgical Journal, Louisiana physician Samuel Cartwright reported his discovery of “drapetomania,” the disease that caused slaves to flee captivity. Cartwright also reported his discovery of “dysaesthesia aethiopis,” the disease that caused slaves to pay insufficient attention to the master’s needs. Early versions of ODD and ADHD?

In Rush’s lifetime, few Americans took anarchia seriously, nor was drapetomania or dysaesthesia aethiopis taken seriously in Cartwright’s lifetime. But these were eras before the diseasing of defiance had a powerful financial ally in Big Pharma.

…

It would certainly be a dream of Big Pharma and those who favor an authoritarian society if every would-be Tom Paine — or Crazy Horse, Tecumseh, Emma Goldman or Malcolm X — were diagnosed as a youngster with mental illness and quieted with a lifelong regimen of chill pills. The question is: Has this dream become reality?

Conflict of interest alert: I work for Chelsea Green Publishing, publishers of Levine’s recent book, Surviving America’s Depression Epidemic.

It’s hard to think of something that counts as an “econ-atrocity” more than the health insurance industry’s practice of paying bonuses to employees who meet targets for cancelling policies of sick customers or refusing to cover the care that the customers need. My uncle sent me this link to the latest revelation published in the LA Times:

Health insurer tied bonuses to dropping sick policyholders

By Lisa Girion, Los Angeles Times Staff Writer
November 9, 2007
One of the state’s largest health insurers set goals and paid bonuses based in part on how many individual policyholders were dropped and how much money was saved.

Woodland Hills-based Health Net Inc. avoided paying $35.5 million in medical expenses by rescinding about 1,600 policies between 2000 and 2006. During that period, it paid its senior analyst in charge of cancellations more than $20,000 in bonuses based in part on her meeting or exceeding annual targets for revoking policies, documents disclosed Thursday showed.

As my uncle put in his email’s subject line, “did somebody say, ’single-payer health plan?’”

*Ha ha!

I’ve tried, oh I’ve tried, but good ole Katha Pollitt has said it better than I’ve ever managed. A tidy summary to why, indeed, poverty is bad for your health–IF you live in an economy like the U.S.’s where access to health care is largely dependent on your financial standing. Poverty, I’m sure, isn’t particularly good for your health if you live in an economy with a sensible, universal health system; but it sure won’t be nearly as outright dangerous to be poor.

An important debate in the social health literature is whether more inequality causes worse health. At some later date I’ll post a bibliography, or maybe commenters can help. In any case the list of publications is long, the contributors illustrious, and the findings varied and at odds with each other. Some of the most important papers representing a range of findings include those by Deaton, Deaton and Lubotsky, Mellor and Milyo, Lynch, et al., Kawachi, Subramanian, et al., Navarro, et al., Wilkinson, et al., and Marmot, et al.

Note that the debate is about the effect of inequality, per se, on health. Everybody knows that being rich reduces mortality and being poor increases it. The relationship between income and health (mortality, infant mortality, life expectancy, morbidity) is so well known in the literature that it is simply known as “the gradient.” It obtains at the macro and micro levels in dozens of studies. For example, let me quote Angus Deaton, who is BTW an inequality-mortality skeptic, “Men in the United States with family incomes in the top 5 percent of the distribution in 1980 had about 25 percent longer to live than did those in the bottom 5 percent. Proportional increases in income are associated with equal proportional decreases in mortality throughout the income distribution” (Angus Deaton “Policy Implications Of The Gradient Of Health And Wealth”). But I digress.

There are three basic channels through which an association between inequality and health could occur. The first two are causal in that social inequality affects individual health.

1. Direct. Inequality creates stress, which is bad for health.
2. Indirect. Inequality disrupts the production of health-supporting public goods or causes the production of health-reducing public bads, which is bad for health.
3. Artifactual. More income improves the health of the poor more than it improves the health of the rich. (The health-income relationship is concave.) A more unequal society will have worse average health than a more equal society with the same mean income because the health gain to the rich from being much richer is not as great as the health loss to the poor from being much poorer. Note that individual income only affects individual health, but the distribution of income affects average health.

A fairly recent entry in the field is Leigh and Jencks, “Inequality and mortality: Long-run evidence from a panel of countries” (Journal of Health Economics 26 (2007) 1-24). Here is a link to a working paper version which is very similar to the published version. In a nutshell, the income share of the richest 10 percent of the population is the measure of inequality, and life expectancy at birth and infant mortality are the two main measures of health outcome.

The 14,500 doctors and 58,000 nurses of this health-care organization serve 7.6 million enrollees, delivering care that outperforms both commericial insurance and Medicare–let alone poor, underfunded Medicaid–on a host of indicators of quality of process and outcome. While Medicare costs increased from $5,000 to $6,800 (36 percent) per patient-year between 1996 and 2004, its costs stayed constant at $5,000 per patient-year. And the patients receiving this high-quality, moderate-cost care are disproportionately poor and disabled.

Is it Kaiser Permanente? Is it a new for-profit chain of health clinics? No, it’s the Veterans Health Administration (VHA).

As summer rolls around, there’s been a spike in interest in the American vacation deficit.

David Moberg, writing in the excellent progressive bi-weekly In These Times, surveys the field in “What Vacation Days?” Since we’re interested in policy, here’s the punch line,

Why do workers in other rich countries have more paid time off? Mainly because laws demand employers provide it. The European Union requires its members to set a minimum standard of four weeks paid vacation (covering part-time workers as well). Finland and France require six weeks paid vacation, plus additional paid holidays. Most countries require workers to take the time off and employers to give them vacation at convenient times. Some governments even require employers to pay bonuses so workers can afford to do more than sit at home on vacation. On top of that, unions in Europe and other rich industrialized countries—whose contracts cover up to 90 percent of the workforce—typically negotiate additional time off. Meanwhile, the standard workweek is slightly shorter in many European countries, and workers retire earlier with better public pensions.

For the heavy quantitative lifting, Moberg cites a survey of comparative vacation legislation, “No-Vacation Nation” recently published by CEPR (May 2007). The summary is here and the full report is here.

This report reviewed international vacation and holiday laws and found that the United States is the only advanced economy that does not guarantee its workers any paid vacation or holidays. As a result, 1 in 4 U.S. workers do not receive any paid vacation or paid holidays. The lack of paid vacation and paid holidays in the U.S. is particularly acute for lower-wage and part-time workers, and for employees of small businesses.

Berkeley economist Brad DeLong offers a qualified (”coming from a guy who is not a real health economist but has an undeserved reputation because he was good at translating the economese spoken by real health economists”) proposal for health care reform. Here are the highlights:

• 20% Deductible/Out of Pocket Cap
• Single-Payer for the Rest
• Sin Taxes [and public-health education, exhortation, etc.]
• Serious Research on Best Public-Health, Chronic-Disease, and Hospital Practices

Here’s what’s good, what’s bad, and what can be improved:What’s good?

• Single payer for the rest. Much of the current health care mess in the U.S. comes directly from the competitive private insurance market. Insurance companies reap rewards for avoiding sick patients and have little incentive to provide continuity of care (follow-up on patients with chronic illness, preventative care, etc.). Administrative costs and profits are also ridiculously high. Single payer, which means that the government or a quasi-governmental trust is the unique, universal insurer, is the obvious solution, a proven winner in one form or another in almost every other industrialized country.
• Serious research (and development). Medical and information technology could be applied much more effectively to monitor and to ameliorate chronic diseases and other health risks. We can learn more at the cutting edge, we can better disseminate and reward the adoption of demonstrated good practices, and we can help people monitor and improve their own health (while respecting their privacy).

What’s bad?

• 20% Deductible/Out of Pocket Cap. DeLong’s proposal would tax 20 percent of income for health care: 15 percentage-points worth would go into a personal health-spending account and 5 percentage-points worth would go into a health insurance pool. The phrase “for the rest” following single payer means that complete insurance would apply all health care problems in excess of 15 percent of income. At least there would be some means testing but there is little else to recommend this proposal. The impetus for high deductible is that patients should be encouraged to shop around and competitive pressures will contain costs. Otherwise, patients, or more likely their providers, face a moral hazard to overuse care. Some so-called cost sharing is compatible with single-payer, but here’s the problem. The 5 percentage points of income isn’t enough to provide insurance to people who need it. Health problems and the associated costs come in very concentrated bursts. According to the director of social scientific research at the Federal agency responsible for health research (AHRQ), “Nearly 30 percent of health care expenditures are accounted for by the top 1 percent of spenders, while more than half of all health care expenditure are accounted for by the top 5 percent of spenders.” Because health-care expenditure is about 16 percent of all income, the top 1 percent of spenders alone use up almost the entire 5-percent insurance pool (because 30 percent of 16 percent is 4.8 percent). There is essentially nothing left to pay for unexpected health care needs for the other 99 percent of the population beginning with the next sickest 4 percent. So we don’t need to debate the morality or excoriate the immorality of the “first out-of-pocket, and only then insurance” approach. Nor do we need to offer (perfectly reasonable albeit difficult to defend) opinions such as, “No one gets excess health care for fun.” Health care costs cannot be contained by widespread cost-sharing because of their fundamental distribution.

What can be improved?

• Sin Taxes [and public-health education, exhortation, etc.] Reinvigorating the public-health approach makes lots of sense. DeLong smartly suggests increasing the employment, skills, and portfolio of nurses, other primary-care providers, health educators, health-care paraprofessionals, nutritionists, et al. A lot of the public-health problem may come from the time bind that Americans face. When the health educator knocks at the door (see the proposal), will anyone be home? We are more likely to be commuting, alone, in a car, to a distant job with long hours. The proposed sin taxes should include unequal incomes and long hours. And public health should include a vacation.

By Helen Scharber, CPE Staff Economist

On February 8, Representative Louise Slaughter (D-NY) introduced the Preservation of Antibiotics for Medical Treatment Act of 2007, a bill designed to limit the use of antibiotics in healthy farm animals. Though their surnames do not lend themselves as aptly to a bill about livestock, Senators Kennedy (D-MA) and Snowe (R-WA) introduced a nearly identical bill to the Senate the following week. Why are lawmakers suddenly so concerned with porcine penicillin? As Snowe explains, “The effectiveness of infectious disease fighting antibiotics continues to be compromised by their overuse for agricultural purposes.” In other words, the antibiotics we’re feeding our edible friends are speeding the development of drug-resistant super bacteria, a type of progress that’s bad for pigs and for people.

It’s extremely common for articles about different health issues to cite some statistic about the drain on the economy that the illness causes, both in terms of direct expenditures for healthcare to deal with it, as well as the indirect costs of missed work time. It was this quote in The Ecologist that got me thinking about this, “The indirect costs [of obesity in the UK] are estimated to be in the region of £2.5 billion per year, including costs to the NHS [National Health Service] and costs to industry through sickness and absence” and typing “economic cost disease” into Google’s Scholar search turns up a slew of examples from the bowels of academia figuring the same way.

By Heidi Garrett-Peltier, CPE Staff Economist

You are what you eat. And according to Michael Pollan, author of The Omnivore’s Dilemma, that means we’re corn. Corn has now made its way into our diet in the form of fillers, sweeteners, oils, alcohols, pills, and breakfast cereals, not to mention of course the indirect path it takes through animal feed. Why should we care? Because cheap corn has been linked to obesity, and obesity will soon overtake tobacco as the leading cause of preventable death.

By Helen Scharber, CPE Staff Economist

When your child’s doctor gives you advice, you’re probably inclined to take it. And if 60,000 doctors gave you advice, ignoring it would be even more difficult to justify. Last month, the American Academy of Pediatrics (AAP) issued a policy statement advising us to limit advertising to children, citing its adverse effects on health. Yes, banning toy commercials might result in fewer headaches for parents (“Please, please, pleeeeeeease, can I have this new video game I just saw 10 commercials for????”), but the AAP is more concerned with other health issues, such as childhood obesity. Advertising in general – and to children specifically – has reached astonishingly high levels, and as a country, we’d be wise to take the doctors’ orders.

By Gerald Friedman, CPE Staff Economist
Dec. 1, 2006

A recent article in the New York Times (October 25, 2006) entitled “Hospitals Try Free Basic Care for Uninsured” raises an intriguing possibility. The Times reports how some local governments and hospitals have found that by providing primary care, supportive services, and preventive care for the uninsured they can save money by avoiding higher costs when conditions worsen down the road. Following the experience of a diabetic patient at Seton, a Roman Catholic hospital network in Texas, the Times shows how preventive care reduced “costs for the hospital” by helping the woman avoid expensive emergency room visits. By improving her health, preventive care cut her medical bills nearly in half. “The money we save,” Dr. Melissa Smith, medical director of three Seton clinics, “money that is not hemorrhaging through the I.C.U., is money we can do so much more with to help her upfront.”

We could all hope that there will be enlightened insurers who will respond to these stories. The Times is certainly hoping to promote a free-market win-win where the poor will receive care that will help them stay healthy, and health insurers and providers will increase their profits by reducing total expenditures. But this worthy goal misses the fundamental flaw of for-profit health insurance: Capitalist businesses, including America’s health insurers, are not eleemosynary institutions. They do not set out to produce useful things. Instead, they seek to create profits; any social value or use is purely coincidental. In the specific case here, our capitalist health care industry is organized to produce profits; any quality health care that it provides is a desirable, but secondary, product.

By Helen Scharber, CPE Staff Economist

The new national bankruptcy laws that went into effect in late 2005 prompted a big stir, not to mention a record-setting level of bankruptcy filings just before the laws changed. What is it about the Bankruptcy Abuse Prevention and Consumer Protection Act of 2005 that caused so much controversy? Like its Orwellian cousins the Clear Skies and Healthy Forest Initiatives, this act—whose very title suggests it will enhance consumer protections—does anything but. Indeed, the problems with this new law have much to do with what it does not include.

By Brenda Wyss, CPE Staff Economist

Jamaica is hemorrhaging nurses and teachers. The Jamaica Gleaner reports that Jamaica loses roughly 8% of its RNs and more than 20% of its specialist nurses annually. Most go to the US or the UK. The US, with 97.2 nurses per 10,000 people, actively recruits nurses from Jamaica, a country with only 11.3 nurses per 10,000 people. Meanwhile, US and British schoolteacher work programs recruit Jamaican teachers for inner city schools in New York City and London. In 2001 alone, 3% of Jamaica’s teachers (almost 500 educators) left the island to accept temporary assignments abroad. Jamaica’s Ministry of Education estimates the country
lost 2,000 teachers between 2000 and 2002. And Jamaica’s brain drain is not limited to nurses and teachers. In fact, an IMF report estimates that more than 60% of all Jamaicans with tertiary education have migrated to the US.

Jamaica’s chronically under-resourced health and education sectors can ill afford the loss of skill. In its 2001 Annual Report, Jamaica’s Ministry of Health reported nationwide vacancy rates of 37% for RN positions, 28% for public health nurses, 17% for nurse practitioners, and 61% for assistant nurses. At the same time, a shortage of trained teachers threatens educational quality. While Jamaica has trained increasing numbers of teachers over the years, the fraction of teachers serving in Jamaica’s schools who are fully trained has declined. Between the 1990-91 and 1996-97 school years, the total share of trained teachers decreased by 11%.

By Kiaran Honderich, CPE Staff Economist

(Reprinted from CPE’s newsletter, “The Popular Economist,” Spring, 2002.)

Over the last year activists have made important progress in the battle against global AIDS. Developing countries won a partial victory at the WTO ministerial meeting in Doha in November, affirming their right to produce affordable generic drugs in a health crisis. And the appalling mainstream consensus that treatment with antiretroviral drugs was too expensive and complex to be made available in poor countries–writing off literally tens of millions of lives at a stroke–is finally giving way to acknowledgement that treatment is possible in resource-poor settings, although it seems likely to be rolled out in a way that neglects rural populations. These battles are by no means finished–the WTO is still hashing out whether poor countries too small to produce their own generic drugs should be permitted to import them from another country; if Bush gains fast track authority then he will be able to take back the gains of Doha; and South Africa’s ANC government is being dragged kicking and screaming by activists towards the treatment programs that its country needs–but real progress is being made.