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interventions in maternity care could save the lives of tens of thousands of babies who die unnecessarily during pregnancy and labour every year. In high-income countries, although infant mortality rates have dropped, stillbirth rates have not changed in more than a decade and there is no room for complacency. More can and must be done to reduce this unacceptable loss of life. Bereaved parents are key to bringing about change. Where parents have joined together to support each other, the silence of stillbirth is broken. By voicing their stories, speaking the unspeakable, and being heard, parents can undo some of the myths that surround stillbirth and focus attention on how things could be done better. In some countries, the powerful role of parents has been demonstrated in a profound transformation in attitudes to bereavement care. Working collaboratively with health professionals, parents’ groups such as Sands in the UK have been able to build a culture of sensitive and caring bereavement support that respects parents’
needs, acknowledging that stillbirths matter and that the quality of care grieving parents receive can have a lifelong effect. Parents can play a similar part in pushing for improvements to reduce stillbirths. Every bereaved parent wants to know what can be done to stop other families experiencing the same heartache. The passion that parents have to save other babies’ lives makes them powerful advocates for change. The energy they bring to fundraising, campaigning, and lobbying, and their bravery in sharing their difficult stories in public, will never bring their own babies back, but it will perhaps one day prevent the unnecessary and ignored death of another child. Janet Scott Sands (Stillbirth and Neonatal Death Charity), London W1B 1LY, UK
[email protected] I declare that I have no conflicts of interest.
Scrambling for Africa? Universities and global health Published Online November 11, 2010 DOI:10.1016/S01406736(10)61920-4 See Health Policy Lancet 2011; 377: 1113
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The Consortium of Universities for Global Health (CUGH) has emerged as a major voice within the field of academic global health.1 Established in 2008 in San Francisco, the group’s membership includes many of the most prestigious universities in the USA, and its leadership is well connected to US policy makers and funding agencies. On Sept 19–21, 2010, the Consortium convened its third meeting at the University of Washington, Seattle, WA, USA. I have attended all three meetings as an anthropologist and participant observer. The 2010 meeting gave an opportunity to confront some of the inequalities emerging within global health, and within CUGH itself. The rapid proliferation of academic programmes in global health is well documented.2 These programmes provide valuable opportunities for collaboration between students and faculty in the global North and South, particularly in sub-Saharan Africa, where most global health programmes are located. However, as global health becomes an increasingly hot field, there is a risk these well-intentioned efforts are creating a 21st-century scramble for Africa by US universities.3,4 It is the responsibility of leaders within the field to ensure that global health programmes benefit African institutions,
and do not become merely a means by which to brand US universities in a competitive academic environment.5 “A substantive, current, long-term relationship with an international partner university in a low- or middleincome country” is a condition for membership in CUGH, and the organisation’s emphasis on “the mutuality of real partnership” represents an important commitment to equitable collaboration between rich and poor nations.6 However, at the inaugural meeting, only four of the 50 invited participants were from resource-limited countries. These scholars stated that their institutions often had little decision-making power in international collaborations, and challenged the audience to consider the possibility that global health was a Northern concept. Although these critiques were included in the meeting’s official notes, they were notably absent from the “common definition of global health” later published on behalf of CUGH in The Lancet.7,8 This omission is particularly noteworthy because the same article asserted that “the developed world does not have a monopoly on good ideas”.7 Participation was similarly limited at the 2009 meeting, where I noted one CUGH leader as saying: “There is lots of discussion about how low and middle income country partners should participate, but there www.thelancet.com Vol 377 April 23, 2011
are no representatives from a partner institution in the room.” The 2010 meeting (which was the first to have open attendance, rather than invitation-only) showed some improvement on this front, with larger attendance and more international participants. Consortium meetings tend to focus on the needs of US universities seeking to expand and sustain their global health programmes abroad. However, as scholars from the University of Botswana recently said: “African higher education faces a crisis.”9 Similar statements have been made about the state of health research in many African countries.10,11 Thus global health partnerships must serve to build up, rather than further debilitate, African universities and teaching hospitals. The 2010 CUGH meeting made an important step towards considering the needs of African institutions by reporting on findings from the Sub-Saharan African Medical Schools Study12 during the opening plenary session. Nonetheless, in their scramble to start programmes in Africa, US universities often establish separate parallel administrative systems to bypass those of their partner institutions. All three CUGH meetings have included extensive discussions about how to establish such enabling platforms. Although this practice provides logistical relief by allowing US universities to bypass African institutional bureaucracies perceived as too difficult, it also undermines local capacity. Prioritising the needs of African universities would instead entail taking the slower route of helping partner institutions rebuild their administrative infrastructure. Prioritising the needs of African universities might also include using the influence of CUGH to lobby funders, such as the National Institutes of Health, to make policy changes that support equitable partnership. For example, the National Institutes of Health currently restricts indirect cost reimbursements to foreign universities at 8%, an extremely low rate that hinders the abilities of underfunded African institutions to administer large US research grants. Successful partnerships do exist. Since 1989, a partnership between Indiana University and Moi University in Kenya has been praised for providing faculty and students in both countries with expanded opportunities for research and training, and for benefiting patient care at Moi Hospital.13 On a smaller scale, Cornell University’s nascent undergraduate global health course in Tanzania enrols equal numbers of Tanzanian and US students. All students receive credit for www.thelancet.com Vol 377 April 23, 2011
Mikkel Ostergaard/Panos
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the 5-week summer course, in which they collaboratively research global health policy issues. Partnership is easy to say, but much more difficult to do. True partnership is especially challenging in global health, in which institutions must forge collaborations across sometimes staggering inequalities. As CUGH grows, it must strive to enact its espousal of partnership by taking action that supports the priorities of institutions in the global South. It is these institutions, after all, that make the global health programmes advocated by CUGH both possible and successful. Johanna Crane Interdisciplinary Arts and Sciences, University of Washington-Bothell, Bothell, WA 98011, USA
[email protected] I declare that I have no conflicts of interest. 1 2
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Consortium of Universities for Global Health. http://cugh.org (accessed Oct 12, 2010). Merson MH, Page KC. The dramatic expansion of university engagement in global health: implications for US policy. April 20, 2009. http://csis.org/ publication/dramatic-expansion-university-engagement-global-health (accessed Aug 11, 2010). Brown D. For a global generation, public health is a hot field. Washington Post Sept 19, 2008: A1. Janes CR, Corbett KK. Anthropology and global health. Annu Rev Anthropol 2009; 38: 167–83. Macfarlane SB, Jacobs M, Kaaya EE. In the name of global health: trends in academic institutions. J Public Health Policy 2008; 29: 383–401. Consortium of Universities for Global Health. Membership brochure. http://www.cugh.org/sites/default/files/cugh-membership-brochure.pdf (accessed Aug 10, 2010). Koplan JP, Bond TC, Merson MH, et al, for the Consortium of Universities for Global Health Executive Board. Towards a common definition of global health. Lancet 2009; 373: 1993–95. Consortium of Universities for Global Health. Inaugural meeting report. 2008. http://www.cugh.org/sites/default/files/inaugural-meeting-report.pdf (accessed Aug 2, 2009).
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Holm JD, Malete L. Nine problems that hinder partnerships in Africa. Chronicle Higher Education June 13, 2010. http://chronicle.com/article/ Nine-Problems-That-Hinder/65892 (accessed Aug 10, 2010). WHO Regional Office for Africa, Division of Health Systems and Services Development. Report of the internal workshop on primary health care and health systems: Brazzaville, 11–13 September 2007. Sept 11–13, 2007. http://www.afro.who.int/en/tanzania/tanzania-publications/cat_ view/1501-english/901-events/902-2008/925-international-conferenceon-primary-health-care-and-health-systems-in-africa/926-backgrounddocuments-.html (accessed Aug 10, 2010).
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Volmink J, Dare L. Addressing inequalities in research capacity in Africa. BMJ 2005; 33: 705–56. Sub-Saharan African Medical Schools Study. http://www.samss.org (accessed Nov 9, 2010). QuigQuigley F. Walking together, walking far. Bloomington: Indiana University Press, 2009.
“Gratuities” for donated organs: ethically indefensible Published Online October 23, 2010 DOI:10.1016/S01406736(10)61419-5
With the encouragement of more than 90 medical bodies (the Declaration of Istanbul)1 and WHO—which in May, 2010, endorsed revised Guiding Principles that confirm the ban on payment for organs from living or deceased donors2—several of the countries that have been the most notorious organ bazaars,3 including Egypt, Pakistan, China, and the Philippines, have recently outlawed organ sales and taken steps to prevent trafficking of organs to transplant tourists.4 Yet the risk to people who are poor remains, as proponents of markets for organs seek to circumvent or reverse the prohibitions. For example, at the end of June, the Minister of Health in the new Philippine Government expressed his opposition to the ban imposed there 2 years ago on foreigners receiving transplants from Filipinos, and his intention to allow organ donors to be compensated by a “gratuity package” as large as US$3200.5 The Minister has joined several US advocates of regulated organ markets to sponsor an international forum on rewarded organ donation, in November in Manila. Yet the ethical arguments raised by those who favour financial incentives for organ donation6 have been Panel: Principle 5 of WHO’s guiding principles on human cell, tissue, and organ transplantation, endorsed by the 63rd World Health Assembly in May, 20102 Cells, tissues, and organs should only be donated freely, without any monetary payment or other reward of monetary value. Purchasing, or offering to purchase, cells, tissues, or organs for transplantation, or their sale by living persons or by the next of kin for deceased persons, should be banned. The prohibition on sale or purchase of cells, tissues, and organs does not preclude reimbursing reasonable and verifiable expenses incurred by the donor, including loss of income, or paying the costs of recovering, processing, preserving, and supplying human cells, tissues, or organs for transplantation.
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repeatedly—and rightly—rejected by WHO because they are unpersuasive and would worsen the plight of patients awaiting transplants.7,8 Drawing on the principle of beneficience, proponents of organ markets claim that sales will increase the availability of desperately needed organs and serve the good of all involved. Yet studies consistently show that vendors are not likely to benefit sustainably,9–11 and that any increase in purchased organs will be matched by a crowding-out of altruistic donations, resulting in a net reduction in transplants and in greater risks for recipients because sellers are more likely to withhold adverse information about their health history.12,13 Next, market proponents contend that allowing organ vending would respect the autonomy of individuals who are poor, augmenting (or at least not curtailing) the already limited options available to them. Invoking free choice might merely seem like armchair philosophy were it not for the documented poverty of organ vendors, which renders this embrace of autonomy more a cruel hoax. When people are choosing between selling their children and their kidneys to meet essential family needs or to temporarily escape crushing debt, coercion and exploitation—not autonomy—are the more apposite terms. Moreover, it seems that few among those who can exercise genuine choice would opt to sell, rather than to donate, an organ.14 Finally, market proponents invoke the principle of justice, arguing that if everyone else involved in transplantation is paid, it is only fair that organ donors get their share. Yet what would be a fair share for providing the “gift of life”? Would this be fixed by the value of life to the recipient? That is not how other participants, such as physicians and nurses, are paid; rather, they are compensated for their services. Or would the amount result from differential pricing in a global market, www.thelancet.com Vol 377 April 23, 2011
