UN"s own expert calls its actions over Haiti cholera outbreak "a disgrace"

The United Nations’ refusal to accept responsibility for the devastating cholera outbreak that has claimed more than 9,000 lives in Haiti has been branded a “disgrace” by the organisation’s own human rights special rapporteur.

Human rights groups working with victims had reacted with jubilation earlier this year following the UN’s first tacit admission that it was to blame for the outbreak after doggedly refusing to address how its peacekeepers brought the disease to Haiti in 2010.

However, in a scathing report (pdf) to the UN general assembly, the organisation’s special rapporteur on extreme poverty and human rights, Philip Alston, said that flawed and unfounded legal advice provided by the UN lawyers was preventing it from accepting responsibility for the outbreak.

“The UN’s explicit and unqualified denial of anything other than a moral responsibility is a disgrace,” Alston said. “If the United Nations bluntly refuses to hold itself accountable for human rights violations, it makes a mockery of its efforts to hold governments and others to account.”

Alston accused the UN’s Office of Legal Affairs (OLA) for coming up with a “patently artificial and wholly unfounded legal pretence for insisting that the organisation must not take legal responsibility for what it has done”.

The criticism comes as the administration of the outgoing UN secretary general, Ban Ki-moon, is moving to provide compensation for the first time to victims of the outbreak. The UN plans to make cash payments from a proposed $ 400m (£328m) cholera response package, the New York Times reported.

Alston added that the OLA’s approach “has been cloaked in secrecy: there has been no satisfactory official explanation of the policy, no public attempt to justify it, and no known assessment of its consequences for future cases. This goes directly against the principles of accountability, transparency and the rule of law that the UN itself promotes globally.”

Peacekeepers who were relocated from Nepal to Haiti in 2010 in the wake of a major earthquake imported the deadly cholera bacterium with them. Studies have found that the UN troops could have been screened for the illness, and the disaster averted, for as little as $ 2,000.

Alston said the UN’s legal position appears to be largely explained by the approach of the US, the main contributor to the UN’s peacekeeping budget.
“Despite numerous requests to do so, the United States itself has never publicly stated its legal position on the responsibility of the UN for causing cholera in Haiti,” he added.

“Instead, it seems to have pressed the UN to adopt the position frequently taken by lawyers in the US that responsibility should never be accepted voluntarily, since it could complicate future litigation. But this rationale is completely inapplicable to the UN, which enjoys absolute immunity from suit in national courts and whose reputation depends almost entirely on being seen to act with integrity.”

The special rapporteur said that the current stance of the UN’s lawyers ensures that it would never admit its responsibility for introducing cholera. “And avoiding legal responsibility hinders the UN from learning lessons and making sure that the fatal mistakes made in Haiti are not repeated elsewhere.”

Ban’s office said in a statement earlier this year that the organisation had decided to step up its efforts to fight cholera in one of the world’s poorest countries. A reference to the UN’s “involvement in the initial outbreak” was greeted as a breakthrough by groups working with cholera victims.

Ban appeared to have been bounced into making a clearer recognition of responsibility than ever before by the advent of a draft report by Alston into how the UN handled the crisis. Alston had also been one of five experts working for the UN who earlier this year wrote a heavily critical letter to Ban in which the secretary general’s resistance to accepting any responsibility was torn apart.

UN"s own expert calls its actions over Haiti cholera outbreak "a disgrace"

How to give up sugar in ten effortless actions

1 Recognize your sugars
Sugars are in nearly almost everything, regardless of whether they’re natural or extra. The crucial to cutting back on yours is to recognize labels. Anything at all that ends in –ose is a sugar. Likewise, factors that have the word “syrup” in them, or fruit juice concentrate.

2 Really don’t be fooled by the natural label
Honey, agave, maple syrup, coconut palm sugar. All these factors might be “all-natural” but they’re just another version of sugar. Do not overlook as well, sugar was initially a organic item coming as it does, from sugar cane.

3 Chuck it out
The first place to start is in your kitchen cupboard. Bin your jars of processed sauces, any biscuits, cookies, jams, chocolate. Cordials need to go, as do flavoured yoghurts, ice creams, processed foods (most have sugar extra to them) – and anything that is sweet.

4 Stock up
Make nuts, full-excess fat plain yoghurts, cinnamon and fresh veggies, organic lean meat and fish your pals. Get a great top quality olive oil, coconut oil and prepare to cook “clean” – ie fresh wholesome food that is not going to be drowned in sauces or marinades.

5 Handle your cravings
From time to time, most of us truly feel a want to consume some thing sweet. As well as consuming cinnamon and growing your protein intake, the essential to beating cravings is to alter what you see as a reward. Meals shouldn’t be emotional, a “treat” or a crutch. As an alternative of my reward following a prolonged challenging day at function becoming a tub of ice cream and a glass of wine, I learnt to see the better skin and slimmer body I was attaining in excess of the lengthy-term as much more rewarding.

6 Be prepared
Eating more protein will assist you overcome sugar cravings. Happily, nuts – which are a excellent type of it – are an effortless snack to carry all around. I like to carry a helpful modest packs of oatcakes in my bag in situation hunger strikes although I’m out and about.

7 Lunches at work
The best point way to take care of lunches is to consider the leftovers from your virtuous dinner the evening just before. But, if you are caught on the hop, chains such as Pret A Manger now do a range of excellent salads with sauces on the side. Their soups are rather very good as are the tiny protein pots – eggs with spinach or crayfish with quinoa.

eight Really do not fall into the “healthful” trap
As a general rule, stay away from sushi (aside from becoming large GI, the white rice has a sweet marinate). Fruit juices incorporate little of the fibrous pulp of the fruit and all of the sugar so these too need to have to go. Likewise granola, extreme amounts of fruit, flavoured “reduced-body fat” products.

Nicole Mowbray on how to give up sugar with no alienating your pals and laying waste to your really like life

9 Inform the men and women you enjoy
Pals and household want to be on your side if you’re going to win your individual war with sugar. Clarify to them why you have picked to ditch the white stuff, and why it’s important to you so they accept your new life-style.

ten To err is human
Accept that you are going to fall off the wagon. Really do not beat your self up about it, dust yourself off and commence once again the following day. Eating one particular sugary snack or obtaining a couple of cocktails or a blow out meal isn’t the finish of the globe. Accept you haven’t wrecked anything, just get back on the wagon.

“Sweet Practically nothing: Why I Gave Up Sugar and How You Can Too” (Orion), by Nicole Mowbray, is obtainable from Telegraph Books

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How to give up sugar in ten effortless actions

Doctor Group Requires Actions To Fulfill The Promise Of Telemedicine

The American Medical Association (AMA) seems very proud of their new,  just announced policy “for ensuring the appropriate coverage of and payment for telemedicine services.”  They believe telemedicine, properly implemented according to their guidelines, can “strengthen the patient-physician relationship,” increase quality of care, improve health outcomes, and save money. Wow. Who would not be in favor of that? But is this one of those instances when something that seems to good to be true, is?  A closer look at the policy report from AMA’s Council on Medical Service  shows that while much optimism is totally justified and appropriate, many reasons for caution remain.

First, a little background on the players and concepts. The Council on Medical Service (CMS) “recommends AMA policies and actions for consideration by the AMA House of Delegates on the socioeconomic factors that influence the practice of medicine.” In this instance, on June 11, 2014 at the AMA annual meeting in Chicago, the AMA voted to adopt a report of the CMS titled, “REPORT 7 OF THE COUNCIL ON MEDICAL SERVICE (A-14): Coverage of and Payment for Telemedicine.” Furthermore, in the report, telemedicine is defined to include all “three broad categories of telemedicine technologies: store-and-forward, remote monitoring, and (real-time) interactive services.” Now let’s look closer at the details.

Statuette of ancient Egyptian physician Imhotep, the first physician from antiquity known by name. (Photo credit: Wikipedia)

While the report articulates 8 specific recommendations, the actual standards of care and practice guidelines are to be left to the “national medical specialty societies and state medical associations.” In other words, what’s good for the dermatologists may not be good for the radiologists. Plus, a rural state in need of additional medical expertise may adopt more telemedicine-friendly policies than a state with large numbers of physicians looking to protect turf. The potential for confusion rather than coordination across specialities and state lines is significant. I think this requires more attention than given it by current AMA policy.

Our techno-future is so compelling we tend to forget how seductive it can be. Technologically-enabled utopian visions abound, including in telehealth. The American Telemedicine Association is a good example of all benefit and no cost, gain without loss. But there is never a free lunch, even in a world of abundance. And the CMS report did a nice job balancing promise and peril. It keeps an eye on both the promise inherent in “future innovation in the use of telemedicine” and the peril of diminished quality of care, impaired physician-patient relationship, and breaches of confidentiality.

The best part of the report was their emphasis on research. One of the 8 specific recommendations is to “encourage additional research to develop a stronger evidence base for telemedicine.” After all, telemedicine is great idea with tremendous game-changing promise. But who knows? As messy and difficult as science can be, it is still the best way we have of finding out what works, what harms, and what is just ineffective. You don’t want to bet your life, or someone else’s, on just a great idea. The history of healthcare is replete with things that seemed like a great idea at the time only to be shown by later research to be, well, not so hot. And telemedicine is bound to be full of such practices.

To their credit, they also emphasized protecting the physician-patient relationship.  In telemedicine, the CMS report asserts a “valid patient-physician relationship must be established, through at minimum a face-to-face examination, if a face-to-face encounter would otherwise be required in the provision of the same service not delivered via telemedicine.” This will prevent, for example, prescribing some medications based on simply filling out a web form.

Unfortunately, the report goes on to state the “face-to-face encounter could occur in person or virtually through real-time audio and video technology.” Such an assumption of functional equivalence between being bodies together and meeting each other as 2-D representations on screens is just wrong. And dangerous.

First, diagnostically relevant dimensions of interaction are blocked with video. I remember one patient in my psychology practice at an initial consultation who was well and carefully dressed. He denied problems. I would have wondered what he was doing in my office at all except for the fact that he smelled bad, like he hadn’t showered in many days, which he had not. Might I have missed this and missed the significant depression he was trying to hide had the interview been done via “real-time audio and video technology.” Perhaps. And for a physician, olfaction can be an even more important dimension of diagnostic information.

Second, and more dangerous and important for a physician, are the different limits each kind of interaction has. Simply put, there is no possibility of touching on video. A physician cannot follow-up a complaint by, for example, palpating lymph nodes. And because of that maybe a patient will not bother to even complain in the first place. The idea that hands-off medicine is functionally the same as hands-on medicine is not just wrong, it also undermines the physician-patient relationship and diminishes us all.

Finally, hope is a fragile thing; placebos a powerful medicine. Equating being bodies together with video interactions seems like trying to get nutrition from a recipe. Sometimes you need the actual meal for full effect. And the power of hope shows us that the representation of a relationship may not heal the same way as do actual relationships.

So, we should appreciate the AMA’s effort, despite some issues. The significant promise of telemedicine deserves care and tending. It just needs to be said we will most likely fulfill that promise by focussing on both what technologies can do and what they can not do. And assuming a video chat is functionally equivalent to sitting in a room with someone is a dangerous mistake that will likely interfere with the ongoing evolution of telehealth.

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Doctor Group Requires Actions To Fulfill The Promise Of Telemedicine

How to rebuild America"s mental well being program, in 5 huge actions | Paul S Appelbaum

No genuine technique of psychological well being care exists in the United States. This country’s diagnosis and treatment of psychological health difficulties are fragmented across a range of companies and payers – and they are all too often unaffordable. If you consider about it, the checklist of problems is practically countless:

• Families of loved ones with psychological sickness recount horror stories, as a number of have in the Guardian’s interactive series this week.


• Individuals transitioning from inpatient to outpatient treatment often fall amongst the cracks.


• Mental well being and standard healthcare therapy are rarely coordinated.


• Substance abuse remedy generally requires location in an entirely distinct method altogether, with tiny coordination.


• Auxiliary interventions that are so crucial to so several men and women with severe psychological illnesses – supported housing, employment coaching, social skills instruction – are supplied via a distinct set of companies altogether … if they are offered at all.

Our mental wellness method is a non-program – and a dysfunctional non-system at that.

The evidence is everywhere that items have been obtaining worse – far more and more Americans with mental illness are stranded in emergency rooms, for instance, and simply for want of hospital beds. And that is in no tiny component simply because no one has experimented with, in far more than 50 many years, to layout a comprehensive psychological wellness technique for all Americans.

It truly is time to consider again.

Mental wellness clinics in 1955 supplied a vision for attentive care that has not been replicated considering that. Photograph: 3 Lions / Getty Images

The final significant rethinking of the system’s flaws started, in 1955, with an act of Congress that resulted in the appointment of something called the Joint Commission on Psychological Illness and Well being. The commission’s report, Action for Psychological Health, provided a vision of local community-based mental well being remedy: a new clinic would be designed for each 50,000 persons – for prevention and early intervention providers. People who once had to wait for their symptoms to become undesirable adequate to go to the hospital just before anything at all could be completed? They would obtain prompt care in their own communities and return swiftly to daily life as normal – back at function, residing with their households, seeing their buddies.

Soon came the downsizing of big state hospitals and, in 1963, the passage of the Neighborhood Mental Well being Act. That legislation envisioned the creation of a network of mental well being centers spanning the country, so that each citizen would have a single stage of entry. A particular person experiencing early signs of mental disorder could receive emergency, inpatient, partial hospitalization and outpatient care – all in the exact same location – whilst her loved ones was educated about her disorder and how very best they could assist.

Regrettably, fewer than half of the centers have been ever developed, and adequate assistance for their operation was never ever presented. As federal funding ceased, many of the current centers shifted away from caring for the most critically ill … to serving having to pay buyers. The guarantee of an successful neighborhood-based mostly technique of care stays unfulfilled.

Nevertheless we are, half a century later on, in a various globe for which a diverse vision may be required – a vision of complete care aimed at helping people with psychological sickness carry on to be working members of society. But the vital notion of obtaining an integrated method of healthcare – a technique that recognizes the spectrum of needs linked with psychological problems, from household treatment to medication to supported housing – is also crucial to relinquish.

President Obama can kick-begin planning for a real technique of mental health care, by establishing a presidential commission to suggest realistic, re-inventive actions forward.

It could be a landmark minute, appropriate now, these days.

Here is what it may well get:

Illustration by Chloe Cushman for the Guardian

• No one struggling with depression or trying to locate assist for a troubled little one ought to have to spend weeks figuring out whom to contact. In each spot of the nation, a single stage of speak to should be designed to reply to concerns and triage people in require of help to acceptable services. Today, considerably of this details can be provided online – believe of the dwell chat boxes on many business and banking websites, or even the pop-up video for client assistance on Amazon’s Kindle Fire tablet.
  
  

Illustration by Chloe Cushman for the Guardian

• Today people are too frequently left to their own devices when it comes to assembling and monitoring the package deal of providers they require. Also usually men and women cannot find what they’re looking for. These solutions can assortment from medication to loved ones therapy to rehabilitation providers. Care coordinators must be available to shoulder those burdens – not patients and families.
  
  

Illustration by Chloe Cushman for the Guardian

• People with psychological ailments want much more than just a pill – but that’s often all that’s available to them. Psychotherapy can assist them understand and deal with the troubles they face. Substance abuse commonly accompanies mental disorders – and need to be addressed equally seriously. Several folks with serious psychological illnesses require assistance with occupation education and housing as essential elements of their recovery.
  
  

Illustration by Chloe Cushman for the Guardian

• Most psychological well being troubles can be dealt with inside a community, but when emergencies arise it becomes essential to have access to crisis providers, short-phrase respite beds and inpatient care. Reduced payments from insurers for psychological health treatment have led to the closure of many inpatient units, resulting in a backlog of folks in crisis getting held in emergency rooms – often for days or weeks.
  
  

Illustration by Chloe Cushman for the Guardian

• These days, paying out for mental well being care is nobody’s obligation. Insurers spend as small as attainable, frequently denying claims on flimsy grounds. States have reduce far more than $ 4bn from their psychological wellness budgets in the last 6 years. The federal government immediately contributes only a small volume to supporting mental wellness treatment method past the coverage it supplies via Medicare and Medicaid. A joint federal-state dedication is essential to funding the infrastructure of a care technique, even though insurers’ feet are held to fire to make specified they dwell up their obligations beneath the Mental Wellness Parity Act.
  
  

In the 21st century, with our instantaneous electronic communications, it could be significantly less essential to property these types of services in a single website – but it really is no less critical to insure that they are all accessible.

A half-century of patchwork efforts to improve a single or an additional element of the mental wellness technique has resulted in abject failure. Except if we get a thorough approach, and mend the security net that protects us all, we will fail again.

Let’s get to operate.

Paul S Appelbaum is the Dollard Professor of Psychiatry, Medicine and Law at Columbia University, and a former president of the American Psychiatric Association.

How to rebuild America"s mental well being program, in 5 huge actions | Paul S Appelbaum