Miguel Kottow – författare

In most developed countries, the epidemiological disease profile has changed from infectious to degenerative, causing major alterations in epidemiological thinking and public health policies. Less developed nations have to deal with a more complex situation, because social disparities create highly unequal health conditions, the affluent being afflicted by degenerative conditions, whereas the poorer social segments continue to suffer infectious diseases, but also begin to feel the effects of chronic illness. At the turn of the 21st century, equity in health care is not being served, and social justice has lost credibility as a conceptual driving force of public health policies. Rampant injustice confirms that theories, reality and suggested practices of just social orders are flawed, leaving the needy without help or hope in a world of flagrant ethical inadequacy. And yet, mainstream bioethics loses meaning and relevance as it clings to the principle of justice and hails such concepts as global justice and universal health-care equity, misleadingly focusing on justice as a desideratum. This book pleads for an urgent turn towards directly addressing injustice as a reality that requires pressingly needed arguments and proposals to inspire realistic public health policies and programs based on an ethics of protection. Ever since Hobbes, all shades of political philosophy accept that the basic obligation of the ruling power is to protect its subjects. The ethics of protection emphasizes aiding the needy and the disempowered in obtaining access to basic goods and services related to health-care. Public health is called upon to fulfill protective obligations to guarantee disease prevention and medical services to the population, taking special care to safeguard those unable to cover their health-care needs in market-oriented medical services and institutions. The bioethics of protection developed in this text presents specific and explicit guide-lines to assure that protective public health actions be efficacious (problem-solving), efficient (sustainable cost/benefit relation) and ethically sound (respecting human rights and the common weal). These guide-lines are designed to give ethical support and justification to public health policies even when they require some unavoidable limitations of individual autonomy to promote social health benefits.

In most developed countries, the epidemiological disease profile has changed from infectious to degenerative, causing major alterations in epidemiological thinking and public health policies. Less developed nations have to deal with a more complex situation, because social disparities create highly unequal health conditions, the affluent being afflicted by degenerative conditions, whereas the poorer social segments continue to suffer infectious diseases, but also begin to feel the effects of chronic illness. At the turn of the 21st century, equity in health care is not being served, and social justice has lost credibility as a conceptual driving force of public health policies. Rampant injustice confirms that theories, reality and suggested practices of just social orders are flawed, leaving the needy without help or hope in a world of flagrant ethical inadequacy. And yet, mainstream bioethics loses meaning and relevance as it clings to the principle of justice and hails such concepts as global justice and universal health-care equity, misleadingly focusing on justice as a desideratum. This book pleads for an urgent turn towards directly addressing injustice as a reality that requires pressingly needed arguments and proposals to inspire realistic public health policies and programs based on an ethics of protection. Ever since Hobbes, all shades of political philosophy accept that the basic obligation of the ruling power is to protect its subjects. The ethics of protection emphasizes aiding the needy and the disempowered in obtaining access to basic goods and services related to health-care. Public health is called upon to fulfill protective obligations to guarantee disease prevention and medical services to the population, taking special care to safeguard those unable to cover their health-care needs in market-oriented medical services and institutions. The bioethics of protection developed in this text presents specific and explicit guide-lines to assure that protective public health actions be efficacious (problem-solving), efficient (sustainable cost/benefit relation) and ethically sound (respecting human rights and the common weal). These guide-lines are designed to give ethical support and justification to public health policies even when they require some unavoidable limitations of individual autonomy to promote social health benefits.

Neglected diseases are severe conditions that mainly affect the world’s poorest people. Those suffering from neglected diseases are mostly suffering from tropical infections that have failed to receive priority in pharmaceutical research and development programs, as well as in public health policies aimed at improving availability and access to preventive, diagnostic and curative medicine. The World Health Organization has issued a number of documents directing attention to the plight affecting one third of the world’s population, assisted by active support from private organizations, notably the Bill and Melissa Gates Foundation, but the overall situation remains dismal. In the wake of major socioeconomic processes including globalization, steadily growing economic disparity, healthcare inequality, the instability created by rogue states and terrorism, as well as massive migration, and epidemic outbreaks, the features of neglected diseases have been changing. Neglected populations affected by tropical diseases are suffering increasingly from non-infectious degenerative conditions and disabilities due to untreated chronic maladies. Pockets of poverty and neglect can also be detected in high-income countries, contributing to the emergence of new diseases and the reemergence of infections believed to be disappearing such as tuberculosis and the measles. Included in the issues of neglect are rare diseases, mostly of genetic origin, affecting a small number of patients that suffer from multiple life-shortening functional impairment and organ defects. Effective medicines are extremely expensive, allegedly because research and development of appropriate drugs is resources and time consuming, requiring exorbitant prices to recoup investment from a small number of consumers. Bioethics has been tardy in addressing the suffering and destitution of neglected and rare diseases. Convinced that permanently repeated denunciations blunt the sensitivity towards suffering, whereas statistics are bloodless and unable to elicit commitment, this book attempts to explore a different strategy. In an upstream approach, bioethics needs to engage in ethnographic fieldwork that confronts and shares the context in which people suffer, vividly presenting what epidemiological research has blunted into statistical data. Additionally, a downstream approach is suggested, requiring bioethics to vigorously and openly denounce unethical biomedical and pharmaceutical research, misdeeds in registration and marketing of drugs, and misalignment of policies with the unmet healthcare needs of the destitute. More than being critical observers, bioethicists ought to shed lurking conflicts of interests and seek active participation in planning research and public healthcare practices aimed at improving the lives of medically neglected populations.

Las naciones de Latinoamérica tienen una historia común de colonialismo y dependencia económica, así como ingentes y persistentes disparidades socioeconómicas. Los sistemas de salud que implementan no logran cubrir las necesidades de sus poblaciones y, pese a numerosas reformas, ha sido difícil establecer políticas sanitarias equitativas, de organización y financiamiento estables. Las tareas de la salud pública son contextuales a la realidad económica y cultural de las sociedades, haciendo imposible establecer agendas comunes de alcance internacional para enfrentar los retos y efectos de la globalización. Cada región, cada país, ha de desarrollar sus políticas sanitarias y sus sistemas médicos en relación con sus necesidades y posibilidades, desafiando la ayuda externa, magra y meramente asistencial. La salud pública depende no solo de su entorno socioeconómico y de la filosofía política que la inspira, sino en gran medida de los valores que se propone sustentar y realizar, configurando una perspectiva donde el aporte de la bioética es central. La disciplina bioética, por su parte, se valida en la medida que logra insertarse en la realidad cultural de su sociedad y en el campo de deliberación que la requiere (clínica, investigación, ecología, salud pública). Desde hace apenas 15 años se perfila una bioética en salud pública con perspectiva propia y específica, siendo Latinoamérica una de las primeras regiones en cultivar lo que actualmente está recibiendo atención prioritaria en organismos internacionales (OMS, UNESCO, OPS). El presente texto es un centinela precoz en proponer una bioética latinoamericana para la salud pública de la región, en un esfuerzo por cultivar lo propio sin desconocer el discurso de la bioética internacional en gran medida elaborada en medios académicos anglosajones. El libro tiene la pretensión de hablar no solo para Latinoamérica sino también desde nuestra región.