The collaborative development through multidisciplinary and advocate consensus of an accessible notice of rights for people with intellectual disabilities in police custody

Background People with intellectual disabilities are over-represented in the criminal justice system. The United Nations' Convention on the Rights of Persons with Disabilities (UNCRPD) enshrines a right to equal access to justice for persons with disabilities (Article 13, UNCRPD). Accessible information is a key aspect of exercising this right. Yet, many jurisdictions, including Ireland, are yet to develop accessible information for disabled people who may be arrested. Aims This paper describes the collaborative development through multidisciplinary and advocate consensus of an accessible (Easy -to- Read) Notice of Rights (ERNR) for people with intellectual disabilities in police custody in Ireland. Methods Guidelines developed by Ireland's representative organisation for people with intellectual disabilities and examples of international practice were used to develop a draft ERNR by the primary researcher in partnership with an expert from a representative organisation for people with intellectual disabilities. The ERNR was developed thereafter through two focus groups with a view to achieving consensus with a focus on accessibility, accuracy and layout. This included a multidisciplinary focus group with participants from a representative organisation for people with intellectual disabilities, psychology, speech and language therapy, the police force, public health, forensic psychiatry, mental health, law and, subsequently, a focus group of people with lived experience of intellectual disability. Results Progressive development of the ERNR resulted in incremental improvements in textual accuracy as well as the inclusion of more accessible language and imagery. Originality/value This is the first attempt at developing an easy-to-read document relating to the legal rights of suspects in police custody in Ireland and, accordingly, this procedural innovation promises to assist, not just persons with intellectual disabilities, but also those with limited literacy at the point of arrest. The methodology used in the preparation of the document, employing a focus group to achieve consensus with participation from both multiple disciplines and persons with an intellectual disability, is in harmony with the ethos of the UNCPRD. This methodology may usefully be employed by other member states that have ratified the Convention but have yet to develop accessible version of the legal rights and entitlements that extend to arrested persons under their domestic law.

In silico prediction of the full United Nations Globally Harmonized System eye irritation categories of liquid chemicals by IATA-like bottom-up approach of random forest method

As an alternative to in vivo Draize rabbit eye irritation test, this study aimed to construct an in silico model to predict the complete United Nations (UN) Globally Harmonized System (GHS) for classification and labeling of chemicals for eye irritation category [eye damage (Category 1), irritating to eye (Category 2) and nonirritating (No category)] of liquid chemicals with Integrated approaches to testing and assessment (IATA)-like two-stage random forest approach. Liquid chemicals (n = 219) with 34 physicochemical descriptors and quality in vivo data were collected with no missing values. Seven machine learning algorithms (Naive Bayes, Logistic Regression, First Large Margin, Neural Net, Random Forest (RF), Gradient Boosted Tree, and Support Vector Machine) were examined for the ternary categorization of eye irritation potential at a single run through 10-fold cross-validation. RF, which performed best, was further improved by applying the 'Bottom-up approach' concept of IATA, namely, separating No category first, and discriminating Category 1 from 2, thereafter. The best performing training dataset achieved an overall accuracy of 73% and the correct prediction for Category 1, 2, and No category was 80%, 50%, and 77%, respectively for the test dataset. This prediction model was further validated with an external dataset of 28 chemicals, for which an overall accuracy of 71% was achieved.

Preventing Violence to Achieve Peaceful and Inclusive Societies

This article is one in a series in which contributing authors discuss how the United Nations (UN) Sustainable Development Goals (SDGs) are linked to everyday clinical issues; national public health emergencies; and other nursing issues, such as leadership, shared governance, and advocacy. The 2030 Agenda for Sustainable Development, a 15-year plan of action to achieve the goals, was unanimously adopted by all UN member states in September 2015 and took effect on January 1, 2016. The Agenda consists of 17 SDGs addressing social, economic, and environmental determinants of health and 169 associated targets focused on five themes: people, planet, peace, prosperity, and partnership. The SDGs build on the work of the UN Millennium Development Goals, which were in effect from 2000 to 2015. The current article highlights SDG 16: "Promote peaceful and inclusive societies for sustainable development, provide access to justice for all, and build effective, accountable, and inclusive institutions at all levels."

Global status of violence against children and how implementation of SDGs must consider this issue

The 30th anniversary of the Convention on the Rights of the Child (CRC) is a historic commemoration to recommit for children and with children. Thirty years ago, the Convention recognized children as rights holders and transformed the way we understand the rights, the agency and power of children. Children went from being passive recipients of services and charities to human rights holders with a voice. The Convention is one of the most comprehensive human rights instruments that have reached almost universal ratification. However, progress towards ending all forms of violence against all children is slow and we need to act better, faster and further in bringing violence against children to an end by 2030 as per the commitment in SDG 16.2.

The role of the Committee on the Rights of the Child in monitoring child abuse and neglect

This article illuminates the important role the Committee on the Rights of the Child played in monitoring child abuse and neglect in the implementation of the now thirty years old Convention on the Rights of the Child (CRC). Attention is first given to the core mandate of the Committee: the monitoring of the progress made and the remaining difficulties in the implementation of the CRC in each of its 196 State parties. The remainder of the article considers how the Committee has attempted to provide guidance in addressing child abuse and neglect through specific recommendations given to individual State parties in its Concluding Observations, thorough considerations presented at the Days of General Discussion, and in the Committee's General Comments.

Accountability in protection of children against violence: Monitoring and measurement

Violence against children (VAC) is a pervasive and persistent injustice around the world. Thirty years after the adoption of the United Nations Convention on the Rights of the Child (CRC), the right of children to be protected against all forms of violence is still routinely violated. It is only within the last twenty years that the scope of this problem has been studied; as many point out, understanding the scope of the problem through comprehensive data collection is necessary to improve child protection. Data collection and data quality have improved drastically over this time. The Office of the High Commissioner on Human Rights recommends using comprehensive indicator systems that collect data on States Parties' structure- and process-related commitments to fulfil human rights, and on the outcomes of these commitments. However, most existing indicator sets on VAC fall short of this comprehensive approach, often focusing only on structural or outcome indicators. An international team of child rights experts is now developing GlobalChild, which will be an online platform consisting of comprehensive sets of structure-, process-, and outcome-related indicators for all 41 substantive rights of the CRC. This system will advance data collection, facilitate the monitoring function of the Committee on the Rights of the Child, and enable research on many rights of children, including their right to protection against violence. VAC is a complex problem, and protection against VAC is a right that is indivisible from other rights under the CRC. Therefore, a comprehensive and systematic approach is required to improve accountability to children around the world.

Health and public health approach to ending child abuse and neglect

The 30^th anniversary of the United Nations Convention on the Rights of the Child provides an opportunity to reflect on whether the approaches to date in dealing with child abuse and neglect (CAN) have been successful. Initial responsibility in most countries to address CAN has been given to Child Protective Services Agencies. Recently, there have been calls for CPS to take a Public Health Approach in their practice. This paper discusses the potential positive and unintended problems that such a shift in approach might entail.

Thirty years of the CRC: Child protection progress, challenges and opportunities

The CRC has a challenging and ambitious agenda in relation to the protection of children from all forms of violence, particularly the large and increasing numbers of children affected by natural disasters, armed conflict, trafficking, poverty and increasing inequality, displacement and trafficking. In this article, we outline some of the issues in the implementation and understanding of the Convention and highlight three major international developments over the last decade: the adoption of General Comment No 13, the work of the Special Representative of the Secretary General on Violence Against Children, and the adoption of the 2030 Agenda for Sustainable Development by the UN General Assembly in 2005. We also identify four broad domains in which the Convention can and is being used to enhance efforts to ensure the protection of children based on a rights framework - advocacy and litigation, policy design, service delivery and research and monitoring methodology - rather than a welfare-based approach. The key to a rights-based approach in efforts to protect children is a focus on children's right to be involved in decision-making - and in research - that affect their lives.

Women's Health and Well-Being in the United Nations Sustainable Development Goals: A Narrative Review of Achievements and Gaps in the Gulf States

Background: In 2014, United Nations member states proposed a set of sustainable development goals (SDGs) to help further the millennium development goals that they had proposed in New York in 2000. Of these 13 SDGs, Goal 3 (i.e., SDG 3) was titled “Good Health and Well-Being.” This goal highlighted women’s health and well-being via two key objectives. The first, SDG 3.1, aimed to reduce maternal mortality rates (MMR) and the second, SDG 3.7, aimed to ensure access to sexual and reproductive health care services. Drawing on all the latest reports, which have been released by Gulf Cooperation Council states (GCC), this paper sheds light on GCC states’ work on women’s wellbeing through SDG 3. Aim: the paper aims to review GCC states’ work on women’s wellbeing in SDG3, which achievements they obtained, which tools they used and which gaps still exist. The paper aims to explain the socio-cultural background behind these achievements, tools, and gaps. Methodology: For the purpose of this study, we used narrative review approach through which we reviewed reports from 2017 and 2018 on SDGs published online by the Ministry of Development and Planning of each GCC state, and latest reports of the WHO on the same states. Findings: the study found similarities and differences between different GCC states, which in turn reveals gaps and areas that are not meeting women’s needs. The findings show that MMR in GCC countries has declined by nearly half. The main strategies they adopted to address SDG 3.1 included awareness campaigns, improving access to healthcare systems and training professionals. The tools used to meet SDG 3.7 included training health professionals and raising awareness of consanguinity. The study reveals several gaps, such as a lack of discussion around challenges and barriers, and a lack of linkage between an SDG and the targets contained within it. Conclusion: The paper concludes that there is a much greater emphasis on reducing MMR, compared to providing access to sexual and reproductive healthcare. This difference is due to different socio-cultural framing of each of these two issues.

Putting your money where your mouth is: Geographic targeting of World Bank projects to the bottom 40 percent

The adoption of the shared prosperity goal by the World Bank in 2013 and Sustainable Development Goal 10, on inequality, by the United Nations in 2015 should strengthen the focus of development interventions and cooperation on the income growth of the bottom 40 percent of the income distribution. This paper contributes to the incipient literature on within-country allocations of development institutions and assesses the geographic targeting of World Bank projects to the bottom 40 percent. Bivariate correlations between the allocation of project funding approved over 2005–14 and the geographical distribution of the bottom 40 as measured by survey income or consumption data are complemented by regressions with population and other potential factors affecting the within-country allocations as controls. The correlation analysis shows that, of the 58 countries in the sample, 41 exhibit a positive correlation between the shares of the bottom 40 and World Bank funding, and, in almost half of these, the correlation is above 0.5. Slightly more than a quarter of the countries, mostly in Sub-Saharan Africa, exhibit a negative correlation. The regression analysis shows that, once one controls for population, the correlation between the bottom 40 and World Bank funding switches sign and becomes significant and negative on average. This is entirely driven by Sub-Saharan Africa and not observed in the other regions. Hence, the significant and positive correlation in the estimations without controlling for population suggests that World Bank project funding is concentrated in administrative areas in which more people live (including the bottom 40) rather than in poorer administrative areas. Furthermore, capital cities receive disproportionally high shares of World Bank funding on average.

Surveying the Geneva impasse: Coercive care and human rights

The United Nations human rights system has in recent years been divided on the question as to whether coercive care interventions, including coercive psychiatric care, can ever be justified under UN human rights standards. Some within the UN human rights community hold that coercive care can comply with human rights standards, provided that the coercive intervention is a necessary and proportionate means to achieve certain approved aims, and that appropriate legal safeguards are in place. Others have held that coercive care is never justified. Disagreement over this issue has produced an impasse in the UN human rights system. We survey the impasse with particular attention to the legal arguments that inform the divergent positions. In doing so we introduce a distinction among a variety of different 'abolitionist' positions regarding coercive care, and draw a distinction between 'non-consensual' and 'coercive' treatment. We conclude with three proposals for moving beyond the current impasse.

Giving substance to 'the best interpretation of will and preferences'

In General Comment No. 1, the UN Committee on the Rights of Persons with Disabilities calls for 'the best interpretation of will and preferences' to replace best interests determinations in decision-making law, but it has given little guidance on the content of this new standard. As a result, 'best interpretation' is sometimes treated as synonymous with 'true interpretation'. On this reading, 'the best interpretation of will and preferences' is just whatever interpretation most accurately represents the interpreted person's will and preferences. This article shows that the conflation of the word 'best' with the word 'true' must be avoided. Interpretative processes contribute to changes in the interpreted person, including changes in their will and preferences. There are both supportive and abusive forms of these contributions, but conflating 'best interpretation' with 'true interpretation' removes both from view. An alternative reading of 'best interpretation' should therefore be preferred: one that requires the process of interpretation to be responsive to both truth and the detailed substantive rights found in the UN Convention on the Rights of Persons with Disabilities.

[The Best Interest of the Child in Neonatology: Is It Best for the Child?]

Since its inceptions, the standard of best interest of the child was linked to decisions about suspend life-sustaining treatments in neonatal units and evaluation of treatments applied to children in terms of their quality of life. This origin has conditioned the interpretation of the standard from two extremes: a vitalistic one, and a non vitalistic interpretation that triumphed in Western bioethics and has led to the consecration of the standard of best interest of the child in the Convention on the Rights of the Child of United Nations. A detailed analysis reveals a simplistic, utilitarian and proportionalist standard, which change the basis of parenthood. We therefore believe that the standard of the best interest of the child is not the best for the child in neonatal intensive care units and especially not in the process of withhold or withdrawal life-sustaining treatments.

The United Nations and One Health: the International Health Regulations (2005) and global health security

The One Health approach encompasses multiple themes and can be understood from many different perspectives. This paper expresses the viewpoint of those in charge of responding to public health events of international concern and, in particular, to outbreaks of zoonotic disease. Several international organisations are involved in responding to such outbreaks, including the United Nations (UN) and its technical agencies; principally, the Food and Agriculture Organization of the UN (FAO) and the World Health Organization (WHO); UN funds and programmes, such as the United Nations Development Programme, the World Food Programme, the United Nations Environment Programme, the United Nations Children's Fund; the UN-linked multilateral banking system (the World Bank and regional development banks); and partner organisations, such as the World Organisation for Animal Health (OIE). All of these organisations have benefited from the experiences gained during zoonotic disease outbreaks over the last decade, developing common approaches and mechanisms to foster good governance, promote policies that cut across different sectors, target investment more effectively and strengthen global and national capacities for dealing with emerging crises. Coordination among the various UN agencies and creating partnerships with related organisations have helped to improve disease surveillance in all countries, enabling more efficient detection of disease outbreaks and a faster response, greater transparency and stakeholder engagement and improved public health. The need to build more robust national public human and animal health systems, which are based on good governance and comply with the International Health Regulations (2005) and the international standards set by the OIE, prompted FAO, WHO and the OIE to join forces with the World Bank, to provide practical tools to help countries manage their zoonotic disease risks and develop adequate resources to prevent and control disease outbreaks, particularly at the animal source. All these efforts contribute to the One Health agenda.

Transformation/dissolution characteristics of a nickel matte and nickel concentrates for acute and chronic hazard classification

For the purposes of aquatic hazard classification under the United Nations Globally Harmonized System of Classification (UNGHS), we have examined the transformation/dissolution (T/D) characteristics of a Ni matte and 4 Ni concentrates at pH 6 using the United Nations (UN) Transformation/Dissolution Protocol (T/DP) for metals and sparingly soluble metal compounds. Among the analytes Ni, Co, and Cu, Ni was released into the T/D solutions in the highest concentrations and was thus the main driver in establishing the hazard classification. We applied an extrapolation-scaling approach to obtain concentrations of total dissolved Ni at low loadings of 0.1 and 0.01 mg/L for derivation of chronic classification outcomes in the European Union (EU) classification, labeling, and packaging (CLP) scheme. The T/D data would classify the Ni matte as Acute 2-Chronic 2 under the Globally Harmonized System (GHS) scheme, and Chronic 1 under the EU CLP. Three of the 4 Ni concentrates would classify as GHS Acute 2-Chronic 2 and EU CLP Chronic 2, whereas the 4th would classify as GHS Acute 3-Chronic 3 and EU CLP Chronic 3. In applying the critical surface area (CSA) approach to the Ni concentrates, acute and chronic hazard classification outcomes were the same as those derived from direct application of the T/D data to the GHS and EU schemes. Such agreement provided confidence that the CSA approach could yield scientifically defensible acute and chronic hazard classification outcomes.

The role of solidarity in social responsibility for health

The Article focuses on the concept of social solidarity, as it is used in the Report of the International Bioethics Committee On Social Responsibility and Health. It is argued that solidarity plays a major role in supporting the whole framework of social responsibility, as presented by the IBC. Moreover, solidarity is not limited to members of particular groups, but potentially extended to all human beings on the basis of their inherent dignity; this sense of human solidarity is a necessary presupposition for a genuinely universalistic morality of justice and human rights.

Ergonomics and occupational safety and health: an ILO perspective

The ILO has a mandate to protect workers against sickness, diseases and injuries due to workplace hazards and risks including ergonomic and work organization risk factors. One of the main functions for the ILO is to develop international standards related to labour and work. ILO standards have exerted considerable influence on the laws and regulations of member States. The ILO standards take the form of international Conventions and Recommendations. ILO Conventions and Recommendations relevant to protection of workers against ergonomic risk factors at the workplace include Convention No. 127 and Recommendation No.128 which specify the international requirements concerning the manual transport of a load. To help member States in applying the ILO standards, the ILO produces practical guides and training manuals on ergonomics at work and collects and analyses national practices and laws on ergonomics at the workplace. The ILO also conducts technical cooperation activities in many countries on ergonomics to support and strengthen the capacities of its tripartite constituents in dealing with workplace ergonomic and work organization risks. The ILO's technical cooperation activities give priorities on the promotion of voluntary, participatory and action-oriented actions to improve working conditions and work organizations of the small and medium sized enterprises. This paper reviews ILO's policies and activities on ergonomics in relation to occupational safety and health and prescribes ILO's considerations for its future work on ergonomics.

Skilled attendance at delivery: who or where?

The third United Nations Process Indicator for emergency obstetric care is the proportion of all births that take place in maternity or obstetric facilities. This is in conflict with the concept of skilled attendance at delivery. Here, a case is made for emphasis to be on who conducts the delivery and not necessarily where.

Health systems and the right to health: an assessment of 194 countries

60 years ago, the Universal Declaration of Human Rights laid the foundations for the right to the highest attainable standard of health. This right is central to the creation of equitable health systems. We identify some of the right-to health features of health systems, such as a comprehensive national health plan, and propose 72 indicators that reflect some of these features. We collect globally processed data on these indicators for 194 countries and national data for Ecuador, Mozambique, Peru, Romania, and Sweden. Globally processed data were not available for 18 indicators for any country, suggesting that organisations that obtain such data give insufficient attention to the right-to-health features of health systems. Where they are available, the indicators show where health systems need to be improved to better realise the right to health. We provide recommendations for governments, international bodies, civil-society organisations, and other institutions and suggest that these indicators and data, although not perfect, provide a basis for the monitoring of health systems and the progressive realisation of the right to health. Right-to-health features are not just good management, justice, or humanitarianism, they are obligations under human-rights law.

The ratification status of ILO conventions related to occupational safety and health and its relationship with reported occupational fatality rates

The aim of this study was to assess the relationship between the ratification status of occupational safety and health (OSH)-related ILO conventions and reported occupational fatality rates of ILO member countries, while controlling for possible confounding factors. ILO member states were divided into 4 levels of income status, based on the gross national income per capita. Seventeen conventions designated as OSH-related were examined. Reported country occupational fatality rates were compared according to the ratification status of these 17 conventions and multiple regression analyses were conducted to assess the relationship between the fatality rates, ratification status, income level and length of ILO membership. Fatality rates were inversely and significantly related to income levels. In general, non-ratifying countries had higher work-related fatality rates than ratifying countries. A statistical model for identifying predictors of fatal injury rates showed that a larger number of conventions ratified was significantly associated with lower fatality rates. The fact that non-ratifying countries generally have higher fatality rates than ratifying ones supports the notion that all countries should promote ratification of ILO conventions aimed at improving OSH conditions.

Counting abortions so that abortion counts: Indicators for monitoring the availability and use of abortion care services

SUMMARY

Maternal mortality reduction has been a focus of major international initiatives for the past two decades. Widespread provision of emergency obstetric care (EmOC) has been shown to be an important strategy for addressing many of the complications that might otherwise lead to maternal death. However, unsafe abortion is one of the major causes of pregnancy-related deaths, and will be only partially addressed by EmOC. This manuscript presents a comprehensive approach to measuring whether abortion-related needs are met.

PROPOSED METHODS

We propose a set of indicators for monitoring the implementation of safe abortion care (SAC) interventions. We build on the model developed for monitoring the availability and use of Emergency Obstetric (EmOC) services. We describe the critical elements ("signal functions") of SAC - including treatment of abortion complications, legal, induced abortion and postabortion contraception - and define the indicators necessary to assess the availability, utilization and quality of abortion-related services.

SAMPLE EVIDENCE

Data from 5 countries suggest there are sufficient service delivery points to provide decentralized abortion care, but that the full range of necessary abortion care services may not be provided at all these sites. Studies from several countries also show that many women receiving services for the treatment of abortion complications accept contraceptive methods when offered prior to discharge. This is an important strategy for reducing unwanted pregnancy, repeat unsafe abortion and risk for abortion-related mortality. Both findings suggest there are considerable opportunities within the present facilities to improve the delivery of abortion care services.

CONCLUSION

This article recommends that the proposed model undergo field-testing on its own or in conjunction with the EmOC indicators, and encourages increased support for this important but often neglected aspect of pregnancy-related health.

Food for Nutrition: Mainstreaming Nutrition in WFP

Most preventable deaths among hungry people take place outside of emergency contexts. In countries not involved in conflicts or natural disasters malnutrition is directly implicated in the deaths of millions of children and mothers each year. Thus, WFP's great efforts focused on saving lives in emergencies should be mirrored by efforts aimed at tackling malnutrition, and hence saving lives, beyond emergencies as well. While food sufficiency is not the same as good nutrition, food is nevertheless an important part of the nutrition equation. New scientific evidence confirms that it is possible to have positive nutritional impacts with food aid. Consistent with Strategic Priority No. 3, WFP seeks to use food resources to achieve nutritional impacts in three complementary ways: a) enhancing the effectiveness and impact of targeted mother and child health and nutrition interventions (MCHN) that combine food and appropriate nonfood inputs; b) enhancing the nutritional value of WFP food (for instance, through micronutrient fortification); and c) enhancing the nutritional impact of other WFP (non-MCHN) interventions. These approaches represent a mainstreaming of nutrition across WFP's activities. Adoption of evidence-based programming, joint interventions with partners, and new project designs offer the promise of greater WFP effectiveness and impact in the coming years.

Torture in China

Torture and inhuman and degrading treatment of persons by state functionaries in China is documented by both international and domestic sources as being fairly widespread. It takes place in pre-trial detention as well as in prisons and labor camps. Its roots are to be found firstly in a weak legal system; the fair trail guarantees are still not observed in the Chinese legal system and the courts are not sufficiently independent from political and economic interests. Secondly, a tradition of coercion and uncontested bureaucratic power, inherited from communist and imperial times, is still alive. Thirdly, China lacks efficient monitoring mechanisms, like complaints boards and a free press. The legislation prohibiting torture is relatively clear, compared to so many other countries, but a huge gap between black-letter-law and practice mar all parts of Chinese society, including the legal procedural system. There are efforts taken by public authorities, legal professionals and activists to combat the use of torture, but these are met with opposition and inertia, especially from the police system, and there is still a long way to go.

The joint food and agriculture organization of the United Nations/World Health Organization Expert Committee on Food Additives and its role in the evaluation of the safety of veterinary drug residues in foods

The Food and Agriculture Organization of the United Nations (FAO) and the World Health Organization (WHO) recommended the evaluation of food additives at the international level through the establishment of an expert committee or committees. These committees evaluated the safety of food additives present as residues resulting from the use of pesticides or veterinary pharmaceuticals. The results of these meetings include international harmonization on acceptable daily intake of these compounds and the maximum residue limit that is permitted to be present within any food of animal or plant origin. The decisions rendered by these committees provide a key element in the elimination of international trade barriers associated with products intended for human consumption.

Pediatricians and the Rights of the Child. UN Convention provides blueprint for monitoring the well-being of children worldwide

The Convention should have a special resonance for pediatricians and others who have both the capacity and responsibility to care for children. A basic tenet of pediatric practice is to advocate for the best interests of the child. According to the Convention, this does not mean that a child's interests will always prevail; rather, it allows for child interests to be considered and given equal weight to competing interests. The pediatric community could benefit in this regard by using a human rights perspective to inform the public debate on children's issues. Pediatricians use growth charts in their daily practices to compare a child's growth to norms for his or her particular age and gender. One may think of the Convention as the growth chart for children's interests, a template by which child advocates can measure progress in promoting the health and well-being of children.

The role of scientific evidence of risks and benefits in determining risk management policies for medications

Recent changes in the regulatory environment have called attention to the need for and potential benefits of greater and more detailed evidence to inform decisions based on the risk-benefit profile of medications. Nevertheless, access to potentially beneficial therapies continues to be impeded by a lack of sufficient information that could help optimize benefits and minimize risks of treatments for patients. Over-reliance on pre-marketing clinical trials and the FDA's spontaneous reporting adverse event system to support regulatory decisions has sustained an information void. Clinical trials are the gold standard for demonstrating efficacy, but they cannot fully predict safety when drugs are used in the real world. Spontaneous reporting can identify new signals, but cannot quantify those signals or place them in appropriate clinical context. In the face of new safety signals, absence of better information on how medications are used and how they perform in the real world setting, regulators are often limited to either continuing drug marketing without significant changes or withdrawing a medication from the market. Experience shows that information collected proactively, to better understand the background risks associated with the underlying disease and to better quantify the product risks, can influence these decisions to include a wider range of options regarding a product's availability, labeling and additional risk management strategies. This article presents several case studies of medications, including those in which insufficient data were available to address important safety signals and decisions were made to withdraw products, as well as those in which epidemiologic data were available to provide reassurance of product safety and allow continued product use, even though some may be marketed with additional risk management programs. More extensive and earlier epidemiologic assessment of risks and benefits of new products will create a new standard of evidence for industry and regulators and is likely to result in more effective and balanced regulatory actions, thereby affording better care for patients.

Protein/energy ratios of current diets in developed and developing countries compared with a safe protein/energy ratio: implications for recommended protein and amino acid intakes

Revised estimates of protein and amino acid requirements are under discussion by the Food and Agriculture Organization (FAO)/World Health Organizaion (WHO), and have been proposed in a recent report on Dietary Reference Intakes (DRIs) from the USA. The nature and magnitude of these requirements are not entirely resolved, and no consideration has been given to the potential influence of metabolic adaptation on dietary requirements. We have examined the implications of these new values, and of the conceptual metabolic framework in which they are used, for defining the nutritional adequacy of protein intakes in developed and developing countries. We have expressed proposed values for protein requirements in relation to energy requirements, predicted for physical activity levels of 1.5, 1.75 and 2.0 times basal metabolic rate, in order to generate reference ratios for protein energy/total energy (reference P/E ratio) as a function of age, body weight, gender and physical activity level. Proposed values for amino acid requirements have been used to adjust the available digestible P/E ratio of foods and diets for protein quality. Focusing on the diets of UK omnivores and vegetarians and on diets in India, the risk of protein deficiency is evaluated from a comparison of P/E ratios of metabolic requirements with protein-quality-adjusted P/E ratios of intakes. A qualitative and conservative estimate of risk of deficiency is made by comparing the adjusted P/E ratio of the intake with a reference P/E ratio calculated for age, body weight, gender and physical activity according to FAO/WHO/United Nations University. A semi-quantitative estimate of risk of deficiency has also been made by the cut point approach, calculated as the proportion of the intake distribution below the mean P/E ratio of the requirement. Values for the quality-adjusted P/E ratio of the diet range from 0.126 for the UK omnivore diet to 0.054 for a rice-based diet of adults in West Bengal, which is lysine-limited, falling to 0.050 for 1-year-old children. The reference P/E ratio for men and women increases with age, is higher for females than males, is higher for small compared with large adults at any age and decreases with physical activity. Thus if a particular diet is potentially limiting in protein, protein deficiency is most likely in large, elderly sedentary women followed by the adolescent female and least likely in moderately active young children, the opposite of what has usually been assumed. Within the currently accepted framework, the diets do not meet the protein needs of the entire population of the UK, have a significant risk of deficiency throughout India for all except extremely active small adults, and are grossly inadequate for all population groups, apart from physically active young children in West Bengal, regardless of body weight or level of food intake. The lysine limitation of the cereal-based Indian diets is dependent on the choice of lysine requirement values from the published range. We consider that the value selected is too high, because of uncertainties and inconsistencies in the approaches used. A more appropriate choice from the lower end of the range would remove the lysine limitation of cereal-based diets, and reduce some of the perceived risk of deficiency. However, diets remain limited by the amount of digestible protein for many population groups, especially in West Bengal. In the context of risk management, one option would be to accept the current values and the conceptual metabolic framework within which they have been derived. This would have major implications for the supplies of high-quality protein to the developing countries. An alternative option would be to re-evaluate the currently proposed values for the requirements for protein and amino acids. We conclude that the choice of values for the adult lysine requirement should be re-evaluated and that serious consideration should be given to the extent to which adaptive mechanisms might enable the metabolic requirement for protein to be met from current intakes. This will entail a better understanding of the relationships between dietary protein and health.

Monitoring obstetric services: putting the 'UN Guidelines' into practice in Malawi: 3 years on

The maternal mortality ratio is difficult to use for monitoring short-term progress in safe motherhood programs. UNICEF/WHO/UNFPA have proposed alternative process indicators monitoring the availability, utilization and quality of obstetric services. There is little experience in the large-scale use of these indicators as part of routine health information systems in developing countries. The Malawi Safe Motherhood Project, which covers a population of over 5 million, was one of the first large projects to implement the new process indicators. At the end of 2000 data were available from the new monitoring system for 3 consecutive years. In 1998, availability of comprehensive emergency obstetric care was adequate but availability of basic emergency obstetric care was very poor. Although institutional delivery rates were over 30%, the met need for obstetric care was only 19.8% and the cesarean section rate was only 1.6%. The mean case fatality rate in District hospitals was nearly 5%. By the end of 2000, improvements in availability, utilization and quality of obstetric care were observed. Participation in developing the monitoring system had also created a strong sense of ownership and interest in analyzing and using the data. Several issues have emerged from routine use of the process indicators. In particular, it has been difficult to be certain that obstetric complications have been recorded correctly. The results confirm that a focus on improving emergency obstetric care in Malawi was justified and that process indicators for obstetric care can be successfully introduced in developing countries. The monitoring system has provided data that are of immediate relevance to service providers, managers, and policy makers and provide many lessons useful for similar programs in other settings.