18. The Automated Patient Medical Record
and Universal Patient Record
in Perspective
The automated patient medical record system may seem to be for physicians, but it is really for patients. With its extension to a universal patient record, these patients could include virtually anyone in the world!
And because there never could be enough physicians in the world, and healthcare is essential, then something else must be tried besides relying solely on physicians. Hopefully, the automated patient medical record system and universal patient record are part of this. The universal patient record can help patients receive better, quicker and more effective medical care, even in remote locations, through telemedicine, where medical care is now impossible, with general physicians and nurse practitioners being the consultants to nurses or other less trained caregivers who care for the patients!
The automated patient medical record system and universal patient record will be very difficult to develop, requiring contributions from many, many people and the cooperation of many people. But what will be far more difficult will be preserving and protecting the system once it is created.
The idea to “preserve and protect” a system is sort of the computer equivalent of “do no harm” [1,2]; and since there are computer systems in healthcare, the two greatly overlap. Good patient care, especially with an automated patient medical record system and a univeral patient record are highly dependent up information systems technology.
The only remotely comparable system to the automated patient medical record system and universal patient record is the Internet! Like the Internet, its implications go far beyond anything that can be conveyed in any book, in particular this book!
Western medicine is oriented toward short-term treatments of
medical conditions.
Recently, my sister-in-law died at age 56 of the many complications of type II diabetes, including kidney and heart failure. I asked the doctor whether her illness, and her ensuing blindness, could have been avoided. He said yes, if she had only taken better care of herself as a young woman.
A medical article I once read said that of 100 people who get hepatitis C, 20 recover on their own and 80 develop chronic infections. Of the 80 who develop chronic infections, 60 remain clinically well despite chronic infection, while 20 develop cirrhosis [3]. If patients with hepatitis C were tracked over their lifetimes and given proper care—with the knowledge of what lifestyle and environmental factors influenced hepatitis C—could these results be improved? If my sister-in-law was given preventive care for type II diabetes, could she have lived a healthier, longer life?
Besides identifying a patient’s medical conditions, a universal patient record could collect lifestyle and environmental factors influencing the health of the patient. The universal patient record would thus serve as a database to associate diseases with lifestyle and environmental factors. Patients could then be identified as having greater risks of a specific disease, with caregivers informing the patients of how the disease could be prevented. Patient care could then become more long-term oriented, preventing, as well as treating, diseases.
Western medicine is the province of physicians, often working
individually in the care of a patient, who are usually restricted to work in
one very specific geographic location of the world.
One billion people in the world lack even the most basic medical services [4,5]. A book, Where There is No Doctor, is a manual for village healthcare workers, informing them on how to give first aid and emergency care to patients and on how to administer public health to the community, such as educating the community on how to have clean drinking water [6]. The healthcare worker is taught to recognize conditions that absolutely need near-term care by a physician; a patient report document appears in the back of the book for a village healthcare worker to communicate a patient's medical condition to a physician. Could the patient report document of the village healthcare worker be automated to communicate it via handheld computer directly to a physician for review and identification of critical medical situations?
There are too few physicians in the world, too few nurses, and too few other healthcare workers. The world must make better use of all its healthcare workers.
An innovative Web site in India that makes specialty care available to a larger population is DoctorAnywhere.com [7]. It affords communication over the Internet between physicians caring for a patient and specialty physicians geographically located anywhere, including communication of x-rays and other medical documents. Could this communication of medical documents be enhanced by a universal patient record?
A universal patient record could foster team care of
patients, serving as a communications vehicle about the patient and his medical
conditions between caregivers and a communications vehicle over a long period
of time between any one caregiver and any other caregiver (including the same
caregiver).
A universal patient record changes medical care from only
being short-term care oriented to long-term, preventative-care, oriented. It removes patient care from being the
province of the single physician to that of the responsibility of many
different healthcare care providers, possibly located anywhere in the world.
With a universal patient record:
· Communication between caregivers of all types would be enhanced, whether the caregivers worked on a single treatment for a patient, over many treatments for a patient (say for a chronic condition), or over a patient's lifetime.
· There would be a single patient medical record, rather than many fragmented ones.
· The lifestyles and environmental conditions that resulted in diseases could be better determined as a result of a research database derived from universal patient records. There would be greater emphasis on preventative care—patients could then be told how they could prevent diseases before they occurred.
· Healthcare workers would work across borders and provide healthcare even when they were located remotely from the patient, or remotely from each other. There would be greater sharing of information on uncommon and emergent diseases.
· Healthcare would become more universal and less costly.
Would there be untoward effects of a universal patient
record?
Do we risk loss of the personal contact between the physician and the patient? Do we risk overworking physicians or having them lose their prestige? Would healthcare suffer for the people who can afford the very best healthcare? Would there be enough financial incentives to bring healthcare to the underserved in the world? Would other factors, such a patient privacy, doom the effort to produce a universal patient record?
Can such a universal patient record revolutionize patient
care? Or must patient care be
revolutionized first to make use of a universal patient record?
All things change, with foresight they improve.
The automated patient medical record system and universal patient record cannot be created by any single company, but someone must initiate it and start it off. There is a big contradiction here, however: Only healthcare organizations have the knowledge, interest and perhaps the money to develop such a system, but healthcare organizations often do not have the type of working culture needed to develop such a system.
In general, healthcare organizations work vastly differently from software development organizations (as does virtually everyone else!). Software development organizations get experts together in many different specialty areas who work with the developers; facilitators insure that all views are considered in the development of a multi-dimensional system. Every other organization, and especially healthcare organizations, work by the worker doing what his or her boss tells him or her to do.
The software development organization is good for innovation, learning and equality. The normal organization is much better for preserving and protecting and for allowing people to be anonymous so they can do other useful things in their lives also!
Related to “doing no harm” is the following idea: Just because something is important, doesn’t mean I it is relevant. But also, just because it is undistinguished, doesn’t mean it is irrelevant. If you see a shadow in the corner of you eye while driving, it could be the most important thing you ever see. And when building the automated patient medical record system, you must be cognizant of very single detail; otherwise, it may not work or, what may be worse, it causes medical harm!
But any large-scale complex software project, including the automated patient medical record and universal patient record, is even more complicated than the sum of its parts. Most of the significant parts are actually hidden, constituting the system’s Infrastructure. Here is part of an old article that very much applies to the new automated patient medical record system, and proposed universal patient record. (Sometimes the older articles are much more relevant than new ones):
“
THE NATURE OF DISCIPLINE
Discipline, which may be defined as behavior or order maintained by training as behavior or order maintained by training and control, takes many forms. Discipline for Olympic athletes, for example, involves a regimen including extensive conditioning, competition, and a controlled diet. The mental disciplines followed by a chess master involves study and memorization of many games, along with in-depth analysis of board positions and possible moves and countermoves.
A different form of discipline can be seen in engineering fields, depending upon conformance to a set of rules and procedures. An engineering effort involves a specific sequence of steps beginning with a general plan, proceeding through detailed design, and concluding with implementation of the design. At each stage of the process, it is essential to carry out a series of activities in order to guarantee the success of the effort.
In constructing a building, for example, one must begin with artistic renderings, proceed to more detailed architectural design, and finally to blueprints prior to the beginning of construction. Also, the building site must be tested and prepared, checking for things such as drainage characteristics, soil quality, and stability. The various aspects of a building -- the plumbing, the electrical system, the heating -- must all be designed in harmony in order to assure that the finished building will be of the desire quality and will function properly. Furthermore, all of these design steps precede the construction.
The steps involved in the design and construction of buildings are well understood; it is possible to impose a specific methodology on the entire process. At the same time, however, there is adequate room for individual creativity and innovation, since detailed design and blueprints can serve to validate the ideas.
DISCIPLINE IN SOFTWARE ENGINEERING
The premise that an engineering type of discipline should be applied to the process of software design and development resulted in the coining of the term “software engineering” in 1968 [8]. It was recognized that software creation was a hit-and-miss business, based largely on ad hoc techniques. A large number of major software projects had failed completely or had been subject to severe time delays, cost overruns, or other serious problems. Many of the software systems exhibited unpredictable, hard-to-correct errors, were poorly documented, and fell short of user requirements such as measures as response time. In addition, these systems were often difficult to maintain, since the code was incomprehensible as a result of poor programming practices.
It became painfully apparent that there was a need to improve the quality and dependability of software production. The techniques being used did not work consistently and had a disturbing tendency to fail whenever a new or complex problem was attempted. The development of suitable programming methodologies presented a number of potential benefits, including the following:
1) improved reliability,
2) verifiability, at least in an informal sense
3) adaptability of programs
4) comprehensibility
5) effective management controls
6) higher user satisfaction.
Now, as in 1968, however, software engineering remains more of a wish than a reality. In the intervening years, however, there has been a great deal of investigation. into the nature of programming and the process of software development. The result of this effort has been the recognition that a form of engineering discipline can be applied to software construction with considerable success.
As with the construction of buildings, the construction of software can be separated into a design stage and a construction stage. If we are given a complete and consistent design for a piece of software (software blueprints), then the process of constructing a program which implements that design is generally straightforward.
One of the problems that has recurred consistently in the software creation process from the construction stage. Instead, there exists an “urge to write code”, to begin the construction process before fully determining the nature of the object to be built. While this technique works up to a point, particularly with smaller programs, it has a tendency to collapse with more complex systems. It can be seen, by analogy, that a building contractor can safely purchase roofing materials, wiring, plumbing fixtures, insulation, and electrical appliances for a house before the design is complete, but is likely to make some incorrect and irrevocable decisions in trying to assemble those components prior to the completion of the design.
Just as a builder must wait for the architect to complete the detailed plans for a building, so must the programmer wait for the “software architect” to complete the system design. This is a key principle in the achievement of a disciplined approach to software design and development.
...”
from ON THE MEANING OF DISCIPLINE IN SOFTWARE DESIGN AND DEVELOPMENT” by Anthony I. Wasserman [9].
Everything must fit together as a whole. A standard approach to developing a large software system is described in figure 18.1 [10].
But the automated patient medical record system, to be useful, is even more complex than this! Rather than the system being eventually replaced, you want a system that is continually replaceable, with parts of the system being replaced by improved components. Rather than figure 18.1, what would be preferable would be to have the system lifecycle that looks more like figure 18.2 [10] instead, with future maintenance phases consisting of component replacement.
And as difficult as it is to build a system, it is even more difficult to predict how the system will interact with its users. Its these interactions of the system with the users who use it that no one can possibly completely predict or figure out!
But these interactions with users are critical. Even the smallest little computer program which is used by many, many, users can have great effects on an organization. And even the largest system, which is not used at all by users, can be worthless.
In this respect, the automated patient medical record system and universal patient record have two possibilities:
1. They are something that gets in the way and no one wants to use them.
2. They help all mankind!
Which of these is true is completely determined by the users!
Thus the users must be involved throughout the entire analysis, database design, program design, construction and maintenance of the system. The users do not only include physicians, but all these listed in section 4.2, including patients!
Now, one could compare the world with and without an automated patient medical record system and universal patient record system, and conclude that it would be much better to have these two systems than not. But these systems could be viewed in a completely different way:
Say, that even one thing goes wrong with the automated patient medical record system and universal patient record system, and as a direct result, a patient dies. You have lost the most precious thing in the world, for at least some one.
Therefore, it must be that these systems are done right. The only way this could be done is getting representatives of everyone who is remotely knowledgeable about the systems, including patients, physicians, nurses, lawyers, and software designers and other technical people who develop the system. After development of these systems and installation, then comes the hard part--preserving and protecting the system, especially from those in power who could destroy it (e.g., presidents, prime ministers, legislators, etc.)
If the Internet goes down, then all that happens is a person doesn’t receive the information he or she was expecting. If the automated patient medical record system or universal patient record system go down a life could be lost--this is perhaps forgivable if it is just fate or due to an “act of God”, but when it is the result of a sloppy programmer error, a design error, a power play of a politician or sabotage, then we as the people involved in the creation and implementation of the system are saying, “perhaps we didn’t consider this project to be as important as we should have”.
These systems potentially could save many lives. These systems could potentially be a huge waste of money if not done right. These systems are definitely not for anyone’s competitive advantage--It could be that the automated patient medical record system and universal patient record system allow us to provide world wide medical care with the few physicians the world has, together with a world of trained caregivers, and a much larger world of untrained caregivers--to support all the patients of the world!
How can such complex systems be done with minimization of errors? One answer is that it must be done with the collaboration of many different categories of qualified people. Another answer is from the master of understanding the complex, Albert Einstein, “Everything should be made as simple as possible, but not simpler”. And a third answer was presented in a previous chapter of this book--For both the automated patient medical record system and universal patient record system, “Build the infrastructure first!”
The author suggests that an HMO who wants to do an automated patient medical record system follow this approach: Buy this book from the author and use the information in here to create an RFP (request for proposal). Send out the RFP to appropriate companies (e.g., such as IBM), trying to get the companies to develop the system (and the start of a Universal Patient Record) for virtually free, based upon the company’s benefit that the company could also sell the system to other HMO’s and healthcare organizations. And publish the whole of this book to encourage other HMO’s and healthcare organizations to use the same approach (IBM, or whoever, needs to be aware of this when they are bidding for the RFP).
Civil engineers who design buildings, bridges and other structures are required by a state to have a civil engineering license to practice, and no such structure can be built without the review of a civil engineer. As a result, a civil engineer—whether self-employed or working for an employer--has the power, and in fact the duty, to refuse to sign off on a structure if there is potential of harm to the public from the building of that structure.
Patient care systems, such as the automated patient medical record system, also have the very real potential of causing harm—harm to patients—if they are not designed and programmed correctly.
The IEEE Computer Society and the ACM have jointly developed a code of ethics for software engineers. In this code of ethics, “the primacy of well-being and quality of life of the public is emphasized” [11]. However, there are practical problems in applying such a code of ethics to software engineers:
Firstly, software engineering, unlike civil engineering, is not recognized as an engineering discipline by any state. And secondly, software engineering is not licensed by any state.
Perhaps, software engineering dealing with patient care systems should also become an established engineering discipline requiring a state license, with the state requiring that all patient care software systems be overseen by a software engineer. The software engineer would then have the power to refuse to sign off on any software project that could cause harm to patients.
Technology could be
a boon to healthcare, but also a hindrance.
On the one hand,
technology and computer systems could provide more complete information on a
patient, together with organization of this information, and filtering and
search capabilities for this information. Technology through computer systems
could provide a means for caregivers to communicate with other caregivers. And
it could provide quick access to information anywhere, including to medical
expertise where otherwise limited expertise would be available.
On the other hand, technology may require a caregiver to learn two ways of doing things, one when the technology is working and one when it is not. It requires an infrastructure to fix things when they go bad and an infrastructure to train users of systems. At its worst, technology may cause information on a patient to be totally unavailable, where it otherwise would be.
Technology could result in a large expense of money that could be used in better ways: on medical supplies, on additional caregivers. And there are ongoing costs for electrical power or batteries and the infrastructure to support the system and train users.
Electrical power to support this technology, even in the supposed richest, most sophisticated, places in the world may be unreliable. In California, blackouts periodically bring down computer systems. In underdeveloped countries, this infrastructure for technology is even more unreliable.
And burning of the fossil fuel that produces much of this electricity may have devastating effects upon the health of humans on this planet. The UN has published a report [12] that predicts increased temperatures, more droughts, higher sea levels, and an increase in tropical cyclones in this century as a result of technology.
But technology on a broader scale has produced a myriad of inventions that have enhanced human health, as varied as refrigerators and stoves, ambulances, x-rays and cat-scans, low-tech solar cookers and water pasteurizers [13], and computer networks and computer systems.
Although the use of computer technology in the poorer parts of developing countries may seem to some to be inappropriate, this may not be true. In developing nations, computer systems could potentially be hand-me-downs from developed nations (like old cars now are). And computer systems could be community appliances, shared by many people in a community (like television sets and telephones are in some places in China). But even in the remote areas of developed nations there are challenges—reference [14] describes the barriers to making the Internet available to small villages in the Alaska and the Yukon and to encouraging people to use it.
A caregiver will want to use an automated patient medical record system if (1) it provided some overwhelming benefit to the caregiver, (2) the caregiver was sufficiently trained in its use, (3) there was sufficient bandwidth to make the system fast, and (4) if the system was available when needed. For caregivers in poor areas, an additional requirement would be that the system is paid for by someone other than the caregiver [14].
When it comes to
healthcare, often anything is better than nothing.
Western medicine, or
least that practiced in the United States, puts many restrictions on medicine.
Only a physician can practice medicine. In order to practice medicine in a
country or a state of the United States, the physician must be licensed in that
country or state. The physician must be highly educated, and consequently is
usually paid extremely well. To protect the patient, malpractice laws allow
patients to sue physicians or other healthcare workers, further increasing the
cost of medicine.
Implicitly, Western
medicine assumes that medicine and practitioners must be “perfect” to practice
medicine and puts on these restrictions to insure that medicine is done
correctly all the time. But what is reality?
There is a great
controversy over what percentage of treatments are actually evidence-based
[15]. In Time magazine in 1999 [16],
Dr. Robert Califf of Duke Med stated that "Only 15% of the decisions a
doctor makes every day are based on evidence."
But there certainly
are treatments that are of definite benefit, without which the patient might be
damaged irreparably or later have a very poor quality of life. These
“treatments” done by physicians and other “healthcare workers” would include
the following:
·
Prevention
and early detection of diseases (e.g., through education, vaccinations,
complaint-based physical assessments in the early stages of diseases, condoms,
some types of preventive care for at-risk populations)
·
Cure and
control of potentially life-threatening and long-duration infections and other
types of treatable diseases
·
Setting
broken bones, installing protheses, fixing other structural problems
·
Prenatal
care and the delivery of babies
·
Prescribing
and fashioning eye glasses to correct poor vision
·
Insuring
access to adequate water and food, including keeping teeth healthy so people
can eat and food refrigerated so it does not spoil
·
Insuring
that drinking water and air is not polluted
·
Insuring
access to adequate shelter
·
Insuring
access to birth control
·
Correcting
cosmetic defects that cause the person to be treated as abnormal, such as cleft
lip or facial injuries.
Some studies have
shown that health—as measured by morbidity rate for many different diseases
(e.g., osteoarthritis, chronic disease, hypertension, cervical cancer) and by
mortality rate—is highly correlated with socialeconomic status [17],
where socialeconomic status is “a
composite measure that typically incorporates economic status, measured by
income; social status, measured by education; and work status, measured by
occupation” [18]. This
correlation of socialeconomic status with health is even the case at the upper
levels of socialeconomic status. Thus, increasing socialeconomic status seems
to be one way to significantly improve a community’s health. One negative
effect on social economic status is gender stereotyping that inhibits women’s
equal participation in many, if not most, societies [19].
All of the above are
health issues, but at least in Western medicine, only some of the above fall in
the realm of medicine. David Werner’s concept of village health care workers in
the books Where There is No Doctor [6] and Where There is No Dentist
[20] does include all these elements of healthcare.
But, even with the
above more all inclusive view of health care, there are problems in many
countries, including very advanced ones:
(1) In the United States, many people do not have access to the total of
healthcare, in particular, to some forms of early detection of diseases. (2) In
the other parts of the world, many people have virtually none of what is listed
above.
Insuring that
healthcare is “perfect” may be a delusion. Restricting healthcare to insure
that it is “perfect” may result in more harm than it does good. If these
restrictions cause healthcare to be too costly, are we not limiting healthcare
for those who cannot afford it? If only physicians can practice medical care
and only patients geographically located in the right place can have
healthcare, aren’t we severely limiting healthcare for most of the people in
the world? The delusion of perfection may be harmful for people both in rich
and poor nations.
There are too few
physicians, nurses, and other healthcare workers in the world. Even in nations
where this is not generally true, physicians and nurses tend to concentrate in
cities, and rural areas are often underserved.
There is not enough
knowledge about the most efficacious treatments. There is an inability to
recognize patients that are at risk for diseases due to lifestyle,
environmental factors, and family history.
By itself, a
universal patient record may not solve these problems, but with a universal
patient record there could be
·
Enhanced
communication between healthcare workers and physicians, no matter where they
are located in the world,
·
Enhanced
knowledge of the patient’s medical history and current medical conditions,
·
Greater
information on what constitutes the best treatments for a particular patient
due to larger database of information on treatments and diseases,
·
Greater
ability to recognize patients who are a risk due of particular medical
conditions due to their lifestyles, environment or family history, and thus
greater ability to inform a patient of ways he could preserve his health,
·
Greater
recognition of the totality of what constitutes good health (e.g., good medical
care, clean water, eye care and healthy teeth), and
· Greater ability to improve people’s lives . . . many more people’s lives.
Often, when we think of ecology, we think of animals and plants and their relationships in a wilderness area. Perhaps, we include man in the equation, often as destroyers or predators. Or perhaps we view ecology as man requiring other animals and plants in order to survive. But there are many other levels of human ecology, including those of pertinence to medicine.
As noted in the last section, if a person is cured of a waterborne disease and the polluted water that caused the disease is not cleaned up, then the disease is likely to reoccur. One form of human ecology is then, the person’s physical environment.
But another form of ecology is the person’s relationship with others, especially with his or her caregivers. If a paraplegic wife is cared for by her husband, physical ailments that incapacitate her husband can cause her to have physical ailments also. If a child with a chronic disease loses her mother, then the child is likely to have more emotional problems, and perhaps also more physical ones. A person without any caregiver may die or become more sick because he or she has no one to turn to for help; even a treatable condition could cause greater ill health or even the person’s death.
There is also an internal ecology within a human being. Metastasis is the spreading of disease from one part of the body to another, such as the spreading of cancer from one organ to another. But also, when one organ weakens, then another organ may weaken. It may be difficult to know the true disease, and after a while it may become irrelevant, as curing the diagnosed disease cannot cure the precursor.
Humans are members of a physical ecology, a relationship ecology, and an internal ecology. If any part fails, then others may also. We need some way of recording and recognizing these parts and interrelationships, so medical and human care can treat the most significant problems, and not just the secondary ones.
References
[1] The physician must be able to tell the antecedents, know the present, and foretell the future--must mediate these things, and have two special objects in view with regard to diseases, mainly, to do good or to do no harm.--HIPPOCRATES (Found in reference [2].)
[2] Lisa Belkin, First, Do No Harm, Fawcett Crest, 1993.
[3] Harvard Medical School, “Hepatitis C: The Silent Epidemic”, Harvard Men’s Health Watch, Vol. No. 12, July 2000.
[4] Pilar Franco, “HEALTH CARE: One Billion People Lack Medical Services”, World News, Inter Press Service, June 9, 2000. Visit websites http://www.oneworld.org/ips2/june00/23_41_126.html and http://www.ips.org.
[5] James B. Mayfield, “CHOICE Village Health Program”, Oct. 5, 1996 at website, http://library.wustl.edu/~listmgr/devel-l/Oct1996/0076.html.
[6] David Werner, Where There is No Doctor: a village health care handbook, The Hesperian Foundation, Fifth printing, April 1999.
[7] http://www.doctoranywhere.com.
[8] Naur, P. and B. Randell (eds.) Software Engineering. Brussels: NATO Science Committee, 1969.
[9] Anthony I. Wasserman, “ON THE MEANING OF DISCIPLINE IN SOFTWARE DESIGN AND DEVELOPMENT”, Tutorial on Software Design Techniques, SECOND EDITION, Peter Freeman, University of California, Irvine; Anthony I. Wasserman, University of California, San Francisco, (through the IEEE Computer Society, IEEE Catalog No. 76CH1145-2 C) 1977.
[10] Duane P. Truex, Richard Baskerville, Heinz Klein, “Growing Systems in Emergent Organizations”, Communications of the ACM, August 1999, Vol. 42, No. 8, pp. 117-123.
[11] Don Gotterbarn, Keith Miller, Simon Rogerson, Executive Committee IEEE-CS/ACM Joint Task Force on Software Engineering Ethics and Professional Practices, Computer, October 1999, Vol. 32, No. 10.
[12] Working Group II of the Intergovernmental Panel on Climate Change, Climate Change 2001: Impacts, Adaptation, and Vulnerability, IPCC (Intergovernmental Panel on Climate Change), February 15, 2001. Also, see website, http://www.ipcc.ch/press/pr.htm.
[13] See a website dealing with solar cooking and solar thermal water pasteurization at http://www.solarcooking.org/.
[14] Seymour E. Goodman, James B. Gottstein, Diane S. Goodman, “Wiring the Wilderness in Alaska and the Yukon”, Communications of the ACM, June 2001, Vol. 44, No. 6, pp. 21-25.
[15] Andrew Booth, Editor, “What portion of healthcare is evidence based? Resource Guide” at website, http://www.shef.ac.uk/~scharr/ir/percent.html.
[16] Dick Thompson, “A Week in the Life of a Hospital: More Science. . . and Much More Money”, October 12, 1998, Vol. 152, No. 15, found at site http://www.time.com/time/magazine/1998/dom/981012/a_week_in_the_life_of_a14a.html.
[17] Nancy Adler, Thomas Boyce, Margaret A. Chesney, Sheldon Cohen, Susan Folkman, Robert L. Kahn, S. Leonard Syme, “13. Socioeconomic Status and Health: The Challenge of the Gradient”, pp. 181-201 in the book Health and Human Rights, Johathan M. Mann, Sofia Gruskin, Michael A. Grodin, George J. Annos, Editors, Routledge, 1999.
[18] Dutton, D.B., and Levine, S., “Overview, methodological critique, and reformulation”, pp. 29-69 in the book Pathways to health, Henry J. Kaiser Family Foundation, Menlo Park, CA.
[19] Rebecca Cook, “17. Gender, Health and Human Rights”, pp. 253-264 in the book Health and Human Rights, Johathan M. Mann, Sofia Gruskin, Michael A. Grodin, George J. Annos, Editors, Routledge, 1999.
[20] Murray Dickson, Where There is No Dentist, The Hesperian Foundation, Ninth printing, January 1999.
Copyright
© 2000-2001 Michael R. McGuire
Duplication not permitted without express written permission
Comments? mailto:Michael.McGuire@abac.com