Friday, May 20, 2011

"Running Away from the Problem" of Health Care Corruption

Despite its likely importance, the very concept of health care corruption remains highly anechoic. 

Last week's Lancet, however, actually mentioned it, albeit indirectly and ironically.(1)  The context was Richard Horton's discussion of a press conference on the final report of the UN Secretary-General's Commission on Information and Accountability for Women's and Children's Health. It appears that accountability, which we consistently advocate, was central to the report:
The big conclusion is that a huge accountability gap exists - we have incredibly weak mechanisms to make sure that the billions spent on women's and children's health are delivering the results we expect.

The report listed "ten commandments of women's and children's health, [which] aim to fill that accountability gap."

While the press conference went on, something unusual happened, as Richard Horton discussed somewhat ironically:
In truth, meetings such as these may not always produce the most exciting moments in the history of health (but this one did). Yet they can produce episodes of raw undiplomatic honesty which make the long waits and dull protocol worthwhile. [Secretary General of the International Telecommunication Union Hamadoun] Toure has a reputation for being blunt and outspoken. He surpassed himself last week. At the end of the first day, he suddenly began a riff of denunciation that left us all speechless. 'There is more corruption in the G8 countries than in the whole of Africa,' he declared with conviction. 'We are just running away from the problem.'

There you have it, one of the few mentions of health care corruption in the medical and health care literature, and one of the very few mentions of health care corruption afflicting developed, not just developing countries.

Interestingly, Horton then documented an immediate attempt by some very important people in global health care to paper over the unpleasantness raised by Toure's honest assessment:
President [Jakaya] Kidwete [of Tanzania] and Margaret Chan, WHO's Director-General, did well to pull their colleague back from the brink of professional suicide. 'This is a partnership effort,' affirmed Kikwete. He wanted no one think the generosity of international donors did not count. 'They are critical for development,' he said. Dr Chan stepped in to assert that 'development money works.'

So there you have it again. Stating that health care corruption is an important problem in developed countries is "professional suicide," even for the Secretary General of the International Telecommunications Union.

Yet Dr Horton, was willing to go a little further, maybe risking his own "professional suicide,"
The President and DG are right. But Toure had a point too. And most of us in the room knew it.

We have noted before that health care corruption is the great unmentionable.  The corruption that is mentioned is that afflicting developing countries.  Hardly anyone seems willing to say that health care corruption is just as big a problem in developed countries, including those that provide most of the funding for health care development in the developing countries.  As we see above, we now have an acknowledgement in one of the most influential medical journals that mentioning health care corruption in the developed world is "professional suicide." 

That is the anechoic effect writ large.  Left unsaid is why this is so.  Presumably, the reason is that corruption is wide-spread.  The corrupt have made a lot of money and become very powerful.  So it is very unwise to offend them.  That, of course, just lets corruption flourish, and so health care gets increasingly expensive, inaccessible, and bad for patients and the public.

If we really want to improve health care in our own countries, and to improve global health, we will all have to be as brave as Mr Toure.

See below for a repeat of our previous summary of the issue of health care corruption.


Many people more distinguished than yours truly have been warning about health care corruption for years. In particular, in 2006, Transparency International's Global Corruption Report asserted in its executive summary, "the scale of corruption is vast in both rich and poor countries." It also noted how diverse is health care corruption:
In the health sphere corruption encompasses bribery of regulators and medical professionals, manipulation of information on drug trials, the diversion of medicines and supplies, corruption in procurement, and overbilling of insurance companies. It is not limited to abuse by public officials, because society frequently entrusts private actors in health care with important public roles. When hospital administrators, insurers, physicians or pharmaceutical company executives dishonestly enrich themselves, they are not formally abusing a public office, but they are abusing entrusted power and stealing precious resources needed to improve health.
It further stated how serious the consequences of corruption may be:
Corruption deprives people of access to health care and can lead to the wrong treatments being administered. Corruption in the pharmaceutical chain can prove deadly....

The poor are disproportionately affected by corruption in the health sector, as they are less able to afford small bribes for health services that are supposed to be free, or to pay for private alternatives where corruption has depleted public health services.

Corruption affects health policy and spending priorities.
On this blog, our limited resources make us focus mainly on the US, and sometimes other English-speaking countries. Yet we now have in our archives some amazing stories that document various forms of corruption, including numerous allegations of corporate misbehavior ending in legal settlements, and examples of outright fraud, bribery, kickbacks and other crimes. Also, as we have noted before, the US Institute of Medicine has defined conflicts of interest
Conflicts of interest are defined as circumstances that create a risk that professional judgments or actions regarding a primary interest will be unduly influenced by a secondary interest.
Given that Transparency International's definition of corruption is
abuse of entrusted power for private gain
One can easily argue that in health care, conflicts of interest defined as above create risks of abuse of power by health care professionals influenced by the private gains provided by their secondary interests. On Health Care Renewal, we have provided a massive set of examples of individual and institutional conflicts of interest. There is evidence that about two-thirds of medical academics(2) and academic leaders(3) have significant conflicts of interest. The huge prevalence of conflicts suggests the enormous risk of major corruption.

So what we all should be shocked, shocked about is how little has been done to fight health care corruption, whether in Mozambique or the US.

However, one can find very few significant efforts to discuss, teach about, or research ways to fight corruption, or to promote accountability, integrity, transparency, honesty and ethics by academic health care institutions. (See this post for how difficult it was to find academic institutions' initiatives to resist conflicts of interest.) One can count the conferences, meetings, symposia, and courses on such topics on one's fingers. When I last looked, I could count only a single course on fighting corruption at any US medical or public health school (at Boston University, by Prof Taryn Vian).

Given the scope of corruption, we should be shocked, shocked at how anechoic it is, and how our respected health care institutions, particularly academic institutions and health care charities have ignored the problem.

Given the scope of corruption, we should be shocked, shocked at how anechoic it is, and how our respected health care institutions, particularly academic institutions and health care charities have ignored the problem.

Of course, one reason we started Health Care Renewal was to make these issues less anechoic. So hear we go again.

PS - If anyone in our vast audience does know about any additional anti-corruption or conflict of interest, or pro-accountability, integrity, transparency, honesty and ethics initiatives, courses, meetings relevant to health care, please let me know and I will do my best to disseminate the information.


1.  Horton R. Offline: ten commandments, G8 corruption, and OBL. Lancet 2011; 377: 1638.  Link here.
2. Campbell EG, Gruen RL, Mountford J et al. A national survey of physician–industry relationships. N Engl J Med 2007; 356:1742-1750. Link here.
3. Campbell EG, Weissman JS, Ehringhaus S et al. Institutional academic-industry relationships. JAMA 2007; 298: 1779-1786. Link here.


Anonymous said...

Check out the AP story: Data reveal how nursing homes spend state dollars sub titled: Medicaid funds used for six-figure salaries, family members’ jobs by Julie Carr Smyth.

You can take from the headline the nature of the story and with this amount being spent how many people are closed out of the program due to lack of funds and how with this cost basis nobody can afford nursing care on their own.

Steve Lucas

Anonymous said...

mentioning health care corruption in the developed world is "professional suicide."

That depends on exactly what one wants to do professionally after being blacklisted, doesn't it?

Afraid said...

My most recent favorite on corruption is the nepotism angle. See

Same old offenders ...

Anonymous said...

Mr. Toure, Secretary General of the International Telecommunication Union Hamadoun, doesn't mention that the healthcare sector in the G8 countries is heavily unionized. Is he open to investigating the unions' roles in the corruption?

I'm guessing not.

Roy M. Poses MD said...

Anonymous of 24 May, 10:57 AM -

Most of the corruption we talk about on this blog is in the US. Very little of it has to do with unions. At least in the US, I could think of a lot of organizations I would investigate before taking on unions.

If you want to know what Mr Toure thinks about investigating unions, you will have to ask him. I have no idea.

It does occur to me that if the issue of health care corruption actually starts getting some public notice, a strategy that health care corporations' public relations departments are likely to use would be to blame it on the unions, and use third parties, including anonymous commentators on social media, to spread it around.

Anonymous said...

Dr Poses,

I'm the Anonymous from 10:57

My comments about Mr Toure were based on what I read in your post. He, the head of a large union, was talking about corruption in various sectors of healthcare and I wondered if he was also willing to look in-house.

My reference to the G8 again came from your post. And I'm not "blaming" anything on unions, just wondering if they are going to be considered along with everybody else.

In the US, the health sector is becoming increasingly unionized with doctors and other professionals joining the SEIU and nurses having their own unions.

As to your inferences about my motives -- I'm just an individual layperson/patient giving my two cents worth. I'm "anonymous" because I choose not to have a Google account and without one, I can only choose "Anonymous" as my identity.

Roy M. Poses MD said...

Anonymous of May 24, 10:57 -

OK, explanation understood.

We are a bit touchy here about sock puppets, since we have been visited a few times.

I do not deny that unions could be implicated in health care corruption, just that they have not been to any great extent so far in the US.

You are right about health care professionals increasingly joining unions, but to some extent that may be their only way to challenge the power of large hospitals/ health care systems, and the increasing role of for-profit corporations in direct care provision and clinical practice.

Note that if you wanted to reveal who you are, you can simply write your name at the bottom of your comment. You need not get a Google account to identify yourself.

Roy M. Poses MD said...


See this post re your citation:

Also see other posts on UPMC: