In this essay, we suggest practical ways to shift the framing of crisis standards of care toward disability justice. We elaborate on the vision statement provided in the 2010 Institute of Medicine (National Academy of Medicine) “Summary of Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations,” which emphasizes fairness; equitable processes; community and provider engagement, education, and communication; and the rule of law. We argue that interpreting these elements through disability justice entails a commitment to both (...) distributive and recognitive justice. The disability rights movement's demand “Nothing about us, without us” requires substantive inclusion of disabled people in decision‐making related to their interests, including in crisis planning before, during, and after a pandemic like Covid‐19. (shrink)

In the year 2020, during the global race to combat the coronavirus, the scientific community experienced a seismic shock when a research paper in the medical science journal The Lancet was retracted [1]. Since then, retractions of research papers in The Lancet have become more frequent. This not only raises concerns about the quality of research within the academic community but also has the potential to erode public trust in science. As transparent retraction notice will help alleviate the (...) negative impacts of retractions on the academia and general public, I used AI (Google Bard) to check whether important information related to the retractions had been provided. (shrink)

It is unknown to what extent medical researchers generalize study findings beyond their samples when their sample size, sample diversity, or knowledge of conditions that support external validity do not warrant it. It is also unknown to what extent medical researchers describe their results with precise quantifications or unquantified generalizations, i.e., generics, that can obscure variations between individuals. We therefore systematically reviewed all prospective studies (n = 533) published in the top four highest ranking medical journals, Lancet, New England (...) Journal of Medicine (NEJM), Journal of the American Medical Association (JAMA), and the British Medical Journal (BMJ), from January 2022 to May 2023. We additionally reviewed all NEJM Journal Watch clinical research summaries (n = 143) published during the same time. Of all research articles reporting prospective studies, 52.5% included generalizations beyond specific national study populations, with the numbers of articles with generics varying significantly between journals (JAMA = 12%; Lancet = 77%) (p < 0.001, V = 0.48). There was no evidence that articles containing broader generalizations or generics were correlated with larger or more nationally diverse samples. Moreover, only 10.2% of articles with generalizations beyond specific national populations reported external validity strengthening factors that could potentially support such extrapolations. There was no evidence that original research articles and NEJM Journal Watch summaries intended for practitioners differed in their use of broad generalizations, including generics. Finally, from the journal with the highest citation impact, articles containing broader conclusions were correlated with more citations. Since there was no evidence that studies with generalizations beyond specific national study populations or with generics were associated with larger, more nationally diverse samples, or with reports of population similarity that may permit extensions of conclusions, our findings suggest that the generalizations in many articles were insufficiently supported. Caution against overly broad generalizations in medical research is warranted. (shrink)

The EAT-Lancet Commission, consisting of 37 nutritionists, ecologists, and other experts from 16 countries, proposed safe operating space for food systems. This space helps to set ranges of food intake to ensure universal human health and a stable Earth system (not passing the planetary boundaries). Eventually, the Commission developed a 2,500-calorie-per-day eating plan for keeping the food systems in a safe operating space.

Methadone maintenance therapy is a cost-effective, evidence-based treatment for heroin dependence. In the USA, a majority of heroin-dependent offenders are forced to detox from methadone when incarcerated. Recent research published in The Lancet has demonstrated the negative health and economic outcomes associated with such policies. Methadone Continuation Versus Forced Withdrawal on Incarceration in a Combined US Prison and Jail: A Randomised, Open Label Trial. The Lancet, 386, 350–359). This novel evidence raises questions as to the justification for current (...) policies of forced detox in American prisons. Opponents of methadone provision in prisons might offer arguments from retributivism, resource allocation and curative effectiveness to justify their position. This article contends that these arguments do not stand up to ethical scrutiny. In light of this, we hold that American policymakers should reform criminal justice policies to allow the initiation and continuation of methadone treatment in correctional settings. This would be consistent with both international recommendations and the example set by a number of other Western countries. (shrink)

This essay is my review of Colleen Dyble’s book, Taming Leviathan: Waging a War of Ideas around the World. Dyble is affiliated with the legendary classical liberal British think tank, the Institute of Economic Affairs. Her anthology is a collection of essays by people around the world who have been involved with similar free-market think tanks in countries with historically statist economic systems. These writers include Greg Lindsay, founder of the Center for Independent Studies in Australia; Margaret Tse, of the (...) Instituto Liberdade in Brazil; Michael Walker, co-founder of the Fraser Institute in Canada; Cristian Larroulet, of Libertad y Desarrollo in Chile; Giancarlo Ibarguen, of the Center for Economic and Social Studies in Guatemala (which actually founded a free-market-oriented university); Parth Shah, founder of the Center for Civil Society in India; Daniel Doron, co-founder of the Israeli Center for Social and Economic Progress; Alberto Mingardi, of the Instituto Bruno Leoni in Italy; Masaru Uchigama, founder of the Japanese for Tax Reform; Elena Leontjeva, co-founder of the Lithuanian Free Market Institute; Alexander Magno, co-founder of the Foundation for Economic Freedom in the Philippines; and last, Leon Louw, of the Free Market Foundation of South Africa. I then discuss seven important reasons why classical liberal think tanks are so important in modern societies. (shrink)

Beginning with an examination of the recent Nature News centered on Harvard-Lancet-Mehra et al. COVID-19 research scandal, I put forth suggestions--for further debate--to safeguard the integrity of science in a time of crisis. In particular, I identify a subtle form of lying published as Nature news. Subsequently, drawing on Scarry's book "Thinking in an Emergency", I argue that slow reasoning and quick action (called for by crises) are not mutually incompatible; thinking can be transformed into conscious-reflex action by way (...) of practice (e.g. firefighters, emergency room physicians). More importantly, I call upon cognitive scientists, with their expertise in reasoning, intuition, habits, and actions, among others, to take a proactive role in crafting crisis preparedness programs for universities and science publishers so that we all can continue to rely on science for truth and facts. (shrink)

The COVID-19 pandemic has caused a lot of challenges to the globalized world. Globally, it has decimated over six million lives. Since 2019, it has shook the world in many respects, especially, it disrupted economies and societies and halted the majority of human endeavor. Commentaries and reports from the World Health Organization (WHO) and the media showed an alarming situation that could be damning in low and middle income countries. Economic pundits and global public health experts also anticipated doom and (...) gloom for African countries. However, in terms of mortality, the Americas, Europe and Asia have suffered more losses. Irrespective of these loses in Europe, Africa’s case needs better appreciation within our contemporary historical discourse. The burgeoning challenge of the COVID disease and mortalities arising thereby, among other things, necessitated the introduction of policies based on the WHO’s historical understanding of how the world has dealt with pandemics in the past. Some of the strategies that were deployed to fight the pandemic included hand washing under running water with soap, the use of alcohol based hand sanitizers, the wearing of nose masks, social distancing, self isolation as well as partial and complete lockdowns of states and communities. The major economic disruption really came about as a result of many lockdown policies that were implemented by several countries in Africa without proper reference to their own societal contexts. These issues notwithstanding, it is important to emphasize that the extent of the impact on different communities differed to a large extent, even though there were similar levels of the nature of the infection and the general economic outlook among the global community. This current contribution on the COVID-19 discourse used political economy and economic shock as bases to highlight the extent of the impact of the disease by highlighting examples from respective countries in Africa, namely, Ghana, Cameroon, Ethiopia, Algeria and South Africa. In particular, the impact of policies like lock-down on some of these African countries are highlighted for further discussions in future empirical research. The study relied on contemporary historical evidence from multidisciplinary sources on health, economics, policy, and other related studies on epidemiology, public health, health education and promotion, reports and sources from the World Health Organization (WHO). Specifically, the authors have used published research in Lancet, the International Journal of Infectious Diseases, BMJ Global Health, Frontiers in Public Health and the Pan African Medical Journal. The others were African Development Review, Transportation Research Interdisciplinary Perspectives, Africa Spectrum and International Journal of Financial Research including several other empirical research. In attempting a social and economic interpretation based on contemporary historical sense, the findings of this present study suggest that African political actors or leaders should make persistent or steady efforts to strengthen the economies of their states to lessen economic shocks and social costs that come about as a result of pandemics such as the COVID-19. It also identified the fact that within the globalized space, application of policies from other countries including international organizations should not be devoid of context. (shrink)

Nos meses de Junho/Julho - 2019, houve relatos de vazamento de patógenos do Fort Detrick, instalação do Comando Médico do Exército dos EUA, conhecido por desenvolver armas biológicas e que abriga um dos muitos laboratórios BSL-4 do país. Em agosto de 2019, a instalação foi fechada para investigação e a imprensa não teve acesso a informações detalhadas. -/- Em setembro de 2019, um vírus mortal começou a se espalhar nos EUA infectando 26 milhões de pessoas naquele outono, com pelo menos (...) 250.000 hospitalizadas e 20.000 mortes. Posteriormente o Dr. Robert Redfield, diretor do Centro de Controle e Prevenção de Doenças dos EUA, reconheceu perante o Comitê do Congresso, que algumas mortes por influenza foram mais tarde diagnosticadas como de Covid-19. -/- Em 18 de outubro de 2019, dia do início dos Jogos Mundiais Militares em Wuhan, que contou com a presença de militares americanos, a Fundação Bill & Melinda Gates e o Johns Hopkins Center for Health Security em parceria com o Fórum Econômico Mundial, promovem uma simulação de pandemia de coronavírus em Nova York, reunindo líderes empresariais e agentes do governo. -/- Em novembro de 2019, o prefeito de Belleville, Nova Jersey, Michael Melham, passou mal e seu diagnóstico foi uma grave pneumonia posteriormente confirmado como sendo Covid-19. Falei com Michael sobre a veracidade dos fatos e ele me confirmou o diagnóstico. Disse que possui dois testes de anticorpos positivos para a Covid-19. -/- Em janeiro de 2019 a revista Science publicou um artigo questionando a teoria oficial de que o vírus havia sido transmitido de um animal para um ser humano no mercado de Wuhan e outro estudo publicado na revista The Lancet, concluiu que 13 das primeiras 41 pessoas diagnosticadas com Covid-19 não tiveram nenhum contato com o mercado de Wuhan, além disso, o Dr. Daniel Lucey, professor de doenças infecciosas da Georgetown University Medical Center, disse baseado em evidências, que o "paciente zero", foi infectado antes de dezembro de 2019, mais precisamente entre outubro e início de novembro de 2019, mas o diagnóstico era de pneumonia e assim o vírus começou a se espalhar por Wuhan. -/- Agora, não é porque o novo coronavírus surgiu na China, que sua origem seja o laboratório de Wuhan, a gripe espanhola por exemplo, se disseminou no mundo a partir da Europa matando 50 milhões de pessoas e sua origem estava no Fort Riley, em Kansas, EUA. (shrink)

Our Viewpoint argues that expanding access to less effective or more toxic treatments is supported not only by utilitarian ethical reasoning but also by two other ethical frameworks: those that emphasise equality and those that emphasise giving priority to the patients who are worst off. The inadequate resources available for global health reflect not only natural constraints but also unwise social and political choices. However, pitting efforts to reduce inequality and better fund global health against efforts to put available resources (...) to their best use mistakes complementary objectives for conflicting ones. (shrink)

In response to commentators, we argue that whether waiving patent rights will meaningfully improve access to COVID-19 vaccines for low income and middle-income countries (LMICs), particularly in the short term, is an empirical matter. We also reject preferentially allocating vaccines to countries that hosted trials because doing so unethically favours those with research infrastructure, rather than those facing the worst burdens from COVID-19.

The COVID-19 pandemic has helped to clarify the fair and equitable allocation of scarce medical resources, both within and among countries. The ethical allocation of such resources entails a three-step process: (1) elucidating the fundamental ethical values for allocation, (2) using these values to delineate priority tiers for scarce resources, and (3) implementing the prioritisation to faithfully realise the fundamental values. Myriad reports and assessments have elucidated five core substantive values for ethical allocation: maximising benefits and minimising harms, mitigating unfair (...) disadvantage, equal moral concern, reciprocity, and instrumental value. These values are universal. None of the values are sufficient alone, and their relative weight and application will vary by context. In addition, there are procedural principles such as transparency, engagement, and evidence-responsiveness. Prioritising instrumental value and minimising harms during the COVID-19 pandemic led to widespread agreement on priority tiers to include health-care workers, first responders, people living in congregate housing, and people with an increased risk of death, such as older adults and individuals with medical conditions. However, the pandemic also revealed problems with the implementation of these values and priority tiers, such as allocation on the basis of population rather than COVID-19 burden, and passive allocation that exacerbated disparities by requiring recipients to spend time booking and travelling to appointments. This ethical framework should be the starting point for the allocation of scarce medical resources in future pandemics and other public health conditions. For instance, allocation of the new malaria vaccine among sub-Saharan African countries should be based not on reciprocity to countries that participated in research, but on maximally reducing serious illness and deaths, especially among infants and children. (shrink)

All parties involved in researching, developing, manufacturing, and distributing COVID-19 vaccines need guidance on their ethical obligations. We focus on pharmaceutical companies' obligations because their capacities to research, develop, manufacture, and distribute vaccines make them uniquely placed for stemming the pandemic. We argue that an ethical approach to COVID-19 vaccine production and distribution should satisfy four uncontroversial principles: optimising vaccine production, including development, testing, and manufacturing; fair distribution; sustainability; and accountability. All parties' obligations should be coordinated and mutually consistent. For (...) instance, companies should not be obligated to provide host countries with additional booster shots at the expense of fulfilling bilateral contracts with countries in which there are surges. Finally, any satisfactory approach should include mechanisms for assurance that all parties are honouring their obligations. This assurance enables countries, pharmaceutical companies, global organisations, and others to verify compliance with the chosen approach and protect ethically compliant stakeholders from being unfairly exploited by unethical behaviour of others. (shrink)

Summary Background Self-binding directives instruct clinicians to overrule treatment refusal during future severe episodes of illness. These directives are promoted as having potential to increase autonomy for individuals with severe episodic mental illness. Although lived experience is central to their creation, service users’ views on self-binding directives have not been investigated substantially. This study aimed to explore whether reasons for endorsement, ambivalence, or rejection given by service users with bipolar disorder can address concerns regarding self-binding directives, decision-making capacity, and human (...) rights. Methods This study used qualitative data from an internet-based survey distributed to the mailing list of the UK charity Bipolar UK, which contained multiple closed and open questions on advance decision-making in bipolar disorder. Quantitative analysis of a closed question about self-binding directives had already demonstrated endorsement amongst a very high proportion of participants with bipolar disorder who completed the survey. We conducted thematic analysis of responses from those participants who answered a subsequent open question about reasons for their view. Research was co-produced within a multi-disciplinary team, with clinical, legal, and ethical expertise, and lived experience of bipolar disorder. Ideas and methodologies associated with all these areas of expertise were used in the analysis of these reasons and to gain insight into the thoughts of individuals with bipolar disorder about self-binding directives and associated issues. Findings Between Oct 23 and Dec 5, 2017, 932 individuals with a self-reported clinical diagnosis of bipolar disorder completed the internet survey, with 565 (154 men; 400 women; 11 transgender or other) providing free text answers to the open question. A large majority of respondents endorsed self-binding directives, nearly all describing a determinate shift to types of distorted thinking and decision-making when unwell as their key justification. Responses indicating ambivalence were dominated by logistical concerns about the drafting and implementation of self-binding directives, while those who rejected self-binding directives also cited logistical concerns, validity of their thinking when unwell, and potential contravention of human rights. Interpretation This study is, to our knowledge, the first large study of reasons why mental health service users might endorse or reject the use of self-binding directives. The findings provide empirical support for introducing self-binding directives into mental health advance decision-making practice and policy and may help to address enduring ethical concerns surrounding possible implementation of the directive while a person retains decision-making capacity. The opinions expressed here in responses given by multiple service users with bipolar disorder challenge a prominent view within international disability rights debates that involuntary treatment and recognition of impaired mental capacity constitute inherent human rights violations. Funding The Wellcome Trust . (shrink)

Background Men with antisocial personality disorder show lifelong abnormalities in adaptive decision making guided by the weighing up of reward and punishment information. Among men with antisocial personality disorder, modifi cation of the behaviour of those with additional diagnoses of psychopathy seems particularly resistant to punishment. Methods We did a case-control functional MRI (fMRI) study in 50 men, of whom 12 were violent off enders with antisocial personality disorder and psychopathy, 20 were violent off enders with antisocial personality disorder but (...) not psychopathy, and 18 were healthy non-off enders. We used fMRI to measure brain activation associated with the representation of punishment or reward information during an event-related probabilistic response-reversal task, assessed with standard general linear-model-based analysis. Findings Offenders with antisocial personality disorder and psychopathy displayed discrete regions of increased activation in the posterior cingulate cortex and anterior insula in response to punished errors during the task reversal phase, and decreased activation to all correct rewarded responses in the superior temporal cortex. This finding was in contrast to results for off enders without psychopathy and healthy non-off enders. Interpretation Punishment prediction error signalling in off enders with antisocial personality disorder and psychopathy was highly atypical. This finding challenges the widely held view that such men are simply characterised by diminished neural sensitivity to punishment. Instead, this fi nding indicates altered organisation of the information processing system responsible for reinforcement learning and appropriate decision making. This difference between violent offenders with antisocial personality disorder with and without psychopathy has implications for the causes of these disorders and for treatment approaches. (shrink)

Despite the frequency of stillbirths, the subsequent implications are overlooked and underappreciated. We present findings from comprehensive, systematic literature reviews, and new analyses of published and unpublished data, to establish the effect of stillbirth on parents, families, health-care providers, and societies worldwide. Data for direct costs of this event are sparse but suggest that a stillbirth needs more resources than a livebirth, both in the perinatal period and in additional surveillance during subsequent pregnancies. Indirect and intangible costs of stillbirth are (...) extensive and are usually met by families alone. This issue is particularly onerous for those with few resources. Negative effects, particularly on parental mental health, might be moderated by empathic attitudes of care providers and tailored interventions. The value of the baby, as well as the associated costs for parents, families, care providers, communities, and society, should be considered to prevent stillbirths and reduce associated morbidity. (shrink)

Short overview of the From Small Beginnings Project and its relevance for resisting eugenics in contemporary society.

Eugenicists at the beginning of the twentieth century feared that the "unfit" were outbreeding the "fit" and promoted interventions like sterilisation as a solution to the perceived problem. Over 60,000 people were sterilised across the United States, victims of eugenic programs implemented in 32 states. Utah had a particularly aggressive eugenic sterilisation program, hailed by eugenicists for sterilising such a large proportion of its population, and lasting well into the 1970s. The goal of the present study was to determine who, (...) at the demographic level, was targeted by this eugenic practice in Utah, and to also estimate how many survivors of the program might still be alive in 2023. (shrink)

Digital Health Tools (DHTs), also known as patient self-surveilling strategies, have increasingly been promoted by health-care policy makers as technologies that have the capacity to transform patients’ lives. At the heart of the debate is the notion of empowerment. In this paper, we argue that what is required is not so much empowerment but rather a shift to enabling DHTs as digital companions. This will enable policy makers and health-care system designers to provide a more balanced view—one that capitalises on (...) the benefits of DHTs, while minimising the risks of potential harms. -/- . (shrink)

On 8th August 2019, Secretary of State for Health and Social Care, Matt Hancock, announced the creation of a £250 million NHS AI Lab. This significant investment is justified on the belief that transforming the UK’s National Health Service (NHS) into a more informationally mature and heterogeneous organisation, reliant on data-based and algorithmically-driven interactions, will offer significant benefit to patients, clinicians, and the overall system. These opportunities are realistic and should not be wasted. However, they may be missed (one may (...) recall the troubled Care.data programme) if the ethical challenges posed by this transformation are not carefully considered from the start, and then addressed thoroughly, systematically, and in a socially participatory way. To deal with this serious risk, the NHS AI Lab should create an Ethics Advisory Board and monitor, analyse, and address the normative and overarching ethical issues that arise at the individual, interpersonal, group, institutional and societal levels in AI for healthcare. (shrink)

Psychiatry has witnessed a new wave of approaches to clinical phenotyping and the study of psychopathology, including the National Institute of Mental Health’s Research Domain Criteria, clinical staging, network approaches, the Hierarchical Taxonomy of Psychopathology, and the general psychopathology factor, as well as a revival of interest in phenomenological psychopathology. The question naturally emerges as to what the relationship between these new approaches is – are they mutually exclusive, competing approaches, or can they be integrated in some way and used (...) to enrich each other? In this opinion piece, we propose a possible integration between clinical staging and phenomenological psychopathology. Domains identified in phenomenological psychopathology, such as selfhood, embodiment, affectivity, etc., can be overlaid on clinical stages in order to enrich and deepen the phenotypes captured in clinical staging (‘high resolution’ clinical phenotypes). This approach may be useful both ideographically and nomothetically, in that it could complement diagnosis, enrich clinical formulation, and inform treatment of individual patients, as well as help guide aetiological, prediction, and treatment research. The overlaying of phenomenological domains on clinical stages may require that these domains are reformulated in dimensional rather than categorial terms. This integrative project requires assessment tools, some of which are already available, that are sensitive and thorough enough to pick up on the range of relevant psychopathology. The proposed approach offers opportunities for mutual enrichment: clinical staging may be enriched by introducing greater depth to phenotypes; phenomenological psychopathology may be enriched by introducing stages of severity and disorder progression to phenomenological analysis. (shrink)

Countermeasures for mpox (formerly known as monkeypox), primarily vaccines, have been in limited supply in many countries during outbreaks. Equitable allocation of scarce resources during public health emergencies is a complex challenge. Identifying the objectives and core values for the allocation of mpox countermeasures, using those values to provide guidance for priority groups and prioritisation tiers, and optimising allocation implementation are important. The fundamental values for the allocation of mpox countermeasures are: preventing death and illness; reducing the association between death (...) or illness and unjust disparities; prioritising those who prevent harm or mitigate disparities; recognising contributions to combating an outbreak; and treating similar individuals similarly. Ethically and equitably marshalling available countermeasures requires articulating these fundamental objectives, identifying priority tiers, and recognising trade-offs between prioritising the people at the highest risk of infection and the people at the highest risk of harm if infected. These five values can provide guidance on preferable priority categories for a more ethically sound response and suggest methods for optimising allocation of countermeasures for mpox and other diseases for which countermeasures are in short supply. Properly marshalling available countermeasures will be crucial for future effective and equitable national responses to outbreaks. (shrink)

Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, quality-adjusted life-years, and (...) disability-adjusted life-years. We recommend an alternative system—the complete lives system—which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles. (shrink)

This article examines a fundamental question of justice in global health. Is it ethically preferable to provide a larger number of people with cheaper treatments that are less effective (or more toxic), or to restrict treatments to a smaller group to provide a more expensive but more effective or less toxic alternative? We argue that choosing to provide less effective or more toxic interventions to a larger number of people is favored by the principles of utility, equality, and priority for (...) those worst-off. Advocates are mistaken to demand that medical care provided in low-income and middle-income countries should be the same as in high-income countries. (shrink)

The COVID-19 pandemic revealed numerous weaknesses in pandemic preparedness and response, including underfunding, inadequate surveillance, and inequitable distribution of countermeasures. To overcome these weaknesses for future pandemics, WHO released a zero draft of a pandemic treaty in February, 2023, and subsequently a revised bureau's text in May, 2023. COVID-19 made clear that pandemic prevention, preparedness, and response reflect choices and value judgements. These decisions are therefore not a purely scientific or technical exercise, but are fundamentally grounded in ethics. The latest (...) treaty draft reflects these ethical considerations by including a section entitled Guiding Principles and Approaches. Most of these principles are ethical—they establish core values that undergird the treaty. Unfortunately, the treaty draft's set of principles are numerous, overlapping, and show inadequate coherence and consistency. We propose two improvements to this section of the draft pandemic treaty. First, key guiding ethical principles should be clearer and more precise than they currently are. Second, the link between ethical principles and policy implementation should be clearly established and define boundaries on acceptable interpretation, ensuring that signatories abide by these principles. (shrink)

Liver transplantation (LT) activities during the COVID-19 pandemic have been curtailed in many countries. The impact of various policies restricting LT on outcomes of potential LT candidates is unclear. We studied all patients on the nationwide LT waitlists in Hong Kong and Singapore between January 2016 and May 2020. We used continuous time Markov chains to model the effects of different scenarios and varying durations of disruption on LT candidates.

Background Previous analyses of democracy and population health have focused on broad measures, such as life expectancy at birth and child and infant mortality, and have shown some contradictory results. We used a panel of data spanning 170 countries to assess the association between democracy and cause-specific mortality and explore the pathways connecting democratic rule to health gains. -/- Methods We extracted cause-specific mortality and HIV-free life expectancy estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (...) and information on regime type from the Varieties of Democracy project. These data cover 170 countries and 46 years. From the Financing Global Health database, we extracted gross domestic product (GDP) per capita, also covering 46 years, and Development Assistance for Health estimates starting from 1990 and domestic health spending estimates starting from 1995. We used a diverse set of empirical methods—synthetic control, within-country variance decomposition, structural equation models, and fixed-effects regression—which together provide a robust analysis of the association between democratisation and population health. -/- Findings HIV-free life expectancy at age 15 years improved significantly during the study period (1970–2015) in countries after they transitioned to democracy, on average by 3% after 10 years. Democratic experience explains 22·27% of the variance in mortality within a country from cardiovascular diseases, 16·53% for tuberculosis, and 17·78% for transport injuries, and a smaller percentage for other diseases included in the study. For cardiovascular diseases, transport injuries, cancers, cirrhosis, and other non-communicable diseases, democratic experience explains more of the variation in mortality than GDP. Over the past 20 years, the average country's increase in democratic experience had direct and indirect effects on reducing mortality from cardiovascular disease (−9·64%, 95% CI −6·38 to −12·90), other non-communicable diseases (−9·14%, −4·26 to −14·02), and tuberculosis (−8·93%, −2·08 to −15·77). Increases in a country's democratic experience were not correlated with GDP per capita between 1995 and 2015 (ρ=–0·1036; p=0·1826), but were correlated with declines in mortality from cardiovascular disease (ρ=–0·3873; p<0·0001) and increases in government health spending (ρ=0·4002; p<0·0001). Removal of free and fair elections from the democratic experience variable resulted in loss of association with age-standardised mortality from non-communicable diseases and injuries. -/- Interpretation When enforced by free and fair elections, democracies are more likely than autocracies to lead to health gains for causes of mortality (eg, cardiovascular diseases and transport injuries) that have not been heavily targeted by foreign aid and require health-care delivery infrastructure. International health agencies and donors might increasingly need to consider the implications of regime type in their efforts to maximise health gains, particularly in the context of ageing populations and the growing burden of non-communicable diseases. (shrink)