Concept Of Global Health Research Articles

Editorial

The 36th Edition of GIRI was carried out under the theme: “GROUNDBREAKING SCIENCE: HOMEOPATHY AND THE FUTURE OF GLOBAL HEALTH” and provided a single opportunity for the participants to exchange scientific experiences, discuss new and standard research protocols, make new friendships, and gather the most important researchers involved with basic and/or clinical homeopathic research worldwide. The multidisciplinary feature of the GIRI meetings fits the concept of global health, since homeopathy favors the interconnection among people, animals, plants, and their environment, promoting its sustainable use in agriculture. The meeting aimed to examine the growing body of evidence around homeopathy and consider its role in addressing many urgent concerns, such as infectious diseases and antimicrobial resistance, aging populations, multimorbidity, polypharmacy, sustainability, and environmental factors, with special focus on the emerging evidence that homeopathic products may help mitigate the impact of climate change on agriculture – making plants and animals more bio-resilient – while also reducing the need for agricultural chemicals known to cause environmental harm.

Reescrever saúde global

Abstract The concept of global health has become popular even though its origins have come under critical scrutiny: namely, its origins in colonial medicine, its links to the protection of international trade and capitalist exploitation and its Orientalist assumptions. To what extent is the concept still adequate or useful? Is it possible to rewrite global health while recognizing and tackling its multiple forms of violence? I reflect on the potentiality of the concept of global health based on an ethics of writing that intends to be analytical (concerning its ability to reflect social tensions, the multiplicity of experiences, the social actors’ justifications and claims, the oppression, and the unrealized potential); critical (concerning its ability to identify the contradiction between what social arrangements ostensibly proclaim and what they actually produce); and political (concerning its potential for emancipation and for the reparation of historical injustices). Five important aspects are identified toward rewriting the concept of global health: the global as planetary; the global as collective; the global as public; the global as peripheral; and the global as everyday.

INTERNATIONAL HEALTH COOPERATION: THE GRAVE NEGLECT OF GLOBAL HEALTH COOPERATION & THE RISE SEVERE ACUTE RESPIRATORY SYNDROME - COVID19 PANDEMIC CASE STUDY

International relations is truly the manner in which inter-state interactions take place, the behaviour by which they concern each other with issues that touch economic performance, political alignments and social cultural relations. However, it is more than that. In order to clearly understand these inter-state relations, one must truly look at the state cooperation or lack thereof. This paper sets the scene for the concept of global health by identifying the link between the concept and international relations. The insight into the need of health impact assessment is reviewed in the international relations where the key assumption is that issues of global health are ignored in international relations. There is hence the review of impact that the incorporation of global health issues can have in international diplomacy. The aim of this study is to stress the great amount of negligence that exists within the world of International cooperation in the field of Global Health. Global health cooperation is more important than ever. The International response to Covid-19 pandemic, as well as the lack of transparency within Global Cooperation, and interstate relations were examined in this study. The clear observation of military expenditure rises, and the extreme lack of financial redirection against states during times COVID-19 is seen. The lack of compassion from governmental and medical institutions in vulnerable states is also demonstrated. This research was undertaken in a form of Case studies in order to demonstrate the real time results and impacts on often quickly dismissed states. 3 One conclusion is the unpreparedness in terms of response in many countries it suggested the need for improved International Health Regulations. Governmental efforts, alongside community based initiatives and contributions towards health care maintenance have been taken into consideration. The issue lies in the neglect of other aspects of Health especially in times of crises. In my view, the term “Global Health” is widely misunderstood and misrepresented. The context within Global Health may arise from different political backgrounds and focused on different disciplinary principles. It requires a certain capability to deal with heterogeneous ideas in macro, micro, and behavioral economics sociology, political science, international affairs, and public policy. Global health will necessitate moving beyond simple health advocacy in order to be fully comprehended. By contrasting different state responses to COVID-19 outbreaks, in hopes to prevent spreading, setting a precedent for populations, health managers, and leaders around the world on how to plan for, track, and respond to possible outbreaks. The Centers for Disease Control and Prevention (CDC) and the Centers for Disease Control and Prevention (CDC) were used to compare outbreak preparedness and management strategies for this report.

The role of the World Health Organization country programs in the development of virology in Spain, 1951-1975.

Within the framework of recent historiography about the role of the World Health Organization (WHO) in modernizing public health and the multifaceted concept of global health, this study addresses the impact of the WHO's "country programs" in Spain from the time it was admitted to this organization in 1951 to 1975. This research adopts a transnational historical perspective and emphasizes attention to the circulation of health knowledge, practices, and people, and focuses on the Spain-0001 and Spain-0025programs, their role in the development of virology in Spain, and the transformation of public health. Sources include historical archives (WHO, the Spanish National Health School), various WHO publications, the contemporary medical press, and a selection of the Spanish general press.

Autodétermination et promotion de la santé chez les adultes présentant une déficience intellectuelle : une revue systématique de la littérature

Despite major improvements in the conceptual and functional approach of disability, some fundamental inequities remain. Among them, lacks in health access and health status are of importance both for research and public health policies. Particularly as regards intellectual disability (ID), in which major inequities remain and contrast with specific and sometimes increased somatic and mental health needs. In this context, health promotion initiatives designed for adult with intellectual disabilities should succeed to integrate several variables such as a holistic view of health, the importance of individual–environmental interaction, as well as the concept of self-determination. These variables have indeed been largely documented as key component in the field of ID. The purpose of this study is to analyse the available literature on health promotion for adults with ID as regards the integration of these variables, both in form and content. The results suggest several lacks in the conception of health promotion initiatives; such as an over-focus on individual abilities at the expense of environmental actions, and low consideration for the concept of global health or the volitional dimension of behaviours. Therefore, once more pointing the gap between knowledge and practice in the field of ID. Results are discussed in terms of future direction for research and clinical practice.

Saúde global, inovação biotecnológica e risco(s)

Objetivo: refletir sobre o conceito de saúde global, a sua origem, sentido(s) e notas caraterizadoras. Compreender em que medida a doutrina se vem referindo a um Direito da Saúde Global, analisando quais os seus principais méritos, limitações e inconvenientes. Analisar alguns dos avanços biotecnológicos que têm aberto as portas a novas potencialidades de incrementação da saúde e do bem-estar à escala global. Metodologia: foi utilizado o método dedutivo a partir da análise de obras monográficas, artigos de revistas da especialidade, bem como de documentos emanados por diversas entidades nacionais e estrangeiras. Resultados: num contexto de crise tecnocientífica, a inovação biotecnológica, embora contribua para a melhoria da saúde global, acarreta inúmeros riscos. Cada vez mais, se tem afirmado a importância do chamado Direito da Saúde Global, o qual procura contribuir para a otimização das possibilidades de melhoria dos índices de saúde à escala global, mormente através da formulação de respostas precaucionais adequadas. Conclusão: a melhoria dos índices de saúde à escala global depende, inter alia, da inovação biotecnológica, a qual só será viabilizada através de uma adequada gestão do risco a realizar a partir do conceito de diligência devida. O Direito da Saúde Global, enquanto sub-ramo jus-internacional do Direito da Saúde, poderá dar valiosos contributos nesse sentido, não obstante as suas múltiplas limitações e dificuldades.

Global Health

Global Health

Access to health care as a human right in international policy: critical reflections and contemporary challenges.

Using the United Nations (UN) and its subordinate body, the World Health Organization (WHO), as a frame of reference, this article explores access to healthcare as a human right in international intergovernmental policies. First, we look at how the theme of health is treated within the UN, focusing on the concept of global health. We then discuss the concept of global health from a human rights perspective and go on to outline the debate surrounding universal coverage versus universal access as a human right, addressing some important ethical questions. Thereafter, we discuss universal coverage versus universal access using the critical and constructivist theories of international relations as a frame of reference. Finally, it is concluded that, faced with the persistence of huge global health inequalities, the WHO began to reshape itself, leaving behind the notion of health as a human right and imposing the challenge of reducing the wide gap that separates international intergovernmental laws from reality.

Orders of worth and the moral conceptions of health in global politics

The article analyzes the contested concept of global health through the lens of orders of worth. Drawing on pragmatist political and social theory, especially the work of Boltanski and Thévenot, I conceptualize orders of worth as moral narratives that connect visions of universal humankind to ideas about moral worth and deficiency. They thereby differ from the self/other narrative of political identity that is emphasized in International Relations scholarship. Orders of worth do not pitch a particularistic identity against foreign identities, but tie collective identity to a higher common good. They provide tools for moral evaluation and the justification of hierarchy. I use this heuristic to reconstruct four main conceptions of health in global politics: The order of survival, the order of fairness, the order of production, and the order of spirit. Each of them articulates a distinct political identity, as ‘we species’, ‘we liberals’, ‘we bodies’ and ‘we souls’, and implies different notions of virtuous and selfish conduct in the global community. These orders are derived from scholarly writings and the policies of global health institutions. Finally, I discuss the nature of compromises between the four orders regarding contested issues such as health emergencies or digital medicine.

Training Young Russian Physicians in Uganda: A Unique Program for Introducing Global Health Education in Russia

BackgroundGlobal health is a new concept in Russia. There has been an ongoing academic collaboration between the Yale School of Medicine in the United States and Makerere University College of Health Sciences in Uganda since 2010, and the US Western Connecticut Health Network/University of Vermont College of Medicine since 2012, to introduce global health concepts to Kazan State Medical University (KSMU) in Russia. The purpose was to educate Russian physicians and medical trainees about the practice of clinical medicine and medical education, as well as the general practice of global health in culturally diverse, resource-limited settings. ObjectivesThe aim of this study was to evaluate the initial outcomes of this multi-institutional partnership and to assess the impact of the global health elective on the participants and on KSMU. MethodsParticipants were selected to attend a 6-week elective in global health at Mulago Hospital in Kampala, Uganda. The elective consisted of clinical experience, education about Uganda's common diseases, and region-specific sociocultural classes. It included a predeparture orientation and, upon return, completion of a standard questionnaire to assess the program's impact. ResultsSince 2010, there have been 20 KSMU members (4 medical students, 4 interns, 9 residents, 2 fellows, and 1 faculty member) who have participated in the program. As a result of the elective, the participants reported increased knowledge of tropical medicine (70%) and HIV/AIDS (75%), and 95% reported increased cultural sensitivity and desire to work with the underserved. The majority noted a very positive impact of their careers (90%) and personal life (80%). KSMU established the first successful collaborative program in global health education in Russia, leading to the integration of tropical medicine and global health courses in medical school curriculum. ConclusionThis elective has proven highly effective in introducing the concept of global health to faculty, fellows, residents, and medical students at KSMU. It trained these participants to address the challenges faced by physicians in culturally diverse and resource-limited countries.

Where no Doctor has Gone Before: Cuba's Place in the Global Health Landscape ‐ by Huish, Robert

Huish, Robert (2013) Where no Doctor has Gone Before: Cuba's Place in the Global Health Landscape, Wilfrid Laurier University Press (Waterloo, ON), xv + 180 pp. $32.99 pbk. Cuba has been lauded internationally for its commitment to education and healthcare. Since the 1960s, the island has developed a reputation for providing international disaster relief, medical training, services and programmes, particularly in disadvantaged areas. In addition to Cuba's substantial human capital and expertise in the medical field, these efforts have largely resulted from Cuba's commitment to overall health equity and from economic and political need. Cuba has participated fully in global health efforts, with over 135,000 Cuban medical professionals working in over 100 countries and training tens of thousands of other professionals from marginalised regions. In recent years, this has become known as ‘medical internationalism’, an invaluable contributor to the island's development. Yet research on that commitment has in many ways been limited. While scholars such as Kirk and Erisman (2009) have contributed significantly to our understanding of that medical internationalism, further research has been needed, in particular focusing on how Cuba engages with global health as a whole. This is precisely the area that Where No Doctor has Gone Before successfully illuminates. Building on the work of others who have contributed to the understanding of global health as a concept, such as Farmer (2001, 2005), Orbinski (2009) and Davies (2010), Huish significantly contributes to the discussion by offering a comprehensive account of Cuba's experience. In addition to his considerable research, Huish also draws on his own personal experiences on the island and abroad, to determine how Cuba's efforts (and in particular its medical internationalism) engage with the global health landscape. The book is divided into six chapters. Discussions of health care as a human right are the focus of the first, while the second chapter explores the Cuban understanding of the right to health and health care. The third explores and analyses international health efforts as foreign policy, while the fourth and fifth chapters discuss questions of ethics related to medical training. The chapters include research on Escuela Latinoamericana de Medicina (ELAM, Latin American School of Medicine) and the specific medical training that promotes equality in health and health care, with a focus on marginalised areas. The final chapter discusses Cuba's efforts within global health, and meaningfully contributes to the greater understanding of how global health care can be achieved. The book offers significant insights into two major areas. First, it provides a full discussion of the evolution of Cuba's unique experience and understanding of health and health care. It follows the development of Cuba's particular health care system, including the view of health as a human right, the development of the system as a whole and the ethics promoted throughout medical training. Little has been written in depth about this area of the Cuban approach; this book thus offers a comprehensive view of Cuba's healthcare model. Second, the book places the island's international efforts within, and contributions to, the global health landscape. These include ELAM and the significant level of medical training provided to international students, as well as specific projects such as Operation Miracle; indeed, it highlights how Cuba draws upon its own unique system to participate in global health. The ongoing difficulty with attempting to place Cuba within the global health landscape, however, is that the concept of global health itself is continually evolving and being redefined. Indeed, it has yet to be fully conceptualised and delineated, necessitating a specific characterisation. While the book could gain from a more complete discussion, or definition, of global health, it significantly adds to the debate through its detailed assessment of the Cuban experience. Overall, Where No Doctor has Gone Before is a welcome and important addition to any specialist or general reader on Cuban medical internationalism or global health. It employs an excellent analysis of Cuba's experiences to highlight the challenges facing global health, and how governments could engage with it.

Global Mental Health: concepts, conflicts and controversies.

This paper introduces, describes and analyses the emerging concept of Global Mental Health (GMH). The birth of GMH can be traced to London, 2007, with the publication of a series of high-profile papers in The Lancet. Since then, GMH has developed into a movement with proponents, adherents, opponents, an ideology and core activities. The stated aims of the Movement for GMH are 'to improve services for people living with mental health problems and psychosocial disabilities worldwide, especially in low- and middle-income countries where effective services are often scarce'. GMH could be considered an attempt to right a historic wrong. During the colonial and post-colonial eras, the mental health of subject populations was accorded a very low priority. This was fuelled by scientific racism, which alleged that mental illness was uncommon in places such as Africa. As developing nations have made the epidemiological transition, the burden of mental illness has proportionately increased, with research suggesting a massive 'treatment gap' between those in need and those actually receiving formal mental health care. As such, much GMH research and action has been devoted to: (i) the identification and scale-up of cost-effective evidence-supported interventions that could be made more widely available; (ii) task-shifting of such intervention delivery to mental-health trained non-specialist Lay Health Workers. GMH has come under sustained critique. Critics suggest that GMH is colonial medicine come full circle, involving the top-down imposition of Western psychiatric models and solutions by Western-educated elites. These critiques suggest that GMH ignores the various indigenous modalities of healing present in non-Western cultures, which may be psychologically adaptive and curative. Relatedly, critics argue that GMH could be an unwitting Trojan horse for the mass medicalisation of people in developing countries, paving the way for exploitation by Big Pharma, while ignoring social determinants of health.

Historical evolution and chinese definition of global health

Under the background of globalization, public health issues are becoming more and more complicated. In the international arena, global health has gradually replaced international health and "global public health" as one of the dominant terms in the field of public health. However, until now, there is no unified understanding and definition for the concept of global health domestically and internationally. In this article, various foreign experts 'views and domestic experts' opinions about the concept of global health are collected and solicited, in order to generalize appropriate Chinese definition of global health of China.

Powerful concepts in global health: Comment on "Knowledge, moral claims and the exercise of power in global health".

In this paper we emphasize the importance of questioning the global validity of significant concepts underpinning global health policy. This implies questioning the concept of global health as such and accepting that there is no global definition of the global. Further, we draw attention to 'quality' and 'empowerment' as examples of world-forming concepts. These concepts are exemplary for the gentle and quiet forms of power that underpin our reasoning within global health.

The future of global health after the Ebola outbreak

Background: This article aims to address the future of Global Health after the Ebola outbreak in West Africa. It analyzes the effectiveness of the response provided from the beginning of the epidemic to its remission.Methods:The article is both retrospective and prospective. It is analytic. It is based on factual considerations rather than clinical trials. The article provides the last statistics provided by the World Health Organization. It discusses the rapid involvement of the scientific and the international community in the production of the vaccine against the Ebola virus. It briefly focuses on the cycle of the production of a vaccine which has not been respected in the case of the Ebola outbreak.Results: The Republic of Guinea recorded its first patients in March 2014. The authorities; at that beginning, remained slow in their response. That negligence resulted in hundreds of deaths in the community. The deadly virus killed thousands of people; mainly in Guinea, Sierra Leone and Liberia. Some of the countries that were previously affected by the virus are now declared free of Ebola, while Guinea continues to record some sporadic cases.Conclusions:It appears that the concept of global health was not working in the proper sense from 1976 to 2014. The concept started to work after noticing the rapid deaths of thousands of people in Guinea, Sierra-Leone, and Liberia. Also, the involvement of the United States of America has accelerated the process of the global response to the Ebola outbreak. Rapidly, a vaccine was developed with 100% effectiveness. The conclusion summarizes the future of Global Health in the World; mainly in Africa. The future of modern medicine will pass by the knowledge of the concept of Global Health which is an inclusive part of the Public Health. For example, Global Health is now taught in developed countries. After the Ebola outbreak, universities in Africa and around the world must include the teaching of Global Health in their curriculum.

Outcome measurements in hand and upper limb surgery

Of marginal importance only 20 years ago, outcome measurement has become one of the most widely published topics in medical literature. The concept of global health is described by the International Classification of Function, Disability and Health. Today, the surgeon's perspective is no longer sufficient to evaluate global health condition of a patient. The patient cannot be reduced to an organ. Outcome measurement must take into consideration body structures and function (symptoms, organ function) as reviewed by a professional, the individual's functional health status in terms of activity and evaluated by the patient himself, and his participation in his social environment. These principles are now being applied to our specialty and it is essential to know them to be able to collect, analyze and publish valid results. This review article defines the rules for using clinical outcome tools, provides the most widely used clinical and self-evaluation forms for our specialty as well as instructions for their use. Global outcome is usually obtained by arithmetic addition of scores; which is a simple but questionable method. The sieving and radar charts can be used for a more comprehensible representation showing areas of relative strength and relative weakness on a graph, as well as depicting general overall performance. The reliability of data is also affected by declaration of conflicts of interest, negligence or fraud. The level of evidence is questionable as long as a data verification system is not implemented.

A taxonomy of global health: a qualitative analysis at a large academic health sciences centre

Abstract Background Despite numerous published definitions of global health, both colloquial and academic notions of global health vary widely. We developed a taxonomy of global health for use at one of the largest academic health science universities in North America. This taxonomy should provide a conceptual and organisational framework with which to efficiently align educational programmes and research projects, and to enhance collaboration and strategic planning. Methods The initial phase of this research programme involved data from a variety of sources: postgraduate physician trainee applications to global health programmes and trainee surveys, clinician applications to global health continuing education programmes, minutes of faculty meetings from the School of Public Health Global Health Division Faculty, and stated academic interests and publications of global health faculty. Data were open coded with accepted qualitative methods. Frequencies were noted and inductive analysis was used to develop the taxonomy. Findings Three axes of classifying global health emerged from the data—one practical, one conceptual, and one relational. The practical axis refers to the so-called target or location of global health interventions or activities; these included countries with low or middle incomes traditionally considered so-called international health, and marginalised or vulnerable populations in inner cities, aboriginal peoples, immigrants and refugees, and very low-income groups. The conceptual axis showed disciplinary tensions, for example, the role of technology versus an emphasis on social determinants of health. The varying understandings of notions of justice, equity, equality, and fairness were also prominent. The relational axis focused on partnerships, interdisciplinarity, and inclusion of alternative local and non-traditional perspectives on health issues. Interpretation The concept of global health cannot, and perhaps ought not, be rigidly defined. Our empirically derived taxonomy of global health deserves testing by others, as does its application in the organisation of global health activities at our and other academic health sciences centres. Funding None.

From sovereignty to solidarity: a renewed concept of global health for an era of complex interdependence

The moment is ripe to revisit the idea of global health. Despite tens of billions of dollars spent over the past decade under the auspices of global health, 1 Institute for Health Metrics and EvaluationFinancing global health 2012: the end of the golden age? Institute for Health Metrics and Evaluation, Seattle2012 Google Scholar a consensus definition for this term remains elusive. 2 Koplan JP Bond TC Merson MH et al. for the Consortium of Universities for Global Health Executive BoardTowards a common definition of global health. Lancet. 2009; 373: 1993-1995 Summary Full Text Full Text PDF PubMed Scopus (820) Google Scholar , 3 Fried LP Bentley ME Buekens P et al. Global health is public health. Lancet. 2010; 375: 535-537 Summary Full Text Full Text PDF PubMed Scopus (117) Google Scholar , 4 McInnes C Lee K Global health and international relations. Polity, Cambridge2012 Google Scholar , 5 Brown TM Cueto M Fee E The World Health Organization and the transition from “international” to “global” public health. Am J Public Health. 2006; 96: 62-72 Crossref PubMed Scopus (445) Google Scholar Yet the way in which we understand global health critically shapes not only which and whose problems we tackle, but also the way in which we raise and allocate funds, communicate with the public and policy makers, educate students, and design the global institutions that govern our collective efforts to protect and promote public health worldwide. EU's external borders: what is the role for global health law?Public health and human rights do not end at national borders. And yet, when thousands of refugees were drowning in the Mediterranean, some northern countries of the European Union (EU) hid behind the excuse that these continuing tragedies were at the EU's external borders, beyond their sovereign territory. Full-Text PDF On global health: stick to sovereigntyDiscussing the concept of global health, Julio Frenk and colleagues (Jan 4, p 94)1 oppose sovereignty and solidarity arguing that a global society might be a substitute for state sovereignty.1 We are not, however, living in a global village but in a world where the distribution of economic, political, and military power is extremely inequitable. The WHO Commission on Social Determinants of Health famously stated that “inequities are killing people on a grand scale.”2 Full-Text PDF

Abstract 4454: Global health as the key to a new paradigm in cancer research

Abstract Promoting perceptions of cancer as an integral part of the global health agenda will help to focus attention on the ever-present and growing threat of cancer, particularly in emerging economies, many of which are in Asia. It is imperative that a blueprint for the future direction for cancer research is founded in the global health context and aimed squarely at overcoming health disparities. As part of its ongoing initiatives the Asia Cancer Forum (ACF) implemented a questionnaire survey targeting cancer specialists, entitled “Survey on Inclusion of Cancer in the Global Health Agenda.” Following up on the survey results gathered at the AACR, the Asia Cancer Forum is committed to creating a common awareness among cancer researchers about the imperative of tackling cancer in the global health context. The outcomes of the UN Meeting on the Prevention and Control of Non-communicable Diseases in September 2011 should be harnessed to give further impetus to a future direction for cancer research. It is therefore essential for an academic basis to be laid out for global health that provides definitions and common language for stakeholders. The ACF is seeking to support the creation of an academic platform, or Global Collaborative Cancer Studies, as a means of further promoting the concept of global health in the cancer research community. Global health is founded on concepts of equality and human rights and universities are therefore ideally positioned to promote multi-disciplinary collaborations between science and the humanities. The knowledge created through collaborative studies could also be utilized to inform policymaking and identify new ways to tackle the existing challenges presented by increasing costs and aging populations in developed societies. Given cultural and historical differences the situation surrounding cancer varies significantly from country to country, with health disparities being particularly apparent in the Asian region. By linking universities in global collaborative efforts we can ensure a bottom-up approach to global health that brings together diverse communities. Given the downturn in the global economy we cannot expect that funding for programs to tackle NCDs will be forthcoming. It is therefore imperative to establish a network for assistance to developing countries that is based on our own experiences of overcoming challenges to create successful outcomes. A major challenge is to implement clinical trials in emerging economies, which will require the provision of technical assistance and stronger links between pharmaceutical companies and cancer researchers in emerging economies. The ACF is continuing its research activities on perceptions of cancer among the research community, seeking to build a global network that will overcome health disparities. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4454. doi:1538-7445.AM2012-4454

Health challenges for this decade: From international co-operation to the concept of global health. Implications of clinical specialist co-operation

Health challenges for this decade: From international co-operation to the concept of global health. Implications of clinical specialist co-operation