The oral biome in the aetiology and management of dental disease: Current concepts and ethical considerations

Our understanding of the complexity of the oral biome and of the role of the various constituent bacteria in the aetiology of dental disease is growing. Probiotics and their relationship with prebiotics, as well as other microbiome‐based interventions, could be useful in preventing and treating dental disease and in promoting oral health. However, given the promise and early stage of this treatment approach, there are also a number of ethical, social and regulatory issues associated with innovative probiotic therapy. In this article, a brief update is given on contemporary theories of the aetiology and management of the two commonest dental diseases, and on the roles of pre‐ and probiotics and oral biome transplant in the management of these diseases. The focus is primarily on four core issues: informed consent, risk–benefit assessment, how to determine suitable healthy donors, and commercialization and regulation. We discuss the safety and benefits of oral probiotics, not only concerning the products and quality control during their manufacture, but also regarding the depth of public knowledge about this topic. We point out that the requirement of listing ingredients honestly might be insufficient, and that the prevalent rhetoric of ‘natural’ and ‘organic’ as well as some health claims in the translational, innovative probiotic industry and markets are themselves misleading and should be carefully scrutinized. Finally, we suggest an ethical imperative to find a balance between scientific research and industry, and public health in the regulation of probiotics.     

美国、加拿大环境和健康风险管理方法

对目前美国和加拿大多个部门使用的风险评价与风险管理方法进行了全面回顾和综合分析,论述各种不同方法的特征,深入探讨各种管理方法的基础、利弊、使用经验,辨识环境、人类健康和职业健康风险综合方法中应该包含的要素,阐述风险管理目标的确定方法,以期为中国的环境风险管理提供经验。     

The dynamics of health and return migration

The increasing importance and complexity of migration globally also implies a global increase in return migration, and thus an increased interest in the health of returning migrants. The health of returning migrants is impacted by the cumulative exposure to social determinants and risk factors of health during the migration process, during the return movement, and following return. Circular migration often occurs among the diaspora, which can result in the transfer of knowledge and skills that contribute to development, including health system strengthening. Migrants with dual nationality often return to countries with better health services than their country of origin when they are sick and can not get care at home. To maintain and improve the health of returning migrants, multi-sectoral policies at global and national levels should facilitate access to appropriate and equitable health services, social services, and continuity of care across and within borders.     

Precautionary Health Risk Assessment: Case Study of Biological Insecticides

In conventional risk assessment approaches, experts define the scientific questions that can legitimately be asked and the burden of proof is on the potentially exposed community to show that a proposal is unsafe. Here I propose an alternative approach, precautionary health risk assessment, in which the scientific questions to be addressed are defined by community consultation. I illustrate the approach with a case study of exposure to biological insecticides. This illustrates how community consultation can have a critical influence on the outcome of a health risk assessment. Government agencies may be reluctant to involve stakeholders in health risk assessments because this involves a loss of political control of the process. However, precautionary approaches are likely to lead to better health outcomes where decision stakes and scientific uncertainty are both high.     

Risk Ranking by the British Public: A Survey of Worry About a Broad Spectrum of Risk Issues

Much attention has focused on people's concerns about technological and environmental risks, but it is important to acknowledge that these are not the only risks that individuals have to face. In this article we present the results of a national survey ranking levels of worry across a broader spectrum of risk issues, including ‘lifestyle’, social welfare, financial and personal safety risks. A total of 1742 interviews were conducted, at home, among a nationally representative quota sample of adults age 15+ in Great Britain. Field work took place between January 24 to 27, 1997. Respondents' spontaneous mentions of worry centered on issues to do with health, education, and money. When prompted, respondents expressed most concern about a number of social issues, while certain ‘lifestyle’ factors identified as significant risks to health were accorded only low levels of worry. The survey demonstrates that risk issues that engage some expert attention do not always have the same immediacy for the general public. Thus, while technological and environmental risks certainly deserve attention, they should not overshadow consideration of other risks that have equal if not greater implications for people's lives.     

Telomeres and race: what can we learn about human biology from health differentials?

The advent of molecular technology that can be applied across large population samples has added – rather than reduced – complexity in the analysis of the intertwined effects of social history and heritable factors on health outcomes. The report by Hunt et al . in this issue of Aging Cell provides an example of the promises and dilemmas associated with this increased complexity.     

Options for Managing Invasive Marine Species

Marine biological invasions are increasingly recognised as a threat to biodiversity and coastal industry, including fisheries. Globally, efforts are underway to contain, if not eradicate, several high-impact marine invasive species. However, working in a marine environment places unique social, political and technical constraints on options for pest control, which we explored in a series of stakeholder workshops. Results suggest that current efforts are low risk and publicly acceptable, but have a low probability of success against established invaders. However, techniques deemed likely to be successful and ultimately needed in a marine context are currently more contentious for social and political reasons. To control introduced marine pests, scientists and managers will need to overcome perceptual biases among marine stakeholders, develop a decision-making framework for what is perceived to be an open system, and focus on technologies likely to be both effective and publicly and politically acceptable.     

The Health Risk Assessment Approach,a Tool for Managing Risks on the Scale of a Territory: A French Experience

In France, regulatory analysis of the environment and human health potential consequences is implemented for an isolated industrial activity that requests an authorization to operate using the health risk assessment method. To date, the question is enlarged to the impact of the combination of multiple sources of pollution on the same territory. The main conclusions of the work launched by the French High Council of Public Health focus on four key points: (i) the utility of conducting such an analysis at a territory scale, (ii) the delimitation of the area, (iii) the conditions for the different stakeholders’ involvement, and (iv) the methodological specificities of the “zone health risk assessment.” The work encompassed literature reviews, seminars, and interviews of stakeholders. The utility of a Z-HRA is the central objective for the management of risk. It can no longer be conducted only for itself. The delimitation of the zone entails economic, political, environmental, and population aspects. Stakeholders become key actors in a steering and monitoring committee. Among methodological specificities, cumulative exposure comes first. Interpretation of the results should focus on risk management objectives. Finally, inclusion of Z-HRAs in flexible regulations that can be adapted to the local context is recommended.     

Society as Cause and Cure: The Norms of Transgender Social Medicine

This article analyzes how trans health was negotiated on the margins of psychiatry from the late 1970s and early 1980s. In this period, a new model of medical transition was established for trans people in Norway. Psychiatrists and other medical doctors as well as psychologists and social workers with a special interest and training in social medicine created a new diagnostic and therapeutic regime in which the social aspects of transitioning took center stage. The article situates this regime in a long Norwegian tradition of social medicine, including the important political role of social medicine in the creation of the postwar welfare state and its scope of addressing and changing the societal structures involved in disease. By using archival material, medical records and oral history interviews with former patients and health professionals, I demonstrate how social aspects not only underpinned diagnostic evaluations but were an integral component of the entire therapeutic regime. Sex reassignment became an integrative way of imagining and practicing psychiatry as social medicine. The article specifically unpacks the social element of these diagnostic and therapeutic approaches in trans medicine. Because the locus of intervention and treatment remained the individual, an approach with subversive potential ended up reproducing the norms that caused illness in the first place: “the social” became a conformist tool to help the patient integrate, adjust to and transform the pathology-producing forces of society.

     

Social Determinants of Health in Environmental Justice Communities: Examining Cumulative Risk in Terms of Environmental Exposures and Social Determinants of Health

Residents of environmental justice (EJ) communities may bear a disproportionate burden of environmental health risk, and often face additional burdens from social determinants of health. Accounting for cumulative risk should include measures of risk from both environmental sources and social determinants. This study sought to better understand cumulative health risk from both social and environmental sources in a disadvantaged community in Texas. Key outcomes were determining what data are currently available for this assessment, clarifying data needs, identifying data gaps, and considering how those gaps could be filled. Analyses suggested that the traditionally defined EJ community in Port Arthur may have a lower environmental risk from air toxics than the rest of the City of Port Arthur (although the entire city has a higher risk than the average for the state), but may have a larger burden from social determinants of health. However, the results should be interpreted in light of the availability of data, the definitions of community boundaries, and the areal unit utilized. Continued focus on environmental justice communities and the cumulative risks faced by their residents is critical to protecting these residents and, ultimately, moving toward a more equitable distribution and acceptable level of risk throughout society.     

Unraveling the Chimera: A Corporate View of the Precautionary Principle

Current controversy regarding how and when the precautionary principle should be applied to the introduction of new technology has created a false dichotomy, a dichotomy between conventional, risk-based decision making and an alternative paradigm that seemingly denounces risk assessment. As we compare views of the precautionary principle relative to our own operating standards for ensuring human and environmental safety, we perceive no irreconcilable conflict. Due precaution is entirely consistent with sound, cost-effective management of the risks and uncertainties inherent in new technologies. The principle guides prudent risk management actions under a prescribed set of circumstances, i.e., potentially serious or irreversible risks, or incomplete characterization (high uncertainty). In order to enable technological innovation toward a more sustainable future, it is critical that any preventative measures taken under these circumstances be provisional in nature, pending adequate risk characterization. As with all risk management decisions, we contend that the principle requires consideration of a suite of factors beyond risk assessment, including political, social, legal and cultural considerations to tailor the measures proportionately to the risk at hand. Overall, we are encouraged to find relatively broad agreement in this interpretation with a number of key multinational governmental and trade institutions.     

HEART DISEASE AND SOCIAL INEQUALITY: ETHICAL ISSUES IN THE AETIOLOGY, PREVENTION AND TREATMENT OF HEART DISEASE

Heart disease is a complex condition that is a leading cause of death worldwide. It is often seen as a disease of affluence, yet is strongly associated with a gradient in socio-economic status. Its highly complex causality means that many different facets of social and economic life are implicated in its aetiology, including factors such as workplace hierarchy and agricultural policy, together with other well-known factors such as what passes for individual 'lifestyle'. The very untangling of causes for heart disease thus inevitably raises social, moral and political issues. These include the proper role of the individual and of larger social forces in its aetiology, prevention and treatment. The construction of risk factors for heart disease likewise is enmeshed with questions of distributive justice in the responsible targeting of those at risk for heart disease, a debate which has received much overt attention in the medical literature, but less attention within the ethical literature. Strategies for addressing a condition of such complex causality can be highly diverse, from pharmaceutical to social interventions, and value issues attach to the choice and presentation of such strategies. For example, prevention strategies may raise complex issues of responsibility and of judgements of what it is to 'live well'. Further ethical debate on this highly political disease would be welcome.     

Public health and carrageenan regulation: a review and analysis

The status of carrageenan in the regulatory sphere influences how and where it may be used, with implications for seaweed farmers, carrageenan manufacturers and consumers. Over the period 1935 to the present the status of carrageenan has been effected by changes in the regulatory environment that reflect new understandings about carrageenan, health and health risks as well as broader trade, social and political changes. This paper reviews regulatory progress from the 1930s to the present. It reflects, in particular, the shifting priorities in public health and their effects on the regulatory status of carrageenan. Four case studies of public controversies about carrageenan safety are discussed in relation to regulatory responses and their public health significance. It is concluded that current assessments of risk associated with carrageenan have, in some contexts, failed to take into account the full spectrum of safety assessments that have been carried out and the maturing of food additive regulations thereby allowing a myth of risk to continue.     

Risk Perception and Chronic Exposure to Organochlorine Pesticides in Maya Communities of Mexico

In order to analyze risk perception related to the use and handling of organochlorine pesticides (OCP) in agricultural and livestock activities among Maya communities of Yucatan, Mexico, and to study their impact on public health and the environment, we conducted an analytical study applying 274 semi-structured interviews in 11 municipalities in the zone called “Ring of Cenotes.” The harmful effects of agrochemicals on water supplies, soils, air, and human health were considered, including the indoor use of pesticides to preserve harvest products. Recent studies showed high levels of OCP in groundwater. A generalized low risk perception related to human health and the environment due to pesticide use was found. Likewise, social parameters were analyzed, including the educational level, as well as risk factors related to groundwater karst vulnerability. Pesticides that have been banned by international conventions are still in use. The occurrence of some diseases such as cervical cancer, with a very high prevalence at the national level, and the practice of obtaining drinking water from polluted wells and sinkholes, may be associated with this low risk perception and with poor social conditions. Establishing programs on health education, agro-ecological production alternatives, and water chemical quality monitoring is recommended.     

The Concept of Data Utility in Health Risk Assessment: A Multi-Disciplinary Perspective

Human and ecological health risk assessments and the decisions that stem from them require the acquisition and analysis of data. In agencies that are responsible for health risk decision-making, data (and/or opinions/judgments) are obtained from sources such as scientific literature, analytical and process measurements, expert elicitation, inspection findings, and public and private research institutions. Although the particulars of conducting health risk assessments of given disciplines may be dramatically different, a common concern is the subjective nature of judging data utility. Often risk assessors are limited to available data that may not be completely appropriate to address the question being asked. Data utility refers to the ability of available data to support a risk-based decision for a particular risk assessment. This article familiarizes the audience with the concept of data utility and is intended to raise the awareness of data collectors (e.g., researchers), risk assessors, and risk managers to data utility issues in health risk assessments so data collection and use will be improved. In order to emphasize the cross-cutting nature of data utility, the discussion has not been organized into a classical partitioning of risk assessment concerns as being either human health- or ecological health-oriented, as per the U.S. Environmental Protection Agency's Superfund Program.     

RISK DETECTION IN INDIVIDUAL HEALTH CARE: ANY LIMITS?

Background: Biomedical science is producing an avalanche of data about risk factors, often with a small predictive value, associated with a broad diversity of diseases. Prevention and screening are increasingly moving from public health into the clinic. Therefore, the question of which risk factors to investigate and disclose in the individual patient, becomes ethically increasingly urgent. In line with Wilson and Jungner's public health‐related 10 principles for screening, it seems crucial to distinguish important from unimportant health risks. Aim: to explore the ways in which clinicians distinguish important from unimportant health risks. Methods: We interviewed 36 respondents (gastroenterologists and gynaecologists/obstetrics) in 5 focus group interviews and 15 open in‐depth interviews on their interpretation of what makes a health risk important. Results: Physicians primarily interpreted importance as the severity of the possible harm, less often its probability. Possibilities of prevention or reassurance strongly influenced their judgment on importance. Discussion: It is not likely that interpreting ‘important’ as ‘severe’ will help in differentiating meaningful from meaningless risk knowledge. A more fundamental change in our ways of dealing with risk may be called for. We discuss existing literature on resilience as an alternative way to deal with risk. Balancing prevention and risk reduction with resilience could be a fruitful direction.     

Panglobalism and pandemics: ecological and ethical concerns

A pandemic is a human medical problem but must be understood at multiple levels. Analysis of social and commercial forces is vital, and, more comprehensively, an ecological framework is necessary for an inclusive picture. Ecological health webworked with political and social determinants surrounds issues of human health. In this constellation of both natural and social factors, ethical concerns will arise at these multiple levels, from human health to the conservation and health of wild nature.     

Institutional Development in the Face of Complexity: Developing Rules for Managing Forest Resources

The ability to develop institutions is constrained by human capacity to cope with complexity. But complexity is multidimensional and it is not clear which forms of complexity present the greatest challenges for institutional development. In the context of natural resources, the predictability of resource availability affects expectations that an individual or group will be able to capture the benefits of management. In addition, incomplete understanding of cause-and-effect relationships creates uncertainty about the consequences of alternative management options. These features influence calculations about resource management. The importance of resource complexity relative to various social, political, and institutional factors known to influence collective choice remains an open question. We evaluate the relative importance of several forms of resource complexity and characteristics of resource users for the development of rules for management for forest products in Indiana.     

Chikotsa--secrets, silence, and hiding: social risk and reproductive vulnerability in central Mozambique

In this article, I examine pregnancy narratives and patterns of reproductive health seeking among women of fertile age in central Mozambique. I map the interplay between gendered economic marginalization, maternal risk perceptions, and pregnancy management strategies. By interpreting my data in light of Shona illness theories, I illuminate the ways that embodied experiences of reproductive vulnerability, risk perceptions, and social inequalities are linked: women attribute the most serious maternal complications to human- or spirit-induced reproductive threats of witchcraft and sorcery. This construction of reproductive vulnerability as social threats related to material and social competition significantly influences prenatal health seeking. Data reveal the structural and cognitive gap between biomedical constructions of risk and lay social threat perceptions. Plural health care systems are strategically utilized by women seeking to minimize both social and biological harm. On-the-ground ethnography shows that maternal health initiatives must take this plurality into full and accommodative account to achieve viable improvements in reproductive care and outcomes.     

Fair regression for health care spending

The distribution of health care payments to insurance plans has substantial consequences for social policy. Risk adjustment formulas predict spending in health insurance markets in order to provide fair benefits and health care coverage for all enrollees, regardless of their health status. Unfortunately, current risk adjustment formulas are known to underpredict spending for specific groups of enrollees leading to undercompensated payments to health insurers. This incentivizes insurers to design their plans such that individuals in undercompensated groups will be less likely to enroll, impacting access to health care for these groups. To improve risk adjustment formulas for undercompensated groups, we expand on concepts from the statistics, computer science, and health economics literature to develop new fair regression methods for continuous outcomes by building fairness considerations directly into the objective function. We additionally propose a novel measure of fairness while asserting that a suite of metrics is necessary in order to evaluate risk adjustment formulas more fully. Our data application using the IBM MarketScan Research Databases and simulation studies demonstrates that these new fair regression methods may lead to massive improvements in group fairness (eg, 98%) with only small reductions in overall fit (eg, 4%).