JUSTICE, STIGMA, AND THE NEW EPIDEMIOLOGY OF HEALTH DISPARITIES

Recent research in epidemiology has identified a number of factors beyond access to medical care that contribute to health disparities. Among the so-called socioeconomic determinants of health are income, education, and the distribution of social capital. One factor that has been overlooked in this discussion is the effect that stigmatization can have on health. In this paper, I identify two ways that social stigma can create health disparities: directly by impacting health-care seeking behaviour and indirectly through the internalization of negative interpersonal judgments. I then argue that social arrangements that foster self-respect can reduce the impact of stigmatization on health disparities. I conclude by showing how John Rawls' conception of justice can be used to address the intersection of stigma, health, and self-respect, in contrast to critics of his position, who have seen him as excessively focused on the allocation of material goods.     

Stigmatization and Denormalization as Public Health Policies: Some Kantian Thoughts

The stigmatization of some groups of people, whether for some characteristic they possess or some behavior they engage in, will initially strike most of us as wrong. For many years, academic work in public health, which focused mainly on the stigmatization of HIV‐positive individuals, reinforced this natural reaction to stigmatization, by pointing out the negative health effects of stigmatization. But more recently, the apparent success of anti‐smoking campaigns which employ stigmatization of smokers has raised questions about whether stigmatization may sometimes be justified, because of its positive effects on public health. Discussion of the issue so far has focused on consequences, and on some Kantian considerations regarding the status of the stigmatized. In this article, I argue that further Kantian considerations regarding the treatment of the general public (the potential stigmatizers) also count against any public health policy involving stigmatization. Attempts to encourage stigmatization are likely to fail to appeal to the rational decision‐making abilities of the general public, and the creation of stigmatized groups (even if they are stigmatized for their voluntary behavior) is an obstacle to the self‐improvement of members of the general public.     

STIGMATIZATION AND PUBLIC HEALTH ETHICS

Encouraged by the success of smoking denormalization strategies as a tobacco‐control measure, public health institutions are adopting a similar approach to other health behaviors. For example, a recent controversial ad campaign in New York explicitly aimed to denormalize HIV/AIDS amongst gay men. Authors such as Scott Burris have argued that efforts like this are tantamount to stigmatization and that such stigmatization is unethical because it is dehumanizing. Others have offered a limited endorsement of denormalization/stigmatization campaigns as being justified on consequentialist grounds; namely, that the potential public health benefits outweigh any stigmatizing side effects. In this paper, I examine and reject the blanket condemnation of stigmatization efforts in public health. I argue that the moral status of such efforts are best evaluated within a contractualist, as opposed to a consequentialist, framework. Contractualism in public health ethics asks whether a particular stigmatizing policy could be justified to reasonable individuals who do not know whether they will be affected by that policy. Using this approach, I argue that it is sometimes permissible for public health institutions to engage in health‐related stigmatization.     

<Emphasis Type="Italic">Isla Evangelista—</Emphasis>A Story of Church and State: Puerto Rico’s Faith-Based Initiatives in Drug Treatment

This article describes the debates leading to Puerto Rico’s Mental Health Law of 2000, which defined addiction as a spiritual and social problem rather than a mental disorder, in order to trace three competing approaches to addiction in Puerto Rico: evangelist, biomedical, and harm-reductionist. Highlighting the ways in which the evangelist approach of Puerto Rican street ministries challenges the individualism underlying US faith-based initiatives and the punitive approach of the US War on Drugs, this article concludes that the virtues of the evangelist approach to addiction would be best supported by public funding for biomedical and harm-reduction approaches within a pluralistic system of treatment for addiction.     

Stigmatization of patients suffering from schizophrenia

For the general public, but also for healthcare professionals, schizophrenia is still one of those areas of medicine connected with feelings of unease, fear and prejudice. These feelings lead to stigmatization and discrimination which are unjust processes which put patients suffering from mental illnesses into undesirable and unequal positions. Aim of this research was to establish the extent of stigmatization of mentally ill patients among the population of healthcare professionals and future healthcare professionals and if they differ from general population. Results show that stigmatization of schizophrenic patients is high among all included populations. Although there were no statistical differences between groups regarding the assessment of schizophrenic patients, nurses employed in psychiatric wards exhibited a tendency towards higher acceptance of schizophrenic patients, as well as better understanding of that illness. This data emphasizes a growing need for continuous education of general population but also of healthcare professionals.     

Childhood sexual abuse and HIV risk among crack-using commercial sex workers in San Salvador, El Salvador: a qualitative analysis

This article explores the relationship between childhood sexual abuse (CSA) and later HIV risk. It draws on qualitative, in-depth interviews with 40 women who either used crack or engaged in commercial sex work in the greater metropolitan area of San Salvador, El Salvador, 28 of whom experienced CSA. Although the relationship between CSA and later HIV risk has been clearly demonstrated, the processes that lead women who have experienced CSA to experience HIV risk are unclear. The theoretical model presented here incorporates the psychological effects of CSA, particularly stigmatization, as well as its social consequences and the larger context of poverty in which these women live. The meanings women draw from past abuse experiences and their rationale for choices made help explain the association between CSA and later risk as mediated through sex work and crack addiction. Self-report data gathered in this study indicate that HIV prevalence may be considerably higher in this high-risk population than Salvadoran national rates.     

Expansion of gambling in Canada: implications for health and social policy

Canada experienced a dramatic increase in legalized gambling in the 1990s, primarily because of governments'' need to increase revenue without additional taxation. This article examines gambling from a public health perspective. The major public health issues include gambling addiction, family dysfunction and gambling by youth. Debates have emerged about the health, social and economic costs and benefits of gambling. Stakeholder and social policy groups have expressed concern about the impact of expanded gambling on the quality of life of individuals, families and communities. Epidemiological studies show that the prevalence of gambling in the general adult population is low but increasing. Of particular concern is the high though steady prevalence of gambling among youth. New technologies have been linked to gambling-related problems such as addiction to gambling by video lottery terminals. Gambling by means of the Internet represents another emerging issue. The article concludes with recommendations for health and social policy related to gambling. These recommendations incorporate a broad public health approach to create a strong research program and to balance risks and benefits.     

Pharmacogenetic approaches to the treatment of alcohol addiction

Addictive disorders are partly heritable, chronic, relapsing conditions that account for a tremendous disease burden. Currently available addiction pharmacotherapies are only moderately successful, continue to be viewed with considerable scepticism outside the scientific community and have not become widely adopted as treatments. More effective medical treatments are needed to transform addiction treatment and address currently unmet medical needs. Emerging evidence from alcoholism research suggests that no single advance can be expected to fundamentally change treatment outcomes. Rather, studies of opioid, corticotropin-releasing factor, GABA and serotonin systems suggest that incremental advances in treatment outcomes will result from an improved understanding of the genetic heterogeneity among patients with alcohol addiction, and the development of personalized treatments.     

A novel cross-talk between endothelin and ErbB receptors controlling glutamate transporter expression in astrocytes

The endothelin and epidermal growth factor (EGF) systems are central to the control of reactive brain processes and are thought to partly exert these tasks by endothelin-induced transactivation of the epidermal growth factor receptor (EGFR) Here we show that beyond EGFR transactivation, endothelins prevent the ligand-induced internalization of the EGFR. We unravel that endothelins abrogate internalization of the EGFR by either promoting the formation of "internalization-deficient" EGFR/ErB2-heterodimers or by activating c-Abl kinase, a negative regulator of EGFR internalization. We further provide evidence that this cross-talk is operational in the control of astrocytic glutamate transport. Specifically, we establish that the inhibitory effects exerted by endothelins on basal as well as EGF-induced expression of the major astroglial glutamate transporter subtype, glutamate transporter 1, are a direct consequence of the endothelin-dependent retention of the EGFR at the cell surface. Together our findings unravel a previously unknown cross-talk between endothelin and epidermal growth factor receptors, which may have implications for a variety of pathological conditions.     

The injustice of fat stigma

Fatness stigma is pervasive. Being fat is widely regarded a bad thing, and fat persons suffer numerous social and material disadvantages in virtue of their weight being regarded that way. Despite the seriousness of this problem, it has received relatively little attention from analytic philosophers. In this paper, I set out to explore whether there is a reasoned basis for stigmatizing fatness, and, if so, what forms of stigmatization could be justified. I consider two lines of reasoning that might be advanced to defend fat stigma. The first is broadly consequentialist. It seeks to justify stigmatizing fatness based on the public health benefits that might be produced by doing so. The second argument takes stigmatizing fatness to be a warranted response to the morally blameworthy failure to slim down exhibited by fat persons. Clarifying and assessing each of these two lines of reasoning is the main task of this paper. I argue that, upon careful examination, both these attempts to justify the stigmatization of fatness fail.     

Economic approaches to smoking

In order to assess regulator's legitimacy in discouraging people from smoking, economists model tobacco addiction. In this paper, we review the extent economic literature about tobacco consumption and tobacco addiction. Two main approaches are singled out. In the first section, we detail the main characteristics of the two main theoretical models : rational addiction on one hand, which stylises individual choosing now to give up their future liberty to choose whether or not to smoke; and health capital on the other hand, following which individuals trade off between current pleasure and life expectancy. Second section gives account of the empirical tests of these two theories, before a last section briefly discusses and concludes. We show that the health capital theory seems to pass the test better than the rational addiction model. It is important to discriminate between these two models, from a political economy point of view. Were rational addiction true, a constant and strong increase of taxes on tobacco would be the soundest policy to curb consumption. On the contrary, if smokers are trapped into addiction and can't stop without pain, then tax increase is imposing too much strain on them, for no result. An efficient policy would be to subsidise quitting programmes, or to help smokers reducing their consumption through partial prohibition (in public transports for instance).     

Clathrin-independent internalization and recycling

The functionality of receptor and channel proteins depends directly upon their expression level on the plasma membrane. Therefore, the ability to selectively adjust the surface level of a particular receptor or channel protein is pivotal to many cellular signaling events. The internalization and recycling pathway plays a major role in the regulation of protein surface level, and thus has been a focus of research for many years. Although several endocytic pathways have been identified, most of our knowledge has come from the clathrin-dependent pathway, while the other pathways remain much less well defined. Considering that clathrin-independent internalization may account for as much as 50% of the total endocytic activity in the cell, the lack of such knowledge constitutes a major gap in our efforts to understand how different internalization pathways are utilized and coordinated. Recent studies have provided valuable insights into this area, yet many more questions still remain. In this review, we will give a panoramic introduction to the current knowledge of various internalization and recycling pathways, with an emphasis on the latest findings that have broadened our view of the clathrin-independent pathways. We will also dedicate one section to the emerging studies of the clathrin-independent internalization pathways in neuronal cells.     

Disease avoidance as a functional basis for stigmatization

Stigmatization is characterized by chronic social and physical avoidance of a person(s) by other people. Infectious disease may produce an apparently similar form of isolation-disease avoidance-but on symptom remission this often abates. We propose that many forms of stigmatization reflect the activation of this disease-avoidance system, which is prone to respond to visible signs and labels that connote disease, irrespective of their accuracy. A model of this system is presented, which includes an emotional component, whereby visible disease cues directly activate disgust and contamination, motivating avoidance, and a cognitive component, whereby disease labels bring to mind disease cues, indirectly activating disgust and contamination. The unique predictions of this model are then examined, notably that people who are stigmatized evoke disgust and are contaminating. That animals too show avoidance of diseased conspecifics, and that disease-related stigma targets are avoided in most cultures, also supports this evolutionary account. The more general implications of this approach are then examined, notably how it can be used to good (e.g. improving hygiene) or bad (e.g. racial vilification) ends, by yoking particular labels with cues that connote disease and disgust. This broadening of the model allows for stigmatization of groups with little apparent connection to disease.     

Internalization and recycling of human mu opioid receptors expressed in Sf9 insect cells

Internalization and recycling of G protein-coupled receptors (GPCRs), such as the mu-opioid receptor, largely depend on agonist stimulation. Agonist-promoted internalization of some GPCRs has been shown to mediate receptor desensitization, resensitization, and down-regulation. In this study, we investigated whether different mu opioid agonists displayed different effects in receptor internalization and recycling, the potential mechanisms involved in ohmefentanyl-induced internalization process. In transfected Sf9 insect cells expressing 6His-tagged wild type mu opioid receptor, exposure to 100 nM ohmefentanyl caused a maximum internalization of the receptor at 30 min and receptors seemed to reappear at the cell membrane after 60 min as determined by radioligand binding assay. Ohmefentanyl-induced human mu opioid receptor internalization was concentration-dependent, with about 40% of the receptors internalized following a 30-min exposure to 1 microM ohmefentanyl. 10 microM morphine and 1 microM DAMGO could also induce about 40% internalization. The antagonist naloxone and pretreatment with pertussis toxin both blocked ohmefentanyl-induced internalization without affecting internalization themselves. Incubation with sucrose 0.45 M significantly inhibited ohmefentanyl-induced internalization of the mu receptor. The removal of agonists ohmefentanyl and morphine resulted in the receptors gradually returning to the cell surface over a 60 min period, while the removal of agonist DAMGO only partly resulted in the receptor recycling. The results of this study suggest that ohmefentanyl-induced internalization of human mu opioid receptor in Sf9 insect cells occurs via Gi/o protein-dependent process that likely involves clathrin-coated pits. In addition, the recycling process displays the differential modes of action of different agonists.     

Modeling neutralization of Shiga 2 toxin by A-and B-subunit-specific human monoclonal antibodies

A mathematical model for Shiga 2 toxin neutralization by A-and B-subunit-specific human monoclonal antibodies initially delivered in the extracellular domain is presented, taking into account toxin and antibodies interaction in the extracellular domain, diffusion of toxin, antibodies, and their reaction products toward the cell, the receptor-mediated toxin and complex composed of toxin and antibody to A-subunit internalization from the extracellular into the intracellular medium and excretion of this complex back to the extracellular environment via recycling endosomal carriers. The retrograde transport of the intact toxin to the endoplasmic reticulum and its anterograde movement back to the vicinity of the plasma membrane with its subsequent exocytotic removal to the extracellular space via the secretory vesicle pathway is also taken into account. The model is composed of a set of coupled PDEs. A mathematical model based on a system of ODEs for Shiga 2 toxin neutralization by antibodies in the absence of cell is also studied. Both PDE and ODE systems are solved numerically. Numerical results are illustrated by figures and discussed.     

Can the Chronic Administration of the Combination of Buprenorphine and Naloxone Block Dopaminergic Activity Causing Anti-reward and Relapse Potential?

Opiate addiction is associated with many adverse health and social harms, fatal overdose, infectious disease transmission, elevated health care costs, public disorder, and crime. Although community-based addiction treatment programs continue to reduce the harms of opiate addiction with narcotic substitution therapy such as methadone maintenance, there remains a need to find a substance that not only blocks opiate-type receptors (mu, delta, etc.) but also provides agonistic activity; hence, the impetus arose for the development of a combination of narcotic antagonism and mu receptor agonist therapy. After three decades of extensive research, the federal Drug Abuse Treatment Act 2000 (DATA) opened a window of opportunity for patients with addiction disorders by providing increased access to options for treatment. DATA allows physicians who complete a brief specialty-training course to become certified to prescribe buprenorphine and buprenorphine/naloxone (Subutex, Suboxone) for treatment of patients with opioid dependence. Clinical studies indicate that buprenorphine maintenance is as effective as methadone maintenance in retaining patients in substance abuse treatment and in reducing illicit opioid use. With that stated, we must consider the long-term benefits or potential toxicity attributed to Subutex or Suboxone. We describe a mechanism whereby chronic blockade of opiate receptors, in spite of only partial opiate agonist action, may ultimately block dopaminergic activity causing anti-reward and relapse potential. While the direct comparison is not as yet available, toxicity to buprenorphine can be found in the scientific literature. In considering our cautionary note in this commentary, we are cognizant that, to date, this is what we have available, and until such a time when the real magic bullet is discovered, we will have to endure. However, more than anything else this commentary should at least encourage the development of thoughtful new strategies to target the specific brain regions responsible for relapse prevention.     

药物成瘾的神经生物学机制研究

药物滥用既是全球普遍存在的公共卫生问题,又是危害严重的社会问题。药物成瘾的本质是一种以药物引起的基因表达和神经突触可塑性改变为基础的病理性记忆。主要介绍国内外近年的重要研究成果。     

Focus: Personalized Medicine: Precision in Addiction Care: Does It Make a Difference?

This perspective article explores the possibilities of precision in addiction care — even better individually fitted or tailor-made care — and examines what changes we need to make in order to realize sensible progress in epidemiological key figures. The first part gives a short review on the development of addiction care and tries to answer the question of where we stand now and what has been achieved in addiction science through the development and evaluation of interventions in the past decades. Following this analysis, attention will be paid to what lies ahead. This second part focuses on the question of how addiction care can deal with the consequences of the emerging paradigm of personalized or precision medicine, which is based on the fundamental assumption that individual differences matter. Finally, some limitations and conditions as well as tasks and goals for progress are raised. In conclusion, it is argued that integration of addiction care in (mental) health care in the future is desirable.     

The Coevolution of Secrecy and Stigmatization

We propose a coevolutionary model of secrecy and stigmatization. According to this model, secrecy functions to conceal potential fitness costs detected in oneself or one’s genetic kin. In three studies, we found that the content of participants’ distressing secrets overlapped significantly with three domains of social information that were important for inclusive fitness and served as cues for discriminating between rewarding and unrewarding interaction partners: health, mating, and social-exchange behavior. These findings support the notion that secrecy functions primarily as a defense against stigmatization by suppressing information about oneself or one’s kin that evolutionarily has been devalued in mating and social exchange.