Responsibility amid the social determinants of health

It is natural to think that there is a tight connection between whether someone is responsible for some outcome and whether it is appropriate to hold her accountable for that outcome. And this natural thought naturally extends to health: if someone is responsible for her health, then, all else being equal, she is accountable for it. Given this, some have thought that responsibility for health has an important role to play in distributing the benefits and burdens of healthcare. But there is a reason for caution. That health is influenced by social, economic, and environmental factors is a matter of consensus. And some have argued that in light of these social determinants of health, individuals are not typically responsible for their health, rendering inappropriate policies that employ a responsibility‐for‐health criterion. This debate implicates a number of overlapping concepts and questions that are often difficult to pull apart. And I worry that those who maintain that social determinants undermine responsibility for health have latched on to the wrong target. The social determinants of health are relevant to such policies, but, I argue, not by globally undermining responsibility. Rather, social determinants are sometimes responsibility‐undermining, sometimes responsibility‐preserving, and often relevant to whether we should hold individuals accountable for their health regardless of their responsibility. This calls for a more nuanced appraisal of the ways in which the social determinants of health are relevant to such policies. And here I attempt to provide one.     

Dynamic health policies for controlling the spread of emerging infections: influenza as an example

The recent appearance and spread of novel infectious pathogens provide motivation for using models as tools to guide public health decision-making. Here we describe a modeling approach for developing dynamic health policies that allow for adaptive decision-making as new data become available during an epidemic. In contrast to static health policies which have generally been selected by comparing the performance of a limited number of pre-determined sequences of interventions within simulation or mathematical models, dynamic health policies produce "real-time" recommendations for the choice of the best current intervention based on the observable state of the epidemic. Using cumulative real-time data for disease spread coupled with current information about resource availability, these policies provide recommendations for interventions that optimally utilize available resources to preserve the overall health of the population. We illustrate the design and implementation of a dynamic health policy for the control of a novel strain of influenza, where we assume that two types of intervention may be available during the epidemic: (1) vaccines and antiviral drugs, and (2) transmission reducing measures, such as social distancing or mask use, that may be turned "on" or "off" repeatedly during the course of epidemic. In this example, the optimal dynamic health policy maximizes the overall population's health during the epidemic by specifying at any point of time, based on observable conditions, (1) the number of individuals to vaccinate if vaccines are available, and (2) whether the transmission-reducing intervention should be either employed or removed.     

Struggling with Imaginaries of Trauma and Trust: The Refugee Experience in Switzerland

This article discusses some effects of migration politics on asylum seekers and refugees and on the Swiss health services. It is based on multisited ethnographic research that tracked interpretative concepts of the refugee experience. Following a grounded theory approach, it identifies imaginaries of trauma and trust as key categories in the field of transnational migration and health. The psychiatric concept of trauma and a more popularized discourse of traumatic memory are strongly emphasized in all of the investigated field sites: the providers of primary health care and psychosocial services and representatives of social welfare agencies and law-making bodies use this "diagnosis" extensively. This leads refugees to develop tactics of a) identifying with the trauma discourse in order to become "good refugees" and achieve legal status in Switzerland; b) struggling with the ascribed pathologies and suffering from retraumatizing effects of these predominant trauma policies; and c) trying to refuse or subvert them by emphasizing the existence of structural violence in the receiving countries. An analysis of the interactions of health providers and refugees shows that it takes place in an environment of social and economic insecurity and in a shared imaginary of (mis)trust, putting at stake the moral economy of recent migration politics and the refugee experience.     

Ecosystem Approach to Rapid Health Assessments among Indigenous Cultures in Degraded Tropical Rainforest Environments: Case Study of Unexplained Deaths among the Secoya of Ecuador

Large-scale economically-driven encroachments into tropical rainforest environments are major factors for disease emergence. A better understanding of the process of disease emergence can be best derived from a multilevel, transdisciplinary ecosystem approach that analyzes health data in its biological, ecological, social, and cultural context. Multiple methods, including ethnographic techniques, are recommended for such an approach. The value of this approach and methodology is presented in this article through a rapid health assessment case study of an unexplained fatal syndrome that occurred among the Secoya peoples of the Ecuadorian Amazon in 1999. This type of study is significant given the lack of health data for indigenous populations at risk of disease emergence. Moreover, indigenous cultures share a long-term, close relationship to the land and each other, which makes information about changes in their environment and health patterns highly salient to them. This local knowledge is of strategic value to researchers working on issues of environmental change and disease emergence.     

Biological impact of social disruption resulting from epidemic disease

Whereas previous research on the disruptive effects of epidemic disease have focused on the ways in which epidemics affect social structure and function, this study focuses on the biological impact of social disruption. The hypothesis is that social disruption resulting from the occurrence of epidemic disease increases the biological impact of the epidemic, as assessed by disease incidence. This hypothesis is explored in terms of a "level of response" model, borrowed from Slobodkin and Rapoport (Q. Rev. Biol. 49:181-200, 1974). The Human Area Relations File (HRAF) provides ethnographic reports of social responses to epidemics. The most frequently reported response in the HRAF is flight or migration away from the locus of the epidemic, followed in frequency by extraordinary preventive and/or therapeutic measures and scapegoating. The model proposes a continuum of responses beginning with responses that are already part of the indigenous response to disease and proceeding through disruptive processes, including flight and rejection of authority systems. Social disruption increases the biological impact of epidemics by robbing the social group of important participants, dismantling public health programs, or producing general economic hardship. The model proposes a scheme for identification of situations under which particular social group responses are "biologically appropriate."     

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.     

Persons, Places, and times: the meanings of repetition in an STD clinic

In this article we work the tensions between the way clinical medicine and public health necessarily construct the problem of "repetition" in the context of a sexually transmitted disease (STD) clinic and the ways patients narrate their illness experiences. This tension-between clinical and epidemiological exigencies and the messiness of lived experience-is a recurring theme of work conducted at the intersections of epidemiology, anthropology, and clinical medicine. Clinically, repeated infections are a threat to the individual body and to "normal" biological processes like reproduction. From a public health perspective, "repeaters" are imagined to be part of a "core group" that keeps infections in circulation, endangering the social body. Yet patients' accounts are anchored in particular social histories, and their experiences rely on different time scales than those implicated in either of these types of readings. Extended analyses are provided of two such accounts: one in which repetition can be "read" as part of a performance of recovery, and one in which repetition is bound up in the effort to avoid becoming the involuntary subject of institutionally administered intervention. We argue the need to open up the category of repeaters to include the social and draw on work by Cheryl Mattingly to suggest that one way to do this in the context of the STD clinic might be to adopt forms of therapeutic practice that make use of interpretive, in addition to technical, skills.     

Negotiating “The Social” and Managing Tuberculosis in Georgia

In this paper I utilize anthropological insights to illuminate how health professionals and patients navigate and negotiate what for them is social about tuberculosis in order to improve treatment outcomes and support patients as human beings. I draw on ethnographic research about the implementation of the DOTS (Directly Observed Therapy, Short Course) approach in Georgia’s National Tuberculosis Program in the wake of the Soviet healthcare system. Georgia is a particularly unique context for exploring these issues given the country’s rich history of medical professionalism and the insistence that the practice of medicine is a moral commitment to society. I argue for critical attention to the ways in which treatment recipients and providers navigate what, for them, is “social” about therapeutic practices and their significance for avoiding biological and social reductionism.     

Diagnostic testing for vaccinomics: is the regulatory approval framework adequate? A comparison of Canada, the United States, and Europe

Vaccinomics aims to integrate variability information from multiple levels of the biological hierarchy from genome to proteome to metabolome, and ways in which these biological parts interact with each other and the environment. Vaccinomics holds significant promise as a new public health tool in designing safer and more effective vaccines for both developed and developing countries. Vaccinomics tests that are envisioned to be used in tandem with vaccine-based health interventions could permit an informed forecast of individual and subpopulation variations in immune responses to vaccines, reduce adverse effects, and contribute to a foundation for rational and directed use of vaccines. A proactive, multidisciplinary engagement with vaccinomics is now timely and much needed in order to develop regulations that best ensure the protection of the public and promote the transition of vaccinomics innovations from discovery to real-life public health applications. This article examines and compares the regulatory oversight of vaccinomics tests in Canada, the United States, and Europe. Recent trends in these jurisdictions suggest that regulatory agencies view personalized genomics/omics medicine, such as vaccinomics, as a desirable goal. At the same time, proposals to increase oversight could impact progress in the field and affect the availability of vaccinomics tests in public health practice and the diagnostic test market. The comparative analysis of vaccinomics in three jurisdictions presented in this article highlights both the convergence and divergence of regulatory oversight. In a rapidly emerging field such as vaccinomics that is pivotal for global public health, achieving better harmonization of policies may be an advantageous target, while ensuring that symmetry exists between the goals of public safety and promoting public health innovation. We suggest it is now timely to proactively initiate a constructive dialogue among all stakeholders (publics, policymakers, researchers, private sector, governments) to foster the development of appropriately targeted regulatory policies in this field.     

Using Risk Assessment as Part of a Systems Approach to the Control and Prevention of HPAIV H5N1

Since its emergence in China in 1996, highly pathogenic avian influenza virus subtype H5N1 has spread across Asia, Africa, and Europe. Countries had to promptly implement control and prevention measures. Numerous research and capacity building initiatives were conducted in the affected regions to improve the capacity of national animal health services to support the development of risk-based mitigation strategies. This paper reviews and discusses risk assessments initiated in several South-East Asian and African countries under one of these projects. Despite important data gaps, the risk assessment results improved the ability of policy makers to design appropriate risk management policies. Disease risk was strongly influenced by various human behavioral factors. The ongoing circulation of HPAIV H5N1 in several Asian countries and in Egypt, despite major disease control efforts, supports the need for an interdisciplinary approach to development of tailored risk management policies, in accordance with the EcoHealth paradigm and the broad concept of risk governance. In particular, active stakeholders engagement and integration of economic and social studies into the policy making process are needed to optimize compliance and sustainable behavioral changes, thereby increasing the effectiveness of mitigation strategies.     

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.     

The practice of health risk assessment in the united states (1975–1995): How the U.S. and other countries can benefit from that experience

The process of quantitatively predicting the likelihood of an adverse response in humans or wildlife due to exposure to one or more chemicals is collectively known as environmental risk assessment. Quantitative risk assessment has been practiced in the United States and Canada for nearly 20 years and is the basis for most environmental and many occupational health regulations in North America. However, only since 1990 has it begun to receive serious consideration in Europe, Australia, Asia, and other regions. This paper reviews the historical evolution of health risk assessment in the United States and the scientific shortcomings in the process that have been introduced due to various regulatory policies. Despite these limitations and the reluctance of some countries to implement risk‐based policies, risk assessment will undoubtedly grow in importance within the international arena as other countries search for an ideal balance between cost and risk reduction. With the emergence of risk analysis as an international tool for understanding environmental issues, several improvements to the risk assessment process are recommended here that the United States and other countries could immediately incorporate into hazard identification, dose‐response and exposure assessments, and risk characterization. Examples of these improvements include use of a weight‐of‐evidence approach, physiologically‐based pharmacokinetic (PB‐PK) modelling, Monte Carlo techniques, and uncertainty analyses. These recommendations could, if coupled with an understanding of the historical experience in the United States, lead to superior environmental risk assessment policies for all countries as they enter the 21st century.     

Salubrious effects of oxytocin on social stress-induced deficits

Social relationships are a fundamental aspect of life, affecting social, psychological, physiological, and behavioral functions. While positive social interactions can attenuate stress and promote health, the social environment can also be a major source of stress when it includes social disruption, confrontation, isolation, or neglect. Social stress can impair the basal function and stress-induced activation of the hypothalamic-pituitary-adrenal (HPA) axis, impairing function of multiple biological systems and posing a risk to mental and physical health. In contrast, social support can ameliorate stress-induced physiological and immunological deficits, reducing the risk of subsequent psychological distress and improving an individual's overall well-being. For better clinical treatment of these physiological and mental pathologies, it is necessary to understand the regulatory mechanisms of stress-induced pathologies as well as determine the underlying biological mechanisms that regulate social buffering of the stress system. A number of ethologically relevant animal models of social stress and species that form strong adult social bonds have been utilized to study the etiology, treatment, and prevention of stress-related disorders. While undoubtedly a number of biological pathways contribute to the social buffering of the stress response, the convergence of evidence denotes the regulatory effects of oxytocin in facilitating social bond-promoting behaviors and their effect on the stress response. Thus, oxytocin may be perceived as a common regulatory element of the social environment, stress response, and stress-induced risks on mental and physical health. This article is part of a Special Issue entitled Oxytocin, Vasopressin, and Social Behavior.     

“Working the System”—British American Tobacco's Influence on the European Union Treaty and Its Implications for Policy: An Analysis of Internal Tobacco Industry Documents

Background

Impact assessment (IA) of all major European Union (EU) policies is now mandatory. The form of IA used has been criticised for favouring corporate interests by overemphasising economic impacts and failing to adequately assess health impacts. Our study sought to assess how, why, and in what ways corporations, and particularly the tobacco industry, influenced the EU''s approach to IA.

Methods and Findings

In order to identify whether industry played a role in promoting this system of IA within the EU, we analysed internal documents from British American Tobacco (BAT) that were disclosed following a series of litigation cases in the United States. We combined this analysis with one of related literature and interviews with key informants. Our analysis demonstrates that from 1995 onwards BAT actively worked with other corporate actors to successfully promote a business-oriented form of IA that favoured large corporations. It appears that BAT favoured this form of IA because it could advance the company''s European interests by establishing ground rules for policymaking that would: (i) provide an economic framework for evaluating all policy decisions, implicitly prioritising costs to businesses; (ii) secure early corporate involvement in policy discussions; (iii) bestow the corporate sector with a long-term advantage over other actors by increasing policymakers'' dependence on information they supplied; and (iv) provide businesses with a persuasive means of challenging potential and existing legislation. The data reveal that an ensuing lobbying campaign, largely driven by BAT, helped secure binding changes to the EU Treaty via the Treaty of Amsterdam that required EU policymakers to minimise legislative burdens on businesses. Efforts subsequently focused on ensuring that these Treaty changes were translated into the application of a business orientated form of IA (cost–benefit analysis [CBA]) within EU policymaking procedures. Both the tobacco and chemical industries have since employed IA in apparent attempts to undermine key aspects of European policies designed to protect public health.

Conclusions

Our findings suggest that BAT and its corporate allies have fundamentally altered the way in which all EU policy is made by making a business-oriented form of IA mandatory. This increases the likelihood that the EU will produce policies that advance the interests of major corporations, including those that produce products damaging to health, rather than in the interests of its citizens. Given that the public health community, focusing on health IA, has largely welcomed the increasing policy interest in IA, this suggests that urgent consideration is required of the ways in which IA can be employed to undermine, as well as support, effective public health policies. Please see later in the article for the Editors'' Summary     

Didactics of molecular ecology

Summary Molecular biology conferred enormous progresses in biosciences during the past few years. This paradigm permutation in biological research certainly challenges biological education. Nevertheless, this is no reason to fundamentally reorganise biological education at the universities. A most entire view of the matter should remain a central request which meets the capacity and imagination of students. Selected biological phenomena taken from the traditional treasury remain suitable in the future too to mediate basic biological ways ot thinking. Forthcoming syllabuses, however, will necessitate the expansion of this concept. The scope of the present contribution is to show, how the integration of molecular biology in the teaching of classical disciplines of biology may be reached. Choosing ecology and environmental biology as examples, molecular biology will not only strengthen explanation models of cause-effect relationships in these disciplines, but also will facilitate the interconnections to interdisciplinary fields such as health education, social, and political education. This may result in an entire structural concept of classical and molecular biology.     

The politics of assessing risk for biological invasions: the USA as a case study

The current regulation of biological invasions rests on an unwarranted presumption (that the invader will cause no harm) and on risk assessment procedures that are narrowly focused, subjective, often arbitrary and unquantified, and subject to political interference. Although this current approach dominates international treaties and most national policies, it has not stemmed the rising tide of biological invasions, as evidenced by several examples from the USA. Technical advances in measuring and predicting impacts of introduced species will improve risk assessments. Additionally, focusing squarely on the risks associated not only with a proposed species introduction, but also on the goals of the introduction and on alternative ways of achieving them, would lead to more-informed decisions permitting the introduction of a species and fewer problematic invaders. In assessing the alternatives to introductions, the precautionary principle should be given heavy weight, as should the distribution of possible costs and benefits.     

Self-efficacy and the promotion of health for depressed single mothers

Single mothers are a vulnerable population at risk for poor mental and physical health. This paper discusses the mental and physical health of single mothers, as well as the psychosocial and socio-economic risk factors placing single mothers at risk for poor health outcomes. Some of these include, gender, income level, educational status, social support, stress and certain personality characteristics. Theoretical models with the potential to explore ways to promote health in depressed single mothers will also be presented. The paper concludes with the application of these models to primary prevention and the promotion of health for single mothers along with recommendations for future research.     

Social responsibility in human genetics – a survey

The potential for molecular biological manipulation of human beings is a challenge to the social responsibility of human geneticists. The concept of individual healthcare is compromised by a reductionist approach to human biology which defines health solely in terms of genetics. The ability of professionals working in the fields of molecular biology and human genetics to understand the wider social context of their work and the effects it may have on individual health is rarely discussed. This is a report of a survey of social attitudes and awareness carried out among molecular biologists and human geneticists in Germany. The results reveal differences in the understanding of health and these perceptions are shown to depend on the age and gender of the professionals involved.