Obstetric violence as immigration injustice: A view from the United States and Colombia

In September 2020, Project South, along with numerous other organizations, released a report detailing abuses in a Georgia Detention Center – including forced hysterectomies. Whatever other factors are at play, one of them is an intrinsic connection between obstetric violence against pregnant migrants and immigration injustice. It is not incidental that these acts – in US detention centers, along the US-Mexico border, in Colombian hospitals and clinics – are being perpetrated on immigrant bodies. And it is not accidental or random which immigrant bodies are vulnerable to these violations. Understanding and confronting obstetric violence directed at pregnant migrants, though, requires reconceptualizing the nature of obstetric violence itself. In particular, we must recognize that obstetric violence against pregnant Latin American migrants in the United States and Colombia is a type of immigration injustice, a means to perpetrate immigration injustice, and a product of immigration injustice. As such, bioethicists need to collaborate with immigration scholars to resist it. After providing some background on the nature of obstetric violence and some ways it is perpetuated against pregnant migrants in the United States and Colombia, I will give a brief overview of how I conceptualize immigration justice. From there, I explain how this type of obstetric violence constitutes a type of immigration injustice, a means to perpetrate immigration injustice, and a product of immigration injustice. My hope is that this analysis motivates bioethicists throughout the Americas to engage with immigration scholars and activists to confront the issue more forcefully.     

Engagement as co‐constructing knowledge: A moral necessity in public health research

Undertaking engagement in public health research is ethically essential. There is a growing emphasis on practicing engagement as the co‐construction of knowledge, which goes beyond other common forms of engagement in health research practice: consulting and informing. Taking such an approach means researchers jointly construct knowledge with research users and beneficiaries; all parties design and conduct research together and share decision‐making power. This article makes the normative argument that such engagement is necessary to achieve the foundational moral aims of public health research—building relations of equality and addressing the health needs of those considered disadvantaged—which reflect the field's underlying commitment to social justice. It next identifies and discusses three ways in which co‐constructing knowledge advances those moral aims: by facilitating self‐determination, supporting individuals’ right to research, and maximizing social knowledge to address cognitive and epistemic injustice. Objections to the arguments presented in the article are then articulated and defended against.     

Weiqu,structural injustice and caring for sick older people in rural Chinese families: An empirical ethical study

This paper examines caregiving for sick older family members in the context of socio-economic transformations in rural China, combining empirical investigation with normative inquiry. The empirical part of this paper is based on a case study, taken from fieldwork in a rural Chinese hospital, of a son who took care of his hospitalized mother. This empirical study highlighted family members’ weiqu (sense of unfairness)—a mental status from experiencing mistreatment and oppression in family care, yet with constrained power to explicitly protest or make care-related choices. Underpinning people’s weiqu and constrained choice, as informed by the conception of structural injustice, is the impact of unjust social structures, organized by unfavourable norms, discriminatory social policies and institutions targeting rural populations. By restraining individual choices and capacities in supporting health care for aging populations, these unjust structures create additional difficulties for and discriminations against rural families and their older members. Some policy recommendations are proposed to mitigate structural injustice so as to empower families and promote care for older people in rural settings.     

Expanded FDA regulation of health and wellness apps

This paper argues that the Food and Drug Administration’s (FDA) policy for health and wellness apps is ethically problematic. Currently, the FDA does not regulate health and wellness apps that are not intended for medical use. As a result of this hands-off policy, preventing harm to consumers is left primarily to developers and app marketplaces. We argue that the FDA’s duties to prevent harm and maintain accountability to the American public require that they play a much stronger role. We also discuss concerns about efficiency and fostering innovation, and argue that while they should help shape FDA regulation of health and wellness apps, they do not justify complete absence of FDA involvement.     

Sex,money, and paternity: The evolutionary psychology of domestic violence

Three hundred sixty-five women, with children between six and 12 years of age, were interviewed and tested on various issues theoretically related to domestic violence. The sample was stratified into three subsamples of volunteer women recruited from: (1) a temporary shelter for battered women, (2) the local community and screened specifically for the reported presence of domestic violence, (3) the same community sources and screened only for the reported presence of children of the specified age group. Factor analytic structural equation models were constructed for the predictors of violence by the woman's main sexual partner toward the woman and towards the woman's child. Common factors were constructed for the four major dimensions of domestic violence— verbal, physical, escalated, and sexual—and for the three major predictors of domestic violence—sex, money, and paternity. The sex factor indexed the general quality of the sexual relationship dynamics, the money factor indexed the couple's socioeconomic relations, and the paternity factor indexed the genetic stakes held in the family by the woman's main sexual partner. These three factors jointly accounted for 60% of the variance in violence toward the woman. Violence towards the woman—the only significant direct effect—accounted for 26% of the variance in violence toward the child. These findings suggest that the principal perpetrators of domestic violence may be competitively disadvantaged males, pursuing coercive sexual and parental strategies without regard to the deleterious indirect effects upon their own genetic offspring.     

Inupiat Health and Proposed Alaskan Oil Development: Results of the First Integrated Health Impact Assessment/Environmental Impact Statement for Proposed Oil Development on Alaska’s North Slope

We report on the first Health Impact Assessment (HIA) for proposed oil and gas development in Alaska’s North Slope region. Public health is not generally analyzed in the Environmental Impact Statement (EIS) process in the U.S. We conducted an HIA for proposed oil development within the National Petroleum Reserve - Alaska in response to growing concerns among North Slope Inupiat communities regarding the potential impacts of regional industrial expansion on their health and culture. We employed a qualitative HIA methodology, involving a combination of stakeholder input, literature review, and qualitative analysis, through which we identified potential health effects. The possible health outcomes identified include increases in diabetes and related metabolic conditions as a result of dietary change; rising rates of substance abuse, domestic violence, and suicide; increased injury rates; more frequent asthma exacerbations; and increased exposure to organic pollutant, including carcinogens and endocrine disruptors. There are also potential benefits, including funding for infrastructure and health care; increased employment and income; and continued funding of existing infrastructure. Based on these findings, we recommend a series of public health mitigation measures. This project represents the first formal effort to include a systematic assessment of public health within the U.S. EIS process. The inclusion of public health concerns within an EIS may offer an important and underutilized avenue through which to argue for environmental management strategies that focus on public health, and may offer communities a stronger voice in the EIS process. An erratum to this article can be found at     

Why Do Medical Professional Regulators Dismiss Most Complaints From Members of the Public? Regulatory Illiteracy,Epistemic Injustice,and Symbolic Power

Drawing on an analysis of complaint files that we conducted for the Irish Medical Council (Madden and O’Donovan 2015), this paper offers three possible explanations for the gap between the ubiquity of official commitments to taking patients’ complaints seriously and medical professional regulators’ dismissal—as not warranting an inquiry—of the vast majority of complaints submitted by members of the public. One explanation points to the “regulatory illiteracy” of many complainants, where the remit and threshold of seriousness of regulators is poorly understood by the general public. Another points to possible processes of “institutional epistemic injustice” (Fricker 2007; Anderson 2012) that unjustly undermine the credibility of certain complainants, such as those with low levels of formal education. A third explanation highlights the marginalization of the general public from “symbolic power” (Bourdieu 1989) to define what matters in medical professional regulation. The paper is offered in a spirit of ideas in progress and raising questions rather than definitive insights into the regulatory process.     

Are ME/CFS Patient Organizations “Militant”?

Myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS) is a contested illness category. This paper investigates the common claim that patients with ME/CFS—and by extension, ME/CFS patient organizations (POs)—exhibit “militant” social and political tendencies. The paper opens with a history of the protracted scientific disagreement over ME/CFS. We observe that ME/CFS POs, medical doctors, and medical researchers exhibit clear differences in opinion over how to conceptualize this illness. However, we identify a common trope in the discourse over ME/CFS: the claim of “militant” patient activism. Scrutinizing this charge, we find no compelling evidence that the vast majority of patients with ME/CFS, or the POs representing them, have adopted any such militant political policies or behaviours. Instead, we observe key strategic similarities between ME/CFS POs in the United Kingdom and the AIDs activist organizations of the mid-1980s in the United States which sought to engage scientists using the platform of public activism and via scientific publications. Finally, we explore the contours of disagreement between POs and the medical community by drawing on the concept of epistemic injustice. We find that widespread negative stereotyping of patients and the marginalization and exclusion of patient voices by medical authorities provides a better explanation for expressions of frustration among patients with ME/CFS.     

A community mobilisation intervention to prevent violence against women and reduce HIV/AIDS risk in Kampala, Uganda (the SASA! Study): study protocol for a cluster randomised controlled trial

ABSTRACT: BACKGROUND: Gender based violence, including violence by an intimate partner, is a major global human rights and public health problem, with important connections with HIV risk. Indeed, the elimination of sexual and gender based violence is a core pillar of HIV prevention for UNAIDS. Integrated strategies to address the gender norms, relations and inequities that underlie both violence against women and HIV/AIDS are needed. However there is limited evidence about the potential impact of different intervention models. This protocol describes the SASA! Study: an evaluation of a community mobilisation intervention to prevent violence against women and reduce HIV/AIDS risk in Kampala, Uganda. METHODS: The SASA! Study is a pair-matched cluster randomised controlled trial being conducted in eight communities in Kampala. It is designed to assess the community-level impact of the SASA! intervention on the following six primary outcomes: attitudes towards the acceptability of violence against women and the acceptability of a woman refusing sex (among male and female community members); past year experience of physical intimate partner violence and sexual intimate partner violence (among females); community responses to women experiencing violence (among women reporting past year physical/sexual partner violence); and past year concurrency of sexual partners (among males). 1583 women and men (aged 18-49 years) were surveyed in intervention and control communities prior to intervention implementation in 2007/8. A follow-up cross-sectional survey of community members will take place in 2012. The primary analysis will be an adjusted cluster-level intention to treat analysis, comparing outcomes in intervention and control communities at follow-up. Complementary monitoring and evaluation and qualitative research will be used to explore and describe the process of intervention implementation and the pathways through which change is achieved. DISCUSSION: This is one of few cluster randomised trials globally to assess the impact of a gender-focused community mobilisation intervention. The multi-disciplinary research approach will enable us to address questions of intervention impact and mechanisms of action, as well as its feasibility, acceptability and transferability to other contexts. The results will be of importance to researchers, policy makers and those working on the front line to prevent violence against women and HIV.     

Social and economic impact of violence in the Americas

Violence is a social and a public health problem that has grown in the Americas in recent decades that has negative effects on social, health, and the economy of countries, communities, families, and individuals. More than 115,000 people are murdered every year, the majority of them are men; other 55,000 commit suicide. In 20 to 60% of households some form of domestic violence against girls, boys, women, and the elderly occurs; juvenile gangs, involved in violent and criminal activities, increases at alarming rate. Other forms of violence are wars and internal or international conflicts, political violence, abductions, lynching, multinational violence by organized crime units involved in narcotic trafficking, sexual trade or smuggling of weapons. The public health approach is based on a methodology of work, as follows: 1. Characterization of the problem in its basic variables of person, place, time, circumstances, and related situations; 2. Identification of causes, associations, or risk factors; 3. Proposal of interventions and their evaluation; 4. Extension of the evaluated interventions. Violence is an intentional act of multicausal origin. Various factors are interconnected showing the relations among them. Those which have been primarily studied or that have shown greater evidence are discussed. A historical look is proposed, that integrates the repression and control, the prevention and the recovery of the social fabric. Violence demands an expenditure of money that represents a significant proportion of the GDP that was estimated in $168 billion dollars for Latin America. Violence can be prevented. Primary prevention projects are driven to avoid the occurrence of a violent act, but if it has already occurred it is necessary to avoid its repetition, through secondary prevention projects. Tertiary prevention is applied in order to avoid major damages; it aims at improving the quality of life of those already traumatized. The programs should be comprehensive and sustained in the medium and long terms. Finally, comments have been made on PAHO and WHO policies, in particular the recently launched World Report on Violence and Health, a working tool for violence prevention.     

Aggression and violence: perspectives on integrating animal and human research approaches

Aggression and violence are concerns that engage us across society as moral and cultural issues. They are also critical issues for mental health research--both for survivors and for understanding how such behaviors occur. Interpersonal violence often explodes in deliberate acts of physical force leaving survivors behind with a diminished sense of control that is often shadowed by persistent fear and anxiety. The treatment of the victims is a clear and immediate concern; from their perspectives the medical consequences require effective attention whether they suffered as a result of acts of nature, mental disease, ideology, or combinations of these. At the same time preventing violent behavior from happening in the first place is a compelling challenge for public health research.     

mHealth: A Strategic Field without a Solid Scientific Soul. A Systematic Review of Pain-Related Apps

Background

Mobile health (mHealth) has undergone exponential growth in recent years. Patients and healthcare professionals are increasingly using health-related applications, at the same time as concerns about ethical issues, bias, conflicts of interest and privacy are emerging. The general aim of this paper is to provide an overview of the current state of development of mHealth.

Methods and Findings

To exemplify the issues, we made a systematic review of the pain-related apps available in scientific databases (Medline, Web of Science, Gale, Psycinfo, etc.) and the main application shops (App Store, Blackberry App World, Google Play, Nokia Store and Windows Phone Store). Only applications (designed for both patients and clinicians) focused on pain education, assessment and treatment were included. Of the 47 papers published on 34 apps in scientific databases, none were available in the app shops. A total of 283 pain-related apps were found in the five shops searched, but no articles have been published on these apps. The main limitation of this review is that we did not look at all stores in all countries.

Conclusions

There is a huge gap between the scientific and commercial faces of mHealth. Specific efforts are needed to facilitate knowledge translation and regulate commercial health-related apps.     

How smartphones are changing the face of mobile and participatory healthcare: an overview,with example from eCAALYX

The latest generation of smartphones are increasingly viewed as handheld computers rather than as phones, due to their powerful on-board computing capability, capacious memories, large screens and open operating systems that encourage application development. This paper provides a brief state-of-the-art overview of health and healthcare smartphone apps (applications) on the market today, including emerging trends and market uptake. Platforms available today include Android, Apple iOS, RIM BlackBerry, Symbian, and Windows (Windows Mobile 6.x and the emerging Windows Phone 7 platform). The paper covers apps targeting both laypersons/patients and healthcare professionals in various scenarios, e.g., health, fitness and lifestyle education and management apps; ambient assisted living apps; continuing professional education tools; and apps for public health surveillance. Among the surveyed apps are those assisting in chronic disease management, whether as standalone apps or part of a BAN (Body Area Network) and remote server configuration. We describe in detail the development of a smartphone app within eCAALYX (Enhanced Complete Ambient Assisted Living Experiment, 2009-2012), an EU-funded project for older people with multiple chronic conditions. The eCAALYX Android smartphone app receives input from a BAN (a patient-wearable smart garment with wireless health sensors) and the GPS (Global Positioning System) location sensor in the smartphone, and communicates over the Internet with a remote server accessible by healthcare professionals who are in charge of the remote monitoring and management of the older patient with multiple chronic conditions. Finally, we briefly discuss barriers to adoption of health and healthcare smartphone apps (e.g., cost, network bandwidth and battery power efficiency, usability, privacy issues, etc.), as well as some workarounds to mitigate those barriers.     

‘To be,or not to be’—The dilemma of ‘silent’ antimicrobial resistance genes in bacteria

Antimicrobial resistance is a serious threat to public health that dramatically undermines our ability to treat bacterial infections. Microorganisms exhibit resistance to different drug classes by acquiring resistance determinants through multiple mechanisms including horizontal gene transfer. The presence of drug resistance genotypes is mostly associated with corresponding phenotypic resistance against the particular antibiotic. However, bacterial communities harbouring silent antimicrobial resistance genes—genes whose presence is not associated with a corresponding resistant phenotype do exist. Under suitable conditions, the expression pattern of such genes often revert and regain resistance and could potentially lead to therapeutic failure. We often miss the presence of silent genes, since the current experimental paradigms are focused on resistant strains. Therefore, the knowledge on the prevalence, importance and mechanism of silent antibiotic resistance genes in bacterial pathogens are very limited. Silent genes, therefore, provide an additional level of complexity in the war against drug-resistant bacteria, reminding us that not only phenotypically resistant strains but also susceptible strains should be carefully investigated. In this review, we discuss the presence of silent antimicrobial resistance genes in bacteria, their relevance and their importance in public health.     

Risk Factors for Men’s Lifetime Perpetration of Physical Violence against Intimate Partners: Results from the International Men and Gender Equality Survey (IMAGES) in Eight Countries

This paper examines men’s lifetime physical intimate partner violence (IPV) perpetration across eight low- and middle-income countries to better understand key risk factors that interventions can target in order to promote gender equality and reduce IPV. We use data from men (n = 7806) that were collected as part of the International Men and Gender Equality Survey (IMAGES) in Bosnia and Herzegovina, Brazil, Chile, Croatia, Democratic Republic of Congo (DRC), India, Mexico, and Rwanda. Results show that there is wide variation across countries for lifetime self-reported physical violence perpetration (range: 17% in Mexico to 45% in DRC), men’s support for equal roles for men and women, and acceptability of violence against women. Across the sample, 31% of men report having perpetrated physical violence against a partner in their lifetime. In multivariate analyses examining risk factors for men ever perpetrating physical violence against a partner, witnessing parental violence was the strongest risk factor, reinforcing previous research suggesting the inter-generational transmission of violence. Additionally, having been involved in fights not specifically with an intimate partner, permissive attitudes towards violence against women, having inequitable gender attitudes, and older age were associated with a higher likelihood of ever perpetrating physical IPV. In separate analyses for each country, we found different patterns of risk factors in countries with high perpetration compared to countries with low perpetration. Findings are interpreted to identify key knowledge gaps and directions for future research, public policies, evaluation, and programming.     

Justice and Medical Research: A Global Perspective

Economic globalization has profound implications for health. The scale of injustice at a global level, reflected in inexorably widening disparities in wealth and health, also has critical implications for health related research – in particular when the opportunities for exploiting research subjects are carefully considered. The challenge of developing universal guidelines for international clinical research is addressed against the background of a polarizing, yet interdependent, world in which all are ultimately threatened by lack of social justice. It is proposed that in such a world there is a need for new ways of thinking about research and its relevance to health at a global level. Responsibility to use knowledge and power wisely requires more radical changes to guidelines for research ethics than are currently under consideration.     

A call from justice to support the people in Gaza

Using Madison Powers and Ruth Faden's definition of ‘well‐being,’ the authors argue that Israel, the international community and public health practitioners have a justice‐based obligation to assist the Palestinian people in the Occupied Palestinian Territories. Focusing on Palestinians in Gaza, the authors first outline a normative framework of justice, as articulated by Powers and Faden. Following Powers and Faden's assumption that empirical assessments of justice can be made using the six dimensions of well‐being, the authors next present current data on the living conditions in Gaza and describe how these conditions prevent residents from achieving sufficient levels of well‐being. Using these indicators to demonstrate that Palestinians living in Gaza suffer deficiencies in these dimensions of well‐being, the authors present a strong argument from justice to assist the residents of Gaza. The medical, public health, and bioethics community cannot sit idle while injustice continues.     

Atmospheric metal pollutants and environmental injustice: A methodological approach to environmental risk analysis using fuzzy logic and tree bark

Air pollution is the single largest environmental risk today and is increasing in developing countries. In addition, exposure to air pollution is correlated to poor socioeconomic conditions owing to political processes and cultural and historic occupation of land. Ports have several structures that are potential emitters of pollutants such as large ship engines, diesel trucks, and trains. Owing to the considerable costs of implementing direct monitoring networks, alternatives like biomonitoring are an interesting approach to evaluate the environmental status of a particular area using living organisms or their parts such as bark, even though the use of bark as a biomonitor has several problems such as difficulties in determining the exposure period and its correlation with human exposure. Therefore, the use of a complementary mathematical logic is necessary. This study describes a methodological approach to evaluate the environmental risk from air pollution integrating data on environmental pollutants from tree bark using Fuzzy logic, based in the port city of Paranaguá in the state of Paraná in Brazil, and validated using income indicators. The results indicate that the risk distribution patterns have an inverse relationship with the income indicator, i.e., higher risk levels indicate lower income levels and vice versa. It was concluded that the system was able to identify the distribution of risk and that there is a context of environmental injustice in the region, where the environmental risk related to air pollution is inversely proportional to income levels. This type of information provides a decision making tool for environmental risk analysis from air pollution and can be used in the definition of public policies.     

What mechanisms can’t do: Explanatory frameworks and the function of the p53 gene in molecular oncology

What has been called the new mechanistic philosophy conceives of mechanisms as the main providers of biological explanation. We draw on the characterization of the p53 gene in molecular oncology, to show that explaining a biological phenomenon (cancer, in our case) implies instead a dynamic interaction between the mechanistic level—rendered at the appropriate degree of ontological resolution—and far more general explanatory tools that perform a fundamental epistemic role in the provision of biological explanations. We call such tools “explanatory frameworks”. They are called frameworks to stress their higher level of generality with respect to bare mechanisms; on the other hand, they are called explanatory because, as we show in this paper, their importance in explaining biological phenomena is not secondary with respect to mechanisms. We illustrate how explanatory frameworks establish selective and local criteria of causal relevance that drive the search for, characterisation and usage of biological mechanisms. Furthermore, we show that explanatory frameworks allow for changes of scientific perspective on the causal relevance of mechanisms going beyond the account provided by the new mechanistic philosophy.