Threshold considerations in fair allocation of health resources: justice beyond scarcity

Application of egalitarian and prioritarian accounts of health resource allocation in low-income countries have both been criticized for implying distribution outcomes that allow decreasing/undermining health gains and for tolerating unacceptable standards of health care and health status that result from such allocation schemes. Insufficient health care and severe deprivation of health resources are difficult to accept even when justified by aggregative efficiency or legitimized by fair deliberative process in pursuing equality and priority oriented outcomes. I affirm the sufficientarian argument that, given extreme scarcity of public health resources in low-income countries, neither health status equality between populations nor priority for the worse off is normatively adequate. Nevertheless, the threshold norm alone need not be the sole consideration when a country's total health budget is extremely scarce. Threshold considerations are necessary in developing a theory of fair distribution of health resources that is sensitive to the lexically prior norm of sufficiency. Based on the intuition that shares must not be taken away from those who barely achieve a minimal level of health, I argue that assessments based on standards of minimal physical/mental health must be developed to evaluate the sufficiency of the total resources of health systems in low-income countries prior to pursuing equality, priority, and efficiency based resource allocation. I also begin to examine how threshold sensitive health resource assessment could be used in the Philippines.     

Access to health services for immigrants in the USA: from the Great Society to the 2010 Health Reform Act and after

Abstract

Over the last fifty years the nature of the provision and financing of health services, and the composition of the foreign-born population in the USA have both evolved significantly. The rapid growth of Mexican immigration in the last fifteen years has created new challenges. Ironically, the Patient Protection and Affordable Care Act of 2010, the sweeping legislation designed to ensure that almost all Americans can obtain health insurance, may reduce access to care for many immigrants by isolating them from the general, formerly uninsured, population. Bi-national and cross-border initiatives between the USA and Mexico along the lines of some developments in Europe are worth encouraging to help ease the current and future barriers to health care for immigrants.     

Measuring and improving the quality of mental health care: a global perspective

Mental disorders are common worldwide, yet the quality of care for these disorders has not increased to the same extent as that for physical conditions. In this paper, we present a framework for promoting quality measurement as a tool for improving quality of mental health care. We identify key barriers to this effort, including lack of standardized information technology‐based data sources, limited scientific evidence for mental health quality measures, lack of provider training and support, and cultural barriers to integrating mental health care within general health environments. We describe several innovations that are underway worldwide which can mitigate these barriers. Based on these experiences, we offer several recommendations for improving quality of mental health care. Health care payers and providers will need a portfolio of validated measures of patient‐centered outcomes across a spectrum of conditions. Common data elements will have to be developed and embedded within existing electronic health records and other information technology tools. Mental health outcomes will need to be assessed more routinely, and measurement‐based care should become part of the overall culture of the mental health care system. Health care systems will need a valid way to stratify quality measures, in order to address potential gaps among subpopulations and identify groups in most need of quality improvement. Much more attention should be devoted to workforce training in and capacity for quality improvement. The field of mental health quality improvement is a team sport, requiring coordination across different providers, involvement of consumer advocates, and leveraging of resources and incentives from health care payers and systems.     

The intersection of social determinants of health,the microbiome,and health outcomes in immigrants: A scoping review

In the present scoping review, we explore whether existing evidence supports the premise that social determinants of health (SDoH) affect immigrant health outcomes through their effects on the microbiome. We adapt the National Institute on Minority Health and Health Disparities' research framework to propose a conceptual model that considers the intersection of SDoH, the microbiome, and health outcomes in immigrants. We use this conceptual model as a lens through which to explore recent research about SDoH, biological factors associated with changes to immigrants' microbiomes, and long-term health outcomes. In the 17 articles reviewed, dietary acculturation, physical activity, ethnicity, birthplace, age at migration and length of time in the host country, socioeconomic status, and social/linguistic acculturation were important determinants of postmigration microbiome-related transformations. These factors are associated with progressive shifts in microbiome profile with time in host country, increasing the risks for cardiometabolic, mental, immune, and inflammatory disorders and antibiotic resistance. The evidence thus supports the premise that SDoH influence immigrants' health postmigration, at least in part, through their effects on the microbiome. Omission of important postmigration social-ecological variables (e.g., stress, racism, social/family relationships, and environment), limited research among minoritized subgroups of immigrants, complexity and inter- and intra-individual differences in the microbiome, and limited interdisciplinary and biosocial collaboration restrict our understanding of this area of study. To identify potential microbiome-based interventions and promote immigrants' well-being, more research is necessary to understand the intersections of immigrant health with factors from the biological, behavioral/psychosocial, physical/built environment, and sociocultural environment domains at all social-ecological levels.     

The contribution of vaccination to global health: past,present and future

Vaccination has made an enormous contribution to global health. Two major infections, smallpox and rinderpest, have been eradicated. Global coverage of vaccination against many important infectious diseases of childhood has been enhanced dramatically since the creation of WHO''s Expanded Programme of Immunization in 1974 and of the Global Alliance for Vaccination and Immunization in 2000. Polio has almost been eradicated and success in controlling measles makes this infection another potential target for eradication. Despite these successes, approximately 6.6 million children still die each year and about a half of these deaths are caused by infections, including pneumonia and diarrhoea, which could be prevented by vaccination. Enhanced deployment of recently developed pneumococcal conjugate and rotavirus vaccines should, therefore, result in a further decline in childhood mortality. Development of vaccines against more complex infections, such as malaria, tuberculosis and HIV, has been challenging and achievements so far have been modest. Final success against these infections may require combination vaccinations, each component stimulating a different arm of the immune system. In the longer term, vaccines are likely to be used to prevent or modulate the course of some non-infectious diseases. Progress has already been made with therapeutic cancer vaccines and future potential targets include addiction, diabetes, hypertension and Alzheimer''s disease.     

Interoception beyond homeostasis: affect,cognition and mental health

Interoception refers to the sensing of the internal state of one''s body. Interoception is distinct from the processing of sensory information concerning external (non-self) stimuli (e.g. vision, hearing, touch and smell) and is the afferent axis to internal (autonomic and hormonal) physiological control. However, the impact of interoception extends beyond homeostatic/allostatic reflexes: it is proposed to be fundamental to motivation, emotion (affective feelings and behaviours), social cognition and self-awareness. This view is supported by a growing body of experimental evidence that links peripheral physiological states to mental processes. Within this framework, the representation of self is constructed from early development through continuous integrative representation of biological data from the body, to form the basis for those aspects of conscious awareness grounded on the subjective sense of being a unique individual. This theme issue of the Philosophical Transactions of the Royal Society B draws together state-of-the-art knowledge concerning theoretical, experimental and clinical facets of interoception with the emphasis on cognitive and affective neuroscience. The multidisciplinary and cross-disciplinary perspectives represented in this theme issue disseminate and entrench knowledge about interoception across the scientific community and provide a reference for the conceptualization and further study of interoception across behavioural sciences.     

Epigenetics for the social sciences: justice,embodiment, and inheritance in the postgenomic age

In this paper, I firstly situate the current rise of interest in epigenetics in the broader history of attempts to go “beyond the gene” in twentieth-century biology. In the second part, after a summary of the main differences between epigenetic and genetic mutations, I consider what kind of implications the sui generis features of epigenetic mutations may have for the social sciences. I focus in particular on two sites of investigation: (a) the blurring of the boundaries between natural and social inequalities in theories of justice and their possible implications for public policy and public health and (b) a deepening of the notion that the constitution of the body is deeply dependent on its material and socially shaped surroundings (“embodied constructivism”). In conclusion, I advance some cautionary reflections on some of the (known and unprecedented) problems that the circulation of epigenetics in wider society may present.     

The social determinants of mental health and disorder: evidence,prevention and recommendations

People exposed to more unfavourable social circumstances are more vulnerable to poor mental health over their life course, in ways that are often determined by structural factors which generate and perpetuate intergenerational cycles of disadvantage and poor health. Addressing these challenges is an imperative matter of social justice. In this paper we provide a roadmap to address the social determinants that cause mental ill health. Relying as far as possible on high-quality evidence, we first map out the literature that supports a causal link between social determinants and later mental health outcomes. Given the breadth of this topic, we focus on the most pervasive social determinants across the life course, and those that are common across major mental disorders. We draw primarily on the available evidence from the Global North, acknowledging that other global contexts will face both similar and unique sets of social determinants that will require equitable attention. Much of our evidence focuses on mental health in groups who are marginalized, and thus often exposed to a multitude of intersecting social risk factors. These groups include refugees, asylum seekers and displaced persons, as well as ethnoracial minoritized groups; lesbian, gay, bisexual, transgender and queer (LGBTQ+) groups; and those living in poverty. We then introduce a preventive framework for conceptualizing the link between social determinants and mental health and disorder, which can guide much needed primary prevention strategies capable of reducing inequalities and improving population mental health. Following this, we provide a review of the evidence concerning candidate preventive strategies to intervene on social determinants of mental health. These interventions fall broadly within the scope of universal, selected and indicated primary prevention strategies, but we also briefly review important secondary and tertiary strategies to promote recovery in those with existing mental disorders. Finally, we provide seven key recommendations, framed around social justice, which constitute a roadmap for action in research, policy and public health. Adoption of these recommendations would provide an opportunity to advance efforts to intervene on modifiable social determinants that affect population mental health.     

Getting personal: ethics and identity in global health research

'Researcher identity' affects global health research in profound and complex ways. Anthropologists in particular have led the way in portraying the multiple, and sometimes tension-generating, identities that researchers ascribe to themselves, or have ascribed to them, in their places of research. However, the central importance of researcher identity in the ethical conduct of global health research has yet to be fully appreciated. The capacity of researchers to respond effectively to the ethical tensions surrounding their identities is hampered by lack of conceptual clarity, as to the nature and scope of the issues involved. This paper strives to provide some clarification of these ethical tensions by considering researcher identity from the perspective of (1) Guillemin and Heggen's (2009) key distinction between procedural ethics and ethics in practice, and (2) our own distinction between perceptions of identity that are either symmetrical or asymmetrical, with the potential to shift research relationships toward greater or lesser ethical harmony. Discussion of these concepts is supported with ethnographic examples from relevant literature and from our own (United States (US) Government-funded) research in South Africa. A preliminary set of recommendations is provided in an effort to equip researchers with a greater sense of organization and control over the ethics of researcher identity. The paper concludes that the complex construction of researcher identity needs to be central among the ethical concerns of global health researchers, and that the conceptual tools discussed in the paper are a useful starting point for better organizing and acting on these ethical concerns.     

The role of trust in global health research collaborations

Collaborations in global health research are on the rise because they enhance productivity, facilitate capacity building, accelerate output and make tackling big, multifactorial research questions possible. In this paper, I examine the concepts of trust and reliance in scientific collaborations in general, but also in the particular context of collaborations in global health research between high‐income countries and low‐and‐middle income countries (LMIC). I propose and defend the argument that given the particular characteristics of collaborations and demands of trust relationships, reliance is a better relational mode for successful collaborations. Although reliance can be difficult to establish in situations where asymmetry of power exists, trust should not be the only relational mode available to LMIC researchers because of the type of vulnerability it introduces to the relationship. I conclude that the promotion of good collaborations requires addressing the power imbalances between partners, and establishing an even playing field in global health research.     

The theory and application of space microbiology: China's experiences in space experiments and beyond

Microorganisms exhibit high adaptability to extreme environments of outer space via phenotypic and genetic changes. These changes may affect astronauts in the space environment as well as on Earth because mutant microbes will inevitably return with the spacecraft. However, the role and significance of these phenotypic changes and the underlying mechanisms are important unresolved questions in the field of space biology. By reviewing, especially the Chinese studies, we propose a space microbial molecular effect theory, that is, the space environment affects the nature of genes and the molecular structure of microorganisms to produce phenotypic changes. In this review, we discussed three basic theories for the research of space microbiology, including (1) space microbial pathogenicity and virulence mutations and the human mutualism theory; (2) space microbial drug‐resistance mutations and metabolism associated with space pharmaceuticals theory; (3) space corrosion, microbial decontamination, and new materials technology theory.     

The management of otherness beyond the state: integration policies and inclusive citizenship as a government paradigm in the Basque Country

The ethnic identity of second-generation immigrant youth has important implications for their association with, and integration in, receiving countries. This paper deals with the ethnic identity formation of second-generation Turkish immigrant youth in Germany, with particular attention paid to the notion of reactive ethnicity. While much of the literature discusses the ethnic retention of this specific group as unwillingness to integrate, this paper frames their ethnic identity formation as reactive ethnicity, which emerges in reaction to social exclusion. Utilizing a case study of Turkish students of disadvantaged schools, the article illustrates that reactive ethnicity is strongly linked to perceived discrimination and that it acquires characteristics of resistance when the dominant group denigrates and invalidates the immigrants' culture.     

The contribution of mass drug administration to global health: past,present and future

Mass drug administration (MDA) is a means of delivering safe and inexpensive essential medicines based on the principles of preventive chemotherapy, where populations or sub-populations are offered treatment without individual diagnosis. High-coverage MDA in endemic areas aims to prevent and alleviate symptoms and morbidity on the one hand and can reduce transmission on the other, together improving global health. MDA is the recommended strategy of the World Health Organisation to control or eliminate several neglected tropical diseases (NTDs). More than 700 million people now receive these essential NTD medicines annually. The combined cost of integrated NTD MDA has been calculated to be in the order of $0.50 per person per year. Activities have recently been expanded due, in part, to the proposed attempt to eliminate certain NTDs in the coming two decades. More than 1.9 billion people need to receive MDA annually across several years if these targets are to be met. Such extensive coverage will require additional avenues of financial support, expanded monitoring and evaluation focusing on impact and drug efficacy, as well as new diagnostic tools and social science strategies to encourage adherence. MDA is a means to help reduce the burden of disease, and hence poverty, among the poorest sector of populations. It has already made significant improvements to global health and productivity and has the potential for further successes, particularly where incorporated into sanitation and education programmes. However logistical, financial and biological challenges remain.     

Designing research funding schemes to promote global health equity: An exploration of current practice in health systems research

International research is an essential means of reducing health disparities between and within countries and should do so as a matter of global justice. Research funders from high‐income countries have an obligation of justice to support health research in low and middle‐income countries (LMICs) that furthers such objectives. This paper investigates how their current funding schemes are designed to incentivise health systems research in LMICs that promotes health equity. Semi‐structured in‐depth interviews were performed with 16 grants officers working for 11 funders and organisations that support health systems research: the Alliance for Health Policy and Systems Research, Comic Relief, Doris Duke Foundation, European Commission, International Development Research Centre, Norwegian Agency for Development Cooperation, Research Council of Norway, Rockefeller Foundation, UK Department of International Development, UK Medical Research Council, and Wellcome Trust. Thematic analysis of the data demonstrates their funding schemes promote health systems research with (up to) five key features that advance health equity: being conducted with worst‐off populations, focusing on research topics that advance equitable health systems, having LMIC ownership of the research agenda, strengthening LMIC research capacity, and having an impact on health disparities. The different types of incentives that encouraged proposed projects to have these features are identified and classified by their strength (strong, moderate, weak). It is suggested that research funders ought to create and maintain funding schemes with strong incentives for the features identified above in order to more effectively help reduce global health disparities.     

Perceived social isolation,evolutionary fitness and health outcomes: a lifespan approach

Sociality permeates each of the fundamental motives of human existence and plays a critical role in evolutionary fitness across the lifespan. Evidence for this thesis draws from research linking deficits in social relationship—as indexed by perceived social isolation (i.e. loneliness)—with adverse health and fitness consequences at each developmental stage of life. Outcomes include depression, poor sleep quality, impaired executive function, accelerated cognitive decline, unfavourable cardiovascular function, impaired immunity, altered hypothalamic pituitary–adrenocortical activity, a pro-inflammatory gene expression profile and earlier mortality. Gaps in this research are summarized with suggestions for future research. In addition, we argue that a better understanding of naturally occurring variation in loneliness, and its physiological and psychological underpinnings, in non-human species may be a valuable direction to better understand the persistence of a ‘lonely’ phenotype in social species, and its consequences for health and fitness.     

Omega-3: a link between global climate change and human health

In recent years, global climate change has been shown to detrimentally affect many biological and environmental factors, including those of marine ecosystems. In particular, global climate change has been linked to an increase in atmospheric carbon dioxide, UV irradiation, and ocean temperatures, resulting in decreased marine phytoplankton growth and reduced synthesis of omega-3 polyunsaturated fatty acids (PUFAs). Marine phytoplankton are the primary producers of omega-3 PUFAs, which are essential nutrients for normal human growth and development and have many beneficial effects on human health. Thus, these detrimental effects of climate change on the oceans may reduce the availability of omega-3 PUFAs in our diets, exacerbating the modern deficiency of omega-3 PUFAs and imbalance of the tissue omega-6/omega-3 PUFA ratio, which have been associated with an increased risk for cardiovascular disease, cancer, diabetes, and neurodegenerative disease. This article provides new insight into the relationship between global climate change and human health by identifying omega-3 PUFA availability as a potentially important link, and proposes a biotechnological strategy for addressing the potential shortage of omega-3 PUFAs in human diets resulting from global climate change.     

The apple,the tree,and a space to grow in

The idea for the study presented in Spanish Legacies: the coming of age of the second generation was sparked by the series of unrests from immigrant youths in a number of cities across Europe. The discontent expressed by the young generation of immigrants presented a sharp indicator of how little is known about young people of foreign origin growing up as immigrant residents in Europe, despite their significant number (10 per cent in France, 13 per cent in Spain and 15 per cent in Ireland by 2010). The success or failure of immigrants’ integrational processes, considering cultural factors and language barriers as challenges experienced by immigrants, can have major political and social impact on the regions where they reside. It is these challenges that are investigated in depth, in this book.     

Moral residue and health justice for the global south: Addressing past issues through current interventions and research

This paper introduces the concept of moral residue to global health, and shows how its presence undermines crucial interventions and research, especially in the global south. Lingering feelings of anxiety, anger, blame or frustration often exist among local populations, where previous interventions or research have left traces of harm and/or exploitation. The existence of such feelings reflects the presence of moral residue, recognizing the moral experiences of epistemic injustices, which in turn undermines critical interventions and research through outright rejection or passive non‐compliance among affected populations. While such situations have been variously interpreted and relevant strategies developed to address the issues, little to no consideration is made on the implications of moral residue experiences in global health contexts and how to address them. This paper demonstrates the presence of moral residue in global health and proffers an African ethical approach, a harmony framework, for addressing moral residue issues, as part of a holistic approach towards tackling population health crises without compromising health gains for affected populations in the global south.     

Assessment of river health: accounting for perturbation pathways in physical and ecological space

1. A full understanding of changes to river ecosystem structure and functioning along the continuum from relatively pristine to profoundly perturbed requires knowledge of physical, chemical and ecological properties at many spatial and temporal scales. Perturbations may span broad spatio-temporal scales or be spatially and temporally discrete. 2. The relevant scale for study depends on the manner in which perturbations move through two kinds of pathways – through the physical space of the catchment hierarchy and through the ecological space of river food webs. Different kinds of perturbation (e.g. inputs of sediment, nitrogen or phosphorus, changes to shading or discharge) vary in the degree and manner in which they are propagated downstream and through food webs. 3. The fundamental importance of disturbance regimes and refugia to river health is now clear and managers need to take this into account when devising river management schemes. 4. A comparison of the physics, chemistry and ecology of streams in catchments of native tussock and exotic pasture grassland in New Zealand serves to emphasize (i) the extreme complexity of interacting factors resulting from land use change, (ii) the importance of disturbance regime (not encapsulated in biotic indices) and biogeographic patterns (usually unmeasured) in determining ecosystem structure and functioning, and (iii) the lack of concordance between any single index of health and various fundamental features of ecosystem functioning. 5. Practical considerations limit most evaluations of river health to a small suite of indices, though it is important that researchers continue to evaluate the spatial, temporal and biological limitations of these indices. The vagaries of history and geography (extinction and colonization trajectories in relation to natural disturbance regimes) and the complexity of interacting physical, chemical and ecological responses to perturbation suggest that multi-scale, multi-temporal studies of river function offer the best opportunity to evaluate river health.     

Tuning in or turning off: performing emotion and building cosmopolitan solidarity in international music competitions

This article suggests that international classical music competitions are becoming sites of the global cultural public sphere. Like post-traditional festivals, they have previously served as arenas where nations compete for supremacy. But as these events become more globalized, they create opportunities to foster cosmopolitan sociability and cultivate global values. Through a discourse analysis of media coverage and online commentary from a selected case, I examine how difference is constructed in the competition context and how these categories complicate attempts to relate musically across differences. This analysis highlights the central role of emotion in the process of cultural inclusion, both as a discursive trope in evaluations of musical authenticity and as a signifier of value justifying the incorporation of a wider range of people into the circle of great musicians.