The importance of ‘social responsibility’ in the promotion of health

The publication of the Report of the International Bioethics Committee of Unesco on Social responsibility and health provides an opportunity to reshape the conceptual framework of the right to health care and its practical implications. The traditional distinctions between negative and positive, civil-political and economic-social, legal and moral rights are to be questioned and probably overcome if the goal is to pursue ‘the highest attainable standard of health’ as a fundamental human right, that should as such be guaranteed to every human being. What we are called upon to, is the commitment not to exclude now and forever anyone from having access to the ‘excellence’ of scientific and medical progress. Therefore, the addressees of this ‘responsibility’ cannot be just the governments and the states within the limits of their ‘jurisdiction’. The challenge is to tackle at the same time the social and global determinants of health.     

Use of the terms ‘race’, ‘ethnicity’, and ‘national origins’: A review of articles in the American journal of public health, 1980–1989

Objectives: To assess the use of the categories of race, ethnicity, and national origin in recent public health research.

Methods: We reviewed all research articles on human populations published in the American Journal of Public Health from January 1980 through December 1989. Articles were classified by (1) mention of the categories, (2) use of the categories, (3) presence of explicit definitions, and (4) definitional criteria.

Results: Specific categories (e.g. ‘black’, ‘Chinese’, ‘Hispanic') or generic categories (e.g. ‘race’, ‘ethnicity’, ‘national origin') were mentioned in 461 (50.4%) of 914 articles on human populations. In most studies (65.1%), single categories (e.g. race or ethnicity) were considered; in 1.3% of studies, two terms (e.g. both race and ethnicity) were examined independently; in 1.3%, categories were used interchangeably; in 5.6% of the studies, combined categories (e.g. race‐ethnicity) were used; and in 27.5% of the studies, specific population groups were named without reference to a generic category. Explicit definitions of categories were present in only 8.4% of the articles in which the categories were considered. Absence of explicit definitions and use of combined and interchangeable categories suggest a lack of clarity and conceptual consistency in research on race, ethnicity, and national origin‐related topics.

Conclusion: To improve our assessment of differences in health status among racial, ethnic, and national origin groups, research involving these categories should assess their validity and should define concepts clearly, explicitly, and consistently. Such research would minimize misclassification, improve the interpretation of findings, facilitate comparison among studies, and enhance the understanding of causes underlying differences in health status among populations of different racial, ethnic, and national origins.     

‘The pitfalls of the “add-and-stir” approach to transdisciplinary public health research’

Health researchers increasingly include social scientific disciplines in their research programs, partly as a result of increasing recognition that complex public health issues benefit from a range of research approaches, and partly because funding bodies increasingly require transdisciplinarity. This commentary addresses the role of epistemology in transdisciplinary public health research (TPHR). We discuss two problems with current TPHR. The first problem is that social scientific input into TPHR is typically circumscribed to social, cultural, economic, and political analyses of a given public health issue, and further that these analyses only use social constructivist epistemologies. This narrow delineation under-utilizes a valuable, yet largely untapped resource; namely, various realist epistemologies regularly employed by social scientists, which are typically committed to anti-reductive and non-social constructivist understandings of scientific practices and knowledge. The second problem is the paucity of meta-analyses of the tacit epistemological cultures driving transdisciplinary research teams. The advantage of such meta-analyses is that they are able to make epistemologies explicit, which is the first step in actually integrating knowledge from different academic disciplines. Given that epistemological commitments guide research agendas – from what questions are asked and what methodologies are selected, to how findings are interpreted – understanding the role of epistemology stands to make an important contribution to improving TPHR.     

The Irish ‘health basket’: a basket case?

The Irish health care system is typically described as complex and inequitable and yet the source of the complexity is difficult to identify. This paper examines and documents the way in which the structure of the Irish system is complicated when compared with other countries. Analysis is conducted in the context of the ‘health basket’ framework. A health basket describes which health care services, and which individuals, are covered by public funding, and to what extent. The Irish health basket is outlined along three dimensions of breadth, depth, and height, and compared with the health baskets of the United Kingdom, Canada, Australia, Sweden and France. Results indicate that it is in the combination of breadth and height that distinguishes the Irish basket from others. The majority of Irish health care services are run on a cost sharing basis; user fees are higher than in other countries particularly in primary care; and the structure of entitlement restrictions are complex. It is difficult to identify other countries in which all these factors operate within one system. In addition, the way in which the Irish health basket is delivered in practice introduces further complexities into the breadth and height of coverage.     

The ‘indirect costs’ of underfunding foreign partners in global health research: A case study

This study of a global health research partnership assesses how U.S. fiscal administrative policies impact capacity building at foreign partner institutions. We conducted a case study of a research collaboration between Mbarara University of Science and Technology (MUST) in Mbarara, Uganda, and originally the University of California San Francisco (UCSF), but now Massachusetts General Hospital (MGH). Our case study is based on three of the authors’ experiences directing and working with this partnership from its inception in 2003 through 2015. The collaboration established an independent Ugandan non-profit to act as a local fiscal agent and grants administrator and to assure compliance with the Ugandan labour and tax law. This structure, combined with low indirect cost reimbursements from U.S. federal grants, failed to strengthen institutional capacity at MUST. In response to problems with this model, the collaboration established a contracts and grants office at MUST. This office has built administrative capacity at MUST but has also generated new risks and expenses for MGH. We argue that U.S. fiscal administrative practices may drain rather than build capacity at African universities by underfunding the administrative costs of global health research, circumventing host country institutions, and externalising legal and financial risks associated with international work.

Abbreviations: MGH: Massachusetts General Hospital; MUST: Mbarara University of Science and Technology; NIH: National Institutes of Health; UCSF: University of California San Francisco; URI: Uganda Research Institute     

The Syrian public health and humanitarian crisis: A ‘displacement’ in global governance?

Ongoing failure by the international community to resolve the Syrian conflict has led to destruction of critical infrastructure. This includes the collapse of the Syrian health system, leaving millions of internally displaced persons (IDPs) in urgent need of healthcare services. As the conflict intensifies, IDP populations are suffering from infectious and non-communicable disease risks, poor maternal and child health outcomes, trauma, and mental health issues, while healthcare workers continually exit the country. Healthcare workers who remain face significant challenges, including systematic attacks on healthcare facilities and conditions that severely inhibit healthcare delivery and assistance. Within this conflict-driven public health crisis, the most susceptible population is arguably the IDP. Though the fundamental ‘right to health’ is a recognised international legal principle, its application is inadequate due to limited recognition by the UN Security Council and stymied global governance by the broader international community. These factors have also negatively impacted other vulnerable groups other than IDPs, such as refugees and ethnic minorities, who may or may not be displaced. Hence, this article reviews the current Syrian conflict, assesses challenges with local and global governance for IDPs, and explores potential governance solutions needed to address this health and humanitarian crisis.     

‘Exotic no more’: Tuberculosis,public debt and global health in Berlin

ABSTRACT

Geographical divisions between North and South are coming increasingly undone in the field of global health. Settings in the global North, such as Berlin, are becoming linked up to those in the global South in manifold ways. In this article, I show through discourse analysis and ethnographic research how tuberculosis and its meanings have been transfigured in Western Europe through the worldwide circulation of the disease and its definition as a global health epidemic returning to the North from the South through global migration routes. I then draw attention to the ways in which public health professionals in Berlin make sense of locally implemented economic processes of debt and austerity that have been in effect since the early 2000s. Such processes of indebtedness and privatisation render the strong public health infrastructures that characterise the global North increasingly fragile, and are comparable to the structural adjustment policies that have been imposed upon countries in the global South. I argue that economic processes of austerity in Berlin complement the meaning of TB as an immigrants’ disease, while older meanings of TB as a disease of poverty resurface.     

Battery-powered health insurance? Stability in coverage of the uninsured

This study assesses the stability of Americans' health insurance status over a four-year period. Relatively few Americans were continuously uninsured for the four years 1996 to 1999, but a sizable number of the uninsured lacked a stable source of coverage. At least as many people were repeatedly uninsured as experienced a single gap in otherwise stable coverage. Given these dynamics, policymakers should think of "uninsured" as referring not to people, but rather to gaps in coverage over time. Reforms that stop short of universal coverage should be evaluated in terms of their likely effects on the continuity and stability of coverage.     

‘Raising the Pulse’: The environmental,nutritional and health benefits of pulse-enhanced foods

Diet is a key modulator of non-communicable diseases, and food production represents a major cause of environmental degradation and greenhouse gas emissions. Yet, ‘nudging’ people to make better food choices is challenging, as factors including affordability, convenience and taste often take priority over the achievement of health and environmental benefits. The overall ‘Raising the Pulse’ project aim is to bring about a step change in the nutritional value of the UK consumers' diet, and to do so in a way that leads to improved health and greater sustainability within the UK food system. To achieve our objectives, UK-specific faba bean production systems that optimise both end users' diets and environmental and economic sustainability of production will be implemented in collaboration with key stakeholders (including industry, the retail sector and government). Palatable faba bean flours will be produced and used to develop ‘Raising the Pulse’ food products with improved nutritional profile and environmental value. Consumer focus groups and workshops will establish attitudes, preferences, drivers of and barriers to increased consumption of such products. They will inform the co-creation of sensory testing and University-wide intervention studies to evaluate the effects of pulses and ‘Raising the Pulse’ foods on diet quality, self-reported satiety, nutritional knowledge, consumer acceptance and market potential. Nutrient bioavailability and satiety will be evaluated in a randomised-controlled postprandial human study. Finally, a system model will be developed that predicts changes to land use, environment, business viability, nutrition and human health after substitution of existing less nutritionally beneficial and environmentally sustainable ingredients with pulses. Government health and sustainability priorities will be addressed, helping to define policy-relevant solutions with significant beneficial supply chain economic impacts and transformed sustainable food systems to improve consumer diet quality, health and the environment.     

Do individuals’ health preferences validate the decentralisation of the public health system in Spain?

The objective of this paper is to estimate individuals’ preferences about public health services in two Spanish regions, the Basque Country (BC) and Canary Islands (CI) and analyse whether they differ. This work was motivated by the actual economic situation, where it is necessary to obtain equilibrium between the needed health services and limited economic resources. With this limitation in mind, politicians have tried to design health policies that maximise individuals’ welfare. Based on the theory of decentralisation, the devolution of public expenditure decisions and management to regional government maximises individuals’ welfare more when individual preferences differ among regions. A discrete choice experiment was implemented with a survey designed to obtain data about individuals’ choices. Using this data and discrete choice models, individual preferences for health services were estimated. Our findings indicate that these preferences differ among regions, so, for reasons of efficiency, decentralising decisions and management of public health policies to regional governments would be recommended. Once health policies are decentralised, our results provide a tool for identifying the health services most valued by the individuals in each region. This information would be useful policymakers designing health policies.     

The utility of ‘country of birth’ for the classification of ethnic groups in health research: the Dutch experience

The relationship between ethnicity and health is attracting increasing attention in international health research. Different measures are used to operationalise the concept of ethnicity. Presently, self-definition of ethnicity seems to gain favour. In contrast, in the Netherlands, the use of country of birth criteria have been widely accepted as a basis for the identification of ethnic groups. In this paper, we will discuss its advantages as well as its limitations and the solutions to these limitations from the Dutch perspective with a special focus on survey studies.

The country of birth indicator has the advantage of being objective and stable, allowing for comparisons over time and between studies. Inclusion of parental country of birth provides an additional advantage for identifying the second-generation ethnic groups. The main criticisms of this indicator seem to refer to its validity. The basis for this criticism is, firstly, the argument that people who are born in the same country might have a different ethnic background. In the Dutch context, this limitation can be addressed by the employment of additional indicators such as geographical origin, language, and self-identified ethnic group. Secondly, the country of birth classification has been criticised for not covering all dimensions of ethnicity, such as culture and ethnic identity. We demonstrate in this paper how this criticism can be addressed by the use of additional indicators.

In conclusion, in the Dutch context, country of birth can be considered a useful indicator for ethnicity if complemented with additional indicators to, first, compensate for the drawbacks in certain conditions, and second, shed light on the mechanisms underlying the association between ethnicity and health.     

Science,policy and the rise of ‘thirdhand smoke’ as a public health issue

‘Thirdhand smoke’, the designated term for the cigarette smoke toxicants that linger on room and car surfaces long after the smoke itself dissipates, is a concept that has gained increasing prominence in tobacco control policy and research over the past six years. In this paper, I track the emergence of thirdhand smoke as a social and scientific concept, conducting a critical analysis of newspaper reports and references to the term in the academic and policy literature. Demonstrating that claims about the health effects of thirdhand smoke occurred in the absence of evidence of harm, I examine the broader sociopolitical conditions that enabled the concept to become meaningful (and useful). I show that some of the concept’s legitimacy came from its presentation as a natural extension of secondhand smoke, and its framing as a particular threat to babies and children. However, I argue that the experiential, embodied dimension of thirdhand smoke itself was crucial to its success.     

The Australian Government's ‘Social Inclusion Agenda’: the intersection between public health and social policy

Social exclusion and social inclusion have been popular policy themes in the UK and Europe, and made more modest appearances in countries such as Canada and New Zealand, for over a decade. In 2007, the Australian Government became the latest country in this trend of structuring social policy around issues of exclusion, launching its ‘Social Inclusion Agenda’ (SIA). The SIA aims to increase social and economic participation through a reorientation of social services and increased attention to issues of equity. At the same time, there has been international consensus on the importance of the social determinants of health (such as education, income and gender) for individuals and populations. The SIA has the potential to make a substantive contribution to the social determinants of health and hence the health and wellbeing of the population. However, much will depend on the extent to which international discourses of inclusion, exclusion, structural inequality and third way politics are taken up, adapted or discarded in the Australian context. At this formative stage of the SIA's development, the public health community is in a unique position to contribute to the development and direction of the SIA to secure the potential health gains it offers. This article outlines the formulation of social inclusion policy in Australia, and discusses the potential promises and pitfalls of a social inclusion approach. Our examination of the Australian experience of social inclusion policy provides an opportunity to reflect on the relationship between social inclusion and health internationally.     

The ethics of ‘public understanding of ethics’—why and how bioethics expertise should include public and patients’ voices

“Ethics” is used as a label for a new kind of expertise in the field of science and technology. At the same time, it is not clear what ethical expertise consists in and what its political status in modern democracies can be. Starting from the “participatory turn” in recent social research and policy, we will argue that bioethical reasoning has to include public views of and attitudes towards biomedicine. We will sketch the outlines of a bioethical conception of “public understanding of ethics,” addressing three different issues: (a) the methodological relevance of moral questions and problems raised by lay persons in everyday life regarding biomedicine and technology, (b) the normative relevance of such lay moralities for the justification of ethical decisions, and (c) the necessity of public deliberation in this context. Finally, we draw conclusions in view of the concepts and methods such a conception of “public understanding of ethics” should employ.     

Reframing the ‘securitization of public health’: a critical race perspective on post-9/11 bioterrorism preparedness in the US

This paper builds on the work of critical health scholars and practitioners who have examined the ‘securitization’ of public health in the US during the post-9/11 period. Adopting a critical race perspective, I delve more deeply into the racialized dimensions of this securitization, analyzing how the emergence of a bioterror-framed view of disease has mobilized a disease-terror imaginary comprised of longstanding suspicion towards bodies of color coupled with more recent anti-Arab and anti-Muslim sentiment. I demonstrate that the incorporation of the central figure of this imaginary – the bioterrorist – into US public health discourse has reconfigured ideas about disease carriers as potentially violent and malicious, in turn reconfiguring approaches to disease control that rely on suspicion and securitized health surveillance. US public health adoption of this orientation towards disease control has, I argue, the potential to exacerbate targeting, stigma, and exclusionary practices towards individuals and populations deemed suspicious vis-à-vis this imaginary. My work, in examining the racial discourses of bioterror that shape ‘securitization’, aims to expand the analytical tools that US public health administrators and practitioners draw on to remain vigilant in ensuring that it serves all of its publics in an equitable manner.     

Re-imagining world: From human health in the world to ‘all-world health’

This article explores the concept of ‘world’ as it frequently appears across health studies; specifically largely humanistic and phenomenological variations in use of ‘the world’ and ‘lifeworld’ are considered as they have helped cast knowledge on health and care. Looking forward, it is argued that world might be reimagined post-humanistically and post-phenomenologically as a vital emergent material entity and property. This is a reimagination that pays dividends by drawing attention to all-world processes and productions, hence to ‘all-world health’. On one level, all-world health involves consideration of the healths of all the world's material and biological entities (all parts of the world). On another level, all-world health involves understanding what an entity gains from its total surround as it moves through life (all parts of its world). Together these levels provide a more processual, relational and holistic understanding of health than that provided by traditional notions of human health states, determinants or meanings, and even by some environmental (ist) ideas on health. All-world health arguably provides a vision of interrelatedness on which greater unity, cooperation and care might be built.     

Fat,queer and sick? A critical analysis of ‘lesbian obesity’ in public health discourse

Recent public health publications identify lesbians as a ‘risk population’ with regards to ‘obesity’ and related comorbidities. Work of this nature argues that lesbian populations have higher rates of obesity due to poor diet and exercise behaviours which are, in turn, blamed on ‘lesbian culture’s’ feminist-informed criticism of patriarchal edicts of beauty, which allow lesbians to develop a greater tolerance for body fat. Also blamed is lesbian sexuality itself, as it is purported that lesbians do not need to work towards the heterosexual feminine ideal, thus avoiding the male gaze which demands thinness. This paper is a comprehensive literature review and critical discourse analysis of public health research on obesity that constructs lesbians as a ‘risk population.’ We outline how public health literature on lesbian obesity relies on old, well-worn discourses of queer sexualities in general as ‘sick’, helping to re-pathologize lesbians through conflating lesbianism and lesbian culture with a condition that is always-already considered insalubrious and, sometimes, diseased. These findings are significant, in that the organization of lesbians as a risk population within public health obesity discourse has yet to be explored in depth by critical obesity and fat studies scholars.     

The three domains of public health: an internationally relevant basis for public health education?

By focusing on the Masters of Public Health course, this study took a pragmatic approach to exploring the interface between public health education and public health practice. The commonly utilized 'three domains of practice' framework could provide a robust and explicit link between educational provision and practice for public health. This model provides the workforce, the university, the students and the potential funders of the course with an easily comprehensible framework for understanding how the modules of an MSc can support the development of competency within the context of practice.     

The economic cost of measles: Healthcare,public health and societal costs of the 2012–13 outbreak in Merseyside,UK

BackgroundMeasles is a highly contagious vaccine-preventable infection that caused large outbreaks in England in 2012 and 2013 in areas which failed to achieve herd protection levels (95%) consistently. We sought to quantify the economic costs associated with the 2012–13 Merseyside measles outbreak, relative to the cost of extending preventative vaccination to secure herd protection.MethodsA costing model based on a critical literature review was developed. A workshop and interviews were held with key stakeholders in the Merseyside outbreak to understand the pathway of a measles case and then quantify healthcare activity and costs for the main NHS providers and public health team incurred during the initial four month period to May 2012. These data were used to model the total costs of the full outbreak to August 2013, comprising those to healthcare providers for patient treatment, public health and societal productivity losses. The modelled total cost of the full outbreak was compared to the cost of extending the preventative vaccination programme to achieve herd protection.FindingsThe Merseyside outbreak included 2458 reported cases. The estimated cost of the outbreak was £4.4 m (sensitivity analysis £3.9 m to £5.2 m) comprising 15% (£0.7 m) NHS patient treatment costs, 40% (£1.8 m) public health costs and 44% (£2.0 m) for societal productivity losses. In comparison, over the previous five years in Cheshire and Merseyside a further 11,793 MMR vaccinations would have been needed to achieve herd protection at an estimated cost of £182,909 (4% of the total cost of the measles outbreak).InterpretationFailure to consistently reach MMR uptake levels of 95% across all localities and sectors (achieve herd protection) risks comparatively higher economic costs associated with the containment (including healthcare costs) and implementation of effective public health management of outbreaks.FundingCommissioned by the Cheshire and Merseyside Public Health England Centre.