Operationalizing the ‘population health’ approach to permit consideration and minimization of unintended harms of public health interventions: a malaria control example

To achieve elimination of malaria, both ‘populations at risk’ strategies and ‘population health’ approaches to intervention are required. While the ‘populations at risk’ vs. ‘population health’ debate is not new to public health, here we advance the discussion by identifying how the ‘population health approach’, coupled with concepts from theories of unintended harms, could be used to identify and guide efforts to minimize unintended harm associated with ‘populations at risk’ strategies, using malaria as an example. We begin by reviewing unintended harm and present the presumptive diagnosis and treatment of malaria clinical practice guideline (PDTM-CPG) as an example of a ‘populations at risk’ strategy for malaria control. We then consider the value of the ‘population health’ approach for identifying and minimizing cultural and economic unintended harms associated with the PDTM-CPG. We outline several concepts that are helpful in terms of the identification and mitigation of unintended harm. Specifically, the ‘population health approach’ emphasizes structural determinants of health that are key to enhancing intervention impact and reducing inequities, while theories of unintended harms emphasize factors that play into the selection and impact of interventions; namely, the breadth and depth of the knowledge base, contextual considerations, basic values, and the perceived need for immediate action. Finally, based on these key concepts, we identify practical discussion questions for district, national, and international public health planners and policy-makers to reflect upon when engaging in intervention design or adaptation. These questions are intended to maximize efforts to achieve malaria elimination while minimizing unintended harms.     

Biobanks and the ‘well-being’ of humanity: integrating consent to research with the capability approach

Among the important ethical challenges that biobanks raise, the shortcoming of the traditional acceptation of informed consent is one of the most debated. The protection of research participants’ autonomy is a central theme in current ethical reasoning on biomedical research. In this article, I argue that moral philosophy offers the opportunity to broaden the debate raised by the shortcomings of the established doctrine of informed consent when applied to biobanking activities. The capability approach and deliberative democracy theories are particularly interesting in analyzing biobanks and informed consent because they shift the focus from the relationships patient/physician and participants in research/investigator–the bioethics focus–to the well-being of research participants and their ability to self-determination understood as a mean by which individuals participate in the societal arrangements that underscore biobanks’ regulation, thus fostering the democratic deliberative process. My claim is that many ethical issues raised are better understood and eventually solved if a broader definition of the notion of autonomy as put forth by moral and political theory is integrated in the discourse of biobanking and informed consent.

Philosophy is like this: eternally unsettled and only occasionally disturbed by new facts

Matt Ridley, Nature via Nurture, p.23     

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.     

The emergence of a ‘dose–response’ analogy in the health improvement domain of public health: a critical review

Public Health specialists have increasingly deployed the concept of ‘dose–response’ in areas such as diet (‘five-a-day’), alcohol (‘21 weekly units’) and physical activity (‘150 minutes of weekly activity’). Using these examples and a case study that sought to establish an optimal dose of physical activity for mental health gain, this article offers a critical assessment of the nature, robustness and function of ‘dose’ in public health. Drawing on a ‘sociology of knowledge’, the article argues that dose–response can best be considered an analogy that does not necessarily translate favourably from its original expression in toxicology to some public health domains – an over-extended analogy. Rather than having technical robustness, its attractiveness and utility is seen to lie in it possessing ‘cultural capital’, here, the ability to link behavioural concerns to clinical practice, to simplify complex ideas and to act as a regulatory form of behavioural governance. The article is skeptical of further empirical pursuits in identifying optimal doses and offers an alternative course for public health framing.     

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.     

‘Falling off the radar’ of public health: The case of uninsured Chinese patients in Vienna,Austria

In public health policy debates, the 2015–2016 refugee crisis made visible that even in European welfare states with (close to) universal health coverage there are specific vulnerable groups with highly limited access to health care. Among them is a population of so-called ‘undocumented’ or ‘irregular’ migrants who have no regular status of residence and falls off the radar of publicly funded health care services and thus from the public health surveillance systems. The aim of our study is to provide the first-of-its-kind evidence on the characteristics, health problems and health care needs of one such vulnerable group in Austria – Chinese migrants residing in Vienna without a regular status. Medical records of 74 uninsured assumingly undocumented Chinese patients were analysed. The data was provided by a Non-governmental organisation (NGO) which delivers primary care to uninsured people in Vienna. The most frequently diagnosed health problems clustered around cardiovascular and metabolic-related diseases (hypertension and diabetics) and there was a high burden of multiple chorionic non-communicable diseases. Further efforts and resources are needed for collecting more data in a systematic way. A trusting relationship between science and practice and a cooperative relationship between and among the government agencies and NGOs are essential for evidence-based public health policy making.     

From ‘trial community’ to ‘experimental publics’: how clinical research shapes public participation

In relation to clinical trials, it is far more usual to speak of the community (singular, static) than of publics (multiple, emergent). Rarely defined, the community is commonly taken to be the existing people in a given area, which the trial will engage, mobilise or sensitise to facilitate successful recruitment and retention. Communities are assumed to pre-exist the research, to be timeless, and to be a whole (sometimes consisting of different parts, referred to as stakeholder groups). In this paper, we suggest a conceptual shift from ‘trial community’ to ‘experimental publics’. Using an empirical case study of an HIV prevention trial in Zambia, we draw out the following key points: firstly, publics do not pre-exist research activities but are enacted in concert with them. Secondly, publics are dynamic and transient. And thirdly, experimental publics are situated at the intersection of various forms of inclusion and exclusion, both locally and globally. Our findings emphasise the need to create long-term forms of participation in science, which transcend both the instrumental goals and the individual timelines of specific trials.     

The causes and health effects of the Great Recession: from neoliberalism to ‘healthy de-growth’

In 2008, the world experienced the worst financial crisis since the Great Depression. The crisis is often described in relation to its proximal risk factors such as the proliferation of risky loans and mortgage-based securities, but the root causes of the Great Recession include distal risk factors such as indiscriminate capital flow, excessive financial deregulation, and high concentration of wealth in the top distribution. Ultimately, the crisis is a byproduct of neoliberal policies and the ‘self-correcting market’ ideology that guided national and global macroeconomic reforms since the 1970s. Evidence indicates that the Great Recession led to increases in unemployment and suicides, especially in Europe and in the US. Estimates based on the effects of previous economic downturns suggest that the crisis produced negative health and nutritional outcomes in developing countries. Data, however, also show that recessions can be characterized by increases in life expectancy at birth. These favorable trends seem associated with policy regimes favoring a more egalitarian distribution of income and stronger social protections that can decouple the link between unemployment and suicides during crises (‘healthy de-growth’.). New rules and regulations at the national and global level are needed to prevent future financial crises. The crisis also provides an opportunity to challenge neoliberalism, the ideology of the ‘self-correcting market’ and envision a new model of economic development where GDP growth is longer the main national policy priority. Governments can achieve a regime of ‘healthy de-growth’ if they step in with appropriate policy interventions toward a more egalitarian distribution of income and stronger social protections.     

Facing the facelessness of public health: what's the public got to do with it?

Despite compelling statistics that show we could eliminate 80%of all heart disease and strokes, 90% of all diabetes, and 60% of all cancers with basic lifestyle changes, we have failed to motivate the public to make these changes and failed to motivate policy makers to make healthy choices the easiest choice. Dr. Katz suggests we have failed because we have focused too much on statistics and too little on passion. He implores all of us to tap into people's passion by connecting each of these statistics with a human story.     

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 angel of the house” in the realm of ART: feminist approach to oocyte and spare embryo donation for research

The spectacular progress in assisted reproduction technology that has been witnessed for the past thirty years resulted in emerging new ethical dilemmas as well as the revision of some perennial ones. The paper aims at a feminist approach to oocyte and spare embryo donation for research. First, referring to different concepts of autonomy and informed consent, we discuss whether the decision to donate oocyte/embryo can truly be an autonomous choice of a female patient. Secondly, we argue the commonly adopted language of gift is misleading and that calling for altruism could put female patients at risk of exploitation. Finally, we point out that the presence of gender stereotypes in the procreative area casts doubt whether even a more robust notion of informed consent manages to overcome this risk.     

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.