Socializing the public: invoking Hannah Arendt’s critique of modernity to evaluate reproductive technologies

The article examines the writings of one of the most influential political philosophers, Hannah Arendt, and specifically focuses on her views regarding the distinction between the private and the public and the transformation of the public to the social by modernity. Arendt’s theory of human activity and critique of modernity are explored to critically evaluate the social contributions and implications of reproductive technologies especially where the use of such technologies is most dominant within Western societies. Focusing on empirical studies on new reproductive technologies in Israel, it is argued, powerfully demonstrates Arendt’s theory, and broadens the perspectives through which society should evaluate these new technologies towards a more reflective understanding of its current laws and policies and their affect on women more generally.     

Windows of sensitivity to toxic chemicals in the development of reproductive effects: an analysis of ATSDR’s toxicological profile database

Development of the fetus is a complex process influenced by many factors including genetics, maternal health, and environmental exposures to toxic chemicals. Adverse developmental effects on the reproductive system have the potential to harm generations beyond those directly exposed. Here, we review the available literature in Agency for Toxic Substances and Disease Registry toxicological profiles related to reproductive-developmental effects in animals following in utero exposure to chemicals. We attempt to identify windows of sensitivity. In the discussion, we correlate the findings with human development. The endpoints noted are fertility, estrus, anogenital distance, sex ratio, spermatogenesis, and mammary gland development. We identified some windows of sensitivity; however, the results were hampered by chronic-exposure studies designed to detect effects occurring throughout developmental, including multi-generational studies. This paper demonstrates the need for more acute studies in animals aimed at understanding time periods of development that are more susceptible to chemically induced adverse effects.     

Informal interpreting in general practice: the migrant patient’s voice

Objective: To explore the perspective of Turkish-Dutch general practitioner (GP) patients on informal interpreting from an integrated theory base, focusing on interpreters’ roles, trust and power.

Design: Semi-structured in depth interviews were conducted with 21 first-generation Turkish-Dutch migrant patients who made use of informal interpreters to communicate with their GPs. An interview guide was designed based on the theoretical framework of interpreter’s roles, trust and power, covering questions about interpreters’ role, trust in informal/professional interpreters and power division in the medical consultation. The interviews were transcribed verbatim and analyzed according to the constant comparative method.

Results: Besides providing linguistic translation, informal interpreters were expected to perform the roles of advocates and caregivers of the patients. Informal interpreters were trusted more than professional interpreters, mainly for fidelity reasons, that is, because the patients assumed that informal interpreters would act in their best interests. Although informal interpreters were often perceived as the primary interlocutor, the patients did not feel dominated by them, but rather empowered by their presence.

Conclusion: Our findings indicate a connection between the role of the advocate, the fidelity dimension of trust and the perceived empowerment of the patients. By linking interpreters’ role to trust and power, this study contributes to theory building in the field of informal interpreting, which is needed to design evidence-based interventions to improve health care delivery to patients with insufficient language ability and thus to advance health care delivery to migrant patients, which is currently lagging behind.     

The impact of memantine in combination with acetylcholinesterase inhibitors on admission of patients with Alzheimer’s disease to nursing homes: cost-effectiveness analysis in France

The costs associated with the care of Alzheimer’s disease patients are very high, particularly those associated with nursing home placement. The combination of a cholinesterase inhibitor (ChEI) and memantine has been shown to significantly delay admission to nursing homes as compared to treatment with a ChEI alone. The objective of this cost-effectiveness analysis was to evaluate the economic impact of the concomitant use of memantine and ChEI compared to ChEI alone. Markov modelling was used in order to simulate transitions over time among three discrete health states (non-institutionalised, institutionalised and deceased). Transition probabilities were obtained from observational studies and French national statistics, utilities from a previous US survey and costs from French national statistics. The analysis was conducted from societal and healthcare system perspectives. Mean time to nursing home admission was 4.57 years for ChEIs alone and 5.54 years for combination therapy, corresponding to 0.98 additional years, corresponding to a gain in quality adjusted life years (QALYs) of 0.25. From a healthcare system perspective, overall costs were €98,609 for ChEIs alone and €90,268 for combination therapy, representing cost savings of €8,341. From a societal perspective, overall costs were €122,039 and €118,721, respectively, representing cost savings of €3,318. Deterministic and probabilistic (Monte Carlo simulations) sensitivity analyses indicated that combination therapy would be the dominant strategy in most scenarios. In conclusion, combination therapy with memantine and a ChEI is a cost-saving alternative compared to ChEI alone as it is associated with lower cost and increased QALYs from both a societal and a healthcare perspective.     

Inventing the Right to Know: Herbert Abrams’s Efforts to Democratize Access to Workplace Health Hazard Information in the 1950s

In the 1980s, the right-to-know movement won American workers unprecedented access to information about the health hazards they faced on the job. The precursors and origins of these initiatives to extend workplace democracy remain quite obscure. This study brings to light the efforts of one of the early proponents of wider dissemination of information related to hazard recognition and control. Through his work as a state public health official and as an advisor to organized labor in the 1950s, Herbert Abrams was a pioneer in advocating not only broader sharing of knowledge but also more expansive rights of workers and their organizations to act on that knowledge.The late 1970s witnessed the emergence of a movement to force American employers to disclose various forms of information regarding the occupational health risks faced by their employees. Right-to-know activists, operating primarily through a network of newly formed local and regional committees on occupational safety and health, the so-called COSH groups, demanded and in the 1980s won rights for individual workers, and in some circumstances for their unions and other designated parties, to see records previously concealed from them. These included the findings of employee medical examinations, the identities and known health effects of the toxic chemicals to which workers were exposed, and the results of management’s monitoring of chemicals and other types of hazards in the working environment. Thus far, historians and others have captured salient aspects of these liberating developments, which included the promulgation of the federal Occupational Safety and Health Administration Hazard Communication Standard in 1983 and similar reforms at the state and local levels.1Yet the existing literature does little to illuminate the precursors and origins of the right-to-know movement. The period before the 1970s is described as a dark age of abject victimization amid manufactured ignorance. A number of studies have brought to light the ways in which industry gathered evidence of occupational disease, either through its own collection of clinical data or through sponsorship of biomedical research, but suppressed publication or other distribution of information regarding adverse outcomes. The aim here is not to overturn that interpretation but rather only to qualify it by calling attention to one of a small number of voices that challenged the autocratic regime and its secretive nature. Along with Anthony Mazzocchi of the Oil, Chemical and Atomic Workers Union and Lorin Kerr and some of his colleagues at the United Mine Workers Welfare and Retirement Fund (and probably others yet to be found by historians), Herbert Abrams precociously raised and persistently asserted in the 1950s a number of the main concerns articulated in the right-to-know campaigns of the decade from the mid-1970s to the mid-1980s.2     

Public health’s social contract: An obstacle in the advancement of effective HIV technologies

ABSTRACT

Evidence from the past 40 years of HIV technology development and implementation indicates that the public health social contract – with its expectations of patient/citizen compliance – has hampered global disease control efforts. Despite the availability of a wide array of effective technologies, including antiretroviral drugs as treatment and prevention, voluntary medical male circumcision procedures, and newly developed intravaginal ring products, new infections among adults globally have not decreased significantly. In this paper, I describe a historical trend of limiting access to effective biomedical technologies to those deemed most deserving and compliant given concerns of misuse (non-adherence), product repurposing (not using the product for purposes originally intended), and the incitement of autonomy (increasing the risk of public exposure to diseases given personal protection from a specific disease). Examining the expectations of good citizenship (compliance, adherence, appropriate product use, and continued risk reduction) as it relates to human-technology interactions, reveals a continuing narrative of initially restricting access to newer technologies perceived fragile or costly based on an assessment of patient/citizen worth. In this, the conventional public health social contract continues to be an obstacle in the advancements of technologies to effectively reduce the global burden of HIV.     

Cherry Picking in the ‘Aina: Inequalities of Access to Dermatologic Care in Hawai‘i

There is evidence that people who are insured by Medicaid have difficulty accessing health care from private providers. This study documents access to dermatology care for a hypothetical patient insured by Medicaid in the State of Hawai‘i. Posing as young Medicaid patient with a changing mole, we called all dermatologists listed on the American Academy of Dermatology website and requested an appointment to be seen. Only 23% of dermatologists contacted accept all Medicaid plans and an additional 12% accept some. Thus 65% of dermatologists called do not provide specialist care to Hawai‘i''s Medicaid population.     

Access to health care in an age of austerity: disabled people’s unmet needs in Greece

Since late 2009, Greece has been dealing with the effects of a debt crisis. The neoliberal principles embedded in the three structural adjustment programmes that the country accepted have required radical cuts in health care funding, which in turn have led to widening inequalities in health. This article focuses on access to health care for people with disabilities in Greece in the context of these structural adjustments. We investigate possible differences in unmet health care needs between people with and without disabilities, using de-identified cross-sectional data from the European Health Interview Survey. The sample included 5400 community-dwelling men and women aged 15 years and over. The results of the logistic regressions showed that people with disabilities report higher unmet health care needs, with cost, transportation, and long waiting lists being significant barriers; experience of all barriers was positively associated with low socio-economic status. These findings suggest that a section of the population who may have higher health care needs face greater barriers in accessing services. Austerity policies impact on access to health care in both direct and indirect ways, producing long-term disadvantage for disabled people. Social policies and comprehensive anti-discrimination legislation might help to address some of the barriers this population faces.     

Scene setting: who is the voice of nutrition in Britain?

Currently the public is being inundated daily with information about diet and health, which is often conflicting and frequently not based on good quality evidence. This situation is fuelled by the ready access to information of variable quality via the internet, which has short circuited the previous checks and balances applied by researchers and the peer review process, whereby scientific findings were batted around and refined within the confines of the scientific research community, occasionally emerging to be incorporated into the advice given by health professionals. This situation, coupled with concern about the growing trend whereby detailed nutrition advice is sold to the public by self-styled 'experts' with no formal degree-level training in the subject, prompted a conference that highlighted the importance of ensuring that nutrition advice is evidence-based, using a series of topical overviews. In recent years the Nutrition Society has played an active role in establishing mechanisms to assist the public in their search for high-quality dietary advice by badging individuals appropriately qualified to offer sound and relevant advice on nutrition.     

Survival of Huntington’s disease patients in Serbia: longer survival in female patients

The objective of this study was to estimate probability of survival of Huntington’s disease (HD) patients in Serbia as a function of CAG repeat length and selected demographic variables. This follow-up study was carried out at the Institute of Neurology, Clinical Centre of Serbia, Belgrade, 1982–2004. The study group consisted of 112 HD patients. The significant inverse correlation was found between CAG repeat length and age at onset of HD (r = −0.732, P = 0.001) and age at death (r = −0.760, P = 0.001). The cumulative probabilities of survival in a five, ten, fifteen, and twenty-years’ period were 90.9, 63.2, 10.3 and 4.5%, respectively. Higher survival probabilities were registered in female patients, as well as in those with older age at onset and lower number of CAG repeat length (≤46). The Cox regression analysis showed that significantly poorer outcome of HD in our population was related to younger age at onset (HR-hazard ratio = 1.9; P = 0.047), and larger CAG numbers (HR = 2.4; P = 0.071). The female sex was statistically significantly associated with longer survival (HR = 0.4; P = 0.007). These data might be of some importance for further exploration of natural history and prognosis of HD.     

Access to physician services: does supplemental insurance matter? Evidence from France

In France, public health insurance is universal but incomplete, with private payments accounting for roughly 25% of all spending. As a result, most people have supplemental private health insurance. We investigate the effects of such insurance on the utilization of physician services using data from the 1998 Enquête sur la santé et la protection sociale, a nationally representative survey of the non-institutionalized French population. Our results indicate that insurance has a strong and significant effect on the utilization of physician services. Individuals with supplemental coverage have substantially more physician visits than those without. While French patients have greater freedom than patients in other countries to choose to see a specialist rather than a general practitioner, we find no evidence that supplemental insurance affects this decision.     

Assessing hospital competition when prices don’t matter to patients: the use of time-elasticities

Health care reforms in several European countries provide health insurers with incentives and tools to become prudent purchasers of health care. The potential success of this strategy crucially depends on insurers’ bargaining leverage vis-à-vis health care providers. An important determinant of insurers’ bargaining power is the willingness of consumers to consider alternative providers. In this paper we examine to what extent consumers are willing to switch hospitals when they are fully covered for hospital services, which is typical for many European countries. Since prices do not matter to these patients, we estimate time-elasticities to assess hospital substitutability. Using data from a large Dutch health insurer on non-emergency neurosurgical outpatient hospital visits in 2003, we estimate a conditional logit model of patient hospital choice taking both patient heterogeneity and hospital characteristics into account. We use the parameter estimates to simulate the demand effect of an artificial increase in travel time by 10% for every patient, holding all other hospital attributes constant. Overall, the resulting point estimates of hospitals’ time-elasticities are fairly high, although variation is substantial (−2.6 to −1.4). Sensitivity tests reveal that these estimates are very robust and differ significantly across individual hospitals. This implies that all hospitals in our study sample have at least one close substitute which is an important precondition for effective hospital competition.     

Acceptability of less than perfect health states in rheumatoid arthritis: the patients’ perspective

Some health problems are considered by many individuals as a ‘normal’ part of ageing. Our aim was to investigate whether patients with rheumatoid arthritis (RA) consider different types and levels of health losses as acceptable beyond a certain age. A multicenter cross-sectional survey was performed involving RA patients at the initiation of the first biological therapy. The EQ-5D and the Health Assessment Questionnaire Disability Index (HAQ-DI) questionnaires were used to describe domain-specific health states. Patients were asked to indicate for each domain from what age and onward (between ages 30 and 80 years in 10 year intervals) they considered moderate and severe problems acceptable or alternatively never acceptable. Seventy-seven RA patients (females 86 %, mean age 50.3, disease duration 9.1 years) completed the questionnaire. Disease activity (DAS28), EQ-5D and HAQ-DI scores were mean 6.00 (SD 0.85), 0.35 (SD 0.36), 1.48 (SD 0.66), respectively. The majority of the patients considered age 70 and beyond as acceptable to have some health problems (EQ-5D: self-care 42 %, pain/discomfort 34 %, mobility 33 %, usual activities 33 %, anxiety/depression 27 %), whilst at ages 30 and 40 as not acceptable. Severe health problems were mostly (57–69 %) considered never acceptable, except the ‘Usual activities’ domain (acceptable from age 80 by 50.6 %). The great majority of the patients (77–96 %) were younger than what they indicated as the acceptability age limit. Similar results were found for the HAQ-DI. This small experimental study suggests that RA patients consider some health problems acceptable. This acceptability is age related and varies by health areas. Further larger studies are needed to explore explanatory variables and to compare with other diseases. Owing to the impact acceptability might have on RA patients’ self-evaluation of current health state and decision-making, the topic deserves methodological improvement and further investigation.