引入剥夺指数促进我国公共卫生财政资源配置的公平性

目的:基于社会剥夺的视角,测量我国各地区社会剥夺指数,分析其与人口健康需要的相关性,并研究将剥夺指数纳入财政分配机制中能否促进我国公共卫生财政投入的公平性。方法:因子分析法测量我国31个地区的社会剥夺指数。该指数与各地人口健康需要指标进行相关分析,并按剥夺指数对我国公共卫生财政重新分配。结果:我国大部分西部地区和中部地区比多数东部地区具有较高的社会剥夺水平;较高剥夺水平的地区,其人口健康需要也较高;我国公共卫生财政配置的公平性较差。结论:财政分配机制中引入剥夺指数将促进我国公共卫生财政投入的公平性,且简单指数具有与合成指数同等的有效性。建议新医改中,政府应支持剥夺水平高的地区,以促进财政分配的公平性,并开发有效的公共卫生财政分配工具。     

Black carbon exposure,socioeconomic and racial/ethnic spatial polarization,and the Index of Concentration at the Extremes (ICE)

BackgroundScant data quantify associations between economic and racial/ethnic spatial polarization and individual's exposure to pollution.MethodsWe linked data on the socioeconomic position (SEP) of 1757 urban working class white, black, and Latino adults (age 25–64; Boston, MA: 2003–2004; 2008–2010) to: (1) spatiotemporal model-based estimates of cumulative black carbon exposure at their exact residential address, and (2) their census tract values for the Index of Concentration at the Extremes (ICE) for SEP and race/ethnicity.ResultsICE measures, but not individual- and household-SEP, remained independently associated with black carbon exposure.ConclusionsThe ICE may be useful for environmental health research.     

Prediction of Resting Metabolic Rate in Critically Ill Patients at the Extremes of Body Mass Index

Background: Although estimation of energy needs by mathematical equation is common in practice, there is relatively little validation data for the equations. This is especially true at the upper and lower extremes of body size. The purpose of the current study was to provide validation data for several common equations in underweight and morbidly obese critically ill patients. Methods: In mechanically ventilated, critical care patients with body mass index ≤21.0 or ≥45.0 kg/m², indirect calorimetry was used to measure resting metabolic rate. Several equation methods were then compared with these measurements, including the Penn State equation, Faisy equation, Ireton‐Jones equation, Mifflin–St Jeor equation, Harris‐Benedict equation, and American College of Chest Physicians (ACCP) standard using ideal, actual, or metabolically active body weight. Results: Accuracy (percentage of estimates falling within 10% of measured) in the morbidly obese group was highest for the Penn State equation (76%) and lowest for the ACCP standard using actual body weight (0%). For the underweight group, the Penn State equation was accurate 63% of the time, but below a body mass index of 20.5, the accuracy rate dropped to 58%. No other equation was more accurate than this in the underweight patients. Conclusion: The Penn State equation is valid in morbid obesity, but the accuracy rate is much lower in underweight critically ill patients. A modification to the equation is suggested to improve accuracy in this group.     

Beyond Bioethics: Reckoning With the Public Health Paradigm

In the wake of scandal over troubling research abuses, the 1970s witnessed the birth of a new system of ethical oversight. The bioethics framework, with its emphasis on autonomy, assumed a commanding role in debates regarding how to weigh the needs of society against the rights of individuals.Yet the history of resistance to oversight underscores that some domains of science hewed to a different paradigm of accountability—one that elevated the common good over individual rights.Federal officials have now proposed to dramatically limit the reach of ethical oversight. The Institute of Medicine has called for a rollback of the federal privacy rule. The changing emphasis makes it imperative to grapple with the history of the public interest paradigm.Only a few years ago, the business of ethical review seemed a juggernaut destined only to expand, inspiring increasingly bitter remonstrations about the “absurd demands” federal research regulation placed on scientists.1 It is remarkable, then, that the Department of Health and Human Services (DHHS) now stands poised to significantly scale back and streamline many institutional oversight procedures.2 In October 2011, DHHS closed the public comment period on a proposal that would expand the categories of social and behavioral research that can be “excused” from institutional review board approval, allow a single institutional review board to oversee multisite studies, and generally adjust the institutional review board system to avoid cases where low-risk studies are subjected to high levels of scrutiny. The pending overhaul comes in the wake of Institute of Medicine recommendations in 2009 to exempt all research from the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule and absolve all “information-based” research from informed consent requirements.3 Taken together, these proposals suggest the regulatory pendulum is taking a swing to the permissive.Much debate around the DHHS proposal has centered on its identification of the HIPAA Privacy Rule as a potential framework for ensuring research data protection and security—an idea that has caused some researchers to fear that the new regime, designed to simplify the review process, will actually lead to even more red tape.4 Yet there are larger issues at stake than simply ensuring that important research can proceed without being slowed by administrative impediments. The prospect of change creates space to reckon with other ethical traditions and paradigms of accountability that might inform research regulation besides the reigning bioethical regime, which emphasizes autonomy and privacy. One such tradition, distinctly opposed to the current bioethics approach, stands out in the long history of the debate over research regulation and privacy protection.For more than a decade, professionals in history, journalism, the social sciences, and public health, which play essential roles in protecting the public from threats of disease and corporate and government misconduct, have argued that the purpose of scientific inquiry is to benefit society as a whole, even sometimes at the expense of individual interests. In debates over the mandate of institutional review boards, researchers in these fields have striven not simply to emancipate important nonmedical research from unnecessary fetters, but to underline an inherent tension between deeply conflicting paradigms of accountability in which very different conceptions of who and what require protection are at stake. We lay out 4 brief histories that bear on nonclinical research regulation and the arguments against it, focusing on fields that most forcefully resisted regulation by articulating a fundamentally different vision of accountability. Before turning to those specific cases, we lay out the broad backdrop against which the debates have unfolded.Following the Nuremberg Code of 1947, the principle of informed consent became the cardinal ethic for scientific research involving human participants. US federal regulations to prevent harm to individual research participants first arose in response to a series of exposés on shocking medical experiments in newspapers and medical journals, culminating in the 1972 revelations about the 40-year-long Tuskegee Syphilis Study. A new system of institutionally based ethical review intended to ensure the safety and voluntary consent of research participants was created.Initially, epidemiologists and social scientists grew alarmed that the new, individual rights–based bioethical framework that provided the moral architecture of the regulatory schema might make their research more difficult or even impossible to conduct. Some closure on these issues was reached in 1981, when social science and epidemiological research was explicitly exempted from institutional review board review if the risk to participants and their privacy was minimal. But before the 20th century closed, for many scholars the promise of streamlined oversight would be transformed into a stultifying specter, hovering over all scientific inquiry, no longer constrained within the boundaries of medicine.In the 1990s, activities that had long remained relatively free from ethical oversight began to be subjected to scrutiny following a spate of research-related incidents at high-profile institutions,5 including the death of an 18-year-old experimental gene therapy patient at the University of Pennsylvania in 1999.6 Federal regulators responded by cracking down, and risk-averse institutions began to apply conventional bioethical human participant protections with new muscle, suppressing alternative discourses, such as those that championed the common good, that struggled to resist such “ethical imperialism.”7 Yet even as the grip of bioethics as a regulatory regime tightened, it quickly became apparent that it was the wrong framework of accountability for some domains of inquiry.It was within this context that debates over research in different disciplines unfolded. For example, when in the early 1990s regulators sought to treat public health surveillance—the often compulsory reporting of the names of individuals diagnosed with certain infectious and chronic diseases by physicians and laboratories to city and state health departments—as research requiring federal ethical oversight, health officials countered that effective surveillance depended on universal reporting of names; it could not depend on informed consent. Such data collection was required by law, and the law reflected the will of the people.8 This was an old argument. As early as 1891, in the face of physician resistance to reporting, health officials argued that surveillance was based on a “contract.”9 It amounted to a public duty in which “the people had consented” in the name of the common good to what might otherwise seem like an “arbitrary” or even “authoritarian” regime.10 Surveillance could demand limitations not only of privacy but even of liberty if the disease in question required mandatory treatment or isolation.11 At stake were questions of what individuals in a civil society owed to one another.12Practitioners of quality assurance in health care, which involves the assessment of medical records to determine the adequacy of care, voiced similar arguments half a century later. The field of quality assurance originated in the 1960s as a response to poor clinical outcomes,13 and became one of the hallmarks of the provision of health care services under Medicare and Medicaid—two of the signature social welfare programs of President Lyndon Baines Johnson’s Great Society.14 By the 1990s, “quality improvement,” which originated as a proactive technique for regulating and improving the delivery of medical care, had become a “positive” watchword of a new era.15Beginning in 2000, after federal regulators received a complaint suggesting that a quality improvement study conducted among dialysis patients should have been classified as research,16 demand for bioethical review of all quality assurance activities escalated.17 But when federal panels began to develop recommendations for determining when quality assurance required ethical oversight,18 administrators at the Centers for Medicare and Medicaid Services resisted.19 “Fiduciary responsibility” served as their lodestar.20 Justified by the need to conserve taxpayer dollars while improving clinical outcomes, at the heart of their claim was an ethos similar to that of public health: those charged with administering the social welfare system bore a public duty to protect the interests of populations, not the rights of individuals.Giving full voice to this public-spirited paradigm were historians, journalists, and others engaged in social science inquiry, who argued that the purpose of research, at its best, was to illuminate critical social and political issues. The primary obligation was ensuring the public’s right to know. “Our job is to hold people accountable,” argued Columbia University historian Alice Kessler-Harris.21 Her point was that the primary commitment of historians was to the unfettered development of knowledge through historical interpretation—not to individual subjects who emerged as the subjects of inquiry. Historians viewed their research not through the lens of bioethics but as serving the “common good” and “vital to democratic debate and civic life.”22 They rested their claims on the centrality of freedom of speech.23 History’s villains could not be allowed to hide behind the regulations governing the protection of human participants.History also served the powerless. So much of social science research had sought to ensure that the perspectives of the socially and politically marginal—former slaves, women, the poor—came to light. Exposure in this context took on a different hue. Whether acting as watchdogs or giving voice to the voiceless, researchers drew on the Constitution for authority. “Simply put,” commented the University of Buffalo’s Michael Frisch, “the core purpose of oral history is to put named people into the historical record—not mask or anonymize them.”24Debate in the 1990s over medical privacy also provided occasion for making the case for the public good. President Bill Clinton’s 1993 proposal for universal health coverage, which raised the prospect of the centralized, computer-based management of medical care, sparked early calls to protect medical privacy. When the Clinton proposal failed, privacy concerns were taken up by Congress as part of HIPAA. From the outset, Congress envisioned shielding public health data from privacy regulations: health departments would not need consent to acquire and share personally identifiable information for the purpose of safeguarding the public’s health. As enacted, the DHHS Privacy Rule (45 CFR Part 160 and Subparts A and E of Part 164) contained what is known as a public health “carve-out.” Privacy advocates did not resist this exemption, and disease advocacy groups strongly supported it.25 The March of Dimes, for instance, noted that

While the individual has an interest in maintaining the privacy of his or her health information, public health authorities have an interest in the overall health and well being of the entire population.26

Thus, although the 2003 HIPAA Privacy Rule significantly enhanced medical privacy, it also formalized the notion that privacy rights are not always sacrosanct.As we debate the protections that must be in place for research participants today, it is essential to acknowledge the difference between social science inquiry and research performed in clinical settings. It goes without question that research with the potential to harm participants must be monitored by third parties. But blanket regulations designed to protect powerless clinical research participants may also inadvertently protect the powerful from necessary social and political scrutiny on the part of investigators in fields that define their mission in terms of the common good. This is not to say that a claim for the common good is always sufficient to justify a release from regulation.27 Our point, rather, is to emphasize that there is an important ethical framework, with a deep and varied history, that has justified affirmative duties to limit rights in the name of public interests.We agree that the time has come to recognize that social inquiry in areas like history, public health, and quality assurance requires an alternative framework of analysis. Yet we cannot let an obsession with rules allow us to overlook the fact that scientific research is guided by a number of different ethical frameworks that do not always agree. Bioethics asserts that individual rights such as privacy require protection; many other frameworks demand that we look past the individual and prioritize the common good. By embracing a new approach for research in public interest domains, the proposed changes implicitly acknowledge this tension. Indeed, there will always be issues where distinct paradigms hewing to different priorities collide. So although the ongoing debate over changes to ethical oversight procedures may resolve certain conflicts, it also sets the stage for the enduring contest between different paradigms of accountability.     

基于集中指数的妇幼健康服务和妇幼健康公平性分析

目的 对妇幼健康公平性进行分析,为促进妇幼保健服务和提高妇幼健康公平程度提供借鉴和参考.方法 利用《中国卫生统计年鉴》《中国卫生和计划生育统计年鉴》《中国统计年鉴》中的相关资料,计算反映妇幼保健服务和妇幼健康水平的各项指标的集中指数.结果 孕产妇系统管理、产前检查、产后访视、儿童保健管理的集中指数均为正值,反映出其主要集中在社会经济发展水平相对富裕的省份,围产儿死亡、孕产妇死亡的集中指数均为负值,反映出其主要集中于社会经济发展水平相对落后的省份.2008-2013年我国妇幼保健服务及妇幼健康的不公平性在各省(市、区)间的差距有所改善.结论 不同省(市、区)的妇幼保健服务和妇幼健康状况的不公平程度有所改善,应发展贫困地区经济,缩小贫富差距,注重对中部地区的支持,提高妇幼保健服务的效率和质量,从而改善妇幼健康.     

With the Best INTENTIONS Lead Research and the Challenge to Public Health

In 2001, Maryland’s court of appeals was asked to decide whether researchers at Johns Hopkins University had engaged in unethical research on children. During the 1990s, Johns Hopkins’s Kennedy Krieger Institute had studied 108 African American children, aged 6 months to 6 years, to find an inexpensive and “practical” means to ameliorate lead poisoning. We have outlined the arguments in the case and the conundrum faced by public health researchers as they confront new threats to our health from environmental and industrial insults. We examined the case in light of contemporary public health ideology, which prioritizes harm reduction over the historical goals of prevention. As new synthetic toxins—such as bisphenyl A, polychlorinated biphenyls, other chlorinated hydrocarbons, tobacco, vinyl, and asbestos—are discovered to be biologically disruptive and disease producing at low levels, lead provides a window into the troubling dilemmas public health will have to confront in the future.IN MAY 2012, THE CENTERS for Disease Control and Prevention officially accepted the recommendations of its Advisory Committee on Childhood Lead Poisoning Prevention and adopted a new, lower standard for “acceptable” blood lead levels in American children. The new standard of 5 micrograms per deciliter of blood halved the older definition of 10 micrograms established 20 years ago and nearly doubled the scope of the lead poisoning epidemic in the United States as the estimated number of at-risk children jumped from about a quarter of a million to nearly one half a million victims.1This staggering number of children whose neurologic integrity, intelligence, and behavior have been threatened by lead makes this epidemic among the broadest and longest lasting in American public health history.2 As public health professionals have uncovered the negative effects of ever-lower exposures to lead, their frustration with the lack of political will to eliminate lead from the walls, soil, and air has grown. For the past 30 years—since the confluence of documentation of the widespread damage to children from low levels of lead and the growing strength of conservative, antigovernment ideology in the broader culture and in government—the public health community has been divided on how to proceed in the future: should we demand a massive program to eliminate lead paint on older structures, the major source of lead in the children’s environment, or should we reduce exposures through various abatement procedures, knowing that low-level lead exposures still threaten poor children living in decaying, older homes? These questions about how to address this age-old hazard are not new but have gained increasing urgency as we discover that there very well may not be any threshold below which lead does not negatively affect children’s neurologic development.No case encapsulates the tensions that have arisen over the conflicting approaches to the epidemic better than the Johns Hopkins Bloomberg School of Public Health’s experience with a lead abatement research project it conducted in the 1990s. That study achieved notoriety because in August 2001, just weeks before the attack on the World Trade Center and the Pentagon diverted the nation’s attention, the Court of Appeals of Maryland, that state’s highest court, handed down a strongly worded, even shocking, opinion that goes to the heart of beliefs about what public health should do and what our responsibility to others should be.3Open in a separate windowThe court had been asked to decide whether researchers at Johns Hopkins University, among the nation’s most prestigious academic institutions, had engaged in unethical research on children. The case pitted two African American children and their families against the Kennedy Krieger Institute (KKI), Johns Hopkins’s children’s clinic and research center, which in the 1990s had conducted a multiyear study in which children were exposed to differing amounts of lead in their homes. The KKI project was designed during the presidency of George H. W. Bush to find a relatively inexpensive and effective method for reducing—though not eliminating—the amount of lead in children’s homes and thereby reducing the devastating effect of lead exposure on children’s brains and, ultimately, on their life chances. The Johns Hopkins researchers had recruited 108 families with young children to live in houses with differing levels of lead, ranging from none to levels just below the existing legal limit in Baltimore, Maryland, and then measured the extent of lead in the children’s blood at periodic intervals. (The overwhelming majority of families were composed of single African American mothers and their children.) By matching the expense of varying levels of partial lead paint abatement—a $1650 investment for the first group of homes, $3500 for the second, and $7000 for the third—with changing levels of lead found in the blood, the researchers hoped to find the most cost-effective means of reducing childhood exposure to the toxin. Completely removing lead paint from the homes, the researchers recognized, would be ideal for children’s health, but they believed, with some justification, that to do so would be considered far too costly in such politically conservative times and likely to result in landlord abandonment of housing in the city’s more poverty-stricken districts.The court of appeals found that Johns Hopkins had engaged in highly suspect research that had direct parallels with some of the most infamous incidents of research abuse of vulnerable populations in the 20th century. The KKI Repair and Maintenance Project, the court argued, differed from but presented

similar problems as those in the Tuskegee Syphilis Study, … the intentional exposure of soldiers to radiation in the 1940s and 50s, the test involving the exposure of Navajo miners to radiation … and the secret administration of LSD to soldiers by the CIA and the army in the 1950s and 60s.

The research defied many aspects of the Nuremberg Code, the court said.4 For the court it was deeply troubling that a major university would conduct research that might eventuate in permanent damage to children.Many in the public health community later argued that this was just a “rogue court,” an out-of-control panel of judges, but the Maryland Court of Appeals was not known for its liberalism. In fact, the judge who wrote the opinion, Dale R. Cathell, was considered one of the more conservative judges on the bench.5 The researchers were not uncaring researchers or unfeeling persons either. In fact, one, J. Julian Chisolm, had dedicated his professional life to uncovering the extent and limiting the damage of lead poisoning in Baltimore, and the other, Mark Farfel, was a young committed public health advocate who had formed close alliances with many in the poor community surrounding Johns Hopkins.This was a complex and troubling story, not just about the KKI research but also about the public health profession, the nation’s dedication to the health of its citizens in the new millennium, and the conundrum that we as a society face as we confront revelations about many new environmental threats in the midst of a very conservative political culture and the continuing legacy of poverty and racism. In its ubiquity and harm, lead is an exemplary instance of these threats. Yet there are many others we encounter in everyday life that entail similar issues, from mercury in the fish we eat that comes from power plants to flame retardants used on our children’s clothes and bisphenol A, which is in many plastics, cans, and glues that we commonly use.6For much of its history the public health field has provided the vision and the technical expertise for remedying the conditions—both biological and social—that created environments conducive to harm and in which disease could spread. And throughout much of its history, public health leaders have joined with social activists to finds ways in the existing political and economic structures to prevent diseases.Although the medical profession has often been given the credit for the vast improvements in the health and life span of Americans over the past century, it was the crusading spirit of public health reformers in the 19th and early 20th centuries who pushed for housing reforms, mass vaccination campaigns, clean water and sewage systems, and pure food laws that played the major role in improving children’s health, lowering infant mortality, and limiting the impact of viral and bacterial diseases such as cholera, typhoid, diphtheria, smallpox, tuberculosis, measles, and whooping cough that had plagued the nation for decade after decade. These broad public health campaigns to control infectious diseases yielded great victories from the 1890s through the 1930s. With the first decades of the 20th century, however, a different view of the profession slowly began to gain ascendancy, redefining the mission of public health in ways that belied its role as an agent of social reform. In this view, the idea was to put the fast-growing science of biological medicine in the service, not of eradicating the conditions that facilitated disease and its spread but of concentrating on treating the disease itself person by person and reducing risk rather than eliminating it.7