The Ethical Imperative of Equity in Oncology: Lessons Learned From 2020 and a Path Forward.

The COVID-19 pandemic and the simultaneous increased focus on structural racism and racial/ethnic disparities across the United States have shed light on glaring inequities in U.S. health care, both in oncology and more generally. In this article, we describe how, through the lens of fundamental ethical principles, an ethical imperative exists for the oncology community to overcome these inequities in cancer care, research, and the oncology workforce. We first explain why this is an ethical imperative, centering the discussion on lessons learned during 2020. We continue by describing ongoing equity-focused efforts by ASCO and other related professional medical organizations. We end with a call to action-all members of the oncology community have an ethical responsibility to take steps to address inequities in their clinical and academic work-and with guidance to practicing oncologists looking to optimize equity in their research and clinical practice.

The Missing Chapter: The Education of Surgery and Anesthesiology Trainees as Civic Advocates.

The SARS-CoV-2 pandemic has highlighted existing systemic inequities that adversely affect a variety of communities in the United States. These inequities have a direct and adverse impact on the healthcare of our patient population. While civic engagement has not been cultivated in surgical and anesthesia training, we maintain that it is inherent to the core role of the role of a physician. This is supported by moral imperative, professional responsibility, and a legal obligation. We propose that such civic engagement and social justice activism is a neglected, but necessary aspect of physician training. We propose the implementation of a civic advocacy education agenda across department, community and national platforms. Surgical and anesthesiology residency training needs to evolve to the meet these increasing demands.

Human rights-based approach to global surgery: A scoping review.

BACKGROUND: Health is a basic human right, yet surgery remains a neglected stepchild of global health. Worldwide, five billion people lack access to safe, timely, and affordable surgical and anesthesia care when needed. This disparity results in over 18 million preventable deaths each year and is responsible for one-third of the global burden of disease. Here, we evaluate the role of surgical care in protecting human rights and attempt to make a human rights argument for universal access to safe surgical care. MATERIAL AND METHODS: A scoping review was done using the PubMed/MEDLINE, Embase, and Scopus databases to identify articles evaluating human rights and disparities in accessing surgical care globally. A conceptual framework is proposed to implement global surgical interventions with a human rights-based approach. RESULTS: Disparities in accessing surgical care remain prevalent around the world, including but not limited to gender inequality, socioeconomic differentiation, sexual stigmatization, racial and religious disparities, and cultural beliefs. Lack of access to surgery impedes lives in full health and economic prosperity, and thus violates human rights. Our normative framework proposes human rights principles to make surgical policy interventions more inclusive and effective. CONCLUSION: Acknowledging human rights in the provision of surgical care around the world is critical to attain and sustain the Sustainable Development Goals and universal health coverage. National Surgical, Obstetric, and Anesthesia Planning and wider health systems strengthening require the integration of human rights principles in developing and implementing policy interventions to ensure equal and universal access to comprehensive health care services.

Black Lives in a Pandemic: Implications of Systemic Injustice for End-of-Life Care.

In recent months, Covid-19 has devastated African American communities across the nation, and a Minneapolis police officer murdered George Floyd. The agents of death may be novel, but the phenomena of long-standing epidemics of premature black death and of police violence are not. This essay argues that racial health and health care disparities, rooted as they are in systemic injustice, ought to carry far more weight in clinical ethics than they generally do. In particular, this essay examines palliative and end-of-life care for African Americans, highlighting the ways in which American medicine, like American society, has breached trust. In the experience of many African American patients struggling against terminal illness, health care providers have denied them a say in their own medical decision-making. In the midst of the Covid-19 pandemic, African Americans have once again been denied a say with regard to the rationing of scarce medical resources such as ventilators, in that dominant and ostensibly race-neutral algorithms sacrifice black lives. Is there such thing as a "good" or "dignified" death when African Americans are dying not merely of Covid-19 but of structural racism?

Inequity in Access: Cataract Surgery Throughput of Chinese Ophthalmologists from the China National Eye Care Capacity and Resource Survey.

Purpose: To investigate the distribution of cataract surgery performed by ophthalmologists in China.Methods: A cross-sectional study was designed to investigate nationwide ophthalmological resources and capacity for cataract surgery in China⁠-The 2014 China National Eye Care Capacity and Resource Survey. Data analyzed in this report included regional distribution, urban-rural comparison, levels and types of medical institutions, and cataract surgery types and volume per surgeon. In China, only ophthalmologists at or above the level of attending are eligible to perform cataract surgery independently, so the ability of cataract surgery for ophthalmologists at or above the level of attending is analyzed in the current study. Descriptive statistics were used.Results: 36,333 ophthalmologists were included in this survey, which is an average of 1.33 ophthalmologists to every 50,000 population. Of the surgeons in this survey, 23,412 (50.22%) were attending or more senior ophthalmologists and were mainly distributed in eastern urban areas. Annual average cataract surgeries per ophthalmologist in China were 259 in 2017, less than 300 cases.Conclusion: The average number of ophthalmologists per population in China has achieved the goal of WHO's Vision 2020; however, these surgeons are concentrated in urban areas. Further, the ability of cataract surgery among ophthalmologists is unbalanced. The annual average cataract surgeries performed by ophthalmologists are insufficient, which is an important factor resulting in the current situation in China that ophthalmic service capacity has not met the requirements for eliminating cataract blindness.

Inequities in occupational diseases recognition in France.

BACKGROUND: In France, complex cases of occupational disease (OD) are submitted to regional committees who are in charge of accepting, or rejecting, the claim. Their mean annual acceptance rate varies from one region to another, which may reflect differences in the cases, or discrepancies between committees. The objective of this study was to assess the comparability of the decisions of the committees on the basis of standardized cases. METHODS: Three experienced occupational physicians specialized in OD were asked to develop 28 clinical cases representative of claims for compensation usually seen in these committees. The cases, in the form of short vignettes, were submitted to the 18 French regional committees, asking if they would recognise each case as an OD. RESULTS: All committees participated. The acceptance rate (recognition of the case as an OD) varied, ranging from 18% to 70%. All the committees took the same decision for only 7 out of the 28 cases, but half accepted and half refused for 3 cases. For 10 cases, one quarter of the committees gave a decision different than the other 75%. The highest discordance rates were observed for the cases concerning musculoskeletal disorders and asbestos related diseases. CONCLUSION: The committees take very different decisions in terms of recognition of OD, especially for the most frequently compensated OD in France, i.e. musculoskeletal disorders and asbestos related diseases. This is a major source of injustice for the employees who seek compensation and there is a need to develop methods to harmonize decisions between committees.

Examining the role of access to care: Racial/ethnic differences in receipt of resection for early-stage non-small cell lung cancer among integrated system members and non-members.

OBJECTIVES: To examine the role of uniform access to care in reducing racial/ethnic disparities in receipt of resection for early stage non-small cell lung cancer (NSCLC) by comparing integrated health system member patients to demographically similar non-member patients. MATERIALS AND METHODS: Using data from the California Cancer Registry, we conducted a retrospective cohort study of patients from four racial/ethnic groups (White, Black, Hispanic, Asian/Pacific Islander), aged 21-80, with a first primary diagnosis of stage I or II NSCLC between 2004 and 2011, in counties served by Kaiser Permanente Northern California (KPNC) at diagnosis. Our cohort included 1565 KPNC member and 4221 non-member patients. To examine the relationship between race/ethnicity and receipt of surgery stratified by KPNC membership, we used modified Poisson regression to calculate risk ratios (RR) adjusted for patient demographic and tumor characteristics. RESULTS: Black patients were least likely to receive surgery regardless of access to integrated care (64-65% in both groups). The magnitude of the black-white difference in the likelihood of surgery receipt was similar for members (RR: 0.82, 95% CI: 0.73-0.93) and non-members (RR: 0.86, 95% CI: 0.80-0.94). Among members, roughly equal proportions of Hispanic and White patients received surgery; however, among non-members, Hispanic patients were less likely to receive surgery (non-members, RR: 0.93, 95% CI: 0.86-1.00; members, RR: 0.98, 95% CI: 0.89-1.08). CONCLUSION: Disparities in surgical treatment for NSCLC were not reduced through integrated health system membership, suggesting that factors other than access to care (e.g., patient-provider communication) may underlie disparities. Future research should focus on identifying such modifiable factors.

Pacientes ilegítimos: Acceso a la salud de los inmigrantes indocumentados en Chile / Illegitimate patients: Undocumented immigrants' access to health care in Chile

RESUMEN Chile se ha ido convirtiendo en un país de destino para las migraciones sudamericanas, las cuales generan un impacto en los servicios públicos, en particular en salud, a nivel económico, social y cultural. El objetivo de este artículo es aportar información documentada sobre los problemas de acceso a la salud de los inmigrantes indocumentados. Trabajamos desde una metodología cualitativa, basada principalmente en una etnografía del espacio clínico. Para el análisis de los resultados nos hemos basado en las teorías de las relaciones asimétricas de poder, así como en las de las relaciones interétnicas. En los resultados de la investigación, se destaca el incumplimiento de la normativa y el ejercicio del criterio personal discrecional como barreras en el acceso. Concluimos que, en Chile, los inmigrantes en general e indocumentados, en particular, son considerados pacientes ilegítimos.

ABSTRACT In recent decades, Chile has become a destination for immigrants from other South American countries, which has significantly impacted public services - particularly the public health system - at the economic, social, and cultural levels. The aim of this paper is to provide substantiated information on issues concerning undocumented immigrants' access to health care in Chile. A qualitative methodology, fundamentally an ethnography of the clinical setting, was used. Results were then analyzed in relation to theories of power asymmetries and interethnic relations. The research results highlight the lack of compliance with existing regulations and the exercise of discretionary personal judgment as barriers to access. It is concluded that in Chile immigrants in general, and undocumented immigrants in particular, are considered to be illegitimate patients.

Effective cataract surgical coverage: An indicator for measuring quality-of-care in the context of Universal Health Coverage.

OBJECTIVE: To define and demonstrate effective cataract surgical coverage (eCSC), a candidate UHC indicator that combines a coverage measure (cataract surgical coverage, CSC) with quality (post-operative visual outcome). METHODS: All Rapid Assessment of Avoidable Blindness (RAAB) surveys with datasets on the online RAAB Repository on April 1 2016 were downloaded. The most recent study from each country was included. By country, cataract surgical outcome (CSOGood, 6/18 or better; CSOPoor, worse than 6/60), CSC (operated cataract as a proportion of operable plus operated cataract) and eCSC (operated cataract and a good outcome as a proportion of operable plus operated cataract) were calculated. The association between CSC and CSO was assessed by linear regression. Gender inequality in CSC and eCSC was calculated. FINDINGS: Datasets from 20 countries were included (2005-2013; 67,337 participants; 5,474 cataract surgeries). Median CSC was 53.7% (inter-quartile range[IQR] 46.1-66.6%), CSOGood was 58.9% (IQR 53.7-67.6%) and CSOPoor was 17.7% (IQR 11.3-21.1%). Coverage and quality of cataract surgery were moderately associated-every 1% CSC increase was associated with a 0.46% CSOGood increase and 0.28% CSOPoor decrease. Median eCSC was 36.7% (IQR 30.2-50.6%), approximately one-third lower than the median CSC. Women tended to fare worse than men, and gender inequality was slightly higher for eCSC (4.6% IQR 0.5-7.1%) than for CSC (median 2.3% IQR -1.5-11.6%). CONCLUSION: eCSC allows monitoring of quality in conjunction with coverage of cataract surgery. In the surveys analysed, on average 36.7% of people who could benefit from cataract surgery had undergone surgery and obtained a good visual outcome.

Requests for VIP Treatment in Pathology: Implications for Social Justice and Systems-Based Practice.

Preferential treatment of patients whom we deem "very important" is a practice that is common in our health care system. The impact of this designation and the care that results is rarely studied or scrutinized. Although we assume that this type of treatment results in superior outcomes, this assumption can be wrong for a variety of reasons, which we discuss here. In addition to expressing unjust preferential treatment for some patients and not others, VIP medicine could compromise patient safety.