[Assessment of Asbestos-related Occupational Diseases: Socio-medical and Legal Aspects]. / Sozialmedizinische und sozialjuristische Aspekte in der Zusammenhangsbegutachtung asbestbedingter Berufskrankheiten.

Occupational diseases are certain diseases designated as such by law. Whereas the medical conditions are described in guidelines, their recognition is based on judicial administrative procedures. Establishing causality is based on requirements of social law. The basic socio-legal concepts are mentioned and the principles of causality in asbestos-related occupational diseases are listed. Exemplary social court judgments are cited. Judgements may not infrequently differ from the medical point of view. The aim of this article is to describe the correct use of social medical understanding in order to carry out adequate assessment of occupational diseases, which implements the legal requirements.

O acesso a medicamentos em sistemas universais de saúde - perspectivas e desafios / Access to medication in universal health systems - perspectives and challenges

RESUMO Este estudo objetivou analisar os desafios do acesso a medicamentos em quatro sistemas universais de saúde da Austrália, do Brasil, do Canadá e do Reino Unido. Estudo qualitativo crítico-reflexivo por meio de revisão integrativa da literatura. Um dos grandes desafios dos sistemas estudados é o da incorporação de medicamentos de alto custo, via análises de custo-efetividade para cumprir a difícil tarefa de conciliar a justiça social e a equidade no acesso com sustentabilidade econômica. Particularmente o Canadá, mesmo sendo um país desenvolvido, ainda vive o dilema de como financiar um sistema de saúde no qual o acesso a medicamentos também seja universal. O Brasil convive com duas realidades problemáticas: primeiro, dar acesso a medicamentos, já padronizados pelo Sistema Único de Saúde (SUS), diante de um financiamento diminuto, segundo, de maneira semelhante aos sistemas australiano, canadense e inglês, vive o dilema de como incorporar novos medicamentos eficazes e com viabilidade econômica, além da questão da judicialização da saúde, um fenômeno complexo resultante da fragilidade pública na organização, financiamento, consolidação do SUS.

ABSTRACT This study aimed to analyze the challenges of access to medicines in four universal health systems in Australia, Brazil, Canada and the United Kingdom. Critical-reflexive qualitative study through Integrative Literature Review. The great challenge of the systems studied is the incorporation of high-cost drugs, through cost-effectiveness analyses to fulfill the difficult task of reconciling social justice and access equity with economic sustainability. Canada, in particular, despite being a developed country, still deals with the dilemma of how to finance a health system in which access to medicines is also universal. Brazil deals with two problematic realities: first, to grant access to medicines that are already standardized by the Unified Health System (SUS), in the face of insufficient funding. Secondly, similarly to the Australian, Canadian, and English systems, the dilemma of how to incorporate new efficient medicines considering its economic feasibility, as well as the issue of health judicialization, a complex phenomenon resulting from public fragility in the organization, financing, and consolidation of the SUS.

Tunisian documentation of «Public Health¼ in post revolution, with a taste of freedom. For a fair, participatory and efficient National Health System.

CONTEXT: Following the Tunisian revolution of 2010/2011, a new Public Health literature emerged, by the ministerial departments as well as the civil society, which was marked by the transparency and the comprehensiveness of the approach. OBJECTIVE: To identify the key ideas of the new Tunisian Public Health discourse, reconciling the principles of a globalizing paradigm with the health problems of a country in transition. METHODS: During this qualitative research, a selected series of three Tunisian reports of Public Health, published in the first quinquennium of the revolution, was read by an independent team of experts in Public Health, not having contributed to their elaboration, to identify the consensual foundations of the new Public Health discourse. These documents were: the "2011 Health Map" of the Department of Studies and Planning of the Ministry of Health, the "Societal Dialogue Report on Health Policies, Strategies and Plans" (2014), and the "Report on the right to health in Tunisia" (2016). RESULTS: The reading of this sample of the Tunisian Public Health literature of the post-revolution brought out three consensual ideas: 1. The constitutional principle of the "right to health" (article 38 of the constitution) with its corollary the State's obligation to ensure access to comprehensive, quality and secure care; 2. The challenge of social "inequalities" of access to care, reinforced by a regional disparity in the distribution of resources, particularly high-tech (specialist doctors, university structures); 3. Advocacy for a National Health System, based on a universal health coverage for its funding and citizen participation in its governance. CONCLUSION: The new Tunisian Public Health literature, in post-revolution, calls on all stakeholders in Preventive and Community Medicine to replace their segmental, technical and hospital practices with a new approach, centered on the implementation of a National Health System that is based on a socialized financing of care and citizen participation in its management.

Challenges Persist Under Americans With Disabilities Act Amendments Act: How Can Oncology Providers Help?

PURPOSE: To determine whether the Amendments to the hallmark Americans with Disabilities Act (ADA; effective January 2009), which provide increased access to the antidiscrimination laws for many with chronic illness, are related to changes in workplace discrimination allegations in individuals with a history of cancer. METHODS: Information collected by the Equal Employment Opportunities Commission was used to compare allegations of discrimination and their merit before (2001 to 2008) and after (2009 to 2011) implementation of the Amendments Act. RESULTS: Allegations related to terms of employment (eg, promotions, wages) were more likely to be filed (odds ratio [OR], 1.34; 95% CI, 1.11 to 1.61) and determined to have merit (OR, 1.35; 95% CI, 1.03 to 1.77) after implementation of the Amendments Act. Allegations related to workplace relations (eg, harassment, discipline, discharge) were also more likely to be filed post Amendments Act (OR, 1.48; 95% CI, 1.23 to 1.78), although the merit of this complaint remained stable. Filing of all other allegations of discrimination (ie, hiring, reasonable accommodation, and termination) and their merit remained unchanged post Amendments Act. CONCLUSION: Despite the implementation of the Amendments Act, discrimination allegations in those with a history of cancer persisted or in certain areas increased. Although prevention of workplace discrimination rests primarily with employers, the oncology care team is uniquely qualified to provide information related to residual symptoms and function that can facilitate more personalized solutions to workplace discrimination, such as successful workplace accommodations. Information is provided that can assist the oncology team in their efforts to improve work outcomes.

Remembering Freddie Gray: Medical Education for Social Justice.

Recent attention to racial disparities in law enforcement, highlighted by the death of Freddie Gray, raises questions about whether medical education adequately prepares physicians to care for persons particularly affected by societal inequities and injustice who present to clinics, hospitals, and emergency rooms. In this Perspective, the authors propose that medical school curricula should address such concerns through an explicit pedagogical orientation. The authors detail two specific approaches-antiracist pedagogy and the concept of structural competency-to construct a curriculum oriented toward appropriate care for patients who are victimized by extremely challenging social and economic disadvantages and who present with health concerns that arise from these disadvantages. In memory of Freddie Gray, the authors describe a curriculum, outlining specific strategies for engaging learners and naming specific resources that can be brought to bear on these strategies. The fundamental aim of such a curriculum is to help trainees and faculty understand how equitable access to skilled and respectful health care is often denied; how we and the institutions where we learn, teach, and work can be complicit in this reality; and how we can work toward eliminating the societal injustices that interfere with the delivery of appropriate health care.

Reflexões sobre práticas psi-jurídicas na triagem da Defensoria Pública Paulista / Reflections on psycho-legal practices in the triage of the Public Defender's Office of São Paulo / Reflexiones acerca de las prácticas psi-jurídicas en la selección de la Defensoría Pública Paulista

Neste artigo, apresentamos alguns desdobramentos da pesquisa de doutorado na qual estudamos encontros psi-jurídicos na Defensoria Pública do Estado de São Paulo, tomando a experiência dos Centros de Atendimento Multidisciplinar (CAMs) como objeto. Por meio da metodologia qualitativa da pesquisa-intervenção que contou com a elaboração de diários e de narrativas, empreendemos o acompanhamento das práticas profissionais que envolviam o trabalho conjunto de defensores, assistentes sociais e psicólogos na Defensoria Pública, entre 2011 e 2013. Aqui, privilegiamos mostrar a triagem, espaço no qual é feito o primeiro atendimento às pessoas que buscam assistência jurídica, que nos possibilitou nos aproximar da gestão dos pedidos e de como eles se transformam em demandas jurídicas, não jurídicas e psicossociais. Para tanto, utilizamos informações das fichas dos encaminhamentos feitos a um CAM nos anos de 2010 e 2011, com situações vivenciadas no percurso da pesquisa. Os operadores conceituais do estudo se apoiam no pensamento foucaultiano e na Análise Institucional francesa. A triagem mostrou que se privilegia a partilha tradicional entre os saberes, tendendo-se a (re)produzir uma assistência jurídica "desintegrada" e disciplinarizada, oferecendo-se um modo familialista de resposta às problemáticas apresentadas pela população. No entanto as questões de saúde mental emergem como algo que escapa às divisões, produzindo desvios no processo de trabalho. Acreditamos que esses modos de saber-fazer engendram uma assistência jurídica que tende à atenção integral, constituindo-se numa experiência de pensar-saber-fazer entre profissões que não se submete aos protocolos e divisões já instituídos.

In this article, we presented some developments of the doctoral research in which were studied psycho-legal encounters at the Defensoria Pública do Estado de São Paulo (Public Defender's Office of the State of São Paulo), taking the experience of the Centros de Atendimento Multidisciplinar (Multidisciplinary Assistance Centers­CAMs, acronym in Portuguese) as subject. Through a qualitative intervention-research methodology based on diaries and narrative construction, we have monitored professional practices involving the joint work of defenders, social workers and psychologists at the Public Defender's Office, between 2011 and 2013. Here, we decided to focus on the triage, space where the first assistance to people who look for legal help is performed, which allowed us to get in contact with the management of requests and the way they become legal, non-legal and psycho-social demands. In order to do that, we used information from referral forms sent to a CAM in the years 2010 and 2011, along with situations experienced in the course of this research. The theoretical references of this study are Foucault's thought and French Institutional Analysis. The triage showed that a traditional division between knowledges is utilized, which tends to (re)produce an "unintegrated" and disciplined legal assistance, providing a familialist mode of response to the problems presented by the population. However, mental health issues emerge as something that escapes divisions, producing shifts in the work process. We believe these ways of knowing-how-to-do generate a legal assistance that tends to be more oriented to comprehensive care, constituting anexperience of thinking-knowing-doing between professions that does not submit to protocols and divisions already established.

En este artículo, presentamos algunas evoluciones de la investigación de Doctorado de en la que estudiamos los encuentros psi-jurídicos en la Defensoría Pública del Estado de São Paulo, teniendo la experiencia de los Centros de Atendimiento Multidisciplinar (CAMs) como objeto. Por intermedio de la metodología cualitativa de la investigación-intervención que incluyó la elaboración de diarios y narrativas, se llevó a cabo el estudio de prácticas profesionales en la Defensoría Pública, entre 2011 y 2013. Aquí, centramos en la que muestra el espacio de selección, en el que se hace la primera atención a las personas que buscan asistencia jurídica, lo que hizo posible acercarse a la gestión de pedidos y respecto a cómo ellos se convierten en exigencias jurídicas, no jurídicas y psicosociales. Para eso, utilizamos informaciones de los registros de derivaciones al CAM, locus de la investigación en 2010 y 2011 y del informe elaborado por la Asesoría Técnica Psicosocial (ATP), cuyos datos presentan el trabajo de equipos de CAM en 2011, además de las situaciones vividas en el camino de la investigación. Los operadores conceptuales del estudio se basan en el pensamiento de Foucault y en el Análisis Institucional francesa. La selección mostró favorecer la división tradicional entre los saberes, tendiendo a (re)producir una asistencia jurídica "desintegrada", disciplinarizada y despolitizada, que ofrece una forma familialista de la respuesta a los problemas presentados por la población. Sin embargo, las cuestiones de salud mental emergen como algo que escapa a las divisiones, produciendo desvíos en el proceso de trabajo. Creemos que estos modos de conocimientos engendran una asistencia jurídica que tiende a la atención integral, constituyéndose en una experiencia de pensar-saber-hacer entre profesiones que no está sujeta a los protocolos y las divisiones ya establecidos.

Asbestos: Socio-legal and Scientific Controversies and Unsound Science in the Context of the Worldwide Asbestos Tragedy - Lessons to be Learned.

Eight to fifteen per cent of lung cancer cases and nearly all mesothelioma cases are caused by asbestos. Problems in compensation issues ensue from strict legal requirements for eligibility and regulations of the statutory accident insurance institution pertaining to eligibility for occupational disease benefits. The latter include the unscientific requirement for set numbers of asbestos bodies or fibers to be found in lung tissue in order to "prove" disease causation if lung specimen are available. Although the validity of such evidence has been discredited by independent scientists, it is still used as evidence by an influential US pathology department. Frequently, epidemiological evidence regarding causal relationships and exposure histories is also often being ignored by insurance-affiliated medical experts.Similar misleading arguments are currently being used in newly industrialized countries where white asbestos - which is carcinogenic and fibrogenic like other asbestos types - is efficiently promoted as being less harmful. As a result, asbestos use is increasing in some of these countries. Behind the worldwide asbestos tragedy, a well-designed strategy orchestrated by certain transnational or multinational industrial interest groups can be perceived.Beyond the asbestos tragedy their covert plan is motivated by economic interests and discounts the ensuing damage to health and the impact of the diseases they create on public health systems.

[Asbestos: Social Legal and Scientific Controversies and Unsound Science in the Context with the Worldwide Asbestos Tragedy - Lessions to be Learned]. / Sozialjuristische und wissenschaftliche Kontroversen sowie Fehlinterpretationen im Kontext mit der weltweiten Asbest-Tragödie - Was ist daraus zu lernen?

8 to 15% of lung cancer cases and nearly all mesothelioma cases are caused by asbestos. Problems in compensation issues refer to high legal as well as insurance barriers in attesting the occupational diseases. Claiming of certain numbers of asbestos bodies or fibers in lung tissue is of special relevance in substantiating legal medical cases. Such evidence, which is disproved by a sound science, is also used by an influential US pathology department. Frequently, also epidemiological evidence with its causal relationships and exposure histories are ignored. Similar misleading arguments are currently found in industrializing countries where white asbestos which is carcinogenic and fibrogenic like other asbestos types, is efficiently promoted as less harm. As a result, the asbestos consumption is increasing in some of these countries. Beyond the worldwide asbestos tragedy a well-designed strategy of certain transnational or global acting industrial interest groups can be recognized. Their plan, hidden from the public eyes, follows rigorously sole economic interests, while leaving the resulting health harm to the public health systems.

Considerations for use of dental photography and electronic media in dental education and clinical practice.

Photography and electronic media are indispensable tools for dental education and clinical practice. Although previous research has focused on privacy issues and general strategies to protect patient privacy when sharing clinical photographs for educational purposes, there are no published recommendations for developing a functional, privacy-compliant institutional framework for the capture, storage, transfer, and use of clinical photographs and other electronic media. The aims of this study were to research patient rights relating to electronic media and propose a framework for the use of patient media in education and clinical care. After a review of the relevant literature and consultation with the University of Washington's director of privacy and compliance and assistant attorney general, the researchers developed a privacy-compliant framework to ensure appropriate capture, storage, transfer, and use of clinical photography and electronic media. A four-part framework was created to guide the use of patient media that reflects considerations of patient autonomy and privacy, informed consent, capture and storage of media, and its transfer, use, and display. The best practices proposed for capture, storage, transfer, and use of clinical photographs and electronic media adhere to the health care code of ethics (based on patient autonomy, nonmaleficence, beneficence, justice, and veracity), which is most effectively upheld by a practical framework designed to protect patients and limit institutional liability. Educators have the opportunity and duty to convey these principles to students who will become the next generation of dentists, researchers, and educators.

[International and national legal mechanisms of ensuring social justice for the elderly].

Increase in the proportion of older persons in the population of most countries entails a change in the scale and structure of morbidity, which requires higher expenditures on health care and social service. Maintaining health and activity of older people is an important indicator of the effectiveness of public policies in the field of health and social welfare. Under these conditions the development of effective measures to promote prosperous aging is required, which includes primarily legislative, administrative and other measures, as well as development of a strategy and action plan of socio-economic nature, taking into account the needs of older people.

[Is "mental health" part of the common good? The sociopolitical framework of psychiatric ethics and the responsibility of health-care elites]. / "Psychische Gesundheit" als Gemeinwohlgut und der soziopolitische Rahmen einer Ethik der Psychiatrie--die Verantwortung der Eliten im Gesundheitswesen.

Psychiatric work can only be that ethical as the framework of a health-care system allows. Thus, the responsibility of the health-care elites to establish a sociopolitical framework that suits psychiatric ethics is discussed on the basis of a theory of the common good and of a philosophical and normative elite theory. "Mental health" is demonstrated to be part of a basic sphere of the common good which cannot be denied to any member of a society. The final section discusses which specific duties can be derived for health-care elites on the ground of the aforementioned conception of "mental health" as a part of the common good.

Rationing just medical care.

U.S. politicians and policymakers have been preoccupied with how to pay for health care. Hardly any thought has been given to what should be paid for--as though health care is a commodity that needs no examination--or what health outcomes should receive priority in a just society, i.e., rationing. I present a rationing proposal, consistent with U.S. culture and traditions, that deals not with "health care," the terminology used in the current debate, but with the more modest and limited topic of medical care. Integral to this rationing proposal--which allows scope to individual choice and at the same time recognizes the interdependence of the individual and society--is a definition of a "decent minimum," the basic package of medical treatments everyone should have access to in a just society. I apply it to a specific example, diabetes mellitus, and track it through a person's life span.

Por un sistema de salud que garantice la protección del derecho: un requisito de justicia social / Towards a health system that guarantees the protection of the right: a social justice requirement / Por um sistema de saúde que garantisse a proteção do direito: um requisito de justiça social

Objetivo: analizar en la teoría liberal igualitaria de John Rawls y en los idearios teóricos de Amartya Sen y Martha Nussbaum, elementos a favor de la protección de la salud como condición necesaria de justicia social. Metodología: investigación de carácter filosófico. Analiza críticamente los fundamentos morales y políticos que sustentan el reconocimiento del derecho a la atención en salud como un requisito de justicia social. Profundiza en las tesis de Amartya Sen y Martha Nussbaum en torno al concepto de capacidades como aquello que las personas pueden ser y hacer y su aseguramiento por parte del Estado como requisito de justicia social. Resultados: en su preocupación por evitar sociedades en las que las diferencias sean injustas, Rawls avanza en un ideal de justicia social como principio de prudencia racional aplicado a una concepción colectiva del bienestar del grupo, con la idea de compatibilizar los valores de igualdad y libertad y de determinar un conjunto de bienes primarios sociales que, se presume, todo ser racional desea. Sen y Nussbaun incluyen la salud en el conjunto de capacidades necesarias para el desarrollo del ser humano. Su enfoque está estrechamente ligado al concepto de derechos humanos y a la dignidad humana. Nussbaum otorga prioridad a la necesidad de asistencia, punto central en la protección del derecho a la salud. Milton Fisk entiende el concepto de “salud” como bien público y el de “sociedad saludable” como una meta social en la que debe comprometerse el conjunto de la sociedad. Conclusiones: se debe proponer un nuevo contrato social en el que se abogue por un derecho innegociable a la protección de la salud, como parte de un ejercicio de ciudadanía. Este acuerdo de voluntades debe apostarle a un sistema de salud justo como un asunto de moralidad política, y a la protección del derecho a la salud como el derecho a su tutela, de manera tal que se garantice al ciudadano el establecimiento de unos mínimos irreductibles que le hagan posible participar de los beneficios de la vida en sociedad.

Objective: to examine in John Rawls’ liberal egalitarian theory and in Amartya Sen and Martha Nussbaum’s theorists ideology, elements favoring health protection as a necessary condition of social justice. Methodology: philosophical research investigation. It critically examines the moral and political foundations that support the recognition of the right to health care as a requirement of social justice. It goes deeper into Amartya Sen and Martha Nussbaum’s theories around the capacities concept on such as what people can be and do, and their assurance by the State as a social justice condition. Results: In his worry for avoiding societies in which differences become unfair, Rawls advances on an ideal of social justice as a principle of rational prudence applied to a collective perception of the group welfare, with the idea of reconciling values like equality and freedom to determine a set of primary social values which are presumed to be what any rational being wants. Sen and Nussbaum include health in the set of necessary capabilities for human development. Their approach is tightly linked to the human rights concept and to human dignity. Nussbaum prioritizes the health assistance need, central point in the protection to the right to health. Milton Fisk understands the concept of “health” as a public asset and that of “healthy society” as a social goal in which, society as a whole, must be committed. Conclusions: a call for a new social contract in which the nonnegotiable right to the protection of health is advocated, as part of an exercise of citizenship must be proposed. This wills agreement must bet on a fair health system as a matter of politics morality and on the right to health protection as the right to its conservatorship in such a way that it guarantees the citizen the establishment of minimum irreducible that make it possible for him to participate from the benefits of living in a society.

Objetivo: analisar na teoria liberal igualitária de John Rawls e nos ideários teóricos de Amartya Sen e Martha Nussbaum, elementos a favor da proteção da saúde como condição necessária de justiça social. Metodología: Pesquisa de caráter filosófico. Analisa criticamente os fundamentos morais e políticos que sustentam o reconhecimento do direito à atenção em saúde como requisito de justiça social. Profundeza na tese na tese de Amartya Sen e Martha Nussbaum em torno ao conceito de capacidades como aquilo que as pessoas podem ser e fazer e seu asseguramento por parte do Estado como requisito de justiça social. Resultados: Em sua preocupação por evitar sociedades nas que as diferencias sejam injustas, Rawls avança num ideal de justiça social como principio de prudência racional aplicado a uma concepção coletiva do bienestar do grupo, com a idéia de compatibilizar os valores de igualdade e liberdade e determinar um conjunto de bens primários sociais que, se presume, todo ser racional deseja. Sen e Nussbaun incluem a saúde no conjunto de capacidade necessária para o desenvolvimento do ser humano. Seu enfoque esta estreitamente unida ao conceito de direitos humanos e à dignidade humana. Nussbaum outorga prioridade à necessidade de assistência, ponto central na proteção do direito à saúde. Milton Fisk entende o conceito de “saúde” como bem publico e o de “sociedade saudável” como uma meta social na que deve comprometesse o conjunto da sociedade. Conclusões: deve propor um novo contato social no que se advogue por um direito inegociável à proteção da saúde, como parte de um exercício de cidadania. Este acordó de vontades deve apostar lhe a um sistema de saúde justo como um assunto de moralidade publica, e a proteção do direito à saúde como o direito a sua tutela, maneira tal como se garantisse ao cidadão o estabelecimento de uns mínimos irredutíveis lhe façam possível participarem dos benefícios da vida em sociedade.

[Essential drugs and pharmaceutical care: reflection on the access to drugs through lawsuits in Brazil]. / Essencialidade e assistência farmacêutica: considerações sobre o acesso a medicamentos mediante ações judiciais no Brasil.

The guarantee of pharmaceutical care as a legal right established by the Brazilian federal constitution of 1988 led to an increase in lawsuits to put that right into practice. This phenomenon has been dubbed the judicialization of pharmaceutical care. Studies on this topic have revealed, on the one hand, deficiencies in the access of Unified Health Care (SUS) users to drugs included in Ministry of Health pharmaceutical care lists, and, on the other hand, limitations of the legal system to deal with the situation. The present article addresses these issues in the context of the conceptual framework that supports the Brazilian drug policy and pharmaceutical care policy, especially the notions of essential drugs and allocation of scarce resources.