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?

Repercusión social de los grupos de Alcohólicos Anónimos en egresados del servicio de Deshabituación en provincia Guantánamo / Repercussão social de grupos de Alcoólicos Anônimos em retirados do serviço de desintoxicação na província de Guantánamo / Social repercussion of Alcoholics Anonymous groups ending of the Detoxification service in Guantanamo province

Introducción: el movimiento internacional de ayuda contra el alcoholismo Alcohólicos Anónimos, consiste en comunidades de hombres y mujeres que comparten su mutua experiencia, fortaleza y esperanza para resolver el problema del alcoholismo en común y ayudar a otros en su recuperación. Objetivo: demostrar la repercusión social de los grupos de Alcohólicos Anónimos en pacientes egresados del servicio de deshabituación del Hospital Psiquiátrico de Guantánamo durante enero y diciembre de 2016. Método: se realizó un estudio observacional, descriptivo donde se utilizó un cuestionario elaborado por los autores y validados por psicólogos. La población y la muestra estuvieron constituidas por 140 pacientes pertenecientes al municipio Guantánamo. Resultados: el sexo masculino fue el más representativo, la edad de comienzo de la ingestión de bebidas alcohólicas estuvo marcada entre los 11 y 39 años, considerando que debían recibir ayuda médica el mayor por ciento, siendo estos atendidos en el servicio de Deshabituación del hospital psiquiátrico y el Hospital de Día de alcohólicos, además de la psicoterapia de la comunidad. Los pacientes encuestados consideran que son discriminados por la sociedad. Conclusiones: el éxito de Alcohólicos Anónimos está en que todos los que pertenecen a la agrupación tienen crítica de la enfermedad y pueden compartir sus propias experiencias en la psicoterapia con un apoyo seguro y seguimiento continuo, siempre al lado de la comunidad profesional, experiencia que en Guantánamo ha ido ganando en beneficio a estos pacientes(AU)

Introduction: the international movement of help against alcoholism Alcoholics Anonymous, consists of communities of men and women who share their mutual experience, strength and hope to solve the problem of common alcoholism and help others in their recovery. Objective: to demonstrate the social repercussion of the Alcoholics Anonymous groups in patients detoxified in the service of the Psychiatric Hospital of Guantanamo during January and December 2016. Method: an observational, descriptive study was carried out where a questionnaire elaborated by the authors and validated by psychologists. The population and the sample consisted of 140 patients belonging to the Guantanamo municipality. Results: the masculine sex was the most representative, the age of beginning of the ingestion of alcoholic drinks was marked between the 11 and 39 years, considering that they had to receive medical aid the greater percent, being these attended in the service of deshabituación of the hospital psychiatric hospital and day hospital for alcoholics, in addition to community psychotherapy. The surveyed patients consider that they are discriminated against by society. Conclusions: the success of Alcoholics Anonymous is that all those who belong to the group have a critique of the disease and can share their own experiences in psychotherapy with a safe support and continuous monitoring, always at the side of the professional community, experience that in Guantánamo has been gaining benefit to these patients(AU)

Introdução: o movimento internacional contra o alcoolismo ajuda Alcoólicos Anônimos consiste de comunidades de homens e mulheres que compartilham suas experiências, forças e esperanças para resolver o problema do alcoolismo em comum e ajudar os outros em sua recuperação. Objetivo: demonstrar o impacto social dos grupos de Alcoólicos Anônimos em pacientes que receberam alta do serviço deshabituación Hospital Psiquiátrico Guantánamo em janeiro e dezembro de 2016. Método: um estudo observacional, descritivo que foi usado foi realizado um questionário elaborado pela autores e validados por psicólogos. A população e a amostra consistiram em 140 pacientes pertencentes ao município de Guantánamo. Resultados: O sexo masculino foi o mais representativo, a idade de início de consumo de álcool foi marcado entre 11 e 39 anos, considerando que eles devem receber assistência médica a maior percentagem, estes sendo tratados no hospital de desintoxicação hospital psiquiátrico e hospital-dia para alcoolistas, além de psicoterapia comunitária. Os pacientes pesquisados consideram que são discriminados pela sociedade. Conclusões: o sucesso de Alcoólicos Anônimos é que todos os que pertencem ao grupo têm doença grave e pode compartilhar suas próprias experiências em psicoterapia com o apoio seguro e monitoramento, sempre ao lado da comunidade profissional, experiência que em Guantánamo vem se beneficiando desses pacientes(AU)

Using a Historical Lens to Envision the Next Generation of Genomic Translation Research.

BACKGROUND: The past 20 years have witnessed successive and exponential advances in genomic discovery and technology, with a broad scientific imperative pushing for continual advancements. The most consistent critique of these advances is that they have vastly outpaced translation of new knowledge into improvements in public health and medicine. METHODS: We employ a historical and epistemological analysis to characterize how prevailing scientific meta-narratives have shaped the pace and priorities of research applying genomics to health promotion. We use four 'pivotal events' - the genetic characterization of Down syndrome, the launch of the Human Genome Research Project, the discovery of BRCA1, and the emergence of direct-to- consumer genetic testing - to illustrate how these scientific meta-narratives have inhibited genomic translation research. RESULTS: The notion that discovery should precede translation research has over-focused translation research on the latest genetic testing platform. The idea that genetic-related research has an exceptional potential for public harm has encouraged research on worst case scenarios. The perceived competition between genetics and social determinants of health has discouraged a unified research agenda to move genomic translation forward. CONCLUSION: We make a case for creating new scientific meta-narratives in which discovery and translation research agendas are envisioned as an interdependent enterprise.

Aplicación de los enfoques de salud de la población y los determinantes sociales en Cuba / Implementation of population health approaches and the social determinants in Cuba

Este trabajo reflexiona sobre algunas ideas en torno a la integración y aplicación de los enfoques de salud de la población y los determinantes sociales del proceso salud-enfermedad-atención en el actual contexto de transformación del Sistema de Salud en Cuba. Se discuten ideas para el fortalecimiento de la conceptualización social de la salud pública y la priorización de las acciones de salud poblacional sobre las de atención médica individual y para que se repiense el objeto y la práctica de esta como practica social. El trabajo intenta poner a debate nuevas y renovadas propuestas estratégicas de cambio basadas en una perspectiva ampliada de la salud pública y en el pensamiento de la medicina social privilegiando el enfoque basado en la población y la inclusión definitiva de un amplio rango de determinantes de la salud. Se sugiere la necesidad de desarrollar o ampliar la polémica sobre la concepción y practica social de la epidemiología y la salud pública sin que ello signifique renunciar a la implementación de necesarias transformaciones de los servicios de salud y de atención médica. Se sostiene la conveniencia de desarrollar un proceso de discusión técnica entre todos los actores y protagonistas, no solo del sistema de salud sino de todo el sector de la salud para lograr una mejor integración y operacionalización del enfoque de salud de la población y los determinantes sociales de la salud(AU)

This paper included some ideas about the integration and implementation of different population health approaches and the social determinants of the health-disease-care process in the current setting of health system changes in Cuba. Several ideas were discussed in order to strengthen the social conceptualization of public health and the prioritization of population health actions over those of individual medical care, as well as to rethink the object and practice in this field as social practice. The paper was intended to put forward new and renewed strategic change proposals based on wider perspectives of public health and on the social medicine thinking, thus favoring the population-based approach and the final inclusion of a wide range of health determinants. The paper also underlined the need of developing or extending the debate on the theory and social practice of epidemiology and public health within the implementation of necessary changes in health services and in medical care. It also stated that it is desirable to carry out a process of technical discussions among all the actors of the health care sector so that better integration and operationalizing of the population health approach and the social determinants of health can be attained(AU)

Essay: leaky pipes.

In the face of great tragedy, the desire to pinpoint blame can be instinctual as a remedy for alleviating one's conscience in a system that causes great suffering. However, to remedy the system that causes such suffering requires a critical analysis of the factors that perpetuate inequitable power structures. This is the story of a journey that broadened my lens of analysis with which to critically evaluate the harmful structural and social determinants magnified in resource-limited settings.

Evidencias actuales en las propuestas de intervención local para el estudio y manejo de los determinantes sociales de la salud en la población cubana / Current evidence on the proposals of local intervention for diagnosis and management of social determinants of health of the Cuban population

Los determinantes sociales de la salud son las condiciones sociales en las cuales las personas que conforman una población determinada nacen, viven y trabajan. El presente artículo tiene el objetivo de documentar las evidencias actuales sobre las propuestas de intervención local para el estudio y manejo de los determinantes sociales de la salud de la población cubana. Desde una perspectiva estructural las variables de servicios de salud muestran diferencias entre territorios, asociadas básicamente a la existencia de un sistema de salud único con cobertura y acceso universal para toda la población. Se observan mayores diferenciales en el comportamiento de los llamados;determinantes no médicos, como densidad poblacional, producción y circulación económica, mostrando estas diferencias un patrón geográfico. También se observan diferenciales en el comportamiento de la mortalidad materna y la hipertensión arterial entre territorios y en el tiempo. La productividad económica y las condiciones de vida están poco relacionadas con otros indicadores de resultados. Ante lo anteriormente expuesto se presenta una propuesta metodológica para el estudio y manejo de los determinantes sociales de la salud. Se requieren espacios de estudio de los determinantes sociales a nivel local, mediante técnicas multivariadas cuyos resultados aporten insumos para el diseño de intervenciones integrales basadas en los enfoques de planificación estratégica, acción intersectorial y participación social. Se impone insertar en la práctica del sistema de salud cubano un enfoque dirigido a trabajar más con los determinantes sociales de la salud, para lo cual se propone un modelo para el estudio e intervención local(AU)

Social determinants of health are the social conditions where members of a particular population are born, live and work. This article was aimed at documenting the current evidence on the proposed local intervention for the study and management of social determinants of health of the Cuban population. From a structural perspective, the health service variables show differences among the regions, mainly associated to the existence of a single health system with universal coverage and access for the entire population. Greatest differences are observed in the behavior of non-medical determinants such as population density, economic production and circulation, these differences showing a geographical pattern. Differentials are also observed in the behavior of maternal mortality and hypertension among regions and in the course of time. Economic productivity and living conditions are poorly related to other result indicators. Given the above-mentioned, a methodological proposal for the study and management of social determinants of health was presented. Some study spaces of local social determinants are required at local level through multivariate techniques whose results provide inputs for the design of integrated interventions, based on strategic planning approaches, intersectoral action and social involvement. Therefore, an approach to work more with the social determinants of health is required to be integrated into the Cuban health system. A model for local study and intervention were suggested in this paper in order to attain this goal(AU)