Disparities in Addiction Treatment: Learning from the Past to Forge an Equitable Future.

The Half-Century long problem of addiction treatment disparities. We cannot imagine addressing disparities in addiction treatment without first acknowledging and deconstructing the etiology of this inequity. This article examines the history of addiction treatment disparities beginning with early twentieth-century drug policies. We begin by discussing structural racism, its contribution to treatment disparities, using opioid use disorder as a case study to highlight the importance of a structural competency framework in obtaining care. We conclude by discussing diversity in the workforce as an additional tool to minimizing disparities. Addiction treatment should be aimed at addressing care delivery in the context of the social, economic, and political determinants of health, which require appreciation of their historical origins to move toward equitable treatment.

Disparities in access to effective treatment for infertility in the United States: an Ethics Committee opinion.

In the United States, economic, racial, ethnic, geographic, and other disparities prevent access to fertility treatment and affect treatment outcomes. This opinion examines the factors that contribute to these disparities, proposes actions to address them, and replaces the document of the same name, last published in 2015.

Antiracist Praxis in Public Health: A Call for Ethical Reflections.

The Covid-19 pandemic has revealed myriad social, economic, and health inequities that disproportionately burden populations that have been made medically or socially vulnerable. Inspired by state and local governments that declared racism a public health crisis or emergency, the Anti-Racism in Public Health Act of 2020 reflects a shifting paradigm in which racism is considered a social determinant of health. Indeed, health inequities fundamentally rooted in structural racism have been exacerbated by the Covid-19 pandemic, which calls for the integration of antiracist praxis to promote ethical public health research processes. This commentary describes ways in which antiracist praxis-which emphasizes empowerment of traditionally marginalized populations-offers strategies to explicitly address power imbalance, stigmatization, and other consequences of structural racism in public health research.

The bioethics of loneliness.

This article poses an invitation for bioethicists to engage with loneliness as a bioethics and public health concern. I argue that loneliness is a relevant issue for bioethicists for three main reasons: it causes ill-health; particularly in the age of Covid-19, it is becoming prominent on the clinical and public health agenda, affecting millions worldwide; and it engenders several ethical and philosophical questions as a social determinant of health with a rich conceptual background. In what follows I first review the link between loneliness and ill-health and argue that it should concern bioethicists because of this link. I also demonstrate how pertinent the issue of loneliness is being considered nowadays, and mark this as another reason for bioethicists to become engaged. I then move on to define loneliness and its various forms, drawing from modern and contemporary philosophers. The way we choose to cope with the pandemic of loneliness depends in part on its theoretical underpinnings, as well as its empirical scope. Theory thus combines with empirical data in order to devise and implement a rational public health policy, necessitating the kind of interdisciplinary approach that is the bedrock of bioethics. I conclude by suggesting future areas of research and recommendations.

No body is expendable: Medical rationing and disability justice during the COVID-19 pandemic.

The health threat posed by the novel coronavirus that caused the COVID-19 pandemic has particular implications for people with disabilities, including vulnerability to exposure and complications, and concerns about the role of ableism in access to treatment and medical rationing decisions. Shortages of necessary medical equipment to treat COVID-19 have prompted triage guidelines outlining the ways in which lifesaving equipment, such as mechanical ventilators and intensive care unit beds, may need to be rationed among affected individuals. In this article, we explore the realities of medical rationing, and various approaches to triage and prioritization. We discuss the psychology of ableism, perceptions about quality of life, social determinants of health, and how attitudes toward disability can affect rationing decisions and access to care. In addition to the grassroots advocacy and activism undertaken by the disability community, psychology is rich in its contributions to the role of attitudes, prejudice, and discriminatory behavior on the social fabric of society. We call on psychologists to advocate for social justice in pandemic preparedness, promote disability justice in health care settings, call for transparency and accountability in rationing approaches, and support policy changes for macro- and microallocation strategies to proactively reduce the need for rationing. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Patient-Reported Experiences of Discrimination in the US Health Care System.

Importance: Although considerable evidence exists on the association between negative health outcomes and daily experiences of discrimination, less is known about such experiences in the health care system at the national level. It is critically necessary to measure and address discrimination in the health care system to mitigate harm to patients and as part of the larger ongoing project of responding to health inequities. Objectives: To (1) identify the national prevalence of patient-reported experiences of discrimination in the health care system, the frequency with which they occur, and the main types of discrimination experienced and (2) examine differences in the prevalence of discrimination across demographic groups. Design, Setting, and Participants: This cross-sectional national survey fielded online in May 2019 used a general population sample from the National Opinion Research Center's AmeriSpeak Panel. Surveys were sent to 3253 US adults aged 21 years or older, including oversamples of African American respondents, Hispanic respondents, and respondents with annual household incomes below 200% of the federal poverty level. Main Outcomes and Measures: Analyses drew on 3 survey items measuring patient-reported experiences of discrimination, the primary types of discrimination experienced, the frequency with which they occurred, and the demographic and health-related characteristics of the respondents. Weighted bivariable and multivariable logistic regressions were conducted to assess associations between experiences of discrimination and several demographic and health-related characteristics. Results: Of 2137 US adult respondents who completed the survey (66.3% response rate; unweighted 51.0% female; mean [SD] age, 49.6 [16.3] years), 458 (21.4%) reported that they had experienced discrimination in the health care system. After applying weights to generate population-level estimates, most of those who had experienced discrimination (330 [72.0%]) reported experiencing it more than once. Of 458 reporting experiences of discrimination, racial/ethnic discrimination was the most common type (79 [17.3%]), followed by discrimination based on educational or income level (59 [12.9%]), weight (53 [11.6%]), sex (52 [11.4%]), and age (44 [9.6%]). In multivariable analysis, the odds of experiencing discrimination were higher for respondents who identified as female (odds ratio [OR], 1.88; 95% CI, 1.50-2.36) and lower for older respondents (OR, 0.98; 95% CI, 0.98-0.99), respondents earning at least $50 000 in annual household income (OR, 0.76; 95% CI, 0.60-0.95), and those reporting good (OR, 0.59; 95% CI, 0.46-0.75) or excellent (OR, 0.41; 95% CI, 0.31-0.56) health compared with poor or fair health. Conclusions and Relevance: The results of this study suggest that experiences of discrimination in the health care system appear more common than previously recognized and deserve considerable attention. These findings contribute to understanding of the scale at which interpersonal discrimination occurs in the US health care system and provide crucial evidence for next steps in assessing the risks and consequences of such discrimination. The findings also point to a need for further analysis of how interpersonal discrimination interacts with structural inequities and social determinants of health to build effective responses.

Tackling Social Determinants Of Health Around The Globe.

A global health equity movement relies on research showing how social factors affect health.

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?

Rights to social determinants of flourishing? A paradigm for disability and public health research and policy.

BACKGROUND: The term evidence based medicine was introduced in the early 1990s in clinical medicine to educate clinicians about how to assess the 'credibility' of research to ensure best treatments for their patients. The evidence based medicine paradigm has become more diffuse in times of austerity and randomised controlled designs are being used to address complex issues in public health and disability research. This research is not addressing inequalities in terms of disability nor how people can live well with disabilities. MAIN TEXT: We argue that there are four ways that public health research needs to change if it wants to address inequalities linked to disability: 1) rethinking theoretical connections between public health and disability; 2) building ethics and equity into interventions through a human rights approach; 3) ensuring ethical inclusion through intersectionality; and 4) evaluating policy and other social impacts to ensure they capture diversity. We argue that these are key issues to building a social determinants of flourishing. CONCLUSIONS: We need to understand how disability might have an accumulative impact across the life course, as well as how to ensure equity for people living with disabilities. This means conceptualising a social determinants of flourishing where we evaluate how exactly randomised controlled trials and public health interventions, not only lead to greater equality but also ensure rights to health and wellbeing.

PrEP and the Judgment of Prevention.

Medicine sometimes fails to address social, economic, and political determinants of health. But how far beyond clinical encounters should intervention efforts extend? Because prevention efforts can marginalize patients by stigmatizing certain behaviors, interrogating the scope of medicine's prevention obligations is important. Additionally, it is important to distinguish clinician preferences regarding patients' personal behaviors (presumably based on clinicians' hopes for patients' positive health outcomes) from clinician biases expressed (consciously or unconsciously) about those behaviors. I illustrate the urgency of asking how far medicine should be expected to go to prevent disease by sharing how my own medical training has stoked my personal fear of acquiring HIV.

Responding to the Changing Face of the Social Determinants of Health.

The social determinants of health (SDoH) are at the top of every health care organization's priority list. The ability to respond to these nonclinical client needs is driving the financial sustainability, if not survivability, of facilities and programs across the globe. Although a number of traditional populations have been long identified with the SDoH, the face of those clients and communities is changing. With these demographic shifts come new ethical challenges for case managers, particularly in response to prevailing personal biases. With the case management positioned on the front lines of care, the workforce must be able to identify and respond ethically and effectively to the emerging new face of the SDoH.

How Should Health Care Professionals Address Social Determinants of Refugee Health?

In the case scenario, RJ is a resettled refugee teenager who presents to his physician with vitamin B12 deficiency, anemia, and symptoms of mental illness. This commentary considers social determinants of refugee health and the moral importance of freedom to achieve well-being. The capabilities framework is used to analyze this case because it offers an ethical framework for understanding and evaluating social determinants of refugee health that either promote or diminish freedom to achieve well-being. By using this framework to consider social isolation as a negative social determinant of refugee health, clinicians and institutions can be caregivers as well as advocates for social justice, fulfilling 2 core ethical obligations to refugee communities.

Partiality, impartiality and the ethics of triage.

In this paper, I discuss the question of partiality and impartiality in the application of triage. Triage is a process in medical research which recommends that patients should be sorted for treatment according to the degree or severity of their injury. In employing the triage protocol, however, the question of partiality arises because socially vulnerable groups will be neglected since there is the likelihood that the social determinants of a patient's health may diminish her chance of survival. As a process that is based on the severity of a patient's injury, triage will be unfair, and hence negatively partial, to socially vulnerable people. Thus, I aim in this paper to show that the triage protocol fails as an impartial evaluative process because its only aim is to maximize survivability. I contend that: (i) triage would lead to the neglect of the social condition of patients or victims, and (ii) it will only serve the utilitarian purpose of maximization of outcomes which may not be justified in some cases.

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)

Shrinking Poor White Life Spans: Class, Race, and Health Justice.

An absolute decline in US life expectancy in low education whites has alarmed policy makers and attracted media attention. Depending on which studies are correct, low education white women have lost between 3 and 5 years of lifespan; men, between 6 months and 3 years. Although absolute declines in life expectancy are relatively rare, some commentators see the public alarm as reflecting a racist concern for white lives over black ones. How ought we ethically to evaluate this lifespan contraction in low education whites? Should we care, or is it racist to care? Does it constitute an injustice or reflect justice being done? I argue that the lifespan contraction in low education whites violates key normative criteria used to make determinations of health justice, and that these judgments do not vitiate concerns about racism. I conclude with reflections on US population health policy and building an inclusive health equity movement.