Immigration Detention in the United States: Identifying Alternatives That Comply With Human Rights and Advance Public Health.

Under international law, the United States is obligated to uphold noncitizens' fundamental rights, including their rights to health. However, current US immigration laws-and their enforcement-not only fail to fulfill migrants' health rights but actively undermine their realization and worsen the pandemic's spread. Specifically, the US immigration system's reliance on detention, which precludes effective social distancing, increases risks of exposure and infection for detainees, staff, and their broader communities. International agreements clearly state that the prolonged, mandatory, or automatic detention of people solely because of their migration status is a human rights violation on its own. But in the context of COVID-19, the consequences for migrants' right to health are particularly acute. Effective alternatives exist: other countries demonstrate the feasibility of adopting and implementing immigration laws that establish far less restrictive, social services-based approaches to enforcement that respect human rights. To protect public health and realize its global commitments, the United States must shift away from detaining migrants as standard practice and adopt effective, humane alternatives-both amid COVID-19 and permanently.

COVID-19 Highlights the Need for Inclusive Responses to Public Health Emergencies in Africa.

COVID-19 is a global public health emergency affecting many countries around the world. Although African governments and other stakeholders are making efforts to contain the pandemic, the outbreak continues to impact human rights and exacerbates inequalities and disparities that are already in existence. The concept of inclusive health focuses on good health and well-being for everyone, and this entails health services that are equitable, affordable, and efficacious. Creating equitable access to mainstream health and healthcare services and ensuring inclusive health responses remain a means of addressing health inequities and disparities. In this article, we argue on the need for inclusive responses to public health emergencies in Africa using COVID-19 as a case example. Africa's response to public health emergencies needs to recognize that for every marginalized/vulnerable group, it is important to strategize to address their particular needs in such a way to surmount any barrier to the right to health. For Africa's public health response to be more inclusive, we therefore need to be more strategic and proactive in reaching out to specific groups and to identify and address their needs. Strengthening the healthcare systems of African countries through increased political will, increased funding to health care, collaboration and cooperation among stakeholders, and effective leadership remains essential in ensuring inclusive responses to health emergencies.

Towards an update of the Italian Ministerial Decree July 5th, 1975.

In recent years, the Scientific Community and the Public Health world, in general, have devoted increasing interest to housing conditions, which are considered, to date, one of the main environmental and social determinants of the population's health. In particular, the Scientific Community has identified and studied various indoor well-being factors (e.g. lighting, temperature, ventilation, air quality, etc.). Some of these factors have been regulated by laws and regulations at various levels: the availability of clear and updated health requirements dictated by the regulations is fundamental to effectively protect public health, especially in confined environments. In the present work, we propose a revision of the Italian Ministerial Decree of July 5th, 1975 titled Modificazioni alle istruzioni ministeriali 20 giugno 1896 relativamente all'altezza minima ed ai requisiti igienico sanitari principali dei locali d'abitazione (Modifications to the ministerial instructions of June 20th, 1896 regarding the minimum height and the main hygienic-sanitary requirements of living spaces) in order to update the definition of the essential elements that qualify a space as habitable from the hygienic-sanitary point of view, taking into account the evidence gathered from the technical and scientific literature on the requirements and contents of the Building Codes of the major European countries.

Intersectoral action on the social determinants of health and health equity in Canada: December 2019 federal government mandate letter review. / Action intersectorielle sur les déterminants sociaux de la santé et l'équité en santé au Canada : examen des lettres de mandat du gouvernement fédéral de décembre 2019.

Mandate letters for the current federal government cabinet ministers identify opportunities for intersectoral action on social determinants of health and health equity. Key areas for intersectoral action identified in 2019 mandate letters include adopting measures of wellbeing in the federal budget, redistributive tax policies, and initiatives in employment, housing, education and other sectors. Continued monitoring and reporting on health inequalities in Canada is important in assessing progress and identifying areas where intersectoral collaboration can be strengthened.

Les lettres de mandat des ministres du gouvernement fédéral définissent les possibilités d'action intersectorielle sur les déterminants sociaux de la santé et sur l'équité en santé. Les principaux domaines d'action intersectorielle définis dans les lettres de mandat de 2019 sont l'adoption de mesures de bien­être dans le budget fédéral, de politiques fiscales de redistribution et d'initiatives dans les secteurs notamment de l'emploi, du logement et de l'éducation. Il est important d'assurer la surveillance continue des inégalités en matière de santé au Canada et d'en rendre compte afin de pouvoir évaluer les progrès et déterminer les secteurs dans lesquels la collaboration intersectorielle peut être renforcée.

A Meta-Narrative Literature Synthesis and Framework to Guide Future Evaluation of Legal Empowerment Interventions.

Legal empowerment is increasingly recognized as a key approach for addressing socio-structural determinants of health and promoting the well-being and human rights of vulnerable populations. Legal empowerment seeks to increase people's capacity to understand and use the law. However, limited consensus remains on the effectiveness of legal empowerment interventions in optimizing health outcomes. Leveraging a meta-narrative approach, we synthesized literature describing how legal empowerment interventions have been operationalized and empirically studied with respect to health determinants. The studies included here document diverse legal empowerment approaches and highlight how interventions changed the context surrounding the health of vulnerable populations. The absence of robust conceptualization, operationalization, and measurement of the risk contexts in which legal empowerment approaches operate limits the clarity with which interventions' impact on health can be ascertained. Despite this, legal empowerment is a promising approach to address the health of marginalized populations. To foster support between the fields of legal empowerment and health, we explore the limitations in study design and measurement of the existing evidence base; such scrutiny could strengthen the rigor of future research. This paper provides a guide to the socio-structural levels across which legal empowerment interventions impact health outcomes in order to inform future interventions.

Carbon trading, co-pollutants, and environmental equity: Evidence from California's cap-and-trade program (2011-2015).

BACKGROUND: Policies to mitigate climate change by reducing greenhouse gas (GHG) emissions can yield public health benefits by also reducing emissions of hazardous co-pollutants, such as air toxics and particulate matter. Socioeconomically disadvantaged communities are typically disproportionately exposed to air pollutants, and therefore climate policy could also potentially reduce these environmental inequities. We sought to explore potential social disparities in GHG and co-pollutant emissions under an existing carbon trading program-the dominant approach to GHG regulation in the US and globally. METHODS AND FINDINGS: We examined the relationship between multiple measures of neighborhood disadvantage and the location of GHG and co-pollutant emissions from facilities regulated under California's cap-and-trade program-the world's fourth largest operational carbon trading program. We examined temporal patterns in annual average emissions of GHGs, particulate matter (PM2.5), nitrogen oxides, sulfur oxides, volatile organic compounds, and air toxics before (January 1, 2011-December 31, 2012) and after (January 1, 2013-December 31, 2015) the initiation of carbon trading. We found that facilities regulated under California's cap-and-trade program are disproportionately located in economically disadvantaged neighborhoods with higher proportions of residents of color, and that the quantities of co-pollutant emissions from these facilities were correlated with GHG emissions through time. Moreover, the majority (52%) of regulated facilities reported higher annual average local (in-state) GHG emissions since the initiation of trading. Neighborhoods that experienced increases in annual average GHG and co-pollutant emissions from regulated facilities nearby after trading began had higher proportions of people of color and poor, less educated, and linguistically isolated residents, compared to neighborhoods that experienced decreases in GHGs. These study results reflect preliminary emissions and social equity patterns of the first 3 years of California's cap-and-trade program for which data are available. Due to data limitations, this analysis did not assess the emissions and equity implications of GHG reductions from transportation-related emission sources. Future emission patterns may shift, due to changes in industrial production decisions and policy initiatives that further incentivize local GHG and co-pollutant reductions in disadvantaged communities. CONCLUSIONS: To our knowledge, this is the first study to examine social disparities in GHG and co-pollutant emissions under an existing carbon trading program. Our results indicate that, thus far, California's cap-and-trade program has not yielded improvements in environmental equity with respect to health-damaging co-pollutant emissions. This could change, however, as the cap on GHG emissions is gradually lowered in the future. The incorporation of additional policy and regulatory elements that incentivize more local emission reductions in disadvantaged communities could enhance the local air quality and environmental equity benefits of California's climate change mitigation efforts.

Elusive implementation: an ethnographic study of intersectoral policymaking for health.

BACKGROUND: For more than 30 years policy action across sectors has been celebrated as a necessary and viable way to affect the social factors impacting on health. In particular intersectoral action on the social determinants of health is considered necessary to address social inequalities in health. However, despite growing support for intersectoral policymaking, implementation remains a challenge. Critics argue that public health has remained naïve about the policy process and a better understanding is needed. Based on ethnographic data, this paper conducts an in-depth analysis of a local process of intersectoral policymaking in order to gain a better understanding of the challenges posed by implementation. To help conceptualize the process, we apply the theoretical perspective of organizational neo-institutionalism, in particular the concepts of rationalized myth and decoupling. METHODS: On the basis of an explorative study among ten Danish municipalities, we conducted an ethnographic study of the development of a municipal-wide implementation strategy for the intersectoral health policy of a medium-sized municipality. The main data sources consist of ethnographic field notes from participant observation and interview transcripts. RESULTS: By providing detailed contextual description, we show how an apparent failure to move from policy to action is played out by the ongoing production of abstract rhetoric and vague plans. We find that idealization of universal intersectoralism, inconsistent demands, and doubts about economic outcomes challenge the notion of implementation as moving from rhetoric to action. CONCLUSION: We argue that the 'myth' of intersectoralism may be instrumental in avoiding the specification of action to implement the policy, and that the policy instead serves as a way to display and support good intentions and hereby continue the process. On this basis we expand the discussion on implementation challenges regarding intersectoral policymaking for health.

Redefining "Medical Care."

President Donald J. Trump has said he will repeal the Affordable Care Act (ACA) and replace it with health savings accounts (HSAs). Conservatives have long preferred individual accounts to meet social welfare needs instead of more traditional entitlement programs. The types of "medical care" that can be reimbursed through an HSA are listed in section 213(d) of the Internal Revenue Code (Code) and include expenses "for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body." In spite of the broad language, regulations and court interpretations have narrowed this definition substantially. It does not include the many social factors that determine health outcomes. Though the United States spends over seventeen percent of gross domestic product (GDP) on "healthcare", the country's focus on the traditional medicalized model of health results in overall population health that is far beneath the results of other countries that spend significantly less. Precision medicine is one exceptional way in which American healthcare has focused more on individuals instead of providing broad, one-size-fits-all medical care. The precision medicine movement calls for using the genetic code of individuals to both predict future illness and to target treatments for current illnesses. Yet the definition of "medical care" under the Code remains the same for all. My proposal for precision healthcare accounts involves two steps-- the first of which requires permitting physicians to write prescriptions for a broader range of goods and services. The social determinants of health are as important to health outcomes as are surgical procedures and drugs--or perhaps more so according to many population health studies. The second step requires agencies and courts to interpret what constitutes "medical care" under the Code differently depending on the taxpayer's income level. Childhood sports programs and payments for fruits and vegetables may be covered for those in the lower income brackets who could not otherwise afford these items and would not choose to spend scarce resources on them if they could. This all assumes that the government takes funds previously used to subsidize the purchase of health insurance under the ACA (or allocates new funds) and puts the funds in individual accounts so the poor or near poor have money to pay for these expenses. Section I of this Article will explore the current definition of medical care, which excludes the social determinants of health from "healthcare" spending. I then address how precision medicine has changed the types of services and treatments that it makes sense to reimburse for each individual. If efficacy can vary from person to person based on genetic code, then it also can vary depending on environment. There is an opportunity to not only vary the types of "medical care" that can be reimbursed or deducted within the traditional range of services and drugs, but also outside of that range. Section II addresses the historical shift towards health financing through individual accounts, and specifically through HSAs. If this is the only avenue for health reform in the next few years, I advocate using it to engage in the type of experiments that are typically only possible under the cover of tax expenditures. My proposal for precision healthcare accounts moves the government to experiment with individual social spending that can lead to improved overall health outcomes. Finally, in Section III, I address two dichotomies that affect any healthcare proposal: (1) entitlement programs v. grants-in-aid, and (2) pooled insurance v. consumer-driven health plans (CDHPs). In the end, I argue that an entitlement method of funding precision HSAs along with pooled insurance subsidized by the government is the most realistic resolution to these dichotomies. Only a broad-based entitlement to funding for all healthcare expenses (medical and social) allows for significant improvements in overall population health.

Interprofessional Medical-Legal Education of Medical Students: Assessing the Benefits for Addressing Social Determinants of Health.

PROBLEM: Screening tools exist to help identify patient issues related to social determinants of health (SDH), but solutions to many of these problems remain elusive to health care providers as they require legal solutions. Interprofessional medical-legal education is essential to optimizing health care delivery. APPROACH: In 2011, the authors implemented a four-session didactic interprofessional curriculum on medical-legal practice for third-year medical students at Morehouse School of Medicine. This program, also attended by law students, focused on interprofessional collaboration to address client/patient SDH issues and health-harming legal needs. In 2011-2014, the medical students participated in pre- and postintervention surveys designed to determine their awareness of SDH's impact on health as well as their attitudes toward screening for SDH issues and incorporating resources, including a legal resource, to address them. Mean ratings were compared between pre- and postintervention respondent cohorts using independent-sample t tests. OUTCOMES: Of the 222 medical students who participated in the program, 102 (46%) completed the preintervention survey and 100 (45%) completed the postintervention survey. Postintervention survey results indicated that students self-reported an increased likelihood to screen patients for SDH issues and an increased likelihood to refer patients to a legal resource (P < .001). NEXT STEPS: Incorporating interprofessional medical-legal education into undergraduate medical education may result in an increased likelihood to screen patients for SDH and to refer patients with legal needs to a legal resource. In the future, an additional evaluation to assess the curriculum's long-term impact will be administered prior to graduation.

Intersectoriality in Danish municipalities: corrupting the social determinants of health?

Action on the social determinants of health (SDH) through intersectoral policymaking is often suggested to promote health and health equity. This paper argues that the process of intersectoral policymaking influences how the SDH are construed and acted upon in municipal policymaking. We discuss how the intersectoral policy process legitimates certain practices in the setting of Danish municipal health promotion and the potential impact this can have for long-term, sustainable healthy public policy. Based on ethnographic fieldwork, we show how the intention of intersectoriality produces a strong concern for integrating health into non-health sectors to ensure productive collaboration. To encourage this integration, health is often framed as a means to achieve the objectives of non-health sectors. In doing so, the intersectoral policy process tends to favor smaller-scale interventions that aim to introduce healthier practices into various settings, e.g. creating healthy school environments for increased physical activity and healthy eating. While other more overarching interventions on the health impacts of broader welfare policies (e.g. education policy) tend to be neglected. The interventions hereby neglect to address more fundamental SDH. Based on these findings, we argue that intersectoral policymaking to address the SDH may translate into a limited approach to action on so-called 'intermediary determinants' of health, and as such may end up corrupting the broader SDH. Further, we discuss how this corruption affects the intended role of non-health sectors in tackling the SDH, as it may impede the overall success and long-term sustainability of intersectoral efforts.