Heterogeneity of risk within racial groups, a challenge for public health programs

Contrasting Narratives of Race and Fatness in Covid-19

The slogan that 'the virus doesn't discriminate' has been belied by the emergence of stark and persistent disparities in rates of infection, hospitalisation, and death from Covid-19 between various social groups. I focus on two groups that have been disproportionately affected, and that have been constructed or designated as particularly 'at-risk' during the Covid-19 pandemic: racial or ethnic minorities and fat people. I trace the range of narratives that have arisen in the context of explaining these disparities, in both the scientific literature and wider expert and public discourse. I show that the scientific and public narratives around these groups have differed significantly, revealing contested and competing conceptions of the basis of these categories themselves. These different conceptions have important impacts on the kinds of interventions that become possible or desirable. I show that in the case of racial or ethnic disparities, genetic narratives have been combatted by a strong focus on structural racism as a driver of pandemic inequalities. However, in the case of fatness, individualising and stigmatising narratives have dominated discussions. I suggest that, given racial or ethnic differences in prevalence of fatness, and scholarship casting anti-fatness as historically racialised, the stigmatisation of fatness disproportionately affects racial or ethnic minorities in terms of placing individual blame or responsibility for the increased burden of Covid-19 on these groups. Despite widespread acknowledgement of the role of structural racism in driving racial inequalities in the burden of Covid-19, anti-obesity rhetoric and research provides a 'backdoor' to placing blame on individuals from racial minorities.

Medicine, anti-realism and ideology: Variation in medical genetics does not show that race is biologically real

Lee McIntyre’s Respecting Truth chronicles the contemporary challenges regarding the relationship amongst evidence, belief formation and ideology. The discussion in his book focusses on the ‘politicisation of knowledge’ and the purportedly growing public (and sometimes academic) tendency to choose to believe what is determined by prior ideological commitments rather than what is determined by evidence-based reasoning. In considering these issues, McIntyre posits that the claim “race is a myth” is founded on a political ideology rather than on support from scientific evidence. He contrasts this view with the argument that racially correlated biomedical outcomes for self-identified racial groups suggest that biological races are real. I explore how McIntyre’s framing of the claim “race is a myth” as fundamentally ideological results in him failing to engage with the arguments and evidence many constructionists and biological anti-realists put forward in support of their views. I also show how the biomedical evidence he thinks supports biological realism is unconvincing.

Ethical issues in the development and implementation of nutrition-related public health policies and interventions: A scoping review

Background

The limited integration of ethics in nutrition-related public health policies and interventions is one major concern for those who have the task of implementing them. Ethical challenges that are overlooked during the development of such interventions could raise serious ethical issues during their implementation and even after. As a result, these decision makers need technical support and ethical guidance for adaptation of interventions to local (cultural, social, economic, etc.) contexts.

Aim

The goal of this scoping review is to delineate and “map” the range of ethical issues in nutrition-related public health interventions, as well as the range of the various fields in which they may arise.

Methods

A scoping review of empirical research and conceptual literature was conducted following the framework of Arksey and O’Malley. Searches using PubMed with Medical Subject Headings (MeSH) categories and Advanced Search Builder as well as in the Global Health Library were performed. The final sample consists of 169 publications.

Results

The ethics of public health prevention or treatment of obesity and non-communicable diseases is the most explicitly and frequently discussed subject. In comparison, ethical issues raised by public health interventions in the fields of undernutrition, breastfeeding, vitamin/mineral supplementation and food fortification, food security, food sustainability and food safety are addressed in a lower proportion of the sample. The results illustrate the various natures, types, and scopes of existing public health nutrition-related interventions, and the various ethical issues that may be raised by these interventions, in addition to the numerous and different contexts in which they may be implemented.

Discussion

The ethical issues faced in the development and implementation of nutrition-related public health interventions are varied and cannot be equated with, nor generalized about, when dealing with specific activities in this field. More importantly, these ethical issues cannot be managed without a careful consideration for the complexity of contexts in which nutrition-related interventions are expected to be implemented. These interventions engage a variety of actors with diverse perspectives and interests. We discuss these challenges and also comment on the importance of considering ethical impacts in the monitoring and evaluation of such interventions.

Conclusion

General ethical frameworks or recommendations–although useful–cannot be expected to provide policy makers, implementators and other public health personnel with sufficient practical ethical guidance as they cannot consider and anticipate the particularities of all specific nutrition-related public health interventions and the complexity of the contexts in which they are implemented. Further research is needed in order to develop more targeted ethical frameworks.

Genetics in an isolated population like Finland: a different basis for genomic medicine?

A unique genetic background in an isolated population like that of Finland offers special opportunities for genetic research as well as for applying the genetic developments to the health care. On the other hand, the different genetic background may require local attempts to develop diagnostics and treatment as the selection of diseases and mutations differs from that in the other populations. In this review, we describe the experiences of research and health care in this genetic isolate starting from the identification of specific monogenic diseases enriched in the Finnish population all the way to implementing the knowledge of the unique genetic background to genomic medicine at population level.

The challenges of choosing and explaining a phenomenon in epidemiological research on the "Hispanic Paradox"

According to public health data, the US Hispanic population is far healthier than would be expected for a population with low socioeconomic status. Ever since Kyriakos Markides and Jeannine Coreil highlighted this in a seminal 1986 article, public health researchers have sought to explain the so-called "Hispanic paradox." Several candidate explanations have been offered over the years, but the debate goes on. This article offers a philosophical analysis that clarifies how two sets of obstacles make it particularly difficult to explain the Hispanic paradox. First, different research projects define the Hispanic paradox phenomenon in substantially different ways. Moreover, using Bas van Fraassen's pragmatic theory of explanation and Sean Valles's extension of it with the concept of "phenomenon choice," it also becomes clear that there are also multiple ways of explaining each individual definition of the phenomenon. A second set of philosophical and methodological challenges arises during any attempt to study "Hispanic" phenomena, with one key challenge being that the "Hispanic" panethnic concept was intentionally made vague as it was developed and popularized during the 1960s-1970s. After comparing this case with similar cases in the philosophical literature, the article concludes with observations on what makes this problem unique, particularly its ethical features.

Panethnic Differences in Blood Pressure in Europe: A Systematic Review and Meta-Analysis

BACKGROUND

People of Sub Saharan Africa (SSA) and South Asians(SA) ethnic minorities living in Europe have higher risk of stroke than native Europeans(EU). Study objective is to provide an assessment of gender specific absolute differences in office systolic(SBP) and diastolic(DBP) blood pressure(BP) levels between SSA, SA, and EU.

METHODS AND FINDINGS

We performed a systematic review and meta-analysis of observational studies conducted in Europe that examined BP in non-selected adult SSA, SA and EU subjects. Medline, PubMed, Embase, Web of Science, and Scopus were searched from their inception through January 31st 2015, for relevant articles. Outcome measures were mean SBP and DBP differences between minorities and EU, using a random effects model and tested for heterogeneity. Twenty-one studies involving 9,070 SSA, 18,421 SA, and 130,380 EU were included. Compared with EU, SSA had higher values of both SBP (3.38 mmHg, 95% CI 1.28 to 5.48 mmHg; and 6.00 mmHg, 95% CI 2.22 to 9.78 in men and women respectively) and DBP (3.29 mmHg, 95% CI 1.80 to 4.78; 5.35 mmHg, 95% CI 3.04 to 7.66). SA had lower SBP than EU(-4.57 mmHg, 95% CI -6.20 to -2.93; -2.97 mmHg, 95% CI -5.45 to -0.49) but similar DBP values. Meta-analysis by subgroup showed that SA originating from countries where Islam is the main religion had lower SBP and DBP values than EU. In multivariate meta-regression analyses, SBP difference between minorities and EU populations, was influenced by panethnicity and diabetes prevalence.

CONCLUSIONS

1) The higher BP in SSA is maintained over decades, suggesting limited efficacy of prevention strategies in such group in Europe;2) The lower BP in Muslim populations suggests that yet untapped lifestyle and behavioral habits may reveal advantages towards the development of hypertension;3) The additive effect of diabetes, emphasizes the need of new strategies for the control of hypertension in groups at high prevalence of diabetes.

Ethics and policy issues for stem cell research and pulmonary medicine

Stem cell research and related initiatives in regenerative medicine, cell-based therapy, and tissue engineering have generated considerable scientific and public interest. Researchers are applying stem cell technologies to chest medicine in a variety of ways: using stem cells as models for drug discovery, testing stem cell-based therapies for conditions as diverse as COPD and cystic fibrosis, and producing functional lung and tracheal tissue for physiologic modeling and potential transplantation. Although significant scientific obstacles remain, it is likely that stem cell-based regenerative medicine will have a significant clinical impact in chest medicine. However, stem cell research has also generated substantial controversy, posing a variety of ethical and regulatory challenges for research and clinical practice. Some of the most prominent ethical questions related to the use of stem cell technologies in chest medicine include (1) implications for donors, (2) scientific prerequisites for clinical testing and use, (3) stem cell tourism, (4) innovation and clinical use of emerging stem cell-based interventions, (5) responsible translation of stem cell-based therapies to clinical use, and (6) appropriate and equitable access to emerging therapies. Having a sense of these issues should help to put emerging scientific advances into appropriate context and to ensure the responsible clinical translation of promising therapeutics.

Coupled Ethical-Epistemic Analysis of Public Health Research and Practice: Categorizing Variables to Improve Population Health and Equity

The categorization of variables can stigmatize populations, which is ethically problematic and threatens the central purpose of public health: to improve population health and reduce health inequities. How social variables (e.g., behavioral risks for HIV) are categorized can reinforce stigma and cause unintended harms to the populations practitioners and researchers strive to serve. Although debates about the validity or ethical consequences of epidemiological variables are familiar for specific variables (e.g., ethnicity), these issues apply more widely. We argue that these tensions and debates regarding epidemiological variables should be analyzed simultaneously as ethical and epistemic challenges. We describe a framework derived from the philosophy of science that may be usefully applied to public health, and we illustrate its application.