Rethinking Research Ethics for Latinos: The Policy Paradox of Health Reform and the Role of Social Justice

Social determinants of participation in genetic research among Puerto Ricans and in the Puerto Rican diaspora

Puerto Ricans are underrepresented in genetic research. This underrepresentation denies Puerto Ricans the benefit from therapeutic developments that could mitigate health disparities arising from conditions for which genetically-derived treatments exist. The Puerto Rican diaspora, especially post-2017 due to economic and environmental crises, has expanded within the USA. Prior research suggests that Latin American diaspora communities are less likely to participate in genetic research. We hypothesized, specifically, that the Puerto Rican diaspora in the USA would be less likely to participate in genetic research than would Puerto Ricans in their homeland's archipelago, and that accounting for social and cultural determinants related to the diaspora experience would mitigate this disparity. We implemented an analytical cross-sectional study of archipelago-residing Puerto Ricans and of the USA-residing diaspora to evaluate this hypothesis. With 1582 Puerto Ricans (723 in Puerto Rico, 859 in the USA), we found that while most participants would participate in genetic research, participation rates varied significantly by diaspora status. Puerto Ricans born and living in the USA were initially more likely to decline participation compared to those in Puerto Rico (OR = 1.54, p < 0.01). However, once adjusted for social and cultural variables, this difference was eliminated (aOR = 1.08, p = n.s.). The factors influencing non-participation include oppression, discrimination, distrust, and social determinants, aligning with the theory of minoritization. An important community in the USA and in the world, Puerto Ricans have the right to participate in well-conducted research and to benefit from its findings, particularly around topics that could help address existing disparities in health outcomes.

Acceptability, feasibility, and ethics of saliva collection in community-based research with Mexican-origin mixed-status families during high immigration enforcement

Background

There are concerns about the representation of vulnerable and underrepresented racial-ethnic minorities in biomedical and public health research, particularly when the research requires the collection of biospecimens. The current paper reports on the acceptability, feasibility, and ethics of saliva collection in a study examining the relationship between chronic stressors among mostly mixed-status, Latinx families (N = 30) during high immigration enforcement.

Methods

Data for this study included anthropometric measures and salivary biospecimens from each family member (N = 110) and a household survey. Data for this analysis are from ethnographic field notes, which were analyzed using a bricolage of critical ethnography and case study analysis techniques.

Results

We discuss the feasibility, aversions, acceptability, and ethical implications of integrating salivary biomarkers with Mexican-origin mixed-status families living in an area with restrictive immigration enforcement policies. We present the recruitment and data collection strategies used by the research team to gain participants’ trust, retain families, and maintain confidentiality.

Conclusion

We recommend that researchers who obtain biospecimens from Latinx, Mexican-origin, and/or immigrant populations answer the participants’ questions honestly and without fear that they will not understand the science to obtain voluntary assent and consent. We recommend that researchers be knowledgeable of the sociopolitical context that the Latinx, immigrant, and in particular, mixed-status families inhabit so that they are prepared to provide informational resources. Finally, we think it is imperative that the study team in the field be bilingual, multicultural Latinx persons who identify with the community.

Mixed-methods Analysis of Adults Likely versus Unlikely to Get a COVID-19 Vaccination

Objectives: This mixed-methods study compared perspectives of those 'very likely' versus 'very unlikely' to receive a hypothetical COVID-19 vaccine. Methods: We used an explanatory, sequential, mixed- methods design to analyze quantitative data from a rural Pennsylvania sample. Of the 976 participants, 67 selected 'very unlikely' to get the COVID-19 vaccine. Responses to open-ended questions: "What worries you the most about the COVID 19 pandemic?" and "What are your thoughts about a potential COVID 19 vaccine?" were qualitatively compared to answers from the 67 participants who selected 'very likely' to get the COVID-19 vaccine. We used descriptive content analysis to compare themes across the 2 groups. Results: Both groups had thematic commonalities related to their concerns. Themes that were more common among those 'very unlikely' to get vaccinated included concern for politics overriding vaccine safety and rushed vaccine development timeline, whereas themes related to hope and optimism about vaccination were exclusive to the 'very likely' group. Conclusions: Shared beliefs existed across groups with different intents to vaccinate; yet, identification with vaccine spokespersons differed. Messaging campaigns can use these commonalities to address vaccine hesitancy.

Awakening: The Unveiling of Historically Unaddressed Social Inequities During the COVID-19 Pandemic in the United States

The violence and victimization brought by colonization and slavery and justified for over a century by race-based science have resulted in enduring inequities for black, Indigenous and people of color (BIPOC) across the United States. This is particularly true if BIPOC individuals have other intersecting devalued identities. We highlight how such longstanding inequities paved the way for the disproportionate burdens of coronavirus disease 2019 (COVID-19) among the BIPOC populations across the country and provide recommendations on how to improve COVID-19 mitigation strategies with the goal of eliminating disparities.

The Legacy of the U. S. Public Health Services Study of Untreated Syphilis in African American Men at Tuskegee on the Affordable Care Act and Health Care Reform Fifteen Years After President Clinton's Apology

This special issue addresses the legacy of the United States Public Health Service Syphilis Study on health reform, particularly the Affordable Care Act (ACA). The 12 manuscripts cover the history and current practices of ethical abuses affecting American Indians, Latinos, Asian Americans and African Americans in the United States and in one case, internationally. Commentaries and essays include the voice of a daughter of one of the study participants in which we learn of the stigma and maltreatment some of the families experienced and how the study has impacted generations within the families. Consideration is given in one essay to utilizing narrative storytelling with the families to help promote healing. This article provides the reader a roadmap to the themes that emerged from the collection of articles. These themes include population versus individual consent issues, need for better government oversight in research and health care, the need for overhauling our bioethics training to develop a population level, culturally driven approach to research bioethics. The articles challenge and inform us that some of our assumptions about how the consent process best works to protect racial/ethnic minorities may be merely assumptions and not proven facts. Articles challenge the belief that low participation rates seen in biomedical studies have resulted from the legacy of the USPHS Syphilis Study rather than a confluence of factors rooted in racism, bias and negative treatment. Articles in this special issue challenge the "cultural paranoia" of mistrust and provide insights into how the distrust may serve to lengthen rather than shorten the lives of racial/ethnic minorities who have been used as guinea pigs on more than one occasion. We hope that the guidance offered on the importance of developing a new framework to bioethics can be integrated into the foundation of health care reform.

Research Challenges and Bioethics Responsibilities in the Aftermath of the Presidential Apology to the Survivors of the U. S. Public Health Services Syphilis Study at Tuskegee

In 1997 President William Clinton issued an apology to the living male survivors of the U.S. Public Health Syphilis Study at Tuskegee. While the apology became the focus for many, little attention has been paid going forward to two very important recommendations by President Clinton that accompanied the apology. President Clinton pointed out that it is through the remembering of the shameful past of the Syphilis Study at Tuskegee that we can build a better present and a better future for the nation. Second, President Clinton directed the Secretary of Health and Human Services to work in partnership with higher education to prepare training materials for medical researchers as well as postgraduate fellowships to train bioethicists to build on core ethical principles of respect for individuals, justice, and informed consent, and how to use these principles effectively in racial/ethnic minority populations, especially African Americans. This article examines bioethical research challenges left in the wake of the U.S. Public Health Syphilis Study at Tuskegee and the presidential apology. This manuscript raises for consideration the inclusion of these issues in health care reform and the implementation of the Affordable Care Act. It asks: What is the right or good thing to do? What are our obligations to one another? Two challenges are examined: 1) Conducting research with African Americans without knowledge of bioethics specific to this population; and 2) The ethical dilemma of conducting research that does not adequately take into account the diversity within the Black population that is a contributing factor in health disparities. Training and policy recommendations responsive to President Clinton's Apology are presented.

Is there a legacy of the U.S. Public Health Syphilis Study at Tuskegee in HIV/AIDS-related beliefs among heterosexual African-Americans and Latinos?

Knowledge of the US Public Health Syphilis Study at Tuskegee is sometime cited as a principal reason for the relatively low participation rates seen among racial/ethnic minorities, particularly African Americans, in biomedical research. However, only a few studies have actually explored this possibility. We use data from a random digit dial telephone survey of 510 African-Americans and 253 Latinos, age 18 to 45 years, to investigate associations between knowledge of the USPHS Syphilis Study at Tuskegee and endorsement of HIV/AIDS conspiracy theories. All respondents were drawn from an area of low-income, predominantly race-segregated inner city households in Los Angeles. Results indicate that African Americans were significantly more likely than Latinos to endorse HIV/AIDS conspiracy theories. Further, African Americans were more aware of the USPHS Syphilis Study at Tuskegee (SST). Nevertheless, 72% of African Americans and 94% of Latinos reported that they have never heard of the Syphilis Study at Tuskegee. Further, while awareness of the Syphilis Study at Tuskegee was a significant predictor of endorsing HIV/AIDS conspiracy theories, results suggest that other factors may be more important in accounting for low biomedical and behavioral study participation rates.