Impact of the Dobbs decision on abortion services from a large tertiary center in Oregon

OBJECTIVE

Evaluate the impact of the Dobbs vs Jackson decision on abortion volume and patient characteristics in Oregon, a state with no legal restrictions on abortion, at a single tertiary care hospital.

METHODS

Electronic health records from patients who received an abortion at Oregon's largest tertiary health center were utilized comparing the year before and after Dobbs.

RESULTS

Monthly average abortions increased from 57.8 pre-Dobbs to 77.1 post-Dobbs (p=0.001). This trend was associated with an increased proportion of out-of-state patients (14.3% vs 9.5%, p=0.004) presenting with gestational duration ≥ 26 weeks (23.6% vs 3.7% in-state, p<0.001).

CONCLUSIONS

The Dobbs decision resulted in increased utilization of hospital-based abortion care in a protective state, characterized by a greater prevalence of patients traveling from out-of-state and presenting at later gestational durations. These trends reflect the critical role of protective states in preserving access to abortion care.

[To Do More and Better Regarding Portugal's Alcohol Consumption, a Social Change Is Needed]

N/a.

Reassessing the VaxTax

To counter the imbalance in vaccine distribution during the COVID-19 pandemic, Albertsen and more recently Germani et al have suggested a new system of taxation coined as 'VaxTax' that would force higher-income countries to fund the access of low-income and middle-income countries (LMICs) to new vaccines in times of pandemic. I will argue that this idea faces numerous challenges of ethical, sociopolitical and economical nature that may hinder any effort to solve the numerous health challenges that LMICs face. I argue that while it is an interesting idea, it is neither sufficient nor will it ever be easily implemented because of socioeconomic or practical reasons.

Enhancing social value considerations in prioritising publicly funded biomedical research: the vital role of peer review

The main goal of publicly funded biomedical research is to generate social value through the creation and application of knowledge that can improve the well-being of current and future people. Prioritising research with the greatest potential social value is crucial for good stewardship of limited public resources and ensuring ethical involvement of research participants. At the National Institutes of Health (NIH), peer reviewers hold the expertise and responsibility for social value assessment and resulting prioritisation at the project level. However, previous research has shown that peer reviewers place more emphasis on a study's methods ('Approach') than on its potential social value (best approximated by the criterion of 'Significance'). Lower weighting of Significance may be due to reviewers' views on the relative importance of social value, their belief that social value is evaluated at other stages of the research priority-setting process or the lack of guidance on how to approach the challenging task of assessing expected social value. The NIH is currently revising its review criteria and how these criteria contribute to overall scores. To elevate the role of social value in priority setting, the agency should support empirical research on how peer reviewers approach the assessment of social value, provide more specific guidance for reviewing social value and experiment with alternative reviewer assignment strategies. These recommendations would help ensure that funding priorities align with the NIH's mission and the obligation of taxpayer-funded research to contribute to the public good.

Ladders and stairs: how the intervention ladder focuses blame on individuals and obscures systemic failings and interventions

Introduced in 2007 by the Nuffield Council on Bioethics, the intervention ladder has become an influential tool in bioethics and public health policy for weighing the justification for interventions and for weighing considerations of intrusiveness and proportionality. However, while such considerations are critical, in its focus on these factors, the ladder overemphasises the role of personal responsibility and the importance of individual behaviour change in public health interventions. Through a study of vaccine hesitancy and vaccine mandates among healthcare workers, this paper investigates how the ladder obscures systemic factors such as the social determinants of health. In overlooking these factors, potentially effective interventions are left off the table and the intervention ladder serves to divert attention away from key issues in public health. This paper, therefore, proposes a replacement for the intervention ladder-the intervention stairway. By broadening the intervention ladder to include systemic factors, the stairway ensures relevant interventions are not neglected merely due to the framing of the issue. Moreover, it more accurately captures factors influencing individual health as well as allocations of responsibility for improving these factors.

Gain-of-function research and model organisms in biology

So-called 'gain-of-function' (GOF) research is virological research that results in a virus substantially more virulent or transmissible than its wild antecedent. GOF research has been subject to ethical analysis in the past, but the methods of GOF research have to date been underexamined by philosophers in these analyses. Here, we examine the typical animal used in influenza GOF experiments, the ferret, and show how despite its longstanding use, it does not easily satisfy the desirable criteria for an animal model We then discuss the limitations of the ferret model, and how those epistemic limitations bear on ethical and policy questions around the risks and benefits of GOF research. We conclude with a reflection on how philosophy of science can contribute to ethical and policy debates around the risks, benefits and relative priority of life sciences research.

The ethical canary: narrow reflective equilibrium as a source of moral justification in healthcare priority-setting

Healthcare priority-setting institutions have good reason to want to demonstrate that their decisions are morally justified-and those who contribute to and use the health service have good reason to hope for the same. However, finding a moral basis on which to evaluate healthcare priority-setting is difficult. Substantive approaches are vulnerable to reasonable disagreement about the appropriate grounds for allocating resources, while procedural approaches may be indeterminate and insufficient to ensure a just distribution. In this paper, we set out a complementary, coherence-based approach to the evaluation of healthcare priority-setting. Drawing on Rawls, we argue that an institutional priority-setter's claim to moral justification can be assessed, in part, based on the extent to which its many normative commitments are mutually supportive and free from dissonance; that is, on the ability to establish narrow reflective equilibrium across the normative content of a priority-setter's policy and practice. While we do not suggest that the establishment of such equilibrium is sufficient for moral justification, we argue that failure to do so might-like the proverbial canary in the coalmine-act as a generalised warning that something is awry. We offer a theoretical argument in support of this view and briefly outline a practical method for systematically examining coherence across priority-setting policy and practice.

Getting rights right: implementing 'Martha's Rule'

The UK government has recently committed to adopting a new policy-dubbed 'Martha's Rule'-which has been characterised as providing patients the right to rapidly access a second clinical opinion in urgent or contested cases. Support for the rule emerged following the death of Martha Mills in 2021, after doctors failed to admit her to intensive care despite concerns raised by her parents. We argue that framing this issue in terms of patient rights is not productive, and should be avoided. Insofar as the ultimate goal of Martha's Rule is the provision of a clinical service that protects patient safety, an approach that focuses on the obligations of the health system-rather than the individual rights of patients-will better serve this goal. We outline an alternative approach that situates rapid clinical review as part of a suite of services aimed at enhancing and protecting patient care. This approach would make greater progress towards addressing the difficult systemic issues that Martha's Rule does not, while also better engaging with the constraints of clinical practice.

Environmental sustainability and the paradox of prevention

The carbon emissions of global healthcare activities make up 4%-5% of total world emissions, with the majority coming from industrialised countries. The solution to healthcare carbon reduction in these countries, ostensibly, would be preventive healthcare, which is less resource intensive than corrective healthcare in itself and, as a double benefit, reduces carbon by preventing diseases which may require higher healthcare carbon to treat. This leads to a paradox: preventive healthcare is designed to give humans longer, healthier lives. But, by extending life spans, the carbon emissions of a person increase both over a lifetime and in the medical industry overall. At the same time, the need for higher carbon end-of-life care does not disappear, particularly in resource intensive countries. This article will first identify sources of healthcare carbon, focusing on the industrialised world, and explain various efforts towards healthcare carbon reduction, which include preventive healthcare. Second, it will develop the 'paradox of prevention'-that preventive healthcare may save healthcare carbon by proximally reducing the need for medical treatments, but also, paradoxically, result in more healthcare carbon both in an individual's life and in the medical industry. The third section will offer ethical principles for approaching the paradox of prevention. The conclusion will emphasise the need for institutional approaches to healthcare carbon reduction in the industrialised world, which will relieve some of the tensions of healthcare industry decarbonisation and individual healthcare carbon use.

Single women's access to egg freezing in mainland China: an ethicolegal analysis

In the name of safeguarding public interests and ethical principles, China's National Health Commission bans unmarried women from using assisted reproductive technology (ART), including egg freezing. Supported by local governments, the ban has restricted single women's reproductive rights nationwide. Although some courts bypassed the ban to allow widowed single women to use ART, they have not adopted a position in favour of single women's reproductive autonomy, but quite the contrary. Faced with calls to relax the ban and allow single women to freeze eggs electively, the National Health Commission refused to amend their policy, partly to protect women's well-being paternalistically and partly to implement the central government's policies to boost the birthrate and maintain traditional family structures. While the government's concerns about elective egg freezing are not entirely unfounded, they have failed to demonstrate that banning single women's egg freezing is a suitable, necessary and proportionate means to safeguard societal interests and ethical principles. The authority's assumptions that women cannot make rational decisions for their health even with adequate informed consent procedures, that banning egg freezing by single women promotes a culture of having children 'at a proper age', and that egg freezing by single women offends China's public moralities have not been substantiated.

Doing Health Policy Analysis: The Enduring Relevance of Simple Models Comment on "Modelling the Health Policy Process: One Size Fits All or Horses for Courses"

The analysis of health policy processes in low- and middle-income countries (LMICs) emerged as a research area in the early 1990s. In their recent editorial Powell and Mannion argue that such research can be deepened by applying public policy theory. In response, we raise three questions to consider: are public policy models fit for purpose in today's world in LMICs (and what other theory can be used)? Is using theory the most important factor in deepening such research? Why do we, as researchers, do this work? Ultimately, we argue that the value of simple models, such as those already used in health policy analysis, lies in their enduring relevance and widespread use. They are supporting the development of the shared understandings that can, in turn, provide the basis for collective action addressing inequities in health and well-being.

Blowing the whistle on mixed gender hospital rooms in Australia and New Zealand: a human rights issue

The practice of placing men and women in the same hospital room (mixed gender rooms) has been prohibited in the UK National Health Service for over a decade. However, recent research demonstrates that the practice is common and increasing in a major New Zealand public hospital. Reports and complaints show that the practice also occurs in Australia. We argue that mixed gender rooms violate the fundamental human rights of personal security and dignity. The high rates of cognitive impairment, sensory impairment and frailty in hospital wards exacerbates the risk for these violations and subsequent harm. We argue for the adoption of specific national policies prohibiting mixed gender rooms and public reporting of breaches. Importantly, these guidelines can be adopted without compromising the rights of gender minorities. In the long term, hospitals should be built with single occupancy rooms.

Changes in retail tobacco product sales and market share among retail payroll establishments in the U.S. Economic Census between 1997 and 2017

The tobacco industry spends the vast majority of their marketing and promotional budget at retail outlets. However, few studies have used publicly available data to examine trends in the number and types of retail establishments where tobacco products are sold. Using the U.S. Economic Census for 1997, 2002, 2007, 2012 and 2017 (the latest year), we examined the number, type, and sales of payroll establishments selling tobacco products. Nine store types accounted for 94% - 99% of tobacco product sales between 1997 and 2017. Gas/convenience stores had the greatest market share (33% - 49% of tobacco sales). The number of warehouse clubs selling tobacco quadrupled; however, market share only increased from 9.6% to 10.3%. Supermarkets experienced the largest decrease in percent of stores selling tobacco. Pharmacy tobacco sales increased in 2012 then decreased in 2017; per store sales volume more than doubled between 1997 and 2012. Online shopping accounted for less than 1% of the market share between 1997 and 2012, but rose to 6.3% in 2017. Between 1997 and 2017, consumers shifted where they purchased tobacco products. Declining tobacco sales in supermarkets is a promising trend for consumers seeking healthy food without exposure to tobacco product marketing; however, the consistently large number of tobacco retailers, and thus widespread tobacco availability, is concerning. Consumer tobacco purchase changes over time support the case for point-of-sale policies that affect different retail types, including pharmacy bans, to reduce tobacco retailer density. Additionally, the rapid shift to online tobacco purchasing in 2017 identifies a new target for enhanced regulation and enforcement.

Policy Makes Politics Comment on "Modelling the Health Policy Process: One Size Fits All or Horses for Courses?"

Powell and Mannion's review of reviews maps the landscape of health policy research, showing a number of problematic and longstanding features. This commentary focuses on the extent to which health parochialism is good for the scientific development of the literature, the extent to which a "tournament of theories" actually develops our understanding of health policy process, and, finally, whether circumscribed theories of the policy process might be missing some of the most important and useful findings of broader comparative politics, which focus on the ways policies create politics over time. It concludes that health parochialism and focus on a circumscribed policy process is not likely to be helpful because it distracts attention from the ways in which coalitions and institutions over time shape politics and policy, a finding explored by scholars of many sectors whose findings should influence health policy research.

Herd immunity, vaccination and moral obligation

The public health benefits of herd immunity are often used as the justification for coercive vaccine policies. Yet, 'herd immunity' as a term has multiple referents, which can result in ambiguity, including regarding its role in ethical arguments. The term 'herd immunity' can refer to (1) the herd immunity threshold, at which models predict the decline of an epidemic; (2) the percentage of a population with immunity, whether it exceeds a given threshold or not; and/or (3) the indirect benefit afforded by collective immunity to those who are less immune. Moreover, the accumulation of immune individuals in a population can lead to two different outcomes: elimination (for measles, smallpox, etc) or endemic equilibrium (for COVID-19, influenza, etc). We argue that the strength of a moral obligation for individuals to contribute to herd immunity through vaccination, and by extension the acceptability of coercion, will depend on how 'herd immunity' is interpreted as well as facts about a given disease or vaccine. Among other things, not all uses of 'herd immunity' are equally valid for all pathogens. The optimal conditions for herd immunity threshold effects, as illustrated by measles, notably do not apply to the many pathogens for which reinfections are ubiquitous (due to waning immunity and/or antigenic variation). For such pathogens, including SARS-CoV-2, mass vaccination can only be expected to delay rather than prevent new infections, in which case the obligation to contribute to herd immunity is much weaker, and coercive policies less justifiable.

Health in All Policies at the Local Level: What Facilitates Success? Comment on "A Realist Explanatory Case Study Investigating How Common Goals, Leadership, and Committed Staff Facilitate Health in All Policies Implementation in the Municipality of Kuopio, Finland"

The paper by Guglielmin and colleagues1 examines the implementation of Health in All Policies (HiAP) in a local government context in Kuopio Finland. The authors use a realist explanatory case study design to explore what has supported HiAP implementation with a focus on two specific hypotheses on what leads to success: common goals and committed leadership and staff. The paper is well argued using appropriate methodology and their findings support the importance of the success factors tested by their two hypotheses. However, the narrowed focus on just two hypotheses underrepresents the complexity of implementing HiAP at any level of government, including local government. Given its local government focus, the paper would have been strengthened by referencing the lessons gained from the Healthy Cities movement. Local government is a critical setting for action to address health and health equity and there is great potential to continue research that adds to the knowledge base on how to successful implement HiAP. Finally, it is important to acknowledge that Finland has a unique HiAP history. It is recognised as a global leader in the field, and the role of local government in Finland differs from many other countries. These factors may impact on the transferability of the case study findings.

Dark side of the principles of non-discrimination and proportionality: the case of mandatory vaccination

Deciding the conflict between various rights and interests, especially in medical ethics where health and lives are in question, has significant challenges, and to obtain appropriate outcomes, it is necessary to properly apply the principles of non-discrimination and proportionality. Using the example of mandatory vaccination policies, we show that this task becomes even more difficult when these principles lead us to counterintuitive and paradoxical results. Although the general purpose of these principles is to ensure that decisions and policies seek the highest and broadest possible enjoyment of rights for all (ie, the least restrictive solution), they achieve the complete opposite when applied to mandatory vaccination policies. To highlight and explain these paradoxical results, we present a typology of fifteen hypothetical mandatory vaccination policies containing various degrees of restriction and apply well-established non-discrimination and proportionality tests from constitutional law to each. We argue that mandatory vaccination policies exhibit two characteristics, namely the non-linear relationship between their general purposes and specific goals and the involvement of life and health, suggesting that more restrictive policies should prevail even though less restrictive policies might fail these tests. Using clearly structured and rigorous methodology from constitutional law, the proposed approach delivers a fresh view on the core ethical principles of non-discrimination and proportionality and a potentially useful tool in helping resolve also other challenges encountered in medical ethics beyond mandatory vaccination policies.

Comparative Analysis on the Policy Approaches in the National Dementia Plans of G7 Countries and Korea and Their Implementation

BACKGROUND

The World Health Organization (WHO) proposed a global action plan for dementia and aimed to have 75% of their member states formulating National Dementia Plans (NDPs) by 2025. The Organization for Economic Cooperation and Development (OECD) proposed the ten key objectives of dementia policy in 2015. Among previous studies on NDPs, few studies have investigated measures for proper implementation of NDPs. This study aimed to compare the implementation basis and specific action plans of NDPs between the G7 countries and South Korea.

METHODS

We investigated the measures for proper implementation of the NDPs of G7 countries and South Korea. To compare the specific policy approaches, the seven action areas of the WHO action plan and the ten key objectives of dementia policy proposed by the OECD were integrated into 11 targets (prevention, diagnosis, awareness, caregiver support, appropriate environments, long-term care, health service, end-of-life care, care coordination, research and technology, information systems).

RESULTS

Although most NDPs included specific action plans of the 11 targets, caregiver support, safe environments, healthcare services, and end-of-life care were lacking in some NDPs. For implementation, some countries reinforced the policy priority of their NDPs by timely updates, evaluation, legislations, or head-of-state leadership. However, only three countries had a legislative basis, and three countries included outcome measures in their latest NDP.

CONCLUSION

Effective measures for feasible implementation are needed. The WHO should promote not only the establishment of NDPs, but also their proper implementation.

Why Should Health Researchers Use Policy Theories? Comment on "Modelling the Health Policy Process: One Size Fits All or Horses for Courses?"

Powell and Mannion suggest that 'health policy process' research should draw more lessons from 'the wider policy process literature.' While health research could continue with sector specific models, the wider literature is 'conceptually stronger.' In that context, I clarify how and why health researchers should use policy theories. I describe a review of the use of policy theories in public health research to show that many researchers use them to not only understand policy-making but also influence policy and policy-making. Most policy theories are not designed for that purpose, but it is still possible to produce practical lessons. I outline the issues that arise when repurposing theory-informed insights, such as that policy change takes a long time, and the scale of policy-making is potentially overwhelming. I then highlight the valuable role of theories in raising dilemmas in relation to modes of governance and evidence production.

A Social, Not a Natural Science: Engaging With Broader Fields in Health Policy Analysis Comment on "Modelling the Health Policy Process: One Size Fits All or Horses for Courses?"

Powell and Mannion's recent editorial discusses how different 'models' of the policy process have been applied within the health policy field. They present two ways forward for scholarship: more 'home grown' development of health-specific models, or deeper engagement with broader public policy scholarship. In this paper I argue for the latter approach for several reasons. First, health policy analysis is a social, not a natural science - and as such is not exceptional to other forms of policy scholarship. Second, many 'health policy models' are often grounded in conceptual work from elsewhere (or may not be health specific). Finally, there has been significant work to develop more nuanced understandings of theories, models, and frameworks available to particular analytical tasks and questions. As such, the growing body of global health policy scholarship may find it can benefit more from deeper engagement with existing conceptual work than constructing its own new models in most cases.

Marketing Responses to the Taxation of Soft Drinks Comment on "Understanding Marketing Responses to a Tax on Sugary Drinks: A Qualitative Interview Study in the United Kingdom, 2019"

The paper by Forde et al provides a useful qualitative consideration of marketing responses to the implementation of the 2018 Soft Drinks Industry Levy (SDIL) in the United Kingdom. This commentary discusses that paper and its conclusions and seeks to place them in a broader context for marketing, fiscal measures and health and public policy. It suggests that modern conceptualisations of marketing and wider considerations of market and non-market strategies could provide a valuable lens to understand the ways in which companies and sectors respond to the threats they perceive and the constantly changing sectoral opportunities. It is important that fiscal measures introduced have the desired effects, and that not only positive behaviours (whether of companies or consumers) are incentivised, but that adverse behaviours are actively disincentivised.

Imagination and idealism in the medical sciences of an ageing world

Imagination and idealism are particularly important creative epistemic virtues for the medical sciences if we hope to improve the health of the world's ageing population. To date, imagination and idealism within the medical sciences have been dominated by a paradigm of disease control, a paradigm which has realised significant, but also limited, success. Disease control proved particularly successful in mitigating the early-life mortality risks from infectious diseases, but it has proved less successful when applied to the chronic diseases of late life (like cancer). The time is ripe for the emergence and prominence of a supplementary medical research paradigm, the paradigm of 'healthy ageing' which prioritises the goal of rate (of ageing) control rather than disease control. This is the difference between extending the human healthspan versus extending survival by managing (or trying to eliminate) the multi-morbidities, frailty and disability currently prevalent in late life. The idealism of the disease control paradigm is myopic because it ignores the health constraints imposed by the inborn ageing process itself, a biological reality which is already inflicting significant economic and disease burdens on the world's ageing populations. Unless the medical sciences retard the rate of biological ageing, these problems will continue to be amplified as larger numbers of persons survive into late life.

Diversity in clinical research: public health and social justice imperatives

It is well established that demographic representation in clinical research is important for understanding the safety and effectiveness of novel therapeutics and vaccines in diverse patient populations. In recent years, the National Institutes of Health and Food and Drug Administration have issued guidelines and recommendations for the inclusion of women, older adults, and racial and ethnic minorities in research. However, these guidelines fail to provide an adequate explanation of why racial and ethnic representation in clinical research is important. This article aims to both provide the missing arguments for why adequate representation of racial and ethnic minorities in clinical research is essential and to articulate a number of recommendations for improving diversity going forward.Appropriate racial and ethnic representation and fair inclusion help (1) increase the generalisability of clinical trial results, (2) equitably distribute any benefits of clinical research and (3) enable trust in the research enterprise.

Please wear a mask: a systematic case for mask wearing mandates

This paper combines considerations from ethics, medicine and public health policy to articulate and defend a systematic case for mask wearing mandates (MWM). The paper argues for two main claims of general interest in favour of MWM. First, MWM provide a more effective, just and fair way to tackle the ongoing COVID-19 pandemic than policy alternatives such as laissez-faire approaches, mask wearing recommendations and physical distancing measures. And second, the proffered objections against MWM may justify some exemptions for specific categories of individuals, but do not cast doubt on the justifiability of these mandates. Hence, unless some novel decisive objections are put forward against MWM, governments should adopt MWM.

Modelling the Health Policy Process: One Size Fits All or Horses for Courses?

A range of conceptual models for understanding the policy process have been applied to the health policy process, largely in particular sub areas or policy domains such as public health. However, these contributions appear to offer different rationales and present different frameworks for understanding the policy process. This Editorial critically examines articles that explore the health policy process with models from wider public policy and from health policy. It can be seen that very few of the wider models have been applied in studies of the health policy process. Conversely, some models feature in studies of the health policy process, but not in the wider policy process literature, which suggests that literature on the health policy process is semi-detached from the wider policy process literature. There seem to be two very different future research directions: focusing on 'home grown' models, or taking greater account of the wider policy process literature. Does 'one size fit all' or is it 'horses for courses'?

Does overruling Roe discriminate against women (of colour)?

On 24 July 2022, the landmark decision Roe v. Wade (1973), that secured a right to abortion for decades, was overruled by the US Supreme Court. The Court decision in Dobbs v. Jackson Women's Health Organisation severely restricts access to legal abortion care in the USA, since it will give the states the power to ban abortion. It has been claimed that overruling Roe will have disproportionate impacts on women of color and that restricting access to abortion contributes to or amounts to structural racism. In this paper, we consider whether restricting abortion access as a consequence of overruling Roe could be understood as discrimination against women of color (and women in general). We argue that banning abortion is indirectly discriminatory against women of color and directly (but neither indirectly, nor structurally) discriminatory against women in general.

Proportionality, wrongs and equipoise for natural immunity exemptions: response to commentators

We would like to thank each of the commentators on our feature article for their thoughtful engagement with our arguments. All the commentaries raise important questions about our proposed justification for natural immunity exemptions to COVID-19 vaccine mandates. Thankfully, for some of the points raised, we can simply signal our agreement. For instance, Reiss is correct to highlight that our article did not address the important US-centric considerations she helpfully raises and fruitfully discusses. We also agree with Williams about the need to provide a clear rationale for mandates, and to obtain different kinds of data in support of possible policies.Unfortunately, we lack the space to engage with every one of the more critical comments raised in this rich set of commentaries; as such, in this response, we shall focus on a discussion of hybrid immunity, which underlies a number of different arguments evident in the commentaries, before concluding with some reflections responding to Lipsitch's concern about the appropriate standard of proof in this context.

Framework for the analysis of renewable energy grid policies in the context of COVID-19

COVID-19 is a severe global pandemic that has caught the whole world unprepared. In the absence of a clear timeline for this pandemic to end, it is need of the hour to investigate the effect of this pandemic on both previous and anticipated investments. Global economic unrest has hindered the ramping deployment of Renewable energy projects.The most quick actions that may be taken to mitigate the effects and to up-rise the investment portfolio policies are a very critical tool in hands of government for a very immediate effect have also been made without keeping the context of COVID-19 into account.New variants of diff rent nature are being discovered and every now and then new lock downs are happening. In this context different policies have to be evaluated under the pandemic scenario. A case study of a large scale renewable energy project for a higher education institute in Pakistan is being used to measure the difference during COVID and pre COVID times. This paper provides a framework to investigate the impact of COVID on renewable energy system projects under current net-metering, net-billing and self-consumption policies. A recent investment in a photovoltaic system is assessed based on previously projected financial benefits versus the pandemic effected ones. This research concludes that investing in photovoltaic systems are still a viable option even in an extreme pandemic situation with less than 0.5 years increase in payback period, and the government can still provide a stimulus for investing in green energy by implementing net-metering policies on a larger scale.

Access to Care for Mental Health Problems in Afghanistan: A National Challenge

BACKGROUND

This paper describes the access to care for mental health problems in Afghanistan, according to the nature of the mental health problems and the service provider. Following the Andersen model, it evaluates the respective roles in access to care of "predisposing," "needs," "enabling" factors, and other "environmental" factors such as exposure to traumatic events and level of danger of the place of residence.

METHODS

Trans-sectional probability survey in general population by multistage sampling in 16 provinces, nationally representative: N=4445 (15 years or older), participation rate of 81%. Face to face interviews using standardized measures of mental health (CIDI, Composite International Diagnostic Interview). Different logistic regression models are presented.

RESULTS

The 12-month rate of mental health help-seeking was 6.56% with substantial regional variation (2.35% to 12.65%). Providers were mainly from the health sector; the non-health sector (religious and healers) was also prevalent. Most consultations were held in private clinics (non-governmental organisation, NGO). The severity of mental health disorders as well as the perceived impairment due to mental health were independently very important: odds ratio (OR) = 6.04 for severe disorder, OR=3.79 for perceived impairment. Living in a dangerous area decreased access to care: for high level of danger and for very high level: OR=0.22. Gender, education and ethnicity were not associated with mental health help-seeking after controlling for exposure to trauma.

CONCLUSION

Access to care for mental health problems depended mainly on the needs as defined as disorder severity level and impairment, and on environmental factors such as exposure to traumatic events. The system seems equitable; however, this is counterbalanced by a very challenging environment. This survey is a testimony to the hardship experienced by the Afghan population and by health professionals, and to the efforts to deliver organized mental healthcare in a challenging situation. This research may inform and support policy-makers and NGOs in other countries undergoing similar challenges.

Hunger relief: A natural experiment from additional SNAP benefits during the COVID-19 pandemic

Background

COVID-19 has directly affected millions of people. Others have been indirectly affected; for example, there has been a startling increase in hunger brought about by the pandemic. Many countries have sought to relieve this problem through public policy. This research examines the effectiveness of enhanced Supplemental Nutrition Assistance Program (SNAP) benefits in the U.S. to alleviate hunger.

Methods

Using a biweekly cross-sectional survey and corresponding population weights from the U.S. Census Bureau, we estimate the effects of enhanced SNAP benefits on hunger in the U.S. as measured by food insufficiency. We use a Bayesian structural time series analysis to predict counterfactual values of food insufficiency. We supplement these findings by examining the effect of enhanced SNAP benefits on observed visits to a food pantry network in a midsized U.S. city.

Findings

Our primary finding estimates that nationwide a total 850,000 (95% credible interval 0·24–1·46 million) instances of food insufficiency were prevented per week by the 15 percent increase in SNAP benefits enacted in January 2021. Secondarily, we find similar effects associated with SNAP benefit increases and local food pantry visits. Specifically, enhanced SNAP benefits resulted in fewer visits to the food pantry network than were predicted in the counterfactual model.

Interpretation

These results not only indicate that the policies enacted to mitigate hunger caused by the COVID-19 pandemic helped, but also quantifies how much these benefits helped on a national scale. As a result, policymakers can use this data to benchmark future policy actions at scale.

Funding

None.

Evaluation of Current Resources Available for Community-Based Cardiac Rehabilitation in Korea: A Nationwide Survey Study

BACKGROUND

In Korea, the actual distribution of cardiac rehabilitation (CR) to the clinical field is insufficient due to the many barriers for cardiovascular patients to participate in CR. Community-based CR is a useful alternative to overcome these obstacles. Through a nationwide survey, we investigated the possibility of regional medical and public health management institutes which can be in charge of community-based CR in Korea.

METHODS

The questionnaires on recognition of CR and current available resources in health-related institutions were developed with reference to the CR evaluation tools of York University and the International Council of Cardiovascular Prevention and Rehabilitation. The questionnaires were sent to regional public and private medical institutions and public health management institutions.

RESULTS

In total, 2,267 questionnaires were sent to 1,186 institutions. There were 241 and 242 responses from 173 and 179 regional private and public medical institutions, respectively. And a total of 244 responses were gathered from 180 public health management institutions. Although many institutions were equipped with the necessary facilities for exercise training, there were few patient-monitoring systems during exercise. Most institutions were aware of the need for CR, but were burdened with the cost of establishing personnel and facilities to operate CR.

CONCLUSION

Most regional medical, and public health management institutions in Korea are unprepared for the implementation of community-based CR programs. To encourage the utilization of such, there should be efforts to establish a national consensus.

National trends in prescription drug expenditures and projections for 2022

Purpose

To report historical patterns of pharmaceutical expenditures, to identify factors that may influence future spending, and to predict growth in drug spending in 2022 in the United States, with a focus on the nonfederal hospital and clinic sectors.

Methods

Historical patterns were assessed by examining data on drug purchases from manufacturers using the IQVIA National Sales Perspectives database. Factors that may influence drug spending in hospitals and clinics in 2022 were reviewed—including new drug approvals, patent expirations, and potential new policies or legislation. Focused analyses were conducted for biosimilars, cancer drugs, generics, COVID-19 pandemic influence, and specialty drugs. For nonfederal hospitals, clinics, and overall (all sectors), estimates of growth of pharmaceutical expenditures in 2022 were based on a combination of quantitative analyses and expert opinion.

Results

In 2021, overall pharmaceutical expenditures in the US grew 7.7% compared to 2020, for a total of $576.9 billion. Utilization (a 4.8% increase), price (a 1.9% increase) and new drugs (a 1.1% increase) drove this increase. Adalimumab was the top drug in terms of overall expenditures in 2021, followed by apixaban and dulaglutide. Drug expenditures were $39.6 billion (a 8.4% increase) and $105.0 billion (a 7.7% increase) in nonfederal hospitals and in clinics, respectively. In clinics and hospitals, new products and increased utilization growth drove growth, with decreasing prices for both sectors acting as an expense restraint. Several new drugs that are likely to influence spending are expected to be approved in 2022. Specialty and cancer drugs will continue to drive expenditures along with the evolution of the COVID-19 pandemic.

Conclusion

For 2022, we expect overall prescription drug spending to rise by 4.0% to 6.0%, whereas in clinics and hospitals we anticipate increases of 7.0% to 9.0% and 3.0% to 5.0%, respectively, compared to 2021. These national estimates of future pharmaceutical expenditure growth may not be representative of any particular health system because of the myriad of local factors that influence actual spending.

Evaluation and prioritization of actions on food environments to address the double burden of malnutrition in Senegal: perspectives from a national expert panel

OBJECTIVE

To evaluate the extent of implementation of public policies aimed at creating healthy eating environments in Senegal compared to international best practice and identity priority actions to address the double burden of malnutrition.

DESIGN

The Healthy Food Environment Policy Index (Food-EPI) was used by a local expert panel to assess the level of implementation of 43 good practice policy and infrastructure support indicators against international best practices using a Likert scale and identify priority actions to address the double burden of malnutrition in Senegal.

SETTING

Senegal, West Africa.

PARTICIPANTS

A national group of independent experts from academia, civil society, non-governmental organizations and United Nations bodies (n =15) and a group of government experts from various ministries (n =16) participated in the study.

RESULTS

Implementation of most indicators aimed at creating healthy eating environments were rated as "low" compared to best practice (31 on 43, or 72%). The Gwet AC2 inter-rater reliability was good at 0.75 (CI 0.70 - 0.80). In a prioritization workshop, experts identified forty-five actions, prioritizing ten as relatively most feasible and important and relatively most effective to reduce the double burden of malnutrition in Senegal (example: Develop and implement regional school menus based on local products (expand to 14 regions) and measure the extent of the promotion of unhealthy foods to children).

CONCLUSIONS

Significant efforts remain to be made by Senegal to improve food environments. This project allowed to establish an agenda of priority actions for the government to transform food environments in Senegal to tackle the double burden of malnutrition.

Towards a more efficient healthcare system: Opportunities and challenges caused by hospital closures amid the COVID-19 pandemic

A substantial number of United States (U.S.) hospitals have closed in recent years. The trend of closures has accelerated during the COVID-19 pandemic, as hospitals have experienced financial hardship from reduced patient volume and elective surgery cases, as well as the thin financial margins for treating patients with COVID-19. This trend of hospital closures is concerning for patients, healthcare providers, and policymakers. In this current opinion piece, we first describe the challenges caused by hospital closures and discuss what policymakers should know based on the existing research. We then discuss unique opportunities for researchers to inform policymakers by conducting careful studies that can shed light on different implications, trade-offs, and consequences of various strategies that can be followed.

Training Undergraduate Students in HIPAA Compliance

The Health Insurance Portability and Accountability Act (HIPAA) has radically changed the way healthcare is conducted, and its relevance continues to expand as healthcare technology evolves. This article describes a method for training inexperienced undergraduate students to become HIPAA-compliant clinical research volunteers in a pediatric traumatic brain injury (TBI) study. Volunteers are trained to use the hospital's electronic health records system (EHR) to identify potential study candidates for approach, and they develop this skill set through google classroom modules/quizzes along with routine zoom calls to solidify their consenting approach. Since the inception of this study in 2018, there have been over one hundred different undergraduate research volunteers involved, and there has not been a single HIPAA violation to date. This compliance success rate is indicative of the efficacy of this training protocol. This paper serves as a guide to implementing HIPAA compliance training and ensuring accountability in new and existing clinical research studies.

It's Not Irony, it's Interest Convergence: A CRT Perspective on Racism as Public Health Crisis Statements

Racism as a Public Health Crisis Statements (RPHCs) acknowledge the reality that racism must be eradicated to ensure health justice: a fair and just opportunity for all individuals to be healthy. Scholars of critical race theory (CRT) have expressed doubt when it comes to the capacity of law-related institutions to catalyze or sustain anti-racist efforts. These strains of skepticism underscore the question of whether so many RPHCS were adopted precisely because, in many instances, they were merely symbolic acts. This commentary argues that the trend in adopting RPHCs carries signs of interest convergence, and asserts that the alliance between government and the movement for health justice reflected in this phenomenon falls short of the substantive anti-racist action needed to realize health justice. The spate of RPHC adoption, in lieu of passing anti-racist policy or meaningfully empowering people of color, signifies that the movement for health justice must be strategic in determining whether to leverage, or be wary of, the power dynamics which shape political change. The health justice framework must expand its toolkit to include CRT.

Comparing mortality from covid-19 to mortality due to overdose: A micromort analysis

OBJECTIVE

To compare the mortality risk due to covid-19 with death due to overdose in British Columbia, Canada. The opioid epidemic was declared a public health emergency in 2016.

METHODS

Mortality risk was calculated in micromorts with covid-19 data for January-October 2020, derived from the BC center for Disease Control, and illicit drug toxicity deaths for January 2010-September 2020, derived from the BC Coroners Service. Age-stratified covid-19 incidence and deaths per 100,000 population and age-stratified illicit drug toxicity death rates per 100,000 population were calculated. A micromort is a unit of risk equivalent to a one-in-a-million chance of death.

RESULTS

During the covid-19 pandemic, illicit drug toxicity deaths reached 1.0 micromorts per day, representing an increase of 0.5 micromorts per day relative to 2019 rates. In comparison, covid-19 mortality risk was 0.05 micromorts per day among individuals from the general population living in British Columbia and 21.1 micromorts per day among those infected with covid-19. Covid-related mortality risk was significantly lower among individuals aged <60 years, relative to older adults, whereas drug toxicity-related mortality was highest for individuals aged 30-59 years.

CONCLUSIONS

The mortality associated with covid-19 is apparent and distributed unevenly across subpopulations. The mortality due to overdose has increased during covid-19 and exceeds mortality due to covid-19. Our results instantiate the triple threat caused by covid-19 (i.e., public health crisis, economic crisis and mental health crisis) and quantitatively highlight the externality of increased mortality due to deaths of despair in response to public health efforts to reduce covid-related mortality.

Fresh Take: Pitfalls of the FDA's Proposed Menthol Ban

In April 2021, the U.S. Food and Drug Administration announced its intention to ban menthol flavoring in cigarettes and cigars. The Agency's decision was based in part on the disproportionate impact of menthol flavoring in Black communities.

Compliance to Online Retail of Electronic Nicotine Delivery Systems (ENDS) in India before and after the 2018 Ban Order of the Government of India

Since their launch globally in 2012, electronic nicotine delivery systems (ENDS) were positioned as a harm reduction strategy and cessation device but it is yet to be proven to have clinical safety or public health benefits. Instead, recent reports suggest that the tobacco industry targeted youth and sponsored research whose evidence was used to mislead policymaking. On August 28, 2018, Ministry of Health & Family Welfare's advisory banned the sale, purchase, and trade of ENDS. A survey was done in two waves. The first survey was done between August 10 and 25 2018 all websites which sold ENDS product were mapped and documented. The survey was repeated (November 30, 2018) were after the restriction to trade on ENDS was proposed by the Department of Customs. The two waves of survey found that no website, whether comprehensive e-commerce portals or dedicated ENDS marketing platforms fully complied with government orders. National and states government enforcement agencies are currently unaware of internet-based sale of ENDS. Although some states have given specific directions to stop the sale and delivery of ENDS within the state through e-commerce, there is limited monitoring and legal compliance by seller. Public health advocates need to stay vigilant and monitor the online sale and point of sale retail of ENDS to ensure strict compliance of national and state regulations.

[Dengue in COVID-19 era]

There are various communicable diseases that continuously affect the homeostasis of society, including vector-borne diseases that despite having special programs for epidemiological surveillance are a challenge for health systems, such as dengue, which persists in various endemic areas in Mexico.

Street-level implementers of population-based oral health policies: the case of water fluoridation supply in Brazil's small towns

BACKGROUND

Knowledge of conditions influencing the performance of street-level operators when implementing population-based policies could increase the understanding of local implementation dynamics.

OBJECTIVE

We analyzed how street-level operators claim to act to implement fluoridation policy in the water treatment units of small Brazilian municipalities and identified conditions shaping behavior against adherence to policy.

METHODS

A case study using narratives obtained through in-depth interviews with key informants in two pairs of municipalities with contrasting levels of implementation. Analysis identified themes in the data and in the street-level bureaucracy literature.

RESULTS

Institutional characteristics such as administrative fragility of local entities, low priority given locally to policy, poor physical structure of the water treatment plants, isolated working relations, low effectiveness of monitoring devices, and local actors' uncertainties about the policy favored the expansion of the discretionary power of street-level operators configuring important barriers for water fluoridation.

CONCLUSION

These data highlight the complexity of policy implementation and inform policymakers about the importance of inter-federal and inter-sectoral coordination when implementing population-based health policies in small towns.

[Social rights: difficult to construct, easy to destroy]

The purpose of this article is to reflect on contemporary tensions between the social protection system in Brazil - which in the past 30 years has come to be organized as a social right and has been part of the construction of democracy in the country - and the current process of its dismantling under an authoritarian populist regime. From the theoretical perspective adopted in this article, structural characteristics and circumstantial factors are examined in order to explain the difficulties that have been faced in constructing a legal and institutional architecture for social rights, and on the other hand, why at present it is so easy to destroy it in practice.

Where in the world is Florence Nightingale's medicine chest?

BACKGROUND

In the 121^st anniversary year of the birth of Florence Nightingale, and during the COVID-19 pandemic, it is both interesting and salient to be reminded of the foundational work of this famous woman who began modern nursing. Her work in nursing care and nursing, health and public policy has been a continuing strong foundation to practices in societies around the world.

METHODS

In this short communication about historical research, various aspects of Florence's life and work are described, as well as the locations, memorials and museum significant to our remembrance of her.

RESULTS

A particular focus of this paper is the description of a larger but little-known medicine chest located at the College of Nursing, University of Saskatchewan, in Saskatoon, SK, Canada, and attributed as belonging to Florence.

CONCLUSION

Best known to this point in time is a smaller medicine chest at the Florence Nightingale Museum in London.