Pediatric Firearm-Related Injuries in the United States

Pediatric firearm-related deaths and injuries are a national public health crisis. In this Special Review Article, we characterize the epidemiology of firearm-related injuries in the United States and discuss public health programs, the role of pediatricians, and legislative efforts to address this health crisis. Firearm-related injuries are leading causes of unintentional injury deaths in children and adolescents. Children are more likely to be victims of unintentional injuries, the majority of which occur in the home, and adolescents are more likely to suffer from intentional injuries due to either assault or suicide attempts. Guns are present in 18% to 64% of US households, with significant variability by geographic region. Almost 40% of parents erroneously believe their children are unaware of the storage location of household guns, and 22% of parents wrongly believe that their children have never handled household guns. Public health interventions to increase firearm safety have demonstrated varying results, but the most effective programs have provided free gun safety devices to families. Pediatricians should continue working to reduce gun violence by asking patients and their families about firearm access, encouraging safe storage, and supporting firearm-related injury prevention research. Pediatricians should also play a role in educating trainees about gun violence. From a legislative perspective, universal background checks have been shown to decrease firearm homicides across all ages, and child safety laws have been shown to decrease unintentional firearm deaths and suicide deaths in youth. A collective, data-driven public health approach is crucial to halt the epidemic of pediatric firearm-related injury.

The Political Future of Social Medicine: Reflections on Physicians as Activists

The academic discipline of social medicine has always had a political and policy advocacy component, in addition to its core functions of research and teaching. Its origins lie in the 18th and 19th centuries, in the work of Johann Peter Frank and Rudolph Virchow, among others. Virchow's dictum that "politics is nothing else but medicine on a large scale" highlights that most social determinants of health are politically determined and shape population health. Yet despite intense epidemiological and sociological research on the social determinants of health, less attention has been paid to this political and policy dimension.During the 1960s, the author and many other clinicians were directly involved in attempts to use health care institutions to foster structural change. However, the author argues that efforts to assist individual patients and more effectively manage their interactions with the health care system, as described in the articles in this issue's special collection on "structural competency," while worthy and useful, do not confront root causes. Going forward, efforts to effect structural change must take place outside the arena of the clinical encounter and involve interprofessional teams and collaborations with nongovernmental organizations. They should intervene directly on the structures that contribute to illness such as poor housing, income and wealth inequality, inferior education, racism and residential segregation, and toxic concentrations of extreme poverty in urban areas. Collectively, these efforts-within and outside the spheres of medicine-represent the real operative form of structural competency.

Mifepristone in Italy: the case of a drug trapped between ethics and clinical practice

In Italy mifepristone is not yet marketed. Gynaecologists in our hospital asked to use this medication as a less traumatic method for voluntary abortions. We followed the standard procedure defined by the Italian Health Ministry (IMH) for purchasing drugs from abroad but encountered several unexpected barriers. Starting from this case, this paper is aimed at identifying these barriers which we found to be not only professional, but also ethical, religious and moral.

Public health and social ideas in modern Brazil

Public health in Brazil achieved remarkable development at the turn of the 20th century thanks in part to physicians and social thinkers who made it central to their proposals for "modernizing" the country. Public health was more than a set of medical and technical measures; it was fundamental to the project of nation building. I trace the interplay between public health and social ideas in the late 19th and early 20th centuries. Physicians and social thinkers challenged the traditional belief that Brazil's sociocultural and ethnic diversity was an obstacle to modernization, and they promoted public health as the best prescription for national unity. Public health ideas in developing countries such as Brazil may have a greater impact when they are intertwined with social thought and with the processes of nation building and construction of a modern society.

[In favour of a "new social psychiatry". Current focuses and trends of mental health care dealing between integrative and health economic perspectives]

Starting from modified sociodemographical, medical, familiar and health economical circumstances it is shown that in different areas of psychiatric supply fundamental offerings are missing or need to be established, thus one has to speak about an undersupply of certain groups (migrants, personality disorders, certain elderly patients). Some of these forward-looking trends and possible prospects in the field of social psychiatry are exemplarily displayed. The thesis is argued and illustrated that the existing social psychiatric institutions require a paradigmatic reorientation, which could be called "New Social psychiatry" and should complement the traditional social psychiatry, which has been orientated to schizophrenic illness, extramural alignment and the rehabilitation purpose of employment up to now.

[Social psychiatry in the field of contrasting context between psychiatry and Social Medicine]

OBJECTIVE

There has been a discussion going on that Social Psychiatry has entered a state of crisis in terms of its socio-scientific roots. Little is known, however, about its relationship to Social Medicine. The question is whether Social Psychiatry, having grown apart from Sociology, has also lost its scientific relation to Social Medicine.

METHOD

A systematic literature analysis of all works published in "Psychiatrische Praxis" - PP and "Das Gesundheitswesen"--GHW in the years 2004/2005 was done. All works concerning Social Psychiatry were analysed. The same procedure was applied to all abstracts, posters and presentations for the annual meetings of the German Society of Social Medicine and Prevention (DGSMP).

RESULTS

10 % off all articles published in GHW and 97 % in PP address issues of Social Psychiatry. Apart from similarities in terms of their theoretical, practical and institutional background and the research methods applied, there are a number of differences.

CONCLUSIONS

Social Psychiatry has not lost its scientific relation to Social Medicine, however, the scientific cooperation between the two needs to be intensified.

How did social medicine evolve, and where is it heading?

A better understanding of how social medicine evolved, says Porter, could help to focus its role in responding to the health needs of a post-industrial, globalizing world.

The shifting locus of risk-reduction: the critical role of HIV infected individuals

This article discusses the shifting locus of control over risk-reduction and examines its implications for the care and support of HIV-positive individuals. We begin by presenting a brief history of the continuum of HIV related risk, illustrating the ways in which advances in risk-assessment and intervention have led to this important shift. Second, we discuss the current state of risk assessment and intervention as it relates to three factors: (a) the point along the continuum of risk at which risk assessment and intervention occurs; (b) the locus of control over risk reduction; and (c) the distinction between primary and secondary risk reduction efforts. Finally, we discuss the meaning of HIV risk and the role of HIV-positive individuals in the new geometry of care that integrates treatment and prevention. How is HIV-risk defined and understood? Who is of risk to whom&#63 Who is responsible for reducing risk&#63.

Sozialmedizinische Aufgaben des ÖGD

Although the German public health service is mainly concerned with social medical tasks there is too little awareness of the fact that social medicine forms the scientific basis of most actions. As a matter of fact social medicine in public health departments is often reduced to mere medical insurance and expert reports. This is mainly due to the historical development of social medicine in Germany. Among the numerous important social medical tasks of the public health service, this article mainly concentrates on local coordination, health promotion, health care, and social compensation, including subsidiary medical care of certain groups of the population and aspects of infectious disease control with particular attention to measures against AIDS. The further development of both the public health service and social medicine requires a closer cooperation between them.

[Strategic controlling in the consideration of social demographic changes in social medical services]

Annually the Medizinische Dienst der Krankenversicherung Westfalen-Lippe (MDK-WL) performs approximately 120,000 nursing care assessments according to the 11th social statute book (SGB XI). A prospective reflection on the amount of expert assessments and the spectrum of services for the Nursing Care Insurance until 2020, was performed in order to establish a long term strategic controlling. The insured party makes the request for nursing care according to their personal estimation when the need for assistance is increasing. To predict the future amount of expert assessments you have to take into consideration the social background of the families in addition to age and gender (there is a clear correlation between age and the need of assistance). The database from nursing care assessments in 2001 was projected on a demographic model for the region of Westfalen-Lippe. The amount of requests correlates as expected with the patients age and increases exponentially. The incidence in the need of care shows relevant gender differences, but taken into consideration the very different age structure, the overall incidence is very similar. Against the background of the current nursing care law, the MDK-WL has to deal with an annual increase in assessments of 2 %. The requests for single persons are extremely often without foundation (55 % not substantially in need of care vs. 35 %). Looking at the requests of couples, it shows that the ones for women are more often unfounded then the ones for men (39 % vs. 32 %). It is necessary to take the development of the amount of single living persons into consideration to achieve more accurate predictions for the amount of assessments.

[Health, social, societal and organizational political effects of the implementation of the ICF on integrated rehabilitation--a vision of the conversion and its consequences]

Fundamental joint principles on expert opinions according to the social law code no. IX (SGB IX) and their application to a virtual individual case history were published recently in this journal. They are based on the ICF (International Classification of Functioning, Disability and Health, WHO 2001). A visionary review of the chances and prospects for the further development of the rehabilitative system is outlined and the necessary steps for their implementation are demonstrated.

[Psychosocial and psychosomatic medicine as well as psychotherapy in Switzerland -- developments over the past fifty years]

The development of psychosocial and psychosomatic medicine in Switzerland is as diverse as the country itself with its four official languages and 26 cantons. Psychosomatic medicine of the past and present can be seen in three phases: Psychogenesis of somatic diseases ( phase 1: from about 1930-1960), bio-psycho-social medicine (phase 2: from 1960-1990) and psychobiology in medicine (phase 3: since 1990). In Switzerland the first phase scarcely noticeable, whereas active development in all fields of psychosomatic medicine and psychotherapy has taken place since 1960. The main tendencies of this development are described. The current situation for patients with psychosomatic and somatopsychic disorders is quite good in the outpatient setting. For inpatient treatment there are only about 400 beds in 19 small departments for the whole country. The strengths of the psychosomatic service system are well-established cooperation of doctors and psychotherapists and only few reactions by health insurance companies. Weaknesses are too few inpatient treatment facilities with long waiting times for patients and a lack of specialized treatment for migrants with psychosomatic disorders. Future prospects are not rosy due to the financial situation in the healthcare system, but neither are they bleak, since patients are emphatically asking for more narrative-based medicine and a partnership-based doctor-patient relationship.

A social-medical approach to violence in Colombia

Violence is the main public health problem in Colombia. Many theoretical and methodological approaches to solving this problem have been attempted from different disciplines. My past work has focused on homicide violence from the perspective of social medicine. In this article I present the main conceptual and methodological aspects and the chief findings of my research over the past 15 years. Findings include a quantitative description of the current situation and the introduction of the category of explanatory contexts as a contribution to the study of Colombian violence. The complexity and severity of this problem demand greater theoretical discussion, more plans for action and a faster transition between the two. Social medicine may make a growing contribution to this field.

[Social pharmacology: a new topic in clinical pharmacology]

Social Pharmacology, a new field in Clinical Pharmacology, describes the relationships between Society and Drugs. Topics of Social Pharmacology are first, the social consequences of populations' exposure to drugs and, secondly, the social factors explaining drug use behind clinical or rational explanations. Social Pharmacology also investigates the reasons for prescription, delivery, consumption and self-medication of drugs (behind clinical or rational factors). The paper discusses the role of the different players of Social Pharmacology in the field of drug development, evaluation, prescription and consumption. For example, the pharmaceutical industry should play an important role in the discovery of new medically and socially "desirable" drugs. Drug companies are also involved in this field for drug information to doctors but also patients. Regulatory agencies are concerned by social factors involved in drug approval, regulation of the maximal level of drug use, application and transferability of clinical trials to daily clinical practice. Social Pharmacologists also investigate the factors (others than clinical or rational) regulating drug use. Drug consumption varies according to social characteristics of physicians (sub-speciality, medical education, cultural origin, etc) or patients (gender, age, education, country, kind of work, social status etc). Relationships between drugs and religion make up a large chapter of Social Pharmacology. Other topics in Social Pharmacology involving other health professionals (pharmacists), lawyers and the media are also discussed. Finally, drugs should be considered as important social markers of population behaviour. The role of the Social Pharmacologist is to identify these social and irrational factors governing drug use in order to adapt and rationalize drug utilization in daily clinical practice.

[Psychosocial medicine--a vision needed in medical education and patient care]

Psychosocial medicine represents the psychosocial aspects in a holistic patient-orientated medicine. It is of great importance in medical education as well as in clinical in- and out-patient treatment. For the near future, further strengthening is necessary in order to prevent the psychosocial aspects from disappearing in medicine. The efficacy and effectiveness of psychosocial therapies need to be further improved.

[Perspectives of public health as a system of knowledge and practice]

For at least 200 years we have experienced extension of the public health scope as an organized activity in favour of human population. It is stimulated by civilization progress and changes in the condition of social life, development of medical knowledge, as well as emerging new hazards and social needs. Within the interest of public health there are various tasks: health status monitoring, identification of hazards and the resulting health risks, setting environmental standards and their surveillance, health education and health promotion, special preventive programs etc. As systems of health care develop, covering the whole population, some quite new tasks are added. They are related to effective and accessible care through better management and rational use of available resources. A question arises to what extent the public health meets these challenges. According to some views the system of public health has been in deep crisis or at least far reaching disarray. Undoubtedly, various measures for improvement of the situation are needed. In Poland, one of the main appropriate measures in this regard is education which will enable building up professional staff in the area of public health.

[Epidemiology, social medicine, environmental medicine--a plea for a difficult but necessary integration]

The origins of environmental medicine date back more than 2000 years. The increasing incidence of environmental disease together with successful research into their etiology and pathogenesis have caused an impetus for this discipline in quantitative terms. A growing interest of patients, but also of politicians and parts of the industry in actual or suspected environmental risk factors for health have given rise to controversies--rendering the development of a rational, quality-oriented environmental medicine difficult, if not impossible. Given these controversies surrounding environmental health issues formal demarcations between the traditional disciplines (environmental) epidemiology, social medicine, occupational medicine, and environmental medicine become obsolete. Instead, a common agenda with respect to research, quality assurance, risk communication, and prevention as well as patient counselling and policy advising calls for a conceptual and institutional integration of these disciplines.

[Necessary and desirable future emphasis in social medicine from the theoretical viewpoint]

Social medicine, like medicine as a whole, is based on biomedical science and has responsibilities in clinical care, at the same time linking the health system, an important element in the welfare state, to society. Social medicine investigates and expands the scientific basis for securing and promoting health by way of social action, sharing common roots with public health. In the biomedical sphere, emphasis is on improving our understanding of the biological foundations of social behaviour; scanning and assessing the ethical, legal, economical and social implications of scientific progress; influencing the social and economic effects of demographic developments, and improving the scientific basis of preventive, styles of living and interventions. In the clinical sphere, the main objectives are to expand such areas as clinical epidemiology and clinical health economics, to assert patients' rights and to promote population-related medicine in the training of doctors. As far as the health care system is concerned, emphasis is on restoring the solidarity concept between the healthy and the sick as the principle of statutory health insurance, and on securing transparency of performance, quality, and cost. A further objective is to encourage more creative management by the health insurance funds by granting freedom of contract. Open public discussion about the rationale of an ethical health care system is required, discussion in which independent experts trained in population-related medicine must play an active part.

[The future of social medicine from the practical viewpoint]

Within the German statutory health care system the practice of sociomedicine as an applied health science is mainly related to individual aspects of theinsured persons. Combining factors due to medical and socio-economical developments it plays an important integrative role as so to say a lawyer of the patients. Furthermore, practical sociomedicine must provide consultant services to support the social insurance in the sphere of shaping the health care system. Profound knowledge on the required level must be acquired by graduate studies and can be deepened by well-planned continuing medical education. Professionalism in providing services and fulfillment of legal obligations can be achieved by standardisation of social medical procedures, scientific orientation towards public health aspects, appropriate methods of delivering medical knowledge, use of information systems, refinement of co-operation, quality management, social medical controlling, application of modern planning and control concepts as well as model leadership.

[Social medicine in social work--a key for improving health-related social work]

The relation between social work and social medicine is the subject of this article. Social work is an independent discipline creating its own knowledge in scientific cooperation with other disciplines. Social Medicine is outlined with its special features as a field and as a medical discipline. The traditional relation between social work and the discipline of Social Medicine operates side by side. Since Social Medicine and social work refer to each other, new perspectives for the development of health-related social work arise. Social Medicine appeared in social work can help in elaborating a sociogenetic model of understanding health and illness as well as the development of sociotherapy in social work. Health-related social work will gain more significance in the treatment of health-related and disease-related questions.

[Welfare and health in the century of social security]

Great achievements for public health in this century include penicillin, oral contraception, vaccination and transplantation, but the greatest contribution to the health of Norwegians may have been made by social security and the welfare state policies. The beneficial effects of social security include: less social inequality, a factor which in itself makes for better health, some degree of financial security for people who are ill and unable to support themselves or their families, universal availability of medical and health services. This paper explores the ideas and sources from which present-day social security legislation stems. The emergence of state based welfare legislation was inspired by developments in Germany under Bismarck; accident insurance for industrial workers was the first to be introduced in 1894. Several periods of active social security legislation followed at times when labour unions and socialist ideas were strong, supported, to some degree, by radical clergy and public health doctors. Social democratic governments, inspired by the British Beveridge plan towards the end of World War II, took the lead during the long post-war period until the mid 1970s. The Scandinavian model of social security is based on universal coverage and a single payer system. However, since the 1980s, as in other countries of Northern Europe, the social security system has come under pressure from market liberalism. Now at the turn of the century, increasing social inequalities cause some concern for the future of the welfare state.

[Realm and goals of social epidemiology. A contribution to determining current status in relation to German language discussion]

A first approach to the word "social epidemiology" is provided by the two components social and epidemiology. They suggest that the social dimension of the distribution of morbidity and mortality should be analysed by means of epidemiological methods. The interest in this topic has risen considerably in recent years, but it is difficult to exactly specify the questions "social-epidemiologists" are analysing or should be analysing. That is why the "Social Epidemiology Working Group" is now reviewing the state of the art of social epidemiology discussions in the German-speaking countries. The overview shows the broad spectrum of social epidemiology topics, but also the difficulties in providing a clear definition. In a brief description of the Anglo-American discussion it is pointed out that social epidemiology have to deal with similar problems there, and that they classify their work as epidemiology rather than social epidemiology. The paper concludes with recommendations by the Working Group concerning the main topics and objectives of current socio-epidemiological research.