Nineteenth-century medical advances were entwined with a conceptual innovation: the idea that many cases of disease which were previously thought to have diverse causes could be explained by the action of a single kind of cause, for example a certain bacterial or parasitic infestation. The focus of modern epidemiology, however, is on chronic non-communicable diseases, which frequently do not seem to be attributable to any single causal factor. This paper is an effort to resolve the resulting tension. The (...) paper criticises the monocausal model of disease, so successful in the nineteenth century. It also argues that a multifactorial model of disease can only be satisfactory if it amounts to more than a mere rejection of the monocausal model. A third alternative, the contrastive model, is proposed and defended on the grounds that it links the notions of disease and of general explanation, while avoiding the philosophical naiveties and practical difficulties of the monocausal model. (shrink)

DISEASE X is the codename given by the World Health Organisation to a pathogen currently unknown to science that could cause havoc to humankind. Emerging infections are sending us multiple warnings that another Disease X is looming. We've had SARS in 2002, H5N1 bird flu in 2004, H1N1 'swine flu' in 2009, MERS in 2012, Ebola in 2014, Zika in 2015 and now COVID-19. These events are not freak events, but are happening continually, and at an increasing cadence. Written by (...) a long-standing ex-Reuters global health and science correspondent, DISEASE X will use privileged access to the body leading international efforts to control viruses, the Coalition for Epidemic Preparedness Innovations (CEPI), and its CEO, Dr Richard Hatchett. CEPI seed-funded three successful COVID vaccines, including Astra-Zeneca and Moderna. DISEASE X will explore the emergence of the novel coronavirus and the crisis it caused, analysing the responses of global health organisations and experts, including the WHO, national governments such as Britain, China and the USA, COVAX, the global vaccine allocation facility, pharmaceutical companies, and leading research scientists. Weaving in insights from the likes of Bill Gates, Sir Jeremy Farrar, Dr Anthony Fauci and Sir Patrick Vallance, the book will explain how the world's public health scientists are embarking on a 100 Days Mission to snuff out future threats before they become deadly pandemics. This is the inside story written for the public. (shrink)

The primary claim of this paper is that COVID-19 stigma must be understood as a structural phenomenon. Doing so will inform the interventions we select and prioritize for the amelioration of such stigma. Thinking about stigma as a macrosocial determinant of health driven by structural factors suggests that downstream remedies are unlikely to be effective in significantly reducing stigma. This paper develops and defends this claim, setting up a recommendation to use a “bundle” of legal and policy levers at meso- (...) and macro- levels to reduce the adverse and inequitable impact of COVID-19 stigma.Historians of public health have long pointed out that outbreaks of communicable disease track social fault lines (Rosenberg... (shrink)

In this view from 2007–2009, the ethical challenges facing a potential global effort to control infectious disease are explored; they provide sobering insight into the challenges of later decades. Despite the devastating pandemic of HIV/AIDS that erupted in the early 1980s, despite the failure to eradicate polio and the emergence of resistant forms of tuberculosis that came into focus in the 1990s, and despite newly emerging diseases like Severe Acute Respiratory Syndrome (SARS) in 2003 and the fearsome prospect of (...) human-to-human avian flu, it is nevertheless a time of some excitement over prospects for effective control of much of infectious disease. Funded by national and international governmental and nongovernmental organizations (NGOs), private foundations, and even popular entertainers, large-scale new efforts are under way to address global killers like AIDS, tuberculosis, and malaria, among others. This “marvelous momentum” can be seen as part of a continuing effort from the time of Jenner onward. Extrapolating from this, we explore the notion of a “comprehensive global effort for the eradication, elimination or control of infectious disease”, with particular attention to the ethical issues that arise. This is to “think big” about disease-control efforts that are now often done in piecemeal ways. This chapter identifies five tracks along which such efforts need to be pursued: (1) national and international organizations and the development of collective will; (2) epidemiological and health care infrastructure; (3) scientific development; (4) religious, social, and cultural considerations; (5) legal and social protections for individuals and groups. Each of these poses significant ethical issues which, we argue, should be viewed in a comprehensive way, to ensure that practice, research, and policy in each of these areas understands the person with communicable infectious disease as both victim and (potential) vector. (shrink)

In the foundational piece in this issue of the journal, “Integrating Law and Social Epidemiology,” Burris, Kawachi, and Sarat present a model for understanding the relationship between law and health. This article uses the case of a specific health condition, the human immunodeficiency virus infection, as an opportunity to flesh out this schema and to test how the model “fits” the world of the HIV pandemic. In applying the model to this communicable disease, we hope to illustrate the multitude (...) of ways that laws affect the course of the pandemic as well as the course of an individual’s vulnerability or resilience to the disease, and how the complexities of an individual’s life dealing with the virus interface with the world of laws and legal institutions. (shrink)

In the foundational piece in this issue of the journal, “Integrating Law and Social Epidemiology,” Burris, Kawachi, and Sarat present a model for understanding the relationship between law and health. This article uses the case of a specific health condition, the human immunodeficiency virus infection, as an opportunity to flesh out this schema and to test how the model “fits” the world of the HIV pandemic. In applying the model to this communicable disease, we hope to illustrate the multitude (...) of ways that laws affect the course of the pandemic as well as the course of an individual’s vulnerability or resilience to the disease, and how the complexities of an individual’s life dealing with the virus interface with the world of laws and legal institutions. (shrink)

Infectious diseases figure prominently as (counter)examples in debates on how to conceptualize “disease.” But crucial epidemiological distinctions are often not heeded in the debate, and pathological and clinical perspectives focusing on individual patients are favored at the expense of perspectives from epidemiology focusing on populations. In clarifying epidemiological concepts, this paper highlights the distinct contributions infectious disease epidemiology can make to the conception of “disease,” and the fact that this is at least tacitly recognized by medical personnel and philosophers. (...) Crucially, infectious disease epidemiology can help elucidate how carrying and transmitting infectious, communicable entities is a disease, even if the carriers themselves are not directly affected by symptoms detrimental to them. (shrink)

In this paper, I utilise the tools of analytic philosophy to amalgamate mono-causal and multi-causal theories of disease. My aim is to better integrate viral and socio-economic explanations of AIDS in particular, and to consider how the perceived divide between mono-causal and multi-causal theories played a role in the tragedy of AIDS denialism in South Africa in the early 2000s. Currently, there is conceptual ambiguity surrounding the relationship between mono-causal and multi-causal theories in biomedicine and epidemiology. Mono-causal theories focus on (...) single, typically microbial, sources of illness and are most concerned with infectious diseases. By contrast, multi-causal theories allow for multiple factors to underpin a disease’s aetiology, including socio-economic and behavioural factors, and they usually focus on chronic non-communicable diseases. However, if these theories are taken to be strictly distinct, this prevents the inclusion of both microbial and socio-economic factors in a single explanation of any particular disease. This strict distinction became a problem when trying to explain the disproportionate prevalence of AIDS in southern Africa and ultimately contributed to the tragedy of AIDS denialism in South Africa. In tandem with viewing how the perceived divide between multi-causal and mono-causal theories underpinned AIDS denialism, I examine Thabo Mbeki’s specific role, while acknowledging that AIDS is being deprioritised on a broader international level. Overall, I will demonstrate that any long-term plan to eliminate AIDS will require viral and socio-economic factors to be considered simultaneously and that such a theoretical approach requires a clearer understanding of the underlying concepts of disease aetiology. (shrink)

Surveillance is essential for communicable disease prevention and control. Traditional notification of demographic and clinical information, about individuals with selected infectious diseases, allows appropriate public health action and is protected by public health and privacy legislation, but is slow and insensitive. Big data–based electronic surveillance, by commercial bodies and government agencies, which draws on a plethora of internet- and mobile device–based sources, has been widely accepted, if not universally welcomed. Similar anonymous digital sources also contain syndromic information, which (...) can be analysed, using customised algorithms, to rapidly predict infectious disease outbreaks, but the data are nonspecific and predictions sometimes misleading. However, public health authorities could use these online sources, in combination with de-identified personal health data, to provide more accurate and earlier warning of infectious disease events—including exotic or emerging infections—even before the cause is confirmed, and allow more timely public health intervention. Achieving optimal benefits would require access to selected data from personal electronic health and laboratory records and the potential to re-identify individuals found to be involved in outbreaks, to ensure appropriate care and infection control. Despite existing widespread digital surveillance and major potential community benefits of extending its use to communicable disease control, there is considerable public disquiet about allowing public health authorities access to personal health data. Informed public discussion, greater transparency and an ethical framework will be essential to build public trust in the use of new technology for communicable disease control. (shrink)

Non-communicable diseases are no longer largely limited to high-income countries and the elderly. The burden of non-communicable diseases is rising across all country income categories, in part because these diseases have been relatively overlooked on the global health agenda. Historically, communicable diseases have been prioritized in many countries as they were perceived to constitute the greatest disease burden, especially among vulnerable and poor populations, and strategies for prevention and treatment, which had been successful (...) in high-income settings, were considered feasible and often affordable in low-income settings. This prioritization has reduced the communicable diseases burden globally but has left non-communicable diseases largely neglected. A new approach is urgently needed to tackle non-communicable diseases. Based on an analysis of potential features which may have underlain the different approaches to non-communicable diseases and communicable diseases until now, including acuity of disease, potential for control or cure, cost, infectiousness, blaming of individuals and logistical barriers, little ethical or rational justification can be found to support continued neglect of non-communicable diseases. Justice demands access to quality and affordable care for all. An equitable approach to non-communicable diseases is therefore strongly mandated on medical, ethical, economic, and public health grounds. Funding must not however be diverted away from communicable diseases, which continue to require attention—but concomitantly, funding for non-communicable diseases must be increased. International and multi-sectoral action is required to accelerate progress towards true universal health coverage and towards achievement of all of the sustainable development goals, such that prevention and access to care for non-communicable disease can become a global reality. (shrink)

Mandeville and colleagues describe a fascinating case where Facebook was used to warn potential contacts that their acquaintance had a communicable disease (Mandeville et al., 2013). They are correct that this case raises important issues about social media, confidentiality and the prevention of harm. However, they underestimate both the dangers of overcommunication via Wall and Timeline postings (and Twitter) and the potential utility of Facebook in cases like this one. Increased awareness of Facebook functionality will allow more accurate targeting (...) of those at risk of infection, while also protecting the confidentiality of the index case. (shrink)

Background Outbreaks of infectious disease cause serious and costly health and social problems. Two new technologies – pathogen whole genome sequencing and Big Data analytics – promise to improve our capacity to detect and control outbreaks earlier, saving lives and resources. However, routinely using these technologies to capture more detailed and specific personal information could be perceived as intrusive and a threat to privacy. Method Four community juries were convened in two demographically different Sydney municipalities and two regional cities in (...) New South Wales, Australia to elicit the views of well-informed community members on the acceptability and legitimacy of: making pathogen WGS and linked administrative data available for public health researchusing this information in concert with data linkage and machine learning to enhance communicable disease surveillance systems Fifty participants of diverse backgrounds, mixed genders and ages were recruited by random-digit-dialling and topic-blinded social-media advertising. Each jury was presented with balanced factual evidence supporting different expert perspectives on the potential benefits and costs of technologically enhanced public health research and communicable disease surveillance and given the opportunity to question experts. Results Almost all jurors supported data linkage and WGS on routinely collected patient isolates for the purposes of public health research, provided standard de-identification practices were applied. However, allowing this information to be operationalised as a syndromic surveillance system was highly contentious with three juries voting in favour, and one against by narrow margins. For those in favour, support depended on several conditions related to system oversight and security being met. Those against were concerned about loss of privacy and did not trust Australian governments to run secure and effective systems. Conclusions Participants across all four events strongly supported the introduction of data linkage and pathogenomics to public health research under current research governance structures. Combining pathogen WGS with event-based data surveillance systems, however, is likely to be controversial because of a lack of public trust, even when the potential public health benefits are clear. Any suggestion of private sector involvement or commercialisation of WGS or surveillance data was unanimously rejected. (shrink)

Non-communicable diseases disproportionately affect low and middle-income countries where nearly three quarters of NCD deaths occur. Bangladesh is also in NCD burden. This cross-sectional study was done on 50 health facilities centres at Gazipur district in Bangladesh from July 2015 to December 2015 to introduce SARA for better monitoring and evaluation of non-communicable diseases health service delivery. The General Service readiness index score was 61.52% refers to the fact that about 62% of all the facilities were (...) ready to provide general services like basic amenities, basic equipment, standard precautions for infection prevention, and diagnostic capacity and essential medicines to the patients. But in case of non-communicable diseases, among all the health facilities 40% had chronic respiratory disease and cardiovascular diseases diagnosis/ management and only 32% had availability of diabetes diagnosis/management. Overall readiness score was 52% in chronic respiratory disease, 73% in cardiovascular disease and 70% in diabetes. Therefore, service availability and readiness of the health facilities to provide NCD related health services were not up to the mark for facing future targets. A full-scale census survey of all the facilities of the study area would give a better understanding of the availability and service readiness. (shrink)

Communicable diseases, especially those that are highly contagious, are on the rise and each of us, no matter who we are or where we live, is equally at risk of transmitting contagious diseases to others as we are of contracting such diseases from others. Because contagious diseases are as readily passed state-to-state as person-to-person, we all have a stake in every country's ability to enact effective infectious disease control policies, while policies grounded in shared values (...) are more likely to gain widespread acceptance and thereby prove most effective. This paper suggests that principlism proved invaluable as an ethical framework for resolving hard medical cases and setting health care policy because it nicely “fits” dilemmas that arise in the context of the special relationship between doctors and patients or within family units. It then argues that communitarianism provides the better foundation for crafting infectious diseases control policies because contagious diseases, which often pass between perfect strangers, raise questions about the moral obligations we owe to (or are entitled to demand of) people with whom we share no “special” relationship. Accordingly, a socially embedded framework such as communitarianism may be a better fit for the more socially embedded ethical dilemmas of communicable diseases. (shrink)

Social media applications such as Twitter, YouTube and Facebook have attained huge popularity, with more than three billion people and organizations predicted to have a social networking account by 2015. Social media offers a rapid avenue of communication with the public and has potential benefits for communicable disease control and surveillance. However, its application in everyday public health practice raises a number of important issues around confidentiality and autonomy. We report here a case from local level health protection where (...) the friend of an individual with meningococcal septicaemia used a social networking site to notify potential contacts. (shrink)

Communicable diseases, especially those that are readily contagious, are on the rise as evidenced by the emergence of viruses like severe acute respiratory syndrome, the global resurgence of resistant forms of ancient mycobacteria such as extensively drug resistant tuberculosis, and the 2009 swine flu outbreak in Mexico. Moreover, each of us, no matter who we are or where we live, is just as likely to transmit contagious diseases to others as we are to contract such diseases (...) from others. As cogently described in the title of a recent book by Margaret Battin et al., we are all potential “victims and vectors.”Just as contagious diseases are readily passed person to person, so too can they readily be passed across local and national boundaries. We therefore all have a stake in the development of effective infectious disease control policies on a national scale, with “effective” being the operative term: regulations and statutes that are neither enforceable nor likely to be complied with may do more harm than good. (shrink)

Managing non-communicable diseases in crisis-affected and fragile humanitarian contexts requires special attention because primary health care systems often collapse or become compromised in such settings. As a result, addressing and managing these diseases become more challenging. Humanitarian organizations that intervene in crisis situations are increasingly including NCD management in the services they support and provide; however, they encounter a range of issues such as ensuring the quality of care, sustainability of programs, and the possibility of unintended harms. (...) This case study explores ethical considerations raised by a mobile NCD program run by an international humanitarian organization in a country affected by a protracted civil war. (shrink)

Increases in international travel and migratory flows have enabled infectious diseases to emerge and spread more rapidly than ever before. Hence, it is increasingly easy for local infectious diseases to become global infectious diseases (GIDs). National governments must be able to react quickly and effectively to GIDs, whether naturally occurring or intentionally instigated by bioterrorism. According to the World Health Organisation, global partnerships are necessary to gather the most up-to-date information and to mobilize resources to tackle GIDs (...) when necessary. Communicable disease control also depends upon national public health laws and policies. The containment of an infectious disease typically involves detection, notification, quarantine and isolation of actual or suspected cases; the protection and monitoring of those not infected; and possibly even treatment. Some measures are clearly contentious and raise conflicts between individual and societal interests. In Europe national policies against infectious diseases are very heterogeneous. Some countries have a more communitarian approach to public health ethics, in which the interests of individual and society are more closely intertwined and interdependent, while others take a more liberal approach and give priority to individual freedoms in communicable disease control. This paper provides an overview of the different policies around communicable disease control that exist across a select number of countries across Europe. It then proposes ethical arguments to be considered in the making of public health laws, mostly concerning their effectiveness for public health protection. (shrink)

The need to protect the public against the spread of communicable disease provides a good example of the need for a commonsense approach to the use of confidential data. Laboratories need to notify different professionals in order to trace the sources of outbreaks of infection and eradicate the cause. It is often not possible to obtain consent from individual patients, given the rapid time scale required. In doing so, however, laboratory staff and others would contravene the Data Protection Act (...) in passing on information without consent. Section 60 of the Health and Social Care Act was designed to overcome barriers to research relying on data accumulated in the past and this type of public health work. But this is proving a sluggish procedure. It is an awkward solution to the problem of data use without specific consent. This problem will be overcome only when the public can have sufficient trust in safeguards that are in place to protect their safety and confidentiality so that these important activities can be pursued without specific informed consent. (shrink)

Obesity has been described as pandemic and a public health crisis. It has been argued that concerted research efforts are needed to enhance our understanding and develop effective interventions for the complex and multiple dimensions of the health challenges posed by obesity. This would provide a secure evidence base in order to justify clinical interventions and public policy. This paper critically examines these claims through the examination of models of public health and public health ethics. I argue that the concept (...) of an effective public health intervention is unclear and underdeveloped and, as a consequence, normative frameworks reliant on meeting the effectiveness criterion may miss morally salient dimensions of the problems. I conclude by arguing for the need to consider both an ecological model of public health and inclusion of a critical public health ethics perspective for an adequate account of the public health challenges posed by obesity. (shrink)

This paper considers how we can conceptualize a “global response” to chronic, non-communicable diseases (NCDs) – including cardiovascular disease, cancer, diabetes, and tobacco-related diseases. These diseases are the leading cause of death and disability in developed countries, and also in developing countries outside sub-Saharan Africa. The paper reviews emerging and proposed initiatives for global NCD governance, explains why NCDs merit a global response, and the ways in which global initiatives ultimately benefit national health outcomes. As the (...) global response to NCDs matures, and the number of initiatives and partnerships increases, it will become increasingly important to map their respective contributions, and to evaluate progress overall. It is not yet clear what institutional mechanism, if any, will rise above the sea of surrounding initiatives to play this global role. This paper therefore aims to provide a conceptual map for making sense of what individual initiatives contribute to global governance. This map also draws attention to the distinctively “global” public health functions that a global response to NCDs should seek to discharge. (shrink)

Judging by their contribution to the global burden of death and disability, chronic, non-communicable diseases are the most serious health challenge facing the world today. The statistics tell a frightening story. Over 35 million people died from chronic diseases in 2005 — principally cardiovascular disease, cancer, and chronic respiratory disease. Driven by population growth and population ageing, deaths from non-communicable diseases are expected to increase by 17% over the period 2005-2015, accounting for 69% of global (...) deaths by 2030.Cardiovascular disease, the leading cause of death in all regions except sub-Saharan Africa, is estimated to rise from 17.1 million deaths to 23.4 million deaths. Cancer deaths will increase from 7.4 million to 11.8 million over the same period. Due to population growth, mergers and acquisitions, and the marketing of global cigarette brands in developing countries, deaths from tobacco will rise from 5.4 million per year, through 6.4 million, to 8.3 million by 2030. These figures include a doubling in tobacco deaths in low- and middle-income countries from 3.4 million to 6.8 million lives annually. By 2015, smoking will cause 50% more deaths than HIV/AIDS. (shrink)

ABSTRACT Because of the nature of preventive vaccination programs, the viability of these public health interventions is particularly susceptible to public perceptions. This is because vaccination relies on a concept of ‘herd immunity’, achievement of which requires rational public behavior that can only be obtained through full and accurate communication about risks and benefits. This paper describes how irrational behavior that threatens the effectiveness of vaccination programs – both in crisis and non‐crisis situations – can be tied to public perceptions (...) created by media portrayals of health risks. I concentrate on childhood vaccination as an exemplar of ‘non‐crisis’ preventive vaccination, and on the recent flu vaccine shortage as a ‘crisis’ situation. The paper concludes with an examination of the steps necessary to resolve these threats through better public communication. (shrink)

Because of the nature of preventive vaccination programs, the viability of these public health interventions is particularly susceptible to public perceptions. This is because vaccination relies on a concept of ‘herd immunity’, achievement of which requires rational public behavior that can only be obtained through full and accurate communication about risks and benefits. This paper describes how irrational behavior that threatens the effectiveness of vaccination programs – both in crisis and non-crisis situations – can be tied to public perceptions created (...) by media portrayals of health risks. I concentrate on childhood vaccination as an exemplar of ‘non-crisis’ preventive vaccination, and on the recent flu vaccine shortage as a ‘crisis’ situation. The paper concludes with an examination of the steps necessary to resolve these threats through better public communication. (shrink)

Epidemiological crisis during recrudescence of pandemic like COVID-19 may stir fear and anxiety leading to prejudices against people and communities, social isolation and stigma. Such behavioral change may wind up into increased hostility, chaos and unnecessary social disruptions. A qualitative exploratory approach was utilized to conduct an extensive review of secondary literature. The case-studies were gathered from academic literature like articles, opinions and perspective pieces published in journals and in grey literature like publications in humanitarian agencies and media reports. Grey (...) literature was included in the scope as the COVID-19 situation is still evolving. I discuss some of the mechanisms of stigmatization and how social connectedness and empathetic understandings can be a way out of negative stereotyping and discrimination met out to the sufferer of the communicable diseases as COVID-19. Empathetic understanding paves a way to approach a problem from the perspective of ‘we’ not limiting one only to ‘I’. The moment when we make an approach from ‘I’ to ‘We’ actually then we embark on a journey of illness to wellness. Keywords: COVID-19, pandemic, stigma, discrimination, mental health, empathy, India, Face-to-face communication, social distancing, suicide. (shrink)

Christopher Boorse’s bio-statistical theory of health and disease argues that the central discipline on which theoretical medicine relies is physiology. His theory has been much discussed but little has been said about its focus on physiology or, conversely, about the role that other biomedical disciplines may play in establishing a theoretical concept of health. Since at least the 1950s, epidemiology has gained in strength and legitimacy as an independent medical science that contributes to our knowledge of health and disease. Indeed, (...) it not only provides important information about disease distribution and aetiology, but the risk-factor approach it employs seems to challenge BST’s binary conception of health and disease. The objective of the article is to show, firstly, how important information deriving from descriptive and analytical epidemiology forms part of our contemporary medical concepts of health and disease, and secondly, that these elements are not taken into account by BST in a satisfactory way. The article’s central contention, therefore, is that if the project of defining the theoretical concept of health is to be maintained, more importance should be accorded to the contribution made by epidemiology—alongside physiology—in defining health. (shrink)

The available resources for global health assistance are far outstripped by need. In the face of such scarcity, many people endorse a principle according to which highest priority should be given to the worst off. However, in order for this prioritarian principle to be useful for allocation decisions, policy-makers need to know what it means to be badly off. In this article, we outline a conception of disadvantage suitable for identifying the worst off for the purpose of making health resource (...) allocation decisions. According to our total advantage view: the worst off are those who have the greatest total lifetime disadvantage; advantage foregone due to premature death should be treated in the same way as other ways of being disadvantaged at a time; how badly off someone is depends on the actual outcomes that will befall her without intervention, not her prospects at a time; and all significant forms of disadvantage count for determining who is worst off, not just disadvantage relating to health. We conclude by noting two important implications of the total advantage view: first, that those who die young are among the globally worst off, and second, that the epidemiological shift in the global burden of disease from communicable to non-communicable diseases should not lead to a corresponding shift in global health spending priorities. (shrink)

Emerging genomic technologies promise more efficient infectious disease control. Whole genome sequencing is increasingly being used in tuberculosis diagnosis, surveillance, and epidemiology. However, while the use of WGS by public health agencies may raise ethical, legal, and socio-political concerns, these challenges are poorly understood. Between November 2017 and April 2018, we conducted semi-structured interviews with 22 key stakeholders across the fields of governance and policy, public health, and laboratory sciences representing the major jurisdictions currently using WGS in national TB programs. (...) Thematic analysis of the interviews was conducted using NVivo 11. Respondents identified several ethical and practical challenges associated with WGS in TB care and surveillance, all related to issues of trust, including: 1) the power of public health; 2) data sharing and profits derived from surveillance efforts; and 3) concerns regarding who has access to, and can benefit from, the technology. Additional challenges included: the potential utility that WGS adds to a public health program, the risks associated with linking necessary epidemiological metadata to the genomic data, and challenges associated with jurisdictional capacity to implement the technology. Successful implementation of WGS is dependent on fostering relationships of trust between those working with genomics technology and those directly impacted by it, including clinicians. Building trust between the public and the public health agencies and within public health agencies themselves is critical due to the inherent complexity of WGS and its implementation for communicable disease control purposes. (shrink)

Photo ID 72893750 © Rawpixelimages|Dreamstime.com ABSTRACT Solidarity is a concept increasingly employed in bioethics whose application merits further clarity and explanation. Given how vital cooperation and community-level care are to mitigating communicable disease transmission, we use lessons from the COVID-19 pandemic to reveal how solidarity is a useful descriptive and analytical tool for public health scholars, practitioners, and policymakers. Drawing upon an influential framework of solidarity that highlights how solidarity arises from the ground up, we reveal how structural forces (...) can impact the cultivation of solidarity from the top down, particularly through ensuring robust access to important social determinants of health. Public health institutions can support solidarity movements among individuals and communities by adopting a lens of social justice when considering public health priorities and, in turn, promote health equity. INTRODUCTION Over the past two decades, scholars have invoked the concept of solidarity when assessing a wide range of topics in bioethics, from CRISPR-Cas9 technology to organ donation to structural racism.[1] However, the growing literature on solidarity has not fully examined the roles and responsibilities of institutions and governments in fostering solidarity, especially regarding public health measures that implicate entire populations. We argue that it remains unclear how public health institutions should engage with solidarity and how their engagement will affect public health and its ethics. We first take Prainsack and Buyx’ three-tiered framework as an analytical starting point.[2] We then explore how public health institutions can foster solidarity by carefully considering factors that may bolster it on an interpersonal, community, and national scale. We conclude that public health institutions should adopt a lens of social justice to promote solidarity at the interpersonal and community levels, thereby promoting equity in future public health efforts. BACKGROUND Calls for solidarity in bioethics raise longstanding normative questions about the nature and limits of our duties to one another and how to weigh autonomy over considerations of justice.[3] Though the term is diversely applied, Prainsack and Buyx propose a potentially unifying definition in the 2011 Nuffield Council report, “Solidarity: Reflections On An Emerging Concept in Bioethics.” The report defines solidarity as an activity involving “shared practices reflecting a collective commitment to carry financial, social, emotional, and or other ‘costs’ to assist others.” Their conceptualization also includes important features that distinguish solidarity from other values like empathy or altruism: solidarity emphasizes action rather than mere internal feeling and recognition of connection as motivation.[4] Bioethicists have since applied this conceptualization when analyzing issues in public and global health, given that population-level efforts need cooperation from individuals and communities. Prainsack and Buyx further note that solidarity is relevant in bioethics discourses about justice and equity, in support of providing aid to low- and middle-income countries, and as a value exemplified by European welfare states.[5] Other bioethicists have argued that promoting solidarity can contribute to community engagement, partnership with Tribal communities, and global health equity.[6] Most recently, scholars have applied solidarity as a lens to assess the COVID-19 pandemic, highlighting the pitfalls of national mitigation efforts and global disparities in disease outcomes.[7] I. Solidarity at Three Levels It seems impossible to foster solidarity in public health if we cannot identify it in general contexts. Prainsack and Buyx articulate three levels of solidarity: interpersonal solidarity, group solidarity, and legal or contractual codifications of solidarity.[8] They argue that each level inherently informs the one ‘above’ it in a unilateral direction. In other words, solidarity is fundamentally a bottom-up phenomenon. Solidarity among individuals influences group norms, which then have the potential to shape policy and institutional practice.[9] Within the Prainsack and Buyx framework, it would seem nonsensical to posit how solidarity might be expressed vertically or from the “top down.” It appears intuitively odd to imagine how a government entity might ‘be’ in solidarity with a person or group if solidarity requires some cognition about their condition per Prainsack and Buyx’ definition. Some have argued that solidarity does not seem like something that one can impose, as instances of it arise from agents recognizing and acting upon some bond rather than in response to a command. Indeed, people may be rightfully hesitant to engage in solidarity if the official messaging is overly paternalistic or coercive.[10] However, some authors have countered that governments can express solidarity through enacting structural and policy changes, though it is ambiguous how these actions are distinct from a justice-driven approach.[11] If a bottom-up approach is thus the most practical means of achieving policy that reflects solidarity, then it does not add much to public health. Institutions would be ineffective without the population’s initiation of the corresponding social norms. However, we find this conclusion overly pessimistic. Fostering a culture of solidarity to improve public health has potential merit. Prainsack and Buyx’ framework overlooks how public health actors can influence solidarity between individuals and across communities. To clarify, we agree with the view that solidarity is a bottom-up phenomenon. Solidarity may not be able to originate in a top-down fashion, but we suggest that public health institutions can take a more active role in providing the public with accurate information, promoting social justice, and intervening in the social determinants of health. II. The COVID-19 Pandemic as a Case Study Lessons learned from the ongoing COVID-19 pandemic support our argument. The pandemic deepened socioeconomic disparities in the US and hindered access to vital resources such as food, housing, and healthcare.[12] Prainsack recently noted: “[n]ext to the immediate health effects of the virus, poverty and grave inequalities have been the root causes of human suffering during the pandemic.”[13] Prior to the pandemic, many rural and low-income populations lacked reliable access to the internet and devices like laptops or smartphones. This continued lack of access restricts the flow of information and prevents people from accessing telemedicine services.[14] Preexisting social, political, and health inequities worsened health outcomes among many marginalized racial and ethnic groups. It is well-documented that communities of color, including Black, American Indian or Alaska Native, and Latinx populations, had greater COVID-related mortality and morbidity due to the effects of structural racism.[15] Although federal US agencies such as the Centers for Disease Control and Prevention enacted laws that provided safety nets (e.g., the Federal Eviction Moratorium), the majority of such programs have ended, leaving many with little assistance and the threat of further hardship.[16] These disparities are relevant because Prainsack, Buyx, and others note that solidarity arises from agents recognizing and acting on some perceived attainable collective goal(s). Income inequality and disparate access to food, education, and health care may lead people to consider public health goals unattainable. This could limit the desire to work toward those goals collectively.[17] The existing literature on collective action theory supports this intuition. It emphasizes that structural conditions, such as an absence of perceived hope for social change among a group, can lead to low ‘group efficacy’ and little willingness to cooperate, both within and across socioeconomic strata.[18] The pandemic spurred countless messages from public health agencies. The messaging did not recognize or attend to the different material realities and circumstances of the US population. How can people feel comfortable getting vaccinated if they deeply distrust the government, including public health institutions? How can people remain motivated to wear masks and distance themselves if they cannot afford basic necessities and work jobs without adequate pay and leave policies? We ask these questions to illustrate how socioeconomic disparities can marginalize people if they feel ignored, apathetic, or resentful of those better off or those in power whom they perceive to “not be doing enough.” This marginalization precludes the formation of solidarity. There are instances when a population has disparate access to resources and social capital, but solidarity may still emerge from a shared goal or vision for the future. For example, a heterogeneous population living in the same town may come together to protest an environmental injustice that impacts their water supply with the common goal of securing access to safe drinking water. However, many populations in the US failed to recognize shared goals of this kind during the COVID-19 pandemic. A significant minority of the US population was reluctant to acknowledge the severity of COVID-19 infection and thus refused to participate in efforts to mitigate its spread. Even between groups who shared the goal of slowing COVID-19 transmission, the methods were widely debated. Approximately 20 percent of the adult population eligible for vaccination remains unvaccinated.[19] Governmental bodies responsible for disseminating information, coordinating the allocation of resources, and establishing guidelines have a large role in mediating these disagreements and intervening in socioeconomic conditions that impact people's ability and willingness to engage in solidarity. III. Solidarity, Social Justice, and the Role of Public Health Institutions Adopting a lens of social justice provides further insights into how public health actors impact solidarity. Powers and Faden argue that the “foundational moral justification for the social institution of public health is social justice.”[20] Their theory of social justice has two aims. First, it ensures that everyone has a sufficient amount of the six core elements of well-being and that public health institutions are responsible for “adopting policies and creating environments” where all can flourish.[21] Second, public health institutions should distribute resources meant to promote well-being and focus on the “needs of those who are the most disadvantaged.”[22] Public health institutions should enact policies that address injustice. In doing so, public health institutions can seed the opportunity to build solidarity from the bottom up. Equipping individuals and communities with resources will foster cooperation and adherence to policies that require solidarity, such as masking and vaccination. This is consistent with arguments illustrating how institutions such as Tribal governments promote the conditions needed for their group, and especially its most vulnerable members, to flourish.[23] Addressing social determinants of health with a social justice lens will create the circumstances under which more individuals and groups can find common causes and foster solidarity. In the long run, such efforts may result in the establishment of values and practices from the bottom up. There are societal and public health preconditions required before institutions can expect their audience to act in solidarity with one another. Through their great influence over information and resources, public institutions do have the power to impact what values are most widespread. Furthermore, public health may foster trust and hope, which are important psychosocial factors that influence collective action,[24] if policies increase access to resources that promote well-being. Messaging efficacy also depends on the context of public trust, education, and whether the institutions meet one’s basic needs. Disparate messaging across different public institutions may confuse or disillusion individuals. To apply our theory of solidarity to the decision to vaccinate, a policy would be to foster conditions that facilitate access to vaccines and information about vaccine efficacy instead of imposing a top-down mandate without first eliciting public trust. IV. Counterargument Some argue that discordant public health messaging, ineffective government, and inadequate social programs can also bring people together under pressure and foster solidarity. One may argue that the most powerful motivators towards solidarity are strife and disparity, as evidenced throughout history. During the pandemic alone, political struggle and personal hardship inspired solidarity in the US, from individual neighbors helping each other to mutual aid groups forming across communities. We thus do not claim that solidarity is possible only when our government programs and public health institutions are most effective. We instead point out that solidarity can be further hindered when people feel alienated, hopeless, and pitted against each other. CONCLUSION Many competing conceptualizations of solidarity persist in the bioethics literature, and Prainsack and Buyx offer one compelling framework that public health ethicists continue to draw upon.[25] However, their framework fails to acknowledge how public health institutions impact interpersonal and group solidarity. Public health institutions can foster solidarity through actions other than mere messaging, invoking catchphrases like “we are all in this together.” Efforts to address socioeconomic preconditions and alleviate health disparities can cultivate group solidarity. As we saw during the pandemic, cooperation and solidarity go hand-in-hand with disease mitigation efforts; solidarity has clear intrinsic value.[26] As this relationship becomes more apparent, we will continue to see attempts from public health institutions to foster or invoke solidarity. Therefore, public health institutions would be remiss to ignore their role in addressing the social determinants of health. Adopting a social justice lens when planning public health interventions will clarify and strengthen their role in facilitating solidarity. Ultimately, if health disparities continue to persist or widen, it is very hard to imagine how group solidarity can ever be achieved. The widescale adoption of many public health measures needed to promote health and well-being would be conducive to solidarity. - Disclaimer: The opinions expressed are the authors’ and do not represent the views of the NIH, DHHS, or the U.S. government. Funding Disclosure: This work was supported in part by the Intramural Program of the National Institutes of Health Clinical Center. - [1] John J Mulvihill et al., “Ethical Issues of CRISPR Technology and Gene Editing through the Lens of Solidarity,” British Medical Bulletin 122 (2017): 17–29, https://doi.org/10.1093/bmb/ldx002; Ben Saunders, “Altruism or Solidarity? The Motives for Organ Donation and Two Proposals,” Bioethics 26, no. 7 (September 2012): 376–81, https://doi.org/10.1111/j.1467-8519.2012.01989.x; -Vanessa Y Hiratsuka, “SPECIAL REPORT: A Critical Moment in Bioethics: Reckoning with Anti-Black Racism through Intergenerational Dialogue A Call for Solidarity in Bioethics: Confronting Anti-Black Racism Together,” 2022, https://doi.org/10.1002/hast.1380. [2] Prainsack and Buyx, Solidarity: Reflections on an Emerging Concept in Bioethics London: Nuffield Council on Bioethics, 2011; Prainsack and Buyx, “Solidarity in Contemporary Bioethics--towards a New Approach.” Bioethics 26, no. 7 (September 2012): 343–50. https://doi.org/10.1111/J.1467-8519.2012.01987.X. [3] Bob Simpson, “A ‘We’ Problem for Bioethics and the Social Sciences: A Response to Barbara Prainsack,” Science, Technology, & Human Values 43, no. 1 (January 12, 2018): 45–55, https://doi.org/10.1177/0162243917735899. [4] Barbara Prainsack and Alena Buyx, Solidarity: Reflections on an Emerging Concept in Bioethics (London: Nuffield Council on Bioethics, 2011). [5] Barbara Prainsack and Alena Buyx, “Solidarity in Contemporary Bioethics--towards a New Approach,” Bioethics 26, no. 7 (September 2012): 343–50, https://doi.org/10.1111/J.1467-8519.2012.01987.X. [6] Bridget Pratt, Phaik Yeong Cheah, and Vicki Marsh, “Solidarity and Community Engagement in Global Health Research,” The American Journal of Bioethics : AJOB 20, no. 5 (May 3, 2020): 43–56, https://doi.org/10.1080/15265161.2020.1745930; Sara Chandros Hull, F. Leah Nez (Diné), and Juliana M. Blome, “Solidarity as an Aspirational Basis for Partnership with Tribal Communities,” The American Journal of Bioethics 21, no. 10 (October 3, 2021): 14–17, https://doi.org/10.1080/15265161.2021.1965258; Mbih J. Tosam et al., “Global Health Inequalities and the Need for Solidarity: A View from the Global South,” Developing World Bioethics 18, no. 3 (September 1, 2018): 241–49, https://doi.org/10.1111/DEWB.12182. [7] Peter West-Oram, “Solidarity Is for Other People: Identifying Derelictions of Solidarity in Responses to COVID-19,” Journal of Medical Ethics 47, no. 2 (February 1, 2021): 65–68, https://doi.org/10.1136/MEDETHICS-2020-106522; Barbara Prainsack, “Solidarity in Times of Pandemics,” Democratic Theory 7, no. 2 (December 1, 2020): 124–33, https://doi.org/10.3167/DT.2020.070215; F. Marijn Stok et al., “Social Inequality and Solidarity in Times of COVID-19,” International Journal of Environmental Research and Public Health 18, no. 12 (June 2, 2021), https://doi.org/10.3390/IJERPH18126339; Ming Jui Yeh, “Solidarity in Pandemics, Mandatory Vaccination, and Public Health Ethics,” American Journal of Public Health 112, no. 2 (February 1, 2022): 255–61, https://doi.org/10.2105/AJPH.2021.306578; Barbara Prainsack, “Beyond Vaccination Mandates: Solidarity and Freedom During COVID-19.,” Am J Public Health 112, no. 2 (February 1, 2022): 232–33, https://doi.org/10.2105/AJPH.2021.306619. [8] Prainsack and Buyx, Solidarity: Reflections on an Emerging Concept in Bioethics London: Nuffield Council on Bioethics, 2011; Prainsack and Buyx, “Solidarity in Contemporary Bioethics--towards a New Approach.” Bioethics 26, no. 7 (September 2012): 343–50. https://doi.org/10.1111/J.1467-8519.2012.01987.X. [9] Prainsack and Buyx, Solidarity: Reflections on an Emerging Concept in Bioethics London: Nuffield Council on Bioethics, 2011; Prainsack and Buyx, “Solidarity in Contemporary Bioethics--towards a New Approach.” Bioethics 26, no. 7 (September 2012): 343–50. https://doi.org/10.1111/J.1467-8519.2012.01987.X. [10] Yeh, “Solidarity in Pandemics, Mandatory Vaccination, and Public Health Ethics”; Prainsack, “Beyond Vaccination Mandates: Solidarity and Freedom During COVID-19.” [11] Ho, Anita, and Iulia Dascalu. "Relational solidarity and COVID-19: an ethical approach to disrupt the global health disparity pathway." Global Bioethics 32, no. 1 (2021): 34-50; West-Oram, Peter. "Solidarity is for other people: identifying derelictions of solidarity in responses to COVID-19." Journal of Medical Ethics 47, no. 2 (2021): 65-68. [12] Monica Webb Hooper, Anna María Nápoles, and Eliseo J. Pérez-Stable, “COVID-19 and Racial/Ethnic Disparities,” JAMA 323, no. 24 (June 23, 2020): 2466, https://doi.org/10.1001/jama.2020.8598. [13] Prainsack, Barbara. “Beyond Vaccination Mandates: Solidarity and Freedom During COVID-19.” Am J Public Health 112, no. 2 (February 1, 2022): 232–33. https://doi.org/10.2105/AJPH.2021.306619. [14] Camille A Clare, “Telehealth and the Digital Divide as a Social Determinant of Health during the COVID-19 Pandemic,” Network Modeling Analysis in Health Informatics and Bioinformatics 10 (2021): 26, https://doi.org/10.1007/s13721-021-00300-y. [15] Patrick Nana-Sinkam et al., “Health Disparities and Equity in the Era of COVID-19,” Journal of Clinical and Translational Science 5, no. 1 (March 16, 2021): e99, https://doi.org/10.1017/cts.2021.23. [16] Kathryn M Leifheit et al., “Expiring Eviction Moratoriums and COVID-19 Incidence and Mortality,” American Journal of Epidemiology 190, no. 12 (December 1, 2021): 2503–10, https://doi.org/10.1093/aje/kwab196. [17] Barbara Prainsack, “Solidarity in Times of Pandemics,” Democratic Theory 7, no. 2 (December 1, 2020): 124–33, https://doi.org/10.3167/DT.2020.070215 [18] Maximilian Agostini and Martijn van Zomeren, “Toward a Comprehensive and Potentially Cross-Cultural Model of Why People Engage in Collective Action: A Quantitative Research Synthesis of Four Motivations and Structural Constraints.,” Psychological Bulletin 147, no. 7 (July 2021): 667–700, https://doi.org/10.1037/bul0000256. [19] Department of Health and Human Services (HHS) Centers for Disease Control and Prevention (HHS/CDC), “COVID Data Tracker,” 2023, https://covid.cdc.gov/covid-data-tracker. [20] Powers, Madison, and Ruth Faden. Social Justice: The Moral Foundation of Public Health and Health Policy. 1st editio. New York: Oxford Press, 2006, p. 9 and Chapter 4 [21] Powers and Faden, Social Justice: The Moral Foundation of Public Health and Health Policy; Madison Powers and Ruth Faden, Structural Injustice: Power, Advantage, and Human Rights (New York: Oxford University Press, 2019). [22] Powers, Madison, and Ruth Faden. Social Justice: The Moral Foundation of Public Health and Health Policy. 1st editio. New York: Oxford Press, 2006, p. 10 [23] Bobby Saunkeah et al., “Extending Research Protections to Tribal Communities,” The American Journal of Bioethics 21, no. 10 (October 3, 2021): 5–12, https://doi.org/10.1080/15265161.2020.1865477. [24] Agostini and van Zomeren, “Toward a Comprehensive and Potentially Cross-Cultural Model of Why People Engage in Collective Action: A Quantitative Research Synthesis of Four Motivations and Structural Constraints.” [25] Prainsack and Buyx, Solidarity: Reflections on an Emerging Concept in Bioethics. [26] Ruth Chadwick, “COVID‐19 and the Possibility of Solidarity,” Bioethics 34, no. 7 (September 8, 2020): 637–637, https://doi.org/10.1111/bioe.12813. (shrink)

Alzheimer disease is a huge and growing societal problem with upwards of 35% of the population over the age of 80 developing the disease. AD results in a loss of memory, the ability to make reasoned and sound decisions, and ultimately the inability to take care of oneself. AD has an impact not only on the sufferer, but their caretakers and loved ones, who must take on a costly and time-consuming burden of care. AD is found in virtually all racial (...) and ethnic groups. Genetic influences on AD are substantial, and there has been a 30 year history of both success and failure. Mutations for rare early onset forms of the disease have been identified, but this information has not yet led to an effective treatment. Multiple common genetic variations have also been identified, and have led to new insights into the potential role of microglia cells in addition to neuronal cells in the brain. Despite intensive efforts, a significant portion of the genetic etiology of AD remains unknown and must be identified. (shrink)

The recent Covid-19 pandemic has brought a broad range of ethical problems to the forefront, raising fundamental questions about the role of government in response to such outbreaks, the scarcity and allocation of health care resources, the unequal distribution of health risks and economic impacts, and the extent to which individual freedom can be restricted. In this clear introduction to the topic Iwao Hirose explores these ethical questions and analyzes the central issues in the ethics of pandemic response and preparedness (...) such as: The general nature of pandemics and the ethics of preparedness Ethical questions about general goals of pandemic response and preparedness The distribution of scarce resources, e.g., ventilators, hospital beds, antiviral drugs and vaccines Restrictions on individual freedom Ethical questions in the wake of pandemics, including contact-tracing, vaccine passports and socioeconomic inequalities. With the use of real-life examples and a clear philosophical approach, The Ethics of Pandemics is a much-needed introduction to some of the most important ethical issues surrounding pandemics. It is essential reading for students of ethics, bioethics, and political philosophy and will also be of interest to those working in related areas such as public policy, public health, health law, nursing and life sciences. (shrink)

35 million people die annually of non-communicable diseases (NCDs), 80% of them in low- and middle-income countries — representing a marked epidemiological transition from infectious to chronic diseases and from richer to poorer countries. The total number of NCDs is projected to rise by 17% over the coming decade, absent significant interventions. The NCD epidemic poses unique governance challenges: the causes are multifactorial, the affected populations diffuse, and effective responses require sustained multi-sectorial cooperation. The authors propose a (...) range of regulatory options available at the domestic level, including stricter food labeling laws, regulation of food advertisements, tax incentives for healthy lifestyle choices, changes to the built environment, and direct regulation of food and drink producers. Given the realities of globalization, such interventions require global cooperation. In 2011, the UN General Assembly held a High-level meeting on NCDs, setting a global target of a 25% reduction in premature mortality from NCDs by 2025. Yet concrete plans and resource commitments for reaching this goal are not yet in the offing, and the window is rapidly closing for achieving these targets through prevention — as opposed to treatment, which is more costly. Innovative global governance for health is urgently needed to engage private industry and civil society in the global response to the NCD crisis. (shrink)

Contagion is more than an epidemiological fact. The medical usage of the term is no more and no less metaphorical than in the entire history of explanations of how beliefs circulate in social interactions. The circulation of such communicable diseases and the circulation of ideas are both material and experiential. Diseases and ideas expose the power and danger of bodies in contact, as well as the fragility and tenacity of social bonds. In the case of the theatre, (...) various tropes of contagion are to be found in both the fictional world on the stage and in many theories defining the rules of interaction between theatre audiences, fictitious characters and/or performers. In consequence, the historically changing concept of contagion has in many respects influenced how mimesis was conceived and understood. The main goal of my article is to demonstrate how the concept of contagion has changed over the last few decades and how it may influence our understanding of the idea of mimesis and participation in performative arts. This will be achieved in two steps. Firstly, I will compare the concept of contagion as the outbreak narrative that had influenced, among others, Antonin Artaud’s The Theater and the Plague with the more recent and dynamic concept of epidemic structured around the tipping point. Secondly, I will look for performative art forms with similar structure of audience responses, analyzing Mariano Pensotti’s project Sometimes I Think, I Can See You, in order to demonstrate new forms of performativity and presentation. (shrink)

Pre-existing medical conditions and co-infections are common to all human populations, although the natures of the pre-existing conditions and the types of co-infections vary. For these reasons, among others, the arrival of a highly infectious pathogenic agent may differentially affect the disease burden in different sub-populations, as a function of varying combinations of endemic disease, chronic disease, genetic or epigenetic vulnerabilities, compromised immunological status, and socially determined risk exposure. The disease burden may also vary considerably by age cohort and socio-economic (...) status. The social consequences of infection, the medical sequelae, and the paths of recovery from infection may also vary, according to these variables. As a result, different sub-populations may have different experiences of a disease process, including when and how an epidemic comes to an end. This essay suggests that historians' engagement with path-breaking biological and medical anthropological research will allow new approaches to understanding disease processes that will enrich the study of epidemics and their endings. It is organized in three sections. The first discusses some general approaches to and assumptions about epidemics that are used by many historians. The second introduces new perspectives on the study of historical epidemics opened up by the medical anthropological concept of syndemic disease interactions and by an engagement with biological scientific perspectives. It briefly discusses two rural epidemics-one of anemia caused by the syndemic interaction of hookworm and malaria co-infections in early 20th-century British Malaya, and the other of rebound infections caused by the loss of acquired immunity to falciparum malaria in mid-20th-century Liberia-that illustrate, respectively, the utility of the concept of syndemic disease interactions and the centrality of immunological status in understanding epidemic outbreaks in these discrete populations. The third section addresses some of the research considerations involved in moving beyond the single pathogen model of epidemic disease. (shrink)

The challenges posed by chronic illness have pointed out to epidemiologists the multifactorial complex nature of disease causality. This notion has been referred to as a web of causality. This web extends theoretically beyond risk markers. It includes determinants of emergence/non-emergence of disease. This web of determinants is a form of complex system. Due to its complexity, the determinants within such system are not linked to each others in a linear, predictable manner only. Predictability is possible only on a short-term (...) basis, and unpredictability sets in over the long run. Understanding such a system of determinants calls for articulation and testing of complex models which synthesize our knowledge of multiple determinants at many scales, both biological and otherwise. Given the complexity of this web and existing knowledge about the nonlinearity of such systems, the following question is posed: Can the challenge of studying causality be adequately addressed if emphasis continues to be placed on using tools and methods that are geared towards looking at such system from a linear paradigm? Or is it time to add to the epidemiologic research agenda the notion of nonlinearity and its relevant form of analytical approaches that are being tested in other disciplines? Furthermore, the question posed here applies as well to the study of determinants of health. Addressing determinants of heath adds further complexity to our task. (shrink)

Although epidemiology as a scientific study of disease in populations claimed an independent disciplinary status already in the mid–nineteenth century, its history in the twentieth century can be seen as a continuous and often contentious attempt to define the field’s social and intellectual boundaries vis-à-vis a variety of neighboring scientific fields and public health practices. In a period dominated by laboratory biomedical sciences, epidemiologists repeatedly tried to spell out how their discipline met the requirements of scientificity despite its focus on (...) disease as a collective phenomenon and its reliance on nonlaboratory methods. This article asks about the relationship between the changing institutional and intellectual contexts of British epidemiological practice and the epidemiologists’attempts to define both science in general and epidemiology in particular. An examination of the epidemiologists’boundary-making endeavors is also used to reflect on the circumstances in which scientists engage in the discourse of disciplinary demarcations. (shrink)

Since the late 1980s, the fetal origins of adult disease, from 2003 developmental origins of health and disease (DOHaD), has stimulated significant interest in and an efflorescence of research on the long-term effects of the intrauterine environment. From the start, this field has been interdisciplinary, using experimental animal, clinical and epidemiological tools. As the influence of DOHaD on public health and policy expanded, it has drawn criticism for reducing the complex social and physical world of early life to women’s reproductive (...) bodies as drivers of intergenerational ills. This paper explains this narrowing of focus in terms of a formative and consequential exchange between David Barker, the British epidemiologist whose work is credited with establishing the field, and the discipline of fetal physiology. We suggest that fetal physiologists were a crucial constituency of support for Barker’s hypothesis about early life origins of disease. Their collaborations with Barker helped secure and sustain the theory amid considerable controversy. The trajectory of DOHaD and its focus on the maternal body can be understood, we argue, as a consequence of this alliance, which brought together two distinct conceptualizations of the intrauterine environment, one from epidemiology and the other from fetal physiology. Along the way, we trace the histories of these conceptualizations, both of which were products of mid-to-late twentieth century British science, and show how Barker’s early emphasis on social and economic conditions was superseded by a narrower focus on physiological mechanisms acting upon the autonomous fetus. (shrink)

Epidemiologists’ discussions on causation are not always very enlightening with regard to the notion of ‘cause’ in epidemiology. Epidemiologists rightly work from a science-based approach to causation in epidemiology, but largely disagree about the matter. Disagreement may be partly due to confusion of the question of useful concepts for causal inference in epidemiological practice with the question of the metaphysical presuppositions of causal concepts used in epidemiology. In other words, epidemiologists seem to confuse the practical results of epidemiological research at (...) the population level with the metaphysical views about the reality of disease causation at the individual level in their writings on causation. (shrink)

In current mental health care psychiatric conditions are defined as compilations of symptoms. These symptom-based disease categories have been severely criticised as contingent and boundless, facilitating the rise to epidemic proportions of such conditions as depression. In this article we look beyond symptoms and stress the role of epidemiology in explaining the current situation. By analysing the parallel development of cardiovascular disease and depression management in Finland, we argue, firstly, that current mental health care shares with the medicine of chronic (...) somatic conditions an attachment to risk factor epidemiology, which accentuates risk and prevention in disease management. However, secondly, due to the symptom-based definitions of psychiatric conditions, depression management cannot differentiate properly between symptoms, signs and risk factors such as, for example, cardiovascular medicine, but treats symptoms as signs or risk factors in contexts of treatment and prevention. Consequently, minor at-risk conditions have become difficult to separate from proper cases of depression. (shrink)

The importance of legal epidemiology in public health law research has undoubtedly grown over the last five years. Scholars and practitioners together have developed guidance on best practices for the field, including: placing emphasis on transdisciplinary collaborations; creating valid, reliable, and repeatable research; and publishing timely products for use in decision-making and change. Despite the energy and expertise researchers have brought to this important work, they name significant challenges in marshalling the diverse skill sets, quality controls, and funding to implement (...) legal epidemiology activities. The Centers for Disease Control and Prevention has worked to develop cross-cutting research and translation on issues of national priority in legal epidemiology, and has explored ways to overcome some of these challenges. As such, this article describes a case study of the use of law to characterize states' prior authorization policies regarding medication used to treat attention-deficit/hyperactivity disorder, a central component of a broader effort to improve behavior therapy options for young children with ADHD. This article highlights the types of legal epidemiology work we have undertaken, the application of this work to an emerging public health problem, and the lessons learned in creating impactful research for the field. (shrink)

Epidemiology is a science of disease which specifies rates (illness prevalences, incidences, distributions, etc.). Evolution is a science of life which specifies changes (gene frequencies, generations, forms, function, etc.). Evolutionary Epidemiology is a synthesis of these two sciences which combines the empirical power of classical methods in genetical epidemiology with the interpretive capacities of neo-darwinian evolutionary genetics. In particular, prevalence rates of genetical diseases are important data points when reformulated for the purpose of analysis in terms of their evolutionary (...) frequencies. Traits which exceedprevalences beyond the rates of mutation (in Hardy-Weinberg calculations) or evidence unusualrange of phenotypic reaction are of special interest. This is because traits which did not confer advantages in the environment of evolutionary adaptation cannot accede, through natural selection, to anything but low rates of genomic prevalence.Evolutionary epidemiology is, in all of medicine, of particular promise in ongoing efforts to better understand psychopathology. Many complexities of phenotypic adjustment arise when new developmental demands are placed on an old genome. The new and complex biosocial ecology of human mass society now evokes different phenotypes than those in the prehistorical ecology to which the genome is structurally and functionally better adapted. Some of these new phenotypes are darwinian failures. In this paper, the theoretical implications of evolutionary epidemiology are extended and some tentative points of clinical application (particularly to psychiatry) are offered. (shrink)

Epidemiology is a science of disease which specifies rates . Evolution is a science of life which specifies changes . ‘Evolutionary Epidemiology’ is a synthesis of these two sciences which combines the empirical power of classical methods in genetical epidemiology with the interpretive capacities of neo-darwinian evolutionary genetics. In particular, prevalence rates of genetical diseases are important data points when reformulated for the purpose of analysis in terms of their evolutionary frequencies. Traits which exceedprevalences beyond the rates of mutation (...) or evidence unusualrange of phenotypic reaction are of special interest. This is because traits which did not confer advantages in the environment of evolutionary adaptation cannot accede, through natural selection, to anything but low rates of genomic prevalence.Evolutionary epidemiology is, in all of medicine, of particular promise in ongoing efforts to better understand psychopathology. Many complexities of phenotypic adjustment arise when new developmental demands are placed on an ‘old’ genome. The new and complex biosocial ecology of human mass society now evokes different phenotypes than those in the prehistorical ecology to which the genome is structurally and functionally better adapted. Some of these new phenotypes are darwinian failures. In this paper, the theoretical implications of evolutionary epidemiology are extended and some tentative points of clinical application are offered. (shrink)

Epidemiological models have played a central role in the COVID-19 pandemic, particularly when urgent decisions were required and available evidence was sparse. They have been used to predict the evolution of the disease and to inform policy-making. In this paper, we address two kinds of epidemiological models widely used in the pandemic, namely, compartmental models and agent-based models. After describing their essentials—some real examples are invoked—we discuss their main strengths and weaknesses. Then, on the basis of this analysis, we make (...) a comparison between their respective merits concerning three different goals: prediction, explanation, and intervention. We argue that there are general considerations which could favour any of those sorts of models for obtaining the aforementioned goals. We conclude, however, that preference for particular models must be grounded case-by-case since additional contextual factors, as the peculiarities of the target population and the aims and expectations of policy-makers, cannot be overlooked. (shrink)

Epidemiologists’ discussions on causation are not always very enlightening with regard to the notion of ‘cause’ in epidemiology. Epidemiologists rightly work from a science-based approach to causation in epidemiology, but largely disagree about the matter. Disagreement may be partly due to confusion of the question of useful concepts for causal inference in epidemiological practice with the question of the metaphysical presuppositions of causal concepts used in epidemiology. In other words, epidemiologists seem to confuse the practical results of epidemiological research at (...) the population level with the metaphysical views about the reality of disease causation at the individual level in their writings on causation. (shrink)

This paper seeks to determine the significance, if any, of epidemiological evidence to prove the specific causation element of liability in negligence or other relevant torts—in particular, what importance can be attached to a relative risk > 2, where that figure represents a sound causal inference at the general level. The paper discusses increased risk approaches to epidemiological evidence and concludes that they are a last resort. The paper also criticizes the proposal that the probability of causation can be estimated (...) with reference to the RR, such that RR > 2 is necessary and sufficient for causation. It is argued, following arguments by Sander Greenland and others, that RR > 2 is not necessary for proof of specific causation, except under restrictive biological assumptions that are not known to be satisfied for any important disease, and therefore must never be required. However, the paper argues that in some circumstances RR > 2 can be sufficient to prove causation at law. This position is defended against the widely held judicial and academic view that epidemiological evidence must be accompanied by something else, particular to the case at hand, if it is to have probative force for specific causation. It is argued that far from being epistemically irrelevant, to achieve correct and just outcomes it is in fact mandatory to take epidemiological evidence into account in deciding specific causation. Failing to consider such evidence when it is available leads to error and injustice. The conclusion is that in certain circumstances epidemiological evidence of RR > 2 is not necessary to prove specific causation but that it is sufficient. This “sufficiency” is confined to circumstances where there is no other evidence, as a way of getting clear on what the epidemiological evidence says. Once we have worked out what it says, this must be weighed against the other relevant evidence, if there is any. (shrink)

Epidemiology is a field torn between practices of surveillance and methods of analysis. Since the onset of COVID-19, epidemiological expertise has been mostly identified with the first, as dashboards of case and mortality rates took centre stage. However, since its establishment as an academic field in the early 20th century, epidemiology’s methods have always impacted on how diseases are classified, how knowledge is collected, and what kind of knowledge was considered worth keeping and analysing. Recent advances in digital epidemiology, (...) this article argues, are not just a quantitative expansion of epidemiology’s scope, but a qualitative extension of its analytical traditions. Digital epidemiology is enabled by deep and digital phenotyping, the large-scale re-purposing of any data scraped from the digital exhaust of human behaviour and social interaction. This technological innovation is in need of critical examination, as it poses a significant epistemic shift to the production of pathological knowledge. This article offers a critical revision of the key literature in this budding field to underline the extent to which digital epidemiology is envisioned to redefine the classification and understanding of disease from the ground up. Utilising analytical tools from science and technology studies, the article demonstrates the disruptive expectations built into this expansion of epidemiological surveillance. Given the sweeping claims and the radical visions articulated in the field, the article develops a tentative critique of what I call a fantasy of pathological omniscience; a vision of how data-driven engineering seeks to capture and resolve illness in the world, past, present and future. (shrink)