Social epidemiology has made a powerful case that health determined not just by individual-level factors such as our genetic make-up, access to medical services, or lifestyle choices, but also by social conditions, including the economy, law, and culture. Indeed, at the level of populations, evidence suggests that these “structural” factors are the predominant influences on health. Legal scholars in public health, including those in the health and human rights movement, have contended that human rights, laws, and legal practices are powerfully (...) linked to health. Social epidemiology and health-oriented legal scholarship are complementary in their focus and their research needs. Legal scholarship has identified plausible ways in which legal and human rights factors could be influencing health, but empirical evidence has been limited. (shrink)

Assessing social risks has proven difficult for IRBs. We undertook a novel effort to empirically investigate social risks before an HIV prevention trial among drug users in Thailand and China. The assessment investigated whether law, policies and enforcement strategies would place research subjects at significantly elevated risk of arrest, incarceration, physical harm, breach of confidentiality, or loss of access to health care relative to drug users not participating in the research. The study validated the investigator's concern that drug users were (...) subject to serious social risks in the site localities, but also suggested that participation in research posed little or no marginal increase in risk and might even have a protective effect. Our experience shows that it is feasible to inform IRB deliberations with actual data on social risks, but also raises the question of whether and when such research is an appropriate use of scare research resources. (shrink)

Criminal law is one of the regulatory tools being used in the United States to influence risk behavior by people who have HIV/AIDS. Several different types of laws have been or could be used in this way These include:HIV-specific exposure and transmission laws — i.e., laws that explicitly mention and exclusively apply to conduct by people with HIV;public health statutes prohibiting conduct that would expose others to communicable diseases and/or sexually transmitted diseases ; andgeneral criminal laws governing attempted murder and (...) assault. (shrink)

Criminal law is one of the regulatory tools being used in the United States to influence risk behavior by people who have HIV/AIDS. Several different types of laws have been or could be used in this way These include:HIV-specific exposure and transmission laws — i.e., laws that explicitly mention and exclusively apply to conduct by people with HIV;public health statutes prohibiting conduct that would expose others to communicable diseases and/or sexually transmitted diseases ; andgeneral criminal laws governing attempted murder and (...) assault. (shrink)

Stigma has become an important concept in public health law. It is widely accepted that certain diseases are disfavored in society, leading to discrimination against people identified with them, which in turn has the tendency to drive an epidemic underground—i.e., to make it more difficult for voluntary public health programs to reach and succeed among populations bent on concealing their disease or risk status. The need to reduce stigma and its effects has been used to justify the passage of privacy (...) and antidiscrimination law to protect people with HIV. More recently, stigma has been part of the arsenal of justification for special genetic antidiscrimination and privacy law. Despite its importance, however, there is no single widely accepted definition of stigma in social science, and its relationship to law has been generally under-theorized and unsupported by data, reducing our ability to effectively deploy law and other tools in the anti-stigma cause. (shrink)

With the publication of the final report of the WHO Commission on the Social Determinants of Health, it becomes clear that there is considerable convergence between a policy agenda rooted on social epidemiology and one rooted in a concern for human rights. As commentators like Jonathan Mann have argued, concern for human rights and the achievement of social justice can inform and improve public health. In this article, we ask a different question: what does a health perspective adds to the (...) enduring fight for a more just world? We consider three possibilities: (1) that public health, in an inversion of Mann's argument, actually provides useful tools for specifying social injustice; (2) that, contrary to the usual critical stance and assumption of weakness, the institutions of public health bring powerful capacities to the practical promotion of social justice; and (3) that health as a banner mobilizes people who would not be mobilized to act in the name of social justice. (shrink)

With the publication of the final report of the WHO Commission on the Social Determinants of Health, it becomes clear that there is considerable convergence between a policy agenda rooted on social epidemiology and one rooted in a concern for human rights. As commentators like Jonathan Mann have argued, concern for human rights and the achievement of social justice can inform and improve public health. In this article, we ask a different question: what does a health perspective adds to the (...) enduring fight for a more just world? We consider three possibilities: (1) that public health, in an inversion of Mann's argument, actually provides useful tools for specifying social injustice; (2) that, contrary to the usual critical stance and assumption of weakness, the institutions of public health bring powerful capacities to the practical promotion of social justice; and (3) that health as a banner mobilizes people who would not be mobilized to act in the name of social justice. (shrink)

The provision of police services and the suppression of crime is one of the first functions of civil government. Article 3 of the Universal Declaration of Human Rights speaks of a right to “security of person.” “The term ‘police’ traditionally connoted social organization, civil authority, or formation of a political community—the control and regulation of affairs affecting the general order and welfare of society,” including the protection of public health. Civil dispute resolution is also an important part of a system (...) that moves people away from self-help and toward reliance on collectively constituted, peaceful channels for working out problems.A safe and secure environment is tied to health. Research in social epidemiology suggests that a shared sense of security from physical violence and interference with property can contribute to better community health. (shrink)

Stigma has become an important concept in public health law. It is widely accepted that certain diseases are disfavored in society, leading to discrimination against people identified with them, which in turn has the tendency to drive an epidemic underground—i.e., to make it more difficult for voluntary public health programs to reach and succeed among populations bent on concealing their disease or risk status. The need to reduce stigma and its effects has been used to justify the passage of privacy (...) and antidiscrimination law to protect people with HIV. More recently, stigma has been part of the arsenal of justification for special genetic antidiscrimination and privacy law. Despite its importance, however, there is no single widely accepted definition of stigma in social science, and its relationship to law has been generally under-theorized and unsupported by data, reducing our ability to effectively deploy law and other tools in the anti-stigma cause. (shrink)

Over two hundred years ago, Thomas Jefferson suggested the need for a broader legal curriculum. As the twenty-first century begins, the practice of law will increasingly demand interdisciplinary knowledge and collaboration — between those trained in law and a broad range of scientific and technical fields, including engineering, biology, genetics, ethics, and the social sciences. The practice of public health law provides a model for both the substantive integration of law with science, and for the way its practitioners work. In (...) addition, public health law also provides a model for interdisciphuy and integrative teaching. (shrink)

One understanding of health conceives of it as a state of freedom from pathology, achieved by an individual, through the mediation of a doctor. On this view, improvements in health flow from the application of science to specific ills of the body, and access to medical care is the chief determinant of health. This “medicalized” view of health underlies the current debate over medical care payment reform. This is the dominant way of talking about health.An alternative is the view of (...) health commonly associated with the practice of public health. On this view, health is an attribute of communities in social and physical environments. Health takes its shape in large numbers—in morbidity and mortality statistics—and, ideally, includes not just a high level of well-being for some, but also its even distribution throughout a society. Improvements in health are seen to arise from healthful changes in the environment. (shrink)

“Public health practice” consists of activities and Programs managed by public health agencies to promote health and prevent disease, injury, and disability. Some of these activities might be deemed to fit within the broad definition of “research” under federal regulations, known as the Common Rule, designed to protect human research subjects. The Common Rule defines research as “a systeniatic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge.” Public health activities that might under some (...) circumstances be considered research include disease reporting, review of medical records, surveys, interviews, focus groups, specimen collection, and laboratory testing.There are questions about the extent to which the Common Rule applies or was intended to apply to public health practice: and it has been suggested in any case that Common Rule regulation of public health practice may not be socially optimal for both practical and principled reasons. (shrink)

“Public health practice” consists of activities and Programs managed by public health agencies to promote health and prevent disease, injury, and disability. Some of these activities might be deemed to fit within the broad definition of “research” under federal regulations, known as the Common Rule, designed to protect human research subjects. The Common Rule defines research as “a systeniatic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge.” Public health activities that might under some (...) circumstances be considered research include disease reporting, review of medical records, surveys, interviews, focus groups, specimen collection, and laboratory testing.There are questions about the extent to which the Common Rule applies or was intended to apply to public health practice: and it has been suggested in any case that Common Rule regulation of public health practice may not be socially optimal for both practical and principled reasons. (shrink)

Over two hundred years ago, Thomas Jefferson suggested the need for a broader legal curriculum. As the twenty-first century begins, the practice of law will increasingly demand interdisciplinary knowledge and collaboration — between those trained in law and a broad range of scientific and technical fields, including engineering, biology, genetics, ethics, and the social sciences. The practice of public health law provides a model for both the substantive integration of law with science, and for the way its practitioners work. In (...) addition, public health law also provides a model for interdisciphuy and integrative teaching. (shrink)

No one who attended the 2010 national public health law conference hosted by the Public Health Law Association and the American Society of Law, Medicine & Ethics could miss the sense of excitement and momentum. The revival of this annual public health law meeting, with the support of the Robert Wood Johnson Foundation, the energetic leadership of the PHLA president and board, ASLME’s expert guidance, and a rousing address by Dr. Tom Frieden, Director of the Centers for Disease Control and (...) Prevention, symbolize the continued commitment of a wide range of important individuals and institutions to the proposition that law is of substantial importance to public health. But there is more than just symbolism to be excited about. CDC’s public health law program continues to champion efforts to promote the use and understanding of law as a public health tool. (shrink)

No one who attended the 2010 national public health law conference hosted by the Public Health Law Association and the American Society of Law, Medicine & Ethics could miss the sense of excitement and momentum. The revival of this annual public health law meeting, with the support of the Robert Wood Johnson Foundation, the energetic leadership of the PHLA president and board, ASLME’s expert guidance, and a rousing address by Dr. Tom Frieden, Director of the Centers for Disease Control and (...) Prevention, symbolize the continued commitment of a wide range of important individuals and institutions to the proposition that law is of substantial importance to public health. But there is more than just symbolism to be excited about. CDC’s public health law program continues to champion efforts to promote the use and understanding of law as a public health tool. (shrink)

No one questions the importance of protecting human subjects of research, but over the past few years dissatisfaction has surfaced with the manner in which the protection is conferred by the federal regulatory system referred to as “The Common Rule. ” Some of the criticism surfaces in print. Some bubbles out anecdotally in conversations among researchers, with complaints about the review process being virtually inevitable whenever the topic arises. Like those in other disciplines that differ more or less dramatically from (...) the world of clinical medical research around which the Common Rule was conceptualized, public health researchers, particularly those working in official public health agencies, have experienced some tension and difficulty in adapting to the rules. The Centers For Disease Control and Prevention has adopted guidelines that require Common Rule review for “research” but not “practice” activities. (shrink)

Surveillance in public health is the means by which people who are responsible for preventing or controlling threats to health get the timely, ongoing, and reliable information they need about the occurrence, antecedents, time course, geographic spread, consequences, and nature of these threats among the populations they serve. “Policy surveillance” is the ongoing, systematic collection, analysis, and dissemination of information about laws and other policies of health importance.

No one questions the importance of protecting human subjects of research, but over the past few years dissatisfaction has surfaced with the manner in which the protection is conferred by the federal regulatory system referred to as “The Common Rule. ” Some of the criticism surfaces in print. Some bubbles out anecdotally in conversations among researchers, with complaints about the review process being virtually inevitable whenever the topic arises. Like those in other disciplines that differ more or less dramatically from (...) the world of clinical medical research around which the Common Rule was conceptualized, public health researchers, particularly those working in official public health agencies, have experienced some tension and difficulty in adapting to the rules. The Centers For Disease Control and Prevention has adopted guidelines that require Common Rule review for “research” but not “practice” activities. (shrink)

One understanding of health conceives of it as a state of freedom from pathology, achieved by an individual, through the mediation of a doctor. On this view, improvements in health flow from the application of science to specific ills of the body, and access to medical care is the chief determinant of health. This “medicalized” view of health underlies the current debate over medical care payment reform. This is the dominant way of talking about health.An alternative is the view of (...) health commonly associated with the practice of public health. On this view, health is an attribute of communities in social and physical environments. Health takes its shape in large numbers—in morbidity and mortality statistics—and, ideally, includes not just a high level of well-being for some, but also its even distribution throughout a society. Improvements in health are seen to arise from healthful changes in the environment. (shrink)

Drug overdose has recently surpassed motor vehicle accidents to become the leading cause of unintentional injury death in the United States. The epidemic is largely driven by opioids such as oxycodone, hydrocodone, and methadone, which kill more Americans than heroin and cocaine combined. The demographics of overdose have changed over the past few decades as well: according to the latest data, the average overdose victim is now a non-Hispanic white man aged 45-54.These deaths — over 16,000 per year — are (...) almost entirely preventable. Opioid overdose kills by slowly depressing respiration, a process that can take several hours. It can be quickly and effectively reversed by the timely administration of naloxone, an opioid antagonist that works by displacing opioids from the brain receptors to which they attach, reversing their depressant effect. Naloxone, also known as Narcan, has many benefits and minimal risks. Although it is a prescription drug, it is not a controlled substance and has no abuse potential. (shrink)

Assessing social risks has proven difficult for IRBs. We undertook a novel effort to empirically investigate social risks before an HIV prevention trial among drug users in Thailand and China. The assessment investigated whether law, policies and enforcement strategies would place research subjects at significantly elevated risk of arrest, incarceration, physical harm, breach of confidentiality, or loss of access to health care relative to drug users not participating in the research. The study validated the investigator's concern that drug users were (...) subject to serious social risks in the site localities, but also suggested that participation in research posed little or no marginal increase in risk and might even have a protective effect. Our experience shows that it is feasible to inform IRB deliberations with actual data on social risks, but also raises the question of whether and when such research is an appropriate use of scare research resources. (shrink)

The prelims comprise: Introduction Public Health Ethics The Public Health Interest in Genetic Screening Discussion Conclusion.

Few now question that population health is significantly shaped by social ecology. Power, wealth, and social status clearly matter: Their enactment in daily life makes them fundamental social determinants of health. Important as it is that we accept the broad importance of social factors in health, it is not enough. Our current grasp of the importance of social factors in health has to be strengthened by research that more precisely delineates the workings of social health through social processes, and the (...) investment in research must in turn be vindicated by interventions that make a difference. The work presented in this issue of the Journal of Law, Medicine & Ethics is intended to advance the agenda for research and action.An ecological theory puts health everywhere. Population health is shaped in the hierarchies of the workplace, the neighborhood, and the home. (shrink)