Precision medicine and molecular systems medicine (MSM) are highly utilized and successful approaches to improve understanding, diagnosis, and treatment of many diseases from bench-to-bedside. Especially in the COVID-19 pandemic, molecular techniques and biotechnological innovation have proven to be of utmost importance for rapid developments in disease diagnostics and treatment, including DNA and RNA sequencing technology, treatment with drugs and natural products and vaccine development. The COVID-19 crisis, however, has also demonstrated the need for systemic thinking and transdisciplinarity and the limits (...) of MSM: the neglect of the bio-psycho-social systemic nature of humans and their context as the object of individual therapeutic and population-oriented interventions. COVID-19 illustrates how a medical problem requires a transdisciplinary approach in epidemiology, pathology, internal medicine, public health, environmental medicine, and socio-economic modeling. Regarding the need for conceptual integration of these different kinds of knowledge we suggest the application of general system theory (GST). This approach endorses an organism-centered view on health and disease, which according to Ludwig von Bertalanffy who was the founder of GST, we call Organismal Systems Medicine (OSM). We argue that systems science offers wider applications in the field of pathology and can contribute to an integrative systems medicine by (i) integration of evidence across functional and structural differentially scaled subsystems, (ii) conceptualization of complex multilevel systems, and (iii) suggesting mechanisms and non-linear relationships underlying the observed phenomena. We underline these points with a proposal on multi-level systems pathology including neurophysiology, endocrinology, immune system, genetics, and general metabolism. An integration of these areas is necessary to understand excess mortality rates and polypharmacological treatments. In the pandemic era this multi-level systems pathology is most important to assess potential vaccines, their effectiveness, short-, and long-time adverse effects. We further argue that these conceptual frameworks are not only valid in the COVID-19 era but also important to be integrated in a medicinal curriculum. (shrink)

Sex differences in mortality rates stem from genetic, physiological, behavioral, and social causes that are best understood when integrated in an evolutionary life history framework. This paper investigates the Male-to-Female Mortality Ratio (M:F MR) from external and internal causes and across contexts to illustrate how sex differences shaped by sexual selection interact with the environment to yield a pattern with some consistency, but also with expected variations due to socioeconomic and other factors.

Age-specific mortality rates have been used to illustrate certain aspects of the characteristics of old age. A consideration of the experience of the ageing person in his fifties and early sixties suggests that during this period he comes to recognize death as being an increasingly common characteristic of his age group. Thus the standard procedure for studying old age problems in a sample of people over the age of 65 may miss the period of life when people are making (...) the crucial adjustments to old age and may give a distorted view of some gerontological problems. Certain demographic aspects of old age are considered in detail with regard to the occurrence of, first, widowhood and, second, social isolation. (shrink)

People with mental illnesses have higher prevalence and mortality rates with regard to common somatic diseases and causes of death, such as cardio-vascular conditions or cancer. One factor contributing to this excess morbidity and mortality is the sub-standard level of physical healthcare offered to the mentally ill. In particular, they are often subject to diagnostic overshadowing: a tendency to attribute physical symptoms to a pre-existing diagnosis of mental illness. This might be seen as an unfortunate instance of (...) epistemic bad luck, where particular features of a group of patients make a timely and correct diagnosis unlikely. While this can explain some cases of diagnostic overshadowing, I argue that in other cases, epistemic injustice is involved. Analyzing the case of diagnostic overshadowing, I distinguish two kinds of testimonial injustice. For one, there are classic cases of transactional testimonial injustice resulting from prejudices against the mentally ill. In addition, there are cases of structural testimonial injustice resulting from features of health care systems. To overcome diagnostic overshadowing, remedies on the individual as well as structural level are thus needed. (shrink)

This paper proposes a new method of measuring excess risk of child mortality in cross-sectional surveys, which is applied to DHS I data for Burundi, Uganda and Zimbabwe. The expected child mortality experience is estimated for each mother on the basis of child's age, mother's age at child's birth and her parity, and compared with her observed experience. Mothers who exceed their expected child mortality experience and also had more than one child die are considered to (...) have excess child mortality. Zimbabwe had the greatest concentration of child deaths as measured by a simple ratio of mothers to deaths, but when observed experience was compared with expected it had less than half as many excess deaths as Uganda and Burundi. In all three countries mother's education had a strong negative association with the risk of excess child mortality, and in Zimbabwe and Burundi there were significant regional differences. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Excited DeliriumWhat’s Psychiatry Got to do With It?Paul B. Lieberman, MDIf in life we are surrounded by death, so too in the health of our intellect by madness.—WittgensteinDelirium is a medical syndrome defined as “a relatively acute decline in cognition that fluctuates over hours or days” whose primary manifestation is a deficit of attention. It is common, estimated to occur in 10% to more than 50% of hospitalized patients, (...) with higher prevalence rates among people in nursing homes and at the end of life. It is often fatal, with a mortality rate in the hospital estimated to be 25% to 33%. Caused by a wide variety of conditions and frequently difficult to diagnose, it lacks characteristic postmortem pathology (Josephson & Miller 2018)‘Excited delirium,’ as Byju and Friesen forcefully argue (Byju & Friesen, 2023), is, if nothing else, an excuse. The ‘diagnosis’ has not been empirically validated and remains controversial (American Psychiatric Association, 2020). And while delirium is usually treated by internists and emergency medicine physicians, psychiatrists should also be concerned about the misuse of a putative medical diagnosis and join actively in discussion about it. For one thing, patients mis-diagnosed with this condition, as Byju and Friesen’s examples suggest, may actually have another psychiatric condition and, so, be people for whose safety we should advocate. Moreover, the kinds of police interventions which Byju and Friesen document as involving excited delirium also befall patients with other psychiatric problems in whom the issue of delirium does not arise.There are at least two broad ways in which psychiatrists are qualified and obligated to engage with this issue. As physicians, we should join our medical colleagues in carefully but persistently telling the scientific, medical truth. As psychiatrists, we should bring psychiatric knowledge into the discussion, for example, by explaining what can happen when people who do not, apparently, have a diagnosable mental disorder interact under stress with other people who, apparently, do.Delirium is a clinical diagnosis, made when characteristic signs and symptoms are present which should not be made ‘by exclusion’ when, as may happen, other causes are not found. There is no evidence of delirium in any of the three clinical descriptions Byju and Friesen provide. Perhaps such evidence exists which is not in their brief reports, but these three people appear to have had, either, another psychiatric condition, such as psychosis or drug intoxication, or perhaps no [End Page 353] diagnosis at all. Psychiatrists are particularly wellpositioned to make this point since patients with mental health problems are often misdiagnosed when they seek medical attention and are told, and treated as if, “it’s all (“just”!) psychological.”Excited delirium, if it exists, is fatal in 10% of cases (Gonin, Beysard, Hersin, & Carron, 2018) and, although this is lower than the rate for delirium in general, it is still high. Medical personnel must be available to evaluate and ensure the safety of patients in custody.The potential conflict between protecting the patient and protecting the public should not be overstated. Although physical trauma and excessive administration of medications, including ketamine 500 mg IV (Orhurhu, Vashicht, Claus, & Cohen, 2023) can be lethal, mechanical restraint by itself is not (Chieze et al., 2019; Gleerup et al., 2019): something else is necessary, such as asphyxiation (Evans, Wood, & Lambert, 2003). Nor is restraint necessary in many cases in which ‘de-escalation’ techniques can be equally effective (Garriga et al., 2016; Fernández-Costa, 2020). Perhaps these points are best made by law enforcement leaders—and they have been—but psychiatrists can add that safe management of potential violence can be provided for agitated people with psychiatric conditions.Although it is not clear what kind of strength ‘superhuman’ strength might be (certainly not medical), relative imperviousness to pain is clinically described. Its locus classicus is Beecher’s observation, during World War II, that injured soldiers awaiting return home from the front, required lower than usual doses of analgesics (Beecher, 1946). And it’s a common experience, scientifically confirmed, that physical trauma may not become painful until sometime after the injury (Melzack, Wall, & Ty, 1982). But pain is a warning. Its absence is not a license, but a caution... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Excited DeliriumWhat’s Psychiatry Got to do With It?Paul B. Lieberman, MDIf in life we are surrounded by death, so too in the health of our intellect by madness.—WittgensteinDelirium is a medical syndrome defined as “a relatively acute decline in cognition that fluctuates over hours or days” whose primary manifestation is a deficit of attention. It is common, estimated to occur in 10% to more than 50% of hospitalized patients, (...) with higher prevalence rates among people in nursing homes and at the end of life. It is often fatal, with a mortality rate in the hospital estimated to be 25% to 33%. Caused by a wide variety of conditions and frequently difficult to diagnose, it lacks characteristic postmortem pathology (Josephson & Miller 2018)‘Excited delirium,’ as Byju and Friesen forcefully argue (Byju & Friesen, 2023), is, if nothing else, an excuse. The ‘diagnosis’ has not been empirically validated and remains controversial (American Psychiatric Association, 2020). And while delirium is usually treated by internists and emergency medicine physicians, psychiatrists should also be concerned about the misuse of a putative medical diagnosis and join actively in discussion about it. For one thing, patients mis-diagnosed with this condition, as Byju and Friesen’s examples suggest, may actually have another psychiatric condition and, so, be people for whose safety we should advocate. Moreover, the kinds of police interventions which Byju and Friesen document as involving excited delirium also befall patients with other psychiatric problems in whom the issue of delirium does not arise.There are at least two broad ways in which psychiatrists are qualified and obligated to engage with this issue. As physicians, we should join our medical colleagues in carefully but persistently telling the scientific, medical truth. As psychiatrists, we should bring psychiatric knowledge into the discussion, for example, by explaining what can happen when people who do not, apparently, have a diagnosable mental disorder interact under stress with other people who, apparently, do.Delirium is a clinical diagnosis, made when characteristic signs and symptoms are present which should not be made ‘by exclusion’ when, as may happen, other causes are not found. There is no evidence of delirium in any of the three clinical descriptions Byju and Friesen provide. Perhaps such evidence exists which is not in their brief reports, but these three people appear to have had, either, another psychiatric condition, such as psychosis or drug intoxication, or perhaps no [End Page 353] diagnosis at all. Psychiatrists are particularly wellpositioned to make this point since patients with mental health problems are often misdiagnosed when they seek medical attention and are told, and treated as if, “it’s all (“just”!) psychological.”Excited delirium, if it exists, is fatal in 10% of cases (Gonin, Beysard, Hersin, & Carron, 2018) and, although this is lower than the rate for delirium in general, it is still high. Medical personnel must be available to evaluate and ensure the safety of patients in custody.The potential conflict between protecting the patient and protecting the public should not be overstated. Although physical trauma and excessive administration of medications, including ketamine 500 mg IV (Orhurhu, Vashicht, Claus, & Cohen, 2023) can be lethal, mechanical restraint by itself is not (Chieze et al., 2019; Gleerup et al., 2019): something else is necessary, such as asphyxiation (Evans, Wood, & Lambert, 2003). Nor is restraint necessary in many cases in which ‘de-escalation’ techniques can be equally effective (Garriga et al., 2016; Fernández-Costa, 2020). Perhaps these points are best made by law enforcement leaders—and they have been—but psychiatrists can add that safe management of potential violence can be provided for agitated people with psychiatric conditions.Although it is not clear what kind of strength ‘superhuman’ strength might be (certainly not medical), relative imperviousness to pain is clinically described. Its locus classicus is Beecher’s observation, during World War II, that injured soldiers awaiting return home from the front, required lower than usual doses of analgesics (Beecher, 1946). And it’s a common experience, scientifically confirmed, that physical trauma may not become painful until sometime after the injury (Melzack, Wall, & Ty, 1982). But pain is a warning. Its absence is not a license, but a caution... (shrink)

It is estimated that up to 7500 people develop schizophrenia each year in the UK. Schizophrenia has significant consequences, with 28% of the excess mortality in schizophrenia being attributed to suicide. Previous research suggests that suicide in schizophrenia may be more related to affective factors such as depression and hopelessness, rather than psychotic symptoms themselves. Considering suicide in schizophrenia within this framework enables us to develop a novel philosophical approach, in which suicide may not be related to loss (...) of self-consciousness, thought processing dysfunctions or perception disturbances. The action of suicide may be due neither to persistent hallucinations nor other psychotic symptoms, such as delusional beliefs, but to other underexamined, perhaps rational reasons, such as extreme social isolation, severe depression or emotional withdrawal. This paper does not examine the moral character of suicide. Instead, it argues that we should conceive the action of suicide in schizophrenia as an act that is not necessarily irrational. People with schizophrenia might end their life based on reasons if suicide is the best means to achieve their ends. However, the paper does not support assisted suicide. It aims to provide a better understanding of the reasons why people take their own lives and suggests that understanding can inform effective interventions to reduce high rates of suicide. (shrink)

Despite triggering one of the largest civilian death tolls in modern history, the policy and human consequences of economic sanctions on Iraq between 1990-2003 remain largely unexamined. This lack of scrutiny mirrors the euphemism and mis-information surrounding the embargo itself and the Oil-for-Food program ostensibly adopted to protect Iraq's civilian population. But it also reflects incomprehension among Western publics - long removed from the realities of hunger and economic destitution - of the intimate link between economic conditions and mortality. (...) Iraq suffered an estimated 1.5 million excess deaths because of a catastrophic undermining of civilian livelihood triggered by the embargo; an outcome termed slow famine in the demographic literature. With much of the population fully dependent on daily food rations of less than 21 cents per person for much of the sanctions period, OfF `relief' was inherently incapable of substituting for a functioning civil economy. Recent positive accounts of the impact of OfF, in the form of the Independent Inquiry Committee into the Oil-for-Food Program, are refuted by close analysis of malnutrition and mortality rates across the sanctions period. The example of Iraq reveals the danger in treating economic sanctions as a cheap, `non-violent' tool for conflict resolution. In reality their deadly power is terrorizing for societies not protected from their application by permanent member status on the UN Security Council, a threat which continues to generate global insecurity. The Iraq experience reveals how current, narrowly framed, international law prohibitions on starvation as a weapon of war need to be extended to cover interference with civilian livelihood and hence access to food. (shrink)

This study investigates the possible effects of pre-term births and low birth weight on infant mortality rates (IMRs) over a 15-year period in Ribeirão Preto, Brazil, based on surveys carried out in 1978/79 and 1994. The 1978/79 survey included 6750 births over a 12-month period and the 1994 survey 2846 births over a 4-month period. Infant deaths were retrieved monthly from the city register. Infant mortality rate decreased from 36·6 to 16·9 deaths per 1000 over 15 years. (...) The decrease in IMR was larger in the 25000·63); it increased to 0·57 (95% CI 0·350·97) when adjusted for length of gestation and other variables. The increase in pre-term births and low birth weight may have had, at most, a marginal effect on the IMR. Progress in the care of newborns may have decreased the mortality risk, but even mild pre-term birth still has an impact on infant mortality. There is room for further improvement in IMR by tackling the high rates of pre-term birth. (shrink)

Extrinsic mortality is a key influence on organisms’ life history strategies, especially on age at maturity. This historical longitudinal study of 125 women in rural Domenica examines effects of extrinsic mortality on human age at maturity and pace of reproduction. Extrinsic mortality is indicated by local population infant mortality rates during infancy and at maturity between the years 1925 and 2000. Extrinsic mortality shows effects on age at first birth and pace of reproduction among these (...) women. Parish death records show huge historical variation in age-specific mortality rates. The infant mortality rate (IMR) in the early 1920s was low, increased dramatically beginning in 1929, and reached a maximum in the 1950s, at which point IMR declined steadily to its present low rate. The mortality rate early in life showed a quadratic association with age at first birth. Women who experienced conditions of low IMR early in life reproduced relatively late in life. Those born into moderately high levels of infant mortality tended to reproduce earlier than those born at low levels. At very high infant mortality levels early in life, women went on to delay reproduction until relatively late, possibly as a result of somatic depletion and energetic stress associated with the conditions that lead to high IMR. Population mortality rates at age of maturity also showed a quadratic association with age at first birth. The pace of reproduction, estimated as number of surviving offspring controlled for maternal age, showed a similar quadratic effect. There were complex interactions between population mortality rates in infancy and at maturity. When extrinsic mortality was high during infancy, extrinsic mortality later in life had little effect on timing of first birth. When extrinsic mortality was low to moderate in infancy, extrinsic mortality later in life had significant effects on adult reproduction. I speculate that these effects are mediated through development of personality facets associated with reproduction. (shrink)

Over thirty years ago, Richard Rorty’s Philosophy and the Mirror of Nature declared the demise of epistemology and the arrival of a new post-Philosophical era. Rorty envisaged the intellectual activity of this predominantly literary culture as an unconstrained large-scale conversation that would flourish in an “ecstasy of spiritual freedom.” Having abandoned all systematic pretensions, edifying philosophers would add their voice to the conversation of mankind, fully aware of the radical incommensurability of the mortal vocabularies they employ. In an attempt to (...) evaluate this radical proposal, the first part of this essay argues that some of Rorty’s most memorable utopian statements are far-fetched, rhetorical and often exaggerated to the point that they damage his broad humanistic vision. Building on this, the second part discusses the “missed potential” of Rorty’s excessively broad notion of a conversation of mankind and of the uncompromisingly anti-essentialist and anti-foundationalist reorientation that he proposes. (shrink)

Neonatal mortality during the first week of life, corresponding to the years 19750·023 per year. This decline cannot be explained by an increase in the mean birth weight (MBW=23440·835−10·107 g per year). From the most frequent of the causes of death to the least were: congenital anomalies, preterm born or low birth weight, respiratory problems, pregnancy difficulties, hypoxaemia/asphyxia, delivery difficulties and infectious diseases. This sequence changed when the specific age at death was considered. The NMR descended evenly for both (...) sexes for the causes indicated above, except for preterm born or low birth weight, in which the male mortality decrease was greater since its rate was more elevated at the beginning of the period studied. For all the causes listed, NMR was more elevated both in urban areas and for males. Early neonatal mortality (first 24 hours) was higher for pregnancy difficulties, preterm born or low birth weight, congenital anomalies and hypoxaemia/asphyxia. (shrink)

:High-fidelity simulation is a relatively new teaching modality, which is gaining widespread acceptance in medical education. To date, dozens of studies have proven the usefulness of HFS in improving student, resident, and attending physician performance, with similar results in the allied health fields. Although many studies have analyzed the utility of simulation, few have investigated why it works. A recent study illustrated that permissive failure, leading to simulated mortality, is one HFS method that can improve long-term performance. Critics maintain, (...) however, that the use of simulated death is troubling and excessive. Given the controversy regarding simulated death, we consider the data about the educational value and the emotional harms associated with them, expecting that evidence could be useful in resolving the question. The goal of this narrative review is to explore the argument against simulated mortality and provide educators with an imperative as to why it can be safely utilized. (shrink)

Indigenous populations in New World nations share the common experience of culture contact with outsiders and a prolonged history of prejudice and discrimination. This historical reality continues to have profound effects on their well-being, as demonstrated by their relative disadvantages in socioeconomic status on the one hand, and in their delayed demographic and epidemiological transitions on the other. In this study one aspect of aboriginals’ epidemiological situation is examined: their mortality experience between the early 1980s and early 1990s. The (...) groups studied are the Canadian Indians, the American Indians and the New Zealand Maori (data for Australian Aboriginals could not be obtained). Cause-specific death rates of these three minority groups are compared with those of their respective non-indigenous populations using multivariate log-linear competing risks models. The empirical results are consistent with the proposition that the contemporary mortality conditions of these three minorities reflect, in varying degrees, problems associated with poverty, marginalization and social disorganization. Of the three minority groups, the Canadian Indians appear to suffer more from these types of conditions, and the Maori the least. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Thinking Mortal ThoughtsDebra SanThere is something quite odd about the ancient Greek advice to “think mortal thoughts” (or “think of mortal things”), for what human being past the flush of youth has not trembled at the thought of mortality? Consciousness of our mortal condition is considered a hall-mark of the human species, and is no doubt the reason we alone among the species on the planet entertain notions (...) of divinity. Why then are we counseled to think about what we cannot help thinking about anyway? And what purpose does the advice serve: are those who tender it eager to promote their own fearful frame of mind? Or, on the contrary, are they urging us to be courageous in the face of death? Perhaps the advice intended is to eat, drink, and be merry, for tomorrow we die. Or perhaps “mortal thoughts” are suicidal thoughts, and the object is to shuffle off this mortal coil in a manner, time, and place of our own choosing.Clearly, taken out of context, the injunction “think mortal thoughts” can mean any number of things. But in the context of ancient Greek culture, “think mortal thoughts” means roughly this:“Since you are not one of the immortal gods, be mindful of your limits as a human being. Consciousness of the inevitability of your death should inform the way you live your life, for just as your lifespan is limited by your mortality, so too are your capacities for understanding, for action, and for achievement. This is the truth of your condition; if you don’t accept it, you’ll be frustrated at best, and at worst you’ll incur divine wrath and retribution for attempting to push past your proper human boundaries into sacred turf where you don’t belong and aren’t wanted. Don’t trespass. Don’t even think about it. Don’t assume, in a futile exercise of hubris, that you’re a special case whose transgression [End Page 16] (huperbasia) will be exempt from dire consequences. Gnothi sauton, know yourself as a mortal being, and meden agan, do nothing to excess, or you will suffer the fate of Icarus, who aimed too high and died for it, or the fate of Phaethon, who was destroyed by forces which he thought he could control.”The advice presented here echoes throughout classical Greek drama, whose tragic protagonists are the theatrical descendants of Icarus and Phaethon. When Antigone compares herself to Niobe, the Chorus must remind her that “she was a god, born of gods, and we are only mortals born to die” (925–26). 1 In her failure to think mortal thoughts, Antigone resembles her father, whose refusal to acknowledge his limits is so profound that even after mutilating himself in horror at the discovery of his own transgressions, he must still be reminded that he is no longer “the master of all things” (1675). 2 Pentheus in the Bacchae lacks the stature of either Oedipus or Antigone, but like them he has pretensions beyond the limits befitting a mortal; he fails to exercise the “simple wisdom [that] shuns the thoughts of proud, uncommon men and all their god-encroaching dreams” (427–29). 3 In his arrogant and unrealistic attempt to pit his own puny powers against the incomparable force of the immortal Dionysus, Pentheus suffers the fate of those whose hubris overcomes the temperate virtue of sōphrosunē, “the wisdom that accepts” (390). Even the bloodthirsty, pre-Eumenides Furies of the Eumenides accept the limits which moderation entails: they understand that Zeus “appointeth the mean as the master in all things” (531). 4One might expect that this cautionary, temperate strain in Greek thinking would appeal to Aristotle, whose doctrine of the mean in Book II of the Nicomachean Ethics might have come straight out of the Oresteia. And yet, when the caution is expressed in the maxim “think mortal thoughts,” Aristotle rejects it, claiming that human beings should try to aim their thoughts at a level so high it cannot really be reached by mortals, which is to say a level as high as that of the immortal gods, whose contemplative, intellectual activity (theōria) soars far above... (shrink)

Australia, Canada, and New Zealand currently apply health requirements to prospective immigrants, denying residency to those with health conditions that are likely to impose an “excessive demand” on their publicly funded health and social service programs. In this paper, I investigate the charge that such policies are wrongfully discriminatory against persons with disabilities. I first provide a freedom-based account of the wrongness of discrimination according to which discrimination is wrong when and because it involves disadvantaging people in the exercise of (...) their freedom on the basis of morally arbitrary features of their identity. Discrimination is permissible, I suggest, when it is necessary to advance a valuable exercise of the discriminating agent’s freedom. I then apply this account to the case of social cost health requirements. Against critics of these requirements, I argue that it is sometimes permissible for states to discriminate against prospective immigrants with disabilities. States may do so, I suggest, when such discriminatory treatment is necessary to prevent an increase in rates of mortality and/or morbidity amongst citizens. Alongside critics of social cost health requirements however, I argue that existing policies are likely a form of wrongful discrimination insofar as they are too broad to satisfy this standard. (shrink)

After World War II, infant mortality rates started dropping steeply. We show how this was accomplished in socialist countries in East-Central Europe. Focusing on the two postwar decades, we explore comparatively how medical experts in Poland, Hungary, Czechoslovakia, and East Germany saved fragile newborns. Based on an analysis of medical journals, we argue that the Soviet Union and its medical practices had only a marginal influence; the four countries followed the recommendations of the World Health Organization instead, despite not (...) being members. Importantly, we analyze the expert clashes over definitions of livebirth, which impact infant mortality statistics. We analyze the divergent practices and negotiations between countries: since the infant mortality rate came to represent the level of socioeconomic advancement, its political significance was paramount. Analyzing the struggle to reduce infant mortality thus helps us understand how socialist countries positioned themselves within the transnational framework while being members of the “socialist bloc.”. (shrink)

Background Inequities in COVID-19 outcomes in the USA have been clearly documented for sex and race: men are dying at higher rates than women, and Black individuals are dying at higher rates than white individuals. Unexplored, however, is how sex and race interact in COVID-19 outcomes. Objective Use available data to characterize COVID-19 mortality rates within and between race and sex strata in two US states, with the aim of understanding how apparent sex disparities in COVID-19 deaths vary across (...) race. Design and Participants This observational study uses COVID-19 mortality data through September 21, 2020, from Georgia (GA) and Michigan (MI). Main Measures We calculate age-specific rates for each sex-race-age stratum, and age-standardized rates for each race-sex stratum. We investigate the sex disparity within race groups and the race disparity within sex groups using age-standardized rate ratios, and rate differences. Key Results Within race groups, men have a higher COVID-19 mortality rate than women. Black men have the highest rate of all race-sex groups (in MI: 254.6, deaths per 100,000, 95% CI: 241.1–268.2, in GA:128.5, 95% CI: 121.0-135.9). In MI, the COVID-19 mortality rate for Black women (147.1, 95% CI: 138.7–155.4) is higher than the rate for white men (39.1, 95% CI: 37.3–40.9), white women (29.7, 95% CI: 28.3–31.0), and Asian/Pacific Islander men and women. COVID-19 mortality rates in GA followed the same pattern. In MI, the male:female mortality rate ratio among Black individuals is 1.7 (1.5–2.0) while the rate ratio among White individuals is only 1.3 (1.2–1.5). Conclusion While overall, men have higher COVID-19 mortality rates than women, our findings show that this sex disparity does not hold across racial groups. This demonstrates the limitations of unidimensional reporting and analyses and highlights the ways that race and gender intersect to shape COVID-19 outcomes. (shrink)

SummaryDuring famines females generally have a mortality advantage relative to males, and the highest levels of mortality occur in the very young and the elderly. One popular hypothesis is that the sex differential in mortality may reflect the greater body fatness combined with lower metabolism of females, which may also underpin the age-related patterns of mortality among adults. This study evaluated the ‘body fat’ hypothesis using a previously published and validated mathematical model of survival during total (...) starvation. The model shows that at a given body weight females would indeed be expected to survive considerably longer than males in the absence of food. At a mass of 70 kg for example a female aged 30 would survive for 144 days compared with life expectancy of only 95 days for a male of the same age and weight. This effect is contributed to by both the higher body fatness and lower metabolism of the females at a given body weight. However, females are generally smaller than males and in addition to a sex effect there was also a major effect of body size – heavier individuals survive longer. When this body size effect was removed by considering survival in relation to BMI the sex effect was much reduced, and could be offset by a relatively small difference in pre-famine BMI between the sexes. Nevertheless, combining these predictions with observed mean BMIs of males and females across 48 countries at the low end of the obesity spectrum suggests that in the complete absence of food females would survive on average about 40% longer than males. The energy balance model also predicted that older adult individuals should survive much longer than younger adult individuals, by virtue of their lower resting metabolic rates and lower activity levels. Observations of the female survival advantage in multiple famines span a much wider range than the model prediction. This suggests in some famines body fatness may be a significant factor influencing the mortality differential between the sexes, but in other famines other factors are likely to be more important. Moreover, the pattern of mortality in relation to age is completely opposite that predicted. These data emphasize the complex nature of famine mortality and suggest that a simple model of energy utilization alone is inadequate to explain the major aspects of this phenomenon. (shrink)

This article describes the long-term trends in marital status mortality differences in the Netherlands using a unique dataset relating to the period 1850–1970. Poisson regression analysis was applied to calculate relative mortality risks by marital status. For two periods, cause-of-death by marital status could be used. Clear differences in mortality by marital status were observed, with strongly increasing advantages for married men and women and a relative increase in the mortality of widowed compared with non-married people. (...) Excess mortality among single and formerly married men and women was visible in many cause-of-death categories, and this became more widespread during the last decades of the nineteenth century. Hypotheses are formulated that might explain why married men and women underwent a stronger decrease in mortality up until the end of World War II. (shrink)

ObjectiveThe aim of this study was to investigate possible associations between obstructive sleep apnea and fatigue. This naturally led to considering the association between OSA and excessive sleepiness, depression, and anxiety.BackgroundOSA is a highly prevalent sleep disorder, associated with a risk of hypertension, cardiovascular events, daytime sleepiness, poor cognitive function, and sudden death during sleep. Both excessive sleepiness, fatigue, and symptoms of depression are frequently reported.Method5,464 patients referred to a university hospital for obstructive sleep apnea underwent standard respiratory polygraphy. The (...) severity of OSA was defined as either mild, moderate, or severe, using the apnea–hypopnea index. Validated questionnaires were used to assess excessive sleepiness, pathological fatigue, depression, and anxiety.ResultsNearly 70% of the patients were men, and median age was 50 years. One in three had moderate-to-severe OSA. Excessive sleepiness and pathological fatigue were present in 43 and 39%, respectively. The prevalence of possible depression and anxiety was 19 and 28%, respectively. The proportion of patients with male sex, obesity, and excessive sleepiness increased with the severity of OSA. In contrast, the proportion of patients with pathological fatigue did not increase with OSA severity, and there was a decrease in depression and anxiety with increasing OSA severity.ConclusionOur study reports that pathological fatigue, as well as anxiety and depression, did not increase with OSA severity, whereas excessive sleepiness did. Knowledge concerning conditions related to OSA severity may be indicative of pretest probability of OSA and thus change the priority for polygraphy. Furthermore, the high prevalence rates of fatigue, anxiety, and depression among these patients warrant further investigations. (shrink)

The youngest population in society is recognized as that at the healthiest stage of life but is burdened by the occurrence of premature death that should be avoidable. There is a need to use adequate statistical methods in assessing the health status of the population of developmental age. The aim of the study was to analyze trends of mortality in children and adolescents by age and gender in the Podlaskie Voivodeship in the years 2003-2012 by joinpoint regression and to (...) identify the causes of mortality. The mortality rate was analysed according to gender and the age groups: 0, 1-4, 5-9, 10-14 and 15-19 years in the Podlaskie Voivodeship. The data were obtained from the Central Statistical Office for the period 2003-2012. Differences in mortality levels between age and gender subgroups were obtained by the Wilcoxon signed-rank test. Join- point regression was used to analyze the trends in mortality. The nomenclature of ICD-10 was used to assess the causes of mortality of children and adolescents. In the Podlaskie Voivodeship in the years 2003-2012 in the 0-19-year-old age group, the highest proportion of deaths (42.4%) occurred during the first year of life. There were differences in mortality rates between boys (8.0/104) and girls (3.1/104) in the 15-19-year-old age group (p < 0.01), and also between the 1-14-year-old and 15-19-year-old age groups (p < 0.01), both among boys (2.1/104 vs. 8.0/104) and girls (1.5/104 vs. 3.1/104). Monotonous trends were shown regarding total mortality rates in infants. There was a drop in the mortality rate of infant girls (AAPC = 5.3%, p < 0.05) and boys (AAPC = 4.7%, p < 0.05). Changes in the direction of the total mortality rate trend were visible in the population of boys aged 1-14 years, in which, between 2003 and 2010, a significant reduction in mortality (AAPC = 9.5%) was observed, while in the years 2010-2012 the trend was not significant. No statistical evidence was found that mortality changed among girls in the 1-14-year-old and 15-19-year-old age groups. Deaths in infancy were due to perinatal conditions and congenital mal- formations. The main causes of mortality in the 1-19-year-old age group were external causes, mainly traffic accidents and intentional self-harm. Joinpoint regression indicated a uniform decrease of mortality in the years 2003-2012 except for boys from 1-14 years old, for whom the decreasing trend was for the years 2003-2010 with subsequent stabilization. The main problems are still infant deaths due to perinatal conditions, traffic accidents and intentional self-harm in boys in the 15-19-year-old age group. (shrink)

SummaryHuman height is a heritable trait that is known to be influenced by environmental factors and general standard of living. Individual and population stature is correlated with health, education and economic achievement. Strong sexual selection pressures for stature have been observed in multiple diverse populations, however; there is significant global variance in gender equality and prohibitions on female mate selection. This paper explores the contribution of general standard of living and gender inequality to the variance in global female population heights. (...) Female population heights of 96 nations were culled from previously published sources and public access databases. Factor analysis with United Nations international data on education rates, life expectancy, incomes, maternal and childhood mortality rates, ratios of gender participation in education and politics, the Human Development Index and the Gender Inequality Index was run. Results indicate that population heights vary more closely with gender inequality than with population health, income or education. (shrink)

ABSTRACT By means of the high ratings that they awarded to subprime mortgage‐backed bonds, the three major rating agencies—Moody's, Standard & Poor's, and Fitch—played a central role in the current financial crisis. Without these ratings, it is doubtful that subprime mortgages would have been issued in such huge amounts, since a major reason for the subprime lending boom was investor demand for high‐rated bonds—much of it generated by regulations that made such bonds mandatory for large institutional investors. And it is (...) even less likely that such bonds would have become concentrated on the balance sheets of the banks, for which they were rewarded by capital regulations that tilted toward high‐rated securities. Why, then, were the agencies excessively optimistic in their ratings of subprime mortgage‐backed securities? A combination of their fee structure, the complexity of the bonds that they were rating, insufficient historical data, some carelessness, and market pressures proved to be a potent brew. This combination was enabled, however, by seven decades of financial regulation that, beginning in the 1930s, had conferred the force of law upon these agencies' judgments about the creditworthiness of bonds and that, since 1975, had protected the three agencies from competition. (shrink)

This paper describes the application of eight statistical and machine-learning methods to derive computer models for predicting mortality of hospital patients with pneumonia from their findings at initial presentation. The eight models were each constructed based on 9847 patient cases and they were each evaluated on 4352 additional cases. The primary evaluation metric was the error in predicted survival as a function of the fraction of patients predicted to survive. This metric is useful in assessing a model’s potential to (...) assist a clinician in deciding whether to treat a given patient in the hospital or at home. We examined the error rates of the models when predicting that a given fraction of patients will survive. We examined survival fractions between 0.1 and 0.6. Over this range, each model’s predictive error rate was within 1% of the error rate of every other model. When predicting that approximately 30°K of the patients will survive, all the models have an error rate of less than 1.5%. The models are distinguished more by the number of variables and parameters that they contain than by their error rates; these differences suggest which models may be the most amenable to future implementation as paper-based guidelines. (shrink)

Background: Black, Asian and minority ethnic groups have a high need for organ transplantation but deceased donation is low. This restricts the availability of well-matched organs and results in relatively long waiting times for transplantation, with increased mortality risks. Objective: To identify barriers to organ donor registration and family consent among the BAME population, and to develop and evaluate a training intervention to enhance communication with ethnic minority families and identify impacts on family consent. Methods: Three-phase programme comprising community-based (...) research involving two systematic reviews examining attitudes and barriers to organ donation and effective interventions followed by 22 focus groups with minority ethnic groups; hospital-based research examining staff practices and influences on family consent through ethics discussion groups with staff, a study on intensive care units and interviews with bereaved ethnic minority families; and development and evaluation of a training package to enhance cultural competence among ICU staff. Setting: Community focus group study in eight London boroughs with high prevalence of ethnic minority populations. Hospital studies at five NHS hospital trusts. Participants: Community studies: 228 focus group participants; hospital studies: 35 nurses, 28 clinicians, 19 hospital chaplains, 25 members of local Organ Donation Committees, 17 bereaved family members; and evaluation: 66 health professionals. Data sources: Focus groups with community residents, systematic reviews, qualitative interviews and observation in ICUs, EDGs with ICU staff, bereaved family interviews and questionnaires for trial evaluation. Review methods: Systematic review and narrative synthesis. Results: Community studies: Organ Donor Register – different ethnic/faith and age groups were at varying points on the ‘pathway’ to organ donor registration, with large numbers lacking knowledge and remaining at a pre-contemplation stage. Key attitudinal barriers were uncertainties regarding religious permissibility, bodily concerns, lack of trust in health professionals and little priority given to registration, with the varying significance of these factors varying by ethnicity/faith and age. National campaigns focusing on ethnic minorities have had limited impact, whereas characteristics of effective educational interventions are being conducted in a familiar environment; addressing the groups’ particular concerns; delivery by trained members of the lay community; and providing immediate access to registration. Interventions are also required to target those at specific stages of the donation pathway. Hospital studies: family consent to donation – many ICU staff, especially junior nurses, described a lack of confidence in communication and supporting ethnic minority families, often reflecting differences in emotional expression, faith and cultural beliefs, and language difficulties. The continuing high proportion of family donation discussions that take place without the collaboration of a specialist nurse for organ donation reflected consultants’ views of their own role in family consent to donation, a lack of trust in SNODs and uncertainties surrounding controlled donations after circulatory death. Hospital chaplains differed in their involvement in ICUs, reflecting their availability/employment status, personal interests and the practices of ICU staff. Evaluation: professional development package – a digital versatile disk-based training package was developed to promote confidence and skills in cross-cultural communication. Initial evaluation produced positive feedback and significant affirmative attitudinal change but no significant difference in consent rate over the short follow-up period with requirements for longer-term evaluation. Limitations: Participants in the focus group study were mainly first-generation migrants of manual socioeconomic groups. It was not permitted to identify non-consenting families for interview with data regarding the consent process were therefore limited to consenting families. Conclusions: The research presents guidance for the effective targeting of donation campaigns focusing on minority ethnic groups and provides the first training package in cultural competence in the NHS. Future work: Greater evaluation is required of community interventions in the UK to enhance knowledge of effective practice and analysis of the experiences of non-consenting ethnic minority families. Funding: The National Institute for Health Research Programme Grants for Applied Research programme. (shrink)

Mitochondrial respiration is the predominant source of ATP. Excessive rates of electron transport cause a higher production of harmful reactive oxygen species (ROS). There are two regulatory mechanisms known. The first, according to Mitchel, is dependent on the mitochondrial membrane potential that drives ATP synthase for ATP production, and the second, the Kadenbach mechanism, is focussed on the binding of ATP to Cytochrome c Oxidase (CytOx) at high ATP/ADP ratios, which results in an allosteric conformational change to CytOx, causing inhibition. (...) In times of stress, ATP‐dependent inhibition is switched off and the activity of CytOx is exclusively determined by the membrane potential, leading to an increase in ROS production. The second mechanism for respiratory control depends on the quantity of electron transfer to the Heme aa3 of CytOx. When ATP is bound to CytOx the enzyme is inhibited, and ROS formation is decreased, although the mitochondrial membrane potential is increased. (shrink)

Two conundrums puzzle COVID‐19 investigators: 1) morbidity and mortality is rare among infants and young children and 2) rates of morbidity and mortality exhibit large variances across nations, locales, and even within cities. It is found that the higher the rate of pneumococcal vaccination in a nation (or city) the lower the COVID‐19 morbidity and mortality. Vaccination rates with Bacillus Calmette–Guerin, poliovirus, and other vaccines do not correlate with COVID‐19 risks, nor do COVID‐19 case or death (...) rates correlate with number of people in the population with diabetes, obesity, or adults over 65. Infant protection may be due to maternal antibodies and antiviral proteins in milk such as lactoferrin that are known to protect against coronavirus infections. Subsequent protection might then be conferred (and correlate with) rates of Haemophilus influenzae type B (Hib) (universal in infants) and pneumococcal vaccination, the latter varying widely by geography among infants, at‐risk adults, and the elderly. Also see the video abstract here https://youtu.be/GODBYRbPL00. (shrink)

BackgroundThe Public Health Service Increased Risk designation identified organ donors at increased risk of transmitting hepatitis B, hepatitis C, and human immunodeficiency virus. Despite clear data demonstrating a low absolute risk of disease transmission from these donors, patients are hesitant to consent to receiving organs from these donors. We hypothesize that patients who consent to receiving offers from these donors have decreased time to transplant and decreased waitlist mortality.MethodsWe performed a single-center retrospective review of all-comers waitlisted for liver transplant (...) from 2013 to 2019. The three competing risk events (transplant, death, and removal from transplant list) were analyzed. 1603 patients were included, of which 1244 (77.6%) consented to offers from increased risk donors.ResultsCompared to those who did not consent, those who did had 2.3 times the rate of transplant (SHR 2.29, 95% CI 1.88–2.79, p < 0.0001), with a median time to transplant of 11 months versus 14 months (p < 0.0001), as well as a 44% decrease in the rate of death on the waitlist (SHR 0.56, 95% CI 0.42–0.74, p < 0.0001). All findings remained significant after controlling for the recipient age, race, gender, blood type, and MELD. Of those who did not consent, 63/359 (17.5%) received a transplant, all of which were from standard criteria donors, and of those who did consent, 615/1244 (49.4%) received a transplant, of which 183/615 (29.8%) were from increased risk donors.ConclusionsThe findings of decreased rates of transplantation and increased risk of death on the waiting list by patients who were unwilling to accept risks of viral transmission of 1/300–1/1000 in the worst case scenarios suggests that this consent process may be harmful especially when involving “trigger” words such as HIV. The rigor of the consent process for the use of these organs was recently changed but a broader discussion about informed consent in similar situations is important. (shrink)

It has been observed that some groups in society tend to report their health to be better than would be expected through more objective measures. The available evidence suggests that while variations in self-assessed measures of health may act as good proxies of mortality and morbidity in homogeneous populations, in some groups, such as the Aboriginal and Torres Strait Islander communities of Australia, these subjective measures may provide a misleading picture. Useful insights into the formation of health perceptions can (...) be drawn from a range of disciplines, in particular, from social comparison theories, models of illness behaviour, survey literature and linguistics. These theories and models help to provide an understanding of the different ways in which illness may be perceived, evaluated and acted upon by different kinds of people. Such considerations can have very direct implications for those planning and evaluating public health programs as well as those responsible for funding such programs. (shrink)

In 2003 and 2018 researchers discussed the perils of blind reliance on randomized controlled trials that have been substituted for medical experience and clinical acumen. Although these past articles do well to shed light on this issue, they neglect to discuss the topic of all-cause mortality in controlled trials. The current essay seeks to fill this void and expand the thought put into the appropriateness of all-cause mortality, especially when trials extend excessively far into the future. To do (...) this effectively the current essay leans on trial data from statin research and evidence from cancer screening—where researchers have explicitly called for all-cause mortality to be used in lieu of cancer or cardiovascular specific mortality. The issue with such an endpoint is that it obfuscates the issue at hand, namely that a specific intervention is intended to have a specific effect, not that a specific intervention is supposed to have any kind of effect. The effect(s) of medical interventions ought to be relevant to their intended mechanism of action and not simply any positive effect that can be pulled from trial data. (shrink)

We investigated the influence of personality and culture on effects of mortality salience over cultural worldview defense. We hypothesized that CWVD reactions to MS differ between Germany and Poland because of the higher conservatism of the latter country, and that they are moderated by action vs. state orientation. In this study German and Polish, participants were exposed either to MS or to a control condition. Punishment ratings to trivial offences and serious social transgressions were measures of CWVD. Results showed (...) that social transgressions in both conditions were more strongly punished in Poland than in Germany. Additionally, compared to the control condition, under MS action oriented punished serious transgressions more strongly in Germany whereas state oriented punished serious transgressions more strongly in Poland. That is, the effects of MS on CWVD are moderated by personality and culture. We interpret the opposite pattern of punishment to serious social transgressions given by action and state orientedin in Germany and Poland, respectively, according to the higher emotional autonomy of action-oriented persons in either culture. (shrink)

Clinical psychologists' and nonpsychiatric physicians' attitudes and behaviors in sexual and confidentiality boundary violations were examined. The 171 participants' responses were analyzed by profession, sex, and status (student, resident, professional) on semantic differential, boundary violation vignettes, and a version of Pope, Tabachnick, and Keith-Spiegel's (1987) ethical scale. Psychologists rated sexual boundary violation as more unethical than did physicians (p<.001). Rationale (p<.01) and timing (p<.001) influenced ratings. Psychologists reported fewer sexualized behaviors than physicians (p<05). Professional experience (p<.01) and sex (p<.05) were (...) associated with confidence-violating behavior. Overall, 78% of the sample reported attitudes or behaviors associated with boundary violations. The behavior violations were correlated (r=.49). Actual violators rated vignette violators more leniently than did nonviolators (p<.01). (shrink)

Although excess blood collection has characterized U.S. national disasters, most dramatically in the case of September 11, periodic shortages of blood have recurred for decades. In response, I propose a new model of medical philanthropy, one that specifically uses charitable contributions to health care as blood donation incentives. I explain how the surge in blood donations following 9/11 was both transient and disaster-specific, failing to foster a greater continuing commitment to donate blood. This underscores the importance of considering blood (...) donation incentives. I defend charitable incentives as an alternative to financial incentives, which I contend would further extend neoliberal market values into health care. I explain my model's potential appeal to private foundations or public–private partnerships as a means for expanding both the pool of blood donors and the prosocial benefit of each act of blood donation. Finally I link my analysis to the empirical literature on blood donation incentives. (shrink)

BackgroundCervical cancer disproportionately burdens disadvantaged women. Organised cervical screening aims to make cancer prevention available to all women in a population, yet screening uptake and cancer incidence and mortality are strongly correlated with socioeconomic status. Reaching underscreened populations is a stated priority in many screening programs, usually with an emphasis on something like ‘equity’. Equity is a poorly defined and understood concept. We aimed to explain experts’ perspectives on how cervical screening programs might justifiably respond to ‘the underscreened’.MethodsThis paper (...) reports on a grounded theory study of cervical screening experts involved in program organisation. Participants were 23 experts from several countries and a range of backgrounds: gynecology; epidemiology; public health; pathology; general practice; policy making. Data were gathered via semi-structured interview and concepts developed through transcript coding and memo writing.ResultsMost experts expressed an intuitive commitment to reducing systematic differences in screening participation or cancer outcomes. They took three different implicit positions, however, on what made organised programs justifiable with respect to underscreened populations. These were: 1) accepting that population screening is likely to miss certain disenfranchised groups for practical and cultural reasons, and focusing on maximising mainstream reach; 2) identifying and removing barriers to screening; and 3) providing parallel tailored screening services that attended to different cultural needs. Positions tended to fall along country of practice lines.ConclusionsExperts emphasised the provision of opportunity for underscreened populations to take up screening. A focus on opportunity appeared to rely on tacit premises not supported by evidence: that provision of meaningful opportunity leads to increased uptake, and that increased uptake of an initial screening test by disadvantaged populations would decrease cervical cancer incidence and mortality. There was little attention to anything other than the point of testing, or the difficulties disadvantaged women can have in accessing follow up care. The different approaches to ‘improving equity’ taken by participants are differently justified, and differently justifiable, but none attend directly to the broader conditions of disadvantage. (shrink)

The problem of charging interest has been discussed since the time of Aristotle. It was condemned in the Christian religion in the Middle Ages. Only when the interest was specified as a payment for productive capital was it considered that the borrower, enriched by the money lent, should let the lender benefit in accordance with the principle of fairness. The borrower should share the profit with the lender, and from this moment the percentage is no longer something shameful and neglected. (...) Religious beliefs and accepted moral values have changed over time, adapting to the circumstances, so has the approach to collecting interest from the capital lent. However, there is still a great deal of criticism of excessive interest rates. The purpose of this paper is to present a discussion related to the charging of interest presented in the tradition of economics and also to show some aspects of the problem in relation to the present times, such as excessive debt and responsible lending. (shrink)

Rate, John In this first Sunday of Advent we are reminded that our lives and our world are moving towards a great finale, as envisioned in our times by the great Teilhard de Chardin. While there are some terrifying aspects to this (our natural fear of death, and the apocalyptic descriptions of the end-times in Luke's Gospel), Luke calms us with his confident admonition: 'Stand erect, hold your heads high, because your liberation is near at hand.' As we allow (...) this truth to influence daily life, we will naturally want to 'stay awake' and 'practise honesty and integrity in the land' (first reading), and we will understand more fully the beautiful Alleluia verse prayer: 'Lord, show us your mercy and love, and grant us your salvation.'. (shrink)