Academic literature on the topic 'Cumberland County Public Library (N.C.)'

The Constitution of Kenya specifically recognizes the freedom of association to form and belong to trade unions. However, despite the adoption of the Labour Relations Act, union practice is still hampered by excessive restrictions. The EPZ companies are labor intensive requiring a large amount of labor to produce its goods or service and thus, the welfare of the employees play a key role in their functions. This study sought to determine the effect of trade union practices on employees’ welfare at export processing zones industries in Athi River, Kenya. The specific objectives sought to determine the effect of collective bargaining agreements, industrial action, dispute resolution and trade union representation on employees’ welfare at export processing zones industries in Athi River, Kenya. The study employed a descriptive research design. Primary data was collected by means of a structured questionnaire. The target population of the study was employees in EPZ companies in Athi River, Kenya with large employees enrolled in active trade unions. The unit of observation was the employees in the trade unions. The findings indicated that collective bargaining agreements had a positive and significant coefficient with employees’ welfare at the EPZ industries. Industrial action had a positive but non-significant effect with employees’ welfare at Export Processing Zones industries. Dispute resolution had a positive and significant coefficient with employees’ welfare at the EPZ industries. Trade union representation had a positive and significant coefficient with employees’ welfare at the EPZ industries. The study recommended that trade union should avoid the path of confrontation but continue dialogue through the collective bargaining process and demands should be realistic in nature with what is obtainable in the related industry. An existence of a formal two way communication between management and trade unions will ensure that right message is properly understood and on time too. Keywords: Collective Bargaining Agreements, Industrial Action, Dispute Resolution, Trade Union Representation, Employees Welfare & Export Processing Zones

ObjectiveTo assess evidence for public health impact of syndromic surveillance.IntroductionSystematic syndromic surveillance is undergoing a transition. Building on traditional roots in bioterrorism and situational awareness, proponents are demonstrating the timeliness and informative power of syndromic surveillance data to supplement other surveillance data.MethodsWe used PubMed and Google Scholar to identify articles published since 2007 using key words of interest (e.g., syndromic surveillance in combinations with emergency, evaluation, quality assurance, alerting). The following guiding questions were used to abstract impact measures of syndromic surveillance: 1) what was the public health impact; what decisions or actions occurred because of use of syndromic surveillance data?, 2) were there specific interventions or performance measures for this impact?, and 3) how, and by whom, was this information used?ResultsThirty-five papers were included. Almost all articles (n=33) remarked on the ability of syndromic surveillance to improve public health because of timeliness and/or accuracy of data. Thirty-four articles mentioned that syndromic surveillance data was used or could be useful. However, evidence of health impact directly attributable to syndromic surveillance efforts were lacking. Two articles described how syndromic data were used for decision-making. One article measured the effect of data utilization.ConclusionsWithin the syndromic surveillance literature instances of a conceptual shift from detection to practical response are plentiful. As the field of syndromic surveillance continues to evolve and is used by public health institutions, further evaluation of data utility and impact is needed.ReferencesAyala, A., Berisha, V., Goodin, K., Pogreba-Brown, K., Levy, C., McKinney, B., Koski, L., & Imholte, S. (2016). Public health surveillance strategies for mass gatherings: Super Bowl XLIX and related events, Maricopa County, Arizona, 2015. Health Security, 14(3), 173-84. doi: 10.1089/hs.2016.0029.Bermis, K., Frias, M., Patel, M.T., & Christiansen, D. (2017). Using an Emergency Department Syndromic Surveillance System to Evaluate Reporting of Potential Rabies Exposures, Illinois, 2013-2015. Public Health Reports 132(Supplement 1) 59S-64S."Borroto, R., Williamson, B., Pitcher, P., Ballester, L., Smith, W., Soetebier, K., & Drenzek, C. (2016). Using Syndromic Surveillance Alert Protocols for Epidemiologic Response in Georgia. Online Journal of Public Health Informatics 9(1):e123. doi:10.5210/ojphi.v9i1.7707."Daly, E.R., Dufault, K., Swenson, D.J., Lakevicius, P., Metcalf, E., & Chan, B.P. (2017). Use of emergency department data to monitor and respond to an increase in opioid overdoses in New Hampshire 2011-2015. Public Health Reports 132(Supplement 1) 73S-79S. doi: 10.1177/0033354917707934Deyneka, L., Hakenewerth, A., Faigen, Z., Ising, A., & Barnett, C. (2017). Using syndromic surveillance data to monitor endocarditis and sepsis among drug users. Online Journal of Public Health Informatics, (9)1. doi: http://dx.doi.org/10.5210/ojphi.v9i1.7708DeYoung, K., Chen, Y., Beum, R., Askenazi, M., Zimmerman, C., & Davidson, A. J. (2017). Validation of a syndromic case definition for detecting emergency department visits potentially related to marijuana. Public Health Reports, epublication.doi: 10.1177/0033354917708987"Dinh, M.M., Kastelein, C., Bein, K.J., Bautovich, T., & Ivers, R. (2015). Use of a syndromic surveillance system to describe the trend in cycling-related presentations to emergency departments in Sydney. Emergency Medicine Australasia, 27(4), 343-7. doi: 10.1111/1742-6723.12422Gevitz, K., Madera, R., Newbern, C., Lojo, J., & Johnson, C. Risk of Fall-Related Injury due to Adverse Weather Events, Philadelphia, Pennsylvania, 2006-2011. Public Health Reports (132) 53S-58S. doi: 10.1177/0033354917706968"Gonzales-Colon, F.J., Lake, I., Barker, G., Smith, G.E., Elliot, A.J., & Morbey, R. (2016). Using Bayesian Networks to assist decision-making in syndromic surveillance. Online Journal of Public Health Informatics, 8(1), e15. doi:10.5210/ojphi.v8i1.6415"Harmon, KJ., Proescholdbell, S., Marshall, S., & Waller, A. (2014). Utilization of emergency department data for drug overdose surveillance in North Carolina. Online Journal of Public Health Informatics 6(1), e174. doi: 10.5210/ojphi.v6i1.5200Harris, J.K., Mansour, R., Choucair, B., Olson, J., Nissen, C., & Bhatt, J. (2014). Health department use of social media to identify foodborne illness—Chicago, Illinois, 2013-2014. MMWR Morbidity and Mortality Weekly Report 63(32), 681-685. Retrieved from: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6332a1.htm"Harrison, C., Jorder, M., Stern, H., Stavinksy, F., Reddy, V., Hanson, H., Waechter, H., Lowe, L., Gravano, L., & Balter, S. (2014). Using online reviews by restaurant patrons to identify unreported cases of foodborne illness — New York City, 2012–2013. MMWR Morbidity and Mortality Weekly Report 63(20), 441-445. Retrieved from:https://www.cdc.gov/MMWr/preview/mmwrhtml/mm6320a1.htm"Hawkins, J.B., Tuli, G., Kluberg, S., Harris, J., Brownstein, J.S., & Nsoesie, E. (2016). A digital platform for local foodborne illness and outbreak surveillance. Online Journal of Public Health Informatics 8(1), e60. http://dx.doi.org/10.5210/ojphi.v8i1.6474Hines, J.Z., Bancroft, J., Powell, M., & Hedberg, K. (2017). Case finding using syndromic surveillance data during an outbreak of Shiga Toxin–Producing Escherichia coli O26 infections, Oregon, 2015. Public Health Reports, epublication. https://doi.org/10.1177/0033354917708994Hudson, L. T., Klekamp, B.G., & Matthews, S.D. (2017). Local Public Health Surveillance of Heroin-Related Morbidity and Mortality, Orange County, Florida, 2010-2014. Public Health Reports (132), 80S-87SHughes, H.E., Morbey, R., Hughes, T.C., Locker, T.E., Pebody, R., Green, H.K., Ellis, J., Smith, G.E., & Elliot, A.J. (2016). Emergency department syndromic surveillance providing early warning of seasonal respiratory activity in England. Epidemiology and Infection, 144(5), 1052-64. doi: 10.1017/S0950268815002125Hughes, H.E., Morbey, R., Hughes, T.C., Locker, T.E., Shannon, T., Carmichael, C., Murray, V., Ibbotson, S., Catchpole, M., McCloskey, B., Smith, G., & Elliot, A.J. (2014). Using an emergency department syndromic surveillance system to investigate the impact of extreme cold weather events. Public Health, 128(7), 628-635. doi: 10.1016/j.puhe.2014.05.007Ising, A., Proescholdbell, S., Harmon, K.J., Sachdeva, N., Marshall, S.W., & Waller, A.E. (2016). Use of syndromic surveillance data to monitor poisonings and drug overdoses in state and local public health agencies. Injury Prevention 22:i43-i49.http://dx.doi.org/10.1136/injuryprev-2015-041821"Johnson, J. I., & Brown, K. (2015). Validation of emergency department and outpatient data using ILI syndrome classifiers. Online Journal of Public Health Informatics, 7(1), e83. http://doi.org/10.5210/ojphi.v7i1.5749Lall, R., Abdelnabi , J., Ngai, S., Parton, H.B., Saunders, K., Sell, J., Wahnich, A., Weiss, D., Marthes, R.W. (2017). Advancing the Use of Emergency Department Syndromic Surveillance Data, New York City, 2012-2016. Public Health Reports (132), 23S-30SLiljeqvist, H. T., Muscatello, D., Sara, G., Dinh, M., & Lawrence, G. L. (2014). Accuracy of automatic syndromic classification of coded emergency department diagnoses in identifying mental health-related presentations for public health surveillance. BMC Medical Informatics and Decision Making, 14(84). http://doi.org/10.1186/1472-6947-14-84Lober, W. B., Reeder, B., Painter, I., Revere, D., Goldov, K., Bugni, P. F., & Olson, D. R. (2014). Technical description of the Distribute Project: a community-basedsyndromic surveillance system implementation. Online Journal of Public Health Informatics, 5(3), 224. http://doi.org/10.5210/ojphi.v5i3.4938Mathes, R. W., Ito, K., & Matte, T. (2011). Assessing syndromic surveillance of cardiovascular outcomes from emergency department chief complaint data in New York City. Public Library of Science ONE, 6(2), e14677. http://doi.org/10.1371/journal.pone.0014677O’Connell, E. K., Zhang, G., Leguen, F., Llau, A., & Rico, E. (2010). Innovative uses for syndromic surveillance. Emerging Infectious Diseases, 16(4), 669–671. http://doi.org/10.3201/eid1604.090688Rumoro, D.P., Hallock, M.M., Silva, J., Shah, S.C., Gibbs, G., Trenholme G.M., & Waddell, M.J. (2013). Why does Influenza-Like Illness surveillance miss true influenza cases in the emergency department?: Implications for health care providers. Annals of Emergency Medicine, 62(4), S75. https://doi.org/10.1016/j.annemergmed.2013.07.024Samoff E, Waller A, Fleischauer A, et al. Integration of Syndromic Surveillance Data into Public Health Practice at State and Local Levels in North Carolina. Public Health Reports. 2012;127(3):310-317.Savard, N., Bédard, L., Allard, R., & Buckeridge, D.L. (2015). Using age, triage score, and disposition data from emergency department electronic records to improve Influenza-Like Illness surveillance. Journal of the American Medical Informatics Association, 22(3): 688-696. doi: 10.1093/jamia/ocu002Seil, K., Marcum, J., Lall, R., & Stayton, C. (2015). Utility of a near real-time emergency department syndromic surveillance system to track injuries in New York City. Injury Epidemiology, 2(1), 11. http://doi.org/10.1186/s40621-015-0044-5Smith, S., Elliot, A. J., Hajat, S., Bone, A., Smith, G. E., & Kovats, S. (2016). Estimating the burden of heat illness in England during the 2013 summer heatwave using syndromic surveillance. Journal of Epidemiology and Community Health, 70(5), 459–465. http://doi.org/10.1136/jech-2015-206079Stephens, E. (2017). Development of syndrome definitions for acute unintentional drug and heroin overdose. Online Journal of Public Health Informatics, (9)1. http://dx.doi.org/10.5210/ojphi.v9i1.7593.Stigi, K., Baer, A., Duchin, J., & Lofy, K. (2014). Evaluation of electronic ambulatory care data for Influenza-Like Illness surveillance, Washington state. Journal of Public Health Management & Practice, 20(6)580-582.doi: 10.1097/PHH.0b013e3182aaa29bVilain, P., Larrieu, S., Mougin-Damour, K., Marianne Dit Cassou, P.J., Weber, M., Combes, X., & Filleul, L. (2017). Emergency department syndromic surveillance to investigate the health impact and factors associated with alcohol intoxication in Reunion Island. Emergency medicine journal 34(6), 386-390. doi: 10.1136/emermed-2015-204987Walsh, A. (2017). Going beyond chief complaints to identify opioid-related emergency department visits. Online Journal of Public Health Informatics, (9)1. http://dx.doi.org/10.5210/ojphi.v9i1.7617.White, J.R., Berisha, V., Lane, K., Menager, H., Gettel, A., & Braun, C.R. (2017). Evaluation of a Novel Syndromic Surveillance Query for Heat-Related Illness Using Hospital Data From Maricopa County, Arizona, 2015. Public Health Reports (132), 31S-39SYih WK, Deshpande S, Fuller C, et al. Evaluating Real-Time Syndromic Surveillance Signals from Ambulatory Care Data in Four States. Public Health Reports. 2010;125(1):111-120.

ObjectiveTo describe the impact of civil unrest on the mental health of a community in near real-time using syndromic surveillance.IntroductionAs part of a wide-spread community discussion on the presence of monuments to Confederate Civil War figures, the Charlottesville city council voted to remove a statue of General Robert E. Lee.1 Multiple rallies were then held to protest the statue’s removal. A Ku Klux Klan (KKK) rally on July 8, 2017 (MMWR Week 27) and a Unite the Right rally on August 12, 2017 (MMWR Week 32) held in Charlottesville both resulted in violence and media attention.2,3 The violence associated with the Unite the Right rally included fatalities connected to motor vehicle and helicopter crashes.Syndromic surveillance has been used to study the impact of terrorism on a community’s mental health4 while more traditional data sources have looked at the impact of racially-charged civil unrest.5 Syndromic surveillance, however, has not previously been used to document the effect of racially-charged violence on the health of a community.MethodsThe Virginia Department of Health (VDH) analyzed syndromic surveillance data from three emergency departments (EDs) in the Charlottesville area (defined to include Charlottesville city and Albemarle county), regardless of patient residence following the Unite the Right rally. Visits to these EDs between January 1 and September 2, 2017 were analyzed using the Enhanced Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE) and Microsoft SQL 2012. Encounters were identified as acute anxiety-related visits based on an International Classification of Diseases, Tenth Revision (ICD-10) discharge diagnosis beginning with ’F41’. Analyses were conducted using the ESSENCE algorithm EWMA 1.2 and SAS 9.3.ResultsThe greatest number of visits with a primary diagnosis of anxiety in 2017 (N=20) was observed in MMWR week 34 (August 20-26). This represented a statistically significant increase over baseline with a p-value of 0.01.By race, a significant increase over baseline in visits with a primary diagnosis of anxiety was observed among blacks or African Americans. The largest volume of visits was observed in MMWR week 33 with a total of 8 identified visits or 1.8% of total ED visit volume. The increase in visits for anxiety observed in weeks 33-35 was 2.2 times greater among blacks or African Americans than it was among whites, p = 0.016, 95% CI [1.14, 4.16].ConclusionsPrevious work done in Virginia to identify ED visits related to anxiety included only chief complaint criteria in the syndrome definition. Due to a change in how one ED in the Charlottesville area reported data during the study period, this syndrome definition could not be applied. In order to remove any potential data artifacts, only those visits with an initial diagnosis of anxiety were included in the analysis. The resulting syndrome definition likely underestimated the occurrence of anxiety in the Charlottesville area, both because it lacked chief complaint information and because syndromic surveillance does not include data on visits to mental health providers outside of EDs. This analysis presents a trend over time rather than a true measure of the prevalence of anxiety.This analysis, while conservative in its inclusion criteria, still identified an increase in visits for anxiety, particularly among blacks or African Americans. In today’s political environment of race-related civil unrest, a way to measure the burden of mental illness occurring in the community can be invaluable for public health response. In Charlottesville, the identification of a community-wide need for mental health support prompted many local providers to offer their services to those in need pro-bono.6References1 Suarez, C. (2017, February 6). Charlottesville City Council votes to remove statue from Lee Park. The Daily Progress. Retrieved from http://bit.ly/2wYOHhv2 Spencer, H., & Stevens, M. (2017, July 8). 23 Arrested and Tear Gas Deployed After a K.K.K. Rally in Virginia. The New York Times. Retrieved from http://nyti.ms/2tCiBGU3 Hanna, J., Hartung, K., Sayers, D., & Almasy, S. (2017, August 13). Virginia governor to white nationalists: ‘Go home … shame on you’. CNN. Retrieved from http://cnn.it/2vvAGHt4 Vandentorren, S., Paty, A. C., Baffert, E., Chansard, P., Caserio-Schönemann, C. (2016, February). Syndromic surveillance during the Paris terrorist attacks. The Lancet (387(10021), 846-847. doi:10.1016/S0140-6736(16)00507-95 Yimgang, D. P., Wang, Y., Paik, G., Hager, E. R., & Black, M. M. Civil Unrest in the Context of Chronic Community Violence: Impact on Maternal Depressive Symptoms. American Journal of Public Health 107(9), 1455-1462. doi:10.2105/AJPH.2017.3038766 DeLuca, P. (2017, August 19). Downtown Charlottesville Library Offers Free Counseling. NBC29.com. Retrieved from http://bit.ly/2yIzHbl

Pentingnya membangun OCB tidak lepas dari komitmen karyawan dalam organisasi. Komitmen karyawan akan mendorong terciptanya OCB dan tanpa adanya kontrol yang baik dalam pemberian kompensasi yang sesuai dengan hasil kerja tentunya memperlambat kerja pegawai. Penelitian ini bertujuan untuk menguji dan menganalisis pengaruh kompensasi dan komitmen organisasi terhadap kepuasan kerja dan OCB. Jumlah responden dalam penelitian ini berjumlah 86 orang. Pengumpulan data diperoleh dengan kuesioner menggunakan skala likert. Metode analisis data menggunakan Path Analysis. Hasil penelitian diperoleh bahwa kompensasi berpengaruh positif dan signifikan terhadap kepuasan kerja dan Kepuasan kerja berpengaruh positif dan signifikan terhadap OCB. Kata Kunci : Komitmen Organisasi, Kompensasi, Kepuasan kerja dan OCBDAFTAR PUSTAKA Bangun, Wilson. (2012). Manajemen Sumber Daya Manusia. Erlangga. Jakarta. Bernardin, H. John, & Joyce E.A Russel. (2003). Human resource management(An Experimental Approach International Edition). Mc. Graw-Hill Inc. Singapore. Baedhowi. (2007). Manajemen Sumber Daya Manusia. Pelita Insani. Semarang Bigliardi, Barbara & Albert, Ivo Dormio. (2012). The Impact of Organizational Culture on The Job Satisfaction of Knowledge Workers. Emerald Group. Vol.2 No.1, 36-51.Blau, P.M. (1964). Exchange and Power in Social Life. Transaction Publishers. Wiley, New York, NY.Bohlander, George, & Snell, Scott. (2010). Principles of Human Resource. Management, 15th ed. Mason, OH: South Western – Cengage Learning Boon, C. & Hartog, D.D. (2014). Human Resource Management and Organizational Citizenship Behavior The Mediating Role of Job Satisfaction. Netherland: Scriptiesonline.uba.uva.nl Cassio, Wayne F. (1997). Managing Human Resources, Productivity, Quality of Work Life Product Fourth Edition, New York: McGraw Hill International. Chinyere N. I. (2013). Job Satisfaction and Organizational Citizenship Behavior of Library Personnel in Selected Nigerian Universities. International Journal of Science and Research (IJSR) ISSN (Online): 2319-7064 Colquitt, Jason A., Jeffery A. LePine., Michael J. Wesson. (2011). Organizational Behaviour. New York: McGraw-Hill International Companies. Delery, E. J. & Doty, H. D. (1996). Modes of Theorizing in Strategic Human ResourcecManagement: Tests of Universalistic, Contingency, and Configurationally PerformancecPredictions, Academy of Management Journal, 39(4), 802–35. Dewi, S., Suwandana, Made. (2016). Pengaruh Kepuasan Kerja Terhadap Organizational Citizenship Behavior (OCB) Dengan Komitmen Organisasional Sebagai Variabel Mediasi. E-Jurnal Manajemen Unud, Vol. 5 No.9 : 5643-5670. Darma, P.S & Supryanto, Achmad.S. (2017). The effect of compensation on satisfaction and employe performance. Management and Economics Journal. E-ISSN: 2598-9537 P-ISSN: 2599-3402. Journal Home Page: http://ejournal.uin-malang.ac.id/index.php/mec. De Saa-Perez, P. & JM. Garcia-Falcon. (2002). A Resource-based View of Human Resource Management & Organizational Capabilities Development. International Journal of Human Resource Management. Vol. 13. 123–40. Dewanggana, B.D., Paramita, P.D. & Haryono, A.T. (2016). Pengaruh Komitmen Organisasi, Kepuasan Kerja, Budaya Organisasi Terhadap Organizational Citizenship Behavior (OCB) Yang Berdampak Pada Prestasi Kerja Karyawan (Studi Pada PT. PLN App Semarang). Journal Of Management, Vol. 2 No. 2 Edy Sutrisno, (2014). Manajemen Sumber Daya Manusia. Cetak Ke Enam. Pranada Media Group. Jakarta. Fahmi, Irham. (2014). Analisa kinerja keuangan. Alfabeta. Bandung. Fitrianasari,D.,Nimran,U.,&Utami,H.,N. (2013).Pengaruh Kompensasi DanKepuasanKerja Terhadap OrganizationalCitizenship Behavior(OCB)dan Kinerja Karyawan. (Studi pada Perawat Rumah SakitUmum “Darmayu”di KabupatenPonorogo”). Jurnal ProfitVol.7 No.1Flippo, Edwin B (1997). Manajemen Personalia, Edisi Indonesia. ErlangaJakarta. Guest, D. (1997). Human Resource Management and Performance: A Review and Research Agenda. The International Journal of Human Resource Management. Vol. 8 (3). 263-76. Hartono, B & Setiawan, R. (2013). Judul penelitian Pengaruh Komitmen Organisasional Terhadap Kepuasan Kerja Karyawan Paparon’s Pizza City Of Tomorrow. AGORAVol.1, No.1, 1-8. Hasibuan, Malayu. (2012). Manajemen Sumber Daya Manusia dan Kunci Keberhasilan. Haji Mas Agung. Jakarta. Handoko,THani.(2014).Manajemen Personalia &SumberdayaManusia.Edisi Kedua.Cetakan Ke-21. BPFE-Yogyakarta. Yogyakarta. Indrawati, Endang Sri. dan Nafi’, C. (2017). Hubungan Antara Kepuasan Kerja Dengan Organizational Citizenship Behavior Pada Karyawan CV. Elfa’s Kudus. Jurnal Empati. Vol. 7 No. 3, 134 – 145. Joarder, M. H. R., Sharif, M. Y., & Ahmmed, K. (2011). Mediating role of affectivecommitment in hrm practices and turnover intention. relationship: a study in adeveloping context. Business and Economics Research Journal, Vol 2 (4), 135–158. Kamel B., El Amine M.B., and Abdeljalil M., (2015). Relationship between Job Satisfaction and Organizational Citizenship Behavior in the National Company for Distribution of Electricity and Gas.European Journal of Business and Management Vol.7, No.30 1-6 Khan, A.H.,Muhammad M.N., Muhammad A &Wasim, H. (2012). Impact ofJob Satisfaction onEmployee Performance:An Empirical Study of Autonomous MedicalInstitutions of Pakistan.African Journalof Business Management,Vol. 6, 2697-2705 Kreitner, R &Kinicki, A. (2014). Perilaku Organisasi. Salemba Empat. Jakarta. Kurniawan, A. (2015). Pengaruh Komitmen Organisasi Terhadap Organizational Citizenship Behavior (OCB) PT X Bandung. Jurnal Manajemen, Vol.15 No.1, 95-118. Kwantes, Karam, Kuo, & Towson. (2009). Culture's influence on the perception of OCB as in-role or extra-role. Kanada. International Journal of Intercultural Relations Luthans, Fred. (2006). Perilaku Organisasi edisi 10. Penerbit ANDI. Yogyakarta. Mangkunegara, A.A. Anwar Prabu. 2013.Manajemen Sumber Daya ManusiaPerusahaan.RemajaRosdakarya. Bandung. Mathis, R.L. & J.H. Jackson. (2006). Human Resource Management: Manajemen Sumber Daya Manusia. Terjemahan Dian Angelia. Salemba Empat. Jakarta. ----------------------------------. (2011). Human Resource Management: Manajemen Sumber Daya Manusia. Terjemahan Dian Angelia. Salemba Empat. Jakarta. Mehboob & Bhutto. (2012). Job Satisfaction as a Predictor of Organizational Citizenship Behavior A Study of Faculty Members at Business Institutes. Jurnal Ilmu Pendidikan, (Online) Vol. 3, No 9(http://www.journal-archieves14.webs.com/1447-1455.pdf) Mondy,R Wayne. (2008).ManajemenSumberDaya Manusia. Jilid 2Edisi 10. PenerbitErlangga. Jakarta. Muguongo, Muguna,, Muriithi. (2015). Effects of Compensation on Job Satisfaction Among Secondary School Teachers in Maara Sub - County o Tharaka Nithi County, Kenya”, Published online October 10, 2015 (http://www.sciencepublishinggroup.com/j/jhrm) ISSN: 2331-0707 (Print); ISSN: 2331-0715 (Online) Nazar, Omer Abdallah Ahmed. (2016). Impact of Human Resource Management Practices on Organizational Citizenship Behavior: An Empirical Investigation from Banking Sector of Sudan. International Review of Management and Marketing. Vol. 6(4), 964-973. Nursyamsi. (2013). Organizational Citizenship Behavior dan Pemberdayaan terhadap Komitmen Organisasi serta Dampaknya terhadap Kinerja Karyawan. Jurnal Keuangan dan Perbankan Vol. 17 No 3, 488-498. Nurandini, A & Lataruva, E. (2014). Judul penelitian Analisis Pengaruh Komitmen Organisasi Terhadap Kinerja Karyawan (Studi Pada Pegawai Perum PERUMNAS Jakarta). JurnalStudiManajemen& Organisasi Vol 11, 78–91. Omer, N. & Ahmed, A. (2017). Impact of Human Resource Management Practices on Organizational Citizenship Behavior: An Empirical Investigation from Banking Sector of Sudan. International Review of Management and Marketing. Vol. 6(4), 964-973. Oyeniyi, K.O, Afolabi, M.A, Olayanju, Mufutau (2014). Effect of Human Resource Management Practices on Job Satisfaction: An Empirical Investigation of Nigeria Banks. International Journal of Academic Research in Business and Social Sciences, Vol. 4, No. 8, 243-251. Organ, D. W. (1990). The motivational basis of organizational citizen ship behavior. In B. M. Staw, & L. L. Cummings (Eds.), Research in organizational behavior (pp. 43-72). Greenwich, CT: JAI Press. Organ, D. W., Podsakoff, P. M., & MacKenzie, S. B. (2006). Organizational citizenship behavior: Its nature, antecedents, and consequences. Thousand Oaks, CA: SAGE. Pala, Fikri. Eker, Semith dkk.2008. The effect of demographic characteristic on organizational commitment and job satisfaction : An Empirical study on Turkish health care staff. The journal of industrial relations and human resources Vol. 10 No. 2 Purwanto, A.H. (2011). Pengaruh Kualitas Layanan Internal dan Orientasi Pemberi Layanan Terhadap Kinerja Pegawai di Kantor Perijinan Kabupaten Lamongan. Jurnal Psikosains. Vol. 3(1) : 55-72. Priyatno, Duwi. (2011). Buku Saku Analisis Statistik Data. Penerbit Media Kom. Yogyakarta. Prowse, Peter & Prowse, Julie. (2009). The dilemma of performance appraisal. Measuring Business Excellence, 13 (4) : 69 – 77. Podsakoff P.M, Michae Ahearne, MacKenzie S.B (1997). Organizational Citizenship Behavior and the Quantity of Work Group Perpormance. American Psychological Association. Vol. 82 No. 2, 262-270. Rahayu, N.M.N & Riana, I.G. (2017). Pengaruh Kompensasi Terhadap Kepuasan Kerja dan Keinginan Keluar Pada Hotel Amaris Legian. E-JurnalManajemen Unud, Vol. 6,No. 11, 5804-5833 Ramadhani, A.A (2013). Pengaruh Kompensasi Terhadap Motivasi Kerja Di PT. Pos Indonesia (Persero) Bandung. Skripsi: Program Studi Manajemen, Universitas Pendidikan Indonesia. (http://repository.upi.edu/1299/ [16 November 2013]Rahmayanti, Febriana, dan Dewi. (2014). Faktor-Faktor yang MempengaruhiOrganizationalCitizenshipBehavior(OCB).JurnalEcopsyVol.1No.3 Retnoningsih, T., Sunuharjo, B.S & Ruhana, I. 2015. Pengaruh Kompensasi Terhadap Kepuasan Kerja Dan Kinerja Karyawan (Studi Pada Karyawan PT PLN (Persero) Distribusi Jawa Timur Area Malang). Richard L. Hughes, Robert C. Ginnett, and Gordon J. Curphy. (2012). Leadership, Enhancing the Lessons of Experience, Alih Bahasa: Putri Izzati. Salemba Humanika. Jakarta. Robbins, S.P., & Judge, T.A. (2008). Perilaku organisasi. organizational behavior. buku 1. edisi 12. Penerjemah: Angelica, D., Cahyani, R., dan Rosyid, A. Salemba Empat. Jakarta. Robbins, S. P. & Coulter, M. (2012). Management (11th ed.). Prentice Hall: River, N.J. Robbins, S.P dan Judge T.A. (2015).Perilaku Organisasi.SalembaEmpat. Jakarta. Rozzaid, Y., Toni Herlambang, T & dan Devi, A.M. (2015). Pengaruh Kompensasi Dan Motivasi Terhadap Kepuasan Kerja Karyawan (Studi Kasus Pada PT. Nusapro Telemedia Persada Cabang Banyuwangi). Jurnal ManajemenDanBisnis IndonesiaVol. 1No. 2, 201-220. Saleem, Sharjeel & Saba, Amin. (2013). The Impact of Organizational Support for Career Development and Supervisory Suppoert on Employee Performance : An Emperical Study From Pakistani Academic Sector. Europen Journal of Business and Management. 5 (5) : 194-207. Samsudin, Sadili. (2010). Manajemen Sumber Daya Manusia. Pustaka Setia. Bandung. Sasilu, J.B, Chinyio & Sures, S. (2015). The impact of compensation on the job satisfaction of public sector construction workers of jigawa state of Nigeria. The Business and Management Review. Vol. 6 No. 4.Schneider, B., dan Bowen, D.E. (1985). Employee and customer perceptions of service in bank: Replication and extension. Journal of Applied Psychology. Vol 70, 423-433. Sekaran, Uma. (2014). Metodologi Penelitian untuk Bisnis (Research Methods for Business). Salemba Empat. Jakarta. Siagian, Sondang., P. (2013). Manajemen Sumber Daya Manusia. Binapura Aksara. Jakarta. --------------------------, (2008). Manajemen Sumber Daya Manusia (EdisiPertama). Binapura Aksara. Jakarta. Siregar, S & Prasetio, A.P. (2015). Pengaruh Kepuasan Kerja dan Komikmen Organisasi Terhadap Organizational Citizenship Behavior (Prilaku OCB) Karyawan Kantor Distribusi PT. PLN (Persero) Distribusi Jawa Barat Dan Banten. E-Proceeding ofManagement.Vol.2 no.3Society for Human Resource Management. (2012). EmployeeJob Satisfaction and Engagement. A research report by SHRM. Retrieved from www.shrmstore. shrm.org. Solihin, Dadang. (2013). Optimalisasi Otonomi Daerah Kebijakan, Strategi dan Upaya. Yayasan Empat Sembilan. Jakarta. Srimulyani, V. A. (2009). Tipilogi dan Anteseden Komitmen Organisasi. Jurnal Ilmiah Widya Wana. Vol. 33 (1), 1-20. Steven, H Appelbaum, Michel Roy & Terry Gilliland. (2011). Globalization of performance appraisals: theory and applications. Management Decision, Vol. 49 (4) : 570-585. Subekhi, A. (2012). Pengantar Manajemen Sumber DayaManusia.PrestasiPustakaJakarta. Jakarta. Sugiyono. (2013). Metode Penelitian Kuantitatif Kualitatif dan R&D. Alfabeta. Bandung. Sutrisno,E. (2011).ManajemenSumberDayaManusia. PrenadaMediaGroup.Jakarta. Tan, R&Tarigan, Z.J.H. (2017). PengaruhKompensasiDanKepuasanKerjaTerhadap OrganizationalCitizenshipBehavior(OCB)MelaluiMotivasi KerjaSebagaiVariabelInterveningPada3HMotosport. AGORAVol. 5,No. 1 Titisari, Purnamie. (2014). Peranan Organizational Citizenship Behaviour (OCB) dalam Meningkatkan Kinerja Karyawan. Mitra Wacana Media. Jakarta. Uma Sankar Mishra, Aurolipy, Madhusmita Dash. (2017). Impact of HRM Practices on Job Satisfaction and Performance: An Empirical Study in Health Care Sector. International journal of economic research. Vol. 14, No. 1 Umar, Husein. (2003). Riset Sumber Daya Manusia Dalam Organisasi. Penerbit Gramedia Pustaka Utama. Jakarta. Wexley, Kenneth. & Gary Yukl. (2003). Perilaku organisasi dan psikologi personalia. Rineka Cipta. Jakarta. Wibowo. (2016). Manajemen Kinerja. PT. Rajagrafindo Persada. Jakarta. Widodo, SE. (2015). Manajemen Pengembangan Sumber Daya Manusia. Pustaka Pelajar. Yogyakarta. Yani. (2012). Manajemen Sumber Daya Manusia. Mitra Wacana Media. Jakarta.Zaenabadi, H. (2010). Job satisfaction and organizational commitment as antecedents of Organizational Citizenship Behavior (OCB) of teachers. Procedia Social and Behavioral Sciences Vol. 5 : 998–1003.

Photo by Richard Catabay on Unsplash ABSTRACT COVID-19 exposed deep-rooted structural inequities. Allocation protocols developed during COVID-19 may cause furtherance of structural inequalities. In this essay, I specifically address the issue of structural inequities in the context of resource allocation during a period of crisis standard of care. In response to the increasing evidence of structural inequities during the pandemic, physicians and bioethicists Douglas White and Bernard Lo proposed incorporating a correction factor into resource allocation protocols. According to them, this would provide an advantage for disadvantaged individuals. The proposed correction factors use the Area Deprivation Index to determine eligibility. I argue that the correction factor is ethically justified and supported by Rawls’s difference principle, Daniels’s equality of opportunity, and Harris’s double jeopardy argument. I also suggest that the proposed correction factor does not go far enough, particularly if used with other objective factors, such as SOFA scoring. At least one study shows that using SOFA scoring for resource allocation during COVID-19 has a discriminatory effect on non-Hispanic black patients. One problem with the correction factor using the ADI is that it only applies to those currently in the reflected socioeconomic status. Additionally, when only one hospital serves a largely socioeconomically disadvantaged community, all admissions will fall within the targeted category for application of the correction factor. Thus, further actions are needed to dismantle structural inequities, such as implementing load balancing or the planned sharing of resources among healthcare systems. INTRODUCTION COVID-19 forced deep-rooted structural inequities to the surface. SARS-CoV-2 was a novel virus, but the connection between structural inequities and the disparate impact of the virus on marginalized populations is not. The history of pandemics reflects how much structural inequities negatively influence health equity.[1] The lack of preparedness and response to the structural inequities exemplify “blistering systemic failures.”[2] Despite warnings from prior threats from SARS and H1N1, we were unprepared for COVID-19. Antommaria and Chelen show that one-half of responding hospitals did not have an allocation protocol in place.[3] When an influx of critically ill patients and limited resources required implementing a crisis standard of care, many hospitals quickly established protocols addressing the allocation of scarce resources. Most crisis standard of care (CSC) protocols reflect public health’s utilitarian focus on saving the most lives.[4] The utilitarian focus ignores the disproportionate impact resulting from structural inequities. In December 2020, two physicians and bioethicists, Douglas White and Bernard Lo responded to the increasing evidence of the disproportionate impact of COVID-19 on disadvantaged communities by adding a correction factor to their CSC resource allocation protocol. The correction factor adjusts triage scores of individuals living in the most disadvantaged neighborhoods by subtracting one point from the triage score.[5] Patients with lower triage scores are more likely to receive life-saving care. Thus, subtracting a point provides an advantage. The correction factor uses a composite measure of disadvantage to determine eligibility called the Area Deprivation Index (ADI).[6] The ADI is a geographic measure of socioeconomic disadvantage that calculates an aggregate disadvantage score on a 10-point scale. The ADI measures seventeen elements of disadvantage related to poverty, education, employment, physical environment, and infrastructure.[7] The correction factor compensates for structural injustices by using ADI scores of patients in the highest quartile of socioeconomic disadvantage or having an ADI score of 8 to 10 since the strongest association between ADI scores and health outcomes occurs at the highest ADI levels.[8] l. Ethical Justifications Various theories of justice support applying the correction factor in the allocation of scarce resources. Rawls’s difference principle provides an ethical justification for the correction factor as it benefits the worse off in the event of resource allocation.[9] Applying the correction factor and subtracting one point from the triage score admittedly creates inequality among two otherwise like patients, but it is justified under Rawls’s theory since it gives the advantage to the least advantaged, addressing equity. Norman Daniels’ argument for protecting fair “equality of opportunity” also supports the correction factor.[10] The correction factor protects the equality of opportunity for those denied access to care because of deep-rooted structural inequities exacerbated by the pandemic. Using the correction factor to provide access to life-saving resources compensates patients with diminished opportunities in other arenas like the social determinants of health. Derek Parfit’s deontic egalitarianism supports the correction factor. Under Parfit’s view of deontic egalitarianism, justification of giving an advantage to the worse off depends on the reason for the inequality. If the unequal status results from circumstances such as a genetic condition or an accidental injury, like Daniel’s equality of opportunity, deontic egalitarianism does not support giving an advantage to the worse-off. If the unequal position results from the unjust actions of another, such as discriminatory treatment of people of color, deontic egalitarianism supports providing the advantage to address the inequity.[11] The disproportionate impact of resource allocation results from unjust treatment such as discrimination and structural inequity.[12] John Harris’s double jeopardy argument adds additional support to the correction factor in that[13] the socioeconomically disadvantaged or those facing racial or ethnic discrimination may have had an increased risk of contracting COVID-19 or having a severe case or death due to structural inequities. If the triage procedures do not compensate for the structural inequities and they are precluded access to critical care based only on traditional triage, they will suffer double jeopardy. The correction factor avoids this double jeopardy. ll. Operationalizing the Correction Factor Those opposing the correction factor might assert the infeasibility of mitigating inequities during a pandemic.[14] Yet one large US health system successfully applied similar criteria in allocating remdesivir[15] and the National Academy of Medicine endorsed disparity-mitigating criteria for allocating scarce vaccines.[16] Applying the correction factor is neither time nor resource intensive. It will not divert resources from the goal of treating illness and reducing morbidity. With the data available about COVID-19’s disproportionate impact, not applying an available tool to lessen inequities is an abrogation of ethical duty. One utilitarian argument asserts that we will save fewer lives if the prioritized patients are more likely to die despite interventions. Yet society bears responsibility for the social policies that created the disparities. Thus, there is an obligation to mitigate those societal problems, even when doing so might save fewer lives.[17] Some clinicians argue that they should have discretion in determining triage scores. This objection to the correction factor in formulating triage procedures reflects the conflict between clinical and public health ethics. Implementing a CSC protocol shifts decision-making from the clinician to a triage committee and from an individual focus to a community focus. Allowing clinicians to determine triage protocols would increase the risk of decisions based on bias and subjectivity. Another open question is whether the correction factor will achieve the intended goal. Nancy Kass suggests that without evidence to support the effectiveness, we cannot ethically implement the policy.[18] Thus, applying the Kass analysis, diverting a scarce resource to someone less likely to survive should require proof that doing so systematically would resolve or improve structural inequity. There is limited empirical evidence, but we may proceed with caution based on the presumptive data and the hypothesis that a triage allocation that uses a correction factor could help. Computer-based modeling or “tabletop” exercises applying the framework to actual patients but not enacting the protocols could assess the possible effects of the protocols.[19] Perhaps the most robust rebuttal in response to the opposition of applying a correction factor is in an argument proffered by Douglas White that no reasonable triage framework maximizes health outcomes if it creates significant inequalities.[20] White’s argument emphasizes the importance of addressing inequity. lll. A More Robust Version of the Correction Factor The burdens associated with any public health intervention typically fall into three categories:[21] privacy and confidentiality, risk to liberty and self-determination, and justice. Most burdens associated with allocating scarce resources fall under the justice category. I not only disagree with the arguments against using a correction factor, but I also argue that the correction factor does not go far enough. First, using the ADI neglects consideration of people of color disproportionately affected by COVID-19 no longer living in a neighborhood with the highest ADI scores. Based on new research, Sequential Organ Failure Assessment (SOFA) scores are also potentially discriminatory and not ideal for addressing structural inequity, racism, or ethnic discrimination in the triage setting, although they are applied to triage.[22] Second, public hospitals in socioeconomically depressed communities and rural locations may serve a population in which nearly the entire community will have ADI scores that qualify for application of the correction factor. lV. Relying on ADI cannot protect all people disadvantaged due to their race or ethnicity The ADI uses seventeen measures of socioeconomic disadvantage. Some racial inequality in healthcare is unrelated to socioeconomic status and can be missed by ADI. Racial inequality in healthcare may be directly related to implicit and explicit bias and past and current discrimination. But the correction factor will not help the Black patient not currently residing in a highly disadvantaged neighborhood or experiencing other vestiges of racism in the form of socioeconomic disadvantage. A correction factor that uses more information than ADI could make up for some of the weaknesses of SOFA as well. V. When all patients have high ADI Scores What happens when triaging occurs in hospitals serving populations where almost all patients have ADI scores of 8 to 10? To illustrate, I will use the example of Belle Glade, Florida, in western Palm Beach County.[23] The overwhelming majority of the neighborhoods served by the one public hospital, Lakeside Medical Center, is at a level 10 state decile, with a few neighborhoods at 8 and 9 state decile.[24] During a surge in that hospital, the correction factor will apply to every patient. The hospital must then resort to other considerations, such as random allocation. This potential dilemma suggests the need to consider further steps, such as load balancing, to lessen the inequities. Vl. Load Balancing Load balancing is a plan in which hospitals report daily census and available beds. Patients are diverted or transferred to hospitals with open beds when one hospital is at maximum capacity. Although identified as a method to avoid the need for triaging, I suggest load balancing is also equity balancing, especially when the overwhelmed hospital is in a high ADI area. Failures in load balancing exacerbate the harm to disadvantaged populations. Disadvantaged individuals are more likely to seek treatment in hospitals with limited ability to increase capacity or care for many critically ill patients. During surges in COVID-19, hospitals in poor neighborhoods were overrun by admissions and lacked resources to treat, while nearby private hospitals had available beds and resources.[25] The Arizona Department of Health Services developed an effective load-balancing system to coordinate the statewide transfer of patients from overloaded hospitals to other hospitals.[26] The system dramatically improved access to care for people of color and rural populations.[27] One of the state’s foremost responsibilities is safeguarding the health and well-being of people threatened when health systems fail to cooperate. Voluntary load balancing is preferable, but if the healthcare systems are unwilling to cooperate and if voluntary efforts are ineffective, state governments should intervene and require private hospitals to take part in load balancing. When needed, public health officials should issue emergency orders to require hospitals to participate in load-balancing efforts, including accepting patient transfers that are not part of their covered population. CONCLUSION Rawls’s difference principle, Daniels’s equality of opportunity, Parfit’s deontic egalitarianism, and Harris’s double jeopardy argument all justify and may even compel using the correction factor. COVID-19 turned academic and hypothetical discussions and debates about allocating scarce resources and making untenable choices of who lives and who dies to real-life responsibilities. Once hospitals move to a crisis standard of care, they may need to allocate scarce resources, so having systems in place that can compensate for past inequities and improve fairness in access to care is the ethical imperative. Dismantling structural inequities and reassessing allocation protocols should incorporate the correction factor as a new foundational framework and then build on it using load balancing and exercising caution if applying SOFA. It is an ethical responsibility to use these tools to dismantle the pervasive structural inequities when allocating scarce resources. - [1] Goldberg, Daniel S. “Against the Medicalization of Public Health (Ethics).” Public Health Ethics 14, no. 2 (2021): 117–19. https://doi.org/10.1093/phe/phab024. [2] Morrissey, Mary Beth, and Jorge L. Rivera-Agosto. “Protecting the Public's Health in Pandemics: Reflections on Policy Deliberation and the Role of Civil Society in Democracy.” Frontiers in Public Health 9 (June 1, 2021): 6. https://doi.org/10.3389/fpubh.2021.678210. [3] Antommaria, Armand H., Tyler S. Gibb, Amy L. McGuire, Paul Root Wolpe, Matthew K. Wynia, Megan K. Applewhite, Arthur Caplan, et al. “Ventilator Triage Policies during the Covid-19 Pandemic at U.S. Hospitals Associated with Members of the Association of Bioethics Program Directors.” Annals of Internal Medicine 173, no. 3 (April 4, 2020): 188–94. https://doi.org/10.7326/m20-1738; Chelan, Julia S., Douglas B. White, Stephanie Zaza, Amanda N. Perry, Deborah S. Feifer, Maia L. Crawford, and Amber E. Barnato. “US Ventilator Allocation and Patient Triage Policies in Anticipation of the Covid-19 Surge.” Health Security 19, no. 5 (2021): 459–67. https://doi.org/10.1089/hs.2020.0166. [4] Lin, Janet Y., and Lisa Anderson-Shaw. “Rationing of Resources: Ethical Issues in Disasters and Epidemic Situations.” Prehospital and Disaster Medicine 24, no. 3 (2009): 215–21. https://doi.org/10.1017/s1049023x0000683x. [5] Executive Summary Allocation of Scarce Critical Care Resources during a ...,” April 9, 2021. https://ccm.pitt.edu/sites/default/files/Model%20hospital%20policy%20for%20allocation%20of%20critical%20care_2020-03-23%20web.pdf. [6]. Executive Summary Allocation of Scarce Critical Care Resources during a ...,” April 9, 2021. https://ccm.pitt.edu/sites/default/files/Model%20hospital%20policy%20for%20allocation%20of%20critical%20care_2020-03-23%20web.pdf. [7] https://www.neighborhoodatlas.medicine.wisc.edu/mapping; Executive Summary Allocation of Scarce Critical Care Resources during a ...,” April 9, 2021. [8] White, Douglas B., and Bernard Lo. “Structural Inequities, Fair Opportunity, and the Allocation of Scarce ICU Resources.” Hastings Center Report 51, no. 5 (2021): 42–47. https://doi.org/10.1002/hast.1285 [9] McKie, John, and Jeff Richardson. “The Rule of Rescue.” Social Science and Medicine 56 (2003): 2407–19 [10] Daniels, Norman. “Justice, Health, and Health Care.” Essay. In Medicine and Social Justice Essays on the Distribution of Health Care, edited by Rosamond Rodes, Margaret P Battin, and Anita Silvers, Seconded., 17–33. Oxford University Press, n.d. [11] Brock, Dan W. “Priority to the Worse Off in Health Care Resource Prioritization .” Essay. In Medicine and Social Justice Essays on the Distribution of Health Care, edited by Rosamond Rhodes, Margaret Battin, and Anita Silvers, 155–64. Oxford University Press, n.d. [12] Brock, Dan W. “Priority to the Worse Off in Health Care Resource Prioritization .” Essay. In Medicine and Social Justice Essays on the Distribution of Health Care, edited by Rosamond Rhodes, Margaret Battin, and Anita Silvers, 155–64. Oxford University Press, n.d. [13] Harris, J. “Qualifying the Value of Life.” Journal of Medical Ethics 13, no. 3 (1987): 117–23. https://doi.org/10.1136/jme.13.3.117. [14] White, Douglas B., and Bernard Lo. “Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic.” American Journal of Respiratory and Critical Care Medicine 203, no. 3 (February 1, 2021): 287–95. https://doi.org/10.1164/rccm.202010-3809cp. [15] White, Douglas B., and Bernard Lo. “Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic.” American Journal of Respiratory and Critical Care Medicine 203, no. 3 (February 1, 2021): 287–95. https://doi.org/10.1164/rccm.202010-3809cp. [16] White, Douglas B., and Bernard Lo. “Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic.” American Journal of Respiratory and Critical Care Medicine 203, no. 3 (February 1, 2021): 287–95. https://doi.org/10.1164/rccm.202010-3809cp. [17] White, Douglas B., and Bernard Lo. “Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic.” American Journal of Respiratory and Critical Care Medicine 203, no. 3 (February 1, 2021): 287–95. https://doi.org/10.1164/rccm.202010-3809cp. [18] Kass, Nancy E. “An Ethics Framework for Public Health.” American Journal of Public Health 91, no. 11 (November 2001): 1776–82. https://doi.org/10.2105/ajph.91.11.1776. [19] White, Douglas B., and Bernard Lo. “Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic.” American Journal of Respiratory and Critical Care Medicine 203, no. 3 (February 1, 2021): 287–95. https://doi.org/10.1164/rccm.202010-3809cp. [20] White, Supra.12 [21] Kass, Nancy E. “An Ethics Framework for Public Health.” American Journal of Public Health 91, no. 11 (November 2001): 1776–82. https://doi.org/10.2105/ajph.91.11.1776. [22] Tolchin, Benjamin, Carol Oladele, Deron Galusha, Nitu Kashyap, Mary Showstark, Jennifer Bonito, Michelle C. Salazar, et al. “Racial Disparities in the SOFA Score among Patients Hospitalized with Covid-19.” PLOS ONE. Public Library of Science, September 17, 2021. https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0257608; SOFA is a prognostic scoring system that assigns points for organ failure evidence within six different organ systems. Higher SOFA scores correlate with higher mortality. New research by Tolchin reveals the flaws in SOFA due to its failure to account for delays in seeking care and overestimates of Black mortality. Also see Antommaria, Armand H., Tyler S. Gibb, Amy L. McGuire, Paul Root Wolpe, Matthew K. Wynia, Megan K. Applewhite, Arthur Caplan, et al. “Ventilator Triage Policies during the Covid-19 Pandemic at U.S. Hospitals Associated with Members of the Association of Bioethics Program Directors.” Annals of Internal Medicine 173, no. 3 (April 4, 2020): 188–94. https://doi.org/10.7326/m20-1738; Chelen, Julia S., Douglas B. White, Stephanie Zaza, Amanda N. Perry, Deborah S. Feifer, Maia L. Crawford, and Amber E. Barnato. “US Ventilator Allocation and Patient Triage Policies in Anticipation of the Covid-19 Surge.” Health Security 19, no. 5 (2021): 459–67. https://doi.org/10.1089/hs.2020.0166; and Pence, Gregory E. Pandemic Bioethics. Peterborough: Broadview Press, 2021. [23] Black – population 59.28 % Median Household income 24,322 Population 20,276 Education: 31.$ HS; 21.71% less than 95 grade, Postsecondary Asso-7%, Bachelors 6.7, ttps://worldpopulationreview.com/us-cities/belle-glade-fl-population [24] Neighborhood atlas®. Neighborhood Atlas - Mapping. (n.d.). Retrieved February 15, 2022, from https://www.neighborhoodatlas.medicine.wisc.edu/mapping [25] White, Douglas, Keynote Address, American Society of Bioethics and Humanities, October 13, 2021, COVID-19 at the Crossroads, https://eventpilotadmin.com/web/planner.php?id=ASBH21 [26] Angelo, A. (2020, May 26). Latest Covid-19 Model Shows Arizona can Meet a Health Care Surge. Retrieved February 15, 2022, from https://communityimpact.com/phoenix/chandler/coronavirus/2020/05/26/latest-covid-19-model-shows-arizona-can-meet-a-health-care-surge/ [27] White, Douglas, Keynote Address, American Society of Bioethics and Humanities, October 13, 2021, COVID-19 at the Crossroads, https://eventpilotadmin.com/web/planner.php?id=ASBH21

Photo by Jo-Anne McArthur on Unsplash ABSTRACT The UK-based campaign group Scrap Factory Farming has launched a legal challenge against industrial animal agriculture; the challenge is in the process of judicial review. While a fringe movement, Scrap Factory Farming has already accrued some serious backers, including the legal team of Michael Mansfield QC. The premise is that factory farming is a danger not just to animals or the environment but also to human health. According to its stated goals, governments should be given until 2025 to phase out industrialized “concentrated animal feeding organizations” (CAFOs) in favor of more sustainable and safer agriculture. This paper will discuss the bioethical issues involved in Scrap Factory Farming’s legal challenge and argue that an overhaul of factory farming is long overdue. INTRODUCTION A CAFO is a subset of animal feeding operations that has a highly concentrated animal population. CAFOs house at least 1000 beef cows, 2500 pigs, or 125,000 chickens for at least 45 days a year. The animals are often confined in pens or cages to use minimal energy, allowing them to put on as much weight as possible in as short a time. The animals are killed early relative to their total lifespans because the return on investment (the amount of meat produced compared to animal feed) is a curve of diminishing returns. CAFOs’ primary goal is efficiency: fifty billion animals are “processed” in CAFOs every year. The bioethical questions raised by CAFOs include whether it is acceptable to kill the animals, and if so, under what circumstances, whether the animals have rights, and what animal welfare standards should apply. While there are laws and standards in place, they tend to reflect the farm lobby and fail to consider broader animal ethics. Another critical issue applicable to industrial animal agriculture is the problem of the just distribution of scarce resources. There is a finite amount of food that the world can produce, which is, for the moment, approximately enough to go around.[1] The issue is how it goes around. Despite there being enough calories and nutrients on the planet to give all a comfortable life, these calories and nutrients are distributed such that there is excess and waste in much of the global North and rampant starvation and malnutrition in the global South. The problem of distribution can be solved in two ways: either by efficient and just distribution or by increasing net production (either increase productivity or decrease waste) so that even an inefficient and unjust distribution system will probably meet the minimum nutritional standards for all humans. This essay explores four bioethical fields (animal ethics, climate ethics, workers’ rights, and just distribution) as they relate to current industrial agriculture and CAFOs. l. Animal Ethics Two central paradigms characterize animal ethics: welfarism and animal rights. These roughly correspond to the classical frameworks of utilitarianism and deontology. Welfarists[2] hold the common-sense position that animals must be treated well and respected as individuals but do not have inalienable rights in the same ways as humans. A typical welfare position might be, “I believe that animals should be given the best life possible, but there is no inherent evil in using animals for food, so long as they are handled and killed humanely.” Animal rights theorists and activists, on the other hand, would say, “I believe non-human animals should be given the best lives possible, but we should also respect certain rights of theirs analogous to human rights: they should never be killed for food, experimented upon, etc.” Jeremy Bentham famously gave an early exposition of the animal rights case: “The question is not Can they reason?, nor Can they talk?, but Can they suffer? Why should the law refuse its protection to any sensitive being?” Those who take an animal welfare stance have grounds to oppose the treatment of animals in CAFOs as opposed to more traditional grass-fed animal agriculture. CAFOs cannot respect the natural behaviors or needs of animals who evolved socially for millions of years in open plains. If more space was allowed per animal or more time for socialization and other positive experiences in the animal’s life, the yield of the farm would drop. This is not commercially viable in a competitive industry like animal agriculture; thus, there is very little incentive for CAFOs to treat animals well. Rampant abuse is documented.[3] Acts of cruelty are routine: pigs often have teeth pulled and tails docked because they often go mad in their conditions and attempt to cannibalize each other; chickens have their beaks clipped to avoid them pecking at each other, causing immense pain; cows and bulls have their horns burned off to avoid them damaging others (as this damages the final meat product, too); male chicks that hatch in the egg industry are ground up in a macerator, un-anaesthetized, in the first 24 hours of their life as they will not go on to lay eggs. These practices vary widely among factory farms and among jurisdictions. Yet, arguably, the welfare of animals cannot be properly respected because all CAFOs fundamentally see animals as mere products-in-the-making instead of the complex, sentient, and emotional individuals science has repeatedly shown them to be.[4] ll. Climate Ethics The climate impact of farming animals is increasingly evident. Around 15-20 percent of human-made emissions come from animal agriculture.[5] and deforestation to create space for livestock grazing or growing crops to feed farm animals. An average quarter-pound hamburger uses up to six kilograms of feed, causes 66 square feet of deforestation, and uses up to 65 liters of water, with around 4kg of carbon emissions to boot – a majority of which come from the cattle themselves (as opposed to food processing or food miles).[6] According to environmentalist George Monbiot, “Even if you shipped bananas six times around the planet, their impact would be lower than local beef and lamb.”[7] The disparity between the impact of animal and plant-based produce is stark. Not all animal products are created equally. Broadly, there are two ways to farm animals: extensive or intensive farming. Extensive animal farming might be considered a “traditional” way of farming: keeping animals in large fields, as naturally as possible, often rotating them between different areas to not overgraze any one pasture. However, its efficiency is much lower than intensive farming – the style CAFOs use. Intensive animal farming is arguably more environmentally efficient. That is, CAFOs produce more output per unit of natural resource input than extensive systems do. However, environmental efficiency is relative rather than absolute, as the level of intensive animal agriculture leads to large-scale deforestation to produce crops for factory-farmed animals. CAFOs are also point-sources of pollution from the massive quantities of animal waste produced – around 1,000,000 tons per day in the US alone, triple the amount of all human waste produced per day – which has significant negative impacts on human health in the surrounding areas.[8] The environmental impacts of CAFOs must be given serious ethical consideration using new frameworks in climate ethics and bioethics. One example of a land ethic to guide thinking in this area is that “[it] is right when it tends to preserve the integrity, stability, and beauty of the biotic community. It is wrong when it tends otherwise.”[9] It remains to be seen whether CAFOs can operate in a way that respects and preserves “integrity, stability, and beauty” of their local ecosystem, given the facts above. The pollution CAFOs emit affects the surrounding areas. Hog CAFOs are built disproportionately around predominantly minority communities in North Carolina where poverty rates are high.[10] Animal waste carries heavy metals, infectious diseases, and antibiotic-resistant pathogens into nearby water sources and houses. lll. Workers’ Rights The poor treatment of slaughterhouse workers has been documented in the US during the COVID-19 pandemic, where, despite outbreaks of coronavirus among workers, the White House ordered that they remain open to maintain the supply of meat. The staff of slaughterhouses in the US is almost exclusively people with low socioeconomic status, ethnic minorities, and migrants.[11] Almost half of frontline slaughterhouse workers are Hispanic, and a quarter is Black. Additionally, half are immigrants, and a quarter comes from families with limited English proficiency. An eighth live in poverty, with around 45 percent below 200 percent of the poverty line. Only one-in-forty has a college degree or more, while one-in-six lacks health insurance. Employee turnover rates are around 200 percent per year.[12] Injuries are very common in the fast-moving conveyor belt environment with sharp knives, machinery, and a crowd of workers. OSHA found 17 cases of hospitalizations, two body part amputations per week, and loss of an eye every month in the American industrial meat industry. This is three times the workplace accident rate of the average American worker across all industries. Beef and pork workers are likely to suffer repetitive strain at seven times the rate of the rest of the population. One worker told the US Department of Agriculture (USDA) that “every co-worker I know has been injured at some point… I can attest that the line speeds are already too fast to keep up with. Please, I am asking you not to increase them anymore.”[13] Slaughterhouses pose a major risk to public health from zoonotic disease transmission. 20 percent of slaughterhouse workers interviewed in Kenya admit to slaughtering sick animals, which greatly increases the risk of transmitting disease either to a worker further down the production line or a consumer at the supermarket.[14] Moreover, due to poor hygienic conditions and high population density, animals in CAFOs are overfed with antibiotics. Over two-thirds of all antibiotics globally are given to animals in agriculture, predicted to increase by 66 percent by 2030.[15] The majority of these animals do not require antibiotics; their overuse creates a strong and consistent selection pressure on any present bacterial pathogens that leads to antibiotic resistance that could create devastating cross-species disease affecting even humans. The World Health Organization predicts that around 10 million humans per year could die of antibiotic-resistant diseases by 2050.[16] Many of these antibiotics are also necessary for human medical interventions, so antibiotics in animals have a tremendous opportunity cost. The final concern is that of zoonosis itself. A zoonotic disease is any disease that crosses the species boundary from animals to humans. According to the United Nations, 60 percent of all known infections and 75 percent of all emerging infections are zoonotic.[17] Many potential zoonoses are harbored in wild animals (particularly when wild animals are hunted and sold in wet markets) because of the natural biodiversity. However, around a third of zoonoses originate in domesticated animals, which is a huge proportion given the relative lack of diversity of the animals we choose to eat. Q fever, or “query fever,” is an example of a slaughterhouse-borne disease. Q fever has a high fatality rate when untreated that decreases to “just” 2 percent with appropriate treatment.[18] H1N1 (swine flu) and H5N1 (bird flu) are perhaps the most famous examples of zoonoses associated with factory farming. lV. Unjust Distribution The global distribution of food can cause suffering. According to research commissioned by the BBC, the average Ethiopian eats around seven kilograms of meat per year, and the average Rwandan eats eight.[19] This is a factor of ten smaller than the average European, while the average American clocks in at around 115 kilograms of meat per year. In terms of calories, Eritreans average around 1600kcal per day while most Europeans ingest double that. Despite enough calories on the planet to sustain its population, 25,000 people worldwide starve to death each day, 40 percent of whom are children. There are two ways to address the unjust distribution: efficient redistribution and greater net production, which are not mutually exclusive. Some argue that redistribution will lead to lower net productivity because it disincentivizes labor;[20] others argue that redistribution is necessary to respect human rights of survival and equality.[21] Instead of arguing this point, I will focus on people’s food choices and their effect on both the efficiency and total yield of global agriculture, as these are usually less discussed. Regardless of the metric used, animals always produce far fewer calories and nutrients (protein, iron, zinc, and all the others) than we feed them. This is true because of the conservation of mass. They cannot feasibly produce more, as they burn off and excrete much of what they ingest. The exact measurement of the loss varies based on the metric used. When compared to live weight, cows consume somewhere around ten times their weight. When it comes to actual edible weight, they consume up to 25 times more than we can get out of them. Cows are only around one percent efficient in terms of calorific production and four percent efficient in protein production. Poultry is more efficient, but we still lose half of all crops we put into them by weight and get out only a fifth of the protein and a tenth of the calories fed to them.[22] Most other animals lie somewhere in the middle of these two in terms of efficiency, but no animal is ever as efficient as eating plants before they are filtered through animals in terms of the nutritional value available to the world. Due to this inefficiency, it takes over 100 square meters to produce 1000 calories of beef or lamb compared to just 1.3 square meters to produce the same calories from tofu.[23] The food choices in the Western world, where we eat so much more meat than people eat elsewhere, are directly related to a reduction in the amount of food and nutrition in the rest of the world. The most influential theory of justice in recent times is John Rawls’ Original Position wherein stakeholders in an idealized future society meet behind a “veil of ignorance” to negotiate policy, not knowing the role they will play in that society. There is an equal chance of each policymaker ending up poverty-stricken or incredibly privileged; therefore, each should negotiate to maximize the outcome of all citizens, especially those worst-off in society, known as the “maximin” strategy. In this hypothetical scenario, resource distribution would be devised to be as just as possible and should therefore sway away from animal consumption. CONCLUSION Evidence is growing that animals of all sorts, including fish and certain invertebrates, feel pain in ways that people are increasingly inclined to respect, though still, climate science is more developed and often inspires more public passion than animal rights do. Workers’ rights and welfare in slaughterhouses have become mainstream topics of conversation because of the outbreaks of COVID-19 in such settings. Environmentalists note overconsumption in high-income countries, also shining a light on the starvation of much of the low-income population of the world. At the intersection of these bioethical issues lies the modern CAFO, significantly contributing to animal suffering, climate change, poor working conditions conducive to disease, and unjust distribution of finite global resources (physical space and crops). It is certainly time to move away from the CAFO model of agriculture to at least a healthy mixture of extensive agriculture and alternative (non-animal) proteins. - [1] Berners-Lee M, Kennelly C, Watson R, Hewitt CN; Current global food production is sufficient to meet human nutritional needs in 2050 provided there is radical societal adaptation. Elementa: Science of the Anthropocene. 6:52, 2018. DOI: https://doi.org/10.1525/elementa.310 [2] : Lund TB, Kondrup SV, Sandøe P. A multidimensional measure of animal ethics orientation – Developed and applied to a representative sample of the Danish public. PLoS ONE 14(2): e0211656. 2019. DOI: https://doi.org/10.1371/ journal.pone.0211656 [3] Fiber-Ostrow P & Lovell JS. Behind a veil of secrecy: animal abuse, factory farms, and Ag-Gag legislation, Contemporary Justice Review, 19:2, p230-249. 2016. DOI: 10.1080/10282580.2016.1168257 [4] Jones RC. Science, sentience, and animal welfare. Biol Philos 28, p1–30 2013. DOI: https://doi.org/10.1007/s10539-012-9351-1 [5] Twine R. Emissions from Animal Agriculture—16.5% Is the New Minimum Figure. Sustainability, 13, 6276. 2021. DOI: https://doi.org/ 10.3390/su13116276 [6] Capper JL. "Is the Grass Always Greener? Comparing the Environmental Impact of Conventional, Natural and Grass-Fed Beef Production Systems" Animals 2, no. 2: 127-143. 2012. DOI: https://doi.org/10.3390/ani2020127 [7] Monbiot, George. “In Trying to Reduce the Impact of Our Diets, … Their Impact Would Be Lower than Local Beef and Lamb.” Twitter, Twitter, 24 Jan. 2020, twitter.com/GeorgeMonbiot/status/1220691168012460032. [8] Copeland C. Resources, Science, and Industry Division. "Animal waste and water quality: EPA regulation of concentrated animal feeding operations (CAFOs)." Congressional Research Service, the Library of Congress, 2006. [9] Leopold A. A Sand County Almanac, and Sketches Here and There. 1949. [10] Nicole W. “CAFOs and environmental justice: the case of North Carolina.” Environmental health perspectives vol. 121:6. 2013: A182-9. DOI: 10.1289/ehp.121-a182 [11] Fremstad S, Brown H, Rho HJ. CEPR’s Analysis of American Community Survey, 2014-2018 5-Year Estimates. 2020. Accessed 08/06/21 at https://cepr.net/meatpacking-workers-are-a-diverse-group-who-need-better-protections [12] Broadway, MJ. "Planning for change in small towns or trying to avoid the slaughterhouse blues." Journal of Rural Studies 16:1. P37-46. 2000. [13] Wasley A. The Guardian. 2018. Accessed 08/06/2021 at https://www.theguardian.com/environment/2018/jul/05/amputations-serious-injuries-us-meat-industry-plant [14] Cook EA, de Glanville WA, Thomas LF, Kariuki S, Bronsvoort BM, Fèvre EM. Working conditions and public health risks in slaughterhouses in western Kenya. BMC Public Health. 17(1):14. 2017. DOI: 10.1186/s12889-016-3923-y. [15] Global trends in antimicrobial use in food animals. Van Boeckel TP, Brower C, Gilbert M, Grenfell BT, Levin SA, Robinson TP, Teillant A, Laxminarayan R. Proceedings of the National Academy of Sciences May 2015, 112 (18) 5649-5654; DOI: 10.1073/pnas.1503141112 [16] Resistance, IICGoA. "No Time to Wait: Securing the future from drug-resistant infections." Report to the Secretary-General of the United Nations: p1-36. 2019. [17] Espinosa R, Tago D, Treich N. Infectious Diseases and Meat Production. Environ Resource Econ 76, p1019–1044. 2020. https://doi.org/10.1007/s10640-020-00484-3 [18] “Q Fever Fact Sheet.” Pennsylvania Department of Health, 4 Jan. 2003. https://www.health.pa.gov/topics/Documents/Diseases%20and%20Conditions/Q%20Fever%20.pdf [19] Ritchie, Hannah. “Which Countries Eat the Most Meat?” BBC News, BBC, 4 Feb. 2019, www.bbc.co.uk/news/health-47057341. [20] Reynolds, Alan. “The Fundamental Fallacy of Redistribution.” Cato.org, 11 Feb. 2016, 1:22 pm, www.cato.org/blog/fundamental-fallacy-redistribution. [21] Patricia Justino Professor and Senior Research Fellow. “Welfare Works: Redistribution Is the Way to Create Less Violent, Less Unequal Societies.” The Conversation, 20 Aug. 2021, theconversation.com/welfare-works-redistribution-is-the-way-to-create-less-violent-less-unequal-societies-128807. [22] Cassidy E, et al, “Redefining Agricultural Yields: From Tonnes to People Nourished Per Hectare.” Environmental Research Letters, V. 8(3), p2-3. IOPScience. 2013, http://iopscience.iop.org/1748-9326/8/3/034015 [23] Poore J, Nemecek T. Reducing food’s environmental impacts through producers and consumers. Science, 360(6392), p987-992. 2018.

Photo by 14825144 © Alita Xander | Dreamstime.com ABSTRACT The US government's approach to the War on Drugs has created laws to deter people from using illicit drugs through negative punishment. These laws have not controlled illicit drug use, nor has it stopped the opioid pandemic from growing. Instead, these laws have created a negative bias surrounding addiction and have negatively affected particularly vulnerable patient populations, including pregnant women with substance use disorder and newborns with neonatal abstinence syndrome. This article highlights some misconceptions and underscores the challenges they face as they navigate the justice and healthcare systems while also providing possible solutions to address their underlying addiction. INTRODUCTION Pregnant women with substance use disorder require treatment that is arguably for the benefit of both the mother and the fetus. Some suggest that addiction is a choice; therefore, those who misuse substances should not receive treatment. Proponents of this argument emphasize social and environmental factors that lead to addiction but fail to appreciate how chronic substance use alters the brain’s chemistry and changes how it responds to stress, reward, self-control, and pain. The medical community has long recognized that substance use disorder is not simply a character flaw or social deviance, but a complex condition that requires adequate medical attention. Unfortunately, the lasting consequences of the War on Drugs have created a stigma around addiction medicine, leading to significant treatment barriers. There is still a pervasive societal bias toward punitive rather than rehabilitative approaches to addiction. For example, many women with substance use disorder lose custody of their baby or face criminal penalties, including fines and jail time.[1] These punitive measures may cause patients to lose trust in their physicians, ultimately leading to high-risk pregnancies without prenatal care, untreated substance misuse, and potential lifelong disabilities for their newborns.[2] As a medical student, I have observed the importance of a rehabilitative approach to addiction medicine. Incentivizing pregnant women with substance use disorder to safely address their chronic health issues is essential for minimizing negative short-term and long-term outcomes for women and their newborns. This approach requires an open mind and supportive perspective, recognizing that substance use disorder is truly a medical condition that requires just as much attention as any other medical diagnosis.[3] BACKGROUND The War on Drugs was a government-led initiative launched in 1970 by President Richard M. Nixon with the aim of curtailing illegal drug use, distribution, and trade by imposing harsher prison sentences and punishments.[4] However, it is worth noting that one can trace the roots of this initiative back further. In 1914, Congress enacted the Harrison Narcotics Tax Act to target the recreational use of drugs such as morphine and opium.[5] Despite being in effect for over four decades, the War on Drugs failed to achieve its intended goals. In 2011, the Global Commission on Drug Policy released a report that concluded that the initiative had been futile, as “arresting and incarcerating tens of millions of these people in recent decades has filled prisons and destroyed lives and families without reducing the availability of illicit drugs or the power of criminal organizations.”[6] One study published in the International Journal of Drug Policy in the same year found that funding drug law enforcement paradoxically contributed to increasing gun violence and homicide rates.[7] The Commission recommended that drug policies focus on reducing harm caused by drug use rather than solely on reducing drug markets. Recognizing that many drug policies were of political opinion, it called for drug policies that were grounded in scientific evidence, health, security, and human rights.[8] Unfortunately, policy makers did not heed these recommendations. In 2014, Tennessee’s legislature passed a “Fetal Assault Law,” which made it possible to prosecute pregnant women for drug use during pregnancy. If found guilty, pregnant women could face up to 15 years in prison and lose custody of their child. Instead of deterring drug use, the law discouraged pregnant women with substance use disorder from seeking prenatal care. This law required medical professionals to report drug use to authorities, thereby compromising the confidentiality of the patient-physician relationship. Some avoided arrest by delivering their babies in other states or at home, while others opted for abortions or attempted to go through an unsafe withdrawal prior to receiving medical care, sacrificing the mother's and fetus's wellbeing. The law had a sunset provision and expired in 2016. During the two years this law was in effect, officials arrested 124 women.[9] The fear that this law instilled in pregnant women with substance use disorder can still be seen across the US today. Many pregnant women with substance use disorders stated that they feared testing positive for drugs. Due to mandatory reporting, they were not confident that physicians would protect them from the law.[10] And if a woman tried to stop using drugs before seeking care to avoid detection, she often ended up delaying or avoiding care.[11] The American College of Obstetricians and Gynecologists (ACOG) recognizes the fear those with substance use disorders face when seeking appropriate medical care and emphasizes that “obstetric–gynecologic care should not expose a woman to criminal or civil penalties, such as incarceration, involuntary commitment, loss of custody of her children, or loss of housing.”[12] Mandatory reporting strains the patient-physician relationship, driving a wedge between the doctor and patient. Thus, laws intended to deter people from using substances through various punishments and incarceration may be doing more harm than good. County hospitals that mainly serve lower socioeconomic patients encounter more patients without consistent health care access and those with substance use disorders.[13] These hospitals are facing the consequences of the worsening opioid pandemic. At one county hospital where I recently worked, there has been a dramatic increase in newborns with neonatal abstinence syndrome born to mothers with untreated substance use disorders during pregnancy. Infants exposed to drugs prenatally have an increased risk of complications, stillbirth, and life-altering developmental disabilities. At the hospital, I witnessed Child Protective Services removing two newborns with neonatal abstinence syndrome from their mother’s custody. Four similar cases had occurred in the preceding month. In the days leading up to their placement with a foster family, I saw both newborns go through an uncomfortable drug withdrawal. No baby should be welcomed into this world by suffering like that. Yet I felt for the new mothers and realized that heart-wrenching custody loss is not the best approach. During this period, I saw a teenager brought to the pediatric floor due to worsening psychiatric symptoms. He was born with neonatal abstinence syndrome that neither the residential program nor his foster family could manage. His past psychiatric disorders included attention deficit disorder, conduct disorder, major depressive disorder, anxiety disorder, disruptive mood dysregulation disorder, intellectual developmental disorder, and more. During his hospitalization, he was so violent towards healthcare providers that security had to intervene. And his attitude toward his foster parents was so volatile that we were never sure if having them visit was comforting or agitating. Throughout his hospital course, it was difficult for me to converse with him, and I left every interview with him feeling lost in terms of providing an adequate short- and long-term assessment of his psychological and medical requirements. What was clear, however, was that his intellectual and emotional levels did not match his age and that he was born into a society that was ill-equipped to accommodate his needs. Just a few feet away from his room, behind the nurses’ station, were the two newborns feeling the same withdrawal symptoms that this teenager likely experienced in the first few hours of his life. I wondered how similar their paths would be and if they would exhibit similar developmental delays in a few years or if their circumstance may follow the cases hyped about in the media of the 1980s and 1990s regarding “crack babies.” Many of these infants who experienced withdrawal symptoms eventually led normal lives.[14] Nonetheless, many studies have demonstrated that drug use during pregnancy can adversely impact fetal development. Excessive alcohol consumption can result in fetal alcohol syndrome, characterized by growth deficiency, facial structure abnormalities, and a wide range of neurological deficiencies.[15] Smoking can impede the development of the lungs and brain and lead to preterm deliveries or sudden infant death syndrome.[16] Stimulants like methamphetamine can also cause preterm delivery, delayed motor development, attention impairments, and a wide range of cognitive and behavioral issues.[17] Opioid use, such as oxycodone, morphine, fentanyl, and heroin, may result in neonatal opioid withdrawal syndrome, in which a newborn may exhibit tremors, irritability, sleeping problems, poor feeding, loose stools, and increased sweating within 72 hours of life.[18] In 2014, the American Association of Pediatrics (AAP) reported that one newborn was diagnosed with neonatal abstinence syndrome every 15 minutes, equating to approximately 32,000 newborns annually, a five-fold increase from 2004.[19] The AAP found that the cost of neonatal abstinence syndrome covered by Medicaid increased from $65.4 million to $462 million from 2004 to 2014.[20] In 2020, the CDC published a paper that showed an increase in hospital costs from $316 million in 2012 to $572.7 million in 2016.[21] Currently, the impact of the COVID-19 pandemic on the prevalence of newborns with neonatal abstinence syndrome is unknown. I predict that the increase in opioid and polysubstance use during the pandemic will increase the number of newborns with neonatal abstinence syndrome, thereby significantly increasing the public burden and cost.[22] In the 1990s, concerns arose about the potentially irreparable damage caused by intrauterine exposure to cocaine on the development of infants, which led to the popularization of the term “crack babies.”[23] Although no strong longitudinal studies supported this claim at the time, it was not without merit. The Maternal Lifestyle Study (NCT00059540) was a prospective longitudinal observational study that compared the outcomes of newborns exposed to cocaine in-utero to those without.[24] One of its studies revealed one month old newborns with cocaine exposure had “lower arousal, poorer quality of movements and self-regulation, higher excitability, more hypertonia, and more nonoptimal reflexes.”[25] Another study showed that at one month old, heavy cocaine exposure affected neural transmission from the ear to the brain.[26] Long-term follow up from the study showed that at seven years old, children with high intrauterine cocaine exposure were more likely to have externalizing behavior problems such as aggressive behavior, temper tantrums, and destructive acts.[27] While I have witnessed this behavior in the teenage patient during my pediatrics rotation, not all newborns with intrauterine drug exposure are inevitably bound to have psychiatric and behavioral issues later in life. NPR recorded a podcast in 2010 highlighting a mother who used substances during pregnancy and, with early intervention, had positive outcomes. After being arrested 50 times within five years, she went through STEP: Self-Taught Empowerment and Pride, a public program that allowed her to complete her GED and provided guidance and encouragement for a more meaningful life during her time in jail. Her daughter, who was exposed to cocaine before birth, had a normal childhood and ended up going to college.[28] From a public health standpoint, more needs to be done to prevent the complications of substance misuse during pregnancy. Some states consider substance misuse (and even prescribed use) during pregnancy child abuse. Officials have prosecuted countless women across 45 states for exposing their unborn children to drugs.[29] With opioid and polysubstance use on the rise, the efficacy of laws that result in punitive measures seems questionable.[30] So far, laws are not associated with a decrease in the misuse of drugs during pregnancy. Millions of dollars are being poured into managing neonatal abstinence syndrome, including prosecuting women and taking their children away. Rather than policing and criminalizing substance use, pregnant women should get the appropriate care they need and deserve. I. Misconception One: Mothers with Substance Use Disorder Can Get an Abortion If an unplanned pregnancy occurs, one course of action could be to terminate the pregnancy. On the surface, this solution seems like a quick fix. However, the reality is that obtaining an abortion can be challenging due to two significant barriers: accessibility and mandated reporting. Abortion laws vary by state, and in Tennessee, for instance, abortions are banned after six weeks of gestation, typically when fetal heart rhythms are detected. An exception to this is in cases where the mother's life is at risk.[31] Unfortunately, many women with substance use disorders are from lower socioeconomic backgrounds and cannot access pregnancy tests, which could indicate they are pregnant before the six-week cutoff. If a Tennessee woman with substance use disorder decides to seek an abortion after six weeks, she may need to travel to a neighboring state. However, this is not always a feasible option, as the surrounding states (WV, MO, AR, MI, AL, and GA) also have restrictive laws that either prohibit abortions entirely or ban them after six weeks. Moreover, she may be hesitant to visit an obstetrician for an abortion, as some states require physicians by law to report their patients' substance use during pregnancy. For example, Virginia considers substance use during pregnancy child abuse and mandates that healthcare providers report it. This would ultimately limit her to North Carolina if she wants to remain in a nearby state, but she must go before 20 weeks gestation.[32] For someone who may or may not have access to reliable transportation, traveling to another state might be impossible. Without resources or means, these restrictive laws have made it incredibly difficult to obtain the medical care they need. II. Misconception Two: Mothers with SUD are Not Fit to Care for Children If a woman cannot take care of herself, one might wonder how she can take care of another human being. Mothers with substance use disorders often face many adversities, including lack of economic opportunity, trauma from abuse, history of poverty, and mental illness.[33] Fortunately, studies suggest keeping mother and baby together has many benefits. Breastfeeding, for example, helps the baby develop a strong immune system while reducing the mother’s risk of cancer and high blood pressure.[34] Additionally, newborns with neonatal abstinence syndrome who are breastfed by mothers receiving methadone or buprenorphine require less pharmacological treatment, have lower withdrawal scores, and experience shorter hospital stays.[35] Opioid concentration in breastmilk is minimal and does not pose a risk to newborns.[36] Moreover, oxytocin, the hormone responsible for mother-baby bonding, is increased in breastfeeding mothers, reducing withdrawal symptoms and stress-induced reactivity and cravings while also increasing protective maternal instincts.[37] Removing an infant from their mother’s care immediately after birth would result in the loss of all these positive benefits for both the mother and her newborn. The newborns I observed during my pediatrics rotation probably could have benefited from breastfeeding rather than bottle feeding and being passed around from one nurse to the next. They probably would have cried less and suffered fewer withdrawal symptoms had they been given the opportunity to breastfeed. And even if the mothers were lethargic and unresponsive while going through withdrawal, it would still have been possible to breastfeed with proper support. Unfortunately, many believe mothers with substance use disorder cannot adequately care for their children. This pervasive societal bias sets them up for failure from the beginning and greatly inhibits their willingness to change and mend their relationship with their providers. It is a healthcare provider’s duty to provide non-judgmental care that prioritizes the patient’s well-being. They must treat these mothers with the same empathy and respect as any other patient, even if they are experiencing withdrawal. III. Safe Harbor and Medication-Assisted Treatment Addiction is like any other disease and society should regard treatment without stigma. There is no simple fix to this problem, given that it involves the political, legal, and healthcare systems. Punitive policies push pregnant women away from receiving healthcare and prevent them from receiving beneficial interventions. States need to enact laws that protect these women from being reported to authorities. Montana, for example, passed a law in 2019 that provides women with substance use disorders safe harbor from prosecution if they seek treatment for their condition.[38] Medication-assisted treatment with methadone or buprenorphine is the first line treatment option and should be available to all pregnant women regardless of their ability to pay for medical care.[39] To promote continuity of care, health officials could include financial incentives to motivate new mothers to go to follow-up appointments. For example, vouchers for groceries or enrollment in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) may offset financial burdens and allow a mother to focus on taking care of her child and her recovery. IV. Mandated Substance Abuse Programs Although the number of people sentenced to state prisons for drug related crimes has been declining, it is still alarming that there were 171,300 sentencings in 2019.[40] Only 11 percent of the 65 percent of our nation’s inmates with substance use disorder receive treatment, implying that the other 89 percent were left without much-needed support to overcome their addiction.[41] It is erroneous to assume that their substance use disorder would disappear after a period without substance use while behind bars. After withdrawal, those struggling with substance use disorder may still have cravings and the likelihood of relapsing remains high without proper medical intervention. Even if they are abstinent for some time during incarceration, the underlying problem persists, and the cycle inevitably continues upon release from custody. In line with the recommendations by Global Commission on Drug Policy and the lessons learned from the failed War on Drugs, one proposed change in our criminal justice system would be to require enrollment and participation in assisted alcohol cessation programs before legal punishment. Policy makers must place emphasis on the safety of the patient and baby rather than the cessation of substance use. This would incentivize people to actively seek medical care, restore the patient-physician relationship, and ensure that they take rehabilitation programs seriously. If the patient or baby is unsafe, a caregiver could intervene while the patient re-enrolls in the program. Those currently serving sentences in prisons and jails can treat their substance use disorder through medication assisted treatment, cognitive behavioral therapy, and programs like Self Taught Empowerment and Pride (STEP). Medication assisted treatment under the supervision of medical professionals can help inmates achieve and maintain sobriety in a healthy and safe way. Furthermore, cognitive behavioral therapy can help to identify triggers and teach healthier coping mechanisms to prepare for stressors outside of jail. Finally, multimodal empowerment programs can connect people to jobs, education, and support upon release. People often leave prisons and jail without a sense of purpose, which can lead to relapse and reincarceration. Structured programs have been shown to decrease drug use and criminal behavior by helping reintegrate productive individuals into society.[42] V. Medical Education: Narcotic Treatment Programs and Suboxone Clinics Another proactive approach could be to have medical residency programs register with the Drug Enforcement Administration (DEA) as Narcotic Treatment Programs and incorporate suboxone clinics into their education and rotations. Rather than family medicine, OB/GYN, or emergency medicine healthcare workers having to refer their patients to an addiction specialist, they could treat patients with methadone for maintenance or detoxification where they would deliver their baby. Not only would this educate and prepare the future generation of physicians to handle the opioid crisis, but it would allow pregnant women to develop strong patient-physician relationships. CONCLUSION Society needs to change from the mindset of tackling a problem after it occurs to taking a proactive approach by addressing upstream factors, thereby preventing those problems from occurring in the first place. Emphasizing public health measures and adequate medical care can prevent complications and developmental issues in newborns and pregnant women with substance use disorders. Decriminalizing drug use and encouraging good health habits during pregnancy is essential, as is access to prenatal care, especially for lower socioeconomic patients. Many of the current laws and regulations that policy makers initially created due to naïve political opinion and unfounded bias to serve the War on Drugs need to be changed to provide these opportunities. To progress as a society, physicians and interprofessional teams must work together to truly understand the needs of patients with substance use disorders and provide support from prenatal to postnatal care. There should be advocation for legislative change, not by providing an opinion but by highlighting the facts and conclusions of scientific studies grounded in scientific evidence, health, security, and human rights. There can be no significant change if society continues to view those with substance use disorders as underserving of care. Only when the perspective shifts to compassion can these mothers and children receive adequate care that rehabilitates and supports their future and empowers them to raise their children. - [1] NIDA. 2023, February 15. Pregnant People with Substance Use Disorders Need Treatment, Not Criminalization. https://nida.nih.gov/about-nida/noras-blog/2023/02/pregnant-people-substance-use-disorders-need-treatment-not-criminalization [2] Substance Use Disorder Hurts Moms and Babies. National Partnership for Women and Families. June 2021 [3] All stories have been fictionalized and anonymized. [4] A History of the Drug War. Drug Policy Alliance. https://drugpolicy.org/issues/brief-history-drug-war [5] The Harrison Narcotic Act (1914) https://www.druglibrary.org/Schaffer/library/studies/cu/cu8.html [6] The War on Drugs. The Global Commission on Drug Policy. Published June 2011. https://www.globalcommissionondrugs.org/reports/the-war-on-drugs [7] Werb D, Rowell G, Guyatt G, Kerr T, Montaner J, Wood E. Effect of drug law enforcement on drug market violence: A systematic review. Int J Drug Policy. 2011;22(2):87-94. doi:10.1016/j.drugpo.2011.02.002 [8] Global Commission on Drug Policy, 2011 [9] Women NA for P. Tennessee’s Fetal Assault Law: Understanding its impact on marginalized women - New York. Pregnancy Justice. Published December 14, 2020. https://www.pregnancyjusticeus.org/tennessees-fetal-assault-law-understanding-its-impact-on-marginalized-women/ [10] Roberts SCM, Nuru-Jeter A. Women’s perspectives on screening for alcohol and drug use in prenatal care. Womens Health Issues Off Publ Jacobs Inst Womens Health. 2010;20(3):193-200. doi:10.1016/j.whi.2010.02.003 [11] Klaman SL, Isaacs K, Leopold A, et al. Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance. J Addict Med. 2017;11(3):178-190. doi:10.1097/ADM.0000000000000308 [12] Substance Abuse Reporting and Pregnancy: The Role of the Obstetrician–Gynecologist. https://www.acog.org/en/clinical/clinical-guidance/committee-opinion/articles/2011/01/substance-abuse-reporting-and-pregnancy-the-role-of-the-obstetrician-gynecologist [13] R. Ghertner, G Lincoln The Opioid Crisis and Economic Opportunity: Geographic and Economic Trends. ASPE. Office of Assistant Secretary for Planning and Evaluation. DHHS Revised September 11, 2018 https://aspe.hhs.gov/reports/economic-opportunity-opioid-crisis-geographic-economic-trends [14] Midon, M. Z., Gerzon, L. R., & de Almeida, C. S. (2021). Crack and motor development of babies living in an assistance shelter. ABCS Health Sciences, 46, e021215-e021215. And for example, see Crack Babies: Twenty Years Later : NPR https://www.npr.org/templates/story/story.php?storyId=126478643 [15] Williams JF, Smith VC, the Committee on Substance Abuse. Fetal Alcohol Spectrum Disorders. Pediatrics. 2015;136(5):e20153113. doi:10.1542/peds.2015-3113 [16] CDC Tobacco Free. Smoking During Pregnancy. Centers for Disease Control and Prevention. Published April 11, 2022. https://www.cdc.gov/tobacco/basic_information/health_effects/pregnancy/index.htm [17] Abuse NI on D. What are the risks of methamphetamine misuse during pregnancy? National Institute on Drug Abuse. https://nida.nih.gov/publications/research-reports/methamphetamine/what-are-risks-methamphetamine-misuse-during-pregnancy [18] CDC. Basics About Opioid Use During Pregnancy | CDC. Centers for Disease Control and Prevention. Published July 21, 2021. https://www.cdc.gov/pregnancy/opioids/basics.html [19] Honein MA, Boyle C, Redfield RR. Public Health Surveillance of Prenatal Opioid Exposure in Mothers and Infants. Pediatrics. 2019;143(3):e20183801. doi:10.1542/peds.2018-3801 [20] Winkelman TNA, Villapiano N, Kozhimannil KB, Davis MM, Patrick SW. Incidence and Costs of Neonatal Abstinence Syndrome Among Infants with Medicaid: 2004–2014. Pediatrics. 2018;141(4):e20173520. doi:10.1542/peds.2017-3520 [21] Strahan AE, Guy GP Jr, Bohm M, Frey M, Ko JY. Neonatal Abstinence Syndrome Incidence and Health Care Costs in the United States, 2016. JAMA Pediatr. 2020;174(2):200-202. doi:10.1001/jamapediatrics.2019.4791 [22] Ghose R, Forati AM, Mantsch JR. Impact of the COVID-19 Pandemic on Opioid Overdose Deaths: a Spatiotemporal Analysis. J Urban Health Bull N Y Acad Med. 2022;99(2):316-327. doi:10.1007/s11524-022-00610-0 [23] Mayes LC, Granger RH, Bornstein MH, Zuckerman B. The Problem of Prenatal Cocaine Exposure: A Rush to Judgment. JAMA. 1992;267(3):406-408. doi:10.1001/jama.1992.03480030084043 [24] NICHD Neonatal Research Network. The Maternal Lifestyle Study. clinicaltrials.gov; 2016. https://clinicaltrials.gov/ct2/show/study/NCT00059540 [25] Lester BM, Tronick EZ, LaGasse L, et al. The maternal lifestyle study: effects of substance exposure during pregnancy on neurodevelopmental outcome in 1-month-old infants. Pediatrics. 2002;110(6):1182-1192. doi:10.1542/peds.110.6.1182 [26] Lester BM, Lagasse L, Seifer R, et al. The Maternal Lifestyle Study (MLS): effects of prenatal cocaine and/or opiate exposure on auditory brain response at one month. J Pediatr. 2003;142(3):279-285. doi:10.1067/mpd.2003.112 [27] Bada HS, Bann CM, Bauer CR, et al. Preadolescent behavior problems after prenatal cocaine exposure: Relationship between teacher and caretaker ratings (Maternal Lifestyle Study). Neurotoxicol Teratol. 2011;33(1):78-87. doi:10.1016/j.ntt.2010.06.005 [28] N, P, R. Crack Babies: Twenty Years Later. NPR. Published May 3, 2010. https://www.npr.org/templates/story/story.php?storyId=126478643 [29] Miranda L, Dixon V, September CRP on, 30, 2015. How States Handle Drug Use During Pregnancy http://projects.propublica.org/graphics/maternity-drug-policies-by-state [30] NCDAS: Substance Abuse and Addiction Statistics [2023]. NCDAS. https://drugabusestatistics.org/ [31] (Tenn. Code Ann. § 39-15-216). [32] Institute G. Interactive Map: US Abortion Policies and Access After Roe. https://states.guttmacher.org/policies/ [33] Whitesell M, Bachand A, Peel J, Brown M. Familial, Social, and Individual Factors Contributing to Risk for Adolescent Substance Use. J Addict. 2013;2013:579310. doi:10.1155/2013/579310 [34] CDC. Five Great Benefits of Breastfeeding. Centers for Disease Control and Prevention. Published July 27, 2021. https://www.cdc.gov/nccdphp/dnpao/features/breastfeeding-benefits/index.html [35] Welle-Strand GK, Skurtveit S, Jansson LM, Bakstad B, Bjarkø L, Ravndal E. Breastfeeding reduces the need for withdrawal treatment in opioid-exposed infants. Acta Paediatr. 2013;102(11):1060-1066. doi:10.1111/apa.12378 [36] Ilett KF, Hackett LP, Gower S, Doherty DA, Hamilton D, Bartu AE. Estimated dose exposure of the neonate to buprenorphine and its metabolite norbuprenorphine via breastmilk during maternal buprenorphine substitution treatment. Breastfeed Med Off J Acad Breastfeed Med. 2012;7:269-274. doi:10.1089/bfm.2011.0096 [37] Pedersen CA, Smedley KL, Leserman J, et al. Intranasal Oxytocin Blocks Alcohol Withdrawal in Human Subjects. Alcohol Clin Exp Res. 2013;37(3):484-489. doi:10.1111/j.1530-0277.2012.01958.x [38] Montana SB0289. https://leg.mt.gov/bills/2019/billhtml/SB0289.htm [39] Mullins N, Galvin SL, Ramage M, Gannon M, Lorenz K, Sager B, Coulson CC. Buprenorphine and Naloxone Versus Buprenorphine for Opioid Use Disorder in Pregnancy: A Cohort Study. J Addict Med. 2020 May/Jun;14(3):185-192. doi: 10.1097/ADM.0000000000000562. PMID: 31567599. [40] Drug Related Crime Statistics [2023]: Offenses Involving Drug Use. NCDAS. https://drugabusestatistics.org/drug-related-crime-statistics/ [41] Association APH. Online only: Report finds most U.S. inmates suffer from substance abuse or addiction. Nations Health. 2010;40(3):E11-E11. [42] Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) | NIDA Archives. Published January 17, 2018. http://archives.nida.nih.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition