Journal articles on the topic 'Lua ethnic minority'

Musculoskeletal disorders (MSDs) are one of the leading causes of occupational injuries and disabilities. The purpose of this study was to assess the prevalence of MSDs and occupational factors affecting MSDs among ethnic lychee–longan harvesting workers in northern Thailand. A cross-sectional study was conducted in the areas of three upper northern provinces of Thailand. The study areas are located in the highlands and rural plains, where many ethnic minority groups live, including Indigenous, Mien, Karen, and Lua. The majority of them work in a farm of perennial fruit trees, mainly lychee and longan. During the harvest season, 404 participants were recruited for the study using the convenience sampling technique. Data were collected using questionnaires that included general information, an ergonomic risk assessment, and a standardized Nordic questionnaire for assessing MSDs in 10 body parts. The average age of lychee–longan harvesting workers was 48.8 years. Almost all (99.5%) reported MSDs in one or more body regions in the previous seven days of work. The prevalence of MSDs was highest in the hands (82.9%), followed by the shoulders (82.2%) and the neck (79.7%). The total ergonomic risk scores, which included awkward posture, heavy carrying and lifting, repetitive activity, land slope, and equipment, were found to be significantly associated with MSDs in part of the neck (AOR = 1.17, 95%CI = 1.11–1.23), shoulder (AOR = 1.15, 95%CI = 1.10–1.21), elbow (AOR = 1.18, 95%CI = 1.12–1.24), hand (AOR = 1.12, 95%CI = 1.07–1.18), finger (AOR = 1.33, 95%CI = 1.24–1.44), upper back (AOR = 1.14, 95%CI = 1.09–1.20), lower back (AOR = 1.16, 95%CI = 1.11–1.22), hip (AOR = 1.11, 95%CI = 1.06–1.15), knee (AOR = 1.18, 95%CI = 1.12–1.24), and feet (AOR = 1.21, 95%CI = 1.15–1.28) when adjusting for ethnicity, sex, age, BMI, and work experience. Many parts of ethnic workers’ bodies have been affected by occupational injuries, with a high risk of upper extremity injury. As a result, using an ergonomic approach to improving the working environment and appropriate posture movement is very beneficial in preventing MSDs among ethnic harvesting workers.

AbstractPolitical science research has repeatedly identified a strong correlation between high socio-economic status and political participation, but this finding has not been as robust for racial and ethnic minorities. As a response, the literature on minority political participation has produced a series of different models for different groups by adding group-specific variables to the standard SES model. In assigning a single model per group, however, the literature tends to overlook intra-group differences as well as inter-group commonalities, thereby effectively reifying the concept of race and ethnicity. Using survey data from Los Angeles, this article develops a different approach aimed at detecting intra-group differences as well as inter-group commonalities through a recognition of political “styles.” First, using latent class analysis (LCA), I identify a set of recurring configurations of individual dispositions (education, political knowledge…) and political acts (voting, protest…) that define different political styles. Then I examine the distribution of these political styles across racial and ethnic groups. The results reveal three novel findings that were invisible in the previous studies: 1) all groups feature a considerable degree of intra-group difference in political styles; 2) each group retains other political styles that cannot be captured by a single model; and 3) there are commonalities of political styles that cut across racial and ethnic boundaries. Overall, this article presents a model for quantitative analysis of race and ethnicity that simultaneously captures intra-group differences and inter-group commonalities.

Background:To determine if there are differences in time spent in physical activity and sedentary behavior between rural African American and Caucasian children.Methods:Children wore accelerometers for 3 weekdays. The students were randomly selected from a larger sample of children participating in a weight gain prevention intervention. Usable data were obtained from 272 of the 310 students who agreed to participate. The outcome data included counts per minute (CPM), time spent in moderate to vigorous (MVPA), light (LPA), and sedentary (SED) activity. The equation and cutoff used to analyze national accelerometry data were used for the current study.Results:The sample had an average age of 10.4 (1.1) years and 76% were African American. Lower SES African Americans had more CPM (P = .012) and spent more time in MVPA (P = .008) compared with middle SES African American and lower SES Caucasian children. Lower SES African American children also spent fewer minutes in SED activity (P = .044) compared with middle SES African American children.Conclusions:These findings support recent results that also used objective activity measures. Children appeared less active and more sedentary than a national sample, warranting interventions in minority and rural populations.

With the improvement of living standards, more and more people are pursuing personalized routes. This paper uses personalized mining of interest points of ethnic minority tourism demand groups, extracts customer data features in social networks, and constructs data features of interesting topic factors, geographic location factors, and user access frequency factors, using LDA topic models and matrix decomposition models to perform feature vectorization processing on user sign-in records and build deep learning recommendation model (DLM). Using this model to compare with the traditional recommendation model and the recommendation model of a single data feature module, the experimental results show the following: (1) The fitting error of DLM recommendation results is significantly reduced, and its recommendation accuracy rate is 50% higher than that of traditional recommendation algorithms. The experimental results show that the DLM constructed in this paper has good learning and training performance, and the recommendation effect is good. (2) In this method, the performance of the DLM is significantly higher than other POI recommendation methods in terms of the accuracy or recall rate of the recommendation algorithm. Among them, the accuracy rates of the top five, top ten, and top twenty recommended POIs are increased by 9.9%, 7.4%, and 7%, respectively, and the recall rate is increased by 4.2%, 7.5%, and 14.4%, respectively.

By the spring of 2021, most of the adult U.S. population became eligible to receive a COVID-19 vaccine. Yet, by the summer of 2021, the vaccination rate stagnated. Given the immense impact COVID-19 has had on society and individuals, and the surge of new variant strains of the virus, it remains urgent to better understand barriers to vaccination, including the impact of variations in trusted sources of COVID-19 information. The goal of the present study was to conduct a cross-sectional, community-engaged, and person-centered study of trusted sources of COVID-19 information using latent profile analysis (LPA). The aims were to (1) identify the number and nature of profiles of trusted sources of COVID-19 information, and (2) determine whether the trust profiles were predictive of COVID-19 vaccination attitudes and various demographic categories. Participants included mostly racial and ethnic minority individuals (82.4%) recruited by various community-based agencies in South Florida. The LPA evidenced an optimal 3-class solution characterized by low (n = 80)-, medium (n = 147)-, and high (n = 52)-trust profiles, with high trust statistically significantly predictive of vaccination willingness. The profiles identified could be important targets for public health dissemination efforts to reduce vaccine hesitancy and increase COVID-19 vaccination uptake. The general level of trust in COVID-19 information sources was found to be an important factor in predicting COVID-19 vaccination willingness.

BackgroundEthnic minority (EM) patients with Rheumatoid Arthritis (RA) have more severe disease, more disability, and less use of biologic disease modifying anti-rheumatic drugs (bDMARDs). A Treat to target (T2T) strategy has been recommended to improve clinical outcomes but barriers include patient preference, access to specialty care and increased administrative effort. Additionally, EM patients in the US often have low health literacy, express greater reluctance to accept physician recommendations, in part due to sociocultural preference and mistrust of a historically biased healthcare system. It is unknown whether improving knowledge of RA would improve T2T outcomes in EM active RA patients.ObjectivesTo assess the proportion of EM RA patients who achieve low disease activity or remission following implementation of a coordinator-based education program highlighting T2T RA strategy.MethodsAdult participants with active RA (RAPID3>6 or CDAI > 10) were invited to participate in a series of five one-on-one 20-minute educational sessions, co-occurring with scheduled routine clinic visits (6 -12-week intervals). Sessions were facilitated by a rheumatology care coordinator, a non-healthcare professional with intensive training over 4 weeks to conduct RA patient education. Sociodemographic data was collected, and disease activity measures (TJC, SJC, RAPID3, CDAI) and validated patient questionnaires on RA Knowledge (ACREU), compliance (CQR5), and physician trust (Trust in Physician Scale) were recorded at baseline and after the final educational session. Descriptive statistics were applied and medians and ranges for instrument scores are reported. Paired T-test was used to test for significant differences in scores after the education sessions. Correlations between the ACREU scores and clinical-demographic variables were measured using Pearson’s correlation coefficient.Results20 EM patients (75% Female, mean age, 58.8 years (12.2) seen by EM physicians were enrolled, with mean RA disease duration of 7 years and poor prognosticators (75% double seropositivity). ACREU scores were low at baseline (mean 0.45 (0.16)), with no significant improvement on completion of educational sessions, and no correlation with years of education or duration of RA. There was a positive correlation between ACREU and compliance scores at baseline (r=0.3). Average duration of the education period was 9.72 months, with a 33% decrease in average RAPID3 over time, and 42% of patients achieving a target of remission or LDA. Trust in Physician scores were high at baseline and persisted with >50% of patients completing at least one medication change during study period.ConclusionRA knowledge did not impact RA patient outcomes in this cohort of EM patients. However, patients had high trust in their providers and achieved clinical remission or LDA despite risk for poor outcomes highlighting the importance of the provider- patient relationship in achieving targeted goals of therapy. Limitations include the small sample size from a single institution, and the lengthy time between initial and final assessment of RA knowledge.References[1]Lineker SC, Badley EM, Hughes EA, Bell MJ. Development of an instrument to measure knowledge in individuals with rheumatoid arthritis: the ACREU rheumatoid arthritis knowledge questionnaire. The Journal of rheumatology. 1997/04// 1997;24(4):647-653.[2]Hughes LD, Done J, Young A. A 5 item version of the Compliance Questionnaire for Rheumatology (CQR5) successfully identifies low adherence to DMARDs. BMC Musculoskeletal Disorders. 2013-12-01 2013;14(1):286. doi:10.1186/1471-2474-14-286[3]Anderson LA, Dedrick RF. Development of the Trust in Physician Scale: A Measure to Assess Interpersonal Trust in Patient-Physician Relationships. Psychological Reports. 1990-12-01 1990;67(3_suppl):1091-1100. doi:10.2466/pr0.1990.67.3f.1091AcknowledgementsSincere gratitude to our patients for their participation, and to the team at Bristol Myers Squibb for supporting this research initiative.Disclosure of InterestsSharon Dowell Speakers bureau: Horizon Pharma, Aurinia Pharmaceuticals Inc, Abbvie, Grant/research support from: Pfizer, Bristol Myers Squibb, Mercedes Quinones Speakers bureau: Abbvie, Sanofi Genzyme, Grant/research support from: Bristol Myers Squibb, Pfizer, Alani Miller: None declared, Oshoze Kadiri: None declared, Tahereh Jamshidi: None declared, Gail Kerr Speakers bureau: Aurinia Pharmaceuticals Inc, Consultant of: CSL Behring, Janssen, Pfizer, Samumed, UCB, Viela Bio/Horizon, Grant/research support from: Novartis

Abstract Despite increasing interest in social support exchanges among older adults, little is known about the interplay between giving and receiving social support, how social support exchanges change over time, and factors associated with such change. Using data on 1,305 older Singaporeans participating in two waves of a national, longitudinal survey conducted in 2016-2017 and 2019, we investigated (1) distinct social support exchange profiles that comprise different types of giving and receiving social support, (2) transitions in social support exchange profiles over time, and (3) association of sociodemographic characteristics and health status with such transitions. Gender-stratified random intercept latent transition analysis (RI-LTA) produced three main findings. First, we identified four social support exchange profiles—multi-exchange, provider, receiver, and low exchange—for both males and females at both waves, although the distribution of profiles varied by gender and waves. Second, males were more likely to transition from the multi-exchange profile to other types, whereas females were relatively more likely to transition into the multi-exchange profile over time. Third, among males, those older, of ethnic minority, unmarried, employed, and with depressive symptoms were more likely to transition into the receiver profile from other types. Females who were younger, of ethnic majority, married, and less educated were more likely to transition into the multi-exchange type from low or receiver profiles. The findings capture the temporal dynamics in social support exchange profiles and their gendered characteristics. Policy interventions should focus on older adults who lack social support exchanges and those who lose social support exchanges over time.

AimsThis audit aims to identify whether newly diagnosed dementia patients are offered post diagnostic support and potential factors influencing patient choice.BackgroundA diagnosis of dementia can be life changing and hence post-diagnostic support for dementia is key. Multiple guidelines suggest that post diagnostic support need to be offered to all patients diagnosed with dementia. The Department of Health and Social Care and other national/ local guidelines suggest that post diagnostic support is offered to all patients diagnosed with dementia.MethodData were collected for 40 patients diagnosed with dementia. Using random number generator, patient group was selected from pool of patients diagnosed with dementia between July’ 2017 - December’ 2017. Data included whether they had been offered support during the initial appointment and what post-diagnostic support was offered. Demographic details obtained to identify patterns of support accessed by patients.ResultAll patients were offered post-diagnostic support. Diagnosis was discussed in appointment in about 93% of patients. Medication was discussed in 82% patients. Driving was discussed in only 64% patients and LPA was discussed in only 63% patients. When given choice between Post diagnostic support group (PDSG) and Dementia adviser (DA), slightly more women tend to choose PDSG group. The only 2 ethnic minority patients chose DA. 21% more patients opted for PDSG group when they had a carer.ConclusionThe positive is that some post-diagnostic support is offered to all patients. Although discussion of diagnosis with patients was done well, discussion of medication, driving and LPA can be improved upon. Ethnicity and family structure/ carer may have a bearing on patient choice of post-diagnostic support.

Background Home delivery (HD) without skilled birth attendants (SBAs) are considered crucial risk factors increasing maternal and child mortality rates in Loa PDR. While a few studies in the literature discuss the choice of delivery in remote areas of minority ethnic groups; our work aims to identify factors that indicated their delivery place, at home or in the health facilities. Methods A community-based qualitative study was conducted between February and March 2020. Three types of interviews were implemented, In-depth interviews with 16 women of eight rural villages who delivered in the last 12 months in Xepon District, Savannakhet Province, Lao PDR. Also, three focus group discussions (FGDs) with nine HCPs and key-informant interviews of ten VHVs were managed. Factors affecting the choice of the delivery place were categorized according to the social-ecological model. Results Our sample included five Tri women and two Mangkong women in the HD group, while the FD group included three Tri women, two Mangkong women, one Phoutai woman, two Laolung women and one Vietnamese. Our investigation inside the targeted minority showed that both positive perceptions of home delivery (HD) and low-risk perception minorities were the main reasons for the choice of HD, on the individual level. On the other hand, fear of complication, the experience of stillbirth, and prolonged labour pain during HD were reasons for facility-based delivery (FD). Notably, the women in our minority reported no link between their preference and their language, while the HCPs dated the low knowledge to the language barrier. On the interpersonal level, the FD women had better communication with their families, and better preparation for delivery compared to the HD group. The FD family prepared cash and transportation using their social network. At the community level, the trend of the delivery place had shifted from HD to FD. Improved accessibility and increased knowledge through community health education were the factors of the trend. At the societal (national policy) level, the free delivery policy and limitation of HCPs’ assisted childbirth only in health facilities were the factors of increasing FD, while the absence of other incentives like transportation and food allowance was the factor of remaining of HD. Conclusions Based on the main findings of this study, we urge the enhancement of family communication on birth preparedness and birthplace. Furthermore, our findings support the need to educate mothers, especially those of younger ages, about their best options regarding the place of delivery. We propose implementing secondary services of HD to minimize the emergency risks of HD. We encourage local authorities to be aware of the medical needs of the community especially those of pregnant females and their right for a free delivery policy.

e18621 Background: Understanding the health-related quality of life (HRQOL) of breast cancer during treatment and survivorship is important; however, little data are available - particularly for long-term ( > 5 year) survivors. Health utility scores anchored between 0 (death) and 1 (perfect/best possible health) have been shown to be a good proxy index score of the overall HRQOL. The aim of this study was to estimate the utilities in the treatment and survivorship of breast cancer using validated preference-based measures(PBMs). Methods: Women (18 years or older) with history of breast cancer (on/off treatment) were recruited via Love Research Army (LRA), an online community of women engaged in breast cancer research. Members of the LRA were invited to participate via email and women who self-selected to be eligible were asked to complete clinical and demographics form and two generic PBMs - EQ-5D and Short Form-12 (SF-12), and one cancer-specific PBM-European Organization for Research and Treatment of Cancer-8D (EORTC-8D). Descriptive statistics and non-parametric analysis of variance tests were used to examine differences between the survivorship groups. Results: 1,636 women aged 46 ± 10 years were included in the analysis. Mean age at primary diagnosis was 35 ± 10 years and most patients were diagnosed with breast cancer stage 0-2 (n = 1362, 83.25%). For women currently on treatments, mean utility values were: chemotherapy (EQ-5D = 0.61, SF-6D = 0.67,EORTC-8D = 0.69), radiation(EQ-5D = 0.71, SF-6D = 0.67, EORTC-8D = 0.66), hormone replacement therapy (EQ-5D = 0.82,SF-6D = 0.76,EORTC-8D = 0.85), targeted therapy (EQ-5D = 0.77, SF-6D = 0.74, EORTC-8D = 0.82), and surgery (EQ-5D = 0.81,SF-6D = 0.69, EORTC-8D = 0.78). For women diagnosed with arm lymphedema (n = 182,11%), utility values were EQ-5D = 0.79,SF-6D = 0.74, EORTC-8D = 0.82. Women who were ≤ 5 years post-primary diagnosis reported slightly lower utility values (EQ-5D = 0.82,SF-6D = 0.76,EORTC-8D = 0.84) than women who were 6-10 years (EQ-5D = 0.83,SF-6D = 0.76,EORTC-8D = 0.85; p = 0.117) post-primary diagnosis. However, when utilities for women who were ≤ 5 years post-primary diagnosis were compared to women who were 11 to 15 years (EQ-5D = 0.86,SF-6D = 0.79,EORTC-8D = 0.88) and over 15 years (EQ-5D = 0.86,SF-6D = 0.81,EORTC-8D = 0.89) post-primary diagnosis, the difference was statistically significant (p = 0.000). Women who belonged to non-White ethnic groups, had lower levels of education (Bachelors or less) and reported less than USD 50,000 annual income in the previous year reported lower utility values across all time points, after adjusting for age and cancer stage. Conclusions: This study shows that the HRQOL decline in the first five years post-primary breast cancer diagnosis persists for several years into survivorship. Further, women from ethnic minority groups and lower socioeconomic background have lower HRQOL, irrespective of their age and cancer stage.

OBJECTIVES/SPECIFIC AIMS: Stigma has been recognized as a major impediment to accessing mental health care among Vietnamese and Asian Americans (Leong and Lau, 2001; Sadavoy et al., 2004; Wynaden et al., 2005; Fong and Tsuang, 2007). The underutilization of mental health care, and disparities in both access and outcomes have been attributed to a large extent to stigma and cultural characteristics of this population (Wynaden et al., 2005; Jang et al., 2009; Leung et al., 2010; Spencer et al., 2010; Jimenez et al., 2013; Augsberger et al., 2015). People with neurotic or behavioral disorders may be considered “bad” as many Vietnamese people believe it is a consequence of one’s improper behavior in a previous life, for which the person is now being punished (Nguyen, 2003). Mental disorders can also been seen as a sign of weakness, which contributes to ambivalence and avoidance of help-seeking (Fong and Tsuang, 2007). Equally important is the need to protect family reputation; having emotional problems often implies that the person has “bad blood” or is being punished for the sins of his/her ancestors (Herrick and Brown, 1998; Leong and Lau, 2001), which disgraces the entire family (Wynaden et al., 2005). In these cases, public stigma (as opposed to internal stigma) is the primary reason for delays in seeking help (Leong and Lau, 2001). Other research has also highlighted the influences of culture on how a disorder may be labeled in different settings, although the presentation of symptoms might be identical (see Angel and Thoits, 1987). In Vietnamese culture, mental disorders are often labeled điên (literally translated as “madness”). A điên person and his or her family are often severely disgraced; consequently the individuals and their family become reluctant to disclose and seek help for mental health problems for fear of rejection (Sadavoy et al., 2004). Despite the critical role of stigma in accessing mental health care, there has been little work in trying to understand how stigmatizing attitudes towards mental illness among Vietnamese Americans manifest themselves and the influences of acculturation on these attitudes. Some previous work indicated a significant level of mental illness stigma among Vietnamese Americans, and experiences of living in the United States might interact with the way stigma manifests among this population (Do et al., 2014). Stigma is a complex construct that warrants a deeper and more nuanced understanding (Castro et al., 2005). Much of the development of stigma-related concepts was based on the classic work by Goffman (1963); he defined stigma as a process by which an individual internalizes stigmatizing characteristics and develops fears and anxiety about being treated differently from others. Public stigma (defined by Corrigan, 2004) includes the general public’s negative beliefs about specific groups, in this case individuals and families with mental illness concerns, that contribute to discrimination. Public stigma toward mental illness acts not only as a major barrier to care, but can also exacerbate anxiety, depression, and adherence to treatment (Link et al., 1999; Sirey et al., 2001; Britt et al., 2008; Keyes et al., 2010). Link and Phelan (2001) conceptualized public stigma through four major components. The first component, labeling, occurs when people distinguish and label human differences that are socially relevant, for example, skin color. In the second component, stereotyping, cultural beliefs link the labeled persons to undesirable characteristics either in the mind or the body of such persons, for example people who are mentally ill are violent. The third component is separating “us” (the normal people) from “them” (the mentally ill) by the public. Finally, labeled persons experience status loss and discrimination, where they are devalued, rejected and excluded. Link and Phelan (2001) emphasized that stigmatization also depends on access to social, economic, and political power that allows these components to unfold. This study aims to answer the following research questions: (1) how does public stigma related to mental illness manifest among Vietnamese Americans? and (2) in what ways does acculturation influence stigma among this population? We investigate how the 4 components of stigma according to Link and Phelan (2001) operationalized and how they depend on the level of acculturation to the host society. Vietnamese Americans is the key ethnic minority group for this study for several reasons. Vietnamese immigration, which did not start in large numbers until the 1970s, has features that allow for a natural laboratory for comparisons of degree of acculturation. Previous research has shown significant intergenerational differences in the level of acculturation and mental health outcomes (e.g., Shapiro et al., 1999; Chung et al., 2000; Ying and Han, 2007). In this study, we used age group as a proxy indicator of acculturation, assuming that those who were born and raised in the United States (the 18–35 year olds) would be more Americanized than those who were born in Vietnam but spent a significant part of their younger years in the United States (the 36–55 year olds), and those who were born and grew up in Vietnam (the 56–75 year olds) would be most traditional Vietnamese. The language used in focus group discussions (FGDs) reflected some of the acculturation, where all FGDs with the youngest groups were done in English, and all FGDs with the oldest groups were done in Vietnamese. METHODS/STUDY POPULATION: Data were collected through a set of FGDs and key informant interviews (KIIs) with experts to explore the conceptualization and manifestation of mental illness public stigma among Vietnamese Americans in New Orleans. Six FGDs with a total of 51 participants were conducted. Participants were Vietnamese American men and women ages 18–75. Stratification was used to ensure representation in the following age/immigration pattern categories: (1) individuals age 56–75 who were born and grew up in Vietnam and immigrated to the United States after age 35; (2) individuals age 36–55 who were born in Vietnam but spent a significant part of their youth in the United States; and (3) individuals age 18–35 who were born and grew up in the United States. These groups likely represent different levels of acculturation, assuming that people who migrate at a younger age are more likely to assimilate to the host society than those who do at a later age. Separate FGDs were conducted with men and women. Eleven KIIS were conducted with 6 service providers and 5 community and religious leaders. In this analysis, we focused on mental illness public stigma from the FGD participants’ perspectives. FGDs were conducted in either English or Vietnamese, whichever participants felt more comfortable with, using semistructured interview guides. All interviews were audio recorded, transcribed and translated into English if conducted in Vietnamese. Data coding and analysis was done using NVivo version 11 (QSR International, 2015). The analysis process utilized a Consensual Qualitative Research (CQR) approach, a validated and well-established approach to collecting and analyzing qualitative data. CQR involves gathering textual data through semistructured interviews or focus groups, utilizing a data analysis process that fosters multiple perspectives, a consensus process to arrive at judgments about the meaning of data, an auditor to check the work of the research team, and the development of domains, core-ideas, and cross-analysis (Hill et al., 2005). The study was reviewed and approved by Tulane University’s Internal Review Board. RESULTS/ANTICIPATED RESULTS: Components of public stigma related to mental illness. The 4 components of public stigma manifest to different extents within the Vietnamese Americans in New Orleans. Labeling was among the strongest stigma components, while the evidence of the other components was mixed. Across groups of participants, Vietnamese Americans agreed that it was a common belief that people with mental disorders were “crazy,” “acting crazy,” or “madness.” “Not normal,” “sad,” and “depressed” were among other words used to describe the mentally ill. However, there were clear differences between younger and older Vietnamese on how they viewed these conditions. The youngest groups of participants tended to recognize the “craziness” and “madness” as a health condition that one would need to seek help for, whereas the oldest groups often stated that these conditions were short term and likely caused by family or economic problems, such as a divorce, or a bankruptcy. The middle-aged groups were somewhere in between. The evidence supporting the second component, stereotyping, was not strong among Vietnamese Americans. Most FGD participants agreed that although those with mental disorders may act differently, they were not distinguishable. In a few extreme cases, mentally ill individuals were described as petty thefts or being violent towards their family members. Similarly to the lack of strong evidence of stereotyping, there was also no evidence of the public separating the mentally ill (“them”) from “us”. It was nearly uniformly reported that they felt sympathetic to those with mental disorders and their family, and that they all recognized that they needed help, although the type of help was perceived differently across groups. The older participants often saw that emotional and financial support was needed to help individuals and families to pass through a temporary phase, whereas younger participants often reported that professional help was necessary. The last component, status loss and discrimination, had mixed evidence. While nearly no participants reported any explicit discriminatory behaviors observed and practiced towards individuals with mental disorders and their families, words like “discrimination” and “stigma” were used in all FGDs to describe direct social consequences of having a mental disorder. Social exclusion was common. Our older participants said: “They see less of you, when they see a flaw in you they don’t talk to you or care about you. That’s one thing the Vietnamese people are bad at, spreading false rumors and discrimination” (Older women FGD). One’s loss of status seemed certain if their or their loved one’s mental health status was disclosed. Shame, embarrassment, and being “frowned upon” were direct consequences of one’s mental health status disclosure and subsequently gossiped about. Anyone with mental disorders was certain to experience this, and virtually everyone in the community would reportedly do this to such a family. “You get frowned upon. In the Vietnamese culture, that’s [a family identified as one with mental health problems] the big no-no right there. When everybody frowns upon your family and your family name, that’s when it becomes a problem” (Young men FGD). This is tied directly to what our participants described as Vietnamese culture, where pride and family reputation were such a high priority that those with mental disorders needed to go to a great extent to protect—“We all know what saving face means” as reported by our young participants. Even among young participants, despite their awareness of mental illness and the need for professional help, the desire to avoid embarrassment and save face was so strong that one would think twice about seeking help. “No, you just don’t want to get embarrassed. I don’t want to go to the damn doctor and be like ‘Oh yeah, my brother got an issue. You can help him?’ Why would I do that? That’s embarrassing to myself…” (Young men FGD). Our middle-aged participants also reported: “If I go to that clinic [mental health or counseling clinic], I am hoping and praying that I won’t bump into somebody that I know from the community” (Middle-aged women FGD). Vietnamese people were also described as being very competitive among themselves, which led to the fact that if a family was known for having any problem, gossips would start and spread quickly wherever they go, and pretty soon, the family would be looked down by the entire community. “I think for Vietnamese people, they don’t help those that are in need. They know of your situation and laugh about it, see less of you, and distant themselves from you” (Older women FGD). Culture and mental illness stigma, much of the described stigma and discrimination expressed, and consequently the reluctance to seek help, was attributed to the lack of awareness of mental health and of mental health disorders. Many study participants across groups also emphasized a belief that Vietnamese Americans were often known for their perseverance and resilience, overcoming wars and natural disasters on their own. Mental disorders were reportedly seen as conditions that individuals and families needed to overcome on their own, rather than asking for help from outsiders. This aspect of Vietnamese culture is intertwined with the need to protect one’s family’s reputation, being passed on from one generation to the next, reinforcing the beliefs that help for mental disorders should come from within oneself and one’s family only. Consequently persons with mental health problems would be “Keeping it to themselves. Holding it in and believing in the power of their friends” (Middle-aged FGD) instead of seeking help. Another dimension of culture that was apparent from FGDs (as well as KIIs) was the mistrust in Western medicine. Not understanding how counseling or medicines work made one worry about approaching service providers or staying in treatment. The habit of Vietnamese people to only go see a doctor if they are sick with physical symptoms was also a hindrance to acknowledging mental illness and seeking care for it. Challenges, including the lack of vocabulary to express mental illness and symptoms, in the Vietnamese language, exaggerated the problem, even among those who had some understanding of mental disorders. It was said in the young men FGD that: “when you classify depression as an illness, no one wants to be sick,… if you call it an illness, no one wants to have that sort of illness, and it’s not an illness that you can physically see…” (Young men FGD). Another young man summarized so well the influence of culture on mental illness stigma: “Us Southeast Asian, like, from my parents specifically has Vietnam War refugees. I think the reason why they don’t talk about it is because it’s a barrier that they have to overcome themselves, right? As refugees, as people who have been through the war… [omitted]They don’t want to believe that they need help, and so the trauma that they carry when they give birth to us is carried on us as well. But due to the language barrier and also the, like, they say with the whole health care, in Vietnam I know that they don’t really believe in Western and Eurocentric medicine. So, from their understanding of how, like from their experience with colonization or French people, and how medicine works, they don’t believe in it” (Young men FGD). One characteristic of the Vietnamese culture that was also often mentioned by our FGD participants (as well as KIIs) was the lack of sharing and openness between generations, even within a family. Grandparents, parents, and children do not usually share and discuss each other’s problems. Parents and grandparents do not talk about problems because they need to appear strong and good in front of their children; children do not talk about problems because they are supposed to do well in all aspects, particularly in school. The competitiveness of Vietnamese and high expectations of younger generations again come into play here and create a vicious cycle. Young people are expected to do well in school, which put pressure on them and may result in mental health problems, yet, they cannot talk about it with their parents because they are not supposed to feel bad about school, and sharing is not encouraged. The Asian model minority myth and the expectations of parents that their children would do well in school and become doctors and lawyers were cited by many as a cause of mental health problems among young people. “Our parents are refugees, they had nothing and our parents want us to achieve this American Dream…. [omitted] It set expectations and images for us…. It was expected for all the Asians to be in the top 10, and for, like a little quick minute I thought I wasn’t going to make it, I was crying” (Yong men FGD). As a result, the mental health problems get worse. “If you’re feeling bad about something, you don’t feel like you can talk about it with anyone else, especially your family, because it is not something that is encouraged to be talked about anyway, so if you are feeling poorly and you don’t feel like you could talk to anybody, I think that just perpetuates the bad feelings” (Middle-aged women FGD). Acculturation and mental illness stigma Acculturation, the degree of assimilation to the host society, has changed some of the understanding of mental illness and stigmatizing attitudes. Differences across generations expressed in different FGDs indicated differences in perceptions towards mental illness that could be attributed to acculturation. For example, the young generation understood that mental illness was a health problem that was prevalent but less recognized in the Vietnamese community, whereas a prominent theme among the older participants was that mental illness was a temporary condition due to psychological stress, that it was a condition that only Caucasians had. Some of the components of public stigma related to mental illness seemed to vary between generations, for example the youngest participants were less likely to put a label on a person with mental health problems, or to stereotype them, compared to the oldest and middle-aged participants. This was attributed to their education, exposure to the media and information, and to them “being more Americanized.” However, there was no evidence that acculturation played an important role in changing the other components of public stigma, including stereotyping, separating, and status loss and discrimination. For example, the need to protect the family reputation was so important that our young participants shared: “If you damage their image, they will disown you before you damage that image” (Young men FGD). Young people, more likely to recognize mental health problems, were also more likely to share within the family and to seek help, but no more likely than their older counterparts to share outside of the family—“maybe you would go to counseling or go to therapy, but you wouldn’t tell people you’re doing that” (Young women FGD). The youngest participants in our study were facing a dilemma, in which they recognized mental health problems and the need for care, yet were still reluctant to seek care or talk about it publicly because of fears of damaging the family reputation and not living up to the parents’ expectations. Many young participants reported that it actually made it very difficult for them to navigate mental health issues between the 2 cultures, despite the awareness of the resources available. “I think it actually makes it harder. Only because you know to your parents and the culture, and your own people, it’s taboo, and it’s something that you don’t talk about. Just knowing that you have the resources to go seek it… You want advice from your family also, but you can’t connect the appointment to your family because you’re afraid to express that to your parents, you know? So I think that plays a big part, and knowing that you are up and coming, but you don’t want to do something to disappoint your family because they are so traditional” (Young men FGD). Some participants felt more comfortable talking about mental health problems, like depression, if it was their friend who experienced it and confided in them, but they would not necessarily felt open if it was their problem. Subtle cultural differences like this are likely overlooked by Western service providers. One older participant summarized it well “They [the young generation] are more Americanized. They are more open to other things [but] I think that mental health is still a barrier.” DISCUSSION/SIGNIFICANCE OF IMPACT: This study investigated how different components of public stigma related to mental illness manifest among Vietnamese Americans, a major ethnic group in the United States, and how acculturation may influence such stigma. The findings highlighted important components of public stigma, including labeling and status loss, but did not provide strong evidence of the other components within our study population. Strong cultural beliefs underlined the understanding of mental health and mental illness in general, and how people viewed people with mental illness. Several findings have been highlighted in previous studies with Asian immigrants elsewhere; for example, a study from the perspectives of health care providers in Canada found that the unfamiliarity with Western biomedicine and spiritual beliefs and practices of immigrant women interacted with social stigma in preventing immigrants from accessing care (O’Mahony and Donnelly, 2007). Fancher et al. (2010) reported similar findings regarding stigma, traditional beliefs about medicine, and culture among Vietnamese Americans. Acculturation played a role in changing stigmatizing attitudes as evidenced in intergenerational differences. However, being more Americanized did not equate to being more open, having less stigmatizing attitudes, or being more willing to seek care for mental health issues. Consistent with previous studies (Pedersen and Paves, 2014), we still found some level of stigma among young people aged 18–35, although some components were lessened with an increased level of acculturation. There was also a conflict among the younger generation, in which the need for mental health care was recognized but accessing care was no easier for them than for their parent and grandparent generations. The study’s findings are useful to adapt existing instruments to measure stigma to this population. The findings also have important program implications. One, they can be directly translated into basic supports for local primary and behavioral health care providers. Two, they can also be used to guide and inform the development and evaluation of an intervention and an additional study to validate the findings in other immigrant ethnic groups in the United States. Finally, based on results of the study, we can develop a conceptual framework that describes pathways through which social, cultural, and ecological factors can influence stigma and the ways in which stigma acts as a barrier to accessing mental health care among Vietnamese Americans. The guiding framework then can be validated and applied in future programs aimed to improve mental health care utilization among ethnic minorities.

After a period of implementing the program on building new rural areas in our country in general and especially for the three regions North West, Central Highlands and South West in particular has made certain achievements but also exposed many shortcomings, effectively building new rural areas programs in many local is not high, not to promote the role of community in the building at the new rural local. Derived from natural conditions, economic - social situation at 3 communes in 3 different areas, especially the difficulties and shortcomings in the process of building new rural areas of three local (Ban Lau commune, Da K’Nang commune, Tan Hiep commune) the author has selected three communes representing three regions (North West, Central Highlands and Southwest) is geographical deployment three points models. The construction of the pilot community organizations build new rural areas in three communes with special difficulties in three districts of poverty (30A programme) of the three regions North West, Central Highlands and Southwest is essential to meet the demands urgent and legitimate aspirations of all levels of government, communities, ethnic minorities and ethnic minority people in the locality

Abstract Background Women have been especially impacted by the COVID-19 pandemic. This exploratory study aimed to characterize women’s adverse experiences related to their work, home lives, and wellbeing during the height of the COVID-19 pandemic and to describe demographic differences of those lived experiences. Methods Using the validated Epidemic-Pandemic Impacts Inventory, we collected data from reproductive-aged women in the state of Georgia about their exposure to adverse events during the pandemic. A latent class analysis (LCA) was performed to identify subgroups of women reporting similar adverse experiences and describe their sociodemographic characteristics. An optional open-ended question yielded qualitative data that were analyzed thematically and merged with subgroup findings. Data were collected from September 2020 to January 2021. Results 423 individuals aged 18–49 completed the survey with 314 (74.2%) providing qualitative responses. The LCA yielded 4 subgroups: (1) a “low exposure” subgroup (n = 123, 29.1%) with relatively low probability of adverse experiences across domains (e.g. financial insecurity, health challenges, barriers to access to healthcare, intimate partner violence (IPV)); (2) a “high exposure” subgroup (n = 46, 10.9%) with high probability of experiencing multiple adversities across domains including the loss of loved ones to COVID-19; (3) a “caregiving stress” subgroup (n = 104, 24.6%) with high probability of experiencing challenges with home and work life including increased partner conflict; and (4) a “mental health changes” subgroup (n = 150, 35.5%) characterized by relatively low probability of adverse experiences but high probability of negative changes in mental health and lifestyle. Individuals in subgroups 1 and 4, which had low probabilities of adverse experiences, were significantly more likely to be non-Hispanic white. Individuals in subgroup 2 were more likely to identify with a sexual or racial/ethnic minority population. Inductive coding of qualitative data yielded themes such as stress, mental health, financial impact, and adaptation/resilience, providing context for pandemic-related adversity. Conclusion Though many individuals in our sample experienced hardship, minority populations were unequally impacted by pandemic-related adversity in work life, home life, and wellbeing. Recovery and future emergency preparedness efforts in Georgia must incorporate support mechanisms for mental health and IPV, focusing especially on the intersectional needs of racial, ethnic, and sexual minorities.

Introduction: Poor diet and physical inactivity is the second leading cause of mortality in the US after smoking. Cross-sectional, ecologic studies have associated specific obesogenic food environments (OFE examples: smaller distance to fast food restaurants, higher counts of fast food per population, larger distance to grocery stores, lower counts of grocery stores per population) to higher rates of poor diet or higher body mass index (BMI). OFEs are more prevalent in some low-income and racial/ethnic minority neighborhoods potentially contributing to widening health disparities. Recent analyses of two longitudinal cohorts (CARDIA; Framingham Offspring Cohort), found no associations between ecologic measures of OFEs and poor diet or BMI, possibly because they do not capture the characteristics of the OFEs associated with poor diet or BMI. Hypothesis: We assessed the hypothesis that current ecologic OFE measures do not capture the link between food environments and BMI because they ignore variability in food store types and actual distance traveled to purchase food. Populations defined by store type or distance may better describe the potential causal link. Methods: The Los Angeles Family and Neighborhood Survey (LAFANS) is a longitudinal cohort of 2619 households in Los Angeles County. In 2001-2, households were asked where they shopped for groceries (store name/location) and self-reported BMI. A six-category food environment measure based on store name and frequency was developed: high-frequency (HF) English-language named stores (“major chain”), discount stores (“less”, “value”, etc. in the name), HF Spanish-language stores, English-language specialty stores, multi-purpose or bulk purchase stores, other HF stores, and other low frequency stores of any language. We analyzed associations of this food environment measure with self-reported BMI, controlling for individual, household, and neighborhood characteristics. Results: In LAFANS households, 2297 (88%) reported both BMI and a valid store name. Of these, 37% of households shop at the nearest grocery store and only 13% shop in their home census tract. In adjusted models, discount store shoppers have substantially higher BMI than the referent group, major chain store shoppers in low disadvantage neighborhoods (BMI difference 1.40 points, (95% CI 0.62 - 2.18, p = 0.004), equivalent to a weight difference of 8.4 lbs. for an individual of median height and weight (5’5”,160 lbs.). Conclusions: In conclusion, distinguishing between store types may better describe the causal link between individuals, stores and BMI than ecologic measures. In L.A. County, discount stores, found almost exclusively in high disadvantage and racial/ethnic minority neighborhoods are associated with individual differences in BMI. Further research should assess whether the association between discount stores and BMI is related to unmeasured elements of store content or individual characteristics. Current policy efforts focused on modifying small markets or building major chain stores in high disadvantage neighborhoods may inadequately address food environment based racial/ethnic and income based health disparities in BMI.

Photo by Sharon McCutcheon on Unsplash ABSTRACT COVID-19 highlighted a disproportionate impact upon marginalized communities that needs to be addressed. Specifically, a focus on equity rather than equality would better address and prevent the disparities seen in COVID-19. A distributive justice framework can provide this great benefit but will succeed only if the medical community engages in outreach, anti-racism measures, and listens to communities in need. INTRODUCTION COVID-19 disproportionately impacted communities of color and lower socioeconomic status, sparking political discussion about existing inequities in the US.[1] Some states amended their guidelines for allocating resources, including vaccines, to provide care for marginalized communities experiencing these inequities, but there has been no clear consensus on which guidelines states should amend or how they should be ethically grounded. In part, this is because traditional justice theories do not acknowledge the deep-seated institutional and interpersonal discrimination embedded in our medical system. Therefore, a revamped distributive justice approach that accounts for these shortcomings is needed to guide healthcare decision-making now and into the post-COVID era. BACKGROUND Three terms – health disparity, health inequities, and health equity – help frame the issue. A health disparity is defined as any difference between populations in terms of disease incidence or adverse health events, such as morbidity or mortality. In contrast, health inequities are health disparities due to avoidable systematic structures rooted in racial, social, and economic injustice.[2] For example, current data demonstrate that Black, Latino, Indigenous Americans, and those living in poverty suffer higher morbidity and mortality rates from COVID-19.[3] Finally, health equity is the opportunity for anyone to attain his or her full health potential without interference from systematic structures and factors that generate health inequities, including race, socioeconomic status, gender, ethnicity, religion, sexual orientation, or geography.[4] ANALYSIS Health inequities for people of color with COVID-19 have led to critiques of states that do not account for race in their resource allocation guidelines.[5] For example, the Massachusetts Department of Public Health revised its COVID-19 guidelines regarding resource allocation to patients with the best chance of short-term survival.[6] Critics have argued that this change addresses neither preexisting structural inequities nor provider bias that may have led to comorbidities and increased vulnerability to COVID-19. By failing to address race specifically, they argue the policy will perpetuate poorer outcomes in already marginalized groups. As the inequities in COVID-19 outcomes continue to be uncovered and the data continue to prove that marginalized communities suffered disproportionately, we, as healthcare providers, must reconsider our role in addressing the injustices. Our actions must be ethically grounded in the concept of justice. l. Primary Theories of Justice The principle of justice in medical ethics relates to how we ought to treat people and allocate resources. Multiple theories have emerged to explain how justice should be implemented, with three of the most prominent being egalitarianism, utilitarianism, and distributive. This paper argues that distributive justice is the best framework for remedying past actions and enacting systemic changes that may persistently prevent injustices. An egalitarian approach to justice states all individuals are equal and, therefore, should have identical access to resources. In the allocation of resources, an egalitarian approach would support a strict distribution of equal value regardless of one’s attributes or characteristics. Putting this theory into practice would place a premium on guidelines based upon first-come, first-served basis or random selection.[7] However, the egalitarian approach taken in the UK continues to worsen health inequities due to institutional and structural discrimination.[8] A utilitarian approach to justice emphasizes maximizing overall benefits and achieving the greatest good for the greatest number of people. When resources are limited, the utilitarian principle historically guides decision-making. In contrast to the egalitarian focus on equal distribution, utilitarianism focuses on managing distributions to maximize numerical outcomes. During the COVID-19 pandemic, guidelines for allocating resources had utilitarian goals like saving the most lives, which may prioritize the youthful and those deemed productive in society, followed by the elderly and the very ill. It is important to reconsider using utilitarian approaches as the default in the post-COVID healthcare community. These approaches fail to address past inequity, sacrificing the marginalized in their emphasis on the greatest amount of good rather than the type of good. Finally, a distributive approach to justice mandates resources should be allocated in a manner that does not infringe individual liberties to those with the greatest need. Proposed by John Rawls in a Theory of Justice, this approach requires accounting for societal inequality, a factor absent from egalitarianism and utilitarianism.[9] Naomi Zack elaborates how distributive justice can be applied to healthcare, outlining why racism is a social determinant of health that must be acknowledged and addressed.[10] Until there are parallel health opportunities and better alignment of outcomes among different social and racial groups, the underlying systemic social and economic variables that are driving the disparities must be fixed. As a society and as healthcare providers, we should be striving to address the factors that perpetuate health inequities. While genetics and other variables influence health, the data show proportionately more exposure, more cases, and more deaths in the Black American and Hispanic populations. Preexisting conditions and general health disparities are signs of health inequity that increased vulnerability. Distributive justice as a theoretical and applied framework can be applied to preventable conditions that increase vulnerability and can justify systemic changes to prevent further bias in the medical community. During a pandemic, egalitarian and utilitarian approaches to justice are prioritized by policymakers and health systems. Yet, as COVID-19 has demonstrated, they further perpetuate the death and morbidity of populations that face discrimination. These outcomes are due to policies and guidelines that overall benefit white communities over communities of color. Historically, US policy that looks to distribute resources equally (focusing on equal access instead of outcomes), in a color-blind manner, has further perpetuated poor outcomes for marginalized communities.[11] ll. Historical and Ongoing Disparities Across socio-demographic groups, the medical system exacerbates historical and current inequities. Members of marginalized races,[12] women,[13] LGBTQ people,[14] and poor people[15] experience trauma caused by discrimination, marginalization, and failure to access high-quality public and private goods. Through the unequal treatment of marginalized communities, these historic traumas continue. In the US, people of color do not receive equal and fair medical treatment. A meta-analysis found that Hispanics and Black Americans were significantly undertreated for pain compared to their white counterparts over the last 20 years.[16] This is partly due to provider bias. Through interviewing medical trainees, a study by the National Academy of Science found that half of medical students and residents harbored racist beliefs such as “Black people’s nerve endings are less sensitive than white people’s” or “Black people’s skin is thicker than white people’s skin.”[17] More than 3,000 Indigenous American women were coerced, threatened, and deliberately misinformed to ensure cooperation in forced sterilization.[18] Hispanic people have less support in seeking medical care, in receiving culturally appropriate care, and they suffer from the medical community’s lack of resources to address language barriers.[19] In the US, patients of different sexes do not receive the same quality of healthcare. Despite having greater health needs, middle-aged and older women are more likely to have fewer hospital stays and fewer physician visits compared to men of similar demographics and health risk profiles.[20] In the field of critical care, women are less likely to be admitted to the ICU, less likely to receive interventions such as mechanical ventilation, and more likely to die compared to their male ICU counterparts.[21] In the US, patients of different socioeconomic statuses do not receive the same quality of healthcare. Low-income patients are more likely to have higher rates of infant mortality, chronic disease, and a shorter life span.[22] This is partly due to the insurance-based discrimination in the medical community.[23] One in three deaths of those experiencing homelessness could have been prevented by timely and effective medical care. An individual experiencing homelessness has a life expectancy that is decades shorter than that of the average American.[24] lll. Action Needed: Policy Reform While steps need to be taken to provide equitable care in the current pandemic, including the allocation of vaccines, they may not address the historical failures of health policy, hospital policy, and clinical care to eliminate bias and ensure equal treatment of patients. According to an applied distributive justice framework, inequities must be corrected. Rather than focusing primarily on fair resource allocation, medicine must be actively anti-racist, anti-sexist, anti-transphobic, and anti-discriminatory. Evidence has shown that the health inequities caused by COVID-19 are smaller in regions that have addressed racial wealth gaps through forms of reparations.[25] Distributive justice calls for making up for the past using tools of allocation as well as tools to remedy persistent problems. For example, Brigham and Women’s Hospital in Boston, MA, began “Healing ARC,” a pilot initiative that involves acknowledgement, redress, and closure on an institutional level.[26] Acknowledgement entails informing patients about disparities at the hospital, claiming responsibility, and incorporating community ideas for redress. Redress involves a preferential admission option for Black and Hispanic patients to specialty services, especially cardiovascular services, rather than general medicine. Closure requires that community and patient stakeholders work together to ensure that a new system is in place that will continue to prioritize equity. Of note, redress could take the form of cash transfers, discounted or free care, taxes on nonprofit hospitals that exclude patients of color,[27] or race-explicit protocol changes (such as those being instituted by Brigham and Women’s Hospital that admit patients historically denied access to certain forms of medical care). In New York, for instance, the New York State Bar Association drafted the COVID-19 resolutions to ensure that emergency regulations and guidelines do not discriminate against communities of color, and even mandate that diverse patient populations be included in clinical trials.[28] Also, physicians must listen to individuals from marginalized communities to identify needs and ensure that community members take part in decision-making. The solution is not to simply build new health centers in communities of color, as this may lead to tiers of care. Rather, local communities should have a chance to impact existing hospital policy and should also use their political participation to further their healthcare interests. Distributive justice does not seek to disenfranchise groups that hold power in the system. It aims to transform the system so that those in power do not continue to obtain unfair benefits at the expense of others. The framework accounts for unjust historical oppression and current injustices in our system to provide equitable outcomes to all who access the system. In this vein, we can begin to address the flagrant disparities between communities that have always – and continue to – exist in healthcare today.[29] CONCLUSION As equality focuses on access, it currently fails to do justice. Instead of outcomes, it is time to focus on equity. A focus on equity rather than equality would better address and prevent the disparities seen in COVID-19. A distributive justice framework can gain traction in clinical decision-making guidelines and system-level reallocation of resources but will succeed only if the medical community engages in outreach, anti-racism measures, and listens to communities in need. There should be an emphasis on implementing a distributive justice framework that treats all patients equitably, accounts for historical harm, and focuses on transparency in allocation and public health decision-making. [1] APM Research Lab Staff. 2020. “The Color of Coronavirus: COVID-19 Deaths by Race and Ethnicity in the U.S.” APM Research Lab. https://www.apmresearchlab.org/covid/deaths-by-race. [2] Bharmal, N., K. P. Derose, M. Felician, and M. M. Weden. 2015. “Understanding the Upstream Social Determinants of Health.” California: RAND Corporation 1-18. https://www.rand.org/pubs/working_papers/WR1096.html. [3] Yancy, C. W. 2020. “COVID-19 and African Americans.” JAMA. 323 (19): 1891-2. https://doi.org/10.1001/jama.2020.6548; Centers for Disease Control and Prevention. 2020. “COVID-19 in Racial and Ethnic Health Disparities.” Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/index.html. [4] Braveman, P., E. Arkin, T. Orleans, D. Proctor, and A. Plough. 2017. “What is Health Equity?” Robert Wood Johnson Foundation. https://www.rwjf.org/en/library/research/2017/05/what-is-health-equity-.html. [5] Bedinger, M. 2020 Apr 22. “After Uproar, Mass. Revises Guidelines on Who Gets an ICU Bed or Ventilator Amid COVID-19 Surge.” Wbur. https://www.wbur.org/commonhealth/2020/04/20/mass-guidelines-ventilator-covid-coronavirus; Wigglesworth, A. 2020 May 11. “Institutional Racism, Inequity Fuel High Minority Death Toll from Coronavirus, L.A. Officials Say.” Los Angeles Times. https://www.latimes.com/california/story/2020-05-11/institutional-racism-inequity-high-minority-death-toll-coronavirus. [6] Executive Office of Health and Human Services Department of Public Health. 2020 Oct 20. “Crises Standards of Care Planning and Guidance for the COVID-19 Pandemic.” Commonwealth of Massachusetts. https://www.mass.gov/doc/crisis-standards-of-care-planning-guidance-for-the-covid-19-pandemic. [7] Emanuel, E. J., G. Persad, R. Upshur, et al. 2020. “Fair Allocation of Scarce Medical Resources in the Time of Covid-19. New England Journal of Medicine 382: 2049-55. https://doi.org/10.1056/NEJMsb2005114. [8] Salway, S., G. Mir, D. Turner, G. T. Ellison, L. Carter, and K. Gerrish. 2016. “Obstacles to "Race Equality" in the English National Health Service: Insights from the Healthcare Commissioning Arena.” Social Science and Medicine 152: 102-110. https://doi.org/10.1016/j.socscimed.2016.01.031. [9] Rawls, J. A Theory of Justice (Revised Edition) (Cambridge, MA: Belknap Press of Harvard University Press, 1999). [10] Zack, N. Applicative Justice: A Pragmatic Empirical Approach to Racial Injustice (New York: The Rowman & Littlefield Publishing Group, 2016). [11] Charatz-Litt, C. 1992. “A Chronicle of Racism: The Effects of the White Medical Community on Black Health.” Journal of the National Medical Association 84 (8): 717-25. http://hdl.handle.net/10822/857182. [12] Washington, H. A. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present (New York: Doubleday, 2006). [13] d'Oliveira, A. F., S. G. Diniz, and L. B. Schraiber. 2002. “Violence Against Women in Health-care Institutions: An Emerging Problem.” Lancet. 359 (9318): 1681-5. https://doi.org/10.1016/S0140-6736(02)08592-6. [14] Hafeez, H., M. Zeshan, M. A. Tahir, N. Jahan, and S. Naveed. 2017. “Health Care Disparities Among Lesbian, Gay, Bisexual, and Transgender Youth: A Literature Review. Cureus 9 (4): e1184. https://doi.org/10.7759/cureus.1184; Drescher, J., A. Schwartz, F. Casoy, et al. 2016. “The Growing Regulation of Conversion Therapy.” Journal of Medical Regulation 102 (2): 7-12. https://doi.org/10.30770/2572-1852-102.2.7; Stroumsa, D. 2014. “The State of Transgender Health Care: Policy, Law, and Medical Frameworks.” American Journal of Public Health. 104 (3): e31-8. https://doi.org/10.2105/AJPH.2013.301789. [15] Stepanikova, I., and G. R. Oates. 2017. “Perceived Discrimination and Privilege in Health Care: The Role of Socioeconomic Status and Race.” American Journal of Preventative Medicine. 52 (1s1): S86-s94. https://doi.org/10.1016/j.amepre.2016.09.024; Swartz, K. “Health Care for the Poor: For Whom, What Care, and Whose Responsibility?” In Cancian, M., and S. Danziger (Eds.). Changing Poverty, Changing Policies (New York: Russell Sage Foundation Press, 2009), 69-74. [16] Meghani, S. H., E. Byun, and R. M. Gallagher. 2012. “Time to Take Stock: A Meta-analysis and Systematic Review of Analgesic Treatment Disparities for Pain in the United States.” Pain Medicine 13 (2): 150-74. https://doi.org/10.1111/j.1526-4637.2011.01310.x; Williams, D. R., and T. D. Rucker. 2000. “Understanding and Addressing Racial Disparities in Health Care.” Health Care Financing Review 21 (4): 75-90. https://scholar.harvard.edu/davidrwilliams/dwilliam/publications/understanding-and-addressing-racial-disparities-health. [17] Hoffman, K. M., S. Trawalter, J. R. Axt, and M. N. Oliver. 2016. “Racial Bias in Pain assessment and treatment recommendations, and false beliefs about biological Differences Between Blacks and Whites.” PNAS 113 (16): 4296-4301. https://doi.org/10.1073/pnas.1516047113. [18] Pacheco, C. M., S. M. Daley, T. Brown, M. Filipp, K. A. Greiner, and C. M. Daley. 2013. “Moving Forward: Breaking the Cycle of Mistrust Between American Indians and Researchers.” American Journal of Public Health. 103 (12): 2152-9. https://doi.org/10.2105/AJPH.2013.301480. [19] Velasco-Mondragon, E., A. Jimenez, A. G. Palladino-Davis, D. Davis, and J. A. Escamilla-Cejudo. 2016. “Hispanic Health in the USA: A Scoping Review of the Literature.” Public Health Reviews 37:31. https://doi.org/10.1186/s40985-016-0043-2. [20] Cameron, K. A., J. Song, L. M. Manheim, and D. D. Dunlop. 2010. “Gender Disparities in Health and Healthcare Use Among Older Adults.” Journal of Women’s Health (Larchmt) 19 (9): 1643-50. https://doi.org/10.1089/jwh.2009.1701. [21] Bierman, A. S. 2007. “Sex Matters: Gender Disparities in Quality and Outcomes of Care. Canadian Medical Association Journal 177 (12): 1520-1. https://doi.org/10.1503/cmaj.071541; Fowler, R. A., S. Sabur, P. Li, et al. 2007. “Sex-and Age-based Differences in the Delivery and Outcomes of Critical Care. Canadian Medical Association Journal 177 (12): 1513-9. https://doi.org/10.1503/cmaj.071112. [22] McLaughlin, D. K., and C. S. Stokes. 2002. “Income Inequality and Mortality in US Counties: Does Minority Racial Concentration Matter?” American Journal of Public Health 92 (1): 99-104. https://doi.org/.10.2105/ajph.92.1.99; Shea, S., J. Lima, A. Diez-Roux, N. W. Jorgensen, and R. L. McClelland. 2016. “Socioeconomic Status and Poor Health Outcome at 10 years of Follow-up in the Multi-ethnic Study of Atherosclerosis.” PLoS One 11 (11): e0165651. https://doi.org/10.1371/journal.pone.0165651. [23] Han, X., K. T. Call, J. K. Pintor, G. Alarcon-Espinoza, and A. B. Simon. 2015. “Reports of Insurance-based Discrimination in Health care and its Association with Access to Care.” American Journal of Public Health 105 Suppl 3 (Suppl 3): S517-25. https://doi.org/10.2105/AJPH.2015.302668. [24] Aldridge, R. W., D. Menezes, D. Lewer, et al. 2019. “Causes of Death Among Homeless People: A Population-based Cross-sectional Study of Linked Hospitalization and Mortality Data in England.” Wellcome Open Research 4:49. https://doi.org/10.12688/wellcomeopenres.15151.1. [25] Richardson, E. T., M. M. Malik, W. A. Darity Jr., et al. 2021. “Reparations for Black American Descendants of Persons Enslaved in the U.S. and their Potential Impact on SARS-CoV-2 Transmission.” Social Science and Medicine 276: 113741. https://doi.org/10.1016/j.socscimed.2021.113741. [26] Wispelwey, B., and M. Morse. 2021. “An Antiracist Agenda for Medicine.” Boston Review. http://bostonreview.net/science-nature-race/bram-wispelwey-michelle-morse-antiracist-agenda-medicine. [27] Johnson, S. F., A. Ojo, and H. J. Warraich. 2021. “Academic Health Centers’ Antiracism Strategies Must Extend to their Business Practices.” Annals of Internal Medicine 174 (2): 254-5. https://doi.org/10.7326/M20-6203; Golub, M., N. Calman, C. Ruddock, et al. 2011. “A Community Mobilizes to End Medical Apartheid.” Progress in Community Health Partnerships: Research, Education, and Action 5 (3): 317-25. https://doi.org/10.1353/cpr.2011.0041. 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1991 An afternoon in late 1991 found me on a Sydney bus reading Brett Easton Ellis’ American Psycho (1991). A disembarking passenger paused at my side and, as I glanced up, hissed, ‘I don’t know how you can read that filth’. As she continued to make her way to the front of the vehicle, I was as stunned as if she had struck me physically. There was real vehemence in both her words and how they were delivered, and I can still see her eyes squeezing into slits as she hesitated while curling her mouth around that final angry word: ‘filth’. Now, almost fifteen years later, the memory is remarkably vivid. As the event is also still remarkable; this comment remaining the only remark ever made to me by a stranger about anything I have been reading during three decades of travelling on public transport. That inflamed commuter summed up much of the furore that greeted the publication of American Psycho. More than this, and unusually, condemnation of the work both actually preceded, and affected, its publication. Although Ellis had been paid a substantial U.S. $300,000 advance by Simon & Schuster, pre-publication stories based on circulating galley proofs were so negative—offering assessments of the book as: ‘moronic … pointless … themeless … worthless (Rosenblatt 3), ‘superficial’, ‘a tapeworm narrative’ (Sheppard 100) and ‘vile … pornography, not literature … immoral, but also artless’ (Miner 43)—that the publisher cancelled the contract (forfeiting the advance) only months before the scheduled release date. CEO of Simon & Schuster, Richard E. Snyder, explained: ‘it was an error of judgement to put our name on a book of such questionable taste’ (quoted in McDowell, “Vintage” 13). American Psycho was, instead, published by Random House/Knopf in March 1991 under its prestige paperback imprint, Vintage Contemporary (Zaller; Freccero 48) – Sonny Mehta having signed the book to Random House some two days after Simon & Schuster withdrew from its agreement with Ellis. While many commented on the fact that Ellis was paid two substantial advances, it was rarely noted that Random House was a more prestigious publisher than Simon & Schuster (Iannone 52). After its release, American Psycho was almost universally vilified and denigrated by the American critical establishment. The work was criticised on both moral and aesthetic/literary/artistic grounds; that is, in terms of both what Ellis wrote and how he wrote it. Critics found it ‘meaningless’ (Lehmann-Haupt C18), ‘abysmally written … schlock’ (Kennedy 427), ‘repulsive, a bloodbath serving no purpose save that of morbidity, titillation and sensation … pure trash, as scummy and mean as anything it depicts, a dirty book by a dirty writer’ (Yardley B1) and ‘garbage’ (Gurley Brown 21). Mark Archer found that ‘the attempt to confuse style with content is callow’ (31), while Naomi Wolf wrote that: ‘overall, reading American Psycho holds the same fascination as watching a maladjusted 11-year-old draw on his desk’ (34). John Leo’s assessment sums up the passionate intensity of those critical of the work: ‘totally hateful … violent junk … no discernible plot, no believable characterization, no sensibility at work that comes anywhere close to making art out of all the blood and torture … Ellis displays little feel for narration, words, grammar or the rhythm of language’ (23). These reviews, as those printed pre-publication, were titled in similarly unequivocal language: ‘A Revolting Development’ (Sheppard 100), ‘Marketing Cynicism and Vulgarity’ (Leo 23), ‘Designer Porn’ (Manguel 46) and ‘Essence of Trash’ (Yardley B1). Perhaps the most unambiguous in its message was Roger Rosenblatt’s ‘Snuff this Book!’ (3). Of all works published in the U.S.A. at that time, including those clearly carrying X ratings, the Los Angeles chapter of the National Organization for Women (NOW) selected American Psycho for special notice, stating that the book ‘legitimizes inhuman and savage violence masquerading as sexuality’ (NOW 114). Judging the book ‘the most misogynistic communication’ the organisation had ever encountered (NOW L.A. chapter president, Tammy Bruce, quoted in Kennedy 427) and, on the grounds that ‘violence against women in any form is no longer socially acceptable’ (McDowell, “NOW” C17), NOW called for a boycott of the entire Random House catalogue for the remainder of 1991. Naomi Wolf agreed, calling the novel ‘a violation not of obscenity standards, but of women’s civil rights, insofar as it results in conditioning male sexual response to female suffering or degradation’ (34). Later, the boycott was narrowed to Knopf and Vintage titles (Love 46), but also extended to all of the many products, companies, corporations, firms and brand names that are a feature of Ellis’s novel (Kauffman, “American” 41). There were other unexpected responses such as the Walt Disney Corporation barring Ellis from the opening of Euro Disney (Tyrnauer 101), although Ellis had already been driven from public view after receiving a number of death threats and did not undertake a book tour (Kennedy 427). Despite this, the book received significant publicity courtesy of the controversy and, although several national bookstore chains and numerous booksellers around the world refused to sell the book, more than 100,000 copies were sold in the U.S.A. in the fortnight after publication (Dwyer 55). Even this success had an unprecedented effect: when American Psycho became a bestseller, The New York Times announced that it would be removing the title from its bestseller lists because of the book’s content. In the days following publication in the U.S.A., Canadian customs announced that it was considering whether to allow the local arm of Random House to, first, import American Psycho for sale in Canada and, then, publish it in Canada (Kirchhoff, “Psycho” C1). Two weeks later, when the book was passed for sale (Kirchhoff, “Customs” C1), demonstrators protested the entrance of a shipment of the book. In May, the Canadian Defence Force made headlines when it withdrew copies of the book from the library shelves of a navy base in Halifax (Canadian Press C1). Also in May 1991, the Australian Office of Film and Literature Classification (OFLC), the federal agency that administers the classification scheme for all films, computer games and ‘submittable’ publications (including books) that are sold, hired or exhibited in Australia, announced that it had classified American Psycho as ‘Category 1 Restricted’ (W. Fraser, “Book” 5), to be sold sealed, to only those over 18 years of age. This was the first such classification of a mainstream literary work since the rating scheme was introduced (Graham), and the first time a work of literature had been restricted for sale since Philip Roth’s Portnoy’s Complaint in 1969. The chief censor, John Dickie, said the OFLC could not justify refusing the book classification (and essentially banning the work), and while ‘as a satire on yuppies it has a lot going for it’, personally he found the book ‘distasteful’ (quoted in W. Fraser, “Sensitive” 5). Moreover, while this ‘R’ classification was, and remains, a national classification, Australian States and Territories have their own sale and distribution regulation systems. Under this regime, American Psycho remains banned from sale in Queensland, as are all other books in this classification category (Vnuk). These various reactions led to a flood of articles published in the U.S.A., Canada, Australia and the U.K., voicing passionate opinions on a range of issues including free speech and censorship, the corporate control of artistic thought and practice, and cynicism on the part of authors and their publishers about what works might attract publicity and (therefore) sell in large numbers (see, for instance, Hitchens 7; Irving 1). The relationship between violence in society and its representation in the media was a common theme, with only a few commentators (including Norman Mailer in a high profile Vanity Fair article) suggesting that, instead of inciting violence, the media largely reflected, and commented upon, societal violence. Elayne Rapping, an academic in the field of Communications, proposed that the media did actively glorify violence, but only because there was a market for such representations: ‘We, as a society love violence, thrive on violence as the very basis of our social stability, our ideological belief system … The problem, after all, is not media violence but real violence’ (36, 38). Many more commentators, however, agreed with NOW, Wolf and others and charged Ellis’s work with encouraging, and even instigating, violent acts, and especially those against women, calling American Psycho ‘a kind of advertising for violence against women’ (anthropologist Elliot Leyton quoted in Dwyer 55) and, even, a ‘how-to manual on the torture and dismemberment of women’ (Leo 23). Support for the book was difficult to find in the flood of vitriol directed against it, but a small number wrote in Ellis’s defence. Sonny Mehta, himself the target of death threats for acquiring the book for Random House, stood by this assessment, and was widely quoted in his belief that American Psycho was ‘a serious book by a serious writer’ and that Ellis was ‘remarkably talented’ (Knight-Ridder L10). Publishing director of Pan Macmillan Australia, James Fraser, defended his decision to release American Psycho on the grounds that the book told important truths about society, arguing: ‘A publisher’s office is a clearing house for ideas … the real issue for community debate [is] – to what extent does it want to hear the truth about itself, about individuals within the community and about the governments the community elects. If we care about the preservation of standards, there is none higher than this. Gore Vidal was among the very few who stated outright that he liked the book, finding it ‘really rather inspired … a wonderfully comic novel’ (quoted in Tyrnauer 73). Fay Weldon agreed, judging the book as ‘brilliant’, and focusing on the importance of Ellis’s message: ‘Bret Easton Ellis is a very good writer. He gets us to a ‘T’. And we can’t stand it. It’s our problem, not his. American Psycho is a beautifully controlled, careful, important novel that revolves around its own nasty bits’ (C1). Since 1991 As unlikely as this now seems, I first read American Psycho without any awareness of the controversy raging around its publication. I had read Ellis’s earlier works, Less than Zero (1985) and The Rules of Attraction (1987) and, with my energies fully engaged elsewhere, cannot now even remember how I acquired the book. Since that angry remark on the bus, however, I have followed American Psycho’s infamy and how it has remained in the public eye over the last decade and a half. Australian OFLC decisions can be reviewed and reversed – as when Pasolini’s final film Salo (1975), which was banned in Australia from the time of its release in 1975 until it was un-banned in 1993, was then banned again in 1998 – however, American Psycho’s initial classification has remained unchanged. In July 2006, I purchased a new paperback copy in rural New South Wales. It was shrink-wrapped in plastic and labelled: ‘R. Category One. Not available to persons under 18 years. Restricted’. While exact sales figures are difficult to ascertain, by working with U.S.A., U.K. and Australian figures, this copy was, I estimate, one of some 1.5 to 1.6 million sold since publication. In the U.S.A., backlist sales remain very strong, with some 22,000 copies sold annually (Holt and Abbott), while lifetime sales in the U.K. are just under 720,000 over five paperback editions. Sales in Australia are currently estimated by Pan MacMillan to total some 100,000, with a new printing of 5,000 copies recently ordered in Australia on the strength of the book being featured on the inaugural Australian Broadcasting Commission’s First Tuesday Book Club national television program (2006). Predictably, the controversy around the publication of American Psycho is regularly revisited by those reviewing Ellis’s subsequent works. A major article in Vanity Fair on Ellis’s next book, The Informers (1994), opened with a graphic description of the death threats Ellis received upon the publication of American Psycho (Tyrnauer 70) and then outlined the controversy in detail (70-71). Those writing about Ellis’s two most recent novels, Glamorama (1999) and Lunar Park (2005), have shared this narrative strategy, which also forms at least part of the frame of every interview article. American Psycho also, again predictably, became a major topic of discussion in relation to the contracting, making and then release of the eponymous film in 2000 as, for example, in Linda S. Kauffman’s extensive and considered review of the film, which spent the first third discussing the history of the book’s publication (“American” 41-45). Playing with this interest, Ellis continues his practice of reusing characters in subsequent works. Thus, American Psycho’s Patrick Bateman, who first appeared in The Rules of Attraction as the elder brother of the main character, Sean – who, in turn, makes a brief appearance in American Psycho – also turns up in Glamorama with ‘strange stains’ on his Armani suit lapels, and again in Lunar Park. The book also continues to be regularly cited in discussions of censorship (see, for example, Dubin; Freccero) and has been included in a number of university-level courses about banned books. In these varied contexts, literary, cultural and other critics have also continued to disagree about the book’s impact upon readers, with some persisting in reading the novel as a pornographic incitement to violence. When Wade Frankum killed seven people in Sydney, many suggested a link between these murders and his consumption of X-rated videos, pornographic magazines and American Psycho (see, for example, Manne 11), although others argued against this (Wark 11). Prosecutors in the trial of Canadian murderer Paul Bernardo argued that American Psycho provided a ‘blueprint’ for Bernardo’s crimes (Canadian Press A5). Others have read Ellis’s work more positively, as for instance when Sonia Baelo Allué compares American Psycho favourably with Thomas Harris’s The Silence of the Lambs (1988) – arguing that Harris not only depicts more degrading treatment of women, but also makes Hannibal Lecter, his antihero monster, sexily attractive (7-24). Linda S. Kauffman posits that American Psycho is part of an ‘anti-aesthetic’ movement in art, whereby works that are revoltingly ugly and/or grotesque function to confront the repressed fears and desires of the audience and explore issues of identity and subjectivity (Bad Girls), while Patrick W. Shaw includes American Psycho in his work, The Modern American Novel of Violence because, in his opinion, the violence Ellis depicts is not gratuitous. Lost, however, in much of this often-impassioned debate and dialogue is the book itself – and what Ellis actually wrote. 21-years-old when Less than Zero was published, Ellis was still only 26 when American Psycho was released and his youth presented an obvious target. In 1991, Terry Teachout found ‘no moment in American Psycho where Bret Easton Ellis, who claims to be a serious artist, exhibits the workings of an adult moral imagination’ (45, 46), Brad Miner that it was ‘puerile – the very antithesis of good writing’ (43) and Carol Iannone that ‘the inclusion of the now famous offensive scenes reveals a staggering aesthetic and moral immaturity’ (54). Pagan Kennedy also ‘blamed’ the entire work on this immaturity, suggesting that instead of possessing a developed artistic sensibility, Ellis was reacting to (and, ironically, writing for the approval of) critics who had lauded the documentary realism of his violent and nihilistic teenage characters in Less than Zero, but then panned his less sensational story of campus life in The Rules of Attraction (427-428). Yet, in my opinion, there is not only a clear and coherent aesthetic vision driving Ellis’s oeuvre but, moreover, a profoundly moral imagination at work as well. This was my view upon first reading American Psycho, and part of the reason I was so shocked by that charge of filth on the bus. Once familiar with the controversy, I found this view shared by only a minority of commentators. Writing in the New Statesman & Society, Elizabeth J. Young asked: ‘Where have these people been? … Books of pornographic violence are nothing new … American Psycho outrages no contemporary taboos. Psychotic killers are everywhere’ (24). I was similarly aware that such murderers not only existed in reality, but also in many widely accessed works of literature and film – to the point where a few years later Joyce Carol Oates could suggest that the serial killer was an icon of popular culture (233). While a popular topic for writers of crime fiction and true crime narratives in both print and on film, a number of ‘serious’ literary writers – including Truman Capote, Norman Mailer, Kate Millet, Margaret Atwood and Oates herself – have also written about serial killers, and even crossed over into the widely acknowledged as ‘low-brow’ true crime genre. Many of these works (both popular or more literary) are vivid and powerful and have, as American Psycho, taken a strong moral position towards their subject matter. Moreover, many books and films have far more disturbing content than American Psycho, yet have caused no such uproar (Young and Caveney 120). By now, the plot of American Psycho is well known, although the structure of the book, noted by Weldon above (C1), is rarely analysed or even commented upon. First person narrator, Patrick Bateman, a young, handsome stockbroker and stereotypical 1980s yuppie, is also a serial killer. The book is largely, and innovatively, structured around this seeming incompatibility – challenging readers’ expectations that such a depraved criminal can be a wealthy white professional – while vividly contrasting the banal, and meticulously detailed, emptiness of Bateman’s life as a New York über-consumer with the scenes where he humiliates, rapes, tortures, murders, mutilates, dismembers and cannibalises his victims. Although only comprising some 16 out of 399 pages in my Picador edition, these violent scenes are extreme and certainly make the work as a whole disgustingly confronting. But that is the entire point of Ellis’s work. Bateman’s violence is rendered so explicitly because its principal role in the novel is to be inescapably horrific. As noted by Baelo Allué, there is no shift in tone between the most banally described detail and the description of violence (17): ‘I’ve situated the body in front of the new Toshiba television set and in the VCR is an old tape and appearing on the screen is the last girl I filmed. I’m wearing a Joseph Abboud suit, a tie by Paul Stuart, shoes by J. Crew, a vest by someone Italian and I’m kneeling on the floor beside a corpse, eating the girl’s brain, gobbling it down, spreading Grey Poupon over hunks of the pink, fleshy meat’ (Ellis 328). In complete opposition to how pornography functions, Ellis leaves no room for the possible enjoyment of such a scene. Instead of revelling in the ‘spine chilling’ pleasures of classic horror narratives, there is only the real horror of imagining such an act. The effect, as Kauffman has observed is, rather than arousing, often so disgusting as to be emetic (Bad Girls 249). Ellis was surprised that his detractors did not understand that he was trying to be shocking, not offensive (Love 49), or that his overall aim was to symbolise ‘how desensitised our culture has become towards violence’ (quoted in Dwyer 55). Ellis was also understandably frustrated with readings that conflated not only the contents of the book and their meaning, but also the narrator and author: ‘The acts described in the book are truly, indisputably vile. The book itself is not. Patrick Bateman is a monster. I am not’ (quoted in Love 49). Like Fay Weldon, Norman Mailer understood that American Psycho posited ‘that the eighties were spiritually disgusting and the author’s presentation is the crystallization of such horror’ (129). Unlike Weldon, however, Mailer shied away from defending the novel by judging Ellis not accomplished enough a writer to achieve his ‘monstrous’ aims (182), failing because he did not situate Bateman within a moral universe, that is, ‘by having a murderer with enough inner life for us to comprehend him’ (182). Yet, the morality of Ellis’s project is evident. By viewing the world through the lens of a psychotic killer who, in many ways, personifies the American Dream – wealthy, powerful, intelligent, handsome, energetic and successful – and, yet, who gains no pleasure, satisfaction, coherent identity or sense of life’s meaning from his endless, selfish consumption, Ellis exposes the emptiness of both that world and that dream. As Bateman himself explains: ‘Surface, surface, surface was all that anyone found meaning in. This was civilisation as I saw it, colossal and jagged’ (Ellis 375). Ellis thus situates the responsibility for Bateman’s violence not in his individual moral vacuity, but in the barren values of the society that has shaped him – a selfish society that, in Ellis’s opinion, refused to address the most important issues of the day: corporate greed, mindless consumerism, poverty, homelessness and the prevalence of violent crime. Instead of pornographic, therefore, American Psycho is a profoundly political text: Ellis was never attempting to glorify or incite violence against anyone, but rather to expose the effects of apathy to these broad social problems, including the very kinds of violence the most vocal critics feared the book would engender. Fifteen years after the publication of American Psycho, although our societies are apparently growing in overall prosperity, the gap between rich and poor also continues to grow, more are permanently homeless, violence – whether domestic, random or institutionally-sanctioned – escalates, and yet general apathy has intensified to the point where even the ‘ethics’ of torture as government policy can be posited as a subject for rational debate. The real filth of the saga of American Psycho is, thus, how Ellis’s message was wilfully ignored. While critics and public intellectuals discussed the work at length in almost every prominent publication available, few attempted to think in any depth about what Ellis actually wrote about, or to use their powerful positions to raise any serious debate about the concerns he voiced. Some recent critical reappraisals have begun to appreciate how American Psycho is an ‘ethical denunciation, where the reader cannot but face the real horror behind the serial killer phenomenon’ (Baelo Allué 8), but Ellis, I believe, goes further, exposing the truly filthy causes that underlie the existence of such seemingly ‘senseless’ murder. But, Wait, There’s More It is ironic that American Psycho has, itself, generated a mini-industry of products. A decade after publication, a Canadian team – filmmaker Mary Harron, director of I Shot Andy Warhol (1996), working with scriptwriter, Guinevere Turner, and Vancouver-based Lions Gate Entertainment – adapted the book for a major film (Johnson). Starring Christian Bale, Chloë Sevigny, Willem Dafoe and Reese Witherspoon and, with an estimated budget of U.S.$8 million, the film made U.S.$15 million at the American box office. The soundtrack was released for the film’s opening, with video and DVDs to follow and the ‘Killer Collector’s Edition’ DVD – closed-captioned, in widescreen with surround sound – released in June 2005. Amazon.com lists four movie posters (including a Japanese language version) and, most unexpected of all, a series of film tie-in action dolls. The two most popular of these, judging by E-Bay, are the ‘Cult Classics Series 1: Patrick Bateman’ figure which, attired in a smart suit, comes with essential accoutrements of walkman with headphones, briefcase, Wall Street Journal, video tape and recorder, knife, cleaver, axe, nail gun, severed hand and a display base; and the 18” tall ‘motion activated sound’ edition – a larger version of the same doll with fewer accessories, but which plays sound bites from the movie. Thanks to Stephen Harris and Suzie Gibson (UNE) for stimulating conversations about this book, Stephen Harris for information about the recent Australian reprint of American Psycho and Mark Seebeck (Pan Macmillan) for sales information. References Archer, Mark. “The Funeral Baked Meats.” The Spectator 27 April 1991: 31. Australian Broadcasting Corporation. First Tuesday Book Club. First broadcast 1 August 2006. Baelo Allué, Sonia. “The Aesthetics of Serial Killing: Working against Ethics in The Silence of the Lambs (1988) and American Psycho (1991).” Atlantis 24.2 (Dec. 2002): 7-24. Canadian Press. “Navy Yanks American Psycho.” The Globe and Mail 17 May 1991: C1. Canadian Press. “Gruesome Novel Was Bedside Reading.” Kitchener-Waterloo Record 1 Sep. 1995: A5. Dubin, Steven C. “Art’s Enemies: Censors to the Right of Me, Censors to the Left of Me.” Journal of Aesthetic Education 28.4 (Winter 1994): 44-54. Dwyer, Victor. “Literary Firestorm: Canada Customs Scrutinizes a Brutal Novel.” Maclean’s April 1991: 55. Ellis, Bret Easton. American Psycho. London: Macmillan-Picador, 1991. ———. Glamorama. New York: Knopf, 1999. ———. The Informers. New York: Knopf, 1994. ———. Less than Zero. New York: Simon & Schuster, 1985. ———. Lunar Park. New York: Knopf, 2005. ———. The Rules of Attraction. New York: Simon & Schuster, 1987. Fraser, James. :The Case for Publishing.” The Bulletin 18 June 1991. Fraser, William. “Book May Go under Wraps.” The Sydney Morning Herald 23 May 1991: 5. ———. “The Sensitive Censor and the Psycho.” The Sydney Morning Herald 24 May 1991: 5. Freccero, Carla. “Historical Violence, Censorship, and the Serial Killer: The Case of American Psycho.” Diacritics: A Review of Contemporary Criticism 27.2 (Summer 1997): 44-58. Graham, I. “Australian Censorship History.” Libertus.net 9 Dec. 2001. 17 May 2006 http://libertus.net/censor/hist20on.html>. Gurley Brown, Helen. 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