Articles de revues sur le sujet « Ethnic groups – Medical care – Great Britain »

Physicians in the United States have been affected by significant changes in the pattern(s) of medical practice evolving over the last several decades. These changes include new measures to 1) curb increasing costs, 2) increase access to patient care, 3) improve quality of healthcare, and 4) pay for prescription drugs. Escalating healthcare costs have focused concerns about the financial solvency of Medicare and this in turn has fostered a renewed interest in the economic basis of interventional pain management practices. The provision and systemization of healthcare in North America and several European countries are difficult enterprises to manage irrespective of whether these provisions and systems are privatized (as in the United States) or nationalized or semi-nationalized (as in Great Britain, Canada, Australia and France). Consequently, while many management options have been put forth, none seem to be optimally geared toward affording healthcare as a maximized individual and social good, and none have been completely enacted. The current physician fee schedule (released on July 12, 2007) includes a 9.9% cut in payment rate. Since the Medicare program was created in 1965, several methods have been used to determine physicians’ rate(s) for each covered service. The sustained growth rate (SGR) system, established in 1998, has evoked negative consequences on physician payment(s). Based on the current Medicare expenditure index, practice expenses are projected to increase by 34.5% from 2002 to 2016, whereas, if actual practice inflation is considered, this increase will be 90%. This is in contrast to projected physician payment cuts that are depicted to be 51%. No doubt, this scenario will be devastating to many practices and the US medical community at large. Resolutions to this problem have been offered by MedPAC, the Government Accountability Office, physician organizations, economists, and various other interested groups. In the past, temporary measures have been proposed (and sometimes implemented) to eliminate physician payment cuts. At present, the US Senate and House of Representatives are separately working on 2 different mechanisms to address and rectify these cost-payment discrepancies. The effects of both the problem and the potential solutions on interventional pain management may be somewhat greater than those on other specialties. Physician payments in interventional pain management may evidence cuts of 10% to 15%, whereas if procedures are performed in an office setting, such cuts may range from 29% to 39% over the period of the next 3 years if the proposed 9.9% cut is not reversed. Medicare cuts also impact other insurance payments, incurring a “ripple effect” such that many insurers will seek to pay at or around the Medicare rate. In this manuscript, we discuss universal healthcare systems, the CMS proposed ruling and its attendant ripple effect(s), historical aspects of the Medicare payment system, the Sustained Growth Rate system, and the potential consequences incurred by both proposed cuts and potential solutions to the discrepant cost-payment issue(s). As well, ethical issues of policy development upon the infrastructure and practice of interventional pain management are addressed. Key words: Health policy, physician payment policy, physician fee schedule, Medicare, sustained growth rate formula, interventional pain management, regulatory reform, ethics

Background Patients with severe-to-profound hearing loss may benefit from management with cochlear implants. These patients need a referral to a cochlear implant team for further assessment and possible surgery. The referral pathway may result in varied access to hearing healthcare. This study aimed to explore referral patterns and whether there were any socioeconomic or ethnic associations with the likelihood of referral. The primary outcome was to determine factors influencing referral for implant assessment. The secondary outcome was to identify factors impacting whether healthcare professionals had discussed the option of referral. Methods and findings A multicentre multidisciplinary observational study was conducted in secondary care Otolaryngology and Audiology units in Great Britain. Adults fulfilling NICE (2019) audiometric criteria for implant assessment were identified over a 6-month period between 1 July and 31 December 2021. Patient- and site-specific characteristics were extracted. Multivariable binary logistic regression was employed to compare a range of factors influencing the likelihood of implant discussion and referral including patient-specific (demographics, past medical history, and degree of hearing loss) and site-specific factors (cochlear implant champion and whether the hospital performed implants). Hospitals across all 4 devolved nations of the UK were invited to participate, with data submitted from 36 urban hospitals across England, Scotland, and Wales. Nine hospitals (25%) conducted cochlear implant assessments. The majority of patients lived in England (n = 5,587, 86.2%); the rest lived in Wales (n = 419, 6.5%) and Scotland (n = 233, 3.6%). The mean patient age was 72 ± 19 years (mean ± standard deviation); 54% were male, and 75·3% of participants were white, 6·3% were Asian, 1·5% were black, 0·05% were mixed, and 4·6% were self-defined as a different ethnicity. Of 6,482 submitted patients meeting pure tone audiometric thresholds for cochlear implantation, 311 already had a cochlear implant. Of the remaining 6,171, 35.7% were informed they were eligible for an implant, but only 9.7% were referred for assessment. When adjusted for site- and patient-specific factors, stand-out findings included that adults were less likely to be referred if they lived in more deprived area decile within Indices of Multiple Deprivation (4th (odds ratio (OR): 2·19; 95% confidence interval (CI): [1·31, 3·66]; p = 0·002), 5th (2·02; [1·21, 3·38]; p = 0·05), 6th (2·32; [1·41, 3·83]; p = 0.05), and 8th (2·07; [1·25, 3·42]; p = 0·004)), lived in London (0·40; [0·29, 0·57]; p < 0·001), were male (females 1·52; [1·27, 1·81]; p < 0·001), or were older (0·97; [0·96, 0·97]; p < 0·001). They were less likely to be informed of their potential eligibility if they lived in more deprived areas (4th (1·99; [1·49, 2·66]; p < 0·001), 5th (1·75; [1·31, 2·33], p < 0·001), 6th (1·85; [1·39, 2·45]; p < 0·001), 7th (1·66; [1·25, 2·21]; p < 0·001), and 8th (1·74; [1·31, 2·31]; p < 0·001) deciles), the North of England or London (North 0·74; [0·62, 0·89]; p = 0·001; London 0·44; [0·35, 0·56]; p < 0·001), were of Asian or black ethnic backgrounds compared to white patients (Asian 0·58; [0·43, 0·79]; p < 0·001; black 0·56; [0·34, 0·92]; p = 0·021), were male (females 1·46; [1·31, 1·62]; p < 0·001), or were older (0·98; [0·98, 0·98]; p < 0·001). The study methodology was limited by its observational nature, reliance on accurate documentation of the referring service, and potential underrepresentation of certain demographic groups. Conclusions The majority of adults meeting pure tone audiometric threshold criteria for cochlear implantation are currently not appropriately referred for assessment. There is scope to target underrepresented patient groups to improve referral rates. Future research should engage stakeholders to explore the reasons behind the disparities. Implementing straightforward measures, such as educational initiatives and automated pop-up tools for immediate identification, can help streamline the referral process.

Background. Socio-cultural factors impact on the extent of suicidal ideation and attempted suicide but the relative importance of these factors among people from different ethnic groups in Britain has not been explored. We examined the prevalence of suicidal ideation, the incidence of attempted suicide, and the extent of service utilization following attempted suicide among representative samples of White, Irish, Black Caribbean, Bangladeshi, Indian and Pakistani individuals living in England.Method. We conducted a secondary analysis of data from the EMPIRIC study, a cross-sectional survey of 4281 adults aged 16–74 years, living in private households in England.Results. Lifetime suicidal ideation was generally lower in ethnic minority groups but higher among those born in the UK than those who migrated to England as adults. Risk factors for suicidal ideation have much in common across different ethnic groups; current symptoms of mental distress being the most important. White British and Irish respondents were twice as likely to receive medical attention following attempted suicide than those from other ethnic groups.Conclusions. Services need to adapt in order to ensure that people from ethnic minorities receive appropriate psychological and medical care following attempted suicide.

International genocide intervention strategies that involve the extended evacuation and/or displacement of refugees often save the physical lives of would-be victims at the expense of psychological and social trauma and cultural erasure. Through a comparison of the international rescue efforts of the Kindertransport program in Great Britain prior to and during the Second World War and the refugee caravans organized by La Benevolencija in Sarajevo during the Bosnian Civil War, the benefits and dangers of inter-ethnic, inter-religious rescue in times of mass violence are examined, along with how the social dynamics of racialized religious identification influenced the occurrence of these intervention strategies. The implications gleaned from this comparison offer guidance for current and future genocide intervention programs, where great care should be taken, whenever possible, to keep family groups intact and together, provide necessary psychological and social services for refugees, and allow for the continued practice of communal cultural and religious traditions without forced assimilation. The moment of physical rescue is only the initial component of a successful intervention into religio-ethnic violence; to truly prevent the genocidal destruction of a people and culture, those people’s ability to identify with their traditions and maintain their way of life is of equal and vital importance.

The Caribbean is a multi-ethnic region with many different cultural differences. The majority of the population is of African descent, but there are also other ethnic groups present such as Indians, Chinese, Syrians and Europeans. The Caribbean region is influenced by countries such as the USA, Great Britain, France and Holland. The countries of the Caribbean have a serious problem with HIV infection and AIDS. The epidemiology of HIV infection in this region, is different from most other parts of the world in that the mode of spread does not easily fit into any of the three WHO patterns. This review shows that the infection initially started in the homosexual/bisexual community, but since then, it has moved to the heterosexual population and this form of contact is now the main mode of transmission of the virus. The Governments of the Caribbean countries have realized the extent of the problem and have taken measures to try to control the epidemic.

Abstract For most of our history as a species, maternal constraint was the main environmental factor affecting biological status at birth. However, the great increase in medical intervention in the20th Century coincided first with an extraordinary reduction in perinatal mortality and later with an increase in preterm and low birth-weight babies. Herein, we analyze these temporary trends in neonate biology in Spain, according to early viability (1980-2010) and ethnic variability (1996-2010). The aim of this study is to evaluate the interaction between maternal and medical environmental constraints affecting the biology of birth and to understand the observed ethnic differences and secular trends. All single births in Spain between 1980 and 2010 are included. Following descriptive analysis, logistic regression analysis was applied to evaluate the effect of secular trends, mode of delivery and mother’s origin on birth outcome after adjustment for other maternal bio-cultural factors. Results highlighted that mean birth weight decreased and prematurity increased in still births, live births and deaths before one day. In regard to ethnic differences, while there were no secular trends in weight by gestational age in the Spanish newborns, there was an increase among the newborns of foreign mothers. Spanish mothers experienced an increasing and higher frequency of low birth weight, while foreigners had an increasing and higher frequency of prematurity. Both groups, however, shared temporal reduction in gestational age, and although this was less marked in foreigners, it suggests a common trend related to medical care and increasing obstetric interventions

In the context of the economic crisis, the availability of medicines for the population is one of the key issues facing pharmaceutical sector of healthcare system. Due to the fact of that, the purpose of the work was to study the social and economic accessibility of medicines, since such studies in the future may provide an opportunity for effective input of medicines costs reimbursement system, which will increase their availability, especially for socially vulnerable groups of population. The data analysis of the clinical protocols of Great Britain, Kazakhstan and Ukraine was conducted, and the indicators of social and economic availability within 2014–2018 were calculated. The obtained results indicate an adequate level of availability of medicines for the able-bodied population and, unfortunately, a low level of accessibility of medicines for people of retirement age with a tendency to further descension. These results point the necessity of the further research and development of government control systems and provision of pharmaceutical care for the population.

Background. The growing number of patients with prostate cancer (PCa) imposes additional requirements on the quality control system in healthcare, including ensuring the widespread availability of innovative algorithms for early diagnosis and treatment. One illustrative example of quality management initiatives is national PCa audit in the UK. Objective. Highlighting the approaches to quality assessments within audit of PCa care in the UK.Materials and methods. The relevant scientific data have been retrieved from Google and PubMed. The search horizon covered the last 10 years. The queries included such wording as: "prostate cancer" AND "audit" OR/AND "Great Britain" AND "quality assurance", etc.Results. At least four basic parameters were used as signal indicators to check the consistency and overall quality of the collected data on PCa patients in England and Wales. The fundamental arrangement of clinical quality indicators for PCa care comprised not less than fourteen measures. The outliers for some indicators were allocated into two groups using such criteria as: 1) more than three standard deviations from the national average (definition of an alarm); 2) more than two but below three standard deviations from the national average (definition of an alert). The outlier policy is usually applied for three treatment outcome performance indicators.Conclusion. The multidisciplinary teams must actively collaborate to provide the best standards of cancer care to the community. The introduction of multicriterial assessments to monitor the performance of highly specialized professional groups would bring a great benefit for cancer patients, particularly, through increasing the affordability of state-of-the-art medical algorithms across the counties.

The state of health disparities in the United States has remained relatively stable over a number of years. Although overall outcomes for all patients have improved, a difference persists in how different racial, ethnic, and gender groups have fared in our health care system. Many programs that have sought to combat this problem have been predicated on the belief that only a small number of providers in the medical community are aware of their own biases. Accordingly, it was believed that bias awareness is the direct conduit for this particular change in the health system. However, the results of such programs have been unsatisfactory. The reason for such ineffectiveness is that many programs have not taken into account the presence of implicit bias within the patient-provider relationship. This complex form of bias operates in specific ways, and must be dealt with appropriately. The use of digital checklists to aid in clinical decision making has proved to be both a way that patients can receive equitable care, and a way to improve overall patient outcomes. Secondly, in order to reach the most at-risk populations, health care must expand beyond the hospital walls, and out into the community. Nurse navigator programs have been shown to accomplish this with great success. Together, checklists and nurse navigators are the necessary next-step in the battle against health care disparities. What’s more, this two-pronged approach is relatively simple to implement. By making use of current electronic medical records, digital checklists can be quickly installed. Likewise, nurse navigator programs, a comparatively inexpensive option, can be rolled out quickly because of their simple design. A focus on the patient-provider relationship and community outreach is critical for progress in eliminating health care disparities.

Background Plastic Surgery is one of the fields that lags behind the rest when it comes to surgeons from backgrounds underrepresented in medicine (URiM). Extensive research has shown that diversity in health care not only fosters inclusivity but also saves lives. The study aim is to quantify how many integrated plastic surgery residency programs have outlined criteria defining diversity goals and/or groups of people they consider to be URiM. Methods All American Council for Graduate Medical Education-accredited integrated plastic surgery program Web sites were reviewed for diversity missions/statements and explicit mentions of the racial and ethnic groups. Web sites were deemed “up-to-date” if they were last updated within 6 months before the initial data collection period. The data collection period was from November 20 to 29, 2022. Results A total of 86 program were reviewed. Only 8 programs (9%) had clear URiM criteria listed on their Web sites, whereas 26 (30%) relied on institution/department-wide criteria, 1 (1%) listed that they were adhering to American Association of Medical Colleges definition of URiM, and 51 programs (60%) had no form of definition for what is considered URiM. When looking at the programs that have some form of criteria for URiM (n = 35 [40%]), all programs (100%) considered African American/Black, Native American/Alaskan Native, Hispanic/Latinx, and Pacific Islander/Native Hawaiian as groups URiM. Assessing the same subset of programs that have a form of criteria listed (n = 35 [40%]), 19 (58%) had listed other groups outside of race/ethnicity considered to be URiM for their program, and 14 (42%) programs did not. Fourteen programs (74%) considered LGBTQIA+ as a URiM group. Conclusion and Significance There still is a great deal of heterogeneity among residency programs when it comes to identifying which medical students are URiM. Numerous plastic surgery organizations have placed diversity and inclusive excellence at the forefront of their agendas; however, it is critical that residency programs also actively align their efforts in an equitable and intentional way. This study serves to encourage residency programs to evaluate their mission toward diversity, equity, and inclusion and to spark discussion toward creating a clearer URiM definition to be consistent among all programs.

Introduction. Despite a considerable quantity of studies focused on the etiology and pathogenesis of ulcer disease, this condition continues to be one of the most relevant in the modern gastroenterology due to its prevalence, relapse rates, and the development of ulcerative-destructive complications. This article deals with the influence level of the genetic predisposition to forming gastric and duodenal ulcers, including from the standpoint of the interrelation between the candidate gene and the disease pattern, considering various ethnic groups. Aim. Based on the analysis of scientific medical literature, we are aiming at describing the current data on the molecular genetic basis of gastric and duodenal ulcers, given its wide prevalence among the population and its great medical and social significance. Materials and Methods. We analyzed publications in databases, such as eLibrary, Scopus, and Pubmed, as well as in science search engines, such as Google Scolar and Web of Science. Over 150 sources were studied in total, of which the most significant ones are included in our references herein. Results and Discussion. The article reflects a contemporary view of the epidemiological and etiopathogenetic aspects of developing gastric and duodenal ulcers with a focus on the role of polymorphism of candidate genes in forming such pathology. Conclusion. The analysis of this literature review showed the importance of how genetic factors affect the risk of developing gastric and duodenal ulcers, as well as the relevance of further studies thereof followed by potentially developing some programs aimed at the primary prevention of ulcer disease and a personalized approach to health care delivery.

Aim. To investigate the prevalence of clinical manifestations of post-coronavirus syndrome and evaluate the effectiveness of medical rehabilitation course in patients after new coronavirus infection (COVID-19) in a day care hospital, taking into account the severity of the disease course. Material and methods. At the first stage of the study, 203 residents of the Ivanovo region (140 women and 63 men) aged 40 to 80 years who had a new coronavirus infection, who had no more than one year since the onset of the disease, were surveyed on the basis of the Ivanovo State Medical Academy (ISMA) of the Ministry of Health of Russia. For this purpose, “COVID-19 Yorkshire Rehabilitation Screening (C19-YRS)” telephone screening questionnaire was used, developed by groups of rehabilitation therapists from the training medical centers of the National Health Service of Great Britain to identify multisystem functional disorders of patients who have suffered a new coronavirus infection, and to address the need for rehabilitation intervention. At the second stage, 54 patients (38 women and 16 men) aged 29-81 years were examined, who were admitted to the 3rd stage of rehabilitation in the department of medical rehabilitation of patients with somatic diseases of the ISMA Clinic after suffering a new coronavirus infection COVID-19. Among them, 3 groups were formed depending on the severity of the infection: 16 patients with a mild course of the disease made up the 1st group, 20 patients who had a moderate course of coronavirus infection – the 2nd group, 18 patients with a severe course of COVID-19 – 3rd group. Results. The questionnaire showed that COVID-19 survivors had a multisystem decrease in functioning, which was maximally pronounced during the first month from the onset of the disease and did not return to the baseline level for 6-12 months. The most significant disturbances occurred with patients who, due to the severity of the condition, were treated in a hospital. The most lasting symptoms were impaired exercise tolerance and increased fatigue, which had a significant impact on daily life. In patients admitted for rehabilitation, functional impairments and disabilities were detected regardless of the severity of the course of the new coronavirus infection (COVID-19). In patients with a mild course of infection, they were manifested mainly by decreased tolerance to physical load, frequent disorders of sleep function, emotions, volitional and motivational functions, in some patients – by mild disorders of respiratory function and cognitive impairment in the form of reduced volume of cranio-temporal memory. In patients with moderate and severe COVID-19, against the background of impaired exercise tolerance function, sleep function, emotions, volitional and motivational functions, we mainly detected moderate and pronounced respiratory disorders, cognitive disorders, which were manifested by decreased short-term memory and attention concentration, increased attention exhaustion, and bradyphrenia. The functional disorders detected in patients primarily led to limitation of their mobility in the form of walking for long distances, ability to self-care and household activities, ability to work, which before the disease did not cause difficulties for patients. Study of the indexes in dynamics showed the effectiveness of rehabilitation measures in improving the functions, regardless of the severity of the course of coronavirus infection. Conclusion. The findings of the present study justify the necessity of early complex rehabilitation of patients by multidisciplinary rehabilitation team taking into account individually detected functional impairment. Individual rehabilitation program should be developed for each patient taking into account the revealed problems on the basis of problem-oriented approach.

Introduction. In recent years, Enhanced recovery after surgery (ERAS), or Fast-track, has been actively developed and introduced into clinical practice in many industry of surgery in Europe and the USA. However, the ERAS® Society has not yet approved a unified protocol in spinal neurosurgery, and most of the publications on the topic have appeared only in the last few years.The purpose of the study is to present a systematic review of the literature to identify the key elements of the ERAS program and the effect of their use, as well as the impact on complications in the following areas of spinal neurosurgery: deformities, trauma, degenerative, infectious and oncology diseases.Materials and methods. The authors analyzed and systematically reviewed all published literature on ERAS in spine and spinal cord surgery up to October 10, 2020 using the main databases of medical literature and search resources PubMed and eLibrary according to the PICOS inclusion and exclusion criteria, as well as the recommendations of the protocol for writing systematic reviews. and PRISMA meta-analyses.Results. We analyzed 13 articles considering the use of ERAS technology in surgery for deformities (n = 3), degenerative (n = 8) and tumor (n = 2) lesions of the spine. The level of evidence of the study is 2a. The publications contain information on the treatment of 2,777 patients, whose average age was 50.5 years (from 14.0 to 72.4 years). The ERAS protocol has been implemented in clinics in the USA (46 %), China (30 %), France (8 %), Russia (8 %) and Great Britain (8 %). The average number of key elements of the ERAS program was 13.7 (range 5 to 24). The most popular are: preoperative patient counseling and education, minimally invasive surgery, multimodal analgesia, early mobilization and enteral loading, as well as active follow-up and care. The introduction of the ERAS protocol in spinal surgery made it possible, compared with the control group, to reduce the duration of hospitalization by 1.8 days (from 0.17 to 3.2 days), the cost of treatment by $ 1,443.75 (from 146 to $ 3,444), the severity of pain syndrome and the use of opioids in 38 % of cases, the consumption of antiemetics after surgery, as well as the time of surgery and blood loss at 29 minutes and 188 ml, respectively. For ERAS-groups, cardiovascular and respiratory complications are more typical, and for control groups – urinary, infectious, thromboembolic complications and liquorrhea. In general, there is a decrease in the total number of complications by 8.5 % (from 2.3 to 9.6 %).Conclusions. Enhanced recovery after surgery is a promising technology for improving the quality of care for patients in spine surgery.

The aim: to assess the state of pharmaceutical provision of patients with dementia in Alzheimer's disease in Ukraine in accordance with international recommendations. Materials and methods. In our studies, we used data from international guidelines, clinical protocols that regulate the organization of medical and pharmaceutical care for these patients in the USA, Australia, Japan, Germany, Great Britain, Finland, India, Kazakhstan, and Ukraine. The actual state of pharmaceutical provision of these patients in Ukraine was studied using a depersonalized database of medical prescriptions, which operates based on a number of specialized healthcare institutions. In addition, data from the Morion information search system were used. We used general theoretical (historical, formal, graphic, hypothetical-deductive, etc.) and applied (clinical-economic, organizational-economic, mathematical-statistical, etc.) research methods. Results. It has been established that a consolidated opinion has been formed in the world scientific community regarding the possibility of effective use in the pathogenetic treatment of patients with dementia in Alzheimer's disease of drugs from the groups N06DA Acetylcholinesterase inhibitors and N06DX-Other drugs for use in case of dementia. Thus, the pharmaceutical component of international recommendations, clinical protocols for the treatment of patients with dementia in Alzheimer's disease contains four drugs used in pathogenetic therapy. These are N06DA02 Donepezil, N06DA03 Rivastigmine, N06DA04 Galantamine and N06DX01 Memantine. It has been reported that all the above drugs are included in the domestic clinical protocol for the treatment of patients with dementia in Alzheimer's disease, the State Drug Formulary (with the exception of N06DA03 Rivastigmine), and the State Drug Registry. At the same time, all of them were absent from the National List of Essential Drugs, which has an important socio-economic and medical-pharmaceutical significance in the health care system. It was found that patients (200 people) received 2487 prescriptions (100.0 %), among which 9.41 % (234 prescriptions) were drugs used in pathogenetic treatment. There is a highly disproportionate nature of the distribution of prescriptions and consumption by international generic names of drugs. Thus, drugs N06DX01 Memantine accounted for 80.41 % (188 prescriptions) of all prescriptions in the group N06D Drugs for use in dementia, and the consumption rate was UAH 84420.20, which accounted for 91.48 % of the amount of expenses directed to patients with carrying out pathogenetic treatment. Significant dominance of drugs N06DX01 Memantine in the structure of prescriptions and consumption indicates the presence of severe, advanced forms of dementia in patients. This fact once again emphasizes the need for early detection and treatment of cognitive impairment, primarily for the rational use of limited health care resources. We have found that there are no prescriptions for N06D A04 Galantamine preparations, which are recommended by the relevant international recommendations in different countries of the world, as well as by the domestic clinical protocol for the pathogenetic treatment of mild and moderate forms of Alzheimer's disease. At the same time, N06DA05 Ipidacrine preparations were used in the treatment of domestic patients, which are not presented in the pharmaceutical component of international recommendations and protocols governing the pathogenetic treatment of the above-mentioned groups of neuropsychiatric patients. Conclusions. The peculiarities of the formation of the pharmaceutical component in the organization of the treatment process of patients with dementia in Alzheimer's disease in Ukraine, established by us, allow further research on the development of rational ways of resource provision of neuropsychiatric patients

The article explores the concept of inclusive development of regions, emphasizing the study of the formation and maintenance of a stable level of public health in the scientific literature. For bibliographic analysis, complex scientometric databases Scopus and Dimensions were used to analyze a set of publications formed according to specific criteria using the software tool VOSviewer. The visualization method was used to visualize the obtained results. The search in scientometric databases was carried out by the criterion of the title of the publication, the content of its annotation and keywords. The analysis showed that the main research clusters form groups of scientists' publications from the United States, Great Britain, Australia, and Canada. The small number of publications, but their growth dynamics and the increasing number of citations (according to Google Scholar) indicate a lack of study of inclusive growth in the region in the public health management system and the prospects for its exploration by scientists. According to the analysis, the interest of scientists in solving the problem of public health in ensuring regional development increased in 2020-2021. Much of the publications relate to such areas of knowledge as business, management and accounting. The main areas of research on public health in the development of the regions include the provision of medical services, the health care system, social determinants of health, and the population's state of health. Scientific clusters are gradually being formed around these keywords. The obtained results of the bibliographic analysis form the basis for a better understanding of public health issues, the search for gaps, the solution of which should be worked on in further research. Particular attention is paid to the issue of the COVID-19 pandemic as a crisis-forming factor that hinders the movement of regional development in a promising direction and ensuring the resilience of the system. It is substantiated that the health factor is essential in forming a robust human potential of the country and the growth of labor productivity.

Provision to every citizen, patient, and person in the system of legal relationship "doctor-patient-pharmacist" the right to life, health, and safety during the circulation of vital medicinal products of all clinical and pharmacological, nomenclature and legal, classification and legal groups, guaranteed by created in in Ukraine the system of standardization and quality control of medicines. The system of standardization and quality control of medicines includes the National System of Standardization of Medicines in Ukraine (1992); The system of state control of the quality of medicinal products (1992); Programs for the development of generic drugs in Ukraine (1995); The school of standardization and quality control of medicinal products; Center for standardization, metrology, and quality control in Ukraine. Ukraine got observer status in the European Pharmacopoeia in 1998. The National Pharmacopoeia of Ukraine (2001) appeared 6-7 years earlier than other countries (Belarus, Kazakhstan, Russian Federation). Two editions of the State Pharmacopoeia of Ukraine, totaling thirteen volumes and 7,208 pages, was developed as of 2022 and put into effect. The State Pharmacopoeia of Ukraine is fully harmonized with the European Pharmacopoeia and is the basis of the entire system of standardization and quality control of medicinal products in Ukraine. A pharmacopeial language (Ukrainian terminological apparatus), which did not exist before, was developed, and implemented. The State Pharmacopoeia of Ukraine is an important reference-informational and educational-methodical material for pharmaceutical enterprises, health care institutions, pharmacies, universities of medical and pharmaceutical profiles. The national system of pharmacopeial standard samples largely meets the needs of national control laboratories, and ranks the 6th in the world in terms of the number of pharmacopeial standard samples. The State Pharmacopoeia of Ukraine is the only pharmacopoeia in the world in which standardized validation procedures have been introduced, which has turned validation into an ordinary routine procedure. Ukraine acquired the status of a full member of the European Pharmacopoeia in 2013. European standards for the quality of medicinal products are in force in Ukraine. The State Pharmacopoeia of Ukraine acquired voting membership in the Pharmacopoeia of the United States in 2010. In order to develop texts that are not in the European Pharmacopoeia (in particular, monographs on ready medicines), the State Pharmacopoeia of Ukraine concluded Agreements with the leading pharmacopoeias of the world – the USA in 2010 and Great Britain in 2013. A powerful market, world- and European-level pharmaceutical industry was created, which was included in the field of health care, which provided the pharmacy network and health care institutions with modern, effective, safe, high-quality, and economically available drugs. The system of legal relations "doctor-patient-pharmacist" is based on the principles of pharmaceutical law, the Constitution of Ukraine, laws, and regulatory acts, timely ensures the right of a person, citizen, and patient suffering from various health disorders in accordance with the ICD-11, on life and health.

Arthritis is the disease that kills the fewest but cripples the most. With the aging of the population in the United States and the antiquated DRG reimbursement system for hospital surgical intervention, it is inevitable that the Medicare assistant will bankrupt itself prior to the proposed bankruptcy date of 2026 if changes are not made. It may change would be to insist that the system in Maryland for reimbursement to hospitals for essential joint replacement surgery of the elderly be adapted nationwide. Medicaid expenditures are driven by a variety of factors, including the demand for care, the complexity of medical services provided, medical inflation, and life expectancy. The Medicare program has two separate trust funds – the Hospital Insurance (HI) Trust Fund and the Supplementary Medical Insurance (SMI) Trust Fund. Under the Hospital Insurance Trust, payroll taxes from workers and their employers go towards paying for the Part A benefits for today’s Medicare beneficiaries. In 2019, Medicare provided benefits to over 60 million elderly patients at an estimated cost of $796 billion [1]. While excluding the significant decrease in payroll taxes during the COVID-19 pandemic, the latest 2020 projections calculate Medicare Hospital Trust insolvency by 2026 [2]. The 2020 report declared that funds would be sufficient to pay for only 90 percent of Part A expenses at the time of this writing. Since inception, the Hospital Insurance Trust has never been insolvent, because there are no provisions in the Social Security Act that govern what would happen if insolvency were to occur. Ten of the last twelve years have witnessed expenditure outflows outpacing the Hospital Insurance Trust inflows, resulting in total Medicare spending obligations outpacing the increasing demands on the federal budget, as the number of elderly beneficiaries and the per capita health care costs continue to grow [2]. One of the principal goals of the following study is to determine how elderly patients, who often suffer from acute stages of arthritis and other orthopedic diseases, due in part to wear and tear, can continue to demand surgical intervention, in particular joint replacement surgery. Arthritis has been described as the disease that kills the fewest but cripples the most. With that in mind, the hospital systems ability to absorb the ever increasing number of elderly patients who demand joint replacement surgeries will continue to outstrip supply. The principal author of this study completed his PhD dissertation at the University of Manchester in 1977 by measuring the cost-benefit analysis of the treatment of chronic rheumatoid arthritis in Great Britain. Therefore, the author of this study aims to show the only reasonable method of payment for the imminent immeasurable demand for treatment for the elderly for age related diseases such as joint replacement surgery [3]. A recent Journal of Rheumatology article projects Medicare will finance approximately 2.67 million joint replacement surgeries by 2035, plus an additional 2.35 million joint replacement surgeries by the year 2040 [4]. The author believes that the current nationwide Diagnostic Related Groups (DRGs) system that helps determine how much Medicare pays the hospital for each “product” needs to be phased out as soon as possible. Our research shows that prior to Medicare implementing the DRGs payment system, Maryland proved that their total cost model of state-wide rewards and penalties compensated “efficient and effective” hospitals, providing care as defined by metrics set up by the Health Services Cost Review Commission (HSCRC). The Maryland legislature granted this independent government agency the broad powers to insulate the HSCRC from conflicts of interests, regulatory capture, and political meddling in the long term. In exchange, the HSCRC had the freedom to design a system that must deliver on three areas: cost reduction of hospital services, health improvement for all Maryland residents, and quality of life care improvements. Since inception of the HSCRC, all stakeholders are legally required to comply with robust auditing and data-submission requirements that allow the agency to collect data on the costs, patient volume, and financial condition of all inpatient, hospital-based outpatient, and emergency services in Maryland. This level of transparency allows the agency to set prices for hospital services, and hospitals must obey because it is Maryland law. Because of this methodology, HSCRC-approved average Maryland hospital markups ranged from 18 percent in 1980 to only 22 percent in 2008. During that same period, the average hospital markup nationally skyrocketed from 20 percent in 1980 to more than 187 percent in 2008 [5]. This strong evidence is the primary reason why the HSCRC has continued to receive a federal waiver from the Centers for Medicare and Medicaid Services, which requires both Medicare and Medicaid to pay the HSCRC-approved rates statewide. No discounts are given because of volume, nor any shifting of costs to other payers. There is a mandate: same price for the same service at the same hospital, no exceptions. Adjustments for uncompensated medical care are automatically bundled into the HSCRC-approved rates, as thus, this financial burden is shared by all hospitals in Maryland. This article explores the important milestones taken by the state of Maryland and how the lessons learned are responsible for the impressive results of their program today. This author believes that by applying the Maryland Total Cost of Care Model (Maryland TCOC Model) nationwide will yield financial savings of at least $227 billion by 2035, plus another $280 billion by 2040, exclusively from joint replacement surgeries reimbursed at HSCRC-approved rates and not any other method.

Background Pregnancy and the period around birth are critical for the development and improvement of population health as well as the health of mothers and babies, with outcomes such as birthweight influencing adult health. Objectives We evaluated the clinical effectiveness and cost-effectiveness of the Health in Pregnancy (HiP) grants in Scotland, looking for differential outcomes when the scheme was in place, as well as before its implementation and after its withdrawal. Design The HiP grants were evaluated as a natural experiment using interrupted time series analysis. We had comparison groups of women who delivered before the grants were introduced and after the grants were withdrawn. Setting Scotland, UK. Participants A total of 525,400 singleton births delivered between 24 and 44 weeks in hospitals across Scotland between 1 January 2004 and 31 December 2014. Intervention The HiP grant was a universal, unconditional cash transfer of £190 for women in Great Britain and Northern Ireland reaching 25 weeks of pregnancy if they had sought health advice from a doctor or midwife. The grant was introduced for women with a due date on or after 6 April 2009 and subsequently withdrawn for women reaching the 25th week of pregnancy on or after 1 January 2011. The programme was paid for by Her Majesty’s Treasury. Main outcome measures Our primary outcome measure was birthweight. Secondary outcome measures included maternal behaviour, measures of size, measures of stage and birth outcomes. Data sources The data came from the Scottish maternity and neonatal database held by the Information and Services Division at the NHS National Services Scotland. Results There was no statistically significant effect on birthweight, with births during the intervention period being, on average, 2.3 g [95% confidence interval (CI) –1.9 to 6.6 g] lighter than would have been expected had the pre-intervention trend continued. Mean gestational age at booking (i.e. the first antenatal appointment with a health-care professional) decreased by 0.35 weeks (95% CI 0.29 to 0.41 weeks) and the odds of booking before 25 weeks increased by 10% [odds ratio (OR) 1.10, 95% CI 1.02 to 1.18] during the intervention but decreased again post intervention (OR 0.91, 95% CI 0.83 to 1.00). The odds of neonatal death increased by 84% (OR 1.84, 95% CI 1.22 to 2.78) and the odds of having an emergency caesarean section increased by 7% (OR 1.07, 95% CI 1.03 to 1.10) during the intervention period. Conclusions The decrease in the odds of booking before 25 weeks following withdrawal of the intervention makes it likely that the HiP grants influenced maternal health-care-seeking behaviour. It is unclear why neonatal mortality and emergency caesarean section rates increased, but plausible explanations include the effects of the swine flu outbreak in 2009 and the global financial crisis. The study is limited by its non-randomised design. Future research could assess an eligibility threshold for payment earlier than the 25th week of pregnancy. Funding The National Institute for Health Research Public Health Research programme. The Social and Public Health Sciences Unit is core funded by the Medical Research Council (MC_UU_12017/13) and the Scottish Government Chief Scientist Office (SPHSU13).

Abstract Background Improvements in breast cancer treatment and care have resulted in improved outcomes and decreased mortality. These improvements, however, come with great expense. Despite efforts from health care systems, a significant proportion of the population remains uninsured. The uninsured population is often underprivileged, undereducated and more likely to come from racial/ethnic minority groups. This combination of factors results in a delay in diagnosis, presentation at later stage, and decreased access and compliance with treatment. The goal of the current study is to describe a method for treating an uninsured, underprivileged breast cancer population and the resulting outcomes. Methods Retrospective review was performed of all breast cancer patients seen at Maricopa Medical Center, the safety net hospital in Phoenix, AZ. All breast cancer patients seen from January 1, 2000 to December 31, 2020 were included. Baseline data for every patient was compiled prospectively, supplemented by retrospective chart review. The data included sociodemographic information, health literacy assessment, and diagnostic tests. Health literacy was assessed using the Newest Vital Sign (NVS). Breast cancer treatment, follow up, and mortality were documented. Beginning on July 1, 2006 a new process was implemented to facilitate care of uninsured patients. More details will be included in the poster presentation. Briefly, however, core needle biopsies were performed in the Breast Clinic by the Breast surgeon or Physician assistant during the initial consultation. Rather than requiring full payment of the planned operation upfront, instead a down payment was made with a plan for payment in installments of the remainder of the cost. For chemotherapy and targeted therapy, a process was implemented to apply for discounted medications for appropriate regimens. There are no radiation therapy facilities at Maricopa Medical Center. An agreement was therefore made with a Radiation oncology group in Phoenix to provide discounted radiation therapy. The treatment was paid through treatment grants as well as fundraising activities by the Health Foundation of the hospital. In 2011, the Breast surgeon underwent training for genetic counseling at City of Hope Medical Center to provide genetic counseling for these patients. Results A total of 1,797 patients were included. Among them, 661 patients were seen before the process (BP) was started, while 1,136 patients were seen after the new process (NP) was implemented. Overall, the mean age of the patients was 52 years with most patients being Hispanic (56%). On average the patients had 10 yrs of education and 18% had adequate health literacy. The majority of patients were not employed (70%) and completely uninsured (56%) or underinsured (31%). Only 18% of patients underwent screening mammography and as a result 67% of patients presented at stage II or later. Despite the barriers mentioned above, the NP group underwent a higher percentage of breast conservation procedures (75% versus 47%, p &lt; 0.001). A higher percentage of the NP group received adjuvant therapy: Chemotherapy (91% vs 70%, p &lt; 0.001), Radiation therapy (91% versus 70%, p &lt; 0.001), and initiated endocrine therapy (87% versus 67%, p &lt; 0.001). At a mean follow up of 8 years, these improvements in adjuvant therapy resulted in a lower incidence of both ipsilateral breast tumor recurrence and chest wall recurrence (2% vs 16%, p &lt; 0.001 and 5% versus 8%, p = 0.21, respectively) and improvement in overall survival (90% vs 81%, p &lt; 0.001). Conclusions Despite treatment of a population with many barriers to breast cancer management, implementation of a treatment process improved access to diagnosis and surgical therapy as well as recommended adjuvant therapy. These improvements resulted in lower local recurrence rates and improved survival in an uninsured population. Citation Format: Ian Komenaka, Trevin Reyes, Jacqueline Gilbert, Chiu-Hsieh Hsu, Waqas Arslan, Gilbert Ramos, John Dover, Herbert Hitchon, Jesse Nodora, Elena Martinez. A successful method for treatment of an uninsured underprivileged breast cancer population [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-09-10.

Abstract Background: Socioeconomic status (SES) and distance from a treatment center are prognostic factors in chronic malignancies, such as head and neck or breast cancer, where relative disease latency enables patients with greater means to travel to receive their care. Little is known about the influence of these demographics on patient outcomes in rapidly-growing cancers, such as AML. Methods: We conducted a retrospective review of all patients receiving remission induction therapy for AML at the Cleveland Clinic between January 1997 and December 2005. Race and residential zipcodes were obtained from information disclosed by patients in their electronic medical records. Average annual household income in a zipcode and distance from the treatment center were obtained using web-based databases (www.melissadata.com, www.zip-codes.com). Data on known prognostic factors (age, WBC at diagnosis, cytogenetic risk groups (as defined by CALGB 8461) and AML etiology (de novo vs. secondary AML)) were collected and controlled for in multivariable analyses. Survival was estimated using the Kaplan-Meier method, and the association between distance and income assessed using the Spearman rank correlation. Results: Anthracycline-based remission induction chemotherapy was administered to 281 patients: 132 (47%) were female, with a median age at diagnosis of 60 years (range 17–80). Median WBC at diagnosis was 9.9 k/uL (range:0.4–550 k/uL). Cytogenetics were favorable in 33 patients (11.7%, 10 of whom had t(15;17)), intermediate in 137 (48.8%), unfavorable in 73 (26%), and unknown in 38 (13.5%). Ninety patients (32%) had secondary AML. The ethnic distribution was consistent with other AML series: 252 (90.6%) were Caucasian (C), 22 (7.9%) were African American (AA), and 4 (1.4%) were neither (non-AA non-C). The median distance from the treatment center was 24.4 miles (range: 0.9–2058), and median average household income was $38,972 (range: $17,496-$143,220). Overall survival (OS) was 30.2% at a median of 22.6 months of follow-up. There was no significant correlation between distance and income. In both univariable and multivariable analyses, age ≥60 years, unfavorable cytogenetics, increased WBC count at presentation and secondary AML were all found to adversely affect survival (p<0.001, p<0.001, p=0.035, and p=0.010, respectively). OS was similar for AA and non-AA non-C patients compared to C (HR=1.12 [95% CI=.61–2.07, p=.71], and HR=.87 [CI=.21–3.62, p=.84], respectively). Neither distance from treatment facility (HR=1.00 [95%CI = .98–1.02 p =.96] for every 20 mile increase in distance) nor SES (HR=1.02 [95%CI=.92–1.13, p=.77] per $10000 increase) had an impact on OS. Similar findings held for CR rates. Conclusion: Contrary to their impact on chronic malignancies, neither SES nor distance from treatment facility affect outcome in patients with AML treated at the same hospital. This supports referring patients for treatment to tertiary facilities skilled at managing AML, even when they live at great distances from those facilities.

Background: Plasmablastic lymphoma (PbL) is an exceedingly rare, aggressive non-Hodgkin lymphoma with overlapping features of myeloma and lymphoma diagnosed most commonly in immunocompromised individuals, especially in the setting of human immunodeficiency virus (HIV) and Epstein-Barr virus (EBV) infection ( Int J Lab Hematol PMID 36074710). Pathologically, it is characterized by lacking CD20 and PAX5 expression with the presence of CD38, CD138, MUM1/IRF4, Blimp1, and XBP1 expression ( Blood Lymphat Cancer PMID 31360094). There is no established standard of care ( Blood PMID 25636338). Due to the disease's rarity, limited information is available on PbL, especially when focusing on underrepresented minorities. This study aims to describe the demographics, treatment patterns, and survival outcome differences in Hispanic (HI) versus non-Hispanic (NH) patients in the United States with PbL. Methods: Data was analyzed on patients with PbL in the US reported to the NCDB between 2010 and 2019. Sociodemographic and treatment characteristics were compared between ethnic groups. Kaplan-Meier and Cox regression analyses were used to compare overall survival (OS) between HI and NH populations. Multivariate analysis and propensity score matching were performed with adjustment for age, stage, co-morbidity score, insurance status, type of facility and great circle distance. Results: Between 2010 and 2019, 1624 patients were diagnosed with PbL with 16% identified as HI. HI were diagnosed at a younger median age of 48 years as compared to NH at 58 years. Diagnosis was made predominately in males (78%) with no statistical difference between HI and NH. Most HI and NH were white (92% and 74% in HI and NH, respectively) with increased racial diversity among NH. 17% of all patients identified as black with 1% HI and 21% NH. Regarding income, 32% HI had an income less than $38,000 versus 23% NH; whereas, 31% NH had an income greater than $63,000 versus 20% HI [p=0.017]. 38% HI had a Charlson-Deyo Comorbidity Index score ≥ 2 as compared to 27% NH [p&lt;0.001]. Table 1 provides additional information on demographics. 45% of all patients had stage IV disease at the time of diagnosis. 86% of all patients received treatment with no statistical difference among HI and NH [p=0.246]. 67% of HI were treated at academic/research programs compared to 50% of NH [p=0.004]. The median distance between the patient's residence and treatment facility was 6.9 miles for HI versus 9.8 miles for NH [p=0.001]. The survival probability at 2, 5, and 10 years for HI was 59%, 52%, and 42%, respectively as compared to NH was 47%, 37%, and 31%, respectively. The median survival time (MS) was 9.4 years in HI versus 1.4 years in NH [p &lt;0.001]. Figure 1 shows the Kaplan Meier curve comparing overall survival (OS) between HI versus NH.When adjusted on multivariate analysis, there were no independent variables associated with better or worse OS; moreover, propensity matched analysis showed no MS difference between HI vs NH (1.79 years versus 1.17 years). Conclusion: This hospital-based analysis noted that HI presented with PbL at a younger age than NH; however, HI more frequently had a higher Charlson-Deyo Comorbidity Index score than NH. There was no statistical difference in the stage at diagnosis between HI and NH. Additionally, HI had a lower income and no medical insurance as compared to NH suggesting HI possibly had inferior access to medical resources. Paradoxically, HI had significantly higher OS rates. Further insight into the disease's intrinsic characteristics, as well as biological factors, is needed to gain a better understanding of these poor outcomes.

These data, coupled with the description of what is really an elegantly simple system of health services, provide a compelling argument for legislators to consider seriously some form of national health insurance for the US. This seems to be the conclusion of many Americans based on recent polls. Other arguments in support of comprehensive health insurance, at least for children, have been heard from some unusual quarters. Many of those advocating reconsideration of this issue, apart from some politicians, include economists, some branches of `organized medicine,' and even business (The Financial Post. November 3, 1989). For example, Lee Iacocca has written: "We've had a war on health care costs in this country for over 10 years, and we've lost it. Those costs have gone up year after year at almost double the rate of inflation, and they now account for about $550 billion a year or over 11% of our GNP." (Inside Guide. 1989:25) He goes on to call attention to the fact that the per capita health bill in the US is 41% higher than Canada's, 61% higher than Sweden's, 85% higher than France's, 131% more than Japan's, and 171% above Great Britain. As Iaccoca points out, if it was the case that the US was getting more for its investment than the others, the higher prices would make sense. But, he adds, "There is little such evidence. Life expectancy in the US is no better than the rest of the Western world, and infant mortality rates are one of the worst. There are nearly 40 million people without any health insurance coverage." He notes that an appendectomy or hysterectomy costs 3.5 times as much in California as in Ontario, and the ratio of costs is 5 times greater for a coronary artery bypass, and 7 times greater for an electrocardiogram. Iacocca's concern arises in large part because American business pays a large part of the costs of what he views as an `overpriced system.' Those costs go directly into the price of goods, and this amounts to an export tax when those goods are sold abroad. He estimates that over $700 of the cost of producing a car in the US goes to pay for health care for employees, compared with $223 in Canada. Between 1978 and 1980, General Motors reportedly spent three times as much on health insurance as it did on the steel used to manufacture its cars! Apart from these hard core economic issues, other differences are more subtle. Once concerns about paying for conventional medical care are set aside, serious consideration can be given to broader questions related to health and health care. In Canada there now appears to be a rapidly growing acceptance of the view that the main factors responsible for the health of populations are clean water, good food, education, employment, housing and, perhaps, good genes. This view has been articulated by the Population Health Group of the Canadian Institute for Advanced Research. Nonetheless, the view that equitable access to medical care is essential to the integrity of a fair and just society remains firmly entrenched. As a consequence Canadians maintain a firm desire to accept even the high costs associated with elaborate hospital care and physician services to be confident that they will continue to be free for all. Many have observed that the major improvements in the health of most Western societies during the last 200 years predated advances in medical diagnosis and therapy by many years. Accordingly, some experts are convinced that the main determinants of health lie beyond traditional medical care. They note that the persistent discrepancies in the health status of different sectors of the population, particularly those divided by income or social class, may reflect complex social and environmental phenomena. Those in higher social class groups may have been quicker to adopt better lifestyles with respect to matters like smoking and diet. Similarly, social relationships, the control one has over one's own life, security of employment, and a sense of self-worth, all appear to be strongly related to health in the aggregate From this perspective it might appear that the arguments of critics of health insurance have some merit. The opponents suggest that it is not the absence of insurance per se that accounts for the embarrassing differences in health statistics when children in the US are compared with those in other nations, but rather differences in population composition. The argument is made that the American population has more poor, more blacks, and generally more heterogeneity than those of countries being compared. Even if that were true (although each point is debatable, and it seems a strange argument coming from what many consider to be one of the richest nations in the world), even if conceded, it seems to make the case for health insurance all the more compelling. This is so because there can be no doubt that one main effect of such insurance is to narrow the gap in access to and the use of services between the rich and the poor. Hence the more poor a nation has, the stronger the case for health insurance. Successive ministers of Health and Welfare in Canada, beginning with Lalonde in 1974 to Epp in 1987, have emphasized the importance of environment and lifestyle, as opposed to physicians and hospitals in obtaining further improvements in the health of Canadians. A cynic might suggest that these calls are motivated largely by the pressure to control spiralling health care costs, but the evidence appears to suggest that regardless of motive, they are on the right track. Contrary to views propagated in the US during the Reagan era, there is no evidence from Canada's experience that deregulation and competition either improves the public's health or reduces costs. In fact, the Canadian example suggests just the opposite, that the more care is made free to the patient at the time of receipt of service, and the more the system is planned and regulated by the state in the public interest, the better is the quality of service, the better the health of the people, and the less it costs. Despite the evidence, spokespersons for "the loyal opposition" persist: "Universal health insurance is not a good idea. . . [it] would fly in the face of the American way of doing things. . . .The United States is unique, and our pluralistic approach is unique. There is no reason to think that an imported system would be successful here or that American citizens would accept its implicit restrictions. . . . Other countries ignore appropriateness and effectiveness; they ignore the many complex elements of high-quality care that we in America demand; and they largely ignore the citizen's right to free choice, a concept we hold very dear." That dissenting opinion, written, perhaps not surprisingly by James S. Todd, of the American Medical Association, is certainly not one shared by most Canadians. It would seem that many Americans would gladly change places with their Canadian cousins or those of any of the other nations who long ago accepted that universal health insurance is a requisite for national self-respect.

Abstract Background and Objective: Benign constitutional neutropenia (BCN) or benign ethnic neutropenia (BEN) is an asymptomatic condition characterized by mild chronic neutropenia in patients with no history of recurrent infections. In most of these patients neutropenia is discovered incidentally in a complete blood count ordered for routine screening. This is particularly concerning for general practitioners because neutropenia is associated with infections and hematologic malignancies. Thus, many patients are commonly referred to a specialist for evaluation, which leads to further testing and increased costs of care without evidence of improved personal or public health. To ensure that individuals with BCN are healthy, some diagnostic methods can be used to assess neutrophil mobilization from reserve compartments, including epinephrine, corticosteroids, endotoxins and vigorous exercise. We herein present an alternative form of assessment for individuals with BCN based on neutrophil circadian variation. Neutrophils in healthy individuals have a physiological increase of between 10 and 20% by early afternoon. In this study, we hypothesized that because patients with BCN have higher G-CSF basal levels and a greater physiological response to this cytokine, a larger increase in neutrophils can be detected in a blood test performed in the afternoon compared to routine tests performed in the morning. A physiological increase in neutrophil levels in individuals with BCN would be of great practical interest. This could reduce costs of laboratory tests and reduce medical and patient concerns. Methods: We studied patients who had neutropenia that was detected in routine blood count and with suspected BCN. Patients with clinical symptoms, laboratory test result changes and history of chronic, inflammatory, autoimmune or neoplastic diseases were excluded. Patients >60 years were excluded because they have a higher prevalence of myelodysplasia and other concomitant diseases. Neutrophil counts were evaluated in patients with BCN using paired blood counts performed in the early morning (between 7:00 and 9:00 am) and in the early afternoon (between 1:00 and 3:00 pm). The neutrophil counts were stratified into the following four groups: < 500, 500-1000, 1000-1500 and 1500-2000/µL. Results: We evaluated 157 patients with neutropenia and 118 individuals met the entry criteria. Their median age was 36 years (range, 3-60 years), and 41 (35%) were male. Median blood count results were as follows: white blood count, 2880/µL; hemoglobin, 12.9 g/dL; and platelets, 223,000/µL. The difference between the median neutrophil counts performed in the morning (1164/µL) and afternoon (2070/µL) was 904/µL (95% CI=770-1040; p<0.001). This difference reflects an increase of 94.3% in neutrophil counts between the two tests. The percent increase in neutrophils between the two assessments was higher in patients with a lower neutrophil count in the morning examination (OR=20.9; p<0.001). The lower the morning neutropenia, the greater the increase observed (513.8%, 110.6%, 70.5% and 46.8%, respectively, in the 500, 500-1000, 1000-1500 and 1500-2000/µL groups). We evaluated categories of neutrophil levels in the blood count in the morning and afternoon. Among the 118 subjects with baseline neutrophil count <2000/µL, 52 (44%) had values >2000/µL in the afternoon. Of the 65 who had remain with neutrophils <2000/µL, 48 (40%) showed an increase to neutrophil categories higher than the initial examination, 18 (15%) remained in the same category and no individual showed a decrease in neutrophil counts between the morning and afternoon. Conclusions: Our findings identify a simple, easy and feasible way to assess neutrophil reserve in patients with BCN, with a potential reduction in costs of the assessment. Disclosures No relevant conflicts of interest to declare.

Today, Great Britain has one of the best hospice care systems for palliative patients in the world, which leads to interest in the path of building a Hospice and Palliative Care (НPC) system in this country. The hospice care system is mainly financed by the volunteer sector, which indicates a significant development of the state-society partnership in the organization of НPC. The national НPC system consists of inpatient care, day palliative care, care in the community and emergency hospitals. 2004–2008 is considered the key moment in the formation of the country's НPC system, which will be the focus of this study. For specialist palliative care, the National Health Service of Great Britain allocated almost £50 million a year in those days until 2004. At the same time, volunteer support was about 4 times greater. More than 220 volunteer support groups for palliative patients operated in the country. The success of building a national НPC system is described in the Palliative Care White Paper. A number of interrelated national programs may be used as a standard of palliative care in 20 years by many other countries. The development of the НPC system has influenced the British homes for the elderly, the system of primary care, the attitude to the НPC problem of doctors, local communities and society as a whole, increased the quality and availability of palliative care. Palliative care since those years has been provided 24/7, managed by coordination centers located outside medical facilities and hospices. High national НPC standards and mechanisms for monitoring their compliance have been created. Narcotic analgesia for palliative patients with chronic pain, the necessary medical, psychological, social and spiritual care is mostly available. The public debates the question of a dignified death without restrictions. The value for money of НPC is recognized by British society as acceptable. Therefore, studying the British experience of НPC organization as one of the "best practices" is useful for other countries with less developed НPC systems. Keywords: "best practices", place of death, palliative care quality standards.

PurposeThe move towards a “person-centred” or “personalised” system of adult social care has been at the heart of policy debates in Great Britain. However, policy developments in Northern Ireland are more limited than in other parts of the UK, and less attention has been paid to reforming adult social care. The purpose of this paper is to examine the views and experiences of adult social care users who receive care at home, to explore if and how a person-centred approach might work for older adults in Northern Ireland.Design/methodology/approachUsing a qualitative approach, semi-structured interviews were carried out with 12 people aged over 70 years who receive social care provision at home.FindingsThe empirical findings show that social care users experienced limited involvement in their care planning process, reflecting a predominantly service-led approach. The importance of care worker continuity and consistency was crucial for all participants, particularly for maintaining discreet routines and promoting personal dignity. However many experienced different care workers which presented challenges caused by the inconsistency of carers.Research limitations/implicationsThe majority of participants in the study were women, despite attempts to achieve greater gender diversity. It was also difficult to recruit a range of ethnic groups for the study. It would be important for future studies to include these groups and to ensure their voices are represented in further work in this area. Nonetheless, the findings offer valuable insight into the views of adult social care users and can form a useful basis for future studies.Originality/valueThe findings provide a more nuanced understanding of what people want and expect in social care to generate future policy debates and discussions in planning long-term adult social care provision in Northern Ireland. It also provides important and timely contribution to this area, where there is currently limited research and information available.

Guideline-directed medical therapies and guideline-directed nonpharmacological therapies improve quality of life and survival in patients with heart failure (HF), but eligible patients, particularly women and individuals from underrepresented racial and ethnic groups, are often not treated with these therapies. Implementation science uses evidence-based theories and frameworks to identify strategies that facilitate uptake of evidence to improve health. In this scientific statement, we provide an overview of implementation trials in HF, assess their use of conceptual frameworks and health equity principles, and provide pragmatic guidance for equity in HF. Overall, behavioral nudges, multidisciplinary care, and digital health strategies increased uptake of therapies in HF effectively but did not include equity goals. Few HF studies focused on achieving equity in HF by engaging stakeholders, quantifying barriers and facilitators to HF therapies, developing strategies for equity informed by theory or frameworks, evaluating implementation measures for equity, and titrating strategies for equity. Among these HF equity studies, feasibility was established in using various educational strategies to promote organizational change and equitable care. A couple include ongoing randomized controlled pragmatic trials for HF equity. There is great need for additional HF implementation trials designed to promote delivery of equitable guideline-directed therapy.

The reform of the medical industry, the problems of medical care that arose in Ukraine in connection with the Covid-19 pandemic and led to a deterioration in the physical, psychological and social well-being of the population, sharply raised the question of the work of the medical industry and the directions for its improvement. In many countries of the world one of the ways to improve the quality of medical services is the implementation of social work in the medical industry.The article is devoted to the analysis of foreign experience of social work in the health care system, the roots of which are deeply connected with the development of modern public health in many countries of the world. Today, many social workers around the world practice health care, drawing on the historical experience of combining clinical, intermediate and population-based approaches to have a greater impact on health. However, the historical significance of this long-standing interdisciplinary collaboration and its implications remain poorly understood. The article is based on primary and modern sources of research on the history of the development of social work in the field of health care, demonstrates examples of successful cooperation between social and medical workers. The main historical stages of the development of social work in the field of health care in the USA, France, Canada, Great Britain, Bulgaria, etc. are considered. The article concludes that despite the temporal, geographical, economic, political, cultural and other differences, social work in the field of health care as an independent professional activity in different countries has common features: a focus on overcoming barriers in the environment for achieving health by individuals, their families, groups and communities; assistance in attracting resources to achieve full health of clients; perception of personality and its health as a whole; the creation of family-oriented, community-centered and consumer-driven services; the development of social work in the field of health was often facilitated by the initiative and perseverance of individuals, etc.

Abstract Background Inappropriate antibiotic prescribing is accelerating antimicrobial resistance (AMR) (Antibiotic resistant infections and associated deaths increase https://www.gov.uk/government/news/antibiotic-resistant-infections-and-associated-deaths-increase). Pharmacy professionals (pharmacists and pharmacy technicians) promote good antibiotic prescribing practice. The traditional role of pharmacy technicians in supporting pharmacists and patients has expanded alongside the clinical expansion of pharmacist roles. (Boughen M, Fenn T. Practice, skill mix and education: the evolving role of pharmacy technicians in Great Britain. Pharmacy (Basel) 2020; 8(2): 50. doi:10.3390/pharmacy8020050) This paper focuses on the opinion of pharmacy technicians and their role in the review of acne management and the evaluation of the UKHSA TARGET acne ‘How to…’ review resources. Aims and objectives To explore the impact of the TARGET resources on the capability, opportunity and motivation of pharmacy technicians in general practice in managing patients with acne. To evaluate the usefulness of the acne ‘How to…’ review resources. Materials and methods A primarily quantitative study using an electronic survey asking UK-based pharmacy technicians to rate their agreement on a five-point Likert scale with 21 predefined statements, themed on the COM-B model and usefulness of the TARGET resources for acne. Discussion The survey found that capability and opportunity in managing acne in the group familiar with TARGET resources was higher than the group not familiar with TARGET resources. Scores for motivation in both groups were high; pharmacy technicians have the motivation to undertake infection management roles, whether or not they are familiar with the TARGET toolkit. The acne ‘How to…’ review resources were overall rated as useful in supporting the review of patients with acne. Conclusion The TARGET materials are effective resources that helps to upskill pharmacy technicians in the area of AMS, increasing capability and opportunity in the management of acne.

Background This study explored whether or not, and how, terminally ill patients from ethnically diverse backgrounds and their family caregivers think ahead about deterioration and dying, and explored their engagement with health-care professionals in end-of-life care planning. Objective The aim was to address the question, what are the barriers to and enablers of ethnically diverse patients, family caregivers and health-care professionals engaging in end-of-life care planning? Design This was a qualitative study comprising 18 longitudinal patient-centred case studies, interviews with 19 bereaved family caregivers and 50 public and professional stakeholder responses to the findings. Setting The study was set in Nottinghamshire and Leicestershire in the UK. Results Key barriers – the predominant stance of patients was to live with hope, considering the future only in terms of practical matters (wills and funerals), rather than the business of dying. For some, planning ahead was counter to their faith. Health-care professionals seemed to feature little in people’s lives. Some participants indicated a lack of trust and experienced a disjointed system, devoid of due regard for them. However, religious and cultural mores were of great importance to many, and there were anxieties about how the system valued and enabled these. Family duty and community expectations were foregrounded in some accounts and concern about being in the (un)care of strangers was common. Key enablers – effective communication with trusted individuals, which enables patients to feel known and that their faith, family and community life are valued. Health-care professionals getting to ‘know’ the person is key. Stakeholder responses highlighted the need for development of Health-care professionals’ confidence, skills and training, Using stories based on the study findings was seen as an effective way to support this. A number of behavioural change techniques were also identified. Limitations It was attempted to include a broad ethnic diversity in the sample, but the authors acknowledge that not all groups could be included. Conclusions What constitutes good end-of-life care is influenced by the intersectionality of diverse factors, including beliefs and culture. All people desire personalised, compassionate and holistic end-of-life care, and the current frameworks for good palliative care support this. However, health-care professionals need additional skills to navigate complex, sensitive communication and enquire about aspects of people’s lives that may be unfamiliar. The challenge for health-care professionals and services is the delivery of holistic care and the range of skills that are required to do this. Future work Priorities for future research: How can health professionals identify if/when a patient is ‘ready’ for discussions about deterioration and dying? How can discussions about uncertain recovery and the need for decisions about treatment, especially resuscitation, be most effectively conducted in a crisis? How can professionals recognise and respond to the diversity of faith and cultural practices, and the heterogeneity between individuals of beliefs and preferences relating to the end of life? How can conversations be most effectively conducted when translation is required to enhance patient understanding? Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. X. See the NIHR Journals Library website for further project information.

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. [28] New York State Bar Association. 2020. “New York State Bar Association House of Delegates: Revised COVID-19 Resolutions.” https://nysba.org/app/uploads/2020/10/Final-Health-Law-Section-COVID-19-Resolutions_10-8-20-1-1.pdf. [29] Egede, L. E. 2006. “Race, Ethnicity, Culture, and Disparities in Health Care.” Journal of General Internal Medicine 21 (6): 667-669. https://doi.org/10.1111%2Fj.1525-1497.2006.0512.x

Abstract Background Perforation of the oesophagus (OP) represent a potentially lethal yet poorly managed clinical condition due to its rarity, variation in clinical presentation and little consensus on the optimal management of these patients. Previous studies have shown that timely and appropriate treatment of OPs is the most important determinant of patient outcomes, and a delay in initiating the correct management within 24 hours increased the mortality rate from 10% to over 60%. Historically, patients have been managed based on the personal experience and preference of the surgeon, and accordingly most patients underwent surgical management based on data from small retrospective case series. Depending on the cause of injury, location of perforation and status of the patient, options include conservative management; endoscopy (stenting or clipping); and surgery (drainage, diversion, primary repair, or oesophagectomy). Currently, there are no recent large-scale studies investigating the outcomes in oesophageal perforation, leading to a paucity of high-grade evidence on the management of oesophageal injuries. This study aims to characterise the variation in the management of OPs, update its epidemiology in the UK; and evaluate the mortality and morbidity outcomes of surgical and non-surgical modalities in managing OP. Methods This was a multi-centred cohort study involving eligible centers from the Association of Upper Gastro-intestinal Surgeons for Great Britain and Ireland (AUGIS) research network. All adult patients who were admitted with a diagnosis of esophageal perforation (iatrogenic, spontaneous or traumatic causes) and managed as an inpatient for more than 24 hours were included in the study. Exclusion criteria were as follows: pediatric population; OP due to anastomotic leaks post-esophagectomy; and unavailability of data matching primary outcome measures. The time period for inclusion of patients was from January 2016 to December 2020. Investigators were asked to actively monitor patients and their electronic medical records to identify post-intervention complications up to 90 days from time of intervention if appropriate. The primary outcome was 90-day mortality. Other secondary outcomes included the incidence of complications secondary to OP or interventions; incidence of 30-day re-intervention; length of hospital stay (LOS) and intensive care unit (ICU) stay; readmission within 30 days; and recurrence. Results During the study period 369 patients with oesophageal perforation from eight centres and were included in the study. The mean age of the population was 63 (18) years, body mass index was 25 (9)kg/m2, 60% were male, 30% were ASA grade 3, and 41% ECOG performance status 0. The aetiology of OP was spontaneous in 57% and iatrogenic in 37%. The mean time from presentation to referral and intervention were 37 hours and 111 hours respectively. In patients transferred from a district general to a tertiary hospital the mean time from presentation to transfer was 100 hours. Surgery was used as the primary treatment approach in 31%, endoscopic intervention in 10% and conservative management in 56%. Thoractomy and laparotomy was used in 20% and 24% respectively, endosponge and endoscopic stent used in 11% and 7% respectively. 90-day mortality was 20% across the cohort, 30-day re-admission rate was 18%, mean ICU stay, and LOS were 10 days and 37 days respectively. 90-day mortality was significantly reduced in the surgery group (9%) when compared with endoscopic (24%) and conservative management groups (28%) (p&lt;0.001). Multivariate analyses identified key patient, procedural, and treatment factors associated with mortality from oesophageal perforation. Conclusions In a centralised oesophageal and gastric cancer service, the management of complex upper gastrointestinal conditions including oesophageal perforation is most commonly centralised to oesophageal and gastric cancer centres. This large multi-centre collaborative study provides robust data concerning modern practices of the management of oesophageal perforation in the UK. Through a detailed and highly granular dataset, we have examined factors associated with the patient pathway, presentation and treatment that are associated with mortality following oesophageal perforation.

Photo by Nathan Dumlao on Unsplash ABSTRACT The demographic of physicians in the United States has failed to include a proportionate population of Latinos in the United States. In what follows, I shall argue that the medical school admission process places an undue burden on low-income Latino applicants. Hence, the underrepresentation of Latinos in medical schools is an injustice. This injustice relates to the poor community health of the Latino community. Health disparities such as diabetes, HIV infection, and cancer mortality are higher amongst the Latino community. The current representation of Latino medical students is not representative of those in the United States. INTRODUCTION The demographic of physicians in the United States has failed to include a proportionate number of Latinos, meaning people of Latin American origin. Medical schools serve as the gatekeepers to the medical field, and they can alter the profession based on whom they admit. With over 60 million Latinos in the United States, people of Latin American origin comprise the largest minority group in the nation.[1] In 2020-2021, only 6.7 percent of total US medical school enrollees and only 4 percent of medical school leadership identified as Latino.[2] Latino physicians can connect to a historically marginalized community that faces barriers including language, customs, income, socioeconomic status, and health literacy. I argue that the medical school admissions process places an undue burden on low-income Latino applicants. This paper explores the underrepresentation of Latinos in medical schools as an injustice. A further injustice occurs as the barriers to medical education result in fewer Latino doctors to effectively deliver health care and preventive health advice to their communities in a culturally competent way. I. Latino Community Health Data The terms Latino and Hispanic have largely been considered interchangeable. US government departments, such as the US Census Bureau and the Centers for Disease Control and Prevention (CDC), define Hispanic people as those with originating familial ties to native Spanish-speaking countries, most of whom are from Latin America. The term Latino is more inclusive because it refers to all of those with strong originating ties to countries in Latin America, including those coming from countries such as Brazil and Belize who are not native Spanish speakers. Throughout this work, I refer to the term Latino because it is more inclusive, although the data retrieved from US government departments may refer to the population as Hispanic. “Low-income” refers to the qualifying economic criteria for the AAMC’s Fee Assistance Program Poverty Guidelines.[3] The AAMC Fee Assistance Program is designed to help individuals who do not have the financial means to pay the total costs of applying to medical school. For this paper, low-income refers to those who qualify for this program. The US government gathers data about Latino community health and its health risks. The Latino community has a higher poverty rate than the non-Hispanic white community.[4] Latino community health has long trailed that of white people collectively. For example, the Latino community experiences higher levels of preventable diseases, including hypertension, diabetes, and hepatitis, than the non-Hispanic white community does.[5] The CDC collects data about Latino community health and provides statistics to the public. Latinos in the United States trail only non-Hispanic blacks in prevalence of obesity. The Latino adult obesity rates are 45.7 percent for males and 43.7 percent for females.[6] Of the 1.2 million people infected with HIV in the United States, 294,200 are Latino.[7] The infection rate of chlamydia is 392.6 per 100,000 ― 1.9 times the rate in the non-Hispanic white population.[8] The tuberculosis incidence rate is eight times higher than that of non-Hispanic white people at 4.4 per 100,000.[9] Furthermore, Latinos have the third highest death rate for hepatitis C among all races and ethnic groups.[10] The prevalence of total diabetes, diagnosed and undiagnosed, among adults aged 18 and older also remains higher than that of non-Hispanic whites at 14.7 percent compared to 11.9 percent.[11] The high disease rate evidences the poor health of the community. Furthermore, 19 percent of Latinos in the United States remain uninsured.[12] Almost a quarter of the Latino population in the United States lives in poverty.[13] The high incidence of disease, lack of insurance, and high poverty rate create a frail health status for the Latino community in the United States. The medical conditions seen are largely preventable, and the incident rates can be lowered with greater investments in Latino community health. Considering the health disparities between Latino and non-Hispanic White people, there is an ethical imperative to provide better medical care and guidance to the Latino community. II. Ethical and Practical Importance of Increasing the Number of Latino Physicians Minorities respond more positively to patient-physician interactions and are more willing to undergo preventative healthcare when matched with a physician of their racial or ethnic background.[14] Latino medical doctors may lead to an improvement in overall community health through improved communication and trusting relationships. Patient-physician racial concordance leads to greater patient satisfaction with their physicians.[15] Identifying with the ethnicity of a physician may lead to greater confidence in the physician-patient relationship, resulting in more engagement on the patient’s behalf. A randomized study regarding African American men and the race of their attending physician found an increase in requests for preventative care when assigned to a black doctor.[16] Although the subjects were African American men, the study has implications applicable to other minority racial and ethnic groups. The application process is unjust for low-income Latinos. The low matriculation of Latinos in medical schools represents a missed opportunity to alleviate the poor community health of the Latino population in the United States. Medical school also would create an opportunity to address health issues that plague the Latino community. Becoming a physician allows low-income Latinos to climb the social ladder and enter the spaces in health care that have traditionally been closed off to them. Nonwhite physicians significantly serve underserved communities.[17] Increasing the number of Latino doctors can boost their presence, potentially improving care for underserved individuals. Teaching physicians cultural competence is not enough to address the health disparities the Latino community faces. Latino physicians are best equipped to understand the healthcare needs of low-income Latinos. I contend that reforming the application process represents the most straightforward method to augment the number of Latino physicians who wish to work in predominantly Latino or diverse communities, thereby improving healthcare for the Latino community. III. Cultural Tenets Affecting Healthcare Interactions “Poor cultural competence can lead to decreased patient satisfaction, which may cause the patient not to attend future appointments or seek further care.”[18] Latino community health is negatively affected when medical professionals misinterpret cultural beliefs. Cultural tenets like a reservation towards medication, a deep sense of respect for the physician, and an obligation to support the family financially and through advocacy affect how Latinos seek and use the healthcare system.[19] First, the Latino population's negative cultural beliefs about medication add a barrier to patient compliance. It is highlighted that fear of dependence upon medicine leads to trouble with medication regimens.[20] The fear stems from the negative perception of addiction in the Latino community. Taking as little medication as possible avoids the chance of addiction occurring, which is why many take the prescribed medicine only until they feel healthier, regardless of the prescribing regimen. Some would rather not take any medication because of the deep-rooted fear. Physicians must address this concern by communicating the importance of patient compliance to remedy the health issue. Explaining that proper use of the medication as prescribed will ensure the best route to alleviate the condition and minimize the occurrence of dependence. Extra time spent addressing concerns and checking for comprehension may combat the negative perception of medication. Second, the theme of respeto, or respect, seems completely harmless to most people. After all, how can being respectful lead to bad health? This occurs when respect is understood as paternalism. Some patients may relinquish their decision-making to the physician. The physician might not act with beneficence, in this instance, because of the cultural dissonance in the physician-patient relationship that may lead to medical misinterpretation. A well-meaning physician might not realize that the patient is unlikely to speak up about their goals of care and will follow the physician’s recommendations without challenging them. That proves costly because a key aspect of the medical usefulness of a patient’s family history is obtaining it through dialogue. The Latino patient may refrain from relaying health concerns because of the misconceived belief that it’s the doctor’s job to know what to ask. Asking the physician questions may be considered a sign of disrespect, even if it applies to signs, symptoms, feelings, or medical procedures the patient may not understand.[21] Respeto is dangerous because it restricts the patients from playing an active role in their health. Physicians cannot derive what medical information may be relevant to the patient without their cooperation. And physicians without adequate cultural competency may not know they need to ask more specific questions. Cultural competency may help, but a like-minded physician raised similarly would be a more natural fit. “A key component of physician-patient communication is the ability of patients to articulate concerns, reservations, and lack of understanding through questions.”[22] As a patient, engaging with a physician of one’s cultural background fortifies a strong physician-patient relationship. Latino physicians are in the position to explain to the patients that respeto is not lost during a physician-patient dialogue. In turn, the physician can express that out of their value of respeto, and the profession compels them to place the patient’s best interest above all. This entails physicians advocating on behalf of the patients to ask questions and check for comprehension, as is required to obtain informed consent. Latino physicians may not have a cultural barrier and may already organically understand this aspect of their patient’s traditional relationship with physicians. The common ground of respeto can be used to improve the health of the Latino community just as it can serve as a barrier for someone from a different background. Third, in some Latino cultures, there is an expectation to contribute to the family financially or in other ways and, above all, advocate on the family’s behalf. Familial obligations entail more than simply translating or accompanying family members to their appointments. They include actively advocating for just treatment in terms of services. Navigating institutions, such as hospitals, in a foreign landscape proves difficult for underrepresented minorities like Latinos who are new to the United States. These difficulties can sometimes lead to them being taken advantage of, as they might not fully understand their rights, the available resources, or the standard procedures within these institutions. The language barrier and unfamiliar institutional policies may misinterpret patients’ needs or requests. Furthermore, acting outside of said institution’s policy norms may be erroneously interpreted as actions of an uncooperative patient leading to negative interactions between the medical staff and the Latino patient. The expectation of familial contribution is later revisited as it serves as a constraint to the low-income Latino medical school applicant. Time is factored out to meet these expectations, and a moral dilemma to financially contribute to the family dynamic rather than delay the contribution to pursue medical school discourages Latinos from applying. IV. How the Medical School Admission Process is Creating an Undue Burden for Low-Income Latino Applicants Applying a bioethics framework to the application process highlights its flaws. Justice is a central bioethical tenet relevant to the analysis of the MD admissions process. The year-long medical school application process begins with the primary application. The student enters information about the courses taken, completes short answer questions and essays, and uploads information about recommenders. Secondary applications are awarded to some medical students depending on the institutions’ policies. Some schools ask all applicants for secondary applications, while others select which applicants to send secondary requests. Finally, interviews are conducted after a review of both primary and secondary applications. This is the last step before receiving an admissions decision. The medical school application process creates undue restrictions against underserved communities. It is understood that matriculating into medical school and becoming a doctor should be difficult. The responsibilities of a physician are immense, and the consequences of actions or inactions may put the patients’ lives in jeopardy. Medical schools should hold high standards because of the responsibility and expertise required to provide optimal healthcare. However, I argue that the application process places an undue burden on low-income Latino applicants that is not beneficial to optimal health care. The burden placed on low-income Latino applicants through the application process is excessive and not necessary to forge qualified medical students. The financial aspect of the medical school application has made the profession virtually inaccessible to the working class. The medical school application proves costly because of the various expenses, including primary applications, secondary applications, and interview logistics. There is financial aid for applications, but navigating some aid to undertake test prep, the Medical College Admission Test (MCAT), and the travel for interviews proves more difficult. Although not mandatory, prep courses give people a competitive edge.[23] The MCAT is one of the key elements of an application, and many medical schools will not consider applications that do not reach their score threshold. This practically makes the preparatory courses mandatory for a competitive score. The preparatory courses themselves cost in the thousands of dollars. There has been talk about adjusting the standardized test score requirements for applicants from medically underserved backgrounds. I believe the practice of holding strict cutoffs for MCAT scores is detrimental to low-income Latino applicants, especially considering the average MCAT scores for Latinos trail that of white people. The American Association of Medical Colleges’ recent data for the matriculating class of 2021 illustrates the wide gap in MCAT scores: Latino applicants average 500.2, and Latino matriculants average 506.6, compared to white applicants, who average 507.5 and white matriculants, who average 512.7.[24] This discrepancy suggests that considerations beyond scores do play some role in medical school matriculation. However, the MCAT scores remain a predominant factor, and there is room to value other factors more and limit the weight given to scores. The practice of screening out applicants based solely on MCAT scores impedes low-income Latino applicants from matriculating into medical school. Valuing the MCAT above all other admissions criteria limits the opportunities for those from underserved communities, who tend to score lower on the exam. One indicator of a potentially great physician may be overcoming obstacles or engaging in scientific or clinical experiences. There are aspects of the application where the applicant can expand on their experiences, and the personal statement allows them to showcase their passion for medicine. These should hold as much weight as the MCAT. The final indicator of a good candidate should not solely rest on standardized tests. There is a cost per medical school that is sent to the primary application. The average medical school matriculant applies to about 16 universities, which drives up the cost of sending the applications.[25] According to the American Association of Medical Colleges, the application fee for the first school is $170, and each additional school is an additional $42. Sending secondary applications after the initial application is an additional cost that ranges by university. The American Medical College Application Service (AMCAS), the primary application portal for Medical Doctorate schools in the United States and Canada, offers the Fee Assistance Program (FAP) to aid low-income medical school applicants. The program reduces the cost of the MCAT from $325 to $130, includes a complimentary Medical School Admission Requirements (MSAR) subscription, and fee waivers for one AMCAS application covering up to 20 schools.[26] The program is an important aid for low-income Latino students who would otherwise not be able to afford to send multiple applications. Although the aid is a great resource, there are other expenses of the application process that the program cannot cover. For a low-income applicant, the burden of the application cost is felt intensely. A study analyzing the American Medical College Application Service (AMCAS) data for applicants and matriculants from 2014 to 2019 revealed an association between income and acceptance into medical school. They state, “Combining all years, the likelihood of acceptance into an MD program increased stepwise by income. The adjusted rate of acceptance was 24.32 percent for applicants with income less than $50 000, 27.57 percent for $50 000 - $74 999, 29.90 percent for $75 000 - $124 999, 33.27 percent for $125 000 - $199 999, and 36.91 percent for $200,000 or greater.”[27] It becomes a discouraging factor when it is difficult to obtain the necessary funds. The interview process for medical schools may prove costly because of travel, lodging, and time. In-person interviews may require applicants to travel from their residence to other cities or states. The applicant must find their own transportation and housing during the interview process, ranging from a single day to multiple days. Being granted multiple interviews becomes bittersweet for low-income applicants because they are morally distraught, knowing the universities are interested yet understanding the high financial cost of the interviews. The expense of multiple interviews can impede an applicant from progressing in the application process. Medical schools do not typically cover travel expenses for the interview process. Only 4 percent of medical school faculty identify as Latino.[28] The medical school admission board members reviewing the application lack Latino representation.[29] Because of this, it is extremely difficult for a low-income Latino applicant to portray hardships that the board members would understand. Furthermore, the section to discuss any hardships only allows for 200 words. This limited space makes it extremely difficult to explain the nuances of navigating higher education as a low-income Latino. Explaining those difficulties is then restricted to the interview process. However, that comes late in the application process when most applicants have been filtered out of consideration. The lack of diversity among the board members, combined with the minimal space to explain hardships or burdens, impedes a connection to be formed between the Latino applicants and the board members. It is not equitable that this population cannot relate to their admissions reviewers because of cultural barriers. Gatekeeping clinical experience inadvertently favors higher socioeconomic status applicants. Most medical schools require physician shadowing or clinical work, which can be difficult to obtain with no personal connections to the field. Using clinical experience on the application is another way that Latinos are disadvantaged compared to people who have more professional connections or doctors in the family and social circles. The already competitive market for clinical care opportunities is reduced by nepotism, which does not work in favor of Latino applicants. Yet some programs are designed to help low-income students find opportunities, such as Johns Hopkins’ Careers in Science and Medicine Summer Internship Program, which provides clinical experience and health professions mentoring.[30] Without social and professional ties to health care professionals, they are forced to enter a competitive job and volunteer market in clinical care and apply to these tailored programs not offered at all academic institutions. While it is not unique to Latinos, the time commitment of the application process is especially harsh on low-income students because they have financial burdens that can determine their survival. Some students help their families pay for food, rent, and utilities, making devoting time to the application process more problematic. As noted earlier, Latino applicants may also have to set aside time to advocate for their families. Because the applicants tend to be more in tune with the dominant American culture, they are often assigned the family advocate role. They must actively advocate for their family members' well-being. The role of a family advocate, with both its financial and other supportive roles ascribed to low-income Latino applicants, is an added strain that complicates the medical school application. As a member of a historically marginalized community, one must be proactive to ensure that ethical treatment is received. Ordinary tasks such as attending a doctor's appointment or meeting with a bank account manager may require diligent oversight. Applicants must ensure the standard of service is applied uniformly to their family as it is to the rest of the population. This applies to business services and healthcare. It can be discouraging to approach a field that does not have many people from your background. The lack of representation emphasizes the applicant's isolation going through the process. There is not a large group of Latinos in medicine to look to for guidance.[31] The group cohesiveness that many communities experience through a rigorous process is not established among low-income Latino applicants. They may feel like outsiders to the profession. Encountering medical professionals of similar backgrounds gives people the confidence to pursue the medical profession. V. Medical School Admission Data This section will rely on the most recent MD medical school students, the 2020-2021 class. The data includes demographic information such as income and ethnicity. The statistics used in this section were retrieved from scholarly peer-reviewed articles and the Medical School Admission Requirement (MSAR) database. Both sources of data are discussed in more detail throughout the section. The data reveals that only 6.7 percent of medical students for the 2020-2021 school year identify as Latino.[32] The number of Latino students in medical school is not proportional to the Latino community in the United States. While Latinos comprise almost 20 percent of the US population (62.1 million), they comprise only 6.7 percent of the medical student population.[33] Below are three case studies of medical schools in cities with a high Latino population. VI. Medical School Application Process Case Studies a) New York University Grossman School of Medicine is situated in Manhattan, where a diverse population of Latinos reside. The population of the borough of Manhattan is approximately 1,629,153, with 26 percent of the population identifying as Latino.[34] As many medical schools do, Grossman School of Medicine advertises an MD Student Diversity Recruitment program. The program, entitled Prospective MD Student Liaison Program, is aimed such that “students from backgrounds that are underrepresented in medicine are welcomed and supported throughout their academic careers.”[35] The program intervenes with underrepresented students during the interview process of the medical school application. All students invited to interviews can participate in the Prospective MD Student Liaison Program. They just need to ask to be part of it. That entails being matched with a current medical student in either the Black and Latinx Student Association (BALSA) or LGBTQMed who will share their experiences navigating medical school. Apart from the liaison program, NYU participates in the Science Technology Entry Program (STEP), which provides academic guidance to middle and high school students who are underrepresented minorities.[36] With the set programs in place, one would expect to find a significantly larger proportion of Latino medical students in the university. The Medical School Admission Requirement (MSAR) database compiled extensive data about participants in the medical school; the data range from tuition to student body demographics. Of the admitted medical students in 2021, only 16 out of 108 identified as Latino, despite the much larger Latino population of New York.[37] Furthermore, only 4 percent of the admitted students classify themselves as being from a disadvantaged status.[38] The current efforts to increase medical school diversity are not producing adequate results at NYU. Although the Latino representation in this medical school may be higher than that in others, it does not reflect the number of Latinos in Manhattan. The Prospective MD Student Liaison Program intervenes at a late stage of the medical school application process. It would be more beneficial for a program to cover the entire application process. The lack of Latino medical students makes it difficult for prospective students to seek advice from Latino students. Introducing low-income Latino applicants to enrolled Latino medical students would serve as a guiding tool throughout the application process. An early introduction could encourage the applicants to apply and provide a resourceful ally in the application process when, in many circumstances, there would be none. Latino medical students can share their experiences of overcoming cultural and social barriers to enter medical school. b) The Latino population in Philadelphia is over 250,000, constituting about 15 percent of the 1.6 million inhabitants.[39] According to MSAR, the cohort of students starting at Drexel University College of Medicine, located in Philadelphia, in 2021 was only 7.6 percent Latino.[40] 18 percent of matriculated students identify as having disadvantaged status, while 21 percent identify as coming from a medically underserved community.[41] Drexel University College of Medicine claims that “Students who attend racially and ethnically diverse medical schools are better prepared to care for patients in a diverse society.”[42] They promote diversity with various student organizations within the college, including the following: Student National Medical Association (SNMA), Latino Medical Student Association (LMSA), Drexel Black Doctors Network, LGBT Medical Student Group, and Drexel Mentoring and Pipeline Program (DMAPP). The Student Center for Diversity and Inclusion of the College of Medicine offers support groups for underrepresented medical students. The support offered at Drexel occurs at the point of matriculation, not for prospective students. The one program that does seem to be a guide for prospective students is the Drexel Pathway to Medical School program. Drexel Pathway to Medical School is a one-year master’s program with early assurance into the College of Medicine and may serve as a gateway for prospective Latino Students.[43] The graduate program is tailored for students who are considered medically underserved or socioeconomically disadvantaged and have done well in the traditional pre-medical school coursework. It is a competitive program that receives between 500 and 700 applicants for the 65 available seats. The assurance of entry into medical school makes the Drexel Pathway to Medical School a beneficial program in aiding Latino representation in medicine. Drexel sets forth minimum requirements for the program that show the school is willing to consider students without the elite scores and grades required of many schools. MCAT scores must be in the 25th percentile or higher, and the overall or science GPA must be at least 2.9.[44] The appealing factor of this program is its mission to attract medically underserved students. This is a tool to increase diversity in medical school. Prospective low-income Latino students can view this as a graduate program tailored to communities like theirs. However, this one-year program is not tuition-free. It may be tempting to assume that patients prefer doctors with exceptional academic records. There's an argument against admitting individuals with lower test scores into medical schools, rooted in the belief that this approach does not necessarily serve the best interests of health care. The argument asserts that the immense responsibility of practicing medicine should be entrusted to the most qualified candidates. Programs like the Drexel Pathway to Medical School are designed to address the lower academic achievements often seen in underrepresented communities. Their purpose is not to admit underqualified individuals into medical school but to bridge the educational gap, helping these individuals take the necessary steps to become qualified physicians. c) The University of California San Francisco School of Medicine reports that 23 percent of its first-year class identifies as Latino, while 34 percent consider themselves disadvantaged.[45] The Office of Diversity and Outreach is concerned with increasing the number of matriculants from underserved communities. UCSF has instilled moral commitments and conducts pipeline and outreach programs to increase the diversity of its medical school student body. The Differences Matter Initiative that the university has undertaken is a complex years-long restructuring of the medical school aimed at making the medical system equitable, diverse, and inclusive.[46] The five-phase commitment includes restructuring the leadership of the medical school, establishing anti-oppression and anti-racism competencies, and critically analyzing the role race, ethnicity, gender, and sexual orientation play in medicine. UCSF offers a post-baccalaureate program specifically tailored to disadvantaged and underserved students. The program’s curriculum includes MCAT preparation, skills workshops, science courses, and medical school application workshops.[47] The MCAT preparation and medical school application workshops serve as a great tool for prospective Latino applicants. UCSF seems to do better than most medical schools regarding Latino medical students. San Francisco has a population of 873,965, of which 15.2 percent are Latino.[48] The large population of Latino medical students indicates that the school’s efforts to increase diversity are working. The 23 percent Latino matriculating class of 2021 better represents the number of Latinos in the United States, which makes up about a fifth of the population. With this current data, it is important to closely dissect the efforts UCSF has taken to increase diversity in its medical school. Their Differences Matter initiative instills a commitment to diversifying their medical school. As mentioned, the school's leadership has been restructuring to include a diverse administrative body. This allows low-income Latino applicants to relate to the admissions committee reviewing their application. With a hopeful outlook, the high percentage of Latino applicants may reflect comprehension of the application process and the anticipated medical school atmosphere and rigor among Latino applicants and demonstrate that the admissions committee understands the applicants. However, there are still uncertainties about the demographics of the Latino student population in the medical school. Although it is a relatively high percentage, it is necessary to decipher which proportion of those students are low-income Latino Americans. UCSF School of Medicine can serve as a model to uplift the Latino community in a historically unattainable profession. VII. Proposed Reform for Current Medical School Application One reform would be toward the reviewing admissions committee, which has the power to change the class composition. By increasing the diversity of the admissions committee itself, schools can give minority applicants a greater opportunity to connect to someone with a similar background through their application. It would address low-income Latino applicants feeling they cannot “get personal” in their application. These actions are necessary because it is not just to have a representative administration for only a portion of the public. Of the three medical schools examined, the University of California San Francisco has the highest percentage of Latino applicants in their entering class. They express an initiative to increase diversity within their medical school leadership via the Differences Matter initiative. This active role in increasing diversity within the medical school leadership may play a role in UCSF’s high percentage of Latino matriculants. That serves as an important step in creating an equitable application process for Latino applicants. An important consideration is whether the medical school administration at UCSF mirrors the Latino population in the United States. The importance of whether the medical school administration at UCSF mirrors the Latino population in the United States lies in its potential to foster diversity, inclusivity, and cultural competence in medical education, as well as to positively impact the healthcare outcomes and experiences of the Latino community. A diverse administration can serve as role models for students and aspiring professionals from underrepresented backgrounds. It can inspire individuals who might otherwise feel excluded or underrepresented in their career pursuits, including aspiring Latino medical students. Furthermore, a diverse leadership can help develop curricula, policies, and practices that are culturally sensitive and relevant, which is essential for addressing health disparities and providing equitable healthcare. It is also important to have transparency so the public knows the number of low-income Latino individuals in medical school. The Latino statistics from the medical school generally include international students. That speaks to diversity but misses the important aspect of uplifting the low-income Latino population of the United States. Passing off wealthy international students from Latin America to claim a culturally diverse class is misleading as it does not reflect income diversity. Doing so gives the incorrect perception that the medical school is accurately representing the Latino population of the United States. There must be a change in how the application process introduces interviews. It needs to be introduced earlier so the admissions committee can form early, well-rounded inferences about an applicant. The interview allows for personal connections with committee members that otherwise would not be established through the primary application. The current framework has the interviews as one of the last aspects of the application process before admissions decisions are reached. At this point in the application process, many low-income Latinos may have been screened out. I understand this is not an easy feat to accomplish. This will lead to an increase in interviews to be managed by the admissions committee. The burden can be strategically minimized by first conducting video interviews with applicants the admission committee is interested in moving forward and those that they are unsure about because of a weakness in a certain area of the application. The video interview provides a more formal connection between the applicants and admission committee reviewers. It allows the applicant to provide a narrative through spoken words and can come off as a more intimate window into their characteristics. It would also allow for an opportunity to explain hardships and what is unique. From this larger pool of video-interviewed applicants, the admission committee can narrow down to traditional in-person interviews. A form of these video interviews may be already in place in some medical school application process. I believe making this practice widespread throughout medical schools will provide an opportunity to increase the diversity of medical school students. There must be an increase in the number of programs dedicated to serving as a gateway to clinical experience for low-income Latino applicants. These programs provide the necessary networking environment needed to get clinical experience. It is important to consider that networking with clinical professionals is an admissions factor that detrimentally affects the low-income Latino population. One of the organizations that aids underserved communities, not limited to Latinos, in clinical exposure is the Summer Clinical Oncology Research Experience (SCORE) program.[49] The SCORE program, conducted by Memorial Sloan Kettering Cancer Center, provides its participants with mentorship opportunities in medicine and science. In doing so, strong connections are made in clinical environments. Low-income Latinos seek these opportunities as they have limited exposure to such an environment. I argue that it is in the medical school’s best interest to develop programs of this nature to construct a more diverse applicant pool. These programs are in the best interest of medical schools because they are culturing a well-prepared applicant pool. It should not be left to the goodwill of a handful of organizations to cultivate clinically experienced individuals from minority communities. Medical schools have an ethical obligation to produce well-suited physicians from all backgrounds. Justice is not upheld when low-income Latinos are disproportionally represented in medical schools. Programs tailored for low-income Latinos supplement the networking this population lacks, which is fundamental to obtaining clinical experience. These programs help alleviate the burden of an applicant’s low socioeconomic status in attaining clinical exposure. VIII. Additional Considerations Affecting the Medical School Application Process and Latino Community Health A commitment to practicing medicine in low-income Latino communities can be established to improve Latino community health.[50] Programs, such as the National Health Service Corps, encourage clinicians to practice in underserved areas by forgiving academic loans for years of work.[51] Increasing the number of clinicians in underserved communities can lead to a positive correlation with better health. It would be ideal to have programs for low-income Latino medical students that incentivize practicing in areas with a high population of underserved Latinos. This would provide the Latino community with physicians of a similar cultural background to attend to them, creating a deeper physician-patient relationship that has been missing in this community. Outreach for prospective Latino applicants by Latino medical students and physicians could encourage an increased applicant turnout. This effort can guide low-income Latinos who do not see much representation in the medical field. It would serve as a motivating factor and an opportunity to network within the medical field. Since there are few Latino physicians and medical students, a large effort must be made to make their presence known. IX. Further Investigation Required It is important to investigate the causes of medical school rejections of low-income Latinos. Understanding this piece of information would provide insight into the specific difficulties this population has with the medical school application. From there, the requirements can be subjected to bioethical analysis to determine whether those unfulfilled requirements serve as undue restrictions. The aspect of legacy students, children of former alumni, proves to be a difficult subject to find data on and merits further research. Legacy students are often given preferred admission into universities.[52] It is necessary to understand how this affects the medical school admissions process and whether it comes at a cost to students that are not legacy. It does not seem like these preferences are something universities are willing to disclose. The aspect of legacy preferences in admissions decisions could be detrimental to low-income Latino applicants if their parents are not college-educated in the United States, which often is the case. It would be beneficial to note how many Latinos in medical school are low-income. The MSAR report denotes the number of Latino-identified students per medical school class at an institution and the number of students who identify as coming from low resources. They do not specify which of the Latino students come from low-income families. This information would be useful to decipher how many people from the low-income Latino community are matriculating into medical schools. CONCLUSION It is an injustice that low-income Latinos are grossly underrepresented in medical school. It would remain an injustice even if the health of the Latino community in the United States were good. The current operation of medical school admission is based on a guild-like mentality, which perpetuates through barriers to admissions. It remains an exclusive club with processes that favor the wealthy over those who cannot devote money and time to the prerequisites such as test preparation courses and clinical internships. This has come at the expense of the Latino community in the United States in the form of both fewer Latino doctors and fewer current medical students. It is reasonable to hope that addressing the injustice of the underrepresentation of low-income Latinos in the medical field would improve Latino community health. With such a large demographic, the lack of representation in the medical field is astonishing. The Latino population faces cultural barriers when seeking healthcare, and the best way to combat that is with a familiar face. An increase in Latino medical students would lead to more physicians that not only can culturally relate to the Latino community, but that are a part of it. This opens the door for a comprehensive understanding between the patient and physician. As described in my thesis, Latino physicians can bridge cultural gaps that have proven detrimental to that patient population. That may help patients make informed decisions, exercising their full autonomy. The lack of representation of low-income Latinos in medicine is a long-known issue. Here, I have connected how the physician-patient relationship can be positively improved with an increase in low-income Latino physicians through various reforms in the admissions process. My hope is to have analyzed the problem of under-representation in a way that points toward further research and thoughtful reforms that can truly contribute to the process of remedying this issue. - [1] Passel, J. S., Lopez, M. H., & Cohn, D. (2022, February 3). U.S. Hispanic population continued its geographic spread in the 2010s. Pew Research Center. https://www.pewresearch.org/fact-tank/2022/02/03/u-s-hispanic-population-continued-its-geographic-spread-in-the-2010s/ [2] Ramirez, A. G., Lepe, R., & Cigarroa, F. (2021). Uplifting the Latino Population From Obscurity to the Forefront of Health Care, Public Health Intervention, and Societal Presence. JAMA, 326(7), 597–598. https://doi.org/10.1001/jama.2021.11997 [3] Association of American Medical Colleges. (2023). Who is eligible to participate in the fee assistance program? https://students-residents.aamc.org/fee-assistance-program/who-eligble-participate-fee-assistance-mprogram [4] U.S. Department of Health and Human Services Office of Minority Health. (2021). Profile: Hispanic/Latino Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64 [5] Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. (2020). Center for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db360.htm; Center for Disease Control and Prevention. (2019). National Diabetes Statistic Report. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf; Hispanics / Latinos | Health Disparities | CDC. (2020, September 14). Health Disparities in HIV, Viral Hepatitis, STDs, and TB. https://www.cdc.gov/nchhstp/healthdisparities/hispanics.html [6] Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. (2020). Center for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db360.htm [7] Center for Disease Control and Prevention. (2021, October). Estimated HIV incidence and prevalence in the United States 2015–2019. https://www.cdc.gov/hiv/pdf/group/racialethnic/hispanic-latino/cdc-hiv-group-hispanic-latino-factsheet.pdf [8] Hispanics / Latinos | Health Disparities | CDC. (2020, September 14). Health Disparities in HIV, Viral Hepatitis, STDs, and TB. https://www.cdc.gov/nchhstp/healthdisparities/hispanics.html [9] CDC. (2020). [10] CDC. (2020). [11] Center for Disease Control and Prevention. (2019). National Diabetes Statistic Report. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf [12] Office of the Assistant Secretary for Planning and Evaluation. (2021, October). Issue Brief No. HP-2021-2. Health Insurance Coverage and Access to Care Among Latinos: Recent Trends and Key Challenges. U.S. Department of Health and Human Services. https://aspe.hhs.gov/reports/health-insurance-coverage-access-care-among-latinos [13] U.S. Department of Health and Human Services Office of Minority Health. (2021). Profile: Hispanic/Latino Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64 [14] Alsan, M., Garrick, O., & Graziani, G. (2019). Does Diversity Matter for Health? Experimental Evidence from Oakland. American Economic Review, 109(12), 4071–4111. https://doi.org/10.1257/aer.20181446 [15] Takeshita, J., Wang, S., Loren, A. W., Mitra, N., Shults, J., Shin, D. B., & Sawinski, D. L. (2020). Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings. JAMA Network Open, 3(11). https://doi.org/10.1001/jamanetworkopen.2020.24583 [16] Alsan, et. al. (2019). [17] Marrast, L., Zallman, L., Woolhandler, S., Bor, D. H., & McCormick, D. (2014). Minority physicians’ role in the care of underserved patients. JAMA Internal Medicine, 174(2), 289. https://doi.org/10.1001/jamainternmed.2013.12756 (“Nonwhite physicians cared for 53.5% of minority and 70.4% of non-English speaking patients.” Increasing the number of Latino doctors could lead to more nonwhite physicians to care for the underserved populations as they serve those populations at disproportionate rates. This may lead to better care for the patients.) [18] Cersosimo, E., & Musi, N. (2011). Improving Treatment in Hispanic/Latino Patients. The American Journal of Medicine, 124(10), S16–S21. https://doi.org/10.1016/j.amjmed.2011.07.019 [19] Flores, G. (2000). Culture and the patient-physician relationship: Achieving cultural competency in health care. The Journal of Pediatrics, 136(1), 14–23. https://doi.org/10.1016/s0022-3476(00)90043-x [20] Cersosimo & Musi. (2011). [21] Flores. (2000). [22] Torres, D. (2019). Knowing How to Ask Good Questions: Comparing Latinos and Non-Latino Whites Enrolled in a Cardiovascular Disease Prevention Study. The Permanente Journal. https://doi.org/10.7812/tpp/18-258 [23] The Princeton Review. (n.d.). Score 513+ on the MCAT, Guaranteed! | The Princeton Review. [24] 2021 FACTS: Applicants and Matriculants Data. (2022). AAMC. https://www.aamc.org/data-reports/students-residents/interactive-data/2021-facts-applicants-and-matriculants-data [25] The Princeton Review. (n.d.). How Many Med Schools Should You Apply To? https://www.princetonreview.com/med-school-advice/how-many-med-schools-should-you-apply-to [26] Association of American Medical Colleges. (n.d.). Fee Assistance Program (FAP). AAMC. https://students-residents.aamc.org/fee-assistance-program/fee-assistance-program-fap [27] Nguyen, M., Desai, M. M., Fancher, T. L., Chaudhry, S. I., Mason, H. R. C., & Boatright, D. (2023). Temporal trends in childhood household income among applicants and matriculants to medical school and the likelihood of acceptance by income, 2014-2019. JAMA. https://doi.org/10.1001/jama.2023.5654 [28] Ramirez, et al. (2021). [29] Ko, M. J., Henderson, M. C., Fancher, T. L., London, M., Simon, M., & Hardeman, R. R. (2023). US medical school admissions leaders’ experiences with barriers to and advancements in diversity, equity, and inclusion. JAMA Network Open, 6(2), e2254928. https://doi.org/10.1001/jamanetworkopen.2022.54928 [30] Johns Hopkins University School of Medicine. (n.d.). JHU CSM SIP. Johns Hopkins Initiative for Careers in Science and Medicine - the Summer Internship Program. https://csmsip.cellbio.jhmi.edu/ [31] Figure 18. Percentage of all active physicians by race/ethnicity, 2018 | AAMC. (2018). AAMC. https://www.aamc.org/data-reports/workforce/data/figure-18-percentage-all-active-physicians-race/ethnicity-2018 [32] Ramirez, et al. (2021). [33] Passel, et al. (2022). [34] Census Reporter. (n.d.). Census profile: Manhattan borough, New York County, NY. https://censusreporter.org/profiles/06000US3606144919-manhattan-borough-new-york-county-ny/ [35] MD Student Diversity Recruitment. (2022). NYU Langone Health. https://med.nyu.edu/our-community/why-nyu-grossman-school-medicine/diversity-inclusion/recruiting-diversity/md-student-diversity-recruitment [36] NYU. (n.d.). STEP Pre-College Program. New York University. https://www.nyu.edu/admissions/undergraduate-admissions/how-to-apply/all-freshmen-applicants/opportunity-programs/pre-college-programs.html [37] Association of American Medical Colleges. (2022). NYU Grossman School of Medicine. Medical School Admission Requirements (MSAR). https://mec.aamc.org/msar-ui/#/medSchoolDetails/152 [38] Association of American Medical Colleges. (2022). [39] U.S. Census Bureau. (2021). U.S. Census Bureau QuickFacts: Philadelphia County, Pennsylvania. Census Bureau QuickFacts. https://www.census.gov/quickfacts/philadelphiacountypennsylvania [40] Association of American Medical Colleges. (2022). Drexel University College of Medicine. Medical School Admission Requirements. https://mec.aamc.org/msar-ui/#/medSchoolDetails/833 [41] Association of American Medical Colleges. (2022). [42] Drexel University College of Medicine. (n.d.). Diversity, Equity & Inclusion For Students. https://drexel.edu/medicine/about/diversity/diversity-for-students/ [43] Drexel University College of Medicine. (n.d.-b). Drexel Pathway to Medical School. https://drexel.edu/medicine/academics/graduate-school/drexel-pathway-to-medical-school/ [44] Drexel University College of Medicine. Drexel Pathway to Medical School. [45] Association of American Medical Colleges. (2022). University of California, San Francisco, School of Medicine. Medical School Admission Requirements. https://mec.aamc.org/msar-ui/#/medSchoolDetails/108 [46] The Regents of the University of California. (n.d.). Differences Matter. UCSF School of Medicine. https://medschool.ucsf.edu/differences-matter [47] The Regents of the University of California. (n.d.-b). Post Baccalaureate Program | UCSF Medical Education. UCSF Medical Education. https://meded.ucsf.edu/post-baccalaureate-program [48] United States Census Bureau. (2021). U.S. Census Bureau QuickFacts: San Francisco County, California. Census Bureau QuickFacts. https://www.census.gov/quickfacts/sanfranciscocountycalifornia [49] Memorial Sloan Kettering Cancer Center. (n.d.). Student Programs. https://www.mskcc.org/about/leadership/office-faculty-development/student-programs [50] Alsan, et al. (2021). [51] National Health Service Corps. (2021, November 2). Mission, Work, and Impact | NHSC. https://nhsc.hrsa.gov/about-us [52] Elam, C. L., & Wagoner, N. E. (2012). Legacy Admissions in Medical School. AMA Journal of Ethics, 14(12), 946–949. https://doi.org/10.1001/virtualmentor.2012.14.12.ecas3-1212

ABSTRACT/EXECUTIVE SUMMARY Why a Task Force on the Family? The practice of pediatrics is unique among medical specialties in many ways, among which is the nearly certain presence of a parent when health care services are provided for the patient. Regardless of whether parents or other family members are physically present, their influence is pervasive. Families are the most central and enduring influence in children’s lives. Parents are also central in pediatric care. The health and well-being of children are inextricably linked to their parents’ physical, emotional and social health, social circumstances, and child-rearing practices. The rising incidence of behavior problems among children attests to some families’ inability to cope with the increasing stresses they are experiencing and their need for assistance. When a family’s distress finds its voice in a child’s symptoms, pediatricians are often parents’ first source for help. There is enormous diversity among families—diversity in the composition of families, in their ethnic and racial heritage, in their religious and spiritual orientation, in how they communicate, in the time they spend together, in their commitment to individual family members, in their connections to their community, in their experiences, and in their ability to adapt to stress. Within families, individuals are different from one another as well. Pediatricians are especially sensitive to differences among children—in their temperaments and personalities, in their innate and learned abilities, and in how they view themselves and respond to the world around them. It is remarkable and a testament to the effort of parents and to the resilience of children that most families function well and most children succeed in life. Family life in the United States has been subjected to extensive scrutiny and frequent commentary, yet even when those activities have been informed by research, they tend to be influenced by personal experience within families and by individual and cultural beliefs about how society and family life ought to be. The process of formulating recommendations for pediatric practice, public policy, professional education, and research requires reaching consensus on some core values and principles about family life and family functioning as they affect children, knowing that some philosophic disagreements will remain unresolved. The growing multicultural character of the country will likely heighten awareness of our diversity. Many characteristics of families have changed during the past 3 to 5 decades. Families without children younger than 18 years have increased substantially, and they are now the majority. The average age at marriage has increased, and a greater proportion of births is occurring to women older than 30 years. Between 1970 and 2000, the proportion of children in 2-parent families decreased from 85% to 69%, and more than one quarter (26%) of all children live with a single parent, usually their mother. Most of this change reflects a dramatic increase in the rate of births to unmarried women that went from 5.3% in 1960 to 33.2% in 2000. Another factor in this change is a slowly decreasing but still high divorce rate that is roughly double what it was in the mid-1950s. Family income is strongly related to children’s health, and the financial resources that families have available are closely tied to changes in family structure. Family income in real dollars has trended up for many decades, but the benefits have not been shared equally. For example, the median income of families with married parents has increased by 146% since 1970, but female-headed households have experienced a growth of 131%. More striking is that in 2000, the median income of female-headed households was only 47% of that of married-couple families and only 65% of that of families with 2 married parents in which the wife was not employed. Not surprising, the proportion of children who live in poverty is approximately 5 times greater for female-headed families than for married-couple families. The composition of children’s families and the time parents have for their children affect child rearing. Consequent to the increase in female-headed households, rising economic and personal need, and increased opportunities for women, the proportion of mothers who are in the workforce has climbed steadily over the past several decades. Currently, approximately two thirds of all mothers with children younger than 18 years are employed. Most families with young children depend on child care, and most child care is not of good quality. Reliance on child care involves longer days for children and families, the stress imposed by schedules and created by transitions, exposure to infections, and considerable cost. An increasing number and proportion of parents are also devoting time previously available to their children to the care of their own parents. The so-called “sandwich generation” of parents is being pulled in multiple directions. The amount and use of family time also has changed with a lengthening workday, including the amount of commuting time necessary to travel between work and home, and with the intrusion of television and computers into family life. In public opinion polls, most parents report that they believe it is more difficult to be a parent now than it used to be; people seem to feel more isolated, social and media pressures on and enticements of their children seem greater, and the world seems to be a more dangerous place. Social and public policy has not kept up with these changes, leaving families stretched for time and stressed to cope and meet their responsibilities. What can and what should pediatrics do to help families raise healthy and well-adjusted children? How can individual pediatricians better support families? Family Pediatrics The American Academy of Pediatrics (AAP) Board of Directors appointed the Task Force on the Family to help guide the development of public policy and recommend how to assist pediatricians to promote well-functioning families (see Appendix). The magnitude of the assigned work required task force members to learn a great deal from research and researchers in the fields of social and behavioral sciences. A review of some critical literature was completed by a consultant to the task force and accompanies this report. That review identified a convergence of pediatrics and research on families by other disciplines. The task force found that a great deal is known about family functioning and family circumstances that affect children. With this knowledge, it is possible to provide pediatric care in a way that promotes successful families and good outcomes for children. The task force refers to that type of care as “family-oriented care” or “family pediatrics” and strongly endorses policies and practices that promote the adoption of this 2-generational approach as a hallmark of pediatrics. During the past decade, family advocates have successfully promoted family-centered care, “the philosophies, principles and practices that put the family at the heart or center of services; the family as the driving force.” Most pediatricians report that they involve families in the decision making regarding the health care of their child and make an effort to understand the needs of the family as well as the child. Family pediatrics, like family-centered care, requires an active, productive partnership between the pediatrician and the family. But family pediatrics extends the responsibilities of the pediatrician to include screening, assessment, and referral of parents for physical, emotional, or social problems or health risk behaviors that can adversely affect the health and emotional or social well-being of their child. Family Context of Child Health The power and importance of families to children arises out of the extended duration for which children are dependent on adults to meet their basic needs. Children’s needs for which only a family can provide include social support, socialization, and coping and life skills. Their self-esteem grows from being cared for, loved, and valued and feeling that they are part of a social unit that shares values, communicates openly, and provides companionship. Families transmit and interpret values to their children and often serve as children’s connection to the larger world, especially during the early years of life. Although schools provide formal education, families teach children how to get along in the world. Often, efforts to discuss families and make recommendations regarding practice or policy stumble over disagreements about the definition of a family. The task force recognized the diversity of families and chose not to operate from the position of a fixed definition. Rather, the task force, which was to address pediatrics, decided to frame its deliberations and recommendations around the functions of families and how various aspects of the family context influence child rearing and child health. One model of family functioning that implicitly guided the task force is the family stress model (Fig 1). Stress of various sorts (eg, financial or health problems, lack of social support, unhappiness at work, unfortunate life events) can cause parents emotional distress and cause couples conflict and difficulty with their relationship. These responses to stress then disrupt parenting and the interactions between parent and child and can lead to short-term or lasting poor outcomes. The earlier these events transpire and the longer that the disruption lasts, the worse the outcomes for children. The task force favors efforts to encourage and support marriage yet recognizes that every family constellation can produce good outcomes for children and that none is certain to yield bad ones. Unequivocally, children do best when they are living with 2 mutually committed and loving parents who respect and support one another, who have adequate social and financial resources, and who are actively engaged in the upbringing of their children. Conclusions From its discussions with family experts, its review of research literature, and its own intensive discussions, the task force was able to draw about the American family a limited number of conclusions that are relevant to pediatrics. Two overriding conclusions were apparent. First, children’s outcomes—their physical and emotional health and their cognitive and social functioning—are strongly influenced by how well their families function. Second, there is much that practicing pediatricians can do to help nurture and support families and, thus, promote optimal family functioning and children’s outcomes. Other conclusions were organized into 4 categories: 1) family function and structure, 2) family circumstances, 3) pediatric practice, and 4) policy. Within the first category, there are conclusions about the effect of family structure, values, beliefs, roles, and relationships on child rearing and child outcomes. The second category, family circumstances, summarizes information on the emotional climate within and outside the home that can promote or impede children’s healthy development. Third, to provide appropriate care for children, pediatricians must expand their practices to encompass the assessment of family relationships, health, and behaviors. They must have the skills and comfort to inquire and learn about individual families, address family issues realistically, and link families to support groups and community resources. Pediatricians’ ability to practice family pediatrics is influenced by training, personal experience and orientation, the work environment, and professional relationships. Finally, there is a need to develop policies that support reimbursement of pediatricians for services for families; that acknowledge the importance of marriage, parenting, and families for children; and that set clear expectations for parents while providing opportunities for them to obtain desired support. Recommendations The task force intended that its recommendations follow logically from the conclusions it was able to draw. The scope of family issues that were reviewed and discussed was very wide; consequently, in some cases, the conclusions are broad and the associated recommendations are numerous. The 80 recommendations also were organized into 4 categories to facilitate their consideration by individual physicians and various bodies within the pediatric profession. The first category, education, offers suggestions on family content for resident training and for continuing education for practitioners. It also contains some guidance on priority topics that should be addressed by parent education materials published by the AAP. The second category, policy and advocacy, suggests public policy positions that would support families and promote good child outcomes. It also addresses reimbursement policies, including diagnostic and procedure coding, which could enable pediatricians to practice family pediatrics. Some suggestions for internal AAP policies that would highlight the importance of a family orientation for the organization also are provided. Finally, opportunities are identified for the AAP to promote local and national policies and activities that support and strengthen families through its chapters and its relationships with other professional organizations. The third and most extensive category comprises recommendations about pediatric practice. This category includes suggestions for how pediatricians can modify their practice behaviors to promote good family functioning and effective parenting. Included are recommendations for how pediatricians can help strengthen parental partnerships in different family types, screen for family circumstances that put children at risk, and help create family-friendly practice environments. For additional guidance, some characteristics of a family-friendly pediatrician are listed in the final table of the report. The final category makes recommendations for research that the AAP should encourage or undertake to better enable pediatricians to provide family-oriented care. Areas for research include the mechanics, content, and effectiveness of family-oriented pediatrics practice; public policies and programs that promote family functioning and family-oriented care; and progress toward adopting the principles and content of family pediatrics among health care organizations, insurers, and AAP members. Taken as a whole, the recommendations provide a comprehensive plan for the AAP and pediatricians to assist families to function well and meet the needs of their children. The scope of work that is required is extensive and touches on nearly every aspect of the work done by the organization. It also requires modifications in pediatric practices to accommodate changes in the characteristics and circumstances of families that are served. Next Steps to Ensure Implementation The task force report is only the first step in what needs to be an ongoing process to ensure that children’s health care is effectively provided in the context of their families. Attention to families should become integrated into the work of the AAP. This report should be reviewed and discussed by AAP staff, committees, sections, and members to determine which recommendations apply to their work and to plan strategies for their implementation. A single entity needs to take ongoing responsibility for monitoring and promoting activities related to the task force’s recommendations. These responsibilities should be assigned with high priority to a standing committee of the AAP.

Photo by Hush Naidoo Jade Photography on Unsplash INTRODUCTION In this collection of narratives, the authors describe their own experiences with and reflections on healthcare worker vaccine hesitancy. The narratives explore each author’s engagement with different communities experiencing vaccine hesitancy, touching on reasons for hesitancy, proposed solutions, and legal aspects. Author’s names appear above their narratives. l. Johanna T. Crane Vaccine hesitancy, defined as “a delay of acceptance or refusal of vaccination despite the availability of vaccination services,”[1] is a worldwide but locally shaped phenomenon that pre-dates the COVID-19 pandemic.[2] Contrary to some portrayals, vaccine hesitancy is not the same as the more absolute antivaccination stance, or what some call “anti-vax.” Many people who are hesitant are not ideologically opposed to vaccines. Hesitancy is also sometimes framed as anti-science, yet reluctance to vaccinate is often about managing risk, trustworthiness, and doubt in the context of uncertainty; it represents an effort to “talk back to science” about unaddressed needs and concerns.[3] In the US, the newness of the vaccines, the unprecedented speed at which they were developed, and their remaining under emergency use authorization at first complicated public confidence. Political polarization and racial and social inequality shape vaccine acceptance and public distrust as well. While vaccine acceptance has increased in the months since the vaccines first became available, many eligible individuals have not yet been vaccinated, including a significant number of healthcare workers.[4] Vaccine hesitancy among healthcare workers may seem surprising, especially given their frontline experience – I confess that it surprised me at first. But when I began interviewing health care workers for a study on COVID vaccine roll-out at community health centers, I learned to take a more complex view. Although the study was focused on patient vaccine access,[5] many of the frontline health care workers we spoke with also described hesitancy among some of their colleagues (and, in a few cases, themselves). From these conversations, I learned that these “healthcare heroes” are also regular people and members of communities. Their concerns about COVID vaccination often reflect the prevailing concerns advanced in their communities, such as worries about vaccine side effects and safety. Like other workers, some fear missing work and losing income, as not all healthcare employers offer paid time off for vaccination or recovery. (Importantly, reluctance to vaccinate is highest among healthcare workers in lower-paid positions with little job security, such as clerks, housekeepers, patient care assistants, and home health aides.)[6] For some healthcare workers of color, the protection offered by the vaccine sits in tension with both current and historical experiences of medical abuse and neglect. Some interviewees, fully vaccinated themselves, rejected the framework of “hesitancy” entirely, arguing that Black and Brown reluctance to be vaccinated first should be understood through the lens of “self-protection”. Due to the nature of their work, healthcare workers have faced great social pressure to vaccinate and vaccinate first. This is understandable, given that vaccination against COVID-19 protects not only workers themselves but aligns with the ethical duty to prevent harm to patients by reducing the risk of transmission in healthcare settings. When the FDA approved COVID-19 vaccines under emergency use authorization in December 2020, many healthcare workers were extremely grateful to be designated “1a” – the first group prioritized to receive the shots.[7] For many bioethicists, prioritization of healthcare workers represented a recognition of the extreme risks that many front-line workers had endured since the onset of the pandemic, including critical shortages in PPE. But it is important to remember that for some workers, going first may have felt like serving as guinea pigs for new vaccines that had yet to be granted full FDA approval. For these individuals, the expectation that they would vaccinate first may have felt like an additional risk rather than a reward. Healthcare workers who are hesitant to vaccinate may feel ashamed or be subject to shaming by others;[8] this may make it difficult to discuss their concerns in the workplace. Throughout the pandemic, healthcare workers have been lauded as “heroes”, and some healthcare employers have promoted vaccination among their workforce as a “heroic” action. This messaging implies that waiting to vaccinate is shameful or cowardly and is echoed in opinion pieces and op-eds describing unvaccinated people as “selfish” or “free riders.”[9] By fostering the proper dialogue, we can respond respectfully to hesitancy among healthcare workers while still working towards the goal of increased vaccination. We in the bioethics and medical community should be willing to listen to our colleagues’ concerns with respect. Top-down approaches aimed at “correcting” hesitancy cannot address the more fundamental issues of trust that are often at stake. Instead, there must be dialogue over time. Conversations with a trusted healthcare provider have a crucial role.[10] Blaming and shaming rhetoric, whether explicit or implicit, gets us nowhere – in fact, it likely moves us backward by likely exacerbating any existing distrust or resentment that workers may hold toward their employers.[11] Lastly, the onus of trust must be with institutions, not individuals. There is a lot of talk about getting communities of color, and Black people, particularly, to "trust" healthcare institutions and the COVID vaccines. This racializes trust and puts the burden on harmed communities rather than on institutions acting in trustworthy ways.[12] Dialogue, respect, and trustworthiness must guide us even in the new era of workplace mandates. Mandates make these strategies even more important as we look toward an uncertain future. As Heidi Larson, founder of the Vaccine Confidence Project, recently said, “We should not forget that we are making people's future history now. Are people going to remember that they were treated respectfully and engaged?”[13] ll. Kara Simpson Since the release of the vaccine for COVID-19 in late 2020, there have been robust discussions within the medical community, the media, and political arenas about vaccine hesitancy among healthcare workers. The public became aware that healthcare workers, the first group to become eligible for the vaccine, were not rushing to “take the shot.” Many people’s opinions were aligned by race, ethnicity, socioeconomic status, and political affiliation. People of color were one of the first groups to be labeled vaccine hesitant as our experiences of distrust of the medical community and the politicization of the vaccine explained the low turnout.[14] It was not uncommon to hear, “this vaccine just came out; let’s wait and see if there are side effects.” Interestingly, many people in the healthcare community and in the public did not understand why healthcare workers of color remained hesitant. Trust is a vital component of any viable relationship, especially in the clinical realm. To have successful health outcomes, it is essential for clinicians to build trusting relationships with their patients and peers. Many people of color are distrustful towards the medical institution due to the years of systemic racism and abuses that they have experienced, witnessed, or learned about. Healthcare workers of color are not excluded from the experiences of their communities outside of work. In fact, I assert that healthcare of color may have an additional burden of hesitation because of their lived experiences of distrust in receiving care and inequality within their professional environment. These dual traumas can work in tandem to strengthen hesitancy. I assert that building trusting clinical relationships will address hesitancy over time. Currently, many healthcare workers are worried about vaccine mandates. For a group of people that have experienced intergenerational enslavement and marginalization, mandates feel coercive and serve as a reminder of how “lesser” bodies are considered unworthy of voice, fundamental human rights, independent decision making. To call the vaccine mandate paternalistic would be an understatement. An unintended result of vaccine mandates will be the reinforcement of hesitancy and distrust of the medical institution as trust and coercion cannot coexist. This mandate will give more power to the conspiracy theories and harm those who already do not seek or receive adequate health care because of systemic inequalities. Furthermore, mandates can also dissuade people of color from becoming healthcare workers, and others may leave the field. In essence, vaccine hesitancy is a symptom of a much larger problem: the distrust of the medical establishment. As bioethicists, our mission should be to support interventions that foster “trustworthiness” of the institutions rather than those that cause trauma. Several organizations have proposed mask mandates and weekly testing as a measure to protect the population at large and still respect the autonomy of the unvaccinated.[15] lll. Jennifer Breznay I work in a very large community teaching hospital in Brooklyn, and we were extremely hard hit by COVID in March 2020. I worked on inpatient medical units and witnessed a lot of suffering. And after nine months of fear and despair about COVID’s toll, I felt tremendous frustration in December when I heard that many healthcare workers would reject the vaccine. As the co-chair of the Bioethics Committee, I drafted a statement recommending vaccination for all employees. When the draft was revised and approved by the Bioethics Committee, I began to discuss it with employees, and I appreciated different perspectives I had not heard before. In the end, rather than releasing the statement, we directed our efforts at creating a dialogue. I also volunteer at a not-for-profit which operates seven early childhood education centers in Northern Brooklyn. The Executive Director invited me to collaborate on strategies to encourage staff vaccination, and we decided to offer a Zoom conference to 20 members of the staff. I was extremely nervous about how the audience would perceive me, a white doctor whom they did not know. I felt awkward about coming to them with an agenda. And there was also the question of whether I was an appropriate messenger compared to a person of color. Yet, I felt like I shouldn't back away from this. So, I chose to simply disclose my discomfort at the beginning of the Zoom. I said, “Thanks for having me. You know, as a white physician, I understand you might have concerns about trusting what I say. Four hundred years of inequity and abuse by the healthcare system can create a lot of mistrust, but I’m here to try to answer your questions.” Ultimately the Executive Director reported that the Zoom was successful in stimulating a lot of conversation among the staff about the vaccine. I think the critical piece is the intimate but open conversation, where you can elicit values. lV. Ashley L. Stewart In the rural areas of our state, healthcare institutions are inextricably tied to their communities. Rural hospitals hire from, serve, and function in the community where they are located. Successful implementation of a vaccine roll-out in such rural areas requires explicit recognition of the role and influence of the community. After identifying issues common to the area, rural institutions can address them. Even when rural institutions find that healthcare worker concerns seem to be unique or personal, they are often related to the larger concerns of the community.[16] Community-based increased vaccine hesitancy may coincide with an underlying issue, such as lack of information rather than principled or experience-based resistance.[17] When the vaccines became available, rural vaccination coordinators encountered a wealth of misinformation that left many people initially undecided. Compounding this lack of information, workers expressed a sense of fear about the professional consequences of voicing concerns, especially in tight-knit communities. Many workers expressed concern about being judged merely for sharing their questions or decisions.[18] They also felt that saying or doing something to promote the value of vaccination might change their relationship with members of the community where they live and work.[19] As there was a fear of engaging in productive conversations, it was difficult for them to find valuable information, and the lack of information discouraged them from being vaccinated. Vaccine coordinators wanted to get information to the entire community based on the most current research and release unbiased, consistent, and timely information from sources all people in the community could trust, including from multiple sources at once. Communication must focus on answering many types of questions, which must often be done in private or anonymously. Where poorly supported or incorrect information is widely available, sharing objective information is crucial to turning the tide of distrust. If the healthcare community dismisses concerns or assumes that answering questions based on misinformation is a waste of time, the community-based institutions will further the distrust. Some may feel that vaccine coordinators should not address misinformation directly, yet avoidance has been widely unsuccessful.[20] Being respectful and non-judgmental in answering questions posed by people who do not know what is true can be hard, but in rural communities, answering completely and honestly without judgment is a critical component of any effort to inform people. Telling people to get vaccinated “for the greater good” can sound the same as being told not to get a vaccine because it is “bad” if both sources of information fail to back up their claims. Ultimately rural institutions are respected because they are a resource to their communities, a priority we must preserve. It is also critical to treat everyone respectfully regardless of vaccine status.[21] People may perceive mandates, divisive policies, or disrespectful treatment of people based on vaccination status as discriminatory or coercive, weakening the appeal of vaccination. Such practices may make people less trusting and more anchored to their position as they come to see vaccination proponents as untrustworthy or authoritarian. We must work to maintain respect for human autonomy. Using unethical means to achieve even a just end will not lead to a “greater good” but rather to the perception that people in positions of authority would achieve a result “by any means necessary.” V. David N. Hoffman The central moral quandary that arises whenever vaccine hesitancy among healthcare workers is discussed is whether workers who refuse to get vaccinated should or could be fired. We should clarify that we are applying a definition of mandate in the employment context for private employers, the violation of which results in loss of employment. Government-controlled provider organizations are just now weighing in on this topic and are generally pursuing strategies that impose periodic, usually weekly, testing requirements for those workers who decline to get vaccinated. In the private sector, employers can require their employees to do a great many things as a condition of employment, and one of them is to get vaccinated against COVID -19. In the most prominent case to date, just such a mandate gave rise to a lawsuit in Texas involving Houston Methodist Hospital. In that case, 170 employees asserted that an employer should not be allowed to force them to get vaccinated. The judge held that, while no employer can force an employee to get vaccinated, no employer is obligated to continue the employment of any employee who declines to follow rules established by that employer, including the obligation to get vaccinated.[22] In Texas, what the judge said is you are not being forced to get vaccinated, but your employer is allowed to set limits and conditions on employment, including vaccination. Employees do not have an obligation to get vaccinated, but they also have no right to their jobs. That is because of a widely misunderstood legal concept: “employment at will.” Employment at will sounds like a rule that employees can do what they want at work, but in fact, employment at will means only that you can quit your job whenever you want (we do not permit indentured servitude). At the same time, your employer can fire you at any time, for any reason or no reason, unless the reason is a pretext and involves one of the protected statuses (race, color, religion, sex, or national origin, and in some jurisdictions gender orientation, gender identity). Generally, any employers, including hospitals, can decide that if someone is not willing to get a vaccination, or if they are not willing to complete sexual harassment training or participate in the hospital’s infection control program, that is the employee’s right, but it will mean that an employer can similarly decline to continue providing employment. The evolution of this hesitancy discussion will be influenced by the narrower debate playing out in the court of public opinion, and the courts of law, over the enforceability of New York’s recently enacted vaccine mandate. Regardless of whether that mandate survives, with or without medical and religious exemptions, healthcare employers will be left with a profound ethical dilemma. At the end of all the litigation, if there is a religious exemption, employers will always be burdened with the responsibility to determine whether an individual employee has asserted a genuine and sincere religious objection to vaccination and whether the employer is able to provide an accommodation that is safe and effective in protecting the interests of co-workers and patients. The anticipated federal mandate, which reportedly will have a test/mask alternative, will only make this ethical task more challenging. This leads to the final point in this analysis, which is that while private employers, including hospitals, can deprive an individual of their employment if those individuals refuse to get vaccinated, just because an employer can do so does not mean it should do so.[23] - [1] MacDonald NE. Vaccine hesitancy: Definition, scope and determinants. Vaccine. 2015;33(34):4161-4164. doi:10.1016/j.vaccine.2015.04.036 [2] Larson HJ, de Figueiredo A, Xiahong Z, et al. The State of Vaccine Confidence 2016: Global Insights Through a 67-Country Survey. EBioMedicine. 2016;12:295-301. doi:10.1016/j.ebiom.2016.08.042 [3] Larson H. Stuck: How Vaccine Rumors Start - and Why They Don’t Go Away. Oxford University Press; 2020; Benjamin R. Informed Refusal: Toward a Justice-based Bioethics. Sci Technol Hum Values. 2016;41(6):967-990. doi:10.1177/0162243916656059 [4] Deepa Shivaram, In The Fight Against COVID, Health Workers Aren't Immune To Vaccine Misinformation September 18, 2021. NPR Special Series: The Coronavirus. https://www.npr.org/2021/09/18/1037975289/unvaccinated-covid-19-vaccine-refuse-nurses-heath-care-workers [5] Crane JT, Pacia D, Fabi R, Neuhaus C, and Berlinger N. Advancing Covid vaccination equity at Federally Qualified Health Centers: A rapid qualitative review. Accepted and awaiting publication at JGIM. [6] Ashley Kirzinger. “KFF/The Washington Post Frontline Health Care Workers Survey - Vaccine Intentions.” KFF, 22 Apr. 2021, https://www.kff.org/report-section/kff-washington-post-frontline-health-care-workers-survey-vaccine-intentions/. [7] Johanna Crane, Samuel Reis-Dennis and Megan Applewhite. “Prioritizing the ‘1a’: Ethically Allocating Scarce Covid Vaccines to Health Care Workers.” The Hastings Center, 21 Dec. 2020, https://www.thehastingscenter.org/prioritizing-the-1a-ethically-allocating-covid-vaccines-to-health-care-workers/. [8] “'I'm Not an Anti-Vaxxer, but...' US Health Workers' Vaccine Hesitancy Raises Alarm.” The Guardian, Guardian News and Media, 10 Jan. 2021, https://www.theguardian.com/world/2021/jan/10/coronavirus-covid-19-vaccine-hesitancy-us-health-workers. [9] Gerson M. If you are healthy and refuse to take the vaccine, you are a free-rider. Washington Post. April 15, 2021. [10] Crane JT, Pacia D, Fabi R, Neuhaus C, and Berlinger N. Advancing Covid vaccination equity at Federally Qualified Health Centers: A rapid qualitative review. Accepted and awaiting publication at JGIM. [11] Larson H. Stuck : How Vaccine Rumors Start - and Why They Don’t Go Away. Oxford University Press; 2020. [12] Benjamin R. Race for Cures: Rethinking the Racial Logics of ‘Trust’ in Biomedicine. Sociology Compass. 2014;8(6):755-769. doi:10.1111/soc4.12167; Warren RC, Forrow L, David Augustin Hodge S, Truog RD. Trustworthiness before Trust — Covid-19 Vaccine Trials and the Black Community. N Engl J Med. Published online October 16, 2020. doi:10.1056/NEJMp2030033 [13] Offri D. Heidi Larson, Vaccine Anthropologist. New Yorker. Published online June 12, 2021. Accessed August 11, 2021. https://www.newyorker.com/science/annals-of-medicine/heidi-larson-vaccine-anthropologist [14] Razai M S, Osama T, McKechnie D G J, Majeed A. Covid-19 Vaccine Hesitancy Among Ethnic Minority Groups. BMJ 2021; 372 :n513 doi:10.1136/bmj.n513 [15] Dasgupta, Sharoda, et al. “Differences in Rapid Increases in County-Level COVID-19 Incidence by Implementation of Statewide Closures and Mask Mandates — United States, June 1–September 30, 2020.” Annals of Epidemiology, vol. 57, Sept. 2021, pp. 46–53., https://doi.org/10.1016/j.annepidem.2021.02.006. [16] Do, Tuong Vi C et al. “COVID-19 Vaccine Acceptance Among Rural Appalachian Healthcare Workers (Eastern Kentucky/West Virginia): A Cross-Sectional Study.” Cureus vol. 13,8 e16842. 2 Aug. 2021, doi:10.7759/cureus.16842; Danabal, K.G.M., Magesh, S.S., Saravanan, S. et al. Attitude towards COVID 19 vaccines and vaccine hesitancy in urban and rural communities in Tamil Nadu, India – a community-based survey. BMC Health Serv Res 21, 994 (2021). https://doi.org/10.1186/s12913-021-07037-4 [17] Scott C. Ratzan MD, MPA, MA, Lawrence O. Gostin JD, Najmedin Meshkati PhD, CPE, Kenneth Rabin PhD & Ruth M. Parker MD (2020) COVID-19: An Urgent Call for Coordinated, Trusted Sources to Tell Everyone What They Need to Know and Do, Journal of Health Communication, 25:10, 747-749, DOI: 10.1080/10810730.2020.1894015 [18] Huang, Pien. “Some Health Care Workers Are Wary of Getting COVID-19 Vaccines.” NPR, NPR, 1 Dec. 2020, https://www.npr.org/sections/health-shots/2020/12/01/940158684/some-health-care-workers-are-wary-of-getting-covid-19-vaccines. Portnoy, Jenna. “Several Hundred Virginia Health-Care Workers Have Been Suspended or Fired over Coronavirus Vaccine Mandates.” The Washington Post, WP Company, 4 Oct. 2021, https://www.washingtonpost.com/local/covid-vaccine-mandate-hospitals-virginia/2021/10/01/b7976d16-21ff-11ec-8200-5e3fd4c49f5e_story.html. [19] Jennifer A. Lueck & Alaina Spiers (2020) Which Beliefs Predict Intention to Get Vaccinated against COVID-19? A Mixed-Methods Reasoned Action Approach Applied to Health Communication, Journal of Health Communication, 25:10, 790-798, DOI: 10.1080/10810730.2020.1865488 [20] Lockyer, Bridget, et al. “Understanding Covid-19 Misinformation and Vaccine Hesitancy in Context: Findings from a Qualitative Study Involving Citizens in Bradford, UK.” Health Expectations, vol. 24, no. 4, 4 May 2021, pp. 1158–1167., https://doi.org/10.1101/2020.12.22.20248259. Scott C. Ratzan & Ruth M. Parker (2020) Vaccine Literacy—Helping Everyone Decide to Accept Vaccination, Journal of Health Communication, 25:10, 750-752, DOI: 10.1080/10810730.2021.1875083. [21] Zimmerman, Anne. Columbia Academic Commons, 2020, Toward a Civilized Vaccination Discussion: Abandoning the False Assumption That Scientific Goals Are Shared by All, https://academiccommons.columbia.edu/doi/10.7916/d8-rzh0-1f73. [22] Bridges, et al v. Houston Methodist Hospital et al, https://docs.justia.com/cases/federal/districtcourts/texas/txsdce/4:2021cv01774/1830373/18 [23] David N. Hoffman, “Vaccine Mandates for Health Care Workers Raise Several Ethical Dilemmas,” Hasting Center Bioethics Forum. August 2021. https://www.thehastingscenter.org/vaccine-mandates-for-health-care-workers-raise-several-ethical-dilemmas/

We'd eat at Cahill's, Cahill's Family Restaurants I believe they were called, and quite plushy looking ... . At Cahill's we'd eat Viennese Schnitzel, with potato salad and some nice red cabbage salad, sort of pickled ... . Even more exotic was Chicken Maryland, served with a banana and a slice of pineapple in batter. It cost 7s 6d. -- Marion Halligan (11) We migrated in the sixties. Born in Cape Town, I was raised in the heart of Jewish Bondi. The flavours of my youth? Probably equal parts peri-peri, horseradish and chicken booster, not bouquet garni. My introduction to what was 'Australian' food was had in restaurants. And yes, I remember Cahill's, though I can't tell you when exactly, or how much things cost. Mid-sixties. I knew, even then, that there were better restaurants, like the places Dad used to take us with checked tablecloths and bottles with candles dripping wax and fish nets everywhere. His favourites were Mother's Cellar and The Gap at Watson's Bay. I think it's still there. This was before they built Australia Square and Dad became obsessed with the Summit, and of course the Blue Angel, where we never doubted that the lobsters were live. Favourite dishes? I would only eat 'chicken in a basket' or spaghetti bolognaise; well, I was very young, and prone to tears. I can remember my father, losing patience and insisting, "you have a basket for the bread, just put the bloody chicken in it". I can't even remember what it was, probably the same Chicken Maryland Halligan mentions, or a cousin. Fried chicken with a battered pineapple ring and chips of course, sometimes magically grated to form a lattice. I know I enjoyed going out to eat but all meals held the prospect of tension. Visser says the tension arises from the prospect of ending up as a main course. In my case, a mere hors d'œuvre for my sarcastic oldest brother. I was the youngest and unsure how to get the best, the most, as much, or even what I wanted. I wouldn't order until I had read the whole menu, which took long enough even when it wasn't in French or Italian. The menu rarely helped me, rather it served to frustrate my entire family because they knew I was going to order spaghetti or chicken anyway, but that made no difference, the menu had to be read before ordering, and no amount of harassment could convince me otherwise. I love the thought of that child, and her passionate sense of propriety. On special occasions Dad would order Spumante and we would all have a glass, and I felt terribly sophisticated; fortunately the experience doesn't seem to have permanently damaged my palate. Spumante reminded Dad of Italy, the war, you know. Granny used to refer to this as "Henry's trip to Europe". My Dad loved the war, and I'm sure it's not all rosy nostalgia because it was the only time he got away from his family. He drove a truck and didn't have to kill anybody and all we ever heard about was the mud, the black market and the girls. So a glass of cheap, sweet fizzy brought it all back, every time, and who am I to scoff, when the merest whiff of retsina and I'm floating in the bath-flat Aegean under a hot blue sky with anybody called Jani? Cahill's, meanwhile, was in the city, in the days when you 'went to town'. Going to town was always a treat but it depended largely on with whom and why. With Mum it meant serious shopping, and though there was the promise of lunch at David Jones Cafeteria, was it worth the endless hours of torture trying on shoes that were too small and school uniforms which were too big, but of course I would grow into them? And how could a pie with sauce in a plastic packet have been a treat? Going to town with Nana was a different story. It was with some expectation that we would descend into the air-conditioned red-walled cavern that was Cahill's. What I remember about Cahill's was the occasion, and the fish and chips. Nana spent her childhood in a Dickensian orphanage and her adulthood in the North of England, waiting for my grandfather to pick a winner, so I imagine that she felt comfortable with what she knew. That she always ordered fish and chips is only strange because Nana was famous for her fish and chips, perhaps she liked to compare. And I really shouldn't find it odd when I find it difficult to order anything other than fritto misto; in two generations we've progressed to "trefe"1 but not past the deep fryer. So I'm sure that I ordered fish and chips too, or perhaps I ate some of hers, because that was the only thing to do, otherwise she would eat one piece, then look around before coughing theatrically into a serviette which she would then drop, casually, over the other piece and put it in her bag. It was absolutely awful, and we grandchildren loved it when she did that. The other thing I have to say about fish and chips is that we Jews like to eat fried fish cold, but then we don't batter the fish, just flour and egg. I suppose it forms a batter anyway but it doesn't separate from the fish, and we like a solid fish, say kingfish, while Australians seem to go for thinner fillets encased in oily batter. Cahill's did something in between. To follow, tea for Nana, while I always ate fruit salad and ice cream; this I also used to eat on our Saturday afternoon excursions to the 'Cross' which Nana said reminded her of Paris, because it was full of 'artists' like herself. So Nana would sip her tea while I ate my tinned fruit salad and we enjoyed each other and the world, and what a delight for a chatty little girl, the undivided attention of such a beloved adult. I do believe that I will never feel as grown up, ever again, as I did when I was a little girl, out for lunch with my Nana. So as you see I have a sentimental attachment to fish and chips. Their cooking and consumption have flavoured my childhood and possibly yours. The association of fish and chips with that Hanson woman2 is therefore particularly galling, and yet also pertinent. I've never believed that it's just a coincidence that she is purveyor of fish and chips; after all, fish and chips are emblematic of 'Englishness'. Hanson wants Australians to maintain their cultural identification with the mother country, she could hardly have achieved her profile were she the proprietor of a noodle shop. So as you see I have a sentimental attachment to fish and chips. Their cooking and consumption have flavoured my childhood and possibly yours. The association of fish and chips with that Hanson woman2 is therefore particularly galling, and yet also pertinent. I've never believed that it's just a coincidence that she is purveyor of fish and chips; after all, fish and chips are emblematic of 'Englishness'. Hanson wants Australians to maintain their cultural identification with the mother country, she could hardly have achieved her profile were she the proprietor of a noodle shop. Here lies the Great Divide and I fear that I may be part of the problem, not the solution. I am hoist on my hybrid petard, uncomfortably, because much as I dislike elitist Epicureanism I have seen that the reality of what we eat in this country is not always pretty. And all the best efforts of the proselytising 'foodie' media are falling on deaf or already converted ears. Back in the mother country, this battleground is already well trod: there remains something shamefaced about the acceptance of fish and chips as a component of 'Englishness' among the 'better classes' ... . This set of perceptions attaches fish and chips to potent patriotic images of land, countryside, industrial might ... and above all, the notion of Britain as a gallant seafaring notion whose little ships do battle with the elements and the foreign enemy to feed and protect the people. (Walton 2) I see Pauline, wrapped in the flag, battered hake in upraised hand ... and let's not forget that fish and chips were one of our first fast foods, at a time when there was little respite for women, often providing the only hot meal of the day, particularly for workers. Of course the practice was seen to be harmful by health care professionals. The consumption of food prepared outside the home was read as poor mothering, a breakdown in the process of policing of 'proper' families and of course no-one is sure just what sort of mother Pauline is. She appears to be estranged from her older children, a case of one Chiko Roll too many? The irony of fish and chips and Englishness is that, according to Walton, fish and chips also symbolise cultural diversity: viewed in other moods and seen from other angles, of course, the image and associations of fish and chips could be very different. They expressed ethnic diversity as well as simplistic national solidarity, from the strong East End Jewish element in the early days of fish frying in London, through the strong Italian presence in the trade from the turn of the century, in urban Scotland and Ireland especially, to the growing importance of the Chinese and Greek Cypriots in the post-Second World War decades. (2) So fish and chips have played a significant role for a number of ethnic groups. They're ours, not hers. But I'm still troubled, I need to tell the gastronomic mafia that Pacific Rim cuisine won't be Oz food until a significant number of Australians are eating it, and I'm afraid "mainstream Australia, out there" is eating extremely boring food. Could it be that the resentment against Asians is because their food is just so much better? Footnotes 1. trefe: (yiddish) animals, seafood or insects considered impure, abomination, not to be eaten under any circumstances, notably pig and shellfish. 2. Pauline Hanson was elected to the Australian Federal Parliament as an independent candidate in 1996, and soon made her presence known with outspoken comments about Aborigines, (mainly Asian) migrants, and welfare recipients [ed.]. 3. Stephanie Alexander is a noted Australian food writer and restaurateur, and her A Shared Table is the latest of a plethora of Australian television series celebrating our gastronomic abundance. References Halligan,Marion. Eat My Words. Sydney: Collins/Angus and Robertson, 1990. Visser, Margaret. The Rituals of Dinner. New York: Grove/Weidenfeld, 1991. Walton, John K. Fish and Chips and the British Working Class: 1870-1940. Leicester: Leicester UP, 1992. Citation reference for this article MLA style: Felicity Newman. "'You Have a Basket for the Bread, Just Put the Bloody Chicken in It'." M/C: A Journal of Media and Culture 2.7 (1999). [your date of access] <http://www.uq.edu.au/mc/9910/basket.php>. Chicago style: Felicity Newman, "'You Have a Basket for the Bread, Just Put the Bloody Chicken in It'," M/C: A Journal of Media and Culture 2, no. 7 (1999), <http://www.uq.edu.au/mc/9910/basket.php> ([your date of access]). APA style: Felicity Newman. (1999) "You have a basket for the bread, just put the bloody chicken in it". M/C: A Journal of Media and Culture 2(7). <http://www.uq.edu.au/mc/9910/basket.php> ([your date of access]).

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

Introduction The scientific validity of climate change claims, how to intervene (if at all) in environmental, economic, political and social consequences of climate change, and the adaptation and mitigation needed with any given climate change scenario, are contested areas of public, policy and academic discourses. For marginalised populations, the climate discourses around adaptation, mitigation, vulnerability and resilience are of particular importance. This paper considers the silence around disabled people in these discourses. Marci Roth of the Spinal Cord Injury Association testified before Congress in regards to the Katrina disaster: [On August 29] Susan Daniels called me to enlist my help because her sister in-law, a quadriplegic woman in New Orleans, had been unsuccessfully trying to evacuate to the Superdome for two days. […] It was clear that this woman, Benilda Caixetta, was not being evacuated. I stayed on the phone with Benilda, for the most part of the day. […] She kept telling me she’d been calling for a ride to the Superdome since Saturday; but, despite promises, no one came. The very same paratransit system that people can’t rely on in good weather is what was being relied on in the evacuation. […] I was on the phone with Benilda when she told me, with panic in her voice “the water is rushing in.” And then her phone went dead. We learned five days later that she had been found in her apartment dead, floating next to her wheelchair. […] Benilda did not have to drown. (National Council on Disability, emphasis added) According to the Intergovernmental Panel on Climate Change (IPCC), adaptation is the “Adjustment in natural or human systems in response to actual or expected climatic stimuli or their effects, which moderates harm or exploits beneficial opportunities” (IPCC, Climate Change 2007). Adaptations can be anticipatory or reactive, and depending on their degree of spontaneity they can be autonomous or planned (IPCC, Fourth Assessment Report). Adaptations can be private or public (IPCC, Fourth Assessment Report), technological, behavioural, managerial and structural (National Research Council of Canada). Adaptation, in the context of human dimensions of global change, usually refers to a process, action or outcome in a system (household, community, group, sector, region, country) in order for that system to better cope with, manage or adjust to some changing condition, stress, hazard, risk or opportunity (Smit and Wandel). Adaptation can encompass national or regional strategies as well as practical steps taken at the community level or by individuals. According to Smit et al, a framework for systematically defining adaptations is based on three questions: (i) adaptation to what; (ii) who or what adapts; and (iii) how does adaptation occur? These are essential questions that have to be looked at from many angles including cultural and anthropological lenses as well as lenses of marginalised and highly vulnerable populations. Mitigation (to reduce or prevent changes in the climate system), vulnerability (the degree to which a system is susceptible to, and unable to cope with, the adverse effects of climate change), and resilience (the amount of change a system can undergo without changing state), are other important concepts within the climate change discourse. Non-climate stresses can increase vulnerability to climate change by reducing resilience and can also reduce adaptive capacity because of resource deployment to competing needs. Extending this to the context of disabled people, ableism (sentiment to expect certain abilities within humans) (Wolbring, “Is there an end to out-able?”) and disablism (the unwillingness to accommodate different needs) (Miller, Parker and Gillinson) are two concepts that will thus play themselves out in climate discourses. The “Summary for Policymakers” of the IPCC 2007 report, Climate Change 2007: Impacts, Adaptation and Vulnerability, states: “Poor communities can be especially vulnerable, in particular those concentrated in high-risk areas. They tend to have more limited adaptive capacities, and are more dependent on climate-sensitive resources such as local water and food supplies.” From this quote one can conclude that disabled people are particularly impacted, as the majority of disabled people live in poverty (Elwan). For instance, CARE International, a humanitarian organisation fighting global poverty, the UN Office for the Coordination of Humanitarian Affairs, and Maplecroft, a company that specialises in the calculation, analysis and visualisation of global risks, conclude: “The degree of vulnerability is determined by underlying natural, human, social, physical and financial factors and is a major reason why poor people—especially those in marginalised social groups like women, children, the elderly and people with disabilities—are most affected by disasters” (CARE International). The purpose of this paper is to expose the reader to (a) how disabled people are situated in the culture of the climate, adaptation, mitigation and resilience discourse; (b) how one would answer the three questions, (i) adaptation to what, (ii) who or what adapts, and (iii) how does adaptation occur (Smit et al), using a disabled people lens; and (c) what that reality of the involvement of disabled people within the climate change discourse might herald for other groups in the future. The paper contends that there is a pressing need for the climate discourse to be more inclusive and to develop a new social contract to modify existing dynamics of ableism and disablism so as to avoid the uneven distribution of evident burdens already linked to climate change. A Culture of Neglect: The Situation of Disabled People As climates changes, environmental events that are classified as natural disasters are expected to be more frequent. In the face of recent disaster responses, how effective have these efforts been as they relate to the needs and challenges faced by disabled people? Almost immediately after Hurricane Katrina devastated the Gulf Coast, the National Council on Disability (NCD) in the United States estimated that 155,000 people with disabilities lived in the three cities hardest hit by the hurricane (about 25 per cent of the cities’ populations). The NCD urged emergency managers and government officials to recognise that the need for basic necessities by hurricane survivors with disabilities was “compounded by chronic health conditions and functional impairments … [which include] people who are blind, people who are deaf, people who use wheelchairs, canes, walkers, crutches, people with service animals, and people with mental health needs.” The NCD estimated that a disproportionate number of fatalities were people with disabilities. They cited one statistic from the American Association of Retired Persons (AARP): “73 per cent of Hurricane Katrina-related deaths in New Orleans area were among persons age 60 and over, although they comprised only 15 per cent of the population in New Orleans.” As the NCD stated, “most of those individuals had medical conditions and functional or sensory disabilities that made them more vulnerable. Many more people with disabilities under the age of 60 died or were otherwise impacted by the hurricanes.” As these numbers are very likely linked to the impaired status of the elderly, it seems reasonable to assume similar numbers for non-elderly disabled people. Hurricane Katrina is but one example of how disabled people are neglected in a disaster (Hemingway and Priestley; Fjord and Manderson). Disabled people were also disproportionately impacted in other disasters, such as the 1995 Great Hanshin Earthquake in Japan (Nakamura) or the 2003 heatwave in France, where 63 per cent of heat-related deaths occurred in institutions, with a quarter of these in nursing homes (Holstein et al.). A review of 18 US heatwave response plans revealed that although people with mental or chronic illnesses and the homeless constitute a significant proportion of the victims in recent heatwaves, only one plan emphasised outreach to disabled persons, and only two addressed the shelter and water needs of the homeless (Ebi and Meehl; Bernhard and McGeehin). Presence of Disabled People in Climate Discourse Although climate change will disproportionately impact disabled people, despite the less than stellar record of disaster adaptation and mitigation efforts towards disabled people, and despite the fact that other social groups (such as women, children, ‘the poor’, indigenous people, farmers and displaced people) are mentioned in climate-related reports such as the IPCC reports and the Human Development Report 2007/2008, the same reports do not mention disabled people. Even worse, the majority of the material generated by, and physically set up for, discourses on climate, is inaccessible for many disabled people (Australian Human Rights Commission). For instance, the IPCC report, Climate Change 2007: Impacts, Adaptation and Vulnerability, contains Box 8.2: Gender and natural disasters, makes the following points: (a) “men and women are affected differently in all phases of a disaster, from exposure to risk and risk perception; to preparedness behaviour, warning communication and response; physical, psychological, social and economic impacts; emergency response; and ultimately to recovery and reconstruction”; (b) “natural disasters have been shown to result in increased domestic violence against, and post-traumatic stress disorders in, women”; and (c) “women make an important contribution to disaster reduction, often informally through participating in disaster management and acting as agents of social change. Their resilience and their networks are critical in household and community recovery.” The content of Box 8.2 acknowledges the existence of different perspectives and contributions to the climate discourse, and that it is beneficial to explore these differences. It seems reasonable to assume that differences in perspectives, contributions and impact may well also exist between people with and without disabilities, and that it may be likewise beneficial to explore these differences. Disabled people are differently affected in all phases of a disaster, from exposure to risk and risk perception; to preparedness behaviour, warning communication and response; physical, psychological, social and economic impacts; emergency response; and ultimately to recovery and reconstruction. Disabled people could also make an important contribution to disaster reduction, often informally through participating in disaster management and acting as agents of social change. Their resilience and their networks are critical in household and community recovery, important as distributors of relief efforts and in reconstruction design. The Bonn Declaration from the 2007 international conference, Disasters are always Inclusive: Persons with Disabilities in Humanitarian Emergency Situations, highlighted many problems disabled people are facing and gives recommendations for inclusive disaster preparedness planning, for inclusive response in acute emergency situations and immediate rehabilitation measures, and for inclusive post-disaster reconstruction and development measures. Many workshops were initiated by disabled people groups, such as Rehabilitation International. However, the disabled people disaster adaptation and mitigation discourse is not mainstreamed. Advocacy by people with disability for accessible transport and universal or “life-cycle” housing (among other things) shows how they can contribute significantly to more effective social systems and public facilities. These benefit everyone and help to shift public expectations towards accessible and flexible amenities and services—for example, emergency response and evacuation procedures are much easier for all if such facilities are universally accessible. Most suggestions by disabled people for a more integrative, accessible physical environment and societal attitude benefit everyone, and gain special importance with the ever-increasing proportion of elderly people in society. The IPCC Fourth Assessment Report is intended to be a balanced assessment of current knowledge on climate change mitigation. However, none of the 2007 IPCC reports mention disabled people. Does that mean that disabled people are not impacted by, or impact, climate change? Does no knowledge of adaptation, mitigation and adaptation capacity from a disabled people lens exist, or does the knowledge not reach the IPCC, or does the IPCC judge this knowledge as irrelevant? This culture of neglect and unbalanced assessment of knowledge evident in the IPCC reports was recognised before for rise of a ‘global’ climate discourse. For instance, a 2001 Canadian government document asked that research agendas be developed with the involvement of, among others, disabled people (Health Canada). The 2009 Nairobi Declaration on Africa’s response to climate change (paragraph 36) also asks for the involvement of disabled people (African Ministerial Conference on the Environment). However, so far nothing has trickled up to the international bodies, like the IPCC, or leading conferences such as the United Nations Climate Change Conference Copenhagen 2009. Where Will It End? In his essay, “We do not need climate change apartheid in adaptation”, in the Human Development Report 2007/2008, Archbishop Desmond Tutu suggests that we are drifting into a situation of global adaptation apartheid—that adaptation becomes a euphemism for social injustice on a global scale (United Nations Development Programme). He uses the term “adaptation apartheid” to highlight the inequality of support for adaptation capacity between high and low income countries: “Inequality in capacity to adapt to climate change is emerging as a potential driver of wider disparities in wealth, security and opportunities for human development”. I submit that “adaptation apartheid” also exists in regard to disabled people, with the invisibility of disabled people in the climate discourse being just one facet. The unwillingness to accommodate, to help the “other,” is nothing new for disabled people. The ableism that favours species-typical bodily functioning (Wolbring, “Is there an end to out-able?”; Wolbring, “Why NBIC?”) and disablism (Miller, Parker, and Gillinson)—the lack of accommodation enthusiasm for the needs of people with ‘below’ species-typical body abilities and the unwillingness to adapt to the needs of “others”—is a form of “adaptation apartheid,” of accommodation apartheid, of adaptation disablism that has been battled by disabled people for a long time. In a 2009 online survey of 2000 British people, 38 per cent believed that most people in British society see disabled people as a “drain on resources” (Scope). A majority of human geneticist concluded in a survey in 1999 that disabled people will never be given the support they need (Nippert and Wolff). Adaptation disablism is visible in the literature and studies around other disasters. The 1988 British Medical Association discussion document, Selection of casualties for treatment after nuclear attack, stated “casualties whose injuries were likely to lead to a permanent disability would receive lower priority than those expected to fully recover” (Sunday Morning Herald). Famine is seen to lead to increased infanticide, increased competitiveness and decreased collaboration (Participants of the Nuclear Winter: The Anthropology of Human Survival Session). Ableism and disablism notions experienced by disabled people can now be extended to include those challenges expected to arise from the need to adapt to climate change. It is reasonable to expect that ableism will prevail, expecting people to cope with certain forms of climate change, and that disablism will be extended, with the ones less affected being unwilling to accommodate the ones more affected beyond a certain point. This ableism/disablism will not only play itself out between high and low income countries, as Desmond Tutu described, but also within high income countries, as not every need will be accommodated. The disaster experience of disabled people is just one example. And there might be climate change consequences that one can only mitigate through high tech bodily adaptations that will not be available to many of the ones who are so far accommodated in high income countries. Desmond Tutu submits that adaptation apartheid might work for the fortunate ones in the short term, but will be destructive for them in the long term (United Nations Development Programme). Disability studies scholar Erik Leipoldt proposed that the disability perspective of interdependence is a practical guide from the margins for making new choices that may lead to a just and sustainable world—a concept that reduces the distance between each other and our environment (Leipoldt). This perspective rejects ableism and disablism as it plays itself out today, including adaptation apartheid. Planned adaptation involves four basic steps: information development and awareness-raising; planning and design; implementation; and monitoring and evaluation (Smit et al). Disabled people have important knowledge to contribute to these four basic steps that goes far beyond their community. Their understanding and acceptance of, for example, the concept of interdependence, is just one major contribution. Including the concept of interdependence within the set of tools that inform the four basic steps of adaptation and other facets of climate discourse has the potential to lead to a decrease of adaptation apartheid, and to increase the utility of the climate discourse for the global community as a whole. References African Ministerial Conference on the Environment. 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In 1996, the iconoclastic economist John Kenneth Galbraith wrote a manifesto, The Good Society, that elaborated his vision for what societal excellence and goodness should amount to. Though nearly 96, Galbraith was still a rabble-rouser, and he castigated the powers that be in the United States for propping up a “democracy of the fortunate” (8). To Galbraith, those who engaged in electoral politics, win or lose on any specific issue, tended to have all the social and economic advantages, while the less well off were deliberately marginalised by ‘the system.’ He lamented that “money, voice and political activism are now extensively controlled by the affluent, very affluent, and business interests" (140), making of the political sphere an "unequal contest" (8).To make democracy American style more inclusive, Galbraith called for “a coalition of the concerned and the compassionate and those now outside the political system” (143), so that all citizens had optimal prospects for enjoying “personal liberty, basic well-being, social and ethnic equality, the opportunity for a rewarding life" (4). Have inroads been made, in the nearly 15 years since first publication of The Good Society, in making come true Galbraith’s version of a good society? If not, how might such a coalition be achieved? What would it look like? Who among Americans would constitute the concerned, compassionate outsiders that would make such a coalition authentically ‘Galbraithian’? A Coalition on the MoveWhat about MoveOn.org? A progressive public advocacy group founded in 1998, MoveOn.org, according to Lelia Green in The Internet, is “an important indicator of the potential for bringing together communities of like-minded individuals” (139). Green singles out MoveOn.org as particularly pivotal in galvanising support for Barack Obama’s presidency (139). The New York Times describes MoveOn.org as “a bottom-up organization that has inserted itself into the political process in ways large and small” (Janofsky and Lee). Indeed, it represents “the next evolutionary change in American politics, a move away from one-way tools of influence like television commercials and talk radio to interactive dialogue, offering everyday people a voice in a process that once seemed beyond their reach.” MoveOn.org has expertly utilised the Internet to mobilise its members “to sign online petitions, organize street demonstrations and donate money to run political advertisements”. Green considers MoveOn.org one of today’s standout “coalitions of interests and political agendas”, “extraordinary” in its ability to “use websites and email lists to build communities around a shared passion” (139). In 2008, its 4.2 million members were at the vortex of a “dynamic that tipped the balance in favour of a more radical agenda with the election of President Barack Obama in 2008” (139). Galbraith, for one, would certainly agree with MoveOn.org’s politics, and likely would claim that their radical agenda is a compassionate and encompassing one that effectively addresses the concerns of everyday citizens. Yet the fact is that millions of disaffected Americans are not liberals, and so are not in sync with MoveOn.org’s interests and agendas, such as its firm insistence that a ‘public option’ is the best way to bring about meaningful health care reform, and its demand that all U.S. troops be immediately withdrawn from Iraq and Afghanistan. Tea Anyone?Another sort of coalition filled the void created by MoveOn.org. Enter the Tea Party. A movement that has been every bit as effective in its way in inspiring once-jaded ordinary citizens to coalesce around a set of interests and agendas – albeit, at least in principal if not necessarily in actual practice, of a professed libertarian strain – the Tea Party got underway in the waning days of the second presidential term of George W. Bush. It started out as a one-issue protest group voicing umbrage over the proposed economic stimulus plan, which it considered an unconstitutional subsidy. After Barack Obama became president, the Tea Party burgeoned into a much more influential movement that now professes to be a grassroots citizens’ watchdog for all unconstitutional activities (or what it deems to be such) on the part of the federal government. A New York Times article notes that many of its members are victims of the economic downturn; they “had lost their jobs, or perhaps watched their homes plummet in value, and they found common cause in the Tea Party’s fight for lower taxes and smaller government” (Zernike). Its members are akin to the millions of middle class Americans who lost their livelihoods during the Great Depression of the 1930s, an unparalleled economic downturn that eventually “mobilized many middle-class people who had fallen on hard times” to join forces in order to have an effective political voice. But those during the Great Depression who were aroused to political consciousness “tended to push for more government involvement”; in contrast, the Tea Party is a coalition that “vehemently wants less”. While Galbraith depicted the Republican Party of his time as “avowedly on the side of the fortunate” (141), the majority of today’s Tea Party members align themselves with the Republican Party, yet they are by no means principally made up of "the fortunate." Erick Erickson, a prominent Tea Party spokesman and a television commentator for the CNN news channel, blogs on Redstate.com that the Tea Party “has gotten a lot of people off the sidelines and into the political arena...” Erickson further contends that the Tea Party has “brought together a lot of likeminded citizens who thought they were alone in the world. They realized that not only were they not alone, but there were millions of others just as concerned.” Galbraithian Coalitions?Do MoveOn.org and Tea Party constitute Galbraithian-type coalitions, each in its own right? Both have inspired millions of once-disenchanted common citizens to come together around common political concerns and become a force to be reckoned with in electoral politics. As such, each has served as an effective counterweight against the money, voice and political activism of the very affluent. While Galbraith would probably have as much disdain for the Tea Party as he would have praise for MoveOn.org, the fact is that both groups have seen to it that an increasing number of regular Americans whose concerns had been ignored in the political arena now have to be reckoned with. But this is by no means where their commonality ends. Above and beyond the fact that both are comprised of millions who had been political outsiders, each has a decided anti-establishmentarian strain, along with a professed sense of alienation from and disdain for "politics as usual" and an impassioned belief in the right to self-government (though they differ on what this right amounts to). Moreover, both consider themselves grassroots-driven, and harbor anathema for professional lobbying organisations, which both regularly criticize for their undue political influence. Even though the two groups usually differ to the nth degree when it comes to those solutions they believe would effectively remedy the most pressing public problems in the U.S., they nonetheless share the conviction that one must initially focus one’s efforts at the local level if one is eventually to have the greatest impact on political decision-making on a national scale. The two groups came of age during the Internet revolution – indeed, it would have been impossible for their like-minded members to have found one another and coalesced so quickly and in such great numbers without the Internet – and they utilise the Internet as the principal tool for spurring concerted activism at the local level among their members. One can consider their shared approach Deweyan, in that Dewey maintained that genuinely democratic community, “in its deepest and richest sense, must always remain a matter of face-to-face intercourse” (367). Yet the two groups’ legion differences prevent them from engaging in meaningful face-to-face exchanges with one another. While the prospect of cultivating linkages between Tea Party and MoveOn.org are remote for the foreseeable future, it might nonetheless be seen as a promising development that some rank and file Tea Party acolytes do at least recognise that they must not identify solely with the Republican Party, lest they discourage potential recruits from rallying around their cause. For instance, one warns fellow members on the Redstate.com blog to be wary of casting their lot with Republicans, “because it would drive away the Democrats and Independents”. He actually uses Galbraith’s coinage in describing the Tea Party: “This movement is a coalition of the concerned, not a Republican outreach program.” Indeed, contrary to popular belief, the Tea Party is not, as a whole, on the conservative fringe (though it does often seem that those members who are given the most attention by the mainstream media are the fringe element, particularly the breakaway Tea Party Express). A Gallup Poll reveals that fully 17 percent of all Americans of voting age identify themselves as affiliated with the Tea Party; and while a majority have Republican leanings, fully 45 percent of all Tea Party members claimed they were either Democrats (17 percent) or independents (28 percent). To Tea Party leader Erick Erickson, the paramount challenge today for the Tea Party is for it to transform itself into a greater umbrella coalition, since the “issues and advocacy within the tea party movement are issues that resonate with the majority of Americans.” After all, he asserts, the Tea Party’s is “a very American cause — the first amendment right to protest, petition, and speak up.” While an expansion of its coalition does not in any way make it incumbent for the Tea Party to find common cause with MoveOn.org, can the claim nonetheless be legitimately made – utilising Erickson’s own criteria – that MoveOn.org’s is equally a very American cause? Christopher Hayes points out in an essay in The Nation that most of MoveOn.org’s members, as with the Tea Party’s, are “not inclined to protest,” but their “rising unease with the direction of the country has led to a new political consciousness.” Hayes could just as well be speaking of the Tea Party when he describes MoveOn.org’s members as made up mostly of “citizens angered, upset and disappointed with their government but [who were] unsure how to channel those sentiments.” For such citizens, MoveOn.org “provides simple, discrete actions: sign this petition, donate money to run this ad, show up at this vigil.” This is convincing evidence that MoveOn.org’s is also “a very American cause”, by the very benchmarks set forth by Erickson. A ‘Higher Coalition’?But is this in any way akin to a demonstrable sign that these unlikeliest of political bedfellows might be inspired at some future point to see themselves as part of a ‘higher coalition’ — one of the unlikeminded, that celebrates difference? Might a critical mass in both movements ever deem it a boon to coalesce around the cause of democratic pluralism? As things stand, neither side embraces such pluralism. Rather, one other attribute they share pervasively is dogmatism: both are convinced that their respective political sensibilities are beyond reproach. As a consequence, over the shorter term, neither group is likely to shed its brand of dogmatism and supplant it with an openness or receptivity to new, much less opposing, points of view. So, for instance, even as the Tea Party seeks to expand its fold, it is no more inclined to change its ideology-based stances on the issues than is MoveOn.org. For the time being, each group not only is entrenched in its own collective political mindset, but each coalesces around a demonstrated antipathy towards alternative approaches to public problem-solving. Is there any remotely plausible scenario by which the members of MoveOn.org and Tea Party might eventually come not just to tolerate their differences but to extol them? One other key Galbraithian element that those comprising an ideal coalition in a democracy must possess is compassion. For members of any coalition to cultivate compassion, they must first, or concomitantly, inculcate empathy, which is typically considered either a precursor to compassion or, along with understanding, a vital component of it. Henning Melber, Executive Director of the Dag Hammarskjold Foundation, and Reinhard Kössler maintain that “(w)hile empathy does not automatically translate into solidarity (nor into ethical behaviour), it can serve as a compass” for doing so, and can lead to a Galbraithian “coalition of the concerned and aware”(37). Such empathy is “a prerequisite for the ability to listen to one another and for permissiveness and openness towards ‘otherness’, and further, can only be born out of a sense of shared suffering” (37). To the authors, it isn’t just that “(s)uffering in its variety of forms requires empathy and solidarity by all,” but that it necessarily “transcends a politically correct ideology” (37). Millions in both the Tea Party and MoveOn.org long suffered from being a mere afterthought to the political establishment, both of them impacted by policies that they are convinced exacerbated rather than ameliorated their woes. But they have shown few if any indications of a willingness to transcend a politically correct ideology. For this to come about, it would, as Melber and Kössler maintain, require “hard, sustained, and imaginative work” (33). How might this come to pass? Greg Anderson, in The Athenian Experiment: Building an Imagined Political Community in Ancient Attica, 508-490 B.C., points to ancient Athens as a paradigmatic example of a society that undertook the hard imaginative work needed to develop the types of mediated connections that over time created a sense of shared belonging to a democratic community. “The process of transformation” in Attica, he argues, is “best understood as a bold exercise in social engineering, an experiment designed to bring together the diverse and far-flung inhabitants of an entire region and forge them into a single, self-governing political community of like-minded individuals” (5). While those males of sufficient socioeconomic distinction who were privileged enough to be citizens in the West’s first experiment in democracy were indeed like-minded, prising a self-governing political community, they were not single-minded; rather, those in the twelve dispersed tribes throughout Attica who coalesced to form a self-governing community apparently thrived on the free exchange and consideration of a wide range of ideas. They held that greater insights emerged only when a variety of views were subjected to scrutiny in the public sphere. Paul Woodruff notes in First Democracy that each Athenian was “given a share of the ability to be citizens, and that ability is understood both as a pair of virtues and as a kind of citizen wisdom.” Governing in this way was based on the shared view that “it is a natural part of being human to know enough to help govern your community” (149). Neither Tea Party nor MoveOn.org followers at present have this shared view on any semblance of a broad scale; rather, each betrays the sensibility that each ‘knows better’. As a consequence, any efforts at expanding their respective folds clearly do not include making overtures (or even extending olive branches) to one another. Even so, as impossibly optimistic as it might seem under current circumstances, I believe eventually they might come to see themselves as part of a greater or higher coalition – one serving the overriding cause of democracy itself – over the much longer term. But for this to become a reality, each group will first have to suffer some more. One other commonality they demonstrate is the power of grassroots activism – and the decided limitations. My hunch is that just as MoveOn.org’s progressives came to feel betrayed when Obama abandoned the liberal agenda of his presidential campaign to engage in political compromise and accommodation, Tea Party activists will come to find that their own expectations for political change will be equally stymied. In the 2010 elections, the Tea Party was a kingmaker in electoral politics, giving Republicans a decisive majority in Congress in the 2010 elections. But I suspect that those candidates the Tea Party supported will eventually resort to the practice of “politics as usual,” largely departing from the Tea Party agenda, in order to accomplish anything in Washington or become irrelevant in the existing system – a system long dominated by two political parties interested above and beyond all else in perpetuating their shared stranglehold on political power, and each equally beholden to corporate America for the contributions to their coffers that enable them to sustain this. If this scenario plays out, then at least some Tea Party activists might plausibly arrive at the unsettling conclusion that their suffering in the political arena is remarkably similar to that experienced by MoveOn.org’s cadre of concerned citizens who catapulted Obama into the office in the land, only to have most of their principal concerns neglected or dismissed, lost in the seamy world of back-room political deal-making. There is another possible scenario: What if either MoveOn.org or Tea Party becomes such an overwhelming force in politics that the other is attenuated, its members relegated once again to the fringe? If this occurred, the public sphere in the United States would be missing a vital dimension that has been part of its makeup since its founding days. For as Joseph Ellis, the Pulitzer Prize-winning historian, points out: the achievement of the revolutionary generation was a collective enterprise that succeeded because of the diversity of personalities and ideologies present in the mix. Their interactions and juxtapositions generated a dynamic form of balance and equilibrium, not because any of them was perfect or infallible, but because their mutual imperfections and fallibilities, as well as their eccentricities and excesses, checked each other… . (17) At the United States’s beginnings, the ties that bound those who revolted against Britain were forged despite their unbridgeable chasms of ideology; their “differing postures toward the twin goals of freedom and equality” were “not resolved so much as built into the fabric of our national identity” (16). Even or especially as irreconcilable differences prompted early Americans to continue waging a battle of ideas in the political trenches, Thomas Jefferson, for one, believed they were all (or nearly all) “constitutionally and conscientiously democrats” (185). Extrapolating from this, one can posit that MoveOn.org and Tea Party, regardless of whether they choose to acknowledge it, are in tandem a modern-day manifestation of the original American coalition. If they could be inspired to see that each is an important player in furthering the democratic experiment as singularly practiced in the U.S., they just might come to care more for one another. Out of such caring, they might realise that neither has a monopoly on political wisdom, and as a result coalesce around the cause of promoting a less hostile body politic. AcknowledgementsThe author is grateful to the two blind peer reviewers for their most helpful suggestions. ReferencesAnderson, Greg. The Athenian Experiment: Building an Imagined Political Community in Ancient Attica, 508-490 B.C. Ann Arbor, MI: University of Michigan Press, 2003. Dewey, John. In J. Boydston (Ed.) John Dewey, Volume 2: 1925-1927. Carbondale, Illinois: Southern Illinois University, 1984. Ellis, Joseph. Founding Brothers: The Revolutionary Generation. New York, NY: Vintage. 2002. Erickson, Erick. “Tea Party Movement 2.0: Moving beyond Protesting to Fighting in Primaries, Ballot Boxes, and Becoming More Effective Activists.” 14 April 2010. 28 Sep. 2010 ‹http://www.redstate.com/erick/2010/04/14/tea-party-movement-20/>.Galbraith, John Kenneth. The Good Society: The Humane Agenda. New York: Mariner Books, 1997. Green, Lelia. The Internet: An Introduction to New Media. Oxford: Berg, 2010.Hayes, Christopher. “MoveOn.org Is Not as Radical as Conservatives Think." The Nation. 16 July 2008. 28 Sep. 2010 ‹http://www.thenation.com/article/moveonorg-not-radical-conservatives-think>. Janofsky, Michael, Jennifer B. Lee. “Net Group Tries to Click Democrats to Power”. New York Times, 18 Nov 2003. 1 Oct. 2010 ‹http://www.nytimes.com/2003/11/18/us/net-group-tries-to-click- democrats-to-power.html?scp=1&sq=%22bottom-up%20organization%22&st=cse>. Jefferson, Thomas. In M. Peterson, ed. The Political Writings of Thomas Jefferson. Chapel Hill, NC: University of North Carolina Press, 1993. Kossler, Reinhart, and Hening Melber. “International Civil Society and the Challenge for Global Solidarity.” Development Dialogue 49 (Oct. 2007): 29-39. Malcolm, Andrew. “Myth-Busting Polls: Tea Party Members Are Average Americans, 41% Are Democrats, Independents.” Los Angeles Times, 5 April 2010 ‹http://latimesblogs.latimes.com/washington/2010/04/tea-party-obama.html>.MoveOn.org. n.d. 27 Sep. 2010 ‹http://moveon.org>. Tea Party. n.d. 1 Oct. 2010 ‹http://teaparty.freedomworks.org>.Tea Party Express. n.d. 1 Oct. 2010 ‹http://www.teapartyexpress.org>. Woodruff, Paul. First Democracy: The Challenge of an Ancient Idea. New York: Oxford University Press, 2006. Zernike, Kate. “With No Jobs, Plenty of Time for Tea Party.” New York Times, 27 Mar. 2010. 29 Sep. 2010 ‹http://www.nytimes.com/2010/03/28/us/politics/28teaparty.html?scp=1&sq=%22watched%20their%20homes%20plummet%20in%20value%22&st=cse>.

Introduction The highly contagious COVID-19 virus has presented particularly difficult public policy challenges. The relatively late emergence of an effective treatments and vaccines, the structural stresses on health care systems, the lockdowns and the economic dislocations, the evident structural inequalities in effected societies, as well as the difficulty of prevention have tested social and political cohesion. Moreover, the intrusive nature of many prophylactic measures have led to individual liberty and human rights concerns. As noted by the Victorian (Australia) Ombudsman Report on the COVID-19 lockdown in Melbourne, we may be tempted, during a crisis, to view human rights as expendable in the pursuit of saving human lives. This thinking can lead to dangerous territory. It is not unlawful to curtail fundamental rights and freedoms when there are compelling reasons for doing so; human rights are inherently and inseparably a consideration of human lives. (5) These difficulties have raised issues about the importance of social or community capital in fighting the pandemic. This article discusses the impacts of social and community capital and other factors on the governmental efforts to combat the spread of infectious disease through the maintenance of social distancing and household ‘bubbles’. It argues that the beneficial effects of social and community capital towards fighting the pandemic, such as mutual respect and empathy, which underpins such public health measures as social distancing, the use of personal protective equipment, and lockdowns in the USA, have been undermined as preventive measures because they have been transmogrified to become a salient aspect of the “culture wars” (Peters). In contrast, states that have relatively lower social capital such a China have been able to more effectively arrest transmission of the disease because the government was been able to generate and personify a nationalist response to the virus and thus generate a more robust social consensus regarding the efforts to combat the disease. Social Capital and Culture Wars The response to COVID-19 required individuals, families, communities, and other types of groups to refrain from extensive interaction – to stay in their bubble. In these situations, especially given the asymptomatic nature of many COVID-19 infections and the serious imposition lockdowns and social distancing and isolation, the temptation for individuals to breach public health rules in high. From the perspective of policymakers, the response to fighting COVID-19 is a collective action problem. In studying collective action problems, scholars have paid much attention on the role of social and community capital (Ostrom and Ahn 17-35). Ostrom and Ahn comment that social capital “provides a synthesizing approach to how cultural, social, and institutional aspects of communities of various sizes jointly affect their capacity of dealing with collective-action problems” (24). Social capital is regarded as an evolving social type of cultural trait (Fukuyama; Guiso et al.). Adger argues that social capital “captures the nature of social relations” and “provides an explanation for how individuals use their relationships to other actors in societies for their own and for the collective good” (387). The most frequently used definition of social capital is the one proffered by Putnam who regards it as “features of social organization, such as networks, norms and social trust that facilitate coordination and cooperation for mutual benefit” (Putnam, “Bowling Alone” 65). All these studies suggest that social and community capital has at least two elements: “objective associations” and subjective ties among individuals. Objective associations, or social networks, refer to both formal and informal associations that are formed and engaged in on a voluntary basis by individuals and social groups. Subjective ties or norms, on the other hand, primarily stand for trust and reciprocity (Paxton). High levels of social capital have generally been associated with democratic politics and civil societies whose institutional performance benefits from the coordinated actions and civic culture that has been facilitated by high levels of social capital (Putnam, Democracy 167-9). Alternatively, a “good and fair” state and impartial institutions are important factors in generating and preserving high levels of social capital (Offe 42-87). Yet social capital is not limited to democratic civil societies and research is mixed on whether rising social capital manifests itself in a more vigorous civil society that in turn leads to democratising impulses. Castillo argues that various trust levels for institutions that reinforce submission, hierarchy, and cultural conservatism can be high in authoritarian governments, indicating that high levels of social capital do not necessarily lead to democratic civic societies (Castillo et al.). Roßteutscher concludes after a survey of social capita indicators in authoritarian states that social capital has little effect of democratisation and may in fact reinforce authoritarian rule: in nondemocratic contexts, however, it appears to throw a spanner in the works of democratization. Trust increases the stability of nondemocratic leaderships by generating popular support, by suppressing regime threatening forms of protest activity, and by nourishing undemocratic ideals concerning governance (752). In China, there has been ongoing debate concerning the presence of civil society and the level of social capital found across Chinese society. If one defines civil society as an intermediate associational realm between the state and the family, populated by autonomous organisations which are separate from the state that are formed voluntarily by members of society to protect or extend their interests or values, it is arguable that the PRC had a significant civil society or social capital in the first few decades after its establishment (White). However, most scholars agree that nascent civil society as well as a more salient social and community capital has emerged in China’s reform era. This was evident after the 2008 Sichuan earthquake, where the government welcomed community organising and community-driven donation campaigns for a limited period of time, giving the NGO sector and bottom-up social activism a boost, as evidenced in various policy areas such as disaster relief and rural community development (F. Wu 126; Xu 9). Nevertheless, the CCP and the Chinese state have been effective in maintaining significant control over civil society and autonomous groups without attempting to completely eliminate their autonomy or existence. The dramatic economic and social changes that have occurred since the 1978 Opening have unsurprisingly engendered numerous conflicts across the society. In response, the CCP and State have adjusted political economic policies to meet the changing demands of workers, migrants, the unemployed, minorities, farmers, local artisans, entrepreneurs, and the growing middle class. Often the demands arising from these groups have resulted in policy changes, including compensation. In other circumstances, where these groups remain dissatisfied, the government will tolerate them (ignore them but allow them to continue in the advocacy), or, when the need arises, supress the disaffected groups (F. Wu 2). At the same time, social organisations and other groups in civil society have often “refrained from open and broad contestation against the regime”, thereby gaining the space and autonomy to achieve the objectives (F. Wu 2). Studies of Chinese social or community capital suggest that a form of modern social capital has gradually emerged as Chinese society has become increasingly modernised and liberalised (despite being non-democratic), and that this social capital has begun to play an important role in shaping social and economic lives at the local level. However, this more modern form of social capital, arising from developmental and social changes, competes with traditional social values and social capital, which stresses parochial and particularistic feelings among known individuals while modern social capital emphasises general trust and reciprocal feelings among both known and unknown individuals. The objective element of these traditional values are those government-sanctioned, formal mass organisations such as Communist Youth and the All-China Federation of Women's Associations, where members are obliged to obey the organisation leadership. The predominant subjective values are parochial and particularistic feelings among individuals who know one another, such as guanxi and zongzu (Chen and Lu, 426). The concept of social capital emphasises that the underlying cooperative values found in individuals and groups within a culture are an important factor in solving collective problems. In contrast, the notion of “culture war” focusses on those values and differences that divide social and cultural groups. Barry defines culture wars as increases in volatility, expansion of polarisation, and conflict between those who are passionate about religiously motivated politics, traditional morality, and anti-intellectualism, and…those who embrace progressive politics, cultural openness, and scientific and modernist orientations. (90) The contemporary culture wars across the world manifest opposition by various groups in society who hold divergent worldviews and ideological positions. Proponents of culture war understand various issues as part of a broader set of religious, political, and moral/normative positions invoked in opposition to “elite”, “liberal”, or “left” ideologies. Within this Manichean universe opposition to such issues as climate change, Black Lives Matter, same sex rights, prison reform, gun control, and immigration becomes framed in binary terms, and infused with a moral sensibility (Chapman 8-10). In many disputes, the culture war often devolves into an epistemological dispute about the efficacy of scientific knowledge and authority, or a dispute between “practical” and theoretical knowledge. In this environment, even facts can become partisan narratives. For these “cultural” disputes are often how electoral prospects (generally right-wing) are advanced; “not through policies or promises of a better life, but by fostering a sense of threat, a fantasy that something profoundly pure … is constantly at risk of extinction” (Malik). This “zero-sum” social and policy environment that makes it difficult to compromise and has serious consequences for social stability or government policy, especially in a liberal democratic society. Of course, from the perspective of cultural materialism such a reductionist approach to culture and political and social values is not unexpected. “Culture” is one of the many arenas in which dominant social groups seek to express and reproduce their interests and preferences. “Culture” from this sense is “material” and is ultimately connected to the distribution of power, wealth, and resources in society. As such, the various policy areas that are understood as part of the “culture wars” are another domain where various dominant and subordinate groups and interests engaged in conflict express their values and goals. Yet it is unexpected that despite the pervasiveness of information available to individuals the pool of information consumed by individuals who view the “culture wars” as a touchstone for political behaviour and a narrative to categorise events and facts is relatively closed. This lack of balance has been magnified by social media algorithms, conspiracy-laced talk radio, and a media ecosystem that frames and discusses issues in a manner that elides into an easily understood “culture war” narrative. From this perspective, the groups (generally right-wing or traditionalist) exist within an information bubble that reinforces political, social, and cultural predilections. American and Chinese Reponses to COVID-19 The COVID-19 pandemic first broke out in Wuhan in December 2019. Initially unprepared and unwilling to accept the seriousness of the infection, the Chinese government regrouped from early mistakes and essentially controlled transmission in about three months. This positive outcome has been messaged as an exposition of the superiority of the Chinese governmental system and society both domestically and internationally; a positive, even heroic performance that evidences the populist credentials of the Chinese political leadership and demonstrates national excellence. The recently published White Paper entitled “Fighting COVID-19: China in Action” also summarises China’s “strategic achievement” in the simple language of numbers: in a month, the rising spread was contained; in two months, the daily case increase fell to single digits; and in three months, a “decisive victory” was secured in Wuhan City and Hubei Province (Xinhua). This clear articulation of the positive results has rallied political support. Indeed, a recent survey shows that 89 percent of citizens are satisfied with the government’s information dissemination during the pandemic (C Wu). As part of the effort, the government extensively promoted the provision of “political goods”, such as law and order, national unity and pride, and shared values. For example, severe publishments were introduced for violence against medical professionals and police, producing and selling counterfeit medications, raising commodity prices, spreading ‘rumours’, and being uncooperative with quarantine measures (Xu). Additionally, as an extension the popular anti-corruption campaign, many local political leaders were disciplined or received criminal charges for inappropriate behaviour, abuse of power, and corruption during the pandemic (People.cn, 2 Feb. 2020). Chinese state media also described fighting the virus as a global “competition”. In this competition a nation’s “material power” as well as “mental strength”, that calls for the highest level of nation unity and patriotism, is put to the test. This discourse recalled the global competition in light of the national mythology related to the formation of Chinese nation, the historical “hardship”, and the “heroic Chinese people” (People.cn, 7 Apr. 2020). Moreover, as the threat of infection receded, it was emphasised that China “won this competition” and the Chinese people have demonstrated the “great spirit of China” to the world: a result built upon the “heroism of the whole Party, Army, and Chinese people from all ethnic groups” (People.cn, 7 Apr. 2020). In contrast to the Chinese approach of emphasising national public goods as a justification for fighting the virus, the U.S. Trump Administration used nationalism, deflection, and “culture war” discourse to undermine health responses — an unprecedented response in American public health policy. The seriousness of the disease as well as the statistical evidence of its course through the American population was disputed. The President and various supporters raged against the COVID-19 “hoax”, social distancing, and lockdowns, disparaged public health institutions and advice, and encouraged protesters to “liberate” locked-down states (Russonello). “Our federal overlords say ‘no singing’ and ‘no shouting’ on Thanksgiving”, Representative Paul Gosar, a Republican of Arizona, wrote as he retweeted a Centers for Disease Control list of Thanksgiving safety tips (Weiner). People were encouraged, by way of the White House and Republican leadership, to ignore health regulations and not to comply with social distancing measures and the wearing of masks (Tracy). This encouragement led to threats against proponents of face masks such as Dr Anthony Fauci, one of the nation’s foremost experts on infectious diseases, who required bodyguards because of the many threats on his life. Fauci’s critics — including President Trump — countered Fauci’s promotion of mask wearing by stating accusingly that he once said mask-wearing was not necessary for ordinary people (Kelly). Conspiracy theories as to the safety of vaccinations also grew across the course of the year. As the 2020 election approached, the Administration ramped up efforts to downplay the serious of the virus by identifying it with “the media” and illegitimate “partisan” efforts to undermine the Trump presidency. It also ramped up its criticism of China as the source of the infection. This political self-centeredness undermined state and federal efforts to slow transmission (Shear et al.). At the same time, Trump chided health officials for moving too slowly on vaccine approvals, repeated charges that high infection rates were due to increased testing, and argued that COVID-19 deaths were exaggerated by medical providers for political and financial reasons. These claims were amplified by various conservative media personalities such as Rush Limbaugh, and Sean Hannity and Laura Ingraham of Fox News. The result of this “COVID-19 Denialism” and the alternative narrative of COVID-19 policy told through the lens of culture war has resulted in the United States having the highest number of COVID-19 cases, and the highest number of COVID-19 deaths. At the same time, the underlying social consensus and social capital that have historically assisted in generating positive public health outcomes has been significantly eroded. According to the Pew Research Center, the share of U.S. adults who say public health officials such as those at the Centers for Disease Control and Prevention are doing an excellent or good job responding to the outbreak decreased from 79% in March to 63% in August, with an especially sharp decrease among Republicans (Pew Research Center 2020). Social Capital and COVID-19 From the perspective of social or community capital, it could be expected that the American response to the Pandemic would be more effective than the Chinese response. Historically, the United States has had high levels of social capital, a highly developed public health system, and strong governmental capacity. In contrast, China has a relatively high level of governmental and public health capacity, but the level of social capital has been lower and there is a significant presence of traditional values which emphasise parochial and particularistic values. Moreover, the antecedent institutions of social capital, such as weak and inefficient formal institutions (Batjargal et al.), environmental turbulence and resource scarcity along with the transactional nature of guanxi (gift-giving and information exchange and relationship dependence) militate against finding a more effective social and community response to the public health emergency. Yet China’s response has been significantly more successful than the Unites States’. Paradoxically, the American response under the Trump Administration and the Chinese response both relied on an externalisation of the both the threat and the justifications for their particular response. In the American case, President Trump, while downplaying the seriousness of the virus, consistently called it the “China virus” in an effort to deflect responsibly as well as a means to avert attention away from the public health impacts. As recently as 3 January 2021, Trump tweeted that the number of “China Virus” cases and deaths in the U.S. were “far exaggerated”, while critically citing the Centers for Disease Control and Prevention's methodology: “When in doubt, call it COVID-19. Fake News!” (Bacon). The Chinese Government, meanwhile, has pursued a more aggressive foreign policy across the South China Sea, on the frontier in the Indian sub-continent, and against states such as Australia who have criticised the initial Chinese response to COVID-19. To this international criticism, the government reiterated its sovereign rights and emphasised its “victimhood” in the face of “anti-China” foreign forces. Chinese state media also highlighted China as “victim” of the coronavirus, but also as a target of Western “political manoeuvres” when investigating the beginning stages of the pandemic. The major difference, however, is that public health policy in the United States was superimposed on other more fundamental political and cultural cleavages, and part of this externalisation process included the assignation of “otherness” and demonisation of internal political opponents or characterising political opponents as bent on destroying the United States. This assignation of “otherness” to various internal groups is a crucial element in the culture wars. While this may have been inevitable given the increasingly frayed nature of American society post-2008, such a characterisation has been activity pushed by local, state, and national leadership in the Republican Party and the Trump Administration (Vogel et al.). In such circumstances, minimising health risks and highlighting civil rights concerns due to public health measures, along with assigning blame to the democratic opposition and foreign states such as China, can have a major impact of public health responses. The result has been that social trust beyond the bubble of one’s immediate circle or those who share similar beliefs is seriously compromised — and the collective action problem presented by COVID-19 remains unsolved. Daniel Aldrich’s study of disasters in Japan, India, and US demonstrates that pre-existing high levels of social capital would lead to stronger resilience and better recovery (Aldrich). Social capital helps coordinate resources and facilitate the reconstruction collectively and therefore would lead to better recovery (Alesch et al.). Yet there has not been much research on how the pool of social capital first came about and how a disaster may affect the creation and store of social capital. Rebecca Solnit has examined five major disasters and describes that after these events, survivors would reach out and work together to confront the challenges they face, therefore increasing the social capital in the community (Solnit). However, there are studies that have concluded that major disasters can damage the social fabric in local communities (Peacock et al.). The COVID-19 epidemic does not have the intensity and suddenness of other disasters but has had significant knock-on effects in increasing or decreasing social capital, depending on the institutional and social responses to the pandemic. In China, it appears that the positive social capital effects have been partially subsumed into a more generalised patriotic or nationalist affirmation of the government’s policy response. Unlike civil society responses to earlier crises, such as the 2008 Sichuan earthquake, there is less evidence of widespread community organisation and response to combat the epidemic at its initial stages. This suggests better institutional responses to the crisis by the government, but also a high degree of porosity between civil society and a national “imagined community” represented by the national state. The result has been an increased legitimacy for the Chinese government. Alternatively, in the United States the transformation of COVID-19 public health policy into a culture war issue has seriously impeded efforts to combat the epidemic in the short term by undermining the social consensus and social capital necessary to fight such a pandemic. Trust in American institutions is historically low, and President Trump’s untrue contention that President Biden’s election was due to “fraud” has further undermined the legitimacy of the American government, as evidenced by the attacks directed at Congress in the U.S. capital on 6 January 2021. As such, the lingering effects the pandemic will have on social, economic, and political institutions will likely reinforce the deep cultural and political cleavages and weaken interpersonal networks in American society. Conclusion The COVID-19 pandemic has devastated global public health and impacted deeply on the world economy. Unsurprisingly, given the serious economic, social, and political consequences, different government responses have been highly politicised. Various quarantine and infection case tracking methods have caused concern over state power intruding into private spheres. The usage of face masks, social distancing rules, and intra-state travel restrictions have aroused passionate debate over public health restrictions, individual liberty, and human rights. Yet underlying public health responses grounded in higher levels of social capital enhance the effectiveness of public health measures. In China, a country that has generally been associated with lower social capital, it is likely that the relatively strong policy response to COVID-19 will both enhance feelings of nationalism and Chinese exceptionalism and help create and increase the store of social capital. 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IntroductionBritish initiatives to manage both the number of arrivals of asylum seekers and the experiences of those who arrive have burgeoned in recent years. The budget dedicated to asylum seeker management increased from £357 million in 1998-1999 to £1.71 billion in 2004-2005, making the Immigration and Nationality Directorate (IND) the second largest concern of the Home Office behind the Prison Service in 2005 (Back et al). The IND was replaced in April 2007 by the Border and Immigration Agency (BIA), whose expenditure exceeded £2 billion in 2007-2008 (BIA). Perhaps as a consequence the number of asylum seekers applying to the UK has fallen dramatically, illustrating the continuing influence of exclusionary state policies despite the globalisation and transnationalisation of migrant flows (UNHCR; Koser).One of the difficulties with the study of asylum seekers is the persistent risk that, by employing the term ‘asylum seeker’, research conducted into their experiences will contribute towards the exclusion of a marginalised and abject group of people, precisely by employing a term that emphasises the suspended recognition of a community (Nyers). The ‘asylum seeker’ is a figure defined in law in order to facilitate government-level avoidance of humanitarian obligations by emphasising the non-refugeeness of asylum claimants (Tyler). This group is identified as supplicant to the state, positioning the state itself as a legitimate arbiter. It is in this sense that asylum seekers suffer a degree of cruel optimism (Berlant) – wishing to be recognised as a refugee while nevertheless subject to state-defined discourses, whatever the outcome. The term ‘forced migrant’ is little better, conveying a de-humanising and disabling lack of agency (Turton), while the terms ‘undocumented migrant’, ‘irregular migrant’ and ‘illegal migrant’ all imply a failure to conform to respectable, desirable and legitimate forms of migration.Another consequence of these co-opted and politically subjugating forms of language is their production of simple imagined geographies of migration that position the foreigner as strange, unfamiliar and incapable of communication across this divide. Such imaginings precipitate their own responses, most clearly expressed in the blunt, intrusive uses of space and time in migration governance (Lahav and Guiraudon; Cohen; Guild; Gronendijk). Various institutions exist in Britain that function to actually produce the imagined differences between migrants and citizens, from the two huge, airport-like ‘Asylum Screening Units’ in Liverpool and London where asylum seekers can lodge their claims, to the 12 ‘Removal Centres’ within which soon-to-be deported asylum seekers are incarcerated and the 17 ‘Hearing Centres’ at which British judges preside over the precise legal status of asylum applicants.Less attention, however, has been given to the tension between mobility and stillness in asylum contexts. Asylum seeker management is characterised by a complex combination of enforced stillness and enforced mobility of asylum seeking bodies, and resistance can also be understood in these terms. This research draws upon 37 interviews with asylum seekers, asylum activists, and government employees in the UK conducted between 2005 and 2007 (see Gill) and distils three characteristics of stillness. First, an association between stillness and safety is clearly evident, exacerbated by the fear that the state may force asylum seekers to move at any time. Second, stillness of asylum seekers in a physical, literal sense is intimately related to their psychological condition, underscoring the affectual properties of stillness. Third, the desire to be still, and to be safe, precipitates various political strategies that seek to secure stillness, meaning that stillness functions as more than an aspiration, becoming also a key political metric in the struggle between the included and excluded. In these multiple and contradictory ways stillness is a key factor that structures asylum seekers’ experiences of migration. Governing through Mobility The British state utilises both stillness and mobility in the governance of asylum seeking bodies. On the one hand, asylum seekers’ personal freedoms are routinely curtailed both through their incarceration and through the requirements imposed upon them by the state in terms of ‘signing in’ at local police stations, even when they are not incarcerated, throughout the time that they are awaiting a decision on their claim for asylum (Cwerner). This requirement, which consists of attending a police station to confirm the continuing compliance of the asylum seeker, can vary in frequency, from once every month to once every few days.On the other hand, the British state employs a range of strategies of mobility that serve to deprive asylum seeking communities of geographical stillness and, consequently, also often undermines their psychological stability. First, the seizure of asylum seekers and transportation to a Removal Centre can be sudden and traumatic, and incarceration in this manner is becoming increasingly common (Bacon; Home Office). In extreme cases, very little or no warning is given to asylum seekers who are taken into detention, and so-called ‘dawn raids’ have been organised in order to exploit an element of surprise in the introduction of asylum seekers to detention (Burnett). A second source of forced mobility associated with Removal Centres is the transfer of detainees from one Removal Centre to another for a variety of reasons, from the practical constraints imposed by the capacities of various centres, to differences in the conditions of centres themselves, which are used to form a reward and sanction mechanism among the detainee population (Hayter; Granville-Chapman). Intra-detention estate transfers have increased in scope and significance in recent years: in 2004/5, the most recent financial year for which figures are available, the British government spent over £6.5 million simply moving detainees from one secure facility to another within the UK (Hansard, 2005; 2006).Outside incarceration, a third source of spatial disruption of asylum seekers in the UK concerns their relationship with accommodation providers. Housing is provided to asylum seekers as they await a decision on their claim, but this housing is provided on a ‘no-choice’ basis, meaning that asylum seekers who are not prepared to travel to the accommodation that is allocated to them will forfeit their right to accommodation (Schuster). In other words, accommodation is contingent upon asylum seekers’ willingness to be mobile, producing a direct trade-off between the attractions of accommodation and stillness. The rationale for this “dispersal policy”, is to draw asylum seekers away from London, where the majority of asylum seekers chose to reside before 2000. The maintenance of a diverse portfolio of housing across the UK is resource intensive, with the re-negotiation of housing contracts worth over a £1 billion a constant concern (Noble et al). As these contracts are renegotiated, asylum seekers are expected to move in response to the varying affordability of housing around the country. In parallel to the system of deportee movements within the detention estate therefore, a comparable system of movement of asylum seekers around the UK in response to urban and regional housing market conditions also operates. Stillness as SanctuaryIn all three cases, the psychological stress that movement of asylum seekers can cause is significant. Within detention, according to a series of government reports into the conditions of removal centres, one of the recurring difficulties facing incarcerated asylum seekers is incomprehension of their legal status (e.g. HMIP 2002; 2008). This, coupled with very short warning of impending movements, results in widespread anxiety among detained asylum seekers that they may be deported or transferred imminently. Outside detention, the fear of snatch squads of police officers, or alternatively the fear of hate crimes against asylum seekers (Tyler), render movement in the public realm a dangerous practice in the eyes of many marginalised migrants. The degree of uncertainty and the mental and emotional demands of relocation introduced through forced mobility can have a damaging psychological effect upon an already vulnerable population. Expressing his frustration at this particular implication of the movement of detainees, one activist who had provided sanctuary to over 20 asylum seekers in his community outlined some of the consequences of onward movement.The number of times I’ve had to write panic letters saying you know you cannot move this person to the other end of the country because it destabilises them in terms of their mental health and it is abusive. […] Their solicitors are here, they’re in process, in legal process, they’ve got a community, they’ve got friends, they may even have a partner or a child here and they would still move them.The association between governance, mobility and trepidation highlights one characteristic of stillness in the asylum seeking field: in contra-distinction to the risk associated with movement, to be still is very often to be safe. Given the necessity to flee violence in origin countries and the tendency for destination country governments to require constant re-positioning, often backed-up with the threat of force, stillness comes to be viewed as offering a sort of sanctuary. Indeed, the Independent Asylum Commission charity that has conducted a series of reviews of asylum seekers’ treatment in the UK (Hobson et al.), has recently suggested dispensing with the term ‘asylum’ in favour of ‘sanctuary’ precisely because of the positive associations with security and stability that the latter provides. To be in one place for a sustained period allows networks of human trust and reciprocity to develop which can form the basis of supportive community relationships. Another activist who had accompanied many asylum seekers through the legal process spoke passionately about the functions that communities can serve in asylum seekers’ lives.So you actually become substitute family […] I think it’s what helps people in the midst of trauma when the future is uncertain […] to find a community which values them, which accepts them, which listens to them, where they can begin to find a place and touch a creative life again which they may not have had for years: it’s enormously important.There is a danger in romanticising the benefits of community (Joseph). Indeed, much of the racism and xenophobia directed towards asylum seekers has been the result of local community hostilities towards different national and ethnic groups (Boswell). For many asylum seekers, however, the reciprocal relations found in communities are crucially important to their well-being. What is more, the inclusion of asylum seekers into communities is one of the most effective anti-state and anti-deportation strategies available to activists and asylum seekers alike (Tyler), because it arrests the process of anonymising and cordoning asylum seekers as an homogenous group, providing instead a chance for individuals to cast off this label in favour of more ‘humane’ characteristics: families, learning, friendship, love.Strategies for StillnessFor this reason, the pursuit of stillness among asylum seekers is both a human and political response to their situations – stillness becomes a metric in the struggle between abject migrants and the state. Crucial to this political function is the complex relationship between stillness and social visibility: if an asylum seeker can command their own stillness then they can also have greater influence over their public profile, either in order to develop it or to become less conspicuous.Tyler argues that asylum seekers are what she calls a ‘hypervisible’ social group, referring to the high profile association between a fictional, dehumanised asylum seeking figure and a range of defamatory characteristics circulated by the popular printed press. Stillness can be used to strategically reduce this imposed form of hypervisibility, and to raise awareness of real asylum seeker stories and situations. This is achieved by building community coalitions, which require physically and socially settled asylum seeking families and communities. Asylum advocacy groups and local community support networks work together in the UK in order to generate a genuine public profile of asylum seekers by utilising local and national newspapers, staging public demonstrations, delivering speeches, attending rallies and garnering support among local organisations through art exhibitions, performances and debates. Some activist networks specialise explicitly in supporting asylum seekers in these endeavours, and sympathetic networks of journalists, lawyers, doctors and radio producers combine their expertise with varying degrees of success.These sorts of strategies can produce strong loyalties between local communities and the asylum seekers in their midst, precisely because, through their co-presence, asylum seekers cease to be merely asylum seekers, but become active and valued members of communities. One activist who had helped to organise the protection of an asylum seeker in a church described some of the preparations that had been made for the arrival of immigration task forces in her middle class parish.There were all sorts of things we practiced: if they did break through the door what would we do? We set up a telephone tree so that each person would phone two or three people. We had I don’t know how many cars outside. We arranged a safe house, where we would hide her. We practiced getting her out of the room into a car […] We were expecting them to come at any time. We always had people at the back […] guarding, looking at strangers who might be around and [name] was never, ever allowed to be on her own without a whole group of people completely surrounding her so she could feel safe and we would feel safe. Securing stillness here becomes more than simply an operation to secure geographic fixity: it is a symbolic struggle between state and community, crystallising in specific tactics of spatial and temporal arrangement. It reflects the fear of further forced movement, the abiding association between stillness and safety, and the complex relationship between community visibility and an ability to remain still.There are, nevertheless, drawbacks to these tactics that suggest a very different relationship between stillness and visibility. Juries can be alienated by loud tactics of activism, meaning that asylum seekers can damage their chances of a sympathetic legal hearing if they have had too high a profile. Furthermore, many asylum seekers do not have the benefits of such a dedicated community. An alternative way in which stillness becomes political is through its ability to render invisible the abject body. Invisibility is taken to mean the decision to ‘go underground’, miss the appointments at local police stations and attempt to anticipate the movements of immigration removal enforcement teams. Perversely, although this is a strategy for stillness at the national or regional scale, mobile strategies are often employed at finer scales in order to achieve this objective. Asylum seekers sometimes endure extremely precarious and difficult conditions of housing and subsistence moving from house to house regularly or sleeping and living in cars in order to avoid detection by authorities.This strategy is difficult because it involves a high degree of uncertainty, stress and reliance upon the goodwill of others. One police officer outlined the situation facing many ‘invisible’ asylum seekers as one of poverty and desperation:Immigration haven’t got a clue where they are, they just can’t find them because they’re sofa surfing, that’s living in peoples coffee shops … I see them in the coffee shop and they come up and they’re bloody starving! Despite the difficulties associated with this form of invisibility, it is estimated that this strategy is becoming increasingly common in the UK. In 2006 the Red Cross estimated that there were some 36 000 refused and destitute asylum seekers in England, up from 25 000 the previous year, and reported that their organisation was having to provide induction tours of soup kitchens and night shelters in order to alleviate the conditions of many claimants in these situations (Taylor and Muir). Conclusion The case of asylum seekers in the UK illustrates the multiple, contradictory and splintered character of stillness. While some forms of governance impose stillness upon asylum seeking bodies, in the form of incarceration and ‘signing in’ requirements, other forms of governance impose mobility either within detention or outside it. Consequently stillness figures in the responses of asylum seeking communities in various ways. Given the unwelcome within-country movement of asylum seekers, and adding to this the initial fact of their forced migration from their home countries, the condition of stillness becomes desirable, promising to bring with it stability and safety. These promises contrast the psychological disruption that further mobility, and even the threat of further mobility, can bring about. This illustrates the affectual qualities both of movement and of stillness in the asylum-seeking context. Literal stillness is associated with social and emotional stability that complicates the distinction between real and emotional spaces. While this is certainly not the case uniformly – incarceration and inhibited personal liberties have opposite consequences – the promises of stillness in terms of stability and sanctuary are clearly significant because this desirability leads asylum advocates and asylum seekers to execute a range of political strategies that seek to ensure stillness, either through enhanced or reduced forms of social visibility.The association of mobility with freedom that typifies much of the literature surrounding mobility needs closer inspection. At least in some situations, asylum seekers pursue geographical stillness for the political and psychological benefits it can offer, while mobility is both employed as a subjugating strategy by states and is itself actively resisted by those who constitute its targets.ReferencesBack, Les, Bernadette Farrell and Erin Vandermaas. A Humane Service for Global Citizens. London: South London Citizens, 2005.Bacon, Christine. The Evolution of Immigration Detention in the UK: The Involvement of Private Prison Companies. Oxford: Refugee Studies Centre, 2005.Berlant, Lauren. “Cruel Optimism.” differences : A Journal of Feminist Cultural Studies 17.3 (2006): 20—36.Border and Immigration Agency. Business Plan for Transition Year April 2007 – March 2008: Fair, Effective, Transparent and Trusted. London: Home Office, 2007.Boswell, Christina. “Burden-Sharing in the European Union: Lessons from the German and UK Experience.” Journal of Refugee Studies 16.3 (2003): 316—35.Burnett, Jon. Dawn Raids. PAFRAS Briefing Paper Number 4. Leeds: Positive Action for Refugees and Asylum Seekers, 2008. ‹http://www.statewatch.org/news/2008/apr/uk-patras-briefing-paper-4-%2Ddawn-raids.pdf›.Cohen, Steve. “The Local State of Immigration Controls.” Critical Social Policy 22 (2002): 518—43.Cwerner, Saulo. “Faster, Faster and Faster: The Time Politics of Asylum in the UK.” Time and Society 13 (2004): 71—88.Gill, Nick. "Presentational State Power: Temporal and Spatial Influences over Asylum Sector." Transactions of the Institute of British Geographers, 2009 (forthcoming).Granville-Chapman, Charlotte, Ellie Smith, and Neil Moloney. Harm on Removal: Excessive Force Against Failed Asylum Seekers. London: Medical Foundation for the Care of Victims of Torture, 2004.Groenendijk, Kees. “New Borders behind Old Ones: Post-Schengen Controls behind the Internal Borders and inside the Netherlands and Germany”. In Search of Europe's Borders. Eds. Kees Groenendijk, Elspeth Guild and Paul Minderhoud. The Hague: Kluwer International Law, 2003. 131—46.Guild, Elspeth. “The Europeanisation of Europe's Asylum Policy.” International Journal of Refugee Law 18 (2006): 630—51.Guiraudon, Virginie. “Before the EU Border: Remote Control of the 'Huddled Masses'.” In Search of Europe's Borders. Eds. Kees Groenendijk, Elspeth Guild and Paul Minderhoud. The Hague: Kluwer International Law, 2003. 191—214.Hansard, House of Commons. Vol. 440 Col. 972W. 5 Dec. 2005. 6 Mar. 2009 ‹http://www.publications.parliament.uk/pa/cm200506/cmhansrd/vo051205/text/51205w18.htm›.———. Vol. 441 Col. 374W. 9 Jan. 2006. 6 Mar. 2009 ‹http://www.publications.parliament.uk/pa/cm200506/cmhansrd/vo060109/text/60109w95.htm›.Hayter, Theresa. Open Borders: The Case against Immigration Controls. London: Pluto P, 2000.HM Inspectorate of Prisons. An Inspection of Campsfield House Immigration Removal Centre. London: HM Inspectorate of Prisons, 2002.———. Report on an Unannounced Full Follow-up Inspection of Campsfield House Immigration Removal Centre. London: HM Inspectorate of Prisons, 2008. Hobson, Chris, Jonathan Cox, and Nicholas Sagovsky. Saving Sanctuary: The Independent Asylum Commission’s First Report of Conclusions and Recommendations. London: Independent Asylum Commission, 2008.Home Office. “Record High on Removals of Failed Asylum Seekers.” Press Office Release, 27 Feb. 2007. London: Home Office, 2007. 6 Mar. 2009 ‹http://press.homeoffice.gov.uk/press-releases/asylum-removals-figures›. Joseph, Miranda. Against the Romance of Community. Minnesota: U of Minnesota P, 2002.Koser, Khalid. “Refugees, Trans-Nationalism and the State.” Journal of Ethnic and Migration Studies 33 (2007): 233—54.Lahav, Gallya, and Virginie Guiraudon. “Comparative Perspectives on Border Control: Away from the Border and outside the State”. Wall around the West: State Borders and Immigration Controls in North America and Europe. Eds. Gallya Lahav and Virginie Guiraudon. The Lanham: Rowman and Littlefield, 2000. 55—77.Noble, Gill, Alan Barnish, Ernie Finch, and Digby Griffith. A Review of the Operation of the National Asylum Support Service. London: Home Office, 2004. Nyers, Peter. "Abject Cosmopolitanism: The Politics of Protection in the Anti-Deportation Movement." Third World Quarterly 24.6 (2003): 1069—93.Schuster, Lisa. "A Sledgehammer to Crack a Nut: Deportation, Detention and Dispersal in Europe." Social Policy & Administration 39.6 (2005): 606—21.Taylor, Diane, and Hugh Muir. “Red Cross Aids Failed Asylum Seekers” UK News. The Guardian 9 Jan. 2006. 6 Mar. 2009 ‹http://www.guardian.co.uk/news/2006/jan/09/immigrationasylumandrefugees.uknews›.Turton, David. Conceptualising Forced Migration. University of Oxford Refugee Studies Centre Working Paper 12 (2003). 6 Mar. 2009 ‹http://www.rsc.ox.ac.uk/PDFs/workingpaper12.pdf›.Tyler, Imogen. “'Welcome to Britain': The Cultural Politics of Asylum.” European Journal of Cultural Studies 9.2 (2006): 185—202.United Nations High Commission for Refugees. Refugees by Numbers 2006 Edition. Geneva: UNHCR, 2006.

Introduction Within wellness circles, there has been growing concern over an increasing focus on Alternative Right (or Alt-right) conspiracy (see Aubry; Bloom and Moskalenko). Greene, referring to a definition provided by the Anti-Defamation League, defines the Alt-right as a loose political network characterised by its rejection of mainstream conservatism, embrace of white nationalism, and use of online platforms (33). The “wellness revolution”, on the other hand, which marked a split from the health care sector in which “thought leaders” replaced medical experts as authorities on health (Pilzer, qtd. in Kickbusch and Payne 275), combines New Age practices with ideological movements that emphasise the “interdependence of body, mind and spirit” (Voigt and Laing 32). It has been noted that there is overlap between the circulation of conspiracy theory and New Age mysticism (see Ward and Voas; Parmigiani). Influencers following the Paleo diet, or Palaeolithic diet, such as Australian celebrity chef and Paleo diet guru Pete Evans, have also come under fire for sharing conspiracy theories and pseudoscience (see Brennan). Johnson notes that the origins of the Paleo diet can be traced back to 1975, with the publication of Dr Walter Voegtlin’s book The Stone Age Diet. This text, however, has been largely disavowed by Paleo leaders due to Voegtlin’s “white supremacist, eugenicist, and generally unpalatable politics”. Nevertheless, it is interesting to consider how white nationalism and conspiracy theory may overlap within the wellness space. A specific example occurred in 2020, when Pete Evans shared an Alt-right conspiracy meme to his Facebook account. The ‘butterfly-caterpillar meme’ contained the image of a black sun, a symbol equated with the swastika (Goodrick-Clarke 3). Though Evans later commented that the sharing of the hate symbol was unintentional, and that he misunderstood the symbol, this case raised questions about the ability of wellness influencers to amplify white nationalist messaging. This essay is concerned with the question: what makes the wellness industry a target for the spreading of white nationalist ideas? It argues that the wellness industry and far-right ideology possess a pre-occupation with bodily purity which makes it more likely that white nationalist material carrying this message will be spread via wellness networks. Through a critical examination of the media surrounding Evans’s sharing of the butterfly-caterpillar meme, this case study will examine the ideological aspects of the Paleo diet and how they appeal to a white nationalist agenda. Focussing on the Australian context, this essay will theorise the spreadability of memes in relation to white nationalist symbolism. It contends that the Paleo diet positions foods that are not organic as impure, and holds a preference for positive messaging. Alt-right propaganda packaged in a positive and New Age frame poses a danger in that it can operate as a kind of contagion for high-profile networks, exponentially increasing its spreadability. This is of particular concern when it is considered that diet can have an impact on people’s actions outside of the online space: it impacts what people consume and do with their bodies, as evidenced by calls for eating disorders created by algorithmic repetition to be considered a ‘cyber-pathy’. This creates the conditions for the wellness industry to be targeted using memes as recruitment material for white nationalist groups. The Paleo Diet and the Sharing of a Neo-Nazi Meme Pete Evans is a famous Australian TV Chef from the hit series My Kitchen Rules, a show that ran from 2010-2020. The show followed pairs from different households as they cooked for Evans and his co-host Manu Feildel. During the show’s run, Evans also became known for spruiking the Paleo diet, producing several cookbooks and a documentary on the topic. According to Catie Gressier, who conducted a study of Paleo dieters in Melbourne, Paleo’s aim is “to eat only those foods available prior to the agricultural revolution: meat, fish, vegetables, nuts, seeds and a small amount of fruit” and that this framed as a more “authentic” diet (3). This is seen as an ideological diet as opposed to others which may consist of rules or eating restrictions. The Paleo diet stresses “real foods” or “organic foods as close to their real state as possible” (Ramachandran et al.). Studies find that the paleo diet can be very nutritious (Cambeses-Franco et al. 2021). However, it is important to note that the presence of multiple influencers and thought leaders in the field means that there can be several variations in the diet. This article will limit its examination to that of the diet promoted by Evans. A common rationale is that the human body is incompatible with certain mass-produced foods (like grains, pulses, and dairy products, sugar, salt, and modification practices (like food processing), and that these are the cause of many modern conditions (Cambeses-Franco et al. 2021). While growing concerns over unnatural additives in foods are warranted, it can be observed that in Evans’s case, the promotion of the Paleo diet increasingly blurred the line between pseudoscience and conspiracy. In his Paleo diet book for toddlers, Evans emphasised the importance of the ideological diet and suggested that parents feed their toddlers bone broth instead of breast milk, prompting a federal investigation by the health department (Brennan). This escalated in 2020 during the global pandemic. In January, Evans promoted the work of a prominent anti-vaccine advocate (Molloy). In April, his Biocharger device, which he claimed could cure coronavirus, earned him a hefty fine from the Therapeutic Goods Administration (White). In November, several months after My Kitchen Rules was cancelled, Evans posted an Alt-right political cartoon with the image of a black sun, a symbol equated with the swastika (Goodrick-Clarke 3), to his Facebook account (Gillespie). In later news reports, it was also pointed out that the black sun symbol was emblazoned on the backpack of the Christchurch shooter (see Sutton and Molloy) who had targeted two mosques in Christchurch, New Zealand, killing 51 people and injuring 40. Initially, when a user on Facebook pointed out that the meme contained a black sun, Evans responded “I was waiting for someone to see that” (Evans, qtd. in Gillespie). Evans eventually recanted the image, writing: sincere apologies to anyone who misinterpreted a previous post of a caterpillar and a butterfly having a chat over a drink and perceived that I was promoting hatred. I look forward to studying every symbol that have ever existed and research them thoroughly before posting. Hopefully this symbol ❤️ resonates deeply into the hearts of ALL! (Evans, qtd. in Gillespie). The post was later deleted. In December of 2020, Evans’s Facebook page of around 1.5 million followers was removed due to its sharing of conspiracy theories and misinformation about the coronavirus (Gillespie). However, it should be noted that the sharing of the caterpillar-butterfly meme was different from the previous instances of conspiracy sharing, in that Evans stated that it was unintentional, and it included imagery associated with neo-Nazi ideology (the black sun). Evans’s response implies that, while the values of the Paleo diet are framed in terms of positivity, the symbols in the butterfly-caterpillar meme are associated with “promoting hatred”. In this way, Evans frames racism as merely and simplistically an act of hatred, rather than engaging in the ways in which it reinforces a racial hierarchy and racially motivated violence. According to Hartzell (10), white nationalists tend to position themselves as superior to other races and see themselves as protectors of the “white race”. “White” in this context is of European descent (Geary, Schofield and Sutton). There are conspiracy theories associated with this belief, one of which is that their race is under threat of extinction because of immigration from ‘undesirable’ countries of origin. This can also be observed in the Alt-right, which is a white nationalist movement that was created and organised online. According to Berger, this movement “seeks to unify the activities of several different extremist movements or ideologies”. This is characterised by anti-immigrant sentiment, conspiracy theories, and support for former US President Donald Trump. It can be argued, in this case, that the symbol links to a larger conspiracy theory in which whiteness must be defended against some perceived threat. The meme implies that there is an ‘us’ versus ‘them’, or ‘good’ versus ‘evil’, and that some people are ‘in the know’ while others are not. Spreadable Memes An important aspect of this case study is that this instance of far-right recruitment used the form of a meme. Memes are highly spreadable, and they have very complex mechanisms for disseminating ideas and ideology. This can have a dramatic impact if that ideology is a harmful one, such a white supremacist symbol. While the digital meme, an image with a small amount of text, is common today, Richard Dawkins originally used the term meme to describe the ways in which units of culture can be spread from person to person (qtd. in Shifman 9). These can be anything from the lyrics of a song to a political idea. Jeff Hemsley and Robert Mason (qtd. in Shifman) see virality as a “process wherein a message is actively forwarded from one person to other, within and between multiple weakly linked personal networks, resulting in a rapid increase in the number of people who are exposed to the message” (55). This also links to Jenkins, Ford, and Green’s notions of spreadability (3-11), a natural selection process by which media content continues to exist through networked sharing, or disappears once it stops being shared. Evans’s response indicates that he merely shared the image. Despite the black sun imagery, a Make America Great Again (MAGA) hat is clearly present. A political presence, and one that is associated with white nationalism, is present despite Evans’s attempts to frame the meme in the language of innocence and positivity. This is not to say Evans is extremist or supports a white nationalist agenda. However, in much the same way that sharing of imagery may not necessarily indicate agreement with its ideological messaging, this framing creates a way in which wellness influencers may avoid criticism (Ma 1). Furthermore, the act of sharing the meme, regardless of intention, amplifies its message exponentially. The Paleo Diet, the Far Right and Purity This overlap between wellness and white nationalist ideology is not new. In Jules Evans’s exploration of why QAnon is popular with New Age and far-right followers, she points to the fact that many Nazi leaders – Hitler, Hess, Himmler – “were into alternative medicine, organic and vegetarian diets, homeopathy, anti-vaxxing, and natural healing”. Similarly, Bernhard Forchtner and Ana Tominc argue that a natural diet which focussed on food purity was favoured by the Nazis (421). In their examination of the German neo-Nazi YouTube channel Balaclava Küche they argue add that “present-day extreme right views on environment and diet are often close to positions found in contemporary Green movements and foodie magazines” (422). Like neo-Nazi preoccupations with food, the Paleo diet’s ideology has its basis in the concept of purity. Gressier found that the Paleo diet contains an “embedded moralism” that “filters into constructions of food as either pure or polluting” (1). This is supported by Ramachandran et al.’s study, which found that the diet “promoted ‘real food’ – or the shift to consuming organic whole foods that are as close to their natural state as possible, with an avoidance of processed foods”. This framing of the food as real creates a binary – if one is real, the other must not be. Another example can be seen in Pete Evans’s Webpage, which lists about 33 Paleo recipes. The Butter Chicken recipe states: the paleo way of life is not meant to be restrictive, as you can see from this lovely butter chicken recipe. All the nasties have been replaced with good-quality ingredients that make it as good, if not better, than the original. I prefer chicken thighs for their superior flavour and tenderness. The term “nasties” here can be seen to create a dichotomy between real and fake, the west and the east. We see these foods are associated with impurity, the foods that are not “real foods” are positioned as a threat. It can be seen as an orientalist approach, othering those not associated with the west. As can be observed in this Butter Chicken recipe that is “getting rid of the nasties”, it appropriates and ‘sanitises’ ingredients. In her article on the campaign to boycott Halal, Shakira Hussein points out that “ethnic food” presents as multiculturalism in the context of white chefs and homecooks, but the opposite is true if the roles are switched (91). Later in her essay “Halal Chops and Fascist Cupcakes”, she discusses the “weaponisation of food” and how specific white nationalist groups express disgust at the thought of consuming Muslim food. This ethnocentric framing of butter chicken projects a western superiority, replacing traditional ingredients with ‘familiar’ ingredients, making it more palatable to nationalistic tastes. Spreading Consumption I have established that the Paleo diet, with its emphasis on ‘real foods’, is deeply embedded with nationalist ideology. I have also discussed how this is highly spreadable in the form of a meme, particularly when it is framed in the language of positivity. Furthermore, I have argued that this is an attempt to escape criticism for promoting white nationalist values. I would like to turn now to how this spreadability through diet can have an impact on the physical actions of its followers through its digital communication. The Paleo diet, and how to go about following it as described by celebrity influencers, has an impact on what people do with their bodies. Hanganu-Bresch discusses the concept of orthorexia, a fixation with eating proper foods that operates as a cyber-pathy, a digitally propagated condition targeting media users. Like the ‘viral’ and ‘spreadable’ meme, this puritanical obsession with eating can also be considered both a spreadable condition and ideology. According to Hanganu-Bresch, orthorexia sees this diet as a way to overcome an illness or to improve general health, but this also begins to feel righteous and even holy or spiritual. This operates within the context of neoliberalism. Brice and Thorpe talk about women’s activewear worn in everyday settings, or ‘athleisure’, as a neoliberal uniform that says, ‘I’m taking control of my body and health’. To take this idea a step further, this uniform could be extended out into digital spaces as well in terms of what people post on their profiles and social media. This ideological aspect operates as not only a highly spreadable message, but one that is targeted at the overall health of its followers. It encourages not only the spreading of ideology, in this case, white nationalist ideology, but also the modification of food consumption. If this were then to be used as a vehicle to spread messages that encourage white nationalist ideology, it can be seen to be not only a kind of contagion but a powerful one at that. White nationalist iconography that is clearly associated with white supremacist propaganda has the potential to spread extremism. However, neoliberal principles of discipline and bodywork operate through “messages of empowerment, choice, and self-care” (Lavrence and Lozanski, qtd. in Brice and Thorpe). While racist extremism does not necessarily equate to neoliberal and ethnocentric values, a frame of growth, purity, and positivity create an overlap that allow extremist messaging to spread more easily through these networks. Conclusion The case of Pete Evans’s sharing of the butterfly-caterpillar meme exemplifies a concerning overlap between white nationalist discourse and wellness. Ideologically based diets that emphasise real foods, such as the Paleo diet, have a preoccupation with purity and consumption that appeals to white nationalism. They also share a tolerance for the promotion of conspiracy theory and tendency to create an ‘us’ versus ‘them’ dichotomy. Noting these points can provide insight into a potential targeting of the wellness industry to spread racist ideology. As research into spreadability shows, memes are extremely shareable, even if the user does not grasp the meaning behind the symbolism. This article has also extended the idea of the cyberpathy further, noting a weaponisation of the properties of the meme, for the purposes of radicalisation, and how these are accelerated by celebrity influence. This is more potent within the wellness industry when the message is packaged as a form of growth and positivity, which serve to deflect accusations of racism. Furthermore, when diet is combined with white nationalist ideology, it may operate like a contagion, creating the conditions for racism. Those exposed may not have the intention of sharing or spreading racist ideology, but its amplification contributes to the promotion of a racist agenda nevertheless. As such, further investigation into the far-right infiltration of the wellness industry would be beneficial as it could provide more insight into how wellness groups are targeted. 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Photo ID 158378414 © Eduard Muzhevskyi | Dreamstime.com ABSTRACT There is a debate about the ethical implications of using human embryos in stem cell research, which can be influenced by cultural, moral, and social values. This paper argues for an adaptable framework to accommodate diverse cultural and religious perspectives. By using an adaptive ethics model, research protections can reflect various populations and foster growth in stem cell research possibilities. INTRODUCTION Stem cell research combines biology, medicine, and technology, promising to alter health care and the understanding of human development. Yet, ethical contention exists because of individuals’ perceptions of using human embryos based on their various cultural, moral, and social values. While these disagreements concerning policy, use, and general acceptance have prompted the development of an international ethics policy, such a uniform approach can overlook the nuanced ethical landscapes between cultures. With diverse viewpoints in public health, a single global policy, especially one reflecting Western ethics or the ethics prevalent in high-income countries, is impractical. This paper argues for a culturally sensitive, adaptable framework for the use of embryonic stem cells. Stem cell policy should accommodate varying ethical viewpoints and promote an effective global dialogue. With an extension of an ethics model that can adapt to various cultures, we recommend localized guidelines that reflect the moral views of the people those guidelines serve. BACKGROUND Stem cells, characterized by their unique ability to differentiate into various cell types, enable the repair or replacement of damaged tissues. Two primary types of stem cells are somatic stem cells (adult stem cells) and embryonic stem cells. Adult stem cells exist in developed tissues and maintain the body’s repair processes.[1] Embryonic stem cells (ESC) are remarkably pluripotent or versatile, making them valuable in research.[2] However, the use of ESCs has sparked ethics debates. Considering the potential of embryonic stem cells, research guidelines are essential. The International Society for Stem Cell Research (ISSCR) provides international stem cell research guidelines. They call for “public conversations touching on the scientific significance as well as the societal and ethical issues raised by ESC research.”[3] The ISSCR also publishes updates about culturing human embryos 14 days post fertilization, suggesting local policies and regulations should continue to evolve as ESC research develops.[4] Like the ISSCR, which calls for local law and policy to adapt to developing stem cell research given cultural acceptance, this paper highlights the importance of local social factors such as religion and culture. I. Global Cultural Perspective of Embryonic Stem Cells Views on ESCs vary throughout the world. Some countries readily embrace stem cell research and therapies, while others have stricter regulations due to ethical concerns surrounding embryonic stem cells and when an embryo becomes entitled to moral consideration. The philosophical issue of when the “someone” begins to be a human after fertilization, in the morally relevant sense,[5] impacts when an embryo becomes not just worthy of protection but morally entitled to it. The process of creating embryonic stem cell lines involves the destruction of the embryos for research.[6] Consequently, global engagement in ESC research depends on social-cultural acceptability. a. US and Rights-Based Cultures In the United States, attitudes toward stem cell therapies are diverse. The ethics and social approaches, which value individualism,[7] trigger debates regarding the destruction of human embryos, creating a complex regulatory environment. For example, the 1996 Dickey-Wicker Amendment prohibited federal funding for the creation of embryos for research and the destruction of embryos for “more than allowed for research on fetuses in utero.”[8] Following suit, in 2001, the Bush Administration heavily restricted stem cell lines for research. However, the Stem Cell Research Enhancement Act of 2005 was proposed to help develop ESC research but was ultimately vetoed.[9] Under the Obama administration, in 2009, an executive order lifted restrictions allowing for more development in this field.[10] The flux of research capacity and funding parallels the different cultural perceptions of human dignity of the embryo and how it is socially presented within the country’s research culture.[11] b. Ubuntu and Collective Cultures African bioethics differs from Western individualism because of the different traditions and values. African traditions, as described by individuals from South Africa and supported by some studies in other African countries, including Ghana and Kenya, follow the African moral philosophies of Ubuntu or Botho and Ukama, which “advocates for a form of wholeness that comes through one’s relationship and connectedness with other people in the society,”[12] making autonomy a socially collective concept. In this context, for the community to act autonomously, individuals would come together to decide what is best for the collective. Thus, stem cell research would require examining the value of the research to society as a whole and the use of the embryos as a collective societal resource. If society views the source as part of the collective whole, and opposes using stem cells, compromising the cultural values to pursue research may cause social detachment and stunt research growth.[13] Based on local culture and moral philosophy, the permissibility of stem cell research depends on how embryo, stem cell, and cell line therapies relate to the community as a whole. Ubuntu is the expression of humanness, with the person’s identity drawn from the “’I am because we are’” value.[14] The decision in a collectivistic culture becomes one born of cultural context, and individual decisions give deference to others in the society. Consent differs in cultures where thought and moral philosophy are based on a collective paradigm. So, applying Western bioethical concepts is unrealistic. For one, Africa is a diverse continent with many countries with different belief systems, access to health care, and reliance on traditional or Western medicines. Where traditional medicine is the primary treatment, the “’restrictive focus on biomedically-related bioethics’” [is] problematic in African contexts because it neglects bioethical issues raised by traditional systems.”[15] No single approach applies in all areas or contexts. Rather than evaluating the permissibility of ESC research according to Western concepts such as the four principles approach, different ethics approaches should prevail. Another consideration is the socio-economic standing of countries. In parts of South Africa, researchers have not focused heavily on contributing to the stem cell discourse, either because it is not considered health care or a health science priority or because resources are unavailable.[16] Each country’s priorities differ given different social, political, and economic factors. In South Africa, for instance, areas such as maternal mortality, non-communicable diseases, telemedicine, and the strength of health systems need improvement and require more focus[17] Stem cell research could benefit the population, but it also could divert resources from basic medical care. Researchers in South Africa adhere to the National Health Act and Medicines Control Act in South Africa and international guidelines; however, the Act is not strictly enforced, and there is no clear legislation for research conduct or ethical guidelines.[18] Some parts of Africa condemn stem cell research. For example, 98.2 percent of the Tunisian population is Muslim.[19] Tunisia does not permit stem cell research because of moral conflict with a Fatwa. Religion heavily saturates the regulation and direction of research.[20] Stem cell use became permissible for reproductive purposes only recently, with tight restrictions preventing cells from being used in any research other than procedures concerning ART/IVF. Their use is conditioned on consent, and available only to married couples.[21] The community's receptiveness to stem cell research depends on including communitarian African ethics. c. Asia Some Asian countries also have a collective model of ethics and decision making.[22] In China, the ethics model promotes a sincere respect for life or human dignity,[23] based on protective medicine. This model, influenced by Traditional Chinese Medicine (TCM), [24] recognizes Qi as the vital energy delivered via the meridians of the body; it connects illness to body systems, the body’s entire constitution, and the universe for a holistic bond of nature, health, and quality of life.[25] Following a protective ethics model, and traditional customs of wholeness, investment in stem cell research is heavily desired for its applications in regenerative therapies, disease modeling, and protective medicines. In a survey of medical students and healthcare practitioners, 30.8 percent considered stem cell research morally unacceptable while 63.5 percent accepted medical research using human embryonic stem cells. Of these individuals, 89.9 percent supported increased funding for stem cell research.[26] The scientific community might not reflect the overall population. From 1997 to 2019, China spent a total of $576 million (USD) on stem cell research at 8,050 stem cell programs, increased published presence from 0.6 percent to 14.01 percent of total global stem cell publications as of 2014, and made significant strides in cell-based therapies for various medical conditions.[27] However, while China has made substantial investments in stem cell research and achieved notable progress in clinical applications, concerns linger regarding ethical oversight and transparency.[28] For example, the China Biosecurity Law, promoted by the National Health Commission and China Hospital Association, attempted to mitigate risks by introducing an institutional review board (IRB) in the regulatory bodies. 5800 IRBs registered with the Chinese Clinical Trial Registry since 2021.[29] However, issues still need to be addressed in implementing effective IRB review and approval procedures. The substantial government funding and focus on scientific advancement have sometimes overshadowed considerations of regional cultures, ethnic minorities, and individual perspectives, particularly evident during the one-child policy era. As government policy adapts to promote public stability, such as the change from the one-child to the two-child policy,[30] research ethics should also adapt to ensure respect for the values of its represented peoples. Japan is also relatively supportive of stem cell research and therapies. Japan has a more transparent regulatory framework, allowing for faster approval of regenerative medicine products, which has led to several advanced clinical trials and therapies.[31] South Korea is also actively engaged in stem cell research and has a history of breakthroughs in cloning and embryonic stem cells.[32] However, the field is controversial, and there are issues of scientific integrity. For example, the Korean FDA fast-tracked products for approval,[33] and in another instance, the oocyte source was unclear and possibly violated ethical standards.[34] Trust is important in research, as it builds collaborative foundations between colleagues, trial participant comfort, open-mindedness for complicated and sensitive discussions, and supports regulatory procedures for stakeholders. There is a need to respect the culture’s interest, engagement, and for research and clinical trials to be transparent and have ethical oversight to promote global research discourse and trust. d. Middle East Countries in the Middle East have varying degrees of acceptance of or restrictions to policies related to using embryonic stem cells due to cultural and religious influences. Saudi Arabia has made significant contributions to stem cell research, and conducts research based on international guidelines for ethical conduct and under strict adherence to guidelines in accordance with Islamic principles. Specifically, the Saudi government and people require ESC research to adhere to Sharia law. In addition to umbilical and placental stem cells,[35] Saudi Arabia permits the use of embryonic stem cells as long as they come from miscarriages, therapeutic abortions permissible by Sharia law, or are left over from in vitro fertilization and donated to research.[36] Laws and ethical guidelines for stem cell research allow the development of research institutions such as the King Abdullah International Medical Research Center, which has a cord blood bank and a stem cell registry with nearly 10,000 donors.[37] Such volume and acceptance are due to the ethical ‘permissibility’ of the donor sources, which do not conflict with religious pillars. However, some researchers err on the side of caution, choosing not to use embryos or fetal tissue as they feel it is unethical to do so.[38] Jordan has a positive research ethics culture.[39] However, there is a significant issue of lack of trust in researchers, with 45.23 percent (38.66 percent agreeing and 6.57 percent strongly agreeing) of Jordanians holding a low level of trust in researchers, compared to 81.34 percent of Jordanians agreeing that they feel safe to participate in a research trial.[40] Safety testifies to the feeling of confidence that adequate measures are in place to protect participants from harm, whereas trust in researchers could represent the confidence in researchers to act in the participants’ best interests, adhere to ethical guidelines, provide accurate information, and respect participants’ rights and dignity. One method to improve trust would be to address communication issues relevant to ESC. Legislation surrounding stem cell research has adopted specific language, especially concerning clarification “between ‘stem cells’ and ‘embryonic stem cells’” in translation.[41] Furthermore, legislation “mandates the creation of a national committee… laying out specific regulations for stem-cell banking in accordance with international standards.”[42] This broad regulation opens the door for future global engagement and maintains transparency. However, these regulations may also constrain the influence of research direction, pace, and accessibility of research outcomes. e. Europe In the European Union (EU), ethics is also principle-based, but the principles of autonomy, dignity, integrity, and vulnerability are interconnected.[43] As such, the opportunity for cohesion and concessions between individuals’ thoughts and ideals allows for a more adaptable ethics model due to the flexible principles that relate to the human experience The EU has put forth a framework in its Convention for the Protection of Human Rights and Dignity of the Human Being allowing member states to take different approaches. Each European state applies these principles to its specific conventions, leading to or reflecting different acceptance levels of stem cell research. [44] For example, in Germany, Lebenzusammenhang, or the coherence of life, references integrity in the unity of human culture. Namely, the personal sphere “should not be subject to external intervention.”[45] Stem cell interventions could affect this concept of bodily completeness, leading to heavy restrictions. Under the Grundgesetz, human dignity and the right to life with physical integrity are paramount.[46] The Embryo Protection Act of 1991 made producing cell lines illegal. Cell lines can be imported if approved by the Central Ethics Commission for Stem Cell Research only if they were derived before May 2007.[47] Stem cell research respects the integrity of life for the embryo with heavy specifications and intense oversight. This is vastly different in Finland, where the regulatory bodies find research more permissible in IVF excess, but only up to 14 days after fertilization.[48] Spain’s approach differs still, with a comprehensive regulatory framework.[49] Thus, research regulation can be culture-specific due to variations in applied principles. Diverse cultures call for various approaches to ethical permissibility.[50] Only an adaptive-deliberative model can address the cultural constructions of self and achieve positive, culturally sensitive stem cell research practices.[51] II. Religious Perspectives on ESC Embryonic stem cell sources are the main consideration within religious contexts. While individuals may not regard their own religious texts as authoritative or factual, religion can shape their foundations or perspectives. The Qur'an states: “And indeed We created man from a quintessence of clay. Then We placed within him a small quantity of nutfa (sperm to fertilize) in a safe place. Then We have fashioned the nutfa into an ‘alaqa (clinging clot or cell cluster), then We developed the ‘alaqa into mudgha (a lump of flesh), and We made mudgha into bones, and clothed the bones with flesh, then We brought it into being as a new creation. So Blessed is Allah, the Best of Creators.”[52] Many scholars of Islam estimate the time of soul installment, marked by the angel breathing in the soul to bring the individual into creation, as 120 days from conception.[53] Personhood begins at this point, and the value of life would prohibit research or experimentation that could harm the individual. If the fetus is more than 120 days old, the time ensoulment is interpreted to occur according to Islamic law, abortion is no longer permissible.[54] There are a few opposing opinions about early embryos in Islamic traditions. According to some Islamic theologians, there is no ensoulment of the early embryo, which is the source of stem cells for ESC research.[55] In Buddhism, the stance on stem cell research is not settled. The main tenets, the prohibition against harming or destroying others (ahimsa) and the pursuit of knowledge (prajña) and compassion (karuna), leave Buddhist scholars and communities divided.[56] Some scholars argue stem cell research is in accordance with the Buddhist tenet of seeking knowledge and ending human suffering. Others feel it violates the principle of not harming others. Finding the balance between these two points relies on the karmic burden of Buddhist morality. In trying to prevent ahimsa towards the embryo, Buddhist scholars suggest that to comply with Buddhist tenets, research cannot be done as the embryo has personhood at the moment of conception and would reincarnate immediately, harming the individual's ability to build their karmic burden.[57] On the other hand, the Bodhisattvas, those considered to be on the path to enlightenment or Nirvana, have given organs and flesh to others to help alleviate grieving and to benefit all.[58] Acceptance varies on applied beliefs and interpretations. Catholicism does not support embryonic stem cell research, as it entails creation or destruction of human embryos. This destruction conflicts with the belief in the sanctity of life. For example, in the Old Testament, Genesis describes humanity as being created in God’s image and multiplying on the Earth, referencing the sacred rights to human conception and the purpose of development and life. In the Ten Commandments, the tenet that one should not kill has numerous interpretations where killing could mean murder or shedding of the sanctity of life, demonstrating the high value of human personhood. In other books, the theological conception of when life begins is interpreted as in utero,[59] highlighting the inviolability of life and its formation in vivo to make a religious point for accepting such research as relatively limited, if at all.[60] The Vatican has released ethical directives to help apply a theological basis to modern-day conflicts. The Magisterium of the Church states that “unless there is a moral certainty of not causing harm,” experimentation on fetuses, fertilized cells, stem cells, or embryos constitutes a crime.[61] Such procedures would not respect the human person who exists at these stages, according to Catholicism. Damages to the embryo are considered gravely immoral and illicit.[62] Although the Catholic Church officially opposes abortion, surveys demonstrate that many Catholic people hold pro-choice views, whether due to the context of conception, stage of pregnancy, threat to the mother’s life, or for other reasons, demonstrating that practicing members can also accept some but not all tenets.[63] Some major Jewish denominations, such as the Reform, Conservative, and Reconstructionist movements, are open to supporting ESC use or research as long as it is for saving a life.[64] Within Judaism, the Talmud, or study, gives personhood to the child at birth and emphasizes that life does not begin at conception:[65] “If she is found pregnant, until the fortieth day it is mere fluid,”[66] Whereas most religions prioritize the status of human embryos, the Halakah (Jewish religious law) states that to save one life, most other religious laws can be ignored because it is in pursuit of preservation.[67] Stem cell research is accepted due to application of these religious laws. We recognize that all religions contain subsets and sects. The variety of environmental and cultural differences within religious groups requires further analysis to respect the flexibility of religious thoughts and practices. We make no presumptions that all cultures require notions of autonomy or morality as under the common morality theory, which asserts a set of universal moral norms that all individuals share provides moral reasoning and guides ethical decisions.[68] We only wish to show that the interaction with morality varies between cultures and countries. III. A Flexible Ethical Approach The plurality of different moral approaches described above demonstrates that there can be no universally acceptable uniform law for ESC on a global scale. Instead of developing one standard, flexible ethical applications must be continued. We recommend local guidelines that incorporate important cultural and ethical priorities. While the Declaration of Helsinki is more relevant to people in clinical trials receiving ESC products, in keeping with the tradition of protections for research subjects, consent of the donor is an ethical requirement for ESC donation in many jurisdictions including the US, Canada, and Europe.[69] The Declaration of Helsinki provides a reference point for regulatory standards and could potentially be used as a universal baseline for obtaining consent prior to gamete or embryo donation. For instance, in Columbia University’s egg donor program for stem cell research, donors followed standard screening protocols and “underwent counseling sessions that included information as to the purpose of oocyte donation for research, what the oocytes would be used for, the risks and benefits of donation, and process of oocyte stimulation” to ensure transparency for consent.[70] The program helped advance stem cell research and provided clear and safe research methods with paid participants. Though paid participation or covering costs of incidental expenses may not be socially acceptable in every culture or context,[71] and creating embryos for ESC research is illegal in many jurisdictions, Columbia’s program was effective because of the clear and honest communications with donors, IRBs, and related stakeholders. This example demonstrates that cultural acceptance of scientific research and of the idea that an egg or embryo does not have personhood is likely behind societal acceptance of donating eggs for ESC research. As noted, many countries do not permit the creation of embryos for research. Proper communication and education regarding the process and purpose of stem cell research may bolster comprehension and garner more acceptance. “Given the sensitive subject material, a complete consent process can support voluntary participation through trust, understanding, and ethical norms from the cultures and morals participants value. This can be hard for researchers entering countries of different socioeconomic stability, with different languages and different societal values.[72] An adequate moral foundation in medical ethics is derived from the cultural and religious basis that informs knowledge and actions.[73] Understanding local cultural and religious values and their impact on research could help researchers develop humility and promote inclusion. IV. Concerns Some may argue that if researchers all adhere to one ethics standard, protection will be satisfied across all borders, and the global public will trust researchers. However, defining what needs to be protected and how to define such research standards is very specific to the people to which standards are applied. We suggest that applying one uniform guide cannot accurately protect each individual because we all possess our own perceptions and interpretations of social values.[74] Therefore, the issue of not adjusting to the moral pluralism between peoples in applying one standard of ethics can be resolved by building out ethics models that can be adapted to different cultures and religions. Other concerns include medical tourism, which may promote health inequities.[75] Some countries may develop and approve products derived from ESC research before others, compromising research ethics or drug approval processes. There are also concerns about the sale of unauthorized stem cell treatments, for example, those without FDA approval in the United States. Countries with robust research infrastructures may be tempted to attract medical tourists, and some customers will have false hopes based on aggressive publicity of unproven treatments.[76] For example, in China, stem cell clinics can market to foreign clients who are not protected under the regulatory regimes. Companies employ a marketing strategy of “ethically friendly” therapies. Specifically, in the case of Beike, China’s leading stem cell tourism company and sprouting network, ethical oversight of administrators or health bureaus at one site has “the unintended consequence of shifting questionable activities to another node in Beike's diffuse network.”[77] In contrast, Jordan is aware of stem cell research’s potential abuse and its own status as a “health-care hub.” Jordan’s expanded regulations include preserving the interests of individuals in clinical trials and banning private companies from ESC research to preserve transparency and the integrity of research practices.[78] The social priorities of the community are also a concern. The ISSCR explicitly states that guidelines “should be periodically revised to accommodate scientific advances, new challenges, and evolving social priorities.”[79] The adaptable ethics model extends this consideration further by addressing whether research is warranted given the varying degrees of socioeconomic conditions, political stability, and healthcare accessibilities and limitations. An ethical approach would require discussion about resource allocation and appropriate distribution of funds.[80] CONCLUSION While some religions emphasize the sanctity of life from conception, which may lead to public opposition to ESC research, others encourage ESC research due to its potential for healing and alleviating human pain. Many countries have special regulations that balance local views on embryonic personhood, the benefits of research as individual or societal goods, and the protection of human research subjects. To foster understanding and constructive dialogue, global policy frameworks should prioritize the protection of universal human rights, transparency, and informed consent. In addition to these foundational global policies, we recommend tailoring local guidelines to reflect the diverse cultural and religious perspectives of the populations they govern. Ethics models should be adapted to local populations to effectively establish research protections, growth, and possibilities of stem cell research. For example, in countries with strong beliefs in the moral sanctity of embryos or heavy religious restrictions, an adaptive model can allow for discussion instead of immediate rejection. In countries with limited individual rights and voice in science policy, an adaptive model ensures cultural, moral, and religious views are taken into consideration, thereby building social inclusion. While this ethical consideration by the government may not give a complete voice to every individual, it will help balance policies and maintain the diverse perspectives of those it affects. Embracing an adaptive ethics model of ESC research promotes open-minded dialogue and respect for the importance of human belief and tradition. By actively engaging with cultural and religious values, researchers can better handle disagreements and promote ethical research practices that benefit each society. This brief exploration of the religious and cultural differences that impact ESC research reveals the nuances of relative ethics and highlights a need for local policymakers to apply a more intense adaptive model. - [1] Poliwoda, S., Noor, N., Downs, E., Schaaf, A., Cantwell, A., Ganti, L., Kaye, A. D., Mosel, L. I., Carroll, C. B., Viswanath, O., & Urits, I. (2022). Stem cells: a comprehensive review of origins and emerging clinical roles in medical practice. Orthopedic reviews, 14(3), 37498. https://doi.org/10.52965/001c.37498 [2] Poliwoda, S., Noor, N., Downs, E., Schaaf, A., Cantwell, A., Ganti, L., Kaye, A. D., Mosel, L. I., Carroll, C. B., Viswanath, O., & Urits, I. (2022). Stem cells: a comprehensive review of origins and emerging clinical roles in medical practice. Orthopedic reviews, 14(3), 37498. https://doi.org/10.52965/001c.37498 [3] International Society for Stem Cell Research. (2023). Laboratory-based human embryonic stem cell research, embryo research, and related research activities. International Society for Stem Cell Research. https://www.isscr.org/guidelines/blog-post-title-one-ed2td-6fcdk; Kimmelman, J., Hyun, I., Benvenisty, N. et al. Policy: Global standards for stem-cell research. Nature 533, 311–313 (2016). https://doi.org/10.1038/533311a [4] International Society for Stem Cell Research. (2023). Laboratory-based human embryonic stem cell research, embryo research, and related research activities. International Society for Stem Cell Research. https://www.isscr.org/guidelines/blog-post-title-one-ed2td-6fcdk [5] Concerning the moral philosophies of stem cell research, our paper does not posit a personal moral stance nor delve into the “when” of human life begins. To read further about the philosophical debate, consider the following sources: Sandel M. J. (2004). Embryo ethics--the moral logic of stem-cell research. The New England journal of medicine, 351(3), 207–209. https://doi.org/10.1056/NEJMp048145; George, R. P., & Lee, P. (2020, September 26). Acorns and Embryos. The New Atlantis. https://www.thenewatlantis.com/publications/acorns-and-embryos; Sagan, A., & Singer, P. (2007). The moral status of stem cells. Metaphilosophy, 38(2/3), 264–284. http://www.jstor.org/stable/24439776; McHugh P. R. (2004). Zygote and "clonote"--the ethical use of embryonic stem cells. The New England journal of medicine, 351(3), 209–211. https://doi.org/10.1056/NEJMp048147; Kurjak, A., & Tripalo, A. (2004). The facts and doubts about beginning of the human life and personality. Bosnian journal of basic medical sciences, 4(1), 5–14. https://doi.org/10.17305/bjbms.2004.3453 [6] Vazin, T., & Freed, W. J. (2010). Human embryonic stem cells: derivation, culture, and differentiation: a review. Restorative neurology and neuroscience, 28(4), 589–603. https://doi.org/10.3233/RNN-2010-0543 [7] Socially, at its core, the Western approach to ethics is widely principle-based, autonomy being one of the key factors to ensure a fundamental respect for persons within research. For information regarding autonomy in research, see: Department of Health, Education, and Welfare, & National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1978). The Belmont Report. Ethical principles and guidelines for the protection of human subjects of research.; For a more in-depth review of autonomy within the US, see: Beauchamp, T. L., & Childress, J. F. (1994). Principles of Biomedical Ethics. Oxford University Press. [8] Sherley v. Sebelius, 644 F.3d 388 (D.C. Cir. 2011), citing 45 C.F.R. 46.204(b) and [42 U.S.C. § 289g(b)]. https://www.cadc.uscourts.gov/internet/opinions.nsf/6c690438a9b43dd685257a64004ebf99/$file/11-5241-1391178.pdf [9] Stem Cell Research Enhancement Act of 2005, H. R. 810, 109th Cong. (2001). https://www.govtrack.us/congress/bills/109/hr810/text; Bush, G. W. (2006, July 19). Message to the House of Representatives. National Archives and Records Administration. https://georgewbush-whitehouse.archives.gov/news/releases/2006/07/20060719-5.html [10] National Archives and Records Administration. (2009, March 9). Executive order 13505 -- removing barriers to responsible scientific research involving human stem cells. National Archives and Records Administration. https://obamawhitehouse.archives.gov/the-press-office/removing-barriers-responsible-scientific-research-involving-human-stem-cells [11] Hurlbut, W. B. (2006). Science, Religion, and the Politics of Stem Cells. Social Research, 73(3), 819–834. http://www.jstor.org/stable/40971854 [12] Akpa-Inyang, Francis & Chima, Sylvester. (2021). South African traditional values and beliefs regarding informed consent and limitations of the principle of respect for autonomy in African communities: a cross-cultural qualitative study. BMC Medical Ethics. 22. 10.1186/s12910-021-00678-4. [13] Source for further reading: Tangwa G. B. (2007). Moral status of embryonic stem cells: perspective of an African villager. Bioethics, 21(8), 449–457. https://doi.org/10.1111/j.1467-8519.2007.00582.x , see also Mnisi, F. M. (2020). An African analysis based on ethics of Ubuntu - are human embryonic stem cell patents morally justifiable? African Insight, 49(4). [14] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics, 22(2), 112–122. https://doi.org/10.1111/dewb.12324 [15] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics, 22(2), 112–122. https://doi.org/10.1111/dewb.12324 [16] Jackson, C.S., Pepper, M.S. Opportunities and barriers to establishing a cell therapy programme in South Africa. Stem Cell Res Ther 4, 54 (2013). https://doi.org/10.1186/scrt204; Pew Research Center. (2014, May 1). Public health a major priority in African nations. Pew Research Center’s Global Attitudes Project. https://www.pewresearch.org/global/2014/05/01/public-health-a-major-priority-in-african-nations/ [17] Department of Health Republic of South Africa. (2021). Health Research Priorities (revised) for South Africa 2021-2024. National Health Research Strategy. https://www.health.gov.za/wp-content/uploads/2022/05/National-Health-Research-Priorities-2021-2024.pdf [18] Oosthuizen, H. (2013). Legal and Ethical Issues in Stem Cell Research in South Africa. In: Beran, R. (eds) Legal and Forensic Medicine. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-32338-6_80, see also: Gaobotse G (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142 [19] United States Bureau of Citizenship and Immigration Services. (1998). Tunisia: Information on the status of Christian conversions in Tunisia. UNHCR Web Archive. https://webarchive.archive.unhcr.org/20230522142618/https://www.refworld.org/docid/3df0be9a2.html [20] Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142 [21] Kooli, C. Review of assisted reproduction techniques, laws, and regulations in Muslim countries. 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In Recent Advances in Theories and Practice of Chinese Medicine (p. 79). InTech. [26] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students. Stem cells international, 2021, 6667743. https://doi.org/10.1155/2021/6667743 [27] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students. Stem cells international, 2021, 6667743. https://doi.org/10.1155/2021/6667743 [28] Zhang, J. Y. (2017). Lost in translation? accountability and governance of Clinical Stem Cell Research in China. Regenerative Medicine, 12(6), 647–656. https://doi.org/10.2217/rme-2017-0035 [29] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences, 8(1). https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199 [30] Chen, H., Wei, T., Wang, H. et al. Association of China’s two-child policy with changes in number of births and birth defects rate, 2008–2017. BMC Public Health 22, 434 (2022). https://doi.org/10.1186/s12889-022-12839-0 [31] Azuma, K. Regulatory Landscape of Regenerative Medicine in Japan. Curr Stem Cell Rep 1, 118–128 (2015). https://doi.org/10.1007/s40778-015-0012-6 [32] Harris, R. (2005, May 19). Researchers Report Advance in Stem Cell Production. NPR. https://www.npr.org/2005/05/19/4658967/researchers-report-advance-in-stem-cell-production [33] Park, S. (2012). South Korea steps up stem-cell work. Nature. https://doi.org/10.1038/nature.2012.10565 [34] Resnik, D. B., Shamoo, A. E., & Krimsky, S. (2006). Fraudulent human embryonic stem cell research in South Korea: lessons learned. Accountability in research, 13(1), 101–109. https://doi.org/10.1080/08989620600634193. [35] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6 [36]Association for the Advancement of Blood and Biotherapies. https://www.aabb.org/regulatory-and-advocacy/regulatory-affairs/regulatory-for-cellular-therapies/international-competent-authorities/saudi-arabia [37] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6 [38] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6 Culturally, autonomy practices follow a relational autonomy approach based on a paternalistic deontological health care model. The adherence to strict international research policies and religious pillars within the regulatory environment is a great foundation for research ethics. However, there is a need to develop locally targeted ethics approaches for research (as called for in Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6), this decision-making approach may help advise a research decision model. For more on the clinical cultural autonomy approaches, see: Alabdullah, Y. Y., Alzaid, E., Alsaad, S., Alamri, T., Alolayan, S. W., Bah, S., & Aljoudi, A. S. (2022). Autonomy and paternalism in Shared decision‐making in a Saudi Arabian tertiary hospital: A cross‐sectional study. Developing World Bioethics, 23(3), 260–268. https://doi.org/10.1111/dewb.12355; Bukhari, A. A. (2017). Universal Principles of Bioethics and Patient Rights in Saudi Arabia (Doctoral dissertation, Duquesne University). https://dsc.duq.edu/etd/124; Ladha, S., Nakshawani, S. A., Alzaidy, A., & Tarab, B. (2023, October 26). Islam and Bioethics: What We All Need to Know. Columbia University School of Professional Studies. https://sps.columbia.edu/events/islam-and-bioethics-what-we-all-need-know [39] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics. Research Ethics, 17(2), 228-241. https://doi.org/10.1177/1747016120966779 [40] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics. Research Ethics, 17(2), 228-241. https://doi.org/10.1177/1747016120966779 [41] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East. Nature 510, 189. https://doi.org/10.1038/510189a [42] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East. Nature 510, 189. https://doi.org/10.1038/510189a [43] The EU’s definition of autonomy relates to the capacity for creating ideas, moral insight, decisions, and actions without constraint, personal responsibility, and informed consent. However, the EU views autonomy as not completely able to protect individuals and depends on other principles, such as dignity, which “expresses the intrinsic worth and fundamental equality of all human beings.” Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3 [44] Council of Europe. Convention for the protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (ETS No. 164) https://www.coe.int/en/web/conventions/full-list?module=treaty-detail&treatynum=164 (forbidding the creation of embryos for research purposes only, and suggests embryos in vitro have protections.); Also see Drabiak-Syed B. K. (2013). New President, New Human Embryonic Stem Cell Research Policy: Comparative International Perspectives and Embryonic Stem Cell Research Laws in France. Biotechnology Law Report, 32(6), 349–356. https://doi.org/10.1089/blr.2013.9865 [45] Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3 [46] Tomuschat, C., Currie, D. P., Kommers, D. P., & Kerr, R. (Trans.). (1949, May 23). Basic law for the Federal Republic of Germany. https://www.btg-bestellservice.de/pdf/80201000.pdf [47] Regulation of Stem Cell Research in Germany. Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-germany [48] Regulation of Stem Cell Research in Finland. Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-finland [49] Regulation of Stem Cell Research in Spain. Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-spain [50] Some sources to consider regarding ethics models or regulatory oversights of other cultures not covered: Kara MA. Applicability of the principle of respect for autonomy: the perspective of Turkey. J Med Ethics. 2007 Nov;33(11):627-30. doi: 10.1136/jme.2006.017400. PMID: 17971462; PMCID: PMC2598110. Ugarte, O. N., & Acioly, M. A. (2014). The principle of autonomy in Brazil: one needs to discuss it ... Revista do Colegio Brasileiro de Cirurgioes, 41(5), 374–377. https://doi.org/10.1590/0100-69912014005013 Bharadwaj, A., & Glasner, P. E. (2012). Local cells, global science: The rise of embryonic stem cell research in India. Routledge. For further research on specific European countries regarding ethical and regulatory framework, we recommend this database: Regulation of Stem Cell Research in Europe. Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-europe [51] Klitzman, R. (2006). Complications of culture in obtaining informed consent. The American Journal of Bioethics, 6(1), 20–21. https://doi.org/10.1080/15265160500394671 see also: Ekmekci, P. E., & Arda, B. (2017). Interculturalism and Informed Consent: Respecting Cultural Differences without Breaching Human Rights. Cultura (Iasi, Romania), 14(2), 159–172.; For why trust is important in research, see also: Gray, B., Hilder, J., Macdonald, L., Tester, R., Dowell, A., & Stubbe, M. (2017). Are research ethics guidelines culturally competent? Research Ethics, 13(1), 23-41. https://doi.org/10.1177/1747016116650235 [52] The Qur'an (M. Khattab, Trans.). (1965). Al-Mu’minun, 23: 12-14. https://quran.com/23 [53] Lenfest, Y. (2017, December 8). Islam and the beginning of human life. Bill of Health. https://blog.petrieflom.law.harvard.edu/2017/12/08/islam-and-the-beginning-of-human-life/ [54] Aksoy, S. (2005). Making regulations and drawing up legislation in Islamic countries under conditions of uncertainty, with special reference to embryonic stem cell research. Journal of Medical Ethics, 31:399-403.; see also: Mahmoud, Azza. "Islamic Bioethics: National Regulations and Guidelines of Human Stem Cell Research in the Muslim World." Master's thesis, Chapman University, 2022. https://doi.org/10.36837/ chapman.000386 [55] Rashid, R. (2022). When does Ensoulment occur in the Human Foetus. Journal of the British Islamic Medical Association, 12(4). ISSN 2634 8071. https://www.jbima.com/wp-content/uploads/2023/01/2-Ethics-3_-Ensoulment_Rafaqat.pdf. [56] Sivaraman, M. & Noor, S. (2017). Ethics of embryonic stem cell research according to Buddhist, Hindu, Catholic, and Islamic religions: perspective from Malaysia. Asian Biomedicine,8(1) 43-52. https://doi.org/10.5372/1905-7415.0801.260 [57] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.), Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues (pp. 79-94). Berkeley: University of California Press. https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005 [58] Lecso, P. A. (1991). The Bodhisattva Ideal and Organ Transplantation. Journal of Religion and Health, 30(1), 35–41. http://www.jstor.org/stable/27510629; Bodhisattva, S. (n.d.). The Key of Becoming a Bodhisattva. A Guide to the Bodhisattva Way of Life. http://www.buddhism.org/Sutras/2/BodhisattvaWay.htm [59] There is no explicit religious reference to when life begins or how to conduct research that interacts with the concept of life. However, these are relevant verses pertaining to how the fetus is viewed. ((King James Bible. (1999). Oxford University Press. (original work published 1769)) Jerimiah 1: 5 “Before I formed thee in the belly I knew thee; and before thou camest forth out of the womb I sanctified thee…” In prophet Jerimiah’s insight, God set him apart as a person known before childbirth, a theme carried within the Psalm of David. Psalm 139: 13-14 “…Thou hast covered me in my mother's womb. I will praise thee; for I am fearfully and wonderfully made…” These verses demonstrate David’s respect for God as an entity that would know of all man’s thoughts and doings even before birth. [60] It should be noted that abortion is not supported as well. [61] The Vatican. (1987, February 22). Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation Replies to Certain Questions of the Day. Congregation For the Doctrine of the Faith. https://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19870222_respect-for-human-life_en.html [62] The Vatican. (2000, August 25). Declaration On the Production and the Scientific and Therapeutic Use of Human Embryonic Stem Cells. Pontifical Academy for Life. https://www.vatican.va/roman_curia/pontifical_academies/acdlife/documents/rc_pa_acdlife_doc_20000824_cellule-staminali_en.html; Ohara, N. (2003). Ethical Consideration of Experimentation Using Living Human Embryos: The Catholic Church’s Position on Human Embryonic Stem Cell Research and Human Cloning. Department of Obstetrics and Gynecology. Retrieved from https://article.imrpress.com/journal/CEOG/30/2-3/pii/2003018/77-81.pdf. [63] Smith, G. A. (2022, May 23). Like Americans overall, Catholics vary in their abortion views, with regular mass attenders most opposed. Pew Research Center. https://www.pewresearch.org/short-reads/2022/05/23/like-americans-overall-catholics-vary-in-their-abortion-views-with-regular-mass-attenders-most-opposed/ [64] Rosner, F., & Reichman, E. (2002). Embryonic stem cell research in Jewish law. Journal of halacha and contemporary society, (43), 49–68.; Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.), Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues (pp. 79-94). Berkeley: University of California Press. https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005 [65] Schenker J. G. (2008). The beginning of human life: status of embryo. Perspectives in Halakha (Jewish Religious Law). Journal of assisted reproduction and genetics, 25(6), 271–276. https://doi.org/10.1007/s10815-008-9221-6 [66] Ruttenberg, D. (2020, May 5). The Torah of Abortion Justice (annotated source sheet). Sefaria. https://www.sefaria.org/sheets/234926.7?lang=bi&with=all&lang2=en [67] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.), Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues (pp. 79-94). Berkeley: University of California Press. https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005 [68] Gert, B. (2007). Common morality: Deciding what to do. Oxford Univ. Press. [69] World Medical Association (2013). World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA, 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053 Declaration of Helsinki – WMA – The World Medical Association.; see also: National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1979). The Belmont report: Ethical principles and guidelines for the protection of human subjects of research. 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