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Abstract: The article argues that we live in a world in which nodal forms of governance are commonplace. Nodal governance is an elaboration of contemporary network theory explaining how a variety of actors operating within social systems interact along networks to govern the systems they inhabit. We draw upon Hayek to argue that any collectivity can be seen as an outcome-generating system whose workings are generally too complex to be fully understood. Governance in such systems is constituted in nodes that mobilize the knowledge and capacity of members to manage the course of events. Nodes have four essential characteristics: mentalities, technologies, resources, and institutions. Nodes govern in a wide variety of ways, including by mobilizing resources, deploying technologies, using rules or laws, and directly governing people within the system. Two case studies illustrate how nodal governance operates and explores its regulatory possibilities. The development of the TRIPS agreement on intellectual property is one story of nodal governance that blurs the line between public and private spheres and has global consequences. It also demonstrates why nodal governance is neither necessarily democratic nor a method that secures more goods than bads for the population as a whole. The Zwelethemba Model of Local Capacity Governance, a security project in poor South African townships, demonstrates that the creation of governing nodes can be a means of promoting democracy and self-efficacy within collectives. It shows that new nodes can change relationships among existing nodes and even change the operation of formal government structures. In sum, nodal governance has potentialities for the weak and the strong, but the possibilities that can be realized depends on how nodal governance is constituted.
Governance, democracy
Abstract: All states have criminal laws that can be used to punish sexual behaviors that pose some risk of HIV transmission; half have HIV-specific laws criminalizing sexual contact by people with HIV unless they abstain from unsafe sex, or disclose their HIV status and obtain consent from their partners. Whether these laws influence behavior is unknown. Illinois and New York exhibit contrasting legal conditions. Illinois has an HIV-specific law explicitly requiring disclosure by HIV+ persons. New York has no HIV-specific law. This study tests the null hypothesis that differences in law and beliefs about the law do not influence condom use in anal or vaginal sex. In this empirical study, 490 people at elevated risk of HIV were interviewed, 248 in Chicago and 242 in New York City. Approximately half in each state were men who have sex with men ("MSM") and half were injecting drug users ("IDUs"). Respondents were classified as MSM if they reported ever having had sex with a man, and as IDUs if they reported having injected drugs at least twice in the last three months. One-hundred sixty two subjects reported known HIV infection (Chicago 58; New York City 104). Three-hundred twenty-eight reported being HIV negative or not knowing their HIV status. Indicators of the law were 1) residence in the state, and 2) belief that it is a crime for a person with HIV to have sex with another person without disclosing his or her serostatus. Using stepwise logistic regression, we examined independent predictors of unprotected sex, adjusting for factors including age, race/ethnicity, disclosure, biological sex at birth, sexual orientation and number of partners. People who lived in a state with a criminal law explicitly regulating sexual behavior of the HIV-infected were little different in their self-reported sexual behavior from people in a state without such a law. People who believed the law required the infected to practice safer sex or disclose their status reported being just as risky in their sexual behavior as those who did not. Our data do not support the proposition that passing a law prohibiting unsafe sex or requiring disclosure of infection influences people's normative beliefs about risky sex. Most people in our study believed that it was wrong to expose others to the virus and right to disclose infection to their sexual partners. These convictions were not influenced by the respondents' beliefs about the law or whether they lived in a state with such a law or not. Because law was not significantly influencing sexual behavior, our results also undermine the claim that such laws drive people with and or at risk of HIV away from health services and interventions. We failed to refute the null hypothesis that criminal law has no influence on sexual risk behavior. Criminal law is not a clearly useful intervention for promoting disclosure by HIV+ people to their sex partners. Given concerns about possible negative effects of criminal law, such as stigmatization or reluctance to cooperate with health authorities, our findings suggest caution in deploying criminal law as a behavior change intervention for seropositives.
HIV/AIDS, criminal law, public health
Abstract: 1990 Americans with Disabilities Act (ADA) was expected to decrease discrimination against people with disabilities. However, discrimination against people with psychiatric disabilities may exist in the legal system that is charged with implementing the ADA. This study describes and compares the characteristics of people with psychiatric and nonpsychiatric disabilities who filed employment discrimination lawsuits under Title I of the Americans with Disabilities Act (ADA) from 1993 to 2001. The paper examines actual and perceived outcomes of these lawsuits, features of the surrounding legal process, effects of psychiatric disability status on receiving a benefit from litigation, and the predictors of overall satisfaction with the experience of bringing an ADA Title 1 claim. A national stratified quasi-random sample of N=537 persons filing ADA employment discrimination lawsuits in federal court was interviewed by telephone. Subsamples of n=148 persons with psychiatric disabilities and n=222 persons with nonpsychiatric disabilities were compared. The primary outcome was receiving a benefit from filing an ADA Title I lawsuit, defined as a court ruling in favor of the plaintiff or a settlement between the parties, with the plaintiff's confirmation of having received some benefit. The secondary outcome was the degree of overall satisfaction with the experience of bringing a claim of employment discrimination from the initial charging process through litigation. The study finds that people with psychiatric disability fared significantly worse in employment discrimination lawsuits than their counterparts with nonpsychiatric disabilities, controlling for other significant predictors of litigation outcome including health status, plaintiff's education, reasons for the lawsuit, and assistance by a lawyer. Plaintiffs with psychiatric disabilities were also significantly less satisfied with the overall process of filing a claim of employment discrimination and bringing a lawsuit under the ADA. The effects of poor outcome on dissatisfaction were mediated by perceived unfairness, lack of "voice," and lack of procedural justice in the charge process and litigation. These disparities are not easily explained by differences in the law, the behavior of employers or lawyers, or the effects of psychiatric illness on perception. Even accounting for the influence of outcome, people with psychiatric disabilities experienced less procedural justice than others. While the disparities are clear, the causes are not. There is no reason to suspect that actors in the legal system - personnel in state agencies, judges, court clerks, lawyers for the defendants, and even lawyers for the plaintiffs - are immune from the stigma of mental illness, but also no reason to jump to the conclusion that the system is rife with "sanism." What should not be doubted is the need for a vigorous response to these findings that ensures that the system that is intended to protect people from discrimination does not discriminate.
Justice, disability, ADA
Abstract: Criminal law is one of the regulatory tools being used in the United States to influence behavior by persons who have HIV/AIDS. This article reports on the characteristics and prevalence of HIV-specific criminal exposure and transmission laws, and the enforcement of those laws through prosecutions during the period 19862001. It also examines the possible mechanisms through which criminal law influences behavior and considers how these might apply to the specific laws described.
Abstract: SARS was a reminder of the continuing threat of epidemic disease in the world. This paper discuss examples of how regions faced with SARS turned to disease control strategies based on public health law, such as "personal control measures" like quarantine and isolation; weaknesses in the ability of nations' legal systems to frame balanced, coordinated and well-executed public health programs for rapid disease containment; and the responses of diverse populations to restrictive personal control measures. The paper uses the experiences of governmental entities of Singapore, the Hong Kong Special Administrative Region, Canada, and the United States to illustrate important public health law and preparedness challenges for infectious disease control. While the experiences of these nations may not perfectly apply in other nations, they represent a spectrum of political and legal cultures. The paper concludes with recommendations encouraging enhanced legal preparations for public health emergencies.
Public Health Law, International Law, WHO
Abstract: There is widespread agreement that governance is important and in flux. But exactly what is governance? How is it changing, what is happening to the state, and how are actors at various levels of social organization promoting or adapting to changes in governance? The aim of this paper is to explore what researchers and theorists in a wide range of fields have made of the ferment in governance, and to identify important lessons for people interested in how to improve it locally, nationally and internationally. Part II, canvasses definitions of governance. Part III looks at how scholars in a variety of fields have described the changes in contemporary governance. The main theme in the literature is the fragmentation of state sovereignty and the consequent multiplication in the number of agencies and forms of power that are active in the management of social systems. Throughout the literature there is discussion of the governing power of transnational corporations. NGOs and foundations, though not generally as wealthy or effective as corporations, are also vital governors at all levels. Dark networks like Al Qaida and criminal cartels are also seen as agencies of governance. Part IV examines efforts to remake governance over the past twenty years, identifying two genres of reform: reinvention of government and reinvention of governance. Reinventing government involves efforts to recalibrate state structures to improve their capacity to exercise centralized control of diffuse systems, often somewhat paradoxically by ceding much of the implementation of policy to non-state actors through devices like self-regulation and governance partnerships. Reinventing governance uses some of the same methods of power, but differs from reinventing government in that it takes innovation beyond the state-centered or hybrid forms into efforts to mobilize governors who may act with little or no connection with the state. The paper concludes with some critical observations about contemporary scholarship on governance innovation.
Governance, Regulation
Abstract: Context: The 1990 Americans with Disabilities Act (ADA) was expected to decrease discrimination against and to increase the well-being of people with disabilities. The tendency of court decisions to limit rights under the ADA has been widely reported, but there have been no large-scale studies of court utilization and the overall pattern of outcomes. Objective: This paper reports the national prevalence and outcomes of ADA employment discrimination lawsuits filed in federal court in the decade after the ADA's passage. Design, Setting, and Cases: A two-stage stratified quasi-random sampling procedure was used to identify 8,777 ADA employment discrimination lawsuits in 16 federal district courts that were filed between January 1, 1993 and March 31, 2001 was screened; 4,114 ADA Title I cases were reviewed. Main Outcome Measure: Receiving a benefit from filing an ADA Title I lawsuit, defined as a court ruling in favor of the plaintiff or a settlement between the parties. Results: 201,371 Title I claims were eligible to be filed in federal court between 1993 and 2001. Of these, only an estimated 27,724 (13.8%) were actually filed. Title I claims took slightly longer than other civil rights or employment claims to be resolved. Plaintiffs received a beneficial outcome in 62% of cases. Plaintiffs benefited primarily through settlement, while defendants won 97% of the cases that were decided by a judge or jury. Attorney representation doubled plaintiffs' chances of benefiting. Conclusions: Published case decisions create a misleading impression of ADA outcomes. ADA lawsuits benefit most people who file them. However, the low rate of filing and the importance of having a lawyer raise concerns about the ability of those experiencing discrimination to file claims or get legal services.
disability, health, policy, law, ADA, employment, discrimination
Abstract: Throughout the HIV epidemic, criminal law has been invoked to deter and punish sexual transmission. The public health community has not favored the enactment of criminal laws specifically targeting people with HIV, nor endorsed the application of general criminal laws to HIV - but neither has it taken a vigorous stand against them. Meanwhile, governments continue to adopt HIV-specific criminal laws, and individuals with HIV continue to be prosecuted under general criminal law around the world. This comment argues that criminal law cannot draw reasonable, enforceable lines between criminal and non-criminal behavior, nor protect individuals or society from HIV transmission. In the protection of women, it is a poor substitute for policies that go to the roots of subordination and gender-based violence. The use of criminal law to address HIV is inappropriate except in rare cases where a person acts with conscious intent to transmit HIV and does so.
human rights, sexual freedom, public health
Abstract: Institutional Review Boards (IRBs) are required, on behalf of universities and other research institutions, to ensure that research on human subjects comports with indeterminate standards of beneficence, justice and autonomy. Writing in 2001, the National Bioethics Advisory Commission (NBAC) complained that IRBs were overwhelmed not only by high workloads and limited resources but also a regulatory system that often distracts from rather than focuses on key ethical issues. Because the quality of an IRBs deliberations, let alone the accuracy of its ethical decisions, cannot readily be verified, institutional compliance with federal regulations is measured almost entirely by review of records and consent forms. NBAC concluded that this emphasis by regulators on procedure is frustrating to IRBs and investigators and also contributes to an atmosphere in which review of research becomes an exercise in avoiding sanctions and liability rather than in maintaining appropriate ethical standards and protecting human participants. The federal Office for Human Research Protection (OHRP) is the primary government agency responsible for enforcing the federal human subject protection regulations, known as the Common Rule, overseeing research at the more than 10,000 federally funded institutions in the country. The OHRP was created in 2000 in response to alleged failures by IRBs and calls for a stronger regulatory oversight role for federal government. Reflecting a trend toward strong protectionism in human subject research, the oversight budget and staff have grown significantly. In this article, we examine OHRP's enforcement letters between January 1, 2002 and June 30, 2004. We find no improvement since NBAC's report, but also that blaming the agency is too simple. The heart of the problem is the paradoxical scheme of embedding virtue in federal regulations, and then constructing an enforcement system that purports to encourage deliberation but in fact enforces procedural diligence and paperwork through top-down command and control methods. This is not to say that the Common Rule is a complete failure; on the contrary, we think IRBs regularly improve the ethicality of studies and help promote ethical consciousness in researchers. It does suggest that fundamental changes in the system will be required to solve the problems identified by NBAC and other critics.
Institutional Review Boards, Research, Implementation
Abstract: Background: The United States has the highest rate of imprisonment of any country in the world. African Americans and Hispanics comprise a disproportionately large share of the prison population. We applied a prison life expectancy to specify differences in exposure to imprisonment by gender and race at the population level. Methods: The impact of imprisonment on life expectancy in the United States was measured for each year from 2000 to 2004, and then averaged. Using the Sullivan method, prison and prison-free life expectancies were estimated by dividing the years lived in each age range of the life table into these two states using prevalence of imprisonment by gender and race. Results: African American males can expect to spend on average 3.09 years in prison or jail over their lifetime and Hispanic and Caucasian males can spend on average 1.06 and 0.50 years, respectively. African American females, on the other hand, can expect to spend on average 0.23 years in these institutions and Hispanic and Caucasian females can expect to spend on average 0.09 and 0.05 years, respectively. Overall, African American males, the highest risk group, can expect to spend on average 61.80 times longer in prison or jail as compared to Caucasian women, the lowest risk group. Conclusion: There are clear gender and racial gradients in life expectancy spent in prison in the United States. Future research needs to examine how current imprisonment practice in the United States may influence population health and health disparities.
race, incarceration, racial disparities
Abstract: Laws and law enforcement practices influence the risk environment for commercial sex workers in China. Law is also a prime potential mode of structural intervention. In China, evidence indicates commercial sex workers as a group are an important segment of the emerging Chinese HIV epidemic. China is undergoing a dramatic economic transition characterized by growing and extreme inequality in the population. This is influencing the growth of the sex industry as a site of economic activity by poorer people, particularly rural women. Sex worker behavior is also influenced by laws and law enforcement practices. Corruption among law enforcement officials, the system for funding law enforcement, and the limited protection of human rights, all have the potential to create a more dangerous environment for sex workers in relation to HIV and STDs. Despite intensive law enforcement action and considerable expense, the state has not achieved the goal of eliminating prostitution. The commercial sex trade has not been forbidden just informally regulated. Police practices are, to some extent, independent of the written laws concerning prostitution. Ethnographic data are reviewed and recommendations are offered for further research.
prostitution, HIV, police, criminal law
Abstract: Urban health promotion is not simply a matter of the right interventions, or even the necessary resources. Urban (and indeed global) health depends to an important extent on governance, the institutions and processes through which societies manage the course of events. This paper describes the concept of governance, distinguishing between reforms aimed at improving how government works and innovations that more fundamentally reinvent governance by developing new institutions and processes of local stakeholder control. The paper highlights strategies urban governors can use to maximize their influence on the national and international decisions that structure urban life. It concludes with some observations on the limitations of local governance strategies and the importance of establishing a "virtuous circuit" of governance through which urban dwellers play a greater role in the formation and implementation of policy at the national and global levels.
Governance, Government, Strategies, Urban Health
Abstract: This essay integrates current thinking about the nature and workings of stigma with current sociolegal research to clarify the relationship between law and stigma in public health. This integrated view has implications for research, policy, and the day-to-day work of providing effective care and prevention services for people with and at risk of stigmatized conditions. It also calls into question, from a moral standpoint, the claim that stigma can be used positively as a tool for changing behavior for the sake of public health.
Abstract: Supervised injection facilities (SIFs) have shown promise in reducing harms and social costs associated with injection drug use. Favorable evaluations in other countries have raised the issue of their implementation in the United States. Recognizing that laws shape health interventions targeting drug users, we analyze the legal environment for publicly authorized SIFs in the United States. States and some municipalities have the power to authorize SIFs under state law, but federal authorities could still interfere with these facilities under the Controlled Substances Act. A state- or locally authorized SIF could proceed free of legal uncertainty only if federal authorities explicitly authorized it or were persuaded not to interfere. Given legal uncertainty, and the similar experience of syringe exchange programs, we recommend a process of sustained health research, strategic advocacy, and political deliberation.
HIV/AIDS, prevention, harm reduction
Abstract: Removal of legal barriers to syringe access has been identified as an important part of a comprehensive approach to reducing HIV transmission among injecting drug users (IDUs). Legal barriers include both law on the books and law on the streets, i.e., the actual practices of law enforcement officers. Changes in syringe and drug control policy can be ineffective in reducing such barriers if police continue to treat syringe possession as a crime or evidence of criminal activity. Despite the integral role of police officers in health policy implementation, little is known of their knowledge of, attitudes toward, and enforcement response to harm-minimization schemes. We conducted qualitative interviews with 14 police officers in an urban police department following decriminalization of syringe purchase and possession. Significant findings include: respondents were generally misinformed about the law legalizing syringe purchase and possession; accurate knowledge of the law did not significantly change self-reported law enforcement behavior; while anxious about accidental needle sticks and acquiring communicable diseases from IDUs, police officers were not trained or equipped to deal with this occupational risk; respondents were frustrated by systemic failures and structural barriers that perpetuate the cycle of substance abuse and crime, but blamed users for poor life choices. These data suggest a need for more extensive study of police attitudes and behaviors towards drug use and drug users. They also suggest changes in police training and management aimed at addressing concerns and misconceptions of the personnel, and ensuring that the legal harm reduction programs are not compromised by negative police interactions with IDUs.
Injection drug use, Harm reduction, Law enforcement attitudes, Police behaviour, Policy implementation, Qualitative studies, Needle stick injuries
Abstract: Title I of the Americans with Disabilities Act prohibits employment discrimination on the basis of disability. Since its passage in 1990, debate has raged about whether the statute is doing any good. A steady stream of narrowing court decisions has led some to declare the law a failure. This article reviews the empirical evidence on the effectiveness of Title I. Many studies find a decline in employment rates among the disabled in the wake of the ADA, but the evidence that these declines were caused by the ADA is weak. Title I protects people who require no more than a "reasonable accommodation" to do the job in question; the employment data include a much broader range of people, many if not most of whom could not meet Title I's qualification standard. Studies that "correct" for this difference find no or even a slightly positive impact on employment. Studies of employer attitudes and practices show a positive change, as do a few studies of the "empowerment" felt by people with disabilities. Many commentators attribute any weakness in the effect of the ADA to the narrow interpretation of key elements of the statute by the federal courts. While the statute has been narrowly interpreted, a more important factor may be the flaws in processing of complaints by the EEOC and state partner agencies. While the limitations of the statute's language are real, Title I has provided benefits to workers with disabilities and could provide more benefits if enforcement mechanisms were improved. We conclude that Congress should revisit the promises it made in the ADA. For people whose disabilities make it difficult to work, even with an accommodation, anti-discrimination law cannot have much of an effect on employment rates except as part of a comprehensive policy encompassing social security, health care, training programs and tax incentives. Only Congress can rewrite the statute to protect people who can work but whose disabilities have been excluded from the statute by the courts. And Congress, state legislatures and the bar must take steps to repair our broken enforcement system for employment discrimination disputes: more funds, greater use of mediation, and better legal services are essential to making the ADA a real remedy for employment discrimination.
employment, discrimination, disability, review
Abstract: Emerging Issues in Chinese Health Law is a survey of some of the most pertinent issues in health law, health regulation, and public health now unfolding in China. It is being published in Chinese with English translations of the article abstracts. Chapter topics include HIV/AIDS control, access to essential medications, malpractice, organ donation, brain death, bioethics and health and human rights.
public health law, health law, bioethics, China
Abstract: Social epidemiology has made a powerful case that health is determined not just by individual-level factors such as our genetic make-up, access to medical services, or lifestyle choices, but also by social conditions, including the economy, law, and culture. Indeed, at the level of populations, evidence suggests that these "structural" factors are the predominant influences on health. Legal scholars in public health, including those in the health and human rights movement, have contended that human rights, laws and legal practices are powerfully linked to health. Social epidemiology and health-oriented legal scholarship are complementary in their focus and their research needs. Legal scholarship has identified plausible ways in which legal and human rights factors could be influencing health, but empirical evidence has been limited. Epidemiology has marshaled considerable evidence that social structures are broadly related to the level and distribution of health in a society, but bolstering claims of causation and intervening both require the elucidation of the mechanisms through which social structures actually influence health. Finding these mechanisms requires the integration of all the sciences that can offer explanations of the phenomena at issue, from the physiology of stress to the sociology of social status. Law, we suggest here, is an important mechanism to pursue. In this article, we present an heuristic framework for including law as a social factor in epidemiological research, and conversely for understanding how law can have health consequences worthy of consideration by lawyers. The framework posits law operating simultaneously in two broadly defined roles: Laws and legal practices contribute to the development, and influence the stability, of social conditions that have been associated with population health outcomes (i.e., law contributes to the creation and perpetuation of fundamental social determinants of health), and law operates as a pathway along which broader social determinants of health have an effect (i.e., law is one of the social systems through which more fundamental social characteristics work to create health effects). Consideration of existing data in epidemiology and the social science of law supports the plausibility and usefulness of this framework.
Human Rights, Public Health Law, Social Capital, Social Determinants of Health
Abstract: Public health activities present important ethical issues and risks to human subjects, whether these activities are considered research or practice. The federal regulations designed to protect human subjects during research studies, known as the Common Rule, may apply to a number of public health activities, such as disease reporting, surveys, or review of medical records. The extent that the Common Rule should apply to public health practice is still debated, but the National Bioethics Advisory Commission (NBAC) suggests that state law could offer meaningful guarantees that public health activities will protect the rights and welfare of individuals. This study sought to evaluate whether state public health law provides protection for people comparable to the Common Rule. State statutes that set the powers and duties of health agencies were reviewed to identify provisions that provided protections analogous to those provided by the Common Rule. The Common Rule contains six key protections: 1) consent for data collection; 2) protection of private information in collected data; 3) use of a bona fide, safe, and effective research design; 4) equitable selection of subjects; 5) appropriate data safety monitoring; and 6) protection of vulnerable populations. Our analysis showed that the protection provided to the subjects of public health practice by state law is comparable to the protection provided to research subjects under the Common Rule, but clearly not identical. The Common Rule requires individual informed consent prior to information collection. By contrast, there is no state law requirement for individualized consent for many kinds of data collection; consent may not be revoked; and notice for most people will be formal rather than actual. Privacy protections and data security requirements, which are explicitly outlined in the Common Rule, vary greatly under state public health laws. Data collection plans are not required under state law to be formally reviewed for either scientific or ethical quality. Ethical performance, including protection or inclusion of vulnerable populations, is not an explicit performance measure in the accountability/ management framework of public health. The Common Rule achieves accountability through the Institutional Review Board system; state law obtains accountability more indirectly through courts, elections, and the media. Ultimately, state public health law is an important regulatory resource to protect human subjects, complementing not only the Common Rule, but other ethical standards. The importance of effective public health practice justifies the development and understanding of regulatory approaches that promote excellent public health practice, including respect for human subjects.
public health, human subjects research, surveillance, Common Rule, public health ethics, public health law, public health regulation, public health practice
Abstract: Virtually all research involving human subjects in the US must be reviewed by an institutional review board, a form of research ethics review board. This article reports the results of qualitative research on how investigators regard this regulatory regime. Interviews were conducted with forty investigators conducting health-related research. Most respondents shared the regulations' goals, but doubted that the regulations, as implemented, promoted these goals efficiently, effectively and fairly. The interviews suggest that efforts to raise researchers' ethical consciousness have been, over time, quite successful, but that implementation of the regulations remains problematic. Research aimed at better defining the problem to be solved by the regulatory system, and at assessing the effectiveness of the regulatory tools for solving properly defined problems, could guide a more productive debate about human subject protection.
Research Ethics, Regulation, Implementation, Human Subjects
Abstract: Security matters to health. Crime victimization causes death, injury and illness. Injury or death is an occupational hazard for police. The criminal justice system causes injury and illness in the course of attempting to punish and deter crime. Policing policies and practices can have a significant impact on the ability of other public and private agencies to successfully implement health interventions. Police themselves routinely deal with people who have serious health needs, and even on occasion are the primary agents implementing health interventions. The health consequences of law enforcement are far from trivial, making it important for health to be integrated as a matter of concern into criminological research and law enforcement practice. The link between health and policing, and the significance of health outcomes, should be more fully accepted in criminology. Likewise, the governance of security is an important matter for public health research and practice. If health outcomes are seen as an important product of security arrangements, conventional policing can be reconfigured to reduce negative health consequences and promote positive ones. There are, however, limits to the extent that state-centered policing can be expected to change. The theory of nodal governance and the programmatic work of innovators in the "governance of security" movement offer useful insights into the coordination of health and security outside the state-centered policing framework. Experience with both health and security-based schemes shows the promise of "microgovernance" strategies that promote health and security by mobilizing local knowledge and capacity among poor people with historically poor relations with conventional police systems. Serious practical and theoretical questions can be raised about the long-term prospects of these strategies, particularly the capacity of small groups of poor people to manage events flowing from more generalized and more powerful sources. While valid in some respects, however, such criticism misses the "democratic experimentalism" as the heart of the governance of security approach.
health, policing, law
Abstract: Under U.S. regulations known as the Common Rule, federally-supported human-subject research must be reviewed by an Institutional Review Board (IRB). The Common Rule system looks from a distance like an innovative instantiation of prescriptions for constitutive regulation and soft law, but in practice has grown into a self-referential, unresponsive and legalistic bureaucracy. The paper reviews the criticism of the system and discusses why it fails to regulate in an efficient and effective way, pointing in particular to the poor fit between the IRB and its assigned tasks. Turning to reforms, the paper uses the heuristic of regulatory space to describe the range of actual and potential regulators with the capacity to set standard, monitor compliance and discipline violators in the realm of research. Three essential conceptual changes are set out to frame the technical regulatory reform discussion: facing up to the built-in limitations of the IRB as an oversight body; narrowing the range of risks the system is tasked to control; and disentangling the conflicting regulatory logics of behavioral standard-setting and virtue promotion. It concludes with a roster of possible changes that would make the IRB a more responsive regulator, enroll a wider range of actors in the promotion of ethical virtue, focus resources on more serious risks, and address the structural causes of researcher misconduct.
censorship, ethics, responsive regulation, institutional review board
Abstract: Historically, public health law has been shaped by the social response to serious epidemics. Boards of health and full-fledged health departments were created in the late 18 and 19th centuries in response to yellow fever and cholera. Disease reporting, mandatory screening, and compulsory treatment became common in the law in response to TB and syphilis. HIV proved to be no exception. The need to respond, and the special role of law as a medium for resolving social disputes in the U.S., gave public health law a renewed importance. Advocates turned to law as a tool for promoting their desired HIV policies. Lawyers, judges, policy-makers and public health officials were challenged to adapt old practices to new needs, and develop new solutions to new problems. In the process, public health law has re-emerged as a vital discipline of public health, with a stronger connection to practice and a deeper intellectual foundation. After a brief overview of the statutes and cases arising from the epidemic, the chapter describes how HIV/AIDS perfected a change in the use of public health power. In the face of HIV/AIDS, public health has accepted the limits of law as a means to coerce behavior change among people with or at risk of communicable disease; at the same time, it has become more interested in understanding and addressing how law contributes to the social conditions in which people would be most likely to behave in healthy ways. The chapter focuses on two examples of this change in practice: the effort to use law to reduce social risk, and the development and application of a human rights framework in public health practice. The chapter concludes with some thoughts on the influence of HIV/AIDS on the future course of law in public health.
HIV, public health law, history, litigation, legislation
Abstract: In the decade following its passage, more than 200,000 employment discrimination complaints were filed under the Americans with Disabilities Act (ADA). This Article presents the findings of an empirical investigation of the implementation of the ADA by the U.S. Equal Employment Opportunity Commission (EEOC) and state and local fair employment practices agencies (FEPAs). Although not as well-covered in the press as ADA litigation, or as debated in the law reviews, these administrative agencies dispose of the vast majority of ADA employment discrimination cases, which must be filed with the agency as a precondition to any later court litigation. Because the EEOC also administers other basic federal antidiscrimination statutes B including Title VII of the Civil Rights Act of 1964, the Age Discrimination in Employment Act, the Equal Pay Act, and Section 501 of the Rehabilitation Act of 1973 B our findings shed important light on the entire enterprise of the enforcement of federal employment discrimination legislation. The article proceeds as follows. Part II is a brief history of the EEOC, describing the transformation of the agency from its creation in 1964 to the present. Our sources of data, and their major limitations, are described in Part III. We provide a basic statistical portrait of the ADA work of the EEOC and FEPAs in Part IV. In Part V, we discuss the factors that are influencing the outcomes of the EEOC process, using a model drawn from policy implementation studies and the results of statistical analyses of our data. Congress passed the ADA with grand promises about the employment of people with disabilities. We conclude that the EEOC simply cannot keep those promises without the resources to do a reasonable investigation of every charge that is not obviously groundless. The ultimate responsibility, and the onus for action, lie on Congress, which has given the EEOC a broad mandate to process employment cases and enforce fair employment laws without ever giving it the resources it would need to do the job properly. Simple fairness to workers and employers alike requires that Congress give the EEOC enough money to properly investigate its charges. Short of that, Congress needs to change the procedures under the Civil Rights Act to allow individuals to drop out of the administrative process sooner, or bypass it altogether.
Disability, Discrimination, Implementation, ADA, Law
Abstract: Ensuring that injection drug users who cannot or will not stop injecting have access to sterile syringes is an important part of a comprehensive approach to reducing the transmission of viral and bacterial infections associated with injection drug use. Despite its public health value, however, syringe access has been politically controversial in the United States. The primary policy questions have been the legality of over-the-counter sales of syringes to IDUs, the legality of syringe possession by IDUs, and the authority of public health officials or private sector providers to initiate access interventions. This Article updates and significantly expands upon prior legal analyses of syringe access. The main focus is the body of law that regulates syringe sale, purchase, possession and disposal in the context of injection drug use in the United States, the District of Columbia, the Virgin Islands and Puerto Rico, including drug paraphernalia laws; syringe prescription laws and regulations; pharmacy regulations and miscellaneous syringe laws; needle exchange laws and regulations; and drug possession laws. To place the law in context, the paper summarizes and critically assesses the public health research on the health effects of syringe access rules and the collateral effects of policies enhancing syringe access for IDUs; examines the public opinion poll results, and discuss the ethics and politics of syringe access reform. It concludes with key recommendations for public policy.
Abstract: Millions of people with cancer, HIV/AIDS and other conditions do not receive the opiod analgesics that would relieve their pain. Millions of others, dependent on illicit opiods, have no access to medication-assisted therapy with methadone or buprenorphine, which has been shown to be effective in treating dependence - and in reducing the risks of HIV infection. There are many reasons for this unfortunate and paradoxical state of affairs, but policy is a crucial factor. In countries throughout the world, drug control policies and outmoded ideas have helped perpetuate negative attitudes about opioids, prevented health care professionals from getting experience in their use, and erected often insurmountable regulatory barriers to their availability. Yet there are numerous stories of successful reduction in policy barriers. With help from the international community, many countries have succeeded in striking a better balance in their drug control laws between law enforcement and good medicine. This report, funded by the U.K. Department for International Development, describes the reform process in four countries - China, India, Romania and Vietnam - highlighting the tactics that international donors, UN agencies and technical experts used to support policy reform.
pain, palliative care, drug treatment, morphine, policy
Abstract: In Stigma and the Ethics of Public Health: Not Can We but Should We, 67 SOCIAL SCIENCE & MEDICINE (2008), Ronald Bayer asks whether "stigmatization always represents a threat to public health?" and whether "there [are] occasions when the mobilization of stigma may effectively reduce the prevalence of behaviors linked to disease and death?" In this commentary, I offer an unambiguous answer: Yes, and No. For purposes of an ethical analysis of stigma in public health practice, we should ignore Erving Goffman's treatment of stigma as a universal phenomenon. We should instead start with his account of how stigma works, and follow scholars like Bruce Link and Jo Phelan in trying to understand stigma as a harmful phenomenon experienced by vulnerable groups. It remains unclear that smokers, the group Bayer chooses as is example, are stigmatized in that sort of framework. If they are, the state and those working under its auspices should not be promoting or indulging that stigma in any way, because stigma is a barbaric form of social control that relies upon the most primitive and destructive of emotions. And chances are it won't work anyway.
Public Health, Ethics, Shaming, tobacco
Abstract: The world's ever-growing urban settlements will not be salubrious without the consistent adoption and effective implementation of healthy public policies. Urban governance is healthy if it promotes a higher level and fairer distribution of health. In the absence of extensive data linking governance directly to health, the review poses two questions as starting points for further study and action: 1) what can we say about how governance is being used to foster healthy public policy at the local level; and 2) how can forms of governance in multi-level systems be arranged to give municipalities more influence on the upstream factors that determine so many of the problems that they face, as well as their capacity to govern? We begin the paper with a basic framework for governance and its relation to health. We then describe a variety of important governance reforms and innovations that have been deployed to improve various aspects of urban life, such as housing, sanitation, security and economic opportunity. We also discuss general reform measures aimed at promoting good government or civic participation across a range of urban policy areas. With these examples in mind, we address the two key challenges of urban governance for health, extracting from the evidence a preliminary set of principles for effective local governance as well as strategies for projecting city power upstream. We conclude with some observations on the limitations of local governance strategies, topics for further study, and the need for people working in health to clarify the nature of their commitment to good governance. An appendix includes case studies.
Abstract: Governance, by which I mean the management of the course of events in a system, is an overarching issue of concern to health from an ecological point of view. Governance consists largely in the policing social relations, environmental conditions and the allocation of resources essential to well-being. Who decides, and how they decide, are key drivers of substantive policy. Moreover, there is at least some epidemiological evidence that the ability of people to participate in the governance of their communities is in itself significant for health. This paper offers an emerging theory of "nodal governance" to describe the management of events in social systems. The use of this theory in mapping, assessing and then productively "destabilizing" these systems is discussed, with particular attention to the extent to which promoting "microgovernance" institutions is a plausible strategy for improving population health. Nodal governance focuses attention on how governance happens - how power is wielded - at specific points within a system, and thus raises essential normative questions about democratic decision making. But the theory, with its obvious intellectual debts to network theory, systems theory and the work of Hayek, also seems to imply a challenge to the sort of thinking about regulation and law often encapsulated in the idea of the "risk society." In the final section of the paper I conclude with some speculations about new, constitutive paradigms for social governance.
Health, Governance, Risk
Abstract: Opioids medicines are the standard of care for treating severe pain. Drugs like methadone and buprenorphine have proven effective in treating dependency on heroin and other opiods. Access to therapeutic opioids is not only medically appropriate - it is the law. The world's drug control treaties recognize that opioid medicines are "indispensable" to proper medical care, and require signatories to take measures to adequately provide for their effective medical use.
In spite of all the reasons that access to therapeutic opioids should be routine everywhere, there remains a huge unmet need and a striking global inequality in access. The WHO has estimated that 80% of the world's cancer patients and half of all people with AIDS suffer untreated severe pain. Millions of injection drug users and illicit opioid users are forced to go without methadone treatment because the opioids needed for care are either overly regulated or under-provided.
The purpose of this report, funded by the U.K. Department for International Development, is to capture what can be learned from past reform efforts, and to set out practical interventions that can help nations at any stage of readiness. Its primary audience is those who fund, advocate for or facilitate policy reform through technical assistance and training. The Blueprint begins with a discussion of the guiding principles of balance and sustainability. It then sets out a strategy for investment in opiod access reform built around an understanding of the cycle of policy learning and identifies tactics for advancing reform that were effective in the countries whose experience we examined.
pain, palliative care, drug treatment, medication-assisted therapy, morphine
Abstract: Law plays essential roles in public health. Law defines health officials' jurisdiction, and specifies how they exercise their authority. It is a tool of public health work used to establish norms for healthy behavior. Policymakers use the law's language of rights, duties and justice in the most important social debates about public health taking place in legislatures, courts and administrative agencies. This article examines the subject and definition of public health, reviews the core functions of public health as they relate to law, identifies challenges confronting communicable disease control, surveys the current landscape of state communicable disease control law, and proposes guidelines for reform of state law to satisfy both legal and public health critiques. The subject of public health. At a minimum the goal of public health is to attain the highest level and widest distribution of physical and mental health that a society reasonably can achieve within the limits of resources available. To effectively combat complex disease threats, the public health approach to disease control must evolve from the microbial, to the behavioral, to the ecological approach. Core functions of public health and the law. Building on the Institute of Medicine's important 1988 study The Future of Public Health, the article identifies the core public health functions necessarily covered by law as: 1) health promotion and disease prevention, 2) assessment, data collection and analysis; 3) provision of medical services; and 4) leadership and policy development. Challenges facing communicable disease control. Health officials must overcome substantial challenges to meet the needs of the public for protection from communicable diseases. These include structural issues such as their limited jurisdiction, popular apathy about public health goals, disease-associated stigma and social hostility that may interfere with effective public health work, and the public's distrust of government health officials. Public health officials must also contend with a crumbling pubic health infrastructure, emergence and re-emergence of old and new disease threats, and changes in the health care environment including managed care and shifting of some disease prevention and surveillance activities from the public to the private sector. Survey of current public health law. Public health law in the United States is ripe for reform. Existing laws often represent multiple layers of provisions from the late 19th and early 20th centuries enacted in response to epidemics of communicable disease. Older statutes do not reflect modern understandings of disease transmission and do not conform to current constitutional or statutory requirements. Proliferation of disease-specific statutes create redundancies in the law that both foster confusion and expend valuable resources. Laws, both old and new, may harbor ambiguities that interfere with public health officials' ability to identify, prevent, and respond to threats to the public's health. State provisions may have weak privacy protection for some types of public health data. Guidelines for reforming public health law. Public health law should: 1) define a broad mission of public health authorities to prevent and control communicable diseases through interventions at the microbial, behavioral and ecological level; 2) be based on uniform provision that apply equally to all communicable diseases, eliminating whenever possible disease-specific statutes; 3) recognize voluntary cooperation as the primary way to obtain compliance with public health measures; 4) base use of compulsory powers on a demonstrated threat of significant risk; 5) provide procedural due process protections; 6) provide a range of options for public health officers including a graded series of alternatives and require use of the least restrictive alternative that will accomplish the public health goal; 7) provide strong privacy protections based on fair information practices, limited disclosure of data, and monitoring of health department practices and substantive justification for data collection.
Abstract: Ecological models of the determinants of health and the consequent importance of structural interventions have been widely accepted. Operationalizing these models in research and practice has been challenging. Examining the role of criminal law enforcement in the "risk environment" of injection drug users (IDUs) provides an opportunity to apply structural thinking to the health problems associated with drug use. This paper reviews international evidence that laws and law enforcement practices influence IDU risk. It argues that more research is needed at four levels - laws; management of law enforcement agencies; knowledge, attitudes, beliefs and practices of front-line officers; and attitudes and experiences of IDUs - and that such research can be the basis of interventions within law enforcement to enhance IDU health.
Injection Drug Use, Structural Interventions, Social Determinants of Health, Law Enforcement, Criminal Law
Abstract: Naloxone hydrochloride is the standard treatment for heroin overdose. It is routinely provided by EMTs or emergency room staff. This medication is simple to administer, effective and has a very low risk of harm. Prescribing naloxone to heroin users for later self-administration in case of need is a simple, inexpensive harm-reduction measure that has the potential to reduce mortality from heroin overdose. Some physicians may be discouraged from distributing naloxone, however, by legal concerns. The legal analysis presented in this paper finds that the legal risks are low. Prescribing naloxone is fully consistent with state and federal laws regulating drug prescribing. The risks of malpractice liability are consistent with those generally associated with providing health care, and can be further minimized by following simple guidelines presented. Legal considerations should therefore not be a major impediment to wider use of take-home naloxone as an anti-overdose intervention in the United States.
Abstract: Drug overdose is quietly competing with vehicular accidents as a leading cause of accidental injury death in this country. Opioid drugs are driving this surge, contributing to the loss of well over 16,000 Americans every year. The rising death toll has several causes including fluctuating drug potency, adulteration of street drugs, and changes in tolerance after a period of abstinence. The most striking aspect of this epidemic is that many overdose fatalities are avoidable. Even after a dangerous dose of opioids is consumed, death can still be prevented. Timely administration of naloxone, an effective antagonist, supported by simple first-aid measures, fully revives the victim in the vast majority of cases. This cheap, generic prescription drug is widely and safely used by emergency rooms and first responders for precisely this purpose. Opioid overdoses typically take substantial time to turn deadly and are often witnessed by others, leaving significant opportunities for life-saving interventions. Yet, for a number of reasons, emergency medical help - including naloxone and basic first aid - often comes too late. Some communities have addressed this problem by initiating naloxone prescription programs (NPPs). These initiatives train drug users and others to identify the symptoms of overdose, call 911, provide rescue breathing, and administer emergency doses of naloxone. Preliminary results show that NPPs are a promising intervention with the potential to save thousands of lives without harmful side effects. Unfortunately, a number of legal and practical obstacles have impeded wider implementation of NPPs. With support from Drug Policy Alliance, the authors convened a summit on opioid overdose in which experts from the field of drug policy, opioid overdose, medicine and public health discussed strategies for preventing avoidable overdose by increasing access to naloxone and important basic overdose education. This White Paper presents the findings from the conference and sets forth recommendations for increasing access to this life saving intervention.
accident poisoning, heroin, drug abuse, public health, naloxone
Abstract: HPTN 058 is an NIH-funded Phase III randomized controlled trial to evaluate the efficacy of drug treatment in prevention of HIV infection among opiate dependent injectors. It is the first randomized trial to compare two approaches to drug treatment as HIV prevention. Participants in this trial are active drug injectors in Chiang Mai, Thailand and Guangxi and Xinjiang Provinces, China. Recognizing the potential for trial participation to disclose the status of the drug using participant and to increase the risk of legal and social harms, the HPTN 058 protocol included the following proviso: Given the status of illegal drug use, the associated social stigma and perceptions of drug users held by many members of the communities in which the study will be conducted, social harms could occur purely as a result of participation in a study targeting drug users. These could include discriminatory treatment and violence associated with possible disclosure of participants' drug or sex-related behaviors or of their HIV serostatus. Prior to site activation, a review of local and national policies and practice affecting injection drug users will be conducted. The purpose of this review will be to verify that law, policies and enforcement strategies do not place participants in the research at significantly elevated risk of arrest, incarceration, physical harm, unwanted disclosure of drug use, or loss of access to health care relative to injection drug users not participating in the research. The assessment will consist of two components. The first component will review and analyze the law relevant to injection drug use by examining laws concerning drug control, drug use, access to health care and privacy of medical information in each study country. This review will identify and collate constitutions and any treaties that have the force of law, statutes passed by the national, regional or local legislature, administrative regulations with the force of law and relevant court decisions interpreting these laws or regulations. This review will be conducted with the close involvement of independent legal experts in each study country. The second component will assess how these laws are put into practice and what possible influence they have on the risks and benefits of IDU participation in the study. Qualitative data regarding the effects of law on IDUs will be gathered, along with data on stigma, social risk, and social attitudes as they apply to IDUs. These data will be collected via interviews with key informants in the legal and public health fields as well as current and former injection drug users. Data will be collected via standardized interview forms by independent researchers at each site. The review will provide a narrative summary and analysis of the law and its likely effects on study participants. As these laws, policies and practice strategies can be expected to change over time, this review will be updated on an annual basis for the duration of HPTN 058. This report summarizes the findings of the social and legal risk analysis. The work was version of Rapid Policy Assessment and Response (RPAR). RPAR combines standard legal research (collecting law on the books) with rapid qualitative assessment of how these laws are actually applied by government agencies and the effects law enforcement has on legally marginalized people at risk of HIV/AIDS (law on the streets). (For more information see the RPAR website). In this application of Rapid Policy Assessment, the protocol team asked the question Does participating in this trial increase risk of arrest and incarceration? The conclusions for all three sites are similar. Being an injection drug user brings with it a substantial amount of risk. Being in the trial would not appear to elevate this risk and might even have a protective effect provided that the study is implemented in an open manner with the approval and cooperation of local authorities. These reports have implications for HIV prevention research beyond this specific protocol. Globally, many of the populations most severely impacted by HIV and AIDS are vulnerable to legal and social discrimination, neglect and abuse. Consequently, as we approach the third decade of the AIDS epidemic, it is critical that prevention researchers continue to develop and evaluate mechanisms to protect research subjects from harms that may accrue merely by their participation in clinical trials research.
HIV, research, ethics, social risk
Abstract: No one questions the importance of protecting human subjects of research, but over the past few years dissatisfaction has surfaced with the manner in which the protection is conferred by the federal regulatory system referred to as "The Common Rule." This paper considers the case for exempting public health agencies from the Common Rule. It finds the case reasonable, and suggests that crafting such an alternative system for public health agencies could suggest ways to improve the Common Rule in other areas of research.
Abstract: Law enforcement activity has been found to influence health risk behavior of injection drug users. Repeated measurements and mixed effects models were used to analyze the effects of an intensive long-term street-level police action to reduce open drug sales on syringe exchange program use. Utilization data for 9 months before and after the beginning of the intervention were analyzed. Use fell across all categories and time periods studied, with significant declines in use among total participants, male participants, and Black participants. Declines in use among Black and male participants were much more pronounced than decreases among White and female participants.
Abstract: It has become a commonplace to claim that HIV has been treated "differently" than other disease by health policy makers. This claim - the "exceptionalism thesis" - is, I argue here, fundamentally ahistorical, overlooking that virtually all major public health threats have inspired political disputes at one time or another. It is not necessary to rehearse the many ways in which the general social response to HIV has been very much like that accorded the killer diseases of the past. Even the sympathetic recognition that HIV is uniquely stigmatizing is only true relative to other present health threats; in their prime, cholera, tuberculosis, and syphilis were all badges of vice and dissipation. The passions that disease can inspire are what make public health as much a political art as a bio-medical science. HIV fits well into a tradition of vigorous policy dispute and social tension. It is also interesting to consider how HIV relates to other health threats. HIV, as a virus, has properties that make it different from other disease-causing microbes. The particular pattern of its spread depends upon contemporary social conditions that are different from conditions of the past. HIV was revealed suddenly, as an epidemic, and epidemic diseases have generally been seen as alarmingly different from more ubiquitous killers societies have learned to bear. The drama and biological peculiarity of HIV should not, however, obscure its similarity to other leading killers, like cancer, heart disease, and accidents. All of these ways of dying can be attributed to behavior, to our culture, and to its values as they are expressed in socially constructed options and individual choices. All of the ways of dying challenge public health to develop effective, long-term social learning strategies to change dangerous behavior, and in so doing all of them pose questions about the government's role in manipulating the lives of the people. One might justly question whether it is even accurate to assert that "traditional" health measures have not been applied to HIV. As Bayer himself noted in a later article, during the HIV epidemic, twenty-five states passed revised health laws authorizing coercive action against HIV-infected people engaging in dangerous behavior, and nineteen states passed HIV-specific criminal law. AIDS is a reportable disease throughout the country, and HIV is reportable in some way in half the states. Public health agencies in many cities have used their summary powers to close or modify bathhouses and other sites of free sexual activity. Legislation mandating screening of various sorts of people, like prostitutes and prisoners, has been common. Even if we suppose that a doctrine of exceptionalism has carried the day among health policymakers, the measures actually enacted by state legislatures across the country reflect, at best, the failure of life to match the elegance of theory. Of course, the argument for exceptionalism does not rest on the many "traditional" measures that have been applied to HIV, but on the undeniably new ones. Even if it is correct to say that the response to HIV is unexceptional in being shaped by contemporary society, the exceptionalists are equally correct in the view that people with HIV have enjoyed unprecedented legal protection of their social status. Conceding that this aspect of the policy response to HIV is something new, I offer a very different account of its meaning and implications than the exceptionalists. Rather than a political concession to effective advocates, the legal protection of people with HIV was an ambitious effort to control, even to change, the social fears that had traditionally made disease control more difficult. I believe that this is consistent with, not antagonistic to, public health, [FN10] and unlike the exceptionalists, I do not believe that the public health rationale for such an approach is losing its force. My fear is not that protecting people with HIV has been a compromise with effective disease control, but that the legal impulse towards protection may not be strong enough to overcome the exceptional fear and revulsion that HIV and other killer diseases traditionally inspire.
public health, human rights, enabling environment, history
Abstract: Naloxone, the standard treatment for heroin overdose, is a safe and effective prescription drug commonly administered by emergency room physicians or first responders acting under standing orders of physicians. High rates of overdose deaths and widely accepted evidence that witnesses of heroin overdose are often unwilling or unable to call 9-1-1 has led to interventions in several US cities and abroad in which drug users are instructed in overdose rescue techniques and provided a "take-home" dose of naloxone. Under current FDA regulations, such interventions require physician involvement. As part of a larger study to evaluate the knowledge and attitudes of doctors towards providing drug treatment and harm reduction services to injection drug users (IDUs), we investigated physician knowledge and willingness to prescribe naloxone. Less than one in four of the respondents in our sample reported having heard of naloxone prescription as an intervention to prevent opiate overdose, and the majority reported that they would never consider prescribing the agent and explaining its application to a patient. Factors predicting a favorable attitude towards prescribing naloxone included fewer negative perceptions of IDUs, assigning less importance to peer and community pressure not to treat IDUs, and increased confidence in ability to provide meaningful treatment to IDUs. Our data suggest that steps to promote naloxone distribution programs should include physician education about evidence-based harm minimization schemes, broader support for such initiatives by professional organizations, and policy reform to alleviate medicolegal concerns associated with naloxone prescription. Food and Drug Administration re-classification of naloxone for over-the-counter sales and promotion of nasal-delivery mechanism for this agent should be urgently explored.
Heroin, Injection drug use, Overdose, Prevention, Naloxone, Physician Behavior, Physician Education, Evidence-Based Practice
Abstract: Evidence from international evaluations suggests that safe injection facilities (SIFs) may represent a medically effective and economically efficient strategy for reducing the incidence and harms of injection drug use among the chronically homeless and otherwise marginalized people. The success of such facilities in other countries has amplified calls for their introduction in the United States where injection drug use among the most difficult to reach groups continues to be an intractable source of numerous individual and public health harms as well as a major financial burden for certain municipalities. In recognition of the fact that even evidence-based health interventions may fall under the ambit of laws targeting drugs and drug users, we analyzed the legal environment for publicly authorized SIFs in the United States. Our conclusions suggest that states and some municipalities have the power to authorize SIFs under their longstanding powers to protect the public’s health, but that federal authorities could still interfere with these facilities under the possession and “Crack House Statute” provisions of the Controlled Substances Act (CSA). We analyze the applicability of these provisions and discuss possible defenses rooted in statutory interpretation, preemption and the Commerce Clause. We conclude that plausible legal arguments exist that those operating an SIF should not (and perhaps can not) be convicted under the auspices of the CSA. However, state- or locally-authorized SIFs can proceed free of legal uncertainty only if federal authorities explicitly authorize them or decide not to interfere. Given legal uncertainty and the similar experience with syringe exchange programs, we recommend a process of sustained health research, strategic advocacy, and political deliberation.
IDU, injection, police power, harm reduction
Abstract: Name-based surveillance for HIV is a useful measure that offers benefits to public health without imposing significant risks of harm upon people whose names are reported. There is little evidence that name-based surveillance directly deters individuals at risk of HIV from being tested, or exposes them to significant social risks. Yet such surveillance has been and remains controversial. Understood in a broader context of the social risks and symbolic politics of HIV, as subjectively experienced by people at risk, this opposition is rational and instructive. Although often debated, the social risks of HIV infection are poorly understood. To the extent these risks have been addressed by privacy and antidiscrimination laws, the solution has been less complete than many public health professionals appear to believe: developments in law and policy, including the increasing prevalence of criminal HIV transmission laws and proposed changes in HIV testing and counseling standards, are contextual factors that help explain why opposition to name-based surveillance persists. Rather than focusing piecemeal on specific barriers to testing and care, an appreciation of the surveillance debate as a social phenomenon suggests a positive undertaking in public health policy to provide the conditions of opportunity, information, motivation and confidence that people with HIV need to accept an effective program of early intervention.
HIV surveillance, public health, discrimination, politics
Abstract: A Rapid Policy Assessment and Response (RPAR) intervention was conducted in Kaliningrad, Russia, to assess the impact of Russian drug policy on the health of drug users in the city and surrounding rural areas. In the RPAR, a team of Russian researchers worked with a Community Action Board (CAB) comprised of law enforcement officials, drug treatment providers, medical officers, NGO leaders, lawyers, judges, and others to collect and analyze laws and policies relevant to health risks in the target populations; existing data on the epidemiological situation and the operation of the criminal justice system; and 3) qualitative interviews with health care providers, lawyers, law enforcement representatives, NGO staff, drug users, sex workers and others who describing how the laws are put into practice. The RPAR uncovered a wide range of problems, including continuing high risk sexual and drug using behavior; lack of prevention and social services (or any concern for) drug users and sex workers; lack of effective, accessible drug treatment; and laws and law enforcement practices that interfere with public health. The reasons for the situation are many and complex, but the RPAR identified several key factors that could be dealt with in pragmatic, policy terms and through good management and coordination in Kaliningrad. At the deepest level is the stigmatization of drug use, which instills in users and non-users alike a false belief that nothing can (and perhaps should) be done. This disdain and discouragement is reflected in and reinforced by law, which categorizes drug users both as criminals and as patients with a right to treatment, and thence in law enforcement practice, which has become an almost complete bar to the development of effective services. Throughout Kaliningrad, there is an absence of public health interventions to prevent disease among IDUs and their sex partners, and a shortage of basic, quality drug treatment services. The CAB and the research team worked together to identify both national and local actions that could make a difference. National policy changes include: * Clarification of current policy on harm reduction and, if necessary, legislative action to eliminate any doubt that harm reduction programs, including NEPs, are legal in the RF * Elimination of the system of narcological registration * Legalization of long-term opioid agonist treatment with methadone, buprenorphine or other appropriate medicine, and an end to the state monopoly on pharmacologically assisted drug dependency treatment RPAR identified a large number of concrete, feasible actions that could be taken in Kaliningrad to immediately improve the well-being of drug users and the state of public health. These include: * Define the legal status of harm reduction programs at the level of the Kaliningrad region - i.e., the relevant health and law enforcement agencies should explicitly authorize harm reduction programs including NEP. * Learn about the international experience of harm reduction programs; include them in a regional strategy to counteract HIV-infection and to provide adequate funding to their work. * Ensure that drug users and sex workers, as the most vulnerable to HIV-infection, hepatitis and STIs, get access to prevention, including harm reduction programs with access to the injection equipment. * Provide vulnerable groups with free of charge testing with voluntary pre- and post-HIV test counseling. * Optimize existing capacity of medical care, social welfare and criminal justice systems for counseling of IDUs on the health risks and providing information on treatment options. * Ensure drug users real access to drug dependence treatment. These measures should include elimination of restrictions to enter drug treatment facility, including a waiting list. When entering in a drug treatment facility, stop the practice of encouraging drug users to enter short-term paid treatment, without providing information on drug abuse as a disease requiring prolonged treatment and rehabilitation. * Develop a simple, transparent procedure for deregistration. * Provide counseling on HIV-infection and other health risks related to drug use to all drug users undergoing drug treatment (detoxification) in state drug treatment facilities. * Provide adequate funding to drug dependence treatment facilities, including the provision of financing to rehabilitation programs implemented by NGOs. * Provide public and non-governmental organizations working in the field of HIV prevention among drug users and sex workers with adequate funding. This report explains the RPAR methodology, and then describes key findings and recommendations for action. Appendices include detailed information about RPAR methods and findings, including epidemiological and criminal justice data, and data on laws on drug dependence treatment, medical care and treatment services to HIV-positive people and HIV prevention among vulnerable groups.
Drug policy, public health, police, stigma, HIV, drug treatment, criminal law, implementation
Abstract: Title I of the Americans with Disabilities Act (ADA) has been the subject of controversy ever since it took effect. Critics argue that it has inspired a barrage of claims brought by people who do not have serious disabilities, that most cases of employment discrimination brought under the ADA involve people who already have jobs, and that this avalanche of frivolous claims may produce a backlash by businesses, ultimately hurting the very people the law was meant to help. In contrast, disability advocates have expressed strong concerns that the federal courts have interpreted the ADA far more narrowly than Congress intended, holding that plaintiffs with significant impairments do not meet the statute's definition of a qualified person with a disability and incorrectly dismissing legitimate claims brought by people the law was designed to protect. This paper contributes to an assessment of the ADA based on data, rather than prior principles. The paper briefly reviews research and theory on disputing; applies disputing theory to data from our ongoing research on ADA employment discrimination administrative claims; reviews American Bar Association data on ADA federal court final decisions; and concludes with some interpretations of the ADA and our own data - and more questions.
Americans with Disabilities Act, ADA, employment discrimination, disputing theory
Abstract: Opioid drug overdose kills over 16,000 Americans every year. Although some victims are famous - like actor Heath Ledger - the seriousness of the overdose epidemic has still not gotten the attention, or the response, it requires. Many of these deaths are completely avoidable because an overdose incident can be effectively reversed by the administration of naloxone - a safe and inexpensive antagonist. With little funding, some 60 programs operating in 17 U.S. states have begun training drug users and others who are likely to witness an overdose to recognize and reverse opioid poisoning by providing first aid and administering emergency doses of naloxone. There has also been work aimed at making it standard medical practice to prescribe companion doses of naloxone to all patients receiving powerful opioid medications. These efforts have resulted in the reversal of thousands of fatalities, without resulting in increase in risky behavior or other negative consequences trumpeted by the programs’ opponents. Despite their unequivocal success, such programs face a number of critical barriers. Naloxone’s prescription status creates many questions about how the drug can be made available to drug users or others who may be in a position to help. Healthcare providers are rarely informed about, or willing to participate in overdose prevention efforts, including naloxone prescription. Lack of robust research and resources hampers many of the existing programs and prevents their scale-up. Whether real or perceived, concerns about legal liability have discouraged government and clinical professionals from supporting these efforts. Law enforcement and political actors also oppose the initiatives for the fear of enabling or sanctioning illegal drug use, while witnesses of overdoses involving illegally-obtained drugs avoid summoning emergency response. After sketching out the contours of the overdose epidemic, this article systematically examines the constellation of regulatory, legal, and policy issues that are limiting the scale-up of vital efforts to stem the tide of opioid overdose in the US. Well-balanced action that integrates state policy reform, proactive FDA action, targeted public and healthcare professional education, and partnership between public health and law enforcement actors are necessary to assure that society can enjoy the benefits of adequate pain care while minimizing overdose deaths and other problematic and harmful use of these powerful drugs.
accident poisoning, heroin drug abuse, public health
Abstract: A Rapid Policy Assessment and Response (RPAR) intervention was conducted in Szczecin, Poland, to assess the impact of drug policy on the health of drug users in the city and surrounding rural areas. In the RPAR, a team of Polish researchers worked with a Community Action Board (CAB) comprised of law enforcement officials, drug treatment providers, medical officers, NGO leaders, lawyers, judges, and others to collect and analyze laws and policies relevant to health risks in the target populations; existing data on the epidemiological situation and the operation of the criminal justice system; and 3) qualitative interviews with health care providers, lawyers, law enforcement representatives, NGO staff, drug users, sex workers and others who describing how the laws are put into practice.
The Szczecin RPAR uncovered evidence of dangerous new drug-use patterns, and significant gaps in the health and drug treatment services available to prevent HIV and other serious health problems among drug users. Key findings include: * Criminalizing drug possession in Poland has not fulfilled its goals in practice * A rise in rural drug use is creating serious unmet needs for prevention, treatment and disease surveillance. * Lack of therapy and HIV prevention methods in prison and difficulties in the social reintegration process * Lack of quality legal services in the criminal and civil justice systems The findings indicate that drug policy in practice does not correspond to the strategies embodied in recent Polish drug legislation, and that urgent action is necessary to prevent serious health problems in rural northwest Poland.
Abstract: Under Title I of the ADA, individuals who believe they have been subjected to disability-based employment discrimination may file an administrative charge. This article looks at who files charges, over what issues, and with what outcomes in both Equal Employment Opportunity Commission (EEOC) field offices, and state and local fair employment practice agencies (FEPAs). The data for the article are computerized records of all ADA charges filed through March 31, 1998. The data indicate that individuals who rely on a FEPA to investigate their charge have a greater likelihood of obtaining a beneficial outcome than individuals who rely on the EEOC, but proportionately more individuals receiving a beneficial outcome are likely to receive monetary benefits from the EEOC than from a FEPA. Further, those who receive beneficial outcomes will probably receive greater monetary benefits from charges investigated by the EEOC than from those investigated by a FEPA.
Abstract: Since the early 1980s the black-white gap in life expectancy at birth increased sharply and subsequently declined, but the causes of these changes have not been investigated. The objective of this study was to determine the contribution of specific age groups and causes of death contributing to the changes in the black-white life expectancy gap from 1983-2003. The main outcome measure was the gap in life expectancy at birth between blacks and whites. The data were drawn from United States vital statistics. We used standard life table techniques to decompose the change in the black-white life expectancy gap by combining absolute changes in age-specific mortality with relative changes in the distribution of causes of death. Among females the black-white life expectancy gap increased 0.5 years from 1983-1993, primarily due to increased mortality from HIV (0.4 years) and slower declines in heart diseases (0.1 years), which were somewhat offset by relative improvements in stroke (-0.1 years). The gap among males increased by 2 years from 1983-1993, principally because of adverse changes in HIV (1.1 years), homicide (0.5 years) and heart diseases (0.3 years). From 1993 to 2003 the female gap decreased by 1 year, from 5.59 to 4.54. Half of the total narrowing of the gap among females was due to relative mortality improvement among blacks in heart diseases (-0.2 years), homicide (-0.2 years), and unintentional injuries (-0.1 year). The decline in the life expectancy gap was larger among males, declining by 25% from 8.44 to 6.33 years. Nearly all the 2.1-year decline among males was due to relative mortality improvement among blacks at ages 15-49 (-2.0 years). Three causes of death accounted for 71% of the narrowing of the gap among males: homicide (-0.6 years), HIV (-0.6 years), and unintentional injuries (-0.3 years), while lack of improvement in heart diseases at older ages kept the gap from narrowing further. After widening during the late 1980s, the black-white life expectancy gap has declined because of mortality improvements in homicide, HIV, unintentional injuries, and, among females, heart diseases. Further narrowing of the gap will require concerted efforts in public health and health care to address the major causes of the remaining gap: cardiovascular diseases, homicide, HIV, and infant mortality.
epidemiology, health disparities, homicide, accidents, race
Abstract: Background: Previous research has identified the impact of law enforcement practices on the behaviors and health of injection drug users (IDUs). We undertook a qualitative study of IDUs' experiences of policing practices in two Mexican cities on the U.S. border. Methods: In 2004, two teams of Mexican interviewers conducted in-depth interviews with IDUs residing in Tijuana and Ciudad Juarez (Cd. Juarez), Mexico who had injected drugs at least once in the prior month. Topics included types of drug used, injection settings, access to sterile needles and experiences with police. Field notes and transcribed interviews were analyzed to identify emergent themes. Results: Among the 43 participants, most reported that it is common for IDUs to be arrested and detained for 36 hours for carrying sterile or used syringes. Most reported that they or someone they knew had been beaten by police. Interviews suggested 5 key themes relating to police influence on the risk environment: 1) impact of policing practices on accessibility of sterile syringes, 2) influence of police on choice of places to inject drugs (e.g., shooting galleries), 3) police violence, 4) police corruption, and 5) perceived changes in policing practices. Conclusion: Findings suggest that some behavior of police officers in Tijuana and Cd. Juarez is inconsistent with legal norms and may be negatively influencing the risk of acquiring blood-borne infections among IDUs. Implementing a comprehensive and successful HIV prevention program among IDUs requires interventions to influence the knowledge, attitudes and practices of law enforcement officers.
Enforcement, Injection Drug Use, Mexico, Drug Policy, Police, Public Health
Abstract: Infectious disease is once again being recognized in the developed world as a major public health threat. This essay draws on the epidemiological literature addressing the causes of illness in the social and physical environment to argue that infectious diseases are themselves symptomatic of deeper maladies. On this structural view, infectious disease is merely yet another mechanism by which social and material inequality takes a disproportionate toll on the relatively poor within countries and across the world. Law may be said to play four distinct roles in the persistence of infectious disease: 1) Law governs and protects the possession and transfer of wealth and goods; 2) Law endows (or fails to endow) individuals with rights that equip them to avoid disease; 3) Law regulates the meaning of identities and behaviors, categorizing some as favored and others as disfavored; and 4) Law provides settings (legislatures, bureaucracies, courts) in which important social issues are debated, and a vocabulary for debating them. Better addressing the legal factors that contribute to population vulnerability to or immunity from infectious disease requires a cross-disciplinary effort to address at least four basic questions: 1) What legal structures can plausibly be linked to infectious diseases in the population? 2) Through what mechanisms do legal structures matter and how can public health advocates effectively intervene? 3) How may public health advocates effectively make the case for intervention in a culture unfamiliar with structural analyses? 4) How may the success of structural changes in complex social processes be measured?
Abstract: Law enforcement activities have been found to negatively influence the health behavuor of injection drug users (IDUs) in many studies. This study, set in the Mexican border cities of Tijuana, Baja California, and Ciudad Juarez, Chihuahua, sought to identify factors associated with receptive syringe sharing among IDUs, and to elucidate the association between syringe possession arrests and syringe sharing. IDUs in Tijuana (N=222) and Cd. Juarez (N=206) were recruited using respondent driven sampling (RDS). An interviewer-administered survey was used to collect quantitative data on sociodemographic, behavioral and contextual characteristics, including self-reported syringe sharing and arrests for syringe possession. Associations with receptive syringe sharing were investigated using logistic regression with RDS adjustment. Overall, 48% of participants reported ever being arrested for carrying an unused/sterile syringe, even though syringe purchase and possession is legal in Mexico. Arrest for possessing unused/sterile syringes was independently associated with receptive syringe sharing, as were injecting in a shooting galler , injecting in the street , and injecting methamphetamine or cocaine (AOR=1.96; 95% CI: 1.15, 3.36). More than half of participants (57%) had been arrested for possessing a used syringe; in a second model, arrest for used syringe possession was also independently associated with receptive sharing. We thus documented high levels of syringe-related arrests in two Mexican-U.S. border cities and an independent association between these arrests and risky injection practices. Public health collaborations with law enforcement to modify the risk environment in which drug use occurs are essential to facilitate safer injection practices.
injection drug use, police, HIV, Mexico, needle sharing, shooting galleries, public health
Abstract: This assessment reviewed and analyzed Thai law relevant to injection drug use by examining laws concerning drug control, drug use, access to health care and privacy of medical information. It identifies and reproduces relevant sections on the constitution, statutes passed by the national, regional or local legislature, administrative regulations with the force of law and relevant decisions interpreting these laws or regulations.
The assessment finds that Thai law criminalizes the possession of extremely minor amounts of drugs, forcing users to carry very small quantities and ultimately leading to difficulty in drug users attaining “highs” through less hazardous methods of administration such as oral intake and encouraging a shift to riskier methods, particularly injecting drug use. The penal regime under the Thai narcotics laws and related enactments prescribes severe punishments, makes all offences under it cognizable and non-bailable, and also gives wide powers of search, seizure, and arrest to the police.
Further, under the existing narcotics law, there is a presumption of guilt against the possessor of any drugs or apparatus for the manufacture of any drugs. The penal regime also makes any attempt or abetment punishable with the same severity as if the offense was actually committed.
This review reports and analyzes these laws, together with recent amendments that recommend a less punitive drug control regime.
Abstract: To explore the intersections between the threats posed by new public health challenges and new theories of governance, in March 2004 Temple Law School's Institute for International Law and Public Policy hosted a meeting on SARS, Public Health and Global Governance. The meeting involved leading public health scholars; international legal experts; students of global governance; current and former government officials; and activists from the U.S. and abroad to engage in a sustained dialogue on these issues. This Symposium issue of the Temple Law Review includes articles based on the papers, and comments on the papers, presented at the meeting: China's Response to SARS Professor Ruotao Wang SARS and International Legal Preparedness Jason W. Sapsin et al. Are Traditional Public Health Strategies Consistent With Contemporary American Values? Mark A. Rothstein Atypical Pneumonia and Ambivalent Law and Politics: SARS and the Response to SARS in China Jacques deLisle Constitutional Outlines of Public Health's New World Order Professor David P. Fidler Politics, Power, and Public Health: A Comment on Public Health's New World Order Professor Laurence R. Helfer Between Isolationalism and Mutual Vulnerability: A South-North Perspective on Global Governance of Epidemics in an Age of Globalization Professor Obijiofor Aginam Is There a Government in the Cockpit: A Passenger's Perspective or Global Public Health: The Role of Human Rights Professor Sofia Gruskin Governance, Microgovernance and Health Professor Scott Burris The Quest for Global Governance in Intellectual Property and Public Health: Structural, Discursive, and Institutional Dimensions Professor Susan K. Sell Intellectual Property and Pharmaceutical Markets: A Nodal Governance Approach Peter Drahos
public health, governance, communicable disease, politics
Abstract: Injection drug users, their sex partners, and their children are at high risk for acquiring HIV infection and other bloodborne diseases. The risk for disease transmission in the United States is partly the result of restricted access to sterile injection equipment. Physicians and pharmacists can play an important role in providing syringe access by prescribing and dispensing syringes to patients who use injection drugs and cannot or will not enter drug treatment. Prescribing and dispensing injection equipment are ethical, clinically appropriate, and fully consistent with current public health guidelines and disease prevention. An analysis of the laws of the 50 U.S. states, the District of Columbia, and Puerto Rico finds that physicians in nearly all these jurisdictions may legally prescribe sterile injection equipment to prevent disease transmission among drug-using patients and that pharmacies in most states have a clear or reasonable legal basis for filling the prescriptions. Given these medical and legal findings, physicians may wish to take a larger role in improving access to sterile injection equipment by prescribing this equipment for their patients where this practice is legal, and by joining efforts to change the law where it poses a barrier.
Abstract: Objective: The outcomes of employment discrimination charges filed under the Americans with Disabilities Act (ADA) by individuals with psychiatric disabilities and those with other disabilities were compared. Methods: Data obtained from the Equal Employment Opportunity Commission (EEOC) consisted of all ADA employment claims closed as of March 31, 1998. Charges were categorized by whether they were investigated by the EEOC or by a Fair Employment Practice Agency (FEPA). Results: Of the 175,226 charges filed, 83.2 percent were closed by March 31, 1998. Of these, 15.7 percent brought some kind of benefit to charging parties, although only 1.7 percent resulted in new hires or reinstatements. Of charges investigated by FEPAs, 23.3 percent led to some benefit, compared with 11.5 percent of charges investigated by the EEOC. Of charges investigated by the EEOC, the median actual monetary benefit was $5,646, compared with $2,400 for charges investigated by FEPAs. A total of 13.6 percent of charges filed by individuals with psychiatric disabilities resulted in benefits, compared with a benefit rate of 16 percent for persons with other disabilities. The median actual monetary benefit received by persons with psychiatric disabilities was $5,000, compared with $3,500 for those with nonpsychiatric disabilities. Individuals whose charges were investigated in the first three years of ADA implementation were more likely to receive benefits than individuals whose charges were investigated more recently. Conclusions: Most employment discrimination charges filed under the ADA do not result in benefits or a finding of reasonable cause. Outcomes for people with psychiatric disabilities do not differ substantially from those for people with other disabilities (Psychiatric Services 50: 1028-1035, 1999).
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