Dr. Valles gives “culture of health” seminar for The London School of Economics and Political Science

“Housing security’s place in a ‘Culture of Health’: Lessons from the pandemic housing crises in the U.S. and England”

Sean Valles photo

Center Director and Associate Professor Sean A. Valles, PhD, gave a seminar last month for The London School of Economics and Political Science Department of Philosophy, Logic and Scientific Method. Valles presented “Housing security’s place in a ‘Culture of Health’: Lessons from the pandemic housing crises in the U.S. and England” as part of the department’s “Conjectures and Refutations” series.

Dr. Valles has provided a summary of his talk below. A recording is available to watch on YouTube via the LSE Philosophy channel.

People experiencing homelessness had been suffering extreme health and economic hardships before the COVID-19 pandemic, and even more so during it. The notion that housing is a human right is gradually picking up momentum in both the U.S. and England. And that ethical recognition is combining with a growing set of scientific evidence of the effectiveness of “housing first” policies, which provide stable long-term housing to people experiencing homelessness, rather than shuffling people in and out of temporary shelters. Every person ethically deserves safe housing, and failing to provide this has also resulted in a system that cruelly (and at great expense) pushes suffering people into emergency rooms and prisons.

England earned praise for its “Everyone In” program, which was aimed to provide safe housing for every person experiencing homelessness beginning early in the pandemic. By contrast, cities across the U.S. continued defying CDC recommendations by bulldozing temporary encampments set up by people experiencing homelessness, including in Lansing. Meanwhile both the U.S. and England banned evictions of renters who fell behind on their rent during the pandemic, but both also failed to make realistic long-term plans for how to secure housing and income for people who have no way of paying past-due rent once the eviction bans expire.  On both sides of the Atlantic, the pandemic inspired governments to stumble toward recognizing how essential housing is for good health in general and also dealing with this fact. The challenge now is to keep up the momentum, and push for universal housing, since trying to survive without secure housing was already difficult before the pandemic, and will remain so after it ends.

Listen: Social Justice-Oriented Bioethics

No Easy Answers in Bioethics Episode 25

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This month the Center was proud to officially announce its new name: Center for Bioethics and Social Justice. This name change reflects an updated mission with a focus on social justice-oriented bioethics. This episode features a conversation between Director Sean Valles, PhD, and Assistant Director Karen Kelly-Blake, PhD. Together they discuss moving forward in the bioethics space, what engaging in service to the people means to them, and the important work to be done to a create a healthier and more socially just world. They also explore questions related to the practical application of bioethics, and the challenge of preparing medical students for clinical practice in an inequitable world.

Ways to Listen

This episode was produced and edited by Liz McDaniel in the Center for Bioethics and Social Justice. Music: “While We Walk (2004)” by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License. Full episode transcript available.

About: No Easy Answers in Bioethics is a podcast series from the Center for Bioethics and Social Justice in the Michigan State University College of Human Medicine. Center faculty and their collaborators discuss their ongoing work and research across many areas of bioethics. Episodes are hosted by H-Net: Humanities and Social Sciences Online.

Center for Bioethics and Social Justice: new name, mission, and leadership

Green Spartan helmet with text: Center for Bioethics and Social Justice, College of Human Medicine, Michigan State University

The MSU Center for Ethics and Humanities in the Life Sciences is proud to announce its new name: Center for Bioethics and Social Justice. This name change as of April 1 reflects an updated mission with a focus on social justice-oriented bioethics. The Center has a vision of a health system that is compassionate, respectful, and responsive to people’s needs, so that equity, inclusion, and social justice are available to all.

Photo of Sean Valles
Director Sean A. Valles, PhD

“Without an orientation, bioethics has no built-in real-world goals; it is merely a field of study. Doing social justice-oriented bioethics means we have a goal—advancing social justice in the real world with meaningful applications—as the north star for our journey as an institution,” said Center Director Sean A. Valles, PhD.

The updated name and mission follow the appointment of Valles as director earlier this year, along with the promotion of Karen Kelly-Blake, PhD, to assistant director.

“One key piece of the new name and mission is a rethinking and a recommitting of our identity,” said Valles. “The Center aims to be a hub for collaborations and conversations around the relationship between social justice and health. To do that, we will actively seek to engage with our college and university colleagues, local communities, and organizations in order to learn their concerns about the ways our society makes it hard to live a healthy life, and to begin trying to help.”

Photo of Karen Kelly-Blake
Assistant Director Karen Kelly-Blake, PhD

The Center’s mission is to educate health professionals with skills, knowledge, and attitudes necessary to contribute to a world in which health practices are equitable, inclusive, and bolstered by conditions of social justice; to research the nature of bioethics and enhance its applications to the pursuit of equitable, inclusive, and just healthy societies; and to engage researchers, clinicians, policymakers, and communities around shared interests in the attainment of a healthier and more just world.

“Building bridges among MSU experts and outward to communities is of value to everyone involved,” added Valles.

The Center began in 1977 with the formation of the Medical Humanities Program. In 1988, the program became the Center for Ethics and Humanities in the Life Sciences. Faculty in the Center are committed to teaching medical students in the College of Human Medicine and developing social context of clinical decisions content for the Shared Discovery Curriculum. Center faculty are also committed to research, scholarship, and public outreach and education—all working toward the goal of creating a more just world.

Visit the Center’s website to learn more about its faculty and outreach activities, such as public seminars, podcast episodes, and monthly blog posts that explore timely bioethics topics.

Related: Announcing Center Director Sean A. Valles and Assistant Director Karen Kelly-Blake

Announcing Center Director Sean A. Valles and Assistant Director Karen Kelly-Blake

The Center for Ethics and Humanities in the Life Sciences is pleased to announce the appointment of Dr. Sean A. Valles as Center Director. Additionally, associate professor Dr. Karen Kelly-Blake has been promoted to Assistant Director.

Sean A. Valles photo
Director Sean A. Valles, PhD

Dr. Sean A. Valles is a philosopher of health specializing in the ethical and evidentiary complexities of how social contexts combine to create patterns of inequitable health disparities. He was most recently an associate professor in Lyman Briggs College and the Department of Philosophy at Michigan State University. He served as Director of Graduate Programs in the Department of Philosophy, and Director of the interdisciplinary Science and Society at State program. His research spans a range of topics in the philosophy of population health, from the use of evidence in medical genetics to the roles played by race concepts in epidemiology.

Dr. Valles is author of the 2018 book Philosophy of Population Health: Philosophy for a New Public Health Era. He is also co-editor of the Oxford University Press book series “Bioethics for Social Justice.” Dr. Valles received his PhD in History and Philosophy of Science from Indiana University Bloomington.

Karen Kelly-Blake photo
Assistant Director Karen Kelly-Blake, PhD

Dr. Karen Kelly-Blake is an associate professor in the Center for Ethics and the Department of Medicine. She has been with the Center since 2009. Her research interests include health services research, shared decision-making, decision aid development and implementation, clinical communication skills and training, mHealth, racism and morbidity and mortality, bioethics, medical workforce policy, and men’s health.

Dr. Kelly-Blake is a co-investigator on the NIH-funded project “Improving Diabetic Patients’ Adherence to Treatment and Prevention of Cardiovascular Disease.” She is also co-chair of the College of Human Medicine Admissions Committee. Dr. Kelly-Blake received her PhD in Medical Anthropology from Michigan State University.

Please visit our website to read a joint statement from Dr. Valles and Dr. Kelly-Blake on moving toward a new health justice and equity mission for the Center.

The White House outbreak: How to criticize irresponsible leaders without getting stuck in the illness blame game

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This post is a part of our Bioethics in the News series

By Sean A. Valles, PhD

In a twist of fate, there was an outbreak of COVID-19 at a White House celebration of the nomination of Amy Coney Barrett for the Supreme Court of the United States. This elicited a wide range of reactions to seeing a gathering of opponents of strict COVID-19 control measures being hurt by the very pandemic they have downplayed. While others have worried about the moral philosophy of taking pleasure in others’ suffering, or the hypocrisy of evading rules one publicly espouses, I have a different worry. A poll shortly after the White House outbreak found that a majority of respondents believed that Trump had acted “irresponsibly” in how he had handled his personal risk of infection from people he interacted with. While I do not worry about the president being blamed for his illness, I do worry about the wider cultural practices of 1) victim-blaming by attributing a person’s illness to their personal moral failure, and 2) insisting that health is a matter of individual choice. While the distinction might not seem important at first, I will argue there is an important difference between victim-blaming the ill and holding leaders accountable for setting bad examples with their conduct and other leadership failures. The first kind of blame is toxic in a society, and the second kind of blame is an important part of a well-functioning democracy.

President Donald Trump in the Oval Office nominating Amy Coney Barrett to the Supreme Court
Image description: President Donald J. Trump and First Lady Melania Trump pose for a photo with Judge Amy Coney Barrett, the President’s nominee for Associate Justice of the Supreme Court of the United States, her husband Jesse and their children on Saturday, Sept. 26, 2020, in the Oval Office of the White House. Image source: Official White House Photo by Andrea Hanks.

Blaming people for their ill health is a strategy with an awful track record. It doesn’t do any good for the people subjected to “you’re too fat” messages. It doesn’t do any good for survivors of sexual assault or domestic violence. When directed inward, we self-blame for failing to do enough de-stressing self-care, rather than directing our blame to more appropriate targets like the needlessly bad working conditions or economic insecurities that make us stressed in the first place. Repeated messages that “sickness is the result of individual moral failure” also reinforce stigma. Stigma is a nasty phenomenon, with a “corrosive impact on the health of populations” and is particularly bad in cases of infectious diseases like COVID-19 because it actively encourages people to hide their infection, which is obviously bad for them and for others who interact with them.

A second problem with blaming people for their ill health is that ethics of blaming individual behavior reflects a misunderstanding of how health behavior works in the first place. Seemingly individualistic choices like diet, condom use, smoking, alcohol consumption, etc. are not made independently. We choose such things in roughly the same way we “choose” our religions or the languages we speak at home. Yes, each of us can choose to practice an entirely different religion (or lack thereof), and each of us can learn and use a different language in the home. Some of us do. In all of these cases, though, the vast majority of us don’t venture too far from a combination of what we learned while growing up and the cues we get from the people we interact with. We eat the foods familiar, convenient, and affordable to us. We adopt the values and beliefs (including trust in aspects of the scientific endeavor) of our communities, etc. Individual choices exist, but they exist within larger social contexts that have powerful but subtle effects on our choices.

Each of our everyday behaviors related to COVID-19 exist in a complex ecosystem of influences. Mask wearing and other social distancing measures have become intensely politicized and tied to masculinity. Masks and other health behavior measures also create new inconveniences and financial expenses. Social pressures also vary vastly from one setting to the next—in one store there are prodding questions and judgmental stares for wearing a mask, at an adjacent store there are similar pressures on those who don’t wear a mask. How we move our bodies and (un)cover our faces within these intense social pressures is not simply an individual choice.

Take the case of one of the attendees of the party at the White House, University of Notre Dame President, the Rev. John I. Jenkins. He did not wear a mask at the indoor/outdoor party, shook hands with attendees, and otherwise did not follow the standards he had imposed on members of his own university. He knew better and did not do better. Many of us have likely also gone against our better judgment to fit the incautious social distancing norms of a setting. Whether it is the university president or the university student, this is indeed hypocritical, and irresponsible in a sense. But, such blame is aside from the point, and more importantly it contributes to the sort of harmful cultural practices mentioned earlier—especially victim-blaming and stigmatizing the ill. Pointing out hypocrisy and the assigning of blame for individual health behavior distracts from the far more damaging thing Jenkins and the other leaders at the White House party did. As cultural leaders, they undercut efforts to build new norms, like public mask-wearing, the habit of greeting people without needlessly touching hands, etc.

We ought to blame Trump, Jenkins, and many other leaders who attended that party. We ought to blame them for failing in their relationships to the people they lead. That is a devastating form of irresponsibility. And it is very important to separate that kind of blame and irresponsibility accusation from the destructive form of blame discussed above: blaming people for having irresponsible relationships with their bodies/health.

The “personal responsibility” blame game has been the go-to talking point of conservative governors as they use their power to obstruct or dismantle public health measures. “You shouldn’t have to order somebody to do what is just in your own best interest and that of your family, friends and neighbors,” according to Alabama Governor Kay Ivey. Scolding people about “personal responsibility” during a public health crisis is a strategy based on how one wishes the world worked and not how it is actually working. Along similar lines, abstinence-only sex education doesn’t work (“teenagers: be sexually responsible by just not having sex before marriage!”), and neither does “just say no to drugs” education. Jenkins was at least right to point out that his behavior was a failure of leadership. As many of my colleagues in population health science say, we need to build a “culture of health.” That will require leaders suited to the task, and we ought to blame them when they fail in that leadership. Just skip the personal health blaming.

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Sean A. Valles, PhD, is an Associate Professor with an appointment in the Michigan State University Lyman Briggs College and the Department of Philosophy (where he is also Associate Chair). His research spans a range of topics in the philosophy of population health, from the use of evidence in medical genetics to the roles played by race concepts in epidemiology. He is author of the 2018 book Philosophy of Population Health: Philosophy for a New Public Health Era. He is also co-editor (with Quill R. Kukla) of the Oxford University Press book series “Bioethics for Social Justice.”

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, November 5, 2020. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

More Bioethics in the News from Dr. Valles: We Need Healthier Schools, and Student Activists Are Stepping Up; Recognizing Menstrual Supplies as Basic Health Necessities: The Bioethics of #FreePeriodsTrump’s Attempt to Reignite the Coal Industry Is Another Health Policy BlunderPolitics and the Other Lead Poisoning: The Public Health Ethics of Gun ViolenceClimate Change and Medical Risk

Continue reading “The White House outbreak: How to criticize irresponsible leaders without getting stuck in the illness blame game”

We Need Healthier Schools, and Student Activists Are Stepping Up

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Sean A. Valles, PhD

California just passed two laws that advance health in schools in ways that might not seem intuitive: pushing middle school and high school start times to after 8am, and banning school districts from “lunch shaming” that treats students differently based on whether they have unpaid school lunch debt. These laws are part of a collection of diverse efforts to make U.S. schools healthier places. The fact that some of these efforts have been led by students themselves is especially heartening.

Bioethics of school policies
The two new laws in California are worthy of attention in a bioethics blog because U.S. schools are, for many students and in many ways, unhealthy places. Not simply because they are crowded spaces infamous for spreading coughs and colds (and stress). For many students, they are also places of food insecurity, social stigma, or even fear of violence. Those problems also shed light on larger problems in society. Even as a child in Los Angeles, I grasped that the local high school having a metal detector at the door signified that something much bigger had gone horribly wrong in my community. Most student problems have their roots outside the school walls, but we can at least do our best to design schools to contend with the difficult realities of young people’s lives.

There is now compelling evidence that later start times for schools are better for adolescent health than early morning ones. As pointed out in one review of the research, adolescents’ bedtimes seem to be more or less independent of when school starts in the morning, partly due to biological clock rhythms changing during puberty. Students forced to begin school early in the morning suffer all of the resulting harms of insufficient sleep (most readers are surely aware that insufficient sleep is bad for physical and mental well-being). This change is surprising in part because the American Academy of Pediatrics has, with limited success until now, been pushing for later school start times, insisting that school start times should facilitate the 8.5-9.5 hours of sleep appropriate for adolescent biology. It will be a difficult schedule transition for some California schools and families/guardians to adjust to, but the health rationale remains powerful.

Stigmatizing and manipulating students are problems, not solutions
It is also encouraging to see California legislate against lunch shaming. Unless prohibited, U.S. schools have the freedom to intentionally or incidentally shame students for being unable to afford their lunch meals. They have done so by giving indebted students inferior meals, marking the students with wristbands or stamps, etc. This is a serious health matter because imposing a stigmatized status upon a child, or even just amplifying an existing one, is a harmful act. Research is quite clear that stigma (“the co-occurrence of labeling, stereotyping, separation, status loss, and discrimination in a context in which power is exercised”) is a powerful and pervasive cause of health injustices. Stigma stresses bodies, socially controls people, and excludes them from social opportunities and resources available to others. Being a child without enough money to pay for lunch is quite hard enough, without one’s school officials metaphorically painting a target on one’s back.

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Image description: Young person at the March for Our Lives protest, holding a placard painted with the words “AM I NEXT?” in red. Image source: Roger Jones/Public Domain.

The desirability of the California law gets clearer when one looks at a policy that goes in the opposite direction. In a widely-criticized lurch backwards, a newly-created policy in a New Jersey school district gives discretion to principals to ban students with lunch debt from participating in extracurricular activities. Which students? Under which circumstances? What goals are achieved by such exclusions? Certainly banning students from soccer practice or chess club doesn’t make money magically appear in their parents’ pockets. The policy is a setback, but I am encouraged by the backlash that gives a new sense of clarity to how remarkably regressive this policy is in light of the opposite trend.

Student advocacy should be welcomed
Most encouraging to me is the fact that students are advocating for themselves and the health of their schools. I am glad that the American Academy of Pediatrics and some California state legislators are advocating for healthier schools, but I have argued at length elsewhere that it is preferable to empower people advocate for themselves. And so students are. For instance, they have been at the forefront of a series of lobbying efforts (successful in Oregon and Utah) to get mental sick days recognized as legitimate reasons for missing school.

It is no coincidence that this push to create space for “mental health days” comes in the middle of a period of worsening mental health of young people in the U.S. Deaths from suicides just replaced deaths from homicides as the second leading cause of death among 15-19-year-olds (deaths from traffic accidents are down, but still exceed both). And homicides are also a target of student activism; after the Parkland school shooting, young people became the unexpected leaders of a new wave of gun control activism.

The late 2010s have been a time of disorienting rapid change, but I suspect that future historians will highlight one global social phenomenon: young people demanding a better world. The most prominent example is the rise of young climate change activists around the world—Greta Thunberg being the most famous—demanding action with a new sense of clarity and resolve. As I write this, Teen Vogue’s website teases an article with a link saying “Why Homeless Advocates Aren’t Happy With the 2020 Presidential Candidates” and an op-ed on radical labor organizing among nail salon workers.

Better health through better spaces
Even though lunch shaming, poor mental health, exhaustion and all sorts of other health problems still tragically afflict young people in schools, I am optimistic because it really does feel that the winds have shifted—thanks in large part to student activists, unhealthy schools are finally getting reforms they have long needed. As I argue at length in the book Philosophy of Population Health, health depends not just on whether we have good medical care, but also on whether the places where we live our everyday lives have been thoughtfully designed to support good health.

Sean Valles photo

Sean A. Valles, PhD, is an Associate Professor with an appointment in Lyman Briggs College and the Department of Philosophy at Michigan State University. His research spans a range of topics in the philosophy of population health, from the use of evidence in medical genetics to the roles played by race concepts in epidemiology. He is author of the 2018 book, Philosophy of Population Health: Philosophy for a New Public Health Era. He is also Director of the MSU Science and Society @ State Program, supporting interdisciplinary faculty collaborations that join the humanities, arts, and sciences.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, November 28, 2019. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

More Bioethics in the News from Dr. Valles: Recognizing Menstrual Supplies as Basic Health Necessities: The Bioethics of #FreePeriodsTrump’s Attempt to Reignite the Coal Industry Is Another Health Policy BlunderPolitics and the Other Lead Poisoning: The Public Health Ethics of Gun Violence; Climate Change and Medical Risk

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Recognizing Menstrual Supplies as Basic Health Necessities: The Bioethics of #FreePeriods

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Sean Valles, PhD

Activism against “period poverty” has gone mainstream

Within the last month, Scotland became the first country to provide free menstrual products in schools, and London student Amika George earned a Campaign Award from the influential Bill and Melinda Gates Foundation for starting the #FreePeriods social activism campaign. Why is the accessibility of menstrual products getting attention from human rights activists and governments? Because for many people* they are basic necessities that remain out of reach.

A survey commissioned by Proctor and Gamble’s Always® brand of menstrual products reports “nearly one in five American girls have either left school early or missed school entirely because they did not have access to period products.” Take that survey with a grain of salt, given who sponsored it, but it provides a sense of the scope of a previously-known problem. Like most problems that disproportionately hurt people who are already most marginalized by society, “period poverty” has only received sporadic attention in media outlets and public conversation. Previous reporting on the subject includes discussions of the problem among people who are homeless in San Francisco, and among adolescents from low-income families, living in the Pine Ridge Indian Reservation and in the Nashville area.

“Period poverty” is gradually getting recognized as one piece of the complex cycle of poverty. Imagine finally getting a job interview after struggling with unemployment, only to have to choose between skipping the interview or trying to make a makeshift pad out of wadded toilet paper or an old sock, then hoping it doesn’t fall out or leak in front of the would-be boss. When one can’t afford the health/hygiene supplies to avoid bleeding on one’s clothes (nor afford to replace any clothes stained by a period), a lack of timely access to menstrual products can have the drastic effect of making it hard to participate in public life.

Bioethics of access to menstrual products

Access to menstrual products is clearly a problem, but is it a bioethics problem? Absolutely. As the FDA will tell you, menstrual pads, reusable menstrual cups, tampons, etc. are medical devices. Menstrual products are medical technologies used to manage one’s hygiene according to cultural norms. It is a bioethical harm to limit a person’s access to the tools a society has decided are necessary for meeting its basic standards of hygiene.

After decades firmly in the U.S.’ collective ethical blind spot, public opinion on how society ought to respond to “period poverty” is divided, and has a conspicuous gender gap. In the U.S., almost three-quarters of women support providing free menstrual supplies in schools, while just over half of men do. Half of women agree public bathrooms should provide free menstrual supplies while just over a third of men do. I’m a little surprised to see that latter set of numbers so low, but I suppose we’re still accustomed to the idea that toilet paper and hand soap are necessary health/hygiene products that must be available in every public bathroom, while menstrual supplies are typically kept in paid dispensers or not available at all.

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Image description: a close up photograph of a menstrual product dispenser, showing coin slots for pads and tampons available for 25 cents each, quarters only. Image source: Beth Van Dam/Flickr Creative Commons.

Adding insult to injury, Michigan continues to impose a sales tax on menstrual products, whereas food and medicines are exempt. Most states have similar taxes on menstrual products, even though legal scholars, such as Crawford and Waldman, have argued that the taxes are doubly unconstitutional; they violate both the Equal Protection Clause and the core constitutional principal that laws must have a rational basis. Legislation to end Michigan’s “Tampon Tax” received unanimous supporting votes in the Senate Finance Committee in March of 2017, but has been effectively ignored by the Senate since then. I suspect that the lack of progress, despite unanimous committee support, is related to the fact that in Michigan’s legislature there are three male legislators for every female legislator (on a related note, take a look at the names of the authors in the bibliography at the end of this post).

That tax loophole is part of a category of problems: bioethical harms resulting from sexist economic inequities. It is not the only example, either. For instance, among personal care products that are marketed to men and women (e.g. razors and shaving cream), there is an average markup of 13% on the items marketed to women. Meanwhile, the gender wage gap leaves women only making around 80% of what men make.

Some of the problems hiding in our bioethical blind spot will be complex and difficult to solve, such as the problem that dental care has long been treated as separate from medical care (Medicare and Medicaid largely exclude coverage). By contrast, the inaccessibility of menstrual products would be far easier to fix. Very minor changes to tax policies and social norms could make menstrual products as widely available as toilet paper. Most households still buy the toilet paper of their choosing, but we expect even the shabbiest public bathrooms to have toilet paper in it for free.

We can fix this

When will we start treating menstrual products like the health/hygiene/medical necessities they are? Scotland has recognized that at the very least no student should miss class because they don’t have access to sanitary pads. What is the argument against this? Perhaps a generic political concern about former social privileges getting recast as legally-mandated rights or socially-demanded expectations? Whatever the merits of that general concern, nobody wins when low-income students miss school and low-income women miss job interviews because they don’t have pads. If nothing else, where is our human empathy for those suffering the preventable indignities of being stuck without a pad?

#FreePeriods.

*A note on biology
Sex, gender, and human bodies are complex and diverse. Not all post-adolescent/pre-menopausal women menstruate. Not all people who menstruate are women. Not all menstrual bleeding happens in the uterus: endometriosis is a common (but too rarely discussed in public) condition in which endometrial (uterine) tissue implants in other parts of the body and responds to menstrual cycles by bleeding much like the uterine tissue does. Complex and diverse.

Sean Valles photo

Sean A. Valles, PhD, is an Associate Professor in Lyman Briggs College and the Department of Philosophy at Michigan State University. His book Philosophy of Population Health: Philosophy For A New Public Health Era was published by Routledge in May 2018.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, November 15, 2018. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

More Bioethics in the News from Dr. Valles: Trump’s Attempt to Reignite the Coal Industry Is Another Health Policy BlunderPolitics and the Other Lead Poisoning: The Public Health Ethics of Gun Violence; Climate Change and Medical Risk

Click through to view references

Trump’s Attempt to Reignite the Coal Industry Is Another Health Policy Blunder

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By Sean A. Valles, PhD

The recently abandoned effort to pass the American Health Care Act (AHCA) was a massive blunder for the Trump administration, failing in its effort to “repeal and replace” Obama’s signature Affordable Care Act, despite Republican control over the House, Senate, and the White House. Less attention has been given to the Trump administration’s second major health policy reform. On March 28, Trump signed an executive order initiating a reversal of Obama-era clean energy plans and seeking “an end to the war on coal.” It was presented as an economic policy reform and an energy policy reform, but it is also a health policy reform since it will have drastic effects on U.S. health.

A short blog entry does not allow me to do justice to the incredible range of ways that coal power plants harm our health. For those interested, Epstein et al. (2011) survey the issue: Coal is one of the leading sources of mercury emissions in the U.S., with horrific effects such as neurological damage in developing fetuses. Meanwhile, much like breathing cigarette smoke, the mix of particles emitted from coal power plants causes increased rates of heart disease, asthma, bronchitis and a host of other diseases.

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Image description: a photo of the Detroit Edison Monroe Power Plant. Image source: Wikipedia

Obama’s Clean Power Plan, already delayed by legal challenges, was designed to hasten the process of replacing U.S. coal power with other energy sources (natural gas, wind, etc.). That replacement process had already been underway because of old-fashioned capitalist market forces. Natural gas recently surpassed coal in U.S. power plants because natural gas is getting cheaper, and renewable sources like wind power are also cutting into the coal market. Meanwhile, manual laborers across the country are finding themselves displaced by new technologies, so even a stable coal industry would offer a diminishing number of coal mining jobs.

The Clean Power Plan was projected, by 2030, to save 1,500-3,600 people from dying prematurely, prevent “90,000 asthma attacks in children,” and prevent “300,000 missed school and work days” (among other benefits). Coal is already struggling to economically compete with other fuel sources, but is even more expensive than it looks if one factors in the harmful side effects it brings into our world: “Accounting for the damages conservatively doubles to triples the price of electricity from coal per [kilowatt hour] generated.”

It is telling that the economists who have defended Trump’s executive order avoid addressing the health data above. Stephen Moore and Nicolas Loris both insist that coal power has gotten much cleaner. Neither of them acknowledges how much harm coal still does, nor how much death and illness the Clean Power Plan would have averted. Loris tries to change the subject, claiming that the Clean Power Plan was really about carbon emissions and climate change, not “pollutants known to harm human health and the environment”. But, climate change causes health harms too, such as the (worsening) heat waves that aggravate cardiovascular and respiratory diseases (see my previous post for Bioethics in the News).

We do not need to choose between caring about health vs. caring about coal industry employees whose jobs are at risk; we should do both. The U.S. safety net leaves much to be desired, but it at least offers: job retraining programs, coordinated by the Department of Labor; access to temporary housing for those who lose their homes, coordinated by the Department of Housing and Urban Development; food assistance for the families that will go hungry, provided by the Department of Agriculture. But… Trump plans to drastically cut the budgets of all of those agencies. And, as if to remove all doubt that his declarations of concern for coal workers are hollow, he specifically wants to eliminate the two federal agencies tasked with improving the economy in struggling coal-producing regions: the Appalachian Regional Commission and the U.S. Economic Development Administration.

We are at a tipping point in U.S. health. The most recent CDC data show that our national life expectancy is actually decreasing, while other countries’ expectancies are rising. Meanwhile, new data on the strengths and limitations of healthcare in the U.S. show us that the benefits of health insurance coverage are ethically essential, but frustratingly limited in their power. Insurance coverage protects people from getting unfairly trapped in medical debt after an unexpected illness, but just having access to doctors and medicines doesn’t automatically make people healthier.

Our health is the cumulative effect of our everyday lives: the food we eat, the air we breathe and so on. It is unethically deceptive and cruel for the Trump administration to advertise dubious economic benefits of reviving the coal industry while there is an abundance of evidence that doing so will cause unethical harms to the millions who will be increasingly left to breathe more soot and eat more mercury. As many of my neighbors in the Great Lakes region already know, mercury deposits from coal have left many of our local fish too contaminated to eat more than occasionally. Adding insult to injury, Trump wants to eliminate the Great Lakes Restoration Initiative that is now working to decontaminate the lakes (a rare program with bipartisan political support at the local and national levels).

Trump earned plenty of criticism for bungling his first major legislative effort, the AHCA healthcare reform bill. The bill infamously tried to slash Medicaid spending by $839 billion over the next decade, the safety net program which—among many other benefits—“covers the costs of nearly half of all births in the United States.” (Note: some rumors are true; yes, the U.S. infant mortality rate is more than double the rate in Sweden and, yes, Cuba is also beating us by a healthy margin). Even his own party refused to rally behind the bill. Trump’s second health policy is his effort to reignite the coal industry with an executive order. But, the U.S. remains a representative democracy and your local legislators have the power to step in and, well, legislate. By all means, tell them what you think of Trump’s second health reform policy.

Sean Valles photoSean A. Valles, PhD, is an Associate Professor in the Lyman Briggs College and Department of Philosophy at Michigan State University. He is a philosopher specializing in ethical and evidentiary issues in contemporary population health sciences.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, May 11, 2017. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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More from Dr. Valles: Climate Change and Medical RiskPolitics and the Other Lead Poisoning: The Public Health Ethics of Gun Violence

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Politics and the Other Lead Poisoning: The Public Health Ethics of Gun Violence

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series

By Sean A. Valles, PhD

This year’s presidential debates drew attention to gun violence in Chicago, as well as the (merely?) short-term reversal in the decades-long decline in US violent crimes. In the process, it reignited the smoldering political dispute over whether gun violence is a public health problem.

Every year, US hospitals and morgues see a stream of around 32,000 preventable deaths and 67,000 preventable injuries from guns. Indeed, hospitals and morgues are where one finds the consequences of public health problems. Yet, Surgeon General Murthy nearly had his Senate confirmation blocked by National Rifle Association lobbying in 2014, because he had once Tweeted: “Tired of politicians playing politics w/guns, putting lives at risk b/c they’re scared of NRA. Guns are a health care issue.” The debate continues.

bullet hole in mirror
Image description: A bullet hole in a mirror. There are cracks extending out from the bullet, and a mirror shows the reflection of blue sky with clouds. Image source: Flickr user Jo Naylor.

Neglecting the medical and public health aspects of gun violence is a tragic lost opportunity to understand and respond to gun injuries and deaths. For example, only some jurisdictions require special permits to purchase handguns, but public health data indicate that adopting such polices helps to prevent both suicides and homicides. Thanks to NRA lobbying (again), the Centers for Disease Control is prohibited from doing any research that serves “to advocate or promote gun control.” The researchers who dare to work in the under-funded field “face emotional and financial demands” (Pettit 2016). Meanwhile, the 14-year-old National Violent Death Reporting System, the federal database for gun violence, still has zero data from ten states.

“Health in all policies”
Though its hands are partly tied, the CDC endorses the mainstream public health position that we must promote “health in all policies.” I.e. gun policies are (failed) health polices because the US continues to be plagued by gunshot wounds. Health is shaped by all manner of different causes, including laws and policies that were not explicitly designed to be health policies. For example, local commercial/residential zoning laws are public health issues. Why? Because they control the distribution of supermarkets, fast food restaurants and liquor stores in each neighborhood, affecting what the local population can/does eat and drink. Poorly designed city zoning laws are public health problems because they keep nutritious foods inaccessible and less nutritious alternatives abundant.

‘But, if guns are a public health problem then that would mean…’
The notion of promoting “health in all policies” has—surprisingly—faced some of the staunchest resistance from professional public health ethicists. Perhaps best illustrating the divide, the American Public Health Association has co-signed a letter with 57 other medical and public health organizations, calling for expanded gun violence monitoring data and gun control measures. Meanwhile, the ethics section editor of the association’s journal has opposed adding crime and other social ills “to the public health agenda”—doing so would make “public health… so broad as to be meaningless” (Rothstein, 2009). Similarly, an influential public health justice text resists calls to treat crime, war and various other social problems as public health problems, arguing that despite the desirability of a “broad scope of public health,” recognizing them as such would leave public health with “no real core, no institutional, disciplinary or social boundaries” (Powers and Faden, 2006).

Outside of the bioethics community, physician and free-market economics advocate Paul Hsieh echoes the idea that treating guns as a public health problem makes ‘public health’ unrecognizably broad, and it also “diverts us from genuine public health threats.” He scoffs that next we could even start thinking of issues like minimum wage and poverty as public health problems. Funny he should mention it; in fact, small differences in income are associated with drastic differences in life expectancy. An American man in the richest 1% has a life expectancy 14 years longer than a man in the poorest 1%! We now know that the causes of death and illness are complex and far-reaching—we must resist the urge to squeeze “public health” until its boundaries are neatly compressed and its efforts are hopelessly hobbled.

When the American Medical Association issued a statement in July that it considers guns “a public health crisis,” Keith Ablow, a member of the “Fox News Medical A-Team,” retorted that we don’t really know how many homicides could be prevented with gun control. But then he went on to say “they’re going to eat away at gun rights with medical research.” Like the NRA’s efforts to restrict CDC gun violence research, it appears that Ablow is very worried about what gun violence public health data would reveal. It would seem that he finds gun violence research more frightening than… gun violence.

It doesn’t have to be this way
But isn’t it foolish to think the medical and public health communities could help with a massive social problem like gun violence? It’s the reply I hear most often, and it always strikes me as an odd moment of pessimism. Odd, that is, in light of the widely-embraced moonshots of eradicating smallpox from every population on the planet (done!), and spending incredible sums to find treatments for the innumerable and mysterious varieties of cancer (optimistic!). Why do I so often see resigned shrugs when I insist we can make public health progress in the problem of Americans using guns to kill ourselves and each other almost five times more often than our Canadian neighbors? After all, when pediatricians talk to parents about gun safety during a child’s checkup, the parents become more likely to use a gun lock, which substantially reduces risks of gun accidents and gun suicides. Sounds like a good start.

We can do better, and some of my bioethics colleagues have been producing excellent work, making the case for why the deep-rooted social problems (violence, poverty, etc.) causing our public health ills must become national public health priorities, and also priorities for individual physicians. The first step though, is admitting that the roughly 100,000 people shot in the US each year each have gun violence medical problems, and that we in the US have a gun violence public health problem.

Sean Valles photoSean A. Valles, PhD, is an Associate Professor in Lyman Briggs College and the Department of Philosophy at Michigan State University. He is a philosopher specializing in ethical and evidentiary issues in contemporary population health sciences.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, December 1, 2016. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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Climate Change and Medical Risk

Bioethics-in-the-News-logo

This post is a part of our Bioethics in the News series. For more information, click here.

By Sean A. Valles, Ph.D.

 After winning the 2007 Nobel Peace Prize, the UN’s Intergovernmental Panel on Climate Change has returned to the headlines. Heeding the growing body of climate evidence, they say, “it is extremely likely [95%-100% likely] that human influence has been the dominant cause of the observed warming since the mid-20th century” (IPCC Working Group I 2013, pp. SPM-2, SPM-12). Unfortunately, according to a March Gallup poll:

In contrast to majority acceptance of global warming as real, Gallup finds Americans less than alarmed. One-third worry “a great deal,” and 34% expect it to threaten their way of life. These could be the attitudes that matter most when it comes to Americans’ support for public policies designed to address the issue (Saad 2013).

That skepticism about climate change’s seriousness (and, to a lesser extent, about humans’ responsibility for it) is impeding democratic action in the US. The leadership provided by a skeptical vocal minority has turned the public dialogue into a dispute over uncertainties in how we predict future climate, whether it is accusing researchers of inadequate “objectivity” (LaFramboise 2013) or publicizing pieces of climate data that seem inadequately explained (Darwall 2013). I encourage my bioethics colleagues to help change the conversation, and re-frame the US climate change dialogue to focus on one crucial fact: even with lingering uncertainties, climate change poses health risks that we would be foolish to ignore.

A 2009 special report by The Lancet and University College London Institute for Global Health Commission declares, “climate change is the biggest global health threat of the 21st century” (Costello, et al. 2009, p. 1693). These are bold words, especially coming from The Lancet—one of the most prestigious medical journals. The report lists a number of health risks: more numerous heat waves will worsen respiratory and cardiovascular symptoms (Costello, et al. 2009, p. 1702), mosquitoes and mosquito-borne diseases will spread and flourish in newly warm areas (Costello, et al. 2009, p. 1702), and extreme weather events will become more common and stronger (impacting mental health, access to food, access to sanitation infrastructure, etc.) (Costello, et al. 2009, p. 1706). The list goes on, and policy groups such as the EPA have demonstrated that they take it quite seriously. A recent article in Bioethics by Cheryl Cox MacPherson explains that such risks make it clear “Climate Change Is a Bioethics Problem” (MacPherson 2013, p. 305).

Unfortunately, bioethicists’ involvement in the climate change dialogue—a crucial medical dialogue—has been the exception rather than the norm. Bioethicists are already expert communicators, researchers, interdisciplinary collaborators, and public advocates in the management of multiple intersecting risks and ethical considerations. They apply this expertise to issues such as tissue donation, vaccination, and pharmaceutical testing. I recommend that they add climate change to their list of priorities. Economic constraints, individual liberty, public welfare, being mindful of social justice; these sorts of difficult climate change considerations are very much in bioethicists’ wheelhouse.

Recent research on science communication indicates that pragmatically it would be a wise strategy to move health out of the background in the climate change dialogue. A recent study compared audience responses to three different presentations of climate change, “emphasizing either the risks to the environment, public health, or national security;” the researchers found that, “across audience segments, a public health focus was the most likely to elicit emotional reactions consistent with support for climate change mitigation and adaptation” (Myers, et al. 2012, p. 1105). Maibach et al. explains that the “dominant mental frame used by most members of the public to organize their conceptions about climate change is that of ‘climate change as an environmental problem’” (Maibach, et al. 2010, p. 2). We all hear plenty of talk about ‘saving the environment,’ but switching to a health frame would offer important benefits.

Re-defining climate change in public health terms should help people make connections to already familiar problems such as asthma, allergies, and infectious diseases experienced in their communities. The frame also presents the opportunity to involve additional trusted communication partners on the issue, notably public health experts and local community leaders (Maibach, et al. 2010, pp. 9-10).

Pictures of forlorn polar bears floating on melting blocks of ice have proved compelling for some people, but a health-centered approach looks more promising as a default strategy.

Shifting the climate dialogue to emphasize medical risk creates a fresh conversation, wherein both unshakable believers and unimpressed skeptics can perhaps recognize the ethical imperative to prevent likely harms. In an analogous situation, I am encouraged by the way that ever-embattled evolutionary biology has become incorporated into the daily life of clinical healthcare workers. The evolutionary biologist Joan Roughgarden points out that (limited) survey data shows “acceptance of evolution is far from unanimous among Christian doctors” (Roughgarden 2006, p. 8). This is cause for great concern, since evolutionary biology shows that the misuse of antibiotics since their introduction in the 1940s has created an environment where natural selection favors the evolution of antibiotic-resistant pathogens, creating a global medical crisis (Chambers, et al. 2009). The good news is that despite the aforementioned (human) evolution skepticism among doctors, as a group they recognize that their actions are partly responsible for the problem of antibiotic resistance. In a recent survey of US physicians (“clinical faculty and residents”), 97% agree “inappropriate [antibiotic] use causes antimicrobial resistance” (Abbo, et al. 2011, pp. 714-715).

Recognizing climate change medical risk as worthy of attention and action does not mean that one must fully understand or even fully trust the underlying science. In the case of the antibiotic-resistant pathogens, the perceived risk (uncontrolled infectious diseases) seems capable of overriding theoretical qualms about natural selection’s role in biology. Analogously, the aforementioned communications research suggests that climate skepticism and climate ambivalence can perhaps be overcome by shifting emphasis to medical risks.

The antibiotic resistance case can also shed light on how to synchronize multiple climate change strategies. Philosopher Stephen Gardiner highlights the dangers of proposed climate change strategies that largely abandon the mitigation of climate change (e.g. reducing greenhouse gas emissions) in order to pursue adaptation strategies to cope with the effects of the change (Gardiner 2004). Indeed, the antibiotic resistance dialogue already incorporates both mitigation strategies (preventing antibiotic overuse in order to slow the evolution of antibiotic resistance) and adaptation strategies (creating treatment guidelines to help patients who have resistant infections) (Centers for Disease Control and Prevention 2013).

Climate change is a growing medical problem, and there is increasing recognition that this needs to be highlighted. Perhaps most importantly, evidence from communications research and the analogous dialogue about antibiotic resistance indicates that framing climate change as a health risk would be a productive shift. I hope bioethicists will increasingly join with their colleagues in climatology, public health, etc., so that together we can make the case for action.

References:

Abbo L, Sinkowitz-Cochran R, Smith L, Ariza-Heredia E, Gómez-Marín O, Srinivasan A, et al. (2011). Faculty and Resident Physicians’ Attitudes, Perceptions, and Knowledge about Antimicrobial Use and Resistance. Infection Control and Hospital Epidemiology, 32(7), 714-718. Retrieved from http://www.jstor.org.proxy1.cl.msu.edu/stable/10.1086/660761

Centers for Disease Control and Prevention (2013). Antibiotic Resistance Threats in the United States, 2013: Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/features/antibioticresistancethreats/

Chambers HF, & DeLeo FR (2009). Waves of Resistance: Staphylococcus Aureus in the Antibiotic Era. Nature Reviews Microbiology, 7(9), 629-641. Retrieved from http://www.nature.com.proxy2.cl.msu.edu/nrmicro/journal/v7/n9/full/nrmicro2200.html

Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R, et al. (2009). Managing the Health Effects of Climate Change. Lancet, 373(9676), 1693-1733. Retrieved from http://www.sciencedirect.com.proxy1.cl.msu.edu/science/article/pii/S0140673609609351

Darwall R (2013). The Political Science of Global Warming. The Wall Street Journal. Retrieved from http://online.wsj.com/news/articles/SB10001424052702303464504579106993839343868

Gardiner SM (2004). Ethics and Global Climate Change. Ethics, 114(3), 555-600. Retrieved from http://www.jstor.org.proxy1.cl.msu.edu/stable/10.1086/382247

IPCC Working Group I (2013). Working Group I Contribution to the IPCC Fifth Assessment Report Climate Change 2013: The Physical Science Basis (Summary for Policymakers). Geneva: Intergovernmental Panel on Climate Change. Retrieved from http://www.climatechange2013.org/images/uploads/WGIAR5-SPM_Approved27Sep2013.pdf

LaFramboise D (2013). Warming Up for Another Climate-Change Report. The Wall Street Journal. Retrieved from http://online.wsj.com/article/SB10001424127887323981304579079030750537994.html

MacPherson CC (2013). Climate Change is a Bioethics Problem. Bioethics, 27(6), 305-308. Retrieved from http://onlinelibrary.wiley.com.proxy2.cl.msu.edu/doi/10.1111/bioe.12029/full

Maibach EW, Nisbet M, Baldwin P, Akerlof K, & Diao G (2010). Reframing Climate Change as a Public Health Issue: an Exploratory Study of Public Reactions. BMC Public Health, 10, 299. Retrieved from http://dx.doi.org.proxy1.cl.msu.edu/10.1186/1471-2458-10-299

McGrath M (2013). IPCC climate report: humans ‘dominant cause’ of warming. BBC News. Retrieved from http://www.bbc.co.uk/news/science-environment-24292615

Myers TA, Nisbet MC, Maibach EW, & Leiserowitz AA (2012). A Public Health Frame Arouses Hopeful Emotions about Climate Change. Climatic Change, 113(3-4), 1105-1112. Retrieved from http://link.springer.com/article/10.1007%2Fs10584-012-0513-6

Roughgarden J (2006). Evolution and Christian Faith: Reflections of an Evolutionary Biologist. Washington, DC: Island Press.

Saad L (2013). Americans’ Concerns About Global Warming on the Rise Retrieved October 4, 2013, from http://www.gallup.com/poll/161645/americans-concerns-global-warming-rise.aspx

Subramanian C (2013). Rebranding Climate Change as a Public Health Issue. Time. Retrieved from http://healthland.time.com/2013/08/08/rebranding-climate-change-as-a-public-health-issue/

United States Environmental Protection Agency (2013). Climate Impacts on Human Health: United States Environmental Protection Agency. Retrieved from http://www.epa.gov/climatechange/impacts-adaptation/health.html

Note: The resources for this post include both public access links and Michigan State University Libraries access links. The MSU library links are available to current MSU faculty, staff and students.

SeanVallesblogphotoSean A. Valles, Ph.D.,  is an Assistant Professor in the Lyman Briggs College and the Department of Philosophy at Michigan State University.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Friday, November 8, 2013. With your participation, we hope to create discussions rich with insights from diverse perspectives. You must provide your name and email address to leave a comment. Your email address will not be made public.