International Journal of Social Determinants of Health and Health Services

The ever-increasing ownership of health service providers, suppliers, and insurers by investor-owned enterprises presents an unforeseen complexity and diversity to health care delivery. This article reviews the history of the for-profit invasion of the health sector, linking corporate purchaser directions to the now dominant mode of delivery in managed care. These dynamics require unceasing reassessment while the United States embarks upon implementation of national health care reform.

This article explores the importance of woman battering for female suicidality, with special attention to the link among black women. Suicidality has classically been framed with a distinctly male bias. As a result, suicide attempts (a predominantly female event) have been defined as “failed suicides” and the distinctive social context of suicidality among women has been missed. The authors propose that suicidality among battered women is evoked by the “entrapment” women experience when they are subjected to “coercive control” by abusive men. A literature review highlights the probable importance of male violence as a cause of female suicidality. Pursuing this possibility, we assess the significance of battering in a sample of women who have attempted suicide, the characteristics of battered women who attempt suicide, and the appropriateness of the medical response. The results indicate that battering may be the single most important cause of female suicidality, particularly among black and pregnant women. The implications of this finding for theory and clinical intervention are discussed.

The authors discuss the results of a survey of the attitudes of Canadian and French (Picardie, Nord-Pas de Calais) physicians toward selective abortion of fetal anomalies detected by ultrasound, amniocentesis, or chorionic villus sampling. The study documents the threshold of acceptability of abortion of fetuses with selected anomalies, as well as the physicians' own perceptions of their role in the decision to abort. While there was no consensus among all Canadian physicians regarding the acceptability of abortion, more than 55 percent from France and Quebec would accept selective abortion of a fetus affected with trisomy 21, Duchenne muscular dystrophy, cystic fibrosis, Huntington's chorea, or spina bifida. In the province of Quebec, Anglophone physicians showed a greater acceptance of abortion than did their French-speaking colleagues. In reference to the physician's role in the decision to abort, French physicians are more directive than North American physicians. Cultural predispositions may explain these differences in attitudes.

To understand more fully the nature of poverty it must be viewed as the result, in part, of inherent features of the social system. The author describes four general approaches to explaining poverty: poverty as a result of inherent individual attributes, as the by-product of contingent individual characteristics, as a by-product of social causes, and as a result of inherent properties of the social system. He then elaborates a class exploitation analysis of poverty by explaining how economic oppression, economic exploitation, and class generate a social system in which poverty plays a crucial functional role. The general problem of poverty must be broken down into two subproblems: poverty generated inside exploitative relations (the working poor) and poverty generated by nonexploitative oppression (the underclass). A class analysis of poverty argues that significant numbers of privileged people have a strong, positive material interest in maintaining poverty. Poverty can be reduced in the United States only through popular mobilization of pressure that challenges the power of the dominant classes.

The dual or segmented economy perspective suggests that the U.S. production system within a capitalist world-system can be divided into distinct sectors based on elements such as levels of industrial concentration, foreign involvement, and unionization. The differing organization of these sectors is argued to influence worker health and safety (WHS) outcomes. An economic segmentation model was applied to national occupational health data to examine the relationship between structural divisions in the economy and occupational hazard exposure, injury, and illness. Workers in more global industrial sectors had only average levels of hazardous exposure but a greater likelihood of occupational injury and illness than workers in other sectors of the economy. These differences are related to the structure of work in the various sectors. The findings suggest the need for (1) greater surveillance and reporting of WHS problems through the general health care system; (2) planning of economic and productive activity that takes WHS issues into account; and (3) greater worker organization and power within and between nations to improve WHS.

The author looks at work environment matters from the perspective of public policy-making and the policy instruments used to deal with workplace health and safety: standard setting; joint health and safety committees; compliance, enforcement, and prosecution; workers' compensation as an economic incentive; and collective bargaining. While regarding all as necessary, the author considers them as separately and collectively, fundamentally flawed and therefore insufficient, because liberal public policy-making itself is problematic. He proposes an alternative way of thinking about this subject from the perspective of the “politics of meaning.”

The United States is experiencing a hepatitis B epidemic that has until recently received relatively little public attention. Many groups of workers are at risk of infection, death, or chronic carriership because of workplace exposure to blood; those at risk include not only health care professionals but police, fire fighters, life guards, hospital-based laundry and cafeteria workers, park rangers, sanitation workers, etc. One of the most important victories against the hepatitis B pandemic in the United States occurred when the Occupational Safety and Health Administration issued a Bloodborne Pathogens Standard that required employers to protect 5½ million workers from infection by offering those at risk free hepatitis B vaccination, and forced employers to bear the costs of providing equipment (e.g., gloves, gowns, masks, puncture-proof containers) to maintain “universal precautions” for employees handling bodily fluids. While most people assume the new standard was primarily aimed at fighting the AIDS epidemic, it was actually based on the more significant risk posed by hepatitis B infection. The standard resulted not from leadership provided by the experts in the Public Health Service mandated to control infectious disease, but rather from pressure applied by labor unions—providing a clear example of the continued importance of unions for worker protection in our supposedly post-union era.

In a recent article, Lexchin asks “who needs faster drug approval times in Canada?” and, on the basis of extremely limited and selective data, draws the conclusion that neither the public nor the pharmaceutical industry does. Whether the Canadian system is really slower is investigated by comparing Canadian and U.S. marketing approval dates and by using information on regulatory approval times from the two countries and elsewhere. Marketing approval dates in Canada are significantly later than those in the United States, although not consistently across all therapeutic categories; anti-cancer and gastrointestinal drugs have earlier approval dates in Canada. However, Canadian and U.S. regulatory approval times are not significantly different, indicating that marketing applications are submitted later in Canada, but both are considerably longer than those in the United Kingdom. The evidence shows that Canadians need faster drug approval times if individuals requiring the medications are not to suffer unnecessarily. A significant decrease in drug approval times and the establishment of comprehensive and effective postmarketing surveillance would reduce the time it takes for new drugs to be made available to Canadians while, at the same time, providing a high level of drug safety.

While Canada has a delay in drug approval dates and regulatory approval times compared with countries such as the United States and the United Kingdom, evidence to show that such delays compromise therapy is lacking. Faster regulatory approval coupled with an effective postmarketing surveillance system can achieve acceptable safety results, but whether such a system is feasible in Canada is unknown. Setting priorities in reforming the Canadian drug regulatory process depends on an assessment of what the most important problems are. Such an assessment reflects the nature of policy making in Canada.

To go back to a period more than five decades ago to talk about the health left is to enter not just another time, but another world. Between the Great Depression and the postwar period, challenging and contradictory social, political, and professional developments were brought to the surface in U.S. life. The health left shared in the opportunities and confusion, enriching the American spirit and participating in both the pleasures and the pain. The 1930s saw economic depression, wars, the birth of fascism, and fears of social collapse. In medicine, despite sporadic scientific advances, the social response was remote and narrow. But social activism motivated medical students and medical practitioners. The 1940s marked a change in both attitudes and values. The left was divided, and bitter factionalism stymied cooperative action. Participation in the war against fascism promoted solidarity, despite the sadness of the evidence of brutality and lack of humanity. The 1950s are sometimes considered regressive, but seeds germinated as the complexity of medical life engendered new approaches to meeting sociomedical needs. As we entered the 1960s a different and more hopeful story unfolded as the rebellions of the poor, blacks, and women brought about a new era of social action.