Equivalence, Justice, Injustice – Health and Social Care Decision Making in Relation to Prison Populations

From Frontiers via Jisc Publications RouterHistory: collection 2021, received 2021-01-05, accepted 2021-06-30, epub 2021-07-14Publication status: PublishedPrisons represent sites of singular healthcare need–characterized by high levels of distress and disorder. In many jurisdictions, practitioners are ethically charged with delivering healthcare that is “equivalent” to that available in the wider community. This claim has been much debated–yet the emergence of a global coronavirus pandemic has highlighted the arguments in a particularly stark manner. In the following conceptual analysis, we explore the emergent discourse of the coronavirus and consider its particular significance for prison healthcare decision making and the concept of equivalence. For example, both the coronavirus pandemic and practice of prison incarceration induce a sense of varied temporality: The discourse of prison is replete in this area–such as the concept of “hard time.” Alongside this, the discourse in relation to coronavirus has highlighted two competing modes of temporal understanding: The political–where the pandemic is conceptualized as has having a discrete “beginning and end”, and the scientific–where the “new normal” reflects the incorporation of the “novel” coronavirus into the wider ecology. The impact of these disparate understandings on the prison population is complex: “Locking down” prisoners–to safeguard the vulnerable against infection–is relatively simple, yet it has traumatic repercussions with respect to liberty and psychosocial health. Easing lockdown, by contrast, is a difficult endeavor and risks collision between the temporalities of prison–where “hard time” is accentuated by separation from the “real world”–the political and the scientific. Whither then the concept of equivalence in relation to a field that is definitively non-equivalent? How can practitioners and policy makers maintain a just ethical stance in relation to the allocation of resources when it comes to a politically marginalized yet manifestly vulnerable population? We argue that further debate and consideration are required in this field–and propose a framework for such discussion

Genetic mechanisms of critical illness in COVID-19.

Host-mediated lung inflammation is present1, and drives mortality2, in the critical illness caused by coronavirus disease 2019 (COVID-19). Host genetic variants associated with critical illness may identify mechanistic targets for therapeutic development3. Here we report the results of the GenOMICC (Genetics Of Mortality In Critical Care) genome-wide association study in 2,244 critically ill patients with COVID-19 from 208 UK intensive care units. We have identified and replicated the following new genome-wide significant associations: on chromosome 12q24.13 (rs10735079, P = 1.65 × 10-8) in a gene cluster that encodes antiviral restriction enzyme activators (OAS1, OAS2 and OAS3); on chromosome 19p13.2 (rs74956615, P = 2.3 × 10-8) near the gene that encodes tyrosine kinase 2 (TYK2); on chromosome 19p13.3 (rs2109069, P = 3.98 ×  10-12) within the gene that encodes dipeptidyl peptidase 9 (DPP9); and on chromosome 21q22.1 (rs2236757, P = 4.99 × 10-8) in the interferon receptor gene IFNAR2. We identified potential targets for repurposing of licensed medications: using Mendelian randomization, we found evidence that low expression of IFNAR2, or high expression of TYK2, are associated with life-threatening disease; and transcriptome-wide association in lung tissue revealed that high expression of the monocyte-macrophage chemotactic receptor CCR2 is associated with severe COVID-19. Our results identify robust genetic signals relating to key host antiviral defence mechanisms and mediators of inflammatory organ damage in COVID-19. Both mechanisms may be amenable to targeted treatment with existing drugs. However, large-scale randomized clinical trials will be essential before any change to clinical practice

Preparing for end-of-life: learning from Do Not Attempt Cardiopulmonary Resuscitation decision-making during COVID-19

Abstract During the COVID-19 pandemic, Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were made differently. This included more prominent roles for specialties such as psychiatry and doctors in training. Concerns about inappropriate DNAR decisions led to anxiety for doctors, patients and the public. Positive outcomes may have included earlier and better-quality end-of life-discussions. However, COVID-19 exposed the need for support, training and guidance in this area for all doctors. It also highlighted the importance of effective public education about advanced care planning

Preparing for end-of-life: learning from Do Not Attempt Cardiopulmonary Resuscitation decision-making during COVID-19

During the COVID-19 pandemic, Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were made differently. This included more prominent roles for specialties such as psychiatry and doctors in training. Concerns about inappropriate DNAR decisions led to anxiety for doctors, patients and the public. Positive outcomes may have included earlier and better-quality end-of life-discussions. However, COVID-19 exposed the need for support, training and guidance in this area for all doctors. It also highlighted the importance of effective public education about advanced care planning.</p

Interventions for the detection, monitoring, and management of chronic non-communicable diseases in the prison population:an international systematic review

Background: High rates of health inequalities and chronic non-communicable diseases exist amongst the prison population. This places people in and/or released from prison at heightened risk of multimorbidity, premature mortality, and reduced quality of life. Ensuring appropriate healthcare for people in prison to improve their health outcomes is an important aspect of social justice. This review examines the global literature on healthcare interventions to detect, monitor and manage chronic non-communicable diseases amongst the prison population and people recently released from prison. Methods: Systematic searches of EMBASE, MEDLINE, CINAHL, Web of Science, Scopus, and the Cochrane Library were conducted and supplemented by citation searching and review of the grey literature. The literature searches attempted to identify all articles describing any healthcare intervention for adults in prison, or released from prison in the past 1 year, to detect, monitor, or manage any chronic non-communicable illness. 19,061 articles were identified, of which 1058 articles were screened by abstract and 203 articles were reviewed by full text. Results: Sixty-five studies were included in the review, involving 18,311 participants from multiple countries. Most studies were quasi-experimental and/or low to moderate in quality. Numerous healthcare interventions were described in the literature including chronic disease screening, telemedicine, health education, integrated care systems, implementing specialist equipment and staff roles to manage chronic diseases in prisons, and providing enhanced primary care contact and/or support from community health workers for people recently released from prison. These interventions were associated with improvement in various measures of clinical and cost effectiveness, although comparison between different care models was not possible due to high levels of clinical heterogeneity. Conclusions: It is currently unclear which interventions are most effective at monitoring and managing chronic non-communicable diseases in prison. More research is needed to determine the most effective interventions for improving chronic disease management in prisons and how these should be implemented to ensure optimal success. Future research should examine interventions for addressing multimorbidity within prisons, since most studies tested interventions for a singular non-communicable disease.</p