Cumulative Harm Research Articles

Social deprivation as a marker for alcohol harms, and implications for local harm reduction policies in England: an ecological study

BackgroundCumulative impact policies restricting the award of new licences to sell alcohol have been implemented in many local authorities across England as a means of tackling alcohol harms. Providing evidence linking local harms with availability, however, can present practical challenges for public health teams. We sought to examine the extent to which measures of availability together with local small area characteristics were associated with both acute and chronic alcohol harms in a local authority in north east England. MethodsRoutinely available data on all adverse alcohol-related events across crime and disorder, and health, were collated for the years 2012–13 to 2014–15. The area concerned has a relatively dispersed population of over 65 000 with one major urban centre. Analysis was done using rates derived from population estimates at Middle Layer Super Output Area level. Rank correlation estimates were derived for the strength of the association between event rates, density of licensed premises, and Index of Multiple Deprivation (IMD) 2010. Scatterplots and correlation coefficients were examined to determine the statistical strength of any associations. Choropleth maps were constructed using ArcView (Esri) to facilitate visual comparisons of the data. FindingsThere was a weak non-significant correlation between outlet density and adverse alcohol-related events (r=0·21; r2=0·044; p=0·09), which was higher and strongly significant when restricted to off-sales only (r=0·55; r2=0·304; p<0·0001). IMD score and the rate of composite alcohol-related events were also significantly correlated (r=0·68; r2=0·461; p<0·0001). Removing police data to rectify double counting arising from its inclusion in IMD determination led to a revised correlation of r=0·84 (r2=0·704; p<0·0001) for composite events, and r=0·79 (r2=0·62; p<0·0001) when restricted to alcohol-related hospital admissions. Correlations were weakly positive but strongly significant between off-sales outlet density and IMD (r=0·44; r2=0·196; p>0·0001). InterpretationThe strongest predictor of the cumulative harm and health harms from alcohol, in keeping with studies from other regions, was social deprivation, as determined by IMD score. The significant positive correlation between off-license density and alcohol health harms in particular, presents a credible argument for restricting off license density in areas with higher social deprivation. FundingNone.

Exploring the Crystallization of ‘Climate Change Jurisdiction’: A Role for Precaution?

Amidst the lively discussion on legal fragmentation and climate change, this article seeks to highlight the windows for the potential interaction of jurisdictional and environmental norms. This is relevant for climate-protective trade measures, which, it is argued, are not exhaustively regulated by WTO law. Exploring the contours of ‘climate change jurisdiction’ in customary international law, the article considers how the traditional jurisdictional principles may be operationalized in the untested territory of cumulative and uncertain environmental harm. With their origins in criminal and economic law, the jurisdictional principles were not originally designed for these challenges. This paper argues that the environmental norm of precaution, which originated out of a need to respond to complex threats, should have a role to play. Precaution governs issues of state regulatory competence in the face of scientific uncertainty. Particularly in relation to questions of foreseeability and causation, this norm may be helpful in navigating the application of the abstract jurisdictional principles, providing opportunities for synergy in the crystallization of the climate change jurisdiction.

Little Cigars, Filtered Cigars, and their Carbonyl Delivery Relative to Cigarettes.

IntroductionLittle cigars and filtered cigars are currently growing in popularity due to their low cost and wide variety of flavors while retaining an appearance similar to cigarettes. Given the health consequences associated with cigarette use, it is important to understand the potential harm associated with these similar products. This includes the potential harm associated with carbonyls (eg, acetaldehyde, acrolein, formaldehyde, etc.), an important class of toxicants and carcinogens in tobacco smoke. Our objective was to determine the carbonyl levels in mainstream smoke from little and filtered cigars compared to cigarettes.MethodsWe examined two brands each of little cigars and filtered cigars, as well as two research cigarettes for carbonyl delivery using the International Organization of Standards (ISO) and the Health Canada Intense (HCI) machine-smoking protocols.ResultsOn a per puff basis, the levels of five of the seven carbonyls were higher from little cigars than filtered cigars and cigarettes (ISO: 56–116%; HCI: 39–85%; p < .05). On a per unit basis, most carbonyl levels were higher from both cigar types than cigarettes using the ISO method (ISO: 51–313%; p < .05) whereas only filtered cigars were higher using the HCI method (HCI: 53–99%; p < .05).ConclusionThese findings suggest that cigar smokers can be exposed to higher levels of carbonyls per cigar than cigarette smokers per cigarette.ImplicationsThese data will increase our understanding of the relative harm from carbonyl exposure from little and filtered cigars both for cigar-only smokers and the cumulative harm among the growing population of cigarette–cigar multi-product smokers.

Pharmacists' interventions to reduce sedative/hypnotic use for insomnia in hospitalized patients

BackgroundHospitalization can contribute to insomnia in many patients and is usually treated symptomatically. However, sedative/hypnotic misuse is associated with complications in this population, especially in the elderly. Such complications include dizziness, falls and over-sedation. Due to the implicit dangers, widespread use of these drugs for insomnia, particularly in older patients, has been discouraged by many hospitals. The aim of this study was to review and evaluate prescribing patterns and to optimize the use of the sedative/hypnotic agents through daily pharmacy interventions at a community hospital. MethodsThis was a biphasic before and after study. Data on sedative/hypnotic use was collected retrospectively for a 2-month period and a sample of 100 patients was randomly selected for analysis. A 2-month prospective phase followed, in which daily orders were reviewed by one pharmacy resident and recommendations made to discontinue any unnecessary, newly prescribed sedative/hypnotic orders when appropriate. Finally, results of both phases were compared for any differences in patient demographics, being prescribed more than one sedative/hypnotic, and complications documented. ResultsDuring the prospective phase, pharmacist interventions led to the discontinuation of 25% of a total of 97 sedative/hypnotic orders in 97 patients. The number of patients receiving more than one sedative/hypnotic agents in the intervention group was significantly lower than the retrospective control group (15 Vs. 34, P = 0.0026). The incidence of complications was not significantly different between the control and intervention groups for the following: over-sedation, falls and delirium (p = 0.835, p = 0.185, p = 0.697, respectively). ConclusionThis study suggests that the use of sedative/hypnotics in the inpatient units (excluding the critical care unit), is somewhat prevalent, and many patients may be on more than one sedative/hypnotic, which could potentially cause cumulative harm. During the intervention phase, 25% of the total in-hospital orders for sedative/hypnotics were discontinued following recommendations made by a pharmacist, and significantly lower number of patients receiving duplicate sedative/hypnotics was noted. Further efforts should be implemented to avoid unnecessary sedative/hypnotic initiation in hospitalized patients, and to ensure monitoring by pharmacists is optimized.

A Review of Cumulative Harm: A Comparison of International Child Protection Practices

This article explores the prevalence of cumulative harm as a subtle and pervasive harm type, often dismissed or ignored in child protection assessment and reporting practices. The author examines a range of trends and research that identifies current gaps in the legislative response to cumulative harm identification and intervention. Through analysis of the current practices informing child protection in Australia, it is clear that there is movement towards a more holistic understanding of harm and the impacts of long-term maltreatment. However, a nationwide level of consistent practice has not yet been achieved, which places cumulative harm and reoccurring maltreatment on an equal footing with episodic maltreatment, particularly in relation to notification and reporting. Internationally, although variations are evident, just as they are in national framework, there is an inclusive impetus towards early intervention as a means of addressing harm prior to the onset of cumulative impact. There is a growing emphasis on children's wellbeing, development and universal right to quality of life and fair treatment.

On Microaggressions: Cumulative Harm and Individual Responsibility

Microaggressions are a new moral category that refers to the subtle yet harmful forms of discriminatory behavior experienced by members of oppressed groups. Such behavior often results from implicit bias, leaving individual perpetrators unaware of the harm they have caused. Moreover, microaggressions are often dismissed on the grounds that they do not constitute a real or morally significant harm. My goal is therefore to explain why microaggressions are morally significant and argue that we are responsible for their harms. I offer a conceptual framework for microaggressions, exploring the central mechanisms used for identification and the empirical research concerning their harm. The cumulative harm of microaggressions presents a unique case for understanding disaggregation models for contributed harms, blame allocation, and individual responsibility within structural oppression. Our standard moral model for addressing cumulative harm is to hold all individual contributors blameworthy for their particular contributions. However, if we aim to hold people responsible for their unconscious microaggressions and address cumulative harm holistically, this model is inadequate. Drawing on Iris Marion Young's social connection model, I argue that we, as individual perpetrators of microaggressions, have a responsibility to respond to the cumulative harm to which we have individually contributed.

Constructing insignificance: critical race perspectives on institutional failure in environmental justice communities

ABSTRACT Environmental justice (EJ) literature rarely offers an explicit theory of race to explain processes of disparate environmental exposure and recourse in non-white and low-income communities. Failing to do so, analyses of environmental inequality risk eliding a central driver of environmental racism. Based on a case study of a contested birth defect cluster in California, this article traces the ways in which the evidence of environmental health harms are rendered conceptually invisible by the institutions mandated to protect public health and the environment. Turning to a theoretical model of contested illness mobilization, I demonstrate the value of critical race perspectives to clarify the production and maintenance of intersecting, cumulative harms without recourse in communities of color. Centered on racially veridical analyses, EJ scholarship can more precisely analyze the recalcitrance of dominant group interests. Ultimately, this enables theorization of the distinct landscape of exposure and recourse in subaltern versus favored bodies and space.

Pharmacovigilance in hospice/palliative care: the net immediate and short-term effects of dexamethasone for anorexia

ObjectivesLoss of appetite is prevalent in palliative care and distressing for patients and families. Therapies include corticosteroids or progestogens. This study explores the net effect of dexamethasone on anorexia.MethodsProspective data...

Making the Decision to Remove a Child from Parental Care: Twelve Decision-Making Criteria

Removing a child from parental care is an important and difficult decision to make. There are far reaching consequences for the child and family. Whilst there is a plethora of literature in relation to child protection practice generally, research on decision making is minimal. In this practice paper, I present 12 decision-making criteria to assist practitioners make decisions about child removal. It is important for child protection practitioners to apply the same set of principles and consider the same factors when making these decisions. These criteria are as follows: the severity of the abusive incident; the presence of cumulative harm; whether the perpetrator has access to the child; the functioning of the parent; whether the perpetrator has been responsible for child abuse or intimate partner violence in the past; the cooperation of the parent; the intent of the perpetrator; the age of the child; the functioning of the child; the voice and expressed wishes of the child; protective relationships available to the child and the statutory requirement to cause no further harm. Referring to these criteria will assist practitioners be clear and explicit about how they reach a decision, and result in greater consistency of outcome for children and families.

Cumulative Constitutional Rights

Cumulative constitutional rights are ubiquitous. Plaintiffs litigate multiple constitutional violations, or multiple harms, and judges use multiple constitutional provisions to inform interpretation. Yet, judges, litigants, and scholars have often criticized the notion of cumulative rights, including in leading Supreme Court rulings, such as Lawrence v. Texas, Employment Division v. Smith, and Miranda v. Arizona. Recently, the Court attempted to clarify some of this confusion. In its recent landmark opinion in Obergefell v. Hodges, the Court struck down state bans on same-sex marriage by pointing to several distinct but overlapping protections inherent in the Due Process Clause, including the right to individual autonomy, the right to intimate association, and the safeguarding of children, while also noting how the rights in question were simultaneously grounded in equal protection. “The Due Process Clause and the Equal Protection Clause are connected in a profound way,” Justice Anthony Kennedy wrote. What the Court did not do was to explain the connection. To redress harms to injured plaintiffs without creating doctrinal incoherence, courts need to understand the categorically distinct ways in which cumulative constitutional harm can occur and how these forms affect constitutional scrutiny. We argue that cumulative constitutional rights cases can be categorized into three general types and that these types need to be analyzed differently. The first type, aggregate harm, occurs when multiple discrete acts, taken together, add up to a harm of constitutional magnitude, even if each individual act, taken alone, would not. The second type, hybrid rights, occurs where a plaintiff claims a single action has violated rights under multiple constitutional provisions. If a court were to apply the proper level of scrutiny to the claims individually, however, none would result in redress. As a result, hybrid rights cases should not ordinarily result in relief. The third type, which we term intersectional rights, occur when the action violates more than one constitutional provision but is only cognizable when the provisions are read to inform and bolster one another. Our aim in this Essay is to provide a framework courts can use to analyze cumulative constitutional rights. While courts should be open to conducting a cumulative analysis, when constitutional rights are mutually reinforcing, those relationships should be clearly set out and defined.

Responding to child deaths: the work of Australia's Victorian Child Death Review Committee

The Victorian Child Death Review Committee (VCDRC) in Australia is a multidisciplinary Ministerial Advisory Committee established to review the deaths of children either currently child protection clients or known to the statutory child protection system. The Committee provides advice about each child death as well as insights into what are the surrounding patterns and issues. Key to this role is examining the contribution of the service sectors to the protection of children and the routine practices that are in place to respond to children and vulnerability. This paper provides a snapshot of the cases referred to the VCDRC and the key messages for practice drawn from them. What emerges is that often the threshold for when statutory child protection services must be involved in child and family matters can be ambiguous and that agreement about intervention, the level and nature of need or risk, and when cumulative harm and neglect require statutory responses are not always shared between agencies. It is clear that the lack of common frameworks about what constitutes child protection intervention challenges services. It is recommended that there be and used agreed definitions and frameworks to ensure shared understandings and collaborative responses across the service and legal systems.

Анализ зарубежного опыта решения проблем накопленного экологического ущерба

Анализ зарубежного опыта решения проблем накопленного экологического ущерба

Equipping child protection practitioners to intervene to protect children from cumulative harm: legislation and policy in Victoria, Australia

Many children are repeatedly reported to statutory child protection services, but do not receive the protection they need. Many such children are suffering chronic maltreatment, which is likely to result in cumulative harm. Chronic maltreatment encompasses emotional abuse and chronic neglect. As a result, children can experience a range of cognitive, emotional, and behavioural problems that are more serious than those associated with other abuse types.This paper focuses on the Victorian statutory child protection system, and considers why cumulative harm is not receiving the attention the legislation intends. Under the Victorian legislation cumulative harm must be proven on grounds of emotional abuse and/or neglect. However, it is difficult for child protection practitioners to place before the court the necessary evidence to establish these grounds.The paper concludes that the legal definitions of emotional abuse and neglect should not require evidence of a link between the abusive actions of the parent and the poor outcomes for the child. The evidentiary focus should be on the actions of the parent. Furthermore, legislation should focus on abusive parental behaviours that are likely to result in cumulative harm, which are more concrete and measureable than emotional abuse and neglect, such as intimate partner violence and parental illicit drug use.

Cumulative Harm, Products Liability, and Bilateral Care

We extend consideration of cumulative harm in products liability to the case of bilateral care. For this specification, the level of care and the level of output chosen by the firm are inextricably interrelated, and different liability regimes yield different combinations of care and output. As in the case of bilateral care with proportional harm, strict liability by itself leads to moral hazard on the part of the consumer, but strict liability with a defense of contributory negligence on the part of the consumer is now a resilient (that is, both robust and convergent) liability rule when harm is cumulative.

Cumulative Harm and Resilient Liability Rules for Product Markets

In the traditional unilateral care model of products liability, expected harm is proportional to usage. Thus, all standard liability regimes yield the efficient choice of care by the firm, independent of the level of usage. This implies that liability for harm can be considered independently of market structure and competition. We find that when expected harm is cumulative (i.e., increasing and convex in usage), then different liability regimes produce different outcomes and yield different implications for social efficiency. Since the responsibilities for product and market performance are divided among relevant agencies and institutions, this presents a challenge to the correct design of rules for agents in the market. We argue for selection among alternative liability regimes based upon what we refer to as resilience. Strict liability is a resilient policy; no liability and negligence are not resilient. Thus, we provide a new argument for strict liability with respect to product-generated harms. (JEL K13, L13, L15)

Everyone's Business: Developing an Integrated Model of Care to Respond to Child Abuse in a Pediatric Hospital Setting

In pediatric hospitals, social work plays a central role in the prevention, identification, and management of child abuse. Children who are suspected of having been abused or neglected require an evaluation of their psychosocial situation. As an integral member of the health care team, the social worker is well placed to undertake comprehensive psychosocial assessments including information on the child's development, parental capacity, family, and community supports. Current practice approaches have seen a shift away from a narrow, “expert” approach to child protection. This article describes the development of an integrated model of social work service delivery to better respond to vulnerable and at-risk children in a pediatric hospital setting. Developing a new model of service required strategic planning, consultation, and endorsement from senior hospital management. The new model aimed to ensure a high quality, responsive social work service to children at risk of physical abuse, neglect, or cumulative harm. The change necessitated understanding of current research evidence, development of best practice guidelines, and effective communication with staff and external stakeholders. Policy development, implementation of practice guidelines, staff training, data collection, and service evaluation are described. The role of social work management and leadership were central in creating change. Visionary leadership is widely regarded as key to successful organizational change. The management approach included consultation with staff, building commitment to the need for change, addressing staff concerns, and providing a vision of enhanced client outcomes as a result of the change process. This article provides a candid overview of challenges and barriers to change. Change strategies described are easily transferable to other social work settings.

Cumulative Harm and Resilient Liability Rules for Product Markets

In the traditional model of the law and economics of torts, harm accrues proportional to use. This has the remarkable implication for products-generated torts that product performance concerns (e.g., issues of care and of liability for harm) can be considered independently of market performance concerns (e.g., market structure and competition). Moreover, the classical analysis finds that all liability regimes (strict liability, no liability, and negligence based on the socially-efficient due care standard) yield the same choice of care by the firm in the unilateral care tort model. We modify the standard model to allow for cumulative harm (that is, the per-unit expected harm is increasing in the level of use); examples from pharmaceuticals, environmental risks, privacy, food products, and mechanical systems are provided. We show that, when expected harm is cumulative, the separation between the level of care and the level of output does not occur. We further show that the different possible liability regimes now produce different outcomes and yield different implications for social efficiency. This implies an interaction between law concerned with liability and law concerned with market performance. Since these generally governmental (and private law) responsibilities are divided among relevant agencies and institutions, and are the subjects of different bodies of law, this presents a challenge to the correct design of rules for agents in the economy. We argue for selection among alternative liability regimes based upon what we refer to as “resilience:” a resilient policy is robust to the incentives for agents to undermine it and flexible with respect to outside influences (e.g., from antitrust authorities or regulators). Strict liability is a resilient policy; no liability and negligence are not resilient. Thus, we provide a new argument for strict liability with respect to product-generated harms.

Human trafficking and health: A conceptual model to inform policy, intervention and research

Human trafficking is an international crime renowned for extreme forms of violence against women, men and children. Although trafficking-related violence has been well-documented, the health of trafficked persons has been a largely neglected topic. For people who are trafficked, health risks and consequences may begin before they are recruited into the trafficking process, continue throughout the period of exploitation and persist even after individuals are released. Policy-making, service provision and research often focus narrowly on criminal violations that occur during the period of exploitation, regularly overlooking the health implications of trafficking. Similarly, the public health sector has not yet incorporated human trafficking as a health concern. We present a conceptual model that highlights the migratory and exploitative nature of a multi-staged trafficking process, which includes: ‘recruitment’, travel-transit’, ‘exploitation’ and ‘integration’ or ‘reintegration’, and for some trafficked persons, ‘detention’ and ‘re-trafficking’ stages. Trafficked persons may suffer from physical, sexual and psychological harm, occupational hazards, legal restrictions and difficulties associated with being marginalised or stigmatised. Researchers and decision-makers will benefit from a theoretical approach that conceptualizes trafficking and health as a multi-staged process of cumulative harm. To address a health risk such as trafficking, which spans geographical boundaries and involves multiple sectors, including immigration and law enforcement, labour, social and health services, interventions must be coordinated between nations and across sectors to promote the protection and recovery of people who are trafficked.

Vulnerability of Health to Market Forces

This article reviews adverse influences of for-profit enterprises on health care and public health, and examines significance for public policy. Narrative review. For-profit health-care industries may increase costs and reduce quality, leading to market failure and contributing to the USA's unflattering position in international comparisons of health-care efficiency. Drug and device corporations use strategies such as making biased inferences, influencing scientists and physicians, marketing rather than informing the public, and lobbying to control their own industry regulations to create market advantage. Successful marketing leads to the increased use of costly profit-making drugs and procedures over cheaper, nonpatented therapies. Because resources are limited, the overuse of costly modalities contributes to expensive health care, which presents a challenge to universal coverage. The free market also fosters the proliferation of industries, such as tobacco, food, and chemicals, which externalize costs to maximize profits, seek to unduly influence research by paying experts and universities, and attempt to control the media and regulatory agencies. Most vulnerable to the cumulative harm of these tactics are children, the poor, the sick, and the least educated. The free market can harm health and health care. The corporate obligation to increase profits and ensure a return to shareholders affects public health. Such excesses of capitalism pose formidable challenges to social justice and public health. The recognition of the health risks entailed by corporation-controlled markets has important implications for public policy. Reforms are required to limit the power of corporations.

Can Life Expectancy and QALYs Be Improved by a Framework for Deciding Whether to Apply Clinical Guidelines to Patients With Severe Comorbid Disease?

Guidelines with short-term harms and long-term benefits are often applied to chronically ill patients who may not benefit. The payoff time framework has been proposed (i.e., do not apply a guideline if a patient's life expectancy (LE) is shorter than when a guideline's cumulative incremental benefits first exceed its cumulative incremental harms), but its health impact is unclear. To investigate whether the payoff time framework improves LE and/or quality-adjusted life-years (QALY) for chronically ill patients. I evaluate impact of the payoff time framework on LE and QALYs, assuming (1) high and constant background mortality rate from chronic illness (≥ 10% per year), (2) immediate guideline-related harm with probability < 1, and (3) constant guideline-related benefit that occurs over an extended time. I apply the framework to questions of whether to screen chronically ill 50-year-old women for colorectal cancer using colonoscopy, and whether to advocate intensive glucose control for chronically ill diabetics. If a guideline's payoff time is greater than a patient's LE, then withholding that guideline will increase LE and QALYs for that patient. For a 50-year-old chronically ill woman with background mortality > 0.15 per year (corresponding to LE < 6.5 years), withholding CR screening will increase LE. For a diabetic with background mortality > 0.11 per year (corresponding to LE < 9.4 years), withholding CR screening will increase QALYs. The payoff time framework may indicate when withholding a guideline with short-term harms and long-term benefits may increase LE and/or QALY.