Category Archives: Populations

Epigenetics and Social Determinants of Health

Social Determinants of Health

“The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.”

From the World Health Organization

 

From the Oxford English Dictionary

  • Diet:  The kinds of food that a person, animal, or community habitually eats.  ‘a vegetarian diet’
  • Epigenetics:  The study of changes in organisms caused by modification of gene expression rather than alteration of the genetic code itself.  ‘epigenetics has transformed the way we think about genomes’
  • Disparity:  A great difference.  ‘economic disparities between different regions of the country’

Epigenetics, Social Determinants of Health and the Social Ecological Model

Keep the social determinants of health in mind while reading “Diet, the Gut Microbiome, and Epigeneticsby Hullar et. Al.  The field of epigenetics is in its infancy.  Consider how access to certain foods and environmental conditions may increase or decrease an individual’s cancer risk.

Remember the social history session from immersion?  When you last took a social history was it in the context of the social ecological model?  Think about your last patient encounter.  Place that patient within the social ecological model.  How has their life and health been influenced by individual, interpersonal, organizational, community and policy level interactions?

Racial Disparities in Cancer Treatment and Outcomes

Not that “Disparities in Cancer Care and Outcomes” was published in the Journal of the American College of Surgery.  This article “explores radical disparities in the context of cancer surgery.”  Take note of Figure 1.  Do you think the steps present in this figure might help you explore disparities in outcomes in other conditions?  How is it similar to the social ecological model?  How is it different?

Carrier Testing and Genetic Counseling

Review the following key ethics terms:

Read Genetic Screening by Burke, et al.  Focus on the content found on pages 154- 156.

Then watch Nathan’s Story:  Tay-Sachs Disease in the Irish Population followed by Dr. Fullerton’s introductory video.

Dr. Fullerton introduces the following case:

“A young couple who are interested in starting a family come to you to discuss undergoing genetic carrier testing prior to trying to conceive.  Both members of the couple are healthy and there is no known history of genetic disease in either patient’s background.  However, the husband does have a younger brother affected by Down Syndrome who lives semi- independently in a group home.  They each self-identify as being of Caucasian (not Irish or French Canadian) ethnicity and report no known Ashkenazi or Jewish Ancestry.”

“They are now aware of a wide range of recessive genetic conditions for which they could be tested.  They simply want to avoid having a child with a truly devastating prognosis such as Tay-Sachs disease.  Therefore, they request a test of the HEXA gene only.”

Review: the 4-Box Method…

Consider (A): how does the 4-Box method apply to Dr. Fullerton’s case using this 4-Box worksheet for guidance.

Consider (B): how might the following ethics concepts help you to (1) categorize the ethical issue(s) and (2) justify a course of action.

  • CONSEQUENCES: What are the harms and benefits?
  • RULES: What are the norms, laws, standards of practice, legal and ethical rights, obligations and responsibilities?
  • VIRTUES: What might it mean to manifest sympathy, empathy, courageousness, trustworthiness, openness, respectfulness, or other virtues in this case?
  • SOCIAL RELATIONS:  Consider the interpersonal relations, social norms, and power structures.

 


Further reading?

These two links are optional and are intended for the student who has prior experience with the topic and/ or a strong desire for additional information.

For more information about genetic testing we would refer you to “Carrier testing for Ashkenazi Jewish disorders in the prenatal setting” by Ferriera et al.  This article was published in the American Journal of Obstetrics and Gynecology.  It is above the level of the average foundations phase student.

For more information about ethical issues around genetic testing in Ashkenazi Jewish populations read A young couple tests compatibility” and then explore the Dor Yeshorim website.