Black women are most likely to receive mastectomies, yet the least likely to have receipt of breast reconstruction. This disparity in breast and plastic surgery care is unethical and has been documented in the literature and has been witnessed clinically, but far most importantly, it is continued to be lived by Black women all over the nation. The bioethical principles of agency and social justice are called into question as Black women are not given an adequate understanding of their reconstructive options and are not being treated equally or equitably by the healthcare system. As noted by literature, race and ethnicity, socioeconomic and insurance status as well as comorbidities are contributing to this gap in care. As far as solutions go, there must be a multifaceted approach to mitigating this disparity. I have adopted Dr. Butler’s categorization of solutions to understand the exact approach we need to have, which includes patient education, legislation and academic medical institution, to make the recovery from breast cancer ethical for all women. In this thesis, I will go through the literature and garner perspectives from surgeons as well as patients who received breast reconstruction to aid in the understanding of this disparity and what needs to be done to fix it. / Urban Bioethics

Structural racism has been identified as a major source of medical vulnerability for urban populations. Police brutality is a consequence of structural racism and a critical social determinant of urban health that is associated with both physical and psychological injury. However, the presence of law enforcement agents is common in the healthcare setting, especially in the emergency department. The emergency department occupies a critical social role as a major source of healthcare for vulnerable urban populations, yet very little is known about patients’ opinions regarding police activity in the ED. This study contributes to the growing body of literature on the pathogenic effects of structural racism by designing trauma informed methodology to investigate patient perceptions of police presence in the emergency room. / Urban Bioethics

Covid-19 shed a light on how disparities, influenced by institutional racism and social determinants of health, led to negative healthcare outcomes. This inspired community organizations such as the Black Doctor’s COVID-19 Consortium to take matters into their own hands and play their part in meeting the needs of the community. With evident gaps in healthcare for marginalized communities, I believe that community-based health interventions are an ethical approach to ensure care for marginalized communities. To ensure that a proper intervention is being crafted for these communities, it is important to define what community-based means. This paper explores four models for categorizing community-based: community as setting, target, resource, and agent. While traditional research focuses on the voice of the academic, using Community Based Participatory Research amplifies and recenters the voice of the community, while providing a means to increase their capacity, fostering agency, and promoting solidarity. This paper explores local community-based health interventions in North Philadelphia and emphasizes partnering with the community to determine their needs before creating an intervention. Using community-based interventions to increase access to healthcare for marginalized communities in tandem with existing models of healthcare, follows a utilitarian approach to ensure that the greatest number of individuals can benefit. Community-based health interventions are the most ethical approach to bringing healthcare to marginalized communities. / Urban Bioethics / Accompanied by 1 PDF file: Francois_temple_0225M_171/Step 2 Recall.pdf

Awareness of critical public health issues stemming from historical and contemporary environmental injustice has been growing, yet institutions are still working to identify how to respond. How do we transform University Health System infrastructure, in the built environment and affiliated community assets and human capital, to center equity and the lived experience of climate injustice in urban communities? Through the application of urban bioethical principles and examination of a public state-related university and its health system in a major U.S. city, I argue that the higher education institutional climate action planning process for medical schools and their attendant university health systems, in concert with public sector actors, can be a vehicle and accelerator for achieving health equity in urban communities and suggest what exactly that could or should look like. This thesis will look at the role of university health systems in addressing climate change and mitigating its impacts. More specifically, it looks to provide context for the influence of “meds and eds” in urban communities: how their status as anchor institutions and sites of economic development implicates their responsibility to anticipate the differentiated material experience of climate change. As sites of care delivery, medical education and training, and major employers these institutions have a duty to ameliorate the associated inequitable health outcomes of climate change. I provide a model for action by all urban university health system stakeholders with recommendations to sustain equitable resilience in the face of environmental crisis. / Urban Bioethics

Currently only 5.7% of physicians in the United States (U.S.) are Black/African American. This comprehensive analysis explores the significant underrepresentation of Black/African American physicians in the United States, a problem that has persisted for over 100 years. This investigation traces this disparity back to the Flexner report, a document that revolutionized medical education for the benefit of the white population but to the detriment of Black and other vulnerable populations. There is a critical examination of the ethical implications of the Flexner report, arguing that it has contributed to health disparities resulting in shortened lives for Black men, women, and children. Moreover, the roles played by private institutions such as the Carnegie Foundation, the Rockefeller Foundation, the Accreditation Council for Graduate Medical Education and the American Medical Association and the U.S. federal government in initiating, funding or upholding the changes resulting from Flexner’s report are delineated. Most importantly, the efforts, as a result of the formation of the National Medical Association to overcome the obstacles placed in front of Black healthcare providers in caring for people of color is revealed. In exposing the damage done to physicians and patients of color there are also proposals of solutions to reverse the ethical harm done because of the Flexner report's implementation, including reparations for Black healthcare providers and patients adversely affected by the Flexner report. In conclusion there is an in-depth analysis of the history and impact of the Flexner report, the ethical and moral imperatives of reparations, and the feasibility and potential impact of these reparations. / Urban Bioethics

Compared to other developed countries, the United States has healthcare spending that far outpaces other nations, but achieves below-average life expectancy. In urban cities, this disparity is most striking among predominantly black and Latino communities. There is increasing recognition that the reason for this is improper allocation of resources; we have a system that funds clinical services which contribute to only 20% of health outcomes, while providing inadequate support for social and environmental factors which account for 80% of the impact. When one considers the history of the United States, it becomes clear that such a system is not only inefficient, but also fundamentally unjust. African American patients have been used (often without consent) to obtain much of our current medical knowledge, but suffer most from healthcare disparities. Medical school is a fascinating lens from which to view this healthcare system, as students stand at the threshold between layperson and physician. Medical students, who predominantly come from backgrounds of privilege, benefit from access to institutions of medical knowledge. They often practice their fledgling skills on urban underserved patients who are disproportionately cared for in academic medical centers. Medical students also participate in service projects in the surrounding community, with common projects involving schools, churches, and free clinics. As a medical student, I spent nearly 100 hours with a class of ninth grade students at a Philadelphia public high school as I developed and implemented a health careers elective program. Through this experience, I gained a firsthand appreciation for the incredible barriers that prevent urban underserved students from equal representation in our medical schools and health care workforce. Here, I reflect on my experiences over the course of medical school, review relevant literature in the fields of ethics, medicine, education, and history, and present recommendations to move us closer to a just healthcare system by increasing investment in underserved communities and instilling in medical students a moral imperative to reduce health disparities, as well as the tools to do so effectively. / Urban Bioethics

As medical students undergo their clinical years, they exhibit a well-documented loss of idealism, increasingly negative attitudes towards poor and underserved patients, and less interest in working with these patients. Here we describe the pilot year of a longitudinal service-learning requirement implemented as a part of the medical student pre-clinical curriculum. We hypothesized that increased non-clinical contact would decrease the formation of negative attitudes towards underserved patients. Students completed service hours at assigned community sites each semester along with written reflections. Surveys were administered to track attitudes towards the underserved. Written reflections were analyzed qualitatively for thematic content as well as feedback on the experience. The requirement was largely acceptable to medical students, and many found value and enjoyment in the experience. The most common critique was that the required hours were insufficient to develop continuity, and that students desired more thorough briefing beforehand to increase their effectiveness. Students reported practicing clinical skills and communication skills. They identified social determinants of health and learned about their patients. They reflected on their professional identity, motivations for entering medicine, and specialty choices. Students experienced moments of connection and belonging, as well as feelings of guilt, otherness, and awareness of privilege. We continue to explore how working collaboratively and learning reciprocally with community members outside of the hospital and clinic may teach students cultural humility and help insulate students from cynicism and negative views of poor and medically underserved patients. / Urban Bioethics

African American women have the highest rates of hypertension, cardiovascular disease (CVD) and mortality rates related to CVD of all ethnic and racial groups in America. Understanding the factors contributing to these health disparities will be crucial to closing the gap in health outcomes. This thesis proposes that stressors and stress coping strategies are contributing as independent risk factors for CVD, thus leading to health disparities. Studies have shown that stress has a direct relationship to neuroendocrine processes in the body leading to elevated blood pressures and increased inflammation. Examining common stress factors among African American women and developing strategies to help relieve the burden of these stress factors will be an important ethical step toward eliminating the CVD health disparity between African American women and other ethnic groups. In addition, developing systemic support for coping with stress through health systems and health centers will be imperative for improving CVD health outcomes and agency among African American women. / Urban Bioethics

Stigmatization remains a significant barrier to the initiation and maintenance of treatment in patients with substance use disorders, with higher levels of stigma being associated with lower levels of treatment initiation and adherence. While societal stigma is frequently discussed, less discussed are the inherent biases expressed by healthcare providers. Healthcare providers often hold comparable or even higher levels of stigma against patients with substance use disorders compared to the general population, and this can have quite a significant impact on patient care. From improper treatment decisions stemming from fear and stigmatization of the medications used for opioid use disorders, to the development of mistrust and poor/worsening self-esteem secondary to poor patient-provider interactions. The effects of stigma on the substance use disorder patient cannot be understated and must be alleviated in the coming years to ensure that patients with SUDs receive the high-quality treatment that they deserve. Several interventions have been validated to help reduce stigma within healthcare providers, subsequently improving treatment outcomes. Words matter. Patient-first language is crucial; verbiage can strongly impact how not only the provider sees the patient, but how the patient views themselves (and as we know, poor self-esteem also hinders treatment outcomes). Education and normalization of SUD medications should be done at the healthcare provider level to ensure that all providers are comfortable with these medications. As higher frequency of interactions with substance use disorders has been shown to reduce levels of stigma seen within healthcare providers, it’s also crucial that trainees receive adequate exposure to this patient population. While these suggestions may take time to show effect, it’s imperative that we get the ball rolling on training future generations of healthcare providers that do not hold inherent biases and who will provide high-quality, care utilizing validated treatments. / Urban Bioethics

The need for transition of care for adult survivors of chronic conditions of childhood onset is an area that has received increasing attention in the healthcare literature; however, gaps in understanding and implementation persist. The complexity of transitioning from pediatric to adult care environments present numerous challenges for patients, their families, and health care providers. Ineffectual transitions can result in increased morbidity, a decline in quality of life, and unnecessary health care spending. The fundamental challenges in transitions of care for this population originates from a lack of institutional support to develop structured transition protocols. Healthcare institutions lack impetus to develop transition programs as their utility has not been sufficiently demonstrated because of inadequate research upon which to base clinical decisions. Therefore, patients transitioning from pediatric to adult care often confront difficulties ranging from fragmented care coordination to extended lapses continuous care, which can exacerbate the progression of their chronic conditions. The primary aim of this study is to examine the current literature regarding the ability of pediatric to adult transition programs for survivors of chronic disease to determine whether they are effective in delaying disease progression. The secondary aim is to examine whether evidence exists to demonstrate cost effectiveness of such interventions. Subsequently we explore potential barriers to adoption for healthcare institutions to adopt pediatric to adult transition care programs on a broad scale. This systematic review employs methodology to extract, analyze and synthesize data from relevant peer-reviewed articles, observational studies, and clinical trials. Preliminary findings indicate that improving transition protocols can indeed enhance patient outcomes, potentially reduce hospital readmissions, and may thereby be cost-effective for health care organizations. We posit that providing optimized transitions of care during this vulnerable life stage could enhance patient outcomes for managing various chronic conditions of childhood onset supporting the argument that better transitions of care are not only desirable but also achievable and worthwhile goals for health care systems to adopt. By examining the intricacies of transitioning care for adult survivors of chronic conditions of childhood onset, we aim to open a critical dialog and make recommendations for future research and clinical practice that may significantly impact health care practices, models, and policies thereby potentially and significantly impacting health for adult survivors. / Urban Bioethics