Harris School of Public Policy

John Rawls en el espejo o la utopía que nos ofrece el internet Por: Butch Cassidy Resumen: Este ensayo es una reflexión sobre las oportunidades de libertad individual y de vivir en una sociedad justa, que se le que presentan al ser humano a través del internet. Utilizo la forma en la que nos representamos por este medio para reflexionar sobre el aspecto procedimental del velo de la ignorancia presente en la Teoría de la Justicia de John Rawls; y qué sucedería si este ejercicio se invirtiera. En esta reflexión se incorporan aspectos metafísicos, metodológicos desde un punto de vista estadístico, y concluye con las medidas que se necesitarían para su implementación. I. Los albores del uso cotidiano de las computadoras Nací en una época anterior a la existencia del internet. Éste se volvió masivo en mi adolescencia tardía. Antes de eso las computadoras habían sido el reino de los geeks. Uno así vivía en mi edificio. Aquellas tardes en las que yo estaba haciendo mi tarea acompañado por el calor de la tarde; él hacía dos cosas: jugaba en su computadora " Carmen San Diego " y tocaba Rondo alla Turca por horas. Lo escuché tantas veces que cuando la vuelvo a oír hoy en día, me transporta a mi hogar. Si muriera en batalla, me imagino que sería una de las canciones que tocaría mi mente antes de morir. La historia del vecino estaba íntimamente vinculada con mi desconfianza a las computadoras y a los que yo pensaba que las utilizaban. Resulta que nosotros nos íbamos casi todos los fines de semana a Yautepec. Un fin de semana mi mamá se extrañó mucho de que no encontraba uno de sus calzones. Lo buscamos por toda la casa cual si hubiera sido un sobreviviente de los Andes; igual que con aquellos jugadores de rugby, después de un tiempo lo dimos por muerto. No obstante, el calzoncillo, igual que los jugadores de rugby, luchó por su vida. Y vaya que nos llevamos una sorpresa cuando una tarde tocó nuestro vecino, con el calzón en la mano y su hijo-el geek-atrás de él, enjuto y cabizbajo. Y no podía creer lo que sucedía ante mis ojos. El padre tenía los calzones de mi madre en su mano y venía a ofrecer una disculpa. Resultaba que su hijo se había metido a nuestro departamento y se los había llevado.

IMPORTANCE Although social determinants of health (SDOH) are important factors in health inequities, they have not been explicitly associated with COVID-19 mortality rates across racial and ethnic groups and rural, suburban, and urban contexts. OBJECTIVES To explore the spatial and racial disparities in county-level COVID-19 mortality rates during the first year of the pandemic. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study analyzed data for all US counties in 50 states and the District of Columbia for the first full year of the COVID-19 pandemic (January 22, 2020, to February 28, 2021). Counties with a high concentration of a single racial and ethnic population and a high level of COVID-19 mortality rate were identified as concentrated longitudinalimpact counties. The SDOH that may be associated with mortality rate across these counties and in urban, suburban, and rural contexts were examined. The 3 largest racial and ethnic groups in the US were selected: Black or African American, Hispanic or Latinx, and non-Hispanic White populations. EXPOSURES County-level characteristics and community health factors (eg, income inequality, uninsured rate, primary care physicians, preventable hospital stays, severe housing problems rate, and access to broadband internet) associated with COVID-19 mortality. MAIN OUTCOMES AND MEASURES Data on county-level COVID-19 mortality rates (deaths per 100 000 population) reported by the US Centers for Disease Control and Prevention were analyzed. Four indexes were used to measure multiple dimensions of SDOH: socioeconomic advantage index, limited mobility index, urban core opportunity index, and mixed immigrant cohesion and accessibility index. Spatial regression models were used to examine the associations between SDOH and countylevel COVID-19 mortality rate. RESULTS Of the 3142 counties included in the study, 531 were identified as concentrated longitudinal-impact counties. Of these counties, 347 (11.0%) had a large Black or African American population compared with other counties, 198 (6.3%) had a large Hispanic or Latinx population compared with other counties, and 33 (1.1%) had a large non-Hispanic White population compared with other counties. A total of 489 254 COVID-19-related deaths were reported. Most concentrated longitudinal-impact counties with a large Black or African American population compared with other counties were spread across urban, suburban, and rural areas and experienced numerous disadvantages, including higher income inequality (297 of 347 [85.6%]) and more preventable hospital stays (281 of 347 [81.0%]). Most concentrated longitudinal-impact counties with a large Hispanic or Latinx population compared with other counties were located in urban areas (114 of 198 [57.6%]), and 130 (65.7%) of these counties had a high percentage of people who lacked health insurance. Most concentrated longitudinal-impact counties with a large non-Hispanic White population compared with other counties were in rural areas (23 of 33 [69.7%]), included a large (continued) Key Points Question How do the associations between structural factors and COVID-19 mortality help explain the disproportionate outcomes experienced by different racial and ethnic groups? Findings In this cross-sectional study of 3142 counties in 50 US states and the District of Columbia, the associations between different measures of social determinants of health and COVID-19 mortality varied across racial and ethnic groups (Black or African American, Hispanic or Latinx, and non-Hispanic White populations) and different community types (rural, suburban, and urban areas). Meaning Findings from this study suggest the need for future research that addresses health inequity and guides policies and programs by further exploring the different dimensions and regional patterns of social determinants of health.

Given that COVID-19 and recent natural disasters exacerbated the shortage of medication for opioid use disorder (MOUD) services and were associated with increased opioid overdose mortality, it is important to examine how a community's ability to respond to natural disasters and infectious disease outbreaks is associated with MOUD access. OBJECTIVE To examine the association of community vulnerability to disasters and pandemics with geographic access to each of the 3 MOUDs and whether this association differs by urban, suburban, or rural classification. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of zip code tabulation areas (ZCTAs) in the continental United States excluding Washington, DC, conducted a geospatial analysis of 2020 treatment location data. EXPOSURES Social vulnerability index (US Centers for Disease Control and Prevention measure of vulnerability to disasters or pandemics). MAIN OUTCOMES AND MEASURES Drive time in minutes from the population-weighted center of the ZCTA to the ZCTA of the nearest treatment location for each treatment type (buprenorphine, methadone, and extended-release naltrexone). RESULTS Among 32 604 ZCTAs within the continental US, 170 within Washington, DC, and 20 without an urban-rural classification were excluded, resulting in a final sample of 32 434 ZCTAs. Greater social vulnerability was correlated with longer drive times for methadone (correlation, 0.10; 95% CI, 0.09 to 0.11), but it was not correlated with access to other MOUDs. Among rural ZCTAs, increasing social vulnerability was correlated with shorter drive times to buprenorphine (correlation, -0.10; 95% CI, -0.12 to -0.08) but vulnerability was not correlated with other measures of access. Among suburban ZCTAs, greater vulnerability was correlated with both longer drive times to methadone (correlation, 0.22; 95% CI, 0.20 to 0.24) and extended-release naltrexone (correlation, 0.15; 95% CI, 0.13 to 0.17). In this study, communities with greater vulnerability did not have greater geographic access to MOUD, and the mismatch between vulnerability and medication access was greatest in suburban communities. Rural communities had poor geographic access regardless of vulnerability status. Future disaster preparedness planning should match the location of services to communities with greater vulnerability to prevent inequities in overdose deaths.

Methadone treatment for opioid use disorder is not available in most suburban and rural US communities. We examined 2 options to expand methadone availability: (1) addiction specialty physician or (2) all clinician prescribing. Using 2022 Health Resources and Services Administration data, we used mental health professional shortage areas to indicate the potential of addiction specialty physician prescribing and the location of federally qualified health centers (ie, federally certified primary care clinics) to indicate the potential of all clinician prescribing. We examined how many census tracts without an available opioid treatment program (ie, methadone clinic) are (1) located within a mental health professional shortage area and (2) are also without an available federally qualified health center. Methadone was available in 49% of tracts under current regulations, 63% of tracts in the case of specialist physician prescribing, and 86% of tracts in the case of all clinician prescri...