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As epidemiology changes and new therapies emerge, the focus of disease control is shifting from the voluntary to the mandatory. This is reflected in debates about routine HIV testing of newborns and the confidentiality of HIV-infected adults. Other issues include access to unproven drugs, the problems posed by co-infection with TB, and prevention through needle and condom distribution.
OBJECTIVE: Western Australia has one of the highest published rates of the use of compulsory treatment orders in the English-speaking world. Differences in patient characteristics, legislation and service setting may explain variations in the reported efficacy of compulsory community treatment. Our objective is to investigate predictors of Community Treatment Orders (CTO) placement in the first year of implementation in Western Australia and see if there were any differences in the type of patients placed on these orders compared to other studies. METHOD: A population-based record linkage study of Mental Health and Offender Databases comparing 265 patients on CTOs with a consecutive control group (CCG) of equal number matched on date of discharge from inpatient care or CTO placement. RESULTS: Previous health service use, after-care placement, mental disorder history including schizophrenic history, a positive forensic history of violence to others as well as patient's marital status were the significant predictors of CTO placement. CONCLUSIONS: Studies of compulsory community treatment appear to be of similar populations. In spite of the comparatively high rate of use, psychiatrists in Western Australia do not appear to be applying community treatment orders to different types of patient compared to elsewhere. We need further research to establish the relative contribution of patient characteristics, legislation and service setting toward the use and outcome of compulsory community treatment.
Alcohol problems are widespread among individuals in county criminal justice probation systems. However, it is unclear why only a small fraction of these problem drinkers receive treatment. In this study, self-administered questionnaires were mailed to 145 probation officers in nine California counties to identify factors that predicted probation officers' use of coercion to mandate alcohol treatment. The questionnaire measured characteristics of probation officers, characteristics of their caseloads, and perceptions about their departments. Principle components analysis combined some of the items into six factor-based scales. Multiple regression analyses identified two significant predictors of use of coercion into treatment: a belief that treatment was effective and a belief that one's peers in the department were using coercion frequently. Implications for increasing treatment entry of probationers with drinking problems include educating probation officers about the effectiveness of substance abuse treatment in general and about coerced treatment in particular. Probation departments are encouraged to develop management styles that facilitate shared normative beliefs about assessing and managing alcohol problems among probationers.
The purpose of this study was to identify the level of psychiatric symptoms reported by probationers involved with a drug court in Hennepin County, Minnesota. Sixty probationers completed a brief demographic interview, the Beck Depression and Anxiety Inventories (BDI and BAI) and a measure of medical quality of life. Fifteen participants completed a structured interview for psychiatric diagnosis (SCID-I). The sample was predominantly male, African American, and unemployed. Over 40% had received treatment for psychiatric problems, including 20% who reported a history of inpatient psychiatric admission and 15% currently taking a psychotropic medication. More than 1/3 of BDI and BAI scores were moderate to severe. The mean Short Form (SF)-36 scores were significantly lower than in the general population. Trends suggested more distress associated with: Caucasian race, female gender, less education, unemployment, and less previous legal involvement. Of 15 participants that completed a SCID-I, 13 participants met lifetime diagnostic criteria for at least one psychiatric disorder. The most common diagnoses were major depressive disorder and posttraumatic stress disorder (PTSD). Three participants met diagnostic criteria for current psychotic disorder. Half of participants who currently met criteria for a disorder reported that they had never received psychiatric treatment. Results indicate participants currently were experiencing high rates of emotional symptoms. Serious mental illness was common. Many of these individuals had not been identified previously as needing psychiatric treatment. More frequent and thorough screening for psychiatric illness in drug court settings is necessary to identify serious psychiatric illnesses.
The first drug treatment court began in Miami, Florida in 1989, in direct response to the backlog of court cases for drug possession and trafficking. By mid-2001, there were 700 operational drug treatment courts and 400 more in the planning stages in the United States. In addition to providing an overview of the growth and development of drug treatment courts in the United States, this special issue examines their development in Australia, Canada, and the United Kingdom. The primary focus is the evaluation research conducted to date, which identifies some of the critical unresolved issues facing drug treatment courts.
The creation of the first drug treatment courts were in response to the revolving door of drug use and recidivism. There was no theoretical basis for these courts and no universal support for them. Twelve years have brought incredible changes. Therapeutic jurisprudence says, in essence, whether intended or not, that legal rules and procedures have therapeutic effects. Drug treatment courts have adopted principles of TJ to enhance their functioning. The Conference of Chief Justices recently issued a resolution supporting "problem-solving" courts. New trial court standards legitimize drug courts' procedures. Drug treatment courts are now mainstream and can no longer be seen as "boutique" courts staffed by renegade judges. Working therapeutically is an appropriate, effective, and productive way for the justice system to function.
The paper begins by placing the emergence of drug treatment courts within the context of rising property crime rates, the development of open-air illicit drug markets, and the rise in opiate overdoses in Australia. The paper then highlights the way in which the U.S. concept of drug treatment courts was adopted and adapted by state politicians in attempts to deal with drug-use-related offenders. This response has been specifically targeted at repeat property offenders "at risk" of imprisonment, and comes within the broad brush of harm minimization strategies for diverting offenders with a drug-use-related problem away from the traditional criminal justice response of imprisonment. The prospects for the future of drug treatment courts in a Federalist system are also discussed.
Drug treatment courts provide a new strategy for providing treatment services to offenders within the criminal justice system. With over 400 drug treatment courts in the United States, the courts have evolved to provide treatment services under different models. This article will review the different typologies for delivery of treatment services to drug user offenders in the drug treatment court setting, and it will raise questions about some of the difficult issues underscoring an integrated service delivery model. The paper then identifies some research questions for the future.
A defining feature of the drug treatment court movement is the judicial adoption of the disease model for explaining drug using behavior; an interpretive paradigm that historically has not played a defining role in the adjudication of drug offenders. In drug treatment courts, however, the disease model finds a very central place in the adjudicative process, and profoundly shapes the way judges view and treat defendants. This article examines the application of the disease model to drug and non-drug-related crimes in the context of drug treatment courts, and considers the significance of these developments as it concerns the meaning of criminal justice.
This essay offers an overview of some of the ethical questions raised by governmental and medical interventions into drug use. With respect to the former, it begins with the liberal assumption that constraints on free action are to be justified by reference to its deleterious impact on others, but then qualifies that assumption by noting the social requisites of free action. With respect to medical interventions, it focuses on the codes that have been developed for treatment providers and their clients, and explores the ethical underpinnings of several of their central provisions--informed consent, privacy, confidentiality, nondiscrimination, professionalism, and accountability.
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Occupational hepatitis B remains a threat to healthcare workers (HCWs) worldwide, even with availability of an effective vaccine. Despite limited resources for public health, the Czech Republic instituted a mandatory vaccination program for HCWs in 1983. Annual incidence rates of acute hepatitis B were followed prospectively through 1995. Despite giving vaccine intradermally from 1983 to 1989 and intramuscularly as half dose from 1990 to 1995, rates of occupational hepatitis B decreased dramatically, from 177 cases per 100,000 workers in 1982 (before program initiated) to 17 cases per 100,000 in 1995. Among high-risk workers, the effect was even more dramatic (from 587 to 23 per 100,000). We conclude that strong public-health leadership led to control of occupational hepatitis B among HCWs in the Czech Republic, despite limited resources that precluded administering full-dose intramuscular vaccine for much of the program. Application of a similar program should be considered for other countries in regions that currently do not have a hepatitis B vaccination program.
BACKGROUND: Goiter rates and iodine deficiency usually show marked improvement in efficacy studies of mandatory iodization of salt, but little is known about the short-term effectiveness of mandatory iodization. OBJECTIVE: The aim of the study was to evaluate, after 1 y, the effectiveness of mandatory iodization of salt at an iodine concentration higher than that occurring under optional iodization on the goiter rates and iodine status of schoolchildren living in an endemically goitrous area. DESIGN: Goiters, measured by palpation, and urinary iodine concentrations of children in grades 4-7 in 4 schools in a known goitrous area in South Africa were assessed before and 1 y after the introduction of mandatory iodization at a higher iodine concentration than occurred with optional iodization. Estimates of the iodine concentration of iodized salt and the proportion of households using iodized salt were also made. RESULTS: Iodine concentration in table salt and household use of iodized salt improved within 1 y. Goiter rates, which varied at baseline from 14. 3% to 30.2% in the 4 schools, remained unchanged, with an overall mean (+/-SE) prevalence of 25.6 +/- 2.5% at baseline and of 27.5 +/- 2.7% 1 y later. The distribution of urinary iodine concentrations in the 4 schools improved substantially from the baseline deficient range. The overall median urinary iodine concentration increased from 0.17 to 1.47 micromol/L. CONCLUSIONS: Mandatory iodization of salt virtually eradicated iodine deficiency within 1 y in South African schoolchildren, but the goiter rate in these children did not decline. Measurement of goiters by palpation may not be appropriate in short-term evaluations of mandatory iodization programs.
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This paper examines the effects of mandatory health insurance on access and equity in access to public and private outpatient care in Indonesia. Data from the second round of the 1997 Indonesian Family Life Survey were used. We adopted the concentration index as a measure of equity, and this was calculated from actual data and from predicted probability of outpatient-care use saved from a multinomial logit regression. The study found that a mandatory insurance scheme for civil servants (Askes) had a strongly positive impact on access to public outpatient care, while a mandatory insurance scheme for private employees (Jamsostek) had a positive impact on access to both public and private outpatient care. The greatest effects of Jamsostek were observed amongst poor beneficiaries. A substantial increase in access will be gained by expanding insurance to the whole population. However, neither Askes nor Jamsostek had a positive impact on equity. Policy implications are discussed.
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The U.S. has a wide range of options in choosing a health care system. Rational choice of a system depends on analysis and prioritization of the basic moral goals of equitable access to all citizens, the just sharing of financial costs between well and ill, respect for the values and choices of subscribers and patients, and efficiency in the delivery of costworthy care. These moral goals themselves, however, tell us little about what health care system the United States should have. Equitable access does not demand a level and scope of care for the poor equal to that rationally chosen by the middle class, and there are ways within mixed systems, though not easy ways, to achieve a fair distribution of costs between well and ill. Despite pluralistic systems' apparent advantage in allowing subscribers to choose their own forms of rationing, problems in translating serious long-term subscriber choices into actual medical practice may be greater in pluralistic than in unitary systems. Final choice of a system hinges primarily on peculiar historical facts about U.S. political culture, not on moral principle.