Global antimicrobial resistance (AMR) is currently governed by a decentralized regime complex composed of multiple institutions with overlapping and sometimes conflicting principles, norms, rules, and procedures. Such a decentralized regime complex provides certain advantages and disadvantages when compared to a centralized regime. A pandemic instrument can optimize the regime complex for AMR by leveraging the strengths of both centralization and decentralization. Existing climate treaties under the UNFCCC offer lessons for achieving this hybrid approach.

Amid undulating conceptions of the role and prowess of federalism emerges its central constitutional role: protecting American liberties against unwarranted governmental intrusions. To the extent that federalism is used as a guise for withdrawing fundamental rights to abortion by the U.S. Supreme Court in Dobbs v. Jackson Women’s Health Organization, individual rights are sacrificed in contravention of constitutional structural norms.

The majority of antimicrobials that are produced are administered to animals, particularly food animals. While the overall impact of antimicrobial use in animals on antimicrobial resistance in humans and the environment is unclear, it undeniably has a role. Yet, some degree of antimicrobial use in animals is necessary for animal health and welfare purposes. Balancing the benefits and risks of antimicrobial use in animals is challenging because of the complexity of the problem and limitations in available data. However, a range of measures can be implemented to reduce, refine and optimize antimicrobial use in animals, with a goal of minimizing the impact on human and environmental health while maintaining necessary therapeutic use in animals. A pandemic instrument can provide the necessary foundation for the whole-of-society and whole-of government One Health approach that is required to strengthen surveillance, communication, collaboration, and action.

A robust body of research supports the centrality of K-12 education to health and well-being. Critical perspectives, particularly Critical Race Theory (CRT) and Dis/ability Critical Race Studies (DisCrit), can deepen and widen health justice’s exploration of how and why a range of educational inequities drive health disparities. The CRT approaches of counternarrative storytelling, race consciousness, intersectionality, and praxis can help scholars, researchers, policymakers, and advocates understand the disparate negative health impacts of education law and policy on students of color, students with disabilities, and those with intersecting identities. Critical perspectives focus upon and strengthen the necessary exploration of how structural racism, ableism, and other systemic barriers manifest in education and drive health disparities so that these barriers can be removed.

Governments can practically and efficiently address zoonoses and AMR –– within the text of the new pandemic instrument. We map the overlaps between the efforts needed to address both pandemic threats, including (a) equitable access to medical countermeasures, (b) globally integrated One Health surveillance and monitoring systems, (c) increased technical and laboratory capacity in low- and middle-income countries, and (d) a regulatory framework governing the stewardship of antimicrobials. By outlining potential dual-purpose provisions that could be included in a pandemic instrument, we argue that addressing AMR in the pandemic instrument is practicable, the most effective use of limited time and resources, and provides the best opportunity for future global pandemic readiness.

Although the federal government and several state governments have recognized that structural discrimination limits less privileged groups’ ability to be healthy, the measures adopted to eliminate health disparities do not address structural discrimination. Historical and modern-day structural discrimination in employment has limited racial and ethnic minority individuals’ economic conditions by segregating them to low wage jobs that lack benefits, which has been associated with health disparities. Health justice provides a community-driven approach to transform the government’s efforts to eliminate health disparities, by acknowledging the problem of structural discrimination; empowering less privileged groups to create and implement structural change; and providing support to redress harm.

The COVID-19 pandemic has shed light on the challenges of complying with public health guidance to isolate or quarantine without access to adequate income, housing, food, and other resources. When people cannot safely isolate or quarantine during an outbreak of infectious disease, a critical public health strategy fails. This article proposes integrating sociolegal needs screening and services into contact tracing as a way to mitigate public health harms and pandemic-related health inequities.

I am pleased to introduce this Symposium Edition of The Journal of Law, Medicine & Ethics, which covers a wide variety of issues central to transgender health equity, including Dr. Jamison Green’s recent history of the impact of health policy on transgender communities, Dr. M. Killian Kinney, Ms. Taylor Pearson, and Prof. Julie Ralston Aoki’s transgender equity tool for legal policy analysis, and Prof. Elizabeth Kukura’s analysis of issues facing transgender, non-binary, and gender expansive people during pregnancy and childbirth.

This essay describes an instrumental advocate’s development, engagement, and accomplishments in transgender health at the intersection of law and medicine. Reflecting on the evolution of insurance policy reforms in conjunction with the need to increase the availability of clinicians who can understand and respectfully treat transgender patients, the author demonstrates how visibility, tenacity, and ingenuity can create far-reaching change.

In this manuscript, “Intersectional Structural Stigma, Community Priorities, and Opportunities for Transgender Health Equity,” Poteat and Simmons outline the legal and policy barriers that impede efforts to end the HIV epidemic among transgender people in the South. They present qualitative and quantitative data from a community engaged research study conducted with transgender adults and other key stakeholders as well as finding from an analysis of policies impacting transgender people in both states. Violence prevention and decriminalization are highlighted as key policy initiatives that would advance health equity for transgender people.

Digital Health Technologies (DHTs) are currently the subject of much debate both in terms of their technological frontiers as well as their ethical, legal and societal implications (ELSI). Regulation of such technologies as medical devices currently lacks behind their level of adoption. Digital Twins are the next evolution step of such DHTs and provide an opportunity to anticipate and act on ELSI before adoption again leaps before the necessary review. This paper introduces the concept and use cases of digital twins in medicine, then frames the debate through the lens of related technologies, machine learning and personalized medicine, and maps ethical challenges stemming from those. Finally, we lay out how digital twins may change and challenge the future practice of medicine.

Transgender conversion practices involve attempts to alter, discourage, or suppress a person’s gender identity and/or desired gender presentation, including by delaying or preventing gender transition. Proponents of the practices have argued that they should be allowed until proven to be harmful. Drawing on the notion of expressive equality, I argue that conversion practices are prima facie unethical because they do not fulfill a legitimate clinical purpose and conflict with the self-understanding of trans communities.

Despite a recent wave in global recognition of the rights of transgender and gender-diverse populations, referred to in this text by the umbrella label of trans*, international law continues to presume a cisgender binary definition of gender — dismissing the lived realities of trans* individuals throughout the world. This gap in international legal recognition and protection has fundamental implications for health, where trans* persons have been and continue to be subjected to widespread discrimination in health care, longstanding neglect of health needs, and significant violations of bodily autonomy.

The sheer gamut of issues impacting transgender health equity may seem overwhelming. This article seeks to introduce readers to the breadth of topics addressed in this symposium edition, exemplifying that transgender health equity is a global issue that demands an interdisciplinary approach.

This article examines the barriers to quality health care for transgender, nonbinary, and gender-expansive people (TGE) who become pregnant and give birth, identifying three central themes that emerge from the literature. These insights suggest that significant reform will be necessary to ensure access to safe, appropriate, gender-affirming care for childbearing TGE people. After illustrating the need for systemic changes that untether rigid gender norms from the provision of perinatal care, the article proposes that the Midwives Model of Care offers a set of values and clinical practices that are well-suited to meet the needs of many TGE patients during pregnancy and childbirth and which should be incorporated into the healthcare system more broadly.

Transgender inclusion within policy is critical yet often missing. We propose a policy tool to assesses human rights, access to resources and opportunities, language, and implications for transgender and nonbinary individuals. Acknowledging trans communities as standard policy practice can serve as an essential practice to shift dialogue and norms.

Mitochondrial replacement therapy (MRT), also called nuclear genome transfer and mitochondrial donation, is a new technique that can be used to prevent the transmission of mitochondrial DNA diseases. Apart from the United Kingdom, the first country to approve MRT in 2015, Australia became the second country with a clear regulatory path for the clinical applications of this technique in 2021. The rapidly evolving clinical landscape of MRT makes the elaboration and evaluation of the responsible use of this technology a pressing matter. As jurisdictions with less strict or non-existent reproductive laws are continuing to use MRT in the clinical context, the need to address the underlying ethical issues surrounding MRT’s clinical translation is fundamental.

Vaccine mandates played a critical role in the success of New York City’s COVID-19 response. By relying on evidence as a substantive basis for the mandates and adhering to procedural requirements and precedent, New York City leveraged its position and expertise as a local governmental authority to devise mandatory vaccine policies that withstood numerous legal challenges. New York City’s experience highlights the role of municipal government in mounting a meaningful public health response, and the strategies adopted by NYC may provide a blueprint for municipalities around the world facing the ongoing COVID-19 pandemic and the threat of future public health emergencies.

Many transgender people need specific medical services to affirm their gender. Gender-affirming health care services may include mental health support, hormone therapy, and reconstructive surgeries. Scant information is available about the utilization or costs of these services among transgender people, which hinders the ability of insurance regulators, health plans, and other health care organizations to plan and budget for the health care needs of this population and to ensure that transgender people can access medically necessary gender-affirming care. This study used almost three decades of commercial insurance claims from a proprietary database containing data on more than 200 million people to identify temporal trends in the provision of gender-affirming hormone therapy and surgeries and to quantify the costs of these services.

Using an implementation science framework, we detail how a national system for covering both standard and telemedicine laboratory testing would support a national PrEP program. Implementation strategies that will facilitate success include minimizing provider burden through uncomplicated billing systems and minimizing patient burden through centralized, online access systems. We anticipate that providing telemedicine and in-person laboratory testing options will optimize PrEP care by making it less burdensome, leading to cost-effective healthcare and improved population health.