Community Practicum Project: Part 1-3

As a scholar with specific subject matter expertise in anthropology and public health, and as an individual living with HIV, a first generation college student, and queer man with history of substance abuse whose work and life are deeply intertwined, I have derived a lot of comfort and hope in bearing witness to the power of community coalitions while accompanying community leaders and advocates in mobilizing to take care of one another, to act, and to engage in necessary fights around issues that have long been in existence: universal and meaningful healthcare, abolition, housing rights, equal employment, gender equality, environmental justice, and rights of marginalized communities, displaced populations, migrants and immigrants.

I have worked alongside community leaders, activists, and health and social providers in the field of HIV and disease prevention who have long refused to accept the status quo, and have instead, created their own forms of care or reimagined the existing systems to meet emergent needs.  They have developed healthcare and support organizations, challenged, and changed how treatment and services are delivered, and demanded that society and the government pay attention and respond. They see this as a necessary, just, moral, and legitimate response to the ongoing precarity characterized by economic scarcity, civic inequality, market-based health care, and exclusionary policies. This also shows us how in the face of such precarity, people also find means of relating to each other, connecting to each other, and taking care of each other. It shows us how people are reimagining precarity and uncertainty as relational, generating circuits of social connections and belonging through the care of others. It is important to amplify these spaces and voices. This involves a deep commitment and sustained action; and in the truest since of the phrase: revolutionary love…

Clay A. Porter

Anthropologist • Epidemiologist • Activist

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Master of Public Health in Epidemiology 

Community Practicum Project Portfolio 

Eastern Virginia Medical School & Virginia Department of Health

Contents:

Section 1. Introduction  

This project was part of the Community Practicum course in the Master of Public Health program at Eastern Virginia Medical School and is the final requirement for students before graduation. I completed my project with Virginia Department of Health in the Division of Disease Prevention. My work involved both policy and data analysis, and was primarily shaped by my interest in HIV and STI syndemic disease disparities and the requirements for the course as outlined in the syllabus. The resulting section are the culmination of over a year of work with VDH and represents my scholarship and reflections on time spent in the DDP. Section 2 describes how I chose the location for my project, followed up an anthropological take on policy analysis in the specific context of HIV decriminalization. The next section is a paper on Viral Suppression among people living with HIV in Virginia with a history of STI. This project used surveillance data from VDH to predict viral suppression outcomes based on PLWH's STI record. Section 5 reviews the different program and track-specific competencies integrated into my project and section 6 is an overall evaluation of my experience in the course. 

Section 2. Site Selection 

Introduction

I have spent almost half of my life working in the HIV milieu, with most experiences beholden to academia. There are only a few instances where my expertise was exemplified in employment settings but ultimately my background is made up of rigorous scholarship and volunteerism, with little relevant work history to report. Consequently, it has been difficult to obtain a paid position in the field because my resume reads as if I were a recent graduate with minimal responsibilities, even though that is not the case. It became necessary to reconcile these representations in determining where I would complete my practicum project and what work I would do to promulgate my agenda.

Rationale for Community Practicum Site Selection

Virginia Department of Health (VDH) afforded me an opportunity to showcase my talents through an internship within the Office of Epidemiology (OEpi) in the Division of Disease Prevention (DDP) and I chose to capitalize on this occasion for my practicum project requirement and ongoing effort to secure employment in the field. I selected Virginia Department of Health as my Community Practicum site for three reasons. The first reason is because VDH is known among all public health professionals, especially those hiring, and I wanted to be able to list my experiences with the agency on my resume and curriculum vitae. Secondly, my rationale for selecting VDH over another organization was the relationship I would cultivate with my supervisor, who in this case was Director of the Division of Disease Prevention, a position that is only three steps away (in terms of organizational hierarchy) from the Governor of Virginia as the leading public health authority in the state; with the goal of leveraging this connection in my future public health work, specifically when applying for jobs. Both the agency and the individuals with whom I would be working were considered in this decision, as the agenda was always set to exceed course requirements and help me secure employment.

LGBT Life Center and CAN Community Health were two other agencies with whom I considered working, but the penultimate reason I chose VDH was because, unlike the other two organizations, which are small, locally service-oriented, with needs exceeding budgetary ends to meet them, VDH is large, fully resourced, and organized in such a way that the interdisciplinarity of my project could be actualized during my practicum work. Namely, the scale of the agency would allow for me to do more, and do so more freely, than I could do at a smaller community-based organization, who would rely more heavily on my work and deliverables; whereas VDH welcomed my project proposal under the auspices that all work would be done independently, and outcomes would be of my own creation. So, the rational for selecting my community practicum site was based on the previous declarations and the assumption that the culmination of my project, together with deliverables, work products, and research outcomes, would result in the greatest opportunity for employment after graduation.

My future goals are multiple and there is not one area of public health that I find myself more interested in than another; and my background in anthropology and experience working in the HIV milieu both academically and in applied employment or volunteer settings, positions me for a variety of jobs at health departments and community-based organizations, be they involved in policy work, epidemiological surveillance and data analysis, program design and evaluation, or administration. I will be pursuing professions in each of these areas, as I consider myself having more of an agenda than a career to develop; and the interdisciplinarity of my practicum experience effectively aligned this project with my future goals. 

Organizational Culture: Mission, Target Service Population, and Structure/Agency

VDH is responsible for the health and well-being of the entire Commonwealth, with each department working on a different project to facilitate the agency’s vision to “become the healthiest state in the nation. The mission of VDH is to protect the health and promote the well-being of all people in Virginia. DDP is a division of OEpi; and has for its mission to maximize public health and safety through the elimination, prevention, and control of disease, disability, and death caused by HIV/AIDS, viral hepatitis, other sexually transmitted infections.

I located myself in several areas of VDH, each with its own mission and function, be it the agency (VDH), OEpi, DDP, or interagency initiatives like Community HIV Planning Group (CHPG). While different departments have their own agendas, the target service population is always Virginia residents. In this case, populations are defined according to their risk or reliance on the agency; for example, VDH is responsible for the health and well-being of all citizens in the Commonwealth, OEpi focuses on those at risk of communicable disease as well as those reliant on services afforded by the department, such as vaccinations and pharmacy services, while DDP targets communities at-risk of HIV/STI infection.

CHPG is part of the DDP which is in OEpi of VDH. The goals of community HIV planning are: (1) reduce new HIV infections in Virginia; (2) increase access to care and improve health outcomes for people living with HIV (PLWH); and (3) reduce HIV-related health disparities. To meet these goals, the CHPG identified me as a new member for the planning process. Together, CHPG develops, implements, and monitors a jurisdictional HIV plan. This plan is a five-year planning document that updated annually, addressing the emerging and changing needs of the community. So, the target service population is always changing while remaining broadly defined as all individuals living with, or at-risk of HIV-infection. 

My Role

Under director supervision by Diana Jordan, Director of Disease Prevention, I worked with staff in all division departments, including STD Prevention and Surveillance, HIV Surveillance, HIV Care Services, and HIV/Hepatitis Prevention Services. For much of my project, which involved work with Virginia General Assembly, Governor Northam was my de facto supervisor as he is the highest-ranking leader over all state agencies; this became especially important when representing the interests of the health department to constituent stakeholders and legislators involved in health and health policy issues. Within the agency, the hierarchy which led to my role as an intern began with the State Health Commissioner, followed by the Deputy Commissioner for Population Health, the State Epidemiologist- who is also the Director of the Office of Epidemiology- and the Director of Disease Prevention, which was my direct supervisor. I was brought in as an intern by Diana Jordan, Director of Disease Prevention. However, my involvement with different projects positioned me in several areas of the agency and allowed me to work with many different staff members. In the HIV Surveillance Unit, I worked on case surveillance, molecular epidemiology activities to monitor viral genetic sequences in treatment naïve new cases, and HIV data analysis, as well as utilized data from both Medical Monitoring as well as National HIV Behavioral Surveillance projects.  Some of my work positioned me in the STD Prevention and Surveillance Unit, although many staff were in local health departments; I had the opportunity to present my project outcomes to the Disease Intervention Specialists at several meetings.

As part of my research, I found myself working closely with HHPS (HIV/Hepatitis Prevention Services) staff, including the manager of biomedical interventions, whose knowledge of pre-exposure prophylaxis (PrEP) would serve invaluable in project development. In the context of my internship, I did not spend much time with the HIV Care Services (HCS) unit; although, in my role as a Community HIV Planning Group member, I had the chance to work directly with HCS management on developing an integrated plan for ending the HIV epidemic in Virginia, including medical care, dental services, case management, mental health and medication assistance, as well as facilitate statewide HIV services planning and quality management. There were also opportunities for collaboration, especially in the context of my work with the General Assembly, where each unit of disease prevention maintained its own relationships with unit divisions in other departments; for example, pharmacy services staff working with STD prevention and Surveillance folks on the development of policies associated with the roll out of PrEP without providers’ prescription- a legislative issue I worked on for the health policy analysis and advocacy portion of my project. A result of the interdisciplinarity of my project was widespread exposure to the different areas of disease prevention, and the related departments working on shared projects. 

Section 3. Policy Analysis

HIV DECRIMINALIZATION

powerful paradigms, powerful people

This report is based on my ethnographic fieldwork on HIV decriminalization in Virginia and critical analysis of both institutional and community-level approaches to legislative efforts in the 2020 and 2021 Virginia General Assembly. I will not consider the analytical frameworks, models, methods, or policy development strategies that have been contemporaneously used by government- and community-based- organizations. Instead, my research draws value from medical anthropology and epidemiology, as well as over four decades of collective wisdom from those working in the HIV/AIDS milieu, to introduce an alternative to current practices in policy analysis and provide a practical solution for understanding and conducting rapid ethnographic assessments (REAs) for public health research and development contexts.

The interdisciplinary, multi-method, low-cost approach results in rich understandings of social, economic, and cultural factors that contribute to the root causes of an emerging situation and provides rapid, practical feedback to stakeholders, policy makers, and programs. It is an applied approach that can facilitate collaborative work with communities and become a catalyst for action. It should appeal to professionals and researchers interested in using REAs for expediting efficiency and productivity as well as action-oriented and translational research in a variety of fields and contexts; and is congruent with current public health scholarship and best practices, and both state and federal plans to end the HIV/STI syndemic.

A key element of a credible policy analysis involves the use of an analytical framework grounded in one or more theories and models of meaning-making or paradigm. These frameworks help to identify and interpret relationships between key variables relevant to the policy issue of interest. The analytical framework provides a common structure for summarizing the advantages and limitations of the proposed policy regarding various aspects relevant to decision making. All analytic tools have their own methods for collecting and communicating information; and each of them is governed by a set of rules for interpretive work which defines its topicality and the limitations of its use in discourse. Together, these divergent perspectives coalesce around the structures of social and scientific action that establish paradigms and sets their epistemological priorities. This is a kind of “lessons learned” approach to reporting on my participant-observation of HIV decriminalization in the specific context of House Bill 864 and Senate Bill 1138.

HB864 and SB1138 were bills introduced in the House and Senate, respectively, to address the problem of HIV criminalization in the Code of Virginia, specifically in the context of Infected Sexual Battery. Del. Levine’s bill was not made a law, and instead was reported back to Committee for Courts of Justice. Del. Levine is an openly gay White male representing Alexandria (NOVA). Sen. Locke is a Black woman whose representative district includes parts of Hampton, Newport News, Portsmouth, and York (Tidewater). SB1138 moved through the legislature successfully but with significant amendments made to the original bill. Key players involved in both processes include: Positive Woman’s Network (PWN), Equality Virginia (EV), ECHO VA, SERO Project, CHPG and independent community activists as well as expert testimony provided by constituents and professional organizations alike. Primary actors include: PWN, EV, and community activists.

Collectively, these agents leveraged their power to “kill the bill” introduced by Del. Levine in 2020 with the recommendation that he involve PWN and other voices in the community for whom this measure is designed to support. HB864 approached the issue through the lens of modernization while SB1138 integrated an abolitionist approach outlined by PWN and called for comprehensive repeal of three VA laws collectively seen as the source of HIV-related inequities and disparities in the medico-legal perspective. The research and development context out of which these legislative actions emerged are as different as their sponsor’s conceptual frameworks for analysis; in that, Del. Levine advanced a modernization agenda that aimed to update the current code to include contemporary treatment and prevention guidelines supported by VDH/CDC. Sen. Locke’s bill came out of a social justice and human rights-based approach to policy. The differences in these two processes (2020 and 2021) are distinct and important to understand for future policy work on public health modernization and HIV decriminalization.

How discourse is framed determines its outcome.

This section uses the anthropologist Gregory Bateson’s conceptualization of framing and his theory of interpersonal communication process to explore how relational realities develop in designed conversation processes. By analyzing the different epistemologies drawn from the 2020-2021 VGA, I attempt to clarify theoretical principles underlying dialogic approaches to juridical change. I also consider the practical implications inherent in these ideas, particularly the possibilities they offer for an individual’s/ institution’s awareness of the (research and development) context in which they are a participating member.

Goffman defined a frame as a “schema of interpretation” that provides a context for understanding information and enables individuals to “locate, perceive, identify and label” (p. 21). In his classic work on frame analysis, Goffman identified various processes involved. Of these, three of the most important were keying, bringing into focus particular aspects of everyday life by recreating past interactions; anchoring, the rooting of ideas in deeper frames of meaning; and fabrication, the recasting of certain dimensions of experience so they are made salient within a situation or interaction.

What is a paradigm?

Paradigms are the culture-cum total frames of reference we use to organize our observations and interpretation. A paradigm is an example serving as a model or pattern. It is a template of and for our thoughts.

What is in a frame?

A frame is a guide. It directs people where to look, but more importantly, helps them interpret what they see. Every message- whether written, spoken, illustrated, or signed- is presented through a frame of some kind. Simply put, every communication is framed.

Framing refers to how individuals/institutions package and present information to a given audience. Accordingly, an individual highlights certain aspect of discourse and places them within a particular content to encourage or discourage certain interpretations. In this way, the individual/institution exercises a selective influence over how people view reality, topicality, and priority. Far from being exclusively located in the sender of information, framing is in four elements of the communication process: the sender, the receiver, the (informative) message and culture.

What does this theory assume?

·         Individuals/Institutions select the topics they will present and decide how they will be presented. This determines the issues audiences think about and how they think about them.

·         Audiences interpret information through their own frames. Audiences’ frames may overlap or contract the individual’s/institution’s frames.

·         Frames are reinforced every time they are evoked, whether positively or negatively.

·         Frame building is a systematic process that occurs over time.

Frames are systems of pre-conceived ideas used to organize and interpret new information. Rather than selecting a frame to process information when confronted with news, people instead view the world through their frames and make new information fit into them. Information that contradicts a frame is usually written off as an exception to the rule or distorted to fit the frame. As a result, people are most likely to notice information that fits into their frames and ignore facts that do not.

Framing occurs in public comment or legislative testimony because of time constraints on what can be reported. Individuals/Institutions must choose which parts of a subject to cover and which to ignore. They must also decide which facts, values and perspectives will be mentioned or given prominence. This means individuals/institutions apply their own interpretive frames when packaging content. Individuals/Institutions are also influenced by culture and their own ideological or political orientations. As a result, some definitions, evaluations, and recommendations contained within a discourse are promoted over others.

People/politicians who want to introduce a new frame to audiences must, therefore, reference culturally popular ideas and develop novel phrases that link existing frames in a compelling way. What makes frames so powerful is how easily they are evoked and, therefore, reinforced. To reference the “war” frame, one only has to mention an idea contained within that frame, such as “tanks.” Negating a frame—such as stating, “There’s no such thing as war”—only reinforces that frame by calling up the images associated with it. The only way to combat a frame is to reframe an issue in another, more powerful way.

Faming is related to agenda-setting tradition.

The greatest challenge for folks working on HIV decriminalization (and its legislative instrument SB1138) was making the connection between infected sexual battery law and stigma and public health outcomes. No one was effectively communicating patterns of causation and the consequences of stigma on disease prevention in the specific context of HIV criminalization. These interassociations were abstracted from their medico-legal context and narrated subjectively as personal testimony instead of reinforcing causal objectivity to make clear their myriad connections. In this way, legislators, and others unfamiliar with the topicality of HIV-related stigma, were bereft of the interpretive tools necessary for building understanding and consensus around the issues interpolating this bill, and the issue of HIV criminalization as a function of stigma moreover. I am talking about conceptual priority, not epistemic priority; by calling attention to the differences in what we know and how we know what we know as disparate principles governing the relations of skepticism and logical independence, which we use to conceptualize coherence and certainty. By cultivating the “priority principles” of objectivity in science over the subjective functions of personal testimony, we establish “epistemic standards” for speaking of evidence.

PWN-USA/ECHO VA and Equality VA are advocacy organizations whose work is informed by social justice and not public health paradigms, which, I think is problematic in the context of influence over legislative action governing critical public health issues. Leadership should come from the medical and health professional community, from those with disciplinary proficiencies in population and community health as well as HIV-related expertise in the social sciences. Namely, the health department and their clinical partners should represent the theoretical perspective used to inform this bill as much as the issue of HIV criminalization. Ultimately, the framework for understanding this issue and addressing the legislative challenges of SB1138 should operate at an instructive level as an interpretive mechanism for organizing the ideas and ideals around this conversation of HIV decriminalization, informing both supportive and opposing ideologies.

Felony repeal was an important issue until it was not, and then it was again in the aftermath with the call for Northam’s executive decriminalization -post hoc. My issue with this is the impact of the felony in carceral and prosecutorial contexts is low, in that there are very few cases where the law has been successfully applied to convict with a felony.  The true power of the felony over population health in VA, specifically for communities at-risk of HIV infection- lies in its symbolic function as a source of stigma; and as such, the true impact of the felony repeal on public health is its interventional capacity as a stigma-reduction strategy, not simply an issue of incarceration. Again, the focus shifts from single-issue aspects of interpretation in SB 1138 to broader thoughts about HIV decriminalization as a function of public health modernization, which interpolates the totality of issues coalescing around HIV-related laws in the Commonwealth. 

Rejecting epistemic priorities used to frame discourse can lead us towards a more pragmatic and socially responsible instrumentation of policy analysis.

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Lessons Learned

Identify issues related to external factors early on and actively strategize around them on a continuous basis throughout the entire life of the process. The lack of understanding around broader political, Cultural*, and economic contexts surrounding communities has been and continues to be a major barrier to achieving HIV decriminalization and public health modernization goals. (Perhaps, we could have predicted the NOVA Progressive + Black Democratic “caucus” coalition that resulted in the felony staying on the books.)

Conduct a careful and thorough pre-planning analysis of the broader political, social, and economic contexts to identify both threats and opportunities to successful program implementation, which, in the context of policy analysis, allows us to avoid addressing legislative barriers in a reactionary manner and will save time and human resources.

Implement a core set of principles for guiding VDH position and solicitation of community involvement on issues related to public health assigned to the agency, including: ongoing stakeholder engagement based upon mutual-respect, coordinating efforts to build political will and accountability over different phases of the policy R&D processes and at different anthropological levels, systematic application of law and policy implementation outcomes (such as using Infected Sexual Battery in a prosecutorial context) in addition to endpoint outcomes that support overall public health modernization efforts.

This should be a public policy platform statement made by leadership to define (however narrow-should not matter) approach to the legislative agenda and issues in debate; and as such, serve as a framework for content inclusion and exclusion in answering questions on bills in committee.

To minimize negative unintended outcomes (such as SB1138 on STIs more broadly/MHS application) policymakers need to be given adequate information on the effects of legislation in application of law and policy implementation processes across cultural ecological borders, especially at community and municipal levels. 

Efforts to advance public health policy should be accompanied with efforts to build social capital* and cultivate the cultural ecological context from which the authority of science is measured and used in public health modernization at an institutional level.

VDH to “frame” discourse on the topicality of public health policy and laws in debate.

Shift authority away from private interests (PWN, ECHO, Sero, and EV) to public institutions

Position VDH at medico-legal intersection

Advise legislators and others involved in policy work about the issues in question from a medico-legal perspective; such that, debate over the topicality of health policy and law is informed by science.  (Such as using empirical evidence to make clear the interassociations between law and policy and stigma, and testing and disclosure; and surmise the effects of implementation, as well as interventional efforts prevent disease and advance population health outcomes.

Provide statistical descriptions of data in support of legislative actions to address health equity and disease prevention efforts at the state and local level.

Critical Inquiries

1. Was more harm done than good here in allowing private interests (“public” advocacy organizations) to shape public policy?
2. What are the implications of SB1138-law on criminal transmission of more common and contagious STIs?
3. What protections are in place for using MHS to prove directionality in prosecutorial contexts citing this law?
4. What diseases does the law apply to now? What defines sexually transmitted infection and by whom is the definition established and applied?
5. Is the bill congruent with National Strategic Plan?
6. Does it specifically address transmission behaviors and risk ratios? And which transmission behaviors? Sexual? Social*? *Drug use? Bodily fluid exchange outside the contexts of sex?
7. How does it address “intent”?
8. How does it address “consent”?
9. What are the implications for disease prevention (testing and treatment intervention)? If I can be charged with a felony for knowingly transmitting HIV/STI, why would I get tested when I could unknowingly continue to engage in sexual practices without fear of prosecution?
10. Does it address whether the individual with HIV was using protective barriers?
11. Can it be applied to transmissible by needle-sharing?
12. Does it account for risk reduction and the role of U=U?
13. What the rules for disclosure now? For what diseases? And, at what point or in what context? Do I have to disclosure HSV-2 before kissing? Or, if I am undetectable, and there is no risk of transmission, do I need to disclose my status (legally)? If I have/had* syphilis, and am accused of transmission, will I be forcibly tested for it- and if so, then how would one define and determine the temporal presence of syphilis is diagnostic blood assay considering if you have had it once, it will also show up in testing?
14. What are the implications for using MHS to provide directionality in response to the need to prove transmission and intent?
15. Is disclosure now required for all STIs?
16. What are the implications for kink and the contextuality of transmission? 

Frameworks of Analysis
Instrumentation	Description	Epistemic Priorities	Framing Typologies
Configurationalism	Configurationalism is the search for cultural patterns, often in the idiom of psychology. It is a theoretical paradigm that views communication as integrated in personality and gives meaning to the details which constitute its epistemological form. Culture is thus a subjective function of communication and configurational analysis is the process by which the sources in this system are named and subjectified. Individual/ institutional identity is culture writ large.	Configurationalism investigates the culture in personality and identifies the interpretive triggers of an individual/ institution so they can be used or avoided in communication.	Situations News Attributes Choices Responsibilities Issues Actions
Health Equity	Health Equity is a science- and justice-based perspective that views issues related to health and health policy as rooted in the development of structure/agency to improve outcomes. It is a framework for analysis of cultural differences informing the structural and contextual environments in which health disparities occur.	This framework was used to liken HIV criminalization to stigma and discrimination, with the goal of leveraging the Governor’s Commission on Racial Inequities in Virginia Law	Issues   Attributes
Medico-Legal	Medico-legal arguments are situated at the intersection of biomedical and juridical paradigms of thought and converge in analysis as a framework for understanding the criminal, ethical, and prosecutorial perspectives coalescing around a particular problem. In HIV decriminalization it is used to examine the biopolitics of stigma as a strategy for controlling HIV in the law, including communicable disease quarantine, testing without consent, diagnostic-based criminality (using a medical procedure to identify something that is used to prosecute someone, such as a blood test positive for illicit drugs, or an HIV exam proving transmission)	Medicolegal frameworks are used to infer meaning from sources of law: constitution, statutory, common, and administrative; and surmise the effects of jurisprudence on medical complexities, such as consent, confidentiality, privacy, and prosecution.	Situations   Responsibilities
Abolitionist	Abolitionism is both a political framework and organizing strategy characterized by its opposition to the social, historical, political, and economic conditions of the Prison-Industrial Complex (PIC)***.   It is best defined by its own Mariame Kaba, abolition is not the elimination of anything but the founding of something new. In this way, it is grounded in liberation theology as well, which embodies a deterministic view of the patterns of causation as consequences, and systemic racism as its own analytical end. Abolitionists embrace the fatalism in this framework, by asserting that every aspect of their work be grounded in and relevant to those communities directly targeted by the PIC.	PIC is a heuristic device used by ECHO (PWN/SERO) to oppose HB864, an analytic argument which follows: If we are advocating that people who are virally suppressed cannot transmit HIV and therefore should not be criminalized under existing statutes, we are implying that people who are not suppressed should be criminalized or should have to go through further scrutiny to avoid incarceration. Focusing on viral load as the dividing line for who can be criminalized deeply undermines our efforts. Not only does it highlight a viral divide, but it will ensure that division happens in alignment with the white supremacist cis heteropatriarchal value of targeting those already with the least access to resources and systemic power, which is often the basis for the increased viral load in the first place.	Issues   Choices   News
Social-justice/ Human-rights	Social-justice/ human rights-based approaches to HIV decriminalization and other health-related policy issues are defined by an identarian foci on marginalized groups, such as LGBTQ, people living with disability, the aging and so on. They extrapolate meaning from the UN Declaration and use human rights law to encode social contemporaneity in the lexicons of their appeal. Equality Virginia embodies this framework for policy analysis and advocacy, with the goal of establishing equality (instead of equity or abolition).	Stigma is a heuristic device used to understanding the relationship between health policy and outcome, which in the context of SB1138 resulted in underdetermination- a gap between theory and evidence that must be bridged by background assumptions that can or should be decided according to shared values or epistemic priorities.	News   Attributes   Issues
Empirical	Socialism applies science to society and uses dialectical materialism to surmise the effects of policy on populations in empirical terms. It is a data-driven approach to analysis emphasizing the corporeality of political economy as an interpretive measure for public debate and describes health policy in the Occident by its interventional effect on the social determinants. In this way, health outcomes in the Occident are referential to the treatment of their contextuality.		Actions

_{**On Prisons and Playhouse: implications of law on criminal transmission by fluid exchange in prisons (where people do not have autonomy over their bodies and therefore cannot consent) and playhouse (defined as places for kink and fetish events, where transmission occurs but does not necessarily involve sex)}

_{***The Prison Industrial Complex (PIC) is a term used by abolitionist organizers, activists, academics, etc. to describe the overlapping interests of government and industry that use surveillance, policing, and imprisonment as solutions to economic, social, and political problems.} 

_{NEXT STEPS}

Engage the Commission on Racial Inequity in Virginia Law.

Establish a plan for public health modernization in the specific context of term search strategy and definitions.

Define the role of VDH in the solicitation of public comment for policy positioning at each point of the legislative process; such that it is clear if VDH should take a position on a bill after it is amended or identified as having broader implications than originally defined.

Outline areas of subject matter expertise to establish clear authority as to which issues.

Situate public/policy issues in a wider interpretive framework to allow for cultural configuration

The practice of “having a position” privately but “not having a position” publicly undermines modernization efforts to build institutional resiliency.

VDH does not need take a position on any public issue in debate (unless otherwise instructed,) other than to account for institutional implications and the impact of instrumentation on outcomes in analytic assessment.

Reject the analysis/ advocacy divide.

Use REAs to examine the research and development contexts out of which policy analysis and advocacy efforts and made meaningful; and delineate policy discourse from structure/agency and develop strategic communiques with specific aims

Understand power and the limits of each paradigm; and select the one that is most appropriate for the setting and its topicality

Educate both legislators and constituents, with epistemic prioritization given to key stakeholders and the communities affected by the actions in question. 

Use “framing theory” to design public health communique that strengthens the cultural authority of science as a preventive strategy to address the spread of “alternative facts” and “fake news.”

Define Stigma, Shame, and Self-denial in every Single Social Situation, and leverage paradigmatic power to reframe its effects