Application of Ethical Principles to Research using Public Health Data in The Global South: Perspectives from Africa

Existing ethics guidelines, influential literature and policies on ethical research generally focus on real‐time data collection from humans. They enforce individual rights and liberties, thereby lowering need for aggregate protections. Although dependable, emerging public health research paradigms like research using public health data (RUPD) raise new challenges to their application. Unlike traditional research, RUPD is population‐based, aligned to public health activities, and often reliant on pre‐collected longitudinal data. These characteristics, when considered in relation to the generally lower protective ethico‐legal frameworks of the Global South, including Africa, highlight ethical gaps. Health and demographic surveillance systems are examples of public health programs that accommodate RUPD in these contexts. We set out to explore the perspectives of professionals with a working knowledge of these systems to determine practical ways of appropriating the foundational principles of health research to advance the ever growing opportunities in RUPD. We present their perspectives and in relation to the literature and our ethical analysis, make context relevant recommendations. We further argue for the development of a framework founded on the discussions and recommendations as a minimum base for achieving optimal ethics for optimal RUPD in the Global South.     

Public Health Risk Assessment Linked to Climatic and Ecological Change

Disturbances of climatic and ecological systems can present risks to human health, which are becoming more evident from health studies linked to climate variability, landuse change and global climate change. Waterborne disease agents, such as Giardia cysts and Cryposporidium oocysts have been positively correlated with rainfall. El Niño-related extreme weather conditions can have a significant impact on vector- and water-borne diseases. The linkages between weather, terrestrial ecology and human health have been discovered for some diseases, such as rodent-borne hantavirus. Marine ecology also plays a role in determining human health risks, such as from cholera, and other enteric pathogens. Deforestation and ensuing changes in landuse, human settlement, commercial development, road construction, and water control systems singly, and in combination have been accompanied by increases in or emergence of diseases like malaria and schistosomiasis in some regions of the world. Long-term climate change may increase the frequency of heat waves and potentially air pollution episodes, increase the number of extreme weather events, cause coastal flooding and salination of fresh water aquifers, and displace coastal settlements. Ultimately, a two-pronged approach (empirical and modeling studies) is required to better understand these linkages between climato-logical and ecological change as determinants of disease.     

Personality Change following Internet-Based Cognitive Behavior Therapy for Severe Health Anxiety

Personality traits have traditionally been viewed as stable, but recent studies suggest that they could be affected through psychological treatment. Internet-based cognitive behavior therapy (ICBT) for severe health anxiety (DSM-IV hypochondriasis) has been shown to be effective in reducing health anxiety, but its effect on measures of personality traits has not been investigated. The main aim of this study was to investigate the impact of ICBT on personality traits in the three broad dimensions - neuroticism, extraversion and aggression. We hypothesized that participants in ICBT would reduce their level of neuroticism compared to controls that did not receive the active treatment. No specific predictions were made regarding extraversion and aggression. Data from a randomized controlled trial were used in which participants were allocated to 12 weeks of ICBT (n = 40) or to a basic attention control condition (n = 41). Personality traits were assessed with the Swedish Universities Scales of Personality and the primary outcome of health anxiety was the Health Anxiety Inventory. There was a significant interaction effect of group and time on neuroticism-related scales, indicating larger pre- to post-treatment reductions in the Internet-based CBT group compared to the control condition. Analyses at 6-month follow-up showed that changes were stable. Traits relating to extraversion and aggression were largely unchanged. This study is the first to demonstrate that a brief ICBT intervention for severe health anxiety causes long-term changes in measures of personality traits related to neuroticism. The treatment thus has a broader impact than just reducing health anxiety.

Trial Registration

Clinicaltrials.gov (ID {"type":"clinical-trial","attrs":{"text":"NCT00828152","term_id":"NCT00828152"}}NCT00828152)     

我国公立医院卫生财政补偿政策变迁及医院成本核算的战略意义

公立医院补偿机制改革与医院监管机制、药品监管机制、医疗保障体制改革密切相关。回顾了改革开放以来我国公立医院财政补偿政策变迁的3个阶段,并从公立医院职能的角度,分析了公立医院成本核算在界定医院财政补偿与市场补偿领域的重要意义。     

Mental Health: The Search for a Definition

Various attempts to define the concept of “mental health” are examined. Value judgments permeate much mental health literature. Their use militates against obtaining an objective definition, capable of universal application. The acceptance of a definition including a value judgment implies taking an attitude toward a particular society and its social ideals.Present limits of competence only allow us to describe “mental health” conceptually. Such “untechnical” proposals are liable to be confused with “technical” (“scientific”) propositions. Multiple criteria are likely to be helpful in improving our concept of “mental health”.The intrusion of morals into the world of health is discussed as part of the contemporary intellectual dilemma of determined human behaviour versus human responsibility and the reality of moral values.It is suggested that “mental health” might consist simply of an individual''s possession of insight into his own personality, combined with an honest recognition and acceptance of his condition.     

The Effectiveness of Public Health Interventions to Reduce the Health Impact of Climate Change: A Systematic Review of Systematic Reviews

Background

Climate change is likely to be one of the most important threats to public health in the coming years. Yet despite the large number of papers considering the health impact of climate change, few have considered what public health interventions may be of most value in reducing the disease burden. We aimed to evaluate the effectiveness of public health interventions to reduce the disease burden of high priority climate sensitive diseases.

Methods and Findings

For each disease, we performed a systematic search with no restriction on date or language of publication on Medline, Web of Knowledge, Cochrane CENTRAL and SCOPUS up to December 2010 to identify systematic reviews of public health interventions. We retrieved some 3176 records of which 85 full papers were assessed and 33 included in the review. The included papers investigated the effect of public health interventions on various outcome measures. All interventions were GRADE assessed to determine the strength of evidence. In addition we developed a systematic review quality score. The interventions included environmental interventions to control vectors, chemoprophylaxis, immunization, household and community water treatment, greening cities and community advice. For most reviews, GRADE showed low quality of evidence because of poor study design and high heterogeneity. Also for some key areas such as floods, droughts and other weather extremes, there are no adequate systematic reviews of potential public health interventions.

Conclusion

In conclusion, we found the evidence base to be mostly weak for environmental interventions that could have the most value in a warmer world. Nevertheless, such interventions should not be dismissed. Future research on public health interventions for climate change adaptation needs to be concerned about quality in study design and should address the gap for floods, droughts and other extreme weather events that pose a risk to health.     

Clinical Data Extraction During Public Health Emergencies: A Blockchain Technology Assessment

Objective:We sought to explore the technical and legal readiness of healthcare institutions for novel data-sharing methods that allow clinical information to be extracted from electronic health records (EHRs) and submitted securely to the Food and Drug Administration''s (FDA''s) blockchain through a secure data broker (SDB).Materials and Methods:This assessment was divided into four sections: an institutional EHR readiness assessment, legal consultation, institutional review board application submission, and a test of healthcare data transmission over a blockchain infrastructure.Results:All participating institutions reported the ability to electronically extract data from EHRs for research. Formal legal agreements were deemed unnecessary to the project but would be needed in future tests of real patient data exchange. Data transmission to the FDA blockchain met the success criteria of data connection from within the four institutions'' firewalls, externally to the FDA blockchain via a SDB.Discussion:The readiness survey indicated advanced analytic capability in hospital institutions and highlighted inconsistency in Fast Healthcare Interoperability Resources format utilitzation across institutions, despite requirements of the 21st Century Cures Act. Further testing across more institutions and annual exercises leveraging the application of data exchange over a blockchain infrastructure are recommended actions for determining the feasibility of this approach during a public health emergency and broaden the understanding of technical requirements for multisite data extraction.Conclusion:The FDA''s RAPID (Real-Time Application for Portable Interactive Devices) program, in collaboration with Discovery, the Critical Care Research Network''s PREP (Program for Resilience and Emergency Preparedness), identified the technical and legal challenges and requirements for rapid data exchange to a government entity using the FDA blockchain infrastructure.

In the previous few decades, the world has been challenged by a barrage of public health emergencies (PHEs), from natural disasters to the infectious disease threats of SARS (severe acute respiratory syndrome), H1N1, Zika, Ebola, and the COVID-19 pandemic. We have learned that PHEs are imminent and that the need for preparedness is paramount to our nation''s resiliency.1In the wake of COVID-19, widespread data collection to understand the virus''s impact and effectiveness of treatment plans are needed. However, the United States'' ability to rapidly collect multisite patient data to understand the impact of a disease and develop a unified and effective response remains a considerable vulnerability despite significant health system and federal investment in electronic health records (EHRs).2,3 The all-hazardscore data set, created in 2015 to characterize serious illness,injuries, and resource requirements to devise a robustresponse to PHEs, remains a challenge to collect giventechnological and regulatory limitations3 in regard to datasharing. This has been observed in the response to COVID-19, where the lack of data to create consensus on effective treatment protocols has been hindered.4–6Several barriers exist to data sharing in PHEs, including academic competition and inadequate human and technological resources during responses to emergency.7–10 Neither a standard approach to data sharing nor a method to negotiate and enforce the requisite data legal agreements exists.11,12 Moreover, effective methods for addressing deficiencies or advancing data sharing in response to PHEs are lacking.12–14 A clear need exists to explore novel methods to secure data collection to bridge the gap in knowledge sharing during PHEs.The complexity of data sharing from disparate sources is a problem experienced in other industries. The finance sector requires the highest level of security to manage financial transactions with speed and integrity. Blockchain technology emerged in the finance industry as a disruptive technology aimed at facilitating a decentralized, secure, and distributed ledger of transactions on a global scale.15,16 Blockchain technology works as blocks of information across a computer network; when chained together, these blocks create a single data asset.Blockchain has been suggested as an information infrastructure that can be used to advance knowledge sharing in the public sector.17 The decentralized nature of blockchain allows for interoperability,15 which is a key functionality needed to enable data sharing among hospital systems. The use of blockchain in medicine has the potential to revolutionize healthcare''s approach to data access, storage, and security17–19 by providing a method to share confidential patient information across many sites regardless of the local technical infrastructure. Large-scale data sharing would contribute to more robust medical research, advanced analytics (e.g., artificial intelligence), and the ability to benchmark the quality of care across institutions.The Food and Drug Administration (FDA) partnered with the Society of Critical Care Medicine''s Discovery, the Critical Care Research Network''s Program for Resilience and Emergency Preparedness (PREP; referred to as “Discovery PREP” hereafter) to explore the feasibility of using blockchain for multisite healthcare data collection in preparation for the required rapid data sharing during a PHE. Discovery PREP is one of many networks forming the Resilience Intelligence Network (RIN) with a combined focus on the nation''s resilience, preparedness, and response.2Discovery PREP and the FDA Real-Time Application for Portable Devices (RAPID) program20 collaborated to test the use of RAPID''s blockchain technology to determine the technical, legal, and resource challenges in the healthcare context. The RAPID program was designed to facilitate the automated extraction of key information from EHR systems needed to respond to adverse events without adding to the burden of data collection on healthcare practitioners.     

Forest Health Monitoring and Forest Inventory Analysis Programs Monitor Climate Change Effects in Forest Ecosystems

The Forest Health Monitoring (FHM) and Forest Inventory and Analyses (FIA) programs are integrated biological monitoring systems that use nationally standardized methods to evaluate and report on the health and sustainability of forest ecosystems in the United States. Many of the anticipated changes in forest ecosystems from climate change were also issues addressed in sections of FHM's National Technical Report 1991 to 1998. The integrated FHM and FIA monitoring systems are currently establishing baseline conditions (status and change) in most States for many of the expected effects, and are projected to have full implementation for all States and Territories in 2003. These monitoring systems utilize a broad suite of indicators of key ecosystem components and processes that are responsive to many biotic and abiotic stressors, including those anticipated from climate change. These programs will contribute essential information for many decades for many of the anticipated changes in forest ecosystem from increasing carbon dioxide concentrations, changing climatic scenarios, and extreme weather events that are probable in the next 30 to 100 years.     

Data Fusion Methods for Human Health Risk Assessment: Review and Application

The improved accessibility to data that can be used in human health risk assessment (HHRA) necessitates advanced methods to optimally incorporate them in HHRA analyses. This article investigates the application of data fusion methods to handling multiple sources of data in HHRA and its components. This application can be performed at two levels, first, as an integrative framework that incorporates various pieces of information with knowledge bases to build an improved knowledge about an entity and its behavior, and second, in a more specific manner, to combine multiple values for a state of a certain feature or variable (e.g., toxicity) into a single estimation. This work first reviews data fusion formalisms in terms of architectures and techniques that correspond to each of the two mentioned levels. Then, by handling several data fusion problems related to HHRA components, it illustrates the benefits and challenges in their application.     

Interactions between Handler Well-Being and Canine Health and Behavior in Search and Rescue Teams

ABSTRACT

This study reports on three years of prospective, longitudinal data on the psychological well-being of the human handlers and the health and behavior of the search and rescue dogs deployed in New York City and Washington, DC in the aftermath of the terrorist attacks on September 11, 2001. Eighty-five human handlers (63 deployed and 22 controls) and ninetyfour dogs (66 deployed, 28 controls) were assessed at multiple time points including 6 months, 1 year, 2 years, and 3 years after the 9/11 attacks. Humans were assessed for psychological health by structured clinical interview and self-report. Dogs were assessed for physical health and behavior by veterinary records and handler report. For humans, deployment after 9/11 did indeed represent a relatively short-term risk factor for developing symptoms of depression and posttraumatic stress disorder (PTSD). By and large, however, the sample showed remarkable resilience as a whole, and overall rates of DSM-IV diagnoses were quite low. By year 3, 9/11 deployment no longer conferred any special risk. On the other hand, long-term employment in an emergency profession did emerge as a significant risk factor for symptoms of PTSD by year 3. With respect to the interaction between handler emotional well-being and canine health and behavior, we found that physical illness and/or death in the dog was prospectively associated with greater symptoms of depression in the handler. We also found that symptoms of depression and PTSD in the handlers prospectively predicted behavioral problems in the dogs over time. Separation anxiety, attachment/attention seeking, chasing, and excitability emerged in the dogs at 1 year. Behavioral problems escalated to aggression towards other dogs at year 2 and separation anxiety, aggression towards other dogs, and aggression towards strangers at year 3. Like any relationship, the partnership between a handler and his or her working dog can confer both protection—when the relationship is going well and both members are healthy—and vulnerability—when either member is physically ill or psychologically or behaviorally distressed.     

我国公立医院应用公私伙伴关系模式办医现状的探讨

随着医改的不断深入,PPP办医模式在我国已得到初步应用。通过探讨政府、公立医院与社会资本在举办医疗机构过程中不同的合作模式,总结PPP办医模式在我国的应用现状,分析其产生的社会效益和存在的风险,提出了坚持政府主导,明确政府职能定位;合理规范合作方的权利与义务,实现多方共赢的建议。