Journal articles on the topic '1497 03 22'

In-hospital arrests are uncommon in pediatrics, making it difficult to identify the risk factors for unrecognized deterioration and to determine the effectiveness of rapid response systems. An emergency transfer (ET) is a transfer from an acute care floor to an intensive care unit (ICU) where the patient received intubation, inotropes, or ≥3 fluid boluses in the first hour after arrival or before transfer. Improvement science work has reduced ETs, but ETs have not been validated against important health outcomes. This case–control study aimed to determine the predictive validity of an ET for outcomes in a free-standing children’s hospital. Controls were matched in terms of age, hospital unit, and time of year. Patients who experienced an ET had a significantly higher likelihood of in-hospital mortality (22% vs 9%), longer ICU length of stay (4.9 vs 2.2 days), and longer posttransfer length of stay (26.4 vs 14.7 days) compared with controls (P < .03 for each).

Abstract We assessed late mortality in 1479 individuals who had survived 2 or more years after allogeneic hematopoietic cell transplantation (HCT). Median age at HCT was 25.9 years and median length of follow-up was 9.5 years. The conditional survival probability at 15 years from HCT was 80.2% (SE = 1.9%) for those who were disease-free at entry into the cohort, and the relative mortality was 9.9 (95% confidence interval, 8.7-11.2). Relative mortality decreased with time from HCT, but remained significantly elevated at 15 years after HCT (standardized mortality ratio = 2.2). Relapse of primary disease (29%) and chronic graft-versus-host disease (cGVHD: 22%) were the leading causes of premature death. Nonrelapse-related mortality was increased among patients older than 18 years at HCT (18-45 years: relative risk [RR] = 1.7; 46+ years: RR = 3.7) and among those with cGVHD (RR = 2.7), and was lower among patients who received methotrexate for GVHD prophylaxis (RR = 0.5). HCT survivors were more likely to report difficulty in holding jobs (odds ratio [OR] = 13.9), and in obtaining health (OR = 7.1) or life (OR = 9.9) insurance compared with siblings. This study demonstrates that mortality rates remain twice as high as that of the general population among 15-year survivors of HCT, and that the survivors face challenges affecting their health and well-being.

<strong>Objectives:</strong> Hawthorn extract consumption is becoming more widespread among the Jordanian population with cardiovascular disorders. We conducted this prospective observational longitudinal study to determine the impact of hawthorn extract on bleeding risk in patients who undergo cardiac surgery. <br /><strong>Methods:</strong> A prospective observational study was performed on 116 patients who underwent cardiac surgery in the period between June 2014 and May 2015. Patients were divided into two groups: Group I (patients recently consumed hawthorn extract) and Group II (patients never consumed hawthorn extract). Endpoint measures included the rates of reopening to control bleeding, early mortality, duration of intensive care unit stay, total in-hospital stay period, and duration and amount of chest tube drainage. <br /><strong>Results:</strong> Hawthorn patients had a significantly higher rate of postoperative bleeding necessitating take back to the operating room compared to the control group (10% versus 1%; <br />P = .03) respectively. The overall mortality rate for group I and II was 4% and 0% respectively; P = .17. Chest tubes were kept in for longer times in group I compared to group II <br />(54 ± 14.6 versus 49 ± 14.7 hours respectively; P = .01). Group I stayed longer in the intensive care unit compared to group II (24 versus 22 hours respectively; P = .01). The total in-hospital stay period was comparable between the two groups. <br /><strong>Conclusion:</strong> Hawthorn extract consumption does increase the potential for bleeding and the amount of chest tube output after cardiac surgery.

A granitic sample from the Danish island of Christiansø in the Ertholmene island group north of Bornholm is described petrographically and geochemically, and dated using U-Pb in zircon and titanite. Zircon systematics in the sample are complicated by abundant Pb loss and a large population of zircons interpreted as being inherited. Removal of highly disturbed zircons, imprecise analyses, and assumed inherited zircons yield an upper intercept date of 1500 ± 18 Ma (MSWD = 13, n = 58). Removal of zircons with high common Pb from this population yields an identical result of 1500 ± 22 Ma (MSWD = 8, n = 34). Zircons that are ≤3% discordant give a weighted average 206Pb/238U age of 1458 ± 12 Ma (MSWD = 3.0, n = 18), and a weighted average 207Pb/206Pb age of 1495 ± 14 Ma (MSWD = 4.7, n = 19). Titanites from the sample yield a lower intercept age of 1448 ± 15 Ma (MSWD = 6.8, n = 45). The sample contains a significant number of inherited grains indicative of ages around 1.7–1.8 Ga. The relatively large MSWDs for these age determinations indicate geological complexity, likely reflecting Pb loss, and the possible presence of inherited zircons which suffered major Pb loss during incorporation in the granitic magma. The zircon and titanite dates agree reasonably well with previous age determinations on felsic lithologies from the Bornholm mainland, as well as from the Blekinge Province of southern Sweden. Petrographically and geochemically, the Christiansø granite is indistinguishable from, and can be correlated with, the A-type granites and gneisses which occur on Bornholm. The high abundance of disturbed and inherited zircons (c. 1.7–1.8 Ga) may indicate that the granite was intruded into and assimilated a nearby region of unexposed Transscandinavian Igneous Belt rocks. The somewhat altered nature of the rock, and overall disturbance of U-Pb zircon systematics, suggest alteration associated with fluid-flow along nearby faults defining the northern margin of the Sorgenfrei–Tornquist Zone.

Abstract Background.—Mantle cell lymphoma (MCL) is characterized by overexpression of cyclin D1, a G1 cyclin that participates in the control of cell cycle progression at the G1 to S phase transition. In addition to cyclin D1, other cell cycle regulatory molecules may be involved in the proliferation and progression of MCL. Mutation of p53, deletion of p16INK4a, and loss of p21WAF1 expression have been reported in some cases of blastoid MCL. Objective.—We sought to examine levels of expression of these proteins in typical and blastoid MCL and to determine whether differences were present between these subtypes of lymphomas. Design.—A retrospective series of typical and blastoid MCLs was evaluated for expression of the cell cycle–related proteins cyclin D1, p21WAF1, p27KIP1, Ki-67, and p53, as well as mitotic index. Paraffin-embedded archival tissues from 24 MCL specimens (17 typical, 7 blastoid) were immunostained with antibodies to p21WAF1, p27KIP1, p53, Ki-67, and cyclin D1. The percentage of positive cells for each specimen was estimated by counting 1500 cells under oil immersion microscopy. Levels of antigen expression were compared for the typical and blastoid MCLs. The mitotic index was estimated using twenty 100× oil immersion fields (OIFs) for each specimen. Results.—Cyclin D1 expression was seen in 22/24 specimens (92%). Blastoid MCLs were characterized by a significantly higher mean mitotic index (&gt;20 mitoses/20 OIFs) and Ki-67 index (&gt;45%) when compared with typical MCLs (P &lt; .001 and P &lt; .008, respectively; Fisher's exact test). High expression of p27KIP1 (&gt;25% staining) was seen more frequently in typical MCLs than in the blastoid variants (P = .03; Fisher's exact test). No significant differences were found between typical and blastoid MCLs for the expression of p21WAF1 or p53. Conclusions.—A significantly higher mitotic index and Ki-67 index were found in blastoid MCLs as compared with typical MCLs. Low p27KIP1 expression was associated with the blastoid MCL variant. These findings confirm the high proliferative nature of blastoid MCL and suggest a role for p27KIP1 in the negative regulation of the cell cycle in MCL.

Abstract Abstract Background Triple negative breast cancer (TNBC) is defined by the lack of expression of the estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2. Prognostic immunohistochemical biomarkers in TNBC have been studied in recent years such as the androgen receptor (AR) which is expressed in 10-40% of TNBC. However the prognostic value of AR expression is not clear. Here, we studied the prognostic significance of AR expression in combination with the presence of a ductal carcinoma in situ (DCIS). Considering DCIS is a precursor of invasive ductal carcinoma, we hypothesize that TNBC with co-existing DCIS and presence of AR expression is less aggressive and patients are older at diagnosis. Methods We analyzed data retrospectively from all patients with stage 1-3 TNBC who underwent primary surgery and adjuvant chemotherapy in the University hospitals Leuven, between 01-01-2000 and 31-12-2017. Patient and tumor related characteristics were compared between two subgroups, one with co-existing DCIS and one with pure invasive carcinoma, without co-existing DCIS. AR expression was assessed by immunohistochemistry (IHC). We used AR expression in ≥1% and ≥10% of cells as cut-off scores. The prognostic role of the expression of AR in combination with a co-existing DCIS was analyzed, using the distant metastasis rate as primary endpoint. Results are presented as hazard ratios (HR) with 95% confidence intervals (CI). Secondary endpoints were associations of AR expression with clinical-pathological characteristics, time between diagnosis and metastasis, and disease specific mortality. Results In the 426 included patients with TNBC, co-existing DCIS was present in 66.7%; AR expression was expressed ≥1% in 29.3% and ≥10% in 21.4% of cases. Median age at diagnosis was 51 years (range: 22-85y). Age at diagnosis was independent of DCIS, dependent of AR expression; in DCIS positive cases, median age was 49 years if AR negative (IHC &lt; 1%), 53 years if AR positive (IHC ≥1%), and 56 years if AR positive (IHC ≥10%) (p=0.006). In contrast in DCIS negative cases, median age was 51 years if AR negative (IHC &lt; 1%), 51 if AR positive (IHC ≥1%), and 51 years if AR positive (IHC ≥10%) (p=0.895). AR expression was DCIS dependent and was ≥1% in 34.9% and ≥10% in 25.0% of patients in the DCIS group compared to 18.3% and 14.1% in the non-DCIS group (p=0.001 and p&lt; 0.001 respectively). In both subgroups there was no significant difference for AR positive versus AR negative cases in lymph node involvement, tumor grade, tumor size and Nottingham Prognostic Index. Patients with a coexisting DCIS and AR expression did not have a different incidence of distant relapse compared to AR negative cases (AR ≥1%: p=0.2803 and AR ≥10%: p=0.5527). Of patients with coexisting DCIS, 12.0% (95% CI: 7.8; 17.1) in the AR negative group, 8.2% (95% CI: 3.8; 14.6) in the AR ≥ 1% group and 7.1% (95% CI: 2.6; 14.7) in the AR ≥ 10% group, had distant relapse within 2 years. Conclusion In patients with TNBC, AR expression is associated with older age in case of co-existing DCIS and patients with co-existing DCIS are more frequently AR positive. In patients with co-existing DCIS, there was no significant difference in distant relapse between AR negative and AR positive cases. Citation Format: Micaëlle Merckx. The prognostic role of androgen receptor status in patients with triple negative breast cancer with an associated ductal carcinoma in situ [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-03-10.

Abstract Background: Datopotamab deruxtecan (Dato-DXd) is an antibody-drug conjugate (ADC) consisting of a humanized anti-TROP2 IgG1 mAb covalently linked to a highly potent topoisomerase I (Topo I) inhibitor payload via a stable, tumor selective, tetrapeptide-based cleavable linker. Dato-DXd has previously shown encouraging activity in heavily pretreated patients (pts) with metastatic TNBC (Krop, SABCS 2021). Here we report updated results from the TROPION-PanTumor01 study in pts with advanced/metastatic TNBC. Methods: TROPION-PanTumor01 (NCT03401385) is a phase 1, multicenter, open-label, 2-part dose-escalation/expansion study evaluating Dato-DXd in previously treated pts with solid tumors. Based on previous clinical and exposure-response results from pts with NSCLC, Dato-DXd 6 mg/kg IV Q3W is being evaluated in pts with advanced TNBC that relapsed/progressed on standard therapies; 2 pts received 8 mg/kg prior to selection of 6 mg/kg. The primary objectives were safety and tolerability. Tumor responses, including objective response rate (ORR; complete response [CR] + partial response [PR]) and disease control rate (DCR; CR + PR + stable disease [SD]), were assessed per RECIST v1.1 by blinded independent central review. Results: As of April 29, 2022, 44 pts received Dato-DXd (median follow-up, 16.6 mo [range, 13-22]) at the time of data cutoff. The primary cause of treatment discontinuation was disease progression (86%; PD or clinical progression), and 4 pts are still receiving therapy. Median age was 53 y (range, 32-82); 32% had de novo metastatic disease. Pts were heavily pretreated with a median of 3 (range, 1-10) prior regimens in the metastatic setting. Prior treatments included taxanes (91%), anthracyclines (75%), capecitabine (61%), platinum (52%), immunotherapy (43%), Topo I inhibitor–based ADC therapy (32%), and PARPi (18%). Treatment-emergent adverse events (TEAEs; all cause) occurred in 100% (any grade) and 50% (grade ≥3) of pts, respectively. Most common TEAEs (any grade, grade ≥3) were stomatitis (73%, 11%), nausea (66%, 2%), vomiting (39%, 5%), fatigue (34%, 7%), and alopecia (36%, 0%). One pt had grade 3 decreased neutrophil count; no cases of interstitial lung disease (ILD) or grade ≥3 diarrhea were observed. Serious TEAEs were reported in 9 pts (20%); no deaths associated with adverse events (AEs) were observed. Dose reductions occurred in 8 pts (18%) due to stomatitis (n=3), fatigue (n=2), dry eye (n=1), retinal exudates (n=1), and dysgeusia (n=1); 12 pts (27%) delayed treatment due to stomatitis (n=5), dry eye (n=1), keratitis (n=1), blurred vision (n=1), fatigue (n=1), bronchitis (n=1), skin infection (n=1), musculoskeletal chest pain (n=1), dysgeusia (n=1), chronic obstructive pulmonary disease (n=1), and dyspnea (n=1; &gt;1 AE per pt). One pt (2%) discontinued treatment due to grade 1 pneumonitis (which was centrally adjudicated as not ILD). ORR in all pts was 32% (1 CR, 13 PRs), DCR was 80% (35/44), and clinical benefit rate (CR + PR + SD ≥6 mo) was 34% (15/44). Median duration of response was not yet reached; median progression-free survival (mPFS) was 4.3 mo (95% CI, 3.0-7.3), and median overall survival (mOS) was 12.9 mo (95% CI, 10.1-14.7). In the subset of pts without prior Topo I inhibitor–based ADC therapy and with measurable disease at baseline, ORR was 44% (12/27). Among all pts without prior Topo I inhibitor–based ADC therapy (n=30), mPFS was 7.3 mo (95% CI, 3.0-NE), and mOS was 14.3 mo (95% CI, 10.5-NE). Conclusions: Dato-DXd continues to demonstrate encouraging and durable antitumor activity, along with a manageable safety profile, in heavily pretreated pts with metastatic TNBC. Based on these findings, the phase 3 randomized TROPION-Breast02 (NCT05374512) trial comparing Dato-DXd vs chemotherapy as 1L therapy for pts with metastatic TNBC is currently underway. Citation Format: Aditya Bardia, Ian Krop, Funda Meric-Bernstam, Anthony W. Tolcher, Toru Mukohara, Aaron Lisberg, Toshio Shimizu, Erika Hamilton, Alexander I. Spira, Kyriakos P. Papadopoulos, Jonathan Greenberg, Wen Gu, Fumiaki Kobayashi, Hong Zebger-Gong, Yui Kawasaki, Rie Wong, Takahiro Kogawa. Datopotamab Deruxtecan (Dato-DXd) in Advanced Triple-Negative Breast Cancer (TNBC): Updated Results From the Phase 1 TROPION-PanTumor01 Study [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-10-03.

AbstractThe effects of energy source and level of digestible undegraded protein (DUP) in concentrates on silage intake and performance of lactating dairy cows, offered one of a range of grass silages differing in digestibility and intake characteristics, were evaluated in a partially balanced change-over design experiment involving 48 cows. Four silages were prepared using differing management practices prior to and during ensiling. All silages were treated with an inoculant additive. For silages A, В, С and D, dry matter (DM) concentrations were 199, 320, 313 and 223 (s.e. 4.6) g/kg, pH values 3.82, 4.03, 4·03 and 5·27 (s.e. 0.056), ammonia nitrogen (N) concentrations 58, 122, 66 and 356 (s.e. 13.2) g/kg total N and in vivo DM apparent digestibilities 077, 0.75 , 0.60 and 0.60 (s.e. 0·013) respectively. When offered as the sole diet to 12 dairy cows in a partially balanced change-over design experiment, silage DM intakes were 14.7, 14.7, 12.7 and 10.5 (s.e. 0·36) kg/day respectively for silages А, В, С and D. Six concentrates containing three starch concentrations, each at two levels of DUP, were formulated to have similar concentrations of crude protein, metabolizable energy (ME) and fermentable ME. For the low and high starch concentrates and low and high levels of DUP, starch concentrations were 22·5 and 273 g/kg DM and DUP levels were 44 and 60 g/kg DM respectively. Silages were offered ad libitum supplemented with 10 kg fresh concentrate per head per day. For silages А, В, С and D, DM intakes were 10.8, 11.2, 10·7 and 9·1 (s.e. 0·26) kg/day and milk yields 29.0, 27.6, 27.1 and 25.7 (s.e. 0.69) kg/day respectively. With the exception of milk protein concentration there were no significant (P> 0.05) silage type by concentrate energy source and/or level of DUP interactions on silage intake, milk output or composition. Concentrate energy source had no effect (P> 0.05) on silage DM intake, the yields of milk, fat, protein or fat plus protein or milk fat concentration. However, increasing starch concentration increased milk protein concentration (P< 0·001), urinary allantoin concentration (P< 0·01) and diet apparent digestibility (P< 0·001). Altering concentrate DUP level had no effect (P> 0·05) on silage DM intake, yields of milk, protein, fat or fat plus protein, milk f at concentrations or diet apparent digestibility. Increasing the level of DUP decreased milk protein (P< 0·05) concentration. It is concluded that with silages of varying digestibility, fermentation and intake characteristics, there were no concentrate energy source and/or level of DUP by silage type interactions on silage intake, milk yield or composition, or diet apparent digestibility with the exception of a silage type by concentrate level of DUP interaction on milk protein concentration. With out-of-parlour feeding of concentrates the results of the present study suggest that there is no evidence to justify the formulation of concentrates differing in energy source or level of DUP to complement individual silage types.

Abstract Purpose To compare the efficacy and safety of core vitrectomy and pars plana vitrectomy for lens exchange in patients with intraocular lens dislocation. Methods This is a retrospective study conducted at one eye center in Zurich, Switzerland. We reviewed 124 eyes with dislocated intraocular lens undergoing lens exchange carried out by two surgeons between 03/2016 and 12/2019 (45 months). Intraocular pressure (IOP) and best-corrected visual acuity (BCVA) were analyzed preoperatively and at 5 time points up to 12 months after lens exchange. Data on postoperative complications were collected. Results There were 124 eyes with intraocular lens dislocation that were referred for lens exchange. Of these eyes, 59 (48%) received core vitrectomy and 65 (52%) received pars plana vitrectomy with lens exchange. Glaucoma was more frequent in the core vitrectomy group (78%) than in the pars plana vitrectomy group (32%; p < 0.001). In the core vitrectomy group, 19 (32%) eyes presented with visual impairment, 17 (29%) eyes presented with high IOP alone, and 23 (39%) eyes presented with both at the same time prior to surgery. Mean preoperative IOP in the core vitrectomy group decreased from 22.4 ± 9.2 mmHg to 14.7 ± 3.1 mmHg 12 months after surgery (p < 0.001). Mean BCVA changed from 0.40 ± 0.41 logMAR preoperatively to 0.32 ± 0.37 logMAR at 12 months postoperatively (p = 0.598) in the core vitrectomy group. In the pars plana vitrectomy group, 44 (68%) eyes presented with a change in vision, 7 (11%) eyes presented with high IOP alone, and 14 (22%) eyes presented with pressure elevation and visual impairment at the visit prior to surgery. Mean preoperative IOP in the pars plana vitrectomy group decreased from 20.9 ± 8.3 mmHg to 15.1 ± 3.5 mmHg at 12 months after lens exchange (p < 0.001). Mean BCVA in the pars plana vitrectomy group was 0.57 ± 0.62 logMAR preoperatively and 0.22 ± 0.35 logMAR 12 months postoperatively (p < 0.001). Postoperative pressure decompensation occurred more frequently in the core vitrectomy group (20%) than in the pars plana vitrectomy group (6%; p = 0.018). There was no statistically significant difference for postoperative cystoid macular edema (p = 0.055), anisometropia (p = 0.986), and high astigmatism (p = 0.362). Conclusion Core vitrectomy and pars plana vitrectomy with lens exchange are equally efficient and safe in the management of intraocular lens dislocation.

Abstract Purpose To compare the efficacy and safety of core vitrectomy and pars plana vitrectomy for lens exchange in patients with intraocular lens dislocation. Methods This is a retrospective study conducted at one eye center in Zurich, Switzerland. We reviewed 124 eyes with dislocated intraocular lens undergoing lens exchange carried out by two surgeons between 03/2016 and 12/2019 (45 months). Intraocular pressure (IOP) and best-corrected visual acuity (BCVA) were analyzed preoperatively and at 5 time points up to 12 months after lens exchange. Data on postoperative complications were collected. Results There were 124 eyes with intraocular lens dislocation that were referred for lens exchange. Of these eyes, 59 (48%) received core vitrectomy and 65 (52%) received pars plana vitrectomy with lens exchange. Glaucoma was more frequent in the core vitrectomy group (78%) than in the pars plana vitrectomy group (32%; p < 0.001). In the core vitrectomy group, 19 (32%) eyes presented with visual impairment, 17 (29%) eyes presented with high IOP alone, and 23 (39%) eyes presented with both at the same time prior to surgery. Mean preoperative IOP in the core vitrectomy group decreased from 22.4 ± 9.2 mmHg to 14.7 ± 3.1 mmHg 12 months after surgery (p < 0.001). Mean BCVA changed from 0.40 ± 0.41 logMAR preoperatively to 0.32 ± 0.37 logMAR at 12 months postoperatively (p = 0.598) in the core vitrectomy group. In the pars plana vitrectomy group, 44 (68%) eyes presented with a change in vision, 7 (11%) eyes presented with high IOP alone, and 14 (22%) eyes presented with pressure elevation and visual impairment at the visit prior to surgery. Mean preoperative IOP in the pars plana vitrectomy group decreased from 20.9 ± 8.3 mmHg to 15.1 ± 3.5 mmHg at 12 months after lens exchange (p < 0.001). Mean BCVA in the pars plana vitrectomy group was 0.57 ± 0.62 logMAR preoperatively and 0.22 ± 0.35 logMAR 12 months postoperatively (p < 0.001). Postoperative pressure decompensation occurred more frequently in the core vitrectomy group (20%) than in the pars plana vitrectomy group (6%; p = 0.018). There was no statistically significant difference for postoperative cystoid macular edema (p = 0.055), anisometropia (p = 0.986), and high astigmatism (p = 0.362). Conclusion Core vitrectomy and pars plana vitrectomy with lens exchange are equally efficient and safe in the management of intraocular lens dislocation.

Abstract Purpose To compare the efficacy and safety of core vitrectomy and pars plana vitrectomy for lens exchange in patients with intraocular lens dislocation. Methods This is a retrospective study conducted at one eye center in Zurich, Switzerland. We reviewed 124 eyes with dislocated intraocular lens undergoing lens exchange carried out by two surgeons between 03/2016 and 12/2019 (45 months). Intraocular pressure (IOP) and best-corrected visual acuity (BCVA) were analyzed preoperatively and at 5 time points up to 12 months after lens exchange. Data on postoperative complications were collected. Results There were 124 eyes with intraocular lens dislocation that were referred for lens exchange. Of these eyes, 59 (48%) received core vitrectomy and 65 (52%) received pars plana vitrectomy with lens exchange. Glaucoma was more frequent in the core vitrectomy group (78%) than in the pars plana vitrectomy group (32%; p < 0.001). In the core vitrectomy group, 19 (32%) eyes presented with visual impairment, 17 (29%) eyes presented with high IOP alone, and 23 (39%) eyes presented with both at the same time prior to surgery. Mean preoperative IOP in the core vitrectomy group decreased from 22.4 ± 9.2 mmHg to 14.7 ± 3.1 mmHg 12 months after surgery (p < 0.001). Mean BCVA changed from 0.40 ± 0.41 logMAR preoperatively to 0.32 ± 0.37 logMAR at 12 months postoperatively (p = 0.598) in the core vitrectomy group. In the pars plana vitrectomy group, 44 (68%) eyes presented with a change in vision, 7 (11%) eyes presented with high IOP alone, and 14 (22%) eyes presented with pressure elevation and visual impairment at the visit prior to surgery. Mean preoperative IOP in the pars plana vitrectomy group decreased from 20.9 ± 8.3 mmHg to 15.1 ± 3.5 mmHg at 12 months after lens exchange (p < 0.001). Mean BCVA in the pars plana vitrectomy group was 0.57 ± 0.62 logMAR preoperatively and 0.22 ± 0.35 logMAR 12 months postoperatively (p < 0.001). Postoperative pressure decompensation occurred more frequently in the core vitrectomy group (20%) than in the pars plana vitrectomy group (6%; p = 0.018). There was no statistically significant difference for postoperative cystoid macular edema (p = 0.055), anisometropia (p = 0.986), and high astigmatism (p = 0.362). Conclusion Core vitrectomy and pars plana vitrectomy with lens exchange are equally efficient and safe in the management of intraocular lens dislocation.

Abstract Abstract 419 Patients with core binding factor (CBF) AML [t(8;21) and inv(16)/t(16;16)] are generally excluded from transplantation in first CR because of their relatively favorable prognostic outcome with conventional chemotherapy. CBF AML is heterogeneous, however, with a number of molecular mutations described that may influence outcome. To ascertain whether the impact of gene mutations known to be recurrent in CBF AML is sufficient to justify alternative therapy such as transplantation in first CR, we have carried out mutational analysis of 355 young adult CBF AML patients treated on the UK MRC/NCRI AML10, 12 and 15 trials between 1988 and 2009. Median age was 40 years, 95% were <60 years. 200 had t(8;21) and 155 inv(16), overall survival (OS) at 5 years 65% and 56% respectively. In total, 28% had a KIT mutation (exons 8 [extracellular], 10+11 [transmembrane] and 17 [tyrosine kinase domain]), 26% an N- and/or K-RAS mutation (codons 12, 13 and 61), 6% a FLT3/ITD, 10% a FLT3/TKD mutation and 6% a c-CBL mutation (exons 8 and 9). Of the 100 KIT-MUT patients, 54% were only in exon 17, 28% in exon 8, 8% in exon 10+11, and 10% had mutations in 2 domains. KIT mutations were not associated with age or disease type (de novo/secondary) but were higher in males than females (33% with vs 22% without a mutation, P=.03) and were associated with a higher WCC (median 28.7×109/L vs 14.7×109/L, P=.01). Of the 94 RAS-MUT patients, 65% were in N-RAS, 32% K-RAS and 3% both. RAS mutations were not associated with age, disease type or sex, but were associated with a higher WCC (median 27.0 ×109/L vs 16.7×109/L, P=.03). There was a negative correlation between KIT and RAS mutations (P<.0001). Excluding patients with a mutation in more than one gene or at more than one location in a specific gene, 294 patients were either wild-type (WT) for all 5 genes (39%) or had a mutation just in KIT (22%), FLT3/ITD (5%), FLT3/TKD (6%), RAS (24%) or CBL (4%). Overall CR rate was high (94%) and no mutation had a significant impact on this. The cumulative incidence of relapse (CIR) and OS were analyzed for each mutational category as both parameters might influence the decision to change therapy. CIR at 5 years was lower and OS higher in the WT and FLT3/TKD-MUT patients than in the poorer prognosis KIT-MUT, RAS-MUT, FLT3/ITD-MUT patients (P=.05 and.01 respectively across all groups) (see Table). If the 3 poorer prognostic categories were combined together, CIR and OS were significantly different compared to the remaining patients (P=.002 and.005 respectively). Comparing t(8;21) and inv(16), KIT mutations were more frequent in inv(16) than t(8;21) (34% vs 23%, P=.01), particularly exon 8 mutations (20% vs 3%, P<.0001), as were RAS (37% vs 18%, P<.0001) and FLT3/TKD mutations (15% vs 6%, P=.006), whereas FLT3/ITDs were more frequent in t(8;21) (3% vs 9%, P=.04). There was no significant heterogeneity between t(8;21) and inv(16) in the impact on OS of the combined group (KIT-MUT, FLT3/ITD, RAS-MUT). In both subtypes the poorer prognostic group did worse than the others (P=.06 for t(8;21), P=.08 for inv(16)) (Table 1). However, for CIR, the poorer risk mutational status had an apparent impact in t(8;21) (P=.09), but not inv(16) patients (P=.2). This implies that in t(8;21) the impact of gene mutations is predominantly seen in the long-term response to first line therapy whereas in inv(16), the good overall survival is in large part due to the excellent response to salvage therapy, with the presence of gene mutations predominantly influencing the response to therapy after relapse has occurred. No cases of t(8;21) were identified with sufficient relapse risk to justify the risks of allogeneic transplantation in first remission, but it may be appropriate to consider intensification in inv(16) with either a KIT or RAS mutation or FLT3/ITD. Disclosures: No relevant conflicts of interest to declare.

Abstract Abstract 5169 Introduction Management of hemoglobinopathies, mainly beta-thalassemia major, is well studied at controlled clinical trials. However, one should keep in mind that real life experience of pediatric patients with thalassemia major show remarkable differences across geographies and social-economic status. The effect of iron overload (IO) and outcome of chelation therapy also vary widely in this population. Chelators differ in side-effect profile, tolerability and ease of adherence, and (to some degree) efficacy for any specific patient. The aim of the present study was to determine the characteristics of children with hemoglobinopathies receiving oral iron chelators (OICs) in the treatment of transfusional IO and to evaluate treatment outcomes, adverse events, and growth and sexual development of these children after 3 years follow-up period. Method In this prospective, multi-center, non-interventional study, patients with 2–18 years of age with hemoglobinopathies and transfusional IO who were on or began to receive oral ICT were enrolled. Four hundred patients were planned to be included and followed for 3 years. The clinical and demographic characteristics of the patients, comorbidities, type and dosage of oral ICT, laboratory results related to IO markers, imaging results and serious adverse events were recorded. Results Four hundred ninety-two patients from 30 centers representing the Turkish patient's profiles were enrolled. This was the baseline analyses of 429 patients, of whom 407 had a primary diagnosis of beta-thalassemia major, and 22 had a primary diagnosis of sickle cell anemia (homozygous). Data about growth and sexual development were also collected and will be reported according to age groups and treatment history. The characteristics of the patients are summarized in Table 1. The type and dosage of current oral ICT and ICT history are presented in Table 2. Discussion To our knowledge this is the largest prospective study in pediatric patients diagnosed with hemoglobinopathies, particularly thalassemia major, and treated with OICs due to IO caused by regular transfusions. In this analysis, we reported baseline characteristics of this pediatric cohort. It is noteworthy to report that the pretransfusion hemoglobin levels of the majority (226 of 405 patients) of the thalassemic cohort were under 9 g/dL, suggesting a suboptimal transfusion regimen. IO was followed mainly with serum ferritin (SF) levels and many patients were not monitored for cardiac or liver IO. Of 429 patients, 339 were enrolled with IO (SF>1000 ng/mL), suggesting a non effective ICT history. Of 25 beta thalassemia patients who were treated with deferiprone (DFP), 22 had SF>1000 ng/mL (mean: 2918. 31±1477. 08). The maximum dose of deferasirox (DFX) was limited by health authority to 30 mg/kg/day during the first 6 months of the 1-year enrollment period. The mean dose of DFX for the patients with SF levels >1000 ng/mL and who were treated with DFX with a dose of ≤30 mg/kg/day was 25. 38±5. 03 mg/kg/day, suggesting a suboptimal dosing for a negative iron balance. This may be one of the reasons of the high mean SF level at baseline. Moreover, the treatment duration with OICs and effectiveness of previous treatment varied. The results of this study will reflect real life experience and help us to understand obstacles in the management of IO in this patient population. Disclosures: Antmen: Novartis Oncology: Speakers Bureau. Organ:Novartis Oncology: Employment. Canatar:Novartis Oncology: Employment. Koseoglu:Novartis Oncology: Consultancy.

Rhodomyrtus tomentosa (Aiton) Hassk. (downy-rose myrtle, family: Myrtaceae), of South Asian origin, is an invasive shrub that has formed monotypic stands in Florida (3). During the winter and spring of 2010 through 2012, a rust disease of epiphytotic proportion was observed on young foliage, stem terminals, and immature fruits of this shrub in natural areas of Martin and Lee counties, Florida. Expanding leaves and succulent stems developed chlorotic flecks on the surface that developed into pustules and ruptured to discharge urediniospores. Symptomatic leaves and stems developed severe necrotic spots and resulted in tissue distortion, defoliation, and stem dieback. Based on symptoms and urediniospore morphology and dimensions (17.7 to 26.1 [22.1 ± 0.3] × 14.7 to 21.1 [17.7 ± 0.2] μm; n = 51) (4), the causal agent was identified as Puccinia psidii Winter; teliospores were not observed in samples since it does not produce these spore stages below 20°C ambient temperature (1). This identification was confirmed by a GenBank BLAST of internal transcribed spacer (ITS) sequences (Accession Nos. KC607876 and KC607877) that showed 99% identity with 42 sequences of P. psidii from diverse host species and locations. P. psidii is believed to be of neotropical origin and has a host range of 129 species in 33 genera within Myrtaceae (2). However, P. psidii caused disease of downy-rose myrtle has not been previously reported in Florida, even though severe infections occurred on another invasive tree, Melaleuca quinquenervia (Cav.) S.F. Blake (3), growing in adjacent areas. In December 2011, urediniospores were collected from downy-rose myrtle, established in aqueous suspension (45,000 spores/ml), and spray inoculated on potted downy-rose myrtle plants (n = 3), which were maintained in 100% ambient humidity, at 20°C, with a 12-h light cycle for 72 h. Plants mock-inoculated with water served as the negative control. Disease symptoms, including chlorotic flecks and raised surfaces, appeared on leaf lamina in 3 to 6 days on P. psidii-inoculated plants, while control plants remained symptomless. Raised surfaces developed into distinct pustules and eventually erupted to discharge urediniospores within 6 to 12 days of inoculation. Tests were repeated once during March and April of 2012 with the same results. The latent and incubation periods reported herein are within the previously reported range for P. psidii (2,4). To our knowledge, this is the first confirmed report of P. psidii epiphytotic on downy-rose myrtle populations in Florida. The recent occurrence of P. psidii epiphytotic on downy-rose myrtle raises critical questions as to why this myrtle rust disease is so severe and widespread on this host after decades of presumed exposure to P. psidii in Florida. Because this rust pathogen has emerged as a major invasive threat to many myrtaceous species around the world, further genotyping and cross-inoculation studies are needed to determine the host specificity and potential origin of the P. psidii isolates derived from downy-rose myrtle (2). References: (1) A. C. Alfenas et al. Australas. Plant Pathol. 32:325, 2003. (2) A. J. Carnegie and J. R. Lidbetter. Australas. Plant Pathol. 41:13, 2012. (3) K. A. Langeland and C. K Burks, eds. Identification and biology of non-native plants in Florida's natural areas. University of Florida, Gainesville, 1998. (4) M. B. Rayachhetry et al. Biol. Contr. 22:38, 2001.

Abstract Abstract 250 Survival of adult ALL has improved over the past decade to >50% with contemporary, risk adapted, targeted treatment strategies. However, published results of relapsed ALL are poor. In 4 retrospective studies with 1494 patients (pts) the CR rate after first salvage therapy was 40% and the long-term survival was only 6% including stem cell transplantation (SCT) (Thomas et al 1999, Tavernier et al 2007, Fielding et al 2007, Oriol et al, 2010). 1638 patients with newly diagnosed ALL were included in studies 06/99 and 07/03 of the German Multicenter Study Group for Adult ALL (GMALL). 547 patients with first hematologic relapse (HemRel) were evaluable for a retrospective analysis (378 chemotherapy, 169 post SCT). Median age was 33 (15–55) yrs. 432 pts had early (< 18 mo of 1st remission duration) and 115 late relapse. Salvage therapy was given according to physicians' choice and results are available in part of the pts. The aim was to achieve a CR and to perform SCT. Molecular relapse (MolRel) defined by standard criteria (Brüggemann et al, Leukemia, 2010) as reappearance of minimal residual disease (MRD) above 10-4 after prior molecular CR and measured by quantitative PCR of individual IgH/TCR rearrangements was detected in 43 pts. Response to salvage was evaluable in 224 pts with Ph-neg ALL with bone marrow (BM) relapse (no CNS involvement) during/after chemotherapy. The CR rate after first salvage was 42% and significantly inferior in early vs late relapse (36% vs 58%; p=.003). In early relapse the most frequently used regimens were FLAG-IDA (N=38; 42% CR) or a combination of HDAC/HDMTX/VP16/VCR/DEXA (N=38; 29% CR) in B-lineage and CLAEG (N=16; 19% CR) in T-lineage. In late relapses most frequently induction was repeated (N=30; 90% CR). In pts with failure after 1st salvage (N=82) the CR-rate after 2nd salvage was 33%. In relapse after SCT (N=48) the CR rate after 1st salvage was 23%. Median overall survival after relapse was 8.4 months and survival at 5 yrs 24%. Survival was significantly inferior in relapse post-SCT versus relapse on chemotherapy (15% vs 28%; p<.0001) and in BM±other vs CNS±other vs isolated extramedullary relapse (23% vs 27% vs 47%; p=.02). Prognostic factors for survival were analysed in 291 pts with Ph-neg ALL and BM relapse (no CNS involvement) on chemotherapy. Survival was superior in late vs early relapse (43% vs 22%; p<.0001), in pts aged 15–25 yrs vs 26–45 yrs vs 46–55 yrs (38% vs 28% vs 12%; p<.0001) and in pts with CR compared to failure/PR after 1st salvage (47% vs 13%; p<.0001). 75% of evaluable pts received SCT in any stage after relapse. Their survival at 5 yrs was 38% vs 0% without SCT (p<.0001). Survival was significantly better if SCT was performed in CR after 1st salvage vs later CR vs no CR (56% vs 39% vs 20%;p<.0001). Of pts with MolRel (N=43) 26% remained untreated, 19% received specific salvage therapy and in 55% first-line treatment was continued without modification. 11% (N=5) remained in CCR, 30% (N=13) underwent SCT in 1st CR and 58% (N=25) developed HemRel. Median remission duration without SCT in CR1 was 92 d until HemRel and no pt was in continuous CR after 3.5 yrs. Survival after 5 yrs was significantly superior in pts with SCT in CR1 (N=13; 100%) compared to those without (N=30; 24%) (p=.0006). Overall survival after 5 yrs was significantly superior after MolRel (45%) compared to HemRel (22%) (p=.003). Survival of pts with relapse during/after chemotherapy was 28% in the GMALL trials and superior compared to published data. Outcome after relapse was not uniformly poor but depended on prognostic factors such as age and time to relapse. The most important prognostic factor, however, was response to first salvage therapy, being very poor in early relapse. These pts suffer from chemorefractory disease and are candidates for experimental, targeted approaches. Improved overall outcome was mainly an effect of a high rate of SCT (75%) which was possible due to stringent donor search (related/unrelated) at diagnosis of relapse. Survival was significantly better if SCT was performed in CR. For the first time it could be demonstrated that outcome after molecular relapse is superior to outcome after hematologic relapse and this result underlines the relevance of MRD follow-up testing. Further improvement should therefore be achievable by early detection of molecular relapse, stratified relapse treatment, experimental approaches in early relapse and rapid transplant realisation with optimised procedures. Disclosures: No relevant conflicts of interest to declare.

e3649016The present experience report aims to describe the effects of an intervention with the theme of sexuality to promote health and prevent violence. Twenty children of both sexes, aged between 7 and 13 years, who attended the activities of a social project during school hours in a city in the interior of São Paulo, Brazil. Children were divided into two groups according to their age (07-09 years; 10-13 years). Throughout the meetings, issues related to physical changes, sexuality, and sexual abuse were developed through the reading of books, the exhibition of films and drawings. It was possible to verify changes in children's behavior related to these issues. It discusses the challenges observed in the practice of activities, seeking to problematize the issues that permeate the theme, as well as to highlight the effects of the experience for children and adolescents involved in the process.ResumoO presente relato de experiência tem como objetivo descrever os efeitos de uma intervenção com a temática de sexualidade para promoção e prevenção de saúde e violência. Participaram 20 crianças de ambos os sexos com idades entre 07 e 13 anos que frequentavam as atividades de um projeto social no contraturno escolar em um município do interior de São Paulo. As crianças foram divididas em grupos de acordo com a idade (07-09 anos; 10-13 anos). Ao longo dos encontros foram trabalhadas questões referentes às mudanças físicas, sexualidade e abuso sexual a partir da leitura de livros, exposição de filmes e desenhos. Foi possível verificar mudanças nos comportamentos das crianças relacionadas a essas questões. Discute-se sobre os desafios observados na prática das atividades, buscando problematizar as questões que permeiam a temática, assim como ressaltar os efeitos da experiência para as crianças e adolescentes envolvidos no processo.Palavras-chave: Gênero, Educação, Adolescência, Sexualidade.Keywords: Gender, Education, Adolescence, Sexuality.ReferencesANDRY, Andrew C.; SCHEPP, Steven. De onde vêm os bebês. In: De onde vêm os bebês. 1988.ARCARI, C. Pipo e Fifi: Prevenção de violência sexual na infância. São Paulo, SP. 2013.BALISCEI, J. P.; CALSA, G. C.; JORDÃO, V. H. O Homem-Malbec e a construção visual da masculinidade. TEXTURA-Revista de Educação e Letras, v. 18, n. 37, 2016.BORGES, M. V. Um mal-estar na educação: uma revisão psicanalítica sobre as questões da sexualidade humana e como a educação se imbrica neste processo. Revista FAROL, v. 8, n. 8, p. 384-397, 2019.BRANCALEONI, A. P. L.; DE OLIVEIRA, R. R. Silêncio! Não desperte os inocentes: sexualidade, gênero e educação sexual a partir da concepção de educadores. Revista Ibero-Americana de Estudos em Educação, v. 10, n. 6, 2016a.BRANCALEONI, A. P. L.; DE OLIVEIRA, R. R. Educação sexual na promoção do respeito à diversidade sexual e de gênero. Revista ELO–Diálogos em Extensão, v. 5, n. 2, 2016b.BRASIL. Ministério da Mulher, da Família e dos Direitos Humanos. Dados de violência sexual contra crianças e adolescentes. Disponível em https://www.gov.br/mdh/pt-br/assuntos/noticias/2020-2/maio/ministerio-divulga-dados-de-violencia-sexual-contra-criancas-e-adolescentes Acesso em 03.09.2020.BRASIL. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas e Estratégicas. Área Técnica de Saúde de Adolescente e Jovem. Caderneta de Saúde do Adolescente (MENINA). Brasília: Editora do Ministério da Saúde; 2013.BRASIL. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas e Estratégicas. 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Estereotipia de gênero nas brincadeiras de faz de conta de crianças adotadas por casais homoparentais. Psico-USF, v. 21, n. 1, p. 125-133, 2016.COLE, B. Mamãe botou um ovo. Tradução de Lenice Bueno da Silva. São Paulo: Ática, 1993.DEMARCO, T. T.; DE PAULA, M. H. P.; SCHLOSSER, A. adultização e erotização infantil: a influência social. Anuário Pesquisa e Extensão Unoesc Videira, v. 4, p. e20431-e20431, 2019.DE SOUZA MONTEIRO, S. A.; RIBEIRO, P. R. M.. Sexualidade e Gênero na atual BNCC: possibilidades e limites. Pesquisa e Ensino, v. 1, p. e202011-e202011, 2020.DIAS, A. B.; AQUINO, E. M. L. Maternidade e paternidade na adolescência: Algumas constatações em três cidades do Brasil. Cadernos de Saúde Pública, 22, 2006, 1447-1458.DOWLING, C. Complexo de cinderela. In: Complexo de Cinderela. 1985.FREIRE, P. ‘Ideologia de gênero' e a política de educação no Brasil: exclusão e manipulação de um discurso heteronormativo. Ex aequo, n. 37, p. 33-46, 2018.FUNDO DAS NAÇÕES UNIDAS PARA A INFÂNCIA (UNICEF). A educação que protege contra a violência, 2018, Disponível em: https://www.unicef.org/brazil/media/4091/file/Educacao_que_protege_contra_a_violencia.pdfGLOBO NEWS. Arquivo N: Caso do assassinato da menina Araceli chocou o país em 1973. Globo.com. Disponível em http://g1.globo.com/globo-news/arquivo-n/videos/v/arquivo-n-caso-do-assassinato-da-menina-araceli-chocou-o-pais-em-1973/5066099 Acesso em 10 Abr. 2017.HABIGZANG, L. F.; KOLLER, S. H.; AZEVEDO, G. A.; MACHADO, P. X. Abuso sexual infantil e dinâmica familiar: Aspectos observados em processos jurídicos. Psicologia: Teoria e Pesquisa, 21(3), 341–348, 2005, https://doi.org/10.1590/S0102-37722005000300011HABIGZANG, L. F.; RAMOS, M. DA S.; KOLLER, S. H. A revelação de abuso sexual: As medidas adotadas pela rede de apoio. Psicologia: Teoria e Pesquisa, 27(4), 467–473, 2011, https://doi.org/10.1590/S0102-37722011000400010HAMES, C.; KEMP, A. T. Diversidade de Gênero e Sexualidade no processo formativo docente. Revista Insignare Scientia-RIS, v. 2, n. 1, p. 67-74, 2019.KIM, Y. O segredo de Nara. Youtube. Postado em 30 de outubro de 2015. Disponível em https://www.youtube.com/watch?v=vgw4yj9jveQ. Acesso em 15 Fev. 2017.LAGEMANN, R. Anjos do Sol. Dailymotion. Postado em 20 de janeiro de 2015. Disponível em https://www.dailymotion.com/video/x2f5vfp . Acesso em 25 Fev. 2017.LOINAZ, I.; BIGAS, N.; SOUSA, A. M. Comparing intra and extra-familial child sexual abuse in a forensic context. Psicothema, 31(3), 271–276, 2019, https://doi.org/10.7334/psicothema2018.351LOVATTO, A. Desvendando o poder do macho: um encontro com Heleieth Saffioti. Lutas Sociais, n. 27, p. 110-118, 2011.LOWENKRON, L. Abuso sexual infantil, exploração sexual de crianças, pedofilia: diferentes nomes, diferentes problemas?. Sexualidad, Salud y Sociedad-Revista Latinoamericana, n. 5, p. 9-29, 2010.MACHADO FILHO, H. Glossário de termos do objetivo de desenvolvimento sustentável 5: alcançar a igualdade de gênero e empoderar todas as mulheres e meninas. [Brasília, DF]: ONUBR, 2016. Disponível em http://www.onumulheres.org.br/onu-mulheres/documentos-de-referencia. Acesso em 31 ago. 2020.ORGANIZAÇÃO MUNDIAL DA SAÚDE. Global plan of action: Health systems address violence against women and girls (WHO/RHR/16.13). Article WHO/RHR/16.13, 2016, disponível em: https://apps.who.int/iris/handle/10665/251664PADILLA, H. Saúde e Sexualidade de Adolescentes. Organização Pan-Americana de Saúde. Ministério da Saúde. 2017.PEIRCE, K. Meninos não Choram. Youtube. Postado em 19 de outubro de 2016. Disponível em https://www.youtube.com/watch?v=Z1we6cwiQzg. Acesso em 03 Mar. 2017.PINTO, A. D. V.; AMARAL MADUREIRA, A. F.. PORNOGRAFIA E QUESTÕES DE GÊNERO: UM OLHAR CRÍTICO DO PODER PEDAGÓGICO DAS IMAGENS NA CONSTRUÇÃO DAS SUBJETIVIDADES. 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DE; GUGLIELMINETTI, R.; MARMO, D. B. Violência doméstica contra crianças e adolescentes: Um desafio. Revista da Associação Médica Brasileira, 58(4), 465–471, 2012, https://doi.org/10.1590/S0104-42302012000400018

Spanish conquest in the New World has two sides, evangelization, and colonization. The former was carried by the missionaries who were heavily influenced by Bartolome de Las Casa and Vitoria, while the latter by conquistadores, the defenders of the conquest. Early missionaries fought for the dignity of the Indios where they clashed with the motives of the conquistadores to exploit human resources. The problematic part was they have to work under the Spanish crown where their point of contact was also their area for friction. When they arrived in the Philippines, that social solidarity and dynamics of social relation continued where it became complex due to the involvement of various groups including the natives and their leaders, the religious orders, and most of all the Spanish Royal Court that had the history of having a heart for the Indians. King Philip II created a space for debates within his agenda of social conscience. Using Durkheim’s structuralist-functionalist approach, historical narratives about early missionaries’ struggles for natives’ dignity in the 16th century Philippines were examined. Durkheim’s social solidarity, dynamics of social relations, and his concepts of anomie as disruptions due to dramatic changes and conflicts were utilized as tools to analyze the quest for total well-being. The achievement of sustainable development goals (SDGs) is authenticated in amplifying the value of human dignity, equality, and respect for each individual. With this, the 500 years of Christianity in the Philippines is worth the celebration.ReferencesAbella, G. (1971) From Indio to Filipino and some historical works. Philippine Historical Review. (Vol. 4).Arcilla, J. S. S.J. (1998). The Spanish conquest. Kasaysayan: The story of the Filipino people. (Vol. 3). C & C Offset Printing Co., Ltd.Bernal, R. 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ABSTRACT This study aims to investigate and analyze e the effect of Operating Expenses Operating Income (BOPO), capital adequacy ratio (CAR), financial slack, sustainability officer, and sustainability committee on green banking disclosure in Islamic banks registered with the Financial Services Authority (OJK) during the period 2017-2021. In this study, panel data regression data analysis techniques were used with the help of Eviews 10 software. The results of this study show that partially the variables Operating costs in operating income (BOPO), capital adequacy ratio (CAR), financial slack, and sustainability officer have no effect on green banking disclosure. While the variable Sustainability Committee has a positive and significant effect on Green Banking disclosure. At the same time, the variables BOPO, CAR, Financial Slack, Sustainability Officer, and Sustainability Committee have a significant effect on Green Banking disclosure. The implication of this research for science is to contribute to the literature related to the factors that influence green banking disclosure. In addition, this research is also expected to help banks in improving their governance, and for the government is expected to help in making policies related to green banking disclosure. Keywords: Operating Expenses on Operating Income, Capital Adequacy Ratio, Financial Slack, Green Banking, Sustainability ABSTRAK Penelitian ini bertujuan untuk mengkaji dan menganalisis pengaruh dari Biaya Operasional Pendapatan Operasional (BOPO), Rasio Kecukupan Modal (CAR), Financial Slack, Sustainability Officer, dan Sustainability committee terhadap pengungkapan green banking pada bank syariah yang terdaftar di OJK selama periode 2017-2021. Teknik sampling yang digunakan adalah Purposive Sampling dengan kriteria tertentu, sehingga sampel didapat sebanyak 45 data dari 9 Bank syariah yang sesuai kriteria. Dan menggunakan teknik analisis data regresi data panel dengan bantuan software Eviews 10. Hasilnya menunjukkan bahwa secara parsial variabel BOPO, Capital Adequacy Ratio (CAR), Financial Slack dan Sustainability Officer tidak berpengaruh terhadap pengungkapan Green banking. Sedangkan variabel Sustainability Committee berpengaruh positif dan signifikan terhadap pengungkapan Green Banking. Secara simultan variabel BOPO, CAR, Financial Slack, Sustainability officer dan Sustainability Committee memiliki pengaruh dan signifikan terhadap pengungkapan Green banking Kata Kunci: Biaya Operasi pada Pendapatan Operasional, Capital Adequacy Ratio, Financial Slack, Green Banking, Sustainability REFERENCES Ahlström, J., & Ficekova, M. (2017). The relationship between current financial slack resources and future CSR Performance. A quantitative study of public companies in the Nordic Markets. Master Thesis, Umea School of Business and Economics. Alim, M., & Sina, D. I. (2020). 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e4942055The article aims to analyze and understand the teachers' conceptions about the curriculum in the pedagogical context of the full-time school, considering their active action in the resignification of curricular practices. The research carried out fits into a qualitative approach, of a descriptive-interpretative character and privileged the case study as methodological guidance, whose development took place in a full-time public school in the state public network of Manaus. For data collection, the semi-structured interview was adopted as the main instrument, applied to teachers, privileged subject-participants. Content analysis is a theoretical and methodological approach to the treatment of empirical data. The different meanings attributed to the curriculum, with a view to comprehensive training, show that the curriculum design, from the perspective of the teachers participating in the research, is based on a plasticity of perspectives and a permanent tension between meeting the demands of large-scale evaluations supported by curricular requirements to increase performance, and the values that teachers believe are important for the integral training of students. It was observed that teachers rework and recreate teaching experiences, imposed by full time and, to some extent, resignify the curriculum and pedagogical practices in curricular management situations that are sometimes ambiguous, contradictory and even potentially transformative.ResumoO artigo tem como objetivo analisar e compreender as concepções dos professores sobre o currículo no contexto pedagógico da escola de tempo integral, considerando a ação ativa destes na ressignificação das práticas curriculares. A pesquisa realizada enquadra-se numa abordagem qualitativa, de caráter descritivo-interpretativo, e privilegiou como orientação metodológica o estudo de caso, cujo desenvolvimento concretizou-se numa escola pública de tempo integral da rede pública estadual de Manaus. Para a recolha de dados, a entrevista semiestruturada foi adotada como instrumento principal, aplicada aos professores, sujeitos-participantes privilegiados. A análise de conteúdo se constituiu como vertente teórico-metodológica para o tratamento dos dados empíricos. Os diversos sentidos atribuídos ao currículo, tendo em vista a formação integral, evidenciam que a concepção de currículo, pela ótica dos professores participantes da pesquisa, assenta-se numa plasticidade de perspectivas e numa permanente tensão entre atender as demandas das avaliações em larga escala, apoiadas em requisitos curriculares de elevação do desempenho, e os valores que os professores julgam ser importantes para a formação integral dos alunos. Observou-se que os professores reelaboram e recriam as experiências de ensino, impingidos pelo tempo integral e, em alguma medida, ressignificam o currículo e as práticas pedagógicas em situações de gestão curricular, por vezes ambíguas, contraditórias e mesmo potencialmente transformadoras.ResumenEl artículo tiene como objetivo analizar y comprender las concepciones de los docentes sobre el currículo en el contexto pedagógico de la escuela de tiempo completo, considerando su acción activa en la resignificación de las prácticas curriculares. La investigación realizada se enmarca en un enfoque cualitativo, de carácter descriptivo-interpretativo y privilegió el estudio de caso como orientación metodológica, cuyo desarrollo tuvo lugar en una escuela pública de tiempo completo en la red pública estatal de Manaus. Para la recolección de datos, se adoptó como instrumento principal la entrevista semiestructurada, aplicada a los docentes, sujetos-participantes privilegiados. El análisis de contenido es un enfoque teórico y metodológico para el tratamiento de datos empíricos. Los diferentes significados atribuidos al currículo, con miras a la formación integral, muestran que el diseño curricular, desde la perspectiva de los docentes que participan en la investigación, se basa en una plasticidad de perspectivas y una tensión permanente entre atender las demandas de evaluaciones de gran escala, apoyado en los requisitos curriculares para incrementar el desempeño, y los valores que los docentes consideran importantes para la formación integral de los estudiantes. Se observó que los docentes reelaboran y recrean experiencias docentes, impuestas por el tiempo completo y, en cierta medida, resignifican el currículo y las prácticas pedagógicas en situaciones de gestión curricular que en ocasiones resultan ambiguas, contradictorias e incluso potencialmente transformadoras.Palavras-chave: Currículo, Educação, Escola de tempo integral, Formação integral.Keywords: Curriculum, Education, Full-time school, Integral formation.Palabras clave: Currículo, Educación, Escuela de tiempo completo, Formación integral.ReferencesAMAZONAS. Secretaria de Estado da Educação e Qualidade do Ensino SEDUC. Proposta Pedagógica das Escolas da Rede Estadual de Ensino de Educação em Tempo Integral. Manaus, 2011.ANDRÉ, Marli Eliza Dalmazo Afonso de. Etnografia da prática escolar. Campinas: Papirus, 2005.APPLE, Michael. Ideologia e currículo. 3ª ed. Porto Alegre: Artmed, 2008.ARROYO, Miguel Gonzáles. Currículo. Território em disputa. 5ª. ed. Petrópolis, RJ: Vozes, 2013. 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Early childhood emotional dysregulation is critical in recognizing and preventing psychological well-being disorders, laying the groundwork for developing healthy emotional behaviors early on. This study aims to determine the direct influence of smartphone addiction, executive function, and the mother-child relationship on emotional dysregulation in early childhood in West Sumatra. This research method is a quantitative survey. The data collection technique in this research uses a questionnaire design on 309 parents who were selected using a simple random sampling method. This data processing tool uses the SmartPLS software. The results of the study indicate that smartphone addiction has a significant impact on emotional dysregulation in early childhood, executive function has a positive and significant effect on emotional dysregulation in early childhood, and the mother-child relationship has a positive and significant influence on emotional dysregulation in early childhood. 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Abstract Background Pericardial effusion (PE) is a commonly encountered condition in clinical practice, but its etiology can be difficult to identify, with many cases remaining classified as idiopathic. This study aimed to investigate whether an association exists between asthma and idiopathic PE (IPE). Methods Patients who had been diagnosed with PE in the authors' outpatient cardiology clinics between March 2015 and November 2018 were retrospectively analyzed. The study population was divided into 2 groups—non-IPE (NIPE) and IPE—based on whether a cause had been identified. Demographic, laboratory, and clinical data for the 2 groups were examined statistically. Results A total of 714 patients were enrolled in the study after exclusion of 40 cases. Of these 714 patients, 558 were allocated to the NIPE group and 156 to the IPE group (NIPE group median [IQR] age, 50 [41–58] years vs IPE group median [IQR] age, 47 [39–56] years; P = .03). Asthma was significantly more prevalent among patients in the IPE group than among those in the NIPE group (n = 54 [34.6%] vs n = 82 [14.7%]; P &lt; .001). In multivariate logistic regression analysis, asthma (odds ratio, 2.67 [95% CI, 1.53–4.67]; P = .001) was found to be an independent predictor of IPE. In the IPE group, patients with asthma had either mild or moderate PE, with the right atrium being the most common location in these patients. Conclusion Asthma was an independent predictor of mild to moderate IPE. The right atrium was the most frequently encountered location for PE in patients with asthma.

Magnolia denudata (Lilytree or Yulan magnolia) is an important ornamental species of the genus Magnolia. It has considerable economical value because of its beautiful fragrant flowers and excellent tree structure (Wang et al. 2010). In Beijing, nurseries cultivate M. denudata as an ornamental plant and traditional medicine. In May 2020, patches of root rotted plants were observed in a field in Beijing, China, with an estimated incidence of approximately 31%. Early symptoms comprised leaves melanocratic shrunken, and the vascular tissue of roots turned brown. Progressively, the roots rotted and the whole plant died (Fig. 1 a-d). Infected roots tissue was surface disinfested and plated on potato dextrose agar (PDA) medium at 25±2 °C and incubated in the dark for 7 days. Pure cultures were obtained by hyphal tip excision (strain MFR1215.4). Fungal colonies were entire margins, and the aerial mycelium was copious, early white, and gradually developed into cream white. Colonies developed to 45.1 mm in 4 days at 25±2 °C on PDA media. On Spezieller Nährstoffarmer Agar (SNA) medium at 25±2 °C for 10 days. The morphological characteristics including macroconidia, microconidia, and chlamydospores were shown in Fig.1 (i-p). These morphological characteristics of the isolate corresponded to the description given for Fusarium solani sensu lato (Nelson et al. 1983, Summerell, 2003). Molecular identification was confirmed via amplification of translation elongation factor 1α (EF-1α), RNA polymerase I beta subunit gene (RPB1), and RNA polymerase II beta subunit gene (RPB2) regions using EF1/EF2, RPB1-Fa/G2R, RPB2-5f2/7cR, and RPB2-7cF/11aR primers (O'Donnell, 2010). Sequences were registered in GenBank. In the Fusarium-ID database, the EF-1α, RPB1, and RPB2 sequences showed 100% (677/677 bp), 99.8% (1568/1571 bp), and 100% (1457/1457 bp) identity with the F. solani species complex (FSSC). The same species-level identification was also found using Fusarium MLST. A best maximum likelihood tree was constructed using PhyloSuite v1.2.2 (Zhang et al. 2020), and the sequences of the MFR1215.4 isolation showed the same homology with FSSC 6. Pathogenicity tests were conducted on healthy one-year-old M. denudata potted seedlings. 200 ml spore suspension (1×106 spores/ml) was poured over the roots of twenty seedlings, and sterile distilled water was irrigated into twenty seedlings as controls in a greenhouse with 25/15°C day/night temperature and 80% relative humidity. The experiment was repeated three times. All inoculated seedlings showed similar symptoms to those in the field after 65 days, whereas the controls remained symptomless. The reisolating pathogens from symptomatic tissues were identical to the original isolates by morphology and EF-1α sequence identification. Based on morphological, molecular, and pathogenic characterization, the isolated pathogen was identified as FSSC 6. Fusarium species have been recorded in various places of the world and are known to be harmful to numerous plants (Trabelsi et al. 2017). It has been reported that FSSC has infected soybeans (Coleman, 2016, Nelson et al. 1989), oil palm (Hafizi et al. 2013), tobacco (Yang et al. 2020), resulting in sudden death syndrome, crown disease, and root rot. To our knowledge, this is the first report of FSSC-induced root rot in M. denudata in China. This research may contribute to the development of epidemiology and management strategies for root rot caused by FSSC on M. denudata.

Soybean (Glycine max (Linn.) Merr.) is one of the important oil crops in China. In September 2022, a new soybean leaf spot disease was found in Zhaoyuan County, Suihua City, Heilongjiang Province, China. Symptoms of the initial formation of irregular brown lesions on the leaves, dark brown inside, the periphery is yellow, vein chlorotic yellow, severe leaf spots connected into pieces, late fall off, not the same as previously reported soybean leaf spot (Fig. 1A). The leaf samples of infected plants were collected, and the leaf tissue (5 × 5 mm) was cut from the edge of the lesion, and then surface sterilized with 3% sodium hypochlorite for 5 min, rinsed with sterile distilled water for 3 times, and inoculated on potato dextrose agar (PDA) at 28°C. Isolates growing around the tissues from samples were subcultured on PDA, and 3 isolates were obtained using the single-spore isolation method. The fungal hyphae were white or grayish white in early stage, and the hyphae with light green concentric ring appeared on the front of the colony after 3 days, appeared orange, pink or white convex, irregular shape, reddish brown on the front of the colony for 10 days and black spherical pycnidium can be produced in the hyphae layer for 15 days (Fig.1D, E). Conidia were oval, hyaline, unicellular, aseptate, and 2.3 to 3.7 × 4.1 to 6.8 μm (n=30, Fig. 1F). Chlamydospores were subglobose, light brown, unicellular or multicellular, and 7.2 to 14.7 × 12.2 to 43.9 μm (n=30, Fig. 1H, I). Pycnidia mostly spheroid, brown, and 47.1 to 114.4 × 72.6 to 167.4 μm (n=30, Fig. 1G). A cetyl trimethyl ammonium bromide method was used to extract DNA from 7-day-old. Internal transcribed spacer (ITS), RNA polymerase II (RPB2) and β-tubulin (TUB) gene were amplified using ITS1/ITS4 (White et al. 1990), RPB2-5F/RPB2-7cR (Liu et al. 1999) and BT2a/Bt2b (O’Donnell et al. 1997) primers respectively. The sequences obtained by polymerase chain reaction (PCR) were sequenced and the results showed that the DNA sequences of the 3 isolates were identical. Therefore, the sequence of isolate DNES22-01, DNES22-02 and DNES22-03 was submitted to GenBank. According to BLAST search, the ITS (OP884646), RPB2 (OP910000) and TUB (OP909999) sequences showed 99.81% similarity to Epicoccum sorghinum strain LC12103 (MN215621.1), 99.07% to strain P-XW-9A (MW446946.1), and 98.85% with the strain UMS (OM048108.1), respectively. Phylogenetic analysis by maximum likelihood method (MEGA7.0) generated based on the ITS, RPB2 and TUB sequences indicated that the isolates formed a supported clade to the related E. sorghinum type sequences. Isolates was found to be most closely related to E. sorghinum and far from other species. Based on morphological and phylogenetic characteristics, isolates DNES22-01, DNES22-02 and DNES22-03 was identified as E. sorghinum (Bao et al. 2019; Chen et al. 2021; Zhang et al. 2022). At the 4-leaf-stage, 10 soybean plants were inoculated by spraying with a conidial suspension (1 × 106 spores·ml-1). Sterile water served as a control. The test was repeated 3 times. All samples were incubated in a growth chamber at 27°C. Symptoms typical developed on the leaves after 7 days, but control samples remained healthy (Fig.1B, C). The fungus was reisolated from symptomatic tissues and identified as E. sorghinum by morphology characteristics and molecular characterization. To our knowledge, this is the first report of E. sorghinum causing leaf spot on soybean in Heilongjiang, China. The results can provide the basis for future studies on the occurrence, prevention, and management of this disease.

Kiwifruit (Actinidia spp.) is one of the most important fruit crops in China. Post-harvest anthracnose symptoms were observed on kiwifruit in October 2021. Kiwifruits ‘Longcheng 2’ (n=200) were obtained from an orchard in Kuandian city of Liaoning province, China (124°32′E, 40°20′N). And cultivar ‘Cuiyu’ (n=100) were harvested from orchards in Mianzhu city, Sichuan Province, China (104°03′E, 31°15′N). After storage at 24 °C and 80% relative humidity (RH) for 8 days, the disease incidence of ‘Longcheng 2’ and ‘Cuiyu’ was 30% and 15%, respectively. Symptoms of diseased fruits appeared as water-soaked, irregular and light brown lesions. Orangish conidial masses were observed on some fruits. Ten lesion margins (5×5 mm) from ‘Longcheng2’ or ‘Cuiyu’ were respectively excised, surface sterilized by 70% ethanol (1 min), 1% NaOCl (5 min), washed, dried, plated on potato dextrose agar (PDA), and incubated at 25 °C for 5 days. Eight isolates were obtained from ‘Longcheng 2’ (LC1-3 to LC1-10) and nine strains from ‘Cuiyu’ (CY1-2 to CY1-10). The representative isolates LC1-3 and CY1-2 were put on PDA, and appeared white to pale gray on the upper side. However, isolate LC1-3 secreted red pigments after 7 days of culture. Conidia of LC1-3 were hyaline, smooth-walled, single-celled, cylindrical (3.0 to 4.9×7.2 to 14.7 µm, n=50). Ellipsoidal single cell conidia of CY1-2 were hyaline, and ranged in size from 3.2 to 5.0×8.5 to 13.9 µm (n=50) born on conidiophores. Appressorium of isolates LC1-3 and CY1-2 were globose to ellipsoid with 4.2 to 7.4×7.3 to 10.8 µm and 3.0 to 4.9×6.3 to 10.3 µm in size, respectively (n=50) (Fu et al. 2019 ). Four genes (ACT, CHS, GAPDH, TUB2) and the ITS region were successfully amplified and sequenced from all isolates (Weir et al. 2012). Based on sequence alignment, the isolates from ‘Longcheng 2’ or ‘Cuiyu’ were identical. BLAST analysis of the ACT, CHS, GAPDH, ITS and TUB2 sequences of LC1-3 (ON018724, ON018722, ON018720, OM980324, ON018718) or CY1-2 (ON018725, ON018723, ON018721, OM980325, ON018719) showed high similarity with C. fioriniae (CBS 128517; JQ949613, JQ948953, JQ948622, MH865005, JQ949943) were 97.1% to 99.7% or 98.1% to 99.7%, respectively. Phylogenetic analysis using concatenated sequences (maximum likelihood method) with MEGA 11 showed LC1-3 and CY1-2 were located within the same clade with C. fioriniae. Previous studies showed that C. fioriniae was classified into three subclades (Damm et al. 2012; Fu et al. 2019). However, LC1-3 and CY1-2 were located within a new subclade, namely the subclade IV. To test pathogenicity, healthy and mature kiwifruits ‘Donghong’, ‘Cuiyu’, ‘Xuxiang’, ‘Hayward’ and ‘Jinyan’ were surface sterilized. Each un-wounded fruit was dropped with 10 μl conidial suspension (105 conidia/ml) on the fruit surface. All fruits were placed into a plastic box and stored at 24 °C under 80% RH. Each treatment consisted of 10 fruits and were repeated three times. After 8 days, typical anthracnose lesions were observed on all inoculated fruits. Whereas, the controls treated with sterile distilled water remained asymptomatic. The pathogens re-isolated from diseased fruits were similar morphological and identical to the original isolates, fulfilling Koch’s postulates. Anthracnose caused by C. fioriniae has been reported on many fruits (Ling et al. 2020; Waller et al. 2021), but to our knowledge, this is the first report of anthracnose on kiwifruit caused by C. fioriniae. The results will provide valuable information for avoiding post-harvest anthracnose on kiwifruit.

Introduction Since his election to the papacy in 2013, Pope Francis has garnered international headlines for his environmental activism. His decision to adopt Francis as his papal name communicated to the public how his papacy would be advocating the environmental ethics associated with his namesake Saint Francis of Assisi. As part of his environmental activism and commitment to centring the socioeconomic injustices faced by the poor in public messages, Pope Francis deliberately incorporates modest, rather bare vestments into his papal uniform. He has emerged as a men’s fashion icon primarily due to his humble institutional uniform and public critiques of the wasteful consumerism commonly associated with contemporary consumer culture and the fashion industry. Pope Francis’s individualised approach to the papal uniform is not unique to his papacy. His selection of vestments and regalia is situated within a larger visual history of pontiffs selecting their religious uniform to brand and circulate their papal persona in public discourse and popular culture, evident through the actions of Pope John Paul II and Pope Benedict XVI. As the leader of the Catholic Church, the pontiff represents the institution’s brand identity. Following Naomi Klein’s analysis of institutional branding, the characteristics associated with a pontiff’s public image provide an opportunity for the Catholic Church to revitalise its image for global audiences (Klein “How Corporate”). Through a textual analysis of select media coverage of pontiffs and their approach to the papal uniform, this article discusses how Pope Francis’s religious uniform functions as a mechanism to extend the symbolic institutional power of the Catholic Church as a brand in popular culture by negotiating ideas of austerity. The Institutional Politics of the Uniform as a Form of Communication Fashion and clothing are important modes of communication that enable an individual to nonverbally signal their identity and belonging to various social groups, causes, and institutions (Barnard; Coghlan; Craik). An understudied but widespread element of everyday life, the uniform is a powerful signifier of the ideological and discursive formations reproduced by social institutions (Craik). Uniforms played not only an essential role for social organisation within modernity, but for Jane Tynan and Lisa Godson their materiality has significantly shaped the imagery of visual culture (8). Scholars including Jennifer Craik, William Keenan, and Q. Colville have addressed how uniforms negotiate gendered politics due to the prevalence of such garments within institutional spheres such as the military, healthcare, and religion. Influenced by Foucault’s view of the uniform as a mechanism to brand the body as under the power, authority, and control of the institution, Tynan and Godson have extended this argument to identify the relationship between uniforms, social structures, and violent practices of colonisation and imperial dominance (10-15). The institutional power of the uniform also extends to the papacy and the Catholic Church. In her historical analysis of papal regalia, Maureen C. Miller argues that during the thirteenth and fourteenth centuries the uniform may not have been viewed by large audiences, but popes were beginning to understand how their vestments were a powerful communicative tool shaping their public image. Combined with the increasing theatrically of the pontiff, Miller argues that “performative uses of clothing were significant not for the complexity of the messages they conveyed but for their strategic aim to make simple points memorably and to promote their diffusion” (293). Her analysis underscores how the papal uniform – and the individual way in which different pontiffs have approached donning vestments – represents a significant visual communicative history which continues to intensify in contemporary media culture. In a retrospective discussing papal regalia, Vanity Fair alluded to this extensive history. Evoking the theatricality discussed by Miller, Vanity Fair compared previous popes’ uniform choices to rap artists and the individuality of Sex and the City characters, noting that the Catholic Church’s leaders “have historically exhibited a daring sense of style over their 2,000 years in the high office” (Miller). Following Miller’s argument, Pope Francis’s approach to his papal uniform is purposefully designed to memorably communicative his environmental message, a core aspect of his brand identity. The message of his simple approach to the papal uniform cannot be adequately addressed without placing it within the sartorial choices of his predecessors, especially Pope Benedict XVI and his preference for communicating authority and power through opulence. Approaches to the Papal Uniform since the 1960s Fashion has always played a significant role in communicating the institutional power and brand identity of the Catholic Church. Beginning in the mid-1960s with the creation of the Second Vatican Council by Pope Paul VI, the vestments comprising the papal uniform became the subject of increased media attention. Pope Paul VI’s move towards eliminating the more ostentatious robes and accessories associated with the papacy included his “dramatic gesture” to auction a papal tiara – which The New York Times estimated was worth roughly $80,000 in 1964 – with proceeds donated to charities and organisations assisting the poor (“Pope Paul Donates His Jeweled Tiara to Poor of World”). In a sociohistorical analysis of papal fashion, The Guardian argued that the decision by Pope Paul VI to auction the accessories of the papal uniform that were intended to mediate the Catholic Church’s institutional power represented his mandate to appear “more in touch with the people” (Conway). Pope Paul VI’s understanding of the communicative power of the papal uniform to symbolise the institutional values of the Catholic Church’s brand identity draws parallels to Pope Francis. The strategic curation of papal vestments and accessories demonstrates that the role of institutional uniforms for practices of brand and image management is not unique to the contemporary cultural moment. Although Pope John Paul II was known to enjoy a fondness for Rolex watches (which Teen Vogue cites as an iconic papal fashion moment), the papacy of Pope Benedict XVI coincided with a drastic resurgence in the grandiose garments neglected by his predecessors (Webster). With a preference for pre-Vatican II luxurious self, velvet, and fur pieces like the cape-style mozzetta, The Guardian contends that Pope Benedict XVI’s papal uniform represented a shift away from the communal emphasis of Pope Paul VI towards reviving the Catholic Church’s hegemonic heritage and tradition within visual culture. The Guardian argues that “at a time of global economic uncertainty, and with the Church struggling to retain its flock in an increasingly secularised world, reinforcing tradition and underlining the continuity of ritual was a bold and, Benedict felt, necessary direction” (Conway). The newspaper situates Pope Benedict XVI’s sartorial preference for his papal uniform within the larger trend of couture houses like Alexander McQueen and Chanel revisiting their archives. Pope Benedict XVI’s papacy oversaw the Catholic Church experiencing a significant decline in global authority and symbolic power due to the continued fallout from numerous scandals, including the longstanding history of sexual abuse allegations and charges of embezzlement at the Institute for the Works of Religion, the official bank of the Vatican. Combined with his highly conservative doctrinal approach and unwillingness to adapt the church’s position on key human rights and social justice issues, including LGBQT+ acceptance within the institution, Pope Benedict XVI’s conspicuous taste and approach to the papal uniform was symbolic of his leadership. His regalia and vestments mediated an undesirable brand identity as a pontiff largely disconnected from the realities of his public. Pope Benedict was also reported by the press to enjoy conspicuous designer accessories, in particular his Gucci sunglasses and, most notably, allegedly preferred to wear Prada for his papal shoes. In line with his symbolic approach to the papacy, Benedict revived the wearing of red shoes by the pope (with red a signifier of martyrs’ blood). Esquire labelled Pope Benedict XVI as their 2007 “Accessorizer of the Year”, primarily for incorporating a signature “ornate” footwear into his institutional religious uniform (“Best Dressed Men in America”). Conversely, Pope John Paul II’s papacy signified a shift away from this aspect of the papal uniform, preferring burgundy over a blood red colouring. The Vatican subsequently corrected that Pope Benedict XVI’s red papal shoes were not Prada but rather commissioned specifically for him by Italian cobblers (Fetters Maloy). However, the idea that Benedict incorporated Prada shoes into the institutional papal uniform had become repeated by numerous cultural intermediaries ranging from the Associated Press to Women’s Wear Daily,to the extent that it is now entrenched into the popular imaginary. Upon his retirement in 2013, The Cut argued Pope Benedict would be primarily remembered for the “pair of bright red Prada loafers that he almost always wore beneath his robes” (Cowles). When Pope Francis arrived in Washington, D.C. for his 2015 visit to the United States, USA Today celebrated the event with the brazen headline, “Pope Francis arrives and he’s not the ‘Prada Pope’” (Puente). Reflecting upon his divisive legacy after his death in December 2022, The Daily Beast continued circulating this narrative, writing that when Benedict XVI was elected to the papacy, he donned “Prada slippers and stumbled his way through a papacy fraught with controversy” (Latza Nadeau). It is within this context of Pope Benedict’s hegemonically ornate approach to the papal uniform that Pope Francis’s modest and humble styling of his vestments registered with the public as a mechanism for branding his public image. The Role of the Uniform for Pope Francis’s Brand Identity For his public introduction after the 2013 papal conclave to those pilgrims gathered in St. Peters Square, Pope Francis shaped the tone, narrative, and messaging of his papacy through his unique and calculated approach to the Church’s institutional uniform. His decision to appear on the balcony wearing a basic white cassock with an unadorned crucifix around his neck exemplifies Tynan and Godson’s argument that uniforms can act as a form of “self-preservation” within the context of institutional power (18). Pope Francis is not only the pontiff, but his image and persona work to maintain the institutional brand identity of the Catholic Church (Moir). His selection and wearing of a cassock demonstrate that Pope Francis is aware of how his image and persona will be critiqued by the public and cultural intermediaries. Pope Francis’s first encyclical published in 2015, Laudato Si’, argues that the environmental crisis (which he blames on wasteful consumerism) disproportionally impacts on the planet’s most socioeconomically marginalised communities. The correlation of climate change with the injustices faced by the poor is highlighted by scholars including Bruno Latour and Anne F. MacLennan for exemplifying Pope Francis’s radical approach prioritising empathy to the papacy. Pope Francis’s uniform performs his environmental activism by signifying how discourses of sustainability and ethical consumption are core social justice issues for the Church. Through rejecting the opulent vestments for a modest white cassock and wearing sandals rather than red shoes, sartorial decisions were strategically made to communicate his symbolic approach to the papacy through the power of the uniform. His sartorial approach to the papal regalia comprising his religious uniform ignited extensive public conversations concerning how Pope Francis’s image – humble, modest, advocating for the poor, environmental activist – would improve the Catholic Church’s brand identity amidst numerous scandals. Fashion critic Vanessa Friedman’s discussion of Pope Francis is a potent example of the type of public commentary from cultural intermediaries that framed the symbolic power of his papal uniform for the Church’s re-branding efforts: Pope Francis hasn’t really had a chance to do anything in terms of influencing doctrine – except appear in moments broadcast to millions … they can all make their own assumption based on how he looks. There was a very clear rationale behind his decision to eschew the more fancy, ermine-trimmed red and purple robes of Pope Benedict in favour of plain white vestments; to swap the fold cross for an iron version. The choices telegraphed the importance of humility; the importance of recognizing and working with the poor; and the need, in a time of austerity, to acknowledge the suffering and deprivations of others. It was a discreet but unmistakable announcement of a new agenda, using the tools most immediately and least aggressively available. (“Pope and Circumstance”) Friedman’s analysis is particularly noteworthy because she underlines how the papal uniform has always been subject to personal interpretation based upon the brand identity of the pontiff. More significantly, she connects Pope Francis’s selection of papal regalia to his environmental politics and social justice activism. The uniform possesses greater symbolic power than Pope Francis’s actions. His uniform emphasises the frames, narratives, and discursive schemas grounding his brand identity that is then circulated by cultural intermediaries as in the example of Friedman’s analysis. In a feature detailing the impact of Pope Francis’s papacy on the fashion industry, The New York Times highlighted the cultural impact of the pontiff’s religious uniform. Italian fashion designer Silvia Venturini Fendi is cited by The New York Times as recognising the rise of sustainability in high fashion, making a direct association to Pope Francis’s criticism of wasteful consumerism: “we have a new pope going back to real Christianity, which lately was far from the church … . People are looking for meaning, and the real meaning of fashion is as a tool to express yourself. Sometimes fashion hides your language, but we look for meaning in materials and fabrics to allow true personality to come out” (Menkes). Esquire named Pope Francis their “Best Dressed Man of 2013”, an honour bestowed upon the pontiff for how his sartorial approach to the papal uniform signified the Catholic Church’s rebranding efforts. Justifying their selection over other candidates like Bradley Cooper and Joseph Gordon-Levitt, Esquire cites New York University professor Ann Pellegrini, who situates Pope Francis’s papal uniform as a powerful signifier of his brand identity: “the humility of his garments offers a way to visibly display his theological and material concerns for the poor. This Holy Roman emperor really does have new clothes” (Berlinger). Fendi and Esquire’s positioning of Pope Francis’s papal regalia as an institutional yet personal communicative tool underscores how his religious uniform performs a critical function to reshape the public narratives and discourses shaping judgements on the Catholic Church. Pope Francis’s celebrity status and the deliberate rejection of lavish vestments helped initiate a wider discourse on the politics of the papal uniform in media and popular culture. In 2018, the Metropolitan Museum of Art’s Costume Institute debuted their annual fashion exhibit Heavenly Bodies: Fashion and the Catholic Imagination, showcasing both the influence of Catholicism for numerous designers (such as Alexander McQueen and Versace) as well as the visual politics of the Church’s institutional uniform (Bolton). The debut of Heavenly Bodies was the focus of the 2018 Costume Institute Gala, the prestigious – and highly exclusionary – annual fundraiser for the Metropolitan Museum of Art. Rihanna attended wearing a papal-inspired Margiela bejewelled minidress with a matching jacket and mitre (Syme). Proclaimed as “Pope Rihanna” by Twitter users, her choice of embodying an opulent imagination of the papal uniform received extensive attention by the press and the public on social media (“The Most Hilarious Twitter Reactions to Rihanna’s Met Gala Look”). Teen Vogue argued that Rihanna’s thematic outfit functioned as a form of activism by highlighting the gender discrimination within the organisational structure of the Catholic Church (Papisova). Despite advocating against social injustices, Pope Francis’s continued denial of women becoming priests remains one of the major criticisms of his papacy. Although Pope Francis has employed his papal vestments and regalia to perform a social justice-oriented mandate for his papacy, there are limits to the advocacy of his institutional uniform which must balance and negotiate the complex politics of the Catholic Church. Conclusion Papal vestments and regalia play an important communicative role in visual culture. Prior to 2018’s Met Gala, Vox argued that “instead of watching celebrities at the MET Gala Monday night, pay attention to what the pope wears everyday” (Burton). Vox highlights the symbolic power of the pontiff as an institutional figure to negotiate various trends and social shifts circulating in public discourse. Heavenly Bodies and the larger discussions by cultural intermediaries analysing papal fashion exemplifies how the papal uniform contributes to the symbolic power of the Catholic Church in public discourse and media culture. The papal vestments comprising the pontiff’s institutional uniform is a critical element of Pope Francis’s public persona, and his sartorial tactics signify a larger visual history of institutional branding through fashion. Pope Francis is an intriguing example of a celebrated public figure utilising the iconicity of his institutional uniform to mediate ideas about sustainability, environmental ethics, austerity, and consumption. 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Follicular lymphoma (FL) is the most common type of indolent lymphoma in the Western world, accounting for approximately 30% of lymphoma cases. FL is known for its recurrent nature, necessitating diverse treatment options. The introduction of rituximab, an anti-CD20 antibody, has greatly improved FL outcomes and paved the way for targeted therapies. In this review, we thoroughly explore the structure, mechanism of action, clinical outcomes, and side effects of currently approved monoclonal antibodies (mAb) for FL. Furthermore, we provide insights into ongoing clinical trials and emerging monoclonal antibodies that hold promise for the future of FL treatment. A comprehensive literature search was conducted using various medical databases, including ASH and ASCO publications, as well as PubMed. The clinicaltrials.gov website was used to compile a list of investigational monoclonal antibodies from ongoing clinical trials. The future of antibody-based therapy for follicular lymphoma shows great promise, with a focus on enhancing antibody efficacy, prioritizing optimized combination therapies to address treatment resistance, and evaluating bispecific antibodies as first-line therapies, all while carefully balancing risks and benefits and sequencing treatments appropriately for better disease management. These directions have the potential to establish antibodies as a central component of follicular lymphoma treatment. Article Details How to Cite MOUSTAFA, Muhamad Alhaj. A Comprehensive Review of Monoclonal Antibodies for the Treatment of Follicular Lymphoma Including Both Approved and Investigational Options. Medical Research Archives, [S.l.], v. 11, n. 11, nov. 2023. ISSN 2375-1924. Available at: <https://esmed.org/MRA/mra/article/view/4745>. Date accessed: 02 dec. 2023. doi: https://doi.org/10.18103/mra.v11i11.4745. 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Why do politicians wear what they wear? Social conventions and parliamentary rules largely shape how politicians dress. Clothing is about power, especially if we think about clothing as uniforms. Uniforms of judges and police are easily recognised as symbols of power. Similarly, the business suit of a politician is recognised as a form of authority. But what if you are a female politician: what do you wear to work or in public? Why do we expect politicians to wear suits and ties? While we do expect a certain level of behaviour of our political leaders, why does the professionalised suit and tie signal this? And what happens if a politician challenges this convention? Female politicians, and largely any women in a position of power in the public sphere, are judged when they don’t conform to the social conventions of appropriate dress. Arguably, male politicians are largely not examined for their suit preferences (unless you are Paul Keating wearing Zenga suits or Anthony Albanese during an election make-over), so why are female politicians’ clothes so scrutinised and framed as reflective of their abilities or character? This article interrogates the political uniform and its gendered contestations. It does so via the ways female politicians are challenging gender norms and power relations in how they dress in public, political, and parliamentary contexts. It considers how rules and conventions around political clothing are political in themselves, through a discussion on how female politicians and political figures choose to adhere to or break these rules. Rules about what dress is worn by parliamentarians are often archaic, often drawn from rules set by parliaments largely made up of men. But even with more women sitting in parliaments, dress rules still reflect a very masculine idea of what is appropriate. Dress standards in the Australian federal parliament are described as a “matter for individual judgement”, however the Speaker of the House of Representatives can make rulings on members’ attire. In 1983, the Speaker ruled dress was to be neat, clean, and decent. In 1999, the Speaker considered dress to be “formal” and “similar to that generally accepted in business and professional circles”. This was articulated by the Speaker to be “good trousers, a jacket, collar and tie for men and a similar standard of formality for women”. In 2005, the Speaker reinforced this ruling that dress should be “formal” in keeping with business and professional standards, adding there was no “dignity of the House for Members to arrive in casual or sportswear” (“Dress”). Clothes with “printed slogans” are not considered acceptable and result in a warning from the Speaker for Australian MPs to “dress more appropriately”. Previous dress rulings also include that members should not remove their jackets in parliament, “tailored safari suits without a tie were acceptable, members could wear hats in parliament but had to remove them while entering or leaving the chamber and while speaking”. The safari suit rule likely refers to the former Foreign Affairs Minister Gareth Evans’s wearing of the garment during the 1980s and 1990s. The Speaker can also rule on what a member of the federal parliament can’t do. While in parliament, members can’t smoke, can’t read a newspaper, can’t distribute apples, may not climb over seats, and can’t hit or kick their desks. Members of parliament can however use their mobile phones for text messaging, and laptops can be used for emails (“Dress”). These examples suggest an almost old-fashioned type of school rules juxtaposed with modern sensibilities, positing the ad-hoc nature of parliamentary rules, with dress rules further evidence of this. While a business suit is considered the orthodoxy of the political uniform for male politicians, this largely governs rules about what female politicians wear. The business suit, the quasi-political uniform for male MPs, is implicit and has social consensus. The suit, which covers the body, is comprised of trousers to the ankle, well cut in muted colours of blue, grey, brown, and black, with contrasting shirts, often white or light colours, ties that may have a splash of colour, often demonstrating allegiances or political persuasions, mostly red or blue, as in the case of Labor and Liberal or Republicans and Democrats. The conventions of the suit are largely proscribed onto women, who wear a female version of the male suit, with some leeway in colour and pattern. Dress for female MPs should be modest, as with the suit, covering much of the body, and especially have a modest neckline and be at least knee length. In the American Congress, the dress code requires “men to wear suit jackets and ties ... and women are not supposed to wear sleeveless tops or dresses without a sweater or jacket” (Zengerle). In 2017, this prompted US Congresswomen to wear sleeveless dresses as a “right to bare arms” (Deutch and Karl). In these two Australian and American examples of a masculine parliamentary wear it is reasonable to suppose a seeming universality about politicians’ dress codes. But who decides what is the correct mode of political uniform? Sartorial rules about what are acceptable clothing choices are usually made by the dominant group, and this is the case when it comes to what politicians wear. Some rules about what is worn in parliament are archaic to our minds today, such as the British parliament law from 1313 which outlaws the wearing of armour and weaponry inside the chamber. More modern rulings from the UK include the banning of hats in the House of Commons (although not the Lords), and women being permitted handbags, but not men (Simm). This last rule reveals how clothing and its performance is gendered, as does the Australian parliament rule that a “Member may keep his hands in his pockets while speaking” (“Dress”), which assumes the speaker is likely a man wearing trousers. Political Dress as Uniform While political dress may be considered as a dress ‘code’ it can also be understood as a uniform because the dress reflects their job as public, political representatives. When dress code is considered as a uniform, homogenisation of dress occurs. Uniformity, somewhat ironically, can emphasise transgressions, as Jennifer Craik explains: “cultural transgression is a means of simultaneously undermining and reinforcing rules of uniforms since an effective transgressive performance relies on shared understandings of normative meanings, designated codes of conduct and connotations” (Craik 210). Codified work wear usually comes under the umbrella of uniforms. Official uniforms are the most obvious type of uniforms, clearly denoting the organisation of the wearer. Military, police, nurses, firefighters, and post-office workers often have recognisable uniforms. These uniforms are often accompanied by a set of rules that govern the “proper” wearing of these items. Uniforms rules do not just govern how the clothing is worn, they also govern the conduct of the person wearing the uniform. For example, a police officer in uniform, whether or not on duty, is expected to maintain certain codes of behaviour as well as dress standards. Yet dress, as Craik notes, can also be transgressive, allowing the wearer to challenge the underpinning conventions of the dress codes. Both Australian Senator Sarah Hanson-Young and US Congresswoman Alexandria Ocasio-Cortez, to name just two, leveraged social understandings of uniforms when they used their clothing to communicate political messages. Fashion as political communication or as ‘fashion politics’ is not a new phenomenon (Oh 374). Jennifer Craik argues that there are two other types of uniform; the unofficial and the quasi-uniform (17). Unofficial uniforms are generally adopted in lieu of official uniforms. They generally arise organically from group members and function in similar ways to official uniforms, and they tend to be identical in appearance, even if hierarchical. Examples of these include the yellow hi-vis jackets worn by the French Gilets Jaunes during the 2018 protests against rising costs of living and economic injustice (Coghlan). Quasi-uniforms work slightly differently. They exist where official and unofficial rules govern the wearing of clothes that are beyond the normal social rules of clothing. For example, the business suit is generally considered appropriate attire for those working in a conservative corporate environment: some workplaces restrict skirt, trouser, and jacket colours to navy, grey, or black, accompanied by a white shirt or blouse. In this way we can consider parliamentary dress to be a form of “quasi-uniform”, governed by both official and unofficial workplaces rules, but discretionary as to what the person chooses to wear in order to abide by these rules, which as described above are policed by the parliamentary Speaker. In the Australian House of Representatives, official rules are laid down in the policy “Dress and Conduct in the Chamber” which allows that “the standard of dress in the Chamber is a matter for the individual judgement of each Member, [but] the ultimate discretion rests with the Speaker” (“Dress”). Clothing rules within parliamentary chambers may establish order but also may seem counter-intuitive to the notions of democracy and free speech. However, when they are subverted, these rules can make clothing statements seem even more stark. Jennifer Craik argues that “wearing a uniform properly ... is more important that the items of clothing and decoration themselves” (4) and it is this very notion that makes transgressive use of the uniform so powerful. As noted by Coghlan, what we wear is a powerful tool of political struggle. French revolutionaries rejected the quasi-uniforms of the French nobility and their “gold-braided coat, white silk stockings, lace stock, plumed hat and sword” (Fairchilds 423), and replaced it with the wearing of the tricolour cockade, a badge of red, blue, and white ribbons which signalled wearers as revolutionaries. Uniforms in this sense can be understood to reinforce social hierarchies and demonstrate forms of power and control. Coghlan also reminds us that the quasi-uniform of women’s bloomers in the 1850s, often referred to as “reform dress”, challenged gender norms and demonstrated women’s agency. The wearing of pants by women came to “symbolize the movement for women’s rights” (Ladd Nelson 24). The wearing of quasi-political uniforms by those seeking social change has a long history, from the historical examples already noted to the Khadi Movement led by Gandhi’s “own sartorial choices of transformation from that of an Englishman to that of one representing India” (Jain), to the wearing of sharecropper overalls by African American civil rights activists to Washington to hear Martin Luther King in 1963, to the Aboriginal Long March to Freedom in 1988, the Tibetan Freedom Movement in 2008, and the 2017 Washington Pink Pussy Hat March, just to name a few (Coghlan). Here shared dress uniforms signal political allegiance, operating not that differently from the shared meanings of the old-school tie or tie in the colour of political membership. Political Fashion Clothing has been used by queens, female diplomats, and first ladies as signs of power. For members of early royal households, “rank, wealth, magnificence, and personal virtue was embodied in dress, and, as such, dress was inherently political, richly materialising the qualities associated with the wearer” (Griffey 15). Queen Elizabeth I (1558-1603), in order to subvert views that she was unfit to rule because of her sex, presented herself as a virgin to prove she was “morally worthy of holding the traditionally masculine office of monarch” (Howey 2009). To do this she dressed in ways projecting her virtue, meaning her thousands of gowns not only asserted her wealth, they asserted her power as each gown featured images and symbols visually reinforcing her standing as the Virgin Queen (Otnes and Maclaren 40). Not just images and symbols, but colour is an important part of political uniforms. Just as Queen Elizabeth I’s choice of white was an important communication tool to claim her right to rule, Queen Victoria used colour to indicate status and emotion, exclusively wearing black mourning clothes for the 41 years of her widowhood and thus “creating a solemn and pious image of the Queen” (Agnew). Dress as a sign of wealth is one aspect of these sartorial choices, the other is dress as a sign of power. Today, argues Mansel, royal dress is as much political as it is performative, embedded with a “transforming power” (Mansel xiiv). With the “right dress”, be it court dress, national dress, military or civil uniform, royals can encourage loyalty, satisfy vanity, impress the outside world, and help local industries (Mansel xiv). For Queen Elizabeth II, her uniform rendered her visible as The Queen; a brand rather than the person. Her clothes were not just “style choices”; they were “steeped with meaning and influence” that denoted her role as ambassador and figurehead (Atkinson). Her wardrobe of public uniforms was her “communication”, saying she was “prepared, reliable and traditional” (Atkinson). Queen Elizabeth’s other public uniform was that of the “tweed-skirted persona whose image served as cultural shorthand for conservative and correct manner and mode” (Otnes and Maclaren 19). For her royal tours, the foreign dress of Queen Elizabeth was carefully planned with a key “understanding of the political semantics of fashion … with garments and accessories … pay[ing] homage to the key symbols of the host countries” (Otnes and Maclaren 49). Madeline Albright, former US Secretary of State, engaged in sartorial diplomacy not with fashion but with jewellery, specifically pins (Albright). She is quoted as saying on good days, when I wanted to project prosperity and happiness, I'd put on suns, ladybugs, flowers, and hot-air balloons that signified high hopes. On bad days, I'd reach for spiders and carnivorous animals. If the progress was slower than I liked during a meeting in the Middle East, I'd wear a snail pin. And when I was dealing with crabby people, I put on a crab. Other ambassadors started to notice, and whenever they asked me what I was up to on any given day, I would tell them, “Read my pins”. (Burack) Two American first ladies, Hillary Rodham Clinton and Michelle Obama, demonstrate how their fashion acted as a political uniform to challenge the ideal notions of American womanhood that for generations were embedded in the first lady (Rall et al.). While modern first ladies are now more political in their championing of causes and play an important role in presidential election, there are lingering expectations that the first lady be the mother of the nation (Caroli). First Lady Hillary Rodham Clinton’s eclectic style challenged the more conservative tone set by prior Republican first ladies, notably Barbara Bush. Rodham Clinton is a feminist and lawyer more interested in policy that the domesticity of White House functions and décor. Her fashion reflects her “independence, individuality and agency”, providing a powerful message to American women (Rall et al. 274). This was not that much of a shift from her appearance as the wife of a Southern Governor who wouldn’t wear makeup and kept her maiden name (Anderson and Sheeler 26). More recently, as Democratic Presidential nominee, Rodham Clinton again used fashion to tell voters that a woman could wear a suit and become president. Rodham Clinton’s political fashion acted to contest the gender stereotypes about who could sit in the White House (Oh 374). Again, the pantsuit was not new for Rodham Clinton; “when I ran for Senate in 2000 and President in 2008, I basically had a uniform: a simple pantsuit, often black” (Mejia). Rodham Clinton says the “benefit to having a uniform is finding an easy way to fit in … to do what male politicians do and wear more or less the same thing every day”. As a woman running for president in 2016, the pantsuit acted as a “visual cue” that she was “different from the men but also familiar” (Mejia). Similarly, First Lady Michelle Obama adopted a political uniform to situate her role in American society. Gender but also race and class played a role in shaping her performance (Guerrero). As the first black First Lady, in the context of post-9/11 America which pushed a “Buy American” retail campaign, and perhaps in response to the novelty of a black First Lady, Obama expressed her political fashion by returning the First Lady narrative back to the confines of family and domesticity (Dillaway and Paré). To do this, she “presented a middle-class casualness by wearing mass retail items from popular chain stores and the use of emerging American designers for her formal political appearances” (Rall et al. 274). Although the number of women elected into politics has been increasing, gender stereotypes remain, and female representation in politics still remains low in most countries (Oh 376). Hyland argues that female politicians are subject to more intense scrutiny over their appearance … they are held to higher standards for their professional dress and expected to embody a number of paradoxes — powerful yet demure, covered-up but not too prim. They’re also expected to keep up with trends in a way that their male counterparts are not. Sexism can too easily encroach upon critiques of what they wear. How female politicians dress is often more reported than their political or parliamentary contributions. This was the case for Australia’s first female Prime Minister Julia Gillard. Jansens’s 2019 research well demonstrates the media preoccupation with political women’s fashion in a number of ways, be it the colours they choose to wear, how their clothing reveals their bodies, and judgements about the professionalism of their sartorial choices and the number of times certain items of clothing are worn. Jansens provides a number of informative examples noting the media’s obsession with Gillard’s choices of jackets that were re-worn and tops that showed her cleavage. One Australian Financial Review columnist reported, I don’t think it’s appropriate for a Prime Minister to be showing her cleavage in Parliament. It’s not something I want to see. It is inappropriate to be in Parliament, it is disrespectful to yourself and to the Australian community and to the parliament to present yourself in a manner that is unprofessional. (Jansens) The media preoccupation with female politicians’ clothing is noted elsewhere. In the 2012 Korean presidential election, Geun-hye Park became the first female president of Korea, yet media reports focussed largely on Park’s fashion: a 2013 newspaper published a four-page analysis titled “Park Geun-hye Fashion Project”. Another media outlet published a review of the 409 formal function outfits worn by Park (Oh 378). The larger focus, however, remains on Park’s choice to wear a suit, referred to as her “combat uniform” (Cho), for her daily parliamentary and political duties. This led Oh to argue that Korean female politicians, including Park, wear a “male suit as a means for benefit and survival”; however, with such media scrutiny “female politicians are left under constant surveillance” (382). As Jansens argues, clothing can act as a “communicative barrier between the body and society”, and a narrative that focusses on how clothes fit and look “illustrates women’s bodies as exceptional to the uniform of the political sphere, which is a masculine aesthetic” (212). Drawing on Entwistle, Jansens maintains that the the uniform “serves the purpose in policing the boundaries of sexual difference”, with “uniforms of gender, such as the suit, enabl[ing] the repetitious production of gender”. In this context, female politicians are in a double bind. Gillard, for example, in changing her aesthetic illustrates the “false dichotomy, or the ‘double bind’ of women’s competency and femininity that women can be presented with regarding their agency to conform, or their agency to deviate from the masculine aesthetic norm” (Jansens 212). This was likely also the experience of Jeannette Rankin, with media reports focusing on Rankin’s “looks and “personal habits,” and headlines such “Congresswoman Rankin Real Girl; Likes Nice Gowns and Tidy Hair” (“Masquerading”). In this article, however, the focus is not on the media preoccupation with female politicians’ political fashion; rather, it is on how female politicians, rather than conforming to masculine aesthetic norms of wearing suit-like attire, are increasingly contesting the political uniform and in doing so are challenging social and political boundaries As Yangzom puts it, how the “embodiment of dress itself alters political space and civic discourse is imperative to understanding how resistance is performed in creating social change” (623). This is a necessary socio-political activity because the “way the media talks about women affects the way women are perceived in society. If women’s appearances are consistently highlighted in the media, inequality of opportunity will follow from this inequality of treatment” (Jansens 215). Contesting the Political Uniform Breaking fashion norms, or as Entwistle argues, “bodies which flout the conventions of their culture and go without the appropriate clothes are subversive of the most basic social codes and risk exclusion, scorn and ridicule” (7), hence the price may be high to pay for a public figure. American Vice-President Kamala Harris’s penchant for comfy sneakers earned her the nickname “the Converse candidate”. Her choice to wear sneakers rather than a more conventional low-heel shoe didn’t necessarily bring about a backlash; rather, it framed her youthful image (possibly to contrast against Trump and Biden) and posited a “hit the ground running” approach (Hyland). Or, as Devaney puts it, “laced up and ready to win … [Harris] knew her classic American trainers signalled a can-do attitude and a sense of purpose”. Increasingly, political women, rather than being the subject of social judgments about their clothing, are actively using their dressed bodies to challenge and contest a range of political discourses. What a woman wears is a “language through which she can send any number of pointed messages” (Weiss). In 2021, US Congresswoman Alexandria Ocasio-Cortez wore a ‘Tax the rich’ dress to the Met Gala. The dress was designed by social activist designers Brother Vellies and loaned to Ocasio-Cortez to attend the $30,000 ticket event. For Ocasio-Cortez, who has an Instagram following of more than eight million people, the dress is “about having a real conversation about fairness and equity in our system, and I think this conversation is particularly relevant as we debate the budget” (“Alexandria”). For Badham, “in the blood-spattered garments of fighting class war” the “backlash to Alexandria Ocasio-Cortez’s … dress was instant and glorious”. At the same event, Congresswomen Carolyn Maloney wore an ‘Equal Rights for Women’ suffragette-themed floor length dress in the suffragette colours of purple, white, and gold. Maloney posted that she has “long used fashion as a force 4 change” (Chamlee). US Senator Kyrsten Sinema is known for her “eccentric hipster” look when sitting in the chamber, complete with “colourful wigs, funky glasses, gold knee-high boots, and a ring that reads ‘Fuck off”’ (Hyland). Simena has been called a “Prada Socialist” and a “fashion revolutionary” (Cauterucci). Similarly, UK politician Harriet Harmen received backlash for wearing a t-shirt which read “This is what a feminist looks like” when meeting PM David Cameron (Pilote and Montreuil). While these may be exceptions rather than the rule, the agency demonstrated by these politicians speaks to the patriarchal nature of masculine political environments and the conventions and rules that maintain gendered institutions, such as parliaments. When US Vice-President Kamala Harris was sworn in, she was “not only … the first woman, Black woman, and South Asian-American woman elected to the position, but also … the first to take the oath of office wearing something other than a suit and tie”, instead wearing a feminised suit consisting of a purple dress and coat designed by African-American designer Christopher John Rogers (Naer). Harris is often photographed wearing Converse sneakers, as already noted, and Timberland work boots, which for Naer is “quietly rebellious” because with them “Harris subverts expectations that women in politics should appear in certain clothing (sleek heels, for instance) in order to compete with men — who are, most often, in flats”. For Elan, the Vice-President’s sneakers may be a “small sartorial detail, but it is linked to the larger cultural moment in which we live. Sneakers are a form of footwear finding their way into many women’s closets as part of a larger challenge to outmoded concepts of femininity” as well as a nod to her multiracial heritage where the “progenitors of sneaker culture were predominantly kids of colour”. Her dress style can act to disrupt more than just gender meanings; it can be extended to examine class and race. In 2022, referencing the Alexandria Ocasio-Cortez 2021 Met dress, Claudia Perkins, the wife of Australian Greens leader Adam Bandt, wore a “white, full-length dress covered in red and black text” that read “coal kills” and “gas kills”, with slick, long black gloves. Bandt wore a “simple tux with a matching pocket square of the same statement fabric” to the federal parliament Midwinter Ball. Joining Perkins was Greens Senator Sarah Hanson-Young, wearing an “hourglass white dress with a statement on the back in black letters” that read: “end gas and coal”. The trim on the bottom was also covered in the same text. Hanson-Young posted on social media that the “dress is made from a 50-year-old damask table cloth, and the lettering is made from a fast fashion handbag that had fallen apart” (Bliszczyk). Federal MP Nicolle Flint posted a video on Twitter asking a political commentator what a woman in politics should wear. One commentator had taken aim at Flint’s sartorial choices which he described “pearl earrings and a pearly smile” and a “vast wardrobe of blazers, coats and tight, black, ankle-freezing trousers and stiletto heels”. Ending the video, Flint removes her black coat to reveal a “grey bin bag cinched with a black belt” (Norman). In 2018, Québec politician Catherine Dorian was criticised for wearing casual clothes, including Dr Marten boots, in parliament, and again in 2019 when Dorian wore an orange hoodie in the parliamentary chamber. The claim was that Dorian “did not respect decorum” (Pilote and Montreuil). Dorian’s response was “it’s supposed to be the people’s house, so why can’t we look like normal people” (Parrillo). Yet the Québec parliament only has dress rules for men — jacket, shirt and ties — and has no specifics for female attire, meaning a female politician can wear Dr Martens or a hoodie, or meaning that the orthodoxy is that only men will sit in the chamber. The issue of the hoodie, somewhat like Kamala Harris’s wearing of sneakers, is also a class and age issue. For Jo Turney, the hoodie is a “symbol of social disobedience” (23). The garment is mass-produced, ordinary, and democratic, as it can be worn by anyone. It is also a sign of “criminality, anti-social behaviour and out of control youth”. If the media are going to focus on what female politicians are wearing rather than their political actions, it is unsurprising some will use that platform to make social and political comments on issues relating to gender, but also to age, class, and policies. While this may maintain a focus on their sartorial choices, it does remind us of the double bind female politicians are in. With parliamentary rules and social conventions enamoured with the idea of a ‘suit and tie’ being the appropriate uniform for political figures, instances when this ‘rule’ is transgressed will risk public ridicule and social backlash. However, in instances were political women have chosen to wear garments that are not the conventional political uniform of the suit and tie, i.e. a dress or t-shirt with a political slogan, or a hoodie or sneakers reflecting youth, class, or race, they are challenging the customs of what a politician should look like. Politicians today are both men and women, different ages, abilities, sexualities, ethnicities, religions, and demographics. To narrowly suppose what a politician is by what they wear narrows public thinking about a person’s contribution or potential contribution to public life. While patriarchal social conventions and parliamentary rules stay in place, the political sphere is weaker for it. References Agnew, Molly. “Victorian Mourning Dress.” Eternal Goddess 27 Nov. 2020. 12 Dec. 2022 <https://www.eternalgoddess.co.uk/posts/esbvxua79pcgcwyjp6iczrdfgw4vm5>. Albright, Madeleine. Read My Pins: Stories from a Diplomat’s Jewel Box. Sydney: Harper Collins, 2010. “Alexandria Ocasio-Cortez Wears Dress with ‘Tax the Rich' Written on It to Met Gala.” NBC 13 Sep. 2021. <https://www.nbcnewyork.com/entertainment/the-scene/met-gala/alexandria-ocasio-cortez-wears-dress-with-tax-the-rich-written-on-it-to-met-gala/3270019/>. Anderson, Karrin, and Kristine Sheeler. Governing Codes: Gender, Metaphor and Political Identity. Lanham: Lexington Books, 2005. Atkinson, Emma. “Power Dressing: The Queen’s Unique Style.” BBC News 1 Jun. 2022. <https://www.bbc.com/news/uk-61593081>. Badham, Van. “AOC’s Guide to Getting Noticed at Parties: Drape Yourself in the GGarments of Class War.” The Guardian 15 Sep. 2021. <https://www.theguardian.com/commentisfree/2021/sep/15/aocs-guide-to-getting-noticed-at-parties-drape-yourself-in-the-garments-of-class-war>. Bliszczyk, Aleksandra. “Adam Bandt’s Wife and Sarah Hanson-Young Slayed Last Nights Midwinter Ball w/ Anti-Coal Dresses.” Pedestrian TV 8 Sep. 2022. <https://www.pedestrian.tv/style/adam-bandt-wife-anti-coal-statement-midwinter-ball/>. Burack, Emily. “An Ode to Madeleine Albright's Best Brooches.” Town and Country 24 Mar. 2022. <https://www.townandcountrymag.com/style/jewelry-and-watches/g39526103/madeleine-albright-brooch-tribute/>. Caroli, Betty. First Ladies: The Ever-Changing Role, from Martha Washington to Melania Trump. 5th ed. Oxford: Oxford UP, 2019. Cauterucci, Christina. “Kyrsten Sinema Is Not Just a Funky Dresser. She’s a Fashion Revolutionary.” Slate 31 Jan. 2019. <https://slate.com/human-interest/2019/01/kyrsten-sinema-fashion-boots.html>. Chamlee, Virginia. “The New York Democrat Also Wore a Bag Emblazoned with ‘ERA YES’, an Endorsement of the Proposed Equal Rights Amendment.” People 14 Sep. 2021. https://people.com/style/congresswoman-carolyn-maloney-wears-suffragette-themed-met-gala-dress. Cho, Jae-eun. “During Election Season, Clothes Make the Politicians.” Korea JoongAng Daily 4 Sep. 2012. <https://koreajoongangdaily.joins.com/2012/09/04/features/During-election-season-clothes-make-the-politician/2958902.html>. Coghlan, Jo. “Dissent Dressing: The Colour and Fabric of Political Rage.” M/C Journal 22.1 (2019). <https://doi.org/10.5204/mcj.1497>. Craik, Jennifer. Uniforms Exposed: From Conformity to Transgression. Oxford: Berg, 2005. Deutch, Gabby, and Emily Karl. “Congresswomen Protest the ‘Right to Bare Arms’.” CNN 14 Jul. 2017. <https://edition.cnn.com/2017/07/14/politics/capitol-dress-code-protest/index.html>. Devaney, Susan. “How Kamala and Her Converse Rewrote the Rule Book on Political Style.” British Vogue 13 Nov. 2020. <https://www.vogue.co.uk/news/article/kamala-harris-sneakers-fashion>. Dillaway, Heather, and Elizabeth Paré. “Locating Mothers: How Cultural Debates about Stay-at-Home versus Working Mothers Define Women and Home.” Journal of Family Issues 29.4 (2008): 437–64. “Dress and Conduct in the Chamber”. Parliament of Australia, 11 Nov. 2022. <https://www.aph.gov.au/About_Parliament/House_of_Representatives/ Powers_practice_and_procedure/Practice7/HTML/Chapter5/Dress_and_conduct_in_the_Chamber>. Elan, Priya. “Kamala Harris: What Her Sneakers Mean”. The Guardian 4 Sep. 2020. <https://www.theguardian.com/fashion/2020/sep/03/kamala-harris-what-her-sneakers-mean>. Entwistle, Joanne. The Fashioned Body: Fashion, Dress, and Modern Social Theory. Cambridge: Polity Press, 2000. Fairchilds, Cissie. “Fashion and Freedom in the French Revolution.” Continuity and Change 15.3 (2000): 419-33. Griffey, Erin. Introduction. Sartorial Politics in Early Modern Europe: Fashioning Women. Ed. Erin Griffey. Amsterdam UP, 2019: 15-32. Guerrero, Lisa. “(M)other-in-Chief: Michelle Obama and the Ideal of Republican womanhood.” New Femininities. Eds. Rosalind Gill and Christina Scharff. London: Palgrave Macmillan, 2011: 68–82. Howey, Catherine. “Dressing a Virgin Queen: Court Women, Dress, and Fashioning the Image of England’s Queen Elizabeth I.” Early Modern Women 4 (2009): 201-208. Hyland, Veronique. “Women in US Politics Have Learnt to Stop Worrying and Embrace Fashion.” Financial Times 17 Mar. 2022. <https://www.ft.com/stream/c5436241-52d7-4e6d-973e-2bcacc8866ae>. Jain, E. “Khadi: A Cloth and Beyond.” Bombay Sarvodaya Mandal & Gandhi Research Foundation, 2018. <https://www.mkgandhi.org/articles/khadi-a-cloth-and-beyond.html> Jansens, Freya. “Suit of Power: Fashion, Politics, and Hegemonic Masculinity in Australia.” Australian Journal of Political Science 52.2 (2019): 202-218. <https://doi.org/10.1080/10361146.2019.1567677>. Ladd Nelson, Jennifer. “Dress Reform and the Bloomer.” Journal of American and Comparative Cultures 23.1 (2002): 21-25. Mansel, Philip. Dressed to Rule: Royal and Court Costume from Louis XIV to Elizabeth II. New Haven: Yale UP, 2005. “Masquerading as Miss Rankin.” US House of Representatives: History, Arts and Archives. 22 Mar. 2017. <https://history.house.gov/Blog/2017/March/3-27-Masquerading-Rankin/>. Mejia, Zameena. “4 Powerful Reasons Hillary Clinton Always Wears Her Famous Pantsuits.” CNBC 14 Sep. 2017. <https://www.cnbc.com/2017/09/14/hillary-clinton-discusses-why-she-wears-pantsuits-in-what-happened.html>. Naer, Danielle. “The 2 Shoe Styles That Kamala Harris Wears on Repeat Might Surprise You.” The Zoe Report 8 Oct. 2020. <https://www.thezoereport.com/p/kamala-harris-shoe-choices-keep-going-viral-heres-why-37827474>. Norman, Jane. “Liberal MP Nicolle Flint Wears a Bin Bag to Call Out 'Sexist Rubbish' after Column Describes Her Clothing Choices.” ABC News 27 July 2020. <https://www.abc.net.au/news/2020-07-27/liberal-nicolle-flint-wears-garbage-bag-to-protest-sexism/12497238>. Oh, Youri. “Fashion in Politics: What Makes Korean Female Politicians Wear ‘the Suit’ NNot ‘a Dress’?” International Journal of Fashion Design, Technology and Education 12:3 (2019): 374-384. Otnes, Celi, and Pauline Maclaren. Royal Fever: The British Monarch in Consumer Culture. Oakland: U of California P, 2015. Parrillo, Felicia. “What Not to Wear: Quebec National Assembly to Review Dress Code.” Global News 5 Dec. 2018. <https://globalnews.ca/news/4732876/what-not-to-wear-quebec-national-assembly-review-dress-code/>. Pilote, Anne-Marie, and Arnaud Montreuil. “It’s 2019: What’s the Proper Way for Politicians to Dress?” The Conversation 15 Nov. 2019. <https://theconversation.com/its-2019-whats-the-proper-way-for-politicians-to-dress-126968>. Rall, Denise, Jo Coghlan, Lisa Hackett, and Annita Boyd. “‘Dressing Up’: Two Democratic First Ladies: Fashion as Political Performance in America.” Australasian Journal of Popular Culture 7.2 (2018): 273–287. Simm, Pippa. “What Not to Wear in Parliament.” BBC News 23 Dec. 2015. <https://www.bbc.com/news/uk-politics-33700928>. Turney, Joanne. Fashion Crimes: Dressing for Deviance. Bloomsbury, 2019. <https://www.bloomsburycollections.com/book/fashion-crimes-dressing-for-deviance/>. 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Photo by Naveed Ahmed on Unsplash ABSTRACT India has had a solid standard for medical ethics since the birth of Ayurvedic holistic science over 5000 years ago. The country’s views on healthcare policy, counsel on how to deal with patients, and what constitutes good behavior within the profession stem from ancient outlines for medical practice. These “codes of conduct” were heavily influenced by religious and spiritual practices, emphasizing the sanctity of life and transcending the needs of the body. With time, however, medical care evolved through shifting priorities in education and governmental pressures. These once-cherished “codes of conduct” were referred to less often, while malpractice issues have steadily increased. There is a need for an open discussion of why this spike in medical malpractice is happening in a country that used to condemn it and how improving ethics, limiting the role of profits, and returning traditional philosophies to the medical ethics curricula could help. INTRODUCTION Currently, India has the largest number of bioethics units of any country, reflecting the importance of ethical behavior in Indian society. These centers do not affiliate with schools, yet they serve as spaces for bioethical discourse. The Indian Psychiatric Society (IPS) was the first to address escalating malpractice cases. Other major medical organizations (e.g., the Indian Medical Association and the Medical Council of India) followed, stressing the importance of standardized ethics. Some have formed symposiums and organized conferences to address these concerns.[1] There have been several calls to revisit the classic “codes of conduct” and their focus on the spiritual concept of life-death-rebirth. Toward this end, modern Indian doctors were reminded that physicians existed not for fortune or status but for the welfare of their patients. These altruistic teachings came from the seminal Ayurvedic texts, the cornerstone of India’s modern medicine. Happiness for the “healer” was to come out of showing compassion for all living beings and prolonging the precious gift of life.[2] In contrast, Indian novelist, Shashi Tharoor, speaking on the current state of medical practice, recently remarked: “India is not an underdeveloped country, but a highly developed one in an advanced state of decay.”[3] Taking a closer look at what caused the core values of an ancient healthcare system to change so drastically involves evaluating how the Indian medical education system evolved. This paper examines the development of medical principles, their influence across the subcontinent, commercialization, and the government’s role in India’s healthcare instability. This paper then lists some of the measures taken by bioethical units to counteract some of the issues brought on by corruption. l. Western Influence Western influence on medical practices came when the French, Portuguese, and British arrived in India. They almost completely reinvented India’s healthcare system. Medical ethics based on the values of spirituality were almost completely stripped away and replaced by Western concepts.[4] Established traditional ethical standards were no longer taught, resulting in less deference to traditional moral beliefs. Coupled with an increase in medical misconduct, the general population lost trust in their healthcare leaders.[5] Before the influence of Western medicine, the Carakha Sumhita, a millennia-old Sanskrit text detailing Ayurveda, helped establish healthcare guidelines. A passage from the text sums up the ethics of that time: “He who practices medicine out of compassion for all creatures, rather than for gain or for gratification of the senses, surpasses all.”[6] The Carakha Sumhita’s focus on medical ethics was ahead of its time, centuries before bioethics became a subject in its own right. Healthcare was predicated on aphorisms that all medical students internalized rather than on business models, as in many developed nations. India’s caste system, established generations ago, permeated every aspect of South Asian society except for when it came to medicine. Healers tended to ignore the conventions of adhering to an individual’s caste. Instead, they treated patients as if they were family and incorporated elements of spirituality when dealing with patients, making ethical misconduct a rare phenomenon. This was the case for almost two centuries.[7] To become practicing physicians, doctors committed to a consecration ceremony to prove their good moral standing to the people they were to serve.[8] Their schooling prepared them for a profession designed to “give back,” not for monetary gain. The core values taught in medical school affect the mentality doctors carry with them. The lack of ethics training may have been at fault for the underlying corruption levels that now plague the healthcare space in India. There is a 110 percent increase in the rise of medical negligence cases in India every year.[9] To pinpoint why this occurred, we must look at current medical training practices and how they influence doctors of our time period. After colonization, many established core values were stripped from the medical curriculum.[10] In fact, by 1998, only one medical college in India, St. John’s in Bangalore, even addressed medical ethics in its curriculum.[11] Graduates across the country were left ill-equipped to deal with the ethical issues that cropped up once they made it into the field. As a result, they were not prepared to think through consequences pertaining to patients and their families. Some suggest that the curriculum changes were linked to rising malpractice cases. “When society at large is corrupt and unethical, how can you expect doctors to be honest?”[12] This topic arises regularly in bioethics discussions and the answer lies in education. Reverting to a system of medicine that encourages students to recognize ethical consequences can solve many of the ethical problems in contemporary society. ll. Privatization and Tuition Some argue that the global increase in capitalism caused the subcontinent’s ethical problems, that the Indian medical education system began its descent into corruption and nepotism, and its loss in prestige, with the privatization of their colleges.[13] In India, just over 50 percent of medical schools are public, and just under 50 percent are private.[14] Through changing policies, private medical schools became increasingly for-profit like other businesses.[15] Despite having more medical schools than any other country, India has a shortage of doctors, primarily due to low enrollment rates and high university fees. While there are 202 medical schools in India, its large population means there are 5 million people per medical school.[16] Christian Medical College, a top-ranked university in Vellore, once had an acceptance rate of 0.25 percent, with only 100 seats for medical students.[17] Now its acceptance rate hovers around 5 percent. There has been minimal progress in making it easier to get a medical school acceptance; there is still a long way to go in equalizing access to education. India’s system for training doctors is now rife with corruption, with bribes accepted under the guise of “donations” and new curricula completely devoid of traditional Indian training methods.[18] Nepotism in the industry has made qualifications even less significant. In 2010, 69 hospitals and medical colleges were reported for selling exam papers to students, and most employed staff lied about their clinical experience.[19] In a cheating scandal in 2013 involving several Indian universities, students purchased falsified entrance exam results. Not only are these students unqualified for the placements they secured, but legal action by the government did not materialize.[20] Dr. Anand Rai, a physician who had to go into protective hiding following death threats for being a whistleblower in the 2013 scandal subsequently remarked: “...the next generation of doctors is being taught to cheat and deceive before they even enter the classroom.”[21] The effects of this scandal can be felt far beyond its borders - India also happens to be the world’s largest exporter of doctors, with about 47,000 currently practicing in the United States.[22] lll. Hospital Privatization With the privatization of major hospitals and the shift to a “United States” business focus, another serious problem emerged. In the recent past, patients hailing from rural villages and often living in poverty could access quality health care from public hospitals. They had access to highly trained doctors, and all costs were usually fully subsidized.[23] This was in keeping with the old tradition that believed in aid no matter the circumstance. As the focus shifted towards maximizing profitability, these opportunities for poor patients vanished. Chains of private hospitals are rapidly replacing public ones. Their purchasing model is to consolidate through a centralized subsidiary.[24] This usually results in significant savings. Instead of passing on some savings to patients through reduced pricing, any savings are used to fulfill a key objective of privatized businesses: maximize profitability. The poor now contend with inflated prices and are being turned away from facilities that once treated them at no cost, all while levels of trust in the healthcare system have plummeted. This distrust can discourage people who cannot afford care from seeking medical aid when they need it. The healthcare system has devolved to the point whereby remaining public hospitals are overrun by huge numbers of patients unable to afford the hugely inflated prices at private institutions. This, coupled with healthcare workers that often have substandard training, has created deplorable public health conditions. lV. Corruption This deplorable public health condition reflects a failing healthcare system. To make matters worse, hospitals hire unqualified graduates untrained in medical ethics to meet India's urgent need for large numbers of qualified doctors. Many hospitals have even resorted to employing corrupt doctors to counteract the physician shortage. According to the Indian Medical Association (IMA), about 45 percent of those who practice medicine in India have no formal training.[25] IMA also reported that close to 700,000 doctors employed at some of the biggest hospitals, who are currently diagnosing, treating, and operating, have neither the training nor experience to do so. A large-scale forgery ring, broken up in 2011, revealed that buyers could pay as little as 100 US dollars for a medical degree from a non-existent college. This “cleared” them for practice.[26] It has been estimated that over 50,000 fraudulent medical degrees have been purchased in the past decade. Government level corruption is widespread, as one can gain placement into medical school, “graduate” with fake degrees, and sell fake practicing licenses. V. Solutions These topics, raised by bioethics centers, are now being taken more seriously by healthcare professionals taking steps to address medical misconduct. As many as five million people in India die each year due to medical negligence.[27] By requiring each physician to complete a new comprehensive Acute Critical Care Course (ACCC), specialists estimate that physicians can reduce the rate of malpractice deaths by as much as 50 percent in rural areas.[28] This intensive two-year course contains detailed training methods built off of current knowledge and walks healthcare professionals through crucial steps designed to reduce errors. Even small errors, such as a poorly inserted IV for fluid or a minor surgery mishap, can be life threatening. The course thoroughly covers these as mandated.[29] The ACCC is unfortunately not a widely spread concept in a lot of rural areas. For now, while many major hospitals continue to ignore the high rates of avoidable deaths, implementation of the ACCC program seems slow. The current Medical Council of India needs to be more effective at addressing malpractice cases, as there are so many of them.[30] One possible solution to the growth of unethical business practices in medicine is to offer physicians incentives to make ethically sound decisions. This can start by increasing the number of slots available for medical students at government-run medical schools. Less student debt would lead more doctors away from overbilling their patients. This is a strategy currently being employed in the state of Tamil Nadu, where a centrally sponsored scheme has approved the induction of an additional 3,496 MBBS seats in government colleges.[31] More students studying at subsidized costs with less competition lowers the inclination toward deceit and profiteering. Another incentive for ethical practice can come from accountability and transparency. The background of every doctor operating should be public information, including the rate of successful surgeries versus unsuccessful ones resulting from personal negligence. This would encourage doctors to keep a clean record and, in turn, encourage hospitals to hire and train those who will preserve or improve their reputation. This information is kept in a medical record monitored in most parts of India through a traditional paper method.[32] While eliminating paper in medical recording and reverting to digital use is the ultimate aim, it will take time to implement a system that takes into account e-signatures and verifiable witnesses. CONCLUSION India’s history of leadership in medical ethics has undergone some major changes. A relatively recent privatization of the education system has caused a shift in values and decimated the medical industry on many levels. The moral principles of doctors have come into question. While industry and government leaders are trying to solve the multi-faceted issues facing the medical industry, it is obvious that this is an undertaking requiring inventive solutions. Prioritizing ethics in medical education, de-privatizing medical schools and hospitals, offering affordable options, and limiting corruption would improve India’s ability to offer high-quality medical care. Adding traditional Indian medical ethics back into the curricula would foster a workforce dedicated to serving patients over profiteering. - [1] Deshpande, SmitaN. 2016. “The UNESCO Movement for Bioethics in Medical Education and the Indian Scenario.” Indian Journal of Psychiatry 58 (4): 359. https://doi.org/10.4103/0019-5545.196722. [2] Mukherjee, Ambarish, Mousumi Banerjee, Vivekananda Mandal, Amritesh C. Shukla, and Subhash C. Mandal. 2014. “Modernization of Ayurveda: A Brief Overview of Indian Initiatives.” Natural Product Communications 9 (2): 1934578X1400900. https://doi.org/10.1177/1934578x1400900239. [3] 2020. Eubios.info. 2020. https://www.eubios.info/EJ102/EJ102E.htm. [4] Arnold, David, ed. 2000. “Western Medicine in an Indian Environment.” Cambridge University Press. Cambridge: Cambridge University Press. 2000. https://www.cambridge.org/core/books/abs/science-technology-and-medicine-in-colonial-india/western-medicine-in-an-indian-environment/28BAB761BE205B06D32BC3DC972E9384. [5] Kulkarni, Vani, Veena Kulkarni, and Raghav Gaiha. 2019. “Trust in Hospitals-Evidence from India.” https://repository.upenn.edu/cgi/viewcontent.cgi?article=1026&context=psc_publications. [6] Bhasin, Dr Sanjay K. 2005 “What Ails Medical Profession.” Www.academia.edu. Accessed September 17, 2022. https://www.academia.edu/7631547/What_Ails_Medical_Profession. [7] Shapiro, Natasha, and Urmila Patel. (2006) “Asian Indian Culture: Influences and Implications for Health Care.” https://www.molinahealthcare.com/~/media/Molina/PublicWebsite/PDF/providers/fl/medicaid/resource_fl_asianindianculture_influencesandimplicationsforhealthcare.pdf. [8] Swihart, Diana L, and Romaine L Martin. 2021. “Cultural Religious Competence in Clinical Practice.” Nih.gov. StatPearls Publishing. 2021. https://www.ncbi.nlm.nih.gov/books/NBK493216/. [9] “India’s Mighty Medical Education Mess.” 2022. Education World. July 11, 2022. https://www.educationworld.in/indias-mighty-medical-education-mess/. [10] Pandya, Sunil. 2020. “Medical Education in India: Past, Present, and Future Perspectives. in Sun Kim, ed. Medical Schools Nova Science Publishers, Inc. (= [11] Ravindran, G. D., T. Kalam, S. Lewin, and P. Pais. 1997. “Teaching Medical Ethics in a Medical College in India.” The National Medical Journal of India 10 (6): 288–89. https://pubmed.ncbi.nlm.nih.gov/9481103/. [12] “Chapter 9: Opinions on Professional Self-Regulation”(2016) https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/code-of-medical-ethics-chapter-9.pdf. [13]Sanjiv Das. 2020. “The Pill for India’s Ailing Medical Education System.” Express Healthcare. February 3, 2020. https://www.expresshealthcare.in/education/the-pill-for-indias-ailing-medical-education-system/416711/. [14] https://www.marketresearch.com/Netscribes-India-Pvt-Ltd-v3676/Private-Medical-Colleges-India-30399614/."There are ~50.89% government medical colleges and ~49.11% private medical colleges in the country.”; NPR.org. (2021) “When Students in India Can’t Earn College Admission on Merit, They Buy Their Way In.” Accessed September 19, 2022. https://www.npr.org/2019/08/04/745182272/when-students-in-india-cant-earn-college-admission-on-merit-they-buy-their-way-i. [15] https://timesofindia.indiatimes.com/india/how-medical-colleges-in-india-became-a-business-one-policy-change-at-a-time/articleshow/69707594.cms [16] Muula A. S. (2006). Every country or state needs two medical schools. Croatian medical journal, 47(4), 669–672. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2080437/ [17] Miglani, Andrew MacAskill, Steve Stecklow, Sanjeev. 2015. “Why India’s Medical Schools Are Plagued with Fraud.” Mint. June 17, 2015. https://www.livemint.com/Politics/BDGOx3SApU3QbsRMjZUK9M/Why-Indias-medical-schools-are-plagued-with-fraud.html. [18] Clark, J. 2015. “Indian Medical Education System Is Broken, Reuters Investigation Finds.” BMJ 350 (jun18 3): h3324–24. https://doi.org/10.1136/bmj.h3324. [19] Reuters. 2015. “Special Report - Why India’s Medical Schools Are Plagued with Fraud,” June 16, 2015, sec. Special Reports. https://www.reuters.com/article/uk-india-medicine-education-specialrepor/special-report-why-indias-medical-schools-are-plagued-with-fraud-idINKBN0OW1N520150616. [20] Andrew Emett. (2015) “Over Two Dozen Witnesses and Suspects Mysteriously Die in Indian Cheating Scandal | NationofChange.” Accessed September 19, 2022. https://www.nationofchange.org/2015/07/08/over-two-dozen-witnesses-and-suspects-mysteriously-die-in-indian-cheating-scandal/. [21] (Reuters 2015) [22] Clark, J. 2015. “Indian Medical Education System Is Broken, Reuters Investigation Finds.” BMJ 350 (jun18 3): h3324–24. https://doi.org/10.1136/bmj.h3324. [23] Barik, Debasis, and Amit Thorat. 2015. “Issues of Unequal Access to Public Health in India.” Frontiers in Public Health 3 (October). https://doi.org/10.3389/fpubh.2015.00245. [24] “Investment Opportunities in India’s Healthcare Sector.” (2021) https://www.niti.gov.in/sites/default/files/2021-03/InvestmentOpportunities_HealthcareSector_0.pdf. [25] Clark, J. 2015. “Indian Medical Education System Is Broken, Reuters Investigation Finds.” BMJ 350 (jun18 3): h3324–24. https://doi.org/10.1136/bmj.h3324. [26] “Are We Importing Fake Doctors?” (2015) Www.workerscompensation.com. Accessed September 19, 2022. https://www.workerscompensation.com/news_read.php?id=21672&forgot=yes. [27] Boston, 677 Huntington Avenue, and Ma 02115 +1495‑1000. 2013. “Millions Harmed Each Year from Unsafe Medical Care.” News. September 19, 2013. https://www.hsph.harvard.edu/news/press-releases/millions-harmed-each-year-from-unsafe-medical-care/. [28] “Specialised Course for Doctors Can Help Cut the Deaths due to Medical Errors; Experts.” 2018. DailyRounds. October 29, 2018. https://www.dailyrounds.org/blog/specialised-course-for-doctors-can-help-cut-the-deaths-due-to-medical-errors-experts/. [29] Sokhal, Navdeep, Akshay Kumar, Richa Aggarwal, Keshav Goyal, Kapil Dev Soni, Rakesh Garg, Ashok Deorari, and Ajay Sharma. 2021. “Acute Critical Care Course for Interns to Develop Competence.” The National Medical Journal of India 34 (3): 167–70. https://doi.org/10.25259/NMJI_103_19. [30] Singhania, Meghna A. 2020. “How Much Punishment?- MCI Formulates Sentencing Guidelines for Cases of Medical Negligence.” Medicaldialogues.in. February 13, 2020. https://medicaldialogues.in/news/health/mci/how-much-punishment-mci-formulates-sentencing-guidelines-for-cases-of-medical-negligence-62645. [31] “Health Ministry Reports 30% Increase in Number of Functional Medical Colleges in Five Years.” (2022) Www.pharmabiz.com. Accessed September 19, 2022. http://www.pharmabiz.com/NewsDetails.aspx?aid=152299&sid=1. [32] Honavar, Santosh G. 2020. “Electronic Medical Records – the Good, the Bad and the Ugly.” Indian Journal of Ophthalmology 68 (3): 417. https://doi.org/10.4103/ijo.ijo_278_20.

The first two months of 2021 saw Google and Facebook ‘go dark’ in terms of news content on the Australia versions of their platforms. In January, Google ran a so-called “experiment” which removed or demoted current news in the search results available to a segment of Australian users. While Google was only darkened for some, in February news on Facebook went completely dark, with the company banning all news content and news sharing for users within Australian. Both of these instances of going dark occurred because of the imminent threat these platforms faced from the News Media Bargaining Code legislation that was due to be finalised by the Australian parliament. This article examines how both Google and Facebook responded to the draft Code, focussing on their threats to go dark, and the extent to which those threats were carried out. After exploring the context which produced the threats of going dark, this article looks at their impact, and how the Code was reshaped in light of those threats before it was finally legislated in early March 2021. Most importantly, this article outlines why Google and Facebook were prepared to go dark in Australia, and whether they succeeded in trying to prevent Australia setting the precedent of national governments dictating the terms by which digital platforms should pay for news content. From the Digital Platforms Inquiry to the Draft Code In July 2019, the Australian Treasurer released the Digital Platforms Inquiry Final Report which had been prepared by the Australian Competition and Consumer Commission (ACCC). It outlined a range of areas where Australian law, policies and practices were not keeping pace with the realities of a digital world of search giants, social networks, and streaming media. Analysis of the submissions made as part of the Digital Platforms Inquiry found that the final report was “primarily framed around the concerns of media companies, particularly News Corp Australia, about the impact of platform companies’ market dominance of content distribution and advertising share, leading to unequal economic bargaining relationships and the gradual disappearance of journalism jobs and news media publishers” (Flew et al. 13). As such, one of the most provocative recommendations made was the establishment of a new code that would “address the imbalance in the bargaining relationship between leading digital platforms and news media businesses” (Australian Competition and Consumer Commission, Digital Platforms Inquiry 16). The ACCC suggested such a code would assist Australian news organisations of any size in negotiating with Facebook, Google and others for some form of payment for news content. The report was released at a time when there was a greatly increased global appetite for regulating digital platforms. Thus the battle over the Code was watched across the world as legislation that had the potential to open the door for similar laws in other countries (Flew and Wilding). Initially the report suggested that the digital giants should be asked to develop their own codes of conduct for negotiating with news organisations. These codes would have then been enforced within Australia if suitably robust. However, after months of the big digital platforms failing to produce meaningful codes of their own, the Australian government decided to commission their own rules in this arena. The ACCC thus prepared the draft legislation that was tabled in July 2020 as the Australian News Media Bargaining Code. According to the ACCC the Code, in essence, tried to create a level playing field where Australian news companies could force Google and Facebook to negotiate a ‘fair’ payment for linking to, or showing previews of, their news content. Of course, many commentators, and the platforms themselves, retorted that they already bring significant value to news companies by referring readers to news websites. While there were earlier examples of Google and Facebook paying for news, these were largely framed as philanthropy: benevolent digital giants supporting journalism for the good of democracy. News companies and the ACCC argued this approach completely ignored the fact that Google and Facebook commanded more than 80% of the online advertising market in Australia at that time (Meade, “Google, Facebook and YouTube”). Nor did the digital giants acknowledge their disruptive power given the bulk of that advertising revenue used to flow to news companies. Some of the key features of this draft of the Code included (Australian Competition and Consumer Commission, “News Media Bargaining Code”): Facebook and Google would be the (only) companies initially ‘designated’ by the Code (i.e. specific companies that must abide by the Code), with Instagram included as part of Facebook. The Code applied to all Australian news organisations, and specifically mentioned how small, regional, and rural news media would now be able to meaningfully bargain with digital platforms. Platforms would have 11 weeks after first being contacted by a news organisation to reach a mutually negotiated agreement. Failure to reach agreements would result in arbitration (using a style of arbitration called final party arbitration which has both parties present a final offer or position, with an Australian arbiter simply choosing between the two offers in most cases). Platforms were required to give 28 days notice of any change to their algorithms that would impact on the ways Australian news was ranked and appeared on their platform. Penalties for not following the Code could be ten million dollars, or 10% of the platform’s annual turnover in Australia (whichever was greater). Unsurprisingly, Facebook, Google and a number of other platforms and companies reacted very negatively to the draft Code, with their formal submissions arguing: that the algorithm change notifications would give certain news companies an unfair advantage while disrupting the platforms’ core business; that charging for linking would break the underlying free nature of the internet; that the Code overstated the importance and reach of news on each platform; and many other objections were presented, including strong rejections of the proposed model of arbitration which, they argued, completely favoured news companies without providing any real or reasonable limit on how much news organisations could ask to be paid (Google; Facebook). Google extended their argument by making a second submission in the form of a report with the title ‘The Financial Woes of News Publishers in Australia’ (Shapiro et al.) that argued Australian journalism and news was financially unsustainable long before digital platforms came along. However, in stark contrast the Digital News Report: Australia 2020 found that Google and Facebook were where many Australians found their news; in 2020, 52% of Australians accessed news on social media (up from 46% the year before), with 39% of Australians getting news from Facebook, and that number jumping to 49% when specifically focusing on news seeking during the first COVID-19 pandemic peak in April 2021 (Park et al.). The same report highlighted that 43% of people distrust news found on social media (with a further 29% neutral, and only 28% of people explicitly trusting news found via social media). Moreover, 64% of Australians were concerned about misinformation online, and of all the platforms mentioned in the survey, respondents were most concerned about Facebook as a source of misinformation, with 36% explicitly indicating this was the place they were most concerned about encountering ‘fake news’. In this context Facebook and Google battled the Code by launching a public relations campaigns, appealing directly to Australian consumers. Google Drives a Bus Across Australia Google’s initial response to the draft Code was a substantial public relations campaign which saw the technology company advocating against the Code but not necessarily the ideas behind it. Google instead posited their own alternative way of paying for journalism in Australia. On the main Google search landing page, the usually very white surrounds of the search bar included the text “Supporting Australian journalism: a constructive path forward” which linked to a Google page outlining their version of a ‘Fair Code’. Popup windows appeared across many of Google’s services and apps, noting Google “are willing to pay to support journalism”, with a button labelled ‘Hear our proposal’. Figure 1: Popup notification on Google Australia directing users to Google’s ‘A Fair Code’ proposal rebutting the draft Code. (Screen capture by author, 29 January 2021) Google’s popups and landing page links were visible for more than six months as the Code was debated. In September 2020, a Google blog post about the Code was accompanied by a YouTube video campaign featuring Australia comedian Greta Lee Jackson (Google Australia, Google Explains Arbitration). Jackson used the analogy of Google as a bus driver, who is forced to pay restaurants for delivering customers to them, and then pay part of the running costs of restaurants, too. The video reinforced Google’s argument that the draft Code was asking digital platforms to pay potentially enormous costs for news content without acknowledging the value of Google bringing readers to the news sites. However, the video opened with the line that “proposed laws can be confusing, so I'll use an analogy to break it down”, setting a tone that would seem patronising to many people. Moreover, the video, and Google’s main argument, completely ignored the personal data Google receives every time a user searches for, or clicks on, a news story via Google Search or any other Google service. If Google’s analogy was accurate, then the bus driver would be going through every passenger’s bag while they were on the bus, taking copies of all their documents from drivers licenses to loyalty cards, keeping a record of every time they use the bus, and then using this information to get advertisers to pay for a tailored advertisement on the back of the seat in front of every passenger, every time they rode the bus. Notably, by the end of March 2021, the video had only received 10,399 views, which suggests relatively few people actually clicked on it to watch. In early January 2021, at the height of the debate about the Code, Google ran what they called “an experiment” which saw around 1% of Australian users suddenly only receive “older or less relevant content” when searching for news (Barnet, “Google’s ‘Experiment’”). While ostensibly about testing options for when the Code became law, the unannounced experiment also served as a warning shot. Google very effectively reminded users and politicians about their important role in determining which news Australian users find, and what might happen if Google darkened what they returned as news results. On 21 January 2021, Mel Silva, the Managing Director and public face of Google in Australia and New Zealand gave public testimony about the company’s position before a Senate inquiry. Silva confirmed that Google were indeed considering removing Google Search in Australia altogether if the draft Code was not amended to address their key concerns (Silva, “Supporting Australian Journalism: A Constructive Path Forward An Update on the News Media Bargaining Code”). Google’s seemingly sudden escalation in their threat to go dark led to articles such as a New York Times piece entitled ‘An Australia with No Google? The Bitter Fight behind a Drastic Threat’ (Cave). Google also greatly amplified their appeal to the Australian public, with a video featuring Mel Silva appearing frequently on all Google sites in Australia to argue their position (Google Australia, An Update). By the end of March 2021, Silva’s video had been watched more than 2.2 million times on YouTube. Silva’s testimony, video and related posts from Google all characterised the Code as: breaking “how Google search works in Australia”; creating a world where links online are paid for and thus both breaking Google and “undermin[ing] how the web works”; and saw Google offer their News Showcase as a viable alternative that, in Google’s view, was “a fair one” (Silva, “Supporting Australian Journalism”). Google emphasised submissions about the Code which backed their position, including World Wide Web inventor Tim Berners-Lee who agreed that the idea of charging for links could have a more wide-reaching impact, challenging the idea of a free web (Leaver). Google also continued to release their News Showcase product in other parts of the world. They emphasised that there were existing arrangements for Showcase in Australia, but the current regulatory uncertainty meant it was paused in Australia until the debates about the Code were resolved. In the interim, news media across Australia, and the globe, were filled with stories speculating what an Australia would look like if Google went completely dark (e.g. Cave; Smyth). Even Microsoft weighed in to supporting the Code and offer their search engine Bing as a viable alternative to fill the void if Google really did go dark (Meade, “Microsoft’s Bing”). In mid-February, the draft Code was tabled in Australian parliament. Many politicians jumped at the chance to sing the Code’s praises and lament the power that Google and Facebook have across various spheres of Australian life. Yet as these speeches were happening, the Australian Treasurer Josh Frydenberg was holding weekend meetings with executives from Google and Facebook, trying to smooth the path toward the Code (Massola). In these meetings, a number of amendments were agreed to, including the Code more clearly taking in to account any existing deals already on the table before it became law. In these meetings the Treasurer made in clear to Google that if the deals done prior to the Code were big enough, he would consider not designating Google under the Code, which in effect would mean Google is not immediately subject to it (Samios and Visentin). With that concession in hand Google swiftly signed deals with over 50 Australian news publishers, including Seven West Media, Nine, News Corp, The Guardian, the ABC, and some smaller publishers such as Junkee Media (Taylor; Meade, “ABC Journalism”). While the specific details of these deals were not made public, the deals with Seven West Media and Nine were both reported to be worth around $30 million Australian dollars (Dudley-Nicholson). In reacting to Google's deals Frydenberg described them as “generous deals, these are fair deals, these are good deals for the Australian media businesses, deals that they are making off their own bat with the digital giants” (Snape, “‘These Are Good Deals’”). During the debates about the Code, Google had ultimately ensured that every Australian user was well aware that Google was, in their words, asking for a “fair” Code, and before the Code became law even the Treasurer was conceding that Google’s was offering a “fair deal” to Australian news companies. Facebook Goes Dark on News While Google never followed through on their threat to go completely dark, Facebook took a very different path, with a lot less warning. Facebook’s threat to remove all news from the platform for users in Australia was not made explicit in their formal submissions the draft of the Code. However, to be fair, Facebook’s Managing Director in Australia and New Zealand Will Easton did make a blog post at the end of August 2020 in which he clearly stated: “assuming this draft code becomes law, we will reluctantly stop allowing publishers and people in Australia from sharing local and international news on Facebook and Instagram” (Easton). During the negotiations in late 2020 Instagram was removed as an initial target of the Code (just as YouTube was not included as part of Google) along with a number of other concessions, but Facebook were not sated. Yet Easton’s post about removing news received very little attention after it was made, and certainly Facebook made no obvious attempt to inform their millions of Australian users that news might be completely blocked. Hence most Australians were shocked when that was exactly what Facebook did. Facebook’s power has, in many ways, always been exercised by what the platform’s algorithms display to users, what content is most visible and equally what content is made invisible (Bucher). The morning of Wednesday, 17 February 2021, Australian Facebook users awoke to find that all traditional news and journalism had been removed from the platform. Almost all pages associated with news organisations were similarly either disabled or wiped clean, and that any attempt to share links to news stories was met with a notification: “this post can’t be shared”. The Australian Prime Minister Scott Morrison reacted angrily, publicly lamenting Facebook’s choice to “unfriend Australia”, adding their actions were “as arrogant as they were disappointing”, vowing that Australia would “not be intimidated by big tech” (Snape, “Facebook Unrepentant”). Figure 2: Facebook notification appearing when Australians attempted to share news articles on the platform. (Screen capture by author, 20 February 2021) Facebook’s news ban in Australia was not limited to official news pages and news content. Instead, their ban initially included a range of pages and services such as the Australian Bureau of Meteorology, emergency services pages, health care pages, hospital pages, services providing vital information about the COVID-19 pandemic, and so forth. The breadth of the ban may have been purposeful, as one of Facebook’s biggest complaints was that the Code defined news too broadly (Facebook). Yet in the Australian context, where the country was wrestling with periodic lockdowns and the Coronavirus pandemic on one hand, and bushfires and floods on the other, the removal of these vital sources of information showed a complete lack of care or interest in Australian Facebook users. Beyond the immediate inconvenience of not being able to read or share news on Facebook, there were a range of other, immediate, consequences. As Barnet, amongst others, warned, a Facebook with all credible journalism banned would almost certainly open the floodgates to a tide of misinformation, with nothing left to fill the void; it made Facebook’s “public commitment to fighting misinformation look farcical” (Barnet, “Blocking Australian News”). Moreover, Bossio noted, “reputational damage from blocking important sites that serve Australia’s public interest overnight – and yet taking years to get on top of user privacy breaches and misinformation – undermines the legitimacy of the platform and its claimed civic intentions” (Bossio). If going dark and turning off news in Australia was supposed to win the sympathy of Australian Facebook users, then the plan largely backfired. Yet as with Google, the Australian Treasurer was meeting with Mark Zuckerberg and Facebook executives behind closed doors, which did eventually lead to changes before the Code was finally legislated (Massola). Facebook gained a number of concessions, including: a longer warning period before a Facebook could be designated by the Code; a longer period before news organisations would be able to expect negotiations to be concluded; an acknowledgement that existing deals would be taken in to account during negotiations; and, most importantly, a clarification that if Facebook was to once again block news this would both prevent them being subject to the Code and was not be something the platform could be punished for. Like Google, though, Facebook’s biggest gain was again the Treasurer making it clear that by making deals in advance on the Code becoming law, it was likely that Facebook would not be designated, and thus not subject to the Code at all (Samios and Visentin). After these concessions the news standoff ended and on 23 February the Australian Treasurer declared that after tense negotiations Facebook had “refriended Australia”; the company had “committed to entering into good-faith negotiations with Australian news media businesses and seeking to reach agreements to pay for content” (Visentin). Over the next month there were some concerns voiced about slow progress, but then major deals were announced between Facebook and News Corp Australia, and with Nine, with other deals following closely (Meade, “Rupert Murdoch”). Just over a week after the ban began, Facebook returned news to their platform in Australia. Facebook obviously felt they had won the battle, but Australia Facebook users were clearly cannon fodder, with their interests and wellbeing ignored. Who Won? The Immediate Aftermath of the Code After the showdowns with Google and Facebook, the final amendments to the Code were made and it was legislated as the News Media and Digital Platforms Mandatory Bargaining Code (Australian Treasury), going into effect on 2 March 2021. However, when it became legally binding, not one single company was ‘designated’, meaning that the Code did not immediately apply to anyone. Yet deals had been struck, money would flow to Australian news companies, and Facebook had returned news to its platform in Australia. At the outset, Google, Facebook, news companies in Australia and the Australian government all claimed to have won the battle over the Code. Having talked up their tough stance on big tech platforms when the Digital Platforms Inquiry landed in 2019, the Australian Government was under public pressure to deliver on that rhetoric. The debates and media coverage surrounding the Code involved a great deal of political posturing and gained much public attention. The Treasurer was delighted to see deals being struck that meant Facebook and Google would pay Australian news companies. He actively portrayed this as the government protecting Australia’s interest and democracy. The fact that the Code was leveraged as a threat does mean that the nuances of the Code are unlikely to be tested in a courtroom in the near future. Yet as a threat it was an effective one, and it does remain in the Treasurer’s toolkit, with the potential to be deployed in the future. While mostly outside the scope of this article, it should definitely be noted that the biggest winner in the Code debate was Rupert Murdoch, executive chairman of News Corp. They were the strongest advocates of regulation forcing the digital giants to pay for news in the first place, and had the most to gain and least to lose in the process. Most large news organisations in Australia have fared well, too, with new revenue flowing in from Google and Facebook. However, one of the most important facets of the Code was the inclusion of mechanisms to ensure that regional and small news publishers in Australia would be able to negotiate with Facebook and Google. While some might be able to band together and strike terms (and some already have) it is likely that many smaller news companies in Australia will miss out, since the deals being struck with the bigger news companies appear to be big enough to ensure they are not designated, and thus not subject to the Code (Purtill). A few weeks after the Code became law ACCC Chair Rod Sims stated that the “problem we’re addressing with the news media code is simply that we wanted to arrest the decline in money going to journalism” (Kohler). On that front the Code succeeded. However, there is no guarantee the deals will mean money will support actual journalists, rather than disappearing as extra corporate profits. Nor is there any onus on Facebook or Google to inform news organisations about changes to their algorithms that might impact on news rankings. Also, as many Australia news companies are now receiving payments from Google and Facebook, there is a danger the news media will become dependent on that revenue, which may make it harder for journalists to report on the big tech giants without some perceptions of a conflict of interest. In a diplomatic post about the Code, Google thanked everyone who had voiced concerns with the initial drafts of the legislation, thanked Australian users, and celebrated that their newly launched Google News Showcase had “two million views of content” with more than 70 news partners signed up within Australia (Silva, “An Update”). Given that News Showcase had already begun rolling out elsewhere in the world, it is likely Google were already aware they were going to have to contribute to the production of journalism across the globe. The cost of paying for news in Australia may well have fallen within the parameters Google had already decided were acceptable and inevitable before the debate about the Code even began (Purtill). In the aftermath of the Code becoming legislation, Google also posted a cutting critique of Microsoft, arguing they were “making self-serving claims and are even willing to break the way the open web works in an effort to undercut a rival” (Walker). In doing so, Google implicitly claimed that the concessions and changes to the Code they had managed to negotiate effectively positioned them as having championed the free and open web. At the end of February 2021, in a much more self-congratulatory post-mortem of the Code entitled “The Real Story of What Happened with News on Facebook in Australia”, Facebook reiterated their assertion that they bring significant value to news publishers and that the platform receives no real value in return, stating that in 2020 Facebook provided “approximately 5.1 billion free referrals to Australian publishers worth an estimated AU$407 million to the news industry” (Clegg). Deploying one last confused metaphor, Facebook argued the original draft of the Code was “like forcing car makers to fund radio stations because people might listen to them in the car — and letting the stations set the price.” Of course, there was no mention that following that metaphor, Facebook would have bugged the car and used that information to plaster the internal surfaces with personalised advertising. Facebook also touted the success of their Facebook News product in the UK, albeit without setting a date for the rollout of the product in Australia. While Facebook did concede that “the decision to stop the sharing of news in Australia appeared to come out of nowhere”, what the company failed to do was apologise to Australian Facebook users for the confusion and inconvenience they experienced. Nevertheless, on Facebook’s own terms, they certainly positioned themselves as having come out winners. Future research will need to determine whether Facebook’s actions damaged their reputation or encouraged significant numbers of Australians to leave the platform permanently, but in the wake of a number of high-profile scandals, including Cambridge Analytica (Vaidhyanathan), it is hard to see how Facebook’s actions would not have further undermined consumer trust in the company and their main platform (Park et al.). In fighting the Code, Google and Facebook were not just battling the Australian government, but also the implication that if they paid for news in Australia, they likely would also have to do so in other countries. The Code was thus seen as a dangerous precedent far more than just a mechanism to compel payment in Australia. Since both companies ensured they made deals prior to the Code becoming law, neither was initially ‘designated’, and thus neither were actually subject to the Code at the time of writing. The value of the Code has been as a threat and a means to force action from the digital giants. How effective it is as a piece of legislation remains to be seen in the future if, indeed, any company is ever designated. For other countries, the exact wording of the Code might not be as useful as a template, but its utility to force action has surely been noted. Like the inquiry which initiated it, the Code set “the largest digital platforms, Google and Facebook, up against the giants of traditional media, most notably Rupert Murdoch’s News Corporation” (Flew and Wilding 50). Yet in a relatively unusual turn of events, both sides of that battle claim to have won. At the same time, EU legislators watched the battle closely as they considered an “Australian-style code” of their own (Dillon). Moreover, in the month immediately following the Code being legislated, both the US and Canada were actively pursuing similar regulation (Baier) with Facebook already threatening to remove news and go dark for Canadian Facebook users (van Boom). For Facebook, and Google, the battle continues, but fighting the Code has meant the genie of paying for news content is well and truly out of the bottle. References Australian Competition and Consumer Commission. 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Silva, Mel. “An Update on the News Media Bargaining Code.” Google Australia, 1 Mar. 2021. <http://www.google.com.au/google-in-australia/an-open-letter/>. ———. “Supporting Australian Journalism: A Constructive Path Forward – An Update on the News Media Bargaining Code.” Google Australia, 22 Jan. 2021. <https://about.google/intl/ALL_au/google-in-australia/jan-6-letter/>. Smyth, Jamie. “Australian Companies Forced to Imagine Life without Google.” Financial Times, 9 Feb. 2021. <https://www.ft.com/content/fa66e8dc-afb1-4a50-8dfa-338a599ad82d>. Snape, Jack. “Facebook Unrepentant as Prime Minister Dubs Emergency Services Block ‘Arrogant.’” ABC News, 18 Feb. 2021. <https://www.abc.net.au/news/2021-02-18/facebook-unrepentant-scott-morrison-dubs-move-arrogant/13169340>. ———. “‘These Are Good Deals’: Treasurer Praises Google News Deals amid Pressure from Government Legislation.” ABC News, 17 Feb. 2021. <https://www.abc.net.au/news/2021-02-17/treasurer-praises-good-deals-between-google-news-seven/13163676>. Taylor, Josh. “Guardian Australia Strikes Deal with Google to Join News Showcase.” The Guardian, 20 Feb. 2021. <http://www.theguardian.com/technology/2021/feb/20/guardian-australia-strikes-deal-with-google-to-join-news-showcase>. Vaidhyanathan, Siva. Antisocial Media: How Facebook Disconnects Us and Undermines Democracy. Oxford: Oxford UP, 2018. 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Photo by Nathan Dumlao on Unsplash ABSTRACT The demographic of physicians in the United States has failed to include a proportionate population of Latinos in the United States. In what follows, I shall argue that the medical school admission process places an undue burden on low-income Latino applicants. Hence, the underrepresentation of Latinos in medical schools is an injustice. This injustice relates to the poor community health of the Latino community. Health disparities such as diabetes, HIV infection, and cancer mortality are higher amongst the Latino community. The current representation of Latino medical students is not representative of those in the United States. INTRODUCTION The demographic of physicians in the United States has failed to include a proportionate number of Latinos, meaning people of Latin American origin. Medical schools serve as the gatekeepers to the medical field, and they can alter the profession based on whom they admit. With over 60 million Latinos in the United States, people of Latin American origin comprise the largest minority group in the nation.[1] In 2020-2021, only 6.7 percent of total US medical school enrollees and only 4 percent of medical school leadership identified as Latino.[2] Latino physicians can connect to a historically marginalized community that faces barriers including language, customs, income, socioeconomic status, and health literacy. I argue that the medical school admissions process places an undue burden on low-income Latino applicants. This paper explores the underrepresentation of Latinos in medical schools as an injustice. A further injustice occurs as the barriers to medical education result in fewer Latino doctors to effectively deliver health care and preventive health advice to their communities in a culturally competent way. I. Latino Community Health Data The terms Latino and Hispanic have largely been considered interchangeable. US government departments, such as the US Census Bureau and the Centers for Disease Control and Prevention (CDC), define Hispanic people as those with originating familial ties to native Spanish-speaking countries, most of whom are from Latin America. The term Latino is more inclusive because it refers to all of those with strong originating ties to countries in Latin America, including those coming from countries such as Brazil and Belize who are not native Spanish speakers. Throughout this work, I refer to the term Latino because it is more inclusive, although the data retrieved from US government departments may refer to the population as Hispanic. “Low-income” refers to the qualifying economic criteria for the AAMC’s Fee Assistance Program Poverty Guidelines.[3] The AAMC Fee Assistance Program is designed to help individuals who do not have the financial means to pay the total costs of applying to medical school. For this paper, low-income refers to those who qualify for this program. The US government gathers data about Latino community health and its health risks. The Latino community has a higher poverty rate than the non-Hispanic white community.[4] Latino community health has long trailed that of white people collectively. For example, the Latino community experiences higher levels of preventable diseases, including hypertension, diabetes, and hepatitis, than the non-Hispanic white community does.[5] The CDC collects data about Latino community health and provides statistics to the public. Latinos in the United States trail only non-Hispanic blacks in prevalence of obesity. The Latino adult obesity rates are 45.7 percent for males and 43.7 percent for females.[6] Of the 1.2 million people infected with HIV in the United States, 294,200 are Latino.[7] The infection rate of chlamydia is 392.6 per 100,000 ― 1.9 times the rate in the non-Hispanic white population.[8] The tuberculosis incidence rate is eight times higher than that of non-Hispanic white people at 4.4 per 100,000.[9] Furthermore, Latinos have the third highest death rate for hepatitis C among all races and ethnic groups.[10] The prevalence of total diabetes, diagnosed and undiagnosed, among adults aged 18 and older also remains higher than that of non-Hispanic whites at 14.7 percent compared to 11.9 percent.[11] The high disease rate evidences the poor health of the community. Furthermore, 19 percent of Latinos in the United States remain uninsured.[12] Almost a quarter of the Latino population in the United States lives in poverty.[13] The high incidence of disease, lack of insurance, and high poverty rate create a frail health status for the Latino community in the United States. The medical conditions seen are largely preventable, and the incident rates can be lowered with greater investments in Latino community health. Considering the health disparities between Latino and non-Hispanic White people, there is an ethical imperative to provide better medical care and guidance to the Latino community. II. Ethical and Practical Importance of Increasing the Number of Latino Physicians Minorities respond more positively to patient-physician interactions and are more willing to undergo preventative healthcare when matched with a physician of their racial or ethnic background.[14] Latino medical doctors may lead to an improvement in overall community health through improved communication and trusting relationships. Patient-physician racial concordance leads to greater patient satisfaction with their physicians.[15] Identifying with the ethnicity of a physician may lead to greater confidence in the physician-patient relationship, resulting in more engagement on the patient’s behalf. A randomized study regarding African American men and the race of their attending physician found an increase in requests for preventative care when assigned to a black doctor.[16] Although the subjects were African American men, the study has implications applicable to other minority racial and ethnic groups. The application process is unjust for low-income Latinos. The low matriculation of Latinos in medical schools represents a missed opportunity to alleviate the poor community health of the Latino population in the United States. Medical school also would create an opportunity to address health issues that plague the Latino community. Becoming a physician allows low-income Latinos to climb the social ladder and enter the spaces in health care that have traditionally been closed off to them. Nonwhite physicians significantly serve underserved communities.[17] Increasing the number of Latino doctors can boost their presence, potentially improving care for underserved individuals. Teaching physicians cultural competence is not enough to address the health disparities the Latino community faces. Latino physicians are best equipped to understand the healthcare needs of low-income Latinos. I contend that reforming the application process represents the most straightforward method to augment the number of Latino physicians who wish to work in predominantly Latino or diverse communities, thereby improving healthcare for the Latino community. III. Cultural Tenets Affecting Healthcare Interactions “Poor cultural competence can lead to decreased patient satisfaction, which may cause the patient not to attend future appointments or seek further care.”[18] Latino community health is negatively affected when medical professionals misinterpret cultural beliefs. Cultural tenets like a reservation towards medication, a deep sense of respect for the physician, and an obligation to support the family financially and through advocacy affect how Latinos seek and use the healthcare system.[19] First, the Latino population's negative cultural beliefs about medication add a barrier to patient compliance. It is highlighted that fear of dependence upon medicine leads to trouble with medication regimens.[20] The fear stems from the negative perception of addiction in the Latino community. Taking as little medication as possible avoids the chance of addiction occurring, which is why many take the prescribed medicine only until they feel healthier, regardless of the prescribing regimen. Some would rather not take any medication because of the deep-rooted fear. Physicians must address this concern by communicating the importance of patient compliance to remedy the health issue. Explaining that proper use of the medication as prescribed will ensure the best route to alleviate the condition and minimize the occurrence of dependence. Extra time spent addressing concerns and checking for comprehension may combat the negative perception of medication. Second, the theme of respeto, or respect, seems completely harmless to most people. After all, how can being respectful lead to bad health? This occurs when respect is understood as paternalism. Some patients may relinquish their decision-making to the physician. The physician might not act with beneficence, in this instance, because of the cultural dissonance in the physician-patient relationship that may lead to medical misinterpretation. A well-meaning physician might not realize that the patient is unlikely to speak up about their goals of care and will follow the physician’s recommendations without challenging them. That proves costly because a key aspect of the medical usefulness of a patient’s family history is obtaining it through dialogue. The Latino patient may refrain from relaying health concerns because of the misconceived belief that it’s the doctor’s job to know what to ask. Asking the physician questions may be considered a sign of disrespect, even if it applies to signs, symptoms, feelings, or medical procedures the patient may not understand.[21] Respeto is dangerous because it restricts the patients from playing an active role in their health. Physicians cannot derive what medical information may be relevant to the patient without their cooperation. And physicians without adequate cultural competency may not know they need to ask more specific questions. Cultural competency may help, but a like-minded physician raised similarly would be a more natural fit. “A key component of physician-patient communication is the ability of patients to articulate concerns, reservations, and lack of understanding through questions.”[22] As a patient, engaging with a physician of one’s cultural background fortifies a strong physician-patient relationship. Latino physicians are in the position to explain to the patients that respeto is not lost during a physician-patient dialogue. In turn, the physician can express that out of their value of respeto, and the profession compels them to place the patient’s best interest above all. This entails physicians advocating on behalf of the patients to ask questions and check for comprehension, as is required to obtain informed consent. Latino physicians may not have a cultural barrier and may already organically understand this aspect of their patient’s traditional relationship with physicians. The common ground of respeto can be used to improve the health of the Latino community just as it can serve as a barrier for someone from a different background. Third, in some Latino cultures, there is an expectation to contribute to the family financially or in other ways and, above all, advocate on the family’s behalf. Familial obligations entail more than simply translating or accompanying family members to their appointments. They include actively advocating for just treatment in terms of services. Navigating institutions, such as hospitals, in a foreign landscape proves difficult for underrepresented minorities like Latinos who are new to the United States. These difficulties can sometimes lead to them being taken advantage of, as they might not fully understand their rights, the available resources, or the standard procedures within these institutions. The language barrier and unfamiliar institutional policies may misinterpret patients’ needs or requests. Furthermore, acting outside of said institution’s policy norms may be erroneously interpreted as actions of an uncooperative patient leading to negative interactions between the medical staff and the Latino patient. The expectation of familial contribution is later revisited as it serves as a constraint to the low-income Latino medical school applicant. Time is factored out to meet these expectations, and a moral dilemma to financially contribute to the family dynamic rather than delay the contribution to pursue medical school discourages Latinos from applying. IV. How the Medical School Admission Process is Creating an Undue Burden for Low-Income Latino Applicants Applying a bioethics framework to the application process highlights its flaws. Justice is a central bioethical tenet relevant to the analysis of the MD admissions process. The year-long medical school application process begins with the primary application. The student enters information about the courses taken, completes short answer questions and essays, and uploads information about recommenders. Secondary applications are awarded to some medical students depending on the institutions’ policies. Some schools ask all applicants for secondary applications, while others select which applicants to send secondary requests. Finally, interviews are conducted after a review of both primary and secondary applications. This is the last step before receiving an admissions decision. The medical school application process creates undue restrictions against underserved communities. It is understood that matriculating into medical school and becoming a doctor should be difficult. The responsibilities of a physician are immense, and the consequences of actions or inactions may put the patients’ lives in jeopardy. Medical schools should hold high standards because of the responsibility and expertise required to provide optimal healthcare. However, I argue that the application process places an undue burden on low-income Latino applicants that is not beneficial to optimal health care. The burden placed on low-income Latino applicants through the application process is excessive and not necessary to forge qualified medical students. The financial aspect of the medical school application has made the profession virtually inaccessible to the working class. The medical school application proves costly because of the various expenses, including primary applications, secondary applications, and interview logistics. There is financial aid for applications, but navigating some aid to undertake test prep, the Medical College Admission Test (MCAT), and the travel for interviews proves more difficult. Although not mandatory, prep courses give people a competitive edge.[23] The MCAT is one of the key elements of an application, and many medical schools will not consider applications that do not reach their score threshold. This practically makes the preparatory courses mandatory for a competitive score. The preparatory courses themselves cost in the thousands of dollars. There has been talk about adjusting the standardized test score requirements for applicants from medically underserved backgrounds. I believe the practice of holding strict cutoffs for MCAT scores is detrimental to low-income Latino applicants, especially considering the average MCAT scores for Latinos trail that of white people. The American Association of Medical Colleges’ recent data for the matriculating class of 2021 illustrates the wide gap in MCAT scores: Latino applicants average 500.2, and Latino matriculants average 506.6, compared to white applicants, who average 507.5 and white matriculants, who average 512.7.[24] This discrepancy suggests that considerations beyond scores do play some role in medical school matriculation. However, the MCAT scores remain a predominant factor, and there is room to value other factors more and limit the weight given to scores. The practice of screening out applicants based solely on MCAT scores impedes low-income Latino applicants from matriculating into medical school. Valuing the MCAT above all other admissions criteria limits the opportunities for those from underserved communities, who tend to score lower on the exam. One indicator of a potentially great physician may be overcoming obstacles or engaging in scientific or clinical experiences. There are aspects of the application where the applicant can expand on their experiences, and the personal statement allows them to showcase their passion for medicine. These should hold as much weight as the MCAT. The final indicator of a good candidate should not solely rest on standardized tests. There is a cost per medical school that is sent to the primary application. The average medical school matriculant applies to about 16 universities, which drives up the cost of sending the applications.[25] According to the American Association of Medical Colleges, the application fee for the first school is $170, and each additional school is an additional $42. Sending secondary applications after the initial application is an additional cost that ranges by university. The American Medical College Application Service (AMCAS), the primary application portal for Medical Doctorate schools in the United States and Canada, offers the Fee Assistance Program (FAP) to aid low-income medical school applicants. The program reduces the cost of the MCAT from $325 to $130, includes a complimentary Medical School Admission Requirements (MSAR) subscription, and fee waivers for one AMCAS application covering up to 20 schools.[26] The program is an important aid for low-income Latino students who would otherwise not be able to afford to send multiple applications. Although the aid is a great resource, there are other expenses of the application process that the program cannot cover. For a low-income applicant, the burden of the application cost is felt intensely. A study analyzing the American Medical College Application Service (AMCAS) data for applicants and matriculants from 2014 to 2019 revealed an association between income and acceptance into medical school. They state, “Combining all years, the likelihood of acceptance into an MD program increased stepwise by income. The adjusted rate of acceptance was 24.32 percent for applicants with income less than $50 000, 27.57 percent for $50 000 - $74 999, 29.90 percent for $75 000 - $124 999, 33.27 percent for $125 000 - $199 999, and 36.91 percent for $200,000 or greater.”[27] It becomes a discouraging factor when it is difficult to obtain the necessary funds. The interview process for medical schools may prove costly because of travel, lodging, and time. In-person interviews may require applicants to travel from their residence to other cities or states. The applicant must find their own transportation and housing during the interview process, ranging from a single day to multiple days. Being granted multiple interviews becomes bittersweet for low-income applicants because they are morally distraught, knowing the universities are interested yet understanding the high financial cost of the interviews. The expense of multiple interviews can impede an applicant from progressing in the application process. Medical schools do not typically cover travel expenses for the interview process. Only 4 percent of medical school faculty identify as Latino.[28] The medical school admission board members reviewing the application lack Latino representation.[29] Because of this, it is extremely difficult for a low-income Latino applicant to portray hardships that the board members would understand. Furthermore, the section to discuss any hardships only allows for 200 words. This limited space makes it extremely difficult to explain the nuances of navigating higher education as a low-income Latino. Explaining those difficulties is then restricted to the interview process. However, that comes late in the application process when most applicants have been filtered out of consideration. The lack of diversity among the board members, combined with the minimal space to explain hardships or burdens, impedes a connection to be formed between the Latino applicants and the board members. It is not equitable that this population cannot relate to their admissions reviewers because of cultural barriers. Gatekeeping clinical experience inadvertently favors higher socioeconomic status applicants. Most medical schools require physician shadowing or clinical work, which can be difficult to obtain with no personal connections to the field. Using clinical experience on the application is another way that Latinos are disadvantaged compared to people who have more professional connections or doctors in the family and social circles. The already competitive market for clinical care opportunities is reduced by nepotism, which does not work in favor of Latino applicants. Yet some programs are designed to help low-income students find opportunities, such as Johns Hopkins’ Careers in Science and Medicine Summer Internship Program, which provides clinical experience and health professions mentoring.[30] Without social and professional ties to health care professionals, they are forced to enter a competitive job and volunteer market in clinical care and apply to these tailored programs not offered at all academic institutions. While it is not unique to Latinos, the time commitment of the application process is especially harsh on low-income students because they have financial burdens that can determine their survival. Some students help their families pay for food, rent, and utilities, making devoting time to the application process more problematic. As noted earlier, Latino applicants may also have to set aside time to advocate for their families. Because the applicants tend to be more in tune with the dominant American culture, they are often assigned the family advocate role. They must actively advocate for their family members' well-being. The role of a family advocate, with both its financial and other supportive roles ascribed to low-income Latino applicants, is an added strain that complicates the medical school application. As a member of a historically marginalized community, one must be proactive to ensure that ethical treatment is received. Ordinary tasks such as attending a doctor's appointment or meeting with a bank account manager may require diligent oversight. Applicants must ensure the standard of service is applied uniformly to their family as it is to the rest of the population. This applies to business services and healthcare. It can be discouraging to approach a field that does not have many people from your background. The lack of representation emphasizes the applicant's isolation going through the process. There is not a large group of Latinos in medicine to look to for guidance.[31] The group cohesiveness that many communities experience through a rigorous process is not established among low-income Latino applicants. They may feel like outsiders to the profession. Encountering medical professionals of similar backgrounds gives people the confidence to pursue the medical profession. V. Medical School Admission Data This section will rely on the most recent MD medical school students, the 2020-2021 class. The data includes demographic information such as income and ethnicity. The statistics used in this section were retrieved from scholarly peer-reviewed articles and the Medical School Admission Requirement (MSAR) database. Both sources of data are discussed in more detail throughout the section. The data reveals that only 6.7 percent of medical students for the 2020-2021 school year identify as Latino.[32] The number of Latino students in medical school is not proportional to the Latino community in the United States. While Latinos comprise almost 20 percent of the US population (62.1 million), they comprise only 6.7 percent of the medical student population.[33] Below are three case studies of medical schools in cities with a high Latino population. VI. Medical School Application Process Case Studies a) New York University Grossman School of Medicine is situated in Manhattan, where a diverse population of Latinos reside. The population of the borough of Manhattan is approximately 1,629,153, with 26 percent of the population identifying as Latino.[34] As many medical schools do, Grossman School of Medicine advertises an MD Student Diversity Recruitment program. The program, entitled Prospective MD Student Liaison Program, is aimed such that “students from backgrounds that are underrepresented in medicine are welcomed and supported throughout their academic careers.”[35] The program intervenes with underrepresented students during the interview process of the medical school application. All students invited to interviews can participate in the Prospective MD Student Liaison Program. They just need to ask to be part of it. That entails being matched with a current medical student in either the Black and Latinx Student Association (BALSA) or LGBTQMed who will share their experiences navigating medical school. Apart from the liaison program, NYU participates in the Science Technology Entry Program (STEP), which provides academic guidance to middle and high school students who are underrepresented minorities.[36] With the set programs in place, one would expect to find a significantly larger proportion of Latino medical students in the university. The Medical School Admission Requirement (MSAR) database compiled extensive data about participants in the medical school; the data range from tuition to student body demographics. Of the admitted medical students in 2021, only 16 out of 108 identified as Latino, despite the much larger Latino population of New York.[37] Furthermore, only 4 percent of the admitted students classify themselves as being from a disadvantaged status.[38] The current efforts to increase medical school diversity are not producing adequate results at NYU. Although the Latino representation in this medical school may be higher than that in others, it does not reflect the number of Latinos in Manhattan. The Prospective MD Student Liaison Program intervenes at a late stage of the medical school application process. It would be more beneficial for a program to cover the entire application process. The lack of Latino medical students makes it difficult for prospective students to seek advice from Latino students. Introducing low-income Latino applicants to enrolled Latino medical students would serve as a guiding tool throughout the application process. An early introduction could encourage the applicants to apply and provide a resourceful ally in the application process when, in many circumstances, there would be none. Latino medical students can share their experiences of overcoming cultural and social barriers to enter medical school. b) The Latino population in Philadelphia is over 250,000, constituting about 15 percent of the 1.6 million inhabitants.[39] According to MSAR, the cohort of students starting at Drexel University College of Medicine, located in Philadelphia, in 2021 was only 7.6 percent Latino.[40] 18 percent of matriculated students identify as having disadvantaged status, while 21 percent identify as coming from a medically underserved community.[41] Drexel University College of Medicine claims that “Students who attend racially and ethnically diverse medical schools are better prepared to care for patients in a diverse society.”[42] They promote diversity with various student organizations within the college, including the following: Student National Medical Association (SNMA), Latino Medical Student Association (LMSA), Drexel Black Doctors Network, LGBT Medical Student Group, and Drexel Mentoring and Pipeline Program (DMAPP). The Student Center for Diversity and Inclusion of the College of Medicine offers support groups for underrepresented medical students. The support offered at Drexel occurs at the point of matriculation, not for prospective students. The one program that does seem to be a guide for prospective students is the Drexel Pathway to Medical School program. Drexel Pathway to Medical School is a one-year master’s program with early assurance into the College of Medicine and may serve as a gateway for prospective Latino Students.[43] The graduate program is tailored for students who are considered medically underserved or socioeconomically disadvantaged and have done well in the traditional pre-medical school coursework. It is a competitive program that receives between 500 and 700 applicants for the 65 available seats. The assurance of entry into medical school makes the Drexel Pathway to Medical School a beneficial program in aiding Latino representation in medicine. Drexel sets forth minimum requirements for the program that show the school is willing to consider students without the elite scores and grades required of many schools. MCAT scores must be in the 25th percentile or higher, and the overall or science GPA must be at least 2.9.[44] The appealing factor of this program is its mission to attract medically underserved students. This is a tool to increase diversity in medical school. Prospective low-income Latino students can view this as a graduate program tailored to communities like theirs. However, this one-year program is not tuition-free. It may be tempting to assume that patients prefer doctors with exceptional academic records. There's an argument against admitting individuals with lower test scores into medical schools, rooted in the belief that this approach does not necessarily serve the best interests of health care. The argument asserts that the immense responsibility of practicing medicine should be entrusted to the most qualified candidates. Programs like the Drexel Pathway to Medical School are designed to address the lower academic achievements often seen in underrepresented communities. Their purpose is not to admit underqualified individuals into medical school but to bridge the educational gap, helping these individuals take the necessary steps to become qualified physicians. c) The University of California San Francisco School of Medicine reports that 23 percent of its first-year class identifies as Latino, while 34 percent consider themselves disadvantaged.[45] The Office of Diversity and Outreach is concerned with increasing the number of matriculants from underserved communities. UCSF has instilled moral commitments and conducts pipeline and outreach programs to increase the diversity of its medical school student body. The Differences Matter Initiative that the university has undertaken is a complex years-long restructuring of the medical school aimed at making the medical system equitable, diverse, and inclusive.[46] The five-phase commitment includes restructuring the leadership of the medical school, establishing anti-oppression and anti-racism competencies, and critically analyzing the role race, ethnicity, gender, and sexual orientation play in medicine. UCSF offers a post-baccalaureate program specifically tailored to disadvantaged and underserved students. The program’s curriculum includes MCAT preparation, skills workshops, science courses, and medical school application workshops.[47] The MCAT preparation and medical school application workshops serve as a great tool for prospective Latino applicants. UCSF seems to do better than most medical schools regarding Latino medical students. San Francisco has a population of 873,965, of which 15.2 percent are Latino.[48] The large population of Latino medical students indicates that the school’s efforts to increase diversity are working. The 23 percent Latino matriculating class of 2021 better represents the number of Latinos in the United States, which makes up about a fifth of the population. With this current data, it is important to closely dissect the efforts UCSF has taken to increase diversity in its medical school. Their Differences Matter initiative instills a commitment to diversifying their medical school. As mentioned, the school's leadership has been restructuring to include a diverse administrative body. This allows low-income Latino applicants to relate to the admissions committee reviewing their application. With a hopeful outlook, the high percentage of Latino applicants may reflect comprehension of the application process and the anticipated medical school atmosphere and rigor among Latino applicants and demonstrate that the admissions committee understands the applicants. However, there are still uncertainties about the demographics of the Latino student population in the medical school. Although it is a relatively high percentage, it is necessary to decipher which proportion of those students are low-income Latino Americans. UCSF School of Medicine can serve as a model to uplift the Latino community in a historically unattainable profession. VII. Proposed Reform for Current Medical School Application One reform would be toward the reviewing admissions committee, which has the power to change the class composition. By increasing the diversity of the admissions committee itself, schools can give minority applicants a greater opportunity to connect to someone with a similar background through their application. It would address low-income Latino applicants feeling they cannot “get personal” in their application. These actions are necessary because it is not just to have a representative administration for only a portion of the public. Of the three medical schools examined, the University of California San Francisco has the highest percentage of Latino applicants in their entering class. They express an initiative to increase diversity within their medical school leadership via the Differences Matter initiative. This active role in increasing diversity within the medical school leadership may play a role in UCSF’s high percentage of Latino matriculants. That serves as an important step in creating an equitable application process for Latino applicants. An important consideration is whether the medical school administration at UCSF mirrors the Latino population in the United States. The importance of whether the medical school administration at UCSF mirrors the Latino population in the United States lies in its potential to foster diversity, inclusivity, and cultural competence in medical education, as well as to positively impact the healthcare outcomes and experiences of the Latino community. A diverse administration can serve as role models for students and aspiring professionals from underrepresented backgrounds. It can inspire individuals who might otherwise feel excluded or underrepresented in their career pursuits, including aspiring Latino medical students. Furthermore, a diverse leadership can help develop curricula, policies, and practices that are culturally sensitive and relevant, which is essential for addressing health disparities and providing equitable healthcare. It is also important to have transparency so the public knows the number of low-income Latino individuals in medical school. The Latino statistics from the medical school generally include international students. That speaks to diversity but misses the important aspect of uplifting the low-income Latino population of the United States. Passing off wealthy international students from Latin America to claim a culturally diverse class is misleading as it does not reflect income diversity. Doing so gives the incorrect perception that the medical school is accurately representing the Latino population of the United States. There must be a change in how the application process introduces interviews. It needs to be introduced earlier so the admissions committee can form early, well-rounded inferences about an applicant. The interview allows for personal connections with committee members that otherwise would not be established through the primary application. The current framework has the interviews as one of the last aspects of the application process before admissions decisions are reached. At this point in the application process, many low-income Latinos may have been screened out. I understand this is not an easy feat to accomplish. This will lead to an increase in interviews to be managed by the admissions committee. The burden can be strategically minimized by first conducting video interviews with applicants the admission committee is interested in moving forward and those that they are unsure about because of a weakness in a certain area of the application. The video interview provides a more formal connection between the applicants and admission committee reviewers. It allows the applicant to provide a narrative through spoken words and can come off as a more intimate window into their characteristics. It would also allow for an opportunity to explain hardships and what is unique. From this larger pool of video-interviewed applicants, the admission committee can narrow down to traditional in-person interviews. A form of these video interviews may be already in place in some medical school application process. I believe making this practice widespread throughout medical schools will provide an opportunity to increase the diversity of medical school students. There must be an increase in the number of programs dedicated to serving as a gateway to clinical experience for low-income Latino applicants. These programs provide the necessary networking environment needed to get clinical experience. It is important to consider that networking with clinical professionals is an admissions factor that detrimentally affects the low-income Latino population. One of the organizations that aids underserved communities, not limited to Latinos, in clinical exposure is the Summer Clinical Oncology Research Experience (SCORE) program.[49] The SCORE program, conducted by Memorial Sloan Kettering Cancer Center, provides its participants with mentorship opportunities in medicine and science. In doing so, strong connections are made in clinical environments. Low-income Latinos seek these opportunities as they have limited exposure to such an environment. I argue that it is in the medical school’s best interest to develop programs of this nature to construct a more diverse applicant pool. These programs are in the best interest of medical schools because they are culturing a well-prepared applicant pool. It should not be left to the goodwill of a handful of organizations to cultivate clinically experienced individuals from minority communities. Medical schools have an ethical obligation to produce well-suited physicians from all backgrounds. Justice is not upheld when low-income Latinos are disproportionally represented in medical schools. Programs tailored for low-income Latinos supplement the networking this population lacks, which is fundamental to obtaining clinical experience. These programs help alleviate the burden of an applicant’s low socioeconomic status in attaining clinical exposure. VIII. Additional Considerations Affecting the Medical School Application Process and Latino Community Health A commitment to practicing medicine in low-income Latino communities can be established to improve Latino community health.[50] Programs, such as the National Health Service Corps, encourage clinicians to practice in underserved areas by forgiving academic loans for years of work.[51] Increasing the number of clinicians in underserved communities can lead to a positive correlation with better health. It would be ideal to have programs for low-income Latino medical students that incentivize practicing in areas with a high population of underserved Latinos. This would provide the Latino community with physicians of a similar cultural background to attend to them, creating a deeper physician-patient relationship that has been missing in this community. Outreach for prospective Latino applicants by Latino medical students and physicians could encourage an increased applicant turnout. This effort can guide low-income Latinos who do not see much representation in the medical field. It would serve as a motivating factor and an opportunity to network within the medical field. Since there are few Latino physicians and medical students, a large effort must be made to make their presence known. IX. Further Investigation Required It is important to investigate the causes of medical school rejections of low-income Latinos. Understanding this piece of information would provide insight into the specific difficulties this population has with the medical school application. From there, the requirements can be subjected to bioethical analysis to determine whether those unfulfilled requirements serve as undue restrictions. The aspect of legacy students, children of former alumni, proves to be a difficult subject to find data on and merits further research. Legacy students are often given preferred admission into universities.[52] It is necessary to understand how this affects the medical school admissions process and whether it comes at a cost to students that are not legacy. It does not seem like these preferences are something universities are willing to disclose. The aspect of legacy preferences in admissions decisions could be detrimental to low-income Latino applicants if their parents are not college-educated in the United States, which often is the case. It would be beneficial to note how many Latinos in medical school are low-income. The MSAR report denotes the number of Latino-identified students per medical school class at an institution and the number of students who identify as coming from low resources. They do not specify which of the Latino students come from low-income families. This information would be useful to decipher how many people from the low-income Latino community are matriculating into medical schools. CONCLUSION It is an injustice that low-income Latinos are grossly underrepresented in medical school. It would remain an injustice even if the health of the Latino community in the United States were good. The current operation of medical school admission is based on a guild-like mentality, which perpetuates through barriers to admissions. It remains an exclusive club with processes that favor the wealthy over those who cannot devote money and time to the prerequisites such as test preparation courses and clinical internships. This has come at the expense of the Latino community in the United States in the form of both fewer Latino doctors and fewer current medical students. It is reasonable to hope that addressing the injustice of the underrepresentation of low-income Latinos in the medical field would improve Latino community health. With such a large demographic, the lack of representation in the medical field is astonishing. The Latino population faces cultural barriers when seeking healthcare, and the best way to combat that is with a familiar face. An increase in Latino medical students would lead to more physicians that not only can culturally relate to the Latino community, but that are a part of it. This opens the door for a comprehensive understanding between the patient and physician. As described in my thesis, Latino physicians can bridge cultural gaps that have proven detrimental to that patient population. That may help patients make informed decisions, exercising their full autonomy. The lack of representation of low-income Latinos in medicine is a long-known issue. Here, I have connected how the physician-patient relationship can be positively improved with an increase in low-income Latino physicians through various reforms in the admissions process. My hope is to have analyzed the problem of under-representation in a way that points toward further research and thoughtful reforms that can truly contribute to the process of remedying this issue. - [1] Passel, J. S., Lopez, M. H., & Cohn, D. (2022, February 3). U.S. Hispanic population continued its geographic spread in the 2010s. Pew Research Center. https://www.pewresearch.org/fact-tank/2022/02/03/u-s-hispanic-population-continued-its-geographic-spread-in-the-2010s/ [2] Ramirez, A. G., Lepe, R., & Cigarroa, F. 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