Articles de revues sur le sujet « Monroe County (N.Y.). Library »

Purpose The purpose of this paper is to determine the morbidity of Giardia in Monroe County, New York attributed to refugees, foreign adoptees and immigrants, and to examine factors related to asymptomatic Giardia infection. Design/methodology/approach A retrospective epidemiological analysis was conducted of Giardia case investigations submitted to the New York State Department of Health on the Communicable Disease Electronic Surveillance System, between January 1, 2003 and December 31, 2013 from Monroe County Department of Public Health. Univariate and multivariate logistic regression models were used to assess odds for asymptomatic Giardia. Findings Of the 1,221 Giardia cases reported in Monroe County during that time, 38 percent (n=467) were refugees, 6 percent (n=77) were foreign adoptees and 1.4 percent (n=17) were immigrants. In total, 95 percent of the refugees and 89 percent of the adoptees/immigrants were asymptomatic, compared to 15 percent of the non-refugee/adoptee/immigrant cases. Unadjusted odds for asymptomatic infection were 113.4 (95 percent CI: 70.6-183.7) for refugees, and 45.6 (95 percent CI: 22.9-91) for adoptees/immigrants. Originality/value This study demonstrates the importance of routine screening for Giardia during refugees’ initial health assessment.

The Library Publishing Toolkit, a 400 page ebook launched on August 1, 2013, offers libraries interested in expanding into publishing a resource “to identify trends in library publishing, seek out best practices to implement and support such programs, and share the best tools and resources.” A product of the combined efforts of Milne Library at SUNY Geneseo and the Monroe County Library System, the Library Publishing Toolkit “looks at the broad and varied landscape of library publishing through discussions, case studies, and shared resources.” [...]

Whenever a library fulfills its mission of purchasing popular books, like best-sellers and titles in high demand, it usually will carry on quietly, without much community controversy. But what happens when the best-seller and in-demand title is also a highly charged sex fantasy full of graphic photographs of one of the most recognizable popular figures of the day, who also happens to be the book’s author? Community outrage, organized protest, multiple and counter legal opinions, terrorist threats to the library, and multiple death threats to the library director were some of the responses to Monroe County Library System’s purchase and open circulation of Madonna’s book Sex.

ABSTRACTBackground:The Behavioral Health Laboratory (BHL), a telephone-based mental health assessment, is a cost-effective approach that can improve mental illness identification and management. The individual BHL instruments, which were originally designed to be administered in-person, have not yet been validated with an in-person BHL assessment. This study therefore aims to characterize the concordance between the BHL data gathered by telephone and in-person interviews.Methods:A cross-sectional study was conducted with English-speaking aging services network (ASN) clients aged 60 years and older in Monroe County, NY who were randomized to a BHL interview either in-person (n = 55) or by telephone (n = 53).Results:There was strong evidence of equivalence between telephone and in-person interviews for depressive disorders, generalized anxiety, panic disorder, drug misuse, psychosis, PTSD, mental illness symptom severity, and five of the six questions assessing suicidality. There was marginal equivalence in PHQ-9 total scores and one of the six questions assessing suicidal ideation, and no evidence of equivalence between interview modalities for assessing cognitive impairment.Conclusions:With a few exceptions, the BHL gathered nearly equivalent information via telephone as compared to in-person interviews. This suggests that the BHL may be a cost-effective approach appropriate for dissemination in a wide variety of settings including the ASN. Dissemination of the BHL has the potential to strengthen the linkages between primary care, mental healthcare, and social service providers and improve identification and management of those with late-life mental illness.

e17520 Background: Patient navigation is a promising strategy for improving cancer care. We examined (1) how navigation influences patients’ perspectives on their cancer care and (2) the most effective (i.e., meaningful or valuable) aspects of navigation from the patient's viewpoint. Methods: We conducted post-study patient interviews from a randomized controlled trial (usual care vs. patient navigation services) from cancer diagnosis through treatment completion. Patients were recruited from 11 primary care, hospital and community oncology practices in Monroe County, NY. We interviewed patients about their specific experiences with cancer care including their expectations and experience of patient navigation or, for non-navigated patients, other sources of assistance. Results: Thirty-five patients (32 female, 3 male) newly diagnosed with breast (n = 28) or colorectal (n = 7) cancer who completed the study and were interviewed from May 2007 through March 2008. Patients who received navigation were very positive about their experience. Valued aspects of navigation included emotional support, assistance with information needs and problem-solving (such as with insurance or financial stressors), and logistical coordination of cancer care. Unmet cancer care needs expressed by patients randomized to usual care consisted of lack of assistance or support with childcare, household responsibilities, coordination of care, and emotional support. Conclusions: Cancer patients value navigation. Instrumental benefits were the most important expectations for navigation from navigated and non-navigated patients. However, when describing their actual experience of navigation, navigated patients frequently mentioned receiving emotional support as well as assistance with information needs, problem-solving, and logistical aspects of cancer care coordination. No significant financial relationships to disclose.

Abstract Background In 2011, persons who inject drugs (PWID) were estimated to be 2.6% of the US population 13 years of age and older. Infectious endocarditis (IE) and hepatitis C infections among PWID are increasing. We describe trends in invasive Staphylococcus aureus (iSA) infections among PWID. Methods Population-based surveillance for invasive (from normally sterile site) methicillin-resistant S. aureus (MRSA) and methicillin-sensitive S. aureus (MSSA) has been conducted in Monroe County, NY (2010 Census population: 744,344) as part of the CDC’s Emerging Infections Program since September 2014. Cases are county residents with an iSA infection; iSA incidence was calculated as cases/100,000 census population. Results During September 2014–August 2017, 1,460 iSA cases were identified; 150 (10%) in PWID. The incidence of PWID-associated iSA doubled among 18–49 year olds during years 1–3 (Table 1). The proportion of cases occurring in PWID increased among both MRSA (7% to 20%) and MSSA (6% to 11%). PWID were significantly younger (P < 0.0001) than noninjection drug users, and more often White (P = 0.003) and non-Hispanic (p = 0.004). Among PWID with iSA, 45% had IE. Almost all PWID with iSA used other illicit drugs (n = 112, 91% of 123 unique cases); 89% (110) were smokers, and 46% (56) had chronic liver disease. PWID with iSA had a longer mean length of stay (26 days [SD 22] vs. 21 [37], P = 0.01); PWID with MRSA were more likely to have septic shock (22% vs. 8%, P = 0.03) and pneumonia (9% vs. 1%, P = 0.04) when compared with PWID with MSSA. Among iSA, a history of recurrent skin abscess/boil (24% vs. 8%, P = 0.02) was more common in PWID with MRSA; fewer PWID with MRSA were obese (2% vs. 15%, p = 0.02). Conclusion The increasing incidence of invasive MRSA/MSSA among PWID, frequently accompanied by concurrent chronic liver disease, polysubstance use, and need for extended hospital stays, poses an increasing challenge to the public health and clinical communities. This highlights the critical need to prevent worsening of the epidemic of injection drug use and provide comprehensive treatment for individuals engaging in highest risk drug-related behaviors. Disclosures All authors: No reported disclosures.

This study purposed to use information and communication technologies for documenting indigenous farming knowledge for improved preservation, accessibility and use in Kilifi County, Kenya. The objectives that guided this study were to assess the awareness and perception of the study community regarding use of ICTs in preservation and management of indigenous farming knowledge, to explore available ICTs tools that can capture and document indigenous farming knowledge, to advance the important role a library repository could play in preservation, management, storage and dissemination of indigenous farming knowledge and to identify barriers and concerns related to IFK preservation, accessibility and use. The outcome of this research is a knowledge asset of captured indigenous farming experiences, processes, and insights to contribute to a pool of indigenous farming knowledge for learning and scaling up preservation and public utilization. This study was conducted in all the seven Sub Counties in Kilifi County namely Malindi, Magarini, Kilifi North, Kilifi South, Ganze, Kaloleni and Rabai where a sample size of ninety eight respondents that was derived using Krejcie and Morgan formula n=X2NP (1-P)/e2 (N-1) +X2P (1-P) that is used when a population is more than ten thousand (10,000) were targeted. The research instruments that were used included questionnaires, interview schedule, personal observation, storytelling and focus group discussions which were recorded using information and communication technology resources such as video recording to come up with a knowledge asset of indigenous farming knowledge experiences for uploading into the County of Kilifi Public Library repository was realized. Cronbach’s alpha was used to test the validity of the instruments. Secondary data was collected from County of Kilifi Demographic Reports, Kilifi County Development plan, County Government of Kilifi Agricultural Sector Development Programme and reputable databases. Data analysis involved the use of inferential statistics using Statistical Package for Social Science (SPSS) and tables of means and standard deviation which were used to present the data. The findings of the study are that indigenous farming knowledge is very valuable and has assisted the community in food security and needs to be passed down to the younger generation. Farmers’ awareness and perception of the role of ICT in preservation of IFK is very good and agreed that if IFK is not documented, it may disappear as they died. The farmers were aware of ICTs tools to capture, document and disseminate indigenous farming experiences for improved preservation and accessibility in Public Libraries in Kilifi County including mobile phones, radios, television, computers, internet, memory cards, social media technologies, iPads and flash discs can be used. The Sub County Agricultural Officers and Librarians have the qualification and experience required to collaborate with the Kaya Elders (Farmers) to document and preserve the IFK for posterity. The public library repository can be a knowledge asset in the preservation, management and dissemination of documented indigenous farming experiences and provide free access to indigenous knowledge information resources, providing places for access to researchers of indigenous knowledge, training users on accessing indigenous knowledge resources and allowing farmers to observe indigenous knowledge practices by offering demonstration site in the library compound. However, there were barriers and concerns including climate change, use of certified seeds instead of indigenous seeds, its accessibility, government introduction of early maturing seeds due to prolonged drought, people’s perception of it being primitive knowledge, its none documentation and inaccessibility, poor preservation, knowledge gaps left by dying indigenous knowledge owners that were noted that can be surmounted by documenting indigenous knowledge practices, creating awareness on indigenous knowledge resources, mentorship (the old passing knowledge to the young), creating platforms to allow access to indigenous knowledge as well as creating indigenous knowledge databases, mainstreaming it into our formal education, building awareness on indigenous farming knowledge, community based indigenous knowledge maintenance, creating national indigenous knowledge inventories and securing intellectual property of indigenous farming knowledge. The study recommended indigenous farming knowledge be incorporated to scientific farming knowledge by embedding it in ICTs tools such as mobile phones, and social media technologies that will enhance its accessibility and mainstreaming with scientific knowledge, educating people on value of indigenous farming knowledge by public libraries’ embracing their role of creating awareness through creation of more platforms including indigenous farming knowledge databases and revamping public libraries to become viable indigenous farming knowledge assets by empowering the public libraries in acquiring, preserving, managing and disseminating IFK in the form of books, audio visual resources, technical skills, human skills, demonstration gardens and adult education learners and double their effort in creating the necessary awareness for them to achieve their intended purpose.

Cilj je rada predstaviti rezultate istraživanja o potrebama nezaposlenih građana Osječko-baranjske županije u svrhu unapređenja spoznaja o poboljšanju službi, usluga, programa i aktivnosti narodnih knjižnica te utjecaja na kvalitetu života nezaposlenih građana. Istraživanje je provedeno kvantitativnom metodom slučajnog uzorka (N = 250). U članku je prikazana slika stanja prije globalne zdravstvene pandemije COVID-19, krize koja je utjecala na cijeli svijet. Prikupljeni podaci statistički su obrađeni u Statističkom paketu za društvene znanosti primjenom opisne i korelacijske analize između dvije skupine varijabli te su izraženi u postotcima. Najvažniji rezultati istraživanja pokazali su da ispitani građani imaju potrebu za učenjem u sastavu cjeloživotnog obrazovanja, ali da su se, s druge strane, u najvećem ukupnom postotku na ponuđene potrebe u knjižničnom prostoru, izjasnili da nemaju potrebe. Najizraženije potrebe ispitanih građana su potrebe za učenjem engleskoga i njemačkoga jezika; računalnim i tehničkim vještinama, potreba za usavršavanjem komunikacijskih vještina; usavršavanjem dodatnih socijalnih vještina kroz timski rad, upoznavanjem pravila poslovnog bontona, stjecanjem organizacijskih vještina, promocijskih vještina, učenjem neverbalne komunikacije ili govora tijela. Rezultat istraživanja pokazao je da, unatoč tomu što je dio ispitanika (41,6 %) član narodne knjižnice, i dalje ima različite potrebe u sastavu cjeloživotnog obrazovanja, a njihova im narodna knjižnica ne pruža mogućnost ispunjavanja. Pokazao je i to da nisu sve narodne knjižnice u Osječko-baranjskoj županiji otvorene za sve korisnike. Nezaposleni, društveno isključeni građani mišljenja su da narodna knjižnica može pomoći u razvoju zajednice, ali ne i nezaposlenima. = The aim of this paper is to present the results of the research on the needs of unemployed citizens in the Osijek-Baranja County with the purpose of improving the knowledge of advancing the services, programs, and activities of public libraries, as well as the quality of life of unemployed citizens. Research was conducted using the random sampling method (N=250). The article presents a picture of the situation before the global COVID-19 health pandemic, the crisis that affected the whole world. The collected data was statistically analyzed in SPSS, the Statistical Package for Social Sciences, using correlation and descriptive analysis on two groups and was thereafter expressed in percentages. The most important results of the research showed that the selected citizens have a need for lifelong learning, but that at the same time the largest percentage of them do not have the need to fulfill the named needs in a library space. Most pronounced needs of tested citizens are the needs to learn English and German; computer and technical skills, the need to perfect communication skills; perfecting additional social skills through teamwork, familiarizing oneself with workspace etiquette, gaining organizational skills, promotional skills, learning nonverbal communication or body language. The results show that public libraries do not allow a portion of the subjects (41.6%) to fulfill their needs, despite them having a membership to the public library and having different needs for lifelong learning. Likewise, results show that not all public libraries within the Osijek-Baranja County are open to all users. Socially excluded unemployed citizens believe that the public library can help develop communities and unemployed citizens alike.

Due to the ever-changing technological environment and digitization of education, Trainers need to use new technologies for content delivery to the trainees. The acceptance and willingness of trainers to use online learning is the key to success and is faced with various challenges. Trainers must use communication technology skills to fit successfully in a knowledge-based society. Moreover, regardless of the availability of technology, trainers need ICT skills for online teaching and learning. The study sought to assess the trainers’ competence in implementing e-Learning in technical institutions. A descriptive research design was used in the study; structured questionnaires, both open-ended and closed, were issued to a sample size of n=77 trainer participants in the six selected technical training institutes in Nandi County. The study revealed that 81.8 % (n=63) of the respondents received prior technical training in e-learning. Trainers also reported difficulty in using the e-Learning platform. Technological expertise is essential to ensure the success of e-learning. Inadequate computer literacy hindered many trainers from content delivery using e-Learning, especially during Covid-19 lockdown times. It was evident that most trainers struggled with the online platforms, accessibility of learning equipment such as whiteboards, projectors, low internet connectivity, and inadequate training skills attributed to slow implementation. The study revealed that trainers had difficulty using the e-Learning platform issued. This is due to the inadequate training that they had received and the complex system used. The study found that trainers preferred other platforms which were user-friendly for e-Learning. Additionally, the institutions’ LAN network is limited to the laboratories and institution library only; hence, some offices at a distance from the administration cannot access the LAN internet. Implementing online learning requires the stakeholders to come together to make online learning successful.

Vienas dabar aktualių klausimų – rūpinimasis organizacijos reputacija ir jos palaikymu. Ypač svarbu išsilaikyti nuolat kintančioje visuomenėje, sudominti savo paslaugomis ar produktais jau esamus ar potencialius vartotojus, didinti suinteresuotųjų pasitikėjimą. Manoma, kad tai ypač svarbu privačioms ar verslo organizacijoms, užmirštant valstybines bei viešąsias organizacijas. Šiame straipsnyje dėmesys telkiamas į valstybines įstaigas – bibliotekas. Jos analizuojamos pasitelkus personalo valdymo dėmenį, o tyrimui pasirinkus Lietuvos apskričių viešąsias bibliotekas.Straipsnis parengtas remiantis magistro darbu „Personalo valdymas bibliotekos reputacijos vadyboje“ (vadovė doc. dr. Renata Matkevičienė; Vilnius, 2010 m.).Pagrindiniai žodžiai: reputacijos vadyba, bibliotekos reputacijos vadyba, personalo valdymas.Role of Personnel Management in Library Reputation ManagementLaura Juchnevič SummaryCaring for the organization’s reputation, its furtherance is among the questions of the day. It is determined by the aim to survive in the ever-changing society, to engage the existing and potential customers in services or products, to increase the trust in services of all interested parties. It is believed that caring for the organization’s reputation is of utmost importance only for private and business organizations, thus forgetting public organizations. This article focuses on public institutions – libraries – while analyzing the problem through the profile of human resource management, using the model of Lithuanian county public libraries. The article is based on the master’s work (supervisor Assoc. Prof. Dr. Renata Matkevičienė; Vilnius, 2010).n>

The intention of this paper was to determine usability of KOHA OPAC in information retrieval with regard to usability testing by undergraduate users at Technical University of Kenya Library (TU-KL) in Nairobi County. Usability testing can be realized by way of assigning tasks to a representative of the user population in order to determine whether users can be able to achieve the desired goal of retrieving information. To a great extent, success will depend on how users perform the tasks assigned to them. This study conducted usability test on actual users of KOHA OPAC at Technical University of Kenya Library. Qualitative data was collected using the think aloud method where study participants were required to verbalize their thought process as they performed search and retrieval tasks using KOHA OPAC. The number of errors made, time taken to complete search and retrieval activities were coded, recorded and analysed during usability testing. This helped the researcher to determine whether KOHA OPAC is easy to use and whether it saves time for the user. Undergraduate students for the study were selected using a stratified random sampling technique. The population of the study (n = 382) was determined using a simplified formula developed by Yamane. The study initiated a usability test which presented search scenarios where participants were invited to participate in searching and retrieving information resources using KOHA OPAC. The results of the usability test of KOHA OPAC at TU-KL showed that users were slow at accomplishing search tasks, they took long duration to access TU-KL website that hosts KOHA OPAC and there was inefficiency in accessing library materials. This study concluded that usability challenges may have an impact on users' overall satisfaction with KOHA OPAC and information retrieval effectiveness. In order to enhance user experience and boost the effectiveness of information retrieval, the study recommends improvement of KOHA OPAC usability by revamping its interface and enhancing its features.

Fasciolosis is a global zoonotic parasitic disease caused by F. hepatica infection that is particularly harmful to cattle and sheep. A biotin–streptavidin signal amplification ELISA (streptavidin-ELISA/SA-ELISA) based on circulating antigens can allow for the early detection of F. hepatica-infected animals and is suitable for batch detection. It is considered to be a better means of detecting F. hepatica infection than traditional detection methods. In this study, using the serum of sheep artificially infected with F. hepatica, the cDNA expression library of F. hepatica was screened, 17 immunodominant antigen genes of F. hepatica were obtained, and glutathione s-transferase (GST) was selected as the candidate detection antigen. Firstly, the GST cDNA sequence was amplified from F. hepatica, followed by the preparation of recombinant protein GST (rFhGST). Then, monoclonal and polyclonal antibodies against rFhGST were prepared using the GST protein. Afterward, the immunolocalization of the target protein in the worm was observed via confocal microscopy, and it was found that the GST protein was localized in the uterus, intestinal tract, and body surface of F. hepatica. Finally, a double-antibody sandwich SA-ELISA based on the detection of circulating antigens was established. There was no cross-reaction with positive sera infected with Dicrocoelium lanceatum (D. lanceatum), Haemonchus contortus (H. contortus), Neospora caninum (N. caninum), or Schistosoma japonicum (S. japonicum). Forty serum and fecal samples from the same batch of sheep in Nong’an County, Changchun City, Jilin Province, China were analyzed using the established detection method and fecal detection method. The positive rate of the SA-ELISA was 17.5%, and the positive rate of the fecal detection method was 15%. The detection results of this method were 100% consistent with commercial ELISA kits. A total of 152 sheep serum samples were tested in Nong’an County, Changchun City, Jilin Province, and the positive rate was 5.92%. This study laid the foundation for the development of serological detection preparations for F. hepatica infection based on the detection of circulating antigens.

ObjectiveTo develop and pilot an encounter-based decision aid (eDA) for people with depression for use in primary care.DesignWe developed an eDA for depression through cognitive interviews and pilot tested it using a one-group pretest, post-test design in primary care. Feasibility, fidelity of eDA use and acceptability were assessed using recruitment rates and semistructured interviews with patients, medical assistants and clinicians. Treatment choice and shared decision-making (SDM) were also assessed.SettingInterviews with adult patients and the public were conducted in a mall and library in Grafton County, New Hampshire, while clinician interviews took place by phone or at the clinician’s office. Pilot testing occurred in a New Hampshire primary care practice.ParticipantsCognitive interviews were conducted with adults, ≥18 years, who could read English from the following stakeholder groups: history of depression, the public and clinicians. Patients with a Patient Health Questionnaire-9 score of ≥5 were recruited for piloting.ResultsThree stages of cognitive interviews were conducted (n=28). Changes to eDA included moving the combination therapy information and access to treatment information, adding colour, modifying pictograms and editing the talk-therapy description. Clinician concerns about patient health literacy were not reflected in patient interviews. Of 59 patients who reviewed study information, 56 were eligible and agreed to participate in pilot testing; however, only 29 could be reached for follow-up. The eDA was widely accepted, though clinicians did not always use it as intended. We found no impact of eDA use on SDM, though patients chose a wider range of treatment options.ConclusionsWe demonstrated the feasibility of the use of an eDA for depression in primary care that was widely accepted. Further research is needed to improve the fidelity with which the eDA is used and to assess its impact on SDM and related health outcomes.

DAS WERDEN DER AGRARLANDSCHAFT IN DER GRAFSCHAFT TIPPERARY (IRLAND). Ingeborg Leister. Marburger Geographische Schriften, Heft 18, 1963. 434 pp. 21 DM.LAND USE IN NORTHERN IRELAND. General Report of the Land Utilisation Survey of Northern Ireland. Editor, Leslie Symons. University of London Press Ltd. 1963. pp. 288. £2–2‐0.WEST CORK RESOURCE SURVEY. Prepared and published by an Foras Talúntais (Agricultural Institute). Dublin 1963. £1.GEOLOGY AND IRELAND. W. E. Nevill. Dublin: Figgis, 1963. 8#fr1/2> × 5#fr1/2> in., xv + 263 pp., 65 text figures. 25s.RECENT RESEARCH ON IRISH RURAL SETTLEMENT. The report of a symposium held at Belfast, January 1963. By Ronald H. Buchanan. Belfast: Geography Department, The Queen's University. 1/‐.COUNTY LONDONDERRY HANDBOOK. Belfast: Nicholson & Bass. (no date) 2s. 6d.L'EUROPE DU NORD ET DU NORD‐OUEST. Tome III. LES ILES BRITANNIQUES. J. Beaujeu‐Garnier and A. Guilcher. ‘Orbis’ Introduction aux Etudes de Geographie. Paris: Presses Universitaires de France, 1963. 560pp. F.32.THE ECONOMIC PATTERN OF MODERN GERMANY, by Norman G. Pounds. London: John Murray, 1963. Pp. 133. 80#fr1/2> × 5#fr1/4> in. 18s.NORTH AMERICA. N. J. G. Pounds. London: John Murray, 2nd. ed., 1964. 238 pp. 18s. 6d.THE EARTH AND YOU. Norman J. G. Pounds. London: John Murry, 1963. 591 pp. 60s.INDUSTRIALISATION AND UNDER‐DEVELOPED COUNTRIES, by Alan B. Mountjoy. London: Hutchinson University Library, 1963. 223 pp. 15s.ATLAS OF CENTRAL EUROPE. London: J. Murray, 1963. 13 ins. × 9#fr1/2> ins. 42s.STATISTICAL MAPPING AND THE PRESENTATION OF STATISTICS. G C. Dickenson. London: Edward Arnold Ltd., 1963. 160pp. 21s.INTERNATIONAL YEARBOOK OF CARTOGRAPHY, III, 1963. Edited by Eduard Imhof. London: George Philip and Son Ltd., 1963. Pp. 232. 9#fr1/2> × 6#fr1/2> in. 40s.

Pale (Vincetoxicum rossicum) and black swallow-wort (V. nigrum) are perennial, twining vines that are increasingly invasive in natural and managed ecosystems in the northeastern United States and southeastern Canada. Both species, introduced from Europe in the 1800s, are listed as noxious weeds or banned invasive species by the USDA-Natural Resource Conservation Service. Observations by C. Southby, a local naturalist, over several years at a meadow populated by pale swallow-wort in Powder Mill Park, Monroe County, NY, revealed a gradual disappearance of pale swallow-wort with restoration of native grasses and some dicotyledonous plant species, in a 6.7-m-diameter area. Diseased swallow-wort plants had extensive yellowing and wilting of foliage, likely due to splitting of the basal stem, with white mycelium throughout the stem and crown; small, reddish brown sclerotia were evident, but roots were not affected. Stem tissue sections from 20 symptomatic plants were vacuum infiltrated with 2% NaOCl for 20 min, then plated onto malt yeast agar and potato dextrose agar amended with 60 mg/liter of penicillin and 80 mg/liter of streptomycin, resulting in development of fast-growing, white mycelium which then formed numerous, irregularly shaped (2 to 4 mm diameter), reddish brown sclerotia at the plate edges. Two individual cultures were identified as S. rolfsii (1) based on size, shape, and color of the sclerotia and presence of characteristic clamp connections in the mycelium. The isolate was suspected to be S. rolfsii var. delphinii due to the reported inability of S. rolfsii to persist in regions with extremely low winter temperatures (4), but molecular data showed otherwise. Sequences of the 18S gene (GenBank JN543690), internal transcribed spacer region (JN543691), and 28S gene (JN543692) of the ribosomal DNA identified the isolate, VrNY, as S. rolfsii (2,3). Pathogenicity tests were conducted with individual 2-month-old seedlings of V. rossicum and V. nigrum grown in steam-sterilized Metromix 360 in SC10 polypropylene conetainers in a growth chamber with a diurnal cycle of 25/20°C, a photoperiod of 14-h light/10-h dark, and fertilized at 3 week intervals. Two independent replications of 12 plants of each species were each inoculated at the stem base with a 4-mm-diameter mycelial agar plug from the growing edge of a colonized plate. The agar plug was held in place with 5 g of sterile sand. Control plants (12 of each species per replication) were treated with sterile agar plugs. Plants for each treatment were placed within a clear plastic bag to maintain 90% relative humidity for 72 h, and then removed from the bags. Disease symptoms developed over 21 days, with >90% of inoculated plants showing symptoms within 2 weeks. Control plants were symptomless. Incidence of mortality was 66 and 60% for V. rossicum and V. nigrum, respectively, by 3 weeks. The fungus reisolated from diseased stem and crown tissue produced characteristic mycelium with irregular sclerotia, consistent with those of S. rolfsii. Since spread of this fungus is based on movement of soilborne sclerotia, this isolate may offer potential as a bio-herbicide for control of swallow-wort in natural ecosystems if the isolate can be demonstrated to have a host range restricted to this invasive weed. References: (1) B. A. Edmunds and M. L. Gleason. Plant Dis. 87:313, 2003. (2) C. E. Harlton et al. Phytopathology 85:1269, 1995. (3) I. Okabe and N. Matsumoto. Mycol. Res. 107:164, 2003. (4) Z. Xu et al. Plant Dis. 92:719, 2008.

BackgroundMultidisciplinary rehabilitation is recommended for Parkinson’s disease, but evidence suggests that benefit is not sustained.Objectives(1) Implement a specialist domiciliary rehabilitation service for people with Parkinson’s and carers. (2) Provide continuing support from trained care assistants to half receiving the rehabilitation. (3) Evaluate the clinical effectiveness of the service, and the value added by the care assistants, compared with usual care. (4) Assess the costs of the interventions. (5) Investigate the acceptability of the service. (6) Deliver guidance for commissioners.DesignPragmatic three-parallel group randomised controlled trial.SettingCommunity, county of Surrey, England, 2010–11.ParticipantsPeople with Parkinson’s, at all stages of the disease, and live-in carers.InterventionsGroups A and B received specialist rehabilitation from a multidisciplinary team (MDT) – comprising Parkinson’s nurse specialists, physiotherapists, occupational therapists, and speech and language therapists – delivered at home, tailored to individual needs, over 6 weeks (about 9 hours’ individual therapy per patient). In addition to the MDT, participants in group B received ongoing support for a further 4 months from a care assistant trained in Parkinson’s (PCA), embedded in the MDT (1 hour per week per patient). Participants in control group (C) received care as usual (no co-ordinated MDT or ongoing support).Main outcome measuresFollow-up assessments were conducted in participants’ homes at 6, 24 and 36 weeks after baseline. Primary outcomes: Self-Assessment Parkinson’s Disease Disability Scale (patients); the Modified Caregiver Strain Index (carers). Secondary outcomes included: for patients, disease-specific and generic health-related quality of life, psychological well-being, self-efficacy, mobility, falls and speech; for carers, strain, stress, health-related quality of life, psychological well-being and functioning.ResultsA total of 306 people with Parkinson’s (and 182 live-in carers) were randomised [group A,n = 102 (n = 61); group B,n = 101 (n = 60); group C,n = 103 (n = 61)], of whom 269 (155) were analysed at baseline, pilot cohort excluded. Attrition occurred at all stages. A per-protocol analysis [people with Parkinson’s,n = 227 (live-in carers,n = 125)] [group A,n = 75 (n = 45); group B,n = 69 (n = 37); group C,n = 83 (n = 43)] showed that, at the end of the MDT intervention, people with Parkinson’s in groups A and B, compared with group C, had reduced anxiety (p = 0.02); their carers had improved psychological well-being (p = 0.02). People with Parkinson’s in groups A and B also had marginally reduced disability (primary outcome,p = 0.09), and improved non-motor symptoms (p = 0.06) and health-related quality of life (p = 0.07), compared with C. There were significant differences in change scores between week 6 (end of MDT) and week 24 (end of PCA for group B) in favour of group B, owing to worsening in group A (no PCA support) in posture (p = 0.001); non-motor symptoms (p = 0.05); health-related quality of life (p = 0.07); and self-efficacy (p = 0.09). Carers in group B (vs. group A) reported a tendency for reduced strain (p = 0.06). At 36 weeks post recruitment, 3 months after the end of PCA support for group B, there were few differences between the groups. Participants reported learning about Parkinson’s, and valued individual attention. The MDT cost £833; PCA support was £600 extra, per patient (2011 Great British pounds).ConclusionsFurther research is needed into ways of sustaining benefits from rehabilitation including the use of care assistants.Study registrationCurrent Controlled Trials: ISRCTN44577970.FundingThis project was funded by the National Institute for Health Research Health Services and Delivery Research programme and the South East Coast Dementias and Neurodegenerative Disease Research Network (DeNDRoN), and the NHS South East Coast. The report will be published in full inHealth Services and Delivery Research; Vol. 2, No. 51. See the NIHR Journals Library website for further project information.

Michael B. Katz. Reconstructing American Education. Cambridge and London: Harvard University Press, 1987. Pp. viii, 212. Cloth, $22.50; E. D. Hirsch, Jr. Cultural Literacy: What Every American Needs to Know. Boston: Houghton Mifflin Co., 1987. Pp. xvii, 251. Cloth, $16.45; Diana Ravitch and Chester E. Finn, Jr. What Do Our 17-Year-Olds Know? A Report on the First National Assessment of History and Literature. New York: Harper & Row, 1987. Pp. ix, 293. Cloth, $15.95. Review by Richard A. Diem of The University of Texas at San Antonio. Henry J. Steffens and Mary Jane Dickerson. Writer's Guide: History. Lexington, Massachusetts, and Toronto: D. C. Heath and Company, 1987. Pp. x, 211. Paper, $6.95. Review by William G. Wraga of Bernards Township Public Schools, Basking Ridge, New Jersey. J. Kelley Sowards, ed. Makers of the Western Tradition: Portraits from History. New York: St. Martin's Press, 1987. Fourth edition. Vol: 1: Pp. ix, 306. Paper, $12.70. Vol. 2: Pp. ix, 325. Paper, $12.70. Review by Robert B. Luehrs of Fort Hays State University. John L. Beatty and Oliver A. Johnson, eds. Heritage of Western Civilization. Englewood Cliffs, New Jersey: Prentice-Hall, Inc., 1987. Sixth Edition. Volume I: Pp. xi, 465. Paper, $16.00; Volume II: pp. xi, 404. Paper, $16.00. Review by Dav Levinson of Thayer Academy, Braintree, Massachusetts. Lynn H. Nelson, ed. The Human Perspective: Readings in World Civilization. New York: Harcourt Brace Jovanovich, 1987. Vol. I: The Ancient World to the Early Modern Era. Pp. viii, 328. Paper, $10.50. Vol. II: The Modern World Through the Twentieth Century. Pp, x, 386. Paper, 10.50. Review by Gerald H. Davis of Georgia State University. Gerald N. Grob and George Attan Billias, eds. Interpretations of American History: Patterns and Perspectives. New York: The Free Press, 1987. Fifth Edition. Volume I: Pp. xi, 499. Paper, $20.00: Volume II: Pp. ix, 502. Paper, $20.00. Review by Larry Madaras of Howard Community College. Eugene Kuzirian and Larry Madaras, eds. Taking Sides: Clashing Views on Controversial Issues in American History. -- Volume II: Reconstruction to the Present. Guilford, Connecticut: The Dushkin Publishing Groups, Inc., 1987. Pp. xii, 384. Paper, $9.50. Review by James F. Adomanis of Anne Arundel County Public Schools, Annapolis, Maryland. Joann P. Krieg, ed. To Know the Place: Teaching Local History. Hempstead, New York: Hofstra University Long Island Studies Institute, 1986. Pp. 30. Paper, $4.95. Review by Marilyn E. Weigold of Pace University. Roger Lane. Roots of Violence in Black Philadelphia, 1860-1900. Cambridge, Massachusetts, and London: Harvard University Press, 1986. Pp. 213. Cloth, $25.00. Review by Ronald E. Butchart of SUNY College at Cortland. Pete Daniel. Breaking the Land: The Transformation of Cotton, Tobacco, and Rice Cultures since 1880. Urbana and Chicago: University of Illinois Press, 1985. Pp. xvi, 352. Paper, $22.50. Review by Thomas S. Isern of Emporia State University. Norman L. Rosenberg and Emily S. Rosenberg. In Our Times: America Since World War II. Englewood Cliffs, New Jersey: Prentice-Hall, 1987. Third edition. Pp. xi, 316. Paper, $20.00; William H. Chafe and Harvard Sitkoff, eds. A History of Our Time: Readings on Postwar America. New York: Oxford University Press, 1987. Second edition. Pp. xiii, 453. Paper, $12.95. Review by Monroe Billington of New Mexico State University. Frank W. Porter III, ed. Strategies for Survival: American Indians in the Eastern United States. New York, Westport, Connecticut, and London: Greenwood Press, 1986. Pp. xvi, 232. Cloth, $35.00. Review by Richard Robertson of St. Charles County Community College. Kevin Sharpe, ed. Faction & Parliament: Essays on Early Stuart History. London and New York: Methuen, 1985. Pp. xvii, 292. Paper, $13.95; Derek Hirst. Authority and Conflict: England, 1603-1658. Cambridge: Harvard University Press, 1986. Pp. viii, 390. Cloth, $35.00. Review by K. Gird Romer of Kennesaw College. N. F. R. Crafts. British Economic Growth During the Industrial Revolution. New York: Oxford University Press, 1985. Pp. 193. Paper, $11.95; Maxine Berg. The Age of Manufactures, 1700-1820. New York: Oxford University Press, 1985. Pp. 378. Paper, $10.95. Review by C. Ashley Ellefson of SUNY College at Cortland. J. M. Thompson. The French Revolution. New York: Basil Blackwell, 1985 reissue. Pp. xvi, 544. Cloth, $45.00; Paper, $12.95. Review by W. Benjamin Kennedy of West Georgia College. J. P. T. Bury. France, 1814-1940. London and New York: Methuen, 1985. Fifth edition. Pp. viii, 288. Paper, $13.95; Roger Magraw. France, 1815-1914: The Bourgeois Century. New York and Oxford: Oxford University Press, 1985. Pp. 375. Cloth, $24.95; Paper, $9.95; D. M.G. Sutherland. France, 1789-1815: Revolution and Counterrevolution. New York and Oxford: Oxford University Press, 1986. Pp. 242. Cloth, $32.50; Paper, $12.95. Review by Fred R. van Hartesveldt of Fort Valley State College. Woodford McClellan. Russia: A History of the Soviet Period. Englewood Cliffs, New Jersey: Prentice-Hall, 1986. Pp. xi, 387. Paper, $23.95. Review by Pasquale E. Micciche of Fitchburg State College. Ranbir Vohra. China's Path to Modernization: A Historical Review from 1800 to the Present. Englewood Cliffs, New Jersey: Prentice-Hall, 1987. Pp. xiii, 302. Paper, $22.95. Reivew by Steven A. Leibo of Russell Sage College. John King Fairbank. China Watch. Cambridge and London: Harvard University Press, 1987. Pp. viii, Cloth, $20.00. Review by Darlene E. Fisher of New Trier Township High School, Winnetka, Illinois. Ronald Takaki, ed. From Different Shores: Perspectives on Race and Ethnicity in America. New York and Oxford: Oxford University Press, 1987. Pp. 253. Paper, $13.95. Review by Robert C. Sims of Boise State University.

In April 2006, sweet onions (Allium cepa) that were grown in Wayne County, GA displayed symptoms typical of either center rot caused by Pantoea ananatis or a foliar blight caused by Iris yellow spot virus (IYSV). After samples tested negative for IYSV by enzyme-linked immunosorbent assay and polymerase chain reaction, isolations were made from basal areas of leaves of infected plants where healthy and diseased tissues converged. All samples yielded yellow colonies on trypticase soy broth agar (TSBA) that were nonfluorescent when transferred to King's medium B. Four strains were characterized and tentatively identified as a Pantoea sp. by yellow pigmentation of colonies, oxidative and fermentative use of glucose, and lack of oxidase. However, the inability to produce indole from tryptophan, negative ice-nucleation activity, ability to reduce nitrate to nitrite, and the presence of phenylalanine deaminase were characteristics more typical of P. agglomerans than P. ananatis. Furthermore, all test strains utilized cellobiose, raffinose, lactose, gelatin, melibiose, and malonate. The identity of the bacterium was confirmed as P. agglomerans by BIOLOG (Hayward, CA). In addition, the 16S gene was amplified using universal primers (forward 5′-AGTTTGATCCTGGCTCAG-3′ and reverse 5′-TACCTTGTTACGACTTCGTCCCA-3′ (1) and sequenced. A BLAST search of the sequence against the NIH GenBank nucleotide library also confirmed the identity of the onion pathogen as P. agglomerans (97% identity) by having 8 of the top 10 bacteria providing significant alignments identified as P. agglomerans. The remaining two matches were uncultured bacteria from environmental samples. To confirm pathogenicity, two onion plants for each of the four test strains were inoculated with a turbid, aqueous bacterial suspension (~1 × 108 CFU ml-1) or sterile water in the lab (n = 8) and the field (n = 8). In addition, two plants each were inoculated with P. ananatis as a positive control and with a water blank and a nonpathogenic strain of P. agglomerans from peach (Png 86-2) as negative controls. All test strains of P. agglomerans produced severe blighting and withering of onion leaves in 4 days, while the water control and Png 86-2 were negative. Results were the same for both lab and field trials. Bacteria recovered from the plants infected with the test strains demonstrated the same characteristics of P. agglomerans as described above. Although P. agglomerans was originally reported as a pathogen of onion in South Africa (2), to the best of our knowledge, this is the first report of P. agglomerans causing a disease of onions in the United States. The long-term impact on the onion industry at this time is unknown. However, considering the close relationship of this organism with P. ananatis and the similarity of disease symptoms with those caused by center rot, there is potential that this bacterium could become established in the onion-growing area of Georgia and become part of a center rot ‘complex’. References: (1) T. De Baere et al. J. Clin. Microbiol. 42:4393, 2004. (2) M. J. Hattingh and D. F. Walters. Plant Dis. 65:615, 1981.

Background Adolescent physical activity levels are low and are associated with rising disease risk and social disadvantage. The Get Others Active (GoActive) intervention was co-designed with adolescents and teachers to increase physical activity in adolescents. Objective To assess the effectiveness and cost-effectiveness of the school-based GoActive programme in increasing adolescents’ moderate-to-vigorous physical activity. Design A cluster randomised controlled trial with an embedded mixed-methods process evaluation. Setting Non-fee-paying schools in Cambridgeshire and Essex, UK (n = 16). Schools were computer randomised and stratified by socioeconomic position and county. Participants A total of 2862 Year 9 students (aged 13–14 years; 84% of eligible students). Intervention The iteratively developed feasibility-tested refined 12-week intervention trained older adolescents (mentors) and in-class peer leaders to encourage classes to undertake two new weekly activities. Mentors met with classes weekly. Students and classes gained points and rewards for activity in and out of school. Main outcome measures The primary outcome was average daily minutes of accelerometer-assessed moderate-to-vigorous physical activity at 10 months post intervention. Secondary outcomes included accelerometer-assessed activity during school, after school and at weekends; self-reported physical activity and psychosocial outcomes; cost-effectiveness; well-being and a mixed-methods process evaluation. Measurement staff were blinded to allocation. Results Of 2862 recruited participants, 2167 (76%) attended 10-month follow-up measurements and we analysed the primary outcome for 1874 (65.5%) participants. At 10 months, there was a mean decrease in moderate-to-vigorous physical activity of 8.3 (standard deviation 19.3) minutes in control participants and 10.4 (standard deviation 22.7) minutes in intervention participants (baseline-adjusted difference –1.91 minutes, 95% confidence interval –5.53 to 1.70 minutes; p = 0.316). The programme cost £13 per student compared with control. Therefore, it was not cost-effective. Non-significant indications of differential impacts suggested detrimental effects among boys (boys –3.44, 95% confidence interval –7.42 to 0.54; girls –0.20, 95% confidence interval –3.56 to 3.16), but favoured adolescents from lower socioeconomic backgrounds (medium/low 4.25, 95% confidence interval –0.66 to 9.16; high –2.72, 95% confidence interval –6.33 to 0.89). Mediation analysis did not support the use of any included intervention components to increase physical activity. Some may have potential for improving well-being. Students, teachers and mentors mostly reported enjoying the GoActive intervention (56%, 87% and 50%, respectively), but struggled to conceptualise their roles. Facilitators of implementation included school support, embedding a routine, and mentor and tutor support. Challenges to implementation included having limited school space for activities, time, and uncertainty of teacher and mentor roles. Limitations Retention on the primary outcome at 10-month follow-up was low (65.5%), but we achieved our intended sample size, with retention comparable to similar trials. Conclusions A rigorously developed school-based intervention (i.e. GoActive) was not effective in countering the age-related decline in adolescent physical activity. Overall, this mixed-methods evaluation provides transferable insights for future intervention development, implementation and evaluation. Future work Interdisciplinary research is required to understand educational setting-specific implementation challenges. School leaders and authorities should be realistic about expectations of the effect of school-based physical activity promotion strategies implemented at scale. Trial registration Current Controlled Trials ISRCTN31583496. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 6. See the NIHR Journals Library website for further project information. This work was additionally supported by the Medical Research Council (London, UK) (Unit Programme number MC_UU_12015/7) and undertaken under the auspices of the Centre for Diet and Activity Research (Cambridge, UK), a UK Clinical Research Collaboration Public Health Research Centre of Excellence. Funding from the British Heart Foundation (London, UK), Cancer Research UK (London, UK), Economic and Social Research Council (Swindon, UK), Medical Research Council, the National Institute for Health Research (Southampton, UK) and the Wellcome Trust (London, UK), under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged (087636/Z/08/Z; ES/G007462/1; MR/K023187/1). GoActive facilitator costs were borne by Essex and Cambridgeshire County Councils.

NORTHERN IRELAND FROM THE AIR. Edited by R. Common, Belfast : Queen's University Geography Department, 1964. 104 pp., 44 plates, 1 folding map. 10 × 8 ins. 25s.THE CANALS OF THE NORTH OF IRELAND, by W. A. McCutcheon. Dawlish : David and Charles, and London : Macdonald and Co., 1965. 180 pp. 8 1/2 × 5 1/4 in. 36s.ULSTER AND OTHER IRISH MAPS c.1600. Edited by G. A. Hayes‐McCoy. Dublin : Irish Manuscripts Commission, 1964. 13 × 19 in. xv + 36 pp., 23. plates. £ 6.SOILS OF COUNTY WEXFORD. Edited by P. Ryan and M. J. Gardiner. Prepared and published by An Foras Talúntais (The Agricultural Institute), Dublin 1964. 171 pp. and three fold‐in maps. 30s.THE GEOGRAPHY OF SOIL, by Brian T. Bunting. London : Hutchinson's University Library, 1965. pp. 213. 14 figs. 12 tables. 7 1/2 × 5 in. 15s.THE HISTORY OF THE STUDY OF LANDFORMS. Vol. I : GEOMORPHOLOGY BEFORE DAVIS. Richard J. Chorley, Anthony J. Dunn and Robert P. Beckinsale. London : Methuen, 1964. 678 pp. 84s.A DICTIONARY OF GEOGRAPHY, by F. J. Monkhouse. London : Edward. Arnold Ltd., 1965. 344 pp. 8 1/2 × 5 1/2 in. 35s.LA REGION DE L'OUEST, by Pierre Flatrès. Collection ‘France de Demain ‘. Paris : Presses Universitaires de France, 1964. 31s. 6d.THE BRITISH ISLES : A SYSTEMATIC GEOGRAPHY. Edited by J. Wreford Watson and J. B. Sissons. Edinburgh : Thomas Nelson, 1964. 452 pp. 45s.SCANDINAVIAN LANDS, by Roy Millward. London : Macmillan, 1964. Pp. 448. 9 × 6 in. 45s.MERSEYSIDE, by R. Kay Gresswell and R. Lawton. British Landscapes Through Maps, No. 6. The Geographical Association, Sheffield, 1964. 36 pp. + 16 plates. 7 1/2 × 9 1/2 in. 5s.WALKING IN WICKLOW, by J. B. Malone. Dublin : Helicon Ltd., 1964. 172 pp. 7 × 4 #fr1/2> in. 7s.GREYSTONES 1864–1964. A parish centenary, 1964. 23 pp. 8 #fr1/4> × 5 1/2 in. 2s. 6d. Obtainable from the A.P.C.K., 37 Dawson Street, Dublin 2.DINNSEANCHAS. Vol. I, No. I. June 1964. An Cumann Logainmneacha, Baile Atha Cliath. Pp. 24. 5s.JOURNAL OF THE ASSOCIATION OF GEOGRAPHY TEACHERS OF IRELAND. Vol. I, Dublin. 1964.MAP READING FOR THE INTERMEDIATE CERTIFICATE, by Michael J. Turner. A. Folens : Dublin. 1964. 92 pp.MAP OF CORK CITY, 1: 15,000. Dublin : Ordnance Survey Office, 1964. 32 × 24 in. On paper, flat, 4s., or folded and covered, 5s.IRELAND, by T. W. Freeman. London : Methuen & Co. Ltd. Third edition, 1965. 5 1/2 × 8 #fr1/2> in. Pp. xx + 560. 65s.THE PLANNING AND FUTURE DEVELOPMENT OF THE DUBLIN REGION. PRELIMINARY REPORT. By Myles Wright. Dublin : Stationery Office, 1965. Pp.55. 8 ins. × 11 3/4 ins. 10s 6d.LIMERICK REGIONAL PLAN. Interim Report on the Limerick—Shannon— Ennis District by Nathaniel Litchfield. The Stationery Office, Dublin 1965. 8 × 12 ins. ; Pp. 83 ; 10s. 6d.ANTRIM NEW TOWN. Outline Plan. Belfast : H. M. Stationery Office, 1965. 10 1/2 × 8 1/2 in. 15s.HEPORT OF THE DEPUTY KEEPER OF THE RECORDS 1954–1959. Belfast : Her Majesty's Stationery Office. Cmd. 490. 138 pp. 10s.ECONOMIC GEOGRAPHY, by Ronald Hope. London : George Philip and Son Ltd., 4th edition, 1965. pp. 296. 15s. 6d.CLIMATE, SOILS AND VEGETATION, by D. C. Money. London : University Tutorial Press, 1965. pp. 272. 18s.TECHNIQUES IN GEOMORPHOLOGY, by Cuchlaine A. M. King. 9 × 5 1/2 in. 342 pp. London : Edward Arnold (Publishers) Ltd., 1966. 40s.BRITISH GEOMORPHOLOGICAL RESEARCH GROUP PUBLICATIONS :— 1. RATES OF EROSION AND WEATHERING IN THE BRITISH ISLES. Occasional Publication No. 2, 1965. Pp. 46. 13 × 8 in. 7s. 6d.2. DEGLACIATION. Occasional Publication No. 3, 1966. Pp. 37. 13 × 8 in. 7s.RECHERCHES DE GÉOMORPHOLOGIE EN ÉCOSSE DU NORD‐OUEST. By A. Godard. Publication de la Faculté des Lettres de l'Université de Strasbourg, 1965. 701 pp. 482 reís.ARTHUR'S SEAT: A HISTORY OF EDINBURGH'S VOLCANO, by G. P. Black. Edinburgh & London : Oliver & Boyd, 1966. 226 pp. 7 1/2 × 5 in. 35s.OFFSHORE GEOGRAPHY OF NORTHWESTERN EUROPE. The Political and Economic Problems of Delimitation and Control, by Lewis M. Alexander. London : Murray, 1966. 35s.GEOGRAPHICAL PIVOTS OF HISTORY. An Inaugural Lecture, by W. Kirk. Leicester University Press, 1965. 6s.THE GEOGRAPHY OF FRONTIERS AND BOUNDARIES, by J. R. V. Prescott. London : Hutchinson, 1965. 15s.THE READER'S DIGEST COMPLETE ATLAS OF THE BRITISH ISLES.. London : Reader's Digest Assoc., 1965. 230 pp. 15 1/4 × 10 1/2 in. £5. 10. 0.ULSTER DIALECTS. AN INTRODUCTORY SYMPOSIUM. Edited by G. B. Adams, Belfast : Ulster Folk Museum, 1964. 201 pp. 9 1/2 × 6 1/2 in. 20s.ULSTER FOLKLIFE, Volume 11. Belfast: The Ulster Folk Museum, 1965. Pp. 139. 9 1/2 × 7 in. 15s.GEOGRAPHICAL ABSTRACTS published and edited by K. M. Clayton, F. M Yates, F. E. Hamilton and C. Board.Obtainable from Geo. Abstracts, Dept. of Geography, London School of Economics, Aldwych, London, W.C.2. Subscription rates as below.THE CLIMATE OF LONDON. T. J. Chandler. London : Hutchinson and Co., 1965. 292 pp., 86 figs., 93 tables. 70/‐.MONSOON LANDS, Part I, by R. T. Cobb and L. J. M. Coleby. London : University Tutorial Press Ltd., 1966, constituting Book Six (Part 1 ) of the Advanced Level Geography Series. 303 pp. 8 1/4 × 5 1/4 in. 20s.PREHISTORIC AND EARLY CHRISTIAN IRELAND. A GUIDE, by Estyn Evans. London : B. T. Batsford Ltd., 1966. xii + 241 pp. 45s.A REGIONAL GEOGRAPHY OF IRELAND, by G. Fahy. Dublin : Browne and Nolan Ltd. No date. 238 pp. 12s.THE CANALS OF THE SOUTH OF IRELAND, by V. T. H. and D. R. Delany. Newton Abbot : David and Charles, 1966. 260 pp. + 20 plates. 8 1/2 × 5 1/2 in. 50s.THE COURSE OF IRISH HISTORY. Edited by T. W. Moody and F. X. Martin. Cork : The Mercier Press. 1967. 404 pp. 5 3/4 × 7 3/4 ins. Paperback, 21s. Hard cover, 40s.NORTH MUNSTER STUDIES. Edited by E. Rynne. Limerick : The Thomond Archaeological Society, 1967. 535 pp. 63s.SOILS OF COUNTY LIMERICK, by T. F. Finch and Pierce Ryan. Dublin: An Foras Talúntais, 1966. 199 pp. and four fold‐in maps. 9 1/2 × 7 1/4 in. 30s.THE FORESTS OF IRELAND. Edited by H. M. Fitzpatrick. Dublin : Society of Irish Foresters. No date. 153 pp. 9 3/4 × 7 1/4 in. 30s.PLANNING FOR AMENITY AND TOURISM. Specimen Development Plan Manual 2–3, Donegal. Dublin : An Foras Forbartha (The National Institute for Physical Planning and Construction Research), 1966. 110 pp. 8 × 11 in. 12s. 6d.NEW DIMENSIONS IN REGIONAL PLANNING. A CASE STUDY OF IRELAND, by Jeremiah Newman. Dublin : An Foras Forbartha, 1967. 128 pp. 8 1/2 × 6 in. 25s.TRAFFIC PLANNING FOR SMALLER TOWNS. Dublin : An Foras Forbartha (The National Institute for Regional Planning and Construction Research), 1966. 35 pp. 8 1/4 × 10 3/4 in. No price.LATE AND POST‐GLACIAL SHORELINES AND ICE LIMITS IN ARGYLL AND NORTH‐EAST ULSTER, by F. M. Synge and N. Stephens. Institute of British Geographers Transactions No. 59, 1966, pp. 101–125.QUATERNARY CHANGES OF SEA‐LEVEL IN IRELAND, by A. R. Orme. Institute of British Geographers Transactions No. 39, 1966, pp. 127–140.LIMESTONE PAVEMENTS (with special reference to Western Ireland), by Paul W. Williams. Institute of British Geographers Transactions No. 40, 1966, pp. 155–172. 50s. for 198 pages.IRISH SPELEOLOGY. Volume I, No. 2, 1966. Pp. 18. 10 × 8 in. 5s., free to members of the Irish Speleological Association.THE GEOGRAPHER'S CRAFT, by T. W. Freeman. Manchester University Press, 1967. pp.204. 8 1/4 × 5 in. 25s.GEOGRAPHY AS HUMAN ECOLOGY. Edited by S. R. Eyre and G. R. J. Jones. London : Edward Arnold Ltd., 1966. 308 pp. 45s.LOCATIONAL ANALYSIS IN HUMAN GEOGRAPHY, by Peter Haggett. London : Edward Arnold (Publishers) Ltd., 1965. 339 pp. 9 × 5 1/2 in. 40s.AGRICULTURAL GEOGRAPHY, by Leslie Symons. London : G. Bell and Sons, Ltd., 1967. 283 pp. 8 1/2 × 5 1/2 ins. 30s.THE GEOLOGY OF SCOTLAND, edited by Gordon Y. Craig. Edinburgh and London : Oliver & Boyd, 1965. Pp. 556. 9 3/4 × 7 1/2 in. 105s.MORPHOLOGY OF THE EARTH, by Lester C. King. Edinburgh : Oliver and Boyd, 2nd ed., 1967. 726 pp. 9 1/2 × 7 in. £5. 5. 0.INTERNATIONAL YEARBOOK OF CARTOGRAPHY, V, 1965. Edited by Eduard Imhof. London : George Philip and Son Ltd., 1965. 222 pp. + 9 plates. 9 3/4 × 6 1/2 in. 47s. 6d.IRISH FOLK WAYS, by E. Estyn Evans. London : Routledge and Kegan Paul, 1967. 324 pp. 16s.A HISTORY OF MEDIEVAL IRELAND, by A.J.Otway‐Ruthven. London: Ernest Benn Limited. New York : Barnes and Noble Inc., 1968. xv + 454 pp. 70s.IRISH AGRICULTURAL PRODUCTION, ITS VOLUME AND STRUCTURE, by Raymond D. Crotty. Cork University Press, 1966. 384 pp. 42s.PLANNING IN IRELAND. Edited by F. Rogerson and P. O hUiginn. Dublin : The Irish Branch of the Town Planning Institute and An Foras Forbartha, 1907. 199 pp.THE SHELL GUIDE TO IRELAND, by Lord Killanin and Michael V. Duignan. London : Ebury Press and George Rainbird (distributed by Michael Joseph) : 2nd edition, 1967. 512 pp. 50s.THE CLIMATE OF NORTH MUNSTER, by P. K. Rohan. Dublin : Department of Transport and Power, Meteorological Service, 1968. 72 pp. 10s. 6d.SOILS OF COUNTY CARLOW, by M.J. Conry and Pierce Ryan. Dublin : An Foras Talúntais, 1967. 204 pp. and four fold‐in maps. 30s.MOURNE COUNTRY, by E. Estyn Evans. Dundalk : Dundalgan Press (W. Tempest) Ltd., 2nd ed., 1967. 244 pp. 63s.THE DUBLIN REGION. Advisory Plan and Final Report, by Myles Wright. Dublin : The Stationery Office, 1967. Part One, pp. 64. 20s. Part Two, pp. 224. 80s.BELFAST : THE ORIGIN AND GROWTH OF AN INDUSTRIAL CITY. Edited by J. C. Beckett and R. E. Glasscock. London : The British Broadcasting Corporation, 1967. 204 pp. 25s.REPORT ON SKIBBEREEN SOCIAL SURVEY, by John Jackson. Dublin : Human Sciences Committee of the Irish National Productivity Committee, 1967. 63 pp. 12s. 6d.AN OUTLINE PLAN FOR GALWAY CITY, by Breandan S. MacAodha. Dublin : Scepter Publishers Ltd., 1966. 15 pp.COASTAL PASSENGER STEAMERS AND INLAND NAVIGATIONS IN THE SOUTH OF IRELAND, by D.B. McNeill. Belfast : The Transport Museum (Transport Handbook No. 6), 1965 (issued in 1967). 44 pp. (text) + 12 pp. (plates). 3s. 6d.CANALIANA, the annual bulletin of Robertstown Muintir na Tire. Robertstown, Co. Kildare : Muintir na Tire, n.d. (issued in 1967). 60 pp. 2s. 6d.CONACRE IN IRELAND, by Breandan S. MacAodha (Social Sciences Research Centre, Galway). Dublin : Scepter Publishers Ltd., 1967, 15 pp. No price.PROCESSES OF COASTAL DEVELOPMENT, by V.P. Zenkovich, edited by J.A. Steers, translated by D.G. Fry. 738 pp. Edinburgh and London : Oliver and Boyd, 1967. £12. 12s.CONGRESS PROCEEDINGS. 20th International Geographical Congress. Edited by J. Wreford Watson. London : Nelson, 1967. 401 pp. 70s.REGIONAL GEOGRAPHY, by Roger Minshull. London : Hutchinson University Library, 1967. 168 pp. 10s. 6d.ATMOSPHERE, WEATHER AND CLIMATE, by R.G. Barry and R.J. Chorley. London : University Paperback, Methuen, 1967. 25s.THE EVOLUTION OF SCOTLAND'S SCENERY, by J.B. Sissons. Edinburgh and London : Oliver and Boyd, 1967. 259 pp. 63s.WEST WICKLOW. BACKGROUND FOR DEVELOPMENT, by F.H.A. Aalen, D.A. Gillmor and P.W. Williams. Dublin : Geography Department, Trinity College, 1966. 323 pp. Unpublished : copy available in the Society's Library.

The Constitution of Kenya specifically recognizes the freedom of association to form and belong to trade unions. However, despite the adoption of the Labour Relations Act, union practice is still hampered by excessive restrictions. The EPZ companies are labor intensive requiring a large amount of labor to produce its goods or service and thus, the welfare of the employees play a key role in their functions. This study sought to determine the effect of trade union practices on employees’ welfare at export processing zones industries in Athi River, Kenya. The specific objectives sought to determine the effect of collective bargaining agreements, industrial action, dispute resolution and trade union representation on employees’ welfare at export processing zones industries in Athi River, Kenya. The study employed a descriptive research design. Primary data was collected by means of a structured questionnaire. The target population of the study was employees in EPZ companies in Athi River, Kenya with large employees enrolled in active trade unions. The unit of observation was the employees in the trade unions. The findings indicated that collective bargaining agreements had a positive and significant coefficient with employees’ welfare at the EPZ industries. Industrial action had a positive but non-significant effect with employees’ welfare at Export Processing Zones industries. Dispute resolution had a positive and significant coefficient with employees’ welfare at the EPZ industries. Trade union representation had a positive and significant coefficient with employees’ welfare at the EPZ industries. The study recommended that trade union should avoid the path of confrontation but continue dialogue through the collective bargaining process and demands should be realistic in nature with what is obtainable in the related industry. An existence of a formal two way communication between management and trade unions will ensure that right message is properly understood and on time too. Keywords: Collective Bargaining Agreements, Industrial Action, Dispute Resolution, Trade Union Representation, Employees Welfare & Export Processing Zones

Anacamptodes pergracilis (Hulst), commonly known as the cypress looper, drew considerable attention in late summer of 1980 with the unexpected defoliation of nearly 28,000 ha of cypress trees in USFS-NPS Big Cypress National Preserve (Collier and Monroe counties). Currently, cypress looper populations are at low levels, even in the Fisheating Creek (Glades County) area, a perennial generator of significant cypress looper defoliation over the past 20 years. This 3-page fact sheet was written by Wayne N. Dixon and published by the UF Department of Entomology and Nematology, April 2013. http://edis.ifas.ufl.edu/in986

Assessments of health variables in wild animal populations have evolved into important tools for characterizing spatiotemporal population trends and fitness, effects of stressors, diseases, and ecosystem health. Blood as a sample matrix can be obtained fairly non-invasively in the field, with preservation and sample processing techniques that allow for readily available routine and advanced diagnostic testing of blood. For wild-caught hawksbill sea turtles (Eretmochelys imbricata) foraging in southeastern Florida, USA, the objectives of this study were to (1) establish reference intervals for hematological and 24 plasma biochemical analytes, (2) determine length-and body condition-specific relationships with blood analytes, and (3) determine how water temperature influenced plasma biochemical analytes. Reference intervals were established for clinically normal juvenile (n = 26) and subadult (n = 39) hawksbills, with descriptive data reported for adult turtles (n = 3). Although subadults (mainly captured at Palm Beach County) were heavier and larger with greater body depth, juveniles (mainly captured at Monroe County) had a higher body condition index. Positive length-specific correlations were identified for packed cell volume, eosinophils, aspartate aminotransferase, phosphorus, cholesterol, glutamate dehydrogenase, total protein, albumin, and globulins, with negative correlations including alkaline phosphatase, creatine kinase, calcium, calcium to phosphorus ratio, and glucose. Subadults had less frequent morphological features of red blood cell regeneration compared to juveniles. These findings provide insight into life-stage class differences regarding hematopoiesis, antigenic stimulation, somatic growth, dietary shifts, nutritional status, osmoregulation, metabolism, physical activity or stress levels, and possible habitat differences. Life-stage class is the likely driver for the observed blood analyte differences, in addition to influences from water temperature. The data herein offer baseline information for a snapshot in time for critically endangered hawksbills inhabiting the Florida reef system and for answering individual-and population-relevant questions of relevance to conservation and population management.

Abstract Background Healthcare personnel (HCP) have remained at high risk for SARS-CoV-2 infection during the COVID-19 pandemic. High and timely COVID-19 vaccine uptake is crucial to protect this at-risk population. Our study aims to characterize HCP who delayed initiation of the primary series, and those who did not receive a booster dose. Methods Data for this analysis came from a cohort of HCP working at a large healthcare system in Monroe County, NY identified between 12/28/2020-12/01/2022. HCP were enrolled as part of the CDC Emerging Infections Program COVID-19 vaccine effectiveness study using a test-negative case-control design. Participants completed a standardized questionnaire assessing demographic and occupational characteristics. Verified COVID-19 vaccination history for each HCP was collected during the study period. HCP were categorized as having early or delayed vaccine initiation if they received their 1st mRNA COVID-19 vaccine between 12/14/2020-03/30/2021 (early) or 04/01/2021-09/28/2021 (delayed) after which employee vaccine mandates were implemented at this hospital system. HCP were also categorized as having received a 3rd mRNA COVID-19 booster dose or not after 09/24/2021. Logistic regression models were run to identify characteristics of HCP who delayed 1st dose receipt or did not receive a booster dose. Results Across the study period, 3,471 HCP were enrolled. Of these, 86.0% had early initiation of their 1st mRNA COVID-19 vaccine, and 82.8% received an mRNA booster dose. Low education, low household income, younger age (< 50), non-White race and public health insurance were all significant predictors of delayed receipt of 1st dose and lack of uptake of a booster. However, advanced professional role was only found to be a significant predictor of early 1st dose receipt (Figure 1). Sensitivity analyses, run by changing dates of early vs delayed initiation to later time points, validated these results.Figure 1.Sociodemographic and Occupational Characteristics Associated with COVID-19 Vaccine Coverage Among Healthcare Personnel (N=3,471) +Adjusted for gender, race/ethnicity, and education. ++Adjusted for gender and race/ethnicity. *Adjusted for professional role, educational attainment, and race/ethnicity. **Adjusted for gender, age, educational attainment, professional role, annual household income, and health insurance type. Other Role with Moderate or Minimal Patient Contact includes: Nonphysician behavioral health provider, chaplain, care coordinator, dietician, environmental services personnel, food services personnel, patient transport personnel, research personnel, social worker, student, facilitates maintenance personnel, medical equipment technician, laboratory personnel or pharmacist. Other Role with Substantial Patient Contact includes: Dental healthcare provider, emergency medical services personnel, occupational therapist, physical therapist or assistant, phlebotomist, respiratory therapist, radiology technician, speech-language pathologist, and surgical, medical or emergency technician. Conclusion Sociodemographic characteristics, rather than occupational, were predictive of high and timely vaccine uptake. Continual monitoring of COVID-19 vaccine uptake among HCP to identify those less likely to receive new booster doses will be crucial for maintaining high vaccination rates in this important population. Disclosures Ghinwa Dumyati, MD, Pfizer: Grant/Research Support

Cultural tourism is a selective form of tourism that needs to be systematically introduced to certain aspects of the library business and is another example of underutilized potential in creating a cultural tourism policy. This paper presents results of the research, which has been conducted in 2010 in Istria on public libraries of the Istrian County with the aim to detect the state and the level of participatio n of public libraries in the cultural tourism services. As a response to the detected problems, the paper brings forth suggestions for further development according to which libraries can fi nd their own growth model, while respecting different development levels and the local communities’ context. Recommendations for the development of public libraries in cultural tourism are set on the basis of new library system structures, introduction of new services and cultural management. They are harmonised with the local community needs obtained through a demographic survey and analysis of the administrative-territorial structure of the County. The presented model of the County’s public library development in cultural tourism can be refl ected in developing new contents for digital libraries connected to publicly available catalogues through contents and services of the developed, cooperating consortium of public libraries.

As of July 22, 2022, there were 3,528,282 total confirmed COVID-19 cases in Illinois, United States. The purpose of this study was to examine how the COVID-19 pandemic has contributed to Illinois Region 4 adult residents’ poor mental health and assess the mental health burden the residents experienced during the pandemic. A cross-sectional survey was administered via Qualtrics. Participants (N=632) living in the Illinois Region 4 counties of Bond, Clinton, Madison, Monroe, Randolph, St. Clair, and Washington were recruited through Facebook. The questionnaire was developed based on the current literature review and was validated by colleagues in public health. Both descriptive statistics and logistic regression were used for data analysis using SPSS. Most of the participants identified as female (86.7%). Many of the participants had an associate’s (23.6%) or a bachelor’s (29.4%) degree. About 84% of the participants reported that COVID-19 had changed things in their daily life (e.g., work, family, and social life). There was significantly more perceived mental health burden during the pandemic than there was before the pandemic (p<0.001). Approximately 68% of participants believed more mental health resources should be made available within their county of residence. Overall, the study findings suggest the perceived mental health burden among Region 4 adults, which highlight the need for mental health issues to be prioritized and the allocation of mental health resources to be optimized.

AbstractChina’s rapid increase in mass excreta and its environmental discharge have attracted substantial attention. However, cropland as a main destination of excreta utilization has not been extensively evaluated. Here, a national survey was used to assess the utilization of manure in croplands across China. The data included the inputs of manure nitrogen (N), phosphorus (P), and potassium (K) for cereals, fruits, vegetables, and other crops, along with the manure proportion of total N, P, and K inputs at the county level. The results showed that the manure N, P, and K inputs were 6.85, 2.14, and 4.65 million tons (Mt), respectively, constituting 19.0%, 25.5%, and 31.1% of the total N, P, and K, respectively. The spatial distribution of the manure proportion of total inputs was lower in Eastern China and higher in Western China. The results provide a detailed description of the utilization of manure nutrients in agricultural areas throughout China, which will serve as basic support for policymakers and researchers involved in future agricultural nutrient management in China.

Abstract Background We sought to identify immune biomarkers associated with severe Coronavirus disease 2019 (COVID-19) in patients admitted to a large public county hospital during the early phase of the SARS-CoV-2 pandemic. We hypothesized that we could identify clinically relevant immune markers at the time of initial hospital admission that could be used to predict the course of COVID-19 illness. Methods The study population consisted of SARS-CoV-2 positive patients admitted for COVID-19 (n = 58) or controls (n = 14) at the Los Angeles County University of Southern California Medical Center between April-December 2020. Immunologic markers including chemokine/cytokines (IL-6, IL-8, IL-10, IP-10, MCP-1, TNFα) and serologic markers against SARS-CoV-2 antigens (including spike subunits S1 and S2, receptor binding domain (RBD), and nucleocapsid (N)) were assessed in serum collected on the day of admission using custom MILLIPLEX® immunoassay panels. Result values were computed using mean fluorescent intensity in individual samples fit to a standard curve using a 5PL logistic formula with power law variance. Comparison of patient demographic, clinical, cytokines and immunoglobulins characteristics between mild vs moderate/severe COVID-19 groups were conducted using Wilcoxon tests for continuous variables and Chi-square tests for categorical variables. Linear support vector machine models were fitted to perform the binary classification task of predicting mild vs moderate/severe COVID-19 using the python library scikit-learn. Results SARS-CoV-2 antibody levels were significantly elevated in patients with the highest COVID-19 disease severity, with IgM S1, IgG N, IgG RBD, IgG S1, and IgG S2 showing statistical significance between mild vs moderate/severe disease group medians (P = 0.037, 0.032, 0.007, 0.003, and 0.015, respectively). Of the chemokines/cytokines tested, only IP-10 showed significance across the disease groups (medians 640.8 pg/mL in mild, 493.3 pg/mL in moderate/severe, and 259.9 pg/mL in control, overall P = 0.005). The linear support vector machine model achieved an accuracy of 64% and an AUROC of 0.81 in predicting COVID-19 severity status. The most important clinical variables for predicting disease severity were white blood cell count, diastolic blood pressure, and platelet count, while the most important serologic markers were IgG anti-SARS-CoV-2 N, S1, S2, TNF-α, IP-10, and IL-10. Conclusion Our results suggest that IP-10 and anti-SARS-CoV-2 antibody measurements could be useful to identify patients most likely to experience the most severe forms of the disease. Strengths of this study include a focus on a racially and ethnically diverse patient population and a combined analysis of both cytokine/chemokine and immune response (antibody) biomarkers. However, we emphasize that our subjects were enrolled at a time before widespread vaccination against SARS-CoV-2.

AbstractTraditionally, learning among young students has taken place within structured, physical classroom settings. However, the emergence of distance learning has introduced a diverse range of learning methods, including online, hybrid, and blended approaches. When the COVID-19 pandemic led to extended delays in in-person instruction, use of educational technologies such as asynchronous videos and online platforms were deployed to deliver mathematics curricula aligned with the Common Core State Standards (CCSS), though best practices for teaching mathematics asynchronously are not well studied. This study focuses on exploring the effectiveness of a math course on proportional reasoning that was co-designed, developed, and deployed in 5th and 6th grade Orange County classrooms. Examining the learning experience design (LXD) paradigm, this research focuses on discerning its influence on (n = 303) children's engagement during their involvement in an online, video-based math course. LXD is implemented by combining evidence-based pedagogical instructional design with human-centered user experience (UX) design. The study utilized a structural equation model to analyze the relationships between learners' user experiences, situational interest, mind-wandering, and online engagement. The results demonstrated significant direct effects between students' situational interest, user experience, and their level of online engagement. Findings also indicate that students' situational interest and mind-wandering significantly mediate the relationship between their user experiences and online engagement. These results have important theoretical and practical implications for researchers, designers, and instructors. By combining evidenced-based pedagogical learning design with human-centered user experience design, LX designers can promote situational interest, reduce mind-wandering, and increase engagement in elementary mathematics courses conducted in asynchronous online settings.

Virus diseases are major constraints to the production of cucurbits in the Texas Lower Rio Grande Valley. In September 2020, a ~8.1 ha butternut squash (Cucurbita moschata) field in Hidalgo County, Texas, was observed with virus-like symptoms of vein yellowing, leaf curl, mosaic, and foliar chlorosis. The proportion of plants with virus-like symptoms in this field was estimated at 30% and seven samples (symptomatic = 5; non-symptomatic = 2) were collected randomly for virus diagnosis. Initially, equimolar mixtures of total nucleic acid extracts (Dellaporta et. al. 1983) from two symptomatic samples from this field and extracts from 12 additional symptomatic samples from six other fields across south and central Texas was used to generate one composite sample for diagnosis by high throughput sequencing (HTS). The TruSeq Stranded Total RNA with Ribo-Zero Plant Kit (Illumina) was used to construct cDNA library from the composite sample, which was then sequenced on the Illumina NextSeq 500 platform. More than 26 million single-end HTS reads (75 nt each) were obtained and their bioinformatic analyses (Al Rwahnih et al. 2018) revealed several virus-like contigs belonging to different species (data not shown). Among them, 6 contigs that ranged in length from 429 to 3,834 nt shared 96 to 100% identities with isolates of squash vein yellowing virus (SqVYV), genus Ipomovirus, family Potyviridae. To confirm the HTS results, total nucleic acid extracts from the cucurbit samples from all seven fields (n = 46) were used for cDNA synthesis with random hexamers and the PrimeScript 1st strand cDNA Synthesis Kit (Takara Bio). A 1-μL aliquot of cDNA was used in 12.5-μL PCR reaction volumes with PrimeSTAR GXL DNA Polymerase (Takara Bio) and two pairs of SqVYV-specific primers designed based on the HTS derived contigs. The primer pairs SqYVV-v4762: 5′-CTGGATTCTGCTGGAAGATCA & SqYVV-c5512: 5′-CCACCATTAAGGCCATCAAAC and SqYVV-v8478: 5′-TTTCTGGGCAAACAAACATGG & SqYVV-c9715: 5′-TTCAGCGACGTCAAGTGAG targeted ~0.75 kb and ~1.2 kb fragments of the cylindrical inclusion (CI) and the complete coat protein (CP) gene sequences of SqVYV, respectively. The expected DNA band sizes were obtained only from the five symptomatic butternut squash samples from the Hidalgo Co. field. Two amplicons per primer pair from two samples were cloned into pJET1.2/Blunt vector (Life Technologies) and bidirectionally Sanger sequenced, generating 753 nt partial CI specific sequences (MW584341-342) and 1,238 nt that encompassed the complete CP (MW584343-344) of SqVYV. In pairwise comparisons, the partial CI sequences shared 100% nt/aa identity with each other and 98-99% nt/aa identity with corresponding sequences of SqVYV isolate IL (KT721735). The CP cistron of TX isolates shared 100% nt/aa identity with each other and 90-98% nt (97-100% aa) identities with corresponding sequences of several SqVYV isolates in GenBank, with isolates IL (KT721735) and Florida (EU259611) being at the high and low spectrum of nt/aa identity values, respectively. This is the first report of SqVYV in Texas, naturally occurring in butternut squash. SqVYV was first discovered in Florida (Adkins et al. 2007) and subsequently reported from few other states in the U.S. (Adkins et al. 2013; Egel and Adkins 2007; Batuman et al. 2015), Puerto Rico (Acevedo et al. 2013), and locations around the world. The finding shows an expansion of the geographical range of SqVYV and adds to the repertoire of cucurbit-infecting viruses in Texas. Further studies are needed to determine the prevalence of SqVYV in Texas cucurbit fields and an assessment of their genetic diversity.

The common bean (Phaseolus vulgaris; family: Fabaceae) is an economically and nutritionally important food crop worldwide (Ganesan et al. 2017). In 2021, several plants collected from different provinces in South Korea had symptoms of viral infections (e.g., mild yellow-greenish speckling, stunting, crinkling, and deformed leaves). To identify the causal pathogens, total RNA was isolated from pooled leaf tissues from all samples (n = 29) for paired-end high-throughput sequencing (HTS). The cDNA library was constructed after eliminating ribosomal RNA using the TruSeq RNA Sample Prep Kit and then sequenced using the Illumina NovaSeq 6000 platform (Macrogen, Korea). The 297,868,156 paired-end clean reads (150 nt) were de novo assembled using Trinity with default parameters. BLASTx was used for the contig analysis, which revealed the pooled samples were infected with several plant viruses (e.g., turnip mosaic virus, zucchini yellow mosaic virus, cucumber mosaic virus, lily mottle virus). Notably, the assembled contigs included a single viral contig (8,472 nt) comprising the nearly complete KLV genome (HTS mean coverage: 39.46%). Kalanchoe latent virus (KLV; genus: Carlavirus; family: Betaflexiviridae) has been detected in Kalanchoë blossfeldiana (Hearon 1982), Chenopodium quinoa (Dinesen et al. 2009), and Graptopetalum paraguayense (Sorrentino et al. 2017). The sequence was most similar (96.28% nucleotide identity; 99% query coverage) to KLV isolate DSMZ PV-0290 (GenBank: OP525283) from Denmark. The contig sequence was validated via reverse transcription-polymerase chain reaction (RT-PCR) using total RNA extracted from the 29 individually stored samples and nine primer sets specific for the KLV contig. All nine contig-specific overlapping fragments were amplified from only a P. vulgaris plant with mild yellowing mosaic symptoms collected on July 6, 2021, in Jeongseon County, South Korea. Additionally, 5′ and 3′ rapid amplification of cDNA ends (RACE)-specific primers were designed for the KLV contig sequence to determine the terminal ends of the genome of the South Korean KLV isolate using the 5′/3′ RACE System (Invitrogen, Carlsbad, CA, USA). All of the amplified and overlapping fragments were cloned into the RBC T&A Cloning Vector (RBC Bioscience, Taipei, Taiwan) and sequenced using the Sanger method. The obtained full-length genomic sequence of the KLV isolate (KLV-SK22) was 8,517 nt long and was deposited in GenBank OQ718816. According to the BLASTn analysis, KLV-SK22 was highly similar (96.30% sequence identity; 100% query coverage) to the DSMZ PV-0290 isolate. Phylogenetic trees constructed on the basis of coat protein and RNA-dependent RNA polymerase amino acid sequences revealed that KLV-SK22 is closely related to the DSMZ PV-0290 and PV-0290B isolates from Denmark, respectively. At the genome and gene levels, the individual sequence identities between the carlaviruses and other KLV isolates were 96.29% to 100% (Adams et al. 2004). Additionally, an RT-PCR analysis using detection primers specific for KLV-SK22 did not detect KLV in 15 samples (P. vulgaris = 3, Glycine max = 8, Pueraria montana = 2, Trifolium repens = 1, and Vigna angularis = 1) randomly collected from different regions in South Korea. Based on these results, KLV infection may not be widespread at this time in South Korea. To the best of our knowledge, this is the first report of KLV in P. vulgaris in South Korea or elsewhere. Our findings will aid future research on the epidemiology and long-term management of KLV-related diseases.

ObjectiveTo assess evidence for public health impact of syndromic surveillance.IntroductionSystematic syndromic surveillance is undergoing a transition. Building on traditional roots in bioterrorism and situational awareness, proponents are demonstrating the timeliness and informative power of syndromic surveillance data to supplement other surveillance data.MethodsWe used PubMed and Google Scholar to identify articles published since 2007 using key words of interest (e.g., syndromic surveillance in combinations with emergency, evaluation, quality assurance, alerting). The following guiding questions were used to abstract impact measures of syndromic surveillance: 1) what was the public health impact; what decisions or actions occurred because of use of syndromic surveillance data?, 2) were there specific interventions or performance measures for this impact?, and 3) how, and by whom, was this information used?ResultsThirty-five papers were included. Almost all articles (n=33) remarked on the ability of syndromic surveillance to improve public health because of timeliness and/or accuracy of data. Thirty-four articles mentioned that syndromic surveillance data was used or could be useful. However, evidence of health impact directly attributable to syndromic surveillance efforts were lacking. Two articles described how syndromic data were used for decision-making. One article measured the effect of data utilization.ConclusionsWithin the syndromic surveillance literature instances of a conceptual shift from detection to practical response are plentiful. As the field of syndromic surveillance continues to evolve and is used by public health institutions, further evaluation of data utility and impact is needed.ReferencesAyala, A., Berisha, V., Goodin, K., Pogreba-Brown, K., Levy, C., McKinney, B., Koski, L., & Imholte, S. (2016). 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ObjectiveTo describe the impact of civil unrest on the mental health of a community in near real-time using syndromic surveillance.IntroductionAs part of a wide-spread community discussion on the presence of monuments to Confederate Civil War figures, the Charlottesville city council voted to remove a statue of General Robert E. Lee.1 Multiple rallies were then held to protest the statue’s removal. A Ku Klux Klan (KKK) rally on July 8, 2017 (MMWR Week 27) and a Unite the Right rally on August 12, 2017 (MMWR Week 32) held in Charlottesville both resulted in violence and media attention.2,3 The violence associated with the Unite the Right rally included fatalities connected to motor vehicle and helicopter crashes.Syndromic surveillance has been used to study the impact of terrorism on a community’s mental health4 while more traditional data sources have looked at the impact of racially-charged civil unrest.5 Syndromic surveillance, however, has not previously been used to document the effect of racially-charged violence on the health of a community.MethodsThe Virginia Department of Health (VDH) analyzed syndromic surveillance data from three emergency departments (EDs) in the Charlottesville area (defined to include Charlottesville city and Albemarle county), regardless of patient residence following the Unite the Right rally. Visits to these EDs between January 1 and September 2, 2017 were analyzed using the Enhanced Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE) and Microsoft SQL 2012. Encounters were identified as acute anxiety-related visits based on an International Classification of Diseases, Tenth Revision (ICD-10) discharge diagnosis beginning with ’F41’. Analyses were conducted using the ESSENCE algorithm EWMA 1.2 and SAS 9.3.ResultsThe greatest number of visits with a primary diagnosis of anxiety in 2017 (N=20) was observed in MMWR week 34 (August 20-26). This represented a statistically significant increase over baseline with a p-value of 0.01.By race, a significant increase over baseline in visits with a primary diagnosis of anxiety was observed among blacks or African Americans. The largest volume of visits was observed in MMWR week 33 with a total of 8 identified visits or 1.8% of total ED visit volume. The increase in visits for anxiety observed in weeks 33-35 was 2.2 times greater among blacks or African Americans than it was among whites, p = 0.016, 95% CI [1.14, 4.16].ConclusionsPrevious work done in Virginia to identify ED visits related to anxiety included only chief complaint criteria in the syndrome definition. Due to a change in how one ED in the Charlottesville area reported data during the study period, this syndrome definition could not be applied. In order to remove any potential data artifacts, only those visits with an initial diagnosis of anxiety were included in the analysis. The resulting syndrome definition likely underestimated the occurrence of anxiety in the Charlottesville area, both because it lacked chief complaint information and because syndromic surveillance does not include data on visits to mental health providers outside of EDs. This analysis presents a trend over time rather than a true measure of the prevalence of anxiety.This analysis, while conservative in its inclusion criteria, still identified an increase in visits for anxiety, particularly among blacks or African Americans. In today’s political environment of race-related civil unrest, a way to measure the burden of mental illness occurring in the community can be invaluable for public health response. In Charlottesville, the identification of a community-wide need for mental health support prompted many local providers to offer their services to those in need pro-bono.6References1 Suarez, C. (2017, February 6). Charlottesville City Council votes to remove statue from Lee Park. The Daily Progress. Retrieved from http://bit.ly/2wYOHhv2 Spencer, H., & Stevens, M. (2017, July 8). 23 Arrested and Tear Gas Deployed After a K.K.K. Rally in Virginia. The New York Times. Retrieved from http://nyti.ms/2tCiBGU3 Hanna, J., Hartung, K., Sayers, D., & Almasy, S. (2017, August 13). Virginia governor to white nationalists: ‘Go home … shame on you’. CNN. Retrieved from http://cnn.it/2vvAGHt4 Vandentorren, S., Paty, A. C., Baffert, E., Chansard, P., Caserio-Schönemann, C. (2016, February). Syndromic surveillance during the Paris terrorist attacks. The Lancet (387(10021), 846-847. doi:10.1016/S0140-6736(16)00507-95 Yimgang, D. P., Wang, Y., Paik, G., Hager, E. R., & Black, M. M. Civil Unrest in the Context of Chronic Community Violence: Impact on Maternal Depressive Symptoms. American Journal of Public Health 107(9), 1455-1462. doi:10.2105/AJPH.2017.3038766 DeLuca, P. (2017, August 19). Downtown Charlottesville Library Offers Free Counseling. NBC29.com. Retrieved from http://bit.ly/2yIzHbl

Pentingnya membangun OCB tidak lepas dari komitmen karyawan dalam organisasi. Komitmen karyawan akan mendorong terciptanya OCB dan tanpa adanya kontrol yang baik dalam pemberian kompensasi yang sesuai dengan hasil kerja tentunya memperlambat kerja pegawai. Penelitian ini bertujuan untuk menguji dan menganalisis pengaruh kompensasi dan komitmen organisasi terhadap kepuasan kerja dan OCB. Jumlah responden dalam penelitian ini berjumlah 86 orang. Pengumpulan data diperoleh dengan kuesioner menggunakan skala likert. Metode analisis data menggunakan Path Analysis. Hasil penelitian diperoleh bahwa kompensasi berpengaruh positif dan signifikan terhadap kepuasan kerja dan Kepuasan kerja berpengaruh positif dan signifikan terhadap OCB. Kata Kunci : Komitmen Organisasi, Kompensasi, Kepuasan kerja dan OCBDAFTAR PUSTAKA Bangun, Wilson. (2012). Manajemen Sumber Daya Manusia. Erlangga. Jakarta. Bernardin, H. John, & Joyce E.A Russel. (2003). 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Photo ID 158378414 © Eduard Muzhevskyi | Dreamstime.com ABSTRACT There is a debate about the ethical implications of using human embryos in stem cell research, which can be influenced by cultural, moral, and social values. This paper argues for an adaptable framework to accommodate diverse cultural and religious perspectives. By using an adaptive ethics model, research protections can reflect various populations and foster growth in stem cell research possibilities. INTRODUCTION Stem cell research combines biology, medicine, and technology, promising to alter health care and the understanding of human development. Yet, ethical contention exists because of individuals’ perceptions of using human embryos based on their various cultural, moral, and social values. While these disagreements concerning policy, use, and general acceptance have prompted the development of an international ethics policy, such a uniform approach can overlook the nuanced ethical landscapes between cultures. With diverse viewpoints in public health, a single global policy, especially one reflecting Western ethics or the ethics prevalent in high-income countries, is impractical. This paper argues for a culturally sensitive, adaptable framework for the use of embryonic stem cells. Stem cell policy should accommodate varying ethical viewpoints and promote an effective global dialogue. With an extension of an ethics model that can adapt to various cultures, we recommend localized guidelines that reflect the moral views of the people those guidelines serve. BACKGROUND Stem cells, characterized by their unique ability to differentiate into various cell types, enable the repair or replacement of damaged tissues. Two primary types of stem cells are somatic stem cells (adult stem cells) and embryonic stem cells. Adult stem cells exist in developed tissues and maintain the body’s repair processes.[1] Embryonic stem cells (ESC) are remarkably pluripotent or versatile, making them valuable in research.[2] However, the use of ESCs has sparked ethics debates. Considering the potential of embryonic stem cells, research guidelines are essential. The International Society for Stem Cell Research (ISSCR) provides international stem cell research guidelines. They call for “public conversations touching on the scientific significance as well as the societal and ethical issues raised by ESC research.”[3] The ISSCR also publishes updates about culturing human embryos 14 days post fertilization, suggesting local policies and regulations should continue to evolve as ESC research develops.[4] Like the ISSCR, which calls for local law and policy to adapt to developing stem cell research given cultural acceptance, this paper highlights the importance of local social factors such as religion and culture. I. Global Cultural Perspective of Embryonic Stem Cells Views on ESCs vary throughout the world. Some countries readily embrace stem cell research and therapies, while others have stricter regulations due to ethical concerns surrounding embryonic stem cells and when an embryo becomes entitled to moral consideration. The philosophical issue of when the “someone” begins to be a human after fertilization, in the morally relevant sense,[5] impacts when an embryo becomes not just worthy of protection but morally entitled to it. The process of creating embryonic stem cell lines involves the destruction of the embryos for research.[6] Consequently, global engagement in ESC research depends on social-cultural acceptability. a. US and Rights-Based Cultures In the United States, attitudes toward stem cell therapies are diverse. The ethics and social approaches, which value individualism,[7] trigger debates regarding the destruction of human embryos, creating a complex regulatory environment. For example, the 1996 Dickey-Wicker Amendment prohibited federal funding for the creation of embryos for research and the destruction of embryos for “more than allowed for research on fetuses in utero.”[8] Following suit, in 2001, the Bush Administration heavily restricted stem cell lines for research. However, the Stem Cell Research Enhancement Act of 2005 was proposed to help develop ESC research but was ultimately vetoed.[9] Under the Obama administration, in 2009, an executive order lifted restrictions allowing for more development in this field.[10] The flux of research capacity and funding parallels the different cultural perceptions of human dignity of the embryo and how it is socially presented within the country’s research culture.[11] b. Ubuntu and Collective Cultures African bioethics differs from Western individualism because of the different traditions and values. African traditions, as described by individuals from South Africa and supported by some studies in other African countries, including Ghana and Kenya, follow the African moral philosophies of Ubuntu or Botho and Ukama, which “advocates for a form of wholeness that comes through one’s relationship and connectedness with other people in the society,”[12] making autonomy a socially collective concept. In this context, for the community to act autonomously, individuals would come together to decide what is best for the collective. Thus, stem cell research would require examining the value of the research to society as a whole and the use of the embryos as a collective societal resource. If society views the source as part of the collective whole, and opposes using stem cells, compromising the cultural values to pursue research may cause social detachment and stunt research growth.[13] Based on local culture and moral philosophy, the permissibility of stem cell research depends on how embryo, stem cell, and cell line therapies relate to the community as a whole. Ubuntu is the expression of humanness, with the person’s identity drawn from the “’I am because we are’” value.[14] The decision in a collectivistic culture becomes one born of cultural context, and individual decisions give deference to others in the society. Consent differs in cultures where thought and moral philosophy are based on a collective paradigm. So, applying Western bioethical concepts is unrealistic. For one, Africa is a diverse continent with many countries with different belief systems, access to health care, and reliance on traditional or Western medicines. Where traditional medicine is the primary treatment, the “’restrictive focus on biomedically-related bioethics’” [is] problematic in African contexts because it neglects bioethical issues raised by traditional systems.”[15] No single approach applies in all areas or contexts. Rather than evaluating the permissibility of ESC research according to Western concepts such as the four principles approach, different ethics approaches should prevail. Another consideration is the socio-economic standing of countries. In parts of South Africa, researchers have not focused heavily on contributing to the stem cell discourse, either because it is not considered health care or a health science priority or because resources are unavailable.[16] Each country’s priorities differ given different social, political, and economic factors. In South Africa, for instance, areas such as maternal mortality, non-communicable diseases, telemedicine, and the strength of health systems need improvement and require more focus[17] Stem cell research could benefit the population, but it also could divert resources from basic medical care. Researchers in South Africa adhere to the National Health Act and Medicines Control Act in South Africa and international guidelines; however, the Act is not strictly enforced, and there is no clear legislation for research conduct or ethical guidelines.[18] Some parts of Africa condemn stem cell research. For example, 98.2 percent of the Tunisian population is Muslim.[19] Tunisia does not permit stem cell research because of moral conflict with a Fatwa. Religion heavily saturates the regulation and direction of research.[20] Stem cell use became permissible for reproductive purposes only recently, with tight restrictions preventing cells from being used in any research other than procedures concerning ART/IVF. Their use is conditioned on consent, and available only to married couples.[21] The community's receptiveness to stem cell research depends on including communitarian African ethics. c. Asia Some Asian countries also have a collective model of ethics and decision making.[22] In China, the ethics model promotes a sincere respect for life or human dignity,[23] based on protective medicine. This model, influenced by Traditional Chinese Medicine (TCM), [24] recognizes Qi as the vital energy delivered via the meridians of the body; it connects illness to body systems, the body’s entire constitution, and the universe for a holistic bond of nature, health, and quality of life.[25] Following a protective ethics model, and traditional customs of wholeness, investment in stem cell research is heavily desired for its applications in regenerative therapies, disease modeling, and protective medicines. In a survey of medical students and healthcare practitioners, 30.8 percent considered stem cell research morally unacceptable while 63.5 percent accepted medical research using human embryonic stem cells. Of these individuals, 89.9 percent supported increased funding for stem cell research.[26] The scientific community might not reflect the overall population. From 1997 to 2019, China spent a total of $576 million (USD) on stem cell research at 8,050 stem cell programs, increased published presence from 0.6 percent to 14.01 percent of total global stem cell publications as of 2014, and made significant strides in cell-based therapies for various medical conditions.[27] However, while China has made substantial investments in stem cell research and achieved notable progress in clinical applications, concerns linger regarding ethical oversight and transparency.[28] For example, the China Biosecurity Law, promoted by the National Health Commission and China Hospital Association, attempted to mitigate risks by introducing an institutional review board (IRB) in the regulatory bodies. 5800 IRBs registered with the Chinese Clinical Trial Registry since 2021.[29] However, issues still need to be addressed in implementing effective IRB review and approval procedures. The substantial government funding and focus on scientific advancement have sometimes overshadowed considerations of regional cultures, ethnic minorities, and individual perspectives, particularly evident during the one-child policy era. As government policy adapts to promote public stability, such as the change from the one-child to the two-child policy,[30] research ethics should also adapt to ensure respect for the values of its represented peoples. Japan is also relatively supportive of stem cell research and therapies. Japan has a more transparent regulatory framework, allowing for faster approval of regenerative medicine products, which has led to several advanced clinical trials and therapies.[31] South Korea is also actively engaged in stem cell research and has a history of breakthroughs in cloning and embryonic stem cells.[32] However, the field is controversial, and there are issues of scientific integrity. For example, the Korean FDA fast-tracked products for approval,[33] and in another instance, the oocyte source was unclear and possibly violated ethical standards.[34] Trust is important in research, as it builds collaborative foundations between colleagues, trial participant comfort, open-mindedness for complicated and sensitive discussions, and supports regulatory procedures for stakeholders. There is a need to respect the culture’s interest, engagement, and for research and clinical trials to be transparent and have ethical oversight to promote global research discourse and trust. d. Middle East Countries in the Middle East have varying degrees of acceptance of or restrictions to policies related to using embryonic stem cells due to cultural and religious influences. Saudi Arabia has made significant contributions to stem cell research, and conducts research based on international guidelines for ethical conduct and under strict adherence to guidelines in accordance with Islamic principles. Specifically, the Saudi government and people require ESC research to adhere to Sharia law. In addition to umbilical and placental stem cells,[35] Saudi Arabia permits the use of embryonic stem cells as long as they come from miscarriages, therapeutic abortions permissible by Sharia law, or are left over from in vitro fertilization and donated to research.[36] Laws and ethical guidelines for stem cell research allow the development of research institutions such as the King Abdullah International Medical Research Center, which has a cord blood bank and a stem cell registry with nearly 10,000 donors.[37] Such volume and acceptance are due to the ethical ‘permissibility’ of the donor sources, which do not conflict with religious pillars. However, some researchers err on the side of caution, choosing not to use embryos or fetal tissue as they feel it is unethical to do so.[38] Jordan has a positive research ethics culture.[39] However, there is a significant issue of lack of trust in researchers, with 45.23 percent (38.66 percent agreeing and 6.57 percent strongly agreeing) of Jordanians holding a low level of trust in researchers, compared to 81.34 percent of Jordanians agreeing that they feel safe to participate in a research trial.[40] Safety testifies to the feeling of confidence that adequate measures are in place to protect participants from harm, whereas trust in researchers could represent the confidence in researchers to act in the participants’ best interests, adhere to ethical guidelines, provide accurate information, and respect participants’ rights and dignity. One method to improve trust would be to address communication issues relevant to ESC. Legislation surrounding stem cell research has adopted specific language, especially concerning clarification “between ‘stem cells’ and ‘embryonic stem cells’” in translation.[41] Furthermore, legislation “mandates the creation of a national committee… laying out specific regulations for stem-cell banking in accordance with international standards.”[42] This broad regulation opens the door for future global engagement and maintains transparency. However, these regulations may also constrain the influence of research direction, pace, and accessibility of research outcomes. e. Europe In the European Union (EU), ethics is also principle-based, but the principles of autonomy, dignity, integrity, and vulnerability are interconnected.[43] As such, the opportunity for cohesion and concessions between individuals’ thoughts and ideals allows for a more adaptable ethics model due to the flexible principles that relate to the human experience The EU has put forth a framework in its Convention for the Protection of Human Rights and Dignity of the Human Being allowing member states to take different approaches. Each European state applies these principles to its specific conventions, leading to or reflecting different acceptance levels of stem cell research. [44] For example, in Germany, Lebenzusammenhang, or the coherence of life, references integrity in the unity of human culture. Namely, the personal sphere “should not be subject to external intervention.”[45] Stem cell interventions could affect this concept of bodily completeness, leading to heavy restrictions. Under the Grundgesetz, human dignity and the right to life with physical integrity are paramount.[46] The Embryo Protection Act of 1991 made producing cell lines illegal. Cell lines can be imported if approved by the Central Ethics Commission for Stem Cell Research only if they were derived before May 2007.[47] Stem cell research respects the integrity of life for the embryo with heavy specifications and intense oversight. This is vastly different in Finland, where the regulatory bodies find research more permissible in IVF excess, but only up to 14 days after fertilization.[48] Spain’s approach differs still, with a comprehensive regulatory framework.[49] Thus, research regulation can be culture-specific due to variations in applied principles. Diverse cultures call for various approaches to ethical permissibility.[50] Only an adaptive-deliberative model can address the cultural constructions of self and achieve positive, culturally sensitive stem cell research practices.[51] II. Religious Perspectives on ESC Embryonic stem cell sources are the main consideration within religious contexts. While individuals may not regard their own religious texts as authoritative or factual, religion can shape their foundations or perspectives. The Qur'an states: “And indeed We created man from a quintessence of clay. Then We placed within him a small quantity of nutfa (sperm to fertilize) in a safe place. Then We have fashioned the nutfa into an ‘alaqa (clinging clot or cell cluster), then We developed the ‘alaqa into mudgha (a lump of flesh), and We made mudgha into bones, and clothed the bones with flesh, then We brought it into being as a new creation. So Blessed is Allah, the Best of Creators.”[52] Many scholars of Islam estimate the time of soul installment, marked by the angel breathing in the soul to bring the individual into creation, as 120 days from conception.[53] Personhood begins at this point, and the value of life would prohibit research or experimentation that could harm the individual. If the fetus is more than 120 days old, the time ensoulment is interpreted to occur according to Islamic law, abortion is no longer permissible.[54] There are a few opposing opinions about early embryos in Islamic traditions. According to some Islamic theologians, there is no ensoulment of the early embryo, which is the source of stem cells for ESC research.[55] In Buddhism, the stance on stem cell research is not settled. The main tenets, the prohibition against harming or destroying others (ahimsa) and the pursuit of knowledge (prajña) and compassion (karuna), leave Buddhist scholars and communities divided.[56] Some scholars argue stem cell research is in accordance with the Buddhist tenet of seeking knowledge and ending human suffering. Others feel it violates the principle of not harming others. Finding the balance between these two points relies on the karmic burden of Buddhist morality. In trying to prevent ahimsa towards the embryo, Buddhist scholars suggest that to comply with Buddhist tenets, research cannot be done as the embryo has personhood at the moment of conception and would reincarnate immediately, harming the individual's ability to build their karmic burden.[57] On the other hand, the Bodhisattvas, those considered to be on the path to enlightenment or Nirvana, have given organs and flesh to others to help alleviate grieving and to benefit all.[58] Acceptance varies on applied beliefs and interpretations. Catholicism does not support embryonic stem cell research, as it entails creation or destruction of human embryos. This destruction conflicts with the belief in the sanctity of life. For example, in the Old Testament, Genesis describes humanity as being created in God’s image and multiplying on the Earth, referencing the sacred rights to human conception and the purpose of development and life. In the Ten Commandments, the tenet that one should not kill has numerous interpretations where killing could mean murder or shedding of the sanctity of life, demonstrating the high value of human personhood. In other books, the theological conception of when life begins is interpreted as in utero,[59] highlighting the inviolability of life and its formation in vivo to make a religious point for accepting such research as relatively limited, if at all.[60] The Vatican has released ethical directives to help apply a theological basis to modern-day conflicts. The Magisterium of the Church states that “unless there is a moral certainty of not causing harm,” experimentation on fetuses, fertilized cells, stem cells, or embryos constitutes a crime.[61] Such procedures would not respect the human person who exists at these stages, according to Catholicism. Damages to the embryo are considered gravely immoral and illicit.[62] Although the Catholic Church officially opposes abortion, surveys demonstrate that many Catholic people hold pro-choice views, whether due to the context of conception, stage of pregnancy, threat to the mother’s life, or for other reasons, demonstrating that practicing members can also accept some but not all tenets.[63] Some major Jewish denominations, such as the Reform, Conservative, and Reconstructionist movements, are open to supporting ESC use or research as long as it is for saving a life.[64] Within Judaism, the Talmud, or study, gives personhood to the child at birth and emphasizes that life does not begin at conception:[65] “If she is found pregnant, until the fortieth day it is mere fluid,”[66] Whereas most religions prioritize the status of human embryos, the Halakah (Jewish religious law) states that to save one life, most other religious laws can be ignored because it is in pursuit of preservation.[67] Stem cell research is accepted due to application of these religious laws. We recognize that all religions contain subsets and sects. The variety of environmental and cultural differences within religious groups requires further analysis to respect the flexibility of religious thoughts and practices. We make no presumptions that all cultures require notions of autonomy or morality as under the common morality theory, which asserts a set of universal moral norms that all individuals share provides moral reasoning and guides ethical decisions.[68] We only wish to show that the interaction with morality varies between cultures and countries. III. A Flexible Ethical Approach The plurality of different moral approaches described above demonstrates that there can be no universally acceptable uniform law for ESC on a global scale. Instead of developing one standard, flexible ethical applications must be continued. We recommend local guidelines that incorporate important cultural and ethical priorities. While the Declaration of Helsinki is more relevant to people in clinical trials receiving ESC products, in keeping with the tradition of protections for research subjects, consent of the donor is an ethical requirement for ESC donation in many jurisdictions including the US, Canada, and Europe.[69] The Declaration of Helsinki provides a reference point for regulatory standards and could potentially be used as a universal baseline for obtaining consent prior to gamete or embryo donation. For instance, in Columbia University’s egg donor program for stem cell research, donors followed standard screening protocols and “underwent counseling sessions that included information as to the purpose of oocyte donation for research, what the oocytes would be used for, the risks and benefits of donation, and process of oocyte stimulation” to ensure transparency for consent.[70] The program helped advance stem cell research and provided clear and safe research methods with paid participants. Though paid participation or covering costs of incidental expenses may not be socially acceptable in every culture or context,[71] and creating embryos for ESC research is illegal in many jurisdictions, Columbia’s program was effective because of the clear and honest communications with donors, IRBs, and related stakeholders. This example demonstrates that cultural acceptance of scientific research and of the idea that an egg or embryo does not have personhood is likely behind societal acceptance of donating eggs for ESC research. As noted, many countries do not permit the creation of embryos for research. Proper communication and education regarding the process and purpose of stem cell research may bolster comprehension and garner more acceptance. “Given the sensitive subject material, a complete consent process can support voluntary participation through trust, understanding, and ethical norms from the cultures and morals participants value. This can be hard for researchers entering countries of different socioeconomic stability, with different languages and different societal values.[72] An adequate moral foundation in medical ethics is derived from the cultural and religious basis that informs knowledge and actions.[73] Understanding local cultural and religious values and their impact on research could help researchers develop humility and promote inclusion. IV. Concerns Some may argue that if researchers all adhere to one ethics standard, protection will be satisfied across all borders, and the global public will trust researchers. However, defining what needs to be protected and how to define such research standards is very specific to the people to which standards are applied. We suggest that applying one uniform guide cannot accurately protect each individual because we all possess our own perceptions and interpretations of social values.[74] Therefore, the issue of not adjusting to the moral pluralism between peoples in applying one standard of ethics can be resolved by building out ethics models that can be adapted to different cultures and religions. Other concerns include medical tourism, which may promote health inequities.[75] Some countries may develop and approve products derived from ESC research before others, compromising research ethics or drug approval processes. There are also concerns about the sale of unauthorized stem cell treatments, for example, those without FDA approval in the United States. Countries with robust research infrastructures may be tempted to attract medical tourists, and some customers will have false hopes based on aggressive publicity of unproven treatments.[76] For example, in China, stem cell clinics can market to foreign clients who are not protected under the regulatory regimes. Companies employ a marketing strategy of “ethically friendly” therapies. Specifically, in the case of Beike, China’s leading stem cell tourism company and sprouting network, ethical oversight of administrators or health bureaus at one site has “the unintended consequence of shifting questionable activities to another node in Beike's diffuse network.”[77] In contrast, Jordan is aware of stem cell research’s potential abuse and its own status as a “health-care hub.” Jordan’s expanded regulations include preserving the interests of individuals in clinical trials and banning private companies from ESC research to preserve transparency and the integrity of research practices.[78] The social priorities of the community are also a concern. The ISSCR explicitly states that guidelines “should be periodically revised to accommodate scientific advances, new challenges, and evolving social priorities.”[79] The adaptable ethics model extends this consideration further by addressing whether research is warranted given the varying degrees of socioeconomic conditions, political stability, and healthcare accessibilities and limitations. An ethical approach would require discussion about resource allocation and appropriate distribution of funds.[80] CONCLUSION While some religions emphasize the sanctity of life from conception, which may lead to public opposition to ESC research, others encourage ESC research due to its potential for healing and alleviating human pain. Many countries have special regulations that balance local views on embryonic personhood, the benefits of research as individual or societal goods, and the protection of human research subjects. To foster understanding and constructive dialogue, global policy frameworks should prioritize the protection of universal human rights, transparency, and informed consent. In addition to these foundational global policies, we recommend tailoring local guidelines to reflect the diverse cultural and religious perspectives of the populations they govern. Ethics models should be adapted to local populations to effectively establish research protections, growth, and possibilities of stem cell research. For example, in countries with strong beliefs in the moral sanctity of embryos or heavy religious restrictions, an adaptive model can allow for discussion instead of immediate rejection. In countries with limited individual rights and voice in science policy, an adaptive model ensures cultural, moral, and religious views are taken into consideration, thereby building social inclusion. While this ethical consideration by the government may not give a complete voice to every individual, it will help balance policies and maintain the diverse perspectives of those it affects. Embracing an adaptive ethics model of ESC research promotes open-minded dialogue and respect for the importance of human belief and tradition. By actively engaging with cultural and religious values, researchers can better handle disagreements and promote ethical research practices that benefit each society. This brief exploration of the religious and cultural differences that impact ESC research reveals the nuances of relative ethics and highlights a need for local policymakers to apply a more intense adaptive model. - [1] Poliwoda, S., Noor, N., Downs, E., Schaaf, A., Cantwell, A., Ganti, L., Kaye, A. D., Mosel, L. I., Carroll, C. B., Viswanath, O., & Urits, I. (2022). Stem cells: a comprehensive review of origins and emerging clinical roles in medical practice. Orthopedic reviews, 14(3), 37498. https://doi.org/10.52965/001c.37498 [2] Poliwoda, S., Noor, N., Downs, E., Schaaf, A., Cantwell, A., Ganti, L., Kaye, A. D., Mosel, L. I., Carroll, C. B., Viswanath, O., & Urits, I. (2022). Stem cells: a comprehensive review of origins and emerging clinical roles in medical practice. Orthopedic reviews, 14(3), 37498. https://doi.org/10.52965/001c.37498 [3] International Society for Stem Cell Research. (2023). Laboratory-based human embryonic stem cell research, embryo research, and related research activities. International Society for Stem Cell Research. https://www.isscr.org/guidelines/blog-post-title-one-ed2td-6fcdk; Kimmelman, J., Hyun, I., Benvenisty, N. et al. Policy: Global standards for stem-cell research. Nature 533, 311–313 (2016). https://doi.org/10.1038/533311a [4] International Society for Stem Cell Research. (2023). Laboratory-based human embryonic stem cell research, embryo research, and related research activities. International Society for Stem Cell Research. https://www.isscr.org/guidelines/blog-post-title-one-ed2td-6fcdk [5] Concerning the moral philosophies of stem cell research, our paper does not posit a personal moral stance nor delve into the “when” of human life begins. To read further about the philosophical debate, consider the following sources: Sandel M. J. (2004). Embryo ethics--the moral logic of stem-cell research. The New England journal of medicine, 351(3), 207–209. https://doi.org/10.1056/NEJMp048145; George, R. P., & Lee, P. (2020, September 26). Acorns and Embryos. The New Atlantis. https://www.thenewatlantis.com/publications/acorns-and-embryos; Sagan, A., & Singer, P. (2007). The moral status of stem cells. Metaphilosophy, 38(2/3), 264–284. http://www.jstor.org/stable/24439776; McHugh P. R. (2004). Zygote and "clonote"--the ethical use of embryonic stem cells. The New England journal of medicine, 351(3), 209–211. https://doi.org/10.1056/NEJMp048147; Kurjak, A., & Tripalo, A. (2004). The facts and doubts about beginning of the human life and personality. Bosnian journal of basic medical sciences, 4(1), 5–14. https://doi.org/10.17305/bjbms.2004.3453 [6] Vazin, T., & Freed, W. J. (2010). Human embryonic stem cells: derivation, culture, and differentiation: a review. Restorative neurology and neuroscience, 28(4), 589–603. https://doi.org/10.3233/RNN-2010-0543 [7] Socially, at its core, the Western approach to ethics is widely principle-based, autonomy being one of the key factors to ensure a fundamental respect for persons within research. For information regarding autonomy in research, see: Department of Health, Education, and Welfare, & National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1978). The Belmont Report. Ethical principles and guidelines for the protection of human subjects of research.; For a more in-depth review of autonomy within the US, see: Beauchamp, T. L., & Childress, J. F. (1994). Principles of Biomedical Ethics. Oxford University Press. [8] Sherley v. Sebelius, 644 F.3d 388 (D.C. Cir. 2011), citing 45 C.F.R. 46.204(b) and [42 U.S.C. § 289g(b)]. https://www.cadc.uscourts.gov/internet/opinions.nsf/6c690438a9b43dd685257a64004ebf99/$file/11-5241-1391178.pdf [9] Stem Cell Research Enhancement Act of 2005, H. R. 810, 109th Cong. (2001). https://www.govtrack.us/congress/bills/109/hr810/text; Bush, G. W. (2006, July 19). Message to the House of Representatives. National Archives and Records Administration. https://georgewbush-whitehouse.archives.gov/news/releases/2006/07/20060719-5.html [10] National Archives and Records Administration. (2009, March 9). Executive order 13505 -- removing barriers to responsible scientific research involving human stem cells. National Archives and Records Administration. https://obamawhitehouse.archives.gov/the-press-office/removing-barriers-responsible-scientific-research-involving-human-stem-cells [11] Hurlbut, W. B. (2006). Science, Religion, and the Politics of Stem Cells. Social Research, 73(3), 819–834. http://www.jstor.org/stable/40971854 [12] Akpa-Inyang, Francis & Chima, Sylvester. (2021). South African traditional values and beliefs regarding informed consent and limitations of the principle of respect for autonomy in African communities: a cross-cultural qualitative study. BMC Medical Ethics. 22. 10.1186/s12910-021-00678-4. [13] Source for further reading: Tangwa G. B. (2007). Moral status of embryonic stem cells: perspective of an African villager. Bioethics, 21(8), 449–457. https://doi.org/10.1111/j.1467-8519.2007.00582.x , see also Mnisi, F. M. (2020). An African analysis based on ethics of Ubuntu - are human embryonic stem cell patents morally justifiable? African Insight, 49(4). [14] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics, 22(2), 112–122. https://doi.org/10.1111/dewb.12324 [15] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics, 22(2), 112–122. https://doi.org/10.1111/dewb.12324 [16] Jackson, C.S., Pepper, M.S. Opportunities and barriers to establishing a cell therapy programme in South Africa. Stem Cell Res Ther 4, 54 (2013). https://doi.org/10.1186/scrt204; Pew Research Center. (2014, May 1). Public health a major priority in African nations. Pew Research Center’s Global Attitudes Project. https://www.pewresearch.org/global/2014/05/01/public-health-a-major-priority-in-african-nations/ [17] Department of Health Republic of South Africa. (2021). Health Research Priorities (revised) for South Africa 2021-2024. National Health Research Strategy. https://www.health.gov.za/wp-content/uploads/2022/05/National-Health-Research-Priorities-2021-2024.pdf [18] Oosthuizen, H. (2013). Legal and Ethical Issues in Stem Cell Research in South Africa. In: Beran, R. (eds) Legal and Forensic Medicine. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-32338-6_80, see also: Gaobotse G (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142 [19] United States Bureau of Citizenship and Immigration Services. (1998). Tunisia: Information on the status of Christian conversions in Tunisia. UNHCR Web Archive. https://webarchive.archive.unhcr.org/20230522142618/https://www.refworld.org/docid/3df0be9a2.html [20] Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142 [21] Kooli, C. Review of assisted reproduction techniques, laws, and regulations in Muslim countries. Middle East Fertil Soc J 24, 8 (2020). https://doi.org/10.1186/s43043-019-0011-0; Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142 [22] Pang M. C. (1999). Protective truthfulness: the Chinese way of safeguarding patients in informed treatment decisions. Journal of medical ethics, 25(3), 247–253. https://doi.org/10.1136/jme.25.3.247 [23] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences, 8(1). https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199 [24] Wang, Y., Xue, Y., & Guo, H. D. (2022). Intervention effects of traditional Chinese medicine on stem cell therapy of myocardial infarction. Frontiers in pharmacology, 13, 1013740. https://doi.org/10.3389/fphar.2022.1013740 [25] Li, X.-T., & Zhao, J. (2012). Chapter 4: An Approach to the Nature of Qi in TCM- Qi and Bioenergy. In Recent Advances in Theories and Practice of Chinese Medicine (p. 79). InTech. [26] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students. Stem cells international, 2021, 6667743. https://doi.org/10.1155/2021/6667743 [27] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students. Stem cells international, 2021, 6667743. https://doi.org/10.1155/2021/6667743 [28] Zhang, J. Y. (2017). Lost in translation? accountability and governance of Clinical Stem Cell Research in China. Regenerative Medicine, 12(6), 647–656. https://doi.org/10.2217/rme-2017-0035 [29] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences, 8(1). https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199 [30] Chen, H., Wei, T., Wang, H. et al. Association of China’s two-child policy with changes in number of births and birth defects rate, 2008–2017. BMC Public Health 22, 434 (2022). https://doi.org/10.1186/s12889-022-12839-0 [31] Azuma, K. Regulatory Landscape of Regenerative Medicine in Japan. Curr Stem Cell Rep 1, 118–128 (2015). https://doi.org/10.1007/s40778-015-0012-6 [32] Harris, R. (2005, May 19). Researchers Report Advance in Stem Cell Production. NPR. https://www.npr.org/2005/05/19/4658967/researchers-report-advance-in-stem-cell-production [33] Park, S. (2012). South Korea steps up stem-cell work. Nature. https://doi.org/10.1038/nature.2012.10565 [34] Resnik, D. B., Shamoo, A. E., & Krimsky, S. (2006). Fraudulent human embryonic stem cell research in South Korea: lessons learned. Accountability in research, 13(1), 101–109. https://doi.org/10.1080/08989620600634193. [35] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6 [36]Association for the Advancement of Blood and Biotherapies. https://www.aabb.org/regulatory-and-advocacy/regulatory-affairs/regulatory-for-cellular-therapies/international-competent-authorities/saudi-arabia [37] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6 [38] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6 Culturally, autonomy practices follow a relational autonomy approach based on a paternalistic deontological health care model. The adherence to strict international research policies and religious pillars within the regulatory environment is a great foundation for research ethics. However, there is a need to develop locally targeted ethics approaches for research (as called for in Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6), this decision-making approach may help advise a research decision model. For more on the clinical cultural autonomy approaches, see: Alabdullah, Y. Y., Alzaid, E., Alsaad, S., Alamri, T., Alolayan, S. W., Bah, S., & Aljoudi, A. S. (2022). Autonomy and paternalism in Shared decision‐making in a Saudi Arabian tertiary hospital: A cross‐sectional study. Developing World Bioethics, 23(3), 260–268. https://doi.org/10.1111/dewb.12355; Bukhari, A. A. (2017). Universal Principles of Bioethics and Patient Rights in Saudi Arabia (Doctoral dissertation, Duquesne University). https://dsc.duq.edu/etd/124; Ladha, S., Nakshawani, S. A., Alzaidy, A., & Tarab, B. (2023, October 26). Islam and Bioethics: What We All Need to Know. Columbia University School of Professional Studies. https://sps.columbia.edu/events/islam-and-bioethics-what-we-all-need-know [39] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics. Research Ethics, 17(2), 228-241. https://doi.org/10.1177/1747016120966779 [40] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics. Research Ethics, 17(2), 228-241. https://doi.org/10.1177/1747016120966779 [41] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East. Nature 510, 189. https://doi.org/10.1038/510189a [42] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East. Nature 510, 189. https://doi.org/10.1038/510189a [43] The EU’s definition of autonomy relates to the capacity for creating ideas, moral insight, decisions, and actions without constraint, personal responsibility, and informed consent. However, the EU views autonomy as not completely able to protect individuals and depends on other principles, such as dignity, which “expresses the intrinsic worth and fundamental equality of all human beings.” Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3 [44] Council of Europe. Convention for the protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (ETS No. 164) https://www.coe.int/en/web/conventions/full-list?module=treaty-detail&treatynum=164 (forbidding the creation of embryos for research purposes only, and suggests embryos in vitro have protections.); Also see Drabiak-Syed B. K. (2013). New President, New Human Embryonic Stem Cell Research Policy: Comparative International Perspectives and Embryonic Stem Cell Research Laws in France. Biotechnology Law Report, 32(6), 349–356. https://doi.org/10.1089/blr.2013.9865 [45] Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3 [46] Tomuschat, C., Currie, D. P., Kommers, D. P., & Kerr, R. (Trans.). (1949, May 23). Basic law for the Federal Republic of Germany. https://www.btg-bestellservice.de/pdf/80201000.pdf [47] Regulation of Stem Cell Research in Germany. Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-germany [48] Regulation of Stem Cell Research in Finland. Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-finland [49] Regulation of Stem Cell Research in Spain. Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-spain [50] Some sources to consider regarding ethics models or regulatory oversights of other cultures not covered: Kara MA. Applicability of the principle of respect for autonomy: the perspective of Turkey. J Med Ethics. 2007 Nov;33(11):627-30. doi: 10.1136/jme.2006.017400. PMID: 17971462; PMCID: PMC2598110. Ugarte, O. N., & Acioly, M. A. (2014). The principle of autonomy in Brazil: one needs to discuss it ... Revista do Colegio Brasileiro de Cirurgioes, 41(5), 374–377. https://doi.org/10.1590/0100-69912014005013 Bharadwaj, A., & Glasner, P. E. (2012). Local cells, global science: The rise of embryonic stem cell research in India. Routledge. For further research on specific European countries regarding ethical and regulatory framework, we recommend this database: Regulation of Stem Cell Research in Europe. Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-europe [51] Klitzman, R. (2006). Complications of culture in obtaining informed consent. The American Journal of Bioethics, 6(1), 20–21. https://doi.org/10.1080/15265160500394671 see also: Ekmekci, P. E., & Arda, B. (2017). Interculturalism and Informed Consent: Respecting Cultural Differences without Breaching Human Rights. Cultura (Iasi, Romania), 14(2), 159–172.; For why trust is important in research, see also: Gray, B., Hilder, J., Macdonald, L., Tester, R., Dowell, A., & Stubbe, M. (2017). Are research ethics guidelines culturally competent? Research Ethics, 13(1), 23-41. https://doi.org/10.1177/1747016116650235 [52] The Qur'an (M. Khattab, Trans.). (1965). Al-Mu’minun, 23: 12-14. https://quran.com/23 [53] Lenfest, Y. (2017, December 8). Islam and the beginning of human life. Bill of Health. https://blog.petrieflom.law.harvard.edu/2017/12/08/islam-and-the-beginning-of-human-life/ [54] Aksoy, S. (2005). Making regulations and drawing up legislation in Islamic countries under conditions of uncertainty, with special reference to embryonic stem cell research. Journal of Medical Ethics, 31:399-403.; see also: Mahmoud, Azza. "Islamic Bioethics: National Regulations and Guidelines of Human Stem Cell Research in the Muslim World." Master's thesis, Chapman University, 2022. https://doi.org/10.36837/ chapman.000386 [55] Rashid, R. (2022). When does Ensoulment occur in the Human Foetus. Journal of the British Islamic Medical Association, 12(4). ISSN 2634 8071. https://www.jbima.com/wp-content/uploads/2023/01/2-Ethics-3_-Ensoulment_Rafaqat.pdf. [56] Sivaraman, M. & Noor, S. (2017). Ethics of embryonic stem cell research according to Buddhist, Hindu, Catholic, and Islamic religions: perspective from Malaysia. Asian Biomedicine,8(1) 43-52. https://doi.org/10.5372/1905-7415.0801.260 [57] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.), Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues (pp. 79-94). Berkeley: University of California Press. https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005 [58] Lecso, P. A. (1991). The Bodhisattva Ideal and Organ Transplantation. Journal of Religion and Health, 30(1), 35–41. http://www.jstor.org/stable/27510629; Bodhisattva, S. (n.d.). The Key of Becoming a Bodhisattva. A Guide to the Bodhisattva Way of Life. http://www.buddhism.org/Sutras/2/BodhisattvaWay.htm [59] There is no explicit religious reference to when life begins or how to conduct research that interacts with the concept of life. However, these are relevant verses pertaining to how the fetus is viewed. ((King James Bible. (1999). Oxford University Press. (original work published 1769)) Jerimiah 1: 5 “Before I formed thee in the belly I knew thee; and before thou camest forth out of the womb I sanctified thee…” In prophet Jerimiah’s insight, God set him apart as a person known before childbirth, a theme carried within the Psalm of David. Psalm 139: 13-14 “…Thou hast covered me in my mother's womb. I will praise thee; for I am fearfully and wonderfully made…” These verses demonstrate David’s respect for God as an entity that would know of all man’s thoughts and doings even before birth. [60] It should be noted that abortion is not supported as well. [61] The Vatican. (1987, February 22). Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation Replies to Certain Questions of the Day. Congregation For the Doctrine of the Faith. https://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19870222_respect-for-human-life_en.html [62] The Vatican. (2000, August 25). Declaration On the Production and the Scientific and Therapeutic Use of Human Embryonic Stem Cells. Pontifical Academy for Life. https://www.vatican.va/roman_curia/pontifical_academies/acdlife/documents/rc_pa_acdlife_doc_20000824_cellule-staminali_en.html; Ohara, N. (2003). Ethical Consideration of Experimentation Using Living Human Embryos: The Catholic Church’s Position on Human Embryonic Stem Cell Research and Human Cloning. Department of Obstetrics and Gynecology. Retrieved from https://article.imrpress.com/journal/CEOG/30/2-3/pii/2003018/77-81.pdf. [63] Smith, G. A. (2022, May 23). Like Americans overall, Catholics vary in their abortion views, with regular mass attenders most opposed. Pew Research Center. https://www.pewresearch.org/short-reads/2022/05/23/like-americans-overall-catholics-vary-in-their-abortion-views-with-regular-mass-attenders-most-opposed/ [64] Rosner, F., & Reichman, E. (2002). Embryonic stem cell research in Jewish law. Journal of halacha and contemporary society, (43), 49–68.; Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.), Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues (pp. 79-94). Berkeley: University of California Press. https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005 [65] Schenker J. G. (2008). The beginning of human life: status of embryo. Perspectives in Halakha (Jewish Religious Law). Journal of assisted reproduction and genetics, 25(6), 271–276. https://doi.org/10.1007/s10815-008-9221-6 [66] Ruttenberg, D. (2020, May 5). The Torah of Abortion Justice (annotated source sheet). Sefaria. https://www.sefaria.org/sheets/234926.7?lang=bi&with=all&lang2=en [67] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.), Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues (pp. 79-94). Berkeley: University of California Press. https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005 [68] Gert, B. (2007). Common morality: Deciding what to do. Oxford Univ. Press. [69] World Medical Association (2013). World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA, 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053 Declaration of Helsinki – WMA – The World Medical Association.; see also: National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1979). The Belmont report: Ethical principles and guidelines for the protection of human subjects of research. U.S. Department of Health and Human Services. https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/read-the-belmont-report/index.html [70] Zakarin Safier, L., Gumer, A., Kline, M., Egli, D., & Sauer, M. V. (2018). Compensating human subjects providing oocytes for stem cell research: 9-year experience and outcomes. Journal of assisted reproduction and genetics, 35(7), 1219–1225. https://doi.org/10.1007/s10815-018-1171-z https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6063839/ see also: Riordan, N. H., & Paz Rodríguez, J. (2021). Addressing concerns regarding associated costs, transparency, and integrity of research in recent stem cell trial. Stem Cells Translational Medicine, 10(12), 1715–1716. https://doi.org/10.1002/sctm.21-0234 [71] Klitzman, R., & Sauer, M. V. (2009). Payment of egg donors in stem cell research in the USA. Reproductive biomedicine online, 18(5), 603–608. https://doi.org/10.1016/s1472-6483(10)60002-8 [72] Krosin, M. T., Klitzman, R., Levin, B., Cheng, J., & Ranney, M. L. (2006). Problems in comprehension of informed consent in rural and peri-urban Mali, West Africa. Clinical trials (London, England), 3(3), 306–313. https://doi.org/10.1191/1740774506cn150oa [73] Veatch, Robert M. Hippocratic, Religious, and Secular Medical Ethics: The Points of Conflict. Georgetown University Press, 2012. [74] Msoroka, M. S., & Amundsen, D. (2018). One size fits not quite all: Universal research ethics with diversity. Research Ethics, 14(3), 1-17. https://doi.org/10.1177/1747016117739939 [75] Pirzada, N. (2022). The Expansion of Turkey’s Medical Tourism Industry. Voices in Bioethics, 8. https://doi.org/10.52214/vib.v8i.9894 [76] Stem Cell Tourism: False Hope for Real Money. Harvard Stem Cell Institute (HSCI). (2023). https://hsci.harvard.edu/stem-cell-tourism, See also: Bissassar, M. (2017). Transnational Stem Cell Tourism: An ethical analysis. Voices in Bioethics, 3. https://doi.org/10.7916/vib.v3i.6027 [77]Song, P. (2011) The proliferation of stem cell therapies in post-Mao China: problematizing ethical regulation, New Genetics and Society, 30:2, 141-153, DOI: 10.1080/14636778.2011.574375 [78] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East. Nature 510, 189. https://doi.org/10.1038/510189a [79] International Society for Stem Cell Research. (2024). Standards in stem cell research. International Society for Stem Cell Research. https://www.isscr.org/guidelines/5-standards-in-stem-cell-research [80] Benjamin, R. (2013). People’s science bodies and rights on the Stem Cell Frontier. Stanford University Press.

Photo by 14825144 © Alita Xander | Dreamstime.com ABSTRACT The US government's approach to the War on Drugs has created laws to deter people from using illicit drugs through negative punishment. These laws have not controlled illicit drug use, nor has it stopped the opioid pandemic from growing. Instead, these laws have created a negative bias surrounding addiction and have negatively affected particularly vulnerable patient populations, including pregnant women with substance use disorder and newborns with neonatal abstinence syndrome. This article highlights some misconceptions and underscores the challenges they face as they navigate the justice and healthcare systems while also providing possible solutions to address their underlying addiction. INTRODUCTION Pregnant women with substance use disorder require treatment that is arguably for the benefit of both the mother and the fetus. Some suggest that addiction is a choice; therefore, those who misuse substances should not receive treatment. Proponents of this argument emphasize social and environmental factors that lead to addiction but fail to appreciate how chronic substance use alters the brain’s chemistry and changes how it responds to stress, reward, self-control, and pain. The medical community has long recognized that substance use disorder is not simply a character flaw or social deviance, but a complex condition that requires adequate medical attention. Unfortunately, the lasting consequences of the War on Drugs have created a stigma around addiction medicine, leading to significant treatment barriers. There is still a pervasive societal bias toward punitive rather than rehabilitative approaches to addiction. For example, many women with substance use disorder lose custody of their baby or face criminal penalties, including fines and jail time.[1] These punitive measures may cause patients to lose trust in their physicians, ultimately leading to high-risk pregnancies without prenatal care, untreated substance misuse, and potential lifelong disabilities for their newborns.[2] As a medical student, I have observed the importance of a rehabilitative approach to addiction medicine. Incentivizing pregnant women with substance use disorder to safely address their chronic health issues is essential for minimizing negative short-term and long-term outcomes for women and their newborns. This approach requires an open mind and supportive perspective, recognizing that substance use disorder is truly a medical condition that requires just as much attention as any other medical diagnosis.[3] BACKGROUND The War on Drugs was a government-led initiative launched in 1970 by President Richard M. Nixon with the aim of curtailing illegal drug use, distribution, and trade by imposing harsher prison sentences and punishments.[4] However, it is worth noting that one can trace the roots of this initiative back further. In 1914, Congress enacted the Harrison Narcotics Tax Act to target the recreational use of drugs such as morphine and opium.[5] Despite being in effect for over four decades, the War on Drugs failed to achieve its intended goals. In 2011, the Global Commission on Drug Policy released a report that concluded that the initiative had been futile, as “arresting and incarcerating tens of millions of these people in recent decades has filled prisons and destroyed lives and families without reducing the availability of illicit drugs or the power of criminal organizations.”[6] One study published in the International Journal of Drug Policy in the same year found that funding drug law enforcement paradoxically contributed to increasing gun violence and homicide rates.[7] The Commission recommended that drug policies focus on reducing harm caused by drug use rather than solely on reducing drug markets. Recognizing that many drug policies were of political opinion, it called for drug policies that were grounded in scientific evidence, health, security, and human rights.[8] Unfortunately, policy makers did not heed these recommendations. In 2014, Tennessee’s legislature passed a “Fetal Assault Law,” which made it possible to prosecute pregnant women for drug use during pregnancy. If found guilty, pregnant women could face up to 15 years in prison and lose custody of their child. Instead of deterring drug use, the law discouraged pregnant women with substance use disorder from seeking prenatal care. This law required medical professionals to report drug use to authorities, thereby compromising the confidentiality of the patient-physician relationship. Some avoided arrest by delivering their babies in other states or at home, while others opted for abortions or attempted to go through an unsafe withdrawal prior to receiving medical care, sacrificing the mother's and fetus's wellbeing. The law had a sunset provision and expired in 2016. During the two years this law was in effect, officials arrested 124 women.[9] The fear that this law instilled in pregnant women with substance use disorder can still be seen across the US today. Many pregnant women with substance use disorders stated that they feared testing positive for drugs. Due to mandatory reporting, they were not confident that physicians would protect them from the law.[10] And if a woman tried to stop using drugs before seeking care to avoid detection, she often ended up delaying or avoiding care.[11] The American College of Obstetricians and Gynecologists (ACOG) recognizes the fear those with substance use disorders face when seeking appropriate medical care and emphasizes that “obstetric–gynecologic care should not expose a woman to criminal or civil penalties, such as incarceration, involuntary commitment, loss of custody of her children, or loss of housing.”[12] Mandatory reporting strains the patient-physician relationship, driving a wedge between the doctor and patient. Thus, laws intended to deter people from using substances through various punishments and incarceration may be doing more harm than good. County hospitals that mainly serve lower socioeconomic patients encounter more patients without consistent health care access and those with substance use disorders.[13] These hospitals are facing the consequences of the worsening opioid pandemic. At one county hospital where I recently worked, there has been a dramatic increase in newborns with neonatal abstinence syndrome born to mothers with untreated substance use disorders during pregnancy. Infants exposed to drugs prenatally have an increased risk of complications, stillbirth, and life-altering developmental disabilities. At the hospital, I witnessed Child Protective Services removing two newborns with neonatal abstinence syndrome from their mother’s custody. Four similar cases had occurred in the preceding month. In the days leading up to their placement with a foster family, I saw both newborns go through an uncomfortable drug withdrawal. No baby should be welcomed into this world by suffering like that. Yet I felt for the new mothers and realized that heart-wrenching custody loss is not the best approach. During this period, I saw a teenager brought to the pediatric floor due to worsening psychiatric symptoms. He was born with neonatal abstinence syndrome that neither the residential program nor his foster family could manage. His past psychiatric disorders included attention deficit disorder, conduct disorder, major depressive disorder, anxiety disorder, disruptive mood dysregulation disorder, intellectual developmental disorder, and more. During his hospitalization, he was so violent towards healthcare providers that security had to intervene. And his attitude toward his foster parents was so volatile that we were never sure if having them visit was comforting or agitating. Throughout his hospital course, it was difficult for me to converse with him, and I left every interview with him feeling lost in terms of providing an adequate short- and long-term assessment of his psychological and medical requirements. What was clear, however, was that his intellectual and emotional levels did not match his age and that he was born into a society that was ill-equipped to accommodate his needs. Just a few feet away from his room, behind the nurses’ station, were the two newborns feeling the same withdrawal symptoms that this teenager likely experienced in the first few hours of his life. I wondered how similar their paths would be and if they would exhibit similar developmental delays in a few years or if their circumstance may follow the cases hyped about in the media of the 1980s and 1990s regarding “crack babies.” Many of these infants who experienced withdrawal symptoms eventually led normal lives.[14] Nonetheless, many studies have demonstrated that drug use during pregnancy can adversely impact fetal development. Excessive alcohol consumption can result in fetal alcohol syndrome, characterized by growth deficiency, facial structure abnormalities, and a wide range of neurological deficiencies.[15] Smoking can impede the development of the lungs and brain and lead to preterm deliveries or sudden infant death syndrome.[16] Stimulants like methamphetamine can also cause preterm delivery, delayed motor development, attention impairments, and a wide range of cognitive and behavioral issues.[17] Opioid use, such as oxycodone, morphine, fentanyl, and heroin, may result in neonatal opioid withdrawal syndrome, in which a newborn may exhibit tremors, irritability, sleeping problems, poor feeding, loose stools, and increased sweating within 72 hours of life.[18] In 2014, the American Association of Pediatrics (AAP) reported that one newborn was diagnosed with neonatal abstinence syndrome every 15 minutes, equating to approximately 32,000 newborns annually, a five-fold increase from 2004.[19] The AAP found that the cost of neonatal abstinence syndrome covered by Medicaid increased from $65.4 million to $462 million from 2004 to 2014.[20] In 2020, the CDC published a paper that showed an increase in hospital costs from $316 million in 2012 to $572.7 million in 2016.[21] Currently, the impact of the COVID-19 pandemic on the prevalence of newborns with neonatal abstinence syndrome is unknown. I predict that the increase in opioid and polysubstance use during the pandemic will increase the number of newborns with neonatal abstinence syndrome, thereby significantly increasing the public burden and cost.[22] In the 1990s, concerns arose about the potentially irreparable damage caused by intrauterine exposure to cocaine on the development of infants, which led to the popularization of the term “crack babies.”[23] Although no strong longitudinal studies supported this claim at the time, it was not without merit. The Maternal Lifestyle Study (NCT00059540) was a prospective longitudinal observational study that compared the outcomes of newborns exposed to cocaine in-utero to those without.[24] One of its studies revealed one month old newborns with cocaine exposure had “lower arousal, poorer quality of movements and self-regulation, higher excitability, more hypertonia, and more nonoptimal reflexes.”[25] Another study showed that at one month old, heavy cocaine exposure affected neural transmission from the ear to the brain.[26] Long-term follow up from the study showed that at seven years old, children with high intrauterine cocaine exposure were more likely to have externalizing behavior problems such as aggressive behavior, temper tantrums, and destructive acts.[27] While I have witnessed this behavior in the teenage patient during my pediatrics rotation, not all newborns with intrauterine drug exposure are inevitably bound to have psychiatric and behavioral issues later in life. NPR recorded a podcast in 2010 highlighting a mother who used substances during pregnancy and, with early intervention, had positive outcomes. After being arrested 50 times within five years, she went through STEP: Self-Taught Empowerment and Pride, a public program that allowed her to complete her GED and provided guidance and encouragement for a more meaningful life during her time in jail. Her daughter, who was exposed to cocaine before birth, had a normal childhood and ended up going to college.[28] From a public health standpoint, more needs to be done to prevent the complications of substance misuse during pregnancy. Some states consider substance misuse (and even prescribed use) during pregnancy child abuse. Officials have prosecuted countless women across 45 states for exposing their unborn children to drugs.[29] With opioid and polysubstance use on the rise, the efficacy of laws that result in punitive measures seems questionable.[30] So far, laws are not associated with a decrease in the misuse of drugs during pregnancy. Millions of dollars are being poured into managing neonatal abstinence syndrome, including prosecuting women and taking their children away. Rather than policing and criminalizing substance use, pregnant women should get the appropriate care they need and deserve. I. Misconception One: Mothers with Substance Use Disorder Can Get an Abortion If an unplanned pregnancy occurs, one course of action could be to terminate the pregnancy. On the surface, this solution seems like a quick fix. However, the reality is that obtaining an abortion can be challenging due to two significant barriers: accessibility and mandated reporting. Abortion laws vary by state, and in Tennessee, for instance, abortions are banned after six weeks of gestation, typically when fetal heart rhythms are detected. An exception to this is in cases where the mother's life is at risk.[31] Unfortunately, many women with substance use disorders are from lower socioeconomic backgrounds and cannot access pregnancy tests, which could indicate they are pregnant before the six-week cutoff. If a Tennessee woman with substance use disorder decides to seek an abortion after six weeks, she may need to travel to a neighboring state. However, this is not always a feasible option, as the surrounding states (WV, MO, AR, MI, AL, and GA) also have restrictive laws that either prohibit abortions entirely or ban them after six weeks. Moreover, she may be hesitant to visit an obstetrician for an abortion, as some states require physicians by law to report their patients' substance use during pregnancy. For example, Virginia considers substance use during pregnancy child abuse and mandates that healthcare providers report it. This would ultimately limit her to North Carolina if she wants to remain in a nearby state, but she must go before 20 weeks gestation.[32] For someone who may or may not have access to reliable transportation, traveling to another state might be impossible. Without resources or means, these restrictive laws have made it incredibly difficult to obtain the medical care they need. II. Misconception Two: Mothers with SUD are Not Fit to Care for Children If a woman cannot take care of herself, one might wonder how she can take care of another human being. Mothers with substance use disorders often face many adversities, including lack of economic opportunity, trauma from abuse, history of poverty, and mental illness.[33] Fortunately, studies suggest keeping mother and baby together has many benefits. Breastfeeding, for example, helps the baby develop a strong immune system while reducing the mother’s risk of cancer and high blood pressure.[34] Additionally, newborns with neonatal abstinence syndrome who are breastfed by mothers receiving methadone or buprenorphine require less pharmacological treatment, have lower withdrawal scores, and experience shorter hospital stays.[35] Opioid concentration in breastmilk is minimal and does not pose a risk to newborns.[36] Moreover, oxytocin, the hormone responsible for mother-baby bonding, is increased in breastfeeding mothers, reducing withdrawal symptoms and stress-induced reactivity and cravings while also increasing protective maternal instincts.[37] Removing an infant from their mother’s care immediately after birth would result in the loss of all these positive benefits for both the mother and her newborn. The newborns I observed during my pediatrics rotation probably could have benefited from breastfeeding rather than bottle feeding and being passed around from one nurse to the next. They probably would have cried less and suffered fewer withdrawal symptoms had they been given the opportunity to breastfeed. And even if the mothers were lethargic and unresponsive while going through withdrawal, it would still have been possible to breastfeed with proper support. Unfortunately, many believe mothers with substance use disorder cannot adequately care for their children. This pervasive societal bias sets them up for failure from the beginning and greatly inhibits their willingness to change and mend their relationship with their providers. It is a healthcare provider’s duty to provide non-judgmental care that prioritizes the patient’s well-being. They must treat these mothers with the same empathy and respect as any other patient, even if they are experiencing withdrawal. III. Safe Harbor and Medication-Assisted Treatment Addiction is like any other disease and society should regard treatment without stigma. There is no simple fix to this problem, given that it involves the political, legal, and healthcare systems. Punitive policies push pregnant women away from receiving healthcare and prevent them from receiving beneficial interventions. States need to enact laws that protect these women from being reported to authorities. Montana, for example, passed a law in 2019 that provides women with substance use disorders safe harbor from prosecution if they seek treatment for their condition.[38] Medication-assisted treatment with methadone or buprenorphine is the first line treatment option and should be available to all pregnant women regardless of their ability to pay for medical care.[39] To promote continuity of care, health officials could include financial incentives to motivate new mothers to go to follow-up appointments. For example, vouchers for groceries or enrollment in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) may offset financial burdens and allow a mother to focus on taking care of her child and her recovery. IV. Mandated Substance Abuse Programs Although the number of people sentenced to state prisons for drug related crimes has been declining, it is still alarming that there were 171,300 sentencings in 2019.[40] Only 11 percent of the 65 percent of our nation’s inmates with substance use disorder receive treatment, implying that the other 89 percent were left without much-needed support to overcome their addiction.[41] It is erroneous to assume that their substance use disorder would disappear after a period without substance use while behind bars. After withdrawal, those struggling with substance use disorder may still have cravings and the likelihood of relapsing remains high without proper medical intervention. Even if they are abstinent for some time during incarceration, the underlying problem persists, and the cycle inevitably continues upon release from custody. In line with the recommendations by Global Commission on Drug Policy and the lessons learned from the failed War on Drugs, one proposed change in our criminal justice system would be to require enrollment and participation in assisted alcohol cessation programs before legal punishment. Policy makers must place emphasis on the safety of the patient and baby rather than the cessation of substance use. This would incentivize people to actively seek medical care, restore the patient-physician relationship, and ensure that they take rehabilitation programs seriously. If the patient or baby is unsafe, a caregiver could intervene while the patient re-enrolls in the program. Those currently serving sentences in prisons and jails can treat their substance use disorder through medication assisted treatment, cognitive behavioral therapy, and programs like Self Taught Empowerment and Pride (STEP). Medication assisted treatment under the supervision of medical professionals can help inmates achieve and maintain sobriety in a healthy and safe way. Furthermore, cognitive behavioral therapy can help to identify triggers and teach healthier coping mechanisms to prepare for stressors outside of jail. Finally, multimodal empowerment programs can connect people to jobs, education, and support upon release. People often leave prisons and jail without a sense of purpose, which can lead to relapse and reincarceration. Structured programs have been shown to decrease drug use and criminal behavior by helping reintegrate productive individuals into society.[42] V. Medical Education: Narcotic Treatment Programs and Suboxone Clinics Another proactive approach could be to have medical residency programs register with the Drug Enforcement Administration (DEA) as Narcotic Treatment Programs and incorporate suboxone clinics into their education and rotations. Rather than family medicine, OB/GYN, or emergency medicine healthcare workers having to refer their patients to an addiction specialist, they could treat patients with methadone for maintenance or detoxification where they would deliver their baby. Not only would this educate and prepare the future generation of physicians to handle the opioid crisis, but it would allow pregnant women to develop strong patient-physician relationships. CONCLUSION Society needs to change from the mindset of tackling a problem after it occurs to taking a proactive approach by addressing upstream factors, thereby preventing those problems from occurring in the first place. Emphasizing public health measures and adequate medical care can prevent complications and developmental issues in newborns and pregnant women with substance use disorders. Decriminalizing drug use and encouraging good health habits during pregnancy is essential, as is access to prenatal care, especially for lower socioeconomic patients. Many of the current laws and regulations that policy makers initially created due to naïve political opinion and unfounded bias to serve the War on Drugs need to be changed to provide these opportunities. To progress as a society, physicians and interprofessional teams must work together to truly understand the needs of patients with substance use disorders and provide support from prenatal to postnatal care. There should be advocation for legislative change, not by providing an opinion but by highlighting the facts and conclusions of scientific studies grounded in scientific evidence, health, security, and human rights. There can be no significant change if society continues to view those with substance use disorders as underserving of care. Only when the perspective shifts to compassion can these mothers and children receive adequate care that rehabilitates and supports their future and empowers them to raise their children. - [1] NIDA. 2023, February 15. Pregnant People with Substance Use Disorders Need Treatment, Not Criminalization. https://nida.nih.gov/about-nida/noras-blog/2023/02/pregnant-people-substance-use-disorders-need-treatment-not-criminalization [2] Substance Use Disorder Hurts Moms and Babies. National Partnership for Women and Families. June 2021 [3] All stories have been fictionalized and anonymized. [4] A History of the Drug War. Drug Policy Alliance. https://drugpolicy.org/issues/brief-history-drug-war [5] The Harrison Narcotic Act (1914) https://www.druglibrary.org/Schaffer/library/studies/cu/cu8.html [6] The War on Drugs. The Global Commission on Drug Policy. Published June 2011. https://www.globalcommissionondrugs.org/reports/the-war-on-drugs [7] Werb D, Rowell G, Guyatt G, Kerr T, Montaner J, Wood E. Effect of drug law enforcement on drug market violence: A systematic review. Int J Drug Policy. 2011;22(2):87-94. doi:10.1016/j.drugpo.2011.02.002 [8] Global Commission on Drug Policy, 2011 [9] Women NA for P. Tennessee’s Fetal Assault Law: Understanding its impact on marginalized women - New York. Pregnancy Justice. Published December 14, 2020. https://www.pregnancyjusticeus.org/tennessees-fetal-assault-law-understanding-its-impact-on-marginalized-women/ [10] Roberts SCM, Nuru-Jeter A. Women’s perspectives on screening for alcohol and drug use in prenatal care. Womens Health Issues Off Publ Jacobs Inst Womens Health. 2010;20(3):193-200. doi:10.1016/j.whi.2010.02.003 [11] Klaman SL, Isaacs K, Leopold A, et al. Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance. J Addict Med. 2017;11(3):178-190. doi:10.1097/ADM.0000000000000308 [12] Substance Abuse Reporting and Pregnancy: The Role of the Obstetrician–Gynecologist. https://www.acog.org/en/clinical/clinical-guidance/committee-opinion/articles/2011/01/substance-abuse-reporting-and-pregnancy-the-role-of-the-obstetrician-gynecologist [13] R. Ghertner, G Lincoln The Opioid Crisis and Economic Opportunity: Geographic and Economic Trends. ASPE. Office of Assistant Secretary for Planning and Evaluation. DHHS Revised September 11, 2018 https://aspe.hhs.gov/reports/economic-opportunity-opioid-crisis-geographic-economic-trends [14] Midon, M. Z., Gerzon, L. R., & de Almeida, C. S. (2021). Crack and motor development of babies living in an assistance shelter. ABCS Health Sciences, 46, e021215-e021215. And for example, see Crack Babies: Twenty Years Later : NPR https://www.npr.org/templates/story/story.php?storyId=126478643 [15] Williams JF, Smith VC, the Committee on Substance Abuse. Fetal Alcohol Spectrum Disorders. Pediatrics. 2015;136(5):e20153113. doi:10.1542/peds.2015-3113 [16] CDC Tobacco Free. Smoking During Pregnancy. Centers for Disease Control and Prevention. Published April 11, 2022. https://www.cdc.gov/tobacco/basic_information/health_effects/pregnancy/index.htm [17] Abuse NI on D. What are the risks of methamphetamine misuse during pregnancy? National Institute on Drug Abuse. https://nida.nih.gov/publications/research-reports/methamphetamine/what-are-risks-methamphetamine-misuse-during-pregnancy [18] CDC. Basics About Opioid Use During Pregnancy | CDC. Centers for Disease Control and Prevention. Published July 21, 2021. https://www.cdc.gov/pregnancy/opioids/basics.html [19] Honein MA, Boyle C, Redfield RR. Public Health Surveillance of Prenatal Opioid Exposure in Mothers and Infants. Pediatrics. 2019;143(3):e20183801. doi:10.1542/peds.2018-3801 [20] Winkelman TNA, Villapiano N, Kozhimannil KB, Davis MM, Patrick SW. Incidence and Costs of Neonatal Abstinence Syndrome Among Infants with Medicaid: 2004–2014. Pediatrics. 2018;141(4):e20173520. doi:10.1542/peds.2017-3520 [21] Strahan AE, Guy GP Jr, Bohm M, Frey M, Ko JY. Neonatal Abstinence Syndrome Incidence and Health Care Costs in the United States, 2016. JAMA Pediatr. 2020;174(2):200-202. doi:10.1001/jamapediatrics.2019.4791 [22] Ghose R, Forati AM, Mantsch JR. Impact of the COVID-19 Pandemic on Opioid Overdose Deaths: a Spatiotemporal Analysis. J Urban Health Bull N Y Acad Med. 2022;99(2):316-327. doi:10.1007/s11524-022-00610-0 [23] Mayes LC, Granger RH, Bornstein MH, Zuckerman B. The Problem of Prenatal Cocaine Exposure: A Rush to Judgment. JAMA. 1992;267(3):406-408. doi:10.1001/jama.1992.03480030084043 [24] NICHD Neonatal Research Network. The Maternal Lifestyle Study. clinicaltrials.gov; 2016. https://clinicaltrials.gov/ct2/show/study/NCT00059540 [25] Lester BM, Tronick EZ, LaGasse L, et al. The maternal lifestyle study: effects of substance exposure during pregnancy on neurodevelopmental outcome in 1-month-old infants. Pediatrics. 2002;110(6):1182-1192. doi:10.1542/peds.110.6.1182 [26] Lester BM, Lagasse L, Seifer R, et al. The Maternal Lifestyle Study (MLS): effects of prenatal cocaine and/or opiate exposure on auditory brain response at one month. J Pediatr. 2003;142(3):279-285. doi:10.1067/mpd.2003.112 [27] Bada HS, Bann CM, Bauer CR, et al. Preadolescent behavior problems after prenatal cocaine exposure: Relationship between teacher and caretaker ratings (Maternal Lifestyle Study). Neurotoxicol Teratol. 2011;33(1):78-87. doi:10.1016/j.ntt.2010.06.005 [28] N, P, R. Crack Babies: Twenty Years Later. NPR. Published May 3, 2010. https://www.npr.org/templates/story/story.php?storyId=126478643 [29] Miranda L, Dixon V, September CRP on, 30, 2015. How States Handle Drug Use During Pregnancy http://projects.propublica.org/graphics/maternity-drug-policies-by-state [30] NCDAS: Substance Abuse and Addiction Statistics [2023]. NCDAS. https://drugabusestatistics.org/ [31] (Tenn. Code Ann. § 39-15-216). [32] Institute G. Interactive Map: US Abortion Policies and Access After Roe. https://states.guttmacher.org/policies/ [33] Whitesell M, Bachand A, Peel J, Brown M. Familial, Social, and Individual Factors Contributing to Risk for Adolescent Substance Use. J Addict. 2013;2013:579310. doi:10.1155/2013/579310 [34] CDC. Five Great Benefits of Breastfeeding. Centers for Disease Control and Prevention. Published July 27, 2021. https://www.cdc.gov/nccdphp/dnpao/features/breastfeeding-benefits/index.html [35] Welle-Strand GK, Skurtveit S, Jansson LM, Bakstad B, Bjarkø L, Ravndal E. Breastfeeding reduces the need for withdrawal treatment in opioid-exposed infants. Acta Paediatr. 2013;102(11):1060-1066. doi:10.1111/apa.12378 [36] Ilett KF, Hackett LP, Gower S, Doherty DA, Hamilton D, Bartu AE. Estimated dose exposure of the neonate to buprenorphine and its metabolite norbuprenorphine via breastmilk during maternal buprenorphine substitution treatment. Breastfeed Med Off J Acad Breastfeed Med. 2012;7:269-274. doi:10.1089/bfm.2011.0096 [37] Pedersen CA, Smedley KL, Leserman J, et al. Intranasal Oxytocin Blocks Alcohol Withdrawal in Human Subjects. Alcohol Clin Exp Res. 2013;37(3):484-489. doi:10.1111/j.1530-0277.2012.01958.x [38] Montana SB0289. https://leg.mt.gov/bills/2019/billhtml/SB0289.htm [39] Mullins N, Galvin SL, Ramage M, Gannon M, Lorenz K, Sager B, Coulson CC. Buprenorphine and Naloxone Versus Buprenorphine for Opioid Use Disorder in Pregnancy: A Cohort Study. J Addict Med. 2020 May/Jun;14(3):185-192. doi: 10.1097/ADM.0000000000000562. PMID: 31567599. [40] Drug Related Crime Statistics [2023]: Offenses Involving Drug Use. NCDAS. https://drugabusestatistics.org/drug-related-crime-statistics/ [41] Association APH. Online only: Report finds most U.S. inmates suffer from substance abuse or addiction. Nations Health. 2010;40(3):E11-E11. [42] Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) | NIDA Archives. Published January 17, 2018. http://archives.nida.nih.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition

Photo by Richard Catabay on Unsplash ABSTRACT COVID-19 exposed deep-rooted structural inequities. Allocation protocols developed during COVID-19 may cause furtherance of structural inequalities. In this essay, I specifically address the issue of structural inequities in the context of resource allocation during a period of crisis standard of care. In response to the increasing evidence of structural inequities during the pandemic, physicians and bioethicists Douglas White and Bernard Lo proposed incorporating a correction factor into resource allocation protocols. According to them, this would provide an advantage for disadvantaged individuals. The proposed correction factors use the Area Deprivation Index to determine eligibility. I argue that the correction factor is ethically justified and supported by Rawls’s difference principle, Daniels’s equality of opportunity, and Harris’s double jeopardy argument. I also suggest that the proposed correction factor does not go far enough, particularly if used with other objective factors, such as SOFA scoring. At least one study shows that using SOFA scoring for resource allocation during COVID-19 has a discriminatory effect on non-Hispanic black patients. One problem with the correction factor using the ADI is that it only applies to those currently in the reflected socioeconomic status. Additionally, when only one hospital serves a largely socioeconomically disadvantaged community, all admissions will fall within the targeted category for application of the correction factor. Thus, further actions are needed to dismantle structural inequities, such as implementing load balancing or the planned sharing of resources among healthcare systems. INTRODUCTION COVID-19 forced deep-rooted structural inequities to the surface. SARS-CoV-2 was a novel virus, but the connection between structural inequities and the disparate impact of the virus on marginalized populations is not. The history of pandemics reflects how much structural inequities negatively influence health equity.[1] The lack of preparedness and response to the structural inequities exemplify “blistering systemic failures.”[2] Despite warnings from prior threats from SARS and H1N1, we were unprepared for COVID-19. Antommaria and Chelen show that one-half of responding hospitals did not have an allocation protocol in place.[3] When an influx of critically ill patients and limited resources required implementing a crisis standard of care, many hospitals quickly established protocols addressing the allocation of scarce resources. Most crisis standard of care (CSC) protocols reflect public health’s utilitarian focus on saving the most lives.[4] The utilitarian focus ignores the disproportionate impact resulting from structural inequities. In December 2020, two physicians and bioethicists, Douglas White and Bernard Lo responded to the increasing evidence of the disproportionate impact of COVID-19 on disadvantaged communities by adding a correction factor to their CSC resource allocation protocol. The correction factor adjusts triage scores of individuals living in the most disadvantaged neighborhoods by subtracting one point from the triage score.[5] Patients with lower triage scores are more likely to receive life-saving care. Thus, subtracting a point provides an advantage. The correction factor uses a composite measure of disadvantage to determine eligibility called the Area Deprivation Index (ADI).[6] The ADI is a geographic measure of socioeconomic disadvantage that calculates an aggregate disadvantage score on a 10-point scale. The ADI measures seventeen elements of disadvantage related to poverty, education, employment, physical environment, and infrastructure.[7] The correction factor compensates for structural injustices by using ADI scores of patients in the highest quartile of socioeconomic disadvantage or having an ADI score of 8 to 10 since the strongest association between ADI scores and health outcomes occurs at the highest ADI levels.[8] l. Ethical Justifications Various theories of justice support applying the correction factor in the allocation of scarce resources. Rawls’s difference principle provides an ethical justification for the correction factor as it benefits the worse off in the event of resource allocation.[9] Applying the correction factor and subtracting one point from the triage score admittedly creates inequality among two otherwise like patients, but it is justified under Rawls’s theory since it gives the advantage to the least advantaged, addressing equity. Norman Daniels’ argument for protecting fair “equality of opportunity” also supports the correction factor.[10] The correction factor protects the equality of opportunity for those denied access to care because of deep-rooted structural inequities exacerbated by the pandemic. Using the correction factor to provide access to life-saving resources compensates patients with diminished opportunities in other arenas like the social determinants of health. Derek Parfit’s deontic egalitarianism supports the correction factor. Under Parfit’s view of deontic egalitarianism, justification of giving an advantage to the worse off depends on the reason for the inequality. If the unequal status results from circumstances such as a genetic condition or an accidental injury, like Daniel’s equality of opportunity, deontic egalitarianism does not support giving an advantage to the worse-off. If the unequal position results from the unjust actions of another, such as discriminatory treatment of people of color, deontic egalitarianism supports providing the advantage to address the inequity.[11] The disproportionate impact of resource allocation results from unjust treatment such as discrimination and structural inequity.[12] John Harris’s double jeopardy argument adds additional support to the correction factor in that[13] the socioeconomically disadvantaged or those facing racial or ethnic discrimination may have had an increased risk of contracting COVID-19 or having a severe case or death due to structural inequities. If the triage procedures do not compensate for the structural inequities and they are precluded access to critical care based only on traditional triage, they will suffer double jeopardy. The correction factor avoids this double jeopardy. ll. Operationalizing the Correction Factor Those opposing the correction factor might assert the infeasibility of mitigating inequities during a pandemic.[14] Yet one large US health system successfully applied similar criteria in allocating remdesivir[15] and the National Academy of Medicine endorsed disparity-mitigating criteria for allocating scarce vaccines.[16] Applying the correction factor is neither time nor resource intensive. It will not divert resources from the goal of treating illness and reducing morbidity. With the data available about COVID-19’s disproportionate impact, not applying an available tool to lessen inequities is an abrogation of ethical duty. One utilitarian argument asserts that we will save fewer lives if the prioritized patients are more likely to die despite interventions. Yet society bears responsibility for the social policies that created the disparities. Thus, there is an obligation to mitigate those societal problems, even when doing so might save fewer lives.[17] Some clinicians argue that they should have discretion in determining triage scores. This objection to the correction factor in formulating triage procedures reflects the conflict between clinical and public health ethics. Implementing a CSC protocol shifts decision-making from the clinician to a triage committee and from an individual focus to a community focus. Allowing clinicians to determine triage protocols would increase the risk of decisions based on bias and subjectivity. Another open question is whether the correction factor will achieve the intended goal. Nancy Kass suggests that without evidence to support the effectiveness, we cannot ethically implement the policy.[18] Thus, applying the Kass analysis, diverting a scarce resource to someone less likely to survive should require proof that doing so systematically would resolve or improve structural inequity. There is limited empirical evidence, but we may proceed with caution based on the presumptive data and the hypothesis that a triage allocation that uses a correction factor could help. Computer-based modeling or “tabletop” exercises applying the framework to actual patients but not enacting the protocols could assess the possible effects of the protocols.[19] Perhaps the most robust rebuttal in response to the opposition of applying a correction factor is in an argument proffered by Douglas White that no reasonable triage framework maximizes health outcomes if it creates significant inequalities.[20] White’s argument emphasizes the importance of addressing inequity. lll. A More Robust Version of the Correction Factor The burdens associated with any public health intervention typically fall into three categories:[21] privacy and confidentiality, risk to liberty and self-determination, and justice. Most burdens associated with allocating scarce resources fall under the justice category. I not only disagree with the arguments against using a correction factor, but I also argue that the correction factor does not go far enough. First, using the ADI neglects consideration of people of color disproportionately affected by COVID-19 no longer living in a neighborhood with the highest ADI scores. Based on new research, Sequential Organ Failure Assessment (SOFA) scores are also potentially discriminatory and not ideal for addressing structural inequity, racism, or ethnic discrimination in the triage setting, although they are applied to triage.[22] Second, public hospitals in socioeconomically depressed communities and rural locations may serve a population in which nearly the entire community will have ADI scores that qualify for application of the correction factor. lV. Relying on ADI cannot protect all people disadvantaged due to their race or ethnicity The ADI uses seventeen measures of socioeconomic disadvantage. Some racial inequality in healthcare is unrelated to socioeconomic status and can be missed by ADI. Racial inequality in healthcare may be directly related to implicit and explicit bias and past and current discrimination. But the correction factor will not help the Black patient not currently residing in a highly disadvantaged neighborhood or experiencing other vestiges of racism in the form of socioeconomic disadvantage. A correction factor that uses more information than ADI could make up for some of the weaknesses of SOFA as well. V. When all patients have high ADI Scores What happens when triaging occurs in hospitals serving populations where almost all patients have ADI scores of 8 to 10? To illustrate, I will use the example of Belle Glade, Florida, in western Palm Beach County.[23] The overwhelming majority of the neighborhoods served by the one public hospital, Lakeside Medical Center, is at a level 10 state decile, with a few neighborhoods at 8 and 9 state decile.[24] During a surge in that hospital, the correction factor will apply to every patient. The hospital must then resort to other considerations, such as random allocation. This potential dilemma suggests the need to consider further steps, such as load balancing, to lessen the inequities. Vl. Load Balancing Load balancing is a plan in which hospitals report daily census and available beds. Patients are diverted or transferred to hospitals with open beds when one hospital is at maximum capacity. Although identified as a method to avoid the need for triaging, I suggest load balancing is also equity balancing, especially when the overwhelmed hospital is in a high ADI area. Failures in load balancing exacerbate the harm to disadvantaged populations. Disadvantaged individuals are more likely to seek treatment in hospitals with limited ability to increase capacity or care for many critically ill patients. During surges in COVID-19, hospitals in poor neighborhoods were overrun by admissions and lacked resources to treat, while nearby private hospitals had available beds and resources.[25] The Arizona Department of Health Services developed an effective load-balancing system to coordinate the statewide transfer of patients from overloaded hospitals to other hospitals.[26] The system dramatically improved access to care for people of color and rural populations.[27] One of the state’s foremost responsibilities is safeguarding the health and well-being of people threatened when health systems fail to cooperate. Voluntary load balancing is preferable, but if the healthcare systems are unwilling to cooperate and if voluntary efforts are ineffective, state governments should intervene and require private hospitals to take part in load balancing. When needed, public health officials should issue emergency orders to require hospitals to participate in load-balancing efforts, including accepting patient transfers that are not part of their covered population. CONCLUSION Rawls’s difference principle, Daniels’s equality of opportunity, Parfit’s deontic egalitarianism, and Harris’s double jeopardy argument all justify and may even compel using the correction factor. COVID-19 turned academic and hypothetical discussions and debates about allocating scarce resources and making untenable choices of who lives and who dies to real-life responsibilities. Once hospitals move to a crisis standard of care, they may need to allocate scarce resources, so having systems in place that can compensate for past inequities and improve fairness in access to care is the ethical imperative. Dismantling structural inequities and reassessing allocation protocols should incorporate the correction factor as a new foundational framework and then build on it using load balancing and exercising caution if applying SOFA. It is an ethical responsibility to use these tools to dismantle the pervasive structural inequities when allocating scarce resources. - [1] Goldberg, Daniel S. “Against the Medicalization of Public Health (Ethics).” Public Health Ethics 14, no. 2 (2021): 117–19. https://doi.org/10.1093/phe/phab024. [2] Morrissey, Mary Beth, and Jorge L. Rivera-Agosto. “Protecting the Public's Health in Pandemics: Reflections on Policy Deliberation and the Role of Civil Society in Democracy.” Frontiers in Public Health 9 (June 1, 2021): 6. https://doi.org/10.3389/fpubh.2021.678210. [3] Antommaria, Armand H., Tyler S. Gibb, Amy L. McGuire, Paul Root Wolpe, Matthew K. Wynia, Megan K. Applewhite, Arthur Caplan, et al. “Ventilator Triage Policies during the Covid-19 Pandemic at U.S. Hospitals Associated with Members of the Association of Bioethics Program Directors.” Annals of Internal Medicine 173, no. 3 (April 4, 2020): 188–94. https://doi.org/10.7326/m20-1738; Chelan, Julia S., Douglas B. White, Stephanie Zaza, Amanda N. Perry, Deborah S. Feifer, Maia L. Crawford, and Amber E. Barnato. “US Ventilator Allocation and Patient Triage Policies in Anticipation of the Covid-19 Surge.” Health Security 19, no. 5 (2021): 459–67. https://doi.org/10.1089/hs.2020.0166. [4] Lin, Janet Y., and Lisa Anderson-Shaw. “Rationing of Resources: Ethical Issues in Disasters and Epidemic Situations.” Prehospital and Disaster Medicine 24, no. 3 (2009): 215–21. https://doi.org/10.1017/s1049023x0000683x. [5] Executive Summary Allocation of Scarce Critical Care Resources during a ...,” April 9, 2021. https://ccm.pitt.edu/sites/default/files/Model%20hospital%20policy%20for%20allocation%20of%20critical%20care_2020-03-23%20web.pdf. [6]. Executive Summary Allocation of Scarce Critical Care Resources during a ...,” April 9, 2021. https://ccm.pitt.edu/sites/default/files/Model%20hospital%20policy%20for%20allocation%20of%20critical%20care_2020-03-23%20web.pdf. [7] https://www.neighborhoodatlas.medicine.wisc.edu/mapping; Executive Summary Allocation of Scarce Critical Care Resources during a ...,” April 9, 2021. [8] White, Douglas B., and Bernard Lo. “Structural Inequities, Fair Opportunity, and the Allocation of Scarce ICU Resources.” Hastings Center Report 51, no. 5 (2021): 42–47. https://doi.org/10.1002/hast.1285 [9] McKie, John, and Jeff Richardson. “The Rule of Rescue.” Social Science and Medicine 56 (2003): 2407–19 [10] Daniels, Norman. “Justice, Health, and Health Care.” Essay. In Medicine and Social Justice Essays on the Distribution of Health Care, edited by Rosamond Rodes, Margaret P Battin, and Anita Silvers, Seconded., 17–33. Oxford University Press, n.d. [11] Brock, Dan W. “Priority to the Worse Off in Health Care Resource Prioritization .” Essay. In Medicine and Social Justice Essays on the Distribution of Health Care, edited by Rosamond Rhodes, Margaret Battin, and Anita Silvers, 155–64. Oxford University Press, n.d. [12] Brock, Dan W. “Priority to the Worse Off in Health Care Resource Prioritization .” Essay. In Medicine and Social Justice Essays on the Distribution of Health Care, edited by Rosamond Rhodes, Margaret Battin, and Anita Silvers, 155–64. Oxford University Press, n.d. [13] Harris, J. “Qualifying the Value of Life.” Journal of Medical Ethics 13, no. 3 (1987): 117–23. https://doi.org/10.1136/jme.13.3.117. [14] White, Douglas B., and Bernard Lo. “Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic.” American Journal of Respiratory and Critical Care Medicine 203, no. 3 (February 1, 2021): 287–95. https://doi.org/10.1164/rccm.202010-3809cp. [15] White, Douglas B., and Bernard Lo. “Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic.” American Journal of Respiratory and Critical Care Medicine 203, no. 3 (February 1, 2021): 287–95. https://doi.org/10.1164/rccm.202010-3809cp. [16] White, Douglas B., and Bernard Lo. “Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic.” American Journal of Respiratory and Critical Care Medicine 203, no. 3 (February 1, 2021): 287–95. https://doi.org/10.1164/rccm.202010-3809cp. [17] White, Douglas B., and Bernard Lo. “Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic.” American Journal of Respiratory and Critical Care Medicine 203, no. 3 (February 1, 2021): 287–95. https://doi.org/10.1164/rccm.202010-3809cp. [18] Kass, Nancy E. “An Ethics Framework for Public Health.” American Journal of Public Health 91, no. 11 (November 2001): 1776–82. https://doi.org/10.2105/ajph.91.11.1776. [19] White, Douglas B., and Bernard Lo. “Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic.” American Journal of Respiratory and Critical Care Medicine 203, no. 3 (February 1, 2021): 287–95. https://doi.org/10.1164/rccm.202010-3809cp. [20] White, Supra.12 [21] Kass, Nancy E. “An Ethics Framework for Public Health.” American Journal of Public Health 91, no. 11 (November 2001): 1776–82. https://doi.org/10.2105/ajph.91.11.1776. [22] Tolchin, Benjamin, Carol Oladele, Deron Galusha, Nitu Kashyap, Mary Showstark, Jennifer Bonito, Michelle C. Salazar, et al. “Racial Disparities in the SOFA Score among Patients Hospitalized with Covid-19.” PLOS ONE. Public Library of Science, September 17, 2021. https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0257608; SOFA is a prognostic scoring system that assigns points for organ failure evidence within six different organ systems. Higher SOFA scores correlate with higher mortality. New research by Tolchin reveals the flaws in SOFA due to its failure to account for delays in seeking care and overestimates of Black mortality. Also see Antommaria, Armand H., Tyler S. Gibb, Amy L. McGuire, Paul Root Wolpe, Matthew K. Wynia, Megan K. Applewhite, Arthur Caplan, et al. “Ventilator Triage Policies during the Covid-19 Pandemic at U.S. Hospitals Associated with Members of the Association of Bioethics Program Directors.” Annals of Internal Medicine 173, no. 3 (April 4, 2020): 188–94. https://doi.org/10.7326/m20-1738; Chelen, Julia S., Douglas B. White, Stephanie Zaza, Amanda N. Perry, Deborah S. Feifer, Maia L. Crawford, and Amber E. Barnato. “US Ventilator Allocation and Patient Triage Policies in Anticipation of the Covid-19 Surge.” Health Security 19, no. 5 (2021): 459–67. https://doi.org/10.1089/hs.2020.0166; and Pence, Gregory E. Pandemic Bioethics. Peterborough: Broadview Press, 2021. [23] Black – population 59.28 % Median Household income 24,322 Population 20,276 Education: 31.$ HS; 21.71% less than 95 grade, Postsecondary Asso-7%, Bachelors 6.7, ttps://worldpopulationreview.com/us-cities/belle-glade-fl-population [24] Neighborhood atlas®. Neighborhood Atlas - Mapping. (n.d.). Retrieved February 15, 2022, from https://www.neighborhoodatlas.medicine.wisc.edu/mapping [25] White, Douglas, Keynote Address, American Society of Bioethics and Humanities, October 13, 2021, COVID-19 at the Crossroads, https://eventpilotadmin.com/web/planner.php?id=ASBH21 [26] Angelo, A. (2020, May 26). Latest Covid-19 Model Shows Arizona can Meet a Health Care Surge. Retrieved February 15, 2022, from https://communityimpact.com/phoenix/chandler/coronavirus/2020/05/26/latest-covid-19-model-shows-arizona-can-meet-a-health-care-surge/ [27] White, Douglas, Keynote Address, American Society of Bioethics and Humanities, October 13, 2021, COVID-19 at the Crossroads, https://eventpilotadmin.com/web/planner.php?id=ASBH21

Photo by Jo-Anne McArthur on Unsplash ABSTRACT The UK-based campaign group Scrap Factory Farming has launched a legal challenge against industrial animal agriculture; the challenge is in the process of judicial review. While a fringe movement, Scrap Factory Farming has already accrued some serious backers, including the legal team of Michael Mansfield QC. The premise is that factory farming is a danger not just to animals or the environment but also to human health. According to its stated goals, governments should be given until 2025 to phase out industrialized “concentrated animal feeding organizations” (CAFOs) in favor of more sustainable and safer agriculture. This paper will discuss the bioethical issues involved in Scrap Factory Farming’s legal challenge and argue that an overhaul of factory farming is long overdue. INTRODUCTION A CAFO is a subset of animal feeding operations that has a highly concentrated animal population. CAFOs house at least 1000 beef cows, 2500 pigs, or 125,000 chickens for at least 45 days a year. The animals are often confined in pens or cages to use minimal energy, allowing them to put on as much weight as possible in as short a time. The animals are killed early relative to their total lifespans because the return on investment (the amount of meat produced compared to animal feed) is a curve of diminishing returns. CAFOs’ primary goal is efficiency: fifty billion animals are “processed” in CAFOs every year. The bioethical questions raised by CAFOs include whether it is acceptable to kill the animals, and if so, under what circumstances, whether the animals have rights, and what animal welfare standards should apply. While there are laws and standards in place, they tend to reflect the farm lobby and fail to consider broader animal ethics. Another critical issue applicable to industrial animal agriculture is the problem of the just distribution of scarce resources. There is a finite amount of food that the world can produce, which is, for the moment, approximately enough to go around.[1] The issue is how it goes around. Despite there being enough calories and nutrients on the planet to give all a comfortable life, these calories and nutrients are distributed such that there is excess and waste in much of the global North and rampant starvation and malnutrition in the global South. The problem of distribution can be solved in two ways: either by efficient and just distribution or by increasing net production (either increase productivity or decrease waste) so that even an inefficient and unjust distribution system will probably meet the minimum nutritional standards for all humans. This essay explores four bioethical fields (animal ethics, climate ethics, workers’ rights, and just distribution) as they relate to current industrial agriculture and CAFOs. l. Animal Ethics Two central paradigms characterize animal ethics: welfarism and animal rights. These roughly correspond to the classical frameworks of utilitarianism and deontology. Welfarists[2] hold the common-sense position that animals must be treated well and respected as individuals but do not have inalienable rights in the same ways as humans. A typical welfare position might be, “I believe that animals should be given the best life possible, but there is no inherent evil in using animals for food, so long as they are handled and killed humanely.” Animal rights theorists and activists, on the other hand, would say, “I believe non-human animals should be given the best lives possible, but we should also respect certain rights of theirs analogous to human rights: they should never be killed for food, experimented upon, etc.” Jeremy Bentham famously gave an early exposition of the animal rights case: “The question is not Can they reason?, nor Can they talk?, but Can they suffer? Why should the law refuse its protection to any sensitive being?” Those who take an animal welfare stance have grounds to oppose the treatment of animals in CAFOs as opposed to more traditional grass-fed animal agriculture. CAFOs cannot respect the natural behaviors or needs of animals who evolved socially for millions of years in open plains. If more space was allowed per animal or more time for socialization and other positive experiences in the animal’s life, the yield of the farm would drop. This is not commercially viable in a competitive industry like animal agriculture; thus, there is very little incentive for CAFOs to treat animals well. Rampant abuse is documented.[3] Acts of cruelty are routine: pigs often have teeth pulled and tails docked because they often go mad in their conditions and attempt to cannibalize each other; chickens have their beaks clipped to avoid them pecking at each other, causing immense pain; cows and bulls have their horns burned off to avoid them damaging others (as this damages the final meat product, too); male chicks that hatch in the egg industry are ground up in a macerator, un-anaesthetized, in the first 24 hours of their life as they will not go on to lay eggs. These practices vary widely among factory farms and among jurisdictions. Yet, arguably, the welfare of animals cannot be properly respected because all CAFOs fundamentally see animals as mere products-in-the-making instead of the complex, sentient, and emotional individuals science has repeatedly shown them to be.[4] ll. Climate Ethics The climate impact of farming animals is increasingly evident. Around 15-20 percent of human-made emissions come from animal agriculture.[5] and deforestation to create space for livestock grazing or growing crops to feed farm animals. An average quarter-pound hamburger uses up to six kilograms of feed, causes 66 square feet of deforestation, and uses up to 65 liters of water, with around 4kg of carbon emissions to boot – a majority of which come from the cattle themselves (as opposed to food processing or food miles).[6] According to environmentalist George Monbiot, “Even if you shipped bananas six times around the planet, their impact would be lower than local beef and lamb.”[7] The disparity between the impact of animal and plant-based produce is stark. Not all animal products are created equally. Broadly, there are two ways to farm animals: extensive or intensive farming. Extensive animal farming might be considered a “traditional” way of farming: keeping animals in large fields, as naturally as possible, often rotating them between different areas to not overgraze any one pasture. However, its efficiency is much lower than intensive farming – the style CAFOs use. Intensive animal farming is arguably more environmentally efficient. That is, CAFOs produce more output per unit of natural resource input than extensive systems do. However, environmental efficiency is relative rather than absolute, as the level of intensive animal agriculture leads to large-scale deforestation to produce crops for factory-farmed animals. CAFOs are also point-sources of pollution from the massive quantities of animal waste produced – around 1,000,000 tons per day in the US alone, triple the amount of all human waste produced per day – which has significant negative impacts on human health in the surrounding areas.[8] The environmental impacts of CAFOs must be given serious ethical consideration using new frameworks in climate ethics and bioethics. One example of a land ethic to guide thinking in this area is that “[it] is right when it tends to preserve the integrity, stability, and beauty of the biotic community. It is wrong when it tends otherwise.”[9] It remains to be seen whether CAFOs can operate in a way that respects and preserves “integrity, stability, and beauty” of their local ecosystem, given the facts above. The pollution CAFOs emit affects the surrounding areas. Hog CAFOs are built disproportionately around predominantly minority communities in North Carolina where poverty rates are high.[10] Animal waste carries heavy metals, infectious diseases, and antibiotic-resistant pathogens into nearby water sources and houses. lll. Workers’ Rights The poor treatment of slaughterhouse workers has been documented in the US during the COVID-19 pandemic, where, despite outbreaks of coronavirus among workers, the White House ordered that they remain open to maintain the supply of meat. The staff of slaughterhouses in the US is almost exclusively people with low socioeconomic status, ethnic minorities, and migrants.[11] Almost half of frontline slaughterhouse workers are Hispanic, and a quarter is Black. Additionally, half are immigrants, and a quarter comes from families with limited English proficiency. An eighth live in poverty, with around 45 percent below 200 percent of the poverty line. Only one-in-forty has a college degree or more, while one-in-six lacks health insurance. Employee turnover rates are around 200 percent per year.[12] Injuries are very common in the fast-moving conveyor belt environment with sharp knives, machinery, and a crowd of workers. OSHA found 17 cases of hospitalizations, two body part amputations per week, and loss of an eye every month in the American industrial meat industry. This is three times the workplace accident rate of the average American worker across all industries. Beef and pork workers are likely to suffer repetitive strain at seven times the rate of the rest of the population. One worker told the US Department of Agriculture (USDA) that “every co-worker I know has been injured at some point… I can attest that the line speeds are already too fast to keep up with. Please, I am asking you not to increase them anymore.”[13] Slaughterhouses pose a major risk to public health from zoonotic disease transmission. 20 percent of slaughterhouse workers interviewed in Kenya admit to slaughtering sick animals, which greatly increases the risk of transmitting disease either to a worker further down the production line or a consumer at the supermarket.[14] Moreover, due to poor hygienic conditions and high population density, animals in CAFOs are overfed with antibiotics. Over two-thirds of all antibiotics globally are given to animals in agriculture, predicted to increase by 66 percent by 2030.[15] The majority of these animals do not require antibiotics; their overuse creates a strong and consistent selection pressure on any present bacterial pathogens that leads to antibiotic resistance that could create devastating cross-species disease affecting even humans. The World Health Organization predicts that around 10 million humans per year could die of antibiotic-resistant diseases by 2050.[16] Many of these antibiotics are also necessary for human medical interventions, so antibiotics in animals have a tremendous opportunity cost. The final concern is that of zoonosis itself. A zoonotic disease is any disease that crosses the species boundary from animals to humans. According to the United Nations, 60 percent of all known infections and 75 percent of all emerging infections are zoonotic.[17] Many potential zoonoses are harbored in wild animals (particularly when wild animals are hunted and sold in wet markets) because of the natural biodiversity. However, around a third of zoonoses originate in domesticated animals, which is a huge proportion given the relative lack of diversity of the animals we choose to eat. Q fever, or “query fever,” is an example of a slaughterhouse-borne disease. Q fever has a high fatality rate when untreated that decreases to “just” 2 percent with appropriate treatment.[18] H1N1 (swine flu) and H5N1 (bird flu) are perhaps the most famous examples of zoonoses associated with factory farming. lV. Unjust Distribution The global distribution of food can cause suffering. According to research commissioned by the BBC, the average Ethiopian eats around seven kilograms of meat per year, and the average Rwandan eats eight.[19] This is a factor of ten smaller than the average European, while the average American clocks in at around 115 kilograms of meat per year. In terms of calories, Eritreans average around 1600kcal per day while most Europeans ingest double that. Despite enough calories on the planet to sustain its population, 25,000 people worldwide starve to death each day, 40 percent of whom are children. There are two ways to address the unjust distribution: efficient redistribution and greater net production, which are not mutually exclusive. Some argue that redistribution will lead to lower net productivity because it disincentivizes labor;[20] others argue that redistribution is necessary to respect human rights of survival and equality.[21] Instead of arguing this point, I will focus on people’s food choices and their effect on both the efficiency and total yield of global agriculture, as these are usually less discussed. Regardless of the metric used, animals always produce far fewer calories and nutrients (protein, iron, zinc, and all the others) than we feed them. This is true because of the conservation of mass. They cannot feasibly produce more, as they burn off and excrete much of what they ingest. The exact measurement of the loss varies based on the metric used. When compared to live weight, cows consume somewhere around ten times their weight. When it comes to actual edible weight, they consume up to 25 times more than we can get out of them. Cows are only around one percent efficient in terms of calorific production and four percent efficient in protein production. Poultry is more efficient, but we still lose half of all crops we put into them by weight and get out only a fifth of the protein and a tenth of the calories fed to them.[22] Most other animals lie somewhere in the middle of these two in terms of efficiency, but no animal is ever as efficient as eating plants before they are filtered through animals in terms of the nutritional value available to the world. Due to this inefficiency, it takes over 100 square meters to produce 1000 calories of beef or lamb compared to just 1.3 square meters to produce the same calories from tofu.[23] The food choices in the Western world, where we eat so much more meat than people eat elsewhere, are directly related to a reduction in the amount of food and nutrition in the rest of the world. The most influential theory of justice in recent times is John Rawls’ Original Position wherein stakeholders in an idealized future society meet behind a “veil of ignorance” to negotiate policy, not knowing the role they will play in that society. There is an equal chance of each policymaker ending up poverty-stricken or incredibly privileged; therefore, each should negotiate to maximize the outcome of all citizens, especially those worst-off in society, known as the “maximin” strategy. In this hypothetical scenario, resource distribution would be devised to be as just as possible and should therefore sway away from animal consumption. CONCLUSION Evidence is growing that animals of all sorts, including fish and certain invertebrates, feel pain in ways that people are increasingly inclined to respect, though still, climate science is more developed and often inspires more public passion than animal rights do. Workers’ rights and welfare in slaughterhouses have become mainstream topics of conversation because of the outbreaks of COVID-19 in such settings. Environmentalists note overconsumption in high-income countries, also shining a light on the starvation of much of the low-income population of the world. At the intersection of these bioethical issues lies the modern CAFO, significantly contributing to animal suffering, climate change, poor working conditions conducive to disease, and unjust distribution of finite global resources (physical space and crops). It is certainly time to move away from the CAFO model of agriculture to at least a healthy mixture of extensive agriculture and alternative (non-animal) proteins. - [1] Berners-Lee M, Kennelly C, Watson R, Hewitt CN; Current global food production is sufficient to meet human nutritional needs in 2050 provided there is radical societal adaptation. Elementa: Science of the Anthropocene. 6:52, 2018. DOI: https://doi.org/10.1525/elementa.310 [2] : Lund TB, Kondrup SV, Sandøe P. A multidimensional measure of animal ethics orientation – Developed and applied to a representative sample of the Danish public. PLoS ONE 14(2): e0211656. 2019. DOI: https://doi.org/10.1371/ journal.pone.0211656 [3] Fiber-Ostrow P & Lovell JS. Behind a veil of secrecy: animal abuse, factory farms, and Ag-Gag legislation, Contemporary Justice Review, 19:2, p230-249. 2016. DOI: 10.1080/10282580.2016.1168257 [4] Jones RC. Science, sentience, and animal welfare. Biol Philos 28, p1–30 2013. DOI: https://doi.org/10.1007/s10539-012-9351-1 [5] Twine R. Emissions from Animal Agriculture—16.5% Is the New Minimum Figure. Sustainability, 13, 6276. 2021. DOI: https://doi.org/ 10.3390/su13116276 [6] Capper JL. "Is the Grass Always Greener? Comparing the Environmental Impact of Conventional, Natural and Grass-Fed Beef Production Systems" Animals 2, no. 2: 127-143. 2012. DOI: https://doi.org/10.3390/ani2020127 [7] Monbiot, George. “In Trying to Reduce the Impact of Our Diets, … Their Impact Would Be Lower than Local Beef and Lamb.” Twitter, Twitter, 24 Jan. 2020, twitter.com/GeorgeMonbiot/status/1220691168012460032. [8] Copeland C. Resources, Science, and Industry Division. "Animal waste and water quality: EPA regulation of concentrated animal feeding operations (CAFOs)." Congressional Research Service, the Library of Congress, 2006. [9] Leopold A. A Sand County Almanac, and Sketches Here and There. 1949. [10] Nicole W. “CAFOs and environmental justice: the case of North Carolina.” Environmental health perspectives vol. 121:6. 2013: A182-9. DOI: 10.1289/ehp.121-a182 [11] Fremstad S, Brown H, Rho HJ. CEPR’s Analysis of American Community Survey, 2014-2018 5-Year Estimates. 2020. Accessed 08/06/21 at https://cepr.net/meatpacking-workers-are-a-diverse-group-who-need-better-protections [12] Broadway, MJ. "Planning for change in small towns or trying to avoid the slaughterhouse blues." Journal of Rural Studies 16:1. P37-46. 2000. [13] Wasley A. The Guardian. 2018. Accessed 08/06/2021 at https://www.theguardian.com/environment/2018/jul/05/amputations-serious-injuries-us-meat-industry-plant [14] Cook EA, de Glanville WA, Thomas LF, Kariuki S, Bronsvoort BM, Fèvre EM. Working conditions and public health risks in slaughterhouses in western Kenya. BMC Public Health. 17(1):14. 2017. DOI: 10.1186/s12889-016-3923-y. [15] Global trends in antimicrobial use in food animals. Van Boeckel TP, Brower C, Gilbert M, Grenfell BT, Levin SA, Robinson TP, Teillant A, Laxminarayan R. Proceedings of the National Academy of Sciences May 2015, 112 (18) 5649-5654; DOI: 10.1073/pnas.1503141112 [16] Resistance, IICGoA. "No Time to Wait: Securing the future from drug-resistant infections." Report to the Secretary-General of the United Nations: p1-36. 2019. [17] Espinosa R, Tago D, Treich N. Infectious Diseases and Meat Production. Environ Resource Econ 76, p1019–1044. 2020. https://doi.org/10.1007/s10640-020-00484-3 [18] “Q Fever Fact Sheet.” Pennsylvania Department of Health, 4 Jan. 2003. https://www.health.pa.gov/topics/Documents/Diseases%20and%20Conditions/Q%20Fever%20.pdf [19] Ritchie, Hannah. “Which Countries Eat the Most Meat?” BBC News, BBC, 4 Feb. 2019, www.bbc.co.uk/news/health-47057341. [20] Reynolds, Alan. “The Fundamental Fallacy of Redistribution.” Cato.org, 11 Feb. 2016, 1:22 pm, www.cato.org/blog/fundamental-fallacy-redistribution. [21] Patricia Justino Professor and Senior Research Fellow. “Welfare Works: Redistribution Is the Way to Create Less Violent, Less Unequal Societies.” The Conversation, 20 Aug. 2021, theconversation.com/welfare-works-redistribution-is-the-way-to-create-less-violent-less-unequal-societies-128807. [22] Cassidy E, et al, “Redefining Agricultural Yields: From Tonnes to People Nourished Per Hectare.” Environmental Research Letters, V. 8(3), p2-3. IOPScience. 2013, http://iopscience.iop.org/1748-9326/8/3/034015 [23] Poore J, Nemecek T. Reducing food’s environmental impacts through producers and consumers. Science, 360(6392), p987-992. 2018.