Disagreement among experts about public health decision making: is it polarisation and does it matter?

It is common for aspects of the COVID-19 response-and other public health initiatives before it-to be described as polarised. Public health decisions emerge from an interplay of facts, norms and preferred courses of action. What counts as 'evidence' is diverse and contestable, and disagreements over how it should be interpreted are often the product of differing choices between competing values. We propose a definition of polarisation for the context of public health expertise that acknowledges and accounts for epistemic and social values as part of evidence generation and its application to public health practice. The 'polarised' label should be used judiciously because the descriptor risks generating or exacerbating the problem by oversimplifying complex issues and positions and creating groups that seem dichotomous. 'Independence' as a one-size-fits-all answer to expert polarisation is insufficient; this solution is premised on a scientistic account of the role of evidence in decision making and does not make room for the value difference that is at the heart of both polarisation and evidence-based decision making.

Experiences of risk in Australian hotel quarantine: a qualitative study.

BACKGROUND: In response to the threat of COVID-19 infection, Australia mandated a 14 day quarantine period in a designated facility for all travellers returning from overseas from late March 2020. These facilities were usually hotels, or hotel-like serviced apartments, and also included a repurposed former mining village in the Northern Territory. This paper aimed to investigate the experiences of risk of people quarantined in designated supervised facilities in Australia, which has not been systematically explored before. METHODS: In this qualitative study semi-structured interviews were conducted with 58 participants quarantined between March 2020 and January 2021. Participants were returned Australian citizens and residents who were required to undergo mandatory supervised quarantine for COVID-19. Interviews were conducted using video teleconferencing (via Zoom), transcribed and coded, then analysed thematically. RESULTS: While participants generally supported the concept of quarantine to protect the Australian public, they were critical of elements of it where they felt exposed to risk (COVID-related or not). They also described instances where infection control within the system seemed inadequate. For some, particularly those quarantined with small children, they reported that the facilities were inadequate or inappropriate for health and wellbeing. Using thematic analysis, three major themes were identified that related to problems in the existing system: perception of being subjected to high risk through lax standards of COVID protection in the quarantine process; risks to the community identified in quarantine; and risk in non-hotel managed quarantine facilities. CONCLUSIONS: There are systemic issues with infection control in hotel quarantine, which can be further undermined by individual non-compliance. Risks to safety for those in quarantine can be reduced, both in terms of infection control within hotel quarantine and, in the case of the Northern Territory facility, timely in-person medical care as needed for non-COVID conditions. Systems of infection control need ongoing review to ensure that people entering quarantine are protected from known risks of infection at every stage. Medical services in quarantine facilities should be examined to ensure timely and appropriate non-COVID medical services are available.

Prioritising access to pandemic influenza vaccine: a review of the ethics literature.

BACKGROUND: The world is threatened by future pandemics. Vaccines can play a key role in preventing harm, but there will inevitably be shortages because there is no possibility of advance stockpiling. We therefore need some method of prioritising access. MAIN TEXT: This paper reports a critical interpretative review of the published literature that discusses ethical arguments used to justify how we could prioritise vaccine during an influenza pandemic. We found that the focus of the literature was often on proposing different groups as priorities (e.g. those with pre-existing health conditions, the young, the old, health care workers etc.). Different reasons were often suggested as a means of justifying such priority groupings (e.g. appeal to best overall outcomes, fairness, belonging to a vulnerable or 'at risk' group etc.). We suggest that much of the literature, wrongly, assumes that we are able to plan priority groups prior to the time of a particular pandemic and development of a particular vaccine. We also point out the surprising absence of various issues from the literature (e.g. how vaccines fit within overall pandemic planning, a lack of specificity about place, issues of global justice etc.). CONCLUSIONS: The literature proposes a wide range of ways to prioritise vaccines, focusing on different groups and 'principles'. Any plan to use pandemic vaccine must provide justifications for its prioritisation. The focus of this review was influenza pandemic vaccines, but lessons can be learnt for future allocations of coronavirus vaccine, if one becomes available.

An empirical study of the 'underscreened' in organised cervical screening: experts focus on increasing opportunity as a way of reducing differences in screening rates.

BACKGROUND: Cervical cancer disproportionately burdens disadvantaged women. Organised cervical screening aims to make cancer prevention available to all women in a population, yet screening uptake and cancer incidence and mortality are strongly correlated with socioeconomic status (SES). Reaching underscreened populations is a stated priority in many screening programs, usually with an emphasis on something like 'equity'. Equity is a poorly defined and understood concept. We aimed to explain experts' perspectives on how cervical screening programs might justifiably respond to 'the underscreened'. METHODS: This paper reports on a grounded theory study of cervical screening experts involved in program organisation. Participants were 23 experts from several countries and a range of backgrounds: gynecology; epidemiology; public health; pathology; general practice; policy making. Data were gathered via semi-structured interview and concepts developed through transcript coding and memo writing. RESULTS: Most experts expressed an intuitive commitment to reducing systematic differences in screening participation or cancer outcomes. They took three different implicit positions, however, on what made organised programs justifiable with respect to underscreened populations. These were: 1) accepting that population screening is likely to miss certain disenfranchised groups for practical and cultural reasons, and focusing on maximising mainstream reach; 2) identifying and removing barriers to screening; and 3) providing parallel tailored screening services that attended to different cultural needs. Positions tended to fall along country of practice lines. CONCLUSIONS: Experts emphasised the provision of opportunity for underscreened populations to take up screening. A focus on opportunity appeared to rely on tacit premises not supported by evidence: that provision of meaningful opportunity leads to increased uptake, and that increased uptake of an initial screening test by disadvantaged populations would decrease cervical cancer incidence and mortality. There was little attention to anything other than the point of testing, or the difficulties disadvantaged women can have in accessing follow up care. The different approaches to 'improving equity' taken by participants are differently justified, and differently justifiable, but none attend directly to the broader conditions of disadvantage.

'Organised' cervical screening 45 years on: How consistent are organised screening practices?

Organised screening programmes have been remarkably successful in reducing incidence and mortality from cervical cancer, while opportunistic screening varies in its effectiveness. Experts recommend that cervical screening or HPV testing be carried out only in the context of an organised programme. We sought to answer the following study questions: What does it mean for a cervical screening programme to be organised? Is there a place for opportunistic screening (in an organised programme)? We reviewed 154 peer-reviewed papers on organised and opportunistic approaches to cervical screening published between 1970 and 2014 to understand how the term 'organised' is used, formally and in practice. We found that despite broad recognition of a prescriptive definition of organisation, in practice the meaning of organisation is much less clear. Our review revealed descriptions of organised programmes that differ significantly from prescribed norms and from each other, and a variety of ways that opportunistic and organised programmes intersect. We describe the breadth of the variation in cervical cancer screening programmes and examine the relationships and overlaps between organised and opportunistic screening. Implications emerging from the review include the need to better understand the breadth of organisation in practice, the drivers and impacts of opportunistic screening and the impact of opportunistic screening on population programme outcomes. Appreciation of the complexity of cervical screening programmes will benefit both screeners and women as programmes are changed to reflect a partially vaccinated population, new evidence and new technologies.

Information provision in cervical screening in Australia.

The National Cervical Screening Program and associated state and territory organisations are responsible for promoting cervical screening. Communication via multiple media channels encourages women to be screened. However, some communications are not clear about the risk of cervical cancer and the protective capacity and reliability of the Pap test. The potential harms of screening are rarely presented. Women usually receive Pap tests from general practitioners, who often screen opportunistically during appointments. Screening targets and incentive payments encourage high screening rates. Consent is an important ethical principle in the delivery of all health care. Provision of material information is one of the elements of valid consent. The combination of arguably ambiguous communications, screening participation targets and opportunistic testing under time pressure seems likely to undermine opportunities for women to be informed. Of particular concern are women who are less likely to benefit, those who are more likely to experience harm, and some groups of disadvantaged women. Improved communications could include providing patients with information on the absolute risk of cervical cancer, and the morbidity and mortality benefits and harms of screening. Screening programs internationally have begun providing such information. Areas for further research include the appropriate roles of the programs, screeners and individuals in providing and seeking information. Such work would identify the optimum method for informing women in the screening process.