How should artificial intelligence be used in Australian health care? Recommendations from a citizens' jury.

OBJECTIVE: To support a diverse sample of Australians to make recommendations about the use of artificial intelligence (AI) technology in health care. STUDY DESIGN: Citizens' jury, deliberating the question: "Under which circumstances, if any, should artificial intelligence be used in Australian health systems to detect or diagnose disease?" SETTING, PARTICIPANTS: Thirty Australian adults recruited by Sortition Foundation using random invitation and stratified selection to reflect population proportions by gender, age, ancestry, highest level of education, and residential location (state/territory; urban, regional, rural). The jury process took 18 days (16 March - 2 April 2023): fifteen days online and three days face-to-face in Sydney, where the jurors, both in small groups and together, were informed about and discussed the question, and developed recommendations with reasons. Jurors received extensive information: a printed handbook, online documents, and recorded presentations by four expert speakers. Jurors asked questions and received answers from the experts during the online period of the process, and during the first day of the face-to-face meeting. MAIN OUTCOME MEASURES: Jury recommendations, with reasons. RESULTS: The jurors recommended an overarching, independently governed charter and framework for health care AI. The other nine recommendation categories concerned balancing benefits and harms; fairness and bias; patients' rights and choices; clinical governance and training; technical governance and standards; data governance and use; open source software; AI evaluation and assessment; and education and communication. CONCLUSIONS: The deliberative process supported a nationally representative sample of citizens to construct recommendations about how AI in health care should be developed, used, and governed. Recommendations derived using such methods could guide clinicians, policy makers, AI researchers and developers, and health service users to develop approaches that ensure trustworthy and responsible use of this technology.

Patients' perspectives on quality and patient safety failures: lessons learned from an inquiry into transvaginal mesh in Australia.

BACKGROUND: Transvaginal mesh (TVM) surgeries emerged as an innovative treatment for stress urine incontinency and/or pelvic organ prolapse in 1996. Years after rapid adoption of these surgeries into practice, they are a key example of worldwide failure of healthcare quality and patient safety. The prevalence of TVM-associated harms eventually prompted action globally, including an Australian Commonwealth Government Senate Inquiry in 2017. METHOD: We analysed 425 submissions made by women (n = 417) and their advocates (n = 8) to the Australian Senate Inquiry, and documents from 5 public hearings, using deductive and inductive coding, categorisation and thematic analysis informed by three 'linked dilemmas' from healthcare quality and safety theory. We focused on women's accounts of: a) how harms arose from TVM procedures, and b) micro, meso and macro factors that contributed to their experience. Our aim was to explain, from a patient perspective, how these harms persisted in Australian healthcare, and to identify mechanisms at micro, meso and macro levels explaining quality and safety system failure. RESULTS: Our findings suggest three mechanisms explaining quality and safety failure: 1. Individual clinicians could ignore cases of TVM injury or define them as 'non-preventable'; 2. Women could not go beyond their treating clinicians to participate in defining and governing quality and safety; and. 3. Health services set thresholds for concern based on proportion of cases harmed, not absolute number or severity of harms. CONCLUSION: We argue that privileging clinical perspectives over patient perspectives in evaluating TVM outcomes allowed micro-level actors to dismiss women's lived experience, such that women's accounts of harms had insufficient or no weight at meso and macro levels. Establishing system-wide expectations regarding responsiveness to patients, and communication of patient reported outcomes in evaluation of healthcare delivery, may help prevent similar failures.

Evidence gaps and challenges in maintaining and increasing vaccine uptake: A Delphi survey with Australian stakeholders.

ISSUE ADDRESSED: Increasing and maintaining vaccination uptake is crucial for preventing and managing infectious diseases. In the context of the post-coronavirus disease 2019 (COVID-19) pandemic landscape, this paper examines the perceptions of immunisation implementers and policymakers to uncover the challenges and evidence gaps in routine immunisation efforts. METHODS: We conducted an online two-round modified Delphi survey with immunisation experts, senior public servants, policymakers, policy advisory groups, and representatives from peak bodies from across Australia. We asked respondents to outline what they see as the greatest challenges to increasing and maintaining uptake of recommended vaccines in Australia; the most difficult aspects of their work in vaccination; the largest evidence gaps in vaccine uptake; and the kinds of social and behavioural research they would like to see prioritised. RESULTS: The two most important challenges for increasing and maintaining vaccine uptake were effectively communicating the benefits of vaccines to parents and the public and ensuring accessible and affordable vaccination services. Participants strongly agreed that 'communication about the importance of vaccination' was the most difficult aspect of their work. Consistently important was the need to better engage specific population groups, such as culturally and linguistically diverse people, pregnant people, at risk cohorts, and health care providers. Social and behavioural research about 'how to effectively address hesitancy' was ranked highly among participants. CONCLUSIONS: Findings from this project help provide an understanding of the behavioural, social, ethical, and policy knowledge needs for immunisation policy and implementation in Australia. To respond to vaccine challenges, increase coverage and build public trust in vaccination, policymakers and governments should incorporate social research into vaccination programmes. SO WHAT?: Australia is preparing to launch a Centre for Disease Control. This study demonstrates the importance of integrating social, behavioural, ethical, and policy research into the fabric of this new enterprise. It underlines the need to capacity-build a workforce able to deliver high-quality research in these areas, address the needs of immunisation implementers and policymakers, and achieve good outcomes for Australians.

Practical, epistemic and normative implications of algorithmic bias in healthcare artificial intelligence: a qualitative study of multidisciplinary expert perspectives.

BACKGROUND: There is a growing concern about artificial intelligence (AI) applications in healthcare that can disadvantage already under-represented and marginalised groups (eg, based on gender or race). OBJECTIVES: Our objectives are to canvas the range of strategies stakeholders endorse in attempting to mitigate algorithmic bias, and to consider the ethical question of responsibility for algorithmic bias. METHODOLOGY: The study involves in-depth, semistructured interviews with healthcare workers, screening programme managers, consumer health representatives, regulators, data scientists and developers. RESULTS: Findings reveal considerable divergent views on three key issues. First, views on whether bias is a problem in healthcare AI varied, with most participants agreeing bias is a problem (which we call the bias-critical view), a small number believing the opposite (the bias-denial view), and some arguing that the benefits of AI outweigh any harms or wrongs arising from the bias problem (the bias-apologist view). Second, there was a disagreement on the strategies to mitigate bias, and who is responsible for such strategies. Finally, there were divergent views on whether to include or exclude sociocultural identifiers (eg, race, ethnicity or gender-diverse identities) in the development of AI as a way to mitigate bias. CONCLUSION/SIGNIFICANCE: Based on the views of participants, we set out responses that stakeholders might pursue, including greater interdisciplinary collaboration, tailored stakeholder engagement activities, empirical studies to understand algorithmic bias and strategies to modify dominant approaches in AI development such as the use of participatory methods, and increased diversity and inclusion in research teams and research participant recruitment and selection.

Transvaginal mesh in Australia: An analysis of news media reporting from 1996 to 2021.

INTRODUCTION: Transvaginal mesh (mesh) surgeries have been used to treat stress urinary incontinence (incontinence) and/or pelvic organ prolapse (prolapse). In Australia, as in many other countries, the harms caused by mesh eventually prompted individual and collective attempts to achieve redress. The rise of mesh surgery as a procedure, the experience of mesh-affected women and the formal inquiries and legal actions that followed all occurred in social, cultural and discursive contexts. One strategy to understand these contexts is to track how the mesh and key actors in the mesh stories have been portrayed in mass media sources. We conducted a media analysis of the most highly read Australian newspapers and online news media platforms, focusing on how mesh and the interaction of stakeholders in mesh stories were presented to the Australian public. METHOD: We searched systematically in the top 10 most-read print and online media outlets in Australia. We included all articles that mentioned mesh, from the date of first use of mesh in Australia to the date of our final search (1996-2021). RESULT: After early scant media reporting focusing on the benefits of mesh procedures, major Australian medicolegal processes created a hook to shift reporting about mesh. The news media then played a significant role in redressing women's experienced epistemic injustice, including by amplifying previously ignored evidence of harm. This created an opportunity for previously unreported suffering to be revealed to powerful actors, in settings beyond the immediate control and epistemic authority of healthcare stakeholders, validating women's testimony and creating new hermeneutic resources for understanding mesh. Over time, media reports show healthcare stakeholders responding sympathetically to these new understandings in public discourse, contrasting with their statements in earlier media coverage. CONCLUSION: We argue that mass media reporting, in synergy with medicolegal actions and the Australian Senate Inquiry, appears to have provided women with greater epistemic justice, giving their testimony privileged epistemic status such that it was considered by powerful actors. Although medical reporting is not recognised in the hierarchy of evidence embedded in the medical knowledge system, in this case, media reporting appears to have contributed to shaping medical knowledge in significant ways. PATIENT OR PUBLIC CONTRIBUTION: We used publicly available data, print and online media outlets, for our analysis. Therefore, this manuscript does not contain the direct contribution of patients, service users, caregivers, people with lived experience or members of the public.

Having a real say: findings from first nations community panels on pandemic influenza vaccine distribution.

BACKGROUND: Recent deliberations by Australian public health researchers and practitioners produced an ethical framework of how decisions should be made to distribute pandemic influenza vaccine. The outcome of the deliberations was that the population should be considered in two categories, Level 1 and Level 2, with Level 1 groups being offered access to the pandemic influenza vaccine before other groups. However, the public health researchers and practitioners recognised the importance of making space for public opinion and sought to understand citizens values and preferences, especially First Nations peoples. METHODS: We conducted First Nations Community Panels in two Australian locations in 2019 to assess First Nations people's informed views through a deliberative process on pandemic influenza vaccination distribution strategies. Panels were asked to make decisions on priority levels, coverage and vaccine doses. RESULTS: Two panels were conducted with eighteen First Nations participants from a range of ages who were purposively recruited through local community networks. Panels heard presentations from public health experts, cross-examined expert presenters and deliberated on the issues. Both panels agreed that First Nations peoples be assigned Level 1 priority, be offered pandemic influenza vaccination before other groups, and be offered two doses of vaccine. Reasons for this decision included First Nations people's lives, culture and families are important; are at-risk of severe health outcomes; and experience barriers and challenges to accessing safe, quality and culturally appropriate healthcare. We found that communication strategies, utilising and upskilling the First Nations health workforce, and targeted vaccination strategies are important elements in pandemic preparedness and response with First Nations peoples. CONCLUSIONS: First Nations Community Panels supported prioritising First Nations peoples for pandemic influenza vaccination distribution and offering greater protection by using a two-dose full course to fewer people if there are initial supply limitations, instead of one dose to more people, during the initial phase of the vaccine roll out. The methodology and findings can help inform efforts in planning for future pandemic vaccination strategies for First Nations peoples in Australia.

Implementation gaps in culturally responsive care for refugee and migrant maternal health in New South Wales, Australia.

BACKGROUND: Refugee and migrant women are at higher risk of childbirth complications and generally poorer pregnancy outcomes. They also report lower satisfaction with pregnancy care because of language barriers, perceived negative attitudes among service providers, and a lack of understanding of refugee and migrant women's needs. This study juxtaposes health policy expectations in New South Wales (NSW), Australia on pregnancy and maternity care and cultural responsiveness and the experiences of maternal healthcare providers in their day-to-day work with refugee and migrant women from non-English speaking backgrounds. METHODS: This study used a qualitative framework method to allow for a comparison of providers' experiences with the policy expectations. Sixteen maternal health service providers who work with refugee and migrant women were recruited from two local health districts in New South Wales, Australia and interviewed (November 2019 to August 2020) about their experiences and the challenges they faced. In addition, a systematic search was conducted for policy documents related to the provision of maternal health care to refugee and migrant women on a state and federal level and five policies were included in the analysis. RESULTS: Framework analysis revealed structural barriers to culturally responsive service provision and the differential impacts of implementation gaps that impede appropriate care resulting in moral distress. Rather than being the programmatic outcome of well-resourced policies, the enactment of cultural responsiveness in the settings studied relied primarily on the intuitions and personal responses of individual service providers such as nurses and social workers. CONCLUSION: Authentic culturally responsive care requires healthcare organisations to do more than provide staff training. To better promote service user and staff satisfaction and wellbeing, organisations need to embed structures to respond to the needs of refugee and migrant communities in the maternal health sector and beyond.

Why ethical frameworks fail to deliver in a pandemic: Are proposed alternatives an improvement?

In the past decade, numerous ethical frameworks have been developed to support public health decision-making in challenging areas. Before the COVID-19 pandemic began, members of the authorship team were involved in research programmes, in which the development of ethical frameworks was planned, to guide (a) the use of new technologies for emerging infectious disease surveillance; and (b) the allocation of scarce supplies of pandemic influenza vaccine. However, as the pandemic evolved, significant practical challenges emerged that led to our questioning the value of these frameworks. We now believe that a normative instrument, such as a framework, cannot adequately or reliably provide the ethical guidance that needs to be incorporated into public health decision-making during natural disasters or infectious disease emergencies. Recently it has been suggested that there are potentially more dynamic, flexible, and effective ways to navigate decisions involving complex considerations entailed in policies and practices during a public health emergency. In this paper, we first outline the key functions of a public health ethics framework, before describing why we believe it would not be fit for purpose during a crisis. We end by considering whether proposed alternative methods to promote ethical public health decision-making goals have the potential to meet these objectives.

Childhood vaccine refusal and what to do about it: a systematic review of the ethical literature.

BACKGROUND: Parental refusal of routine childhood vaccination remains an ethically contested area. This systematic review sought to explore and characterise the normative arguments made about parental refusal of routine vaccination, with the aim of providing researchers, practitioners, and policymakers with a synthesis of current normative literature. METHODS: Nine databases covering health and ethics research were searched, and 121 publications identified for the period Jan 1998 to Mar 2022. For articles, source journals were categorised according to Australian Standard Field of Research codes, and normative content was analysed using a framework analytical approach. RESULTS: Most of the articles were published in biomedical journals (34%), bioethics journals (21%), and journals that carry both classifications (20%). Two central questions dominated the literature: (1) Whether vaccine refusal is justifiable (which we labelled 'refusal arguments'); and (2) Whether strategies for dealing with those who reject vaccines are justifiable ('response arguments'). Refusal arguments relied on principlism, religious frameworks, the rights and obligations of parents, the rights of children, the medico-legal best interests of the child standard, and the potential to cause harm to others. Response arguments were broadly divided into arguments about policy, arguments about how individual physicians should practice regarding vaccine rejectors, and both legal precedents and ethical arguments for vaccinating children against a parent's will. Policy arguments considered the normative significance of coercion, non-medical or conscientious objections, and possible reciprocal social efforts to offset vaccine refusal. Individual physician practice arguments covered nudging and coercive practices, patient dismissal, and the ethical and professional obligations of physicians. Most of the legal precedents discussed were from the American setting, with some from the United Kingdom. CONCLUSIONS: This review provides a comprehensive picture of the scope and substance of normative arguments about vaccine refusal and responses to vaccine refusal. It can serve as a platform for future research to extend the current normative literature, better understand the role of cultural context in normative judgements about vaccination, and more comprehensively translate the nuance of ethical arguments into practice and policy.

The dilemmas of antimicrobial stewardship in aged care: The perspectives of the family members of older Australians.

Antimicrobial resistance makes the misuse of antibiotics in residential aged care facilities (RACFs) a significant concern. Family members influence antibiotic prescribing for RACF residents, but there is limited understanding of the beliefs and knowledge that drive their involvement. Drawing on a fictional scenario, forty-six participants with a parent aged 75 or over took part in eight dialogue groups exploring family members' perspectives on antibiotic use and risks in older relatives. Main themes were identified using framework analysis. Participants supported judicious use of antibiotics in RACFs, but perceived vulnerabilities of older people, both structural and physiological prompt family pressure for antibiotics. Empirical antibiotic use became more acceptable when pathways to a prompt diagnosis are not apparent or confidence in RACF monitoring and care is lacking. The role of antibiotics in end-of-life decision-making was significantly under-recognised. Overall, elevation of discussion around antibiotics and end of life care are required.

An argument for pandemic risk management using a multidisciplinary One Health approach to governance: an Australian case study.

The emergence of SARS-CoV-2 and the subsequent COVID-19 pandemic has resulted in significant global impact. However, COVID-19 is just one of several high-impact infectious diseases that emerged from wildlife and are linked to the human relationship with nature. The rate of emergence of new zoonoses (diseases of animal origin) is increasing, driven by human-induced environmental changes that threaten biodiversity on a global scale. This increase is directly linked to environmental drivers including biodiversity loss, climate change and unsustainable resource extraction. Australia is a biodiversity hotspot and is subject to sustained and significant environmental change, increasing the risk of it being a location for pandemic origin. Moreover, the global integration of markets means that consumption trends in Australia contributes to the risk of disease spill-over in our regional neighbours in Asia-Pacific, and beyond. Despite the clear causal link between anthropogenic pressures on the environment and increasing pandemic risks, Australia's response to the COVID-19 pandemic, like most of the world, has centred largely on public health strategies, with a clear focus on reactive management. Yet, the span of expertise and evidence relevant to the governance of pandemic risk management is much wider than public health and epidemiology. It involves animal/wildlife health, biosecurity, conservation sciences, social sciences, behavioural psychology, law, policy and economic analyses to name just a few.The authors are a team of multidisciplinary practitioners and researchers who have worked together to analyse, synthesise, and harmonise the links between pandemic risk management approaches and issues in different disciplines to provide a holistic overview of current practice, and conclude the need for reform in Australia. We discuss the adoption of a comprehensive and interdisciplinary 'One Health' approach to pandemic risk management in Australia. A key goal of the One Health approach is to be proactive in countering threats of emerging infectious diseases and zoonoses through a recognition of the interdependence between human, animal, and environmental health. Developing ways to implement a One Health approach to pandemic prevention would not only reduce the risk of future pandemics emerging in or entering Australia, but also provide a model for prevention strategies around the world.

'Get your own house in order': Qualitative dialogue groups with nonvaccinating parents on how measles outbreaks in their community should be managed.

OBJECTIVE: Communities with high levels of vaccine rejection present unique challenges to vaccine-preventable disease outbreak management. We sought perspectives of nonvaccinating parents to inform public health responses in such communities. METHODS: Nineteen purposively sampled nonvaccinating Australian parents participated in one of seven online dialogue groups. We asked what they thought parents, school principals and public health professionals should do in a hypothetical school measles outbreak and used a framework approach to data analysis. RESULTS: Parents' views were grounded in strong beliefs in parental responsibility and the belief that vaccines are not effective, thus unvaccinated children do not therefore pose a threat. They then reasoned that the forced exclusion of unvaccinated children from school in a measles outbreak was disproportionate to the risk they pose, and their child's right to education should not be overridden. Nonvaccinating parents judged that all parents should keep sick children at home regardless of disease or vaccination status; that school principals should communicate directly with parents and avoid using social media; that public health professionals should provide information to parents so they can decide for themselves about excluding their children from school; that public health responses should avoid accidental identification of unvaccinated children and that mainstream media should be avoided as a communication tool. CONCLUSION: Nonvaccinating parents do not always agree with current Australian approaches to measles outbreak management. Their perspectives can inform approaches to outbreak responses in communities with high levels of vaccine rejection. PATIENT OR PUBLIC CONTRIBUTION: We sought input from individuals who did and did not vaccinate on study design in its early phases. Individual conversations were used deliberately as we felt the group advisory situation may have felt less safe for nonvaccinating parents, given the divisive and often hostile nature of the topic.

Responsibility-sharing for pets in disasters: lessons for One Health promotion arising from disaster management challenges.

During disasters, the behaviour of pet owners and of pets themselves may compromise the ability of emergency responders to perform their duties safely. Furthermore, pet loss can have deleterious effects on personal and community recovery. To explore these issues and their implications for health promotion and disaster management practice, we conducted semi-structured interviews with 27 emergency responders in Australia, where disaster policy embraces shared responsibility yet does not acknowledge pets. We found that responders commit to being responsible for protecting human lives, especially members of their teams. Frontline emergency responders did not regard pets as their responsibility, yet decisions made with tragic consequences for pets exacted an emotional toll. Emergency managers consider community education as a pivotal strategy to support building people's capacity to reduce their own risk in disasters. While important, we question whether this is sufficient given that human life is lived in more-than-human contexts. Reformulating the parameters of the Ottawa Charter for Health Promotion as 'One Health Promotion' may help to account for the intermeshed lives of people and pets, while acknowledging human priority in public policy and programming. To acknowledge the influence of people's pets in disaster responses and recovery, we recommend five overlapping spheres of action: (i) integrate pets into disaster management practice and policy; (ii) create pet-friendly environments and related policies; (iii) engage community action in disaster management planning; (iv) develop personal skills by engaging owners in capacity building and (v) reorient health and emergency services toward a more-than-human approach.

Pets can influence people's decision-making during disasters, potentially impacting the ability of emergency service responders to safely perform their duties. The loss of pets in disasters also has detrimental effects on people's health and wellbeing post-disaster. To better understand these issues and their implications for health promotion and disaster management practice, we conducted in-depth interviews with 27 emergency responders in Australia. We found that responders commit to a 'humans first' tenet, and while they do not consider themselves responsible for pets, decisions made with tragic consequences for pets exact an emotional toll. Community education was considered a key strategy for building people's capacity to reduce their risk in disasters. We question whether this is sufficient and adapt the five action areas of the Ottawa Charter for Health Promotion to account for the intermeshed lives of people and pets, while acknowledging human priority in disaster management policy and programming.

Ethical implementation of mitochondrial donation in Australia.

Australia has recently legalised mitochondrial donation. However, key ethical and legal issues still need to be addressed. This paper maps the relevant issues and offers some suggestions for how they ought to be resolved.

Should Digital Contact Tracing Technologies be used to Control COVID-19? Perspectives from an Australian Public Deliberation.

Mobile phone-based applications (apps) can promote faster targeted actions to control COVID-19. However, digital contact tracing systems raise concerns about data security, system effectiveness, and their potential to normalise privacy-invasive surveillance technologies. In the absence of mandates, public uptake depends on the acceptability and perceived legitimacy of using technologies that log interactions between individuals to build public health capacity. We report on six online deliberative workshops convened in New South Wales to consider the appropriateness of using the COVIDSafe app to enhance Australian contact tracing systems. All groups took the position (by majority) that the protections enacted in the app design and supporting legislation were appropriate. This support is contingent on several system attributes including: the voluntariness of the COVIDSafe app; that the system relies on proximity rather than location tracking; and, that data access is restricted to local public health practitioners undertaking contact tracing. Despite sustained scepticism in media coverage, there was an underlying willingness to trust Australian governing institutions such that in principle acceptance of the new contact tracing technology was easy to obtain. However, tensions between the need to prove system effectiveness through operational transparency and requirements for privacy protections could be limiting public uptake. Our study shows that informed citizens are willing to trade their privacy for common goods such as COVID-19 suppression. But low case numbers and cautionary public discourses can make trustworthiness difficult to establish because some will only do so when it can be demonstrated that the benefits justify the costs to individuals.

Public health practitioner perspectives on dealing with measles outbreaks if high anti-vaccination sentiment is present.

BACKGROUND: Communities with low vaccination rates are at greater risk during outbreaks of vaccine preventable diseases. Most Australian parents support vaccines, but some refuse and are often judged harshly by their community, especially during an outbreak. We sought the perspectives of Australian public health experts on the key issues faced when managing a measles outbreak in an area with high anti-vaccination sentiment. METHODS: A measles outbreak scenario formed the basis of a 3-round modified Delphi process to identify key practitioner concerns in relation to parents/carers who don't follow the recommended vaccination schedule. We surveyed a range of professionals in the field: policymakers, infectious disease experts, immunisation program staff, and others involved in delivering childhood vaccinations, to identify key priorities when responding to an outbreak in a community with low vaccination coverage. RESULTS: Findings indicate that responses to measles outbreaks in communities with high anti-vaccination sentiment are motivated by concerns about the potential for a much larger outbreak event. The highest operational priority is to isolate infected children. The two most highly ranked practical issues are mistrust from non-vaccinating members of the local region and combatting misinformation about vaccines. Trying to change minds of such individuals is not a priority during an outbreak, nor is vaccinating their children. Using media and social media to provide information about the outbreak and measures the public can take to limit the spread of the disease was a focus. CONCLUSIONS: Our findings provide a deeper understanding of the challenges faced during an outbreak and priorities for communicating with communities where there is a high level of anti-vaccination sentiment. In the context of a global pandemic, the results of this study also have implications for managing public health responses to community transmission of SARS-CoV-2, as COVID-19 vaccines becomes widely available.

More philosophical work needed in One Health on ethical frameworks and theory.

We thank Zohar Lederman and Benjamin Capps for engaging with our paper on One Health (OH) and ethical frameworks, however we want to take issue with them on three points. First, they appear to misunderstand the distinction we appeal to between ethical theory and ethical frameworks, and so misinterpret what we are trying to achieve in our paper. Second, in spite of what they seem to imply, we agree that an OH approach can obscure differences in values, and that to progress the field there needs to be recognition of competing values and their implications for OH. Finally, we are puzzled by their interest in pursuing a deliberative process, as this seems at odds with other positions they take in their paper, and also opens up many questions that need to be addressed.

Perspectives of Vietnamese, Sudanese and South Sudanese immigrants on targeting migrant communities for latent tuberculosis screening and treatment in low-incidence settings: A report on two Victorian community panels.

BACKGROUND: Tuberculosis (TB) elimination strategies in Australia require a focus on groups who are at highest risk of TB infection, such as immigrants from high-burden settings. Understanding attitudes to different strategies for latent TB infection (LTBI) screening and treatment is an important element of justifiable elimination strategies. METHOD: Two community panels were conducted in Melbourne with members of the Vietnamese (n = 11), Sudanese and South Sudanese communities (n = 9). Panellists were provided with expert information about LTBI and different screening and health communication strategies, then deliberated on how best to pursue TB elimination in Australia. FINDINGS: Both panels unanimously preferred LTBI screening to occur pre-migration rather than in Australia. Participants were concerned that post-migration screening would reach fewer migrants, noted that conducting LTBI screening in Australia could stigmatize participants and that poor awareness of LTBI would hamper participation. If targeted screening was to occur in Australia, the Vietnamese panel preferred 'place-based' communication strategies, whereas the Sudanese and South Sudanese panel emphasized that community leaders should lead communication strategies to minimize stigma. Both groups emphasized the importance of maintaining community trust in Australian health service providers, and the need to ensure targeting did not undermine this trust. CONCLUSION: Pre-migration screening was preferred. If post-migration screening is necessary, the potential for stigma should be reduced, benefit and risk profile clearly explained and culturally appropriate communication strategies employed. Cultural attitudes to health providers, personal health management and broader social vulnerabilities of targeted groups need to be considered in the design of screening programs.

From more-than-human solidarity to multi-species biographical value: insights from a veterinary school about ethical dilemmas in One Health promotion.

This article features a partnership between a veterinary school and a charity that aims to enhance the wellbeing of low-income people. Through this partnership, the charity periodically hosts veterinary clinics for clients and their pets. Even as the veterinarians and veterinary students duly examine people's pets, these pop-up clinics aim to help people and their pets. Hence our analysis revolves around the ethics of 'more-than-human solidarity'. By 'more-than-human solidarity', we mean efforts to help others that either center on or that implicate non-human beings. To delve into the ethical and sociological implications of subsidised veterinary services, and to assist with program planning, we conducted several in-depth interviews with veterinarians. Most substantively, we found that the veterinary school's outreach clinics give rise to multi-species biographical value, which is prized as a pedagogical resource for veterinary students. The veterinarians whom we interviewed felt troubled by the extent to which the pop-up clinics ultimately benefited the veterinary school, but also by the shortage of subsidised veterinary services in the vicinity. Based on these interviews and our own reflections, we invite more scholarship on cultural, economic and political influences that shape the lives of human beings and non-human animals alike.

Community perspectives on the benefits and risks of technologically enhanced communicable disease surveillance systems: a report on four community juries.

BACKGROUND: Outbreaks of infectious disease cause serious and costly health and social problems. Two new technologies - pathogen whole genome sequencing (WGS) and Big Data analytics - promise to improve our capacity to detect and control outbreaks earlier, saving lives and resources. However, routinely using these technologies to capture more detailed and specific personal information could be perceived as intrusive and a threat to privacy. METHOD: Four community juries were convened in two demographically different Sydney municipalities and two regional cities in New South Wales, Australia (western Sydney, Wollongong, Tamworth, eastern Sydney) to elicit the views of well-informed community members on the acceptability and legitimacy of: making pathogen WGS and linked administrative data available for public health researchusing this information in concert with data linkage and machine learning to enhance communicable disease surveillance systems Fifty participants of diverse backgrounds, mixed genders and ages were recruited by random-digit-dialling and topic-blinded social-media advertising. Each jury was presented with balanced factual evidence supporting different expert perspectives on the potential benefits and costs of technologically enhanced public health research and communicable disease surveillance and given the opportunity to question experts. RESULTS: Almost all jurors supported data linkage and WGS on routinely collected patient isolates for the purposes of public health research, provided standard de-identification practices were applied. However, allowing this information to be operationalised as a syndromic surveillance system was highly contentious with three juries voting in favour, and one against by narrow margins. For those in favour, support depended on several conditions related to system oversight and security being met. Those against were concerned about loss of privacy and did not trust Australian governments to run secure and effective systems. CONCLUSIONS: Participants across all four events strongly supported the introduction of data linkage and pathogenomics to public health research under current research governance structures. Combining pathogen WGS with event-based data surveillance systems, however, is likely to be controversial because of a lack of public trust, even when the potential public health benefits are clear. Any suggestion of private sector involvement or commercialisation of WGS or surveillance data was unanimously rejected.