How One Health Instrumentalizes Nonhuman Animals.

This article interrogates anthropocentrism and nonhuman animal instrumentalization in One Health (OH). It argues that OH's approach to human health and zoonosis focuses too narrowly on furthering certain human interests at the expense of nonhuman animals, which is not sustainable, just, or compassionate. This article also offers an alternative vision for protecting and promoting health for all over the long term that includes the human right to self-determination and the nonhuman animal right to not be exploited or abused. This rights-based approach recognizes that the root causes of zoonosis should be identified and addressed via policies and actions that challenge nonhuman animal exploitation.

Toward an Anti-Maleficent Research Agenda.

Important advances in biomedical and behavioral research ethics have occurred over the past few decades, many of them centered on identifying and eliminating significant harms to human subjects of research. Comprehensive attention has not been paid to the totality of harms experienced by animal subjects, although scientific and moral progress require explicit appraisal of these harms. Science is a public good and the prioritizing within, conduct of, generation of, and application of research must soundly address questions about which research is morally defensible and valuable enough to support through funding, publication, tenure, and promotion. Likewise, educational pathways of re-imagined science are critical.

Genitourinary Systems Entangled with Shifting Environments in a Salvadoran Subsistence Farming Community.

Diseases of the genitourinary system are the leading cause of hospital deaths in El Salvador, and chronic kidney disease of unknown origin has been gaining attention as a public health problem among farmers in particular. Epidemiological studies point, in part, to environmental risk factors, which have shifted over time with the deployment of modern agricultural science and ongoing climate change. We examined how diseases of the genitourinary system were situated at several margins of an epidemic in one rural Salvadoran municipality where these environmental and epidemiological changes are occurring, albeit relatively slow. By using this approach to study diseases of the genitourinary system, we illustrate one way in which shifting human/environment entanglements can be experimentally "known" in the context of human diseases associated with them. Our approach offers a unique perspective in thinking with ethnographic data to compliment ongoing epidemiological investigations of kidney disease in El Salvador.

Twelve tips for incorporating the study of human rights into medical education.

In order for patients to be adequately cared for by clinicians, an awareness and acknowledgement of the factors that affect their well-being, including adherence to internationally recognized human rights, should be part of the professional education of all health care professionals. Worldwide conflicts, which have led to record forced global displacement, and ongoing international human rights violations have had profound effects on the health and well-being of millions of patients. Trainees early in their careers should be educated about these and related population-level issues that affect the health of their patients, so they can better care and advocate for their patients and communities throughout their careers.

A Belmont Report for Animals?

Human and animal research both operate within established standards. In the United States, criticism of the human research environment and recorded abuses of human research subjects served as the impetus for the establishment of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, and the resulting Belmont Report. The Belmont Report established key ethical principles to which human research should adhere: respect for autonomy, obligations to beneficence and justice, and special protections for vulnerable individuals and populations. While current guidelines appropriately aim to protect the individual interests of human participants in research, no similar, comprehensive, and principled effort has addressed the use of (nonhuman) animals in research. Although published policies regarding animal research provide relevant regulatory guidance, the lack of a fundamental effort to explore the ethical issues and principles that should guide decisions about the potential use of animals in research has led to unclear and disparate policies. Here, we explore how the ethical principles outlined in the Belmont Report could be applied consistently to animals. We describe how concepts such as respect for autonomy and obligations to beneficence and justice could be applied to animals, as well as how animals are entitled to special protections as a result of their vulnerability.

Asylum Medicine: Standard and Best Practices.

Due to global events in recent years, applications for political asylum have increased, although the number of people granted asylum in the United States and elsewhere has declined. Physicians and other health care professionals can play a crucial role in the evaluation of individuals seeking asylum, since appropriately documented objective clinical evidence of torture and other forms of persecution can increase the likelihood that survivors of human rights abuses obtain asylum. Many clinicians have the requisite expertise and skills needed to conduct forensic asylum evaluations. However, despite growing interest in this area, the demand for medical and psychiatric forensic evaluations exceeds the number of clinicians who are prepared to conduct asylum evaluations. In an effort to increase the number of qualified clinicians interested and involved in medical and psychiatric evaluations of asylum seekers, this article offers a summary of standard and best practices in the area, including recommended qualifications and competencies relevant to the practice of forensic asylum evaluations, guidance on effective approaches to the medical and psychiatric evaluation of asylum seekers, and recommendations related to medicolegal documentation and testimony. We also highlight gaps in evidence regarding best practices.

The little tissue that couldn't - dispelling myths about the Hymen's role in determining sexual history and assault.

Conclusions about women's and girls' sexual history are made in some settings based on assumptions about the hymen, a small membranous tissue with no known biological function, which typically occupies a portion of the external vaginal opening in females. Clinicians, however, continue to refer to changes in the hymen to assess for a history of consensual or nonconsensual sexual intercourse. We reviewed published evidence to dispel commonly held myths about the hymen and its morphology, function, and use as evidence in cases of sexual violence.An examination of the hymen is not an accurate or reliable test of a previous history of sexual activity, including sexual assault. Clinicians tasked with performing forensic sexual assault examinations should avoid descriptions such as "intact hymen" or "broken hymen" in all cases, and describe specific findings using international standards and terminology of morphological features.We call on clinicians to consider the low predictive value of a hymen examination and to: 1) avoid relying solely on the status of the hymen in sexual assault examinations and reporting; 2) help raise awareness of this issue among their peers and counterparts in law enforcement and the judicial system; and 3) promote fact-based discussions about the limitations of hymenal examinations as part of clinical education for all specialties that address the sexual or reproductive health of women and girls.

Attitudes Toward Sexual Violence Survivors: Differences Across Professional Sectors in Kenya and the Democratic Republic of the Congo.

Sexual violence survivors who decide to report their assault interact with health care, law enforcement, and legal and judicial professionals. Professionals' attitudes about sexual violence and survivors play an important role in caring for survivors and in the pursuit of justice. Despite evidence showing the relationship between service provider beliefs and survivor outcomes, relatively little is known about professionals' beliefs about sexual violence or their attitudes toward sexual violence survivors. Between June 2012 and December 2014, our study examined the beliefs and attitudes of 181 professionals from the health care, legal, and law enforcement sectors in the Eastern Democratic Republic of the Congo (DRC) and the Rift Valley region of Kenya, areas with a high prevalence of sexual violence. To determine correlates of beliefs and attitudes about sexual violence and sexual violence survivors, multiple logistic regression models were adjusted for demographic and occupational characteristics. Respondents who agreed that survivors got what they deserved (7%) or that survivors should feel ashamed (9%) were the minority, while those who would be willing to care for a family member with a history of sexual violence (94%) were the majority. Profession was significantly associated with beliefs and attitudes about sexual violence and survivors. Law enforcement professionals were more likely than health professionals and lawyers to indicate that survivors should feel ashamed. Our findings suggest a need for interventions that adequately address potentially harmful beliefs and attitudes of some professionals serving sexual violence survivors.

mJustice: Preliminary Development of a Mobile App for Medical-Forensic Documentation of Sexual Violence in Low-Resource Environments and Conflict Zones.

Digital health development and use has been expansive and operationalized in a variety of settings and modalities around the world, including in low- and middle-income countries. Mobile applications have been developed for a variety of health professionals and frontline health workers including physicians, midwives, nurses, and community health workers. However, there are no published studies on the development and use of digital health related to human rights fieldwork and to our knowledge no mobile health platforms exist specifically for use by frontline health workers to forensically and clinically document sexual violence. We describe a participatory development and user design process with Congolese end-users of a novel human rights app for clinicians intended to standardize the documentation of sexual violence evidence for forensic and legal purposes, called MediCapt. The app, yet to be launched and still in the future proofing phase, has included several development phases: (1) initial needs assessment conducted in 2011, (2) prototype development and field-testing in 2014 with 8 Congolese physicians, (3) prototype refinement and field-testing in 2015 with 9 clinicians. Feedback from the first field-testing phase was incorporated into the design of the second prototype; key features that were added to MediCapt include the ability for users to take photographs and draw on a pictogram to include as part of the evidence package, as well as the ability to print a form with the completed data. Questionnaires and key-informant interviews during the second and third field-testing phases revealed overall positive attitudes about MediCapt, but multiple perceived and actual barriers to implementation were identified, from personal behaviors, such as individual clinicians' comfort with new technology, to more systemic and infrastructure factors, such as strong cultural preferences for print documentation of evidence and limited Internet connectivity. Next phases of development include consideration of patients' acceptance of this technology, how it actually fits in the clinical workflow, and testing of how to transfer the collected evidence to law enforcement and legal authorities. Ultimately, we plan on conducting a robust evaluation to assess effectiveness of the app on medical, legal, and human rights outcomes. We believe our experience of collecting data that will potentially serve as legal evidence broadens the traditional scope of digital health and crosses a wide range of fields including medical, technological, legal, and ethical, and thus propose refining and defining this unique field of exploration as mobile justice, or mJustice.

"Their Stories Have Changed My Life": Clinicians' Reflections on Their Experience with and Their Motivation to Conduct Asylum Evaluations.

Many clinicians perform asylum evaluations yet no studies describe the motivation to perform them or their perceived rewards. The number of asylum seekers in the US is increasing and more clinicians are needed as evaluators. A survey to an asylum evaluators' network asked participants to qualitatively reflect on their experience and motivation. Answers were analyzed for themes and sentiment. Respondents cited commitment to humanistic and moral values, noted personal and family experiences, having skills, expertise, and career interests as drivers. They found the experience very rewarding personally and professionally, and in their perceived benefit to asylees. Negative sentiment was less frequent and centered on emotions related to client narratives. Process-oriented frustrations were also noted. This is the first published study describing clinicians' motivation and experience with asylum evaluations. It may illuminate clinicians' drive to volunteer, and serve as a resource for organizations for recruitment and education.

The ethical challenges of animal research.

In 1966, Henry K. Beecher published an article entitled "Ethics and Clinical Research" in the New England Journal of Medicine, which cited examples of ethically problematic human research. His influential paper drew attention to common moral problems such as inadequate attention to informed consent, risks, and efforts to provide ethical justification. Beecher's paper provoked significant advancements in human research policies and practices. In this paper, we use an approach modeled after Beecher's 1966 paper to show that moral problems with animal research are similar to the problems Beecher described for human research. We describe cases that illustrate ethical deficiencies in the conduct of animal research, including inattention to the issue of consent or assent, incomplete surveys of the harms caused by specific protocols, inequitable burdens on research subjects in the absence of benefits to them, and insufficient efforts to provide ethical justification. We provide a set of recommendations to begin to address these deficits.

Harms and deprivation of benefits for nonhuman primates in research.

The risks of harm to nonhuman primates, and the absence of benefits for them, are critically important to decisions about nonhuman primate research. Current guidelines for review and practice tend to be permissive for nonhuman primate research as long as minimal welfare requirements are fulfilled and human medical advances are anticipated. This situation is substantially different from human research, in which risks of harms to the individual subject are typically reduced to the extent feasible. A risk threshold is needed for the justification of research on nonhuman primates, comparable to the way risk thresholds are set for vulnerable human subjects who cannot provide informed consent. Much of the laboratory research conducted today has inadequate standards, leading to common physical, psychological, and social harms.

Mood and anxiety disorders in chimpanzees (pan troglodytes): A response to Rosati et al. (2012).

Assessing the psychological health of nonhuman primates living in captivity is essential, since many experiments and behavioral observations involve captive animals. This area is a research priority because it has ethical consequences, in addition to its applications for understanding human and nonhuman primate behavior. In 2011, we published our international study's findings that chimpanzees with prior histories of experimentation, orphanage, illegal seizure, or violent human conflict were more likely to display signs of mood and anxiety disorders, compared with chimpanzees living in the wild. Here, in response to Rosati and colleagues (2012), we address methodological challenges relevant to the application of human diagnostic psychiatric criteria to nonverbal animals. We also review the importance of understanding psychopathology using a holistic approach based on evolutionary psychiatry and suggest a way forward, integrating ethological, veterinary, and human psychiatric approaches.

Prolonged pain research in mice: trends in reference to the 3Rs.

This literature review documents trends in the use of mice in prolonged pain research, defined herein as research that subjects mice to a source of pain for at least 14 days. The total amount of prolonged pain research on mice has increased dramatically in the past decade for the 3 pain categories examined: neuropathic, inflammatory, and chronic pain. There has also been a significant rise in the number of prolonged mouse pain studies as a proportion of all mouse studies and of all mouse pain studies. The use of transgenic mice has also risen significantly in prolonged pain research, though not as a proportion of all mice used in prolonged pain research. There has not been significant overall change in the number of mice being used per study for any of the 3 pain categories or for any of 3 common pain inducement models: chronic constriction injury, partial sciatic nerve ligation, and complete Freund's adjuvant. Finally, although most authors referred to approval of experiments by an institutional nonhuman animal use committee, there were no references to the "3Rs" in a random selection of 55 papers examined. Given the proportionally high volume of mice used in invasive research and the gravity of studies that inflict lasting pain, these trends raise serious questions about whether the 3Rs principles of Replacement, Reduction, and Refinement are being appropriately implemented by researchers and institutions.

Parallels in sources of trauma, pain, distress, and suffering in humans and nonhuman animals.

It is widely accepted that animals often experience pain and distress as a result of their use in scientific experimentation. However, unlike human suffering, the wide range of acute, recurrent, and chronic stressors and trauma on animals is rarely evaluated. In order to better understand the cumulative effects of captivity and laboratory research conditions on animals, we explore parallels between human experiences of pain and psychological distress and those of animals based on shared brain structures and physiological mechanisms. We review anatomical, physiological, and behavioral similarities between humans and other animals regarding the potential for suffering. In addition, we examine associations between research conditions and indicators of pain and distress. We include 4 case studies of common animal research protocols in order to illustrate incidental and experimental factors that can lead to animal suffering. Finally, we identify parallels between established traumatic conditions for humans and existing laboratory conditions for animals.