Unconventional natural gas development and human health: thoughts from the United States.

If unconventional gas development (UGD) continues to expand in Australia, the potential health and environmental impacts should be adequately addressed and preventive public health measures should be implemented. The United States has embraced UGD and has decades of experience that could be beneficial to Australia as stakeholders debate the potential benefits and harms of the technique. Additional research on the health impacts of UGD is necessary. Baseline and trend morbidity and mortality data need to be collected to assess changes in population health over time. To date, few health or epidemiological studies have been conducted, so it remains difficult to assess actual health outcomes. In the absence of scientific consensus, there are two possible risks: failing to develop unconventional natural gas when the harms are manageable; or developing it when the harms are substantial. Many government bodies around the world have chosen to minimise the risk of the latter until the impacts of UGD are better understood. Policies should be informed by empirical evidence based on actual experience rather than assurance of best practices. There is a strong rationale for precautionary measures based on the health and environmental risks identified in the scientific literature.

Public cervical cancer screening recommendations from US cancer centers: Assessing adherence to national guidelines.

Though widespread adoption of cervical cancer screening (CCS) in the US has been associated with a reduction in cervical cancer incidence and mortality, screening also carries with it potential risks. Newer national guidelines recommend decreased screening frequency to optimize the benefit/risk balance and to prevent over-screening. Here, we examined the alignment of US cancer center websites' public recommendations on CCS with national guidelines. We reviewed the websites of 1024 cancer centers accredited by the US Commission on Cancer during January-August 2022. We recorded the recommended frequency and type of CCS and any screening risks mentioned, comparing against national US Preventive Service Task Force (USPSTF) and American Cancer Society (ACS) guidelines. Of 1024 US cancer centers, 60% (610) provided CCS recommendations. Most centers are in alignment with the screening starting age (96%, 544/565) and stopping age (94%, 440/470) recommended by national guidelines. Of 508 centers specifying the frequency of standalone cervical cytology, 83% (419) recommended a screening interval of three years; however, 14% (73) recommended cervical cytology more frequently than the three-year interval recommended by the ACS/USPSTF. Screening risks were mentioned by 20% (124/610) of centers. Our findings highlight the importance of education on screening benefits and risks for physicians and patients to enable shared decision making based on evidence-based guidelines.

Strategies for primary HPV test-based cervical cancer screening programme in resource-limited settings in India: Results from a quasi-experimental pragmatic implementation trial.

BACKGROUND: In order for low and middle income countries (LMIC) to transition to Human Papilloma Virus (HPV) test based cervical cancer screening, a greater understanding of how to implement these evidence based interventions (EBI) among vulnerable populations is needed. This paper documents outcomes of an implementation research on HPV screening among women from tribal, rural, urban slum settings in India. METHODS: A mixed-method, pragmatic, quasi-experimental trial design was used. HPV screening on self-collected cervical samples was offered to women aged 30-60 years. Implementation strategies were 1) Assessment of contextual factors using both qualitative and quantitative methods like key informant interviews (KII), focus group discussions (FGDs), pre-post population sample surveys, capacity assessment of participating departments 2) enhancing provider capacity through training workshops, access to HPV testing facility, colposcopy, thermal ablation/cryotherapy at the primary health care centers 3) community engagement, counselling for self-sampling and triage process by frontline health care workers (HCWs). Outcomes were assessed using the RE-AIM (Reach, Effectiveness, adoption, implementation, maintenance) framework. RESULTS: Screening rate in 8 months' of study was 31.0%, 26.7%, 32.9%, prevalence of oncogenic HPV was 12.1%, 3.1%, 5.5%, compliance to triage was 53.6%, 45.5%, 84.6% in tribal, urban slum, rural sites respectively. Pre-cancer among triage compliant HPV positive women was 13.6% in tribal, 4% in rural and 0% among urban slum women. Unique challenges faced in the tribal setting led to programme adaptations like increasing honoraria of community health workers for late-evening work and recalling HPV positive women for colposcopy by nurses, thermal ablation by gynaecologist at the outreach camp site. CONCLUSIONS: Self-collection of samples combined with HCW led community engagement activities, flexible triage processes and strengthening of health system showed an acceptable screening rate and better compliance to triage, highlighting the importance of identifying the barriers and developing strategies suitable for the setting. TRIAL REGISTRATION: CTRI/2021/09/036130.

The shale gas boom and the need for rational policy.

High-volume, slick water hydraulic fracturing of shale relies on pumping millions of gallons of surface water laced with toxic chemicals and sand under high pressure to create fractures to release the flow of gas. The process, however, has the potential to cause serious and irreparable damage to the environment and the potential for harm to human and animal health. At issue is how society should form appropriate policy in the absence of well-designed epidemiological studies and health impact assessments. The issue is fraught with environmental, economic, and health implications, and federal and state governments must establish detailed safeguards and ensure regulatory oversight, both of which are presently lacking in states where hydraulic fracturing is allowed.

Willingness to HPV self-sampling for cervical cancer screening and its predictors among women attending outpatient clinics in Meru District, Arusha Region, Northern Tanzania.

Background: The ability for women to self-collect human papillomavirus (HPV) samples can potentially reduce the risk of cervical cancer and increase screening coverage. Objectives: To assess the willingness to HPV self-sampling for cervical cancer screening and its predictors among women attending outpatient clinics in Arusha region, northern Tanzania. Methods: A hospital-based cross-sectional study was conducted among 706 women aged 18-55 years in Meru District Hospital and Usa River Health Centre from March to April 2019. Face-to-face intervies were conducted using a questionnaire. Data analysis was performed using Stata version 14.0. The log-binomial regression was used to determine factors associated with willingness to self-collection of HPV samples. Results: Majority (70%) of the women were willing to self-collection of HPV samples for cervical cancer screening and was associated with attending Meru District hospital (PR=2.02, 95%CI 1.77-2.31); good knowledge about cervical cancer warning signs (PR=1.11, 95%CI 1.01-1.22), prevention (PR=1.13, 95%CI 1.04-1.20), and symptoms (PR=1.61, 95%CI 1.33-1.93); and having formal employment (PR=1.22, 95%CI 1.07-1.37). Conclusion: The majority of women were willing to self-collect HPV samples for cervical cancer screening. Self-collection is, therefore, an acceptable and viable means of screening for cervical cancer, which has great implications for Tanzania from a health policy perspective.

What Do Global Health Practitioners Think about Decolonizing Global Health?

The growing awareness of colonialism's role in global health partnerships between HICs and LMICs and the associated calls for decolonization in global health has led to discussion for a paradigm shift that would lead to new ways of engagement and partnerships, as well as an acknowledgement that colonialism, racism, sexism, and capitalism contribute to inequity. While there is general agreement among those involved in global health partnerships that the current system needs to be made more equitable, suggestions for how to address the issue of decolonization vary greatly, and moving from rhetoric to reform is complicated. Based on a comprehensive (but not exhaustive) review of the literature, there are several recurring themes that should be addressed in order for the inequities in the current system to be changed. The degree to which decolonization of global health will be successful depends on how the global health community in both the HICs and LMICs move forward to discuss these issues. Specifically, as part of a paradigm shift, attention needs to be paid to creating a more equal and equitable representation of researchers in LMICs in decision-making, leadership roles, authorship, and funding allocations. There needs to be agreement in defining basic principles of best practices for global partnership, including a universal definition of 'decolonization of global health'; the extent to which current policies allow the perpetuation of power imbalance between HICs and LMICs; a set of principles, best practices, and models for equitable sharing of funds and institutional costs among partners; a mechanism to monitor progress prospectively the equitable sharing of credits (e.g., leadership, authorship), including a set of principles, best practices, and models; and, a mechanism to monitor progress prospectively the extent to which decolonialization will contribute to strengthening institutional capacity in the LMIC institutions.

Improved Water and Waste Management Practices Reduce Diarrhea Risk in Children under Age Five in Rural Tanzania: A Community-Based, Cross-Sectional Analysis.

Diarrhea remains a significant cause of morbidity and mortality among children in developing countries. Water, sanitation, and hygiene practices (WASH) have demonstrated improved diarrhea-related outcomes but may have limited implementation in certain communities. This study analyzes the adoption and effect of WASH-based practices on diarrhea in children under age five in the rural Busiya chiefdom in northwestern Tanzania. In a cross-sectional analysis spanning July-September 2019, 779 households representing 1338 under-five children were surveyed. Among households, 250 (32.1%) reported at least one child with diarrhea over a two-week interval. Diarrhea prevalence in under-five children was 25.6%. In per-household and per-child analyses, the strongest protective factors against childhood diarrhea included dedicated drinking water storage (OR 0.25, 95% CI 0.18−0.36; p < 0.001), improved waste management (OR 0.37, 95% CI 0.27−0.51; p < 0.001), and separation of drinking water (OR 0.38, 95% CI 0.24−0.59; p < 0.001). Improved water sources were associated with decreased risk of childhood diarrhea in per-household analysis (OR 0.72, 95% CI 0.52−0.99, p = 0.04), but not per-child analysis (OR 0.83, 95% CI 0.65−1.05, p = 0.13). Diarrhea was widely treated (87.5%), mostly with antibiotics (44.0%) and oral rehydration solution (27.3%). Targeting water transportation, storage, and sanitation is key to reducing diarrhea in rural populations with limited water access.

The rush to drill for natural gas: a public health cautionary tale.

Efforts to identify alternative sources of energy have focused on extracting natural gas from vast shale deposits. The Marcellus Shale, located in western New York, Pennsylvania, and Ohio, is estimated to contain enough natural gas to supply the United States for the next 45 years. New drilling technology-horizontal drilling and high-volume hydraulic fracturing of shale (fracking)-has made gas extraction much more economically feasible. However, this technique poses a threat to the environment and to the public's health. There is evidence that many of the chemicals used in fracking can damage the lungs, liver, kidneys, blood, and brain. We discuss the controversial technique of fracking and raise the issue of how to balance the need for energy with the protection of the public's health.

Feasibility and acceptability of human papillomavirus self-sampling in a semi-urban area in northern Tanzania.

OBJECTIVE: To assess the feasibility and acceptability of HPV self-sampling in Arusha region, northern Tanzania, because the ability for women to self-collect HPV samples can help reduce the number of health facility visits and improve cervical cancer screening coverage rates. METHODS: We conducted a facility- and community-based cross-sectional study among 350 women aged 25-55 years in Arumeru district, Arusha region, northern Tanzania. Women were trained to self-collect an HPV sample, and follow-up visits were used to provide results after laboratory testing. Data were analyzed using Stata version 15.1 and summarized using mean and standard deviation for numeric variables and frequencies and percentages for categorical variables. RESULTS: Among 350 women, 65 (18.6%) ever screened for cervical cancer, all provided self-collected samples, and 349 (99.4%) would advise their female friends to undergo the same procedure. The prevalence of positive HPV results was 31 (8.9%), of which 26 (83.9%) were further examined. Two women found with lesions were treated following the national guidelines. CONCLUSION: This study has demonstrated that the HPV self-sampling intervention for cervical cancer screening is a feasible and acceptable intervention, especially in resource-limited countries like Tanzania. Scaling-up policies should consider addressing the potential barriers to the uptake of this intervention.

Mobile technology and cancer screening: Lessons from rural India.

BACKGROUND: Rates of cervical and oral cancer in India are unacceptably high. Survival from these cancers is poor, largely due to late presentation and a lack of early diagnosis and screening programmes. Mobile Health ('mHealth') shows promise as a means of supporting screening activity, particularly in rural and remote communities where the required information infrastructure is lacking. METHODS: We developed a mHealth prototype and ran training sessions in its use. We then implemented our mHealth-supported screening intervention in 3 sites serving poor, low-health-literacy communities: RUHSA (where cervical screening programmes were already established), Mungeli (Chhattisgarh) and Padhar (Madhya Pradesh). Screening was delivered by community health workers (CHWs - 10 from RUHSA, 8 from Mungeli and 7 from Padhar), supported by nurses (2 in Mungeli and Padhar, 5 in RUHSA): cervical screening was by VIA; oral cancer screening was by mouth inspection with illumination. Our evaluation comprised an analysis of uptake in response to screening and follow-up invitations, complemented by qualitative data from 8 key informant interviews and 2 focus groups. RESULTS: 8686 people were screened through the mHealth intervention - the majority (98%) for oral cancer. Positivity rates were 28% for cervical screening (of whom 37% attended for follow-up) and 5% for oral cancer screening (of whom 31% attended for follow-up). The mHealth prototype was very acceptable to CHWs, who felt it made the task of screening more reliable. A number of barriers to screening and follow-up in test-positive individuals were identified. Use of the mHealth prototype has had a positive effect on the social standing of the CHWs delivering the interventions. CONCLUSIONS: mHealth approaches can support cancer screening in poor rural communities with low levels of health literacy. However, they are not sufficient to overcome the range of social, cultural and financial barriers to screening and follow-up. Approaches which combine mHealth with extensive community education, tailored to levels of health literacy in the target population, and well-defined diagnostic and treatment pathways are the most likely to achieve a good response in these communities.

Risk factors for pediatric asthma in the South Bronx.

We identified main asthma risk factors for children living in the South Bronx, where asthma rates are eight times higher than the national average. This case-control study enrolled 261 children at Lincoln Medical and Mental Health Center from 2002 to 2003. We questioned the mothers on medical history and home environment. The most important risk factors for asthma in the South Bronx pediatric population are Hispanic ethnicity, family history of asthma, and exposure to tobacco smoke. South Bronx children limited to breast-feeding during the first 3 months of age are less likely to develop asthma.

Teaching medical students about different health care systems: an international exchange program.

Understanding how different health care systems are organized and financed is rarely taught in medical school. In 1997, several U.S. and European medical schools formed an ongoing, innovative, and collaborative exchange program to enable their medical students to gain an insight into the dynamics of another country's health care system. One student from each participating institution completes a month-long rotation at a host medical school under the supervision of a faculty mentor. Selected target diagnoses serve as the basis for comparative case studies. To enable the student to effectively study the host country's health care system, each is assigned a patient with the preselected specific diagnosis. The students view the patient's care within the context of the host country's delivery system rather than being limited to the clinical diagnosis and treatment of the disease. Matching the student with a patient permits the student to see how medical care is delivered and financed in the host country. Each student is required to prepare a written report focusing on costs; organization and delivery of care; quality and outcomes of care; politics, culture, and ethics; and learning. The case studies permit comparisons of health care systems among the participating U.S. and European Union countries, as well as opportunities for institutional and individual learning.

Initiating abortion training in residency programs: issues and obstacles.

OBJECTIVES: Early abortion is a common outpatient procedure, but few family medicine residencies provide abortion training. We wished to assess experiences and obstacles among residency programs that have worked to establish early abortion services. METHODS: From 2001-2004, 14 faculty participated in a collaborative program to initiate abortion training at seven family medicine residencies. Ten focus groups with all trainees were followed by individual semi-structured interviews with a smaller group (n=9) that explored the progress and obstacles they experienced. Individual interviews were recorded and analyzed to identify major themes and sub-themes related to initiating abortion training. RESULTS: Five of seven sites established abortion training. Five major themes were identified: (1) establishing support, (2) administration, (3) finance, (4) legal matters, and (5) security/demonstrators. Faculty from sites where training was ultimately established rated the sub-themes of billing/reimbursement, obtaining staff support, and state/hospital regulations as most difficult. Gaining support from within the department and institution was most difficult for the two sites that could not establish training. None experienced difficulty with security/demonstrators. CONCLUSIONS: Developing the clinical and administrative capacity to provide early abortion services in family medicine residency programs is feasible. Support from leadership within departments and from the wider institution is important for implementation.

Considerations for the development of shale gas in the United Kingdom.

The United States shale gas boom has precipitated global interest in the development of unconventional oil and gas resources. Recently, government ministers in the United Kingdom started granting licenses that will enable companies to begin initial exploration for shale gas. Meanwhile, concern is increasing among the scientific community about the potential impacts of shale gas and other types of unconventional natural gas development (UGD) on human health and the environment. Although significant data gaps remain, there has been a surge in the number of articles appearing in the scientific literature, nearly three-quarters of which has been published since the beginning of 2013. Important lessons can be drawn from the UGD experience in the United States. Here we explore these considerations and argue that shale gas development policies in the UK and elsewhere should be informed by empirical evidence generated on environmental, public health, and social risks. Additionally, policy decisions should take into account the measured effectiveness of harm reduction strategies as opposed to hypothetical scenarios and purported best practices that lack empirical support.

Teaching about the changing U.S. health care system: an innovative clerkship.

Changes in the U.S. health care system have necessitated modifying the scope and content of existing courses in the medical school curricula. In 1996, the Weill Medical College of Cornell University created a new, integrated public health curriculum to reflect the changes in the ways that medical care is organized, financed, and delivered. Teaching medical students to understand the constantly changing health care system is a primary objective of the new curriculum. As part of this curriculum, the medical college instituted a required public health clerkship that focused on the health care system, to be taken in either the third or fourth year. Students are prepared for the clerkship by taking courses in epidemiology, biostatistics, and evidence-based medicine in the first year and an introduction to the health system in the second year. The two-week clerkship, which may be unique in U.S. medical education, seeks to present an in-depth exposure to issues in health care financing and delivery by means of lectures, panel discussions with experts in the field, seminars, and field assignments to health care organizations and agencies.

Safety of vendor-prepared foods: evaluation of 10 processing mobile food vendors in Manhattan.

OBJECTIVES: Unsanitary food handling is a major public health hazard. There are over 4,100 mobile food vendors operating in New York City, and of these, approximately forty percent are processing vendors--mobile food units on which potentially hazardous food products are handled, prepared, or processed. This pilot study assesses the food handling practices of 10 processing mobile food vendors operating in a 38-block area of midtown Manhattan (New York City) from 43rd Street to 62nd Street between Madison and Sixth Avenues, and compares them to regulations stipulated in the New York City Health Code. METHODS: Ten processing mobile food vendors located in midtown Manhattan were observed for a period of 20 minutes each. Unsanitary food handling practices, food storage at potentially unsafe temperatures, and food contamination with uncooked meat or poultry were recorded. RESULTS: Over half of all vendors (67%) were found to contact served foods with bare hands. Four vendors were observed vending with visibly dirty hands or gloves and no vendor once washed his or her hands or changed gloves in the 20-minute observation period. Seven vendors had previously cooked meat products stored at unsafe temperatures on non-heating or non-cooking portions of the vendor cart for the duration of the observation. Four vendors were observed to contaminate served foods with uncooked meat or poultry. CONCLUSIONS: Each of these actions violates the New York City Code of Health and potentially jeopardizes the safety of these vendor-prepared foods. More stringent adherence to food safety regulations should be promoted by the New York City Department of Health.