Trailblazing paths: iconic women through time [reading list]

In honor of Women’s History Month, we’re celebrating trailblazing paths taken by women whose courage and vision transformed societies. This reading list features five biographies that highlight women who resisted systemic barriers, confronted entrenched hierarchies, and fought for the dignity and safety of others. From activists and reformers to scientists and cultural leaders, these stories reveal how women—often overlooked or silenced—have pushed boundaries, protected the vulnerable, and inspired movements for justice. Together, they remind us that progress toward gender equality has always been driven by those who refused to accept the limits imposed on them.

1. A Slumless America: Mary K. Simkhovitch and the Dream of Affordable Housing by Betty Boyd Caroli

In this biography, Mary K. Simkhovitch emerges as a pioneering force in the settlement house movement and a central architect of American public housing reform. Betty Boyd Caroli traces Simkhovitch’s founding of Greenwich House in 1902 and her influential role in shaping early 20th‑century urban policy, including her leadership in New Deal housing initiatives, the creation of the National Housing Conference, and co‑authoring the landmark 1937 National Housing Act. Balancing an unconventional marriage, family life, and a relentless public mission, Simkhovitch became widely admired—once even depicted as a “Wonder Woman of History”—for her ability to confront urban poverty while advocating fiercely for immigrant communities and affordable housing. This biography, rich with historical insight, positions her as an enduringly relevant figure whose work helped define the federal government’s responsibility to support low‑income families.

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2. American Infidelity: The Gilded Age Battle Over Freethought, Free Love, and Feminism by Steven K. Green

American Infidelity traces the dramatic late‑19th‑century clash between a dominant evangelical culture and a rising coalition of freethinkers, feminists, and sexual reformers who sought greater personal liberty and challenged religious authority. Historian Steven K. Green follows this struggle through the activists who fought for birth control, divorce reform, and women’s autonomy, as well as the moral crusaders—including Elizabeth Cady Stanton—who worked to suppress them. Revealing how these “infidels” pushed for a more open, rational, and egalitarian society, Green shows how their movements were ultimately stifled but left a powerful legacy that continues to shape today’s debates over reproductive rights, censorship, and the role of religion in public life.

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3. COMBEE: Harriet Tubman, the Combahee River Raid, and Black Freedom During the Civil War by Edda L. Fields-Black

Winner of the 2025 Pulitzer Prize for History

This book recounts the often‑overlooked story of Harriet Tubman’s 1863 Combahee River Raid, a daring Civil War operation in which she led Union spies, scouts, and two Black regiments up South Carolina’s river to destroy major rice plantations and liberate 730 enslaved people. Drawing on newly examined documents—including Tubman’s pension file and plantation records—historian Edda L. Fields‑Black, a descendant of one of the raiders, brings to life the enslaved families and communities who escaped to freedom that night and later helped shape the Gullah Geechee culture. Through this vivid reconstruction, the book reveals one of Tubman’s most extraordinary military achievements and the enduring legacy of those who fought for liberation.

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4. The Things She Carried: A Cultural History of the Purse in America by Kathleen B. Casey

The Things She Carried reveals how purses, bags, and sacks have long been critical tools for women asserting privacy, autonomy, and political power in America. Kathleen Casey shows how these objects—from 19th‑century reticules to the handbags carried by immigrant workers, civil rights activists, and Rosa Parks herself—became symbolic extensions of women’s rights struggles, allowing them to navigate male‑dominated spaces, protect personal dignity, and challenge discriminatory systems. Drawing on sources ranging from vintage purses to photographs, advertisements, and legal archives, Casey uncovers how women of all backgrounds used the bags they carried to assert agency, cross restrictive social boundaries, and shape pivotal moments in the fight for gender and racial equality.

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5. Frances Oldham Kelsey, the FDA, and the Battle against Thalidomide by Cheryl Krasnick Warsh

This biography tells the remarkable story of Dr. Frances Oldham Kelsey, the FDA medical officer who, in the early 1960s, prevented the dangerous drug thalidomide from being approved in the United States, sparing countless Americans from catastrophic birth defects. A pioneering scientist who earned advanced degrees in an era with few female researchers, Kelsey resisted intense pressure from Merrell Pharmaceutical and spent nineteen months demanding solid evidence of the drug’s safety. Her unwavering stance not only kept thalidomide off the U.S. market but also spurred sweeping reforms in drug regulation through the 1962 Drug Amendment, which established modern clinical trials, informed consent, and stronger FDA oversight. Drawing on archival records and family papers, the book reveals her lifelong commitment to ethical science, her battles against industry hostility and institutional barriers, and her enduring legacy as a vigilant protector of public health.

Read more.

Explore our extended list of titles on Bookshop (UK | US) and Amazon (UK | US).

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The truth about the microbiome: what’s real and what isn’t?

What’s really happening with those microbes inside us? Are we really superorganisms or is it all hype? Dr Berenice Langdon reveals the truth about the microbiome.

Does ‘microbiome’ mean our friendly gut bacteria?

Yes, sort of. Many people are aware that the term ‘microbiome’ refers to ‘friendly gut bacteria’. But ‘microbiome’ also refers to all the microbes or germs inside us. These are mainly bacteria – but they also include fungi, viruses, and many others. The word ‘microbiome’ also refers to where these microbes are: the ‘biome’ part of the word. They couldbe in our gut, or on our skin but a microbiome can also refer to much bigger locations outside the body: the microbiome of a forest, even an ocean.

And going back to the human gut; are these microbes friendly? Well, some are and some aren’t. Like all best buddies, sometimes even the ‘friendly’ ones can be awkward sometimes.

Is it true that our microbiome helps protect us from infections?

We know that if we take antibiotics, they can reduce our gut microbiome, and we can get a diarrhoea infection moving into our gut. On the other hand, we know that the microbiome is mainly made up of bacteria, and bacteria often cause infections. So does our microbiome protect us from infections, or does it cause infections?

The answer is a little bit of both. Our gut microbiome is usually made up of benign bacteria, the sort that don’t cause us harm. These benign bacteria keep the ‘baddy bacteria’, the pathogens, out of the gut. They do this either by outcompeting the bad bacteria, or by making the gut a bit too acidic for the bad bacteria to grow. In this way we can see that the gut microbiome is helping us, just a bit, to avoid gastrointestinal infections.

On the other hand, if our ‘friendly’ gut bacteria happen to get out of our guts and into the wrong place—like our blood stream or our brain—even though these bacteria are generally benign and friendly, they can cause a very serious infection.

Is it true that probiotics are live microorganisms that improve our health?

We know that probiotics are live microorganisms. This is part of their definition, and the idea is that taking them is meant to improve our health in some way. It’s the ‘improve our health’ part that’s difficult to prove.

Scientists have been testing probiotics for decades to determine if they have an effect on our health. They’ve tested their effect on all sorts of medical conditions, including constipation, diarrhoea, ulcerative colitis, and irritable bowel syndrome, as well as other non-gut related conditions such as Parkinson’s and autism. So far, however, there’s no evidence to show that probiotics help any of these conditions. The American Gastroenterological Society mainly does not recommend taking probiotics except as part of a research trial.

Many probiotics currently on the market contain bacteria that are found in our food anyway (in yoghurt, for example), or in fact, are already inside us. Some probiotic packaging even says so itself: contains live microorganisms that naturally exist in the body.

If probiotics don’t do much, are they at least safe? The answer for most people is: yes, probably. The bacteria that make up probiotics are usually fairly benign and don’t usually try and attack us.

But for people who are very ill or in intensive care, probiotics are not recommended. Research shows that probiotics can translocate from the gut to the blood stream. Once in the wrong place—just like the microbes in our gut microbiome—probiotics can cause life threatening infections or even death.

Is it true that a microbiome is essential for survival?

Amazingly, the microbiome is not essential for survival for all sorts of animals including rats, mice, guinea pigs, chickens, flies, and even fish. All of these creatures have been successfully raised without a microbiome. Even more amazingly, this isn’t new. Scientists have been doing this for over a hundred years. It’s absolutely possible for certain animals to survive just fine without a microbiome, and even have babies. This is a fascinating field of research, and these animals are sometimes known as gnotobiotic animals or germ-free animals.

However, it is true that herbivores can’t survive without a microbiome. They are dependent on gut microbes to help them ferment grass or foliage and extract the necessary calories. Herbivores really couldn’t survive without a microbiome.

Is it true that fermented foods and drinks are healthy?

We know that not all fermented foods and drinks are healthy and interestingly, not all fermented foods and drinks have microbes in their final product. Alcohol is an obvious example of this; a fermented drink with known health risks and also one in which the final product contains no microbes whatsoever. Other popular fermented products such as soy sauce are full of salt and are also clearly not universally healthy, while the acid contained in the very popular fermented product cider vinegar can dissolve our teeth and is a known cause of oesophagitis.

However, we still love fermented foods. Fermentation often makes foods taste great and helps us preserve our food. So, while there are certain benefits to fermented food and drink in terms of food production and preservation, overall fermentation doesn’t automatically make foods healthy.

Is it true that we need to pay attention to our diets to improve our microbiomes?

We should of course pay attention to our diet, by not eating too much, having a varied diet and including plenty of fibre, as this is the route to good health. But from a microbiome point of view, the bacteria in our guts don’t need much help.

Our colon typically contains a quadrillion bacteria per ml or 1,000,000,000,000 – a mind-blowingly large number. We also have a wide variety of bacteria inside us, constantly changing minute by minute. We obtain these effortlessly from the bacteria that coat the outside of our foods – even those foods we think of as ‘clean’ like bread and fruit as well as the bacteria naturally found within certain fermented foods mentioned above.

A wide variety of bacteria in our gut is regarded by some as a mark of health and is easily achieved by eating a wide variety of foods and by daily contact with each other, with the outside world, and with nature.

Is it true that together with our microbiomes we are superorganisms?

No, this is not true. Together with our microbiomes we are not superorganisms. While microbes do help us a bit—helping us digest a little bit more food, avoiding certain infections—they also cause us a lot of work, as we have to protect ourselves from them and avoid infections. It is not a universally positive relationship.

But ultimately, we are not superorganisms simply because we do not evolve as one unit. Microbes evolve inside us at a vastly faster rate than we do. And we evolve slowly, evolving protective mechanisms against the microbes, but making use of them when we can.

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Open Access Week: Nothing about me, without me

In a 2011 speech about shared decision making in healthcare, the UK Secretary of State, Andrew Lansley, coined the phrase “nothing about me, without me”. Used at the time to summarise efforts to empower patients in decisions about their care, the phrase has since been borrowed by advocates and activists on a range of social justice topics.

This year’s Open Access Week poses the question: “How, in a time of disruption, can communities reassert control over the knowledge they produce?” Here at OUP, we were inspired to delve into our open access publishing for examples of research that doesn’t just study communities, but actively involves them. From shaping research questions to guiding implementation, these projects center the voices and experiences of the people at their heart. This commitment to community-led knowledge creation isn’t limited to the articles themselves. It’s reflected in the editorial policies, peer review practices, and team structures that support our journals—ensuring that open access is not just about availability, but about equity and inclusion in research and publishing processes:

• Our Editors and authors publishing with Oxford Open Immunology use the Sex and Gender Equity in Research (SAGER) Guidelines to promote reporting of sex- and gender dimensions in research.
• The European Journal of Public Health is one example of a publication creating space for the promotion of the CARE Principles for Indigenous Data Governance, supporting the ability of Indigenous Peoples to control the use and application of Indigenous Knowledge and data for collective benefit.
• Many of our journals, Nucleic Acids Research included, utilise Early Career Boards to ensure their publications are managed in a way that serves the next generation of researchers and provides those earlier in their careers with experience contributing to journal development.
• Health Promotion International has created a special collection of research on participatory approaches in health promotion.
• Oxford Open Immunology has an open call for papers promoting the use of patient knowledge in research literature.
• JNCI: Journal of the National Cancer Institute and JNCI Cancer Spectrum are committed to supporting and advancing diversity, equity, and inclusion in editorial practices and published content. Recognizing that many populations have been systematically excluded from scholarly publishing, the journals have several initiatives strengthening diversity.

From participatory research approaches to elder care, to self-determination paths for trans and gender diverse people, to rural ownership of businesses in areas of high tourism, and citizen empowerment during energy transitions – our open access publishing is full of examples of the benefits of including people in the process of generating knowledge about them. All articles included here are published with an open access license, ensuring peer-reviewed, trusted knowledge and diverse voices can reach everyone, anywhere in the world:

Diversity in Health Interventions

Self-determination and self-affirmative paths of trans* and gender diverse people in Portugal: Diverse identities and healthcare by C Moleiro et al, European Journal of Public Health

Counting everyone: evidence for inclusive measures of disability in federal surveys by Jean P Hall et al, Health Affairs Scholar

Creating inclusive communities for LGBTQ residents and staff in faith-based assisted living communities by Carey Candrian, Innovation in Aging

Developing a co-designed, culturally responsive physical activity program for Pasifika communities in Western Sydney, Australia by Oscar Lederman et al, Health Promotion International

Co-creating a Mpox Elimination Campaign in the WHO European Region: The Central Role of Affected Communities by Leonardo Palumbo et al, Open Forum Infectious Diseases

Participatory development of a community mental wellbeing support package for people affected by skin neglected tropical diseases in the Kasai province, Democratic Republic of Congo by Motto Nganda et al, International Health

Inclusive Digital Health Strategies

The ATIPAN project: a community-based digital health strategy toward UHC by Pia Regina Fatima C Zamora et al, Oxford Open Digital Health

From disease specific to universal health coverage in Lesotho: successes and challenges encountered in Lesotho’s digital health journey by Monaheng Maoeng et al, Oxford Open Digital Health

Implementing an inclusive digital health ecosystem for healthy aging: a case study on project SingaporeWALK by Edmund Wei Jian Lee PhD et al, JAMIA Open

Developing the BornFyne prenatal management system version 2.0: a mixed method community participatory approach to digital health for reproductive maternal health by Miriam Nkangu et al, Oxford Open Digital Health

Equitable Energy Transitions

Energy communities—lessons learnt, challenges, and policy recommendations by L Neij et al, Oxford Open Energy

Solar-Powered Community Art Workshops for Energy Justice: New Directions for the Public Humanities by Anne Pasek et al, ISLE: Interdisciplinary Studies in Literature and Environment

Community participation and the viability of decentralized renewable energy systems: evidence from a hybrid mini-grid in rural South Africa by Mahali Elizabeth Lesala et al, Oxford Open Energy

Quantifying energy transition vulnerability helps more just and inclusive decarbonization by Yifan Shen et al, PNAS Nexus

Renewable energy and energy justice in the Middle East: international human rights, environmental and climate change law and policy perspectives by A F M Maniruzzaman et al, The Journal of World Energy Law & Business

Protecting Local Cultures

Enriching Cultural Heritage Communities: New Tools and Technologies by Alan Dix et al, Interacting with Computers

A framework for tourism value chain ownership in rural communities by Michael Chambwe et al, Community Development Journal

Local government engagement practices and Indigenous interventions: Learning to listen to Indigenous voices by Christine Helen Elers et al, Human Communication Research

The strengths, gender, and place framework: a new tool for assessing community engagement by Justin See et al, Community Development Journal

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5 books to master your transition to college [reading list]

As the days get cooler and autumn approaches, it’s the perfect time for a fresh start. Back to school is here. Whether your teen is heading off for another year at college or just beginning the transition, we’ve curated a selection of helpful guides to make the journey smoother. These titles are perfect companions for navigating this exciting new chapter.

Mastering the Transition to College: The Ultimate Guidebook for Parents of Teens With ADHD

Sending a teen off to college is a thrilling milestone, but for parents and caregivers of teens with ADHD, it can also bring unique challenges. Mastering the Transition to College is designed to ease those concerns by offering expert advice, practical strategies, and proven tools to help teens thrive both academically and emotionally during this transition.

Learn more about Mastering the Transition to College by Michael C. Meinzer

College Mental Health 101: A Guide for Students, Parents, and Professionals 

College Mental Health 101 offers more answers, relief, resources, and research backed information for families, students, and staff already at college or beginning the application process. With simple charts and facts, informal self-assessments, quick tips for students and those who support them, the book includes hundreds of voices addressing common concerns.

Learn more about College Mental Health 101 by Christopher Willard, Blaise Aguirre, and Chelsie Green

Supporting Your Teen’s Mental Health: Science-Based Parenting Strategies for Repairing Relationships and Helping Young People Thrive

Teen mental health issues are rising at an alarming rate, and many families are unsure of how to best help their children. Supporting Your Teen’s Mental Health is an essential resource for parents and caregivers looking to support teenagers who are struggling with mental health concerns. Written in a conversational tone by psychologist and fellow parent Andrea Temkin-Yu, the workbook is a thorough, evidence-based guide to essential parenting strategies that have been proven to help improve relationships and behavior.

Learn more about Supporting Your Teen’s Mental Health by Andrea Temkin-Yu

If Your Adolescent Has Autism: An Essential Resource for Parents 

While adolescence can be a tough time for parents and their teens, autistic teenagers may face specific challenges and need targeted support from the adults in their lives. The road ahead can be difficult for parents and caregivers, too, especially because the teenage years can involve surprising changes in their child and in society’s expectations of them.

Learn more about If Your Adolescent Has Autism by Emily J. Willingham

The Parents’ Guide to Psychological First Aid: Helping Children and Adolescents Cope With Predictable Life Crises 

Just as parents can expect their children to encounter physical bumps, bruises, and injuries along the road to adulthood, emotional distress is also an unavoidable part of growing up. The sources of this distress range from toddlerhood to young adulthood, from the frustration of toilet training to the uncertainty of leaving home for the first time. 

Learn more about The Parents’ Guide to Psychological First Aid edited by Gerald P. Koocher, Annette M. La Greca, Olivia Moorehead-Slaughter, and Nadja N. Lopez 

Check out these books and more on Bookshop and Amazon.

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Back to school for happy and healthy kids

Every September, caregivers and kids alike prepare for one big change: the start of a new school year. As the weeks of summer draw to a close, families are cramming in the last moments of summer fun while simultaneously gearing up for school drops offs and new classroom schedules. While it can be an incredibly exciting time, filled with first day of school outfits and new school gear, it can also be incredibly stressful. This can be particularly true for teenagers who, compared to younger kids, are facing higher academic demands and social pressure while experiencing the major physical and developmental changes that come during adolescence. On top of that, a 2023 Center of Disease Control report showed that teens of today have higher rates of mental health concerns, such as anxiety and depression, and that suicidal thoughts and behaviors are increasing. This can make the return to school daunting for teens, as well as parents who are worried about how their child will manage the transition and demands of the year. 

Fortunately, there are several tools that parents and caregivers can use to prepare kids and teens for the first few weeks in September. This includes setting clear expectations, skills to encourage helpful behavior, and strategies that help kids feel supported by their parents.  

Setting expectations 

While many kids prefer to keep their heads in the sand when it comes to a new academic cycle, it can be incredibly helpful to set expectations for the school year a few weeks in advance. The most basic version of this includes outlining differences between summer versus school schedules, such as changes to sleep and wake times, limits to screens, or daily responsibilities. This preview can help kids’ brains prepare for the upcoming shifts in their daily lives and make the transition a little smoother. It’s also a great idea to talk to kids about how the upcoming school year might be different than the last one. This could include providing information on class size, the structure of the day, or increased expectations. The goal is not to scare your kids about everything coming their way, but rather to provide them with simple clear information in a manner that builds excitement. For example, “It’s so fun that you get to go to go off-campus for lunch this year. I bet it will make the day feel way more interesting!” Or, “I know high school is bigger than middle school. It may feel a little overwhelming, but it’s also such a great time for you to see how capable you are.”  

Encouraging positive behaviors 

Once expectations have been set, parents can also work to encourage brave or skillful behavior. This may include things like taking more responsibility (e.g., managing their own communication with teachers and coaches), growing outside of their comfort zone (e.g., joining a new club or social circle), or challenging themselves with new opportunities or roles (e.g., a first job or harder courseload). This most effective way to do this is through a skill called “labeled praise.”  

Labeled praise is when you show appreciation for a specific behavior or characteristic your child is demonstrating. When it comes to a new school year, parents can look for opportunities to praise preparation, flexibility, and bravery. For example, “I know you really loved your teachers last year, and I appreciate how openminded you are about your new schedule.” Another parent may say, “Great call on getting to bed a little earlier this week. It’ll make the start of school so much easier!” For teens who haven’t mastered brave or skillful choices, parents can offer cheerleading and encouragement. Phrases like “I know you’re going to do a beautiful job making friends because you’ve done it before!” or “10^th grade is tough, and I have total confidence that you’re going to find a way to balance everything” send a message that they really believe in their kid. This can go a long way towards encouraging positive behaviors.   

Providing validation 

When you do notice your child having a hard time, whether it’s nerves, low mood, or difficulty organizing themselves for a new semester, it’s always a great idea to offer validation. Validation is a skill used to show somebody that you can see their perspective or understand where they are coming from. Validation can be a tricky skill to master for caregivers because it is sometimes hard to put yourself in your child’s shoes, or you are eager to get them to see a new perspective. For example, when your child complains about their new math teacher who they have heard is a hard grader, it’s tempting to say “Nah! I’m sure it’ll be fine!” This may work for some kids. However, it can come off as dismissive and hard to believe for a teen whose anxiety or stress is high. Instead, try validation: “It makes sense that you’re nervous based on what you’ve heard!” While you aren’t agreeing with your child’s worries, you are acknowledging them, and that can help increase a sense of connection and communication. Once your child feels understood, they’ll be better able to think clearly about the situation and problem solve as needed.  

As you navigate another year of permission slips, homework, and extracurricular activities, remember that you have a handful of tools in your pocket to help ease the way. With a little bit of preparation, encouragement, and support, you and child can start the school year off on a great foot.  

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Shining light on sun safety for Sun Awareness Week 2025

Kicking off today, Sun Awareness Week (12-18 May) is the start of the British Association of Dermatologists’ (BAD) summer-long campaign to encourage everyone to protect their skin from sun damage and skin cancer, the most common cancer in the UK.

There are several types of skin cancer, with melanoma and non-melanoma skin cancers being the most common. Melanoma develops from melanocytes, cells in deeper layers of the skin that give skin its colour. Non-melanoma skin cancers, such as basal and squamous cell carcinoma, develop from cells known as keratinocytes found in the outer layer of the skin. Simple steps like using sunscreen, avoiding sun in the middle of the day, wearing sun hats, and reducing the amount of direct sun exposure can lower your risk of both.

Recent research from the BAD journals—British Journal of Dermatology, Clinical and Experimental Dermatology, and Skin Health and Disease—offers new insights into preventing, diagnosing, and treating melanoma and non-melanoma skin cancers. Here are some highlights:

Why sunscreen matters

Using sunscreen every day is one of the best ways to stay safe. The sun gives off ultraviolet (UV) rays that harm your skin and raise skin cancer risk, and regular use of high-SPF sunscreen can protect you. Sunscreen comes in many forms, like creams, lotions, sprays, and sticks. Apply it 15-30 minutes before going outside. Reapply every 2 hours, or after swimming or intense physical activity.

Sunscreen prevents skin cancer and premature ageing (called photoageing), but it’s good to know the facts. A recent narrative review found possible downsides of using sunscreen, like allergic skin reactions and concerns about endocrine disruption. Some ingredients, like preservatives and fragrances, may cause allergic skin reactions, though evidence suggests these reactions are rare. Concerns about hormone effects are low, as sunscreen stays mostly on the skin’s surface.

Photoageing: a key concern

UV rays don’t just increase skin cancer risk—they also age your skin early, causing wrinkles and spots. A recent survey across 17 countries found that people often worry more about photoageing than skin cancer. So, talking about photoageing in sun awareness campaigns could motivate more people to engage in sun protective behaviours.

A digital sun protection campaign for healthcare workers

Researchers from University of Limerick Hospital Group in Ireland tried a new digital campaign to promote skin cancer awareness among hospital staff. Their study found that staff became more positive about sun protective behaviours after the campaign, showing that digital tools could work for everyone in encouraging sun protection.

Better sun habits, better outcomes

Campaigns like Sun Awareness Week make a real difference. A study from Austria found that people who improved their sun protection habits after being diagnosed with melanoma lived longer, showing that these behavioural changes can save lives.

Global melanoma trends

A population-level study across 162 countries found that melanoma diagnoses are rising over time, but death rates are steady or growing slowly. This may be related to improved screening and awareness programs for melanoma. However, this may be compounded by melanoma overdiagnosis, with some cases caught early that may not have been deadly. Researchers are still exploring this complex phenomenon.

Melanoma and gender

Men and women face different melanoma risks. This study from Australia found that, on average, women are often diagnosed with melanoma years earlier than men, especially on the torso and for thinner melanomas. Their findings suggest that sex-tailored approaches to melanoma control could improve prevention and care.

Sun safety policy in primary schools

As per the World Health Organization, school sun protection programmes may be the key to skin cancer prevention. This study carried out an online survey of primary schools in Wales to understand their sun safety policies and practices. Of 471 schools that responded, only 183 enforced their policy. Those who did not have a policy were ‘not aware of the need’ (34.6%); ‘need assistance with policy or procedure development’ (30.3%); or ‘not got around to it just yet’ (26.8%).

Skin cancer and blood cancers

This study in the Netherlands found that patients with blood cancers have a higher risk of developing skin cancers across their lifetime. This means that targeted awareness campaigns for sun protection are vital for this patient population.

Diabetes drugs and skin cancer

In this systematic review, the authors found that drugs for type 2 diabetes, especially metformin, may lower risk of non-melanoma skin cancer. This is good news for people with type 2 diabetes who are worried about developing skin cancer.

This Sun Awareness Week, we are urging everyone to prioritise sun protection to prevent skin cancer and premature skin ageing. Check your skin regularly and see a doctor if you notice any new or changing moles or other skin lesions.

Join the #SunAwarenessWeek conversation and share your sun safety tips! You can explore the latest research from the BAD journals here.

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Ultra-processed foods are making us old beyond our years

In recent years, ultra-processed food (UPFs) consumption has surged globally, raising concerns about its impact on health.

Ultra-processed foods are industrial formulations typically containing ingredients not commonly used in home cooking, such as hydrogenated oils, high-fructose corn syrup, flavour enhancers, and emulsifiers. Examples of these types of foods include chips, soft drinks, instant noodles, ice cream, chocolate, biscuits, ready-to-eat meals, sausages, burgers, chicken and fish nuggets, sweet or savoury packaged snacks, and energy bars.

These foods, and the ingredients they contain, are designed for convenience and long shelf life, and to enhance palatability, but often come at the cost of nutritional value.

Now, a groundbreaking study, led by Monash University, has shed light on a particularly alarming consequence – the acceleration of biological ageing.

Biological age refers to how old a person seems based on various molecular biomarkers, compared to chronological age, which is the number of years a person has lived.

A person’s biological age is a relatively new way of measuring a person’s health, and can be traced back to 2013, when geneticist Steve Horvath developed the epigenetic clock, which measures DNA methylation levels. DNA methylation is a process that modifies the function of genes.

A second generation of epigenetic clocks was developed a few years later that incorporated environmental variants such as smoking or chronological age. Among these was the PhenoAge and GrimAge clocks.

As well as diet, biological age can be influenced by genetics, general lifestyle, and environmental factors, and it can differ significantly from chronological age.

A person with a healthy lifestyle may have a biological age younger than their chronological age, while poor lifestyle choices, such as a diet high in UPFs, can accelerate biological ageing.

The Monash University study, published in the journal Age and Ageing, was led by nutritional biochemist Dr Barbara Cardoso, a senior lecturer in the University’s Department of Nutrition, Dietetics and Food. It involved 16,055 participants from the United States aged 20-79, whose health and lifestyles were comparable to those in other Western countries such as Australia. The study used the PhenoAge clock to assess biological ageing.

It found a significant association between increased UPF consumption and accelerated biological ageing. For every 10% increase in UPF consumption, the gap between biological and chronological age widened by approximately 2.4 months.

Participants in the highest UPF consumption quintile (68-100% of energy intake in their diet) were biologically 0.86 years older than those in the lowest quintile (39% or less of energy intake in their diet).

Dr Cardoso said the findings underlined the importance of eating as many unprocessed and minimally-processed foods as possible.

“The significance of our findings is tremendous, as our predictions show that for every 10% increase in total energy intake from ultra-processed food consumption there is a nearly 2% increased risk of mortality and 0.5% risk of chronic disease over two years,” she said.

“Assuming a standard diet of 2000 calories [8500 kilojoules] per day, adding an extra 200 calories of ultra-processed food, which roughly equals an 80-gram serving of chicken bites or a small chocolate bar, could lead to the biological ageing process advancing by more than two months compared to chronological ageing.”

The study used data from the US National Health and Nutrition Examination Survey (NHANES) 2003-2010. Diet quality was assessed with the American Heart Association (AHA) 2020 and the Healthy Eating Index 2015 (HEI-15).

The association between UPF intake and biological ageing remained significant after adjusting for diet quality and total energy intake, using the above data as a baseline.

This suggested the association could be due to other factors such as lower intake of flavonoids or phytoestrogens, which occur in natural foods such as fresh fruit and vegetables, or higher exposure to packaging chemicals and compounds formed during food processing.

“Adults with higher UPF tended to be biologically older,” the study found. “This association is partly independent of diet quality, suggesting that food processing may contribute to biological ageing acceleration. Our findings point to a compelling reason to target UPF consumption to promote healthier ageing.”

The results also support earlier research linking UPF consumption to ageing markers such as telomere length (a shorter telomere length is a sign of cell ageing), frailty, cognitive decline, and dementia. 

Dr Cardoso said while the study participants were from the US, the relevance of the findings apply to Australians too – on average, ultra-processed foods represented almost 40% of total energy intake among Australian adults.

She said given the global population continued to age, demonstrating the adverse effects of UPFs reinforced the need for dietary-focused public health strategies to prolong a healthy lifespan.

“Our findings indicate that reducing ultra-processed foods in the diet may help slow the biological ageing trajectory, bringing another reason to target ultra-processed foods when considering strategies to promote healthy ageing,” she said.

Mechanisms behind UPFs and ageing

Mechanisms by which UPFs may accelerate biological ageing include:

1. Nutrient deficiency: UPFs are often low in essential nutrients such as vitamins, minerals, and antioxidants, which are crucial for maintaining cellular health and preventing oxidative stress.
2. Chemical additives: Many UPFs contain artificial additives and preservatives that may have adverse effects on health, including promoting inflammation and disrupting metabolic processes.
3. Packaging chemicals: Exposure to chemicals from food packaging, such as bisphenol A (BPA), has been linked to various health issues, including accelerated ageing.

Practical steps to reduce UPF intake

To mitigate the adverse effects of UPFs, individuals can take several practical steps:

1. Increase whole foods: Emphasise whole, minimally processed foods such as fruits, vegetables, whole grains, nuts, and seeds in your diet.
2. Read labels: Be mindful of food labels and avoid products with long lists of unfamiliar ingredients.
3. Cook at home: Preparing meals at home allows for greater control over ingredients and cooking methods.
4. Limit convenience foods: Reduce reliance on ready-to-eat meals and snacks, opting instead for healthier alternatives.

This work was carried out in collaboration with senior author Euridice Martinez Steele, from the University of Sao Paulo (Brazil), Daniel Belsky, from Columbia University (US), Dayoon Kwon, from the University of California at Los Angeles, Priscila Machado, from Deakin University, and Junxiu Liu, from Icahn School of Medicine at Mount Sinai (US).

This article was first published on Monash Lens. Read the original article.

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Searching DNA databases: cold hits and hot-button issues

Many criminal investigations, including “cold cases,” do not have a suspect but do have DNA evidence. In these cases, a genetic profile can be obtained from the forensic specimens at the crime scene and electronically compared to profiles listed in criminal DNA databases. If the genetic profile of a forensic specimen matches the profile of someone in the database, depending on other kinds of evidence, that individual may become the prime suspect in what was heretofore a suspect-less crime.

Searching DNA databases to identify potential suspects has become a critical part of criminal investigations ever since the FBI reported its first “cold hit” in July 1999, linking six sexual assault cases in Washington, D.C., with three sexual assault cases in Jacksonville, Florida. The match of the genetic profiles from the evidence samples with an individual in the national criminal database ultimately led to the identification and conviction of Leon Dundas.

How the statistical significance of a match obtained with a database search is presented to the jury should, in my view, be straightforward but, given the adversarial nature of our criminal justice system, remains contentious. One view is that if the profiles of the evidence and a suspect who had been identified by the database search match, then the estimated population frequency of that particular genetic profile (equivalent to the Random Match Probability in a non-database search case) is still the relevant statistic to be presented to the jury. The Random Match Probability (RMP) is an estimate of the probability that a randomly chosen individual in a given population would also match the evidence profile. The RMP is estimated as the population frequency of the specific genetic profile, which is calculated by multiplying the probabilities of a match at each individual genetic marker (the “Product Rule”).

An alternative view, often invoked by the defense, is that the size of the database should be multiplied by the RMP. For example, if the RMP is 1/100 million and the database that was searched is 1 million, this perspective argues that the number 1/100 is the one that should be presented to the jury. This calculation, however, represents the probability of getting a “hit” (match) with the database and not the probability of a coincidental match between the evidence and suspect (1/100 million), the more relevant metric for interpreting the probative significance of a DNA match. Although these arguments may seem arcane, the estimates that result from these different statistical metrics could be the difference between conviction and acquittal.

There are many different kinds of DNA databases. Ethnically defined population databases are used to calculate genotype frequencies and, thus, to estimate RMPs but are not useful for searching. The first DNA searches were of databases of convicted felons. In some jurisdictions, databases of arrestees have also been established and searched. These searches have recently been expanded to include “partial matches,” potentially implicating relatives of the individuals in the database. This strategy, known as “familial searching,” has been very effective but contentious, with discussions typically focused on the “trade-offs” between civil liberties and law enforcement. In some jurisdictions, the “trade-off” has been between two different controversial criminal database programs. In Maryland, for example, an arrestee database (albeit one specifying arraignment) was allowed but familial searching was outlawed. Familial searching has been critiqued as turning relatives of people in the database into “suspects.” A more accurate description is that these partial matches revealed by familial searching identify “persons of interest” and that they provide potential leads for investigation.

Recently, searching for partial matches in the investigation of suspect-less crimes has expanded from criminal databases to genealogy databases, as applied in the Golden State Killer case in 2018. These databases consist of genetic profiles from people seeking information about their ancestry or trying to find relatives. Genetic genealogy involves constructing a large family tree going back several generations based on the individuals identified in the database search and on genealogical records. Identifying several different individuals in the database whose profile shares a region of DNA with the evidence profile allows a family tree to be constructed. The shorter the shared region between two individuals or between the evidence and someone in the database, the more distant the relationship. This is because genetic recombination, the shuffling of DNA regions that occurs in each generation, reduces the length of shared DNA segments over time. So, in the construction of a family tree, the length of the shared region indicates how far back in time you have to go to locate the common ancestor. Tracing the descendants in this family tree who were in the area when the crime was committed identifies a set of potential suspects.

The DNA technologies used in investigative genetic genealogy (IGG) are different from those typically used in analyzing the evidence samples or the criminal database samples, which are based on around 25 short tandem repeat markers (STRs). The genotyping technology used to generate profiles in genealogy databases is based on analyzing thousands of single nucleotide polymorphisms (SNPs). With the recent implementation of Next Generation Sequencing technology to sequence the whole genome, even more informative searching for shared DNA regions can be accomplished. (Next Generation Sequencing of the whole genome is so powerful that it can now distinguish identical (monozygotic) twins!)

Investigative genetic genealogy (IGG) has completely upended the trade-offs and guidelines proposed for familial searching as well as many of the arguments. Many of the rationales justifying familial searching of criminal databases, such as the recidivism rate, and the presumed relinquishing by convicts of certain rights do not apply to genealogical databases. Also, the concerns about racial disparities in criminal databases don’t apply to these non-criminal databases either. In general, it’s very hard to draw lines in the sand when the sands are shifting so rapidly and the technology is evolving so quickly. And it is particularly difficult when dramatic successes in identifying the perpetrators of truly heinous unsolved crimes are lauded in the media, making celebrities of the forensic scientists who carried out the complex genealogical analyses that finally led to the arrest of the Golden State Killer and, shortly thereafter, to many others.

It’s still possible and desirable to set some guidelines for IGG, a complex and expensive procedure. It should be restricted to serious crimes. The profiles in the database should be restricted to those individuals who have consented to have their personal genomic data searched for law enforcement purposes. With the appropriate guidelines, the promise of DNA database searching to solve suspect-less crimes can truly transform our criminal justice system.

_{Featured image by TanyaJoy via iStock.}

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The best of <i>Health Affairs Scholar</i> 2024

As we welcome 2025, we reflect on the milestones and achievements that shaped Health Affairs Scholar in 2024. Among the highlights, we introduced our first Calls for Papers, focusing on the critical topics of: Global Aging, Intersections of Social Policies and Health, and Policy Options for the 340B Discount Program. These ongoing series continue to invite submissions, fostering meaningful discourse on pressing policy issues.

The journal also launched its inaugural Featured Paper Series, Health Workforce Issues and Challenges in the Post-Pandemic Era, with contributions from each of the nine federally funded Health Workforce Research Centers. Building on this momentum, three additional Featured Paper Series are set to publish in 2025, each exploring distinct, timely topics and supported by different sponsoring organizations. The papers below kick-off two of these series, with the introduction to the third series on Emergency Room Care coming soon.

• Health And Political Economy: Building A New Common Sense In The United States by Victor Roy, Darrick Hamilton, and Dave Chokshi
• Evidence To Inform Biopharmaceutical Policy: Call For Research On The Impact Of Public Policies On Investment In Drug Development by Sandra Barbosu, Kirsten Axelsen, and Stephen Ezell

In addition to these exciting new initiatives, we’re pleased to share that the journal is now indexed in the Web of Science, as well as PubMed Central, The Directory of Open Access Journals, and Google Scholar.

As we look back on a successful year, we also want to highlight the top ten most read papers published in 2024. These papers reflect some of the timeliest issues of 2024, including contraceptive access and use in the post-Dobbs era, mapping pharmacy deserts across the country, prior authorization burdens and solutions, and much more.

1. Has the Fall of Roe Changed Contraceptive Access and Use? New Research from Four US States Offers Critical Insights by Megan L Kavanaugh and Amy Friedrich-Karnik

In this brief report, Megan Kavanaugh and Amy Friedrich-Karnik examine the broad impact the overturning of Roe v. Wade has had on contraceptive access and use. The report highlights decreased access to quality contraceptive care across four states and emphasizes the need for evidence-based policies and programs to better support people’s contraceptive needs in the post-Dobbs era.

2. The Evolution and Scope of Medicaid Section 1115 demonstrations to address nutrition: a US survey by Erika Hanson and others

Medicaid Section 1115 demonstration waivers offer states the opportunity to pilot coverage for nutrition-based services to address health disparities. Erika Hanson and coauthors provide insight into the evolution and current landscape of food-based initiatives supported by these demonstrations across 19 states.

3. Return On Investments In Social Determinants Of Health Interventions: What Is The Evidence? by Sayeh Nikpay, Zhanji Zhang, Pinar Karaca-Mandic

Sayeh Nikpay and coauthors quantify the return on investment for interventions focused on combating food and housing insecurity, emphasizing the role these estimates play in encouraging future investment by health plans and other private actors in the health care space.

4. Why Does The Cost Of Employer-Sponsored Coverage Keep Rising? Salpy Kanimian, Vivian Ho

Salpy Kanimian and Vivian Ho explore the rising gap between health insurance costs and wages, highlighting the role hospitals play in driving premiums. Between 2006 and 2023, hospital price index rose faster than insurance premiums, and hospitals consistently maintained high profit margins than insurers.

5. Life Cycle Of Private Equity Investments In Physician Practices: An Overview Of Private Equity Exits by Yashaswini Singh, Megha Reddy, Jane M Zhu

Yashaswini Singh and colleagues explore the often rapid turnover of private equity investments in physician practices. Their analysis reveals that private equity firms increase affiliated practices by 595% on average in just three years, raising concerns about the long-term sustainability of care and workforce investments.

6. Locations and Characteristics of Pharmacy Deserts in the United States: A Geospatial Study by Rachel Wittenauer and coauthors

Rachel Wittenauer and coauthors use pharmacy address data and Census Bureau surveys to map pharmacy deserts across the United States. Their findings show that 4.7% of Americans in both rural and urban communities live in these deserts, demonstrating an urgent need to improve access to pharmaceutical services.

7. Perceptions Of Prior Authorization Burdens And Solutions by Nikhil R Sahni and coauthors

Nikhil R. Sahni and colleagues examine the perceived challenges related to prior authorization processes and the barriers that impede the adoption of automated solutions including the use of artificial intelligence.

8. Balancing Innovation And Affordability In Anti-Obesity Medications: The Role Of An Alternative Weight-Maintenance Program by David D Kim, Jennifer H Hwang, Mark Fendrick

Anti-obesity medications have garnered significant attention for their effectiveness, but their high price poses a major challenge to accessibility. Using a policy simulation model, David Kim, Jennifer Hwang, and Mark Fendrick evaluate the impact of an economical weight-maintenance program after weight loss plateau as an alternative to continuous medication use.

9. Infant Mortality In Ghana: Investing In Health Care Infrastructure And Systems by Danielle Poulin and coauthors

A policy inquiry by Danielle Poulin and coauthors provides recommendations for policymakers to address the persistently high rates of infant and neonatal mortality in Ghana, despite efforts to improve financial accessibility to care. The authors suggest that a systems approach is needed to minimize barriers to pre- and post-natal care, including investment in medical facility and transportation infrastructure, increased workforce development, and improvement in claims reimbursement.

10. Physicians Working With Physician Assistants And Nurse Practitioners: Perceived Effects On Clinical Practice by Xiaochu Hu and coauthors

A national survey of US physicians reveals that most view working with physician assistants and nurse practitioners as positively impacting their clinical practice. Physicians in medical schools and with higher incomes were particularly likely to report benefits, while those in specialties with higher women’s representation had lower ratings.

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The risks of dopamine agonists for the treatment of restless legs syndrome

An extraordinary breakthrough of modern medicine occurred in 2005 when the FDA approved ropinirole for the treatment of restless legs syndrome (RLS). With the first drug ever approved for this misery-inducing condition, patients finally had a highly effective treatment with relatively few side effects. Nearly 20 years later, ropinirole and its cousin pramipexole are among the most prescribed treatments for RLS, and they have been considered first-line therapy for over a decade.

Restless legs syndrome is an unpleasant sensation, typically described as an intense urge to move, that worsens later in the day, is provoked by holding still, and improves while moving. It can affect people of all ages, but it gets more common around middle age. For people with this condition, life can become unbearable. They are unable to sit long enough to enjoy a meal or watch a movie. Taking a flight or a long car ride is torture. Having an effective treatment like ropinirole and pramipexole was beyond a miracle for patients with severe symptoms.

Ropinirole and pramipexole fall under the drug category of dopamine agonists. This means that these drugs stimulate dopamine receptors in the brain. While it was known long before 2005 that dopamine-related drugs could improve RLS symptoms, those drugs had unacceptable risks. The two new dopamine agonists—which were joined in 2008 by a third drug, rotigotine—were considered much safer, and doctors who treated RLS flocked to them. Dopamine agonists were how RLS was treated. Problem solved, apparently.

Another extraordinary event is taking place in 2024, though. Dopamine agonists are not only being removed as first-line treatment for RLS, new guidelines by the American Academy of Sleep Medicine place dopamine agonists on the “do not use” list. This complete about-face is a result of years of observing that dopamine agonists are not the RLS saviors they were once thought to be. In fact, they have almost certainly caused even more suffering.

Dopamine agonists have two major problems: augmentation and impulse control disorders. Augmentation occurs when consistent use of a dopamine agonist starts to make RLS symptoms worse. This might manifest as patients having symptoms earlier in the day or having symptoms in other body parts, such as the arms.

Augmentation is thought to be the result of the brain shutting down its own natural dopamine production to rely more and more on the pills to stimulate dopamine receptors. As a result, patients require higher or more frequent doses to achieve the same degree of relief. Eventually, even those doses don’t provide relief, and the suffering starts to spread throughout the day. These drugs are particularly insidious because each time the dose is increased, patients feel better. Temporarily. If they try to decrease their dose, they feel worse. Essentially, patients become dependent on these drugs; they’re addictive.

The only treatment for augmentation is to stop the offending medication. Dopamine agonists must be weaned off, and the process can be brutal: insomnia, severe pain, anxiety, depression, thoughts of suicide, and more. When it’s over, though, the RLS symptoms are inexorably better.

The elevated doses of dopamine agonists that patients with augmentation often take can also cause a highly destructive condition called impulse control disorders (ICDs). ICDs are a form of compulsive behavior in which patients find it difficult or impossible to stop doing things that are harmful to them. The most common ICDs related to dopamine agonists are eating, shopping, gambling, and pornography consumption. Patients with a gambling ICD, for example, might spend 24 straight hours at a blackjack table. Those with a shopping ICD might start buying gifts they can’t afford for all their friends and family members just because an advertisement came on TV. The financial and social losses incurred by these patients can be massive, and many of them have no idea that their RLS medication is the cause.

With decades of experience, it became clear to physicians treating RLS that dopamine agonists were a seductive enemy to RLS patients. Exposing patients to the risks of augmentation and ICDs could no longer be justified, and they are no longer recommended for daily use. If patients do take dopamine agonists, the doses must be kept low, and ideally, used only sparingly for situations likely to trigger the RLS, like a long flight.

Fortunately, there are highly effective alternatives to dopamine agonists now. The most important treatment, bar none, is iron. A low level of iron in the brain is a very common cause of RLS and a very treatable one. Successful treatment of RLS begins with ensuring adequate levels of brain iron. After that, first-line drug therapy is now gabapentin, a drug originally approved for seizures that is highly effective for RLS, along with its related drug gabapentin enacarbil and their counterpart pregabalin. The other highly effective class of medications for RLS is opioids, including methadone and buprenorphine. Dipyridamole, a drug that used to be used to help prevent strokes, is starting to be used for RLS now. And earlier this year, a nerve stimulator band worn below the knees entered the American market for a drug-free treatment option. Each of these therapies can be considered for the treatment of RLS.

It is crucial for doctors and patients to understand the risks of dopamine agonists, including augmentation and ICDs. There are many alternatives to help this long-suffering group of people without the threat of making them worse over time. Patients who suffer with RLS should know they need not suffer forever.

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We need to support our health and social care system

Do you remember when we Clapped for Carers?

UK health and social care systems are world leaders in so many ways. Whether it’s leading in medicine and treatments, to providing a social justice-based social care, the system does a great job in supporting the health and additional needs of some of the most vulnerable individuals in society. However, there is no doubt that UK health and social care systems are experiencing significant stress. Virtually every week we are hearing new initiatives from political parties about how they will save the system, or how record amounts of money are being put into the NHS.

The health and social care workforce face difficulties at almost every turn. They are often blamed when serious and distressing events occur, despite doing everything in their power to support those experiencing distress. They have difficulties in workload, satisfaction, looking after extreme events … all of which is against the backdrop of UK Covid lockdowns, where we were implored to stand on our doorstep and ‘Clap for Carers’ all while they were being disproportionately affected by Covid.

The Political Blame Game

In late 2023, the former UK prime minister stated that “we were making progress on bringing the overall numbers [of those on NHS waiting lists] down—what happened? We had industrial action and we got strikes”. Despite NHS waiting lists increasing steadily since 2012, with obvious increases during and following the end of Covid lockdowns, and December 2023 having some of the longest waiting lists ever (although there had been a small decline in that month), the blame is on the workforce for waiting lists that had been increasing year on year since 2012.

Far too often health and social care workers are blamed. The decision of the Conservative government to prevent social care workers from bringing their families to this country from abroad, for example, suggests that the immigration which is needed to keep the care system afloat is a problem. Indeed, nearly one in five of the social care sector are international, and The King’s Fund suggests that without them the sector will struggle to function. As such, governmental actions have inevitably had knock-on effects on the availability of care provision in this country.

We need a political system that supports and guides health and social care workers—not one which demonises and detracts from them.

The Organisational Effects on the Workforce

When health and social care professions go on strike, evidence from studies across the health and social care (and wider public services) sectors suggest that pay is only one of the myriad issues fuelling their discontent—even though we have seen teachers and social workers face amongst the worst fall in wages of all professions in the UK.

Perhaps amongst the most damning evidence comes from national surveys and research which look at the impacts of organisational working conditions on the health and social care workforce. For example, since 2018/19 we have seen that social workers have among the worst working conditions of any occupation and profession in the country. These conditions have been consistently poor, and are undoubtedly contributing to the continually high levels of sickness absence and high turnover rates in the sector. These conditions are typified by high caseloads and long working hours. For example, Ravalier found that social workers worked, on average, over 8 hours per week more than they were contracted to. The picture is similar in other social and health care roles.

I would bravely suggest that, even if our health and social care workers could have regular decent wage increases, what would make more of a difference is decent support, at a level which provides the resources they need to make a difference. After all, study after study has shown that this is why they join the sector—to make a difference in the lives of the ill and vulnerable people who live in their very communities.

So what do we need to do to support our health and social care workforce? Well, firstly, claps don’t work. While they started as a nice gesture, they do not make up for the political, societal, and/or organisational issues highlighted above. We need better investment and support of the workforce which is so vital to the UK and beyond. We need to allow health and social care workers to have the resources they need to make a real difference. This will reduce turnover, improve satisfaction, and reduce sickness absence.

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Second-hand smoke exposure—it’s time to move beyond the pregnant woman herself

Second-hand smoke (SHS) exposure causes approximately 1.2 million deaths globally each year. Exposure to SHS during pregnancy has negative health effects both for the mother and for her baby, including preterm delivery, low birth weight, and congenital malformations. Most of the exposure to smoking during pregnancy occurs at home, mainly from the pregnant woman’s partner and/or other household members who smoke.

Studies have shown that SHS is more prevalent among disadvantaged populations such those from a low socio-economic background and ethnic minorities. Consequently, SHS exposure might be more prevalent among pregnant women who live in more ‘traditional’ or patriarchal families. A recent study in which we interviewed 68 pregnant and postpartum Israeli Jewish and Arab women regarding their experiences of SHS exposure during pregnancy, showed that many felt helpless in their ability to change their exposure. These feelings of helplessness were also evident in a similar study among Arab Israeli women regarding SHS exposure at home (not specifically during pregnancy), mentioning that cultural norms, such as the man owning the house and the woman’s social status, contribute to women’s lack of ability to prevent their SHS exposure.

Many of the interventions to date have been directed at the pregnant woman herself, meaning that the pregnant woman is expected to influence her partner to change his behavior. However, this does not take into account the familial and social context and the woman’s ability to influence her partner’s behavior. Social circumstances may preclude women from feeling it is safe or that they are able to confront their partner and ask him to avoid smoking at home and in the car. The few interventions that did include the partner focused on getting him to quit smoking, which has a low success rate even when one is highly motivated.

A recent qualitative study we conducted among 24 Israeli expectant fathers revealed that many of them wanted to protect their spouse and their baby to the best of their ability, but felt that the addiction was too strong, coupled with many other stressors that were considered as significant barriers to quitting smoking. More importantly, expectant fathers explicitly spoke about wanting it to be their “own” decision, without being told what they “have” to do. Therefore, providing options that can support expectant fathers to reduce their spouse and baby’s exposure, such as through a gradual implementation of a smoke free home and car, might show promise as a future direction for interventions. A study among fathers in Scotland found similar results, highlighting how fathers perceive themselves in the ‘father-protective’ role, and their need to also be a positive role model for their children.

Furthermore, a few recent studies have shown promise for a new strategy of using Nicotine Replacement Therapies (NRT) as an aid to creating a smoke-free home (without quitting). NRT are currently used as a smoking cessation pharmacotherapy, sold over the counter, available in different forms such as gum and lozenges, and can be used sporadically as needed. Therefore, NRT might be an acceptable strategy for expectant fathers to overcome some of the barriers they have, using them within the home/car to deal with craving when unable to go outside to smoke.

In conclusion, future interventions to reduce SHS exposure during pregnancy should move beyond the pregnant woman, and be inclusive of the partner and all family members who smoke. Findings from recent studies mentioned above and published in Nicotine and Tobacco Research, have highlighted several strategies that might improve future interventions directed explicitly at expectant fathers, including a focus on their autonomy using a more masculine lens, highlighting shifting views on their role as fathers, and using NRT as an aid to creating a smoke free home and car.

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Cooperation and the history of life: is natural selection a team sport?

Cooperation is in our nature, for good and for ill, but there is still a nagging doubt that something biological in us compels us to be selfish—our genes. This is the paradox: genes are inexorably driven by self-replication, and yet cooperation continually rears its head. Not only are humans fundamentally team players, but all of nature has been teaming up since the dawn of life four billion years ago. The rules of cooperation that we encounter in our daily lives are fundamentally the same as those that apply to how our cells cooperate within the body, how the parts of the cell came to work together, and how selfish genes cooperate to make social beings. Though simple, these rules play out in complicated and fascinating ways that illuminate everything from the profound to the trivial.

Cooperation is defined as a social behaviour by one individual that benefits another at a cost to the cooperator. It evolves when the benefits to the cooperator exceed the cost of cooperation—a situation that might seem rare, but in fact is very common. Benefits can accrue to a cooperator in two ways, either directly or indirectly, through relatives. Benefits to relatives, or kin selection, explain why, for example, long-tailed tits will help their neighbours raise a brood when their own has been lost. Neighbours tend to be relatives. The cells of a multicellular organism cooperate for essentially the same reason: all are relatives. We don’t usually think of the cells of the body as being relatives of one another, but that is what they are, albeit genetically identical ones.

Uncovering the benefits as well as the costs to cooperation is key to understanding both its evolution and the situations in which it breaks down. Cooperative behaviour is conditional on there being a net benefit and it can disappear when the advantage is lost. Even an intimate symbiosis like a mycorrhizal association between a plant and a fungus will dissolve if the plant can obtain nutrients normally supplied by the fungus more easily from elsewhere.

I like to think of groups of cooperators as teams, because this idea is familiar and captures the essence of how cooperation produces benefits for individuals. Calling the plant and fungus in a mycorrhizal association a team may sound like a metaphor, but it is more than that because the individual benefits of cooperating in a team are the same, whether the game is football or natural selection.

Teaming up can produce direct benefits to team members in two distinct ways: through force of numbers and through division of labour. A team of 11 will beat a team of 2. This has to be how social insects with thousands of workers evolved. But force of numbers alone is not enough. The highest score that a team of 11 goalies can expect is nil-nil. A division of labour among the team, placing players in different positions according to their skills and the overall strategy, wins matches. Likewise, social insects have one or a very limited number of queens with the exclusive role of reproduction. Other castes such as workers assume different tasks, depending on their phenotype, age, and the size of the colony.

Individuals stick with the team so long as their interests are aligned with those of other team members, but this can never be taken for granted. Since cooperation involves costs as well as benefits, there is always the possibility that some individuals will try to take the benefits for free—or in other words—cheat. Tumour cells are cheats. Mutation breaks the alignment of interests that normally exists among the cells in a body, allowing a cancer cell to escape the many mechanisms that normally limit cell proliferation and to multiply at the expense of the host. The most dangerous and successful tumours recruit the assistance of normal cell types, acquiring a blood supply. Such cells cross the line from cooperation to parasitism.

Cheats may be found wherever there is cooperation, but cooperation thrives, nonetheless. Its most spectacular successes occur when members of a symbiotic team start to reproduce as a team, uniting their reproductive fates within a new kind of individual. This is what happened when the ancestor of the eukaryotic cell teamed up with the bacterial ancestor of the mitochondrion. The union of the two ancestral cell types produced a new kind of cell and a major transition in evolution.

Metaphors can help explain a difficult concept, but they can also mislead because at some point even good metaphors fail when taken literally. ‘Selfish gene’ is exactly such a metaphor. It has illuminated the science of social evolution for half a century since it was coined by Richard Dawkins, but it has also misled people into underestimating the importance of cooperation. Instead, let us think of natural selection as a team sport: on every level, from genes and cells to social beings, the team structure of life exists.

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Speech, AI, and the future of neurology

Imagine what your life would be like if you did not know where you are or who you are with, and a young man told you, “We’re home and I’m your son.” Now imagine how you would feel if your body became still when you want to walk or shaky when you try to keep still. Do it. Take a moment and think about it.

Those who do not need to imagine are the 55 million people living with Alzheimer’s and the 10 million living with Parkinson’s, respectively, as they experience similar challenges every day. While these figures raise concern, future projections are alarming: by 2050, the number of cases is expected to double in high-income countries and triple in low/middle-income countries. Things are particularly bleak in the latter, as they account for 60% of the cases but less than 25% of global investment in research, prevention, diagnosis, and treatment.

With growing patient-per-clinic ratios and soaring inequities across the globe, how will we detect these diseases early and massively enough for timely intervention? What solutions could balance the scales of brain health worldwide? An unsuspected answer involves combining natural speech and artificial intelligence. Yes, this sounds like another flight of imagination, but it all rests on solid science.

Tracking diseases

Alzheimer’s and Parkinson’s are neurodegenerative disorders, characterized by progressive atrophy of distinct brain regions. Alzheimer’s usually begins with neuron degeneration in the hippocampus and temporal lobe, affecting memory and several other abilities. In Parkinson’s, neuronal degradation begins in the basal ganglia, leading to motor and cognitive difficulties. Yet, this is just the tip of the iceberg. For patients, these diseases are disabling and often fatal. For families, they undermine emotional stability, financial solvency, and quality of life. For governments, they challenge health systems’ infrastructure and finances. Thus, these conditions project from the brain onto society, tracing a devastating trajectory.

That is why timely detection is crucial. Early diagnosis can mitigate the impact of symptoms, reduce their emotional burden on patients and caregivers, increase time to plan neuroprotective habits, and reduce costs by favoring routine over emergency care. Note that these diseases are incurable. Rapid and mass detection is our best alternative; and this is precisely where the need for innovation emerges.

Today, diagnosis rests on interviews with specialists, extensive paper-and-pencil tests, and, when conditions allow, brain MRI studies and biomarker assessments. These procedures are invaluable, but imperfect. Many countries lack enough qualified personnel and appropriate technology (and when these resources exist, their costs can be prohibitive). Furthermore, outcomes depend on the judgments of examiners, who vary in training and experience. Moreover, assessments are usually stressful and appointments take weeks or months. Worse yet, these limitations are exacerbated as patient numbers increase and socioeconomic disparities between countries deepen. An urgent need thus arises for new affordable, user-friendly, scalable, and immediate approaches.

Red flags in speech

This is where digital speech biomarkers come into play. Suppose that Tom, who is pushing 70, has been showing signs of cognitive decline and you suspect he might be suffering from Alzheimer’s. What if you asked him to recount a memory and an app detected traces of the disease in his speech? This non-invasive, low-cost approach offers real-time results without the need to visit a clinic, sparking great enthusiasm. Yet, how exactly does it work?

The key is that when we speak, we engage multiple brain regions that are affected by these diseases. Some, such as the hippocampus and the temporal lobe, are involved in accessing words as discourse unfolds; others, like the basal ganglia, coordinate the physical movements during speech production. So, if such regions were atrophied, one would expect alterations in the types of words used, their articulation, or other relevant aspects. By testing specific linguistic dimensions, we can uncover the integrity or dysfunction of those brain areas.

The first step is to record the natural speech of individuals with and without a given disease (the more, the better). Subsequently, complex algorithms quantify multiple aspects of the recording (say, speech rhythm) and its transcription (say, word properties). These metrics are used to train computational models that learn the typical speech characteristics of diagnosed individuals and healthy ones. Once the model is trained, it is presented with acoustic and linguistic measures from Tom, and, essentially, queried with this question: “Model, based on what you’ve learned, does Tom have the disease or not?”

In a recent study, our team identified Alzheimer’s disease with nearly 90% success via word property analysis. The model learned that patients, compared to their healthy peers, use words with higher frequency (‘doctor’ rather than ‘physician’), lower specificity (‘dog’ instead of ‘poodle’), and more common sound sequences (like ‘bat’, which resembles ‘cat’, ‘fat’, ‘mat’, ‘rat’, ‘bet’, ‘bit’, ‘bought’, ‘boot’, ‘bad’, ‘bag’, and ‘ban’; as opposed to ‘giraffe’, whose sound sequence is quite unique). Indeed, these lexical properties predicted the patients’ level of cognitive decline and brain atrophy. The reason is quite simple: word selection is a central function of semantic memory, which becomes impaired since the onset of temporo-hippocampal atrophy in Alzheimer’s. When navigating semantic memory, people with the disease prioritize the most accessible parts of their vocabulary, consisting of frequent, unspecific, and common-sounds words. And the more severe their disorder is, the simpler the words they favor.

In another study, we detected Parkinson’s disease with over 90% accuracy by measuring motor aspects of speech. We found that patients, compared to healthy individuals, leave longer pauses between words and produce less recognizable sounds. These patterns even differentiated between disease variants. Once again, the finding is clear. Speech production requires coordinating movements of the tongue, lips, and vocal cords, among other organs. Since basal ganglia atrophy affects motor skills, these actions in people with Parkinson’s prove slow, shaky, and imprecise. The audio signal carries traces of these alterations.

The breakthroughs do not stop there. These methods can anticipate who will develop specific conditions in the future. Some studies also suggest that they outperform standard tests in estimating disease severity and discriminating between syndromes. The approach has been validated with data acquired in hospitals and over the phone, incorporated in clinical trials, and harnessed by user-friendly apps. These are critical milestones towards rethinking clinical assessments.

A story in the making

For all its promise, this story is only beginning. The approach requires more validation, especially in large groups of patients. New studies should focus on vulnerable populations to balance the abundant data coming from high-income countries. More generally, a digital medical culture must be cultivated for clinicians to incorporate computational tools. Of course, these milestones demand concerted efforts of scientists, medical professionals, patients, family members, companies, and policymakers. None of this is easy or immediate. The path from science to clinical practice and public policy is long, crooked, and uphill.

Fortunately, this is not an isolated endeavor. Various teams are working on other digital tools for disease detection, including eye-tracking devices, motion sensors, and gamified cognitive tests. Speech analysis is part of a vast movement pushing for clinical equity through technological innovations.

To conclude, imagine that we can detect these diseases before Tom shows symptoms of decline. Imagine doing so by reducing the social gaps among world nations. And imagine a future where all this needs no longer be imagined. If such a day ever arrives, it will be through disruptions like this.

_{Featured image by TungArt7 via Pixabay.}

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Behind the scenes: what it’s like to be a junior author for the <em>OHCM</em>

To mark the release of the much anticipated 11th edition of the Oxford Handbook of Clinical Medicine (OHCM), Oxford University Press spoke with the three new authors of this edition: Peter Hateley, a GP based in New Zealand; Dearbhla Kelly, a Critical Care Medicine fellow in Oxford; and Iain McGurgan, a Neurology Resident in Switzerland. The author team shared their experiences of writing the world’s best-selling medical handbook.

How did you get involved with being a junior author for OHCM?

PH: I’d done some medical editing and journalism while at medical school. I really enjoy teaching and, in particular, the place where teaching meets writing. I loved reading the OHCM while at medical school, so I threw myself at the chance when I saw an advert online to be a junior author.

DK: I read a tweet from a previous author whom I greatly admire, in which she promoted the opportunity and described what a positive experience it had been for her. Like Pete, I also needed little encouragement as the OHCM holds a special place in my heart as the talisman of my (very) junior doctor days.

IMG: The OHCM is an institution that carried me through medical school and beyond; I couldn’t resist when I saw the call for applications! Funnily, Dearbhla and I worked in the same service at the time, but we didn’t clock that we had both applied until we had made the final cut many months later, when we asked one another to cover a shift at the exact same day and time (the final interview).

What were the best things about your experience as an OHCM author?

PH: Working towards a book that provided so much enjoyment (and frantic revision material) for me personally, and for many more internationally. I had particular fun writing some of the more creative parts of the OHCM; as is the tradition, the book is peppered with asides that encourage thinking about the world from the patient’s perspective. The team at OHCM have been brilliant, a great source of support and knowledge throughout the process.

DK: I enjoyed getting to add new sections or pages that I vividly recall searching for in vain during my time as an intern! It was also a very educational and enriching experience to read the literature and guidelines across such a range of medical specialties. I too am grateful for the kindness and patience of all the senior authors and OHCM publishing team.

IMG: The opportunity to work alongside and learn from such an incredible team (co-authors, senior authors, specialist readers, junior readers, editors, and the publishing team at OUP). I had (and still have) a great deal of imposter syndrome!

And what were the most challenging parts?

PH: As with most of our readers, we had the challenge of the pandemic and its aftermath to juggle alongside our other clinical work. This left our writing on the back burner for a while, and some updated guidelines to read on our return! It’s been a fun challenge reducing each topic to be most useful and relevant to our readers.

DK: Balancing pertinent detail with succinctness/word count limits! As Pete acknowledges, the pandemic-sized interruption in the middle of our writing created some challenges in terms of keeping the writing up to date since the nature of evidence-based medicine and best clinical practice is so dynamic.

IMG: Keeping the H in the OHCM! The temptation was always to add more and more material. I learned that it’s so much easier to write than remove.

How did you manage to juggle writing with your clinical work, studies, and home life?

PH: With great difficulty! All my time planning went out of the window with the pandemic (the best-laid schemes of mice and men…). Making time for writing alongside exams led to a few long evenings of writing. It’s been a good lesson on balancing work and life a little better, and a reminder of the value of supportive family, friends, and colleagues!

DK: I am still looking for some suggestions! For me, it was forgiving family, friends, and colleagues.

IMG: My experiences were identical to those of Pete and Dearbhla above. Sleep was the ball the most frequently dropped for me. I felt it was too hypocritical to add a sleep hygiene section to the book, so that will have to wait until the 12th edition and a better time-managing author than me.

What tips would you pass on to aspiring Handbook authors?

PH: In our digital age, information is often already there to be searched but can be dry to read. I’d suggest considering: how will my writing help people to really remember that information? More importantly, how will I incorporate the human, empathic core of being a doctor? I think the OHCM does that really well.

DK: Perfection is the enemy of good! The expert feedback of the specialist reviewers is also such a helpful and practical resource when wading through the waters of an unfamiliar medical specialty.

IMG: I tried to review my work as if I were reading it for the first time, frantically poring over every word on a trembling page on the eve of exam, or hiding out of sight of the ward round to assimilate some knowledge that I ought to have had already! This helped me to keep it (I hope) relevant, reliable, and readable.

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When health care professionals unintentionally do harm

The Hippocratic Oath, which is taken by physicians and implores them to ‘first, do no harm,’ is foundational in medicine (even if the nuances of the phrase are far more complex than meets the eye). Yet what happens when doctors bring about great harm to patients without even realizing it? In this article, we define microaggressions, illustrate how they can hinder the equitable delivery of healthcare, and discuss why the consequences of microaggressions are often anything but “micro”.

What are microaggressions?

Microaggressions can be defined as actions, gestures, or even environments that subtly and often unintentionally harm members of marginalized groups. Some examples include when a healthcare professional speaks slowly and loudly to an elderly patient (who is neither hard of hearing nor cognitively impaired) and when medical clinics don’t have hospital gowns or blood pressure cuffs that fit people with larger bodies (or furniture that they can comfortably use).

In response, you might think that in the first case, it’s just an honest mistake committed by a well-meaning individual; and in the second case, it’s not a big deal since it’s nobody’s fault—there’s not even a specific individual to hold responsible.

So how and why are each of these examples microaggressions? And what kind of harm do they cause?

The healthcare professional who speaks loudly and slowly to an elderly patient, based on assumptions and stereotypes about what elderly people are like, might be thinking that they are acting in a way that can benefit the patient. Their reasoning (conscious or not) might be something like this: “elderly patients tend to be hard of hearing and suffer from cognitive impairment and thus the louder and more slowly I speak, the more it will help the patient hear and understand what I’m saying.” However, this elderly patient is not hard of hearing or cognitively impaired. In fact, the loud, slow speaking lands quite differently from their perspective. It might make them feel as though the healthcare professional has not taken the time to get to know them. This can lead to the patient not feeling properly seen, heard, or understood. And this, in turn, can result in the patient not feeling comfortable around the healthcare professional and not trusting them.

With regards to medical clinics not having hospital gowns or blood pressure cuffs that fit patients with larger bodies, or furniture that can comfortably accommodate them, one might think that given the relatively small number of patients who might need to make use of these resources, the impact is relatively low. But the Hippocratic Oath and the imperative to “first, do no harm” applies to all patients—some patients should not be excluded from proper care simply because their bodies fall outside of a normative ideal of what bodies ought to look like. All patients deserve recognition, respect, and the means to receive comprehensive, high-quality care. To be denied this sends the message that one is abnormal, that they do not belong, or that they are not respected enough to be treated fairly in healthcare spaces.

How do microaggressions hinder the delivery of healthcare?

As we can see from these examples, the harms of microaggressions are only “micro” from the perspective of the one committing them. From the perspective of patients, the harms aren’t “micro” at all. Microaggressions can result in the immediate harms of feeling disrespected or invisible. But they can also contribute to long-term harms. For the elderly patient, even though the microaggression was committed with no ill intent, the healthcare professional failed to treat the patient as a dignified human being, worthy of respect. As a result, the patient’s sense of self is undermined and the stigma associated with being elderly in an ageist society is worsened.

The same is true with pervasive anti-fat bias both within and beyond medical contexts. People with larger bodies are disrespected, degraded, and pathologized. When they enter medical spaces only to find that their larger bodies literally cannot be contained by the furniture, that medical devices cannot be used on them, and that medical gowns cannot cover their bodies, their sense of self and self-worth is harmed. This can worsen anti-fat stigma and bias, making fat patients feel shame and hesitant to seek medical care at all.

The consequences of microaggressions are anything but “micro”

Trust is the cornerstone of high-quality medical care. Yet microaggressions can corrode the trust of patients: both their trust of individual providers but also their trust in the institution of medicine more broadly. Distrust in practitioners and institutions can contribute to delaying or foregoing medical treatment, missed or incorrect diagnoses, prolonged illness, and sometimes even unnecessary death.

The upshot is this: when one’s health, well-being, and in many cases one’s very life is at stake, it’s imperative for there to be a trusting, positive relationship with those in charge of the treatment and care. Experiencing microaggressions in medical contexts, however, can undermine this trust. Thus, we must bring attention to microaggressions that arise within medical contexts in order to work to diminish them as much as possible. Doing so can be one important step in building a more just and equitable healthcare system.

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The importance of sun safety: Sun Awareness Week 2024

Sun Awareness Week (6-12 May) kicks off the British Association of Dermatologists’ (BAD) summer-long campaign dedicated to raising awareness of non-melanoma skin cancer, a very common type of cancer. The week also aims to teach the public about the importance of good sun protection habits, including ways you can check for signs of skin cancer.  

What is non-melanoma skin cancer, and how does it differ from melanoma?

Non-melanoma skin cancer is a group of cancers that develop in the outer layer of the skin, unlike melanoma which starts in the cells that produce pigment in the skin.

The two most common types of non-melanoma skin cancer are basal cell and squamous cell carcinomas, which are keratinocyte cancers. They can be prevented and treated with sun avoidance behaviours, but their prevalence is on the rise.

John Ingram, Editor-in-Chief of the British Journal of Dermatology, believes that Sun Awareness Week is a good time to spotlight recent research outputs in the fields of melanoma and non-melanoma skin cancer. A new collection from the BAD journals presents key research studies on the topic, ranging from the use of artificial intelligence large language models in management advice, to skin risk evaluation for people of colour with a history of non-melanoma skin cancer.

Let’s look at some of the key findings from the collection:

Actinic keratosis is a global health concern

Actinic keratosis is a form of dry, scaly patches of skin caused by sun damage. In a recent systematic review, it was found that actinic keratosis has a global prevalence rate of 14%, with prevalence increasing the closer you get to the equator. Wearing sunscreen and sun-protective clothing has been shown to help reduce its prevalence.

Genetic factors may put you at higher risk of nodular melanoma

Nodular melanoma is an invasive type of melanoma that appears as an enlarging lump that is often diagnosed at later stages than non-nodular forms of melanoma. A study found that an increased number of rare gene variants could help identify patients at higher risk of this form of melanoma.

People of colour at risk of developing melanoma following keratinocyte carcinomas

Patients with a history of keratinocyte carcinomas are at an increased risk of developing melanoma but there is a lack of research on patients with skin of colour. A recent retrospective study investigated the risk of melanoma in skin of colour patients with a history of keratinocyte carcinoma and found that it was associated with an 85% increased risk of melanoma.

Non-melanoma skin cancer is predicted to have a higher mortality rate than malignant melanoma

In another recent study, it was predicted that non-melanoma skin cancer mortality will soon be higher than malignant melanoma, reaching this threshold first in Scotland (2028), followed by the United States (2031), Australia (2033), and England (2038), but later for Nordic countries (beyond 2050).  

Autoimmune hepatitis is linked to melanoma and non-melanoma skin cancer

Autoimmune hepatitis is a disorder characterized by its remitting course, often requiring long-term immunosuppressive therapy. A study showed that patients with autoimmune hepatitis had increased odds of developing basal cell carcinoma, cutaneous squamous cell carcinoma and melanoma. Due to their increased risk of skin cancer, patients may benefit from regular dermatological care and skin examinations.   

IBD drug is linked to a higher risk of cutaneous squamous cell carcinoma

Azathioprine is a drug used to treat inflammatory bowel disease (IBD). A recent study found a 56% increase in the risk of cutaneous squamous cell carcinoma in patients taking azathioprine compared with those taking other immunosuppressive drugs. As newer immunosuppressive agents become available, clinicians should carefully consider the individual’s skin cancer risk before prescribing. 

Self-perception impacts sun-related behaviours

A survey of over 5,000 people found that those who perceived their health as positive were associated with higher odds of tanning and sunburn history. These individuals may be more likely to spend time outdoors and be more willing to practise risky behaviours.

Low sunscreen use recorded in students 

Sunscreen use in the United States was shown to be relatively low in a student study, with men of colour and older adolescents at the greatest risk for not using sunscreen at all. Reasons for avoiding sunscreen use were multifactorial, including lower levels of skin cancer knowledge, viewing sunscreen as a beauty product, and social-cultural norms. Skin cancer prevention will need to target these specific populations to generate the most significant impact on changing sunscreen habits.

Can artificial intelligence (AI) provide clinical advice about melanoma?

This study showed that ChatGPT marginally outperforms BARD and BingAI in providing reliable, evidence-based clinical advice for melanoma. However, these technologies still face limitations in depth and specificity and further research is needed to improve their performance.

Sun Awareness Week highlights the need for sun protection, education, and awareness about lesser-known skin cancers, as well as the increasing burden of non-melanoma skin cancer. If there are any changes to skin lesions or moles, then it is best to consult your doctor.

Contribute to the conversation this #SunAwarenessWeek and explore the latest research collection from the BAD journals.

_{Featured image by NicholayFrolochkin via Pixabay.}

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The hidden toll of war

During war, the news media often focus on civilian injuries and deaths due to explosive weapons. But the indirect health impacts of war among civilians occur more frequently—often out of sight and out of mind.

These indirect impacts include communicable diseases, malnutrition, exacerbations of chronic noncommunicable diseases, maternal and infant disorders, and mental health problems. They are caused primarily by forced displacement of populations and by damage to civilian infrastructure, including farms and food supply systems, water treatment plants, healthcare and public health facilities, and networks for electric power, communication, and transportation.

Increasingly, damage to civilian infrastructure is caused by targeted attacks—as a strategy of war, resulting in reduced access to food, safe drinking water, healthcare, and shelter. When water treatment plants and supply lines are damaged during war, people often have no choice but to drink water from sources that may be contaminated with microorganisms or toxic substances. Healthcare facilities have been increasingly targeted during war; for example, during the first 18 months of the war in Ukraine, there were 1,014 attacks on healthcare facilities, which injured and killed many patients and healthcare workers, and caused much damage, which reduced access to healthcare for many people.

Globally, there are now more than 108 million people who have been displaced from their homes, many as a result of war. Most of these displaced people have been internally displaced within their own countries, often facing greater health and security risks than refugees, who have fled to other countries. And during war, many more people live in continual fear that they may be forcibly displaced.

Major categories of communicable diseases during war include diarrheal diseases and respiratory disorders. These diarrheal diseases result mainly from decreased access to safe drinking water and reduced levels of sanitation and hygiene, leading to increased fecal-oral transmission of bacterial and viral agents. Among respiratory disorders, measles is of great concern because it is highly contagious and associated with high mortality rates among unimmunized children. Another major concern is tuberculosis, which can spread easily among war-affected populations and is difficult to treat without continuity of care. Crowding in bomb shelters, refugee camps, and other locations during war facilitates the spread of both diarrheal diseases and respiratory disorders. Disruption of public health services leads to reduced access to immunizations and reduced resources to investigate and control outbreaks of communicable disease. During war, bacterial resistance to antibiotics increases because people have decreased access to antibiotics and therefore take inappropriate antibiotics or shortened courses of treatment.

Malnutrition often increases during war, thereby increasing the risks of acquiring and dying from many communicable diseases. Infants and children are at greatest risk of becoming malnourished and suffering from its adverse health consequences. Micronutrient deficiencies during pregnancy can lead to birth defects. And severe malnutrition during war can increase the risk of hypertension, coronary artery disease, and diabetes in later life.

During war, exacerbations of preexisting cases of noncommunicable disease increase, mainly because of reduced access to medical care and medications for treating common chronic diseases. For example, a survey by the World Health Organization in Ukraine in 2022 found that about half of the respondents experienced reduced access to medical care and almost one-fourth could not acquire necessary medications that they needed. Without these medications, people with hypertension were at increased risk of myocardial infarction and stroke, people with asthma were at increased risk of life-threatening attacks, people with diabetes were at increased risk of serious complications, and people with epilepsy were at increased risk of seizures.

War exerts adverse effects on reproductive health. Access to prenatal care, postpartum and neonatal care, and reproductive health services are frequently decreased. As a result, complications of pregnancy, including maternal deaths, occur more frequently and there are increased rates of infant deaths and of infants being born prematurely or with low birthweight.

Mental and behavioral disorders occur more frequently during war, including posttraumatic stress disorder (PTSD), depression and anxiety, alcoholism and drug abuse, and suicide. There are many contributing factors to increasing the risk of these disorders, including physical and sexual trauma, witnessing of atrocities, forced displacement, family separation, deaths of loved ones, loss of employment and education, and uncertainty about the future.

Violations of human rights and international humanitarian law occur frequently during war. In addition to those already mentioned, these violations include gender-based violence, summary executions, kidnapping, denial of humanitarian aid, and use of indiscriminate weapons, such as antipersonnel landmines.

The possible use of nuclear weapons represents a profound threat whenever nuclear powers are engaged in war, partly because these weapons could be launched by accident or because of misinterpretation or miscommunication. Even a small nuclear war could cause huge numbers of deaths and severe injuries and could lower temperatures globally, leading to widespread famine.

Environmental damage during war can result from chemical contamination of air, water, and soil; presence of landmines and unexploded ordnance; release of ionizing radiation from nuclear power plants or conventional weapons containing radioactive materials (“dirty bombs”); destruction of the built environment; and damage to animal habitats and ecosystems. In addition, war and the preparation for war consume large amounts of fossil fuels, which generate greenhouse gases, which, in turn, cause global warming.

Protection of civilians and civilian infrastructure during war and improved humanitarian assistance can reduce the indirect health impacts of war. But the only way to eliminate these impacts is to eliminate war. The risk of war can be reduced by resolving disputes before they turn violent; by reducing the root causes of war, such as socioeconomic inequities, militarism, ethnic and religious hatred, poor governance, and environmental stress; and by strengthening the infrastructure for peace. Peace can be achieved and sustained by rehabilitating nations and reintegrating people after war has ended, strengthening civil society, promoting the rule of law, ensuring citizen participation, and holding aggressors accountable.

Barry S. Levy is the author of From Horror to Hope: Recognizing and Preventing the Health Impacts of War (Oxford University Press, 2022). He is an Adjunct Professor of Public Health at Tufts University School of Medicine and a past president of the American Public Health Association.

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Who do you think you are? Genetics and identity

Ethnicity and ethnic identity have been recently brought to the fore in the Western world. One important reason is that immigration and globalization have resulted in a variety of clashes among different groups in very different contexts. However, there is another reason: DNA ancestry testing. Margo Georgiadis, president & chief executive officer of the major company in the field, Ancestry.com, has estimated that in early 2020, 30 million people had taken a DNA test, of which over 16 million was with her company. These companies tell you that by simply spitting into a tube or swabbing the inside of your cheek, you can find out a lot about your origins and your ancestors through DNA. Indeed, the way these tests are sometimes marketed may make people think that ethnicity is something “written” in their DNA. In many cases, people have to deal with surprising revelations that make them reconsider their ethnic identity, and in some cases reveal that the person whom they called father is their biological one.

Identity matters a lot to people, because it affects both how we perceive ourselves and how we are perceived by others. There are two big issues with how people tend to think about ethnic identity. On the one hand, it is assumed that people of the same ethnicity are a lot more similar than they actually are. On the other hand, it is assumed that people of different ethnicities are much more different from one another than they actually are. Therefore, once considered as members of particular ethnic groups, each person is no longer considered as an individual, but as a representative of particular ethnic types. This has an important consequence: people are not considered on the basis of what they really are, but rather on the basis of what they are expected to be given the ethnic group to which they belong. And this is where false stereotypes can easily prevail. Here DNA ancestry companies enter the scene by arguing that their tests can indicate to which ethnic group one belongs. Thus, these tests privilege notions of ethnicity based on genetics, contributing to the myth of genetic ethnicities.

Research in psychology has supported the conclusion that people believe that they have internal, immutable essences that influence who they are. This kind of thinking is called psychological essentialism; when genes, and DNA more general, are considered as being these internal and immutable essences, the view is described as genetic essentialism. This is an intuitive view that makes people find natural that they belong in one or another group, as well as that these groups are internally homogeneous and entirely discrete from one another. Therefore, if people intuitively tend to think of ethnic groups in genetic essentialist terms, it might seem natural to them that there exist discrete ethnic groups that are both genetically homogeneous and genetically distinct from one another.

Ethnic groups are real, but are socially and culturally constructed. More often than not, these groups have not had continuity across time historically, linguistically, culturally, and of course biologically. However, people intuitively tend to essentialize these groups, and DNA often serves as the placeholders for this. Population genetics provides an objective means for distinguishing among human groups; however, even though there are many different ways to do this, people (and researchers themselves) often tend to privilege those groupings that align with previously perceived, extant categories, such as continental and racial groupings. People living in the same continent are indeed more likely to have recent common ancestors among themselves than with people living in other continents. But what really exists at the genetic level are gradients of genetic variation, not distinct groupings. Human genetic variation is continuous and the genetic differences among people are overall very minor. For this reason, ethnic groups, nations, or races are not biological entities.

As a result, any ethnically, nationally, or racially distinctive genetic markers exist only in a probabilistic sense, and what ancestry tests provide are just probabilistic estimations of similarities between the test-takers and particular reference populations, consisting of people living today. But being related genetically to people living today somewhere does not necessarily mean that their ancestors came from that place. Furthermore, as more people take such tests, these reference groups change and as a result the ethnicity estimates for the same person can change across time. DNA provides partial information about our ancestors, which is the outcome of a process of interpretation. Therefore, DNA cannot reveal our true ethnic identity and the genetic ethnicities to which test-takers are assigned are imagined. However, this does not devalue these tests as their results can indeed provide some valuable insights and information to people who may not know much about their ancestors. Indeed, the tests are very good for finding close relatives, and this is perhaps why the industry should be rebranded to DNA family testing.

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The need for expertise in quality improvement at every stage of a healthcare worker’s career

The quality improvement in healthcare movement has been around for the past 25 years with variable degrees of success. The focus on quality and safety commenced with the publication of a few seminal reports: Crossing the Quality Chasm and To Err is Human in the USA, and Organisation with a Memory in the United Kingdom. In 2018, just prior to the pandemic, two international reports, Crossing the Global Quality Chasm, a follow up of the initial report, and the Lancet Commission reported on the quality and safety of healthcare world-wide. These reports demonstrated that in lower middle income countries there was a challenge to improve safety and quality in the context of delivering universal health coverage. The quality of healthcare in upper income countries has improved but is variable. In 2021, the World Health Organisation published the Global Action Plan for Patient Safety, starting the decade with a focus on patient safety. All the reports documented the need to improve quality and safety of patient care. The COVID pandemic added to this imperative, and added new dimensions, such as the wellbeing of all.

Academics often focus on writing such reports, which are called for by policy makers who use them to develop strategic plans for action. The NHS and other health systems are littered with strategies that come and go with each leadership change. Strategies result in setting standards with a system of inspection and regulation. The reports and standards should be an impetus to change, but they are far removed from the realities of working on the frontline of healthcare. Standards and strategies to implement change do not necessarily improve the quality of care. The real question is how do we get smart people, i.e. doctors and nurses and other health professionals, to deliver safe, high quality care all of the time. An ongoing challenge has been spreading successful improvement outcomes at scale. Partly, this is due to a lack of sound implementation processes; partly, due to a lack of data on what works; and finally to a simplistic view that what is successful in one context can be applied elsewhere.

Healthcare policy planners have stated they want to have safe and person-centred healthcare services that are efficient and effective. The desired outcomes have not been widely achieved for several reasons including:

• the theories and methods are not understood or accepted by clinicians,
• there is limited published evidence that they are effective ,
• implementation is dependent on context,
• improvement initiatives may not have been applied in a logical and consistent manner,
• and there are competing demands and resultant time constraints.

The lack of uptake within the medical profession, and to a lesser degree by nursing and other healthcare workers, has been a specific challenge. This may be the result of jargon, the variable evidence base, and their lack of knowledge of the new sciences of improvement and implementation. The study of improvement theory and method is not an integral part of the medical curricula. We train healthcare workers to have excellence in subject matter knowledge but do not provide them with the education to apply that knowledge equally. If one adds the complexity of professionalism it is difficult to decrease the widespread variation that exists in the delivery of healthcare.

The understanding of what is required to improve healthcare and to be safe and person centred is now well understood. However, implementing what we know works is not easy. Setting standards is essential and can be regarded as Quality 1.0. Unfortunately, many see this as the solution when in fact it is only the start of the quality journey. Learning technical skills using the theories and methods of improvement can be termed Quality 2.0. This is where the focus has been for the past 25 years. Most interventions to improve quality of care have focussed on teaching healthcare workers patient safety or quality improvement methodology. This is essential but will not achieve quality care at scale. One must add ideas of implementation science and make quality relevant to the workforce in an age of pressing issues—such as climate change and the delivery of equitable care. This leads to a different approach to achieving quality.

The future of quality in healthcare is the coproduction of solutions and interventions, Quality 3.0. This process may use standards and improvement as well as safety theories and methods, but will be owned by the patients as well as doctors, nurses, or other healthcare workers. The transfer of power is challenging and complex. Yet if not adopted, it will be difficult to achieve high quality care at scale. Every healthcare worker requires the power, agency, and/or courage to improve care, supported by knowledge and expertise. Only then can there be a difference for the people receiving care.

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Could lonely and isolated older adults be prescribed a cat by their doctor?

Many older adults struggle with isolation and loneliness. Could cats be the solution? At the same time, many humane societies have more cats to rehome than they can manage. Could lonely older adults be the solution?

Researchers at the University of Georgia and Brenau University developed a novel program where older adults were paired with a foster cat coming from a local humane society, with the opportunity to adopt. A Human-Animal Bond Research Institute (HABRI)-funded feasibility study explored the impact of this program on the older adult participants and the cats. Researchers explored how fostering a shelter cat could impact loneliness and well-being in older adults living alone. They also wanted to learn if these older adults would be more likely to adopt their foster cat after common barriers, such as pet deposit fees, were paid by the study. Could it really be a win-win situation?

The study enrolled adults aged 60 and older living alone and without any pets. Participants completed health surveys before placement with cats and completed follow-up surveys at 1-month and 4-months post-placement. Participants could choose to adopt their foster cat any time between 1- and 4-months post-placement. If participants chose to adopt their foster cat, the study paid the adoption fee, and a 12-month post-placement survey was completed.

Findings from the study revealed that loneliness scores significantly decreased at the 4-month mark after the cat fostering began. A similar 4-month improvement that approached statistical significance was observed for mental health. However, at the 12-month follow-up, loneliness scores were no longer statistically significant. The researchers suggest that these one-year reports were impacted by the COVID-19 pandemic, which resulted in a substantial proportion of older adults experiencing elevated levels of loneliness. 

Alexis Winger and Ambi

Alexis states that before she got Ambi, “I lived alone, and the loneliness was becoming oppressive. Ambi has brought an end to oppressive loneliness. There are still times when I am away from people too long, when I have no one to talk to and lonelines settles in, but then Ambi settles into my lap or just runs through the room, and I am not alone. Ambi has brought me smiles, laughter, responsibility and love.”

The day that Alexis picked out Ambi at the Athens Area Humane Society to foster. Alexis states “I didn’t expect to find a cat for me at the first visit, but as I walked in, my eyes connected with hers in the end cage. The minute she was in my arms, she was mine.”

This is a picture and text message that Alexis sent to Sherry Sanderson, one of the researchers in the study, during the Pandemic.

Photo Credit: Alexis Winger

Alexis still gets lonely occasionally, but it is not the oppressive loneliness she felt before she got Ambi. Alexis says “Ambi has brought me an end to oppressive loneliness.”

Photo credit: Photo and text message Alexis Winger sent to Sherry Sanderson.

What about the cats? Almost all (95.7%) of study participants decided to adopt their foster cat at the completion of the study. Dr. Sherry Sanderson, the team lead and Associate Professor at the University of Georgia’s College of Veterinary Medicine, noted: “Our results show that by removing some perceived barriers to pet ownership, including pet deposit fees, pet adoption fees, pet care supplies and veterinary support, we can not only help older adults live healthier, happier lives but we can also encourage the fostering and adoption of shelter cats into loving homes”.

Dr. Kerstin Emerson, a Gerontologist in the College of Public Health’s Institute of Gerontology, Health Policy & Management at the University of Georgia, and an investigator from the study states, “In May of 2023, the U.S. Surgeon General stated that loneliness and isolation is an epidemic in this country, and their report placed an emphasis on the urgent need for a cure.” Dr. Don Scott, a Geriatrician and Campus Director of Geriatrics and Palliative Care from the Augusta University-University of Georgia Medical Partnership and also a researcher from the study, added, “The ill effects of loneliness and social isolation, particularly for older adults, are well-documented, and more strategies are needed to improve health outcomes for this population.” The investigators from this study plan to do a larger scale study. The hope is when an older adult seeks to prevent or ward off loneliness and isolation, they will collaborate with a support team prepared to explore feline companionship as part of an individualized holistic approach to care, and there will be programs in place and funding available to support this new approach to treating loneliness in older adults.

Judith Atkins and Bashi

Judith is semi-retired from nursing, but she still provides nursing care to some of the residents in the Senior Living Residence that she lives in. When recently asked what Bashi means to her, Judith sent back the following reply:

“He (Bashi) has been a comfort to two of my neighbors. While providing nursing care to a resident who was in hospice care, Bashi stayed with her until she died. I also took him to visit a resident with cancer and breathing problems when I went to visit. I also took Bashi to the nursing home to visit two people I took care of there.”

Judith went on to say, “He still enjoys catching balls and batting them into the hall closet, continues to steal straws from my drinks and claims all boxes. Best of all, he still likes my left shoulder to put his head on to make sure his world is okay. At night at times, I find him asleep on a pillow by my head. His love of people is unlimited, and he will try and go in any apartment with the door open to be loved on by strangers. He escapes into the hall to force me to exercise chasing him, and needless to say he is always the winner.”

Judith was ready to enroll in the study just days before the Pandemic occurred, and the Foster Cat Study was shut down for six months. Once the study resumed, participants were no longer allowed to go to the shelter to pick out their cats to foster. Rather Dr. Sanderson, would go to the shelter and send them pictures and videos of available cats they may be interested in. The picture on the left is from the very first time Judith met Bashi in her apartment. The picture on the right shows that their Human-Animal Bond remains strong. Photo credit: Sherry Sanderson

Judith and Bashi getting ready to make the rounds in the building to visit people. Photo credit: Sherry Sanderson

Judith and Bashi love to hold birthday parties at the Senior Living Residence where they both live. Here are pictures from Bashi’s second birthday party. Photo credit: (L) Sherry Sanderson; (R) Judith Atkins

_{Feature image by Pietro Schellino via Unsplash, public domain.}

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A spotlight on Native American language and religion [podcast]

The October release of Martin Scorsese’s latest film Killers of the Flower Moon has thrust the sordid history of America’s treatment of its indigenous peoples back into the public eye.

On today’s episode of The Oxford Comment, the last for 2023, inspired by the themes in Killers of the Flower Moon, and in celebration of National Native American Heritage Month in the United States, we spotlight two aspects of Native American culture that transcend tribe and nation and have been the recent focus of OUP scholars: language and religious beliefs.

For our first interview, we were joined by Rosemarie Ostler, author of The United States of English: The American Language from Colonial Times to the Twenty-First Century, to speak about the Native American English dialect, how English became more widely spoken amongst Native Americans, and current programs to preserve Native American languages. We then spoke with Gregory Shushan, author of Near-Death Experience in Indigenous Religions about near-death experiences, Native American myths, shamanism, and religious revitalization movements across indigenous cultures in North America.

Check out Episode 89 of The Oxford Comment and subscribe to The Oxford Comment podcast through your favourite podcast app to listen to the latest insights from our expert authors.

Recommended reading

You can read the chapter “Ethnic Dialects” from Rosemarie Ostler’s book, The United States of English: The American Language from Colonial Times to the Twenty-First Century, which presents the evolution of American English not as a dry collection of linguistic facts, but as an ever-changing story that’s part of the country’s larger cultural and political history.

Read the chapter exploring near-death experiences (NDEs) in “North America” from Gregory Shushan’s book, Near-Death Experience in Indigenous Religions, which examines the role culture plays in how people experience and interpret NDEs, and reveals how afterlife beliefs often originate in such extraordinary experiences.

You may also be interested in the chapter “Possession and dispossession: religion in Native America”, from Timothy Beal’s Religion in America: A Very Short Introduction.

If you want to learn more about Indigenous languages, keep an eye out for Lyle Campbell’s upcoming title, The Indigenous Languages of the Americas: History and Classification, and Nicholas Limerick’s Recognizing Indigenous Languages: Double Binds of State Policy and Teaching Kichwa in Ecuador.

_{Featured image: Arapaho Ghost Dance, 1900, U.S. National Archives and Records Administration via Wikimedia Commons (public domain)}

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Five unexpected things about medical debt

Debt is a subject that so many of us dread. It is a drain not only on our wallets but also on our minds, leaving us with the sense that our lives and our freedom are being slowly drained away. The consequences of medical debt, which is held by 100 million Americans, are even worse. Medical debt causes people to forgo (or be denied) necessary medical care, harms people’s credit, and leaves their property (including their bank accounts and even their homes) vulnerable to foreclosure.

In Your Money or Your Life: Debt Collection in American Medicine, I detailed some odd particularities about medical debt. Here are five:

1. Your medical debt can land you in jail

Debtors’ prisons have been illegal in the United States for centuries, but Americans are still jailed because of medical debt. If hospitals and their debt collectors decide to sue a patient for medical debt and win the judgment, a patient might be summoned to court for a hearing to “discover” where their assets are located. If a patient fails to appear in court for an oral examination as part of this process of discovery, the creditor can request that the court issues a “body attachment” directing the sheriff to arrest the debtor. Technically, the debtor is being arrested for contempt of court, not the debt itself, but the debt is the fundamental cause of the arrest.

The American Civil Liberties found that in 2020, 44 states still allowed the arrest of a debtor for failing to appear in court or failing to provide information to creditors after a judgment against them. Medical debtors are frequent victims of this practice. In Idaho, for instance, Medical Recovery Services LLC sought and obtained the arrest of more debtors than any other collector in the state between 2010 and 2016. In one case, a judge set bail at more than twice the amount of the debt. After being arrested for failing to appear for a hearing in Utah for unpaid debt for an ambulance ride, Rex Iverson was arrested and brought to the county jail. Later that day, when the police went to check the holding cell, they found Iverson dead; a subsequent investigation determined that Iverson had committed suicide by strychnine poisoning.

2. Hospitals can wipe away your bill before you see the doctor

To receive a tax exemption, every nonprofit hospital in the United States must have a financial assistance policy. These policies specify income qualifications for free and discounted care. But even if patients qualify for this “charity care,” they are usually made to complete onerous and detailed applications. But there is an easier way. Hospitals can use existing “presumptive eligibility” software to determine, at the point of care, whether a patient is likely to qualify for financial assistance. This is relatively easy to determine; for instance, if a patient is enrolled in food stamps, they meet eligibility criteria for most hospitals.

At Oregon Health and Sciences University in Portland, Oregon, the billing department started this using this software in 2017. Since instituting this process, patients have been offered free care earlier in the process, and the billing department no longer has to deal with as many incomplete applications.

Still, this effort to bring some efficiency and equity to billing is still not common practice. Hospitals must pay every time they use proprietary software to screen a patient. Most hospitals would rather not bother with the expense, so they leave the onus on patients to apply for financial assistance.

3. Medical debt is bought, sold, and collected by some of America’s wealthiest and most powerful people

The medical debt collection industry includes some of the world’s richest and most powerful people. In 2014, medical debt collector Transworld Systems was sold to a private equity firm called Platinum Equity. This firm was headquartered in Beverly Hills and owned by billionaire Tom Gores. As of July 2022, Gores was the 424^th richest person in the world, just behind Twitter founder Jack Dorsey and Star Wars creator George Lucas. Gores is best known as owner of the NBA’s Detroit Pistons, and as a philanthropist. He is a member of the Board of Directors of the UCLA Medical Center, a donor to Children’s Hospital Los Angeles and to various causes Detroit and Flint, Michigan, where he grew up. He is a giant of industry, and a fixture in the civic life of two great American cities.

Under Gores’ stewardship, Transworld Systems Inc. was not nearly so charitable as his public image. By 2017, it was the company with the most medical debt collection complaints on the CFPB’s database. One person in Georgia claimed that TSI had called a friend to find him (which is allowed), but during that call had said it was in regard to a medical debt that he owed (which is not). A resident of Illinois complained that a negative action had been filed on his credit report by TSI for a medical debt that he had never heard of, and was sure he did not owe. He said he had tried to call TSI numerous times to settle the matter but could never get anyone on the other end of the line.  Another in Missouri claimed that TSI called his work cell phone so often, and despite his pleas to them to contact them at home instead, that his supervisor became annoyed and passed him over for a pay raise.

4. Aggressive debt collection earns hospitals very little money

Not all hospitals are in financial trouble. In 2019, America’s hospitals recorded their highest average profit margin ever, at 6.7%. And while many hospitals struggled during the early days of the COVID pandemic, massive federal support led them to finish the year with similar profit margins as in 2019. Of course, there are many hospitals that do not operate with such comfortable margins; many struggle to stay afloat, and each year, some close.

But hounding patients who cannot afford to pay does precious little to help. TransUnion Healthcare reports that in 2016, 68% hospital bills of bills under $500 were not paid in full. Heftier bills were even less likely to be paid; 99% of hospital bills over $3,000 were not paid in full in 2016. This meager repayment is the reason why when hospitals sell their debt to outside buyers, they receive mere cents on the dollar. Most patients in arrears just don’t have the money to pay without risking their financial health, a problem that has given rise to a saying long in use among hospital administrators: “self-pay equals no pay.”

Suing patients does not meaningfully contribute to a hospital’s financial well-being. A study of Virginia hospitals that garnished the wages of patients found that they collected, on average, 0.1% of hospital revenue through this practice. Even the hospital that sued the most patients in the state, Mary Washington Hospital in Fredericksburg, gained only 0.2% of its revenue from wage garnishments. And most often it is not the struggling safety-net or rural access hospital filling the court dockets. Institutions that pursue patients as aggressively as possible frequently have comfortable operating margins and very well-paid executives.

5. Widows and widowers are being held responsible for repaying the debts of their late spouses

This strange fact is the result of a tangled legal history. Every state law includes a “doctrine of necessaries,” which makes parents liable for the support of their children; they must, in other words, provide what is “necessary for the health and well-being” of their children. In some states, however, this doctrine is also held to make spouses liable for the financial support of one another. This does not exist everywhere: in some states, such as Georgia, the spousal doctrine of necessaries has been repealed by the legislature, while in others, such as Florida, it has been ruled unconstitutional by the courts. But in states where the spousal doctrine remains, hospitals have used it to sue spouses when the patient has died before paying their bills. In fact, medical debt is the predominant kind of debt for which the doctrine of necessaries is invoked.

The doctrine of necessaries is a relic of early English common law in which women had no right to own property or assume debts independent of their husbands, so husbands were deemed to have an obligation to pay the necessary expenses of their wives. In an ironic interpretive move, given the burden it places on widows and widowers, the very fact that medical care is so necessary is what makes it so easy for hospitals to invoke the doctrine in court.

Widows have even been made to do manual labor to pay off the debts of their late spouses. Grieving the recent death of her husband after a prolonged hospitalization, Ms. Wilson faced medical debt she could never hope to repay on her fixed income. In 1995, Danville Regional Medical Center in southern Virginia gave her the option of entering a “Service-Credit” program, where patients owing between $300 and $20,000 were put to work typing, filing, housekeeping, lawn care and working in the print shop. For their labor, they earned $5 per hour toward settling their debts.  “Net pay is applied directly to the bill, so no cash changes hands,” explained a rather upbeat front-page article in the Richmond Times-Dispatch. Nowhere in the article was the possibility mentioned that the medical center, a non-profit, might just write off the unpaid debts of low-income patients as charity care. The journalist called the program a “working cure,” without a hint of irony.

The road ahead

The history recounted in Your Money or Your Life shows how medical debt transformed from a personal negotiation between doctor and patient into an impersonal financial instrument, bought and sold by people with no role in patient care and no social bonds to patients. Hospitals and their debt collectors have become aggressive in pursuing debts, threatening patients’ physical and financial health. There have long been people working to alleviate the suffering caused by medical debt, as well as abolitionists who aim for an America where such debt is a thing of the past. By better understanding how medical debt came to be so pervasive and so harmful to patients, we might help that day come sooner.

_{Featured image by camilo jimenez on Unsplash (public domain)}

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Infrastructure, public policy, and the Anthropocene [podcast]

On today’s episode of The Oxford Comment, we discuss the state of human infrastructure in the Anthropocene with a particular focus on how research can best be used to inform public policy.  

First, we welcomed Patrick Harris, co-editor-in-chief of the new transdisciplinary journal, Oxford Open Infrastructure and Health, to speak about the aims and scopes of OOIH, how OOIH is poised to meet the challenges of the Anthropocene, and the kind of research the editors are seeking. We then interviewed Jonathan Pickering, co-author of The Politics of the Anthropocene, the winner of the 2019 Clay Morgan Award Committee for Best Book in Environmental Political Theory. We spoke with him about how the shift from the Holocene to the Anthropocene has affected our core infrastructure systems and how good governance can help us mitigate the many challenges we’ll face in the future.

Check out Episode 88 of The Oxford Comment and subscribe to The Oxford Comment podcast through your favourite podcast app to listen to the latest insights from our expert authors.

Recommended reading

Upon the initial launch of Oxford Open Infrastructure and Health, co-editors Evelyne de Leeuw and Patrick Harris penned this blog post on the OUPblog, introducing the journal and detailing how OOIH will provide a link between infrastructure and both (inter)planetary and human health.

OOIH’s opening editorial, also written by the co-editors, elaborates on their vision for OOIH, provided greater context for the intersection between infrastructure and well-being, and presented the foundations of what future research published by the journal will need to include.

Human activities have a decisive causal influence on the Earth system, but to date the responses of the social sciences to the challenge have been inadequate. It is necessary to do better. Delve into the scholarship of our guest, Jonathan Pickering, and his co-author John S. Dryzek as they unravel the good, the bad, and the inescapable of our new epoch in this chapter from their book, The Politics of the Anthropocene.

The Anthropocene will not recede, and the central question of environmental management will be whether we can develop ways to reflexively and sustainably manage ecosystems, habitats, and human needs. This chapter examines four possible normative underpinnings for such management, from The Oxford Handbook of Environmental Political Theory.

The Anthropocene has emerged as a powerful new narrative of the relationship between humans and nature. Anthropocene: A Very Short Introduction draws on the work of geologists, geographers, environmental scientists, archaeologists, and humanities scholars to explain the science and wider implications of the Anthropocene. This chapter explores why we should accept that a new chapter of Earth history might indeed be unfolding, with humans playing a leading role.

This response to the editors’ essay by Phil McManus offered a clarification on what is termed infrastructure, and examined the history of urbanist programs as a means to inform today’s relationship between health and infrastructure as their intersection is more clearly defined.

The Anthropocene is not only a geological event but also a political, philosophical, and theological one. This chapter, from Call Your “Mutha’”: A Deliberately Dirty-Minded Manifesto for the Earth Mother in the Anthropocene, proposes that key to its undoing is decolonization, including of lands, waters, minds, and spirit, by drawing upon unjustly discredited knowledges, including Indigenous ontological conceptions of spiritual meanings that recognize the awareness and being of all terrestrial life, the inherent value of matter and the agency of Nature-Earth.

Explore the following Open Access articles from our journals:

• “The Paradox of Anthropocene Inaction: Knowledge Production, Mobilization, and the Securitization of Social Relations” by Madeleine Fagan in International Political Sociology (February 2023)
• “Ecosystems and Ordering: Exploring the Extent and Diversity of Ecosystem Governance” by Cristiana Maglia and Elana Wilson Rowe in Global Studies Quarterly (June 2023)

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Science in the time of war: voices from Ukraine

On 23 February 2022, I drove back to Michigan after giving a talk at the University of Kentucky on genome diversity in Ukraine. My niece Zlata Bilanin, a recent college graduate from Ukraine, was with me. She was calling her friends in Kyiv, worried. A single question was on everyone’s mind: will there be a war tomorrow? The thought of invasion, though, seemed unimaginable, illogical, even absurd.

At 2am, Zlata woke me up. “They are coming,” she said. I remember the color of her face–pale green. The world would never be the same again.

Indeed, the war has changed everything; priorities are no longer the same. Many researchers enlisted and went to fight. Others, their homes destroyed, fled. Many packed and crossed the border in the hope of a better life in the West.

Nearly 600 days later, the war continues, each day amplifying the human tragedy, of lives and futures lost—lives that could have otherwise been dedicated to better and more meaningful purposes.

As a researcher, my colleagues and I could not help but think about the crushing blow the war delivered to the vibrant Ukrainian scientific community. Ukraine is a country with incredible resources, unique human genetics given the land once served as a human migration crossroads, and a large dedicated, community of researchers working on numerous and varied projects. Now, however, research centers have been destroyed, and universities have few new students, as they now go to study abroad where there are opportunities, and they cannot be drafted.

Through all this, although my laboratory is at Oakland University, I continue to work with my colleagues back home, building a research program in genomics at my alma mater, Uzhhorod National University (UzhNU). Several years ago, my colleagues and I dreamed up a project to sequence a hundred Ukrainian genomes to provide data for researchers to have tools to study the history of migration, admixture, and distribution of medically relevant variation in the local population. This collaboration started with President of UzhNU, Prof Volodymyr Smolanka, a neurosurgeon by training, an effective administrator, and an active scientist.

Given his work and his position, for this blog post, I wanted a comment from him on the state of Ukrainian science since the start of the war. I called and asked, simply: “Is it harder or easier?” His reply was one that matches the current thoughts of those now involved in retaining and rebuilding Ukrainian scientific programs, “One thing I can say is that there is a lot less government funding. That’s clearly a negative. On the other hand, there seem to be more grant opportunities from international sources, and this helps us to stay afloat.”

“What about the people,” I ask, “How do they feel about science?”

“I would not say that they were optimistic. I am not sure that pessimistic would be the right word either. You know, those scientists that did not leave, they are working, they really want to work in science.”

Thinking about those who are not leaving, I contacted an old colleague who has stayed: Dr Serghey Gashchak, a legendary field biologist, who, among many things, worked in the Chornobyl Exclusion Zone and knew everything there was to know about animals in Chornobyl. We used to call him “Stalker” in reference to a 1979 Soviet science fiction art film about a post-apocalyptic wasteland called “The Zone.”

Given his research background and work in a disaster zone, I emailed Serghey about his thoughts on the current situation. “It’s impossible to work in the Zone these days,” he said. “The barbarians are not at the gates anymore, but there are no research projects, and if there were, there’s no one to work on them. Many of the research staff are fighting in the war. Perhaps it is time to close.”

I was stunned to hear that, knowing Serghey’s inquisitive nature, it was hard for me to believe he would just stop doing research, Worse, I realized, this was likely felt by many. While my head said this might be true, my heart felt there must be a way forward. But, with the war’s destruction of institutions and financial mechanisms, such a mechanism couldn’t rely on expensive infrastructure and top-down government funding schemes. That would take decades to rebuild. What was needed was a way to integrate Ukrainian research into the worldwide research community: to bring opportunity and virtual infrastructure to Ukraine. In fact, the basic mechanisms for bringing research to places all around the world have been in place for decades in the form of international courses and conferences, remote learning, and worldwide collaboration — quite simply we could take the current international infrastructure and modify it to empower researchers in disaster zones.

A case in point is a summer research program developed in 2022—during the war—that takes place at Uzhhorod National University, which, although it is in Ukraine, is a safe distance from the war zone. This research program is led by an international team: Drs Fyodor Kondrashov (OIST, Japan), Roderic Guigo (CRG, Spain), Serghei Mangul (USC), and Wolfgang Huber (EMBL, Germany). Here, international faculty come to Ukrainian students and continue to train them and engage them in work around the globe.

I called Dr Kondrashov at his home in Okinawa and asked what research area he thought would be most useful to bring to a devastated Ukraine. He replied immediately: “Bioinformatics is a good choice because you could accomplish a lot more with the same amounts of resources than in other disciplines, such as molecular biology.”

He was right. The hybrid nature of bioinformatics—combining biology, computer science, mathematics, and statistics—encourages cross-disciplinary collaborations essential for solving complex biological problems—that can easily be carried out across borders. More, skills in these areas are highly transferable, can involve people who work remotely, and can serve as a catalyst for revitalizing war-affected regions.

This is just one example of how already in-place international infrastructure can be brought to Ukrainian research, and it is now one of many ongoing projects to allow Ukrainian researchers to continue their work. Many more examples are presented in the recent review, Scientists without Borders in GigaScience. In fact, we have come to realize, and have described in the review, that these mechanisms can be expanded: taking suitable and already existing international mechanisms and infrastructure to areas anywhere in the world that have been destroyed by political strife and natural disasters.

For Ukraine, and personal involvement, I teach and train Ukrainian students remotely. It is well worth it: an example of the passion of young researchers to continue their training, to embrace new opportunities is Valerii Pokrytiuk. He was admitted to my graduate program in bioinformatics at Oakland University in Michigan, but before he could come, the war broke out. Valerii volunteered to fight and is doing so somewhere in Eastern Ukraine. Periodically, when conditions allow, Valerii still joins us online for book club discussions, lab meetings, and to listen to courses I teach.

The war continues. And so does our fight.

_{Featured image: “Bucha, Ukraine, June 2022” by U.S. Embassy Kyiv Ukraine, Wikimedia Commons (public domain)}

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