Journal articles on the topic 'Committee for Public Justice (U.S.)'

The aim of this paper is to review, based on the available sources, the role of democratic and civic forces in Montenegro which were against sending Montenegrin reservists to war in Croatia and Bosnia and Herzegovina. However, this topic can be analyzed from different aspects, social, political, national, sociological, international, historical, etc. The objective of this study is to highlight the most notable individuals, groups of intellectuals, political organizations, and other associations that advocated for anti-war policies, their treatment by the authorities, and the humiliation and persecution they suffered for their views, all within the social and political context of the time. One of the challenges in writing this paper was the lack of access to archival materials, which are still not available. Consequently, this study relied heavily on the excerpts of the only independent publication in Montenegro at the time, Monitor, and the newspaper Liberal, the publications of the Liberal Alliance, as they reported on anti-war protests, interviews with prominent intellectuals, forms of resistance of various organizations and parties. Although the press is a secondary source, it provided valuable testimony in the absence of archival material. Until recently, in Montenegro almost nothing has been written about the 90’s wars. What are the reasons? This can be the subject of a separate work. But we must state that this is no longer the case. The sources from a very valuable monograph were used in this paper, the monograph in which the facts about the new Montenegrin history were revealed to the scientific and wider general public - the facts which were kept as a secret until now. However, the participation of Montenegrin reservists both in the war in Bosnia and Herzegovina and in Croatia cannot be justified by any facts. Nevertheless, it should be kept in mind that at that time, Montenegro was a member of a two-member federation (Serbia and Montenegro) and was involved in the war following the instructions of the Supreme Military Command and the political leadership in Belgrade. Unfortunately, the Montenegrin leadership blindly followed that politic. The ruling elite of the Montenegrin politics in the conjunction with the military elite deceived the people by referring to the “heroic past”, tradition, patriarchal norms which dictated that it was a shame not to respond to a military call for “the defense of the homeland”. Progressive civic forces in Montenegrin society did not think this way, and a broad anti-war movement was formed, although it remained in the shadow of those who held power in their hands. Nevertheless, the actions of civic and reformist forces in Montenegro in the 1990s have left an indelible mark on modern Montenegrin history. In addition to trying to promote reason and help the voice of justice to win, they simultaneously fought for the restoration of state independence. It was a difficult and exhausting struggle, which is still not acknowledged properly. The committed mistakes, if they can even be called like that, for that is too mild a word, were accepted late by those who were at the head of political top of Montenegro. Many of the most vocal opponents of Montenegro’s participation in the war affected former Yugoslav republics and bearers of the fight for the renewal of the independence, like Slavko Perović. were totally forgotten.

Abstract Individuals and non-governmental organizations’ access to justice in environmental matters may be hindered by a variety of obstacles, such as the fulfillment of legal standing conditions. In this regard, the Convention on Access to Information, Public Participation in Decision-making and Access to Justice in Environmental Matters (Aarhus Convention), on its Article 9(3), imposes on each State Party the obligation to ensure members of the public, “where they meet the criteria, if any, laid down in its national law”, to have access to justice in order to challenge any violation of national environmental law. In this contribution, I focus on this provision with the purpose of assessing its normative content regarding the criteria for legal standing. To this end, I analyze the interpretation of Article 9(3) given by the Aarhus Convention Compliance Committee (accc), as well as the relevant case law of domestic courts and the Court of Justice of the European Union (cjeu).

The American Library Association (ALA), founded in 1876, demonstrated its advocacy for immigrants' rights and multiculturalism in adult library services, from 1918 to 1948 in the Committee on Work with the Foreign Born (CWFB), which served as a clearinghouse for Americanization (assimilation) services within a philosophical framework of cultural pluralism, now known as multiculturalism. The ALA CWFB throughout its existence depended on grants from the Carnegie Corporation from 1911 to 1961 through the American Association for Adult Education (1915-41), and the Ford Foundation, through its Fund for Adult Education (1951-61). Beginning in 1956 with the Library Services Act, the federal government began to fund libraries, including programs for immigrants, African Americans, Native Americans, and adult illiterates. Since 1972, the Reference & User Services Association (RUSA) has provided literacy training for foreign- and native-born adult illiterates; and the Public Library Association (PLA) has supported programs to prepare New Americans for citizenship. Since 1983, the ALA Ethnic and Multicultural Information Exchange Round Table (EMIERT) has encouraged access to multicultural publications and collaborates with ALA affiliates for various ethnic and minority groups. The ALA advocates for the rights of DACA recipients and supports the need for a DREAMER (Development, Relief, and Education for Alien Minors) Act.

The 1991 films of David Achkar, a French-Guinean filmmaker, and Raoul Peck, a Haitian filmmaker whose family spent many years in the Congo, intersect around Patrice Lumumba (1925-1961), the first Congolese prime minister and victim of a political murder. Both films remain intensely personal if not intimate. Achkar is reminiscent of Beckett in the depiction of “waiting for” an occurrence ever differed. What is haunting about Achkar’s quest is that the filmmaker is in search of his father Marof David Achkar (1930-1971), a choreographer of the Keïta Fodeba “Ballets Africains” (1955-1960) and cultural counsellor to the Guinean embassy in Washington (1960-1964). Marof had replaced Telli Diallo at the United Nations (1964-1968) when he worked against apartheid in South Africa; in 1968 U. Thant (secretary to the United Nations) recommended him to a post of high commissioner to the World Organization in Namibia, a proposal rejected by Sékou Touré (elected as the first President of Guinea, serving from 1958 until his death in 1984) who recalled him to Conakry. Upon his return to Guinea, Marof Achkar was arrested and brought to camp Boiro, where he was tortured, made to sign charges of embezzlement and executed on January 25, 1971. At the time, David Achkar was a child — something of the child remains in the biography of his father. Beyond his father’s political ordeal is the first-hand demonstration of the personal impact the execution had on him; he connects more publicly and didactically with the administration of justice versus political murders in his last film, Kiti, justice en Guinée (1996). Both Achkar and Peck employ collages of family reels, documentaries, and film that may be inspired by Surrealism, a movement mentioned in Death of a Prophet (1991). Peck also moved toward a stronger Marxist message in his 2017 film about the German philosopher, and though he has done several documentaries, he is attached to the current relevance of legacies when he depicts Marx as appealing to today’s youth. In both 1991 films, the sliding distance of political heroes, from public careers to intimate family documents is further complicated by the filmmakers’ decision to intertwine plain autobiography to their biographies. They are working from the premises of affective encounters to create a sense of community. Eventually, Achkar and Peck raise issues about the philosophical nature of identity and the autobiography involved in the encounter with sacrificed or resurrected prophets as interpreted in Allah-Tantou—God’s Will be Done [À la grâce de Dieu] (1991) by David Achkar (1960-1998) and Death of a Prophet, by Raoul Peck (1954-present).

Although American biomedical science relies heavily on the Federal Government for research funding, individual scientists have traditionally shunned politics and public policy. In years past, scientists were not encouraged to mingle with politicians, most of whom viewed scientists as fuzzballs and eggheads with whom they had little in common. Scientists generally believed that government and society valued their services and would always provide substantial support for research and training. Today, biomedical research funding requires a keen knowledge of the U. S. Congress and the political process. Indeed, our professional survival and that of our students and trainees requires active involvement in Washington politics. We can no longer defer the task of justifying our role in society to institutions or blue ribbon panels of elite science experts. Democratic decision-making at its best is process-oriented, time-consuming, and bottom-up, not top-down. Through its proactive policies involving networking, congressional testimony, education and targeted funding goals, the Public Policy Committee of the American Society for Cell Biology has provided a model strategy for member-oriented commitment to science and public policy.

Inquiry committees are the opposition’s sharpest sword in the German Bundestag . In con- trast to the European Parliament, the U .S . Congress, and other international examples, however, TV or Internet transmissions of witness hearings are not common in practice . In the German Bundestag, a double barrier to transmission exists and it consists of the con- cerned person’s consent as well as that of a two-thirds majority in the committee . The author argues in favor of facilitating TV or Internet transmissions of investigative commit- tees by elevating it to an opposition’s minority right while maintaining the requirement of witnesses’ consent to transmissions . That way witnesses could also protect themselves from media distorting their statements, while at the same time fact-finding by a critical public would be supported, and even help to avoid theatrical staging of investigative committees .

The paper highlights some of the deterioration of the defendant, s position in the 2011 Code of criminal procedure of Serbia. On the other hand, it points to some relatively new institutions that go behind the traditional role of the defendant, which is reflected in the opposition to the charges. These are three types of defendant, s agreement with the public prosecution. The first form is a diversionary model, which is applied in the pre-trial procedure. The second is the plea agreement. Both forms were introduced before the confluence to relieve criminal justice, but the defendant himself benefits. The third form is the conclusion of an agreement between the defendant and the sentenced person on testimony in other to successfully detect, prove or prevent the criminal acts referred to in article 162, paragraph 1, item 1 of the Code of criminal procedure.

Purpose Exemption from hospital charges may appear as an essential policy in order to support the poor. Such policies can function for the fulfillment of governments’ social- and justice-based responsibilities in public hospitals. The purpose of this paper is to investigate the pattern of offering discounts to the poor and the effect of Iran’s recent Health Sector Evolution Plan on it. Design/methodology/approach The authors conducted analytical research longitudinally on the data related to cash discounts offered to the poor within a teaching hospital. Data were collected through the period of four months, September to December 2013, before the establishment of the Health Sector Evolution Plan, and in the similar months through 2014, after the establishment of the Health Sector Evolution Plan, in order to compare the amount of cash discounts. The type of insurance, length of stay, amount of discounts offered to patients, and total costs of hospital charges were studied and compared by referring to the social working department. Data were analyzed using the χ2-test, Mann-Whitney U test, ANOVA, and regression analysis aided by SPSS 20. Findings The number of patients offered discounts or exempted from payment in 2014 reduced compared to the number in 2013. The highest rate of demand for discounts was related to patients covered by Emdad Committee followed by those who had no insurance. The ratio of discount to cost in the oncology ward was higher than other groups. Originality/value The results of the present study can contribute to the plans of health system policy makers in organizing measures for supporting poor patients toward accessing healthcare services.

Az 1980-ban megjelent első kiadás óta az Amerikaiaknak szóló étrendi ajánlások (Dietary Guidelines for Americans) tudományosan megalapozott tanácsokat adnak arra vonatkozóan, hogy mit kell enni és inni az egészség megőrzése, a krónikus betegségek kockázatának csökkentése és a tápanyagszükséglet kielégítése érdekében. Az étrendi ajánlások közzétételét az 1990. évi Nemzeti Táplálkozásfigyelő és Kapcsolódó Kutatási Törvény (National Nutrition Monitoring and Related Research Act) írja elő, amely kimondja, hogy az Egyesült Államok Mezőgazdasági Minisztériuma (U. S. Departments of Agriculture, USDA) és az Egészségügyi és Humán Szolgáltatások Minisztériuma (Health and Human Services, HHS) legalább öt évente közösen tegyen közzé egy jelentést, amely táplálkozási és étrendi információkat, ajánlásokat tartalmaz a lakosság számára. A törvény (Public Law 101-445, 7 United States Code 5341 et seq.) előírja, hogy az étrendi ajánlásoknak a jelenlegi tudományos és orvosi ismereteken kell alapulniuk. Az étrendi ajánlások 2020-2025-ös kiadása a 2015-ös kiadásra épül, a 2020-as étrendi ajánlások tanácsadó bizottságának tudományos jelentésén (Scientific Report of the 2020 Dietary Guidelines Advisory Committee) alapuló felülvizsgálatokkal, valamint a szövetségi ügynökségek és a lakossági észrevételek figyelembevételével.

The aim of the article: to analyze the criminogenic situation in the cities of Dnipropetrovsk region during the Holodomor of 1932–1933 and the measures of the regional authorities to combat crime. Methods: comparative-historical, problem-chronological, historical-genetic. Processing of archival documents are carried out using the methods of source studying and hermeneutic analysis. The scientific novelty of the article is that the author characterizes the criminogenic situation in the cities of Dnipropetrovsk region during the Holodomor of 1932–1933 and the measures of the regional authorities to combat crime for the first time. Practical meaning: the results of the research can be used for studying the socio-psychological consequences of the Holodomor of 1932–1933. The originality of the study is based on the identification and analytical and synthetic processing of previously unknown archival documents of the Dnipropetrovsk Regional Committee of the CP(b)U, Dnipropetrovsk Regional Police Department, Dnipropetrovsk City Prosecutor`s Office from the State Archives of Dnipropetrovsk region. Main results. It is shown that the main reasons for the increase in crime were famine and large-scale repression, which led to the emergence of the so-called declassed element – the peasants, deprived of livelihood. Thefts, robberies, fraud with grocery documents were the main types of crimes in cities during the Holodomor of 1932–1933. It was proved that the crime situation in the Dnipropetrovsk region remained difficult throughout 1933 despite the measures taken by the Soviet party leadership. The justice authorities and the GPU, created to fight the counter-revolution, were unable to protect the property and life of city dwellers. The ineffectiveness of fight against crime was determined by the authorities desire to eliminate the phenomenon without eliminating its causes. Іt was impossible to stop thefts, robberies, and murders of the urban population, since most of the thieves were “criminals of despair”. It was also impossible without stabilizing the food situation. Type of article: theoretical, research.

In March 2022, the public was stunned to learn that Virginia Thomas, wife of Justice Clarence Thomas, was in steady communication with Mark Meadows, Donald Trump's Chief of Staff, supporting Trump's efforts to overturn the presidential election results of the 2020 election. Moreover, political leaders and legal practitioners were troubled that Clarence Thomas had not recused himself in Trump v. Thompson, 142 S. Ct. 680, 680 (2022), a case involving Trump's application for an injunction against the National Archives turning over thousands of presidential documents to the House Select Committee, which was investigating the January 6, 2021 insurrection at the U.S. Capitol. This severe ethical lapse by Thomas is the latest in a series of ethical improprieties going back 30 years. The first in the catalogue of Thomas' ethical violations was his decision in ALPO Petfoods, Inc. v. Ralston Purina Co., 913 F.2d 958 (D.C. Cir. 1990), which materially changed the law of Lanham Act remedies in the D.C. Circuit. The article delves into Thomas' bizarre and erroneous legal analysis that resulted in overturning a multimillion-dollar false advertising damage award against pet food manufacturer Ralston-Purina. It will also discuss the unusually close mentor-mentee relationship between Thomas and Senator John Danforth of Missouri, grandson of the founder of Ralston-Purina and whose family owned a large holding of stock in the company. Danforth was instrumental in guiding Thomas' entire career and had a hand in obtaining every job in Thomas' post-law school life, including his present one. This extraordinarily close relationship created a conflict of interest that should have led Thomas to recuse himself from considering the Alpo case.

During 1991, the security services of Bosnia and Herzegovina began to monitor the telephone conversations of high-ranking officials of the Serbian Democratic Party (SDS). These recorded conversations reveal part of the truth to the preparations for the war and the genocide that followed. Intercepted conversations also show the connections that Serbian officials in Bosnia and Herzegovina had with Belgrade, that is, with Slobodan Milošević and other officials of the Yugoslav leadership. These conversations were recorded until the beginning of the aggression, that is, until they left the territory of the Republic of Bosnia and Herzegovina in March and April 1992, by persons whose phones were tapped. This paper will deal with conversations that were recorded in the period from May 1991 to March 1992. One of the most common topics of these conversations was the issue of Islam, that is, the thematization of terms such as „Islamic Republic“, „Islamic Declaration“, „Islamic way of life“, „Islamic fundamentalism“, etc. The paper shows how the Serbian political elite used this terminology to instill fear in public opinion, but to a certain extent they also believed that an increased birth rate would lead to the establishment of a Muslim-majority state. For the purposes of writing this paper, research was done on primary sources, i.e. transcripts of intercepted conversations. The transcripts were used as evidence by the Prosecutor's Office of the Hague Tribunal during the trial of high-ranking Serbian officials. In addition to the research, sorting and analysis of the transcripts, this paper will also identify the most prominent participants in the conversation of the Serbian leadership. Also, given the aforementioned specificity of telephone conversations through their private nature, it is possible to dissect important topics in the conversations, which are often not military and political, and will contribute to finding additional answers. This makes these conversations even more important because they show a more intimate side of the genocidal strategist. Participants such as high-ranking officials Slobodan Milošević, Radovan Karadžić, Biljana Plavšić, Nikola Koljević, Momčilo Krajišnik, Dobrica Čosić and others, shows what and how those at the top thought in their private telephone conversations in those days in 1991 and 1992. On the other hand, through the conversations, one can see how well the SDS leadership managed the situation on the ground. Low-ranking figures who performed various political and social tasks such as Todor Dutin, director of the SRNA, Rajko Dukić, president of the SDS Executive Committee and a local strongman in Milići appear in the conversations; Vojo Kuprešanin, member of the Main Board of SDS and a key man in Krajina; Vitomir Žepinić, Deputy Minister of Internal Affairs of Bosnia and Herzegovina; Radoslav Brđanin, head of the Autonomous Region of Krajina, Zvonko Bajagić, a prominent member of the SDS in Vlasenica, Gojko Đogo, writer and essayist, a close friend of Karadžić, Momčilo Momo Mandić, Deputy Minister of Internal Affairs of Bosnia and Herzegovina and later wartime Minister of Justice of the so-called „Republic Serbian“,; Trifko Komad, head of Radovan Karadžić's Cabinet and member of the SDS Main Board and many others. Also, what is important to mention is the visible 'radicalization' of the participants in the talks. As the political situation on the ground worsened, hate speech and threats became more frequent and serious. This paper aims to further approach this important topic of intercepted conversations and to popularize its greater use in scientific research works. With the advancement of technology and means of communication, the primary sources for research are slowly shifting and taking on a new look. Thus, this paper also tries to analyze these intercepted conversations to give some insight into the complexity of understanding the genocidal intentions of the Bosnian Serb leadership.

“Tiesības tikt aizmirstam” ir samērā jauns tiesību institūts, kura aktualizēšanas priekšnosacījums ir tehnoloģiju attīstība un globalizācija, kas šobrīd ļauj padarīt informāciju, tostarp arī personas datus un sensitīvus datus, publiski pieejamu visā pasaulē. Iepriekšminētais rada nepieciešamību veicināt personas datu aizsardzību. “Tiesības tikt aizmirstam” īpaši tika aktualizētas saistībā ar Eiropas Savienības tiesas lēmumu lietā C-131/12 Google Spain SL, Google Inc. pret Agencia de Protección de Datos, Mario Costeja González (t. s. Google v Spain lieta). Arī Eiropas Cilvēktiesību tiesa saskaras ar jaunām koncepcijām, no kurām viena ir “tiesības tikt aizmirstam”. Veicot pētījumu, tika gūtas šādas atziņas: Latvijas Republikas normatīvajos aktos paredzētie aizsardzības līdzekļi, atbildība un sankcijas tikai daļēji veicina “tiesību tikt aizmirstam” ievērošanu. Pētījumā iesaistītās valsts iestādes neapzinās ar fizisko personu datu apstrādi saistītos potenciālos riskus un tos novērsa (veica nepieciešamās izmaiņas datu apstrādes sistēmās) tikai pēc privātpersonas(-u) iesnieguma saņemšanas. Šī iemesla dēļ, lai stiprinātu Latvijas iedzīvotāju uzticēšanos valsts iestādēm jautājumā par tiešsaistē atrodamiem datiem un panāktu jaunu pakalpojumu, tostarp arī publisko e-pārvaldības pakalpojumu izmantošanu, tādējādi sekmējot ekonomikas izaugsmi, valsts iestādēm ir jāpārskata sava prakse saistībā ar personas datu apstrādi un pieejamību tiešsaistē. The “right to be forgotten” is a relatively new legal institution and the prerequisite for it are rapid technological developments and globalisation allowing information, including personal data and sensitive data, publicly available worldwide. The above mentioned requires the enhancement of the personal data protection. The “right to be forgotten” had been brought up to date particularly in relation to the EU Court of Justice decision in case C-131/12 Google Spain SL and Google Inc. v Agencia Española de Protección de Datos (AEPD) and Mario Costeja González. The European Court of Human Rights is being faced with new concepts such as that of the “right to be forgotten”. The following conclusions are drawn when conducting the research: the remedies, liability and sanctions as provided in Latvian regulation only partially contribute to the compliance with the “right to be forgotten”. The state institutions interviewed while carrying out this research are not aware of the potential risks concerning processing of personal data and make necessary changes in their data processing systems only in response to the individual/-s application. Therefore, to strengthen the trust of Latvian inhabitants in online data kept by public authorities and to enhance usage of e-government services, thus facilitating economic growth, the public authorities must review their existing practices regarding the processing of personal data and access online.

BackgroundDuring the COVID-19 pandemic, it remains a major concern whether patients with rheumatic musculoskeletal disease treated with conventional (cs) or biologic (b) disease modifying drugs (DMARDs) exhibit an adequate immune response to the currently available SARS-CoV2 vaccines. There remains an urgent need for more data on SARS-CoV-2 vaccine efficacy to inform healthcare providers on the efficiency of the applied vaccination, potential need of and period for booster and/ or re-vaccination.ObjectivesTo assess and compare the efficacy of the SARS-CoV2 vaccines BNT162b2 vaccine (Pfizer/BioNTech) and mRNA-1273 vaccine (Moderna). (The vaccines were administered as part of the Danish vaccine roll out and offered each with two doses and approximately four weeks apart).Patients’ SARS-CoV2 IgG serum level was used as proxy to determine vaccination response.MethodsWe established the ‘Detection of SARS-CoV2 antibodies in Danish Inflammatory Rheumatic Outpatients’ study (DECODIR) as a longitudinal prospective cohort study. Patients with rheumatoid arthritis (RA), spondyloarthropathies (SpA) or psoriatic arthritis (PsA) receiving their outpatient treatment and monitored in the Danish DANBIO registry at the Danish Hospital for Rheumatic Diseases (DG), Sonderborg were included (April - June 2021).Bloods, patient reported outcome measurements (PROMS), clinical data and treatment information (cs/bDMARD) were collected at baseline (prior to vaccination) and after six weeks and six months. SARS-CoV2 IgG levels in serum were assessed by ELISA (ThermoFischer), and manufacturer’s cut-off (>=10 EliA U/mL) selected as definition of sufficient IgG response.Associations between antibody response, age, gender, disease (RA/PsA/SpA), treatment with no or cs/bDMARDs and disease activity were tested using proportional odds regression and bootstrapped tests of medians. Results were reported using mean, median (IqR) and bootstrapped 95% confidence interval (CI) of the median.ResultsA total of 243 patients were included at baseline and after six weeks; at six months’ follow-up data were available for 233 patients.After six weeks, vaccination was followed by a significant increase in IgG levels (median of <0.7 EliA U/mL at baseline versus 36.5 EliA U/mL). Patients treated with a combination of both cDMARD and bDMARD had significantly lower IgG levels compared to patients without any DMARD treatment (8,2 EliA U/mL vs 19.5 EliA U/mL (p<0.001)). Patients treated with oral prednisolone (any dose) also showed significantly lower median IgG levels compared to patients without DMARD treatment (3,8 EliA U/mL vs 19.5 EliA U/mL (p<0.01)).The actual measurements six months after baseline demonstrated a significant decrease of IgG levels for the whole study population (median of 16 EliA U/mL at six month vs 36.5 EliA U/mL at six weeks, p < 0.001) (Figure 1).Figure 1.IgG-level stratified by treatmentSimilar to week 6, lowest response rates were found in patients treated with prednisolone or combination of csDMARD and bDMARD. After 6 months, the proportional odds model revealed significantly lower median IgG antibody level in patients who received Pfizer compared to Moderna (median 15 EliA U/mL (95%CI: 13-18) vs 44.5 EliA U/mL (95%CI: 36-83) (p<0.001).ConclusionIgG levels decreased markedly six months after the initial double dose regimen. Patients treated with a combination of cs/bDMARD or oral prednisolone are at higher risk of inadequate vaccine response as measured by IgG level.Our results support the decision for the need of a third booster vaccine in patients with inflammatory rheumatic diseases, especially in the case of cs/bDMARD combination treatment and prednisolone. The data may indicate a need for further revaccination in these patients.Reference[1]Schreiber K. et al. Reduced Humoral Response of SARS-CoV-2 Antibodies following Vaccination in Patients with Inflammatory Rheumatic Diseases— an Interim Report from a Danish Prospective Cohort Study. Vaccines 2022, 10(1), 35.AcknowledgementsWe acknowledge all patients contributing to the DANBIO registry. The DanishRheumatologic Biobank is acknowledged for handling and storage of biological material. Lab technician Charlotte Drachmann is acknowledged for her assistanceDisclosure of InterestsChristine Graversgaard: None declared, Karen Schreiber Consultant of: UCB Advisory Board, Randi Petersen: None declared, Henning Jakobsen: None declared, Anders Bo Bojesen: None declared, Niels Steen Krogh: None declared, Bente Glintborg Grant/research support from: AbbVie, BMS, Pfizer, Merete Lund Hetland Grant/research support from: AbbVie, Biogen, BMS, Celtrion, Eli Lilly Denmark A/S, Janssen Biologics B.V, Lundbeck Fonden, MSD, Pfizer, Roche, Samsung Biopis, Sandoz. MLH chairs the steering committee of the Danish Rheumatology Quality Registry (DANBIO), which receives public funding from the hospital owners and funding from pharmaceutical companies. MLH co-chairs EuroSpA, which generates real-world evidence of treatment of psoriatic arthritis and axial spondylorthritis based on secondary data and is partly funded by Novartis., Oliver Hendricks Grant/research support from: AbbVie, Novartis, Pfizer

ABSTRACT This study aims to investigate and analyze e the effect of Operating Expenses Operating Income (BOPO), capital adequacy ratio (CAR), financial slack, sustainability officer, and sustainability committee on green banking disclosure in Islamic banks registered with the Financial Services Authority (OJK) during the period 2017-2021. In this study, panel data regression data analysis techniques were used with the help of Eviews 10 software. The results of this study show that partially the variables Operating costs in operating income (BOPO), capital adequacy ratio (CAR), financial slack, and sustainability officer have no effect on green banking disclosure. While the variable Sustainability Committee has a positive and significant effect on Green Banking disclosure. At the same time, the variables BOPO, CAR, Financial Slack, Sustainability Officer, and Sustainability Committee have a significant effect on Green Banking disclosure. The implication of this research for science is to contribute to the literature related to the factors that influence green banking disclosure. In addition, this research is also expected to help banks in improving their governance, and for the government is expected to help in making policies related to green banking disclosure. Keywords: Operating Expenses on Operating Income, Capital Adequacy Ratio, Financial Slack, Green Banking, Sustainability ABSTRAK Penelitian ini bertujuan untuk mengkaji dan menganalisis pengaruh dari Biaya Operasional Pendapatan Operasional (BOPO), Rasio Kecukupan Modal (CAR), Financial Slack, Sustainability Officer, dan Sustainability committee terhadap pengungkapan green banking pada bank syariah yang terdaftar di OJK selama periode 2017-2021. Teknik sampling yang digunakan adalah Purposive Sampling dengan kriteria tertentu, sehingga sampel didapat sebanyak 45 data dari 9 Bank syariah yang sesuai kriteria. Dan menggunakan teknik analisis data regresi data panel dengan bantuan software Eviews 10. Hasilnya menunjukkan bahwa secara parsial variabel BOPO, Capital Adequacy Ratio (CAR), Financial Slack dan Sustainability Officer tidak berpengaruh terhadap pengungkapan Green banking. Sedangkan variabel Sustainability Committee berpengaruh positif dan signifikan terhadap pengungkapan Green Banking. Secara simultan variabel BOPO, CAR, Financial Slack, Sustainability officer dan Sustainability Committee memiliki pengaruh dan signifikan terhadap pengungkapan Green banking Kata Kunci: Biaya Operasi pada Pendapatan Operasional, Capital Adequacy Ratio, Financial Slack, Green Banking, Sustainability REFERENCES Ahlström, J., & Ficekova, M. (2017). The relationship between current financial slack resources and future CSR Performance. A quantitative study of public companies in the Nordic Markets. Master Thesis, Umea School of Business and Economics. Alim, M., & Sina, D. I. (2020). 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When women die at the hands of men, a not infrequent defence is that she consented to, or initiated, the beating, strangulation and penetration which contributed to her death. While strangulation has been a typical method of killing in male on female intimate partner homicide 1 for many decades (‘thou little recognised), what has changed is men’s excuses for their violence. Excuses such as ‘She made me lose my self-control in an argument’ or ‘She was unfaithful to me’ are being supplanted by ‘She consented to rough sex’. 2 Since the dead cannot speak, nor is there any property in the dead, the defendant’s tactic of impugning the deceased’s character cannot be easily rebutted, and he, while maligning her in this way, may profit from a lighter sentence. Law reformers, politicians, academics and activists 3 are pressing for legal reform to shut down this misogyny. On 16 June 2020, during the Public Committee stage of the Domestic Abuse Bill, 4 cls 4 and 5 were approved. Clause 4, ‘No defence for consent to death’, provides ‘(1) If a person (“A”) wounds, assaults or asphyxiates another person (“B”) to whom they are personally connected as defined in section 2 of this Act causing death, it is not a defence to a prosecution that B consented to the infliction of injury. (2) Subsection (1) applies whether or not the death occurred in the course of a sadomasochistic encounter’. Clause 5, ‘No defence for consent to injury’, provides ‘(1) If a person (“A”) wounds, assaults or asphyxiates another person (“B”) to whom they are personally connected as defined in section 2 of this Act causing actual bodily harm or more serious injury, it is not a defence to a prosecution that B consented to the infliction of injury or asphyxiation. (2) Subsection (1) applies whether or not the actual bodily harm, non-fatal strangulation, or more serious injury occurred in the course of a sadomasochistic encounter’. These two new clauses would prevent the alleged consent of the victim from being used as a defence to a prosecution in intimate partner homicides and non-fatal assault which result in s 47 assault occasioning actual bodily harm, Offences Against the Person Act 1861, or more serious injury. Additional new clauses including, proposing that consent of the Director of Public Prosecutions would be required, in the case of death, to accept a charge to anything less than murder (cl 6); the requirement to consult with the family of the deceased regarding charges (cl 7); the prohibition of reference to sexual history of the deceased in domestic homicide trials (cl 10); anonymity of victims of domestic homicide (cl 11); and anonymity of domestic violence survivors (cl 14); the Parliamentary Under-Secretary of State for Justice (Alex Chalk), while sympathetic, said there were difficulties with the clauses in their present form. 5 Of the proposal to make non-fatal strangulation 6 (cl 8) a standalone offence, he considered that ‘creating a new offence could limit the circumstances covered, and create additional evidential burdens’. 7 These motions reflect the several debates since October 2019, when MPs, Harriet Harman and Mark Garnier, introduced the ‘No defence for consent’ amendment to the second reading of the Domestic Abuse Bill. 8 Since men also plead the ‘sexual consent defence’ on ‘first dates’, which may fall outside the definition of ‘domestic abuse’ as set out in the Bill, 9 a loophole also recognised by Alex Chalk at the Public Committee stage, 16 June 2020, this too will be addressed. 10 The murder of Grace Millane, in New Zealand 11 in 2018, murdered on a ‘first date’ provides such an example.

The article researches the essence and content of multicultural pedagogical paradigms common in the world practice. Thus, J. Benx's pedagogical model is understood as a continuous process that requires long-term investments of time and effort, as well as carefully planned actions and monitoring. L. Frazierer's pedagogical concept is aimed at the development of cultural diversity through the introduction of specially designed methodological materials into the educational practices and a special procedure of this material submission. U. Hunter offers multicultural education through the establishment of structural educational priorities, in which the emphasis is shifted towards cultural pluralism and the maintenance of the cultural heritage of disappearing ethnic groups. In the concept of B. Parekh, the content of pedagogical multicultural practices, first of all, is freedom in the study of other cultures, acquainting students with different models of historic knowledge through the use of the entire world cultural heritage. The content of multicultural education for K. Grant is the approval and popularization of an alternative lifestyle for all people on the basis of equality of education and ensuring the availability of knowledge of all cultural diversity. B. Sizemor under multicultural education understands the assimilation of knowledge about various groups and organizations that counteract the oppression and exploitation by studying the realities and ideas which result from their work. S. Nieto considers multicultural education as the pedagogical process aimed at counteracting all forms of discrimination, deepening of interpersonal contacts between pupils and students, spreading the principles of democracy and social justice in the pedagogical process.From the socio-philosophical standpoint, the analysis of the prospects of introducing elements of multicultural pedagogical models into the domestic educational space of the educational institutions as an instrument of tolerance of intercultural relations between Ukraine and Poland is conducted.The problem of the emergence of intercultural contradictions in the context of the existence of the historical memory of separate individuals and the nation as a source of conflict is considered. The priority directions of practical implementation of elements of multicultural pedagogy in the sphere of education, family, church, activity of cultural and educational centers, public associations, mass media with the aim of establishing intercultural dialogue and tolerance of relations between bearers of different cultural traditions are determined.

Amount raised: N$19,948,000/U$1,672,509 Background and context: The Cancer Association of Namibia presented the project “An apple a day can keep cancer away” to one of the local commercial banks close to 2 decades ago. The concept of “Eat Healthy. Live Healthy. Prevent Cancer” became a massive hit and in subsequent years the “Bank Windhoek Cancer Apple Project” has become a flagship fundraiser for the association. For 1 month of the year (usually June or July - winter in Namibia) we convert all Bank Windhoek branches nationwide into “apple stores” with bank employees, CAN volunteers and school learners marketing and selling apples to raise funds for CAN, raise awareness on cancer and support screening interventions to promote earlier detection to save lives. Aim: Create awareness and educate on cancer, support the Cancer Association of Namibia financially to fund the National Cancer Outreach Program and the 2 interim homes operated by the association. Strategy/Tactics: National endeavor - for 1 month a year, the entire commercial bank is “converted” into apple stores, selling apples! Program process: An executive planning committee between Bank Windhoek as facilitator and the Cancer Association of Namibia plan and coordinates the annual event, sourcing one million red apples (the bank´s official color) from the Western Cape apple farms. Numerous project partners support the program from transport, cold storage, package and delivery, to media and sales partners. An “Apple Roadshow” kicks off the marketing and PR of the annual event, and then for one month a year the bank staff, CAN volunteers and especially high school learners (as part of the school challenge) promote bulk orders, while loose apple sales are conducted in bank branches country-wide. Costs and returns: All project partners offer their “time” and “manpower” as a donation in support of CAN through their CSI portfolio. Apples are sourced at a bulk reduced rate (± N$2, 50 each) and resold to the public at a N$5 donation per apple. What was learned: Logistics and supply chain management is a profession that must be highly respected! But, education, awareness and community collaboration makes one of the strongest support chains imaginable. Communicating “why” are we doing this, then taking the funds and “showing” what we the money goes (through the medical outreaches and sustaining the interim homes) speak to the heart of the nation. Transparency, accountability and inclusive community interaction is key when it comes to community driven fundraising.

Ключові слова: релігійні свята, Уманська округа, місцева преса, радянська влада, 1923–1925 роки, антирелігійна політика. Анотація У статті розглядається офіційне ставлення партійних, державних, громадських структур в Уманській окрузі до релігійних свят у 1923–1925 рр. Проаналізовані відповідні матеріали вміщені на сторінках газети «Робітниче-селянська правда» – органу Уманського окружного комітету КП(б)У і окрвиконкому Уманщини. Зроблено висновок, що в Уманській окрузі, як і загалом в радянській Україні у той період, відносно більш толерантне офіційне ставлення до релігії поєднувалося із подальшим насадженням нетерпимості до неї. Це досить виразно виявлялося в неприйнятті релігійних свят та всього пов’язаного з ними і вело до руйнації традиційних духовно-культурних цінностей тих релігійних конфесій, які були представлені у цьому регіоні. Посилання «Seider», 1923 – «Seider» y «Tainaia vecheria» ["Seider" and "The Last Supper"] // Robitnyche-selianska pravda. 1923. 22 bereznia. № 63. S. 2. Pidpys: F. N. [in Ukrainian]. Antyrelihiina propahanda, 1923 – Antyrelihiina propahanda v s. Tanskomu [Anti-religious propaganda in the village of Tanske] // Robitnyche-selianska pravda. 1923. 11 kvitnia. № 78. S. 3 Pidpys: V. B. [in Ukrainian]. Antyrelihiina propahanda, 1924 – Antyrelihiina propahanda v s. Taliankakh [Anti-religious propaganda in the village of Talianki] // Robitnyche-selianska pravda. 1924. 16 sichnia. № 9. S. 2. Pidpys: M. [in Ukrainian]. Babenko, 2010 – Babenko L. Osoblyvosti antyrelihiinoi propahandy 1920-kh rokiv ta yii alternatyvy [Features of anti-religious propaganda of the 1920s and its alternatives] // Filosofski obrii. 2010. № 24. S. 222–235. URL: http://dspace.nbuv.gov.ua/bitstream/handle/123456789/25951/18-Babenko.pdf?sequence=1 [in Ukrainian]. Baidachenko, 1925 – Baidachenko H. Proty Peruna y Khrysta – elektryka y radio [Against Perun and Christ – electricity and radio] // Robitnyche-selianska pravda. 1925. 31 hrudnia. № 298. S. 3 [in Ukrainian]. Bezbozhnyk, 1923 – Relihiina dyskusiia v s. Nesterivtsi [Religious discussion in the village of Nesterivka] // Robitnyche-selianska pravda. 1923. 29 kvitnia. № 94. S. 2. Pidpys: Bezbozhnyk [in Ukrainian]. Bliau, 1923 – Bliau D. Blahochestyvыe masloboishchyky [Pious chippers] // Robitnyche-selianska pravda. 1923. 16 travnia. № 107. S. 4 [in Russian]. Bondarchuk, 1925 – Relihiinyi durman ta babski zabobony [Religious dope and women superstitions] // Robitnyche-selianska pravda. 1925. 5 liutoho. № 28. S. 2. Pidpys: Bondarchuk [in Ukrainian]. Borotba komnezamu, 1923 – Borotba komnezamu s. Kniazhykiv z relihiinymy zabobonamy [The struggle of the komnezam of the village of Knyazhyky with religious prejudices] // Robitnyche-selianska pravda. 1923. 29 kvitnia. № 94. S. 2. Pidpys: B. [in Ukrainian]. Brusianin, 1925 – Brusianin V. Komu potribni relihiini sviata? [Who needs religious holidays?] // Robitnyche-selianska pravda. 1925. 12 kvitnia. № 83. S. 1 [in Ukrainian]. Vecher antyrelyhyoznoi propahandы, 1923 – Vecher antyrelyhyoznoi propahandы v teatre «Kommuna» [An evening of anti-religious propaganda at the Kommuna theater] // Robitnyche-selianska pravda. 1923. 11 kvitnia. № 78. S. 3. Pidpys: D. [in Russian]. Vecher v klube, 1923 – Vecher v klube polyhrafystov [Evening at the club of printers] // Robitnyche-selianska pravda. 1923. 4 kvitnia. № 74. S. 2. Pidpys: D. [in Russian]. Vidhadai, 1923 – Bez boha khlib matymesh, a z bohom torbu chipliatymesh [Without God you will have bread, and with God you will cling to a bag] // Robitnyche-selianska pravda. 1923. 15 veresnia. № 209. S. 3. Pidpys: Selkor Vidhadai [in Ukrainian]. Vitrynska, 2016 – Vitrynska O. V. Polityka radianskoi vlady shchodo yudaizmu v Ukraini v 1921–1929 rokakh. [The policy of the Soviet government towards Judaism in Ukraine in 1921–1929] Dys… kand. ist. nauk. Poltava, 2016. 254 s. URL: https://shron1.chtyvo.org.ua/Vitrynska_Olena/Polityka_radianskoi_vlady_schodo_iudaizmu_v_Ukraini_v_1921–1929_rokakh.pdf [in Ukrainian]. Volska, 1925 – Ne derzhit uchniv vdoma v relihiini sviata [Do not keep students at home on religious holidays] // Robitnyche-selianska pravda. 1925. 19 hrudnia. № 290. S. 3. Pidpys: Selkorka Volska [in Ukrainian]. Haievska, 2013 – Haievska T. Derzhavni radianski sviata: istoryko-kulturolohichnyi aspekt [State Soviet holidays: historical and cultural aspect] // Kulturolohichna dumka. 2013. № 6. S. 153–159. URL: http://nbuv.gov.ua/UJRN/ Kultdum_2013_6_21 [in Ukrainian]. Demennyi, 1923 – Shkola s. Kamianechoho boretsia z relihiinymy zabobonamy [School in the village of Kameneche struggles religious prejudices] // Robitnyche-selianska pravda. 1923. 14 kvitnia. № 81. S. 2. Pidpys: Demennyi [in Ukrainian]. Didus, 1923 – Antyrelihiina propahanda na paskhalni sviata v s. Hromakh [Anti-religious propaganda on Easter holidays in the village of Gromy] // Robitnyche-selianska pravda. 1923. 4 kvitnia. № 74. S. 2. Pidpys Didus [in Ukrainian]. Yev. Hen, 1924 – Shcho take sviato rizdva? [What is a Christmas holiday?] // Robitnyche-selianska pravda. 1924. 25 hrudnia. № 225. S. 2. Pidpys: Yev. Hen [in Ukrainian]. Zakrepym pobedu, 1923 – Zakrepym pobedu [Let's consolidate the victory] // Robitnyche-selianska pravda. 1923. 4 kvitnia. № 74. S. 1 [in Russian]. K antyrelyhyoznoi propahande, 1923 – K antyrelyhyoznoi propahande v paskhalnыe dny [To anti-religious propaganda on Easter days] // Robitnyche-selianska pravda. 1923. 24 bereznia. № 65. S. 1 [in Russian]. K Komsomolskoi paskhe, 1923 – K Komsomolskoi paskhe [For Komsomolskaya Easter] // Robitnyche-selianska pravda. 1923. 29 bereznia. № 69. S. 3 [in Russian]. Kak obmanыvaiut, 1923 – Kak obmanыvaiut Yehovu [How Jehovah is Deceived] // Robitnyche-selianska pravda. 1923. 1 kvitnia. № 72. S. 2 [in Russian]. Kyrydon, 2017 – Kyrydon A. M. Indoktrynatsiia radianskosti: obriadovo-sviatkovyi kanon yak marker formuvannia ateizovanoho suspilstva (1920–1930-i rr.) [The indoctrination of Sovietness: a ceremonial-festive canon as a marker of the formation of an atheistic society (1920s–1930s)] // Umanska starovyna. 2017. Vypusk 3. S. 5–20. URL: http://www.irbis-nbuv.gov.ua/cgi-bin/irbis_nbuv/cgiirbis_64.exe?I21DBN=LINK&P21DBN=UJRN&Z21ID=&S21REF=10&S21CNR=20&S21STN=1&S21FMT=ASP_meta&C21COM=S&2_S21P03=FILA=&2_S21STR=umanst_2017_3_3 [in Ukrainian]. Labenskyi, 1924 – S. Kniazhyky [The village of Knyazhiki] // Robitnyche-selianska pravda. 1924. 6 serpnia. № 107. S. 3. Pidpys: Labenskyi [in Ukrainian]. Litstudiia, 1925 – Litstudiia «Pluhu» pry Umanskim Ahrotekhnikumi [Litstudio "Plow" at Uman Agricultural College] // Robitnyche-selianska pravda. 1925. 15 kvitnia. № 85. S. 2. Pidpys: P. K. [in Ukrainian]. Makukha, 1923 – Borotba z relihiinymy zabobonamy v s. Pidvysokomu [Struggle against religious prejudices in the village of Pidvysoke] // Robitnyche-selianska pravda. 1923. 29 kvitnia. № 94. S. 2. Pidpys: Makukha [in Ukrainian]. Matukhno, 2017 – Matukhno Yu. O. Problema klasyfikatsii radianskykh sviat u pershe porevoliutsiine desiatylittia [The problem of classifying Soviet holidays in the first post-revolutionary decade] // Naukovi pratsi istorychnoho fakultetu Zaporizkoho natsionalnoho universytetu. 2017. Vyp. 48. S. 139–142. URL: http://www.irbis-nbuv.gov.ua/cgi-bin/irbis_nbuv/cgiirbis_64.exe?C21COM=2&I21DBN=UJRN&P21DBN=UJRN&IMAGE_FILE_DOWNLOAD=1&Image_file_name=PDF/Npifznu_2017_48_27.pdf Medsanrabotnyky, 1923 – Medrabotnyky ne otstaiut [Medical workers are not lagging behind] // Robitnyche-selianska pravda. 1923. 6 kvitnia. № 76. S. 2 [in Russian]. Na obshchem sobranyy, 1923 – Na obshchem sobranyy transportnykov y stroytelei [At a general meeting of transport workers and builders] // Robitnyche-selianska pravda. 1923. 31 bereznia. № 71. S. 3 [in Ukrainian]. Naiblyzhchi zavdannia, 1924 – Naiblyzhchi zavdannia raionnykh komisii po protyrelihiinii propahandi [Immediate tasks of district commissions for anti-religious propaganda] // Robitnyche-selianska pravda. 1924. 11 sichnia. № 7. S. 3 [in Ukrainian]. Novoselytskyi, 1923 – Novoselytskyi F. Stradaiushchye y voskresaiushchye bohy y yskuplenye ymy liudskykh hrekhov [Suffering and resurrecting gods and their atonement for human sins] // Robitnyche-selianska pravda. 1923. 20 bereznia. № 61. S. 2 [in Russian]. Paskhalnaia kampanyia, 1923 – Paskhalnaia kampanyia [Easter campaign] // Robitnyche-selianska pravda. 1923. 28 bereznia. № 68. S. 3 [in Russian]. Polytprosvet, 1923 – Prazdnyk Paskhy y paskhalnыe obriadы [Easter holiday and Easter ceremonies] // Robitnyche-selianska pravda. 1923. 20 bereznia. № 61. S. 2. Pidpys: Polytprosvet Ukoma KSM [in Russian]. Polishchuk, 2009 – Polishchuk V. Onoprii Turhan – zhurnalist i pysmennyk [Onopriy Turgan is a journalist and writer] URL: https://umanliteratura.ucoz.ua/news/v_polishhuk_onoprij_turgan_zhurnalist_i_pismennik/2010-12-20-256 [in Ukrainian]. Popova, 1925 – Popova O. Sviatkuimo ne bozhi sviata, a sviata pratsi y peremohy [Let us celebrate not God's holidays, but the holidays of work and victory] // Robitnyche-selianska pravda. 1925. 12 kvitnia. № 83. S. 2 [in Ukrainian]. Proletshkola, 1923 – Proletshkola protyv boha [Proletarian school against god] // Robitnyche-selianska pravda. 1923. 28 bereznia. № 68. S. 2 [in Russian]. Rabkor, 1923 – Budem borotsia s relyhyei kak y s vooruzhennыm vrahom [We will fight religion like an armed enemy] // Robitnyche-selianska pravda. 1923. 3 kvitnia. № 73. S. 3. Pidpys: Rabkor K. [in Ukrainian]. Rabota ahytpropa, 1923 – Rabota ahytpropa v aprele [Agitprop work in April] // Robitnyche-selianska pravda. 1923. 9 travnia. № 101. S. 3 [in Russian]. Robitnyk, 1924 – Osvitu zhintsi na seli [Education for a woman in the countryside] // Robitnyche-selianska pravda. 1924. 8 liutoho. № 18. S. 3. Pidpys: Robitnyk [in Ukrainian]. Robitnyche zhyttia, 1924 – Robitnyche zhyttia [Working life] // Robitnyche-selianska pravda. 1924. 23 kvitnia. № 48. S. 3 [in Ukrainian]. Sylantiev, 2005 – Sylantiev V. I. Vlada i pravoslavna tserkva v Ukraini (1917–1930 rr.) [Authorities and the Orthodox Church in Ukraine (1917–1930)] Avtoref. dys… dokt. ist. nauk. Kharkiv, 2005. 46 s. [in Ukrainian]. Syrotiuk, 1924 – Zubrytskyi KNS ne porvav shche z relihiieiu [The Zubrytsia CРР has not yet broken with religion] // Robitnyche-selianska pravda. 1924. 5 sichnia. № 4. S. 2. Pidpys: Syrotiuk [in Ukrainian]. Sidorenko, 1923 – Sidorenko Z. Neobkhidna chystka komnezamu s. Pobiinoi [It is necessary to clean the komnezam of the village of Pobiyna] // Robitnyche-selianska pravda. 1923. 19 kvitnia. № 85. S. 2 [in Ukrainian]. Soloviov, 1924 – Soloviov D. Nebazhane yavyshche [An undesirable phenomenon] // Robitnyche-selianska pravda. 1924. 16 sichnia. № 9. S. 2 [in Ukrainian]. Tabel, 1924 – Tabel sviat i nerobochykh dniv. Oboviazkova postanova Kyivskoho hubvykonkomu № 49 vid 19 bereznia 1924 roku [Table of holidays and non-working days. Mandatory Resolution of the Kyiv Provincial Executive Committee № 49 of March 19, 1924] // Vistnyk Kyivskoho hubvykonkomu. 1924. 2 kvitnia. № 14. S. 2 [in Ukrainian]. Tarapon, 2016 – Tarapon O. Derzhavni sviata v Ukraini 1920–1930-kh rr. yak zasib formuvannia radianskykh politychnykh tsinnostei [Public holidays in Ukraine in the 1920s and 1930s as a means of forming Soviet political values] // Aktualni pytannia humanitarnykh nauk: mizhvuzivskyi zbirnyk naukovykh prats molodykh vchenykh Drohobytskoho derzhavnoho pedahohichnoho universytetu imeni Ivana Franka. Drohobych, 2016. Vyp. 15. S. 96–102. URL: http://nbuv.gov.ua/UJRN/apgnd_2016_15_13 [in Ukrainian]. Tolko 40 pyshchevykov, 1923 – Tolko 40 pyshchevykov ne odurachenы relyhyei [Only 40 food workers are not fooled by religion] // Robitnyche-selianska pravda. 1923. 31 bereznia. № 71. S. 3 [in Russian]. Turhan, 1924 – Turhan O. Proty staroho rizdva [Against old Christmas] // Robitnyche-selianska pravda. 1924. 24 hrudnia. № 224. S. 2 [in Ukrainian]. Fiialko, 1923 – Fiialko S. Antyrelihiina propahanda v s. Ksendzivtsi [Anti-religious propaganda in the village of Ksendzivka] // Robitnyche-selianska pravda. 1923. 19 kvitnia. № 85. S. 2 [in Ukrainian]. Flerovskyi, 1923 – Flerovskyi Y. Stradaiushchyi, umershyi y voskresshyi... [Suffering, dead and resurrected...] // Robitnyche-selianska pravda. 1923. 6 kvitnia. № 76. S. 3 [in Russian]. Flierovskyi, 1925 – Flierovskyi I. Zvidky pishly tserkovni sviata [Where did the church holidays come from?] // Robitnyche-selianska pravda. 1925. 10 kvitnia. № 81. S. 2 [in Ukrainian]. Tserkvy, 1923 – Tserkvy, kostelы, synahohy – pod klubы y teatrы [Churches, churches, synagogues - for clubs and theaters] // Robitnyche-selianska pravda. 1923. 6 kvitnia. № 76. S. 2 [in Russian]. Chuchalin, 2019 – Chuchalin O. P. Vplyv ateistychnoi propahandy radianskoi presy na relihiinu sytuatsiiu v USRR u 1920–1930-ti rr. [The influence of atheistic propaganda of the Soviet press on the religious situation in the USSR in the 1920s and 1930s] // Hileia: naukovyi visnyk. 2019. Vypusk 142(1). S. 182–188. URL: http://www.irbis-nbuv.gov.ua/cgi- bin/irbis_nbuv/cgiirbis_64.exe?I21DBN=LINK&P21DBN=UJRN&Z21ID=&S21REF=10&S21CNR=20&S21STN=1&S21FMT=ASP_meta&C21COM=S&2_S21P03=FILA=&2_S21STR=gileya_2019_142(1)__39 [in Ukrainian]. Yunenko, 1925 – Yunenko S. Nash KNS [Our СPP] // Robitnyche-selianska pravda. 1925. 16 sichnia. № 9. S. 3 [in Ukrainian].

performance of current athletes by building confidence and contributing to favorable conditions of retired athletes. This study investigated the influences of the years of retirement and physical self-inventory on human sufferings experienced by the retired athletes. Based on the literature review, there were limited empirical studies on the conditions of former athletes after years of retirement, their glory, physical inventory, and sufferings, and the relationships among these characteristics. Using mixed research methods, this research studied the conditions of retired athletes in Metro Manila. The study confirmed that physical self-inventory influenced post-retirement human suffering. Post-retirement athletic identity, financial status and decisions to voluntary retire were observed to be the most prevalent experiences related to human suffering. 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BackgroundMetastatic castration-resistant prostate cancer (mCRPC) and Ewing sarcoma (EWS) are diseases for which immune therapies could potentially provide benefit. STEAP1 (Six Transmembrane Epithelial Antigen of the Prostate 1) is a cell surface protein with elevated expression in mCRPC 1 and EWS.2MethodsWe designed AMG 509, a novel, half-life extended, STEAP1 x CD3 XmAb® 2+1 bispecific antibody to induce T cell-mediated cytotoxicity against STEAP1-expressing cancer cells. AMG 509 contains two identical anti-STEAP1 Fab domains, an anti-CD3 scFv domain, and an effectorless Fc domain that extends serum half-life. We characterized STEAP1 expression in normal and tumor tissues by immunohistochemistry, and we assessed the pharmacological properties of AMG 509 including binding, T cell-mediated redirected lysis, and in vivo antitumor activity.ResultsWe detected high STEAP1 surface expression on 80% of primary prostate tumors (n=88), 89% of mCRPC lesions (n=114), including 84% of mCRPC bone metastases (n=31), and 63% of EWS samples (n=35). In contrast, in normal tissues (n=72), low STEAP1 expression was detected in only six other tissues, including the normal prostate. AMG 509 bound to recombinant human CD3ε with a KD of 27.6 nM, and it bound specifically to 293T cells transfected with human STEAP1 with an EC50 of 3.8 nM. AMG 509 triggered potent T cell-redirected lysis of STEAP1-positive cancer cells, with a median EC50 of 37 pM across 19 cancer cell lines that endogenously express various levels of STEAP1. AMG 509-mediated cytotoxicity was specific, as it showed no activity against prostate cancer cells in which STEAP1 was knocked out. AMG 509 was 65-fold more potent in inducing the redirected lysis of prostate cancer cells in vitro than an XmAb® molecule with a single anti-STEAP1 Fab domain. AMG 509 had greater cytotoxic activity against high STEAP1-expressing cancer cells than against low STEAP1-expressing cancer cells, and it had minimal activity against normal cells. This preferential killing of high STEAP1-expressing cells is likely driven by the avidity conferred by the dual STEAP1-binding domains, a feature that may help reduce off-target effects in the clinic. In vivo, AMG 509 induced robust anti-tumor activity in prostate cancer and EWS mouse xenograft models, with concomitant CD8+ T-cell activation and expansion in tumors.ConclusionsAMG 509 is a specific, first-in-class T cell-recruiting antibody with avidity-driven activity against STEAP1-positive malignancies. AMG 509 is currently being evaluated for safety, pharmacokinetics, and efficacy in a phase 1, first-in-human study in patients with mCRPC (NCT04221542).AcknowledgementsThe authors acknowledge Micah Robinson, PhD of Amgen Inc. for medical writing support.Trial RegistrationClinicalTrials. gov Identifier: NCT04221542Ethics ApprovalAll animal experimental protocols were approved by an Institutional Animal Care and Use Committee (IACUC protocol number 2015-01243) and were conducted in accordance with the guidelines of the Association for Assessment and Accreditation of Laboratory Animal Care (AAALAC) (Amgen) or the standards of the Public Health Service (PHS) Policy on Humane Care and Use of Laboratory Animals (IACUC protocol number 15015x) in a facility certified with an Office of Laboratory Animal Welfare (OLAW) (UTHSA).ReferencesGrunewald TGP, Ranft A, Esposito I, Silva-Buttkus P da, Aichler M, Baumhoer D, Schaefer KL, Ottaviano L, Poremba C, Jundt G, Jurgens H, Dirksen U, Richter GHS, Burdach S. High STEAP1 expression is associated with improved outcome of Ewing’s sarcoma patients. Ann Oncol 2012; 23:2185–2190.Hubert RS, Vivanco I, Chen E, Rastegar S, Leong K, Mitchell SC, Madraswala R, Zhou Y, Kuo J, Raitano AB, Jakobvits A, Saffran SC, Afar DE. STEAP: a prostate-specific cell-surface antigen highly expressed in human prostate tumors. Proc Natl Acad Sci USA 1999;96:14523–14528.

<p><strong>List of abstracts and authors:</strong></p><p><strong>1. Bipolar disorder not otherwise specified -overdiagnosed or underdiagnosed?</strong></p><p>E Allers</p><p><strong>2. The prognosis of major depression untreated and treated: Does the data reflect the true picture of the prognosis of this very common disorder?</strong></p><p>E Allers</p><p><strong>3. Can we prolong our patients' life expectancy? Providing a better quality of life for patients with severe mental illness</strong></p><p>O A Betencourt</p><p><strong>4. The scope of ECT practice in South Africa</strong></p><p>J Benson-Martin, P Milligan</p><p><strong>5. Biomarkers for schizophrenia: Can we evolve like cancer therapeutics?</strong></p><p>P Buckley<strong></strong></p><p><strong>6. Relapse in schizophrenis: Major challenges in prediction and prevention</strong></p><p>P Buckley</p><p><strong>7. Informed consent in biological treatments: The right to know the duty to inform</strong></p><p><strong></strong>I Chetty</p><p><strong>8. Effectiveness of a long-acting injectable antipsychotic plus an assertive monitoring programme in first-episode schizophrenia</strong></p><p><strong></strong>B Chiliza, L Asmal, O Esan, A Ojagbemi, O Gureje, R Emsley</p><p><strong>9. Name, shame, fame</strong></p><p>P Cilliers</p><p><strong>10. Can we manage the increasing incidence of violent raging children? We have to!</strong></p><p>H Clark</p><p><strong>11. Serotonin, depression and antidepressant action</strong></p><p>P Cowen</p><p><strong>12. Prevalence and correlates of comorbid psychiatris illness in patients with heroin use disorder admitted to Stikland Opioid Detoxification Unit</strong></p><p>L Dannatt, K J Cloete, M Kidd, L Weich</p><p><strong>13. Investigating the association between diabetes mellitus, depression and psychological distress in a cohort of South African teachers</strong></p><p>A K Domingo, S Seedat, T M Esterhuizen, C Laurence, J Volmink, L Asmal</p><p><strong>14. Neuropeptide S -emerging evidence for a role in anxiety</strong></p><p>K Domschke</p><p><strong>15. Pathogenetics of anxiety</strong></p><p>K Domschke</p><p><strong>16. The effects of HIV on the fronto-striatal system</strong></p><p>S du Plessis, M Vink, J Joska, E Koutsilieri, C Scheller, B Spottiswoode, D Stein, R Emsley</p><p><strong>17. Effects of acute antipsychotic treatment on brain morphology in schizophrenia</strong></p><p>R Emsley, L Asmal, B Chiliza, S du Plessis, J Carr, A Goosen, M Kidd, M Vink, R Kahn</p><p><strong>18. Development of a genetic database resource for monitoring of breast cancer patients at risk of physical and psychological complications</strong></p><p>K Grant, F J Cronje, K Botha, J P Apffelstaedt, M J Kotze</p><p><strong>19. Unipolar mania reconsidered: Evidence from a South African study</strong></p><p><strong></strong>C Grobler</p><p><strong>20. Antipsychotic-induced movement disorders: Occurence and management</strong></p><p>P Haddad</p><p><strong>21. The place of observational studies in assessing the effectiveness of long-acting injectable antipsychotics</strong></p><p>P Haddad</p><p><strong>22. Molecular mechanisms of d-cycloserine in fear extinction: Insights from RNS sequencing</strong></p><p>S Hemmings, S Malan-Muller, L Fairbairn, M Jalali, E J Oakeley, J Gamieldien, M Kidd, S Seedat</p><p><strong>23. Schizophrenia: The role of inflammation</strong></p><p>DC Henderson</p><p><strong>24. Addictions: Emergent trends and innovations</strong></p><p>V Hitzeroth</p><p><strong>25. The socio-cultural-religious context of biological psychiatric practice</strong></p><p>B Janse van Rensburg</p><p><strong>26. Biochemical markers for identifying risk factors for disability progression in multiple sclerosis</strong></p><p><strong></strong>S Janse van Rensburg, M J Kotze, F J Cronje, W Davis, K Moremi, M Jalali Sefid Dashti, J Gamieldien, D Geiger, M Rensburg, R van Toorn, M J de Klerk, G M Hon, T Matsha, S Hassan, R T Erasmus</p><p><strong>27. Alcohol-induced psychotic disorder: Brain perfusion and psychopathology - before and after antipsychotic treatment</strong></p><p>G Jordaan, J M Warwick, D G Nel, R Hewlett, R Emsley</p><p><strong>28.'Pump and dump': Harm reduction strategies for breastfeeding while using substances</strong></p><p>L Kramer</p><p><strong>29. Adolescent neuropsychiatry - an emerging field in South African adolescent psychiatric services</strong></p><p>A Lachman</p><p><strong>30. Recovery versus remission, or what it means to be healthy for a psychiatric patient?</strong></p><p>B Latecki</p><p><strong>31. Holistic methods utilised to normalise behaviours in youth diagnosed with neuro-biochemical disorders</strong></p><p>P Macqueen</p><p><strong>32. Candidate genes and novel polymorphisms for anxiety disorder in a South African cohort</strong></p><p>N McGregor, J Dimatelis, S M J Hemmings, C J Kinnear, D Stein, V Russel, C Lochner</p><p><strong>33. Higher visual functioning</strong></p><p>A Moodley</p><p><strong>34. The effects of prenatal methylmercury exposure on trace element and antioxidant levels in rat offspring following 6-hydroxydopamine-induced neuronal insult</strong></p><p>Z M Moosa, W M U Daniels, M V Mabandla</p><p><strong>35. Paediatric neuropsychiatric movement disorders</strong></p><p>L Mubaiwa</p><p><strong>36. The South African national female offenders study</strong></p><p>M Nagdee, L Artz, C de Clercq, P de Wet, H Erlacher, S Kaliski, C Kotze, L Kowalski, J Naidoo, S Naidoo, J Pretorius, M Roffey, F Sokudela, U Subramaney</p><p><strong>37. Neurobiological consequences of child abuse</strong></p><p>C Nemeroff</p><p><strong>38. What do Stellenbosch Unviversity medical students think about psychiatry - and why should we care?</strong></p><p>G Nortje, S Suliman, K Seed, G Lydall, S Seedat</p><p><strong>39. Neurological soft skins in Nigerian Africans with first episode schizophrenia: Factor structure and clinical correlates</strong></p><p><strong></strong>A Ojagbemi, O Esan, O Gureje, R Emsley</p><p><strong>40. Should psychiatric patients know their MTHFR status?</strong></p><p>E Peter</p><p><strong>41. Clinical and functional outcome of treatment refractory first-episode schizophrenia</strong></p><p>L Phahladira, R Emsley, L Asmal, B Chiliza</p><p><strong>42. Bioethics by case discussion</strong></p><p>W Pienaar</p><p><strong>43. Reviewing our social contract pertaining to psychiatric research in children, research in developing countries and distributive justice in pharmacy</strong></p><p>W Pienaar</p><p><strong>44. The performance of the MMSE in a heterogenous elderly South African population</strong></p><p>S Ramlall, J Chipps, A I Bhigjee, B J Pillay</p><p><strong>45. Biological basis addiction (alocohol and drug addiction)</strong></p><p>S Rataemane</p><p><strong>46. Volumetric brain changes in prenatal methamphetamine-exposed children compared with healthy unexposed controls</strong></p><p><strong></strong>A Roos, K Donald, G Jones, D J Stein</p><p><strong>47. Single voxel proton magnetic resonance spectroscopy of the amygdala in social anxiety disorder in the context of early developmental trauma</strong></p><p>D Rosenstein, A Hess, S Seedat, E Meintjies</p><p><strong>48. Discussion of HDAC inhibitors, with specific reference to supliride and its use during breastfeeding</strong></p><p>J Roux</p><p><strong>49. Prevalence and clinical correlates of police contact prior to a first diagnosis of schizophrenia</strong></p><p>C Schumann, L Asmal, K Cloete, B Chiliza, R Emsley</p><p><strong>50. Are dreams meaningless?</strong></p><p>M Solms</p><p><strong>51. The conscious id</strong></p><p>M Solms<strong></strong></p><p><strong>52. Depression and resilience in HIV-infected women with early life stress: Does trauma play a mediating role?</strong></p><p>G Spies, S Seedat</p><p><strong>53. State of affairs analysis for forensic psychiatry in SA</strong></p><p>U Subramaney</p><p><strong>54. Escitalopram in the prevention of post-traumatic stress disorder: A pilot randomised controlled trial</strong></p><p>S Suliman, S Seedat, J Pingo, T Sutherland, J Zohar, D J Stein</p><p><strong>55. Epigenetic consequences of adverse early social experiences in primates</strong></p><p>S Suomi</p><p><strong>56. Risk, resilience, and gene x environment interactions in primates</strong></p><p>S Suomi</p><p><strong>57. Biological aspects of anorexia nervosa</strong></p><p>C Szabo</p><p><strong>58. Agents used and profiles of non-fatal suicidal behaviour in East London</strong></p><p>H Uys</p><p><strong>59. The contributions of G-protein coupled receptor signalling to opioid dependence</strong></p><p>J van Tonder</p><p><strong>60. Emerging trend and innovation in PTSD and OCD</strong></p><p>J Zohar</p><p><strong>61. Making the SASOP treatment guidelines operational</strong></p><p>E Allers</p><p><strong>Poster Presentations</strong></p><p><strong>62. Neuropsychological deficits in social anxiety disorder in the context of early developmental trauma</strong></p><p><strong></strong>S Bakelaar, D Rosenstein, S Seedat</p><p><strong>63.Social anxiety disorder in patients with or without early childhood trauma: Relationship to behavioral inhibition and activation and quality of life</strong></p><p><strong></strong>S Bakelaar, C Bruijnen, A Sambeth, S Seedat</p><p><strong>64. Exploring altered affective processing in obssessive compulsive disorder symptom subtypes</strong></p><p>E Breet, J Ipser, D Stein, C Lochner<strong><br /></strong></p><p><strong>65. To investigate the bias toward recognising the facial expression of disgust in obsessive compulsive disorder as well as the effect of escitalopram</strong></p><p>E Breet, J Ipser, D Stein, C Lochner</p><p><strong>66. A fatal-case of nevirapine-induced Stevens-Johnson's syndrome in HIV mania</strong></p><p>A Bronkhorst, Z Zingela, W M Qwesha, B P Magigaba<strong></strong></p><p><strong>67. Association of the COMT G472A (met/met) genotype with lower disability in people diagnosed with multiple sclerosis</strong></p><p>W Davis, S J van Rensburg, L Fisher, F J Cronje, D Geiger, M J Kotze</p><p><strong>68. Homocycsteine levels are associated with the fat mass and obesity associated gene FTO(intron 1 T&gt;A) polymorphism in MS patients</strong></p><p>W Davis, S J Van Rensburg, M J Kotze, L Fisher, M Jalali, F J Cronje, K Moremi, J Gamieldien, D Geiger, M Rensburg, R van Toorn, M J de Klerk, G M Hon, T Matsha, S Hassan, R T Erasmus</p><p><strong>69. Analysis of the COMT 472 G&gt;A (rs4680) polymorphism in relation to environmental influences as contributing factors in patients with schizophrenia</strong></p><p>D de Klerk, S J van Rensburg, R A Emsley, D Geiger, M Rensburg, R T Erasmus, M J Kotze</p><p><strong>70. Dietary folate intake, homocysteine levels and MTHFR mutation detection in South African patients with depression: Test development for clinical application </strong></p><p>D Delport, N vand der Merwe, R Schoeman, M J Kotze</p><p><strong>71. The use ofexome sequencing for antipsychotic pharmacogenomic applications in South African schizophrenia patients</strong></p><p>B Drogmoller, D Niehaus, G Wright, B Chiliza, L Asmal, R Emsley, L Warnich</p><p><strong>72. The effects of HIV on the ventral-striatal reward system</strong></p><p>S du Plessis, M Vink, J Joska, E Koutsilieri, C Scheller, B Spottiswoode, D Stein, R Emsley</p><p><strong>73. Xenomelia relates to asymmetrical insular activity: A case study of fMRI</strong></p><p>S du Plessis, M Vink, L Asmal</p><p><strong>74. Maternal mental helath: A prospective naturalistic study of the outcome of pregancy in women with major psychiatric disorders in an African country</strong></p><p>E du Toit, L Koen, D Niehaus, B Vythilingum, E Jordaan, J Leppanen</p><p><strong>75. Prefrontal cortical thinning and subcortical volume decrease in HIV-positive children with encephalopathy</strong></p><p>J P Fouche, B Spottiswoode, K Donald, D Stein, J Hoare</p><p><strong>76. H-magnetic resonance spectroscopy metabolites in schizophrenia</strong></p><p>F Howells, J Hsieh, H Temmingh, D J Stein</p><p><strong>77. Hypothesis for the development of persistent methamphetamine-induced psychosis</strong></p><p><strong></strong> J Hsieh, D J Stein, F M Howells</p><p><strong>78. Culture, religion, spirituality and psychiatric practice: The SASOP Spirituality and Psychiatry Special Interest Group Action Plan for 2012-2014</strong></p><p>B Janse van Rensburg</p><p><strong>79. Cocaine reduces the efficiency of dopamine uptake in a rodent model of attention-deficit/hyperactivity disorder: An <em>in vivo</em> electrochemical study</strong></p><p><strong></strong>L Kellaway, J S Womersley, D J Stein, G A Gerhardt, V A Russell</p><p><strong>80. Kleine-Levin syndrome: Case in an adolescent psychiatric unit</strong></p><p>A Lachman</p><p><strong>81. Increased inflammatory stress specific clinical, lifestyle and therapeutic variables in patients receiving treatment for stress, anxiety or depressive symptoms</strong></p><p>H Luckhoff, M Kotze, S Janse van Rensburg, D Geiger</p><p><strong>82. Catatonia: An eight-case series report</strong></p><p>M Mabenge, Z Zingela, S van Wyk</p><p><strong>83. Relationship between anxiety sensitivity and childhood trauma in a random sample of adolescents from secondary schools in Cape Town</strong></p><p>L Martin, M Viljoen, S Seedat</p><p><strong>84. 'Making ethics real'. An overview of an ethics course presented by Fraser Health Ethics Services, BC, Canada</strong></p><p>JJ McCallaghan</p><p><strong>85. Clozapine discontinuation rates in a public healthcare setting</strong></p><p>M Moolman, W Esterhuysen, R Joubert, J C Lamprecht, M S Lubbe</p><p><strong>86. Retrospective review of clozapine monitoring in a publica sector psychiatric hospital and associated clinics</strong></p><p>M Moolman, W Esterhuysen, R Joubert, J C Lamprecht, M S Lubbe</p><p><strong>87. Association of an iron-related TMPRSS6 genetic variant c.2007 C&gt;7 (rs855791) with functional iron deficiency and its effect on multiple sclerosis risk in the South African population</strong></p><p>K Moremi, S J van Rensburg, L R Fisher, W Davis, F J Cronje, M Jalali Sefid Dashti, J Gamieldien, D Geiger, M Rensburg, R van Toorn, M J de Klerk, G M Hon, T Matsha, S Hassan, R T Erasmus, M Kidd, M J Kotze</p><p><strong>88. Identifying molecular mechanisms of apormophine-induced addictive behaviours</strong></p><p>Z Ndlazi, W Daniels, M Mabandla</p><p><strong>89. Effects of lifestyle factors and biochemistry on the major neck blood vessels in patients with mutiple sclerosis</strong></p><p>M Nelson, S J van Rensburg, M J Kotze, F Isaacs, S Hassan</p><p><strong>90. Nicotine protects against dopamine neurodegenration and improves motor deficits in a Parkinsonian rat model</strong></p><p>N Ngema, P Ngema, M Mabandla, W Daniels</p><p><strong>91. Cognition: Probing anatomical substrates</strong></p><p>H Nowbath</p><p><strong>92. Chronic exposure to light reverses the effects of maternal separation on the rat prefrontal cortex</strong></p><p>V Russel, J Dimatelis</p><p><strong>93. Evaluating a new drug to combat Alzheimer's disease</strong></p><p>S Sibiya, W M U Daniels, M V Mabandla</p><p><strong>94. Structural brain changes in HIV-infected women with and without childhood trauma</strong></p><p>G Spies, F Ahmed, C Fennema-Notestine, S Archibald, S Seedat</p><p><strong>95. Nicotine-stimulated release of hippocampal norepinephrine is reduced in an animal model of attention-deficit/ hyperactivity disorder: the spontaneously hypertensive rat</strong></p><p>T Sterley</p><p><strong>96. Brain-derive neurotrophic factor (BDNF) protein levels in anxiety disorders: Systematic review and meta-regression analysis</strong></p><p>S Suliman, S M J Hemmings, S Seedat</p><p><strong>97. A 12-month retrospective audit of the demographic and clinical profile of mental healthcare users admitted to a district level hospital in the Western Cape, South Africa</strong></p><p>E Thomas, K J Cloete, M Kidd, H Lategan</p><p><strong>98. Magnesium recurarization: A comparison between reversal of neuromuscular block with sugammadex v. neostigmine/ glycopyrrolate in an <em>in vivo</em> rat model</strong></p><p><strong></strong>M van den Berg, M F M James, L A Kellaway</p><p><strong>99. Identification of breast cancer patients at increased risk of 'chemobrain': Case study and review of the literature</strong></p><p>N van der Merwe, R Pienaar, S J van Rensburg, J Bezuidenhout, M J Kotze</p><p><strong>100. The protective role of HAART and NAZA in HIV Tat protein-induced hippocampal cell death</strong></p><p>S Zulu, W M U Daniels, M V Mabandla</p>

Indonesia is a country that has a high potential for natural disasters. Picture story book is a form of disaster management learning that can help children from an early age to prepare for a natural disaster. The aims of this study to develop story books as a disaster management learning media, to improve knowledge and skills of children and teacher about the understanding, principles, and actions of rescue when facing the natural disasters, to increase the teacher’s learning quality in disaster management. Developmental research approach is used to execute the study. A total of 48 children aged 5-6 years have to carry out pre-test and post-test. Pre-test data shows that children's knowledge about disaster management with an average of 47.92% and its improved at post-test with 76,88%. Five theme of story books involves floods, landslides, earthquakes, tsunamis, lands and forest fires is the product. 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ABSTRACT This study aims to explain and analyze the effect of product market competition, financial leverage, and risk of financing on the stability of Islamic banks in Indonesia in 2018-2022. The sampling technique used is Islamic banks listed on the Indonesia Stock Exchange. Source of data obtained from the annual report of each bank. The analytical method used is panel regression analysis with Eviews 10 software with the Common Effect Model (CEM) model as the best model. The variables used consist of product market competition (PCM), financial leverage (DER proxy), and financing risk (NPF proxy) on banking stability (proximate Natural Logarithm Z-Score). The results of this study found that product market competition did not affect bank stability. Meanwhile, financial leverage and financing risk have a negative effect on the stability of Islamic banks in Indonesia. From the results of this study, it is hoped that competition for Islamic banks in Indonesia can always run normally as it is today. In addition, the financial leverage and financing risks of Islamic banks have a negative impact on banking stability. Therefore, this research can be used as an early warning and reference for Islamic banks to make funding decisions through debt capital and excessive financing. keywords: Banking stability, product market competition, financial leverage, financing risk ABSTRAK Penelitian ini bertujuan untuk menjelaskan dan menganalisis pengaruh persaingan pasar produk, financial leverage, dan risk of financing terhadap stabilitas bank syariah di Indonesia pada 2018-2022. Teknik pengambilan sampel yang digunakan bank syariah yang terdaftar di Bursa Efek Indonesia. Sumber data diperoleh dari laporan tahunan masing masing bank. Metode analisis yang digunakan adalah analisis regresi panel dengan software Eviews 10 dengan model Common Effect Model (CEM) sebagai model terbaik .Variabel yang digunakan terdiri dari persaingan pasar produk (PCM), financial leverage (proksi DER) dan resiko pembiayaan (proksi NPF) terhadap stabilitas perbankan (doproksikan Natural Logarithm Z-Score. Hasil dari penelitian ini menemukan bahwa persaingan pasar produk tidak berpengaruh terhadap stabilitas bank. Sementara financial leverage dan resiko pembiayaan berpengaruh negative terhadap stabilitas bank syariah di Indonesia. Dari hasil penelitian ini, diharapkan persaingan bank syariah di Indonesia dapat selalu berjalan berjalan normal seperti saat ini. Selain itu, financial leverage dan resiko pembiayaan bank syariah berdampak buruk pada stabilitas perbankan. Oleh karena itu, penelitian ini dapat dijadikan early warning dan acuan bagi bank syariah untuk mengambil keputusan pendanaan melalui modal hutang dan pembiayaan yang berlebihan. Kata Kunci: Stabilitas perbankan, product market competition, financial leverage, resiko pembiayaan REFERENCES Aiyubbi, D. El, Widarjono, A., & Amir, N. (2022). Dampak diversifikasi pembiayaan sektoral terhadap non-performing financing Bank Pembiayaan Rakyat Syariah. Jurnal Ekonomi Syariah Teori dan Terapan, 9(2), 140–155. doi:10.20473/vol9iss20222pp140-155 Ali, M., & Puah, C. H. (2018). Does Bank Size and Funding Risk Effect Banks’ Stability? A Lesson from Pakistan. Global Business Review, 19(5), 1166–1186. doi:10.1177/0972150918788745 Ardyanfitri, H., Pratikto, M. I. S., & Faizah, E. A. K. (2019). Analisis kesehatan bank dan potensi financial distress menggunakan metode rgec pada bank Btpn Syariah tahun 2014-2018. Jurnal MEBIS (Manajemen dan Bisnis), 4(2), 131–141. doi:10.33005/mebis.v4i2.63 BI, LPS, & OJK. 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Parents play an important role in the development of their children. This research reflects the role of parents in developing children. Through four stages of identification, screening, eligibility, and acceptable results, this method uses a systematic literature review using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) method. The findings from the fourteen articles examined show that parenting skills play an important role in a child's growth and development from birth to death. The determining factor in the development of physical, motoric, moral, language, social-emotional, and life skills aspects is the role of both parents as important teachers for children from birth to adulthood. Parents can also use a variety of parenting strategies and skills, many of which they have learned throughout their lives and passed on to their children, to help their children grow. 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Resumen: En el período de referencia no hay nuevas quejas “abiertas” o “en seguimiento” ante el Comité de Libertad Sindical que afecten al Estado español. Tampoco el Informe del Comité de Libertad Sindical núm. 387, adoptado en su 334.ª reunión (Ginebra, 25 de octubre – 8 de noviembre de 2018) refieran alguna problemática en relación al Reino de España.Ocho sentencias del TEDH son objeto de comentario, seis que afectan directamente al estado Español, y otras dos, relativas a la influencia de la ética religiosa en el empleo y al devengo de las vacaciones no dis­frutadas por fallecimiento del trabajador que pueden iluminar algunos aspectos de la legislación nacional.La primera sentencia analizada del Tribunal de Justicia es la del 11 de julio de 2019 [asunto: C-60/17]. Somoza Hermo c. Esabe Vigilancia en un supuesto de subrogación contractual en transmisión de empresas por imperativo del convenio colectivo. Se trata comprobar si es posible que el convenio colectivo limite la responsabilidad solidaria característica de la normativa comunitaria en supuestos de transmisión de empresas. La STJUE de 25 de julio de 2018 [asunto: C-96/17]. Vernoza Ayovi c. Consorci Sanitari analiza el sistema singular del sistema de extinción de los contratos de trabajo de los trabajadores indefinidos no fijos y su acomodación a la normativa comunitaria.En la STJUE de 7 de agosto de 2018 [asunto: C-472/16]. Colino Sigüenza c. Ayuntamiento de Va­lladolid se aborda el problema de la si existe una transmisión de empresa cuando una empresa continua con una actividad tras el cese de la anterior empresa en una adjudicación pública (escuela municipal de música) si ha existido un tiempo sin actividad por parte de ninguna empresa.La STJUE de 11 de septiembre de 2018 [asunto: C-68/17]. IR c. JQ, en un asunto que no afecta a España, analiza si las actividades profesionales cuya ética se sustenta en la religión pueden discriminar a un trabajador por haberse vuelto a casar sin haber anulado el anterior matrimonio. De lo que se trata es de averiguar qué requisitos y bajo qué condiciones es legítimo imponer que determinados trabajadores profesen la ética de la entidad religiosa para la que trabajan.La STJUE de 19 de septiembre de 2018 [asunto: C-41/17]. González Casto c. Mutua Umivale, sí afecta al ordenamiento español. Se trata de determinar si la evaluación de riesgos en el trabajo nocturno debe ser predicable de trabajadores que efectúan trabajo a turnos en los que alguno de ellos, efectiva­mente puede ser en horario nocturno, especialmente en aquellos casos en los que la trabajadora ha soli­citado la prestación por riesgos durante la lactancia natura.En la muy interesante S TJUE de 6 de noviembre de 2018 [asuntos acumulados: C-569/16 y C-570/16]. Stadt Wuppertal y V.W c. M.B. se analiza, para el ordenamiento jurídico alemán, qué ocurre con el disfrute de las vacaciones anuales retribuidas de aquellos trabajadores que no pudieron disfrutar de ellas aunque ya había trabajado tiempo suficiente para devengar una parte sustancial de las mismas. Como resolución singular para nuestro ordenamiento debe citarse la S TJUE de 21 de noviembre de 2018 [asunto: C-619/17]. Ministerio de Defensa c. Diego Porras II, que versa sobre la indemnización que procede por terminación de un contrato de interinidad.La STJUE de 21 de noviembre de 2018 [asunto: C-245/17]. Viejobueno y Vara c. Consejería de Educación aborda una problemática muy específica, la finalización de la relación laboral del docente al acabar el curso académico, y la discriminación que sufrirían los trabajadores por no disfrutar las vaca­ciones anuales retribuídas.En el ámbito del TEDH se ha reseñado la sentencia de 6 de noviembre de 2018 en el Asunto: Vicent del Campco c. España (demanda núm.: 25527/13), sobre responsabilidad patrimonial de la ad­ministración y acoso en lugar de trabajo. En un procedimiento para la exención de la responsabilidad de la Administración (educativa, en este caso) por no haber evitado una situación de acoso laboral en el trabajo se condena a la Administración a satisfacer una determinada cantidad económica a una víctima de acoso. Pero el Tribunal identifica al acosador por su nombre y apellidos y relata de manera detallada las circunstancias del caso. El acosador no sólo no había sido parte en el procedimiento Contencioso-Administrativo, sino que tampoco tenido conocimiento de la tramitación de dicho procedimiento. Se entiende perjudicado y acude al TEDH solicitando la reparación de su derecho pues entiende que se han vulnerado su derecho a la vida privada y familiar (art. 8) y su derecho a un proceso justo (art. 6).Palabras clave: convenio colectivo, transmisión de empresas, trabajador indefinido no fijo, ad­judicación de servicio público a otra empresa, discriminación por motivos religiosos, trabajo a turnos, trabajo nocturno, prevención de riesgos laborales, riesgo durante la lactancia natural, vacaciones anuales retribuidas, fallecimiento del trabajador, contrato de interinidad, indemnización por finalización de con­trato, funcionarios docentes interinos, extinción objetiva del contrato de trabajo por falta de necesidades docentes, responsabilidad patrimonial de la Administración, procedimiento Contencioso-Administrati­vo, acoso en lugar de trabajo.Abstract: In the reference period, there are no new “open” or “follow-up” complaints before the Committee on Freedom of Association that affect the Spanish State. Nor does the Report of the Commit­tee on Freedom of Association, No. 387, adopted at its 334th meeting (Geneva, October 25 - November 8, 2018) refer to some problems in relation to the Kingdom of Spain.Eight judgments of the ECHR are subject to comment, six that directly affect the Spanish state, and two others, relating to the influence of religious ethics on employment and the accrual of holidays not enjoyed due to the death of the worker that can illuminate some aspects of the national legislation.The first judgment analyzed by the Court of Justice is that of July 11, 2019 [case: C-60/17]. So­moza Hermo c. Esabe Surveillance in a case of contractual subrogation in the transfer of companies by virtue of the collective agreement. The aim is to check whether it is possible for the collective agreement to limit the joint and several liability that is characteristic of Community legislation in cases of transfer of companies.The S TJUE of 25 July 2018 [case: C-96/17]. Vernoza Ayovi c. Consorci Sanitari analyzes the sin­gular system of the system of extinction of the work contracts of undefined non-fixed workers and their adaptation to the community regulations.In the SJJE dated 7 August 2018 [case: C-472/16]. Colin Sigüenza c. Valladolid City Council addresses the problem of whether there is a transfer of company when a company continues with an activity after the cessation of the previous company in a public award (municipal music school) if there has been a time without activity by any company.The SJJE of 11 September 2018 [case: C-68/17]. IR c. JQ, in a matter that does not affect Spain, analyzes whether professional activities whose ethics are based on religion can discriminate against a worker for having remarried without having annulled the previous marriage. What it is about is to find out what requirements and under what conditions it is legitimate to impose that certain workers profess the ethics of the religious entity for which they work.The S CJEU of 19 September 2018 [case: C-41/17]. González Casto c. Mutua Umivale, does affect the Spanish legal system. The aim is to determine if the assessment of risks in night work should be pre­dicable of workers who work shifts in which some of them can actually be at night, especially in those cases in which the worker has requested the benefit for risks during lactation natura.In the very interesting S TJUE of November 6, 2018 [cumulative matters: C-569/16 and C-570/16]. Stadt Wuppertal and V.W c. M.B. it is analyzed, for the German legal system, what happens with the enjoyment of paid annual holidays of those workers who could not enjoy them even though they had already worked enough time to earn a substantial part of them.As a singular resolution for our ordinance, the SJJEJ of November 21, 2018 [case: C-619/17] must be cited. Ministry of Defense c. Diego Porras II, which deals with the compensation that comes from the termination of an interim contract.The S TJUE of 21 November 2018 [case: C-245/17]. Viejobueno y Vara c. The Ministry of Education addresses a very specific problem, the termination of the teacher’s employment relationship at the end of the academic year, and the discrimination suffered by workers for not enjoying the annual paid vacation.In the field of the ECHR the sentence of November 6, 2018 in the Subject: Vicent del Campco c. Spain (demand no .: 25527/13), on property liability of the administration and harassment in place of work. In a procedure for the exemption of the responsibility of the Administration (educational, in this case) for not having avoided a situation of labor harassment at work, the Administration is condemned to satisfy a certain amount of money to a victim of harassment. But the Court identifies the harasser by his first and last name and tells in detail the circumstances of the case. The harasser not only had not been a party to the Contentious-Administrative proceedings, but also had no knowledge of the processing of said procedure. The injured party is considered to be in the ECHR requesting the reparation of his right, since he understands that his right to private and family life has been violated (Article 8) and his right to a fair trial (Article 6).Keywords: collective agreement,transmission of companies, indefinite worker not fixed, adju­dication of public service to another company, discrimination on religious grounds, night work, pre­vention of occupational hazards, risk during breastfeeding, paid annual holidays,death of the wor­ker, interim contract, compensation for termination of contract, temporary teaching staff,objective termination of the employment contract due to lack of teaching needs, management liability of the Administration,contentious-Administrative Procedure, harassment in the workplace.

The social and political changes in Poland led to abolition of Realsozialismus which is now being replaced with a democratic country governed by Rechtostaat (Art. 1 of the Constitution) from aspirations after national freedom and respect of human rights in public life. The problem of protection of individual freedom made itself particularly felt here; it is also subject of the present paper which discusses the protection of individual subjectivity in the light or the institutions of arrest and detention awaiting trial. Until quite recently, Poland was one of the many Communist countries where human rights were violated much too often, also on the occasion of arrest and detention awaiting trial. Many factors were conductive to this situation, such as faulty legislation; inadequate socjal consciousness; depreciation of the authorities, law and other norms; prevalence of repressiveness in dealing with social pathologies; and absence of social control of the activity of law enforcement agencies, the police and prison staff in particular. But the weakness of legal protection of individual resulted also from a strong relation of the activities of practically all governemental and social bodies those dealing with prosecution and investigation as well as administration of justice included, to politics. This political nature of functioning of those agencies, resulting monopolistic power of the Communist party, led to a limitation of the independance of the judiciary. The adoption of new political principles of Polish State and election of the new Parliament (on June 4, 1989), together with formaion of the non-Communist Cabinet, created the conditions for a new criminal policy based step by step on European standards. The institutions of arrest and detention awaiting trial well illustrate the pathology of functioning of the agencies of legal order and the direction of changes taking place in criminal policy. They also demonstrate a specific paradox; the Polish people’s great devotion to freedom and the simultaneous unfeeling tramling of that freedom. The two institutions have been discussed from the viewpoint of protection of human rights on both the normative plane and in the practice of the years 1980–1990. Arrest is one of the forms of coercion which consists in a short-term deprivation of liberty. The Polish legal system provides for procedural, preventive and administrative arrest. Each of these types has a separate legal regulation (procedural arrest, the Act of 19 April 1969 – Code of criminal procedure; preventive arrest, the Act of 6 June 1990 on the police and another Act bearing that same date on State Protection Office, together with their executory acts; and administrative arrest, the Act of 28 October 1982 on education to sobriety and control of alcoholism). Moreover, each type of arrest is to serve different aims (procedural arrest, protection of propriety of criminal proceedings; preventive arrest, protectton of order and public safety, human life and health, and property; and administrative arrest, control of alcoholism). Also different are the conditions of arrest, the agencies authorized to apply it, and the period for which a person can be detained. The present authors focus mainly on preventive arrest related to the administrative function of the police as guardian of order. That form was particularly abused and human rights were often violated in the course of its execution. Preventive arrest has recently undergone significant changes both in the normative sphere and in practice. As compared to the former one, its present regulation: 1. defines its legal grounds with greater accuracy; 2. broadens the detainee’s rights; and 3. introduced judicial review. This has contributed to the curbing of arbitrary police activities in this sphere. Duration of arrest is specified in the Constitution (Art. 87) and in the provision of Art. 207 of the code of criminal procedure. It cannot be londer than 48 hours from the moment of detention, and 24 hours in the case of administrative arrest (Art. 40 of the act on education to sobriety and control of alcoholism). Violations of these provisions have so far been frequent. In the case of procedural and preventive arrest, the rights of the detainee are the same. According to the valid provisions, the detainee has the following rights among others: the right to be informed in writing as to the time and reasons of arrest; the right to be advised as to the possibility of complaining to the court against the application of that measure, and to the public prosecutor against the way of its execution: the right to health care. The catalogue of the detainee’s rights is insufficient: e.g. it does not contain the right, to legal assistance (conseul). What particularly impairs the protection of the detainee’s personal interests is the absence of by-laws concerning the execution of arrest in the police house of detention, as the duplicated set of provisions called ,,By-laws for Detainees”, introduced by an order of the Chief of Civic Militia in 1959, hardly comes up to the standards. The provisions now in force have broadened the range of legal means of vindication of his rights that are at the detainee’s disposal. Particularly notable here is the reintroduction of the institution of habeas corpus. Namely, the detainee has been granted the right to complain to the court against arrest (Art. 207 point ”a,, of the Code of criminal procedure) and to the public prosecutor against the way of execution of arrest (Art. 15.7 of the Act on the police). If the arrest has been obviously unjustified, the detainee is due indemnity from the Treasury and monetary compensation of moral injury (Art. 487 of the Code of criminal procedure); the same concerns the situation where he has suffered damage or injury as a result of an improper execution of arest (Art.Art. 417-419 of the Civil code). Besides, the detainee may approach the court with a claim in virtue of protection of his personal interests (Art.Art. 23 and 24 of the civil code). In the latter half of 1990, arrest was executed in 798 police houses of detention all over the country, that is fewer by a whole 71,7 per cent as compared to 1989. The recent changes have made it possible to abolish the division of houses of detention into categories (of which there used to be three according to the duration of detention). The number of arrests amounted to over 500,000 a year at times (with the peak of 572,220 in 1982 – see Table 1). Starting from 1988, it gradually went down to nearly one-third of its original value which reflects above all the general liberalization of the police approach towards crime and other deviations. In the period under analysis, the living conditions in the police jails were – and still are primitive and many a time offensive to human dignity. This has been confirmed by the present author’s own study and two surveys of those jails carried out by the National Ombudsperson. An acute problem is the right to apply constraint during and upon detention. It is regulated by provisions of the police Act and an Ordinance of the Council of Ministere of 17 September 1990 which specifies the situations, conditions and ways in which direct coercion can be used by the police. Without questioning the grounds for such coercion, not only the legal conditions of its application but also the faults or even abuses in this sphere have been pointed out. What the authors find the most severe violation of human dignity are neither humiliating conditions of isolation nor illicit prolongation of detention but first and foremost beating of a person after he has surrendered to the power of enforcement officers. Cases of beating have again started growing in number this year (as has been found by the Helsinki Committee in PoIand and the National Ombudsperson). The activities of the public prosecutor’s office in this sphere have been criticised in the article. The paper also discusses the consequences of the introduction of Art. 209 of the Code of criminal procedure which made it possible to commit to the police jails persons detained awaiting trial (for up to ten days or three months), and even those sentenced to a prison term (of up to six months). This provision has recently been quashed, but the police press for its reintroduction. Until quite recently, the police jails were submitted to no supervision whatever. The public prosecutor’s. office remained passive and carried out but most perfunctory supervision, if any. This situation hardly served the protection of detainees’ rights. It was only improved in 1988 when the police jails were submitted to supervision by the Ombudsperson and later also by Commissions: of Administration and Internal Affairs of the Diet and of the Rule of Law and Human Rigths of the Senate, and by other agencies and institutions. Also pre-trial detention is a serious interference with human rights. It is one of the preventive measures provided for by the Code of criminal procedure, and at the stage of execution – by the Code of execution of penalties and the Ordinance of Minister of Justice of 2 May 1989 – by-laws of execution of detention awaiting trial. The discussed measure can be applied by the court, and before the indictment also by the public prosecutor. The present authors find the latter’s right to apply pre-trial detention contradictory to provisions of international law, the covenants ratified by Poland included (see Art. 9,3 of the International Covenant on Political and Civil Rights). The legal provisions fail to specify the upper limit of duration of pre-trial detention. The amendement of the Code of criminal procedure and the changed policy of application of dotention resulted in a fall in the number of those detained awaiting trial. There were 9,722 such detainees on July 31, 1989 (see Tables 4–5). There was also a radical drop in the number of persons detained for over 12 months: in 1990, as few as 0,03 per cent of those kept at the public prosecutor’s disposal had been detained for at least 12 months. However, an alarming upward tendency in the number of persons detained awaiting trial can be noted lately. Discussing the conditions for optional or obligatory pre-trial detention, the authors criticize some of them as estimative in nature, and thus involving the danger of arbitrary use of this measure. The reasoning has been based on decisions of the Supreme Court which is of particular importance for the effective protection of the detainee’s rights. There have been a lot of faults in the practice of application and execution of pre-trial detention which was frequently used as a means of pressure aimed at forcing a person to plead guilty or to denounce an accomplice. In Poland, the application of pre-trail detention is the domain of the public prosecutor’s office. In the years 1975–1989, prosecutors applied this measure in nine out of every ten cases. The population of houses of detention and other penitentiary institutions shaped differently starting from 1945. A comparison of changes in the numer in the number of convicted persons with those of persons detained awaiting trial shows that the latter population was more stable starting from the 1960’s and never changed as radically in number as that of prisoners. That was the case despite the increased frequency of application of detention in the 1970’s. What contributed to this situation above all was the shortening of preparatory proceedings. In the period under analysis, the total number of persons detained awaiting trial in a given year largely approximated that of prisoners in that same year, and showed the same fluctuations resulting from the aggravated or relaxed criminal policy in the country. The trends here have nothing in common with the actual dynamics of crime as such. The authors assume that the number of persons detained awaiting trial reflects decisions in the sphere of criminal policy rather than the actual changes in crime, the economic situation, or even severe political tensions. What is also characteristic of the practice in this respect is the fact of a faulty application of the discussed measure. In the years 1975–1989, at least every 111th and at most every 71st person previously detained awaiting trial was subsequently found not guilty by the court. In some years, there were over 500 such persons. The authors discuss preventive barriers defined by the Supreme Court which are to ban clearly unjustified detention. As follows from analysis of the practical application of conditions for pre-trial detention, the one most frequently quoted was the alleged considerable social danger of the crime. Repressive conditions prevailed over the purely procedural ones. ln order to find out about the actual dimensions of the problem of pre-trial detention, the authors consulted the data concerning the use of preventive measure not involving isolation in criminal proceedings (such measures being financial and non-financial pledge, police supervision, and safe-conduct; see Table 6). It turned out that in the years 1978-1990, preventive measures other than detention awaiting trial never amounted to more than 43,5 and to less than 18 per cent of all preventive measures applied. After the above-mentioned Art. 209 of the code of execution of penalties has been quashed, detention awaiting trial can only be executed in the houses of detention created and run by the Ministry of Justice (Art.Art. 4 and 83 of the code of execution of ponalties). On December 31, 1990, there were 65 such institutions in Poland. Twenty-seven of them had additional wards for convicted persons, while 48 prisons had special wards for those detained awaiting trial. Thus pre-trial detention could be executed in the total of 114 of the 151 institutions of the Prison Department. The houses of detention had the total capacity of 18,263 beds, while the number of detainees was 16,200; the discussed institutions were therefore populated in 88,7 per cent. The rights of the discussed category of detainees are specified in the Code of execution of penalties and by-laws of execution of pre-trial deteotion awaiting trial. What is particularly worthy of attention is the provision which states that the detainee enjoys rights that should at least equal those of a convicted person, and that the only limitations allowed in this sphere are those indispensable for securing the proper course of criminal proceedings, maintaining order and safety in the institution, and preventing mutual demoralization of detainees (Art. 86 para 1 of the Code of execution of penalties). A person detained awaiting trial has many legal measures at his disposal to protect his own rights in relation to the application and execution of detention. Thus the detainee can lodge a complaint with a supreme agency of the penitentiary administration (Art. 48 para 4 of the Code of execution of penalties); with the public prosecutor and penitentiary judge (Art.Art. 27–33 and 48 point 5); to the supreme State agencies, the National Ombudsperson included (Art. 48 point 5); he may apeal against a decision of the administration of the house of detention concerning the actual execution of that measure to the penitentiary court (Art. I4,l of the Code of execution of penaltes); he may also sue the Treasury for damage suffered during detention by guilt of functionaries of the penitentiary administration (Art.Art. 417–l9 of the Civil code); he may claim indemnity for obviously unjustified detention (Art.Art. 487–49l of the Code of criminal procedure); and he may bring legal action by virtue of infringement of his personal interests (Art.Art. 23–24 of the Civil code). As shown by experience, the persons detained awaiting trial either never resort to some of these means or do that ineffectively. The living conditions of the discussed category of detainees are specified mainly in the by-laws of pre-trial detention. Many faults and shortcomings have been found here in practice. Some of such faults were so drastic as to make it necessary to close several houses of detention in 1990 to mention just one example (the institutions were either liquidated or designed for repairs). The authors also assume an attitude towards the treatment of some categories of offenders (women, particularly dangerous detainees, persons with mental disorders, HIV carriers), and discuss the treatment of juvenile detainees. Ending the paper, the authors stress the gradual improvement in the treatment of detainees since 1989. It results both from the legislative changes and from a relatively liberal criminal policy. The legal and to some extent also the organizational conditions have been created for implementation of the rule of law. Further changes are necessary, though, including in particular the passing of a new Constitution and penal codes. The drafts of the latter suggest, many new solutions in the sphere of arrest and detention awaiting trial which would make those institutions meet the European standards. What can considered valuable are the trends towards limiting the application of the two measures, specifying the conditions of their application, importantly, extending the guaranties of detainees’ rights.

The World Trade Center Attack or 9/11 tragedy has awakened the international community, particularly the United States (US) to sharpen its foreign policy in facing security threats coming from ‘weak states’. One of the most prominent weak states examples that pose a grave threat to other countries are the Northern Triangle Countries of Central America that referred to Guatemala, Honduras, and El Salvador. Hence, this paper will discuss the rationale behind US initiatives in dealing with security threats in El Salvador as one of the Northern Triangle Countries. In analyzing the case, the writers will use the weak state concept and national interest concept. The result of this paper finds that El Salvador corresponds to the elements of a weak state and further poses security threats by giving rise to transnational criminal organizations, drug trafficking, and migrant problems in which overcoming those security threats has become US vital national interest. However, we also find that although decreasing security threats and strengthening El Salvador government capacity is highly correlated, strengthening El Salvador governance through the providence of aid and assistance is actually classified as US important national interest. Keywords: Security threats; Northern Triangle; weak state; El Salvador; national interest REFERENCES Ambrus, Steven. “Guatemala: The Crisis of Rule of Law and a Weak Party System.” Ideas Matter, January 28, 2019. https://blogs.iadb.org/ideas-matter/en/guatemala-the-crisis-of-rule-of-law-and-a-weak-party-system/. Andrade, Laura. Transparency In El Salvador. 1st ed. 1. El Salvador: University Institute for Public Opinion, Asmann, Parker. “El Salvador Citizens Say Gangs, Not Government 'Rule' the Country.” InSight Crime, August 19, 2020. https://insightcrime.org/news/brief/el-salvador-citizens-say-gangs-not- government-rules-country/. Accessed July 11, 2021. Art, Robert J. A. Grand Strategy for America. 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Dudley, Steven, and Avalos, Silva “MS13 In the Americas: How the World’s Most Notorious Gang Defies Logic, Resists Destruction. National Institute of Justice”, 2018. “El Salvador Homicides Jump 56 Percent as Gang Truce Unravels.” Reuters, December 30,2014.https://www.reuters.com/article/us-el-salvador-violence-idUSKBN0K81HR20141230. Eizenstat, Stuart E., John Edward Porter, and Jeremy M. Weinstein. “Rebuilding Weak States.”Foreign Affairs 84, no. 1 (2005): 134. https://doi.org/10.2307/20034213. FOXBusiness. “How MS-13, One of America's Most Dangerous Gangs, Is Funded.” Fox Business.Fox Business, April 19, 2017.https://www.foxbusiness.com/features/how-ms-13-one-of-americas-most-dangerous-gangs-is-funded. Accessed July 11, 2021. Fukuyama, Francis.Cornell University Press. Ithaca, USA: Cornell University Press, 2004. Galdamez, Eddie. “Water Pollution in El Salvador. Getting Worse Every Year.” El Salvador INFO,June 30, 2021. https://elsalvadorinfo.net/water-pollution-in-el-salvador/. Accessed July 11, 2021. Gies, Heather. “Once Lush, El Salvador Is Dangerously Close to Running out of Water.” Environment. National Geographic, May 4, 2021.https://www.nationalgeographic.com/environment/article/el-salvador-water-crisis-drought-climate-change. Accessed July 11, 2021. Giedraityte, Ieva. “Empire, Leadership OR Hegemony: US Strategies towards the Northern Triangle Countries in the 21st Century.” Latin American Yearbook – Political Science and International Relations 7 (2019): 175. https://doi.org/10.17951/al.2019.7.175-192. “Government Revenues.” Government Revenues - Countries - List. Accessed August 4, 2021.https://tradingeconomics.com/country-list/government-revenues. “Guatemala: An Assessment of Poverty.” Poverty Analysis - Guatemala: An Assessment of Poverty. 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RESUMENEl riesgo de morir en duelo fue consustancial a la cultura del honor. Incluso en países, como Francia o España, donde la muerte en duelo no era habitual. El nexo entre honor y vida, o entre sus contrarios, deshonor y muerte, permeaba el imaginario cultural de las élites liberales. La épica de los duelos giraba en torno a la probabilidad de que un combatiente pereciera, y aun cuando la muerte no fuese el objetivo buscado en el lance, siempre pesaba la incertidumbre: la amenaza de recibir una estocada dolorosa o la eventualidad de una lesión grave. La muerte planeaba sobre los desafíos y que acudiera, o no, al campo del honor dependía de diversas variables: la fogosidad de los rivales, la habilidad de los padrinos al concertar el duelo, que uno de los contendientes fuese militar, la naturaleza de la ofensa o que esta girara en torno a una mujer… También se cernía sobre el duelista la amenaza de la muerte eterna, pues la Iglesia condenaba los lances de honor y prohibía que los caídos en combate sin confesión recibieran sepultura sagrada. De todo lo anterior tratan las siguientes páginas, centradas en la cultura del duelo en España, enmarcada en el contexto internacional, y en la presencia en ella de la muerte. Palabras clave: honor, muerte, duelos, masculinidadTopónimos: España, EuropaPeriodo: Siglos xix y xx ABSTRACTThe risk of dying in a duel was consubstantial to the culture of honor, even in countries such as France or Spain, where death in a duel was not usual. The link between honor and life, or between their opposites, dishonor, and death, permeated the cultural imaginary of the liberal elites. The epic of duels revolved around the probability that a combatant would perish; and even when death was not the intended objective of the duel, uncertainty always weighed heavily: the threat of receiving a painful thrust or the eventuality of a serious injury. Death hovered over the challenges and whether it would come to the field of honor depended on several variables: the fierceness of the rivals, the skill of the godfathers in arranging the duel, whether one of the contenders was a military man, the nature of the offense or whether it revolved around a woman... The threat of eternal death also hung over the duelist, since the Church condemned duels and prohibited those who fell in combat without confession with receiving a sacred burial. 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A., Masculinity and males codes of honor in modern France, Berkeley, University of California Press, 1998.Núñez Florencio, R., Militarismo y antimilitarismo en España (1888-1906), Madrid, CSIC, 1990Onieva, A. J., Pushkin, Madrid, Epesa, 1969. Parker, D. S., “Law, Honor, and Impunity in Spanish America: The Debate over Dueling, 1870-1920”, Law and History Review 19/2 (2001) pp. 311-341.Piccato, P., The Tyranny of Opinion: Honor in the Construction of the Mexican Public Sphere, Durham, Duke University Press, 2010. Ponce Alberca, J. y Lagares García, D., Honor de oficiales: los tribunales de honor en el ejército de la España contemporánea (siglos XIX-XX), Barcelona, Carena, 2000. Ramos Domingo, J., Crónica e información en el sermonario español, Salamanca, Universidad Pontificia, 2008. Ramos Yzquierdo, L., Código del duelo extractado y traducido de varios autores nacionales y extrangeros, Cienfuegos, 1889.Rangel, D. M., “O código d’honra e as alterações na prática de duelar em Portugal nos séculos XIX-XX”, Cultura, Espaço Memoria 2 (2011) pp. 244-264.Reyfman, I., “The Emergence of Duel in Russia: Corporal Punishment and the Honor Code”, The Russian Review, 54 (1995) pp. 26-43.Ruiz Albéniz, V., ¡Aquel Madrid! (1900-1914), Madrid, Artes Gráficas Municipales, 1944. Ruiz Fornells, E., La educación moral del soldado, Toledo, 1899.Sánchez, R., “Honor de periodistas. Libertad de prensa y reputación pública en la España liberal”, en R. Sánchez y J. A. Guillén (coords.), La cultura de la espada. De honor, duelos y otros lances, Madrid, Universidad Rey Juan Carlos, 2019, pp. 305-332.— “El duelo es una necesidad de los tiempos presentes»: opiniones sobre el carácter civilizador del duelo en la España del siglo XIX”, Memoria y civilización, 23 (2020), pp. 1-21.— “Aristocrats for Peace: The Anti-Duellist Conference of Budapest (1908)”, Ler História, 80 (2022) pp. 137-158. 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Background and Aims: Dukan diet, a popular diet with high content of protein and carbohydrate and fat restriction has been widely used for weight loss. We aimed to compare the effects of the Dukan diet with traditional low-calorie diet in nutritional, laboratory and vascular parameters in obese subjects. Methods and Results: Obese subjects classes I or II of both genders, aging 19 to 65 years were allocated into two groups: Traditional low-calorie diet (n=17) and Dukan Diet (n=17). Anthropometric, laboratory and vascular evaluations were performed at baseline, 3, 6 and 12 months. Body composition was evaluated by bioelectric impedance and endothelial function by flow-mediated dilation of the brachial artery, at same times. After 12 months, it was verified that Dukan diet was more effective (p<0.05) than traditional diet for: weight loss (-10.6 vs -2.9 kg), body mass index (-3.7 vs -1.1 kg/m2), waist circumference (-11.2 vs -2.1 cm), fat (-5.7 vs -2.0 kg) and lean mass (-4.8 vs 0.8 kg) and basal metabolic rate (-152 vs -28 cal). In Dukan diet group, improvement (p<0.05 vs baseline) was observed in triglyceride levels (172.40 to 111.90 mg/dL) and insulin resistance, based on HOMA-IR index (4.98 to 3.26). The glomerular filtration rate decreased in this group after 3 months (132.50 to 113.80 mL/min) and no changes in flow-mediated dilation were observed throughout the study with both diets. Conclusion: Dukan diet was more effective than traditional diet for weight loss and laboratory parameters and without changes in endothelial function, in the 12-months follow-up of obese subjects. Introduction Low-carbohydrate diets have been one of the most recently used dietary therapies in patients with diabetes and obesity in clinical studies(1). Among them, in addition to carbohydrate restriction, fat restriction and high protein concentration, as in the Diet Dukan, has been widely used by the general population, aiming at weight loss. The Dukan diet is designed to reduce carbohydrate and fat intake in the first phase of the diet, with exclusive intake of protein, followed by another Three phases, with progressive and slow reintroduction of other nutrients such as fiber, carbohydrates and fats. In recent years, there has been increasing interest in the effectiveness of very low carbohydrate diets, called ketogenic diets, in the effectiveness of weight loss in order to combat obesity and cardiovascular disease risk(2). In this diet, ketone bodies are formed and they are used as an alternative energy source in the absence of glucose. Ketogenic diet promotes weight loss reducing appetite, increasing satiety and thermogenesis, due to the high protein consumption(3) affect hormones that control appetite, such as ghrelin and leptin(4) reduces lipogenesis and increases lipolysis(5,6) and gluconeogenesis(7). Replacing carbohydrates by proteins in the diet have been the aim of several studies but with inconsistent results. High protein intake has positive effects on weight loss, acting on satiety, body composition, lipid profile and glucose homeostasis. Furthermore, it increases thermogenesis, energy expenditure(8) and the elevation in the amino acid level in the plasma acts on the satiety center, decreasing appetite, since amino acids also stimulate insulin secretion resulting in decreased or maintained blood glucose levels(9). Few studies have been published with Dukan diet. Freeman et al. were the first to publish an article with the Dukan Diet in 2014, describing adverse effects in one patient undergoing this diet(10). Nouvenne et al. reviewed studies about the influence of popular diets on kidney stone formation risk. In this article, the authors suggest that in the Dukan diet, due to the high consumption of animal protein, urinary calcium can increase and the citrate urinary excretion can decrease, increasing the risk of kidney stone formation(11). In 2015, Wyka et al. evaluated dietary consumption in women adopting the Dukan-diet, based on the menu consumed in each of 4 phases of diet. They observed weight loss of around 15 kg after 8 to 10 weeks of diet and higher intake of proteins, mainly of animal origin, high consumption of potassium, iron and vitamins A, D and B2 and reduced consumption of carbohydrates, vitamin C and folates. They suggest that this diet may be harmful to health if adopted for a long time, developing of kidney and liver disease, osteoporosis and cardiovascular disease(12). Considering that the Dukan Diet is widely disseminated and it is used by the population in general for weight loss and few scientific studies are found in the literature, we propose to evaluate the nutritional, laboratory parameters related to cardiovascular disease, comparing this diet with traditional hypocaloric diet in obese individuals. Methods Study design This study was a clinical trial with nutritional intervention, for one year. Patients were recruited from the Lipids, Atherosclerosis and Vascular Biology Division of the Universidade Federal de São Paulo (UNIFESP). The study conforms to the ethical guidelines and approval was obtained from the ethics committee and it was registered in the Brazilian Registry of Clinical Trials. All participants provided written informed consent and received no monetary incentive. A total of 40 subjects were initially recruited and the participants were followed up clinically by a cardiologist and nutritionist during the 12-month period with monthly visits. Of the 40 participants who started the study, 34 completed the 12-month follow-up, whose data are presented in this study. The inclusion criteria were: both genders, aging 19-65 years old, obesity grade I or II (body mass index between 30 kg/m² and 39.9 kg/m²), stable body weight in the previous 3 months and desire to lose weight. The main exclusion criteria were: patients in primary or secondary prevention of coronary heart disease with low-density lipoprotein cholesterol (LDL-C) levels greater than 190 mg/dL and triglycerides greater than 400 mg/dL; diabetes mellitus; untreated hypothyroidism; psychiatric and hepatic disease; chronic renal failure; cardiac and respiratory insufficiency; systemic infections; use of antidepressants, corticoids, diuretics and diabetes medications; bariatric surgery, cancer and failure to accept the conditions necessary to conduct the research. Two groups were constituted: Traditional low-calorie diet (TD): n=17, 14 females and 3 males, 45±11 years old, 90±11 Kg body weight and body mass index (BMI) 34±2Kg/m2; High protein/Low carbohydrate diet-Dukan Diet (DD): n=17, 10 females and 7 males, 38±11 years old, 95±9 Kg of body weight and BMI 34±2 Kg/m2. The TD group received orientations according to the Food Guideline for the Brazilian Population, with 1 500–1 800 calories/day. They were stimulated to improve healthy eating habits increasing the consumption of natural foods without preservatives, such as vegetables and fruits rich in fiber and antioxidants. Daily consumption of fruits and vegetables at meals was recommended; carry out the fractionation of the meals throughout the day, avoiding prolonged fasting. Hydration and regular physical activity were recommended, according to healthier life habits(13). The DD group followed the high-protein/low-carbohydrate diet as proposed by Dukan Diet, available at https://www.dietadukan.com.br and received an illustrated book about this diet(14). This diet is structured in four phases: two for weight loss (1st and 2nd phases) and two for weight maintenance (3rd and 4th phases): 1st stage - Attack: For 5 consecutive days, it is allowed to consume only proteins with lean meats, eggs, light cheese and milk, 1.5 tablespoons of oat bran per day and light physical activity for 20 minutes. 2nd stage - Cruise: This phase is maintained until the desired weight loss. The vegetables are introduced alternating with the pure protein day (first stage). It is recommended 2 tablespoons of oat bran per day and light physical activity for 30 minutes. 3rd phase - Consolidation: The time of this phase is equivalent to 10 days per kg of lost weight. In this stage carbohydrates and lipids are introduced by a controlled and moderate way, being divided in two parts: in the first part, corresponding to half of the period to be followed, is allowed: 1 fruit, 2 slices of bread (50 g) or 1 spoon of farinaceous per day and 1 gala dinner per week. In the second part, it is allowed 2 fruits, 4 slices of bread (100 g) or 2 spoons of farinaceous per day and 2 gala dinners per week. This phase has one rule: make one day of the week with pure protein (first stage) and it is recommended 2.5 tablespoons of oat bran per day and light physical activity for 35 minutes. 4th phase - Stabilization: In this phase, three rules must to be followed: one day a week it should follow up the pure protein diet, the daily consumption of 3 tablespoons of oat bran and at least 40 minutes of daily walking. From this phase, the participants followed up the low calorie diet. The adherence of the participants was monitored by the interview with the nutritionist and qualitative evaluation of ketone bodies in the urine, using Labtest UriAction 10 reagent strips. At baseline, 3, 6 and 12 months, the following evaluations were performed: nutritional assessment determining anthropometry, blood samples were collected for laboratory tests. Endothelial function was evaluated in fasting and 2-hours post prandial situations. In the periods between the predetermined visits, the participants were followed up by the nutritionist monthly and by telephone contact whenever requested and with medical attention whenever necessary. Nutritional evaluation Nutritional assessment was performed by anthropometric determinations of weight, height, BMI, abdominal circumference and bioelectric impedance (BIA). BIA was carried out using the Biodynamics Model 450 TBW® apparatus, with portable plethysmograph and patients were instructed according to the manufacturer's instruction(15). Laboratory parameters Peripheral blood samples were collected for dosages of total cholesterol and fractions, triglycerides, glucoses, insulin, iron, ferritin, ALT, AST, urea, creatinine, hemoglobin and hematocrit. Biochemical parameters were determined through the automated colorimetric enzymatic method in Cobas Mira® (Roche, Switzerland) and LDL-c was estimated by the Friedewald equation. Serum insulin concentration was determined by immunofluorometry and the insulin resistance calculated by the HOMA-IR – Homeostasis Model Assessment Insulin Resistance, and values ≥ 2.5 values were considered as presence of insulin resistance(16). Glomerular Filtration Rate (GFR) was estimated by the Cockroft-Gault equation adapted to obese patients(17). Endothelial function Endothelial function was assessed by Endothelial-dependent flow-mediated dilation (FMD) of the brachial artery(18), using an ultrasound system (Sonos5500; Hewlett-Packard-Phillips, Palo Alto, CA), equipped with vascular software for two-dimensional imaging, color and spectral Doppler ultrasound modes, internal electrocardiogram monitor and linear-array transducer with a frequency range from 7.5 to 12.0 MHz. FMD evaluation was performed in two stages: fasted at least 6 hours and 2 hours after the consumption of a small meal, according to each diet. These meals were consisted of 374.04 calories, 36g proteins, 16g carbohydrates and 18g lipids in the DD and in TD, it was composed by 361.20 calories, 24g of protein, 41g of carbohydrates and 11g of lipids. Statistical Analysis The variables were expressed as mean and standard deviation. The distribution of the date normality was analyzed by the Kolmogorov-Smirmov (KS) test. When they did not present normal distribution, a logarithm [log(Y)] transformation was performed prior to analysis. The comparison between the variables of two groups was performed using Student's t-test for independent numerical variables and Fisher's exact test for categorical variables. Comparisons between more than two groups were performed by analysis of variance (ANOVA) for repeated measures, followed by the Tukey test, if differences were found. For the sample power calculation, the Statistical Software, Statistica Ultimate Academic, version 12.7, Concurrent Network was used. Values of p ≤ 0.05 were considered for statistical significance and analysis was performed using the software [GraphPadPrism 4.0 (GraphPad Software, San Diego, CA, USA)]. Results Participants’ characteristics At the beginning of the study, the groups were matched for age, gender, weight and BMI. At 3 months, all participants of DD group (100%) were in phase 2; at 6 months, 13 participants (76.4%) were in phase 3 and 4 (23.5%) in phase 2; and at 12 months, all (100%) were already in phase 4. The TD group followed the same recommendation during the 12 months. The qualitative evaluation of the presence of ketone bodies in the urine of the DD group participants, which were still in phase 2, was positive in 94% at 3rd month and 80% at the 6th month. The following adverse effects have been reported during the course of the study: weakness, fatigue, dizziness, lack of concentration, irritability, constipation, ketone breath and social life impairment. These symptoms were of low intensity and transient, especially in the early stages of the DD diet. These adverse effects were not causes for withdrawal from the study. Anthropometry The changes in body weight, BMI, waist abdominal circumference and BMR were more effective in DD than TD group during all follow-up evaluations. The changes after 12 months in relation to baseline of the anthropometric parameters in the DD and DT groups respectively were: Weight loss (-10.6 Kg, p<0.0001 and – 2.9 Kg, p<0.0001), BMI (-3.7 Kg/m2, p<0.0001 and -1.1 Kg/m2, p<0.0001), waist abdominal circumference (-11.2 cm, p<0.0001 and -2.1 cm, p=0.0008) and BMR (-152 cal, p<0.0001 and -28 cal, p=0.0198). After 12 months, the participants of DD group reached the overweight level but the TD group was still within the obesity range. Reductions were observed in both groups, in fat mass (-5.7 Kg, p<0.0001 and -2.0 Kg, p<0.0001), and in lean mass (-4.8 Kg, p<0.0001 and -0.8 Kg, p=0.0196, in DD and DT group, respectively). Laboratory parameters and endothelial function In TD group, there was only hematocrit reduction after 6 months (p=0.0103) and glucose level after 3 months (p=0.0021) compared to baseline. In DD group, laboratory alterations occurred in relation to hemoglobin, hematocrit, triglycerides, insulin, HOMA-IR and GFR. It was observed an improvement in the triglycerides levels (172.40 ± 62.36 mg/dL and 111.90 ± 43.22 mg/dL, p=0.0001) and insulin resistance determined by HOMA-IR at all times of study (4.98 ± 3.03 and 3.26 ± 2.03, p=0.0008) at baseline and 12 months, respectively. GFR was reduced only after 3 months (132.50 ± 31.13 and 113.80 ± 24.25 mL/min, p=0.0063) in the DD group. No differences were observed in endothelial function in the two study groups, in both fasting and postprandial. Discussion This study demonstrated higher weight loss in the Dukan diet group, compared to the traditional low calorie diet. The effect of weight loss in the DD group was persistent and remained until 6th month, but in 12 months it was observed a gain around 3.41 ± 0.21 Kg. The DD is performed in phases, with severe restriction until the 3rd phase and at about the 6th month; carbohydrates and a gala meal are reintroduced, promoting a weight gain. Sacks et al. observed that regardless of the nutritional composition of the diet, obese participants that had a weight loss, after 12 months of treatment, they can gain weight, but with a reduction of approximately 11.4% of the initial weight(19). We observed that participants of TD group also presented significant weight reduction, suggesting the effectiveness of the close follow up with nutritionist and physician. Abdominal circumference is an indirect parameter of fat mass corresponding to visceral fat that is associated with a higher risk for cardiovascular diseases. In our data, we observed a reduction in waist circumference in both groups after 12 months. Moreno et al. comparing ketogenic diet with standard diet in a group of obese patients found an important reduction in abdominal circumference with partial recovery after 24 months(20). Although DEXA Scan is considered the gold standard for body composition determination, BIA is a non-invasive and relatively inexpensive method and widely used(21). A significant reduction in the relative values of body fat was observed at 3 and 6 months in the DD group and only after 3 months in the TD. Increase in percent of lean mass was observed in the DD group at 3 and 6 months, but this increase does not represent a gain of lean mass, since the relative increase is a result of the reduction of body weight, promoting a relative increase in the values of lean mass. The loss of lean mass in the DD group may be due to the low caloric intake of the diet, as Chaston et al. (2007) pointed out that diet with low-calorie diet promote marked weight loss, but there is a decline in lean mass resulting from this process(22) . In our study, in spite of consuming a large amount of protein, this nutrient alone is not enough to promote the maintenance of lean mass and exercise stimulation is still necessary, which did not happen in this study, since the participants were all sedentary. In obese individuals, weight gain after marked loss is common, with reduction in basal metabolic rate(23). Several studies have observed this phenomenon during rapid weight loss(24) and diets with low carbohydrate intake are among the factors that influence metabolic adaptation. Some studies suggest that low amounts of carbohydrate (<45%) decrease the basal metabolic rate during and after weight loss. This type of diet can promote fat mass loss and preservation of lean mass during weight loss, reducing the basal metabolic rate. Reduction in BMR was observed in both groups, but in the DD group, the reduction occurred at all times in relation to baseline whereas in TD group the reduction was greater only after 6 months of intervention. Improvement in insulin resistance and triglycerides were observed only in the DD group. Individuals with insulin resistance have greater difficulty to metabolize carbohydrates, diverting a greater amount of dietary carbohydrates to the liver, where much of it is converted to fat (lipogenesis), rather than being oxidized in energy in the skeletal muscle. For this reason, very low carbohydrate diets applied in obese individuals, in addition to leading to weight loss also improves glycemic and lipid control. The effects of the very prolonged ketogenic diet are still poorly investigated and for this reason this diet should only be used for a limited period (from 3 weeks to a few months) to stimulate fat loss, improve metabolism, and then adjusting a transition to a normal diet(25). No changes in levels of total cholesterol, HDL-c and LDL-c were observed in any group. However, only in the DD group there was a significant reduction in TG level. In general, diets with reduced carbohydrates and high levels of proteins and fats increase LDL-c and TG levels showing beneficial effects of the ketogenic diet on cardiovascular risk factors. Most studies show that reducing carbohydrates can bring significant benefits in reducing total cholesterol, increases in HDL-c and reduction of triglycerides in the blood. HMG-CoA reductase, a key enzyme in the synthesis of endogenous cholesterol is activated by insulin, so that a reduction in blood glucose and hence insulin levels, leads to lower cholesterol synthesis. Thus, a reduction in dietary carbohydrate associated with adequate cholesterol consumption leads to inhibition of cholesterol biosynthesis(26). When insulin is elevated, lipolysis is reduced and lipogenesis is increased, resulting in overproduction of VLDL containing TG, formation of small and dense LDL particles and reduction of HDL. Low concentrations of glucose and insulin also reduce the expression of the carbohydrate-sensitive response element binding protein (ChREBP) transcription factor, and expression of the binding protein of the sterol regulatory element (SREBP-1c), responsible for the synthesis of fatty acids, as well as their incorporation into triglycerides and phospholipids, activating the main lipogenic enzymes, reducing hepatic lipogenesis and VLDL production(27). When we evaluated the GFR, a reduction only in DD group was observed at 3 months of intervention, but still in normal reference levels. Our results did not show significant changes in serum creatinine levels, but GFR decrease in DD group. Carbohydrate-restricted diets have higher amounts of protein may affect glomerular filtration leading to progressive loss of renal function(28). In the study conducted by Brinkworfh et al. (2010), renal function was evaluated in 68 obese individuals without renal dysfunction who consumed two similar hypocaloric diets for one year, one with carbohydrate reduction and another with high carbohydrate content, and observed that creatinine serum levels and the GFR did not change in any of the dietary groups(29). In general, endothelial function improves after weight loss in obese individuals(30). However, associations between changes in endothelial function with anthropometric and biochemical parameters are still controversial(31). We observed that the endothelial function did not present a significant difference in the two study groups, both in fasting and in the 2 hours postprandial. Volek et al. (2009) observed that low-carbohydrate diet improves postprandial vascular function compared to a low-fat diet in overweight individuals with moderate hypertriglyceridemia(32). Low-carbohydrate diets, may improve vascular function in individuals with metabolic adaptations(32) and carbohydrate-restricted diets may induce benefits in endothelial function in the presence of insulin resistance, since impaired insulin action may be related to endothelial dysfunction. In our study, the meal offered for postprandial evaluation was not high in fat, but correspond to the diet proposed in each group. According to Nicholls et al. (2006), a single carbohydrate-restricted meal does not alter endothelial function(33) and this may be the reason we did not observe a change in endothelial function in the DD group in this study. Conclusion Comparing the nutritional and laboratory effects of traditional and hyper-protein diets with carbohydrate reduction, we can conclude that Dukan diet was more effective than traditional diet for weight loss, as well as for laboratory parameters and without changes in endothelial function, in the 12-months follow-up of obese subjects. Conflict of interest No conflict of interest. Acknowledgement Patricia Naomi Sakae had a scholarship from CAPES – Brazil. References Gogebakan O.; Kohl A.; Osterhoff MA.; van Baak MA.; Jebb SA.; Papadaki A.; et al. Effects of weight loss and long-term weight maintenance with diets varying in protein and glycemic index on cardiovascular risk factors: the diet, obesity, and genes (DiOGenes) study: a randomized, controlled trial. Circulation. 2011, 124(25), 2829-2838. Merino J.; Kones R.; Ferre R.; Plana N.; Girona J.; Aragones G.; et al. 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Education in Oceania continues to reflect the embedded implicit and explicit colonial practices and processes from the past. This paper conceptualises a cultural approach to education and leadership appropriate and relevant to the Republic of the Marshall Islands. As elementary school leaders, we highlight Kanne Lobal, a traditional Marshallese navigation practice based on indigenous language, values and practices. We conceptualise and develop Kanne Lobal in this paper as a framework for understanding the usefulness of our indigenous knowledge in leadership and educational practices within formal education. Through bwebwenato, a method of talk story, our key learnings and reflexivities were captured. We argue that realising the value of Marshallese indigenous knowledge and practices for school leaders requires purposeful training of the ways in which our knowledge can be made useful in our professional educational responsibilities. Drawing from our Marshallese knowledge is an intentional effort to inspire, empower and express what education and leadership partnership means for Marshallese people, as articulated by Marshallese themselves. Introduction As noted in the call for papers within the Waikato Journal of Education (WJE) for this special issue, bodies of knowledge and histories in Oceania have long sustained generations across geographic boundaries to ensure cultural survival. For Marshallese people, we cannot really know ourselves “until we know how we came to be where we are today” (Walsh, Heine, Bigler & Stege, 2012). Jitdam Kapeel is a popular Marshallese concept and ideal associated with inquiring into relationships within the family and community. In a similar way, the practice of relating is about connecting the present and future to the past. Education and leadership partnerships are linked and we look back to the past, our history, to make sense and feel inspired to transform practices that will benefit our people. In this paper and in light of our next generation, we reconnect with our navigation stories to inspire and empower education and leadership. Kanne lobal is part of our navigation stories, a conceptual framework centred on cultural practices, values, and concepts that embrace collective partnerships. Our link to this talanoa vā with others in the special issue is to attempt to make sense of connections given the global COVID-19 context by providing a Marshallese approach to address the physical and relational “distance” between education and leadership partnerships in Oceania. Like the majority of developing small island nations in Oceania, the Republic of the Marshall Islands (RMI) has had its share of educational challenges through colonial legacies of the past which continues to drive education systems in the region (Heine, 2002). The historical administration and education in the RMI is one of colonisation. Successive administrations by the Spanish, German, Japanese, and now the US, has resulted in education and learning that privileges western knowledge and forms of learning. This paper foregrounds understandings of education and learning as told by the voices of elementary school leaders from the RMI. The move to re-think education and leadership from Marshallese perspectives is an act of shifting the focus of bwebwenato or conversations that centres on Marshallese language and worldviews. The concept of jelalokjen was conceptualised as traditional education framed mainly within the community context. In the past, jelalokjen was practiced and transmitted to the younger generation for cultural continuity. During the arrival of colonial administrations into the RMI, jelalokjen was likened to the western notions of education and schooling (Kupferman, 2004). Today, the primary function of jelalokjen, as traditional and formal education, it is for “survival in a hostile [and challenging] environment” (Kupferman, 2004, p. 43). Because western approaches to learning in the RMI have not always resulted in positive outcomes for those engaged within the education system, as school leaders who value our cultural knowledge and practices, and aspire to maintain our language with the next generation, we turn to Kanne Lobal, a practice embedded in our navigation stories, collective aspirations, and leadership. The significance in the development of Kanne Lobal, as an appropriate framework for education and leadership, resulted in us coming together and working together. Not only were we able to share our leadership concerns, however, the engagement strengthened our connections with each other as school leaders, our communities, and the Public Schooling System (PSS). Prior to that, many of us were in competition for resources. Educational Leadership: IQBE and GCSL Leadership is a valued practice in the RMI. Before the IQBE programme started in 2018, the majority of the school leaders on the main island of Majuro had not engaged in collaborative partnerships with each other before. Our main educational purpose was to achieve accreditation from the Western Association of Schools and Colleges (WASC), an accreditation commission for schools in the United States. The WASC accreditation dictated our work and relationships and many school leaders on Majuro felt the pressure of competition against each other. We, the authors in this paper, share our collective bwebwenato, highlighting our school leadership experiences and how we gained strength from our own ancestral knowledge to empower “us”, to collaborate with each other, our teachers, communities, as well as with PSS; a collaborative partnership we had not realised in the past. The paucity of literature that captures Kajin Majol (Marshallese language) and education in general in the RMI is what we intend to fill by sharing our reflections and experiences. To move our educational practices forward we highlight Kanne Lobal, a cultural approach that focuses on our strengths, collective social responsibilities and wellbeing. For a long time, there was no formal training in place for elementary school leaders. School principals and vice principals were appointed primarily on their academic merit through having an undergraduate qualification. As part of the first cohort of fifteen school leaders, we engaged in the professional training programme, the Graduate Certificate in School Leadership (GCSL), refitted to our context after its initial development in the Solomon Islands. GCSL was coordinated by the Institute of Education (IOE) at the University of the South Pacific (USP). GCSL was seen as a relevant and appropriate training programme for school leaders in the RMI as part of an Asia Development Bank (ADB) funded programme which aimed at “Improving Quality Basic Education” (IQBE) in parts of the northern Pacific. GCSL was managed on Majuro, RMI’s main island, by the director at the time Dr Irene Taafaki, coordinator Yolanda McKay, and administrators at the University of the South Pacific’s (USP) RMI campus. Through the provision of GCSL, as school leaders we were encouraged to re-think and draw-from our own cultural repository and connect to our ancestral knowledge that have always provided strength for us. This kind of thinking and practice was encouraged by our educational leaders (Heine, 2002). We argue that a culturally-affirming and culturally-contextual framework that reflects the lived experiences of Marshallese people is much needed and enables the disruption of inherent colonial processes left behind by Western and Eastern administrations which have influenced our education system in the RMI (Heine, 2002). Kanne Lobal, an approach utilising a traditional navigation has warranted its need to provide solutions for today’s educational challenges for us in the RMI. Education in the Pacific Education in the Pacific cannot be understood without contextualising it in its history and culture. It is the same for us in the RMI (Heine, 2002; Walsh et al., 2012). The RMI is located in the Pacific Ocean and is part of Micronesia. It was named after a British captain, John Marshall in the 1700s. The atolls in the RMI were explored by the Spanish in the 16th century. Germany unsuccessfully attempted to colonize the islands in 1885. Japan took control in 1914, but after several battles during World War II, the US seized the RMI from them. In 1947, the United Nations made the island group, along with the Mariana and Caroline archipelagos, a U.S. trust territory (Walsh et al, 2012). Education in the RMI reflects the colonial administrations of Germany, Japan, and now the US. Before the turn of the century, formal education in the Pacific reflected western values, practices, and standards. Prior to that, education was informal and not binded to formal learning institutions (Thaman, 1997) and oral traditions was used as the medium for transmitting learning about customs and practices living with parents, grandparents, great grandparents. As alluded to by Jiba B. Kabua (2004), any “discussion about education is necessarily a discussion of culture, and any policy on education is also a policy of culture” (p. 181). It is impossible to promote one without the other, and it is not logical to understand one without the other. Re-thinking how education should look like, the pedagogical strategies that are relevant in our classrooms, the ways to engage with our parents and communities - such re-thinking sits within our cultural approaches and frameworks. Our collective attempts to provide a cultural framework that is relevant and appropriate for education in our context, sits within the political endeavour to decolonize. This means that what we are providing will not only be useful, but it can be used as a tool to question and identify whether things in place restrict and prevent our culture or whether they promote and foreground cultural ideas and concepts, a significant discussion of culture linked to education (Kabua, 2004). Donor funded development aid programmes were provided to support the challenges within education systems. Concerned with the persistent low educational outcomes of Pacific students, despite the prevalence of aid programmes in the region, in 2000 Pacific educators and leaders with support from New Zealand Aid (NZ Aid) decided to intervene (Heine, 2002; Taufe’ulungaki, 2014). In April 2001, a group of Pacific educators and leaders across the region were invited to a colloquium funded by the New Zealand Overseas Development Agency held in Suva Fiji at the University of the South Pacific. The main purpose of the colloquium was to enable “Pacific educators to re-think the values, assumptions and beliefs underlying [formal] schooling in Oceania” (Benson, 2002). Leadership, in general, is a valued practice in the RMI (Heine, 2002). Despite education leadership being identified as a significant factor in school improvement (Sanga & Chu, 2009), the limited formal training opportunities of school principals in the region was a persistent concern. As part of an Asia Development Bank (ADB) funded project, the Improve Quality Basic Education (IQBE) intervention was developed and implemented in the RMI in 2017. Mentoring is a process associated with the continuity and sustainability of leadership knowledge and practices (Sanga & Chu, 2009). It is a key aspect of building capacity and capabilities within human resources in education (ibid). Indigenous knowledges and education research According to Hilda Heine, the relationship between education and leadership is about understanding Marshallese history and culture (cited in Walsh et al., 2012). It is about sharing indigenous knowledge and histories that “details for future generations a story of survival and resilience and the pride we possess as a people” (Heine, cited in Walsh et al., 2012, p. v). This paper is fuelled by postcolonial aspirations yet is grounded in Pacific indigenous research. This means that our intentions are driven by postcolonial pursuits and discourses linked to challenging the colonial systems and schooling in the Pacific region that privileges western knowledge and learning and marginalises the education practices and processes of local people (Thiong’o, 1986). A point of difference and orientation from postcolonialism is a desire to foreground indigenous Pacific language, specifically Majin Majol, through Marshallese concepts. Our collective bwebwenato and conversation honours and values kautiej (respect), jouj eo mour eo (reciprocity), and jouj (kindness) (Taafaki & Fowler, 2019). Pacific leaders developed the Rethinking Pacific Education Initiative for and by Pacific People (RPEIPP) in 2002 to take control of the ways in which education research was conducted by donor funded organisations (Taufe’ulungaki, 2014). Our former president, Dr Hilda Heine was part of the group of leaders who sought to counter the ways in which our educational and leadership stories were controlled and told by non-Marshallese (Heine, 2002). As a former minister of education in the RMI, Hilda Heine continues to inspire and encourage the next generation of educators, school leaders, and researchers to re-think and de-construct the way learning and education is conceptualised for Marshallese people. The conceptualisation of Kanne Lobal acknowledges its origin, grounded in Marshallese navigation knowledge and practice. Our decision to unpack and deconstruct Kanne Lobal within the context of formal education and leadership responds to the need to not only draw from indigenous Marshallese ideas and practice but to consider that the next generation will continue to be educated using western processes and initiatives particularly from the US where we get a lot of our funding from. According to indigenous researchers Dawn Bessarab and Bridget Ng’andu (2010), doing research that considers “culturally appropriate processes to engage with indigenous groups and individuals is particularly pertinent in today’s research environment” (p. 37). Pacific indigenous educators and researchers have turned to their own ancestral knowledge and practices for inspiration and empowerment. Within western research contexts, the often stringent ideals and processes are not always encouraging of indigenous methods and practices. However, many were able to ground and articulate their use of indigenous methods as being relevant and appropriate to capturing the realities of their communities (Nabobo-Baba, 2008; Sualii-Sauni & Fulu-Aiolupotea, 2014; Thaman, 1997). At the same time, utilising Pacific indigenous methods and approaches enabled research engagement with their communities that honoured and respected them and their communities. For example, Tongan, Samoan, and Fijian researchers used the talanoa method as a way to capture the stories, lived realities, and worldviews of their communities within education in the diaspora (Fa’avae, Jones, & Manu’atu, 2016; Nabobo-Baba, 2008; Sualii-Sauni & Aiolupotea, 2014; Vaioleti, 2005). Tok stori was used by Solomon Islander educators and school leaders to highlight the unique circles of conversational practice and storytelling that leads to more positive engagement with their community members, capturing rich and meaningful narratives as a result (Sanga & Houma, 2004). The Indigenous Aborigine in Australia utilise yarning as a “relaxed discussion through which both the researcher and participant journey together visiting places and topics of interest relevant” (Bessarab & Ng’andu, 2010, p. 38). Despite the diverse forms of discussions and storytelling by indigenous peoples, of significance are the cultural protocols, ethics, and language for conducting and guiding the engagement (Bessarab & Ng’andu, 2010; Nabobo-Baba, 2008; Sualii-Sauni & Aiolupotea, 2014). Through the ethics, values, protocols, and language, these are what makes indigenous methods or frameworks unique compared to western methods like in-depth interviews or semi-structured interviews. This is why it is important for us as Marshallese educators to frame, ground, and articulate how our own methods and frameworks of learning could be realised in western education (Heine, 2002; Jetnil-Kijiner, 2014). In this paper, we utilise bwebwenato as an appropriate method linked to “talk story”, capturing our collective stories and experiences during GCSL and how we sought to build partnerships and collaboration with each other, our communities, and the PSS. Bwebwenato and drawing from Kajin Majel Legends and stories that reflect Marshallese society and its cultural values have survived through our oral traditions. The practice of weaving also holds knowledge about our “valuable and earliest sources of knowledge” (Taafaki & Fowler, 2019, p. 2). The skilful navigation of Marshallese wayfarers on the walap (large canoes) in the ocean is testament of their leadership and the value they place on ensuring the survival and continuity of Marshallese people (Taafaki & Fowler, 2019; Walsh et al., 2012). During her graduate study in 2014, Kathy Jetnil-Kijiner conceptualised bwebwenato as being the most “well-known form of Marshallese orality” (p. 38). The Marshallese-English dictionary defined bwebwenato as talk, conversation, story, history, article, episode, lore, myth, or tale (cited in Jetnil Kijiner, 2014). Three years later in 2017, bwebwenato was utilised in a doctoral project by Natalie Nimmer as a research method to gather “talk stories” about the experiences of 10 Marshallese experts in knowledge and skills ranging from sewing to linguistics, canoe-making and business. Our collective bwebwenato in this paper centres on Marshallese ideas and language. The philosophy of Marshallese knowledge is rooted in our “Kajin Majel”, or Marshallese language and is shared and transmitted through our oral traditions. For instance, through our historical stories and myths. Marshallese philosophy, that is, the knowledge systems inherent in our beliefs, values, customs, and practices are shared. They are inherently relational, meaning that knowledge systems and philosophies within our world are connected, in mind, body, and spirit (Jetnil-Kijiner, 2014; Nimmer, 2017). Although some Marshallese believe that our knowledge is disappearing as more and more elders pass away, it is therefore important work together, and learn from each other about the knowledges shared not only by the living but through their lamentations and stories of those who are no longer with us (Jetnil-Kijiner, 2014). As a Marshallese practice, weaving has been passed-down from generation to generation. Although the art of weaving is no longer as common as it used to be, the artefacts such as the “jaki-ed” (clothing mats) continue to embody significant Marshallese values and traditions. For our weavers, the jouj (check spelling) is the centre of the mat and it is where the weaving starts. When the jouj is correct and weaved well, the remainder and every other part of the mat will be right. The jouj is symbolic of the “heart” and if the heart is prepared well, trained well, then life or all other parts of the body will be well (Taafaki & Fowler, 2019). In that light, we have applied the same to this paper. Conceptualising and drawing from cultural practices that are close and dear to our hearts embodies a significant ontological attempt to prioritize our own knowledge and language, a sense of endearment to who we are and what we believe education to be like for us and the next generation. The application of the phrase “Majolizing '' was used by the Ministry of Education when Hilda Heine was minister, to weave cultural ideas and language into the way that teachers understand the curriculum, develop lesson plans and execute them in the classroom. Despite this, there were still concerns with the embedded colonized practices where teachers defaulted to eurocentric methods of doing things, like the strategies provided in the textbooks given to us. In some ways, our education was slow to adjust to the “Majolizing '' intention by our former minister. In this paper, we provide Kanne Lobal as a way to contribute to the “Majolizing intention” and perhaps speed up yet still be collectively responsible to all involved in education. Kajin Wa and Kanne Lobal “Wa” is the Marshallese concept for canoe. Kajin wa, as in canoe language, has a lot of symbolic meaning linked to deeply-held Marshallese values and practices. The canoe was the foundational practice that supported the livelihood of harsh atoll island living which reflects the Marshallese social world. The experts of Kajin wa often refer to “wa” as being the vessel of life, a means and source of sustaining life (Kelen, 2009, cited in Miller, 2010). “Jouj” means kindness and is the lower part of the main hull of the canoe. It is often referred to by some canoe builders in the RMI as the heart of the canoe and is linked to love. The jouj is one of the first parts of the canoe that is built and is “used to do all other measurements, and then the rest of the canoe is built on top of it” (Miller, 2010, p. 67). The significance of the jouj is that when the canoe is in the water, the jouj is the part of the hull that is underwater and ensures that all the cargo and passengers are safe. For Marshallese, jouj or kindness is what living is about and is associated with selflessly carrying the responsibility of keeping the family and community safe. The parts of the canoe reflect Marshallese culture, legend, family, lineage, and kinship. They embody social responsibilities that guide, direct, and sustain Marshallese families’ wellbeing, from atoll to atoll. For example, the rojak (boom), rojak maan (upper boom), rojak kōrā (lower boom), and they support the edges of the ujelā/ujele (sail) (see figure 1). The literal meaning of rojak maan is male boom and rojak kōrā means female boom which together strengthens the sail and ensures the canoe propels forward in a strong yet safe way. Figuratively, the rojak maan and rojak kōrā symbolise the mother and father relationship which when strong, through the jouj (kindness and love), it can strengthen families and sustain them into the future. Figure 1. Parts of the canoe Source: https://www.canoesmarshallislands.com/2014/09/names-of-canoe-parts/ From a socio-cultural, communal, and leadership view, the canoe (wa) provides understanding of the relationships required to inspire and sustain Marshallese peoples’ education and learning. We draw from Kajin wa because they provide cultural ideas and practices that enable understanding of education and leadership necessary for sustaining Marshallese people and realities in Oceania. When building a canoe, the women are tasked with the weaving of the ujelā/ujele (sail) and to ensure that it is strong enough to withstand long journeys and the fierce winds and waters of the ocean. The Kanne Lobal relates to the front part of the ujelā/ujele (sail) where the rojak maan and rojak kōrā meet and connect (see the red lines in figure 1). Kanne Lobal is linked to the strategic use of the ujelā/ujele by navigators, when there is no wind north wind to propel them forward, to find ways to capture the winds so that their journey can continue. As a proverbial saying, Kanne Lobal is used to ignite thinking and inspire and transform practice particularly when the journey is rough and tough. In this paper we draw from Kanne Lobal to ignite, inspire, and transform our educational and leadership practices, a move to explore what has always been meaningful to Marshallese people when we are faced with challenges. The Kanne Lobal utilises our language, and cultural practices and values by sourcing from the concepts of jouj (kindness, love), kautiej (respect), and jouj eo mour eo (reciprocity). A key Marshallese proverb, “Enra bwe jen lale rara”, is the cultural practice where families enact compassion through the sharing of food in all occurrences. The term “enra” is a small basket weaved from the coconut leaves, and often used by Marshallese as a plate to share and distribute food amongst each other. Bwe-jen-lale-rara is about noticing and providing for the needs of others, and “enra” the basket will help support and provide for all that are in need. “Enra-bwe-jen-lale-rara” is symbolic of cultural exchange and reciprocity and the cultural values associated with building and maintaining relationships, and constantly honouring each other. As a Marshallese practice, in this article we share our understanding and knowledge about the challenges as well as possible solutions for education concerns in our nation. In addition, we highlight another proverb, “wa kuk wa jimor”, which relates to having one canoe, and despite its capacity to feed and provide for the individual, but within the canoe all people can benefit from what it can provide. In the same way, we provide in this paper a cultural framework that will enable all educators to benefit from. It is a framework that is far-reaching and relevant to the lived realities of Marshallese people today. Kumit relates to people united to build strength, all co-operating and working together, living in peace, harmony, and good health. Kanne Lobal: conceptual framework for education and leadership An education framework is a conceptual structure that can be used to capture ideas and thinking related to aspects of learning. Kanne Lobal is conceptualised and framed in this paper as an educational framework. Kanne Lobal highlights the significance of education as a collective partnership whereby leadership is an important aspect. Kanne Lobal draws-from indigenous Marshallese concepts like kautiej (respect), jouj eo mour eo (reciprocity), and jouj (kindness, heart). The role of a leader, including an education leader, is to prioritise collective learning and partnerships that benefits Marshallese people and the continuity and survival of the next generation (Heine, 2002; Thaman, 1995). As described by Ejnar Aerōk, an expert canoe builder in the RMI, he stated: “jerbal ippān doon bwe en maron maan wa e” (cited in Miller, 2010, p. 69). His description emphasises the significance of partnerships and working together when navigating and journeying together in order to move the canoe forward. The kubaak, the outrigger of the wa (canoe) is about “partnerships”. For us as elementary school leaders on Majuro, kubaak encourages us to value collaborative partnerships with each other as well as our communities, PSS, and other stakeholders. Partnerships is an important part of the Kanne Lobal education and leadership framework. It requires ongoing bwebwenato – the inspiring as well as confronting and challenging conversations that should be mediated and negotiated if we and our education stakeholders are to journey together to ensure that the educational services we provide benefits our next generation of young people in the RMI. Navigating ahead the partnerships, mediation, and negotiation are the core values of jouj (kindness, love), kautiej (respect), and jouj eo mour eo (reciprocity). As an organic conceptual framework grounded in indigenous values, inspired through our lived experiences, Kanne Lobal provides ideas and concepts for re-thinking education and leadership practices that are conducive to learning and teaching in the schooling context in the RMI. By no means does it provide the solution to the education ills in our nation. However, we argue that Kanne Lobal is a more relevant approach which is much needed for the negatively stigmatised system as a consequence of the various colonial administrations that have and continue to shape and reframe our ideas about what education should be like for us in the RMI. Moreover, Kannel Lobal is our attempt to decolonize the framing of education and leadership, moving our bwebwenato to re-framing conversations of teaching and learning so that our cultural knowledge and values are foregrounded, appreciated, and realised within our education system. Bwebwenato: sharing our stories In this section, we use bwebwenato as a method of gathering and capturing our stories as data. Below we capture our stories and ongoing conversations about the richness in Marshallese cultural knowledge in the outer islands and on Majuro and the potentialities in Kanne Lobal. Danny Jim When I was in third grade (9-10 years of age), during my grandfather’s speech in Arno, an atoll near Majuro, during a time when a wa (canoe) was being blessed and ready to put the canoe into the ocean. My grandfather told me the canoe was a blessing for the family. “Without a canoe, a family cannot provide for them”, he said. The canoe allows for travelling between places to gather food and other sources to provide for the family. My grandfather’s stories about people’s roles within the canoe reminded me that everyone within the family has a responsibility to each other. Our women, mothers and daughters too have a significant responsibility in the journey, in fact, they hold us, care for us, and given strength to their husbands, brothers, and sons. The wise man or elder sits in the middle of the canoe, directing the young man who help to steer. The young man, he does all the work, directed by the older man. They take advice and seek the wisdom of the elder. In front of the canoe, a young boy is placed there and because of his strong and youthful vision, he is able to help the elder as well as the young man on the canoe. The story can be linked to the roles that school leaders, teachers, and students have in schooling. Without each person knowing intricately their role and responsibility, the sight and vision ahead for the collective aspirations of the school and the community is difficult to comprehend. For me, the canoe is symbolic of our educational journey within our education system. As the school leader, a central, trusted, and respected figure in the school, they provide support for teachers who are at the helm, pedagogically striving to provide for their students. For without strong direction from the school leaders and teachers at the helm, the students, like the young boy, cannot foresee their futures, or envisage how education can benefit them. This is why Kanne Lobal is a significant framework for us in the Marshall Islands because within the practice we are able to take heed and empower each other so that all benefit from the process. Kanne Lobal is linked to our culture, an essential part of who we are. We must rely on our own local approaches, rather than relying on others that are not relevant to what we know and how we live in today’s society. One of the things I can tell is that in Majuro, compared to the outer islands, it’s different. In the outer islands, parents bring children together and tell them legends and stories. The elders tell them about the legends and stories – the bwebwenato. Children from outer islands know a lot more about Marshallese legends compared to children from the Majuro atoll. They usually stay close to their parents, observe how to prepare food and all types of Marshallese skills. Loretta Joseph Case There is little Western influence in the outer islands. They grow up learning their own culture with their parents, not having tv. They are closely knit, making their own food, learning to weave. They use fire for cooking food. They are more connected because there are few of them, doing their own culture. For example, if they’re building a house, the ladies will come together and make food to take to the males that are building the house, encouraging them to keep on working - “jemjem maal” (sharpening tools i.e. axe, like encouraging workers to empower them). It’s when they bring food and entertainment. Rubon Rubon Togetherness, work together, sharing of food, these are important practices as a school leader. Jemjem maal – the whole village works together, men working and the women encourage them with food and entertainment. All the young children are involved in all of the cultural practices, cultural transmission is consistently part of their everyday life. These are stronger in the outer islands. Kanne Lobal has the potential to provide solutions using our own knowledge and practices. Connie Joel When new teachers become a teacher, they learn more about their culture in teaching. Teaching raises the question, who are we? A popular saying amongst our people, “Aelon kein ad ej aelon in manit”, means that “Our islands are cultural islands”. Therefore, when we are teaching, and managing the school, we must do this culturally. When we live and breathe, we must do this culturally. There is more socialising with family and extended family. Respect the elderly. When they’re doing things the ladies all get together, in groups and do it. Cut the breadfruit, and preserve the breadfruit and pandanus. They come together and do it. Same as fishing, building houses, building canoes. They use and speak the language often spoken by the older people. There are words that people in the outer islands use and understand language regularly applied by the elderly. Respect elderly and leaders more i.e., chiefs (iroj), commoners (alap), and the workers on the land (ri-jerbal) (social layer under the commoners). All the kids, they gather with their families, and go and visit the chiefs and alap, and take gifts from their land, first produce/food from the plantation (eojōk). Tommy Almet The people are more connected to the culture in the outer islands because they help one another. They don’t have to always buy things by themselves, everyone contributes to the occasion. For instance, for birthdays, boys go fishing, others contribute and all share with everyone. Kanne Lobal is a practice that can bring people together – leaders, teachers, stakeholders. We want our colleagues to keep strong and work together to fix problems like students and teachers’ absenteeism which is a big problem for us in schools. Demetria Malachi The culture in the outer islands are more accessible and exposed to children. In Majuro, there is a mixedness of cultures and knowledges, influenced by Western thinking and practices. Kanne Lobal is an idea that can enhance quality educational purposes for the RMI. We, the school leaders who did GCSL, we want to merge and use this idea because it will help benefit students’ learning and teachers’ teaching. Kanne Lobal will help students to learn and teachers to teach though traditional skills and knowledge. We want to revitalize our ways of life through teaching because it is slowly fading away. Also, we want to have our own Marshallese learning process because it is in our own language making it easier to use and understand. Essentially, we want to proudly use our own ways of teaching from our ancestors showing the appreciation and blessings given to us. Way Forward To think of ways forward is about reflecting on the past and current learnings. Instead of a traditional discussion within a research publication, we have opted to continue our bwebwenato by sharing what we have learnt through the Graduate Certificate in School Leadership (GCSL) programme. Our bwebwenato does not end in this article and this opportunity to collaborate and partner together in this piece of writing has been a meaningful experience to conceptualise and unpack the Kanne Lobal framework. Our collaborative bwebwenato has enabled us to dig deep into our own wise knowledges for guidance through mediating and negotiating the challenges in education and leadership (Sanga & Houma, 2004). For example, bwe-jen-lale-rara reminds us to inquire, pay attention, and focus on supporting the needs of others. Through enra-bwe-jen-lale-rara, it reminds us to value cultural exchange and reciprocity which will strengthen the development and maintaining of relationships based on ways we continue to honour each other (Nimmer, 2017). We not only continue to support each other, but also help mentor the next generation of school leaders within our education system (Heine, 2002). Education and leadership are all about collaborative partnerships (Sanga & Chu, 2009; Thaman, 1997). Developing partnerships through the GCSL was useful learning for us. It encouraged us to work together, share knowledge, respect each other, and be kind. The values of jouj (kindness, love), kautiej (respect), and jouj eo mour eo (reciprocity) are meaningful in being and becoming and educational leader in the RMI (Jetnil-Kijiner, 2014; Miller, 2010; Nimmer, 2017). These values are meaningful for us practice particularly given the drive by PSS for schools to become accredited. The workshops and meetings delivered during the GCSL in the RMI from 2018 to 2019 about Kanne Lobal has given us strength to share our stories and experiences from the meeting with the stakeholders. But before we met with the stakeholders, we were encouraged to share and speak in our language within our courses: EDP05 (Professional Development and Learning), EDP06 (School Leadership), EDP07 (School Management), EDP08 (Teaching and Learning), and EDP09 (Community Partnerships). In groups, we shared our presentations with our peers, the 15 school leaders in the GCSL programme. We also invited USP RMI staff. They liked the way we presented Kannel Lobal. They provided us with feedback, for example: how the use of the sail on the canoe, the parts and their functions can be conceptualised in education and how they are related to the way that we teach our own young people. Engaging stakeholders in the conceptualisation and design stages of Kanne Lobal strengthened our understanding of leadership and collaborative partnerships. Based on various meetings with the RMI Pacific Resources for Education and Learning (PREL) team, PSS general assembly, teachers from the outer islands, and the PSS executive committee, we were able to share and receive feedback on the Kanne Lobal framework. The coordinators of the PREL programme in the RMI were excited by the possibilities around using Kanne Lobal, as a way to teach culture in an inspirational way to Marshallese students. Our Marshallese knowledge, particularly through the proverbial meaning of Kanne Lobal provided so much inspiration and insight for the groups during the presentation which gave us hope and confidence to develop the framework. Kanne Lobal is an organic and indigenous approach, grounded in Marshallese ways of doing things (Heine, 2002; Taafaki & Fowler, 2019). Given the persistent presence of colonial processes within the education system and the constant reference to practices and initiatives from the US, Kanne Lobal for us provides a refreshing yet fulfilling experience and makes us feel warm inside because it is something that belongs to all Marshallese people. Conclusion Marshallese indigenous knowledge and practices provide meaningful educational and leadership understanding and learnings. They ignite, inspire, and transform thinking and practice. The Kanne Lobal conceptual framework emphasises key concepts and values necessary for collaborative partnerships within education and leadership practices in the RMI. The bwebwenato or talk stories have been insightful and have highlighted the strengths and benefits that our Marshallese ideas and practices possess when looking for appropriate and relevant ways to understand education and leadership. Acknowledgements We want to acknowledge our GCSL cohort of school leaders who have supported us in the development of Kanne Lobal as a conceptual framework. A huge kommol tata to our friends: Joana, Rosana, Loretta, Jellan, Alvin, Ellice, Rolando, Stephen, and Alan. References Benson, C. (2002). Preface. In F. Pene, A. M. Taufe’ulungaki, & C. Benson (Eds.), Tree of Opportunity: re-thinking Pacific Education (p. iv). Suva, Fiji: University of the South Pacific, Institute of Education. Bessarab, D., Ng’andu, B. (2010). Yarning about yarning as a legitimate method in indigenous research. International Journal of Critical Indigenous Studies, 3(1), 37-50. Fa’avae, D., Jones, A., & Manu’atu, L. (2016). Talanoa’i ‘a e talanoa - talking about talanoa: Some dilemmas of a novice researcher. AlterNative: An Indigenous Journal of Indigenous Peoples,12(2),138-150. Heine, H. C. (2002). A Marshall Islands perspective. In F. Pene, A. M. Taufe’ulungaki, & C. Benson (Eds.), Tree of Opportunity: re-thinking Pacific Education (pp. 84 – 90). Suva, Fiji: University of the South Pacific, Institute of Education. Infoplease Staff (2017, February 28). Marshall Islands, retrieved from https://www.infoplease.com/world/countries/marshall-islands Jetnil-Kijiner, K. (2014). Iep Jaltok: A history of Marshallese literature. (Unpublished masters’ thesis). Honolulu, HW: University of Hawaii. Kabua, J. B. (2004). We are the land, the land is us: The moral responsibility of our education and sustainability. In A.L. Loeak, V.C. Kiluwe and L. Crowl (Eds.), Life in the Republic of the Marshall Islands, pp. 180 – 191. Suva, Fiji: University of the South Pacific. Kupferman, D. (2004). Jelalokjen in flux: Pitfalls and prospects of contextualising teacher training programmes in the Marshall Islands. Directions: Journal of Educational Studies, 26(1), 42 – 54. http://directions.usp.ac.fj/collect/direct/index/assoc/D1175062.dir/doc.pdf Miller, R. L. (2010). Wa kuk wa jimor: Outrigger canoes, social change, and modern life in the Marshall Islands (Unpublished masters’ thesis). Honolulu, HW: University of Hawaii. Nabobo-Baba, U. (2008). Decolonising framings in Pacific research: Indigenous Fijian vanua research framework as an organic response. AlterNative: An Indigenous Journal of Indigenous Peoples, 4(2), 141-154. Nimmer, N. E. (2017). Documenting a Marshallese indigenous learning framework (Unpublished doctoral thesis). Honolulu, HW: University of Hawaii. Sanga, K., & Houma, S. (2004). Solomon Islands principalship: Roles perceived, performed, preferred, and expected. Directions: Journal of Educational Studies, 26(1), 55-69. Sanga, K., & Chu, C. (2009). Introduction. In K. Sanga & C. Chu (Eds.), Living and Leaving a Legacy of Hope: Stories by New Generation Pacific Leaders (pp. 10-12). NZ: He Parekereke & Victoria University of Wellington. Suaalii-Sauni, T., & Fulu-Aiolupotea, S. M. (2014). Decolonising Pacific research, building Pacific research communities, and developing Pacific research tools: The case of the talanoa and the faafaletui in Samoa. Asia Pacific Viewpoint, 55(3), 331-344. Taafaki, I., & Fowler, M. K. (2019). Clothing mats of the Marshall Islands: The history, the culture, and the weavers. US: Kindle Direct. Taufe’ulungaki, A. M. (2014). Look back to look forward: A reflective Pacific journey. In M. ‘Otunuku, U. Nabobo-Baba, S. Johansson Fua (Eds.), Of Waves, Winds, and Wonderful Things: A Decade of Rethinking Pacific Education (pp. 1-15). Fiji: USP Press. Thaman, K. H. (1995). Concepts of learning, knowledge and wisdom in Tonga, and their relevance to modern education. Prospects, 25(4), 723-733. Thaman, K. H. (1997). Reclaiming a place: Towards a Pacific concept of education for cultural development. The Journal of the Polynesian Society, 106(2), 119-130. Thiong’o, N. W. (1986). Decolonising the mind: The politics of language in African literature. 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Like many other fields, ornithology and birding are addressing their legacy of colonialism, including re‐examining their naming practices. Discussions about eponyms, when species are named to honour people, sit at the intersection of nomenclatural stability and social justice concerns. In response to a charged debate about the future of eponymous common names, members of the American Ornithological Society (AOS)'s Diversity and Inclusion Committee held one‐on‐one listening sessions in 2020 with stakeholder groups across the birding and ornithology community and, in 2021, organized a Community Congress where stakeholders shared thoughts with a public audience. These two events aimed to create spaces for thoughtful dialogue around an inflamed topic and to identify areas of consensus for moving forward. Here we summarize the main findings from these two activities. We found broad agreement among stakeholders that (1) social justice is a valid reason to change names, (2) many issues – especially the technical, decision‐making and public‐engagement aspects of name changes – need to be considered, and (3) educational opportunities are not only abundant but critical in any name‐change process to achieve the stated goals of increasing diversity and belonging in birding and ornithology. Our work highlights the importance of including many voices in conversations when proposed changes to public use systems, such as common names, appear to conflict with current decision‐making methods. By creating a space away from knee‐jerk reactions, our listening sessions and the Community Congress found that the scientists, birders, educators, data/wildlife managers and field guide authors we spoke with are willing to engage in crucial conversations of how to deal with eponymous common names, as part of engaging with ornithology's colonialist history.

Photo by niu niu on Unsplash ABSTRACT Shackling prisoners has been implemented as standard procedure when transporting prisoners in labor and during childbirth. This procedure ensures the protection of both the public and healthcare workers. However, the act of shackling pregnant prisoners violates the principles of ethics that physicians are supposed to uphold. This paper will explore how shackling pregnant prisoners violates the principle of justice and beneficence, making the practice unethical. INTRODUCTION Some states allow shackling of incarcerated pregnant women during transport and while in the hospital for labor and delivery. Currently, only 22 states have legislation prohibiting the shackling of pregnant women.[1] Although many states have anti-shackling laws prohibiting restraints, these laws also contain an “extraordinary circumstances” loophole.[2] Under this exception, officers shackle prisoners if they pose a flight risk, have any history of violence, and are a threat to themselves or others.[3] Determining as to whether a prisoner is shackled is left solely to the correctional officer.[4] Yet even state restrictions on shackling are often disregarded. In shackling pregnant prisoners during childbirth, officers and institutions are interfering with the ability of incarcerated women to have safe childbirth experiences and fair treatment. Moreover, physicians cannot exercise various ethical duties as the law constrains them. In this article, I will discuss the physical and mental harms that result from the use of restraints under the backdrop of slavery and discrimination against women of color particularly. I argue that stereotypes feed into the phenomenon of shackling pregnant women, especially pregnant women of color. I further assert that shackling makes it difficult for medical professionals to be beneficent and promote justice. BACKGROUND Female incarceration rates in the United States have been fast growing since the 1980s.[5] With a 498 percent increase in the female incarceration population between 1981 and 2021, the rates of pregnancy and childbirth by incarcerated people have also climbed.[6],[7] In 2021, over 1.2 million women were incarcerated in the United States.[8] An estimated 55,000 pregnant women are admitted to jails each year.[9],[10] Many remain incarcerated throughout pregnancy and are transported to a hospital for labor and delivery. Although the exact number of restrained pregnant inmates is unclear, a study found that 83 percent of hospital prenatal nurses reported that their incarcerated patients were shackled.[11] I. Harms Caused by Shackling Shackling has caused many instances of physical and psychological harm. In the period before childbirth, shackled pregnant women are at high risk for falling.[12] The restraints shift pregnant women’s center of gravity, and wrist restraints prevent them from breaking a fall, increasing the risk of falling on their stomach and harming the fetus.[13] Another aspect inhibited by using restraints is testing and treating pregnancy complications. Delays in identifying and treating conditions such as hypertension, pre-eclampsia, appendicitis, kidney infection, preterm labor, and especially vaginal bleeding can threaten the lives of the mother and the fetus.[14] During labor and delivery, shackling prevents methods of alleviating severe labor pains and giving birth.[15] Usually, physicians recommend that women in labor walk or assume various positions to relieve labor pains and accelerate labor.[16] However, shackling prevents both solutions.[17] Shackling these women limits their mobility during labor, which may compromise the health of both the mother and the fetus.[18] Tracy Edwards, a former prisoner who filed a lawsuit for unlawful use of restraints during her pregnancy, was in labor for twelve hours. She was unable to move or adjust her position to lessen the pain and discomfort of labor.[19] The shackles also left the skin on her ankles red and bruised. Continued use of restraints also increases the risk of potentially life-threatening health issues associated with childbirth, such as blood clots.[20] It is imperative that pregnant women get treated rapidly, especially with the unpredictability of labor. Epidural administration can also become difficult, and in some cases, be denied due to the shackled woman’s inability to assume the proper position.[21] Time-sensitive medical care, including C-sections, could be delayed if permission from an officer is required, risking major health complications for both the fetus and the mother.[22] After childbirth, shackling impedes the recovery process. Shackling can result in post-delivery complications such as deep vein thrombosis.[23] Walking prevents such complications but is not an option for mothers shackled to their hospital beds.[24] Restraints also prevent bonding with the baby post-delivery and the safe handling of the baby while breast feeding.[25] The use of restraints can also result in psychological harm. Many prisoners feel as though care workers treat them like “animals,” with some women having multiple restraints at once— including ankles, wrists, and even waist restraints.[26] Benidalys Rivera describes the feeling of embarrassment as she was walking while handcuffed, with nurses and patients looking on, “Being in shackles, that make you be in stress…I about to have this baby, and I’m going to go back to jail. So it’s too much.”[27] Depression among pregnant prisoners is highly prevalent. The stress of imprisonment and the anticipation of being separated from their child is often overwhelming for these mothers.[28] The inhumane action has the potential to add more stress, anxiety, and sadness to the already emotionally demanding process of giving birth. Shackling pregnant prisoners displays indifference to the medical needs of the prisoner.[29] II. Safety as a Pretense While public safety is an argument for using shackles, several factors make escape or violence extremely unlikely and even impossible.[30] For example, administering epidural anesthesia causes numbness and eliminates flight risk.[31] Although cited as the main reason for using shackles, public safety is likely just an excuse and not the main motivator for shackling prisoners. I argue that underlying the shackling exemplifies the idea that these women should not have become pregnant. The shackling reflects a distinct discrimination: the lawmakers allowing it perhaps thought that people guilty of crimes would make bad mothers. Public safety is just a pretense. The language used to justify the use of restraint of Shawanna Nelson, the plaintiff in Nelson v. Correctional Medical Services, discussed below, included the word “aggressive.”[32] In her case, there was no evidence that she posed any danger or was objectively aggressive. Officer Turnesky, who supervised Nelson, testified that she never felt threatened by Nelson.[33] The lack of documented attempts of escape and violence from pregnant prisoners suggests that shackling for flight risk is a false pretense and perhaps merely based on stereotypes.[34] In 2011, an Amnesty International report noted that “Around the USA, it is common for restraints to be used on sick and pregnant incarcerated women when they are transported to and kept in hospital, regardless of whether they have a history of violence (which only a minority have) and regardless of whether they have ever absconded or attempted to escape (which few women have).”[35] In a 2020 survey of correctional officers in select midwestern prisons, 76 percent disagreed or strongly disagreed with restraining pregnant women during labor and delivery.[36] If a correctional officer shackles a pregnant prisoner, it is not because they pose a risk but because of a perception that they do. This mindset is attributed to select law enforcement, who have authority to use restraints.[37] In 2022, the Tennessee legislature passed a bill prohibiting the use of restraints on pregnant inmates. However, legislators amended the bill due to the Tennessee Sherriff Association’s belief that even pregnant inmates could pose a “threat.”[38] Subjecting all prisoners to the same “precautions” because a small percentage of individuals may pose such risks could reflect stereotyping or the assumption that all incarcerated people pose danger and flight risk. To quell the (unjustified) public safety concern, there are other options that do not cause physical or mental harm to pregnant women. For example, San Francisco General Hospital does not use shackles but has deputy sheriffs outside the pregnant women’s doors.[39] III. Historical Context and Race A. Slavery and Post-Civil War The treatment of female prisoners has striking similarities to that of enslaved women. Originally, shackling of female slaves was a mechanism of control and dehumanization.[40] This enabled physical and sexual abuses. During the process of intentionally dehumanizing slaves to facilitate subordination, slave owners stripped slave women of their feminine identity.[41] Slave women were unable to exhibit the Victorian model of “good mothering” and people thought they lacked maternal feelings for their children.[42] In turn, societal perception defeminized slave women, and barred them from utilizing the protections of womanhood and motherhood. During the post-Civil War era, black women were reversely depicted as sexually promiscuous and were arrested for prostitution more often than white women.[43] In turn, society excluded black women; they were seen as lacking what the “acceptable and good” women had.[44] Some argue that the historical act of labeling black women sexually deviant influences today’s perception of black women and may lead to labeling them bad mothers.[45] Over two-thirds of incarcerated women are women of color.[46] Many reports document sexual violence and misconduct against prisoners over the years.[47] Male guards have raped, sexually assaulted, and inappropriately touched female prisoners. Some attribute the physical abuse of black female prisoners to their being depicted or stereotyped as “aggressive, deviant, and domineering.”[48] Some expect black women to express stoicism and if they do not, people label them as dangerous, irresponsible, and aggressive.[49] The treatment of these prisoners mirrors the historical oppression endured by black women during and following the era of slavery. The act of shackling incarcerated pregnant women extends the inhumane treatment of these women from the prison setting into the hospital. One prisoner stated that during her thirty-hour labor, while being shackled, she “felt like a farm animal.”[50] Another pregnant prisoner describes her treatment by a guard stating: “a female guard grabbed me by the hair and was making me get up. She was screaming: ‘B***h, get up.’ Then she said, ‘That is what happens when you are a f***ing junkie. You shouldn’t be using drugs, or you wouldn’t be in here.”[51] Shackling goes beyond punishing by isolation from society – it is an additional punishment that is not justified. B. Reproductive Rights and “Bad Mothers” As with slaves not being seen as maternal, prisoners are not viewed as “real mothers.” A female prison guard said the following: “I’m a mother of two and I know what that impulse, that instinct, that mothering instinct feels like. It just takes over, you would never put your kids in harm’s way. . . . Women in here lack that. Something in their nature is not right, you know?”[52] This comment implies that incarcerated women lack maternal instinct. They are not in line with the standards of what society accepts as a “woman” and “mother” and are thought to have abandoned their roles as caretakers in pursuit of deviant behaviors. Without consideration of racial discrimination, poverty issues, trauma, and restricted access to the child right after delivery, these women are stereotyped as bad mothers simply because they are in prison. Reminiscent of the treatment of female black bodies post-civil war and the use of reproductive interventions (for example, Norplant and forced sterilization) in exchange for shorter sentences, I argue that shackles are a form of reproductive control. Justification for the use of shackles even includes their use as a “punitive instrument to remind the prisoner of their punishment.”[53] However, a prisoner’s pregnancy should have no relevance to their sentence.[54] Using shackles demonstrates to prisoners that society tolerates childbirth but does not support it.[55] The shackling is evidence that women are being punished “for bearing children, not for breaking the law.”[56] Physicians and healthcare workers, as a result, are responsible for providing care for the delivery and rectifying any physical problems associated with the restraints. The issues that arise from the use of restraints place physicians in a position more complex than they experience with regular healthy pregnancies. C. Discrimination In the case of Ferguson v. City of Charleston, a medical university subjected black woman to involuntary drug testing during pregnancy. In doing so, medical professionals collaborated with law enforcement to penalize black women for their use of drugs during pregnancy.[57] The Court held the drug tests were an unreasonable search and violated the Fourth Amendment. Ferguson v. City of Charleston further reveals an unjustified assumption: the medical and legal community seemed suspicious of black women and had perhaps predetermined them more likely to use drugs while pregnant. Their fitness to become mothers needed to be proven, while wealthy, white women were presumed fit.[58] The correctional community similarly denies pregnant prisoners’ medical attention. In the case of Staten v. Lackawanna County, an African American woman whose serious medical needs were treated indifferently by jail staff was forced to give birth in her cell.[59] This woman was punished for being pregnant in prison through the withholding of medical attention and empathy. IV. Failure to Follow Anti-Shackling Laws Despite 22 states having laws against shackling pregnant prisoners, officers do not always follow these laws. In 2015, the Correctional Association of New York reported that of the 27 women who gave birth under state custody, officers shackled 23 women in violation of the anti-shackling laws.[60] The lawyer of Tracy Edwards, an inmate who officers shackled unlawfully during her twelve-hour labor stated, “I don’t think we can assume that just because there’s a law passed, that’s automatically going to trickle down to the prison.”[61] Even with more restrictions on shackling, it may still occur, partly due to the stereotype that incarcerated women are aggressive and dangerous. V. Constitutionality The Eighth Amendment protects people from cruel and unusual punishment. In Brown vs. Plata, the court stated, “Prisoners retain the essence of human dignity inherent in all persons.”[62] In several cases, the legal community has held shackling to be unconstitutional as it violates the Eighth Amendment unless specifically justified. In the case of Nelson v. Correctional Medical Services, a pregnant woman was shackled for 12 hours of labor with a brief respite while she pushed, then re-shackled. The shackling caused her physical and emotional pain, including intense cramping that could not be relieved due to positioning and her inability to get up to use a toilet.[63] The court held that a clear security concern must justify shackling. The court cited a similar DC case and various precedents for using the Eighth Amendment to hold correctional facilities and hospitals accountable.[64] An Arkansas law similarly states that shackling must be justified by safety or risk of escape.[65] If the Thirteenth Amendment applied to those convicted of crimes, shackling pregnant incarcerated people would be unconstitutional under that amendment as well as the Eighth. In the Civil Rights Cases, Congress upheld the right “to enact all necessary and proper laws for the obliteration and prevention of slavery with all its badges and incidents.”[66] Section two of the Thirteenth Amendment condemns any trace or acts comparable to that of slavery. Shackling pregnant prisoners, stripping them of their dignity, and justification based on stereotypes all have origins in the treatment of black female slaves. Viewed through the lens of the Thirteenth Amendment, the act of shackling would be unconstitutional. Nonetheless, the Thirteenth Amendment explicitly excludes people convicted of a crime. VI. Justice As a result of the unconstitutional nature of shackling, physicians should have a legal obligation, in addition to their ethical duty, to protect their patients. The principle of justice requires physicians to take a stand against the discriminatory treatment of their patients, even under the eye of law enforcement.[67],[68] However, “badge and gun intimidation,” threats of noncompliance, and the fear of losing one’s license can impede a physician’s willingness to advocate for their patients. The American College of Obstetricians and Gynecologists (ACOG) finds the use of physical restraints interferes with the ability of clinicians to practice medicine safely.[69] ACOG, The American Medical Association, the National Commission on Correctional Health Care, and other organizations oppose using restraints on pregnant incarcerated people.[70] Yet, legislators can adopt shackling laws without consultation with physicians. The ACOG argues that “State legislators are taking it upon themselves to define complex medical concepts without reference to medical evidence. Some of the penalties [faced by OBGYNs] for violating these vague, unscientific laws include criminal sentences.”[71] Legislation that does not consider medical implications or discourages physicians’ input altogether is unjust. In nullifying the voice of a physician in matters pertaining to the patient’s treatment, physicians are prevented from fulfilling the principle of justice, making the act of shackling patients unethical. VII. Principle of Beneficence The principle of beneficence requires the prevention of harm, the removal of harm, and the promotion of good.[72] Beneficence demands the physician not only avoid harm but benefit patients and promote their welfare.[73] The American Board of Internal Medicine Foundation states that physicians must work with other professionals to increase patient safety and improve the quality of care.[74] In doing so, physicians can adequately treat patients with the goal of prevention and healing. It is difficult to do good when law enforcement imposes on doctors to work around shackles during labor and delivery. Law enforcement leaves physicians and healthcare workers responsible not only to provide care for the delivery, but also rectify any ailments associated with the restraints. The issues arising from using restraints place physicians in a position more complex than they experience with other pregnancies. Doctors cannot prevent the application of the shackles and can only request officers to take them off the patient.[75] Physicians who simply go along with shackling are arguably violating the principle of beneficence. However, for most, rather than violating the principle of beneficence overtly, physicians may simply have to compromise. Given the intricate nature of the situation, physicians are tasked with minimizing potential harm to the best of their abilities while adhering to legal obligations.[76] It is difficult to pin an ethics violation on the ones who do not like the shackles but are powerless to remove them. Some do argue that this inability causes physicians to violate the principle of beneficence.[77] However, promoting the well-being of their patients within the boundaries of the law limits their ability to exercise beneficence. For physicians to fulfill the principle of beneficence to the fullest capacity, they must have an influence on law. Protocols and assessments on flight risks made solely by the officers and law enforcement currently undermine the physician’s expertise. These decisions do not consider the health and well-being of the pregnant woman. As a result, law supersedes the influence of medicine and health care. CONCLUSION People expect physicians to uphold the four major principles of bioethics. However, their inability to override restraints compromises their ability to exercise beneficence. Although pledging to enforce these ethical principles, physicians have little opportunity to influence anti-shackling legislation. Instead of being included in conversations regarding medical complexities, legislation silences their voices. Policies must include the physician's voice as they affect their ability to treat patients. Officers should not dismiss a physician's request to remove shackles from a woman if they are causing health complications. A woman's labor should not harm her or her fetus because the officer will not remove her shackles.[78] A federal law could end shackling pregnant incarcerated people. Because other options are available to ensure the safety of the public and the prisoner, there is no ethical justification for shackling pregnant prisoners. An incarcerated person is a human being and must be treated with dignity and respect. To safeguard the well-being of incarcerated women and the public, it is essential for advocates of individual rights to join forces with medical professionals to establish an all-encompassing solution. - [1] Ferszt, G. G., Palmer, M., & McGrane, C. (2018). Where does your state stand on shackling of Pregnant Incarcerated Women? Nursing for Women’s Health, 22(1), 17–23. https://doi.org/10.1016/j.nwh.2017.12.005 [2] S983A, 2015-2016 Regular Sessions (N.Y. 2015). https://legislation.nysenate.gov/pdf/bills/2015/S983A [3] Chris DiNardo, Pregnancy in Confinement, Anti-Shackling Laws and the “Extraordinary Circumstances” Loophole, 25 Duke Journal of Gender Law & Policy 271-295 (2018) https://scholarship.law.duke.edu/djglp/vol25/iss2/5 [4] Chris DiNardo (2018) [5] U.S. Bureau of Justice Statistics. 1980. " Prisoners in 1980 – Statistical Tables”. Retrieved April 20, 2023 (https://bjs.ojp.gov/content/pub/pdf/p80.pdf). [6] U.S. Bureau of Justice Statistics. 2022. " Prisoners in 2021 – Statistical Tables”. Retrieved April 20, 2023 (https://bjs.ojp.gov/sites/g/files/xyckuh236/files/media/document/p21st.pdf). [7] U.S. Bureau of Justice Statistics (1980) [8] Sufrin C, Jones RK, Mosher WD, Beal L. Pregnancy Prevalence and Outcomes in U.S. Jails. Obstet Gynecol. 2020;135(5):1177-1183. doi:10.1097/AOG.0000000000003834 [9] Kramer, C., Thomas, K., Patil, A., Hayes, C. M., & Sufrin, C. B. (2022). Shackling and pregnancy care policies in US prisons and jails. Maternal and Child Health Journal, 27(1), 186–196. https://doi.org/10.1007/s10995-022-03526-y [10] House, K. T., Kelley, S., Sontag, D. N., & King, L. P. (2021). Ending restraint of incarcerated individuals giving birth. AMA Journal of Ethics, 23(4). https://doi.org/10.1001/amajethics.2021.364 [11] Goshin, L. S., Sissoko, D. R., Neumann, G., Sufrin, C., & Byrnes, L. (2019). Perinatal nurses’ experiences with and knowledge of the care of incarcerated women during pregnancy and the postpartum period. Journal of Obstetric, Gynecologic &amp; Neonatal Nursing, 48(1), 27–36. https://doi.org/10.1016/j.jogn.2018.11.002 [12] Shackling and separation: Motherhood in prison. (2013). AMA Journal of Ethics, 15(9), 779–785. https://doi.org/10.1001/virtualmentor.2013.15.9.pfor2-1309 [13] King, L. (2018). Labor in chains: The shackling of pregnant inmates. Policy Perspectives, 25, 55–68. https://doi.org/10.4079/pp.v25i0.18348 [14] King, L. (2018). [15] AMA Journal of Ethics (2013) [16] Lawrence, A., Lewis, L., Hofmeyr, G. J., & Styles, C. (2013). Maternal positions and mobility during first stage labour. Cochrane database of systematic reviews, (8). [17] Association of Women’s Health, Obstetric and Neonatal Nurses. (2011). AWHONN position statement: Shackling incarcerated pregnant women. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 40(6), 817–818. doi:10.1111/j.1552-6909.2011.01300.x [18] Ferszt, G. G., Palmer, M., & McGrane, C. (2018). Where does your state stand on shackling of Pregnant Incarcerated Women? Nursing for Women’s Health, 22(1), 17–23. https://doi.org/10.1016/j.nwh.2017.12.005 [19] Thompson, E. (2022, August 30). Woman sues NC state prison system for mistreatment while pregnant. North Carolina Health News. Retrieved March 12, 2023, from https://www.northcarolinahealthnews.org/2022/05/25/woman-sues-nc-state-prison-system-for-mistreatment-while-pregnant/ [20] CBS Interactive. (2019, March 13). Shackling pregnant inmates is still a practice in many states. CBS News. Retrieved March 12, 2023, from https://www.cbsnews.com/news/shackling-pregnant-inmates-is-still-a-practice-in-many-states/ [21] Griggs, Claire Louise. "Birthing Barbarism: The Unconstitutionality of Shackling Pregnant Prisoners." American University Journal of Gender Social Policy and Law 20, no. 1 (2011): 247-271. [22] American Civil Liberties Union. (2012, October 12). ACLU briefing paper: The shackling of pregnant women & girls in U.S ... American Civil Liberties Union (ACLU). https://www.aclu.org/wp-content/uploads/legal-documents/anti-shackling_briefing_paper_stand_alone.pdf [23] King.L (2018) [24] Griggs, Claire Louise (2011) [25] American Civil Liberties Union. (2012) [26] Clarke, J. G., & Simon, R. E. (2013). Shackling and separation: Motherhood in prison. AMA Journal of Ethics, 15(9), 779–785. https://doi.org/10.1001/virtualmentor.2013.15.9.pfor2-1309 [27] Berg, M. D. (2014, April 18). Pregnant prisoners are losing their shackles - The Boston Globe. BostonGlobe.com. Retrieved March 12, 2023, from https://www.bostonglobe.com/magazine/2014/04/18/taking-shackles-off-pregnant-prisoners/7t7r8yNBcegB8eEy1GqJwN/story.html [28] Levi, R., Kinakemakorn, N., Zohrabi, A., Afanasieff, E., & Edwards-Masuda, N. (2010). Creating the bad mother: How the U.S. approach to pregnancy in prisons violates the right to be a mother. UCLA Women's Law Journal, 18(1). https://doi.org/10.5070/l3181017816 [29] Chris DiNardo (2018) [30] Griggs, Claire Louise (2011). [31] Allen, J. E. (2010, October 21). Shackled: Women Behind Bars Deliver in Chains. ABC News. https://abcnews.go.com/Health/WomensHealth/pregnant-shackled-women-bars-deliver-chains/story?id=11933376&page=1 [32] Nelson v. Correctional, 533 F.3d 958 (8th Cir. 2009) [33] Nelson v. Correctional(2009) [34] House, K. T., Kelley, S., Sontag, D. N., & King, L. P. (2021). Ending restraint of incarcerated individuals giving birth. AMA Journal of Ethics, 23(4). https://doi.org/10.1001/amajethics.2021.364 [35] Amnesty International USA. (1999, March). “Not part of my sentence” Violations of the Human Rights of Women in Custody. Amnesty International USA. Retrieved March 12, 2023, from https://www.amnestyusa.org/reports/usa-not-part-of-my-sentence-violations-of-the-human-rights-of-women-in-custody/ [36] Pendleton, V., Saunders, J. B., & Shlafer, R. (2020). Corrections officers' knowledge and perspectives of maternal and child health policies and programs for pregnant women in prison. Health & justice, 8(1), 1. https://doi.org/10.1186/s40352-019-0102-0 [37] Elizabeth Alexander, Unshackling Shawanna: The Battle Over Chaining Women Prisoners during Labor and Delivery, 32 U. ARK. LITTLE ROCK L. REV. 435 (2010). Available at: https://lawrepository.ualr.edu/lawreview/vol32/iss4/1 [38] Hernandez, J. (2022, April 22). More states are restricting the shackling of pregnant inmates, but it still occurs. NPR. Retrieved March 12, 2023, from https://www.npr.org/2022/04/22/1093836514/shackle-pregnant-inmates-tennessee [39] Sufrin, C. (2012, June 24). End practice of shackling pregnant inmates. SFGATE. Retrieved March 12, 2023, from https://www.sfgate.com/opinion/openforum/article/End-practice-of-shackling-pregnant-inmates-3176987.php [40] Mullings, L. (1997). On our own terms: Race, class, and gender in the lives of African American women. Routledge [41] Ocen, Priscilla A., (2011). [42] Ladd-Taylor, M. (1998). "Bad" mothers: The politics of blame in Twentieth-century America. New York Univ. Press. [43] Hine, D. C. (1998). Hine Sight: Black women and the re-construction of American history. Indiana University Press. [44] Baldwin, L. (2019). Excluded from good motherhood and the impact of prison: Motherhood and Social Exclusion, 129–144. https://doi.org/10.2307/j.ctvk12qxr.13 [45] Ocen, Priscilla A., Punishing Pregnancy: Race, Incarceration, and the Shackling of Pregnant Prisoners (October 3, 2011). California Law Review, Vol. 100, 2012, Available at SSRN: https://ssrn.com/abstract=1937872 [46] Johnson, P. C. (2004). Inner lives: Voices of african american women in prison. New York University Press. [47] Thomas, D. Q. (1996). All too familiar: Sexual abuse of women in U.S. state prisons. Human Rights Watch. [48] Ocen, Priscilla A., (2011). [49] Ashley W. The angry black woman: the impact of pejorative stereotypes on psychotherapy with black women. Soc Work Public Health. 2014;29(1):27-34. doi: 10.1080/19371918.2011.619449. PMID: 24188294. [50] CBS Interactive. (2019, March 13). Shackling pregnant inmates is still a practice in many states. CBS News. Retrieved March 12, 2023, from https://www.cbsnews.com/news/shackling-pregnant-inmates-is-still-a-practice-in-many-states/ [51] Guardian News and Media. (2020, January 24). Pregnant and shackled: Why inmates are still giving birth cuffed and bound. The Guardian. Retrieved March 25, 2023, from https://www.theguardian.com/us-news/2020/jan/24/shackled-pregnant-women-prisoners-birth [52] Oparah, J. C. (2015). Birthing justice: Black women, pregnancy, and childbirth. Routledge. [53] Chris DiNardo (2018) [54] Griggs, Claire Louise (2011). [55] Chris DiNardo (2018) [56] Griggs, Claire Louise (2011). [57] Song, Ji Seon, Policing the Emergency Room (June 10, 2021). 134 Harvard Law Review 2646 (2021), Available at SSRN: https://ssrn.com/abstract=3864225 [58] Ocen, Priscilla A., (2011). [59] Staten v. Lackawanna Cnty., No. 4:07-CV-1329, 2008 WL 249988, at *2 (M.D. Pa. Jan. 29, 2008) [60] Lovett, K. (2018, April 9). Pregnant inmates at New York prisons will no longer be shackled under new law. New York Daily News. Retrieved March 12, 2023, from https://www.nydailynews.com/new-york/new-york-pregnant-inmates-no-longer-shackled-article-1.2474021 [61] Thompson, E. (2022, August 30). Woman sues NC state prison system for mistreatment while pregnant. North Carolina Health News. Retrieved March 12, 2023, from https://www.northcarolinahealthnews.org/2022/05/25/woman-sues-nc-state-prison-system-for-mistreatment-while-pregnant/ [62] Brown v. Plata, 563 U.S. 493 (2011) [63] Nelson v. Correctional Medical Serices, et al., Nelson v. Correctional Med. Servs, 583 F.3d 522 (8th Cir. 2009) [64] Nelson citing Women Prisoners of D.C. Dep't of Corr. v. District of Columbia, 877 F.Supp. 634, 668-69 (D.D.C. 1994), modified in part on other grounds, 899 F.Supp. 659 (D.D.C. 1995). [65] Ark. Dep't of Corr. Admin. Reg. 403 § V (1992) [66] Civil Rights Cases, 109 U.S. 3 (1883) [67] Physician charter. ABIM Foundation. (2022, October 18). Retrieved March 10, 2023, from https://abimfoundation.org/what-we-do/physician-charter#:~:text=Principle%20of%20social%20justice.&text=Physicians%20should%20work%20actively%20to,or%20any%20other%20social%20category. [68] Riddick FA Jr. The code of medical ethics of the american medical association. Ochsner J. 2003 Spring;5(2):6-10. PMID: 22826677; PMCID: PMC3399321. [69] American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women (2021). Reproductive Health Care for Incarcerated Pregnant, Postpartum, and Nonpregnant Individuals: ACOG Committee Opinion, Number 830. Obstetrics and gynecology, 138(1), e24–e34. https://doi.org/10.1097/AOG.0000000000004429 [70] American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women (2021). [71] American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women (2021). [72] Beauchamp, T. L., & Childress, J. F. (2019). Principles of Biomedical Ethics. Oxford University Press. [73] Varkey, B. (2020). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28. https://doi.org/10.1159/000509119 [74] Medical professionalism in the new millennium: A physician charter. (2002). Annals of Internal Medicine, 136(3), 243. https://doi.org/10.7326/0003-4819-136-3-200202050-00012 [75] Allen, J. E. (2010, October 21). Shackled: Women Behind Bars Deliver in Chains. ABC News. https://abcnews.go.com/Health/WomensHealth/pregnant-shackled-women-bars-deliver-chains/story?id=11933376&page=1 [76] Jonsen, A. R. (2010). The Birth of Bioethics. Oxford University Press. [77] Beauchamp, T. L., & Childress, J. F. (2019). [78] Amnesty International USA. (1999, March). “Not part of my sentence” Violations of the Human Rights of Women in Custody. Amnesty International USA. Retrieved March 12, 2023, from https://www.amnestyusa.org/reports/usa-not-part-of-my-sentence-violations-of-the-human-rights-of-women-in-custody/

It is often assumed that judicial reporting is biased in favor of criminal offences and violent crimes and at the expense of administrative, civil or labor court cases (e.g., Delitz, 1989; Eberle 1996; Machill, Beiler & Hellmann, 2007). In order to be able to test this assumption, the variable “legal fields“ is used to categorize the judicial trial or case reported in the media. Field of application/theoretical foundation: The legal field serves - among other variables – as an indicator of the representativeness of judicial reporting. Thus, the results of the content analysis are often compared with extra-media data on the distribution of trials in different fields of law (Strother, 2017). Example study: Oehmer (work in progress) Information on Oehmer (work in progress) Research interest: The study focuses on three sets of questions concerning 1) the selection and representativeness of court reporting, 2) the information function of court reporting and 3) the presentation of court reporting. Object of analysis: court coverage in Swiss newspapers (Tagesanzeiger, NZZ, Neue Luzerner Zeitung, Südostschweiz, Blick, Gratiszeitung, 20Minuten) Time frame of analysis: January 2007 – December 2017 Codebook: available (see attachment) Info about variable: Variable name/definition: legal fields [Rechtsgebiete der berichteten Justizfälle] Level of analysis: most covered court case in article General coding instruction: The legal system is mostly characterized by a division of the legal fields into private law (or civil law) and public law. The following basic rule applies for the assignment to the legal areas: if only private individuals are involved, then it is private law (Code 10 ff.), if a public organization or a state is involved, then it usually refers to public law (Code 20 ff.). Unless otherwise stated, the following definitions are based on corresponding entries from the Gabler Wirtschaftslexikon. Springer, available at: https://wirtschaftslexikon.gabler.de/ (16.09.20) Variable name Values & coding instructions Rechtsgebiet des Prozesses 10 Privatrecht: Privatrecht umfasst alle Rechtssätze, die die rechtlichen Beziehungen der einzelnen zueinander nach dem Grundsatz der Gleichordnung regeln. Der Staat oder ein anderer hoheitlicher Träger sind hier nicht beteiligt. Codierhinweis: Dieser Code wird gewählt, wenn keine Spezialform (Code 11f) vorliegt. Dazu zählen folgende Rechtsgebiete: - Familienrecht - Erbrecht - Sachenrecht 11 Handelsrecht: Teilgebiet des Privatrechts. Handelsrecht ist das Sonderrecht des Kaufmanns. Die Vorschriften des Handelsrechts betreffen im Wesentlichen die Rechtsbeziehungen des Kaufmanns zu seinen Geschäftspartnern, die wettbewerbsrechtlichen und gesellschaftsrechtlichen Beziehungen zu anderen Unternehmern. Dazu zählen folgende Rechtsgebiete: - Kapitalmarktrecht, - Wettbewerbsrecht, - Versicherungsrecht - Patentrecht - Urheberrecht - Markenrecht 12 Arbeitsrecht: zählt überwiegend zum Privatrecht. Gesamtheit aller Rechtsregeln, die sich mit der unselbstständigen, abhängigen Arbeit befassen, d.h. der Arbeit, die von Personen geleistet wird, die in einem Betrieb eingegliedert fremdbestimmte Arbeit leisten und dabei an Weisungen hinsichtlich Art, Ausführung, Ort und Zeit der Arbeit gebunden sind. 13 Mietrecht 20 Öffentliches Recht: regelt, im Gegensatz zum Privatrecht, die Beziehungen des Einzelnen zum Staat und den Körperschaften des öffentlichen Rechts sowie der Träger öffentlicher Gewalt zueinander. Im öffentlichen Recht ist der Einzelne (anders als im Privatrecht) dem Staat untergeordnet. Der Staat oder ein Träger hoheitlicher Gewalt tritt mit Hoheitsgewalt auf (Forstmoser/Vogt 2012, S.118) Codierhinweis: Dieser Code wird gewählt, wenn keine Spezialform (Code 21f) vorliegt. 21 Verwaltungsrecht: Mit Verwaltungstätigkeit ist die Tätigkeit der öffentlichen Verwaltung gemeint. Die „öffentliche Verwaltung“ wird von den Einrichtungen der unmittelbaren und mittelbaren Staatsverwaltung (Bund, Ländern, Gemeinden, Gemeindeverbänden und sonstigen Körperschaften, Anstalten und Stiftungen des öffentlichen Rechts) gebildet (institutioneller Begriff). Quelle: Bader, Ronellenfitsch, 2016, § 1 Rn. 8-10.1). Dazu zählen u.a. folgende Rechstgebiete: - Verwaltungsgerichtsbarkeit - Bauplanung, Naturschutz - Ausländer, Staatsbürgerrecht - Beamten/Soldatenrecht - Schul/Hochschulrecht - Verkehrs/Wegerecht - Leistungs/Sozialrecht - Rundfunkrecht - Gewerbe/Lebensmittel - Waffenrecht - Kommunalrecht - Veranstaltungs-/Demonstrationsrecht - Wohnungsrecht 22 Verfassungsrecht: Rechtliche Grundordnung eines Staates, Gesamtheit der geschriebenen und ungeschriebenen Rechtssätze über die Bildung, den Aufgabenkreis und die Organisation der obersten Staatsorgane, das Verhältnis der einzelnen Staatsorgane zueinander, die staatlichen Aufgaben, den staatsrechtlichen Aufbau des Staates und die Rechte des Bürgers gegen den Staat (Grundrechte) (Quelle: http://wirtschaftslexikon.gabler.de/Archiv/4350/oeffentliches-recht-v5.html) 23 Steuerrecht: Gesamtheit der Rechtsnormen unserer Rechtsordnung, die sich - im weitesten Sinn - auf Steuern beziehen. Diese schaffen und regeln die Rechtsbeziehungen (Rechte und Pflichten) zwischen den Trägern der Steuerhoheit und den ihnen unterworfenen natürlichen und juristischen Personen. 24 Sozialrecht: Teilgebiet des öffentlichen Verwaltungsrechts. Das Sozialrecht soll zur Verwirklichung sozialer Gerechtigkeit und sozialer Sicherheit dienen. Dazu zählen folgende Rechtsgebiete: - Sozialgerichtsbarkeit - Unfallversicherung - Rentenversicherung - Krankenversicherung - Kriegsopferversorgung - Arbeitslosenversicherung - Kassenarztrecht 25 Internationales Recht 26 Strafrecht (hier auch Jugendstrafrecht): Inbegriff der Rechtsnormen, in denen die Voraussetzungen für die Straftat und ihre Rechtsfolgen festgelegt sind; umfasst i.w.S. auch das Strafverfahrensrecht, das der Durchsetzung des staatlichen Strafanspruchs dient. Strafrecht ist Teil des öffentlichen Rechts, was nach allen gängigen Differenzierungstheorien (Subordinationstheorie, Interessentheorie, neuere Subjektstheorie) deutlich nachweisbar ist. Codierhinweis: a) Beim Strafrecht sind aufgrund seiner zu erwartenden Sonderstellung in der Berichterstattung möglichst detaillierte Codes zu vergeben. b) Werden im Rahmen einer Verhandlung mehrere Delikte verhandelt, so wird das Delikt codiert, dem in der Berichterstattung der meiste Raum beigemessen wird. Werden sämtliche Delikte im gleichen Ausmass behandelt, so wird das Erstgenannte codiert. 27 Tötung 28 Körperverletzung 29 Raub 30 Sexualdelikte 31 Eigentumsdelikte 32 Gemeingefährliche Delikte 33 Rauschgiftdelikte 34 Delikte gegen die öffentliche Ordnung 35 Beleidigung 36 Amtsdelikte 37 Ordnungswidrigkeit 99) Sonstiges Intercoder reliability: Holsti .81; Krippendorff’s Alpha: .68 (2 Coder) References Delitz, J. (1989). Tagespresse und Justiz. Gerichtsberichterstattung als Vermittlung institutioneller Wirklichkeit. Hamburg. [Daily press and justice. Court reporting as a mediator of institutional reality.] Eberle, R. G. (1996). Verwaltungsgerichte in der Medienberichterstattung am Beispiel von Tageszeitungen in Hessen. Zeitschrift für Rechtssoziologie, 17(2), S. 300-309. [Administrative courts in media coverage using the example of daily newspapers in the federal state of Hesse.] Bader, J. & Ronellenfitsch, M. (2016). Verwaltungsverfahrensgesetz: VwVfG. Beck. [Administrative Procedure Act] Forstmoser. P.& Vogt, H-U. (2012). Einführung in das Recht. 5. Vollständig überarbeitete Auflage. Stämpfli. [Introduction to law.] Machill, M., Beiler, M. & Hellmann, I. (2007). The selection process in local court reporting. Journalism Practice, 1(1), S. 62-81. Oehmer, Franziska. Die dritte Gewalt in den Medien. Eine repräsentative quantitative Inhaltsanalyse der Gerichtsberichterstattung Schweizer Medien (work in progress). [Justice in the media. A representative quantitative content analysis of court reporting in the Swiss media]. Strother, L. (2017). How expected political and legal impact drive media coverage of Supreme Court cases, Political Communication, 34(4), S. 571-589.

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(Barbara Stollberg-Rilinger, Berlin/Münster) Füssel, Marian, Der Preis des Ruhms. Eine Weltgeschichte des Siebenjährigen Krieges. 1756 – 1763, München 2019, Beck, 656 S. / Abb., € 32,00. (Florian Schönfuß, Oxford) Flügel, Wolfgang, Pastoren aus Halle und ihre Gemeinden in Pennsylvania 1742 – 1820. Deutsche Lutheraner zwischen Persistenz und Assimilation (Hallische Beiträge zur Geschichte des Mittelalters und der Frühen Neuzeit, 14), Berlin / Boston 2019, de Gruyter, 480 S. / Abb., € 99,95. (Marianne Taatz-Jacobi, Halle a. d. S.) Braun, Christine, Die Entstehung des Mythos vom Soldatenhandel 1776 – 1813. Europäische Öffentlichkeit und der „hessische Soldatenverkauf“ nach Amerika am Ende des 18. Jahrhunderts (Quellen und Forschungen zur hessischen Geschichte, 178), Darmstadt / Marburg 2018, Selbstverlag der Historischen Kommission Darmstadt und der Historischen Kommission für Hessen, 296 S., € 28,00. (Stefan Kroll, Rostock) Die Tagebücher des Ludwig Freiherrn Vincke 1789 – 1844, (Heinz Duchhardt, Mainz) Bd. 7: 1813 – 1818, bearb. v. Ludger Graf von Westphalen (Veröffentlichungen des Vereins für Geschichte und Altertumskunde Westfalens, Abteilung Münster, 7; Veröffentlichungen der Historischen Kommission für Westfalen. Neue Folge, 58; Veröffentlichungen des Landesarchivs Nordrhein-Westfalen, 76), Münster 2019, Aschendorff, 777 S. / Abb., € 86,00. (Heinz Duchhardt, Mainz) Bd. 8: 1819 – 1824, bearb. v. Hans-Joachim Behr (Veröffentlichungen des Vereins für Geschichte und Altertumskunde Westfalens, Abteilung Münster, 8; Veröffentlichungen der Historischen Kommission für Westfalen. Neue Folge, 22; Veröffentlichungen des Landesarchivs Nordrhein-Westfalen, 48), Münster 2015, Aschendorff, 632 S. / Abb., € 79,00. (Heinz Duchhardt, Mainz) Bd. 9: 1825 – 1829, bearb. v. Hans-Joachim Behr (Veröffentlichungen des Vereins für Geschichte und Altertumskunde Westfalens, Abteilung Münster, 9; Veröffentlichungen der Historischen Kommission für Westfalen. Neue Folge, 23; Veröffentlichungen des Landesarchivs Nordrhein-Westfalen, 49), Münster 2015, Aschendorff, 508 S. / Abb., € 72,00. (Heinz Duchhardt, Mainz) Bd. 11: 1840 – 1844, bearb. v. Hans-Joachim Behr / Christine Schedensack (Veröffentlichungen des Vereins für Geschichte und Altertumskunde Westfalens, Abteilung Münster, 11; Veröffentlichungen der Historischen Kommission für Westfalen. Neue Folge, 55; Veröffentlichungen des Landesarchivs Nordrhein-Westfalen, 74), Münster 2019, Aschendorff, 516 S. / Abb., € 74,00. (Heinz Duchhardt, Mainz)

Photo by Waranont (Joe) on Unsplash INTRODUCTION The age-adjusted COVID-19 mortality rate among Black Americans is twice as high as White Americans.[1] This shocking evidence of health disparities, coincident to a public reckoning with the history of racism in the US, highlights the inverse relationship between race and health. Public sentiment may now favor addressing these pressing public health issues, but the sprawling healthcare system largely focuses on clinical care; it lacks tools to influence the social determinants of health at the point of the healthcare institution. Reinvigorating organizational ethics, sometimes called institutional ethics, may provide such a tool. BACKGROUND Organizational ethics became part of the healthcare system during the upheavals in financing and organization of health care in the 1990s. Yet organizational ethics in a medical setting must be more than simple business ethics.[2] Just as health care professionals are granted special privileges in society in exchange for adherence to a code of medical ethics and duties, healthcare organizations and systems also must now adhere to ethical requirements in exchange for their privileged position that includes the right to provide, and be reimbursed for, health care.[3] In the 1990s, ethicists began to discuss how clinical ethics committees might develop an understanding of business ethics in order to provide comprehensive organizational ethics reviews.[4] Some bioethicists even believed that the challenges of integrating business and medical care would compel ethics committees to look outward, engaging in public advocacy around ethical issues in health care.[5] To fulfill the mission of maintaining organizational ethics standards within the healthcare system, ethics committees would need to advocate for patients in the public sphere. Ethics committees might even take positions at odds with those of the healthcare institutions in which they work. Organizational ethics committees might have served as watchdogs, ensuring that healthcare organizations fulfill their fiduciary duties to their patients and communities. Bioethicists soon realized that the vision of a robust ethics committee involving administrators, bioethicists, and medical staff advising multiple divisions of large organizations and policy makers would fall short.[6] The two ethical systems remained separate: most organizations developed a combination of a clinical ethics committee adjunct to the medical staff with a compliance department to oversee organizational ethics. However, organizational ethics really goes beyond compliance; it “cannot be addressed by focusing narrowly on business matters or by quasi-legal mechanisms to assure that behavior conforms to pre-established codes or rules.”[7] As a result, there is no centralized entity with power in each healthcare institution that can treat healthcare inequities as an institutional ethical failure that must be addressed. Current research on specific inequitable outcomes due to bias in clinical care includes specialties such as maternal care,[8]cardiac care,[9] pain management, and technology.[10] Implicit bias and racist clinical interactions, once identified, may be addressed through staff training and other interventions. Yet the ethics of clinical care requires little attention to the social determinants of health such as high levels of police surveillance in the community which may cause increased rates of hypertension,[11] pre-term birth,[12] and may affect mental health. Leaving these problems to the public health realm disconnects health practitioners and institutions from the ability to remedy some of the causes of health problems in their patients. Simply treating the effects of racism in the practice of medicine is not curative – it is really palliative care.[13] ANALYSIS The term “organizational ethics” is too limited to encompass the scope of change needed to address structural racism and the social determinants of health in today’s healthcare institutions. Structural Justice Ethics[14] better describes a plan and a process that requires the healthcare system and professionals to look both inward and outward to take on the structural causes of racism and health disparities. Building on organizational and clinical ethics, Structural Justice Ethics could amplify the research on systemic issues such as the effects of social determinants of health, racism in clinical care, and necessary advocacy with the local community. To be effective and complete, organizations should recognize duties to patients that arrive at their doorstep, damaged by generations of subordination and racism. To ethically treat patients who have experienced racism, the system and health practitioners must acknowledge and work to reduce the inequities in society that cause harm to their health in the clinical setting. Accreditation companies such as The Joint Commission could amend their standards to require top-rated healthcare organizations to form new Structural Justice Ethics committees in their organizations, taking affirmative steps to acknowledge the ethical implications of racism and the social determinants of health. Many bioethicists have already called for the field of bioethics to address racism as an ethical issue in healthcare, some even calling for a new Black Bioethics.[15] This frustration with the profession of bioethics has developed in other areas, such as disability ethics and feminist ethics, and reflects a belief that mainstream bioethics is a rigidly principlist endeavor. The education of new bioethicists is grounded in practical philosophy graduate programs, entwined with academia’s history of exclusivity. As a relatively young academic subject, bioethics has the potential to expand and grow into a more practical and justice-oriented tool, learning how to counter the overly individualistic bioethics that has roots in our racist and Protestant-dominant history.[16] Expanding organizational ethics into Structural Justice Ethics in health care could bring Black bioethicists into the center of healthcare ethics and provide the tools to implement changes needed to address racism in health care. Healthcare organizations should not expect Black healthcare practitioners to take on these Structural Justice Ethics roles as “extra” work. Too often, people of color are expected to bear the burden of explaining racism and working to eradicate it.[17]The Structural Justice Ethics committee should be a new model, centered in ethics and policy, with professional-level staffing that reflects the racial and ethnic makeup of the community it serves. Calling on bioethicists as moral agents in the world, and particularly within the medical system, to act as social justice advocates against systemic injustice in a system where they have privilege and power seems logical and surprisingly necessary. “Going forward, bioethics needs to engage with the nuances of race with the same vigor that it has approached discussions of moral theories and biotechnologies.”[18] Graduate-level bioethics programs have expanded significantly in recent years, with 45 current master’s level programs,[19] and there should be a wealth of professionals ready to oversee the role of encouraging and monitoring justice in the system. These programs focus primarily if not exclusively on the dominant paradigm of bioethics, yet as ethics programs, they should be able to course-correct and embrace greater diversity in people and thought. Structural Justice Ethicists can guide healthcare organizations to become learning institutions open to the idea that bias and inequity are ethical harms that they can and should address. Some may question whether such close attention to Black health care needs amounts to reparations or “reverse” discrimination, a controversial topic in our political discussions. However, when posed as an ethical duty of health care, there is no option to continue to treat Black people unethically. Of course, healthcare systems will have to balance competing budgetary interests; even with unlimited funding, disparities in health care would not disappear overnight.[20] In a fair process where decisionmakers must weigh the demands of stakeholders, the ethical obligation to address the social determinants of health must have an advocate. Moreover, setting high ethical standards is not the same as government spending to make reparations for past harms. In fact, Structural Justice Ethics does not look to the past at all but looks to the needs of subordinated communities of patients as they exist today. Any community that is harmed by structural injustice in health care can be the focus of a Structural Justice Ethics review. The Joint Commission and other accrediting organizations can require healthcare organizations to meet the challenges of health inequities by adopting new Structural Justice Ethics committees, just as The Joint Commission added organizational ethics to its requirements in 1995. Admittedly, Structural Justice Ethics is an amorphous concept and its role within healthcare institutions needs to be refined and assigned specific tasks. However, there is substantial research on the social determinants of health; the challenge for the Structural Justice Ethics is to recommend systemic changes from within, rather than beginning this research anew. The Joint Commission’s Center for Transforming Healthcare, as a data-driven and process-oriented patient safety organization, is well-primed to take on this task. The Center can collaborate with existing academic and governmental health equity researchers to set short- and long-term goals for Structural Justice Ethics committees. To begin with, a Structural Justice Ethics committee can pose the question of “how is racism operating here” and: a. connect with current research on specific inequitable outcomes due to bias in medicine and bring best practices to the attention of medical staff. b. work with human resources and medical staff to support and increase diverse populations in the workforce. c. ensure that implicit bias and other trainings are properly provided to all staff, as well as expanding the scope of such trainings to address developing areas such as epistemic harm, or the harm of one’s own physical experience being discounted by medical professionals.[21] The health care workforce should also be trained in Title VI law.[22] d. evaluate research data on the organization’s own potential disparate outcomes due to race, to determine areas for improvement both within and outside of the organization. e. invite the local community to come in for listening and learning sessions, to better understand the community’s concerns and perspective on health equity. f. improve advocacy on behalf of community members to state and local authorities, effectively taking a stand for health care equity for local stakeholders. Dr. Camara P. Jones describes a collaborative endeavor like this as critical to anti-racist work and likens it to adopting a community health center model where the health facility takes responsibility for the health and well-being of the local community.[23] AMA policy already encourages this type of effort in opinion 8.11 of the AMA Code, which states that, alongside diagnosis and treatment, “physicians also have a professional commitment to prevent disease and promote health and well-being for their patients and the community.”[24] A theoretical framework and concrete plan for radical improvement in the ethics of the healthcare system will help all healthcare professionals. Some healthcare practitioners may not recognize their own biases and need training to meet best practices standards in light of health inequities. Other healthcare practitioners may feel disillusioned because they know they face individual patients suffering the effects of structural racism, yet they can treat only the illness.[25] The scope of the problem may overwhelm practitioners, and without a belief that the system is committed to improvement, practitioners may become numb to the suffering, a trauma reaction that affects both the practitioners and their patients. Unfortunately, when current medical students ask the question, “what can I do to fight systemic racism?” the answer is usually “call it out.” But putting the onus on newly minted individual practitioners to call out racism in an established structure is unrealistic, unfair, and destined to be unsuccessful. Just as we should not expect subordinated individuals to “overcome” their social determinants of health, we should not expect health professionals to make this change individually. Addressing injustices in the institution and adjusting medical ethics accordingly can alleviate the burden of these ethical dilemmas. CONCLUSION Structural Justice Ethics must be woven into the ethics committees at the institutional level. Organizational ethics committees can evaluate healthcare organizations by their integrity, i.e., how well their actions fulfill the moral obligations they have undertaken.[26] Our healthcare system has avoided the moral obligation to address racism and the social determinants of health by focusing on clinical ethics, leaving public health to academics and the government. Expanding organizational ethics to take on the issues of structural injustice within each healthcare institution will help organizations better measure, change, and ultimately fulfill their moral obligations to their patients and communities. [1] “Color of Coronavirus: COVID-19 Deaths Analyzed by Race and Ethnicity,” APM Research Lab, accessed June 1, 2021, https://www.apmresearchlab.org/covid/deaths-by-race. [2] M. Constantinescu, “Seeing the Forest beyond the Trees: A Holistic Approach to Health-Care Organizational Ethics,” in Contemporary Debates in Bioethics: European Perspectives, 2018, 86–96, https://doi.org/10.2478/9783110571219-009. [3] See Norman Daniels, Just Health: Meeting Health Needs Fairly (Cambridge: Cambridge University Press, 2008) at 219. [4] Elizabeth Heitman and Ruth Ellen Bulger, “The Healthcare Ethics Committee in the Structural Transformation of Health Care: Administrative and Organizational Ethics in Changing Times,” HEC Forum 10, no. 2 (June 1, 1998): 152–76, 162, https://doi.org/10.1023/A:1008865603499. [5] Cohen, Cynthia B. "Ethics Committees as Corporate and Public Policy Advocates." The Hastings Center Report 20, no. 5 (1990): 36+. Gale Academic OneFile (accessed May 6, 2021). https://link.gale.com/apps/doc/A8998890/AONE?u=nysl_oweb&sid=AONE&xid=84a1cade. [6] Linda L. Emanuel, “Ethics and the Structures of Healthcare Special Section: Issues in Organization Ethics and Healthcare,” Cambridge Quarterly of Healthcare Ethics 9, no. 2 (2000): 151–68, 166. [7] George Khushf and Rosemarie Tong, “Setting Organizational Ethics within a Broader Social and Legal Context,” HEC Forum 14, no. 2 (June 2002): 77–85, 78. [8] Olivia Pham, Usha Ranji Published: Nov 10, and 2020, “Racial Disparities in Maternal and Infant Health: An Overview - Issue Brief,” KFF (blog), November 10, 2020, https://www.kff.org/report-section/racial-disparities-in-maternal-and-infant-health-an-overview-issue-brief/. [9] Eberly Lauren A. et al., “Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center,” Circulation: Heart Failure 12, no. 11 (November 1, 2019): e006214, https://doi.org/10.1161/CIRCHEARTFAILURE.119.006214. [10] Michael W. Sjoding et al., “Racial Bias in Pulse Oximetry Measurement,” New England Journal of Medicine 383, no. 25 (December 17, 2020): 2477–78, https://doi.org/10.1056/NEJMc2029240. [11] Alyasah Ali Sewell et al., “Illness Spillovers of Lethal Police Violence: The Significance of Gendered Marginalization,” Ethnic and Racial Studies 44, no. 7 (July 22, 2020): 1–26, https://doi.org/10.1080/01419870.2020.1781913. [12] Brad N. Greenwood et al., “Physician–Patient Racial Concordance and Disparities in Birthing Mortality for Newborns,” Proceedings of the National Academy of Sciences 117, no. 35 (September 1, 2020): 21194–200, https://doi.org/10.1073/pnas.1913405117. [13] The term “palliative care” as applied to patients suffering from the social determinants of health was used by Dr. Michelle Morse at a webinar entitled “Medical Stereotypes: Confronting Racism and Disparities in US Health Care: A Health Policy and Bioethics Consortium” presented by the Harvard Petrie-Flom Center on February 12, 2021. [14] Linda L. Emanuel coined the term “Structural Ethics” in 2000. This term did not seem to generate much interest from the bioethics community at the time. Her explanation of this term is consistent with my thinking, although I expand it to address the health system as an entity, and focus on improving health equity. [15] Keisha Shantel Ray, “Black Bioethics and How the Failures of the Profession Paved the Way for Its Existence | Bioethics.Net,” www.bioethics.net, August 6, 2020, http://www.bioethics.net/2020/08/black-bioethics-and-how-the-failures-of-the-profession-paved-the-way-for-its-existence/; Yolonda Y. Wilson, “Racial Injustice and Meaning Well: A Challenge for Bioethics,” The American Journal of Bioethics 21, no. 2 (February 1, 2021): 1–3, https://doi.org/10.1080/15265161.2020.1866875. [16] See Catherine Myser, “Differences from Somewhere: The Normativity of Whiteness in Bioethics in the United States,” The American Journal of Bioethics 3, no. 2 (May 2003): 1–11, https://doi.org/10.1162/152651603766436072. [17] Ushe Blackstock, “Why Black Doctors like Me Are Leaving Academic Medicine,” STAT (blog), January 16, 2020, https://www.statnews.com/2020/01/16/black-doctors-leaving-faculty-positions-academic-medical-centers/. [18] Zamina Mithani, Jane Cooper, and Boyd J. Wesley, “Race, Power, and COVID-19: A Call for Advocacy within Bioethics,” The American Journal of Bioethics21, no. 2 (2021): 11–18, 13 https://doi.org/10.1080/15265161.2020.1851810. [19] “Graduate Programs,” The Hastings Center, accessed 2 June, 2021, https://www.thehastingscenter.org/publications-resources/bioethics-careers-education/graduate-programs-2/. [20] Norman Daniels, Just Health: Meeting Health Needs Fairly, at 299. [21] Ian James Kidd and Havi Carel, “Epistemic Injustice and Illness,” Journal of Applied Philosophy 34, no. 2 (2017): 172–90, https://doi.org/10.1111/japp.12172. [22] Ruqaiijah Yearby, “Sick and Tired of Being Sick and Tired: Putting an End to Separate and Unequal Health Care in the United States 50 Years after the Civil Rights Act of 1964,” Health Matrix 25, no. 1 (January 1, 2015): 1–33, at 11. [23] Jones CP, Maybank A, Nolen L, Fields N, Ogunwole M, Onuoha C, Williams J, Tsai J, Paul D, Essien UR, Khazanchi, R. “Episode 5: Racism, Power, and Policy: Building the Antiracist Health Systems of the Future.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. January 19, 2021. [24] Sienna Moriarty, “AMA Policies and Code of Medical Ethics’ Opinions Related to Health Promotion and Community Development,” AMA Journal of Ethics 21, no. 3 (March 1, 2019): 259–61, https://doi.org/10.1001/amajethics.2019.259. [25] Constantinescu, “Seeing the Forest beyond the Trees,” at 92. [26] Ana Smith Iltis, “Organizational Ethics: Moral Obligation and Integrity,” in Institutional Integrity in Health Care, ed. Ana Smith Iltis, Philosophy and Medicine (Dordrecht: Springer Netherlands, 2003), 175–82, https://doi.org/10.1007/978-94-017-0153-2_10.

Purpose Recognising current, significant rates of youth sexual violence and abuse (YSVA) and the need for more comprehensive prevention approaches to combat this social issue, new approaches are required to ensure that agency is given to the people who are most affected and who know their lives the best. This paper aims to report a youth-led (Young Voices United [YVU] Committee) participatory design approach aimed at delivering the highest level of engagement to understand what people agree is needed to reduce YSVA in their own communities. Design/methodology/approach The seven-step co-design (Trischler et al., 2019) process was implemented following ethical clearance. Over five months, 13 group co-design sessions involving 102 young people aged 12–25 years, 17 parents/caregivers (including young mums) and 9 teacher/guidance officers were conducted. Purposive sampling was undertaken to ensure that young people who had previously experienced YSVA or were most at risk of experiencing YSVA were overrepresented. Convenience sampling was used to gain wider community involvement in co-design. Four sessions were facilitated by YVU members, who were aged between 12 and 25 years, and more than 66 people helped the design team. Inductive thematic analysis identified emergent themes across completed co-design sessions. Findings New ideas and solutions to prevent YSVA can be identified by young people who have previously experienced violence, carers, other young people and community members. A core finding in this study is the need for positive relationship role models and an enhanced understanding of consent. Education and training, a community promotional campaign, sector involvement, capacity-building and consideration of the unique needs of different target audiences were key ideas emerging from youth-led co-design. The YVU Committee provided recommendations for resource prioritisation. Social implications This youth-led co-design process empowered the community. Project stakeholders have since formed partnerships won funding and used that funding to co-design and trial a new programme aiming to provide a safe haven for young people at risk of YSVA. The pilot programme delivers a safe and supportive environment for young people delivered at a time when it is needed most. Other geographical areas are now seeking to replicate the programme. The co-design processes and tools detailed in this study can be adapted to the design of programmes for those already engaged with the youth justice system and should be considered as part of a public health approach to effectively prevent and respond to YSVA and other youth crimes. Originality/value This paper advances understanding, providing a practical approach that ensures youth views are given weight [audience and influence described in Lundy’s (2007) participatory framework]. This paper explains how the YVU Committee, established at the commencement of the project, oversaw the community co-design effort, which followed Trischler et al.’s (2019) seven-step co-design process. Ideas were generated, and consensus views were consolidated, delivering the highest level of engagement according to Willmott et al.’s (2022) methodology, agent of change, training and engagement taxonomy. The participatory design method led to high levels of community engagement, and the success of the project is attributed to the establishment of the YVU Committee and stakeholder support.

For Socrates the act of communication is grounded in the world of original forms, archetypes, or abstract ideas. These ideas exist independently of the human mind and reflect a reality that is truer than the world of everyday experience. The task of the speaker is to draw the listener closer to the truth of these ideas, and this requires an intimate coupling of the form of speech to the character of the listener. In Phaedrus, Socrates explains, ". . . a would-be speaker must know how many types of soul there are. The number is finite, and they account for a variety of individual characters. When these are determined one must enumerate the various types of speech, a finite number also." The types of soul must then be carefully paired with the types of speech. This theoretical knowledge by itself, however, is not sufficient. A speaker must also know when ". . . he has actually before him a specific example of a type which he has heard described, and that this is what he must say and this is how he must say it if he wants to influence his hearer in this particular way" (Plato 91-92). Thus, the aspiring speaker must sharpen his powers of observation. Exactly how a speaker goes about discerning the various types of souls in his audience is not discussed in Phaedrus, but one assumes it is by mastering the art of face reading, or physiognomy. The science of physiognomy was of particular importance to the ancient Greeks. Nearly all the well-known Greek writers had something to say about the subject. Pythagoras is claimed to be the first Greek to formalize it systematically as a science. Hippocrates wrote voluminously on the subject, as did Aristotle. Socrates not only recommended physiognomy to his students (Tytler) but he is also reported to have demonstrated his facility with the science at least twice: once in predicting the promotion of Alcibiades and once upon first meeting Plato, whom he immediately recognized as a man of considerable philosophical talent (Encyclopedia Britannica). Writing is inferior to speech, Socrates tells Phaedrus, precisely because it cannot see and adapt the message to the reader. Like a painting of an object, writing is merely the image of dissociated speech. What is missing in writing-and what writing seems ever intent on reconstructing-is the human face. Pressing Faces Behind the Typeface Although physiognomy was banned by the Church, as it was associated with paganism and devil worship (practitioners of the science were burnt at the stake), it was revived in the Renaissance and became an obsession with the advent of the printing press. The printing press heralds democracy. But as human rights grew, urban centers developed, and new professions and classes emerged, people were no longer able to divine their own destiny or to predict the behavior and destiny of others. It became imperative to find other more reliable means of identifying the good and the bad, the talented and the unremarkable. Two books were considered indispensable: the Bible and Lavater's Essays on Physiognomy (Juengel). Physiognomy was the science that helped people decipher class and profession. It became the spelling book of character, one that people diligently studied so that they could learn to read not only the marks of character in others but also the signs of talent and potential in their own faces and in the faces of their children. Face reading was egalitarian and leveling (Juengel). The heads of state could be read and debunked in the flourishing art of caricature, and people delighted in decoding the physiognomy of the ordinary faces that crowded the pages of the popular press. The populace applauded the artists that succeeded in revealing the whole spectrum of a character-class, intentions, profession-in the masterly strokes of the pen (Wechsler). Unfortunately, so intense was the interest in face reading that many people were forced to cover their faces when out in public (Zebrowitz). Inside the religious, medical, educational, and criminal justice institutions, authorities scanned faces to identify the virtuous and the vile. People were hanged because of the shape of their jaws ("A physiognomic auto-da-fé,") and sometimes convicted of crimes because of an unfortunate physiognomy, even before any crimes were committed (Lichtenberg. 93). Mass Consumption of the Face Open a magazine. What do you see? I counted over 200 faces in the September 15, 2003 issue of Newsweek, 120 faces in the September 29, 2003 issue of Forbes, 124 faces in the September 15, 2003 issue of Time, and 37 faces in the November, 2003 issue of Handgunner (I included the masked faces). Whereas, in the 19th century, face reading was used by the religious, medical, and criminal justice authorities to identify a person's character, in the modern world face reading becomes face righting. Early in the century, people came to be viewed less as individuals than as masses that were dynamically statistical with fluctuations of opinions and tastes that could be sampled and manipulated. It quickly became apparent to the behemoth advertising industry that was erected with the advent of mass media that product designs and packages could be collated with viewer reactions. The audience is scrutinized, labeled, and targeted. What people are fed are fleshless images of themselves. Horkheimer and Adorno have observed that the media have reduced the individual to the stereotype. Stereotypes package people, typically in unflattering boxes. Mediated faces are used to mirror, to prime, and to manipulate the audience (Kress and van Leeuwen). On television and in print, images of canned faces proliferate. Not all stereotypes are unsavory. Nothing recommends itself nor sells like a beautiful face, but even beautiful faces must be retouched, even recomposed from features extracted from databases of perfect facial features. So important is the image of the face that media icons routinely visit the plastic surgeon. Michael Jackson is the most extreme example of what has been derogatorily termed a "scalpel slave." Plastic surgery is not exclusive to celebrities; countless millions of ordinary Americans feel compelled to undergo various cosmetic surgeries. The 20th-century consumption of the face has ended by consuming the face. Facing the Face Interface Text has made a comeback in hypertext. Empowered by the hyperlink, readers have become writers as they assemble texts with the clicks of a mouse (Landow). Electronic texts are pushed as well as pulled. Businesses have learned to track and to query users, building individual profiles that are then used to assemble personalized pages and email messages. Socrates' objection that writing is unable to perceive the reader no longer holds. The virtual text is watching you. And it is watching you with virtual eyes. There is a growing interest in developing face interfaces that are capable of perceiving and talking. The technical requirements are enormous. Face interfaces must learn to make eye contact, follow speaking faces with their eyes, mirror emotion, lip synch, and periodically nod, raise eyebrows, and tilt the head (Massaro). Face interfaces are also learning to write faces, to map rhetorical forms to the character of their interlocutors in ways Socrates could not have imagined. Socrates did not teach his students to consider the rhetorical effects of their faces: the speaker's face was thought to be fixed, a true reflection of the inner soul. Virtual faces are not so constrained. Smart faces are being developed that are capable of rendering their own appearances from within a statistical model of the users' impressions of faces. The goal is for these virtual faces to learn to design, through their interactions with users, facial appearances that are calibrated to elicit very specific impressions and reactions in others (Brahnam). Some people will disapprove of virtual faces. Just as the media use faces to manipulate the viewer and perpetuate facial stereotypes, smart faces run the risk of doing the same. Some may also worry that virtual faces will be attributed more intelligence and social capacity then they actually possess. Do we really want our children growing up talking to virtual faces? Can they satisfy our need for human contact? What does it mean to converse with a virtual face? What kind of conversation is that? For the present at least, virtual faces are more like the orators and bards of old. They merely repeat the speeches of others. Their own speech is nearly incomprehensible, and their grammatical hiccups annoyingly disrupt the suspension of disbelief. On their own, without the human in the loop, no one believes them. Thus, the virtual face appears on the screen, silently nodding and smiling. Not yet a proper student of classical rhetoric, it is much like the virtual guide at artificial-life.com that recently greeted her visitors wearing the following placard: A virtual guide that greeted visitors at artificial-life.com. Access date: October 2003. Works Cited Brahnam, Sheryl. "Agents as Artists: Automating Socially Intelligent Embodiment," Proceedings of the First International Workshop on the Philosophy & Design of Socially Adept Technologies, in conjunction with CHI 2002. Minneapolis, MN, 2002: 15-18. Encyclopedia Britannica. "Physiognomy." LoveToKnow Free Online Encyclopedia, 1911. Available: http://21.1911encyclopedia.org Horkheimer, Max, and Theodor W. Adorno. Dialectic of Enlightenment. Trans. John Cumming. New York: Seabury, 1944. Juengel, Scott Jordan. "About Face: Physiognomics, Revolution, and the Radical Act of Looking." Ph.D. dissertation. University of Iowa, 1997. Kress, Gunther, and Theo van Leeuwen. Reading Images: The Grammar of Visual Design. London: Routledge, 1996. Landow, P. George. Hypertext 2.0: The Convergence of Contemporary Critical Theory and Technology. Baltimore: John Hopkins U P, 1997. Lavater, Johann Caspar. Essays on Physiognomy: For the Promotion of the Knowledge and the Love of Mankind. Trans. Thomas Holcroft. London: printed by C. Whittingham for H. D. Symonds, 1804. Lichtenberg. Quoted in Frey, Siegfried. "Lavater, Lichtenberg, and the Suggestive Power of the Human Face." The Faces of Physiognomy: Interdisciplinary Approaches to Johann Caspar Lavater. Ed. Ellis Shookman. Studies in German Literature, Linguistics, and Culture. Columbia, S.C.: Camden House, 1993. 64-103. Massaro, D. M. Perceiving Talking Faces: From Speech Perception to a Behavioral Principle. Cambridge, MA: MIT P, 1997. Plato. Phaedrus and the Seventh and Eighth Letters. Trans. Walter Hamilton. London: Penguin, 1973. Tytler, Graeme. Physiognomy in the European Novel: Faces and Fortunes. Princeton, N.J.: Princeton U P, 1982. Wechsler, Judith. A Human Comedy: Physiognomy and Caricature in 19th Century Paris. London: U of Chicago P, 1982. Zebrowitz, Leslie A. Reading Faces: Window to the Soul? Boulder, Col.: Westview, 1998. Web Links http://vhost.oddcast.com/vhost_minisite/ http://mrl.nyu.edu/~perlin/facedemo/ http://www.faceinterfaces.com http://www.artificial-life.com Citation reference for this article MLA Style Brahnam, Sheryl. "Type/Face" M/C: A Journal of Media and Culture <http://www.media-culture.org.au/0401/04-brahnam.php>. APA Style Brahnam, S. (2004, Jan 12). Type/Face. M/C: A Journal of Media and Culture, 7, <http://www.media-culture.org.au/0401/04-brahnam.php>

The variable “actors” records individuals or collectives, who appear as a source for assertions of facts and evaluations and whose actions, interests or demands are addressed in an article (Hillebrand, 2005). In the case of media self-coverage, and especially when dealing with media policy issues, media organizations themselves might be affected by them. Hence, media organizations may strategically use their privileged access to the public to promote their own interests, for example by selecting actors and positions that will be publicly heard. Several studies have found a predominance of “opportune actors” and experts representing a position that supports media organization’s own interests (Kemner, Scherer, & Weinacht, 2008; Lichtenstein, 2011; Maier & Dogruel, 2016). Field of application/theoretical foundation The variable serves to identify the actors involved in specific media discourses and can serve as an indicator for attempted influence by media organizations through biased selection. Example study Pedrazzi. 2020 Information on Pedrazzi, 2020 Research interest: Pedrazzi (2020) investigates Swiss media coverage of media policy, public service in general and the Swiss public service organization SRG SSR in the context of the referendum on the revision of the Federal Act on Radio and Television (RTVA) in 2015 and the No-Billag initiative in 2018. Object of analysis: Representative samples of articles covering each the revision of the RTVA and the No-Billag initiative in twelve regional and national Swiss German print and online publications with different ownership. Time frame of analysis: January 1, 2010 to March 4, 2018 Information about variable Level of analysis: article Operationalization/Coding instructions: “The main actor and the two most important secondary actors mentioned in the article and who speak directly or indirectly on media policy issues, i.e. either on one of the proposals (revision of RTVA and/or No-Billag initiative) and its consequences, on the subject of public service, on Swiss public service organization SRG SSR or on the media market, are recorded. However, if an actor is only mentioned - without an explanation of his/her views - he/she is not coded. The main actor is the one who is presented as central in the title, subtitle and/or lead. The title, subtitle (if available) and lead are the first criteria for the assignment. If several actors appear in the same text subunit, the order is decisive. If no clear assignment can be made due to title/subtitle/lead, the entire contribution is used. The main actor is then the most extensively presented actor in terms of volume. The most important secondary actor is determined according to the same criteria as the main actor (if the main actor is not taken into account). The second most important secondary actor is determined according to the same criteria as the main actor (if the main actor and the most important secondary actor are not considered). The journalist can also be coded as an actor if he/she reveals his/her opinion. In the case of commentaries/columns, the author counts as the main actor. In the case of interviews, the interviewee counts as the main actor, but not the journalist.” Values: Pedrazzi (2020) Government, administration, parliament or courts as a body or institution and/or individual representatives of the executive, legislative or judiciary system (however, not individual politicians speaking for themselves or their party) Federal Council Federal Council as a whole or individual members Federal departments, authorities and commissions Departments (e.g. DETEC), federal offices (e.g. OFCOM) authorities and commissions (e.g. ComCom) and their representatives National Council and Council of States Parliament or commissions, including commission presidents or spokespersons when acting in this capacity. Note: Individual parliamentarians must be coded as members of their parties. Cantonal government Cantonal Government as a whole or individual members acting in this capacity Cantonal administration Cantonal administration and their representatives Cantonal parliament Cantonal parliaments Municipalities Members of the municipal council, administration, etc.) Courts Federal court / cantonal court / district court etc. as well as judges acting in their function Other bodies or institutions of the government, administration, parliament or justice Parties and party representatives (incl. party subsections) BDP, Bürgerlich-Demokratische Partei Junge BDP CVP, Christlich-demokratische Volkspartei (inkl. CSP) Junge CVP EVP, Evangelische Volkspartei Junge EVP FDP, die Liberalen (inkl. LPS/Liberale Partei der Schweiz) Jungfreisinnige GLP, Grünliberale Partei Junge Grünliberale GPS, Grüne Partei der Schweiz Junge Grüne SP, Sozialdemokratische Partei JUSO SVP, Schweizerische Volkspartei Junge SVP Lega dei Ticinesi Mouvement Citoyens Romand Independents Other parties Initiative, referendum and counter committees Referendum Committee against the revision of the RTVG Committee "Ja zum RTVG" Committee "Nein zur neuen Billag-Mediensteuer" Initiative Committee No Billag incl. Olivier Kessler Committee "NEIN zu No-Billag" Committee "Nein zum Sendeschluss" Other initiative, referendum and counter committees Media, telecommunications and advertising companies and their representatives (incl. owners, editors) SRG SSR incl. SRF, RTS, RSI, RTR NZZ Mediengruppe incl. Radio FM1, TVO, Tele 1, Radio Pilatus, etc. Tamedia Ringier incl. Radio NRJ AZ Medien incl. Radio Argovia, Radio 24, Radio 32, Tele M1, Tele Züri, Tele Bärn, etc. Somedia incl. Radio Südostschweiz, Tele Südostschweiz, etc. Basler Zeitung Medien 3+ Gruppe ProSieben Sat.1 Gruppe RTL Gruppe Teleclub/Swisscom UPC Cablecom Sunrise Orange/Salt Publisuisse Goldbach Medien Other private media companies Media associations and their representatives Verband Schweizer Medien – Médias Suisses – Stampa Svizzera VSP - Verband Schweizer Privatradios RRR - Radio Régionales Romandes Unikom – Union nicht-kommerzorientierter Lokalradios Telesuisse - Verband der Schweizer Regionalsender impressum – Schweizer JournalistInnen Syndicom SSM – Schweizer Syndikat Medienschaffender Swisscable asut Schweizer Werbung – Publicité Suisse – Publicità Svizzera Other media associations Other associations (economic, cultural, civil society, etc.) economiesuisse Schweizerischer Gewerbeverband Schweizerischer Arbeitgeberverband avenir suisse Schweizerischer Gewerkschaftsbund Kaufmännischer Verband KV Schweiz Travail Suisse Stiftung für Konsumentenschutz Konsumentenforum Fédération romande des consommateurs Associazione consumatrici della Svizzera italiana Think tanks Cultural associations Incl. film and music professionals Sports associations Civil society organizations and associations Other associations Other economic or socio-cultural actors Industry experts Companies not operating in the media, telecommunications or advertising industry Science, research Celebrities From sports, culture, show business, etc. Members of the audience (viewers, readers, users) or simple citizens (without representative function) Author (in case of op-ed articles) Other actors Intercoder reliability: Intercoder reliability (Krippendorff’s Alpha) coefficient of .77 across categories (9 coders) Codebook available at (last accessed on 09.12.2020): https://doi.org/10.5281/zenodo.4312912 Information on Hillebrand, 2005 Research interest: Hillebrand (2005) examines how print media outlets report on television (which content, actors, concerns and ways of addressing issues dominate in the coverage and to what extent it includes criticism).Object of analysis: Purposive sample (four times two weeks around media-relevant events) of articles containing a reference to television in six national daily newspapers, two national weekly newspapers, three television magazines and two media trade journals from Germany. Time frame of analysis: August 1, 2002 to July 31, 2003 Information about variable Level of analysis: article Operationalization/Coding instructions: Hillebrand (2005, Anhang A, own translation):“Coding is intended to record the actors, sources and witnesses appearing in the article. A main actor and a secondary actor (if applicable) are coded.Main actor: Who is at the center of the article? Whose actions or statements, interests or preferences are at the core of the article? Who takes up the most space? Whose actions or statements form the reference point to which others then react? Who appears as the ‘source’ for statements of facts or for evaluations?The author(s) of an article are not considered as actors! This also applies in cases where TV celebrities such as Kalkofe (TV-Spielfilm) or Beckmann (Zeit) have permanent columns. As actor is recorded the person or collective, who is reported on, whose actions are commented on, etc.Secondary actor: Who else is it about? Same codes to be used as for the main actor.” Values: Hillebrand (2005) Members of the audience (viewers, readers, users), participants, simple citizens (without representative function) Media companies, media executives, journalists, celebrities of the media industry Politicians and all members of the executive and judiciary system Companies (outside the media industry) Interest groups (of companies or professions outside the media industry, e.g. from the environmental sector, etc.), churches, etc. Interest groups (of companies or professions outside the media industry, e.g. from the environmental sector, etc.), churches, etc. Science, experts, interpreters (writers etc.) - from research and scientific institutions or as self-employed, formally independent from companies, political parties and interest groups Others No secondary actor/not decidable Intercoder reliability: Intercoder reliability coefficient of .84 across categories (4 coders), not specified for individual categoryCodebook available at (last accessed on 09.12.2020): https://www.hans-bredow-institut.de/uploads/media/Publikationen/cms/media/d666beb1d9130d241ec01915684342eb582b3d42.pdf.ReferencesHillebrand, C. (2005). Das Fernsehen im Spiegel der Printmedien – Konturen der Berichterstattung. In R. Weiß (Ed.), Zur Kritik der Medienkritik. Wie Zeitungen das Fernsehen beobachten (pp. 33-81). Berlin: Vistas.Kemner, B., Scherer, H., & Weinacht, S. (2008). Unter der Tarnkappe. Publizistik, 53(1), 65-84. doi:10.1007/s11616-008-0006-9Lichtenstein, D. (2011). Kommerzialisierung des Medienjournalismus? Eine empirische Untersuchung zum „Fall Berliner Zeitung“. M&K Medien & Kommunikationswissenschaft, 59(2), 216-234. doi:10.5771/1615-634x-2011-2-216Maier, D., & Dogruel, L. (2016). Akteursbeziehungen in der Zeitungsberichterstattung über die Online-Aktivitäten des öffentlich-rechtlichen Rundfunks. Publizistik, 61(2), 145-166. doi:10.1007/s11616-016-0258-8 Pedrazzi, S. (2020). Codebuch zur Studie «Eigeninteressen in der Berichterstattung über medienpolitische Vorlagen und den Service public in der Schweiz». Zenodo. doi:10.5281/zenodo.4312912

Photograph by Gonzalo Echeverria (2010)We need to get some broad-based support, to capture the public’s imagination … so we have to offer up scary scenarios, make simplified, dramatic statements and make little mention of any doubts … each of us has to decide what the right balance is between being effective and being honest (Hulme 347). Acclaimed climate scientist, the late Stephen Schneider, made this comment in 1988. Later he regretted it and said that there are ways of using metaphors that can “convey both urgency and uncertainty” (Hulme 347). What Schneider encapsulates here is the great conundrum for those attempting to communicate climate change to the everyday public. How do scientists capture the public’s imagination and convey the desperation they feel about climate change, but do it ethically? If scientific findings are presented carefully, in boring technical jargon that few can understand, then they are unlikely to attract audiences or provide an impetus for behavioural change. “What can move someone to act?” asks communication theorists Susan Moser and Lisa Dilling (37). “If a red light blinks on in a cockpit” asks Donella Meadows, “should the pilot ignore it until in speaks in an unexcited tone? … Is there any way to say [it] sweetly? Patiently? If one did, would anyone pay attention?” (Moser and Dilling 37). In 2010 Tim Flannery was appointed Panasonic Chair in Environmental Sustainability at Macquarie University. His main teaching role remains within the new science communication programme. One of the first things Flannery was emphatic about was acquainting students with Karl Popper and the origin of the scientific method. “There is no truth in science”, he proclaimed in his first lecture to students “only theories, hypotheses and falsifiabilities”. In other words, science’s epistemological limits are framed such that, as Michael Lemonick argues, “a statement that cannot be proven false is generally not considered to be scientific” (n.p., my emphasis). The impetus for the following paper emanates precisely from this issue of scientific uncertainty — more specifically from teaching a course with Tim Flannery called Communicating climate change to a highly motivated group of undergraduate science communication students. I attempt to illuminate how uncertainty is constructed differently by different groups and that the “public” does not necessarily interpret uncertainty in the same way the sciences do. This paper also analyses how doubt has been politicised and operates polemically in media coverage of climate change. As Andrew Gorman-Murray and Gordon Waitt highlight in an earlier issue of M/C Journal that focused on the climate-culture nexus, an understanding of the science alone is not adequate to deal with the cultural change necessary to address the challenges climate change brings (n.p). Far from being redundant in debates around climate change, the humanities have much to offer. Erosion of Trust in Science The objectives of Macquarie’s science communication program are far more ambitious than it can ever hope to achieve. But this is not necessarily a bad thing. The initiative is a response to declining student numbers in maths and science programmes around the country and is designed to address the perceived lack of communication skills in science graduates that the Australian Council of Deans of Science identified in their 2001 report. According to Macquarie Vice Chancellor Steven Schwartz’s blog, a broader, and much more ambitious aim of the program is to “restore public trust in science and scientists in the face of widespread cynicism” (n.p.). In recent times the erosion of public trust in science was exacerbated through the theft of e-mails from East Anglia University’s Climate Research Unit and the so-called “climategate scandal” which ensued. With the illegal publication of the e-mails came claims against the Research Unit that climate experts had been manipulating scientific data to suit a pro-global warming agenda. Three inquiries later, all the scientists involved were cleared of any wrongdoing, however the damage had already been done. To the public, what this scandal revealed was a certain level of scientific hubris around the uncertainties of the science and an unwillingness to explain the nature of these uncertainties. The prevailing notion remained that the experts were keeping information from public scrutiny and not being totally honest with them, which at least in the short term, damaged the scientists’s credibility. Many argued that this signalled a shift in public opinion and media portrayal on the issue of climate change in late 2009. University of Sydney academic, Rod Tiffen, claimed in the Sydney Morning Herald that the climategate scandal was “one of the pivotal moments in changing the politics of climate change” (n.p). In Australia this had profound implications and meant that the bipartisan agreement on an emissions trading scheme (ETS) that had almost been reached, subsequently collapsed with (climate sceptic) Tony Abbott's defeat of (ETS advocate) Malcolm Turnbull to become opposition leader (Tiffen). Not long after the reputation of science received this almighty blow, albeit unfairly, the federal government released a report in February 2010, Inspiring Australia – A national strategy for engagement with the sciences as part of the country’s innovation agenda. The report outlines a commitment from the Australian government and universities around the country to address the challenges of not only communicating science to the broader community but, in the process, renewing public trust and engagement in science. The report states that: in order to achieve a scientifically engaged Australia, it will be necessary to develop a culture where the sciences are recognized as relevant to everyday life … Our science institutions will be expected to share their knowledge and to help realize full social, economic, health and environmental benefits of scientific research and in return win ongoing public support. (xiv-xv) After launching the report, Innovation Minister Kim Carr went so far as to conflate “hope” with “science” and in the process elevate a discourse of technological determinism: “it’s time for all true friends of science to step up and defend its values and achievements” adding that, "when you denigrate science, you destroy hope” (n.p.). Forever gone is our naïve post-war world when scientists were held in such high esteem that they could virtually use humans as guinea pigs to test out new wonder chemicals; such as organochlorines, of which DDT is the most widely known (Carson). Thanks to government-sponsored nuclear testing programs, if you were born in the 1950s, 1960s or early 1970s, your brain carries a permanent nuclear legacy (Flannery, Here On Earth 158). So surely, for the most part, questioning the authority and hubristic tendencies of science is a good thing. And I might add, it’s not just scientists who bear this critical burden, the same scepticism is directed towards journalists, politicians and academics alike – something that many cultural theorists have noted is characteristic of our contemporary postmodern world (Lyotard). So far from destroying hope, as the former Innovation Minister Kim Carr (now Minister for Innovation, Industry, Science and Research) suggests, surely we need to use the criticisms of science as a vehicle upon which to initiate hope and humility. Different Ways of Knowing: Bayesian Beliefs and Matters of Concern At best, [science] produces a robust consensus based on a process of inquiry that allows for continued scrutiny, re-examination, and revision. (Oreskes 370) In an attempt to capitalise on the Macquarie Science Faculty’s expertise in climate science, I convened a course in second semester 2010 called SCOM201 Science, Media, Community: Communicating Climate Change, with invaluable assistance from Penny Wilson, Elaine Kelly and Liz Morgan. Mike Hulme’s provocative text, Why we disagree about climate change: Understanding controversy, inaction and opportunity provided an invaluable framework for the course. Hulme’s book brings other types of knowledge, beyond the scientific, to bear on our attitudes towards climate change. Climate change, he claims, has moved from being just a physical, scientific, and measurable phenomenon to becoming a social and cultural phenomenon. In order to understand the contested nature of climate change we need to acknowledge the dynamic and varied meanings climate has played in different cultures throughout history as well as the role that our own subjective attitudes and judgements play. Climate change has become a battleground between different ways of knowing, alternative visions of the future, competing ideas about what’s ethical and what’s not. Hulme makes the point that one of the reasons that we disagree about climate change is because we disagree about the role of science in today’s society. He encourages readers to use climate change as a tool to rigorously question the basis of our beliefs, assumptions and prejudices. Since uncertainty was the course’s raison d’etre, I was fortunate to have an extraordinary cohort of students who readily engaged with a course that forced them to confront their own epistemological limits — both personally and in a disciplinary sense. (See their blog: https://scom201.wordpress.com/). Science is often associated with objective realities. It thus tends to distinguish itself from the post-structuralist vein of critique that dominates much of the contemporary humanities. At the core of post-structuralism is scepticism about everyday, commonly accepted “truths” or what some call “meta-narratives” as well as an acknowledgement of the role that subjectivity plays in the pursuit of knowledge (Lyotard). However if we can’t rely on objective truths or impartial facts then where does this leave us when it comes to generating policy or encouraging behavioural change around the issue of climate change? Controversial philosophy of science scholar Bruno Latour sits squarely in the post-structuralist camp. In his 2004 article, “Why has critique run out of steam? From matters of fact to matters of concern”, he laments the way the right wing has managed to gain ground in the climate change debate through arguing that uncertainty and lack of proof is reason enough to deny demands for action. Or to use his turn-of-phrase, “dangerous extremists are using the very same argument of social construction to destroy hard-won evidence that could save our lives” (Latour n.p). Through co-opting (the Left’s dearly held notion of) scepticism and even calling themselves “climate sceptics”, they exploited doubt as a rationale for why we should do nothing about climate change. Uncertainty is not only an important part of science, but also of the human condition. However, as sociologist Sheila Jasanoff explains in her Nature article, “Technologies of Humility”, uncertainty has become like a disease: Uncertainty has become a threat to collective action, the disease that knowledge must cure. It is the condition that poses cruel dilemmas for decision makers; that must be reduced at all costs; that is tamed with scenarios and assessments; and that feeds the frenzy for new knowledge, much of it scientific. (Jasanoff 33) If we move from talking about climate change as “a matter of fact” to “a matter of concern”, argues Bruno Latour, then we can start talking about useful ways to combat it, rather than talking about whether the science is “in” or not. Facts certainly matter, claims Latour, but they can’t give us the whole story, rather “they assemble with other ingredients to produce a matter of concern” (Potter and Oster 123). Emily Potter and Candice Oster suggest that climate change can’t be understood through either natural or cultural frames alone and, “unlike a matter of fact, matters of concern cannot be explained through a single point of view or discursive frame” (123). This makes a lot of what Hulme argues far more useful because it enables the debate to be taken to another level. Those of us with non-scientific expertise can centre debates around the kinds of societies we want, rather than being caught up in the scientific (un)certainties. If we translate Latour’s concept of climate change being “a matter of concern” into the discourse of environmental management then what we come up with, I think, is the “precautionary principle”. In the YouTube clip, “Stephen Schneider vs Skeptics”, Schneider argues that when in doubt about the potential environmental impacts of climate change, we should always apply the precautionary principle. This principle emerged from the UN conference on Environment and Development in Rio de Janeiro in 1992 and concerns the management of scientific risk. However its origins are evident much earlier in documents such as the “Use of Pesticides” from US President’s Science Advisory Committee in 1962. Unlike in criminal and other types of law where the burden of proof is on the prosecutor to show that the person charged is guilty of a particular offence, in environmental law the onus of proof is on the manufacturers to demonstrate the safety of their product. For instance, a pesticide should be restricted or disproved for use if there is “reasonable doubt” about its safety (Oreskes 374). Principle 15 of the Rio Declaration on Environment and Development in 1992 has its foundations in the precautionary principle: “Where there are threats of serious or irreversible environmental damage, lack of full scientific certainty should not be used as a reason for postponing measures to prevent environmental degradation” (n.p). According to Environmental Law Online, the Rio declaration suggests that, “The precautionary principle applies where there is a ‘lack of full scientific certainty’ – that is, when science cannot say what consequences to expect, how grave they are, or how likely they are to occur” (n.p.). In order to make predictions about the likelihood of an event occurring, scientists employ a level of subjectivity, or need to “reveal their degree of belief that a prediction will turn out to be correct … [S]omething has to substitute for this lack of certainty” otherwise “the only alternative is to admit that absolutely nothing is known” (Hulme 85). These statements of “subjective probabilities or beliefs” are called Bayesian, after eighteenth century English mathematician Sir Thomas Bayes who developed the theory of evidential probability. These “probabilities” are estimates, or in other words, subjective, informed judgements that draw upon evidence and experience about the likelihood of event occurring. The Intergovernmental Panel on Climate Change (IPCC) uses Bayesian beliefs to determine the risk or likelihood of an event occurring. The IPCC provides the largest international scientific assessment of climate change and often adopts a consensus model where viewpoint reached by the majority of scientists is used to establish knowledge amongst an interdisciplinary community of scientists and then communicate it to the public (Hulme 88). According to the IPCC, this consensus is reached amongst more than more than 450 lead authors, more than 800 contributing authors, and 2500 scientific reviewers. While it is an advisory body and is not policy-prescriptive, the IPCC adopts particular linguistic conventions to indicate the probability of a statement being correct. Stephen Schneider convinced the IPCC to use this approach to systemise uncertainty (Lemonick). So for instance, in the IPCC reports, the term “likely” denotes a chance of 66%-90% of the statement being correct, while “very likely” denotes more than a 90% chance. Note the change from the Third Assessment Report (2001), indicating that “most of the observed warming in over the last fifty years is likely to have been due to the increase in greenhouse gas emissions” to the Fourth Assessment (February 2007) which more strongly states: “Most of the observed increase in global average temperatures since the mid twentieth century is very likely due to the observed increase in anthropogenic greenhouse gas concentrations” (Hulme 51, my italics). A fiery attack on Tim Flannery by Andrew Bolt on Steve Price’s talkback radio show in June 2010 illustrates just how misunderstood scientific uncertainty is in the broader community. When Price introduces Flannery as former Australian of the Year, Bolt intercedes, claiming Flannery is “Alarmist of the Year”, then goes on to chastise Flannery for making various forecasts which didn’t eventuate, such as that Perth and Brisbane might run out of water by 2009. “How much are you to blame for the swing in sentiment, the retreat from global warming policy and rise of scepticism?” demands Bolt. In the context of the events of late 2009 and early 2010, the fact that these events didn’t materialise made Flannery, and others, seem unreliable. And what Bolt had to say on talkback radio, I suspect, resonated with a good proportion of its audience. What Bolt was trying to do was discredit Flannery’s scientific credentials and in the process erode trust in the expert. Flannery’s response was to claim that, what he said was that these events might eventuate. In much the same way that the climate sceptics have managed to co-opt scepticism and use it as a rationale for inaction on climate change, Andrew Bolt here either misunderstands basic scientific method or quite consciously misleads and manipulates the public. As Naomi Oreskes argues, “proof does not play the role in science that most people think it does (or should), and therefore it cannot play the role in policy that skeptics demand it should” (Oreskes 370). Doubt and ‘Situated’ Hope Uncertainty and ambiguity then emerge here as resources because they force us to confront those things we really want–not safety in some distant, contested future but justice and self-understanding now. (Sheila Jasanoff, cited in Hulme, back cover) In his last published book before his death in mid-2010, Science as a contact sport, Stephen Schneider’s advice to aspiring science communicators is that they should engage with the media “not at all, or a lot”. Climate scientist Ann Henderson-Sellers adds that there are very few scientists “who have the natural ability, and learn or cultivate the talents, of effective communication with and through the media” (430). In order to attract the public’s attention, it was once commonplace for scientists to write editorials and exploit fear-provoking measures by including a “useful catastrophe or two” (Moser and Dilling 37). But are these tactics effective? Susanne Moser thinks not. She argues that “numerous studies show that … fear may change attitudes … but not necessarily increase active engagement or behaviour change” (Moser 70). Furthermore, risk psychologists argue that danger is always context specific (Hulme 196). If the risk or danger is “situated” and “tangible” (such as lead toxicity levels in children in Mt Isa from the Xstrata mine) then the public will engage with it. However if it is “un-situated” (distant, intangible and diffuse) like climate change, the audience is less likely to. In my SCOM201 class we examined the impact of two climate change-related campaigns. The first one was a short film used to promote the 2010 Copenhagen Climate Change Summit (“Scary”) and the second was the State Government of Victoria’s “You have the power: Save Energy” public awareness campaign (“You”). Using Moser’s article to guide them, students evaluated each campaign’s effectiveness. Their conclusions were that the “You have the power” campaign had far more impact because it a) had very clear objectives (to cut domestic power consumption) b) provided a very clear visualisation of carbon dioxide through the metaphor of black balloons wafting up into the atmosphere, c) gave viewers a sense of empowerment and hope through describing simple measures to cut power consumption and, d) used simple but effective metaphors to convey a world progressed beyond human control, such as household appliances robotically operating themselves in the absence of humans. Despite its high production values, in comparison, the Copenhagen Summit promotion was more than ineffective and bordered on propaganda. It actually turned viewers off with its whining, righteous appeal of, “please help the world”. Its message and objectives were ambiguous, it conveyed environmental catastrophe through hackneyed images, exploited children through a narrative based on fear and gave no real sense of hope or empowerment. In contrast the Victorian Government’s campaign focused on just one aspect of climate change that was made both tangible and situated. Doubt and uncertainty are productive tools in the pursuit of knowledge. Whether it is scientific or otherwise, uncertainty will always be the motivation that “feeds the frenzy for new knowledge” (Jasanoff 33). Articulating the importance of Hulme’s book, Sheila Jasanoff indicates we should make doubt our friend, “Without downplaying its seriousness, Hulme demotes climate change from ultimate threat to constant companion, whose murmurs unlock in us the instinct for justice and equality” (Hulme back cover). The “murmurs” that Jasanoff gestures to here, I think, can also be articulated as hope. And it is in this discussion of climate change that doubt and hope sit side-by-side as bedfellows, mutually entangled. Since the “failed” Copenhagen Summit, there has been a distinct shift in climate change discourse from “experts”. We have moved away from doom and gloom discourses and into the realm of what I shall call “situated” hope. “Situated” hope is not based on blind faith alone, but rather hope grounded in evidence, informed judgements and experience. For instance, in distinct contrast to his cautionary tale The Weather Makers: The History & Future Impact of Climate Change, Tim Flannery’s latest book, Here on Earth is a biography of our Earth; a planet that throughout its history has oscillated between Gaian and Medean impulses. However Flannery’s wonder about the natural world and our potential to mitigate the impacts of climate change is not founded on empty rhetoric but rather tempered by evidence; he presents a series of case studies where humanity has managed to come together for a global good. Whether it’s the 1987 Montreal ban on CFCs (chlorinated fluorocarbons) or the lesser-known 2001 Stockholm Convention on POP (Persistent Organic Pollutants), what Flannery envisions is an emerging global civilisation, a giant, intelligent super-organism glued together through social bonds. He says: If that is ever achieved, the greatest transformation in the history of our planet would have occurred, for Earth would then be able to act as if it were as Francis Bacon put it all those centuries ago, ‘one entire, perfect living creature’. (Here on Earth, 279) While science might give us “our most reliable understanding of the natural world” (Oreskes 370), “situated” hope is the only productive and ethical currency we have. ReferencesAustralian Council of Deans of Science. What Did You Do with Your Science Degree? A National Study of Employment Outcomes for Science Degree Holders 1990-2000. Melbourne: Centre for the Study of Higher Education, University of Melbourne, 2001. Australian Government Department of Innovation, Industry, Science and Research, Inspiring Australia – A National Strategy for Engagement with the Sciences. Executive summary. Canberra: DIISR, 2010. 24 May 2010 ‹http://www.innovation.gov.au/SCIENCE/INSPIRINGAUSTRALIA/Documents/InspiringAustraliaSummary.pdf›. “Andrew Bolt with Tim Flannery.” Steve Price. Hosted by Steve Price. Melbourne: Melbourne Talkback Radio, 2010. 9 June 2010 ‹http://www.mtr1377.com.au/index2.php?option=com_newsmanager&task=view&id=6209›. Carson, Rachel. Silent Spring. London: Penguin, 1962 (2000). Carr, Kim. “Celebrating Nobel Laureate Professor Elizabeth Blackburn.” Canberra: DIISR, 2010. 19 Feb. 2010 ‹http://minister.innovation.gov.au/Carr/Pages/CELEBRATINGNOBELLAUREATEPROFESSORELIZABETHBLACKBURN.aspx›. Environmental Law Online. “The Precautionary Principle.” N.d. 19 Jan 2011 ‹http://www.envirolaw.org.au/articles/precautionary_principle›. Flannery, Tim. The Weather Makers: The History & Future Impact of Climate Change. Melbourne: Text Publishing, 2005. ———. Here on Earth: An Argument for Hope. Melbourne: Text Publishing, 2010. Gorman-Murray, Andrew, and Gordon Waitt. “Climate and Culture.” M/C Journal 12.4 (2009). 9 Mar 2011 ‹http://journal.media-culture.org.au/index.php/mcjournal/article/viewArticle/184/0›. Harrison, Karey. “How ‘Inconvenient’ Is Al Gore’s Climate Change Message?” M/C Journal 12.4 (2009). 9 Mar 2011 ‹http://journal.media-culture.org.au/index.php/mcjournal/article/viewArticle/175›. Henderson-Sellers, Ann. “Climate Whispers: Media Communication about Climate Change.” Climatic Change 40 (1998): 421–456. Hulme, Mike. Why We Disagree about Climate Change: Understanding, Controversy, Inaction and Opportunity. Cambridge: Cambridge UP, 2009. Intergovernmental Panel on Climate Change. A Picture of Climate Change: The Current State of Understanding. 2007. 11 Jan 2011 ‹http://www.ipcc.ch/pdf/press-ar4/ipcc-flyer-low.pdf›. Jasanoff, Sheila. “Technologies of Humility.” Nature 450 (2007): 33. Latour, Bruno. “Why Has Critique Run Out of Steam? From Matters of Fact to Matters of Concern.” Critical Inquiry 30.2 (2004). 19 Jan 2011 ‹http://criticalinquiry.uchicago.edu/issues/v30/30n2.Latour.html›. Lemonick, Michael D. “Climate Heretic: Judith Curry Turns on Her Colleagues.” Nature News 1 Nov. 2010. 9 Mar 2011 ‹http://www.nature.com/news/2010/101101/full/news.2010.577.html›. Lyotard, Jean-Francois. The Postmodern Condition: A Report on Knowledge. Minneapolis: U of Minnesota P, 1984. Moser, Susanne, and Lisa Dilling. “Making Climate Hot: Communicating the Urgency and Challenge of Global Climate Change.” Environment 46.10 (2004): 32-46. Moser, Susie. “More Bad News: The Risk of Neglecting Emotional Responses to Climate Change Information.” In Susanne Moser and Lisa Dilling (eds.), Creating a Climate for Change: Communicating Climate Change and Facilitating Social Change. Cambridge: Cambridge UP, 2007. 64-81. Oreskes, Naomi. “Science and Public Policy: What’s Proof Got to Do with It?” Environmental Science and Policy 7 (2004): 369-383. Potter, Emily, and Candice Oster. “Communicating Climate Change: Public Responsiveness and Matters of Concern.” Media International Australia 127 (2008): 116-126. President’s Science Advisory Committee. “Use of Pesticides”. Washington, D.C.: The White House, 1963. United Nations Declaration on Environment and Development. Rio de Janeiro, 1992. 19 Jan 2011 ‹http://www.unep.org/Documents.Multilingual/Default.asp?DocumentID=78&ArticleID=1163›. “Scary Global Warming Propaganda Video Shown at the Copenhagen Climate Meeting – 7 Dec. 2009.” YouTube. 21 Mar. 2011‹http://www.youtube.com/watch?v=jzSuP_TMFtk&feature=related›. Schneider, Stephen. Science as a Contact Sport: Inside the Battle to Save Earth’s Climate. National Geographic Society, 2010. ———. “Stephen Schneider vs. the Sceptics”. YouTube. 21 Mar. 2011 ‹http://www.youtube.com/watch?v=7rj1QcdEqU0›. Schwartz, Steven. “Science in Search of a New Formula.” 2010. 20 May 2010 ‹http://www.vc.mq.edu.au/blog/2010/03/11/science-in-search-of-a-new-formula/›. Tiffen, Rodney. "You Wouldn't Read about It: Climate Scientists Right." Sydney Morning Herald 26 July 2010. 19 Jan 2011 ‹http://www.smh.com.au/environment/climate-change/you-wouldnt-read-about-it-climate-scientists-right-20100727-10t5i.html›. “You Have the Power: Save Energy.” YouTube. 21 Mar. 2011 ‹http://www.youtube.com/watch?v=SCiS5k_uPbQ›.

ObjectiveWe aimed to assess the effect of the amended Public Health act of 2013 on facility-based HIV testing in Princess Marina Hospital.IntroductionHIV testing remains the mainstay of optimal HIV care and is pivotal to control and prevention of the disease, however efforts to attain optimal testing levels have been undermined by low HIV testing especially in developing countries. Botswana in response, amended its Public Health Act in September 2013 but the effect of this action on facility based HIV testing rates has not been evaluated.MethodsWe carried out an effect assessment using interrupted time-series analysis method, where we accessed electronic medical records of patients seen in Princess Marina Hospital from June 2011 to May 2015. Rates were developed from the proportion of patients that tested each month out of the number that registered, and that figure used that as our data point in the series. September 2013 served as our intervention period in the series. We ran the (i) crude and (ii) sex-stratified model regression models in stata® yielding Newey-West coefficients with their 95% confidence intervals. Graphical display of the models were also produced to visual appreciation and inspection.ResultsTwo hundred and twenty-nine thousand six hundred and ninety two patients were registered between June 2011 and May 2015. Of those tested the significant majority being females (65%). From the Newey-regression output there was no significant change in the level of HIV testing immediately after the intervention however there was a change in trend(p=0.002) post the intervention. Stratification by gender, revealed no statistically significant difference between males and females, either in the levels nor the trend post intervention compared to pre-intervention.ConclusionsThe amendment of the Public Health act of 2013, has brought about trend change in HIV testing however there has not been any apparent difference in the levels nor trends on HIV testing between males and females. Nationwide health facility-based studies could assist assess the overall effect of the amended act on HIV testing rates.References1. Provider Initiated HIV Testing and Counseling: One Day Training Programme, Field Test Version. WHO Guidelines Approved by the Guidelines Review Committee. Geneva2011.2. Donnell D, Baeten JM, Kiarie J, Thomas KK, Stevens W, Cohen CR, et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. The Lancet. 2010;375(9731):2092-8.3. Lawn SD, Harries AD, Anglaret X, Myer L, Wood R. Early mortality among adults accessing antiretroviral treatment programmes in sub-Saharan Africa. Aids. 2008;22(15):1897-908.4. McMahon JM, Pouget ER, Tortu S, Volpe EM, Torres L, Rodriguez W. Couple-based HIV counseling and testing: a risk reduction intervention for US drug-involved women and their primary male partners. Prevention science : the official journal of the Society for Prevention Research. 2015;16(2):341-51.5. Shan D, Duan S, Gao J, Yang Y, Ye R, Hu Y, et al. [Analysis of early detection of HIV infections by provider initiated HIV testing and counselling in regions with high HIV/AIDS epidemic in China]. Zhonghua yu fang yi xue za zhi [Chinese journal of preventive medicine]. 2015;49(11):962-6.6. Hensen B, Baggaley R, Wong VJ, Grabbe KL, Shaffer N, Lo YRJ, et al. Universal voluntary HIV testing in antenatal care settings: a review of the contribution of provider initiated testing & counselling. Tropical Medicine & International Health. 2012;17(1):59-70.7. Ijadunola K, Abiona T, Balogun J, Aderounmu A. Provider-initiated (Opt-out) HIV testing and counselling in a group of university students in Ile-Ife, Nigeria. The European journal of contraception & reproductive health care : the official journal of the European Society of Contraception. 2011;16(5):387-96.8. Baisley K, Doyle AM, Changalucha J, Maganja K, Watson-Jones D, Hayes R, et al. Uptake of voluntary counselling and testing among young people participating in an HIV prevention trial: comparison of opt-out and opt-in strategies. PloS one. 2012;7(7):e42108.9. Topp SM, Chipukuma JM, Chiko MM, Wamulume CS, Bolton-Moore C, Reid SE. Opt-out provider-initiated HIV testing and counselling in primary care outpatient clinics in Zambia. Bulletin of the World Health Organization. 2011;89(5):328-35A.10. Tlhakanelo JT, Mulumba-Tshikuka JG, Molefi M, Magafu MG, Matchaba-Hove RB, Masupe T. The burden of opportunistic-infections and associated exposure factors among HIV-patients admitted at a Botswana hospital. 2015.11. Bernard EJ. BOTSWANA’S DRACONIAN PUBLIC HEALTH BILL APPROVED BY PARLIAMENT, BONELA WILL CHALLENGE IT AS UNCONSTITUTIONAL ONCE PRESIDENT SIGNS INTO LAW (UPDATE 3). HIV justice Network. 2013.12. Biglan A, Ary D, Wagenaar AC. The value of interrupted time-series experiments for community intervention research. Prevention science : the official journal of the Society for Prevention Research. 2000;1(1):31-49.

Photo by Nathan Dumlao on Unsplash ABSTRACT The demographic of physicians in the United States has failed to include a proportionate population of Latinos in the United States. In what follows, I shall argue that the medical school admission process places an undue burden on low-income Latino applicants. Hence, the underrepresentation of Latinos in medical schools is an injustice. This injustice relates to the poor community health of the Latino community. Health disparities such as diabetes, HIV infection, and cancer mortality are higher amongst the Latino community. The current representation of Latino medical students is not representative of those in the United States. INTRODUCTION The demographic of physicians in the United States has failed to include a proportionate number of Latinos, meaning people of Latin American origin. Medical schools serve as the gatekeepers to the medical field, and they can alter the profession based on whom they admit. With over 60 million Latinos in the United States, people of Latin American origin comprise the largest minority group in the nation.[1] In 2020-2021, only 6.7 percent of total US medical school enrollees and only 4 percent of medical school leadership identified as Latino.[2] Latino physicians can connect to a historically marginalized community that faces barriers including language, customs, income, socioeconomic status, and health literacy. I argue that the medical school admissions process places an undue burden on low-income Latino applicants. This paper explores the underrepresentation of Latinos in medical schools as an injustice. A further injustice occurs as the barriers to medical education result in fewer Latino doctors to effectively deliver health care and preventive health advice to their communities in a culturally competent way. I. Latino Community Health Data The terms Latino and Hispanic have largely been considered interchangeable. US government departments, such as the US Census Bureau and the Centers for Disease Control and Prevention (CDC), define Hispanic people as those with originating familial ties to native Spanish-speaking countries, most of whom are from Latin America. The term Latino is more inclusive because it refers to all of those with strong originating ties to countries in Latin America, including those coming from countries such as Brazil and Belize who are not native Spanish speakers. Throughout this work, I refer to the term Latino because it is more inclusive, although the data retrieved from US government departments may refer to the population as Hispanic. “Low-income” refers to the qualifying economic criteria for the AAMC’s Fee Assistance Program Poverty Guidelines.[3] The AAMC Fee Assistance Program is designed to help individuals who do not have the financial means to pay the total costs of applying to medical school. For this paper, low-income refers to those who qualify for this program. The US government gathers data about Latino community health and its health risks. The Latino community has a higher poverty rate than the non-Hispanic white community.[4] Latino community health has long trailed that of white people collectively. For example, the Latino community experiences higher levels of preventable diseases, including hypertension, diabetes, and hepatitis, than the non-Hispanic white community does.[5] The CDC collects data about Latino community health and provides statistics to the public. Latinos in the United States trail only non-Hispanic blacks in prevalence of obesity. The Latino adult obesity rates are 45.7 percent for males and 43.7 percent for females.[6] Of the 1.2 million people infected with HIV in the United States, 294,200 are Latino.[7] The infection rate of chlamydia is 392.6 per 100,000 ― 1.9 times the rate in the non-Hispanic white population.[8] The tuberculosis incidence rate is eight times higher than that of non-Hispanic white people at 4.4 per 100,000.[9] Furthermore, Latinos have the third highest death rate for hepatitis C among all races and ethnic groups.[10] The prevalence of total diabetes, diagnosed and undiagnosed, among adults aged 18 and older also remains higher than that of non-Hispanic whites at 14.7 percent compared to 11.9 percent.[11] The high disease rate evidences the poor health of the community. Furthermore, 19 percent of Latinos in the United States remain uninsured.[12] Almost a quarter of the Latino population in the United States lives in poverty.[13] The high incidence of disease, lack of insurance, and high poverty rate create a frail health status for the Latino community in the United States. The medical conditions seen are largely preventable, and the incident rates can be lowered with greater investments in Latino community health. Considering the health disparities between Latino and non-Hispanic White people, there is an ethical imperative to provide better medical care and guidance to the Latino community. II. Ethical and Practical Importance of Increasing the Number of Latino Physicians Minorities respond more positively to patient-physician interactions and are more willing to undergo preventative healthcare when matched with a physician of their racial or ethnic background.[14] Latino medical doctors may lead to an improvement in overall community health through improved communication and trusting relationships. Patient-physician racial concordance leads to greater patient satisfaction with their physicians.[15] Identifying with the ethnicity of a physician may lead to greater confidence in the physician-patient relationship, resulting in more engagement on the patient’s behalf. A randomized study regarding African American men and the race of their attending physician found an increase in requests for preventative care when assigned to a black doctor.[16] Although the subjects were African American men, the study has implications applicable to other minority racial and ethnic groups. The application process is unjust for low-income Latinos. The low matriculation of Latinos in medical schools represents a missed opportunity to alleviate the poor community health of the Latino population in the United States. Medical school also would create an opportunity to address health issues that plague the Latino community. Becoming a physician allows low-income Latinos to climb the social ladder and enter the spaces in health care that have traditionally been closed off to them. Nonwhite physicians significantly serve underserved communities.[17] Increasing the number of Latino doctors can boost their presence, potentially improving care for underserved individuals. Teaching physicians cultural competence is not enough to address the health disparities the Latino community faces. Latino physicians are best equipped to understand the healthcare needs of low-income Latinos. I contend that reforming the application process represents the most straightforward method to augment the number of Latino physicians who wish to work in predominantly Latino or diverse communities, thereby improving healthcare for the Latino community. III. Cultural Tenets Affecting Healthcare Interactions “Poor cultural competence can lead to decreased patient satisfaction, which may cause the patient not to attend future appointments or seek further care.”[18] Latino community health is negatively affected when medical professionals misinterpret cultural beliefs. Cultural tenets like a reservation towards medication, a deep sense of respect for the physician, and an obligation to support the family financially and through advocacy affect how Latinos seek and use the healthcare system.[19] First, the Latino population's negative cultural beliefs about medication add a barrier to patient compliance. It is highlighted that fear of dependence upon medicine leads to trouble with medication regimens.[20] The fear stems from the negative perception of addiction in the Latino community. Taking as little medication as possible avoids the chance of addiction occurring, which is why many take the prescribed medicine only until they feel healthier, regardless of the prescribing regimen. Some would rather not take any medication because of the deep-rooted fear. Physicians must address this concern by communicating the importance of patient compliance to remedy the health issue. Explaining that proper use of the medication as prescribed will ensure the best route to alleviate the condition and minimize the occurrence of dependence. Extra time spent addressing concerns and checking for comprehension may combat the negative perception of medication. Second, the theme of respeto, or respect, seems completely harmless to most people. After all, how can being respectful lead to bad health? This occurs when respect is understood as paternalism. Some patients may relinquish their decision-making to the physician. The physician might not act with beneficence, in this instance, because of the cultural dissonance in the physician-patient relationship that may lead to medical misinterpretation. A well-meaning physician might not realize that the patient is unlikely to speak up about their goals of care and will follow the physician’s recommendations without challenging them. That proves costly because a key aspect of the medical usefulness of a patient’s family history is obtaining it through dialogue. The Latino patient may refrain from relaying health concerns because of the misconceived belief that it’s the doctor’s job to know what to ask. Asking the physician questions may be considered a sign of disrespect, even if it applies to signs, symptoms, feelings, or medical procedures the patient may not understand.[21] Respeto is dangerous because it restricts the patients from playing an active role in their health. Physicians cannot derive what medical information may be relevant to the patient without their cooperation. And physicians without adequate cultural competency may not know they need to ask more specific questions. Cultural competency may help, but a like-minded physician raised similarly would be a more natural fit. “A key component of physician-patient communication is the ability of patients to articulate concerns, reservations, and lack of understanding through questions.”[22] As a patient, engaging with a physician of one’s cultural background fortifies a strong physician-patient relationship. Latino physicians are in the position to explain to the patients that respeto is not lost during a physician-patient dialogue. In turn, the physician can express that out of their value of respeto, and the profession compels them to place the patient’s best interest above all. This entails physicians advocating on behalf of the patients to ask questions and check for comprehension, as is required to obtain informed consent. Latino physicians may not have a cultural barrier and may already organically understand this aspect of their patient’s traditional relationship with physicians. The common ground of respeto can be used to improve the health of the Latino community just as it can serve as a barrier for someone from a different background. Third, in some Latino cultures, there is an expectation to contribute to the family financially or in other ways and, above all, advocate on the family’s behalf. Familial obligations entail more than simply translating or accompanying family members to their appointments. They include actively advocating for just treatment in terms of services. Navigating institutions, such as hospitals, in a foreign landscape proves difficult for underrepresented minorities like Latinos who are new to the United States. These difficulties can sometimes lead to them being taken advantage of, as they might not fully understand their rights, the available resources, or the standard procedures within these institutions. The language barrier and unfamiliar institutional policies may misinterpret patients’ needs or requests. Furthermore, acting outside of said institution’s policy norms may be erroneously interpreted as actions of an uncooperative patient leading to negative interactions between the medical staff and the Latino patient. The expectation of familial contribution is later revisited as it serves as a constraint to the low-income Latino medical school applicant. Time is factored out to meet these expectations, and a moral dilemma to financially contribute to the family dynamic rather than delay the contribution to pursue medical school discourages Latinos from applying. IV. How the Medical School Admission Process is Creating an Undue Burden for Low-Income Latino Applicants Applying a bioethics framework to the application process highlights its flaws. Justice is a central bioethical tenet relevant to the analysis of the MD admissions process. The year-long medical school application process begins with the primary application. The student enters information about the courses taken, completes short answer questions and essays, and uploads information about recommenders. Secondary applications are awarded to some medical students depending on the institutions’ policies. Some schools ask all applicants for secondary applications, while others select which applicants to send secondary requests. Finally, interviews are conducted after a review of both primary and secondary applications. This is the last step before receiving an admissions decision. The medical school application process creates undue restrictions against underserved communities. It is understood that matriculating into medical school and becoming a doctor should be difficult. The responsibilities of a physician are immense, and the consequences of actions or inactions may put the patients’ lives in jeopardy. Medical schools should hold high standards because of the responsibility and expertise required to provide optimal healthcare. However, I argue that the application process places an undue burden on low-income Latino applicants that is not beneficial to optimal health care. The burden placed on low-income Latino applicants through the application process is excessive and not necessary to forge qualified medical students. The financial aspect of the medical school application has made the profession virtually inaccessible to the working class. The medical school application proves costly because of the various expenses, including primary applications, secondary applications, and interview logistics. There is financial aid for applications, but navigating some aid to undertake test prep, the Medical College Admission Test (MCAT), and the travel for interviews proves more difficult. Although not mandatory, prep courses give people a competitive edge.[23] The MCAT is one of the key elements of an application, and many medical schools will not consider applications that do not reach their score threshold. This practically makes the preparatory courses mandatory for a competitive score. The preparatory courses themselves cost in the thousands of dollars. There has been talk about adjusting the standardized test score requirements for applicants from medically underserved backgrounds. I believe the practice of holding strict cutoffs for MCAT scores is detrimental to low-income Latino applicants, especially considering the average MCAT scores for Latinos trail that of white people. The American Association of Medical Colleges’ recent data for the matriculating class of 2021 illustrates the wide gap in MCAT scores: Latino applicants average 500.2, and Latino matriculants average 506.6, compared to white applicants, who average 507.5 and white matriculants, who average 512.7.[24] This discrepancy suggests that considerations beyond scores do play some role in medical school matriculation. However, the MCAT scores remain a predominant factor, and there is room to value other factors more and limit the weight given to scores. The practice of screening out applicants based solely on MCAT scores impedes low-income Latino applicants from matriculating into medical school. Valuing the MCAT above all other admissions criteria limits the opportunities for those from underserved communities, who tend to score lower on the exam. One indicator of a potentially great physician may be overcoming obstacles or engaging in scientific or clinical experiences. There are aspects of the application where the applicant can expand on their experiences, and the personal statement allows them to showcase their passion for medicine. These should hold as much weight as the MCAT. The final indicator of a good candidate should not solely rest on standardized tests. There is a cost per medical school that is sent to the primary application. The average medical school matriculant applies to about 16 universities, which drives up the cost of sending the applications.[25] According to the American Association of Medical Colleges, the application fee for the first school is $170, and each additional school is an additional $42. Sending secondary applications after the initial application is an additional cost that ranges by university. The American Medical College Application Service (AMCAS), the primary application portal for Medical Doctorate schools in the United States and Canada, offers the Fee Assistance Program (FAP) to aid low-income medical school applicants. The program reduces the cost of the MCAT from $325 to $130, includes a complimentary Medical School Admission Requirements (MSAR) subscription, and fee waivers for one AMCAS application covering up to 20 schools.[26] The program is an important aid for low-income Latino students who would otherwise not be able to afford to send multiple applications. Although the aid is a great resource, there are other expenses of the application process that the program cannot cover. For a low-income applicant, the burden of the application cost is felt intensely. A study analyzing the American Medical College Application Service (AMCAS) data for applicants and matriculants from 2014 to 2019 revealed an association between income and acceptance into medical school. They state, “Combining all years, the likelihood of acceptance into an MD program increased stepwise by income. The adjusted rate of acceptance was 24.32 percent for applicants with income less than $50 000, 27.57 percent for $50 000 - $74 999, 29.90 percent for $75 000 - $124 999, 33.27 percent for $125 000 - $199 999, and 36.91 percent for $200,000 or greater.”[27] It becomes a discouraging factor when it is difficult to obtain the necessary funds. The interview process for medical schools may prove costly because of travel, lodging, and time. In-person interviews may require applicants to travel from their residence to other cities or states. The applicant must find their own transportation and housing during the interview process, ranging from a single day to multiple days. Being granted multiple interviews becomes bittersweet for low-income applicants because they are morally distraught, knowing the universities are interested yet understanding the high financial cost of the interviews. The expense of multiple interviews can impede an applicant from progressing in the application process. Medical schools do not typically cover travel expenses for the interview process. Only 4 percent of medical school faculty identify as Latino.[28] The medical school admission board members reviewing the application lack Latino representation.[29] Because of this, it is extremely difficult for a low-income Latino applicant to portray hardships that the board members would understand. Furthermore, the section to discuss any hardships only allows for 200 words. This limited space makes it extremely difficult to explain the nuances of navigating higher education as a low-income Latino. Explaining those difficulties is then restricted to the interview process. However, that comes late in the application process when most applicants have been filtered out of consideration. The lack of diversity among the board members, combined with the minimal space to explain hardships or burdens, impedes a connection to be formed between the Latino applicants and the board members. It is not equitable that this population cannot relate to their admissions reviewers because of cultural barriers. Gatekeeping clinical experience inadvertently favors higher socioeconomic status applicants. Most medical schools require physician shadowing or clinical work, which can be difficult to obtain with no personal connections to the field. Using clinical experience on the application is another way that Latinos are disadvantaged compared to people who have more professional connections or doctors in the family and social circles. The already competitive market for clinical care opportunities is reduced by nepotism, which does not work in favor of Latino applicants. Yet some programs are designed to help low-income students find opportunities, such as Johns Hopkins’ Careers in Science and Medicine Summer Internship Program, which provides clinical experience and health professions mentoring.[30] Without social and professional ties to health care professionals, they are forced to enter a competitive job and volunteer market in clinical care and apply to these tailored programs not offered at all academic institutions. While it is not unique to Latinos, the time commitment of the application process is especially harsh on low-income students because they have financial burdens that can determine their survival. Some students help their families pay for food, rent, and utilities, making devoting time to the application process more problematic. As noted earlier, Latino applicants may also have to set aside time to advocate for their families. Because the applicants tend to be more in tune with the dominant American culture, they are often assigned the family advocate role. They must actively advocate for their family members' well-being. The role of a family advocate, with both its financial and other supportive roles ascribed to low-income Latino applicants, is an added strain that complicates the medical school application. As a member of a historically marginalized community, one must be proactive to ensure that ethical treatment is received. Ordinary tasks such as attending a doctor's appointment or meeting with a bank account manager may require diligent oversight. Applicants must ensure the standard of service is applied uniformly to their family as it is to the rest of the population. This applies to business services and healthcare. It can be discouraging to approach a field that does not have many people from your background. The lack of representation emphasizes the applicant's isolation going through the process. There is not a large group of Latinos in medicine to look to for guidance.[31] The group cohesiveness that many communities experience through a rigorous process is not established among low-income Latino applicants. They may feel like outsiders to the profession. Encountering medical professionals of similar backgrounds gives people the confidence to pursue the medical profession. V. Medical School Admission Data This section will rely on the most recent MD medical school students, the 2020-2021 class. The data includes demographic information such as income and ethnicity. The statistics used in this section were retrieved from scholarly peer-reviewed articles and the Medical School Admission Requirement (MSAR) database. Both sources of data are discussed in more detail throughout the section. The data reveals that only 6.7 percent of medical students for the 2020-2021 school year identify as Latino.[32] The number of Latino students in medical school is not proportional to the Latino community in the United States. While Latinos comprise almost 20 percent of the US population (62.1 million), they comprise only 6.7 percent of the medical student population.[33] Below are three case studies of medical schools in cities with a high Latino population. VI. Medical School Application Process Case Studies a) New York University Grossman School of Medicine is situated in Manhattan, where a diverse population of Latinos reside. The population of the borough of Manhattan is approximately 1,629,153, with 26 percent of the population identifying as Latino.[34] As many medical schools do, Grossman School of Medicine advertises an MD Student Diversity Recruitment program. The program, entitled Prospective MD Student Liaison Program, is aimed such that “students from backgrounds that are underrepresented in medicine are welcomed and supported throughout their academic careers.”[35] The program intervenes with underrepresented students during the interview process of the medical school application. All students invited to interviews can participate in the Prospective MD Student Liaison Program. They just need to ask to be part of it. That entails being matched with a current medical student in either the Black and Latinx Student Association (BALSA) or LGBTQMed who will share their experiences navigating medical school. Apart from the liaison program, NYU participates in the Science Technology Entry Program (STEP), which provides academic guidance to middle and high school students who are underrepresented minorities.[36] With the set programs in place, one would expect to find a significantly larger proportion of Latino medical students in the university. The Medical School Admission Requirement (MSAR) database compiled extensive data about participants in the medical school; the data range from tuition to student body demographics. Of the admitted medical students in 2021, only 16 out of 108 identified as Latino, despite the much larger Latino population of New York.[37] Furthermore, only 4 percent of the admitted students classify themselves as being from a disadvantaged status.[38] The current efforts to increase medical school diversity are not producing adequate results at NYU. Although the Latino representation in this medical school may be higher than that in others, it does not reflect the number of Latinos in Manhattan. The Prospective MD Student Liaison Program intervenes at a late stage of the medical school application process. It would be more beneficial for a program to cover the entire application process. The lack of Latino medical students makes it difficult for prospective students to seek advice from Latino students. Introducing low-income Latino applicants to enrolled Latino medical students would serve as a guiding tool throughout the application process. An early introduction could encourage the applicants to apply and provide a resourceful ally in the application process when, in many circumstances, there would be none. Latino medical students can share their experiences of overcoming cultural and social barriers to enter medical school. b) The Latino population in Philadelphia is over 250,000, constituting about 15 percent of the 1.6 million inhabitants.[39] According to MSAR, the cohort of students starting at Drexel University College of Medicine, located in Philadelphia, in 2021 was only 7.6 percent Latino.[40] 18 percent of matriculated students identify as having disadvantaged status, while 21 percent identify as coming from a medically underserved community.[41] Drexel University College of Medicine claims that “Students who attend racially and ethnically diverse medical schools are better prepared to care for patients in a diverse society.”[42] They promote diversity with various student organizations within the college, including the following: Student National Medical Association (SNMA), Latino Medical Student Association (LMSA), Drexel Black Doctors Network, LGBT Medical Student Group, and Drexel Mentoring and Pipeline Program (DMAPP). The Student Center for Diversity and Inclusion of the College of Medicine offers support groups for underrepresented medical students. The support offered at Drexel occurs at the point of matriculation, not for prospective students. The one program that does seem to be a guide for prospective students is the Drexel Pathway to Medical School program. Drexel Pathway to Medical School is a one-year master’s program with early assurance into the College of Medicine and may serve as a gateway for prospective Latino Students.[43] The graduate program is tailored for students who are considered medically underserved or socioeconomically disadvantaged and have done well in the traditional pre-medical school coursework. It is a competitive program that receives between 500 and 700 applicants for the 65 available seats. The assurance of entry into medical school makes the Drexel Pathway to Medical School a beneficial program in aiding Latino representation in medicine. Drexel sets forth minimum requirements for the program that show the school is willing to consider students without the elite scores and grades required of many schools. MCAT scores must be in the 25th percentile or higher, and the overall or science GPA must be at least 2.9.[44] The appealing factor of this program is its mission to attract medically underserved students. This is a tool to increase diversity in medical school. Prospective low-income Latino students can view this as a graduate program tailored to communities like theirs. However, this one-year program is not tuition-free. It may be tempting to assume that patients prefer doctors with exceptional academic records. There's an argument against admitting individuals with lower test scores into medical schools, rooted in the belief that this approach does not necessarily serve the best interests of health care. The argument asserts that the immense responsibility of practicing medicine should be entrusted to the most qualified candidates. Programs like the Drexel Pathway to Medical School are designed to address the lower academic achievements often seen in underrepresented communities. Their purpose is not to admit underqualified individuals into medical school but to bridge the educational gap, helping these individuals take the necessary steps to become qualified physicians. c) The University of California San Francisco School of Medicine reports that 23 percent of its first-year class identifies as Latino, while 34 percent consider themselves disadvantaged.[45] The Office of Diversity and Outreach is concerned with increasing the number of matriculants from underserved communities. UCSF has instilled moral commitments and conducts pipeline and outreach programs to increase the diversity of its medical school student body. The Differences Matter Initiative that the university has undertaken is a complex years-long restructuring of the medical school aimed at making the medical system equitable, diverse, and inclusive.[46] The five-phase commitment includes restructuring the leadership of the medical school, establishing anti-oppression and anti-racism competencies, and critically analyzing the role race, ethnicity, gender, and sexual orientation play in medicine. UCSF offers a post-baccalaureate program specifically tailored to disadvantaged and underserved students. The program’s curriculum includes MCAT preparation, skills workshops, science courses, and medical school application workshops.[47] The MCAT preparation and medical school application workshops serve as a great tool for prospective Latino applicants. UCSF seems to do better than most medical schools regarding Latino medical students. San Francisco has a population of 873,965, of which 15.2 percent are Latino.[48] The large population of Latino medical students indicates that the school’s efforts to increase diversity are working. The 23 percent Latino matriculating class of 2021 better represents the number of Latinos in the United States, which makes up about a fifth of the population. With this current data, it is important to closely dissect the efforts UCSF has taken to increase diversity in its medical school. Their Differences Matter initiative instills a commitment to diversifying their medical school. As mentioned, the school's leadership has been restructuring to include a diverse administrative body. This allows low-income Latino applicants to relate to the admissions committee reviewing their application. With a hopeful outlook, the high percentage of Latino applicants may reflect comprehension of the application process and the anticipated medical school atmosphere and rigor among Latino applicants and demonstrate that the admissions committee understands the applicants. However, there are still uncertainties about the demographics of the Latino student population in the medical school. Although it is a relatively high percentage, it is necessary to decipher which proportion of those students are low-income Latino Americans. UCSF School of Medicine can serve as a model to uplift the Latino community in a historically unattainable profession. VII. Proposed Reform for Current Medical School Application One reform would be toward the reviewing admissions committee, which has the power to change the class composition. By increasing the diversity of the admissions committee itself, schools can give minority applicants a greater opportunity to connect to someone with a similar background through their application. It would address low-income Latino applicants feeling they cannot “get personal” in their application. These actions are necessary because it is not just to have a representative administration for only a portion of the public. Of the three medical schools examined, the University of California San Francisco has the highest percentage of Latino applicants in their entering class. They express an initiative to increase diversity within their medical school leadership via the Differences Matter initiative. This active role in increasing diversity within the medical school leadership may play a role in UCSF’s high percentage of Latino matriculants. That serves as an important step in creating an equitable application process for Latino applicants. An important consideration is whether the medical school administration at UCSF mirrors the Latino population in the United States. The importance of whether the medical school administration at UCSF mirrors the Latino population in the United States lies in its potential to foster diversity, inclusivity, and cultural competence in medical education, as well as to positively impact the healthcare outcomes and experiences of the Latino community. A diverse administration can serve as role models for students and aspiring professionals from underrepresented backgrounds. It can inspire individuals who might otherwise feel excluded or underrepresented in their career pursuits, including aspiring Latino medical students. Furthermore, a diverse leadership can help develop curricula, policies, and practices that are culturally sensitive and relevant, which is essential for addressing health disparities and providing equitable healthcare. It is also important to have transparency so the public knows the number of low-income Latino individuals in medical school. The Latino statistics from the medical school generally include international students. That speaks to diversity but misses the important aspect of uplifting the low-income Latino population of the United States. Passing off wealthy international students from Latin America to claim a culturally diverse class is misleading as it does not reflect income diversity. Doing so gives the incorrect perception that the medical school is accurately representing the Latino population of the United States. There must be a change in how the application process introduces interviews. It needs to be introduced earlier so the admissions committee can form early, well-rounded inferences about an applicant. The interview allows for personal connections with committee members that otherwise would not be established through the primary application. The current framework has the interviews as one of the last aspects of the application process before admissions decisions are reached. At this point in the application process, many low-income Latinos may have been screened out. I understand this is not an easy feat to accomplish. This will lead to an increase in interviews to be managed by the admissions committee. The burden can be strategically minimized by first conducting video interviews with applicants the admission committee is interested in moving forward and those that they are unsure about because of a weakness in a certain area of the application. The video interview provides a more formal connection between the applicants and admission committee reviewers. It allows the applicant to provide a narrative through spoken words and can come off as a more intimate window into their characteristics. It would also allow for an opportunity to explain hardships and what is unique. From this larger pool of video-interviewed applicants, the admission committee can narrow down to traditional in-person interviews. A form of these video interviews may be already in place in some medical school application process. I believe making this practice widespread throughout medical schools will provide an opportunity to increase the diversity of medical school students. There must be an increase in the number of programs dedicated to serving as a gateway to clinical experience for low-income Latino applicants. These programs provide the necessary networking environment needed to get clinical experience. It is important to consider that networking with clinical professionals is an admissions factor that detrimentally affects the low-income Latino population. One of the organizations that aids underserved communities, not limited to Latinos, in clinical exposure is the Summer Clinical Oncology Research Experience (SCORE) program.[49] The SCORE program, conducted by Memorial Sloan Kettering Cancer Center, provides its participants with mentorship opportunities in medicine and science. In doing so, strong connections are made in clinical environments. Low-income Latinos seek these opportunities as they have limited exposure to such an environment. I argue that it is in the medical school’s best interest to develop programs of this nature to construct a more diverse applicant pool. These programs are in the best interest of medical schools because they are culturing a well-prepared applicant pool. It should not be left to the goodwill of a handful of organizations to cultivate clinically experienced individuals from minority communities. Medical schools have an ethical obligation to produce well-suited physicians from all backgrounds. Justice is not upheld when low-income Latinos are disproportionally represented in medical schools. Programs tailored for low-income Latinos supplement the networking this population lacks, which is fundamental to obtaining clinical experience. These programs help alleviate the burden of an applicant’s low socioeconomic status in attaining clinical exposure. VIII. Additional Considerations Affecting the Medical School Application Process and Latino Community Health A commitment to practicing medicine in low-income Latino communities can be established to improve Latino community health.[50] Programs, such as the National Health Service Corps, encourage clinicians to practice in underserved areas by forgiving academic loans for years of work.[51] Increasing the number of clinicians in underserved communities can lead to a positive correlation with better health. It would be ideal to have programs for low-income Latino medical students that incentivize practicing in areas with a high population of underserved Latinos. This would provide the Latino community with physicians of a similar cultural background to attend to them, creating a deeper physician-patient relationship that has been missing in this community. Outreach for prospective Latino applicants by Latino medical students and physicians could encourage an increased applicant turnout. This effort can guide low-income Latinos who do not see much representation in the medical field. It would serve as a motivating factor and an opportunity to network within the medical field. Since there are few Latino physicians and medical students, a large effort must be made to make their presence known. IX. Further Investigation Required It is important to investigate the causes of medical school rejections of low-income Latinos. Understanding this piece of information would provide insight into the specific difficulties this population has with the medical school application. From there, the requirements can be subjected to bioethical analysis to determine whether those unfulfilled requirements serve as undue restrictions. The aspect of legacy students, children of former alumni, proves to be a difficult subject to find data on and merits further research. Legacy students are often given preferred admission into universities.[52] It is necessary to understand how this affects the medical school admissions process and whether it comes at a cost to students that are not legacy. It does not seem like these preferences are something universities are willing to disclose. The aspect of legacy preferences in admissions decisions could be detrimental to low-income Latino applicants if their parents are not college-educated in the United States, which often is the case. It would be beneficial to note how many Latinos in medical school are low-income. The MSAR report denotes the number of Latino-identified students per medical school class at an institution and the number of students who identify as coming from low resources. They do not specify which of the Latino students come from low-income families. This information would be useful to decipher how many people from the low-income Latino community are matriculating into medical schools. CONCLUSION It is an injustice that low-income Latinos are grossly underrepresented in medical school. It would remain an injustice even if the health of the Latino community in the United States were good. The current operation of medical school admission is based on a guild-like mentality, which perpetuates through barriers to admissions. It remains an exclusive club with processes that favor the wealthy over those who cannot devote money and time to the prerequisites such as test preparation courses and clinical internships. This has come at the expense of the Latino community in the United States in the form of both fewer Latino doctors and fewer current medical students. It is reasonable to hope that addressing the injustice of the underrepresentation of low-income Latinos in the medical field would improve Latino community health. With such a large demographic, the lack of representation in the medical field is astonishing. The Latino population faces cultural barriers when seeking healthcare, and the best way to combat that is with a familiar face. An increase in Latino medical students would lead to more physicians that not only can culturally relate to the Latino community, but that are a part of it. This opens the door for a comprehensive understanding between the patient and physician. As described in my thesis, Latino physicians can bridge cultural gaps that have proven detrimental to that patient population. That may help patients make informed decisions, exercising their full autonomy. The lack of representation of low-income Latinos in medicine is a long-known issue. Here, I have connected how the physician-patient relationship can be positively improved with an increase in low-income Latino physicians through various reforms in the admissions process. My hope is to have analyzed the problem of under-representation in a way that points toward further research and thoughtful reforms that can truly contribute to the process of remedying this issue. - [1] Passel, J. S., Lopez, M. H., & Cohn, D. (2022, February 3). U.S. Hispanic population continued its geographic spread in the 2010s. Pew Research Center. https://www.pewresearch.org/fact-tank/2022/02/03/u-s-hispanic-population-continued-its-geographic-spread-in-the-2010s/ [2] Ramirez, A. G., Lepe, R., & Cigarroa, F. (2021). Uplifting the Latino Population From Obscurity to the Forefront of Health Care, Public Health Intervention, and Societal Presence. JAMA, 326(7), 597–598. https://doi.org/10.1001/jama.2021.11997 [3] Association of American Medical Colleges. (2023). Who is eligible to participate in the fee assistance program? https://students-residents.aamc.org/fee-assistance-program/who-eligble-participate-fee-assistance-mprogram [4] U.S. Department of Health and Human Services Office of Minority Health. (2021). Profile: Hispanic/Latino Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64 [5] Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. (2020). Center for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db360.htm; Center for Disease Control and Prevention. (2019). National Diabetes Statistic Report. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf; Hispanics / Latinos | Health Disparities | CDC. (2020, September 14). Health Disparities in HIV, Viral Hepatitis, STDs, and TB. https://www.cdc.gov/nchhstp/healthdisparities/hispanics.html [6] Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. (2020). Center for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db360.htm [7] Center for Disease Control and Prevention. (2021, October). Estimated HIV incidence and prevalence in the United States 2015–2019. https://www.cdc.gov/hiv/pdf/group/racialethnic/hispanic-latino/cdc-hiv-group-hispanic-latino-factsheet.pdf [8] Hispanics / Latinos | Health Disparities | CDC. (2020, September 14). Health Disparities in HIV, Viral Hepatitis, STDs, and TB. https://www.cdc.gov/nchhstp/healthdisparities/hispanics.html [9] CDC. (2020). [10] CDC. (2020). [11] Center for Disease Control and Prevention. (2019). National Diabetes Statistic Report. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf [12] Office of the Assistant Secretary for Planning and Evaluation. (2021, October). Issue Brief No. HP-2021-2. Health Insurance Coverage and Access to Care Among Latinos: Recent Trends and Key Challenges. U.S. Department of Health and Human Services. https://aspe.hhs.gov/reports/health-insurance-coverage-access-care-among-latinos [13] U.S. Department of Health and Human Services Office of Minority Health. (2021). Profile: Hispanic/Latino Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64 [14] Alsan, M., Garrick, O., & Graziani, G. (2019). Does Diversity Matter for Health? Experimental Evidence from Oakland. American Economic Review, 109(12), 4071–4111. https://doi.org/10.1257/aer.20181446 [15] Takeshita, J., Wang, S., Loren, A. W., Mitra, N., Shults, J., Shin, D. B., & Sawinski, D. L. (2020). Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings. JAMA Network Open, 3(11). https://doi.org/10.1001/jamanetworkopen.2020.24583 [16] Alsan, et. al. (2019). [17] Marrast, L., Zallman, L., Woolhandler, S., Bor, D. H., & McCormick, D. (2014). Minority physicians’ role in the care of underserved patients. JAMA Internal Medicine, 174(2), 289. https://doi.org/10.1001/jamainternmed.2013.12756 (“Nonwhite physicians cared for 53.5% of minority and 70.4% of non-English speaking patients.” Increasing the number of Latino doctors could lead to more nonwhite physicians to care for the underserved populations as they serve those populations at disproportionate rates. This may lead to better care for the patients.) [18] Cersosimo, E., & Musi, N. (2011). Improving Treatment in Hispanic/Latino Patients. The American Journal of Medicine, 124(10), S16–S21. https://doi.org/10.1016/j.amjmed.2011.07.019 [19] Flores, G. (2000). Culture and the patient-physician relationship: Achieving cultural competency in health care. The Journal of Pediatrics, 136(1), 14–23. https://doi.org/10.1016/s0022-3476(00)90043-x [20] Cersosimo & Musi. (2011). [21] Flores. (2000). [22] Torres, D. (2019). Knowing How to Ask Good Questions: Comparing Latinos and Non-Latino Whites Enrolled in a Cardiovascular Disease Prevention Study. The Permanente Journal. https://doi.org/10.7812/tpp/18-258 [23] The Princeton Review. (n.d.). Score 513+ on the MCAT, Guaranteed! | The Princeton Review. [24] 2021 FACTS: Applicants and Matriculants Data. (2022). AAMC. https://www.aamc.org/data-reports/students-residents/interactive-data/2021-facts-applicants-and-matriculants-data [25] The Princeton Review. (n.d.). How Many Med Schools Should You Apply To? https://www.princetonreview.com/med-school-advice/how-many-med-schools-should-you-apply-to [26] Association of American Medical Colleges. (n.d.). Fee Assistance Program (FAP). AAMC. https://students-residents.aamc.org/fee-assistance-program/fee-assistance-program-fap [27] Nguyen, M., Desai, M. M., Fancher, T. L., Chaudhry, S. I., Mason, H. R. C., & Boatright, D. (2023). Temporal trends in childhood household income among applicants and matriculants to medical school and the likelihood of acceptance by income, 2014-2019. JAMA. https://doi.org/10.1001/jama.2023.5654 [28] Ramirez, et al. (2021). [29] Ko, M. J., Henderson, M. C., Fancher, T. L., London, M., Simon, M., & Hardeman, R. R. (2023). US medical school admissions leaders’ experiences with barriers to and advancements in diversity, equity, and inclusion. JAMA Network Open, 6(2), e2254928. https://doi.org/10.1001/jamanetworkopen.2022.54928 [30] Johns Hopkins University School of Medicine. (n.d.). JHU CSM SIP. Johns Hopkins Initiative for Careers in Science and Medicine - the Summer Internship Program. https://csmsip.cellbio.jhmi.edu/ [31] Figure 18. Percentage of all active physicians by race/ethnicity, 2018 | AAMC. (2018). AAMC. https://www.aamc.org/data-reports/workforce/data/figure-18-percentage-all-active-physicians-race/ethnicity-2018 [32] Ramirez, et al. (2021). [33] Passel, et al. (2022). [34] Census Reporter. (n.d.). Census profile: Manhattan borough, New York County, NY. https://censusreporter.org/profiles/06000US3606144919-manhattan-borough-new-york-county-ny/ [35] MD Student Diversity Recruitment. (2022). NYU Langone Health. https://med.nyu.edu/our-community/why-nyu-grossman-school-medicine/diversity-inclusion/recruiting-diversity/md-student-diversity-recruitment [36] NYU. (n.d.). STEP Pre-College Program. New York University. https://www.nyu.edu/admissions/undergraduate-admissions/how-to-apply/all-freshmen-applicants/opportunity-programs/pre-college-programs.html [37] Association of American Medical Colleges. (2022). NYU Grossman School of Medicine. Medical School Admission Requirements (MSAR). https://mec.aamc.org/msar-ui/#/medSchoolDetails/152 [38] Association of American Medical Colleges. (2022). [39] U.S. Census Bureau. (2021). U.S. Census Bureau QuickFacts: Philadelphia County, Pennsylvania. Census Bureau QuickFacts. https://www.census.gov/quickfacts/philadelphiacountypennsylvania [40] Association of American Medical Colleges. (2022). Drexel University College of Medicine. Medical School Admission Requirements. https://mec.aamc.org/msar-ui/#/medSchoolDetails/833 [41] Association of American Medical Colleges. (2022). [42] Drexel University College of Medicine. (n.d.). Diversity, Equity & Inclusion For Students. https://drexel.edu/medicine/about/diversity/diversity-for-students/ [43] Drexel University College of Medicine. (n.d.-b). Drexel Pathway to Medical School. https://drexel.edu/medicine/academics/graduate-school/drexel-pathway-to-medical-school/ [44] Drexel University College of Medicine. Drexel Pathway to Medical School. [45] Association of American Medical Colleges. (2022). University of California, San Francisco, School of Medicine. Medical School Admission Requirements. https://mec.aamc.org/msar-ui/#/medSchoolDetails/108 [46] The Regents of the University of California. (n.d.). Differences Matter. UCSF School of Medicine. https://medschool.ucsf.edu/differences-matter [47] The Regents of the University of California. (n.d.-b). Post Baccalaureate Program | UCSF Medical Education. UCSF Medical Education. https://meded.ucsf.edu/post-baccalaureate-program [48] United States Census Bureau. (2021). U.S. Census Bureau QuickFacts: San Francisco County, California. Census Bureau QuickFacts. https://www.census.gov/quickfacts/sanfranciscocountycalifornia [49] Memorial Sloan Kettering Cancer Center. (n.d.). Student Programs. https://www.mskcc.org/about/leadership/office-faculty-development/student-programs [50] Alsan, et al. (2021). [51] National Health Service Corps. (2021, November 2). Mission, Work, and Impact | NHSC. https://nhsc.hrsa.gov/about-us [52] Elam, C. L., & Wagoner, N. E. (2012). Legacy Admissions in Medical School. AMA Journal of Ethics, 14(12), 946–949. https://doi.org/10.1001/virtualmentor.2012.14.12.ecas3-1212

Photo by Richard Catabay on Unsplash ABSTRACT COVID-19 exposed deep-rooted structural inequities. Allocation protocols developed during COVID-19 may cause furtherance of structural inequalities. In this essay, I specifically address the issue of structural inequities in the context of resource allocation during a period of crisis standard of care. In response to the increasing evidence of structural inequities during the pandemic, physicians and bioethicists Douglas White and Bernard Lo proposed incorporating a correction factor into resource allocation protocols. According to them, this would provide an advantage for disadvantaged individuals. The proposed correction factors use the Area Deprivation Index to determine eligibility. I argue that the correction factor is ethically justified and supported by Rawls’s difference principle, Daniels’s equality of opportunity, and Harris’s double jeopardy argument. I also suggest that the proposed correction factor does not go far enough, particularly if used with other objective factors, such as SOFA scoring. At least one study shows that using SOFA scoring for resource allocation during COVID-19 has a discriminatory effect on non-Hispanic black patients. One problem with the correction factor using the ADI is that it only applies to those currently in the reflected socioeconomic status. Additionally, when only one hospital serves a largely socioeconomically disadvantaged community, all admissions will fall within the targeted category for application of the correction factor. Thus, further actions are needed to dismantle structural inequities, such as implementing load balancing or the planned sharing of resources among healthcare systems. INTRODUCTION COVID-19 forced deep-rooted structural inequities to the surface. SARS-CoV-2 was a novel virus, but the connection between structural inequities and the disparate impact of the virus on marginalized populations is not. The history of pandemics reflects how much structural inequities negatively influence health equity.[1] The lack of preparedness and response to the structural inequities exemplify “blistering systemic failures.”[2] Despite warnings from prior threats from SARS and H1N1, we were unprepared for COVID-19. Antommaria and Chelen show that one-half of responding hospitals did not have an allocation protocol in place.[3] When an influx of critically ill patients and limited resources required implementing a crisis standard of care, many hospitals quickly established protocols addressing the allocation of scarce resources. Most crisis standard of care (CSC) protocols reflect public health’s utilitarian focus on saving the most lives.[4] The utilitarian focus ignores the disproportionate impact resulting from structural inequities. In December 2020, two physicians and bioethicists, Douglas White and Bernard Lo responded to the increasing evidence of the disproportionate impact of COVID-19 on disadvantaged communities by adding a correction factor to their CSC resource allocation protocol. The correction factor adjusts triage scores of individuals living in the most disadvantaged neighborhoods by subtracting one point from the triage score.[5] Patients with lower triage scores are more likely to receive life-saving care. Thus, subtracting a point provides an advantage. The correction factor uses a composite measure of disadvantage to determine eligibility called the Area Deprivation Index (ADI).[6] The ADI is a geographic measure of socioeconomic disadvantage that calculates an aggregate disadvantage score on a 10-point scale. The ADI measures seventeen elements of disadvantage related to poverty, education, employment, physical environment, and infrastructure.[7] The correction factor compensates for structural injustices by using ADI scores of patients in the highest quartile of socioeconomic disadvantage or having an ADI score of 8 to 10 since the strongest association between ADI scores and health outcomes occurs at the highest ADI levels.[8] l. Ethical Justifications Various theories of justice support applying the correction factor in the allocation of scarce resources. Rawls’s difference principle provides an ethical justification for the correction factor as it benefits the worse off in the event of resource allocation.[9] Applying the correction factor and subtracting one point from the triage score admittedly creates inequality among two otherwise like patients, but it is justified under Rawls’s theory since it gives the advantage to the least advantaged, addressing equity. Norman Daniels’ argument for protecting fair “equality of opportunity” also supports the correction factor.[10] The correction factor protects the equality of opportunity for those denied access to care because of deep-rooted structural inequities exacerbated by the pandemic. Using the correction factor to provide access to life-saving resources compensates patients with diminished opportunities in other arenas like the social determinants of health. Derek Parfit’s deontic egalitarianism supports the correction factor. Under Parfit’s view of deontic egalitarianism, justification of giving an advantage to the worse off depends on the reason for the inequality. If the unequal status results from circumstances such as a genetic condition or an accidental injury, like Daniel’s equality of opportunity, deontic egalitarianism does not support giving an advantage to the worse-off. If the unequal position results from the unjust actions of another, such as discriminatory treatment of people of color, deontic egalitarianism supports providing the advantage to address the inequity.[11] The disproportionate impact of resource allocation results from unjust treatment such as discrimination and structural inequity.[12] John Harris’s double jeopardy argument adds additional support to the correction factor in that[13] the socioeconomically disadvantaged or those facing racial or ethnic discrimination may have had an increased risk of contracting COVID-19 or having a severe case or death due to structural inequities. If the triage procedures do not compensate for the structural inequities and they are precluded access to critical care based only on traditional triage, they will suffer double jeopardy. The correction factor avoids this double jeopardy. ll. Operationalizing the Correction Factor Those opposing the correction factor might assert the infeasibility of mitigating inequities during a pandemic.[14] Yet one large US health system successfully applied similar criteria in allocating remdesivir[15] and the National Academy of Medicine endorsed disparity-mitigating criteria for allocating scarce vaccines.[16] Applying the correction factor is neither time nor resource intensive. It will not divert resources from the goal of treating illness and reducing morbidity. With the data available about COVID-19’s disproportionate impact, not applying an available tool to lessen inequities is an abrogation of ethical duty. One utilitarian argument asserts that we will save fewer lives if the prioritized patients are more likely to die despite interventions. Yet society bears responsibility for the social policies that created the disparities. Thus, there is an obligation to mitigate those societal problems, even when doing so might save fewer lives.[17] Some clinicians argue that they should have discretion in determining triage scores. This objection to the correction factor in formulating triage procedures reflects the conflict between clinical and public health ethics. Implementing a CSC protocol shifts decision-making from the clinician to a triage committee and from an individual focus to a community focus. Allowing clinicians to determine triage protocols would increase the risk of decisions based on bias and subjectivity. Another open question is whether the correction factor will achieve the intended goal. Nancy Kass suggests that without evidence to support the effectiveness, we cannot ethically implement the policy.[18] Thus, applying the Kass analysis, diverting a scarce resource to someone less likely to survive should require proof that doing so systematically would resolve or improve structural inequity. There is limited empirical evidence, but we may proceed with caution based on the presumptive data and the hypothesis that a triage allocation that uses a correction factor could help. Computer-based modeling or “tabletop” exercises applying the framework to actual patients but not enacting the protocols could assess the possible effects of the protocols.[19] Perhaps the most robust rebuttal in response to the opposition of applying a correction factor is in an argument proffered by Douglas White that no reasonable triage framework maximizes health outcomes if it creates significant inequalities.[20] White’s argument emphasizes the importance of addressing inequity. lll. A More Robust Version of the Correction Factor The burdens associated with any public health intervention typically fall into three categories:[21] privacy and confidentiality, risk to liberty and self-determination, and justice. Most burdens associated with allocating scarce resources fall under the justice category. I not only disagree with the arguments against using a correction factor, but I also argue that the correction factor does not go far enough. First, using the ADI neglects consideration of people of color disproportionately affected by COVID-19 no longer living in a neighborhood with the highest ADI scores. Based on new research, Sequential Organ Failure Assessment (SOFA) scores are also potentially discriminatory and not ideal for addressing structural inequity, racism, or ethnic discrimination in the triage setting, although they are applied to triage.[22] Second, public hospitals in socioeconomically depressed communities and rural locations may serve a population in which nearly the entire community will have ADI scores that qualify for application of the correction factor. lV. Relying on ADI cannot protect all people disadvantaged due to their race or ethnicity The ADI uses seventeen measures of socioeconomic disadvantage. Some racial inequality in healthcare is unrelated to socioeconomic status and can be missed by ADI. Racial inequality in healthcare may be directly related to implicit and explicit bias and past and current discrimination. But the correction factor will not help the Black patient not currently residing in a highly disadvantaged neighborhood or experiencing other vestiges of racism in the form of socioeconomic disadvantage. A correction factor that uses more information than ADI could make up for some of the weaknesses of SOFA as well. V. When all patients have high ADI Scores What happens when triaging occurs in hospitals serving populations where almost all patients have ADI scores of 8 to 10? To illustrate, I will use the example of Belle Glade, Florida, in western Palm Beach County.[23] The overwhelming majority of the neighborhoods served by the one public hospital, Lakeside Medical Center, is at a level 10 state decile, with a few neighborhoods at 8 and 9 state decile.[24] During a surge in that hospital, the correction factor will apply to every patient. The hospital must then resort to other considerations, such as random allocation. This potential dilemma suggests the need to consider further steps, such as load balancing, to lessen the inequities. Vl. Load Balancing Load balancing is a plan in which hospitals report daily census and available beds. Patients are diverted or transferred to hospitals with open beds when one hospital is at maximum capacity. Although identified as a method to avoid the need for triaging, I suggest load balancing is also equity balancing, especially when the overwhelmed hospital is in a high ADI area. Failures in load balancing exacerbate the harm to disadvantaged populations. Disadvantaged individuals are more likely to seek treatment in hospitals with limited ability to increase capacity or care for many critically ill patients. During surges in COVID-19, hospitals in poor neighborhoods were overrun by admissions and lacked resources to treat, while nearby private hospitals had available beds and resources.[25] The Arizona Department of Health Services developed an effective load-balancing system to coordinate the statewide transfer of patients from overloaded hospitals to other hospitals.[26] The system dramatically improved access to care for people of color and rural populations.[27] One of the state’s foremost responsibilities is safeguarding the health and well-being of people threatened when health systems fail to cooperate. Voluntary load balancing is preferable, but if the healthcare systems are unwilling to cooperate and if voluntary efforts are ineffective, state governments should intervene and require private hospitals to take part in load balancing. When needed, public health officials should issue emergency orders to require hospitals to participate in load-balancing efforts, including accepting patient transfers that are not part of their covered population. CONCLUSION Rawls’s difference principle, Daniels’s equality of opportunity, Parfit’s deontic egalitarianism, and Harris’s double jeopardy argument all justify and may even compel using the correction factor. COVID-19 turned academic and hypothetical discussions and debates about allocating scarce resources and making untenable choices of who lives and who dies to real-life responsibilities. Once hospitals move to a crisis standard of care, they may need to allocate scarce resources, so having systems in place that can compensate for past inequities and improve fairness in access to care is the ethical imperative. Dismantling structural inequities and reassessing allocation protocols should incorporate the correction factor as a new foundational framework and then build on it using load balancing and exercising caution if applying SOFA. It is an ethical responsibility to use these tools to dismantle the pervasive structural inequities when allocating scarce resources. - [1] Goldberg, Daniel S. “Against the Medicalization of Public Health (Ethics).” Public Health Ethics 14, no. 2 (2021): 117–19. https://doi.org/10.1093/phe/phab024. [2] Morrissey, Mary Beth, and Jorge L. Rivera-Agosto. “Protecting the Public's Health in Pandemics: Reflections on Policy Deliberation and the Role of Civil Society in Democracy.” Frontiers in Public Health 9 (June 1, 2021): 6. https://doi.org/10.3389/fpubh.2021.678210. [3] Antommaria, Armand H., Tyler S. Gibb, Amy L. McGuire, Paul Root Wolpe, Matthew K. Wynia, Megan K. Applewhite, Arthur Caplan, et al. “Ventilator Triage Policies during the Covid-19 Pandemic at U.S. Hospitals Associated with Members of the Association of Bioethics Program Directors.” Annals of Internal Medicine 173, no. 3 (April 4, 2020): 188–94. https://doi.org/10.7326/m20-1738; Chelan, Julia S., Douglas B. White, Stephanie Zaza, Amanda N. Perry, Deborah S. Feifer, Maia L. Crawford, and Amber E. Barnato. “US Ventilator Allocation and Patient Triage Policies in Anticipation of the Covid-19 Surge.” Health Security 19, no. 5 (2021): 459–67. https://doi.org/10.1089/hs.2020.0166. [4] Lin, Janet Y., and Lisa Anderson-Shaw. “Rationing of Resources: Ethical Issues in Disasters and Epidemic Situations.” Prehospital and Disaster Medicine 24, no. 3 (2009): 215–21. https://doi.org/10.1017/s1049023x0000683x. [5] Executive Summary Allocation of Scarce Critical Care Resources during a ...,” April 9, 2021. https://ccm.pitt.edu/sites/default/files/Model%20hospital%20policy%20for%20allocation%20of%20critical%20care_2020-03-23%20web.pdf. [6]. Executive Summary Allocation of Scarce Critical Care Resources during a ...,” April 9, 2021. https://ccm.pitt.edu/sites/default/files/Model%20hospital%20policy%20for%20allocation%20of%20critical%20care_2020-03-23%20web.pdf. [7] https://www.neighborhoodatlas.medicine.wisc.edu/mapping; Executive Summary Allocation of Scarce Critical Care Resources during a ...,” April 9, 2021. [8] White, Douglas B., and Bernard Lo. “Structural Inequities, Fair Opportunity, and the Allocation of Scarce ICU Resources.” Hastings Center Report 51, no. 5 (2021): 42–47. https://doi.org/10.1002/hast.1285 [9] McKie, John, and Jeff Richardson. “The Rule of Rescue.” Social Science and Medicine 56 (2003): 2407–19 [10] Daniels, Norman. “Justice, Health, and Health Care.” Essay. In Medicine and Social Justice Essays on the Distribution of Health Care, edited by Rosamond Rodes, Margaret P Battin, and Anita Silvers, Seconded., 17–33. Oxford University Press, n.d. [11] Brock, Dan W. “Priority to the Worse Off in Health Care Resource Prioritization .” Essay. In Medicine and Social Justice Essays on the Distribution of Health Care, edited by Rosamond Rhodes, Margaret Battin, and Anita Silvers, 155–64. Oxford University Press, n.d. [12] Brock, Dan W. “Priority to the Worse Off in Health Care Resource Prioritization .” Essay. In Medicine and Social Justice Essays on the Distribution of Health Care, edited by Rosamond Rhodes, Margaret Battin, and Anita Silvers, 155–64. Oxford University Press, n.d. [13] Harris, J. “Qualifying the Value of Life.” Journal of Medical Ethics 13, no. 3 (1987): 117–23. https://doi.org/10.1136/jme.13.3.117. [14] White, Douglas B., and Bernard Lo. “Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic.” American Journal of Respiratory and Critical Care Medicine 203, no. 3 (February 1, 2021): 287–95. https://doi.org/10.1164/rccm.202010-3809cp. [15] White, Douglas B., and Bernard Lo. “Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic.” American Journal of Respiratory and Critical Care Medicine 203, no. 3 (February 1, 2021): 287–95. https://doi.org/10.1164/rccm.202010-3809cp. [16] White, Douglas B., and Bernard Lo. “Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic.” American Journal of Respiratory and Critical Care Medicine 203, no. 3 (February 1, 2021): 287–95. https://doi.org/10.1164/rccm.202010-3809cp. [17] White, Douglas B., and Bernard Lo. “Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic.” American Journal of Respiratory and Critical Care Medicine 203, no. 3 (February 1, 2021): 287–95. https://doi.org/10.1164/rccm.202010-3809cp. [18] Kass, Nancy E. “An Ethics Framework for Public Health.” American Journal of Public Health 91, no. 11 (November 2001): 1776–82. https://doi.org/10.2105/ajph.91.11.1776. [19] White, Douglas B., and Bernard Lo. “Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic.” American Journal of Respiratory and Critical Care Medicine 203, no. 3 (February 1, 2021): 287–95. https://doi.org/10.1164/rccm.202010-3809cp. [20] White, Supra.12 [21] Kass, Nancy E. “An Ethics Framework for Public Health.” American Journal of Public Health 91, no. 11 (November 2001): 1776–82. https://doi.org/10.2105/ajph.91.11.1776. [22] Tolchin, Benjamin, Carol Oladele, Deron Galusha, Nitu Kashyap, Mary Showstark, Jennifer Bonito, Michelle C. Salazar, et al. “Racial Disparities in the SOFA Score among Patients Hospitalized with Covid-19.” PLOS ONE. Public Library of Science, September 17, 2021. https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0257608; SOFA is a prognostic scoring system that assigns points for organ failure evidence within six different organ systems. Higher SOFA scores correlate with higher mortality. New research by Tolchin reveals the flaws in SOFA due to its failure to account for delays in seeking care and overestimates of Black mortality. Also see Antommaria, Armand H., Tyler S. Gibb, Amy L. McGuire, Paul Root Wolpe, Matthew K. Wynia, Megan K. Applewhite, Arthur Caplan, et al. “Ventilator Triage Policies during the Covid-19 Pandemic at U.S. Hospitals Associated with Members of the Association of Bioethics Program Directors.” Annals of Internal Medicine 173, no. 3 (April 4, 2020): 188–94. https://doi.org/10.7326/m20-1738; Chelen, Julia S., Douglas B. White, Stephanie Zaza, Amanda N. Perry, Deborah S. Feifer, Maia L. Crawford, and Amber E. Barnato. “US Ventilator Allocation and Patient Triage Policies in Anticipation of the Covid-19 Surge.” Health Security 19, no. 5 (2021): 459–67. https://doi.org/10.1089/hs.2020.0166; and Pence, Gregory E. Pandemic Bioethics. Peterborough: Broadview Press, 2021. [23] Black – population 59.28 % Median Household income 24,322 Population 20,276 Education: 31.$ HS; 21.71% less than 95 grade, Postsecondary Asso-7%, Bachelors 6.7, ttps://worldpopulationreview.com/us-cities/belle-glade-fl-population [24] Neighborhood atlas®. Neighborhood Atlas - Mapping. (n.d.). Retrieved February 15, 2022, from https://www.neighborhoodatlas.medicine.wisc.edu/mapping [25] White, Douglas, Keynote Address, American Society of Bioethics and Humanities, October 13, 2021, COVID-19 at the Crossroads, https://eventpilotadmin.com/web/planner.php?id=ASBH21 [26] Angelo, A. (2020, May 26). Latest Covid-19 Model Shows Arizona can Meet a Health Care Surge. Retrieved February 15, 2022, from https://communityimpact.com/phoenix/chandler/coronavirus/2020/05/26/latest-covid-19-model-shows-arizona-can-meet-a-health-care-surge/ [27] White, Douglas, Keynote Address, American Society of Bioethics and Humanities, October 13, 2021, COVID-19 at the Crossroads, https://eventpilotadmin.com/web/planner.php?id=ASBH21

Introduction Fashion has long been associated with resistance movements across Asia and Australia, from the hand-spun cotton Khadi of Mahatma Gandhi’s freedom struggle to the traditional ankle length robe worn by Tibetans in the ‘White Wednesday Movement’ (Singh et al.; Yangzom). There are many reasons why fashion and activism have been interlinked. Fashion can serve as a form of nonverbal communication (Crane), which can convey activists’ grievances and concerns while symbolising solidarity (Doerr). It can provide an avenue to enact individual agency against repressive, authoritarian regimes (Yangzom; Doerr et al.). Fashion can codify a degree of uniformity within groups and thereby signal social identity (Craik), while also providing a means of building community (Barry and Drak). Fashion, therefore, offers activists the opportunity to develop the three characteristics which unite a social or environmental movement: a shared concern about an issue, a sense of social identity, and connections between individuals and groups. But while these fashion functions map onto movement characteristics, it remains unclear whether activists across the world deliberately include fashion into their protest action repertoires. This uncertainty exists partly because of a research and media focus on large scale, mass protests (Lester and Hutchins), where fashion characteristics are immediately visible and amenable to retrospective interpretation. This focus helps explain the rich volume of research examining the manifestation of fashion in past protests, such as the black, red, and yellow colours worn during the 1988 Aboriginal Long March of Freedom, Justice, and Hope (Maynard Dress; Coghlan), and the pink anti-Trump ‘pussyhats’ (Thompson). However, the protest events used to identify these fashion characteristics are a relatively small proportion of actions used by environmental activists (Dalton et al.; Gulliver et al.), which include not only rallies and marches, but also information evenings, letter writing sessions, and eco-activities such as tree plantings. This article aims to respond to Barnard’s (Looking) call for more empirical work on what contemporary cultural groups visually do with what they wear (see also Gerbaudo and Treré) via a content analysis of 36,676 events promoted on Facebook by 728 Australian environmental groups between 2010 and 2019. The article firstly reports findings from an analysis of this dataset to identify how fashion manifests in environmental activism, building on research demonstrating the role of protest-related nonverbal communications, such as protest signage (Bloomfield and Doolin), images (Kim), and icons, slogans, and logos (Goodnow). The article then considers what activists may seek to achieve through incorporating fashion into their action repertoire, and whether this suggests solidarity with activists seeking to effect environmental change across the wider Asian region. Fashion Activism Fashion is created through a particular assemblage of clothes, accessories, and hairstyles (Barry and Drak), which in turn forms a prevailing custom or style of dress (Craik). It is a cultural practice, providing ‘real estate’ (Benda 7) for an individual to express their social roles (Craik) and political identity (Behnke). Some scholars argue that fashion became overtly political during the 1960s and 70s, as social movements politicised appearance (Edwards). This has only increased in relevance with the rise of far right, populist, and authoritarian regimes, whose sub-cultures enact politicised identities through their distinct fashion characteristics (Gaugele and Titton; Gaugele). Fashion can therefore play an important role in protest movements, as “political subjectivities, political authority, political power and discipline are rendered visible, and thereby real, by the way fashion co-establishes them” (Behnke 3). Across the literature scholars have identified two primary avenues by which fashion and activism are connected. The first of these relates to activism targeting the fashion industry. This type of activism is found in both Asia and Australia, and promotes sustainable consumption choices such as buying used goods and transforming existing items (Chung and Yim), as well as highlighting garment worker exploitation within the fashion industry (Khan and Richards). The second avenue is called ‘fashion activism’: the use of fashion to intentionally signal a message seeking to evoke social and/or political change (Thompson). In this conceptualisation, clothing is used to signify a particular message (Crane). An example of this type of fashion activism is the ‘SlutWalk’, a protest where participants deliberately wore outfits described as slutty or revealing as a response to victim-blaming of women who had experienced sexual assault (Thompson). A key element of fashion activism thus appears to be its message intentionality. Clothes are specifically utilised to convey a message, such as a grievance about victim-blaming, which can then be incorporated into design features displayed on t-shirts, pins, and signs both on the runway and in protest events (Titton). However, while this ‘sender/receiver’ model of fashion communication (Barnard, Fashion as) can be compelling for activists, it is complex in practice. A message receiver can never have full knowledge of what message the sender seeks to signify through a particular clothing item, nor can the message sender predict how a receiver will interpret that message. Particular arrangements of clothing only hold communicative power when they are easily interpreted and related to the movement and its message, usually only intelligible to a specific culture or subculture (Goodnow). Even within that subculture it remains problematic to infer a message from a particular style of dress, as demonstrated in examples where dress is used to imply sexual consent; for example, in rape and assault cases (Lennon et al.). Given the challenges of interpreting fashion, do activists appear to use the ‘real estate’ (Benda 7) afforded by it as a protest tool? To investigate this question a pre-existing dataset of 36,676 events was analysed to ascertain if, and how, environmental activism engages with fashion (a detailed methodology is available on the OSF). Across this dataset, event categories, titles, and descriptions were reviewed to collate events connecting environmental activism to fashion. Three categories of events were found and are discussed in the next section: street theatre, sustainable fashion practices, and disruptive protest. Street Theatre Street theatre is a form of entertainment which uses public performance to raise awareness of injustices and build support for collective action (Houston and Pulido). It uses costumes as a vehicle for conveying messages about political issues and for making demands visible, and has been utilised by protesters across Australia and Asia (Roces). Many examples of street theatre were found in the dataset. For example, Extinction Rebellion (XR) consistently promoted street theatre events via sub-groups such as the ‘Red Rebels’ – a dedicated team of volunteers specialising in costumed street theatre – as well as by inviting supporters to participate in open street theatre events, such as in the ‘Halloween Dead Things Disco’. Dressed as spooky skeletons (doot, doot) and ghosts, we'll slide and shimmy down Sydney's streets in a supernatural style, as we bring attention to all the species claimed by the Sixth Mass Extinction. These street theatre events appeared to prioritise spectacle rather than disruption as a means to attract attention to their message. The Cairns and Far North Environment Centre ‘Climate Action Float’, for example, requested that attendees: Wear blue and gold or dress as your favourite reef animal, solar panel, maybe even the sun itself!? Reef & Solar // Blue & Gold is the guiding theme but we want your creativity take it from there. Most groups used street theatre as one of a range of different actions organised across a period of time. However, Climacts, a performance collective which uses ‘spectacle and satire to communicate the urgency of the climate and biodiversity crisis’ (Climacts), utilised this tactic exclusively. Their Climate Guardians collective used distinctive angel costumes to perform at the Climate Conference of Parties 26, and in various places around Australia (see images on their Website). Fig. 1: Costumed protest against Downer EDI's proposed work on the Adani coalmine; Image by John Englart (CC BY-SA 2.0). Sustainable Fashion Practices The second most common type of event which connected fashion with activism were those promoting sustainable fashion practices. While much research has highlighted the role of activism in raising awareness of problems related to the fashion industry (e.g. Hirscher), groups in the dataset were primarily focussed on organising activities where supporters communally created their own fashion items. The most common of these was the ‘crafternoon’, with over 260 separate crafternoon events identified in the dataset. These events brought activists together to create protest-related kit such as banners, signs, and costumes from recycled or repurposed materials, as demonstrated by Hume Climate Action Now’s ‘Crafternoon for Climate’ event: Come along on Sunday arvo for a relaxed arvo making posters and banners for upcoming Hume Climate Action Now events… Bring: Paints, textas, cardboard, fabric – whatever you’ve got lying around. Don’t have anything? That’s cool, just bring yourself. Events highlighting fashion industry problems were less frequent and tended to prioritise sharing of information about the fashion industry rather than promoting protests. For example, Transition Town Vincent held a ‘Slowing Down Fast Fashion – Transition Town Vincent Movie Night’ while the Green Embassy promoted the ‘Eco Fashion Week’. This event, held in 2017, was described as Australia’s only eco-fashion week, and included runway shows, music, and public talks. Other events also focussed on public talks, such as a Conservation Council of ACT event called ‘Green Drinks Canberra October 2017: Summer Edwards on the fashion industry’ and a panel discussion organised by a group called SEE-Change entitled ‘The Sustainable Wardrobe’. Disruptive Protest and T-Shirts Few events in the dataset mentioned elements of fashion outside of street theatre or sustainable fashion practices, with only one organisation explicitly connecting fashion with activism in its event details. This group – Australian Youth Climate Coalition – organised an event called ‘Activism in Fashion: Tote Bags, T-shirts and Poster Painting!’, which asked: How can we consistently be involved in campaigning while life can be so busy? Can we still be loud and get a message across without saying a word? The iconic 21st century activist "t-shirt and tote-bag" combination is hard to miss these days! Unlike street theatre and sustainable fashion practices, fashion appeared to be a consideration for only a small number of disruptive protests promoted by environmental groups in Australia. XR Brisbane sought to organise a fashion parade during the 2019 Rebellion Week, while XR protesters in Melbourne stripped down to underwear for a march through Melbourne city arcades (see also Turbet). Few common fashion elements appeared consistently on individual activists participating in events, and these were limited to accessories, such as ‘Stop Adani’ earrings, or t-shirts sold for fundraising and promotional purposes. Indeed, t-shirts appeared to be the most promoted clothing item in the dataset, continuing a long tradition of their use in protests (e.g. Maynard, Blankets). Easy to create, suitable for displaying both text and imagery, t-shirts sharing anti-coal messages featured predominantly in the Stop Adani campaign, while yellow t-shirts were a common item in Knitting Nanna’s anti-coal seam gas mining protests. Fig. 2: Stop Adani earrings and t-shirts; Image by John Englart (CC BY-SA 2.0). The Role of Fashion in Environmental Activism As these findings demonstrate, fashion appears to be deliberately utilised in environmental activism primarily through street theatre and the promotion of sustainable fashion practices. While fewer examples of fashion in disruptive protest were found and no consistent fashion assemblage was identified, accessories and t-shirts were utilised by many groups. What may activists be seeking to achieve through incorporating fashion via street theatre and sustainable fashion practices? Some scholars have argued that incorporating fashion into protest allows activists to signal political dissent against authoritarian control. For example, Yanzoom noted that by utilising fashion as a means of communication, Tibetan activists were able to embody their political goals despite repression of speech and movement by political powerholders. However, a consistent fashion repertoire across protests in this Australian dataset was not found. The opportunities afforded by protected protest rights in Australia and absence of violent police repression of disruptive protests may be one explanation why distinctive dress such as the masks and black attire of Hong Kong pro-democracy protesters did not manifest in the dataset. Other scholars have observed that fashion sub-cultures also developed partly to express anti-establishment politics, such as the punk movement in the 1970s. Radical clothing accessorised by symbols, bright hair colours, body piercings, and heavy-duty books signalled opposition to the dominant political ideology (Craik). However, none of these purposes appeared to play a role in Australian environmental activism either. Instead, it appears that Maynard’s contention that Australian protest fashion barely deviates from everyday dress remains true today. Fashion within the events promoted in this large empirical dataset retained the ‘prevalence of everyday clothing’ (Maynard, Dress 111). The lack of a clearly discernible single protest fashion style within the dataset may be related to the shortcomings of the sender/receiver model of fashion communication. As Barnard (Fashion Statements) argued, fashion is not always used as a vehicle for conveying messages, but also as a platform for constructing and reproducing identity. Indeed, a multiplicity of researchers have noted how fashion acts as a signal of what social groups individuals belong to (see Roach-Higgins and Eicher). Activist groups have a variety of goals, which not only include promoting environmental change but also mobilising more people to join their cause (Gulliver et al., Understanding). Stereotyping can hinder achievement of these goals. It has been demonstrated, for example, that individuals who hold negative stereotypes of ‘typical’ activists are less likely to want to associate with them, and less likely to adopt their behaviours (Bashir et al.). Accordingly, some activist groups have been shown to actively promote dress associated with other identity groups, specifically to challenge cultural constructions of environmental activist stereotypes (see also Roces). For example, Bloomfield and Doolins’s study of the NZ anti-GE group MAdGE (Mothers against Genetic Engineering in Food and the Environment) demonstrated how visual protest artifacts conveyed the protesters’ social identity as mothers and customers rather than environmental activists, claiming an alternative cultural mandate for challenging the authority of science (see also Einwohner et al.). The data suggest that Australian activists are seeking to avoid this stereotype as well. The absence of a consistent fashion promoted within the dataset may reflect awareness of problematic stereotypes that activists may be then deliberately seeking to avoid. Maynard (Dress), for example, has noted how the everyday dress of Australian protesters serves to deflect stereotypical labelling of participants. This strategy is also mirrored by the changing nature of groups within the Australian environmental movement. The event database demonstrates that an increasing number of environmental groups are emerging with names highlighting non-stereotypical environmental identities: groups such as ‘Engineers Declare’ and ‘Bushfire Survivors for Climate Action’. Beyond these identity processes, the frequent use of costumed street theatre protest suggests that activists recognise the value of using fashion as a vehicle for communicating messages, despite the challenges of interpretation described above. Much of the language used to promote street theatre in the Facebook event listings suggests that these costumes were deliberately designed to signify a particular meaning, with individuals encouraged to dress up to be ‘a vehicle for myth and symbol’ (Lavender 11). It may be that costumes are also utilised in protest due to their suitability as an image event, convenient for dissemination by mass media seeking colourful and engaging imagery (Delicath and Deluca; Doerr). Furthermore, costumes, as with text or colours presented on t-shirts, may offer activists an avenue to clearly convey a visual message which is more resistant to stereotyping. This is especially relevant given that fashion can be re-interpreted and misinterpreted by audiences, as well as reframed and reinterpreted by the media (Maynard, Dress). While the prevalence of costumed performance and infrequent mentions of fashion in the dataset may be explained by stereotype avoidance and messaging clarity, sustainable fashion practices were more straightforward in intent. Groups used multiple approaches to educate audiences about sustainable fashion, whether through fostering sustainable fashion practices or raising awareness of fashion industry problems. In this regard, fashion in protest in Australia closely resembles Asian sustainable fashion activism (see e.g. Chon et al. regarding the Singaporean context). In particular, the large number of ‘crafternoons’ suggests their importance as sites of activism and community building. Craftivism – acts such as quilting banners, yarn bombing, and cross stitching feminist slogans – are used by many groups to draw attention to social, political and environmental issues (McGovern and Barnes). This type of ‘creative activism’ (Filippello) has been used to challenge aesthetic and political norms across a variety of contested socio-political landscapes. These activities not only develop activism skills, but also foster community (Barry and Drak). For environmental groups, these community building events can play a critical role in sustaining and supporting ongoing environmental activism (Gulliver et al., Understanding) as well as demonstrating solidarity with workers across Asia experiencing labour injustices linked to the fashion industry (Chung and Yim). Conclusion Studies examining protest fashion demonstrate that clothing provides a canvas for sharing protest messages and identities in both Asia and Australia (Benda; Yangzom; Craik). However, despite the fashion’s utility as communication tool for social and environmental movements, empirical studies of how fashion is used by activists in these contexts remain rare. This analysis demonstrates that Australian environmental activists use fashion in their action repertoire primarily through costumed street theatre performances and promoting sustainable fashion practices. By doing so they may be seeking to use fashion as a means of conveying messages, while avoiding stereotypes that can demobilise supporters and reduce support for their cause. Furthermore, sustainable fashion activism offers opportunities for activists to achieve multiple goals: to subvert the fast fashion industry, to provide participation avenues for new activists, to help build activist communities, and to express solidarity with those experiencing fast fashion-related labour injustices. These findings suggest that the use of fashion in protest actions can move beyond identity messaging to also enact sustainable practices while co-opting and resisting hegemonic ideas of consumerism. By integrating fashion into the vibrant and diverse actions promoted by environmental movements across Australia and Asia, activists can construct and perform identities while fostering the community bonds and networks from which movements demanding environmental change derive their strength. Ethics Approval Statement This study was approved by the Research Ethics Committee of the University of Queensland (2018000963). Data Availability A detailed methodology explaining how the dataset was constructed and analysed is available on the Open Science Framework: <https://osf.io/sq5dz/?view_only=9bc0d3945caa443084361f10b6720589>. References Barnard, Malcolm. “Fashion as Communication Revisited.” Popular Communication 18.4 (2020): 259–271. ———. “Fashion Statements: Communication and Culture.” Fashion Statements. Eds. Ron Scapp and Brian Seitz. Routledge, 2010. ———. “Looking Sharp: Fashion Studies.” The Handbook of Visual Culture. Eds. Ian Heywood and Barry Sandywell. Bloomsbury Publishing, 2017. Barry, Ben, and Daniel Drak. “Intersectional Interventions into Queer and Trans Liberation: Youth Resistance against Right-Wing Populism through Fashion Hacking.” Fashion Theory – Journal of Dress Body and Culture 23.6 (2019): 679–709. Bashir, Nadia Y., et al. “The Ironic Impact of Activists: Negative Stereotypes Reduce Social Change Influence.” European Journal of Social Psychology 43.7 (2013): 614–626. 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Introdução: O padrão ouro atual para detectar o RNA de SARS-CoV-2 é por reação em cadeia da polimerase em tempo real de transcrição reversa (RT-rtPCR) em swabs nasofaríngeos (NPS). Por esse motivo, a demanda pelos NPS aumentou e sua escassez se tornou uma realidade em muitos países. Com isso o uso da saliva se mostra uma alternativa promissora na triagem epidemiológica além de ser de fácil coleta e não invasiva. Objetivo: realizar uma revisão sistemática da literatura para avaliar o uso da saliva como um espécime alternativo para a detecção de SARS-CoV-2. Metodologia: A pesquisa sistemática foi realizada em sete bancos de dados (PubMed, Cochrane Library, Lilacs, Scielo, Web of Science, Scopus e Google Scholar) usando a variação dos termos de pesquisa (COVID-19 OR SARS-CoV-2 OR 2019-nCoV) AND "Saliva" no ano de 2020, recuperando 5480 publicações. Resultados: Após a leitura dos títulos e resumos, 411 textos foram conduzidos para leitura integral e 30 publicações foram consideradas para avaliação qualitativa do artigo. Conclusão: A saliva se apresenta um método alternativo eficaz para a detecção de SARS-CoV-2 e diagnóstico de COVID-19.Descritores: Infecções por Coronavírus; Betacoronavirus; Saliva; Diagnóstico.ReferênciasHuang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497-506.Wang L, Wang Y, Ye D, Liu Q. A review of the 2019 Novel Coronavirus (COVID-19) based on current evidence. J Antimicrob Agents 2020;105948.Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med 2020;382:727-733.Coronaviridae Study Group of the International Committee on Taxonomy of V. 2020. 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Int J Mol Sci. 2016;17.Principais itens para relatar Revisões sistemáticas e Meta-análises: A recomendação PRISMA. Epidemiol. E Serviços Saúde 2015;24:335–42.Abdul MSM, Fatima U, Khanna SS, Bhanot R, Sharma A, Srivastava AP. Oral Manifestations of Covid-19-Are they the introductory symptoms?. J Adv Dent Sci Res. 2020;8:5.Azzi L, Carcano G, Dalla Gasperina D, Sessa F, Maurino V, Baj A. Two cases of COVID-19 with positive salivary and negative pharyngeal or respiratory swabs at hospital discharge: A rising concern. Oral Dis. 2020;00:1-3.Azzi L, Carcano G, Gianfagna F, Grossi P, Dalla Gasperina D, Genoni A, et al. Saliva is a reliable tool to detect SARS-CoV-2. J Infect. 2020;81:45-50.Becker D, Sandoval E, Amin A, De Hoff P, Leonetti N, Lim YW, et al. Saliva is less sensitive than nasopharyngeal swabs for COVID-19 detection in the community setting. medRxiv. 2020;20092338.Braz-Silva PH, Pallos D, Giannecchini S, To KKW. SARS-CoV-2: What can saliva tell us?. Oral Dis. 2020;13365.Chan JFW, Yip CCY, To KKW, Tang THC, Wong SCY, Leung KH, et al. Improved molecular diagnosis of COVID-19 by the novel, highly sensitive and specific COVID-19-RdRp/Hel real-time reverse transcription-PCR assay validated in vitro and with clinical specimens. J Clin Microbiol. 2020;58:5.Chen L, Zhao J, Peng J, Li X, Deng X, Geng Z, et al. Detection of 2019-nCoV in saliva and characterization of oral symptoms in COVID-19 patients. Lancet. 2020;3556665.Cheng VC, Wong SC, Chen JH, Yip CC, Chuang VW, Tsang OT, et al. Escalating infection control response to the rapidly evolving epidemiology of the Coronavirus disease 2019 (COVID-19) due to SARS-CoV-2 in Hong Kong. Infect Control Hosp Epidemiol. 2020;41:493-498.Han P, Ivanovski S. Saliva—Friend and Foe in the COVID-19 Outbreak. Diagn. 2020;10:290.Iwasaki S, Fujisawa S, Nakakubo S, Kamada K, Yamashita Y, Fukumoto T, et al. Comparison of SARS-CoV-2 detection in nasopharyngeal swab and saliva. J Infect. 2020;20:30349.Krajewska J, Krajewski W, Zub K, Zatoński T. COVID-19 in otolaryngologist practice: a review of current knowledge. Eur Arch Otorhinolaryngol. 2020;1-13.Lalli MA, Chen X, Langmade SJ, Fronick CC, Sawyer CS, Burcea LC, et al. Rapid and extraction-free detection of SARS-CoV-2 from saliva with colorimetric LAMP. medRxiv. 2020;7273276.Li X, Geng M, Peng Y, Meng L, Lu S. Molecular immune pathogenesis and diagnosis of COVID-19. J Pharm Anal. 2020;10:101-108.Li H, Liu SM, Yu XH, Tang SL, Tang CK. Coronavirus disease 2019 (COVID-19): current status and future perspective. Int J Antimicrob Agents. 2020;105951.McCormick-Baw C, Morgan K, Gaffney D, Cazares Y, Jaworski K, Byrd A, et al. Saliva as an Alternate Specimen Source for Detection of SARS-CoV-2 in Symptomatic Patients Using Cepheid Xpert Xpress SARS-CoV-2. J Clin Microbiol. 2020;01109-20.Pasomsub E, Watcharananan SP, Boonyawat K, Janchompoo P, Wongtabtim G, Suksuwan W, et al. Saliva sample as a non-invasive specimen for the diagnosis of coronavirus disease-2019 (COVID-19): a cross-sectional study. Clin Microbiol Infect. 2020;20302780.Sabino-Silva R, Jardim ACG, Siqueira WL. Coronavirus COVID-19 impacts to dentistry and potential salivary diagnosis. Clinical oral investigations. 2020;1-3.Sapkota D, Thapa SB, Hasséus B, Jensen JL. Saliva testing for COVID-19?. BDJ. 2020;228:658-659.Sharma S, Kumar V, Chawla A, Logani A. Rapid detection of SARS-CoV-2 in saliva: Can an endodontist take the lead in point-of-care COVID-19 testing?. Int Endod J. 2020;13317.Tang YW, Schmitz JE, Persing DH, Stratton CW. Laboratory Diagnosis of COVID-19: Current Issues and Challenges. J Clin Microbiol. 2020;58(6).Tatikonda SS, Reshu P, Hanish A, Konkati S, Madham S. A Review of Salivary Diagnostics and Its Potential Implication in Detection of Covid-19. Cureus. 2020;12(4).To KKW, Tsang OTY, Leung WS, Tam AR, Wu TC, Lung DC, et al. Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study. Lancet Infect Dis. 2020;20:565-574.Vinayachandran D, Saravanakarthikeyan B. Salivary diagnostics in COVID-19: Future research implications. J Dent Sci. 2020;7177105.Williams E, Bond K, Zhang B, Putland M, Williamson DA. Saliva as a non-invasive specimen for detection of SARS-CoV-2. J Clin Microbiol. 2020;00776-20.Wyllie AL, Fournier J, Casanovas-Massana A, Campbell M, Tokuyama M, Vijayakumar P, et al. Saliva is more sensitive for SARS-CoV-2 detection in COVID-19 patients than nasopharyngeal swabs. Medrxiv. 2020;20067835.Yoon JG, Yoon J, Song JY, Yoon SY, Lim CS, Seong H, et al. Clinical Significance of a High SARS-CoV-2 Viral Load in the Saliva. J Korean Med Sci. 2020;35(20).Zheng S, Yu F, Fan J, Zou Q, Xie G, Yang X, et al. Saliva as a Diagnostic Specimen for SARS-CoV-2 by a PCR-Based Assay: A Diagnostic Validity Study. Lancet. 2020;3543605.Zhong F, Liang Y, Xu J, Chu M, Tang G, Hu F, et al. Continuously High Detection Sensitivity of Saliva, Viral Shedding in Salivary Glands and High Viral Load in Patients with COVID-19. Lancet. 2020;3576869.

The UP Manila Health Policy Development Hub recognizes the invaluable contribution of the participants in theseries of roundtable discussions listed below: RTD: Beyond Hospital Beds: Equity,quality, and service1. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD,Faculty, College of Public Health, UP Manila2. Leonardo R. Estacio, Jr., MCD, MPH, PhD, Dean,College of Arts and Sciences, UP Manila3. Michael Antonio F. Mendoza, DDM, MM, Faculty,College of Dentistry, UP Manila4. Hilton Y. Lam, MHA, PhD, Chair, UP Manila HealthPolicy Development Hub; Director, Institute of HealthPolicy and Development Studies, University of thePhilippines Manila5. Irma L. Asuncion, MHA, CESO III, Director IV,Bureau of Local Health Systems Development,Department of Health6. Renely Pangilinan-Tungol, MD, CFP, MPM-HSD,Municipal Health Officer, San Fernando, Pampanga7. Salome F. Arinduque, MD, Galing-Pook AwardeeRepresentative, Municipal Health Officer, San Felipe,Zambales8. Carmelita C. Canila, MD, MPH, Faculty, College ofPublic Health, University of the Philippines Manila9. Lester M. Tan, MD, MPH, Division Chief, Bureau ofLocal Health System Development, Department ofHealth10. Anthony Rosendo G. Faraon, MD, Vice President,Zuellig Family Foundation (ZFF)11. Albert Francis E. Domingo, MD, Consultant, HealthSystem strengthening through Public Policy andRegulation, World Health Organization12. Jesus Randy O. Cañal, MD, FPSO-HNS, AssociateDirector, Medical and Regulatory Affairs, AsianHospital and Medical Center13. Christian Edward L. Nuevo, Health Policy and SystemsResearch Fellow, Health Policy Development andPlanning Bureau, Department of Health14. Paolo Victor N. Medina, MD, Assistant Professor 4,College of Medicine, University of the PhilippinesManila15. Jose Rafael A. Marfori, MD, Special Assistant to theDirector, Philippine General Hospital16. Maria Teresa U. Bagaman, Committee Chair, PhilippineSociety for Quality, Inc.17. Maria Theresa G. Vera, MSc, MHA, CESO III, DirectorIV, Health Facility Development Bureau, Departmentof Health18. Ana Melissa F. Hilvano-Cabungcal, MD, AssistantAssociate Dean for Planning & Development, Collegeof Medicine, University of the Philippines Manila19. Fevi Rose C. Paro, Faculty, Department of Communityand Environmental Resource Planning, University ofthe Philippines Los Baños20. Maria Rosa C. Abad, MD, Medical Specialist III,Standard Development Division, Health Facilities andServices Regulation21. Yolanda R. Robles, RPh, PhD, Faculty, College ofPharmacy, University of the Philippines Manila22. Jaya P. Ebuen, RN, Development Manager Officer,CHDMM, Department of Health23. Josephine E. Cariaso, MA, RN, Assistant Professor,College of Nursing, University of the Philippines Manila24. Diana Van Daele, Programme Manager, CooperationSection, European Union25. Maria Paz de Sagun, Project Management Specialist,USAID26. Christopher Muñoz, Member, Yellow Warriors SocietyPhilippinesRTD: Health services and financingroles: Population based- andindividual-based1. Hilton Y. Lam, MHA, PhD, Chair, University of thePhilippines Manila Health Policy Development Hub;Director, Institute of Health Policy and DevelopmentStudies, University of the Philippines Manila2. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD,Faculty, College of Public Health, University of thePhilippines Manila3. Leonardo R. Estacio, Jr., MCD, MPH, PhD, Dean,College of Arts and Sciences, University of thePhilippines Manila4. Michael Antonio F. Mendoza, DDM, MM, Faculty,College of Dentistry, University of the PhilippinesManila5. Mario C. Villaverde, Undersecretary, Health Policyand Development Systems and Development Team,Department of Health6. Jaime Z. Galvez Tan, MD, Former Secretary, Department of Health7. Marvin C. Galvez, MD, OIC Division Chief, BenefitsDevelopment and Research Department, PhilippineHealth Insurance Corporation8. Alvin B. Caballes, MD, MPE, MPP, Faculty, Collegeof Medicine, University of the Philippines Manila9. Carlos D. Da Silva, Executive Director, Association ofMunicipal Health Maintenance Organization of thePhilippines, Inc.10. Anthony Rosendo G. Faraon, MD, Vice President,Zuellig Family Foundation (ZFF) 11. Albert Francis E. Domingo, MD, Consultant, HealthSystem strengthening through Public Policy andRegulation, World Health Organization12. Salome F. Arinduque, MD, Galing-Pook AwardeeRepresentative, Municipal Health Officer, San Felipe,Zambales13. Michael Ralph M. Abrigo, PhD, Research Fellow,Philippine Institute for Developmental Studies14. Oscar D. Tinio, MD, Committee Chair, Legislation,Philippine Medical Association15. Rogelio V. Dazo, Jr., MD, FPCOM, Legislation,Philippine Medical Association16. Ligaya V. Catadman, MM, Officer-in-charge, HealthPolicy Development and Planning Bureau, Department of Health17. Maria Fatima Garcia-Lorenzo, President, PhilippineAlliance of Patients Organization18. Tomasito P. Javate, Jr, Supervising Economic DevelopmentSpecialist, Health Nutrition and Population Division,National Economic and Development Authority19. Josefina Isidro-Lapena, MD, National Board ofDirector, Philippine Academy of Family Physicians20. Maria Eliza Ruiz-Aguila, MPhty, PhD, Dean, Collegeof Allied Medical Professions, University of thePhilippines Manila21. Ana Melissa F. Hilvano-Cabungcal, MD, AssistantAssociate Dean for Planning & Development, College ofMedicine, University of the Philippines Manila22. Maria Paz P. Corrales, MD, MHA, MPA, Director III,Department of Health-National Capital Region23. Karin Estepa Garcia, MD, Executive Secretary, PhilippineAcademy of Family Physicians24. Adeline A. Mesina, MD, Medical Specialist III,Philippine Health Insurance Corporation25. Glorey Ann P. Alde, RN, MPH, Research Fellow,Department of HealthRTD: Moving towards provincelevel integration throughUniversal Health Care Act1. Hilton Y. Lam, MHA, PhD, Chair, University of thePhilippines Manila Health Policy Development Hub;Director, Institute of Health Policy and DevelopmentStudies, University of the Philippines Manila2. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD,Faculty, College of Public Health, University of thePhilippines Manila3. Leonardo R. Estacio, Jr., MCD, MPH, PhD, Dean,College of Arts and Sciences, University of thePhilippines Manila4. Michael Antonio F. Mendoza, DDM, MM, Faculty,College of Dentistry, University of the PhilippinesManila5. Mario C. Villaverde, Undersecretary of Health, HealthPolicy and Development Systems and DevelopmentTeam, Department of Health6. Ferdinand A. Pecson, Undersecretary and ExecutiveDirector, Public Private Partnership Center7. Rosanna M. Buccahan, MD, Provincial Health Officer,Bataan Provincial Office8. Lester M. Tan, MD, Division Chief, Bureau of LocalHealth System Development, Department of Health9. Ernesto O. Domingo, MD, FPCP, FPSF, FormerChancellor, University of the Philippines Manila10. Albert Francis E. Domingo, MD, Consultant, HealthSystem strengthening through Public Policy andRegulation, World Health Organization11. Leslie Ann L. Luces, MD, Provincial Health Officer,Aklan12. Rene C. Catan, MD, Provincial Health Officer, Cebu13. Anthony Rosendo G. Faraon, MD, Vice President,Zuellig Family Foundation14. Jose Rafael A. Marfori, MD, Special Assistant to theDirector, Philippine General Hospital15. Jesus Randy O. Cañal, MD, FPSO-HNS, Consultant,Asian Hospital and Medical Center16. Ramon Paterno, MD, Member, Universal Health CareStudy Group, University of the Philippines Manila17. Mayor Eunice U. Babalcon, Mayor, Paranas, Samar18. Zorayda E. Leopando, MD, Former President,Philippine Academy of Family Physicians19. Madeleine de Rosas-Valera, MD, MScIH, SeniorTechnical Consultant, World Bank20. Arlene C. Sebastian, MD, Municipal Health Officer,Sta. Monica, Siargao Island, Mindanao21. Rizza Majella L. Herrera, MD, Acting Senior Manager,Accreditation Department, Philippine Health InsuranceCorporation22. Alvin B. Caballes, MD, MPE, MPP, Faculty, Collegeof Medicine, University of the Philippines Manila23. Pres. Policarpio B. Joves, MD, MPH, MOH, FPAFP,President, Philippine Academy of Family Physicians24. Leilanie A. Nicodemus, MD, Board of Director,Philippine Academy of Family Physicians25. Maria Paz P. Corrales, MD, MHA, MPA, Director III,National Capital Region Office, Department of Health26. Dir. Irma L. Asuncion, MD, MHA, CESO III, DirectorIV, Bureau of Local Health Systems Development,Department of Health27. Bernard B. Argamosa, MD, Mental Health Representative, National Center for Mental Health28. Flerida Chan, Chief, Poverty Reduction Section, JapanInternational Cooperation Agency29. Raul R. Alamis, Chief Health Program Officer, ServiceDelivery Network, Department of Health30. Mary Anne Milliscent B. Castro, Supervising HealthProgram Officer, Department of Health 31. Marikris Florenz N. Garcia, Project Manager, PublicPrivate Partnership Center32. Mary Grace G. Darunday, Supervising Budget andManagement Specialist, Budget and Management Bureaufor the Human Development Sector, Department ofBudget and Management33. Belinda Cater, Senior Budget and Management Specialist,Department of Budget and Management34. Sheryl N. Macalipay, LGU Officer IV, Bureau of LocalGovernment and Development, Department of Interiorand Local Government35. Kristel Faye M. Roderos, OTRP, Representative,College of Allied Medical Professions, University ofthe Philippines Manila36. Jeffrey I. Manalo, Director III, Policy Formulation,Project Evaluation and Monitoring Service, PublicPrivate Partnership Center37. Atty. Phebean Belle A. Ramos-Lacuna, Division Chief,Policy Formulation Division, Public Private PartnershipCenter38. Ricardo Benjamin D. Osorio, Planning Officer, PolicyFormulation, Project Evaluation and MonitoringService, Public Private Partnership Center39. Gladys Rabacal, Program Officer, Japan InternationalCooperation Agency40. Michael Angelo Baluyot, Nurse, Bataan Provincial Office41. Jonna Jane Javier Austria, Nurse, Bataan Provincial Office42. Heidee Buenaventura, MD, Associate Director, ZuelligFamily Foundation43. Dominique L. Monido, Policy Associate, Zuellig FamilyFoundation44. Rosa Nene De Lima-Estellana, RN, MD, Medical OfficerIII, Department of Interior and Local Government45. Ma Lourdes Sangalang-Yap, MD, FPCR, Medical OfficerIV, Department of Interior and Local Government46. Ana Melissa F. Hilvano-Cabungcal, MD, AssistantAssociate Dean for Planning & Development, College ofMedicine, University of the Philippines Manila47. Colleen T. Francisco, Representative, Department ofBudget and Management48. Kristine Galamgam, Representative, Department ofHealth49. Fides S. Basco, Officer-in-charge, Chief Budget andManagement Specialist, Development of Budget andManagementRTD: Health financing: Co-paymentsand Personnel1. Hilton Y. Lam, MHA, PhD, Chair, University of thePhilippines Manila Health Policy Development Hub;Director, Institute of Health Policy and DevelopmentStudies, University of the Philippines Manila2. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD,Faculty, College of Public Health, University of thePhilippines Manila3. Leonardo R. Estacio, Jr., MCD, MPH, PhD, Dean,College of Arts and Sciences, University of thePhilippines Manila4. Michael Antonio F. Mendoza, DDM, MM, Faculty,College of Dentistry, University of the Philippines Manila5. Ernesto O. Domingo, MD, Professor Emeritus,University of the Philippines Manila6. Irma L. Asuncion, MHA, CESO III, Director IV,Bureau of Local Health Systems Development,Department of Health7. Lester M. Tan, MD, MPH, Division Chief, Bureau ofLocal Health System Development, Department ofHealth8. Marvin C. Galvez, MD, OIC Division Chief, BenefitsDevelopment and Research Department, PhilippineHealth Insurance Corporation9. Adeline A. Mesina, MD, Medical Specialist III, BenefitsDepartment and Research Department, PhilippineHealth Insurance Corporation10. Carlos D. Da Silva, Executive Director, Association ofHealth Maintenance Organization of the Philippines,Inc.11. Ma. Margarita Lat-Luna, MD, Deputy Director, FiscalServices, Philippine General Hospital12. Waldemar V. Galindo, MD, Chief of Clinics, Ospital ngMaynila13. Albert Francis E. Domingo, MD, Consultant, HealthSystem strengthening through Public Policy andRegulation, World Health Organization14. Rogelio V. Dazo, Jr., MD, Member, Commission onLegislation, Philippine Medical Association15. Aileen R. Espina, MD, Board Member, PhilippineAcademy of Family Physicians16. Anthony R. Faraon, MD, Vice President, Zuellig FamilyFoundation17. Jesus Randy O. Cañal, Associate Director, Medical andRegulatory Affairs, Asian Hospital and Medical Center18. Jared Martin Clarianes, Technical Officer, Union of LocalAuthorities of the Philippines19. Leslie Ann L. Luces, MD, Provincial Health Officer,Aklan20. Rosa Nene De Lima-Estellana, MD, Medical OfficerIII, Department of the Interior and Local Government21. Ma. Lourdes Sangalang-Yap, MD, Medical Officer V,Department of the Interior and Local Government 22. Dominique L. Monido, Policy Associate, Zuellig FamilyFoundation23. Krisch Trine D. Ramos, MD, Medical Officer, PhilippineCharity Sweepstakes Office24. Larry R. Cedro, MD, Assistant General Manager, CharitySector, Philippine Charity Sweepstakes Office25. Margarita V. Hing, Officer in Charge, ManagementDivision, Financial Management Service Sector,Department of Health26. Dr. Carlo Irwin Panelo, Associate Professor, College ofMedicine, University of the Philippines Manila27. Dr. Angelita V. Larin, Faculty, College of Public Health,University of the Philippines Manila28. Dr. Abdel Jeffri A. Abdulla, Chair, RegionalizationProgram, University of the Philippines Manila29. Christopher S. Muñoz, Member, Philippine Alliance ofPatients Organization30. Gemma R. Macatangay, LGOO V, Department ofInterior and Local Government – Bureau of LocalGovernment Development31. Dr. Narisa Portia J. Sugay, Acting Vice President, QualityAssurance Group, Philippine Health InsuranceCorporation32. Maria Eliza R. Aguila, Dean, College of Allied MedicalProfessions, University of the Philippines Manila33. Angeli A. Comia, Manager, Zuellig Family Foundation34. Leo Alcantara, Union of Local Authorities of thePhilippines35. Dr. Zorayda E. Leopando, Former President, PhilippineAcademy of Family Physicians36. Dr. Emerito Jose Faraon, Faculty, College of PublicHealth, University of the Philippines Manila37. Dr. Carmelita C. Canila, Faculty, College of PublicHealth, University of the Philippines ManilaRTD: Moving towards third partyaccreditation for health facilities1. Hilton Y. Lam, MHA, PhD, Chair, University of thePhilippines Manila Health Policy Development Hub;Director, Institute of Health Policy and DevelopmentStudies, University of the Philippines Manila2. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD,Faculty, College of Public Health, University of thePhilippines Manila3. Leonardo R. Estacio, Jr., MCD, MPH, PhD, Dean,College of Arts and Sciences, University of thePhilippines Manila4. Michael Antonio F. Mendoza, DDM, MM, Faculty,College of Dentistry, University of the PhilippinesManila5. Rizza Majella L. Herrera, MD, Acting SeniorManager, Accreditation Department, Philippine HealthInsurance Corporation6. Bernadette C. Hogar-Manlapat, MD, FPBA, FPSA,FPSQua, MMPA, President and Board of Trustee,Philippine Society for Quality in Healthcare, Inc.7. Waldemar V. Galindo, MD, Chief of Clinics, Ospital ngMaynila8. Amor. F. Lahoz, Division Chief, Promotion andDocumentation Division, Department of Trade andIndustry – Philippine Accreditation Bureau9. Jenebert P. Opinion, Development Specialist, Department of Trade and Industry – Philippine AccreditationBureau10. Maria Linda G. Buhat, President, Association ofNursing Service Administrators of the Philippines, Inc.11. Bernardino A. Vicente, MD, FPPA, MHA, CESOIV, President, Philippine Tripartite Accreditation forHealth Facilities, Inc.12. Atty. Bu C. Castro, MD, Board Member, PhilippineHospital Association13. Cristina Lagao-Caalim, RN, MAN, MHA, ImmediatePast President and Board of Trustee, Philippine Societyfor Quality in Healthcare, Inc.14. Manuel E. Villegas Jr., MD, Vice Treasurer and Board ofTrustee, Philippine Society for Quality in Healthcare,Inc.15. Michelle A. Arban, Treasurer and Board of Trustee,Philippine Society for Quality in Healthcare, Inc.16. Joselito R. Chavez, MD, FPCP, FPCCP, FACCP,CESE, Deputy Executive Director, Medical Services,National Kidney and Transplant Institute17. Blesilda A. Gutierrez, CPA, MBA, Deputy ExecutiveDirector, Administrative Services, National Kidney andTransplant Institute18. Eulalia C. Magpusao, MD, Associate Director, Qualityand Patient Safety, St. Luke’s Medical Centre GlobalCity19. Clemencia D. Bondoc, MD, Auditor, Association ofMunicipal Health Officers of the Philippines20. Jesus Randy O. Cañal, MD, FPSO-HNS, AssociateDirector, Medical and Regulatory Affairs, Asian Hospitaland Medical Center21. Maria Fatima Garcia-Lorenzo, President, PhilippineAlliance of Patient Organizations22. Leilanie A. Nicodemus, MD, Board of Directors,Philippine Academy of Family Physicians23. Policarpio B. Joves Jr., MD, President, PhilippineAcademy of Family Physicians24. Kristel Faye Roderos, Faculty, College of Allied MedicalProfessions, University of the Philippines Manila25. Ana Melissa Hilvano-Cabungcal, MD, AssistantAssociate Dean, College of Medicine, University of thePhilippines Manila26. Christopher Malorre Calaquian, MD, Faculty, Collegeof Medicine, University of the Philippines Manila27. Emerito Jose C. Faraon, MD, Faculty, College ofPublic Health, University of the Philippines Manila 28. Carmelita Canila, Faculty, College of Public Health,University of the Philippines Manila29. Oscar D. Tinio, MD, Representative, Philippine MedicalAssociation30. Farrah Rocamora, Member, Philippine Society forQuality in Healthcare, IncRTD: RA 11036 (Mental Health Act):Addressing Mental Health Needs ofOverseas Filipino Workers1. Hilton Y. Lam, MHA, PhD, Chair, University of thePhilippines Manila Health Policy Development Hub;Director, Institute of Health Policy and DevelopmentStudies, University of the Philippines Manila2. Leonardo R. Estacio, Jr., MCD, MPH, PhD, UPManila Health Policy Development Hub; College ofArts and Sciences, UP Manila3. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD, UPManila Health Policy Development Hub; College ofPublic Health, UP Manila4. Michael Antonio F. Mendoza, DDM, UP ManilaHealth Policy Development Hub; College of Dentistry,UP Manila5. Frances Prescilla L. Cuevas, RN, MAN, Director,Essential Non-Communicable Diseases Division,Department of Health6. Maria Teresa D. De los Santos, Workers Education andMonitoring Division, Philippine Overseas EmploymentAdministration7. Andrelyn R. Gregorio, Policy Program and Development Office,Overseas Workers Welfare Administration8. Sally D. Bongalonta, MA, Institute of Family Life &Children Studies, Philippine Women’s University9. Consul Ferdinand P. Flores, Department of ForeignAffairs10. Jerome Alcantara, BLAS OPLE Policy Center andTraining Institute11. Andrea Luisa C. Anolin, Commission on FilipinoOverseas12. Bernard B. Argamosa, MD, DSBPP, National Centerfor Mental Health13. Agnes Joy L. Casino, MD, DSBPP, National Centerfor Mental Health14. Ryan Roberto E. Delos Reyes, Employment Promotionand Workers Welfare Division, Department of Laborand Employment15. Sheralee Bondad, Legal and International AffairsCluster, Department of Labor and Employment16. Rhodora A. Abano, Center for Migrant Advocacy17. Nina Evita Q. Guzman, Ugnayan at Tulong para saMaralitang Pamilya (UGAT) Foundation, Inc.18. Katrina S. Ching, Ugnayan at Tulong para sa MaralitangPamilya (UGAT) Foundation, Inc.RTD: (Bitter) Sweet Smile of Filipinos1. Dr. Hilton Y. Lam, Institute of Health Policy andDevelopment Studies, NIH2. Dr. Leonardo R. Estacio, Jr., College of Arts andSciences, UP Manila3. Dr. Ma. Esmeralda C. Silva, College of Public Health,UP Manila4. Dr. Michael Antonio F. Mendoza, College of Dentistry,UP Manila5. Dr. Ma. Susan T. Yanga-Mabunga, Department ofHealth Policy & Administration, UP Manila6. Dr. Danilo L. Magtanong, College of Dentistry, UPManila7. Dr. Alvin Munoz Laxamana, Philippine DentalAssociation8. Dr. Fina Lopez, Philippine Pediatric Dental Society, Inc9. Dr. Artemio Licos, Jr.,Department of Health NationalAssociation of Dentists10. Dr. Maria Jona D. Godoy, Professional RegulationCommission11. Ms. Anna Liza De Leon, Philippine Health InsuranceCorporation12. Ms. Nicole Sigmuend, GIZ Fit for School13. Ms. Lita Orbillo, Disease Prevention and Control Bureau14. Mr. Raymond Oxcena Akap sa Bata Philippines15. Dr. Jessica Rebueno-Santos, Department of CommunityDentistry, UP Manila16. Ms. Maria Olivine M. Contreras, Bureau of LocalGovernment Supervision, DILG17. Ms. Janel Christine Mendoza, Philippine DentalStudents Association18. Mr. Eric Raymund Yu, UP College of DentistryStudent Council19. Dr. Joy Memorando, Philippine Pediatric Society20. Dr. Sharon Alvarez, Philippine Association of DentalColleges

Photo by Owen Beard on Unsplash Introduction Through its professional associations and healthcare organizations, the medical community has made numerous anti-racism statements in the past year, including the American Medical Association’s (“AMA’s) Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity.[1] Converting these statements into practical change will take time and money. In addition to implementing anti-bias training and education on racism in clinical practice, the medical community should also advocate to enhance and enforce Title VI anti-discrimination laws. The current limitations on enforcement conflict with the medical community’s ethical duty to improve health equity and treat all patients with a high standard of care. Advocating for legislation that meets the standards of other civil rights laws to hold the healthcare industry legally responsible for discrimination should be part of medical professionals’ anti-racism work. Development of Civil Rights in Health Care Despite the lack of a federal constitutional right to health care, the United States does acknowledge the importance of health and health care through its laws and spending decisions. In 2010, the Affordable Care Act (“ACA”) created health insurance options for 20 million additional Americans and reduced the gap in healthcare access among populations.[2] Although it did not ensure a right to health care and it does not guarantee a right to health, healthcare access is an important element of a healthy life and broadening the reach of health insurance is a worthy goal. Outside of the ACA’s offer of affordable health insurance, only a few stakeholders have gained “weak” statutory rights to publicly funded health care such as incarcerated people, the elderly, disabled, and the very poor.[3] Yet, the adoption of the public insurance programs Medicaid and Medicare in 1965, along with Title VI of the 1964 Civil Rights Act (“Title VI”), did create some rights to sue for discrimination in health care, even for people who are not recipients of Medicaid and Medicare benefits. Under Title VI, private institutions that receive federal financial assistance are prohibited from discriminating on the basis of race, color, and national origin.[4] Initially, this civil rights legislation had a major effect on health care because more than 1000 segregated hospitals immediately integrated their facilities in order to comply with the legislation and participate in Medicaid and Medicare.[5] Medical professionals interested in anti-racist work would do well to learn the history of Title VI; grassroots support of civil rights laws in the 1960s encouraged huge steps forward in eliminating de jure segregation in health care.[6] Title VI Lacks Mechanisms to Combat Structural Racism Title VI has been less effective when addressing more subtle forms of discrimination. Despite being one of the broadest anti-discrimination statutes, Title VI has been referred to as a “sleeping giant” because its full power has not been used to great effect.[7] The ACA included some attempts to improve Title VI’s effectiveness (see below), but much more could be done. Like most civil rights laws, Title VI discrimination may be alleged as disparate treatment (intentional) or disparate impact. Disparate impact claims are challenging to prove and may involve arguments such as how moving a hospital from an inner-city area to a wealthier suburban location will have a disparate impact on the local Black population. Besides the evidentiary challenges involved in demonstrating disparate impact, such a claim fails unless the plaintiffs can prove that a reasonable explanation for the action, such as cost savings, is a pretext for discrimination.[8] Title VI claims are also challenging because of the limitation on plaintiffs, the limitation on the scope of defendants, and enforcement issues. In 2001, the US Supreme Court held that individual plaintiffs cannot sue under Title VI for disparate impact claims, requiring a federal agency to do so.[9] While hospitals and other entities are potential defendants under Title VI, individual medical professionals are not, even though approximately 40 percent of Medicaid and Medicare reimbursements now go to physician and outpatient care.[10] The primary enforcement mechanism for Title VI healthcare claims is forcing compliance with the law through the threat of withdrawal of federal reimbursement.[11] The threat of financial punishments may harm communities, however, when low-resourced hospitals lose funding or are forced to fund rehabilitation programs.[12] Inequities between hospitals in different locations currently cannot be addressed under Title VI. Recent attempts to improve Title VI have failed. In the ACA, legislators included several updates to Title VI that appeared to improve its potential as a tool for reducing healthcare inequities. Section 1557 of the ACA changed the definition of “federal financial assistance” programs to include Medicaid and Medicare Advantage, thus expanding the pool of possible defendants to include individual providers.[13] However, the Department of Health and Human Services issued an implementing rule that specifically did not include Medicare Part B, so as of now patients cannot bring suit against sue their doctors for Title VI discrimination.[14] Some authors argue that the ACA also repealed the Supreme Court decision that prevented individuals from bringing disparate impact claims under Title VI.[15] So far, however, courts still interpret Title VI as supporting private claims only for intentional discrimination.[16] Individuals can still bring disparate impact claims to the Office of Civil Rights (“OCR”) and the Federal government may take action on their behalf. Because of the lack of available private action, however, there is no robust group of Title VI attorneys developing these civil rights cases.[17] If the legislature wants to encourage private enforcement of Title VI discrimination cases, it could also add punitive and compensatory damages to the available remedies, as it did with Title VII employment discrimination cases,[18] thus empowering plaintiffs and their lawyers to seek private remedies for discrimination in health care. Private litigation could be used as an additional lever in strategic approaches to eliminating discriminatory practices and improving health equity.[19] In 2003, the Institute of Medicine’s Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care recommended that the federal government increase funding for the OCR to encourage investigations into violations of Title VI based on systemic discrimination in health care.[20] The committee saw such enforcement as a “last line” of defense against systemic racism in health care, and a way to find such suspected racism through proactive investigations. Unfortunately, the OCR continues to be “notoriously” underfunded, but future administrations may be encouraged to rectify that problem.[21] Permitting more individual lawsuits may improve Title VI by providing better enforcement mechanisms and broadening the scope of possible defendants. These litigation tools will never bring about a right to health but can reduce inequities in access to and treatment in the healthcare system. Health professionals can support such proposals as individuals and through their professional associations. Of course, not all stakeholders agree that the federal government should enforce greater access to health care; after several states brought suit, the US Supreme Court struck down the ACA provision that would have effectively required states to expand Medicaid eligibility.[22] In addition, many health professionals will object to individual Title VI lawsuits. Distinguishing between malpractice litigation and discrimination litigation will be important so that healthcare practitioners do not feel their livelihoods are threatened by Title VI. If improving health equity and combating racism is seen part of one’s ethical duty, then medical professionals should embrace a willingness to be held accountable personally, and even more importantly, as part of a healthcare organization. The AMA has a well-documented history of racism, and the organization has apologized and sought atonement. Part of that history includes a failure to support civil rights legislation in the 1960s and active opposition to Medicare, Medicaid, and the desegregation of hospital staff.[23] Notably, the National Medical Association, an African American medical association, worked hard to support civil rights laws and integration in the 1960s, but could not convince the “White” AMA to follow suit. As part of its anti-racism efforts, the AMA could work with legislators to craft appropriate changes to Title VI and take on the task of educating its membership. Health professionals should understand that the shortcomings of Title VI in eradicating racism in health care were due to decisions about and interpretations of the law which were influenced by the medical profession itself. Educating all the stakeholders about the connections between health, healthcare access, and strong enforcement of our civil rights statutes and regulations is one way that health professionals can actively engage in anti-racism work in the healthcare profession. [1] “The AMA’s Strategic Plan to Embed Racial Justice and Advance Health Equity,” American Medical Association, accessed June 25, 2021, https://www.ama-assn.org/about/leadership/ama-s-strategic-plan-embed-racial-justice-and-advance-health-equity. [2] “How ACA Narrowed Racial Ethnic Disparities Access to Health Care | Commonwealth Fund,” accessed March 10, 2021, https://www.commonwealthfund.org/publications/2020/jan/how-ACA-narrowed-racial-ethnic-disparities-access. [3] Aeyal Gross and Colleen Flood, The Right to Health at the Public/Private Divide : A Global Comparative Study, New York (Cambridge University Press, 2014), , 348, https://web-a-ebscohost-com.ezproxy.cul.columbia.edu/ehost/ebookviewer/ebook/ZTAyNXhuYV9fNzcwMjExX19BTg2?sid=5201c555-548f-4599-ae3d-857f6911322f@sessionmgr4007&vid=0&format=EB&lpid=lp_261&rid=0. [4] Title VI of the 1964 Civil Rights Act, § 2000d (“No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.”) [5] Amitabh Chandra, Michael Frakes, and Anup Malani, “Challenges to Reducing Discrimination and Health Inequity Through Existing Civil Rights Laws,” Health Affairs (Project Hope) 36, no. 6 (June 1, 2017): 1041–47, 1042, https://doi.org/10.1377/hlthaff.2016.1091. [6] David Barton Smith, “The ‘Golden Rules’ for Eliminating Disparities: Title VI, Medicare, and the Implementation of the Affordable Care Act,” Health Matrix, 2015, Gale OneFile: LegalTrac. [7] Olatunde C. A. Johnson, “Lawyering That Has No Name: Title VI and the Meaning of Private Enforcement,” Stanford Law Review 66, 6 (June 2014): 1293-1331, at 1294. [8] Chandra, Frakes, and Malani, at 1043. [9] Alexander v. Sandoval, 532 U.S. 275 (2001). [10] Chandra, Frakes, and Malani, at 1043. [11] See 42 U.S.C. §2000d-1. [12] Chandra, Frakes, and Malani, at 1045. [13] 42 U.S.C. §18116. [14] Chandra, Frakes, and Malani, at 1045. [15] Sarah G. Steege, “Finding a Cure in the Courts: A Private Right of Action for Disparate Impact in Health Care,” Michigan Journal of Race & Law 16, 439 (April 2011): 439- 468. [16] See, e.g., Lemon v. Aurora Health Care North Inc., 19-CV-1384 (E.D. WI Feb. 22, 2021). [17] Johnson, “Lawyering That Has No Name,” at 1295. [18] Pub. L. No. 102-166, § 102, 105 Stat. 1071, 1072-72 (codified as amended at 42 U.S.C. § 1981a). [19] Sara Rosenbaum and Sara Schmucker, “Viewing Health Equity through a Legal Lens: Title VI of the 1964 Civil Rights Act,” Journal of Health Politics, Policy and Law 42, no. 5 (October 1, 2017): 771–88, 777, https://doi.org/10.1215/03616878-3940423. [20] Institute of Medicine (US) Committee On Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, ed. Brian D. Smedley, Adrienne Y. Stith, and Alan R. Nelson (Washington (DC): National Academies Press (US), 2003), http://www.ncbi.nlm.nih.gov/books/NBK220358/. [21] Chandra, Frakes, and Malani, at 1045. [22] National Federation of Independent Business v. Sebelius, 567 U.S. 519 (2012). [23] Harriet A. Washington et al., “Segregation, Civil Rights, and Health Disparities: The Legacy of African American Physicians and Organized Medicine, 1910-1968,” Journal of the National Medical Association 101, no. 6 (June 2009): 513–27, https://doi.org/10.1016/S0027-9684(15)30936-6.

Introduction The term monster might have its roots in the Latin word monere (to warn), but it has since evolved to have various symbolic meanings, from a terrifying mythical creature to a person of extreme cruelty. No matter the flexibility in use, the term is mostly meant to be derogatory (Asma). As Gilmore puts it, monsters “embody all that is dangerous and horrible in the human imagination” (1). However, it may be argued that monsters sometimes perform the much-needed work of defining and policing our norms (Mittman and Hensel). Since their archetype is predisposed to transgressing boundaries of human integrity (Gilmore), they help establish deviation between human and in-human. Their cognition and action are considered ‘other’ (Kearney) and a means with which people can understand what is right and wrong, and what is divergent from appropriate ways of being. The term monster need not even refer to the werewolves, ogres, vampires, zombies and the like that strike fear in audiences through their ‘immoral, heinous or unjust’ appearance or behaviours. Rather, the term monster can be, and has been, readily applied as a metaphor to describe the unthinkable, unethical, and brutal actions of human beings (Beville 5). Inadvertently, “through their bodies, words, and deeds, monsters show us ourselves” (Mittman and Hensel 2), or what we consider monstrous about ourselves. Therefore, humans acting in ways that deviate from societal norms and standards can be viewed as monstrous. This is evident in the representations of public relations practitioners in media offerings. In the practice of public relations, ethical standards are advocated as the norm, and deviating from them considered unprofessional (Fawkes), and as we contend: monstrous. However, the practice has long suffered a negative stereotypical perception of being deceptive, and with public relations roles receiving less screen time than shows and films about lawyers, accountants, teachers and the like, these few derogatory depictions can distort how audiences view the occupation (Johnston). Depictions of professions (lawyers, cops, journalists, etc.) tend to be cliché, but our contention is that fewer depictions of public relations practitioners on screen further limit the possibility for diverse depictions. The media can have a socialising impact and can influence audiences to view the content they consume as a reflection of the real world around them (Chandler). Television, in particular, with its capacity to prompt heuristic processing in audiences (Shurm), has messages that can be easily decoded by people of various literacies as they become immersed in the viewing experiences (Gerbner and Gross). These messages gain potency because, despite being set in fictional worlds, they can be understood as reflective of the world and audiences’ experiences of it (Gerbner and Gross). Tsetsura, Bentley, and Newcomb add that popular stories recounted in the media have authoritative power and can offer patterns of meaning that shape individual perceptions. Admittedly, as Stuart Hall suggests, media offerings can be encoded with ideologies and representations that are considered appropriate according to the dominant elite, but these may not necessarily be decoded as preferred meanings. In other words, those exposed to stories of monstrous public relations practitioners can agree with such a position, oppose this viewpoint, or remain neutral, but this is dependent on individual experiences. Without other frames of reference, it could be that viewers of negative portrayals of public relations accept the encoded representation that inevitably does a disservice to the profession. When the representations of the field of public relations suggest, inaccurately, that the industry is dominated by men (Johnston), and women practitioners are shown as slick dressers who control and care little about ethics (Dennison), the distortions can adversely impact on the identities of public relations practitioners and on how they are collectively viewed (Tsetsura et al.). Public relations practitioners view this portrayal as the ‘other’ and tend to distance the ideal self from it, continuing to be stuck in the dichotomy of saints and sinners (Fawkes). Our observation of television offerings such as Scandal, Flack, Call My Agent!, Absolutely Fabulous, Sex and the City, You’re the Worst, and Emily in Paris reveals how television programmes continue to perpetuate the negative stereotypes about public relations practice, where practitioners are anything but ethical—therefore monstrous. The characters, mostly well-groomed women, are shown as debased, liars and cheaters who will subvert ethical standards for personal and professional gain. Portrayals of Public Relations Practitioners in Television and Media According to Miller, the eight archetypical traits identified in media representations of public relations practitioners are: ditzy, obsequious, cynical, manipulative, money-minded, isolated, accomplished, or unfulfilled. In later research, Yoon and Black found that television representations of public relations tended to suggest that people in these roles were heartless, manipulative bullies, while Lambert and White contend that the depiction of the profession has improved to be more positive, but nonetheless continues to do a disservice to the practice by presenting female workers, especially, as “shallow but loveable” (18). We too find that public relations practitioners continue to be portrayed as morally ambiguous characters who are willing to break ethical codes of conduct to suit the needs of their clients. We discuss three themes prevalent as popular tropes in television programmes that characterise public relations practitioners as monstrous. To Be or Not to Be a Slick and Skilful Liar? Most television programmes present public relations practitioners as slick and skilful liars, who are shown as well-groomed and authoritative, convinced that they are lying only to protect their clients. In fact, in most cases the characters are shown to not only believe but also advocate to their juniors that ‘a little bit of lying’ is almost necessary to maintain client relationships and ensure campaign success. For example, in the British drama Flack, the main character of Robyn (played by Anna Paquin) is heard advising her prodigy “just assume we are lying to everyone”. The programmes also feature characters who are in dilemma about the monstrous expectations from their roles, struggling to accept that that they engage in deception as part of their jobs. However, most of them are presented as somewhat of an ugly duckling or the modest character in the programme, who is not always rational or in an explicit position of power. For example, Emily from Emily in Paris (played by Lily Collins), while working as a social media manager, regularly questions the approaches taken by the firm she works for. Her boss Sylvie Grateux (played by Philippine Leroy-Beaulieu), who embodies the status quo, is constantly disapproving of Emily’s lack of sophisticated self-presentation, among other aspects. In the episode ‘Faux Amis’, Sylvie quips “it’s not you personally. It’s everything you stand for. You’re the enemy of luxury because luxury is defined by sophistication and taste, not emilyinparis”. Similarly, in the first episode of Call My Agent!, Samuel Kerr (played by Alain Rimoux), the head of a film publicity firm, solves the conundrum faced by his anxious junior Gabriel (played by Grégory Montel) by suggesting that he lie to his client about the real reason why she lost the film. When a modestly dressed Gabriel questions how he can lie to someone he cares for, Samuel, towering over him in an impeccable suit and a confident demeanour, advises “who said anything about lying? Don’t lie. Simply don’t tell her the truth”. However, the subtext here is that the lie is to protect the client from unnecessary hurt and in doing so nurtures the client relationship. So, it lets the audience decide the morality of lying here. It may be argued that moral ambiguity may not necessarily be monstrous. Such grey characters are often crafted because they allow audiences to relate more readily to themselves by encouraging what Hawkins refers to as mental play. Audiences are less interested in the black and white of morality and veer towards shows such as Call My Agent! where storylines hone in on the need to do bad for the greater good. In these ways, public relations practitioners still transgress moral standards but are less likely to be considered monstrous because the impact and effect on others is utilitarian in nature. It is also interesting to note that in these programmes physical appearance is made to play a crucial role in showcasing the power and prestige of the senior public relations practitioner. This focus on attire can tend to further perpetuate unfavourable stereotypes about public relations practitioners being high income earners (Grandien) who are styled with branded apparel but lacking in substance and morals (Fröhlich and Peters). Promiscuous Women The urge to attract audiences to a female character can also lead to developing and cementing unfavourable stereotypes of public relations practitioners as uninhibited women who live on blurred lines between personal and professional. These characters are not portrayed as inherently bad, but instead are found to indulge in lives of excess. In her definition of the monstrous, Arumugam suggests that excess and insatiable appetites direct the monster’s behaviour, and Kearney outlines that this uncontainable excess is what signals the difference between humans and others. Such excess is readily identifiable in the character of Patsy Stone (played by Joanna Lumley) in Absolutely Fabulous. She is an alcoholic, regularly uses recreational drugs, is highly promiscuous, and chain-smokes throughout the series. She is depicted as prone to acting deceptively to maintain her vices. In Flack, Robyn is shown as regularly snorting cocaine and having sex with her clients. Those reviewing the show highlight how it will attract those interested in “its dark, acidic sense of humour” (Greene) while others condemn it because it emphasises the “depraved publicist” trope (Knibbs) and call it “one of the worst TV shows ever made” even though it is trying to highlight concerns raised in the MeToo movement about how men need to respect women (McGurk). Female characters such as Robyn, with her willingness to question why a client has not tried to sleep with her, appear to undermine the empowerment of the movement rather than support it, and continue to maintain the archetypes that those working in the field of public relations abhor. Similarly, Samantha Jones (played by Kim Cattrell) of Sex and the City is portrayed as sexually liberated, and in one episode another character describes Samantha’s vagina as “the hottest spot in town: it’s always open”. In many ways Samantha’s sexual behaviour reflects a post-feminist narrative of empowerment, agency, and choice, but it could also be read as a product of being a public relations practitioner frequenting parties and bars as she rubs shoulders with clients, celebrities, and high-profile businesspeople. To this end, Patsy, Samantha, and Robyn glamourise public relations and paint it as simply an extension of their liberated and promiscuous selves, with little care for any expectation of professionalism or work ethic. This is also in stark contrast to the reality, where women often tend to occupy technical roles that see much of their time spent in doing the hard yards of publicity and promotion (Krugler). Making Others Err Public relations practitioners are not just shown as being morally ambiguous themselves, but often quite adept at making others do deceitful acts on their behalf, thus nonchalantly oppressing others to get their way. For example, although lauded for elevating an African-American woman to the lead role despite the show maintaining misrepresentations of race (Lambert), the main character of Olivia Pope (played by Kerry Washington) in the television programme Scandal regularly subverts the law for her clients despite considering herself one of the “good guys” and wearing a “white hat”. Over the course of seven seasons, Olivia Pope is found to rig elections, plant listening devices in political figures’ offices, bribe, threaten, and conduct an affair with the President. In some cases, she calls on the services of her colleague Huck to literally, and figuratively, get rid of the barriers in the way of protecting her clients. For example, in season one’s episode Crash and Burn she asks Huck to torture a suspect for information about a dead client. Her willingness to request such actions of her friend and colleague, regardless of perceived good motivations, reinforces Mittman’s categorisation that monsters are identified by their effect and impact on others. Here, the impact includes the torturing of a suspect and the revisiting of psychological trauma by Huck’s character. Huck struggles to overcome his past as a killer and spends much of the show trying to curb his monstrous tendencies which are often brought on by PR woman Olivia’s requests. Although she is sometimes striving for justice, Olivia’s desire for results can lead her to act monstrously, which inadvertently contributes to the racist and sexist ideologies that have long been associated with monsters and perceptions of the Other. Across time and space, certain ethnic groups, such as those of African descent, have been associated with the demonic (Cohen). Similarly, all that is feminine often needs to be discarded as the monster to conform to the patriarchal order of society (Creed). Therefore, Olivia Pope’s monstrous behaviour not only does a disservice to representations of public relations practitioners, but also inadvertently perpetuates negative and inaccurate stereotypes about women of African American descent. Striving to be Ethical The majority of public relations practitioners are encouraged, and in some cases expected, to conform to ethical guidelines to practice and gain respect, admiration, and in-group status. In New Zealand, those who opt to become members of the Public Relations Institute of New Zealand (PRINZ) are required to abide by the association’s code of ethics. The code stipulates that members are bound to act in ways that serve public interests by ensuring they are honest, disclose conflict of interests, follow the law, act with professionalism, ensure openness and privacy are maintained, and uphold values of loyalty, fairness, and independence (PRINZ). Similarly, the Global Alliance of Public Relations and Communication Management that binds practitioners together identifies nine guiding principles that are to be adhered to to be recognised as acting ethically. These include obeying laws, working in the public’s interest, ensuring freedom of speech and assembly, acting with integrity, and upholding privacy in sensitive matters (to name a few). These governing principles are designed to maintain ethical practice in the field. Of course, the trouble is that not all who claim to practice public relations become members of the local or global governing bodies. This implies that professional associations like PRINZ are not able to enforce ethics across the board. In New Zealand alone, public relations consultants have had to offer financial reparations for acting in defamatory ways online (Fisher), or have been alleged to have bribed an assault victim to prevent the person giving evidence in a court case (Hurley). Some academics have accused the industry of being engaged in organised lying (Peacock), but these are not common, nor are these moral transgressors accepted into ethical bodies that afford practitioners authenticity and legitimacy. In most cases, public relations practitioners view their role as acting as the moral conscience of the organisations they support (Schauster, Neill, Ferrucci, and Tandoc). Furthermore, they rated better than the average adult when it came to solving ethical dilemmas through moral reasoning (Schuaster et al.). Additionally, training of practitioners through guidance of mentors has continued to contribute to the improved ethical ratings of public relations. What these findings suggest is that the monsters of public relations portrayed on our television screens are exaggerations that are not reflective of most of the practice. Women of Substance, But Not Necessarily Power Exploring the role of women in public relations, Topic, Cunha, Reigstad, Jele-Sanchez, and Moreno found that female practitioners were subordinated to their male counterparts but were found to be more inclined to practice two-way communication, offer balanced perspectives, opt to negotiate, and build relationships through cooperation. The competitiveness, independence, and status identified in popular media portrayals were found to be exhibited more by male practitioners, despite there being more women in the public relations industry than men. As Fitch argues, popular culture continues to suggest that men dominate public relations, and their preferred characteristics end up being those elements that permeate the media messages, regardless of instances where the lead character is a woman or the fact that feminist values of “loyalty, ethics, morality, [and] fairness” are advocated by female practitioners in real life (Vardeman-Winter and Place 333). Additionally, even though public relations is a feminised field, female practitioners struggle to break the glass ceiling, with male practitioners dominating executive positions and out-earning women (Pompper). Interestingly, in public relations, power is not just limited due to gender but also area of practice. In her ethnographic study of the New Zealand practice, Sissons found that practitioners who worked in consultancies were relatively powerless vis-à-vis their clients, and often this asymmetry negatively affected the practitioner’s decision-making. This implies that in stark contrast to the immoral, glamourous, and authoritative depiction of public relations women in television programmes, in reality they are mired by the struggles of a gendered occupation. Accordingly, they are not in fact in a position to have monstrous power over and impact on others. Therefore, one of the only elements the shows seem to capture and emphasise is that public relations is an occupation that specialises in image management; but what these shows contribute to is an ideology that women are expected to look and carry themselves in particular ways, ultimately constructing aesthetic standards that can diminish women’s power and self-esteem. Conclusion Miller’s archetypes may be over twenty years old, but the trend towards obsequious, manipulative, and cynical television characters remains. Although there have been identifiable shifts to loveable, yet shallow, public relations practitioners, such as Alexis Rose on Schitt’s Creek, the appeal of monstrous public relations practitioners remains. As Cohen puts it, monsters reveal to audiences “what a member of that society can become when those same dictates are rejected, when the authority of leaders or customs disintegrates and the subordination of individual to hierarchy is lost” (68). In other words, audiences enjoy watching the stories of metaphorical monsters because they exhibit the behaviours that are expected to be repressed in human beings; they depict what happens when the social norms of society are disturbed (Levina and Bui). At the very least, these media representations can act, much as monster narratives do, as a cautionary tale on how not to think and act to remain accepted as part of the in-group rather than being perceived as the Other. As Mittman and Hensel argue, society can learn much from monsters because monsters exist within human beings. According to Cohen, they offer meaning about the world and can teach audiences so they can learn, in this case, how to be better. Although the representations of public relations in television can offer insights into roles that are usually most effective when they are invisible (Chorazy and Harrington), the continued negative stereotypes of public relations practitioners can adversely impact on the industry if people are unaware of the practices of the occupation, because lacking a reference point limits audiences’ opportunities to critically evaluate the media representations. This will certainly harm the occupation by perpetuating existing negative stereotypes of charming and immoral practitioners, and perhaps add to its struggles with gendered identity and professional legitimacy. References Absolutely Fabulous. Created by Jennifer Saunders and Dawn French. 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