Public Health Ethics: Cases Spanning the Globe

Public health ethics can be seen both as the application of principles and norms to guide the practice of public health and as a process for identifying, analyzing, and resolving ethical issues inherent in the practice of public health. Public health ethics helps us decide what we should do and why. Although the practice of public health has always considered ethical issues, the emergence of public health ethics as a discipline is relatively new. Although rooted in bioethics and clinical and research ethics, public health ethics has many characteristics that set it apart. The defining characteristics are its focus on achieving social goods for populations while respecting individual rights and recognizing the interdependence of people. Currently there are few practical training resources for public health practitioners that consider ethical issues and dilemmas likely to arise in the practice of public health. In public health ethics training, we have found it advantageous to use cases to illustrate how ethical principles can be applied in practical ways to decision making. The use of cases encourages reflection and discussion of ethics, reinforces basic ethical concepts through application to concrete examples, highlights practical decision making, allows learners to consider different perspectives, and sensitizes learners to the complex, multidimensional context of issues in public health practice. The case-based approach (known as casuistry) contrasts with the theoretical approach to considering moral principles, rules, and theories. By describing scenarios, cases allow the learner to use ethical principles in the context of a realistic situation that sheds light on ethical challenges and illustrates how ethical principles can help in making practical decisions. This casebook comprises a broad range of cases from around the globe to highlight the ethical challenges of public health. For those new to public health ethics, Section I introduces public health ethics. Chapter 1, “Public Health Ethics: Global Cases, Practice, and Context” by Ortmann and colleagues, summarizes basic concepts and describes how public health ethics differ from bioethics, clinical ethics, and research ethics. The chapter also includes an approach for conducting an ethical analysis in public health. In Chap. 2, “Essential Cases in the Development of Public Health Ethics,” Lee, Spector-Bagdady, and Sakhuja highlight important events that shaped the practice of public health and explain how practitioners address and prevent ethical challenges. Section II is organized into chapters that discuss the following public health topics: • Resource allocation and priority setting • Disease prevention and control • Chronic disease prevention and health promotion • Environmental and occupational public health • Vulnerability and marginalized populations • International collaboration for global public health • Public health research We have invited some of the leading writers and thinkers in public health ethics to provide an overview of the major ethical considerations associated with each topic. The topic overviews offer the authors’ perspectives about applicable ethical theories, frameworks, and tools and draw attention to the cases that follow. The cases are meant to highlight the ethical issues in practice. Each represents the work of authors from around the globe who responded to a solicitation from the U.S. Centers for Disease Control and Prevention. We worked with the authors to ensure that each case included a concise articulation of a public health situation that raises ethical tensions, challenges, or concerns that require decisions or recommendations from public health officials or practitioners. The cases are presented in a standard format that includes a background, case description, discussion questions, and references. However, we also allowed for variation in the amount of detail provided in each section and the approach used to set up the case. Our goal was to include just enough contextual information to orient the reader who is not an expert in the case topic. We include the case setting, population, or intervention in question, legal or regulatory landscape, and questions to stimulate discussion on core ethical issues. Each case—although fictionalized—is as realistic as possible to reflect the ethical challenges that public health practitioners face daily. Sometimes the cases were based on actual or composite events. In these instances, the case details were modified to exclude identifying information that could be considered private, sensitive, or disputable by others involved in the case. We deliberately did not attempt to provide a resolution or solution for the cases. Often in public health practice, there is no single correct answer. Instead, ethical analysis in public health is a process to identify the ethical dimensions of the options available and to arrive at a decision that is ethically justifiable, through deliberation and consideration of relevant facts, values, and contexts. The cases and other writings in this book represent the opinions, findings, and conclusions of the authors and do not necessarily reflect the official position, views, or policies of the editors, the editors’ host institutions, or the authors’ host institutions. We decided which topic category to place the case in to best distribute the cases across chapters. However, you may note that some cases cross topic areas and could just as easily have been included in another chapter. This casebook is written for public health practitioners, including frontline workers, field epidemiology trainers and trainees, and managers, planners, and decision makers with an interest in learning about how to integrate ethical analysis in their day-to-day public health practice. However, the casebook will also be useful to instructors in schools of public health and public health students as well as to academic ethicists who can use the book to teach public health ethics and distinguish it from clinical and research ethics. Our hope is that the casebook will increase awareness and understanding of public health ethics and the value of ethical analysis in public health practice in all of its forms. This includes applied public health research; public health policy development, implementation, and evaluation; and public health decision making in national and international field settings and training programs. By emphasizing prospective practical decision making, rather than just presenting a theoretical academic discussion of ethical principles, we hope this casebook will serve as a useful tool to support instruction, debate, and dialogue about the nature of ethical challenges encountered in public health practice and how to resolve these challenges. We recommend discussing the cases in small groups and using the discussion questions, the ethical framework described in Chap. 1, and the information provided in the topic area overview sections as a starting place for exploring the ethical issues reflected in the cases. The ultimate goal of case-based learning is to develop skills in ethical analysis and decision making in daily public health practice. The ethical framework provides a convenient tool for putting our ideas into practice

Biosolids application and soil organic carbon dynamics: a meta-analysis.

Soil carbon sequestration has been recognized as a potential “direct action” tool in mitigating climate change. Organic matter rich biosolids from wastewater industry has been applied to soils as one of the strategies to the carbon sequestration. However, most of the short- and long-term studies as influenced by land application of biosolids have been showed quite inconsistent results in carbon increments in soils. Therefore, soil carbon sequestration resulted by biosolids application is yet to be needed further studies to elucidate. This study presents a comprehensive MetaAnalysis (MA) on soil carbon sequestration as influenced by biosolids application. Datasets comprised with 175 independent paired-treatments across 25 countries were fed in to Comprehensive Meta-Analysis (version 3) programme and modelled. The MA compared Soil Organic Carbon (SOC as g/kg) changes as the functions of time after biosolids application and its rate over twelve groups under two categories: application age (time after application) as 11 year, and cumulative application rate as 251 tonnes/ha.The fixed model is applied to explicate overall effects of analysed data derived from the MA. The MA showed overall positive influences on soil carbon sequestration towards increasing SOC. For example, the highest effect on SOC was observed at 1-3 age group suggesting the need of short term biosolids application to develop carbon storage in soils. Overall, this study shows that land application of biosolids can be used to increase soil carbon storage and therefore has the potential to be a strategy for mitigating climate change towards carbon sequestration in soils

A Saffron Spice Separation System with Computer Vision

A separation device is described to obtain saffron spice after harvesting. To set the separation device, a vertical wind tunnel is developed which measures the terminal velocities of parts of saffron flower, with variations for different regions and years of production. The separation device is equipped with a vision system, which evaluates the separation and the percentage of purity of the saffron spice obtained after separation. In this paper, the design and the realization of the wind tunnel and of the separation device are described and the separation of the flower is performed and discussed, evaluating the separation efficiency

Tetraspanin (TSP-17) Protects Dopaminergic Neurons against 6-OHDA-Induced Neurodegeneration in <i>C. elegans</i>

Parkinson's disease (PD), the second most prevalent neurodegenerative disease after Alzheimer's disease, is linked to the gradual loss of dopaminergic neurons in the substantia nigra. Disease loci causing hereditary forms of PD are known, but most cases are attributable to a combination of genetic and environmental risk factors. Increased incidence of PD is associated with rural living and pesticide exposure, and dopaminergic neurodegeneration can be triggered by neurotoxins such as 6-hydroxydopamine (6-OHDA). In C. elegans, this drug is taken up by the presynaptic dopamine reuptake transporter (DAT-1) and causes selective death of the eight dopaminergic neurons of the adult hermaphrodite. Using a forward genetic approach to find genes that protect against 6-OHDA-mediated neurodegeneration, we identified tsp-17, which encodes a member of the tetraspanin family of membrane proteins. We show that TSP-17 is expressed in dopaminergic neurons and provide genetic, pharmacological and biochemical evidence that it inhibits DAT-1, thus leading to increased 6-OHDA uptake in tsp-17 loss-of-function mutants. TSP-17 also protects against toxicity conferred by excessive intracellular dopamine. We provide genetic and biochemical evidence that TSP-17 acts partly via the DOP-2 dopamine receptor to negatively regulate DAT-1. tsp-17 mutants also have subtle behavioral phenotypes, some of which are conferred by aberrant dopamine signaling. Incubating mutant worms in liquid medium leads to swimming-induced paralysis. In the L1 larval stage, this phenotype is linked to lethality and cannot be rescued by a dop-3 null mutant. In contrast, mild paralysis occurring in the L4 larval stage is suppressed by dop-3, suggesting defects in dopaminergic signaling. In summary, we show that TSP-17 protects against neurodegeneration and has a role in modulating behaviors linked to dopamine signaling

Chemotherapy-associated liver morphological changes in hepatic metastases (CALMCHeM)

PURPOSETo review imaging findings in chemotherapy-associated liver morphological changes in hepatic metastases (CALMCHeM) on computed tomography (CT)/magnetic resonance imaging (MRI) and its association with tumor burden.METHODSWe performed a retrospective chart review to identify patients with hepatic metastases who received chemotherapy and subsequent follow-up imaging where CT or MRI showed morphological changes in the liver. The morphological changes searched for were nodularity, capsular retraction, hypodense fibrotic bands, lobulated outline, atrophy or hypertrophy of segments or lobes, widened fissures, and one or more features of portal hypertension (splenomegaly/venous collaterals/ascites). The inclusion criteria were as follows: a) no known chronic liver disease; b) availability of CT or MRI images before chemotherapy that showed no morphological signs of chronic liver disease; c) at least one follow-up CT or MRI image demonstrating CALMCHeM after chemotherapy. Two radiologists in consensus graded the initial hepatic metastases tumor burden according to number (≤10 and >10), lobe distribution (single or both lobes), and liver parenchyma volume affected (10 in 64.4% of patients. The volume of liver involved was <50% in 79.8% and ≥50% in 20.2% of cases. The severity of CALMCHeM at the first imaging follow-up was associated with a larger number of metastases (P = 0.002) and volume of the liver affected (P = 0.015). The severity of CALMCHeM had progressed to moderate to severe changes in 85.9% of patients, and 72.5% of patients had one or more features of portal hypertension at the last follow-up. The most common features at the final follow-up were nodularity (95.0%), capsular retraction (93.4%), atrophy (66.2%), and ascites (65.7%). The Cox proportional hazard model showed metastases affected ≥50% of the liver (P = 0.033), and the female gender (P = 0.004) was independently associated with severe CALMCHeM.CONCLUSIONCALMCHeM can be observed with a wide variety of malignancies, is progressive in severity, and the severity correlates with the initial metastatic liver disease burden

Acalabrutinib monotherapy in patients with chronic lymphocytic leukemia who are intolerant to ibrutinib.

The Bruton tyrosine kinase (BTK) inhibitor ibrutinib improves patient outcomes in chronic lymphocytic leukemia (CLL); however, some patients experience adverse events (AEs) leading to discontinuation. Acalabrutinib is a potent, covalent BTK inhibitor with greater selectivity than ibrutinib. We evaluated the safety and efficacy of 100 mg of acalabrutinib twice daily or 200 mg once daily in patients with CLL who discontinued ibrutinib because of intolerance as determined by the investigators. Among 33 treated patients (61% men; median age, 64 years; range, 50-82 years), median duration of prior ibrutinib treatment was 11.6 months (range, 1-62 months); median time from ibrutinib discontinuation to acalabrutinib start was 47 days (range, 3-331 days). After a median of 19.0 months (range, 0.2-30.6 months), 23 patients remained on acalabrutinib; 10 had discontinued (progressive disease, n = 4; AEs, n = 3). No acalabrutinib dose reductions occurred. During acalabrutinib treatment, the most frequent AEs included diarrhea (58%), headache (39%), and cough (33%). Grade 3/4 AEs occurred in 58%, most commonly neutropenia (12%) and thrombocytopenia (9%). Of 61 ibrutinib-related AEs associated with intolerance, 72% did not recur and 13% recurred at a lower grade with acalabrutinib. Overall response rate was 76%, including 1 complete and 19 partial responses and 5 partial responses with lymphocytosis. Among 25 responders, median duration of response was not reached. Median progression-free survival (PFS) was not reached; 1-year PFS was 83.4% (95% confidence interval, 64.5%-92.7%). Acalabrutinib was well tolerated with a high response rate in patients who were previously intolerant to ibrutinib. This trial was registered at www.clinicaltrials.gov as #NCT02029443

Agronomic Management of Indigenous Mycorrhizas

Many of the advantages conferred to plants by arbuscular mycorrhiza (AM) are associated to the ability of AM plants to explore a greater volume of soil through the extraradical mycelium. Sieverding (1991) estimates that for each centimetre of colonized root there is an increase of 15 cm3 on the volume of soil explored, this value can increase to 200 cm3 depending on the circumstances. Due to the enhancement of the volume of soil explored and the ability of the extraradical mycelium to absorb and translocate nutrients to the plant, one of the most obvious and important advantages resulting from mycorrhization is the uptake of nutrients. Among of which the ones that have immobilized forms in soil, such as P, assume particular significance. Besides this, many other benefits are recognized for AM plants (Gupta et al, 2000): water stress alleviation (Augé, 2004; Cho et al, 2006), protection from root pathogens (Graham, 2001), tolerance to toxic heavy metals and phytoremediation (Audet and Charest, 2006; Göhre and Paszkowski, 2006), tolerance to adverse conditions such as very high or low temperature, high salinity (Sannazzaro et al, 2006), high or low pH (Yano and Takaki, 2005) or better performance during transplantation shock (Subhan et al, 1998). The extraradical hyphae also stabilize soil aggregates by both enmeshing soil particles (Miller e Jastrow, 1992) and producing a glycoprotein, golmalin, which may act as a glue-like substance to adhere soil particles together (Wright and Upadhyaya, 1998). Despite the ubiquous distribution of mycorrhizal fungi (Smith and Read, 2000) and only a relative specificity between host plants and fungal isolates (McGonigle and Fitter, 1990), the obligate nature of the symbiosis implies the establishment of a plant propagation system, either under greenhouse conditions or in vitro laboratory propagation. These techniques result in high inoculum production costs, which still remains a serious problem since they are not competitive with production costs of phosphorus fertilizer. Even if farmers understand the significance of sustainable agricultural systems, the reduction of phosphorus inputs by using AM fungal inocula alone cannot be justified except, perhaps, in the case of high value crops (Saioto and Marumoto, 2002). Nurseries, high income horticulture farmers and no-agricultural application such as rehabilitation of degraded or devegetated landscapes are examples of areas where the use of commercial inoculum is current. Another serious problem is quality of commercial available products concerning guarantee of phatogene free content, storage conditions, most effective application methods and what types to use. Besides the information provided by suppliers about its inoculum can be deceiving, as from the usually referred total counts, only a fraction may be effective for a particular plant or in specific soil conditions. Gianinazzi and Vosátka (2004) assume that progress should be made towards registration procedures that stimulate the development of the mycorrhizal industry. Some on-farm inoculum production and application methods have been studied, allowing farmers to produce locally adapted isolates and generate a taxonomically diverse inoculum (Mohandas et al, 2004; Douds et al, 2005). However the inocula produced this way are not readily processed for mechanical application to the fields, being an obstacle to the utilization in large scale agriculture, especially row crops, moreover it would represent an additional mechanical operation with the corresponding economic and soil compaction costs. It is well recognized that inoculation of AM fungi has a potential significance in not only sustainable crop production, but also environmental conservation. However, the status quo of inoculation is far from practical technology that can be widely used in the field. Together a further basic understanding of the biology and diversity of AM fungi is needed (Abbott at al, 1995; Saito and Marumoto, 2002). Advances in ecology during the past decade have led to a much more detailed understanding of the potential negative consequences of species introductions and the potential for negative ecological consequences of invasions by mycorrhizal fungi is poorly understood. Schwartz et al, (2006) recommend that a careful assessment documenting the need for inoculation, and the likelihood of success, should be conducted prior to inoculation because inoculations are not universally beneficial. Agricultural practices such as crop rotation, tillage, weed control and fertilizer apllication all produce changes in the chemical, physical and biological soil variables and affect the ecological niches available for occupancy by the soil biota, influencing in different ways the symbiosis performance and consequently the inoculum development, shaping changes and upset balance of native populations. The molecular biology tools developed in the latest years have been very important for our perception of these changes, ensuing awareness of management choice implications in AM development. In this context, for extensive farming systems and regarding environmental and economic costs, the identification of agronomic management practices that allow controlled manipulation of the fungal community and capitalization of AM mutualistic effect making use of local inoculum, seem to be a wise option for mycorrhiza promotion and development of sustainable crop production

Microbial functional diversity and carbon use feedback in soils as affected by heavy metals

Soil microorganisms are an important indicator of soil fertility and health. However, our state of knowledge about soil microbial activities, community compositions and carbon use patterns under metal contaminations is still poor. This study aimed to evaluate the influences of heavy metals (Cd and Pb) on soil microorganisms by investigating the microbial community composition and carbon use preferences. Metal pollution was approached both singly and jointly with low (25 and 2500 mg kg−1) and high (50 and 5000 mg kg−1) concentrations of Cd and Pb, respectively, in an artificially contaminated soil. In a laboratory incubation experiment, bio-available and potentially bio-available metal concentrations, selected soil properties (pH, electrical conductivity, total organic carbon and total nitrogen), and microbial parameters (microbial activity as basal respiration, microbial biomass carbon (MBC) and microbial functional groups) were determined at two sampling occasions (7 and 49 days). Metal contamination had no effect on the selected soil properties, while it significantly inhibited both microbial activity and MBC formation. Contaminated soils had higher microbial quotient (qCO2), suggesting there was higher energy demand with less microbially immobilized carbon as MBC. Notably, the efficiency of microbial carbon use was repressed as the metal concentration increased, yet no difference was observed between metal types (p > 0.05). Based on the microbial phospholipid fatty acids (PLFA) analysis, total PLFAs decreased significantly under metal stress at the end of incubation. Heavy metals had a greater negative influence on the fungal population than bacteria with respective 5–35 and 8–32% fall in abundances. The contaminant-driven (metal concentrations and types) variation of soil PLFA biomarkers demonstrated that the heavy metals led to the alteration of soil microbial community compositions and their activities, which consequently had an adverse impact on soil microbial carbon immobilization