tag:theconversation.com,2011:/institutions/johns-hopkins-university-1256/articlesJohns Hopkins University2024-03-04T18:23:24Ztag:theconversation.com,2011:article/2236212024-03-04T18:23:24Z2024-03-04T18:23:24Z¿Arrepentimiento transgénero? una investigación pone en duda los relatos sobre las cirugías de reasignación de sexo<figure><img src="https://images.theconversation.com/files/575703/original/file-20240115-19-obyz75.jpg?ixlib=rb-1.1.0&rect=135%2C23%2C5179%2C3519&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Las cirugías de reafirmación del género dan a las personas transexuales la oportunidad de alinear su cuerpo con su identidad de género.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/transgender-woman-prepares-another-womans-makeup-prior-to-news-photo/1484588805?adppopup=true">Luke Dray/Getty Images</a></span></figcaption></figure>
<p>A menudo escucharás a <a href="https://www.nytimes.com/2023/05/16/us/politics/transgender-care-detransitioners.html">legisladores</a>, <a href="https://www.youtube.com/watch?v=dJMMqREtQJc">activistas</a> y <a href="https://www.cbsnews.com/news/60-minutes-transgender-health-care-issues-2021-05-23/">críticos</a> argumentar que muchas personas transgénero se arrepienten de su decisión de someterse a operaciones quirúrgicas de reasignación de sexo, una creencia que ha estado alimentando una <a href="https://www.lgbtmap.org/equality-maps/healthcare_youth_medical_care_bans">oleada legislativa</a> que restringen el acceso a la atencióne sanitaria de afirmación de género.</p>
<p>La atención sanitaria de afirmación de género puede incluir procedimientos quirúrgicos como la reconstrucción facial, <a href="https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/top-surgery">cirugía de la parte “superior”</a> y la <a href="https://transcare.ucsf.edu/guidelines/vaginoplasty">cirugía genital o “inferior”</a>.</p>
<p>Pero en <a href="https://jamanetwork.com/journals/jamasurgery/article-abstract/2813212">un artículo</a> que publicamos recientemente en JAMA Surgery, ponemos en duda la idea de que las personas transgénero suelen arrepentirse de las cirugías de reasignación de sexo.</p>
<p>Los datos indican que menos del 1 % de las personas transgénero que se someten a una cirugía de reasignación de sexo se arrepienten. Esta proporción es aún más sorprendente si se compara con el hecho de que el 14,4 % de la población en general se arrepiente de cirugías similares.</p>
<p>Por ejemplo, los estudios han revelado que entre el <a href="https://doi.org/10.1016/j.pec.2017.06.032">5 % y el 14 %</a> de todas las mujeres que se someten a una mastectomía para reducir el riesgo de desarrollar cáncer de mama dicen que se arrepienten de haberlo hecho. Sin embargo, menos del 1 % de los hombres transgénero que se someten a la misma intervención dicen arrepentirse.</p>
<p>Estas estadísticas se basan en revisiones de <a href="https://journals.lww.com/prsgo/fulltext/2021/03000/regret_after_gender_affirmation_surgery__a.22.aspx">estudios existentes</a> que investigaron el arrepentimiento entre 7 928 personas transgénero que recibieron cirugías de reasignación de sexo. Aunque algunas de estas investigaciones previas <a href="https://journals.lww.com/prsgo/fulltext/2021/11000/letter_to_the_editor__regret_after.29.aspx">han sido criticadas</a> por pasar por alto el hecho de que el arrepentimiento a veces puede tardar años en desarrollarse, coinciden con el creciente número de estudios que muestran resultados de salud positivos entre las personas transgénero que reciben atención que afirma el género.</p>
<h2>¿Por qué es importante el acceso a la cirugía de asignación de sexo?</h2>
<p>Alrededor de <a href="https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/">1,6 millones de personas</a> en Estados Unidos se identifican como transgénero. Aunque solo <a href="https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf">alrededor del 25 %</a> de estas personas se han sometido a cirugías de reasignación de sexo, <a href="https://www.doi.org/10.1001/jamanetworkopen.2023.30348">estos procedimientos se han vuelto más comunes</a>. De 2016 a 2020, aproximadamente 48 000 personas trans en los Estados Unidos recibieron cirugías de reasignación de sexo.</p>
<p>Estos procedimientos brindan a las personas transgénero la oportunidad de alinear su cuerpo físico con su identidad de género, lo que podría repercutir positivamente en su salud mental. <a href="https://doi.org/10.1080/19359705.2021.2016537">Las investigaciones demuestran</a> que el acceso a las cirugías de reasignación de sexo puede reducir los niveles de depresión, ansiedad e ideación suicida entre las personas transgénero.</p>
<p>Los beneficios para la salud mental pueden explicar los bajos niveles de arrepentimiento. Las personas transgénero presentan <a href="https://doi.org/10.1080/09540261.2022.2093629">tasas mucho más elevadas</a> de problemas de salud mental que las personas cisgénero, o aquellas cuya identidad de género coincide con su sexo de nacimiento. Esto se debe en gran medida a que las personas transgénero tienen más dificultades para <a href="https://theconversation.com/what-the-new-science-of-authenticity-says-about-discovering-your-true-self-175314">vivir auténticamente</a> sin sufrir <a href="https://www.cdc.gov/mmwr/volumes/68/wr/mm6803a3.htm?s_cid=mm6803a3_w">discriminación, acoso y violencia.</a></p>
<p>La cirugía de reasignación de sexo suele implicar <a href="https://doi.org/10.1080/26895269.2022.2100644">pasar por una serie de pruebas</a>: periodos de espera, terapia hormonal y aprendizaje sobre los posibles riesgos y beneficios de los procedimientos. Aunque la mayoría de las cirugías están reservadas para adultos, las <a href="https://www.wpath.org/">principales directrices</a> recomiendan que los pacientes tengan al menos 15 años.</p>
<p>Este minucioso proceso por el que pasan las personas trans antes de someterse a una intervención quirúrgica también puede explicar los menores niveles de arrepentimiento.</p>
<p>Además, muchas personas cisgénero se someten a cirugías que, en su mundo ideal, no recibirían. Pero lo hacen para evitar un problema de salud.</p>
<p>Por ejemplo, una mujer cisgénero que se somete a una mastectomía para evitar el cáncer de mama puede acabar arrepintiéndose de la decisión si no le gusta su nuevo aspecto. En cambio, es más probable que un hombre transgénero que se someta a la misma intervención esté satisfecho con un pecho de aspecto masculino.</p>
<h2>Mejorar la investigación y las políticas públicas</h2>
<p>Es importante señalar que esta investigación no es concluyente. Las opiniones sobre las intervenciones quirúrgicas <a href="https://doi.org/10.1007/s00268-017-3895-9">pueden cambiar con el tiempo</a>, y los pacientes pueden opinar de forma muy distinta sobre sus resultados ocho años <a href="https://doi.org/10.1007/s10508-014-0300-8">después de la intervención</a> que un año después.</p>
<p>No obstante, el consenso entre los expertos, incluidos los de la <a href="https://www.ama-assn.org/press-center/press-releases/ama-reinforces-opposition-restrictions-transgender-medical-care">Asociación Médica Estadounidense</a>, es que la cirugía de reasignación de sexo puede mejorar la salud de las personas transgénero y no debe prohibirse.</p>
<p><a href="https://www.lgbtmap.org/equality-maps/healthcare_youth_medical_care_bans">Estados de EE. UU.</a> como Oklahoma y Dakota del Norte han ignorado este consenso y han restringido el acceso a estos procedimientos. En respuesta, 12 estados se han designado a sí mismos “<a href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2812422">santuarios</a>” para la atención que afirma el género.</p>
<p>Aunque nuestras estadísticas sobre arrepentimiento quirúrgico pueden cambiar a medida que los investigadores aprendan más, son los mejores datos que tienen los profesionales sanitarios. Y las políticas públicas basadas en los mejores datos disponibles son las que más pueden mejorar la vida de las personas.</p>
<p><em>Spanish translation by: Santiago Echeverri</em></p><img src="https://counter.theconversation.com/content/223621/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Harry Barbee receives funding from the National Institute on Aging. </span></em></p><p class="fine-print"><em><span>Bashar Hassan and Fan Liang do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Los resultados contradicen la idea de que muchas personas transexuales acaban deseando no haberse sometido a operaciones de reafirmación de género.Harry Barbee, Assistant Professor of Health, Behavior and Society, Johns Hopkins UniversityBashar Hassan, Postdoctoral Research Fellow in Plastic and Reconstructive Surgery, Johns Hopkins UniversityFan Liang, Assistant Professor of Plastic and Reconstructive Surgery, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2231682024-02-13T02:12:12Z2024-02-13T02:12:12ZEstudo contesta narrativas sobre arrependimento em cirurgias de afirmação de gênero<figure><img src="https://images.theconversation.com/files/574484/original/file-20240115-19-obyz75.jpg?ixlib=rb-1.1.0&rect=111%2C31%2C5171%2C3511&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Os achados contrariam discurso de que muitas pessoas transgênero acabam desejando voltar atrás nos procedimentos que alinharam seus corpos físicos à sua identidade de gênero</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/transgender-woman-prepares-another-womans-makeup-prior-to-news-photo/1484588805?adppopup=true">Luke Dray/Getty Images</a></span></figcaption></figure><p>É cada vez mais frequente ouvir <a href="https://www.nytimes.com/2023/05/16/us/politics/transgender-care-detransitioners.html">legisladores</a>, <a href="https://www.youtube.com/watch?v=dJMMqREtQJc">ativistas</a> e <a href="https://www.cbsnews.com/news/60-minutes-transgender-health-care-issues-2021-05-23/">comentaristas</a> argumentarem que muitas pessoas transgênero se arrependem de sua decisão de fazer cirurgias de afirmação de gênero - uma crença que tem alimentado uma <a href="https://www.lgbtmap.org/equality-maps/healthcare_youth_medical_care_bans">onda de legislação</a> que restringe o acesso a cuidados de saúde de afirmação de gênero.</p>
<p>O atendimento de afirmação de gênero pode incluir procedimentos cirúrgicos como reconstrução facial, <a href="https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/top-surgery">cirurgia torácica, ou “superior”</a> e <a href="https://transcare.ucsf.edu/guidelines/vaginoplasty">cirurgia genital, ou “inferior”</a>.</p>
<p>Mas em <a href="https://jamanetwork.com/journals/jamasurgery/article-abstract/2813212">um artigo</a> que publicamos recentemente no periódico científico JAMA Surgery, contestamos a noção de que as pessoas transgênero geralmente se arrependem das cirurgias de afirmação de gênero. </p>
<p>As evidências sugerem que menos de 1% das pessoas transgênero que se submetem à cirurgia de afirmação de gênero relatam arrependimento. Essa proporção é ainda mais impressionante quando comparada ao fato de que 14,4% da população em geral relata arrependimento após cirurgias semelhantes. </p>
<p>Por exemplo, estudos descobriram que entre <a href="https://doi.org/10.1016/j.pec.2017.06.032">5% e 14%</a> de todas as mulheres que se submetem a mastectomias para reduzir o risco de desenvolver câncer de mama dizem que se arrependeram. No entanto, menos de 1% dos homens transgêneros que recebem o mesmo procedimento relatam arrependimento.</p>
<p>Essas estatísticas se baseiam em revisões de <a href="https://journals.lww.com/prsgo/fulltext/2021/03000/regret_after_gender_affirmation_surgery__a.22.aspx">estudos existentes</a> que investigaram o arrependimento entre 7.928 indivíduos transgêneros que fizeram cirurgias de afirmação de gênero. Embora algumas dessas pesquisas anteriores <a href="https://journals.lww.com/prsgo/fulltext/2021/11000/letter_to_the_editor__regret_after.29.aspx">tenham sido criticadas</a> por negligenciarem o fato de que o arrependimento às vezes pode levar anos para se desenvolver, elas se alinham com o crescente número de estudos que mostram resultados positivos de saúde entre pessoas transgênero que recebem cuidados de afirmação de gênero. </p>
<h2>Por que o acesso à cirurgia de afirmação de gênero é importante</h2>
<p>Cerca de <a href="https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/">1,6 milhão de pessoas</a> nos EUA se identificam como transgêneros, embora apenas <a href="https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf">cerca de 25%</a> desses indivíduos tenham feito cirurgias de afirmação de gênero, <a href="https://www.doi.org/10.1001/jamanetworkopen.2023.30348">esses procedimentos se tornaram mais comuns</a>. De 2016 a 2020, cerca de 48 mil pessoas trans nos EUA fizeram cirurgias de afirmação de gênero.</p>
<p>Esses procedimentos oferecem às pessoas transgênero a oportunidade de alinhar seus corpos físicos com sua identidade de gênero, o que pode ter um impacto positivo na saúde mental. <a href="https://doi.org/10.1080/19359705.2021.2016537">Pesquisas mostram</a> que o acesso a cirurgias de afirmação de gênero pode reduzir os níveis de depressão, ansiedade e ideação suicida entre pessoas transgênero. </p>
<p>Os benefícios para a saúde mental podem explicar os baixos níveis de arrependimento. As pessoas transgênero têm <a href="https://doi.org/10.1080/09540261.2022.2093629">taxas muito mais altas</a> de preocupações com a saúde mental do que as pessoas cisgênero, ou pessoas cuja identidade de gênero se alinha com seu sexo no nascimento. Isso ocorre principalmente porque as pessoas transgênero têm mais dificuldade para <a href="https://theconversation.com/what-the-new-science-of-authenticity-says-about-discovering-your-true-self-175314">viver autenticamente</a> sem sofrer <a href="https://www.cdc.gov/mmwr/volumes/68/wr/mm6803a3.htm?s_cid=mm6803a3_w">discriminação, assédio e violência</a>.</p>
<p>A cirurgia de afirmação de gênero geralmente envolve <a href="https://doi.org/10.1080/26895269.2022.2100644">passar por uma série de etapas</a>: períodos de espera, terapia hormonal e aprendizado sobre os possíveis riscos e benefícios dos procedimentos. Embora a maioria das cirurgias seja reservada para adultos, as <a href="https://www.wpath.org/">principais diretrizes</a> recomendam que os pacientes tenham pelo menos 15 anos de idade.</p>
<p>Esse processo minucioso pelo qual as pessoas trans passam antes de serem operadas também pode explicar os níveis mais baixos de arrependimento. </p>
<p>Além disso, muitas pessoas cisgênero fazem cirurgias que, em seu mundo ideal, não fariam. Mas elas fazem a cirurgia para evitar um problema de saúde. </p>
<p>Por exemplo, uma mulher cisgênero que faz uma mastectomia para evitar o câncer de mama pode acabar se arrependendo da decisão se não gostar de sua nova aparência. Por outro lado, um homem transgênero que se submete ao mesmo procedimento tem maior probabilidade de ficar satisfeito com um tórax de aparência masculina.</p>
<h2>Aprimorando a pesquisa e as políticas públicas</h2>
<p>É importante observar que essa pesquisa não é conclusiva. As opiniões sobre as cirurgias <a href="https://doi.org/10.1007/s00268-017-3895-9">podem mudar com o tempo</a> e os pacientes podem se sentir bem diferentes sobre seus resultados oito anos <a href="https://doi.org/10.1007/s10508-014-0300-8">após a cirurgia</a> em comparação com um ano após a cirurgia.</p>
<p>No entanto, o consenso entre os especialistas, inclusive na <a href="https://www.ama-assn.org/press-center/press-releases/ama-reinforces-opposition-restrictions-transgender-medical-care">Associação Médica Americana</a>, é de que a cirurgia de afirmação de gênero pode melhorar a saúde das pessoas transgênero e não deve ser proibida. </p>
<p><a href="https://www.lgbtmap.org/equality-maps/healthcare_youth_medical_care_bans">Estados dos EUA</a> como Oklahoma e Dakota do Norte ignoraram esse consenso e restringiram o acesso a esses procedimentos. Em resposta, 12 estados se autodenominaram “<a href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2812422">santuários</a>” para atendimento de afirmação de gênero.</p>
<p>Embora nossas estatísticas sobre arrependimento cirúrgico possam mudar à medida que os pesquisadores aprendam mais, elas são os melhores dados que os prestadores de serviços de saúde têm. E as políticas públicas que se baseiam nas melhores evidências disponíveis têm o maior potencial de melhorar a vida das pessoas.</p><img src="https://counter.theconversation.com/content/223168/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Harry Barbee recebeu financiamento do National Institute on Aging por trabalhos anteriores</span></em></p><p class="fine-print"><em><span>Bashar Hassan e Fan Liang não presta consultoria, trabalha, possui ações ou recebe financiamento de qualquer empresa ou organização que poderia se beneficiar com a publicação deste artigo e não revelou nenhum vínculo relevante além de seu cargo acadêmico.</span></em></p>Os achados contrariam discurso de que muitas pessoas transgênero acabam desejando voltar atrás nos procedimentos que alinharam seus corpos físicos à sua identidade de gêneroHarry Barbee, Assistant Professor of Health, Behavior and Society, Johns Hopkins UniversityBashar Hassan, Postdoctoral Research Fellow in Plastic and Reconstructive Surgery, Johns Hopkins UniversityFan Liang, Assistant Professor of Plastic and Reconstructive Surgery, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2209412024-02-05T22:24:10Z2024-02-05T22:24:10ZThe uncertain fate of patients needing life-saving dialysis treatment in Gaza<p>More than 100 days into the brutal assault on Gaza, over <a href="https://news.un.org/en/story/2024/02/1146157">27,000 Palestinians have been killed — of whom 60 per cent have been children and women</a> — and 66,000 injured, according to the World Health Organization (WHO).</p>
<p>The destruction of Gaza’s health-care system has been catastrophic. The <a href="https://news.un.org/en/story/2024/01/1145317#:%7E:text=Hundreds%20of%20facilities%20hit,seven%20deaths%20and%2052%20injuries.">WHO says</a> that, as of Jan. 5, there have been more than 600 attacks on health-care facilities, with 26 out of 36 hospitals in Gaza severely damaged and 79 ambulances targeted. Over <a href="https://doi.org/10.1136/bmj.q203">300 health-care workers have been killed and over 200 have been detained by Israeli forces</a>. </p>
<p><a href="https://www.msf.org/letter-gaza-un-security-council">In an open letter</a> to the United Nations Security Council, Médecins Sans Frontières (MSF) president Christos Christou wrote: </p>
<blockquote>
<p>“Israel has shown a blatant and total disregard for the protection of Gaza’s medical facilities. We are watching as hospitals are turned into morgues and ruins. These supposedly protected facilities are being bombed, are being shot at by tanks and guns, encircled and raided, killing patients and medical staff.”</p>
</blockquote>
<p>Most of the resources within the collapsing health-care system in Gaza are directed towards treating acute trauma victims, such as the injured <a href="https://www.reuters.com/world/middle-east/baby-saved-gaza-rubble-after-mother-killed-israeli-strike-2023-12-29/">babies pulled from rubble</a>, the toddlers requiring <a href="https://www.reuters.com/world/middle-east/gazas-child-amputees-face-further-risks-without-expert-care-2024-01-04/">limb amputations</a> and the civilians suffering from <a href="https://reliefweb.int/report/occupied-palestinian-territory/gaza-strip-msf-treating-patients-severe-burns-following-airstrike">severe burn injuries</a>. This leaves patients with chronic life-threatening diseases, such as cancer, heart failure and end-stage kidney disease, with severely limited access to the ongoing medical care they need to survive.</p>
<h2>Patients unable to access care for chronic conditions</h2>
<p>As nephrologists and internal medicine physicians, we are gravely concerned about patients in Gaza with chronic diseases who are unable to access care. There are more than <a href="https://www.aljazeera.com/features/2023/10/25/terrifying-hope-shrinks-for-gazas-dialysis-patients-at-packed-hospitals">1,100 dialysis patients, including 38 children, in Gaza</a>. </p>
<p><a href="https://kidney.ca/Kidney-Health/Living-With-Kidney-Failure/Dialysis">Hemodialysis</a> is a treatment for patients with kidney failure that involves removing blood from the patient’s circulation and circulating it through a dialysis machine that clears toxins and removes excess fluid. Without adequate dialysis, fluid and toxins accumulate and patients typically die within days to weeks from respiratory failure or cardiac arrest. </p>
<p>Dialysis is a resource-intensive therapy that requires a dialysis facility, dialysis machines, filters, water supply and fuel, along with a team of technicians, nurses and nephrologists. Each one of these components has been severely and directly compromised since Israel’s assault on Gaza. </p>
<p>Israel’s complete blockade of food, fuel and water has left over <a href="https://abcnews.go.com/International/500000-people-gaza-face-catastrophic-hunger-unrwa/story?id=106593939">500,000 Gazans facing catastrophic hunger</a> according to the United Nations Relief and Works Agency (UNRWA), and Gazan children face a <a href="https://www.unicef.org/press-releases/barely-drop-drink-children-gaza-strip-do-not-access-90-cent-their-normal-water-use">90 per cent reduction in access to water</a>.</p>
<p>Several hospitals, including Al-Aqsa, reported being completely out of fuel, putting all patients in grave danger, <a href="https://www.aljazeera.com/news/2024/1/13/blackout-in-gazas-al-aqsa-hospital-as-fuel-runs-out-babies-at-high-risk">particularly those on life support, babies in incubators and those requiring dialysis</a>. </p>
<p>Even before the current conflict, the 16-year blockade of Gaza put the lives of kidney failure patients at risk due to chronic shortages of fuel and medical supplies. Al Jazeera reports that since Oct. 7, <a href="https://www.aljazeera.com/features/2023/10/25/terrifying-hope-shrinks-for-gazas-dialysis-patients-at-packed-hospitals">the number of patients at Al-Aqsa Hospital requiring dialysis has more than doubled</a> from 143 to about 300, including 11 children, who have just 24 dialysis machines between them. </p>
<p>This has forced dialysis units to significantly cut treatments, with patients receiving two-hour sessions rather than the typically prescribed 3.5-hour treatments. Treatment frequency, typically prescribed three times weekly, are now only available one or two times per week. </p>
<p>This decrease in treatment time and frequency is grossly insufficient to sustain life. But in a health-care system under assault, patients are fortunate to receive any dialysis at all. </p>
<h2>Patients needing life-saving treatment</h2>
<p>Ismail Al Tawil was a 44-year-old patient in Gaza who died of kidney failure after he was unable to access dialysis. In an interview with Al-Jazeera’s AJ+ social media arm, <a href="https://www.instagram.com/ajplus/reel/C15bdLAOVVi/">his widow described desperately trying to get him to dialysis at Al-Shifa hospital</a>, but being shot at by Israeli snipers who surrounded the hospital. </p>
<p>She then attempted to access dialysis at Al-Awda and Kamal Adwan hospitals, but both facilities had insufficient capacity to treat him. </p>
<p>Since Oct. 7, <a href="https://www.hrw.org/news/2023/12/20/most-gazas-population-remains-displaced-and-harms-way">1.9 million people or 85 per cent of the population of Gaza have been internally displaced</a>, according to Human Rights Watch. This is a tremendous challenge for dialysis patients who are faced with the uncertainty of when, where or if they will access their life-saving therapy. </p>
<p>Anssam, age 12, was displaced from Jabaliya in northern Gaza to seek treatment in Deir El Balah in central Gaza. She had gone 15 days without dialysis and had to leave with her mother to receive life-saving medical treatment. <a href="https://www.thenationalnews.com/mena/palestine-israel/2023/12/18/gaza-dialysis-patients-hospital/">In an interview with <em>The National News</em></a>, Anssam said: </p>
<blockquote>
<p>“I hope for this war to end and for us to go back to the way we were, happy and playing, and to go back to doing dialysis three times a week… Now, without filters, I cannot have dialysis and so I will die. My life depends on dialysis.” </p>
</blockquote>
<h2>Loss of medical personnel</h2>
<p>Beyond the destruction of health-care facilities and a critical shortage of supplies, the loss of medical personnel may have the most devastating and longest-lasting impact on the health-care system in Gaza. </p>
<p>Dr. Hammam Alloh was one of the only nephrologists in Gaza, <a href="https://www.democracynow.org/2023/11/13/medical_workers_killed_colleagues_mourn_hammam">described as a committed physician and a beacon of light by his colleagues</a>. He was 36 years old and a father of two young children. He had hopes to expand dialysis care in Gaza and build a nephrology educational training program.</p>
<p><a href="https://www.cbc.ca/news/world/gaza-hamman-alloh-killed-1.7027623">He was killed on Nov. 12</a> by an <a href="https://www.frontlinedefenders.org/en/profile/hammam-alloh">Israeli airstrike to his family’s home</a>, where he was taking a short rest after a busy shift at Al Shifa Hospital. His loss resonated far beyond his family, patients and colleagues in Gaza. Dr. Alloh’s <a href="https://www.presstv.ir/Detail/2023/11/19/714879/humans-of-gaza-hammam-alloh-nephrologist-alshifa-hospital">courage and dedication has become a powerful source of inspiration</a> for physicians and health-care workers around the world. </p>
<p>Multiple sources have reported the number of civilians who have been killed by the bombs and bullets during the assault on Gaza. We may never know how many cancer patients will die from lack of chemotherapy; or diabetics from lack of insulin; or kidney failure patients from inadequate dialysis. The consequences of the collapsed health-care system in Gaza will be felt for years to come. </p>
<p>The <a href="https://www.cbc.ca/news/canada/chilling-effect-pro-palestinian-1.7064510">attempts to silence, intimidate and smear health-care workers</a> for calling out the atrocities in Gaza have been well documented. These efforts not only attempt to rob us of our freedom of speech, but of our professional and moral duty as physicians to promote global health and protect the vulnerable. </p>
<p>As physicians, we will not be silent as our colleagues in Gaza are being killed, as hospitals are being targeted and attacked, and as vulnerable patients are endangered. We <a href="https://news.un.org/en/story/2024/01/1145462">join the UN</a>, the <a href="https://doi.org/10.1016/S0140-6736(23)02627-2">WHO</a>, <a href="https://www.doctorswithoutborders.ca/msf-immediate-ceasefire-is-needed-in-gaza-to-stop-the-bloodshed/">MSF</a> and the <a href="https://www.bma.org.uk/what-we-do/working-internationally/our-international-work/bma-position-israel-gaza-conflict">British Medical Association</a>, along with millions around the world, who call for an immediate ceasefire and unimpeded humanitarian aid. </p>
<p>We stand in solidarity with the true health-care heroes of Gaza who continue to work in harrowing conditions, and we honour the legacies of those like Dr. Alloh who lost their lives while upholding the highest values of our profession.</p><img src="https://counter.theconversation.com/content/220941/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Patients with kidney failure need regular dialysis treatments to survive. However, the equipment, supplies and medical staff needed for dialysis have been largely destroyed by the assault on Gaza.Ali Iqbal, Transplant Nephrologist, Assistant Professor of Medicine, McMaster UniversityAliya Khan, Clinical professor, Faculty of Health Sciences, McMaster UniversityBen Thomson, Masters of Public Health student, Bloomberg School of Public Health, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2206422024-01-22T13:30:00Z2024-01-22T13:30:00ZTransgender regret? Research challenges narratives about gender-affirming surgeries<figure><img src="https://images.theconversation.com/files/569390/original/file-20240115-19-obyz75.jpg?ixlib=rb-1.1.0&rect=135%2C23%2C5179%2C3519&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Gender-affirming surgeries give transgender people the opportunity to align their bodies with their gender identity.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/transgender-woman-prepares-another-womans-makeup-prior-to-news-photo/1484588805?adppopup=true">Luke Dray/Getty Images</a></span></figcaption></figure><figure class="align-center ">
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<p>You’ll often hear <a href="https://www.nytimes.com/2023/05/16/us/politics/transgender-care-detransitioners.html">lawmakers</a>, <a href="https://www.youtube.com/watch?v=dJMMqREtQJc">activists</a> and <a href="https://www.cbsnews.com/news/60-minutes-transgender-health-care-issues-2021-05-23/">pundits</a> argue that many transgender people regret their decision to have gender-affirming surgeries – a belief that’s been fueling a <a href="https://www.lgbtmap.org/equality-maps/healthcare_youth_medical_care_bans">wave of legislation</a> that restricts access to gender-affirming health care.</p>
<p>Gender-affirming care can include surgical procedures such as facial reconstruction, <a href="https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/top-surgery">chest or “top” surgery</a>, and <a href="https://transcare.ucsf.edu/guidelines/vaginoplasty">genital or “bottom” surgery</a>.</p>
<p>But in <a href="https://jamanetwork.com/journals/jamasurgery/article-abstract/2813212">an article</a> we recently published in JAMA Surgery, we challenge the notion that transgender people often regret gender-affirming surgeries. </p>
<p>Evidence suggests that less than 1% of transgender people who undergo gender-affirming surgery report regret. That proportion is even more striking when compared to the fact that 14.4% of the broader population reports regret after similar surgeries. </p>
<p>For example, studies have found that between <a href="https://doi.org/10.1016/j.pec.2017.06.032">5% and 14%</a> of all women who receive mastectomies to reduce the risk of developing breast cancer say they regretted doing so. However, less than 1% of transgender men who receive the same procedure report regret.</p>
<p>These statistics are based on reviews of <a href="https://journals.lww.com/prsgo/fulltext/2021/03000/regret_after_gender_affirmation_surgery__a.22.aspx">existing studies</a> that investigated regret among 7,928 transgender individuals who received gender-affirming surgeries. Although some of this prior research <a href="https://journals.lww.com/prsgo/fulltext/2021/11000/letter_to_the_editor__regret_after.29.aspx">has been criticized</a> for overlooking the fact that regret can sometimes take years to develop, it aligns with the growing body of studies that show positive health outcomes among transgender people who receive gender-affirming care. </p>
<h2>Why access to gender-affirming surgery matters</h2>
<p>About <a href="https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/">1.6 million people</a> in the U.S. identify as transgender. While only <a href="https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf">about 25%</a> of these individuals have obtained gender-affirming surgeries, <a href="https://www.doi.org/10.1001/jamanetworkopen.2023.30348">these procedures have become more commonplace</a>. From 2016 to 2020, roughly 48,000 trans people in the U.S. received gender-affirming surgeries.</p>
<p>These procedures provide transgender people with the opportunity to align their physical bodies with their gender identity, which could positively impact mental health. <a href="https://doi.org/10.1080/19359705.2021.2016537">Research shows</a> that access to gender-affirming surgeries may reduce levels of depression, anxiety and suicidal ideation among transgender people. </p>
<p>The mental health benefits may explain the low levels of regret. Transgender people have <a href="https://doi.org/10.1080/09540261.2022.2093629">far higher rates</a> of mental health concerns than cisgender people, or people whose gender identity aligns with their sex at birth. This is largely because transgender people have a more difficult time <a href="https://theconversation.com/what-the-new-science-of-authenticity-says-about-discovering-your-true-self-175314">living authentically</a> without experiencing <a href="https://www.cdc.gov/mmwr/volumes/68/wr/mm6803a3.htm?s_cid=mm6803a3_w">discrimination, harassment and violence</a>.</p>
<p>Gender-affirming surgery often involves <a href="https://doi.org/10.1080/26895269.2022.2100644">going through a number of hoops</a>: waiting periods, hormone therapy and learning about the potential risks and benefits of the procedures. Although most surgeries are reserved for adults, the <a href="https://www.wpath.org/">leading guidelines</a> recommend that patients be at least 15 years old.</p>
<p>This thorough process that trans people go through before receiving surgery may also explain the lower levels of regret. </p>
<p>In addition, many cisgender people get surgeries that, in their ideal world, they wouldn’t receive. But they go through with the surgery in order to prevent a health problem. </p>
<p>For instance, a cisgender woman who receives a mastectomy to avoid breast cancer may ultimately regret the decision if she dislikes her new appearance. Meanwhile, a transgender man who receives the same procedure is more likely to be pleased with a masculine-looking chest.</p>
<h2>Improving research and public policy</h2>
<p>It’s important to note that this research is not conclusive. Views of surgeries <a href="https://doi.org/10.1007/s00268-017-3895-9">can change over time</a>, and patients can feel quite differently about their outcomes eight years <a href="https://doi.org/10.1007/s10508-014-0300-8">after their surgery</a> as opposed to one year after their surgery.</p>
<p>Nonetheless, the consensus among experts, including at the <a href="https://www.ama-assn.org/press-center/press-releases/ama-reinforces-opposition-restrictions-transgender-medical-care">American Medical Association</a>, is that gender-affirming surgery can improve transgender people’s health and should not be banned. </p>
<p><a href="https://www.lgbtmap.org/equality-maps/healthcare_youth_medical_care_bans">U.S. states</a> such as Oklahoma and North Dakota have ignored this consensus and have restricted access to these procedures. In response, 12 states have designated themselves “<a href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2812422">sanctuaries</a>” for gender-affirming care.</p>
<p>Although our statistics on surgical regret may change as researchers learn more, they are the best data that health care providers have. And public policies that are based on the best available evidence have the most potential to improve people’s lives.</p><img src="https://counter.theconversation.com/content/220642/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Harry Barbee has received funding from the National Institute on Aging for their past work. </span></em></p><p class="fine-print"><em><span>Bashar Hassan and Fan Liang do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The findings push back against the notion that many transgender people end up wishing they hadn’t gone through with gender-affirming surgeries.Harry Barbee, Assistant Professor of Health, Behavior and Society, Johns Hopkins UniversityBashar Hassan, Postdoctoral Research Fellow in Plastic and Reconstructive Surgery, Johns Hopkins UniversityFan Liang, Assistant Professor of Plastic and Reconstructive Surgery, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2182992023-12-11T03:21:08Z2023-12-11T03:21:08ZDemam “Gadis Kretek”: ekspor adiksi rokok yang mengancam pengendalian tembakau lintas negara<p>Sambutan meriah <a href="https://www.netflix.com/tw/title/81476989"><em>Gadis Kretek</em></a> dari penonton dan sineas Indonesia tercermin dengan ramainya pemberitaan dan perbincangan di sosial media.</p>
<p>Apalagi dengan tembusnya serial Netflix pertama dari Indonesia ini di <a href="https://www.liputan6.com/lifestyle/read/5414887/serial-gadis-kretek-tayang-di-busan-international-film-festival-2023-dian-sastrowardoyo-hingga-putri-marino-tampil-memukau-di-red-carpet?page=2">Busan International Film Festival</a> di Korea Selatan. </p>
<p>Namun, di tengah sorotan positif terhadap serial yang mendapat rating usia 13+ atau TV-14 ini, terdapat ‘gajah di dalam ruangan’ yang luput oleh media dan penggemar: kretek itu sendiri.</p>
<p>Sebenarnya, penayangan rokok atau adegan merokok bukan hal baru dalam film layar lebar dan <em>streaming</em>.</p>
<p>Studi <a href="https://truthinitiative.org/tobacco-starring-role">Truth Initiative pada 2021</a> menemukan bahwa dari 15 program <em>streaming</em> yang paling digemari oleh anak muda usia 15-24 tahun di Amerika Serikat (AS), 60% menampilkan produk tembakau, menarik perhatian 25 juta anak muda di negara tersebut.</p>
<p>Ironisnya, fenomena ini terjadi saat sudah <a href="https://journals.sagepub.com/doi/10.1177/10901981221086944">banyak studi yang menemukan bahwa paparan adegan merokok di film</a> dapat meningkatkan risiko remaja mulai merokok, bahkan hampir dua kali lipat dibandingkan remaja yang tidak terpapar. </p>
<p>Karena itu, <a href="https://www.who.int/news/item/01-02-2016-films-showing-smoking-scenes-should-be-rated-to-protect-children-from-tobacco-addiction#:%7E:text=Taking%20concrete%20steps%2C%20including%20rating,related%20addiction%2C%20disability%20and%20death.">adegan merokok di film, televisi, dan <em>online streaming</em></a> sudah dianggap sebagai bentuk promosi produk tembakau secara halus tapi efektif. </p>
<p>Taktik ini menjadi cara teranyar untuk mempromosikan adiksi rokok di tengah semakin ketatnya aturan iklan produk tembakau dan nikotin di media konvensional. </p>
<p>Lalu apa yang membuat <em>Gadis Kretek</em> berbeda sekaligus mengkawatirkan? Film ini menyebarkan aura positif industri rokok dan mengekspor adiksi rokok lintas negara via <em>streaming</em>, yang minim regulasi. </p>
<h2>Romantisasi industri rokok</h2>
<p>Berbeda dari sebagian besar hiburan sinematik lainnya yang juga menayangkan adegan merokok, cerita <em>Gadis Kretek</em> berporos pada industri kretek. </p>
<p>Kisah cinta fiktif antara tokoh utama bernama Jeng Yah, seorang peracik saus kretek yang cerdas dan ambisius, dengan Soeraja, yang kemudian menjadi konglomerat perusahaan rokok Indonesia, berlangsung pada era 1960-an saat bisnis rumahan kretek di Indonesia mulai tumbuh subur dan saling berkompetisi. </p>
<p>Penonton diajak melihat ke dalam dunia industri kretek: proses pembuatan dan pemasaran kretek, dari mulai pembelian daun tembakau hingga penyebaran pamflet iklan produk kreteknya.</p>
<p>Sejak serial ini diluncurkan pada awal November lalu, gejala “glamorisasi”–serba gemerlapan, elok, atau menarik–merokok di dunia maya mulai tampak. Fenomena ini berpotensi membentuk citra positif industri rokok yang masih dianggap <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-08640-6">bisnis normal di Indonesia</a>, bahkan penting bagi perekonomian negara. </p>
<p>Misalnya, viralnya video kompilasi adegan Jeng Yah yang diperankan oleh Dian Sastro, aktris papan atas Indonesia yang banyak diidolakan anak muda, menghisap kretek banyak dikomentari dengan nada kagum oleh warganet dan tidak sedikit yang berkomentar ingin mencoba merokok.</p>
<p>Rokok di serial ini bukan hanya berperan sebagai dekorasi atau mendramatisasi karakter, tapi sentral untuk membangun karakter utama dan cerita serial ini secara keseluruhan.</p>
<p>Di samping itu, anggapan bahwa kretek adalah “warisan budaya” Indonesia yang perlu dilestarikan dapat bangkit kembali dengan diangkatnya aspek historis dan tradisional kretek di serial ini. Di kehidupan nyata, narasi bahwa kretek harus dilindungi kerap <a href="https://bmjopen.bmj.com/content/7/9/e016975">digaungkan untuk menolak usulan kebijakan pengendalian tembakau yang lebih ketat</a>. </p>
<p>Padahal, kretek telah <a href="https://news.detik.com/berita/d-3044064/komisi-x-dpr-ri-hapus-pasal-kretek-dari-ruu-kebudayaan">ditolak</a> untuk dimasukkan ke dalam UU Kebudayaan sebagai warisan budaya pada 2015.</p>
<p>Citra positif kretek bukan tidak mungkin dapat menguntungkan industri rokok secara umum. Hal tersebut dapat mengaburkan fakta industri rokok saat ini yang <a href="https://www.ijhpm.com/article_3834.html">manipulatif dan eksploitatif</a> di sepanjang rantai pasokan dari petani tembakau hingga pemasaran rokok jadi. </p>
<p>Padahal, usaha rokok di Indonesia bukan lagi didominasi oleh perusahaan domestik kecil ala <em>Gadis Kretek</em> melainkan korporat-korporat raksasa yang <a href="https://tobaccocontrol.bmj.com/content/21/3/306.long">sudah banyak diakuisisi</a> oleh perusahaan transnasional seperti Philip Morris International. </p>
<p>Selain itu, normalisasi rokok dan industrinya akan semakin memuluskan jalan industri untuk mengintervensi kebijakan publik. </p>
<p>Laporan terbaru <a href="https://exposetobacco.org/global-index/">Global Tobacco Industry Interference Index</a> menunjukkan Indonesia selama lima tahun berturut-turut berada pada peringkat lima besar negara dengan campur tangan industri tembakau terbanyak. </p>
<p>Alhasil, intervensi ini senantiasa menghambat penerapan kebijakan pengendalian tembakau yang melindungi dan berpihak kepada kesehatan masyarakat.</p>
<h2>Promosi rokok lintas negara</h2>
<p>Ketika negara lain berlomba menurunkan konsumsi tembakau di kalangan rakyatnya dan melakukan denormalisasi industrinya, Indonesia justru dengan bangga mengekspor banyak adegan merokok melalui serial ini ke luar negeri. </p>
<p>Kenyataan bahwa <em>Gadis Kretek</em> dapat ditonton remaja dan ditayangkan di Netflix mancanegara, bahkan menempati <a href="https://www.jawapos.com/music-movie/013289679/bangga-karya-film-indonesia-gadis-kretek-masuk-dalam-top-10-netflix-series-non-english-di-22-negara">10 teratas di Malaysia dan Amerika Latin,</a> mengindikasikan adanya ekspor promosi benda adiktif ini kepada anak-anak di luar negeri.</p>
<p>Hal ini mengkhawatirkan mengingat <a href="https://untobaccocontrol.org/impldb/indicator-report/?wpdtvar=3.2.7.2.j">belum semua negara melarang promosi dan iklan produk tembakau</a> lintas negara. </p>
<p>Selain itu, Netflix dan media <em>streaming</em> lainnya belum mengatur penayangan adegan merokok atau produknya di program-program mereka.
Pada 2019, Netflix pernah <a href="https://www.npr.org/2019/07/04/738719658/netflix-promises-to-quit-smoking-on-most-original-programming">mengumumkan komitmennya</a> untuk mengeliminasi tayangan rokok di program-program bagi anak milik mereka, tapi hingga kini hanya janji belaka.</p>
<p>Berbagai usaha pun dilakukan oleh kelompok masyarakat termasuk <a href="https://www.markey.senate.gov/news/press-releases/senators-markey-van-hollen-and-blumenthal-push-netflix-on-tobacco-nicotine-and-vaping-imagery-for-young-people">anggota legislatif</a> dan <a href="https://naagweb.wpenginepowered.com/wp-content/uploads/2020/10/2019-08-06-NAAG-Letter-to-Producers-.pdf">badan hukum</a> di AS untuk menekan industri hiburan dan media supaya segera menerapkan aturan yang melindungi anak muda dari paparan promosi rokok.</p>
<p>Hingga saat ini, <a href="https://economictimes.indiatimes.com/news/india/india-becomes-a-global-leader-by-regulating-anti-tobacco-warnings-on-ott-platforms/articleshow/100641978.cms">India</a> adalah satu-satunya negara yang memiliki aturan rokok di media <em>streaming</em>. Mereka mewajibkan penayangan pesan kesehatan anti-tembakau di semua program yang menampilkan produk tembakau atau penggunaannya.</p>
<h2>Perlu aturan yang komprehensif dan kerjasama lintas negara</h2>
<p>Persoalan <em>Gadis Kretek</em> ini merupakan puncak dari gunung es yang perlu diatasi akar permasalahannya: normalisasi, bahkan “glamorisasi”, rokok di Indonesia. Pengendalian tembakau yang lemah, terutama dalam aspek iklan dan promosi rokok, adalah salah satu penyebab utamanya. </p>
<p>Pemerintah dan komunitas media perlu mengambil langkah penting untuk melindungi kesehatan generasi masa depan kita.</p>
<p>Pertama, media <em>streaming</em> perlu menetapkan rating ‘R’ atau ‘18+’ untuk program-program mereka yang menayangkan produk tembakau atau penggunaannya dengan cara memasukkannya sebagai kriteria penentuan rating usia. </p>
<p>Menurut laporan di AS, mengadopsi aturan seperti itu berpotensi mengurangi jumlah merokok pada remaja <a href="https://publications.aap.org/pediatrics/article-abstract/130/2/228/29881/Influence-of-Motion-Picture-Rating-on-Adolescent?redirectedFrom=fulltext">sebanyak 18%</a> atau mencegah hingga <a href="https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/movies/index.htm#:%7E:text=If%20current%20rates%20continue%2C%205.6,die%20from%20tobacco%20related%20diseases.&text=Giving%20an%20R%20rating%20to,smoking%20among%20children%20alive%20today.">1 juta anak</a> di AS untuk memulai merokok. </p>
<p><a href="https://www.businessinsider.com/disney-bans-smoking-in-movies-2015-3">Disney, contohnya,</a> sejak 2007 telah melarang penayangan adegan merokok atau produknya di film-film mereka yang ditargetkan untuk anak atau remaja (rating PG-13).</p>
<p>Kedua, Indonesia perlu menutup celah dalam kebijakan pengendalian tembakau yang selama ini masih memungkinkan promosi produk tembakau dan nikotin di internet. Peraturan Pemerintah <a href="https://peraturan.bpk.go.id/Details/5324/pp-no-109-tahun-2012">No. 109 Tahun 2012</a> hanya melarang wujud rokok di ranah film, sinetron, dan acara TV lainnya. Tayangan rokok dan adegan merokok di program <em>streaming</em> dan media digital lainnya belum diatur.</p>
<p>Konvensi Kerangka Kerja Pengendalian Tembakau WHO (WHO FCTC) memiliki <a href="https://fctc.who.int/publications/m/item/tobacco-advertising-promotion-and-sponsorship">rekomendasi dan panduan</a> bagi negara-negara anggotanya untuk menerapkan aturan komprehensif terkait promosi dan iklan rokok. Rekomendasinya cukup tegas: larang total penayangan produk tembakau di media digital meskipun tidak memiliki hubungan dengan entitas bisnis produk tersebut. </p>
<p>Larangan bukan hanya pada media <em>streaming</em>, <a href="https://termcommunity.com/issue-brief/66/protecting-youth-from-online-e-cigarette-marketing-findings-from-a-new-study-in-india-indonesia-and-mexico">media sosial</a> dan yang terbaru <a href="https://termcommunity.com/issue-brief/103/the-next-frontier-in-tobacco-marketing-the-metaverse-nfts-advergames-and-more">metaverse</a> juga tidak boleh luput dari peraturan pemerintah. </p>
<p>Penelitian telah menyibak banyaknya konten komersil yang memanfaatkan <em>influencer-influencer</em> di media sosial untuk <a href="https://termcommunity.com/report/95/indonesia-situation-report-march-april-2023-english">mempromosikan produk tembakau</a> atau nikotin lainnya seperti <a href="https://termcommunity.com/issue-brief/22/vape-tricks-in-indonesia-how-e-cigarette-companies-use-social-media-to-hook-youth">rokok elektrik</a>. </p>
<p>Terakhir, kerja sama lintas negara perlu dijalin mengingat <em>Gadis Kretek</em> dan produk hiburan serupa tidak hanya ditonton oleh audiens domestik. </p>
<p>Dalam rekomendasinya, WHO juga mendorong negara-negara untuk memastikan bahwa iklan dan promosi produk tembakau lintas negara yang berasal dari wilayah mereka untuk diatur dengan cara yang sama seperti aturan dalam negeri. </p>
<p>Selain itu, negara perlu menggunakan hak kedaulatan mereka untuk mencegah masuknya iklan dan promosi tembakau ke wilayah mereka.</p>
<p>Hampir <a href="https://untobaccocontrol.org/impldb/indicator-report/?wpdtvar=3.2.7.2.b">setengah dari negara-negara di dunia yang meratifikasi WHO FCTC</a>, tidak termasuk Indonesia, telah melarang iklan dan promosi rokok di internet. <a href="https://health.ec.europa.eu/tobacco/ban-cross-border-tobacco-advertising-and-sponsorship_en#latest-updates">Uni Eropa</a>, misalnya, telah mewajibkan semua negara anggotanya untuk melarang promosi dan iklan produk tembakau antarnegara mereka di berbagai media, termasuk program <em>streaming</em>.</p>
<p>Perusahaan hiburan, kreator, distributor, seniman, aktor, dan para pengambil keputusan di pemerintahan perlu memahami dampak dari industri hiburan terhadap kesehatan masyarakat. </p>
<p>Di Indonesia, konsumsi tembakau telah merenggut nyawa <a href="https://www.tobaccofreekids.org/problem/toll-global/asia/indonesia">290 ribu rakyat</a> setiap tahun dan merugikan negara <a href="https://tobaccocontrol.bmj.com/content/31/Suppl_2/s133">hingga Rp410 triliun</a>. </p>
<p>Industri hiburan harus menolak platform mereka dimanfaatkan oleh industri tembakau yang menempatkan generasi muda dalam risiko kecanduan nikotin sepanjang hayat yang akan menimbulkan kesakitan dan kematian.</p><img src="https://counter.theconversation.com/content/218299/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Pandangan dan opini yang diungkapkan dalam artikel ini adalah milik penulis dan tidak selalu mencerminkan opini atau posisi dari institusi yang terafiliasi dengan penulis.</span></em></p>Film ini menyebarkan aura positif industri rokok dan mengekspor adiksi rokok lintas negara via streaming, yang minim regulasi.Beladenta Amalia, Postdoctoral Fellow at the Institute for Global Tobacco Control, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2184382023-12-09T01:23:12Z2023-12-09T01:23:12ZBelt and Road Initiative’s new approach and what it means for Chinese investments in Indonesia<figure><img src="https://images.theconversation.com/files/564458/original/file-20231208-29-nxsay.jpg?ixlib=rb-1.1.0&rect=0%2C20%2C4633%2C3063&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Jakarta-Bandung high-speed train, the first in Southeast Asia, was funded by China as part of its decade-old Belt and Road Initiative (BRI) project.</span> <span class="attribution"><a class="source" href="https://branda.antaranews.com/data/content_photo_wire.php?pubid=1699614630&getcod=dom">ANTARA FOTO/Hreeloita Dharma Shanti/sgd/aww</a></span></figcaption></figure><p>A shift in China’s international Belt and Road Initiative (BRI) from focusing on massive projects such as roads, railways and ports to <a href="https://thechinaproject.com/2023/10/19/belt-and-road-forum-round-up/">“small but beautiful”</a> ones has been announced by President Xi Jinping. </p>
<p>Launched in 2013, the initiative <a href="https://www.weforum.org/agenda/2023/11/china-belt-road-initiative-trade-bri-silk-road/">provides loans to build infrastructure in partner countries</a> worldwide, with <a href="https://www.cfr.org/backgrounder/chinas-massive-belt-and-road-initiative">connectivity</a> as its main focus.</p>
<p>Indonesia is <a href="https://www.icwa.in/show_content.php?lang=1&level=3&ls_id=4797&lid=2818#:%7E:text=The%20bar%20diagram%20in%20figure,Vietnam%20with%20US%20%24%20151.1%20billion.">BRI’s biggest recipient in Southeast Asia</a>. The initiative has helped the country finance <a href="https://www.aseanbriefing.com/news/indonesia-launches-southeast-asias-first-high-speed-railway/#:%7E:text=Indonesia%20has%20launched%20Southeast%20Asia'%20s,rail%20on%20October%202%2C%202023.%22">Southeast Asia’s first high-speed train project</a> and <a href="https://www.wsj.com/articles/how-china-came-to-dominate-the-worlds-largest-nickel-source-for-electric-cars-4c081a12">poured billions of dollars of investment into nickel processing, unlocking a critical mineral asset</a>. </p>
<p>As a scholar in political economy and a former government relations consultant working closely with the Indonesian business sector, I’ve been considering what the “small-but-beautiful” approach means for Chinese investment in Indonesia.</p>
<h2>What does “small-but-beautiful” BRI mean?</h2>
<p>This shift in BRI strategy signifies a focus on projects that are of a smaller scale more efficient and less risky. It is a sensible move for China, considering the global <a href="https://www.ft.com/content/b5a2443f-96ba-450a-bf4d-93db786f0fb5">economic slowdown, the country’s moderating domestic economy</a>, and <a href="https://theconversation.com/the-china-us-rivalry-is-not-a-new-cold-war-it-is-way-more-complex-and-could-last-much-longer-144912">trade tensions with the US</a>.</p>
<p>It is also an attempt to repair China’s global image, amid fears it is seen as <a href="https://foreignpolicy.com/2023/05/09/china-debt-lending-paris-club-bri-development-finance/">a loan shark</a>. Several countries, such as <a href="https://apnews.com/article/china-debt-banking-loans-financial-developing-countries-collapse-8df6f9fac3e1e758d0e6d8d5dfbd3ed6">Zambia and Sri Lanka</a>, have already gone into default. China’s reputation will suffer if too many countries fail to pay debts. </p>
<p>Defaults are a liability for the BRI cash flow and the Chinese economy. Beijing should find reliable debtors with solid and promising economic performance. That is precisely what Beijing sees in Jakarta: <a href="https://www.adb.org/news/indonesia-economy-looking-robust-2023-and-2024-adb">stable politics, a growing domestic market and pragmatic economic policies</a>. </p>
<h2>Chinese state investment in Indonesia</h2>
<p>China’s state-driven investment in Indonesia <a href="https://www.kompas.id/baca/english/2023/10/04/en-satu-dekade-sabuk-dan-jalan-dalam-kerja-sama-china-indonesia">focuses on public infrastructure project</a> run by Indonesian state-owned enterprises and funded by Chinese state-owned lenders. The Jakarta-Bandung high-speed train is an example of China’s investments in Indonesia.</p>
<p>Indonesia received <a href="https://www.cnbc.com/2023/08/31/indonesias-china-backed-high-speed-train-sparks-concerns-of-debt-trap.html#:%7E:text=A%20142%2Dkilometre%20rail%20line,loan%20from%20China%20Development%20Bank.">a loan from the China Development Bank</a> for the project and began construction in 2016. The project hit a <a href="https://www.benarnews.org/english/news/indonesian/china-obor-rail-project-indonesia-10122021145027.html">US$2 billion</a> cost overrun due to <a href="https://www.pwc.com/id/en/media-centre/infrastructure-news/september-2022/jakarta-bandung-high-speed-railway-at-risk-of-another-delay.html">problems</a> in its land acquisition and feasibility study. </p>
<p>Due to the ballooning costs, China asked for financial reassurance from the Indonesian government. This prompted the <a href="https://www.lowyinstitute.org/the-interpreter/geopolitics-jakarta-bandung-high-speed-railway">use of the state budget</a> the public having been promised that the project would not touch any government funds.</p>
<p>This might <a href="https://theconversation.com/indonesia-should-reject-chinas-request-to-put-state-budget-as-collateral-for-jakarta-bandung-high-speed-train-project-204106">set a precedent for future Chinese investment</a> requiring state collateral – especially given Indonesia’s plan to persuade China to invest in Indonesia’s new capital project in East Kalimantan.</p>
<p>Indonesia has <a href="https://www.benarnews.org/english/news/indonesian/joko-widodo-china-10172023155348.html">asked China to chip in to the US$35-billion project</a>, which has struggled to secure <a href="https://www.bloomberg.com/news/features/2022-12-05/indonesia-s-new-rainforest-city-president-jokowi-s-nusantara-plans-face-trouble?embedded-checkout=true">investment</a>. There has been no formal answer from the Chinese on the request thus far. However, investing in the new capital – which is far bigger and riskier than the high-speed railway project – does not fit the “small-and-beautiful” approach due to its high risks.</p>
<p>China may still opt to invest in the mega-project, but a more modest input seems more likely. And as part of risk sharing, Indonesian government collateral will be likely critical for its willingness to invest.</p>
<h2>The Chinese private sector</h2>
<p>While Chinese state-owned firms focus on funding public infrastructure projects, its private sector is more profit-oriented. This means that changes in BRI – which now emphasises more on less risky, bankable projects – is unlikely to affect Chinese private investment in Indonesia.</p>
<p>One of the critical projects between the two countries’ private sectors is <a href="https://dinsights.katadata.co.id/read/2021/09/17/tsingshans-subsidiary-becomes-indonesias-top-nickel-producer">a joint venture</a> between Tsingshan Holding Group Company Limited, the China-based <a href="https://www.reuters.com/markets/funds/china-tsingshans-overseas-nickel-footprint-2022-03-09/">biggest private investor in nickel processing</a>, and Merdeka Copper and Gold. </p>
<p>Close relationships with domestic tycoons have helped Chinese private sector firms navigate Indonesia’s <a href="https://asianews.network/despite-reforms-red-tape-still-main-problem-for-indonesias-regional-projects/">planning rules</a> and guide the engagement with the country’s domestic politics. </p>
<p>Chinese private companies such as Tsingshan are also backed by their state-owned firms in their Indonesian ventures. <a href="https://nickelindustries.com/tsingshan-collaboration/indonesian-morowali-industrial-park-imip/">The Morowali Industrial Park</a> in Central Sulawesi, Tsingshan’s most prominent project and the largest nickel processing park in Asia, is funded with loans from <a href="https://thepeoplesmap.net/project/indonesia-morowali-industrial-park-imip/">Chinese state-owned banks</a>. The park’s processing technology contractor is mainly run by a Chinese state-owned subsidiary.</p>
<p>The Chinese state-owned companies find Tshinghan and other Chinese private sector operators successful in navigating their investment in complex and highly political sectors such as natural resources and critical minerals processing due to their strong links with Indonesia’s powerful politicians and business people.</p>
<p>Chipping in via profit-oriented projects run by private companies makes more sense for some Chinese state-owned firms than being directly involved in Indonesia’s public infrastructure projects. The investments driven by Chinese private sectors are relatively more risk-averse and commercially sound.</p>
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Baca juga:
<a href="https://theconversation.com/victims-of-the-green-energy-boom-the-indonesians-facing-eviction-over-a-china-backed-plan-to-turn-their-island-into-a-solar-panel-ecocity-214755">Victims of the green energy boom? The Indonesians facing eviction over a China-backed plan to turn their island into a solar panel 'ecocity'</a>
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<p>In the future, we will likely see a continuing trend of Chinese private sectors, supported by their state-owned firms, partnering with domestic business groups to invest in Indonesia’s profitable critical minerals and other sectors.</p><img src="https://counter.theconversation.com/content/218438/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ahmad Syarif tidak bekerja, menjadi konsultan, memiliki saham, atau menerima dana dari perusahaan atau organisasi mana pun yang akan mengambil untung dari artikel ini, dan telah mengungkapkan bahwa ia tidak memiliki afiliasi selain yang telah disebut di atas.</span></em></p>The shift in focus in the Belt and Road Initiative (BRI) will change how China does its business in Indonesia – that might mean less money for the latter’s ambitious infrastructure projects.Ahmad Syarif, Doctor of International Affairs candidate, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2169152023-11-13T14:43:04Z2023-11-13T14:43:04ZBad food choices: clearer labels aim to help South Africans pick healthier options<p>South Africans have a hard time figuring out which foods are unhealthy when they go shopping. But this is about to change.</p>
<p>South African supermarkets currently sell <a href="https://doi.org/10.1017/S1368980022000374">large amounts of unhealthy, ultra-processed foods</a>. Packaged foods in particular have high levels of sugar, salt and saturated fat – all things that are bad for our health.</p>
<p><a href="https://www.nature.com/articles/s41366-020-00650-z">Research</a> shows that the consumption of these foods is linked to increasing rates of obesity and related diseases such as diabetes.</p>
<p>Many countries have been looking for better labelling systems which help consumers understand whether a product is unhealthy. Countries that have adopted simpler labelling systems have seen consumers making <a href="https://www.oecd-ilibrary.org/content/paper/c1f4d81d-en">healthier choices</a> about food. </p>
<p>South Africa’s health minister published draft <a href="https://www.gov.za/sites/default/files/gcis_document/202304/48428rg11572gon3287.pdf">food labelling regulations</a> in April. These will introduce a new labelling scheme, limit advertising of unhealthy foods, and restrict the use of misleading health claims.</p>
<p>The draft regulations propose clearer food labels, which include a new triangle highlighting that the food contains ingredients that are unhealthy. These logos will be placed on the front of a product.</p>
<p>We are part of the <a href="https://www.globalfoodresearchprogram.org/nutrient-warning-labels-work-in-south-africa-results-from-a-randomized-controlled-trial">working group</a> that advised the Department of Health on front-of-package nutrition labelling, drawing on our expertise in dietetics, nutrition, public health and the law. </p>
<p>We worked with consumers and experts on food labelling, advertising and obesity prevention to create a system designed to work well in South Africa.</p>
<p>But it was a complicated process. This is how we did it. </p>
<h2>How do we know which food is unhealthy?</h2>
<p>The first step is to find a way to identify unhealthy foods. There are <a href="https://www.emro.who.int/nutrition/reduce-fat-salt-and-sugar-intake/index.html">international guidelines</a> on how much sugar, salt and saturated fat people should be eating. These can be used to measure whether a food has too much of these ingredients. </p>
<p>Figuring out whether a food is unhealthy can be tricky, but luckily, other countries around the world have adopted systems like this before, known as <a href="https://doi.org/10.3390/nu13082584">nutrient profile models</a>, and we could build on what they had already done. </p>
<p>We looked at what foods were being sold in South African supermarkets. We searched for nutrient profiling models that identify unhealthy foods and work well in other countries and tested these on the South African food supply.</p>
<p>We found that the <a href="https://doi.org/10.3390/nu13082584">Chilean model</a>, which focuses only on unhealthy ingredients, sugar, sodium and saturated fat, would work well because it was simple to implement and was able to identify unhealthy products very easily and accurately. </p>
<p>We then modified the Chilean model to make it work for South Africa.</p>
<h2>Choosing the right label</h2>
<p>The next thing to decide was what kind of label South Africa should use. There are lots of different systems but not all work well. </p>
<p>One uses colour coding. For example, a low level of salt would get a green marker while high sugar would get a red one.</p>
<p>There are also descriptive labels which don’t tell consumers whether the amounts are good or bad – just whether they are present.</p>
<p>Then there are warning labels, often shaped like traffic signs, to alert consumers to the high levels of unhealthy ingredients such as saturated fat, sugar and salt.</p>
<p>We looked at how to design a label that would be <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0257626">understandable</a> to the average South African. We consulted South Africans on each element of the label, from the wording and size to the symbols and colour.</p>
<p>We developed a black triangle – inspired by a danger warning sign – which would stand out on colourful food packages and included pictures so that anyone, even those who can’t read or speak English, would be able to understand them.</p>
<p>The last part of this work was a nationally representative randomised, control trial of different labelling systems. Almost <a href="https://www.sciencedirect.com/science/article/pii/S0195666322003749">2,000</a> people across different income groups and education levels participated. </p>
<p>We also found that the warning labels led to consumers <a href="https://www.sciencedirect.com/science/article/pii/S0195666322003749">changing their minds</a> about what food they would consider buying.</p>
<p>Earlier this year, South Africans had the opportunity to give comments on the regulations that will see this labelling system implemented. Now it’s up to the department to decide when and how to put these regulations into action.</p>
<p>Hopefully soon all South Africans will be able to see at a glance which foods are bad for their health.</p><img src="https://counter.theconversation.com/content/216915/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Safura Abdool Karim receives funding from Bloomberg Philanthropies. </span></em></p><p class="fine-print"><em><span>Makoma Bopape receives funding from Bloomberg Philanthropies</span></em></p><p class="fine-print"><em><span>Rina Swart receives funding from Bloomberg Philanthropies, the National Department of Health and the DSI/NRF COE in Good Security. </span></em></p><p class="fine-print"><em><span>Tamryn Frank receives funding from Bloomberg Philanthropies. </span></em></p>Countries that have adopted clear food labels have seen the health benefits. Researchers explain how a new system to alert South African consumers to unhealthy choices was developed.Safura Abdool Karim, Postdoctoral fellow, Johns Hopkins UniversityMakoma Bopape, Lecturer in Department of Human Nutrition and Dietetic, University of LimpopoRina Swart, Professor, University of the Western CapeTamryn Frank, Researcher, University of the Western CapeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2156982023-11-01T12:35:53Z2023-11-01T12:35:53ZCancer has many faces − 5 counterintuitive ways scientists are approaching cancer research to improve treatment and prevention<figure><img src="https://images.theconversation.com/files/553918/original/file-20231016-15-3osk1.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2700%2C1758&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Cancer cells don't follow the typical rules that allow a multicellular collective to function.</span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Cancer_cells_(1).jpg">Dr. Cecil Fox/National Cancer Institute</a></span></figcaption></figure><p>How researchers conceptualize a disease informs how they treat it. Cancer is often described as uncontrollable cell growth triggered by genetic damage. But cancer can also be seen from angles that emphasize mathematics, evolutionary game theory and physics, among others.</p>
<p>Molecular biology has brought significant advances in making it possible to live with cancer as a chronic illness rather than a fatal disease. Alternative frameworks, however, can offer scientists additional insights on how to prevent tumors from spreading throughout the body and becoming resistant to treatment.</p>
<p>Here are a few unconventional lenses through which researchers are viewing cancer with fresh eyes, drawn from The Conversation’s archives.</p>
<h2>1. Evolution and natural selection of cancer</h2>
<p>The body is far from a wonderland for cells. Each individual cell competes against trillions of others for finite space and nutrients. If they’re able to cooperate in an orderly enough fashion, sharing resources and dividing labor, the collective functions effectively. Cancer cells, however, <a href="https://theconversation.com/microbes-in-your-food-can-help-or-hinder-your-bodys-defenses-against-cancer-how-diet-influences-the-conflict-between-cell-cooperators-and-cheaters-195810">cheat the system</a>: They hog resources, take up as much space as possible and <a href="https://theconversation.com/what-are-hela-cells-a-cancer-biologist-explains-169913">refuse to die</a>.</p>
<p>In this way, cancer can be thought of as <a href="https://theconversation.com/every-cancer-is-unique-why-different-cancers-require-different-treatments-and-how-evolution-drives-drug-resistance-199249">an evolutionary disease</a> – these are cells that have developed the genetic mutations to outcompete their neighbors, and subsequent cell generations inherit this survival advantage. Cancer cells benefit at the expense of the collective until the entire organism collapses.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/554078/original/file-20231016-27-4u7mpn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Microscopy image of pancreas tumor with multicolored cell subgroups" src="https://images.theconversation.com/files/554078/original/file-20231016-27-4u7mpn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/554078/original/file-20231016-27-4u7mpn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=458&fit=crop&dpr=1 600w, https://images.theconversation.com/files/554078/original/file-20231016-27-4u7mpn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=458&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/554078/original/file-20231016-27-4u7mpn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=458&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/554078/original/file-20231016-27-4u7mpn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=575&fit=crop&dpr=1 754w, https://images.theconversation.com/files/554078/original/file-20231016-27-4u7mpn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=575&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/554078/original/file-20231016-27-4u7mpn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=575&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Most tumors are made of many different kinds of cancer cells, as shown in this pancreatic cancer sample from a mouse.</span>
<span class="attribution"><a class="source" href="https://visualsonline.cancer.gov/details.cfm?imageid=10654">Ravikanth Maddipati/Abramson Cancer Center at the University of Pennsylvania via National Cancer Institute</a></span>
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<p>Oncologist <a href="https://cancer.psu.edu/researchers/individual/-/researcher/5B6500F63D6A38DBE0540010E056499A/monika-joshi-md-mrcp">Monika Joshi</a> and pathologists <a href="https://cancer.psu.edu/researchers/individual/-/researcher/5F6E820FF5C14A2DE0540010E056499A/joshua-warrick-md">Joshua Warrick</a> and <a href="https://scholar.google.com/citations?user=YEqQHkIAAAAJ&hl=en">David DeGraff</a> believe that understanding evolution is key to understanding cancer. Screening programs are effective, for example, because removing a nascent tumor is easier than treating one that has evolved the ability to spread. Cancer cells likewise become resistant to treatments because they’re pushed to further evolve to survive.</p>
<p>Some researchers are applying the principles of evolutionary game theory to <a href="https://theconversation.com/cancers-are-in-an-evolutionary-battle-with-treatments-evolutionary-game-theory-could-tip-the-advantage-to-medicine-17017">reduce treatment resistance</a> and optimize <a href="https://theconversation.com/cancer-in-kids-is-different-from-cancer-in-grown-ups-figuring-out-how-could-lead-to-better-pediatric-treatments-212738">therapies for children</a>.</p>
<p>“The fight against cancer is a fight against evolution, the fundamental process that has driven life on Earth since time immemorial,” they wrote. “This is not an easy fight, but medicine has made tremendous progress.”</p>
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Read more:
<a href="https://theconversation.com/every-cancer-is-unique-why-different-cancers-require-different-treatments-and-how-evolution-drives-drug-resistance-199249">Every cancer is unique – why different cancers require different treatments, and how evolution drives drug resistance</a>
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<h2>2. Fluid mechanics of cancer</h2>
<p>As much as cancer is a disease that respects no boundaries, tumor cells are still shaped by their environment. Unlike healthy cells that take the hint when their presence isn’t wanted, however, tumor cells not only <a href="https://theconversation.com/stopping-the-cancer-cells-that-thrive-on-chemotherapy-research-into-how-pancreatic-tumors-adapt-to-stress-could-lead-to-a-new-treatment-approach-197768">survive but thrive in stressful conditions</a>. Isolated cancer cells able to adapt to harsh settings are the ones that establish metastatic colonies and become resistant to treatment.</p>
<p>While researchers have focused on how biochemical signals direct cells to move from one location to another, a cell’s physical environment also affects where it migrates. Mechanical engineer <a href="https://scholar.google.com/citations?user=nKmJNpQAAAAJ&hl=en">Yizeng Li</a> found that a cell’s “solid” and “fluid” surroundings influence its movement.</p>
<p>Cancer cells encounter varying degrees of fluid viscosity, or thickness, as they travel through the body. Li and her team found that breast cancer cells counterintuitively move faster in high viscosity environments by changing their structure. This meant that fluid viscosity serves as a <a href="https://theconversation.com/how-cancer-cells-move-and-metastasize-is-influenced-by-the-fluids-surrounding-them-understanding-how-tumors-migrate-can-help-stop-their-spread-195792">mechanobiological cue for cancer cells to metastasize</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/502975/original/file-20230103-105030-c8xq8d.gif?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Animation comparing two fluids with lower and higher viscosity." src="https://images.theconversation.com/files/502975/original/file-20230103-105030-c8xq8d.gif?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/502975/original/file-20230103-105030-c8xq8d.gif?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=463&fit=crop&dpr=1 600w, https://images.theconversation.com/files/502975/original/file-20230103-105030-c8xq8d.gif?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=463&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/502975/original/file-20230103-105030-c8xq8d.gif?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=463&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/502975/original/file-20230103-105030-c8xq8d.gif?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=582&fit=crop&dpr=1 754w, https://images.theconversation.com/files/502975/original/file-20230103-105030-c8xq8d.gif?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=582&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/502975/original/file-20230103-105030-c8xq8d.gif?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=582&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The blue fluid on the left has a lower viscosity relative to the orange fluid on the right.</span>
<span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/File:Viscosities.gif">Synapticrelay/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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</figure>
<p>“Cancer patients usually don’t die from the original source of the tumor but from its spread to other parts of the body,” Li wrote. “Understanding how fluid viscosity affects the movement of tumor cells could help researchers figure out ways to better treat and detect cancer before it metastasizes.”</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-cancer-cells-move-and-metastasize-is-influenced-by-the-fluids-surrounding-them-understanding-how-tumors-migrate-can-help-stop-their-spread-195792">How cancer cells move and metastasize is influenced by the fluids surrounding them – understanding how tumors migrate can help stop their spread</a>
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<hr>
<h2>3. Inflammation link to cardiovascular disease</h2>
<p>Apart from being leading causes of death around the world, cardiovascular disease and cancer may not initially seem to have much in common. The many risk factors they share, however – like poor diet, smoking and chronic stress – coalesce with chronic inflammation: persistent, low-grade activation of the immune system can damage cells in ways that encourage either disease to develop. </p>
<p>For biomedical engineer <a href="https://scholar.google.com/citations?user=wD6KbXkAAAAJ&hl=en">Bryan Smith</a>, the developmental parallels between these diseases signal they could be <a href="https://theconversation.com/could-a-single-drug-treat-the-two-leading-causes-of-death-in-the-us-cancer-and-cardiovascular-disease-205461">treated at the same time</a>.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/TNfYzima37c?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Nanoparticles can ‘eat’ the plaques that cause heart disease.</span></figcaption>
</figure>
<p><a href="https://theconversation.com/drugs-4-essential-reads-on-how-theyre-made-how-they-work-and-how-context-can-make-poison-a-medicine-192590">Drugs can be repurposed</a> to target diseases for which they weren’t originally designed. Certain drugs, for example, can direct immune cells called macrophages to consume both cancer cells and the cellular debris that contribute to cardiovascular plaques.</p>
<p>“As basic science discovers other molecular parallels between these diseases, patients will be the beneficiaries of better therapies that can treat both,” wrote Smith.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/could-a-single-drug-treat-the-two-leading-causes-of-death-in-the-us-cancer-and-cardiovascular-disease-205461">Could a single drug treat the two leading causes of death in the US: cancer and cardiovascular disease?</a>
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<hr>
<h2>4. Mathematics of cancer</h2>
<p>In certain contexts, math has unique strengths in <a href="https://theconversation.com/big-bang-of-numbers-the-conversations-book-club-explores-how-math-alone-could-create-the-universe-with-author-manil-suri-213690">describing the natural world</a>. For instance, epigenetics – where and when genes are turned on or off – plays as much a role in cancer progression as direct changes to the genetic code. Epigenetic changes can alter healthy cells to the point of losing their normal form and function. But the randomness of these changes makes it difficult to tease out pathological from normal genetic activity.</p>
<p>A mathematical concept called stochasticity – or how the randomness of the steps of a process influences how predictable its outcome will be – lends a logical framework to the <a href="https://theconversation.com/cancer-evolution-is-mathematical-how-random-processes-and-epigenetics-can-explain-why-tumor-cells-shape-shift-metastasize-and-resist-treatments-199398">epigenetic changes contributing to cancer</a>, clarifying when healthy cells rapidly develop into tumor cells. </p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/_aAhcNjmvhc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Twins sharing the exact same genome can develop in completely different ways because of epigenetics.</span></figcaption>
</figure>
<p>Stochasticity is commonly used to study stock market behavior and epidemic disease spread, and researchers quantify it by examining the degree of uncertainty, or entropy, of a particular outcome. Identifying high entropy areas in the genome could offer another approach to cancer detection and drug design.</p>
<p>Cancer geneticist <a href="https://scholar.google.com/citations?user=tbj-LpcAAAAJ&hl=en">Andrew Feinberg</a> has been using entropy to quantitatively describe the epigenetics of cancer. He and his colleagues found that high entropy regions of the genome in the skin become even more entropic with sun damage, increasing the chance of developing cancer. This offers a potential explanation for why cancer risk significantly increases with age.</p>
<p>“Epigenetic entropy shows that you can’t fully understand cancer without mathematics,” Feinberg wrote. “Biology is catching up with other hard sciences in incorporating mathematical methods with biological experimentation.”</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/cancer-evolution-is-mathematical-how-random-processes-and-epigenetics-can-explain-why-tumor-cells-shape-shift-metastasize-and-resist-treatments-199398">Cancer evolution is mathematical – how random processes and epigenetics can explain why tumor cells shape-shift, metastasize and resist treatments</a>
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<hr>
<h2>5. A public health issue</h2>
<p>Cancer is a disease that develops in an individual, but its socially derived causes and societal-wide effects are hardly limited to a single person.</p>
<p>Take the case of lung cancer. It is stigmatized as a disease brought on by poor lifestyle choices – a consequence of a personal decision to use tobacco products. But as thoracic oncologist <a href="https://doctors.umiamihealth.org/provider/Estelamari+Rodriguez/1257821">Estelamari Rodriguez</a> noted, the face of lung cancer has changed.</p>
<p>“Over the past 15 years, more women, never-smokers and younger people are being diagnosed with lung cancer,” she wrote. While lung cancer rates have significantly decreased for men, they have <a href="https://theconversation.com/lung-cancer-rates-have-decreased-for-the-marlboro-man-but-have-risen-steeply-for-nonsmokers-and-young-women-an-oncologist-explains-why-197581">substantially risen for women</a> around the world. Despite being the leading cause of cancer death among women, screening rates remain low compared with other cancers.</p>
<p>More broadly, cancer symptoms are often unrecognized or misdiagnosed, not only <a href="https://theconversation.com/ovarian-cancer-is-not-a-silent-killer-recognizing-its-symptoms-could-help-reduce-misdiagnosis-and-late-detection-181415">for women</a> but also for many marginalized populations, including <a href="https://theconversation.com/biopsies-confirm-a-breast-cancer-diagnosis-after-an-abnormal-mammogram-but-structural-racism-may-lead-to-lengthy-delays-185824">people of color</a>, <a href="https://theconversation.com/doctors-often-arent-trained-on-the-preventive-health-care-needs-of-gender-diverse-people-as-a-result-many-patients-dont-get-the-care-they-need-191933">transgender patients</a> and <a href="https://theconversation.com/how-obamacare-has-helped-poor-cancer-patients-85306">the uninsured</a>.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/yRDDMX8vFrg?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">An increasing number of lung cancer diagnoses are among people who never smoked.</span></figcaption>
</figure>
<p>These disparities are due in part to biases in medical education and <a href="https://theconversation.com/yes-black-patients-do-want-to-help-with-medical-research-here-are-ways-to-overcome-the-barriers-that-keep-clinical-trials-from-recruiting-diverse-populations-185337">clinical research</a> that fail to prepare clinicians to care for the diversity of patients they’ll encounter. <a href="https://theconversation.com/the-next-attack-on-the-affordable-care-act-may-cost-you-free-preventive-health-care-166087">Tenuous access to preventive care</a> and disproportionate <a href="https://theconversation.com/arsenic-contamination-of-food-and-water-is-a-global-public-health-concern-researchers-are-studying-how-it-causes-cancer-200689">exposure to carcinogens</a> among certain populations compound these inequities.</p>
<p>The purview of cancer goes far beyond a single discipline. It takes a village of researchers, policymakers and patient advocates to achieve effective and accessible cancer care for all.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/lung-cancer-rates-have-decreased-for-the-marlboro-man-but-have-risen-steeply-for-nonsmokers-and-young-women-an-oncologist-explains-why-197581">Lung cancer rates have decreased for the Marlboro Man, but have risen steeply for nonsmokers and young women – an oncologist explains why</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/215698/count.gif" alt="The Conversation" width="1" height="1" />
From math to evolutionary game theory, looking at cancer through different lenses can offer further insights on how to approach treatment resistance, metastasis and health disparities.Vivian Lam, Associate Health and Biomedicine EditorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2162452023-10-26T12:32:16Z2023-10-26T12:32:16ZUN warns that Gaza desperately needs more aid − an emergency relief expert explains why it is especially tough working in Gaza<figure><img src="https://images.theconversation.com/files/555675/original/file-20231024-27-axqx74.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A Palestinian boy sits in a World Health Organization truck near a hospital in the southern area of the Gaza Strip. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/palestinian-boy-sits-in-a-truck-of-the-world-health-news-photo/1741639361?adppopup=true">Ahmed Zakot/SOPA Images/LightRocket via Getty Images</a></span></figcaption></figure><p><em>United Nations agencies on Oct. 24, 2023, <a href="https://www.reuters.com/world/middle-east/un-palestinian-refugee-agency-calls-unimpeded-flow-aid-gaza-2023-10-24/">pleaded for more aid</a> to be allowed into Gaza, saying that more than 20 times the amount of food, water and medical supplies and other items that are currently reaching people is needed.</em></p>
<p><em>Egypt first opened its borders for <a href="https://www.reuters.com/world/middle-east/trucks-enter-gaza-carrying-medical-supplies-food-hamas-2023-10-21/">aid deliveries into Gaza on Oct. 21</a>, and since then, <a href="https://www.reuters.com/world/middle-east/third-gaza-bound-aid-convoy-enters-rafah-crossing-egypt-sources-2023-10-23">54 trucks</a> with medical supplies had entered Gaza as of Oct. 23, according to the U.N.</em></p>
<p><em>But the U.N. and other <a href="https://reliefweb.int/report/occupied-palestinian-territory/we-desperately-need-more-humanitarian-aid-come-gaza">international aid groups are warning</a> that the 2.3 million people living in Gaza remain in dire need of more clean water, food, fuel and medical care. The U.N.’s relief agency in Gaza, UNRWA, is also saying that without more fuel, it will have to <a href="https://www.ochaopt.org/content/hostilities-gaza-strip-and-israel-flash-update-18">stop its work</a> on everything from providing medical care to setting up shelters for displaced people on Oct. 25.</em> </p>
<p><em>Safely delivering aid in Gaza has unique complications – including the fact that the U.S. and the European Union classify Hamas as a terrorist group.</em> </p>
<p><em>The Conversation spoke with <a href="https://publichealth.jhu.edu/faculty/664/paul-b-spiegel">Paul Spiegel</a>, an expert on complex humanitarian emergencies at the Center for Humanitarian Health at Johns Hopkins Bloomberg School of Public Health, to better understand the particular challenges this reality creates and how it affects delivering aid to civilians in Gaza.</em> </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/555676/original/file-20231024-29-xm3ju6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="People wearing yellow vests wave Egyptian flags at a large white truck." src="https://images.theconversation.com/files/555676/original/file-20231024-29-xm3ju6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/555676/original/file-20231024-29-xm3ju6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/555676/original/file-20231024-29-xm3ju6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/555676/original/file-20231024-29-xm3ju6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/555676/original/file-20231024-29-xm3ju6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/555676/original/file-20231024-29-xm3ju6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/555676/original/file-20231024-29-xm3ju6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">People greet trucks loaded with humanitarian aid preparing to enter Gaza from Egypt on Oct. 22, 2023.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/trucks-loaded-with-humanitarian-aid-prepare-to-enter-gaza-news-photo/1740638103?adppopup=true">Ahmed Gomaa/Xinhua via Getty Images</a></span>
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<h2>What are the challenges with providing aid in conflict zones like Gaza?</h2>
<p>Providing humanitarian assistance in any sudden emergency, like the one <a href="https://apnews.com/article/israel-palestinians-gaza-captives-border-aid-f5976ed58ba508f14d45b72b428125ac">currently happening in Gaza</a>, is complex – in terms of security, logistics and financing. </p>
<p>Often, there are simply not enough appropriate supplies available to quickly get into an acute emergency, which might be in a remote area or might be in a restricted area, as is the case with Gaza. There are <a href="https://reliefweb.int/report/world/aid-worker-security-report-2022-collateral-violence-managing-risks-aid-operations-major-conflict">often security issues</a> that may affect an aid group’s access to a population. And there is the risk that <a href="https://www.icrc.org/en/document/syria-attack-humanitarian-convoy-attack-humanity">aid workers will be attacked</a>, as has <a href="https://www.aidworkersecurity.org/incidents/report">happened increasingly</a> over the last several years. </p>
<p>Typically, a U.N. agency like the World Health Organization would try to get assurances from all groups that are part of a conflict, so that those providing assistance will not be targets of violence. These assurances do not always happen, and then the agencies need to decide if they deliver <a href="https://reliefweb.int/report/world/aid-worker-security-report-2023-figures-glance">the aid or wait until they get a guarantee</a> they won’t be attacked. </p>
<p>There are also concerns about aid, which is intended only for civilians, being diverted for military purposes. This can vary from combatants secretly taking small amounts of supplies for their troops or stealing large truckloads of goods.</p>
<h2>How do politics affect humanitarian work, which is supposed to be neutral?</h2>
<p>Humanitarians try to follow basic principles of <a href="https://guide-humanitarian-law.org/content/article/3/humanitarian-principles/">humanity, independence, neutrality and impartiality</a>. We are not addressing the underlying causal issues related to a crisis. But the politics surrounding an emergency are still often a major, complicating factor in our work. </p>
<p>For example, at the Egyptian <a href="https://www.bbc.com/news/world-middle-east-67121372">Rafah crossing into Gaza</a>, various issues needed to be resolved, such as searching aid convoys for weapons, which items Hamas or other groups could divert from civilians and the assurance that refugees would not cross into Egypt. These and other aspects continue to delay much-needed aid for civilians in Gaza.</p>
<p>In this conflict, I have also seen aid workers express concern that the <a href="https://reliefweb.int/report/occupied-palestinian-territory/interview-israel-palestine-lack-fuel-gaza-now-critical-says-wfp">limited amount of aid</a> currently allowed into Gaza would stay in the south, and consequently be a pull factor for people being displaced from their homes. Or, there is a concern that the aid may not get to where it is most needed, such as all hospitals throughout Gaza. </p>
<p>In other crises, like those in the <a href="https://www.usaid.gov/humanitarian-assistance/democratic-republic-of-the-congo">Democratic Republic of Congo</a> or in Syria, we have heard concerns from all sides of a conflict about how aid may be unevenly or inequitably distributed, depending on where people live or what particular ethnic or religious group they belong to. This can cause tensions and even fighting among different communities.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/555677/original/file-20231024-22-hd2tks.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two children sit on the ground between rows of white tents and clothing hung on white laundry lines." src="https://images.theconversation.com/files/555677/original/file-20231024-22-hd2tks.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/555677/original/file-20231024-22-hd2tks.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/555677/original/file-20231024-22-hd2tks.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/555677/original/file-20231024-22-hd2tks.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/555677/original/file-20231024-22-hd2tks.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/555677/original/file-20231024-22-hd2tks.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/555677/original/file-20231024-22-hd2tks.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Children play around tents on Oct. 19, 2023, at a U.N. camp set up for Palestinians who fled to the southern Gaza Strip.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/kids-play-around-tents-at-a-camp-set-up-by-the-united-news-photo/1733642681?adppopup=true">Mustafa Hassona/Anadolu via Getty Images</a></span>
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</figure>
<h2>How does Hamas factor into this planning?</h2>
<p>The U.S. and the <a href="https://www.consilium.europa.eu/en/policies/fight-against-terrorism/terrorist-list/#applied">European Union</a> have very <a href="https://www.state.gov/executive-order-13224/">strict rules</a> that will block the financial assets of organizations that give money or support to Hamas, or any other organization they classify as a terrorist group. </p>
<p>These sanctions also prohibit any direct contact between aid groups and a listed <a href="https://www.state.gov/foreign-terrorist-organizations/">terrorist organization like Hamas</a>.</p>
<h2>Can you give an example of what this looks like in practice?</h2>
<p>I arrived in Afghanistan immediately after the <a href="https://www.cfr.org/backgrounder/taliban-afghanistan">Taliban took over</a> in 2021 with the World Health Organization. When that happened, the nongovernmental organizations and U.N. agencies – which receive the largest <a href="https://www.cfr.org/article/funding-united-nations-what-impact-do-us-contributions-have-un-agencies-and-programs">amount of money from the U.S.</a> than from any other country – were not allowed to officially work with the Taliban and their ministries, or to give any money to them. </p>
<p>Previously, most of the global funding for health, for instance, was given to the Afghan Ministry of Public Health, which then had systems in place to disburse the money and monitor how it was spent. These new restrictions made it harder for aid to be delivered. We needed to find new ways of doing work, in order to bypass the Taliban and the Ministry of Public Health, which the former now controlled. This disruption created challenges in terms of both distributing aid quickly and in terms of sustainability, as many of the employees at the ministry left.</p>
<h2>What are the long-term effects of navigating around governments that are classified by some countries as terrorist groups?</h2>
<p>When international assistance is not allowed to go through local governments because of sanctions, the U.N. and international nongovernmental organizations develop and run parallel services, like schools or hospitals. </p>
<p>While this may work in the short term and save lives, these parallel systems have longer-term, negative effects. Government officials may leave their jobs for higher-paying jobs in the U.N. and with NGOs, for example. </p>
<p>We have seen the negative, long-term effects of this firsthand in numerous countries, like Afghanistan, South Sudan and other places where the U.S. and other governments are concerned about terrorism, and consequently have imposed sanctions. </p>
<p>At this point in time, I think that lifesaving aid desperately needs to be provided to civilians in Gaza. Despite the various challenges I have mentioned in this discussion, I believe that humanity must prevail, over all other aspects. It truly is a matter of life and death.</p><img src="https://counter.theconversation.com/content/216245/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Spiegel does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Government sanctions against Hamas, which the US and the European Union consider a terrorist group, mean that aid groups are not able to directly work with Hamas.Paul Spiegel, Director of the Center for Humanitarian Health, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2145732023-10-05T12:35:46Z2023-10-05T12:35:46ZLego’s ESG dilemma: Why an abandoned plan to use recycled plastic bottles is a wake-up call for supply chain sustainability<figure><img src="https://images.theconversation.com/files/551813/original/file-20231003-27-dy1q3j.jpg?ixlib=rb-1.1.0&rect=0%2C13%2C2995%2C1994&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Legos are designed to last for decades. That posed a challenge when the toymaker tried to switch to recycled plastics.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/JapanLegoVermeer/44d6901361e34da99801b802fd976bb2/photo">AP Photo/Shizuo Kambayashi</a></span></figcaption></figure><p>Lego, the world’s <a href="https://www.statista.com/statistics/241241/revenue-of-major-toy-companies-worldwide/">largest toy manufacturer</a>, has built a reputation not only for the <a href="https://www.smithsonianmag.com/smart-news/how-much-abuse-can-a-single-lego-brick-take-343398/">durability of its bricks</a>, designed to <a href="https://www.theguardian.com/sustainable-business/lego-design-sustainability-circular-economy">last for decades</a>, but also for its substantial investment in sustainability. The company has <a href="https://www.esgtoday.com/lego-to-invest-over-1-4-billion-to-reduce-emissions-commits-to-net-zero-by-2050/">pledged US$1.4 billion</a> to reduce carbon emissions by 2025, despite netting <a href="https://apnews.com/article/lego-profit-sales-higher-prices-denmark-daa98df56563de4b9fa02185862b1b3a">annual profits of just over $2 billion</a> in 2022. </p>
<p>This commitment isn’t just for show. Lego sees its core customers as children and their parents, and <a href="https://www.un.org/en/academic-impact/sustainability">sustainability</a> is fundamentally about ensuring that future generations inherit a planet as hospitable as the one we enjoy today. </p>
<p>So it was surprising when the Financial Times reported on <a href="https://www.ft.com/content/6cad1883-f87a-471d-9688-c1a3c5a0b7dc">Sept. 25, 2023</a>, that Lego had pulled out of its widely publicized “<a href="https://www.reuters.com/business/sustainable-business/bottles-bricks-lego-finds-right-fit-with-recycled-plastic-2021-06-23/">Bottles to Bricks</a>” initiative.</p>
<p>This ambitious project aimed to replace traditional Lego plastic with a new material made from recycled plastic bottles. However, when Lego assessed the project’s environmental impact throughout its supply chain, it found that producing bricks with the recycled plastic would <a href="https://www.theguardian.com/lifeandstyle/2023/sep/24/lego-abandons-effort-to-make-bricks-from-recycled-plastic-bottles">require extra materials and energy</a> to make them durable enough. Because this conversion process would result in higher carbon emissions, the company decided to stick with its current fossil fuel-based materials while <a href="https://www.lego.com/en-us/aboutus/news/2023/september/the-lego-group-remains-committed-to-make-lego-bricks-from-sustainable-materials">continuing to search</a> for more sustainable alternatives.</p>
<p>As <a href="https://tinglongdai.com">experts</a> in <a href="https://www.gsb.stanford.edu/faculty-research/faculty/hau-l-lee">global supply chains</a> and <a href="https://scholar.google.com/citations?user=Kk-QbksAAAAJ&hl=en">sustainability</a>, we believe Lego’s pivot is the beginning of a larger trend toward developing sustainable solutions for entire supply chains in a circular economy. New regulations <a href="https://www.isscorporatesolutions.com/library/are-european-companies-ready-for-scope-3-disclosures/">in the European Union</a> – and <a href="https://www.reuters.com/world/us/california-climate-bill-clears-senate-governor-newsom-have-final-say-2023-09-12/">expected in California</a> – are about to speed things up.</p>
<h2>Examining all the emissions, cradle to grave</h2>
<p>Business leaders are increasingly <a href="https://doi.org/10.1287/serv.2021.0295">integrating environmental, social and governance factors</a>, commonly known as ESG, into their operational and strategic frameworks. But the pursuit of sustainability requires attention to the entire life cycle of a product, from its materials and manufacturing processes to its use and ultimate disposal.</p>
<p>The results can lead to counterintuitive outcomes, as Lego discovered.</p>
<p>Understanding a company’s entire carbon footprint requires looking at <a href="https://www.epa.gov/climateleadership/scope-1-and-scope-2-inventory-guidance">three types of emissions</a>: Scope 1 emissions are generated directly by a company’s internal operations. Scope 2 emissions are caused by generating the electricity, steam, heat or cooling a company consumes. And <a href="https://www.epa.gov/climateleadership/scope-3-inventory-guidance">scope 3</a> emissions are generated by a company’s supply chain, from upstream suppliers to downstream distributors and end customers. </p>
<figure class="align-center ">
<img alt="Lists of examples of sope 1, 2, 3 emissions sources with an illustration of a factory in the center" src="https://images.theconversation.com/files/450130/original/file-20220304-13-727hza.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/450130/original/file-20220304-13-727hza.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=509&fit=crop&dpr=1 600w, https://images.theconversation.com/files/450130/original/file-20220304-13-727hza.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=509&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/450130/original/file-20220304-13-727hza.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=509&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/450130/original/file-20220304-13-727hza.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=640&fit=crop&dpr=1 754w, https://images.theconversation.com/files/450130/original/file-20220304-13-727hza.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=640&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/450130/original/file-20220304-13-727hza.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=640&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">What scope 1, 2 and 3 emissions involve.</span>
<span class="attribution"><a class="source" href="https://www.americanprogress.org/article/why-companies-should-be-required-to-disclose-their-scope-3-emissions/">Chester Hawkins/Center for American Progress</a></span>
</figcaption>
</figure>
<p>Currently, <a href="https://www.isscorporatesolutions.com/library/are-european-companies-ready-for-scope-3-disclosures">fewer than 30%</a> of companies report meaningful scope 3 emissions, in part because these emissions are difficult to track. Yet, companies’ scope 3 emissions are on average <a href="https://www.cdp.net/en/research/global-reports/transparency-to-transformation">11.4 times greater</a> than their <a href="https://www.epa.gov/climateleadership/scope-1-and-scope-2-inventory-guidance">scope 1</a> emissions, data from corporate disclosures reported to the nonprofit CDP show.</p>
<p>Lego is a case study of this lopsided distribution and the importance of tracking scope 3 emissions. A staggering <a href="https://www.lego.com/en-us/sustainability/environment/our-co2-footprint">98% of Lego’s carbon emissions</a> are categorized as scope 3. </p>
<p>From 2020 to 2021, the company’s total emissions increased by 30%, amid surging demand for Lego sets during the COVID-19 lockdowns – even though the company’s scope 2 emissions related to purchased energy such as electricity decreased by 40%. The increase was almost entirely in its scope 3 emissions.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/C3oiy9eekzk?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Lego’s tour of how its toy bricks are made doesn’t address the supply chain, where most of Lego’s greenhouse gas emissions originate.</span></figcaption>
</figure>
<p>As more companies follow in Lego’s footsteps and begin reporting scope 3 emissions, they will likely find themselves in the same position, realizing that efforts to reduce carbon emissions often boil down to supply chain and consumer-use emissions. And the results may force them to make some tough choices.</p>
<h2>Policy and disclosure: The next frontier</h2>
<p>New regulations in the European Union and pending in California are designed to increase corporate emissions transparency by including supply chain emissions.</p>
<p>The EU in June 2023 adopted the first set of European Sustainability Reporting Standards, which will require publicly traded companies in the EU to <a href="https://www.isscorporatesolutions.com/library/are-european-companies-ready-for-scope-3-disclosures/%22%22">disclose their scope 3 emissions</a>, starting in their reports for fiscal year 2024.</p>
<p>California’s legislature <a href="https://www.reuters.com/world/us/california-climate-bill-clears-senate-governor-newsom-have-final-say-2023-09-12/#:%7E:text=Sept%2012%20(Reuters)%20%2D%20California's,in%20setting%20corporate%20climate%20rules.%22%22">passed similar legislation</a> requiring companies with revenues of more than $1 billion to disclose their scope 3 emissions. California’s governor has until Oct. 14, 2023, to consider the bill and <a href="https://apnews.com/article/california-governor-gavin-newsom-climate-bills-global-warming-2c5adbb29e67b753e396169195430ffb">is expected to sign it</a>.</p>
<p>At the federal level, the U.S. Securities and Exchange Commission released a proposal in March 2022 that, if finalized, <a href="https://www.wsj.com/articles/secs-climate-disclosure-rule-isnt-here-but-it-may-as-well-be-many-businesses-say-854789bd/">would require</a> all public companies to report climate-related risk and emissions data, including scope 3 emissions. After <a href="https://news.bloomberglaw.com/securities-law/sec-climate-rules-pushed-back-amid-bureaucratic-legal-woes%22%22">receiving significant pushback</a>, the SEC began reconsidering the scope 3 reporting rule. But SEC Chairman Gary Gensler suggested during a congressional hearing in late September 2023 that California’s move <a href="https://www.reuters.com/sustainability/sec-chief-says-new-california-law-could-change-baseline-coming-sec-climate-rule-2023-09-27/">could influence federal regulators’ decision</a>.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/MacoRZSLzTc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">SEC Chairman Gary Gensler explains the importance of climate-related risk disclosures.</span></figcaption>
</figure>
<p>This increased focus on disclosure of scope 3 emissions will undoubtedly increase pressure on companies. </p>
<p>Because scope 3 emissions are significant, yet often not measured or reported, <a href="https://doi.org/10.1007/s10551-022-05151-9">consumers are rightly concerned</a> that companies that claim to have low emissions <a href="https://makersite.io/insights/whitepaper-the-cost-of-greenwashing/">may be greenwashing</a> without taking action to reduce emissions in their supply chains to combat climate change. </p>
<p>At the same time, we suspect that as more investors support sustainable investing, they may prefer to invest in companies that are transparent in disclosing all areas of emissions. Ultimately, we believe consumers, investors and governments will demand more than lip service from companies. Instead, they’ll expect companies to take actionable steps to reduce the most significant part of a company’s carbon footprint – scope 3 emissions. </p>
<h2>A journey, not a destination</h2>
<p>The Lego example serves as a cautionary tale in the complex ESG landscape for which <a href="https://www.reuters.com/sustainability/three-quarters-firms-globally-are-not-ready-new-esg-rules-kpmg-finds-2023-09-26/">most companies are not well prepared</a>. As more companies come under scrutiny for their entire carbon footprint, we may see more instances where well-intentioned sustainability efforts run into uncomfortable truths. </p>
<p>This calls for a nuanced understanding of sustainability, not as a checklist of good deeds, but as a complex, ongoing process that requires vigilance, <a href="https://theconversation.com/esg-investing-has-a-blind-spot-that-puts-the-35-trillion-industrys-sustainability-promises-in-doubt-supply-chains-170199">transparency</a> and, above all, a commitment to the benefit of future generations.</p><img src="https://counter.theconversation.com/content/214573/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Corporate supply chains are riddled with high, uncounted emissions, as Lego discovered. New regulations mean more companies will face tough, sometimes surprising, choices.Tinglong Dai, Professor of Operations Management & Business Analytics, Carey Business School, Johns Hopkins UniversityChristopher S. Tang, Professor of Supply Chain Management, University of California, Los AngelesHau L. Lee, Professor of Operations, Information & Technology, Stanford UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2128992023-09-06T09:49:22Z2023-09-06T09:49:22ZWagner, les conflits et la pauvreté font que le taux de mortalité en République centrafricaine dépasse les niveaux de la crise : mais où est l'aide ?<p>La République centrafricaine (RCA) est l'un des <a href="https://www.statista.com/statistics/728281/gross-domestic-product-gdp-per-capita-in-central-african-republic/">pays les plus pauvres</a> du monde. En 2022, son PIB par habitant était estimé à 491 USD par an.</p>
<p>Cette nation d'environ <a href="https://data.who.int/countries/140">5 millions</a> d'habitants est en proie à des troubles politiques depuis une prise de pouvoir violente en 2013. Un <a href="https://www.bbc.com/news/world-africa-13150044">“effondrement total de l'ordre public”</a> persiste depuis près de 20 ans. Près de la moitié des campagnes <a href="https://www.polgeonow.com/search/label/central%20african%20republic">échappe</a> au contrôle du gouvernement.</p>
<p>Pour tenter de reprendre le contrôle, le gouvernement a lancé en 2020 une campagne menée par les mercenaires russes du groupe Wagner. Un <a href="https://thesentry.org/reports/architects-of-terror/">rapport</a> documentant les violations généralisées des droits de l'homme en RCA par le groupe Wagner décrit “des campagnes bien planifiées de massacres, de tortures et de viols”. Ce qui reflète généralement le contenu des <a href="https://www.ohchr.org/en/press-releases/2021/11/car-russian-wagner-group-harassing-and-intimidating-civilians-un-experts">communiqués de presse</a> et des <a href="https://www.ohchr.org/en/speeches/2023/03/central-african-republic-atrocities-must-end-says-volker-turk">discours</a> émanant du Haut Commissariat des Nations unies aux droits de l'homme. </p>
<p>En conséquence, la RCA connaît aujourd'hui une crise humanitaire aiguë.</p>
<p>L'un des symptômes de cet effondrement est le taux de mortalité élevé du pays. Deux études publiées au cours des deux dernières années ont suggéré que de vastes régions du pays connaissaient un taux de mortalité qui dépasse les seuils d'alerte. L'une était une <a href="https://conflictandhealth.biomedcentral.com/articles/10.1186/s13031-021-00385-2">enquête réalisée par Médecins sans Frontières en 2020 dans la préfecture de Ouaka</a>. L’<a href="https://conflictandhealth.biomedcentral.com/articles/10.1186/s13031-021-00381-6">autre</a> couvrait la majeure partie de la préfecture de Ouham-Pende et a été réalisée avec l'International Rescue Committee en 2018. Les études ont révélé que 4,9 % et 5,0 % des populations étudiées mouraient chaque année. </p>
<p>Ces estimations sont quatre fois plus élevées que <a href="https://data.worldbank.org/indicator/SP.DYN.CDRT.IN?locations=CF">l'estimation de mortalité de l'ONU</a> de 1,1 % par an pour 2020 pour la RCA. La plupart des agences, telles que les <a href="https://pesquisa.bvsalud.org/portal/resource/pt/des-11113">Centers for Disease Control and Prevention</a>, considèrent le doublement de la mortalité de base comme une crise, et le quadruplement de la mortalité de base est l'un des trois critères utilisés pour définir une famine. </p>
<p>En raison de la discordance entre les mesures récentes de la mortalité et le taux de mortalité officiel, nous avons, en tant que chercheurs en santé publique ayant une expérience de recherche dans les situations de conflit, mené une enquête pour mesurer le taux de mortalité brut de la nation - la fraction de la population qui meurt par unité de temps sans tenir compte du fait qu'il s'agit d'une population jeune ou âgée.</p>
<p>Notre <a href="https://pubmed.ncbi.nlm.nih.gov/37072800/">étude</a> a révélé que 5,6 % de la population mourrait en 2022. Il s'agit d'un taux de mortalité stupéfiant, compte tenu de l'ampleur de la souffrance et de l'erreur des statistiques officielles. La plupart de ces décès sont dus au paludisme et à la diarrhée. Nous avons également constaté que la mortalité était nettement plus élevée dans les zones échappant au contrôle du gouvernement. </p>
<p>Les conditions désastreuses dans lesquelles vivent les habitants de la République centrafricaine n'ont suscité que très peu d'intérêt ou de réponse humanitaire de la part du reste du monde. Pourtant, comme le montrent les chiffres de la mortalité, l'aide alimentaire, les programmes de travail et la distribution de semences et d'outils font cruellement défaut. </p>
<p>Ces besoins sont particulièrement importants dans les zones rurales qui échappent au contrôle du gouvernement. Bien que certains acteurs humanitaires fassent de leur mieux pour répondre à la situation, le taux de mortalité au niveau de la crise suggère que les besoins en RCA sont largement insatisfaits.</p>
<h2>Mortalité</h2>
<p>Nous avons mené une enquête dans deux régions. L'une dans la partie du pays contrôlée par le gouvernement (environ la moitié du pays), et l'autre dans les zones qui échappent en grande partie à son contrôle. Nous avons sélectionné au hasard 40 groupes de 10 ménages chacun. </p>
<p>Nous avons constaté que le taux de natalité était plus faible et le taux de mortalité nettement plus élevé dans les zones échappant au contrôle du gouvernement. Les familles ont décrit le paludisme, la fièvre et la diarrhée comme les principales causes de décès. La violence représentait 6 % de l'ensemble des décès.</p>
<p>Les gens ont cité l'accès à la nourriture et l'accès aux soins médicaux comme étant leurs plus grands défis. Les ménages ont déclaré avoir pris environ deux fois moins de repas en 2022 qu'en 2020. Seuls 15 % d'entre eux avaient bénéficié des distributions d'aide alimentaire en 2022, malgré les <a href="https://reports.unocha.org/en/country/car/card/2jVaaAZR3Y/">niveaux élevés de malnutrition</a> enregistrés dans le pays. </p>
<p>Ces deux défis interagissent l'un avec l'autre. Les enfants et les autres personnes vulnérables, comme les personnes âgées, qui survivraient normalement à un épisode de paludisme ou de diarrhée, ont besoin de soins médicaux appropriés pour survivre en cas de malnutrition. Or, en raison de la détresse économique et de la violence, la fréquentation des cliniques rurales est généralement en baisse par rapport aux années précédentes. </p>
<p>Le coût des soins de santé est un autre facteur. Certaines ONG fournissent des soins gratuits, mais la plupart de celles qui ont été visitées par notre équipe de recherche demandent une modeste participation aux frais. Bien qu'ils ne soient pas standardisés, ils demandent généralement un montant équivalant à une fourchette d'un demi dollar à un dollar américain, et facturent parfois les médicaments séparément. Les coûts non liés à la clinique, tels que le transport, peuvent être encore plus élevés.</p>
<p>Il s'y ajoute un autre coût : les paiements informels qu'on est obligés d'effectuer lorsqu'on tente de se rendre dans des établissements de soins de santé. De nombreuses personnes ont indiqué que la police ou les soldats rebelles leur demandaient de l'argent pour passer les points de contrôle. Dans la préfecture de Ouaka, où l'organisation caritative Médecins Sans Frontières fournit des services médicaux sans frais d'utilisation. Une personne interrogée nous a raconté que sa fille avait récemment accouché à la maison plutôt que d'aller à l'hôpital, parce que les policiers aux postes de contrôle savaient qu'une femme enceinte serait désespérée et qu'ils lui demanderaient plus que les 500 francs (environ 0,8 USD) habituels pour la faire passer.</p>
<h2>Quelles perspectives?</h2>
<p>Des taux de mortalité nationaux plus élevés ont été enregistrés en Afrique par le passé. Les estimations suggèrent qu'au moins 500 000 des 7 millions <a href="https://www.tandfonline.com/doi/epdf/10.1080/14623528.2019.1703329?needAccess=true&role=button#page=1">de Rwandais sont morts violemment en 1994</a>. Au cours de la guerre sécessionniste du Nigeria au Biafra de 1967 à 1970, on estime qu'entre <a href="https://edisciplinas.usp.br/pluginfile.php/3949853/mod_resource/content/1/Toyin%20Falola%20-%20A%20History%20of%20Nigeria%20cap7.pdf#page=158">1 et 3 millions</a> de personnes sont mortes. Ces événements ont déclenché une forte accélération de la riposte en matière d'aide humanitaire, de l'aide financière et de l'attention politique. </p>
<p>Notre étude n'a pas pu déterminer l'importance relative des décennies de conflit en cours, de l'extrême pauvreté, des perturbations économiques depuis 2020 ou des efforts de perturbation généralisés du groupe Wagner dans la cause de l'extrême mortalité observée en République centrafricaine. </p>
<p>Néanmoins, il est clair qu'ils contribuent tous au taux de mortalité. Nous n'avons trouvé aucun exemple depuis 1994 d'une nation entière mourant à un taux aussi élevé que celui que nous avons mesuré en RCA en 2022. </p>
<p>Les acteurs humanitaires tirent la sonnette d'alarme <a href="https://reliefweb.int/report/central-african-republic/major-food-crisis-central-african-republic-car-malnutrition-rates">depuis plus de dix ans</a>. L'ONU <a href="https://www.ipcinfo.org/ipc-country-analysis/details-map/en/c/1152894/">met en garde</a> contre l'insécurité alimentaire extrême depuis deux ans. À la décharge de certaines agences, les ménages font état de distributions de nourriture dans certaines des zones les plus critiques. </p>
<p>Nos conclusions montrent qu'en dépit de ces efforts, l'aide est largement insuffisante. Etant donné que le <a href="https://www.state.gov/u-s-relations-with-central-african-republic/">gouvernement américain a donné à lui seul plus de 330 millions de dollars</a> d'aide à la RCA en 2021 et 2022, on peut se demander si la communauté humanitaire peut faire mieux. En particulier, la communauté humanitaire ignore-t-elle l'une des pires crises humanitaires au monde ?</p><img src="https://counter.theconversation.com/content/212899/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Le taux de natalité était plus faible et le taux de mortalité nettement plus élevé dans les zones échappant au contrôle du gouvernement en République centrafricaine.Leslie Roberts, Professor Emeritus of Population and Family Health at CUMC, Columbia UniversityJennifer O'Keeffe, Doctoral Candidate, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins UniversityKarume Baderha Augustin Gang, Doctoral Candidate, Université Evangélique en AfriqueLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2119432023-09-04T14:54:17Z2023-09-04T14:54:17ZWagner, conflict and poverty drive Central African Republic death rate above crisis levels: but where’s the aid?<p>The Central African Republic (CAR) is one of the <a href="https://www.statista.com/statistics/728281/gross-domestic-product-gdp-per-capita-in-central-african-republic/">poorest countries</a> in the world. Its GDP per capita in 2022 was estimated at US$491 per year.</p>
<p>The nation of roughly <a href="https://data.who.int/countries/140">5 million</a> people has been in political turmoil since a violent takeover of power in 2013. A <a href="https://www.bbc.com/news/world-africa-13150044">“total breakdown of law and order”</a> has persisted for nearly 20 years. Roughly half of the countryside has been <a href="https://www.polgeonow.com/search/label/central%20african%20republic">outside the government’s control</a>.</p>
<p>In an attempt to gain back control, the government unleashed a campaign led by the Russian mercenaries, the Wagner Group, in 2020. A <a href="https://thesentry.org/reports/architects-of-terror/">report</a> documenting widespread human rights abuses in the CAR by the Wagner Group describes “well-planned campaigns of mass killing, torture, and rape”. This is consistent with the broader content of <a href="https://www.ohchr.org/en/press-releases/2021/11/car-russian-wagner-group-harassing-and-intimidating-civilians-un-experts">press releases</a> and <a href="https://www.ohchr.org/en/speeches/2023/03/central-african-republic-atrocities-must-end-says-volker-turk">speeches</a> coming from the UN Office of the High Commissioner for Human Rights. </p>
<p>The result is that CAR is now experiencing an acute humanitarian crisis.</p>
<p>One of the symptoms of the collapse is the country’s high mortality rate. Two surveys published over the last two years have suggested that large areas of the country were experiencing mortality above the emergency threshold. One was a <a href="https://conflictandhealth.biomedcentral.com/articles/10.1186/s13031-021-00385-2">survey done by Médecins sans Frontières in 2020 in Ouaka Prefecture</a>. The <a href="https://conflictandhealth.biomedcentral.com/articles/10.1186/s13031-021-00381-6">other</a> covered most of Ouham-Pende Prefecture and was done with the International Rescue Committee in 2018. The studies found that 4.9% and 5.0% of the studied populations were dying per year. </p>
<p>These estimates are four times higher than the 2020 <a href="https://data.worldbank.org/indicator/SP.DYN.CDRT.IN?locations=CF">UN mortality estimate of 1.1% per year</a> for the CAR. Most agencies, such as the <a href="https://pesquisa.bvsalud.org/portal/resource/pt/des-11113">Centers for Disease Control and Prevention</a>, consider the doubling of the baseline mortality as a crisis, and four times the baseline is one of the three criteria used to define a famine. </p>
<p>Because of the discordance of recent mortality measures and the official mortality rate, as scholars of public health with research experience in conflict settings, we conducted a survey to measure the nation’s crude mortality rate – the fraction of the population dying per unit of time without considering whether it is a young or old population.</p>
<p>Our <a href="https://pubmed.ncbi.nlm.nih.gov/37072800/">study</a> found that 5.6% of the population died in 2022. This is an astonishing mortality rate, in terms of how people are suffering and how wrong the official statistics are. Most of these deaths were from malaria and diarrhoea. We also found that mortality was markedly higher in the areas outside government control. </p>
<p>The dire conditions under which people are living in the CAR have elicited very little interest or humanitarian response from the rest of the world. Yet, as the mortality figures show, there is a desperate need for food aid, along with work programmes and seed and tool distribution. </p>
<p>This is of particular importance in rural areas outside government control. While some humanitarian actors are doing their best to respond, the crisis-level mortality rate suggests that the needs in the CAR are largely unmet.</p>
<h2>Mortality</h2>
<p>We carried out a survey in two areas. One was in the part of the country within the government’s control (roughly half of the country), and one in the areas mostly outside its control. We randomly selected 40 clusters of 10 households in each. </p>
<p>We found that the birth rate was lower and the death rate markedly higher in areas outside government control. Families described malaria or fever and diarrhoea as the primary reported causes of death. Violence accounted for 6% of all deaths.</p>
<p>People cited access to food and access to medical care as their biggest challenges. Households reported eating roughly half as many meals in 2022 as they had in 2020. Only 15% had received food aid distributions in 2022 despite <a href="https://reports.unocha.org/en/country/car/card/2jVaaAZR3Y/">high levels of malnutrition</a> recorded in the country. </p>
<p>These two challenges interact with each other. Children and other vulnerable people like the elderly who would normally survive an episode of malaria or diarrhoea need competent medical attention to survive when malnourished. Yet, because of economic strife and violence, attendance in rural clinics is generally down compared to previous years. </p>
<p>The cost of healthcare is another factor. Some NGOs provide free healthcare, but most visited by our research team charge a modest user fee. While not standardised, they typically charge an amount equivalent to between half and one US dollar, and sometimes charge separately for drugs. The non-clinic costs such as transport can be even greater.</p>
<p>Another cost is that people are forced to make informal and illegitimate payments when trying to get to healthcare facilities. Many mentioned that police or rebel soldiers demanded money to pass at checkpoints. In Ouaka Prefecture, where the charity Médecins Sans Frontières, also known as Doctors Without Borders, provides medical services with no user fees, an interviewee told us that his daughter had recently given birth at home rather than going to the hospital, because the police at the checkpoints knew a pregnant woman would be desperate to get by and they would charge more than the usual 500 franc (about US$0.8) fee for her to pass.</p>
<h2>What next</h2>
<p>Higher nationwide death rates have occurred in Africa in the past. Estimates suggest that at least 500,000 of 7 million <a href="https://www.tandfonline.com/doi/epdf/10.1080/14623528.2019.1703329?needAccess=true&role=button#page=1">Rwandans died violently in 1994</a>. During Nigeria’s secessionist war in Biafra from 1967 to 1970 <a href="https://edisciplinas.usp.br/pluginfile.php/3949853/mod_resource/content/1/Toyin%20Falola%20-%20A%20History%20of%20Nigeria%20cap7.pdf#page=158">between 1 million and 3 million</a> are estimated to have died. These events triggered dramatic escalations in humanitarian response, aid money and political attention. </p>
<p>Our study couldn’t distinguish the relative importance of decades of ongoing conflict, extreme poverty, the economic disruptions since 2020, or the widespread disruption efforts of the Wagner Group in causing the extreme mortality observed in the CAR. </p>
<p>Nevertheless, it’s clear that they are all contributing to the mortality rate. We can find no examples since 1994 of an entire nation dying at such a high rate as we measured in the CAR in 2022. </p>
<p>Humanitarian actors have been raising the alarm <a href="https://reliefweb.int/report/central-african-republic/major-food-crisis-central-african-republic-car-malnutrition-rates">for over a decade</a>. The UN <a href="https://www.ipcinfo.org/ipc-country-analysis/details-map/en/c/1152894/">has been warning</a> of extreme food insecurity for two years. To the credit of certain agencies, households report food distributions in some of the most critical areas. </p>
<p>Our findings show that despite these efforts, aid is woefully insufficient. Given that the <a href="https://www.state.gov/u-s-relations-with-central-african-republic/">US government alone gave over US$330 million</a> in assistance to the CAR in 2021 and 2022, one has to ponder whether the humanitarian community can do better. In particular, are we in the humanitarian community ignoring one of the world’s worst humanitarian crises?</p><img src="https://counter.theconversation.com/content/211943/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The birth rate was lower and the death rate markedly higher in areas outside government control in the Central African Republic.Leslie Roberts, Professor Emeritus of Population and Family Health at CUMC, Columbia UniversityJennifer O'Keeffe, Doctoral Candidate, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins UniversityKarume Baderha Augustin Gang, Doctoral Candidate, Université Evangélique en AfriqueLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2074972023-06-16T05:02:57Z2023-06-16T05:02:57ZRiset: kandungan kimia rokok berperasa di Indonesia kaburkan bahaya rokok<figure><img src="https://images.theconversation.com/files/532330/original/file-20230616-27-eh6zzx.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sampel bungkus rokok kretek dan rokok putih yang diteliti. </span> <span class="attribution"><span class="source">Author provided</span></span></figcaption></figure><p>Belum banyak yang memahami bahwa di balik “nikmatnya” hisapan kretek rasa mentol atau rokok dengan kapsul rasa buah-buahan yang bisa dihancurkan seperti “<a href="https://www.blibli.com/p/esse-change-double-click-mangoburst-applecrush-rokok-filter-20-batang-bungkus/ps--BL2-60021-00234">Applecrush</a>”, yang makin digandrungi anak muda, terkandung setidaknya 130 zat kimia.</p>
<p>Salah satu strategi perusahaan rokok di Indonesia untuk memperluas pasar konsumen ke kalangan perokok pemula adalah menambahkan berbagai zat perasa kimia seperti mentol ke dalam rokok. Ini juga strategi mereka untuk mengaburkan risiko kesehatan dari mengisap rokok.</p>
<p>Riset <a href="https://tobaccocontrol.bmj.com/content/early/2023/04/24/tc-2022-057827">terbaru kami menunjukkan bahwa eugenol</a>, zat aromatik cengkeh yang kuat, ditemukan di semua sampel varian kretek dalam konsentrasi signifikan, yaitu 2,8–33,8 mg per batang. Namun, zat serupa tidak ditemukan sama sekali pada rokok putih. Ini menandakan bahwa eugenol adalah kandungan khas kretek. </p>
<p>Eugenol yang kami temukan di semua varian kretek telah diketahui memiliki <a href="https://www.sciencedirect.com/science/article/pii/S0273230014002906?via%3Dihub">potensi toksisitas pada hewan dan manusia</a>, misalnya menimbulkan perdarahan paru, infeksi dan peradangan parah pada sistem pernapasan.</p>
<iframe width="100%" height="315" src="https://www.youtube.com/embed/Y8gV1Kfn0Qw?si=iCmKWfWJoM3Qe9gm" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen=""></iframe>
<p>Kami menganalisis konsentrasi <a href="https://tobaccocontrol.bmj.com/content/early/2023/04/24/tc-2022-057827">kandungan 180 zat kimia</a> dari total 24 varian kretek dan 9 varian rokok putih berbagai merek yang dibeli pada 2021 dan 2022 di Indonesia. Beberapa zat kimia utama yang kami teliti di antaranya mentol dan 5 zat yang berkaitan dengan cengkeh, yaitu eugenol, methyl eugenol, β-caryophyllene, α-caryophyllene, dan acetyl eugenol.</p>
<p>Mentol ditemukan pada 14 dari 24 varian sampel kretek dengan konsentrasi berkisar 2,8-12,9 mg per batang, dan pada 5 dari 9 sampel rokok putih, dengan konsentrasi 3,6–10,8 mg per batang. Zat perasa lainnya, seperti rasa buah-buahan, juga ditemukan di beberapa sampel kretek dan rokok putih. </p>
<p>Total terdapat 130 zat perasa yang terdeteksi setidaknya sekali di sampel kretek dan rokok putih kami dalam konsentrasi minimal 0,001 mikrogram per batang. </p>
<p>Penemuan zat mentol dan zat perasa lainnya pada produk kretek menandakan bahwa perusahaan rokok dengan sengaja menambahkan zat perasa tersebut ke dalam kretek yang sebenarnya sudah memiliki rasa khas. </p>
<p>Sulit untuk tidak berprasangka bahwa <a href="https://exposetobacco.org/resource/menthol-flavors/">intensi penambahan berbagai zat perasa tersebut</a> adalah upaya perusahaan untuk menjual lebih banyak batang rokok ke pemula mengingat kretek terkenal cukup berat untuk dihisap.</p>
<hr>
<p>
<em>
<strong>
Baca juga:
<a href="https://theconversation.com/disneyland-untuk-industri-rokok-aturan-yang-lemah-buat-generasi-muda-indonesia-kecanduan-rokok-97857">'Disneyland untuk industri rokok': aturan yang lemah buat generasi muda Indonesia kecanduan rokok</a>
</strong>
</em>
</p>
<hr>
<h2>Bahaya kandungan rokok berperasa</h2>
<p>Penambahan mentol, misalnya, dengan sensasinya yang dingin dan menyegarkan dapat <a href="https://tobaccocontrol.bmj.com/content/20/Suppl_2/ii1">mengaburkan efek kasar</a> dan iritasi di tenggorokan saat menghisap rokok. Hal ini mempermudah perokok pemula untuk menghabiskan rokoknya. </p>
<p>Selain itu, efek mentol menimbulkan persepsi yang salah bagi perokok bahwa <a href="https://tobaccocontrol.bmj.com/content/20/Suppl_2/ii1">rokok tersebut kurang berbahaya</a> dibandingkan rokok yang tidak berperasa.</p>
<p>Sedangkan methyl eugenol, zat turunan dari eugenol, telah terbukti <a href="https://www.ncbi.nlm.nih.gov/books/NBK373178/">menyebabkan kanker pada hewan dan berpotensi juga pada manusia</a>. Acetyl eugenol, komponen aktif dari eugenol, <a href="http://fragrancematerialsafetyresource.elsevier.com/sites/default/files/93-28-7.pdf">ditemukan bersifat racun bagi organ reproduksi dan pertumbuhan janin hewan coba.</a></p>
<h2>Tak ada pembenaran</h2>
<p><a href="https://fctc.who.int/docs/librariesprovider12/meeting-reports/partial-guidelines-for-implementation-article-9-10-en.pdf?sfvrsn=1ee182e4_31&download=true">Badan Kesehatan Dunia (WHO) telah menyatakan</a> bahwa tidak ada pembenaran untuk mengizinkan penggunaan zat perasa di produk tembakau. Sebab, zat perasa dapat membuat produk tersebut makin atraktif dan mendorong konsumsinya, terutama di kalangan anak muda.</p>
<p>Dengan total 68 juta perokok dewasa dan di tengah varian rasa rokok yang membanjiri pasaran, Indonesia belum mengatur produk tembakau yang berperasa atau beraroma.</p>
<p>Per September 2022, semua negara <a href="https://www.tobaccocontrollaws.org/legislation/find-by-policy?policy=cigarette-contents&matrix=contents-and-or-ingredients-of-cigarettes-regulated&handle=cigarette-contents&status=Y">Uni Eropa dan 23 negara lainnya</a> sudah setidaknya membatasi zat perasa, termasuk mentol, dalam produk tembakau. <a href="https://thehill.com/policy/finance/219755-us-indonesia-settle-clove-cigarette-dispute/">Amerika Serikat</a> sejak 2009 telah melarang penjualan kretek di negara tersebut.</p>
<p>Kretek tergolong rokok berperasa karena terbuat dari campuran tembakau dan cengkih yang dipadukan dengan ‘saus’ perasa. Ini merupakan jenis rokok yang paling banyak dikonsumsi di Indonesia, <a href="https://id.elsevier.com/as/authorization.oauth2?platSite=SD%2Fscience&scope=openid%20email%20profile%20els_auth_info%20els_idp_info%20els_idp_analytics_attrs%20urn%3Acom%3Aelsevier%3Aidp%3Apolicy%3Aproduct%3Ainst_assoc&response_type=code&redirect_uri=https%3A%2F%2Fwww.sciencedirect.com%2Fuser%2Fidentity%2Flanding&authType=SINGLE_SIGN_IN&prompt=none&client_id=SDFE-v3&state=retryCounter%3D0%26csrfToken%3Dcffa7aa2-7784-4599-b317-1585eff7a004%26idpPolicy%3Durn%253Acom%253Aelsevier%253Aidp%253Apolicy%253Aproduct%253Ainst_assoc%26returnUrl%3D%252Fscience%252Farticle%252Fpii%252FS0091743519300647%253Fvia%25253Dihub%26prompt%3Dnone%26cid%3Darp-8c5eda18-2774-49c2-88e6-a46b17767705">sebanyak 73% perokok mengonsumsi kretek</a>. Digadang-gadang dan diklaim sebagai “<a href="https://www.beritasatu.com/kesehatan/361877/rokok-kretek-bukan-warisan-budaya-seperti-borobudur">warisan budaya dan sejarah</a>”, kretek telah diketahui menghasilkan <a href="https://academic.oup.com/ntr/article-abstract/24/5/778/6387828?redirectedFrom=fulltext">partikel polutan halus</a>, nikotin, <a href="https://www.sciencedirect.com/science/article/pii/S0091305702010766?via%3Dihub">tar, dan karbon monoksida</a> dengan level lebih tinggi dibandingkan rokok biasa (rokok putih). </p>
<p>Selain itu, sudah banyak merek kretek yang diproduksi oleh perusahaan rokok multinasional, seperti Marlboro (Philip Morris International), Esse (Korea Tobacco & Ginseng Corporation), dan Camel (Japan Tobacco International), sehingga membuatnya tidak lagi eksklusif dan identik dengan produk lokal. </p>
<h2>Buku pedoman industri tembakau</h2>
<p>Temuan kami konsisten dengan <a href="http://dx.doi.org/10.1136/tobaccocontrol-2020-056173">hasil penelitian di Meksiko</a> yang juga menemukan banyaknya kandungan zat perasa tambahan di produk rokok, seperti buah-buahan, vanilla, dan rasa lainnya.</p>
<p>Penelitian lain sebelumnya juga <a href="https://www.sciencedirect.com/science/article/pii/S0278691507001524?via%3Dihub">menemukan eugenol</a> dalam konsentrasi tinggi di produk kretek. Ini menandakan bahwa industri rokok menggunakan buku pedoman yang sama dalam memproduksi dan memasarkan produknya di berbagai negara.</p>
<p>Meski penelitian kami tidak dapat digeneralisasi ke semua produk rokok di pasaran Indonesia karena pemilihan sampel rokok tidak dilakukan secara acak, temuan kami cukup untuk menunjukkan bahwa dengan jumlah sampel yang kecil, terdapat banyak sekali variasi profil zat kimia perasa di produk rokok yang ditawarkan kepada konsumen.</p>
<p>Riset kami menjawab kelangkaan kajian yang menguak kandungan rokok berperasa di Indonesia secara komprehensif.</p>
<h2>Rokok berperasa perlu diatur</h2>
<p>Temuan kami menunjukkan pentingnya pembatasan, jika bukan pelarangan, zat perasa tambahan untuk semua produk rokok, baik kretek, rokok putih, cerutu, di Indonesia.</p>
<p>Riset menunjukkan bahwa <a href="http://dx.doi.org/10.1136/tobaccocontrol-2015-052418">pelarangan produk tembakau berperasa</a>, termasuk mentol, dapat mengurangi konsumsi rokok dan meningkatkan usaha berhenti merokok. Dukungan publik untuk <a href="https://www.sciencedirect.com/science/article/abs/pii/S009174351930338X?via%3Dihub">meloloskan kebijakan seperti ini juga</a> cukup besar.</p>
<p>Akan lebih baik jika aturan tersebut dapat dibarengi dengan kebijakan terkait kemasan rokok yang mengatur atau membatasi desain, seperti warna, gambar, dan deskripsi di bungkus rokok yang dapat diasosiasikan dengan rasa.</p>
<p>Banyak kemasan rokok di sampel ini yang memiliki warna cerah dan <a href="http://dx.doi.org/10.1136/tobaccocontrol-2021-056905">desain cukup menarik untuk anak muda</a>. Sudah banyak bukti yang <a href="https://tobaccocontrol.bmj.com/content/26/3/307">menunjukkan</a> bahwa deskripsi rasa, gambar, dan warna bungkus rokok memengaruhi ketertarikan konsumen terhadap produk tersebut.</p>
<hr>
<p>
<em>
<strong>
Baca juga:
<a href="https://theconversation.com/perusahaan-rokok-rayu-anak-muda-dengan-konser-musik-dan-media-sosial-94330">Perusahaan rokok rayu anak muda dengan konser musik dan media sosial</a>
</strong>
</em>
</p>
<hr>
<p>Oleh karena itu, sudah saatnya kebijakan tentang rokok berperasa dimasukkan ke dalam agenda pengendalian tembakau. </p>
<p>Di negara yang tanpa atau minim aturan, <em>sky is the limit</em> (langit adalah batasan) bagi industri rokok. Mereka akan terus membuat produknya menarik dan diminati banyak kalangan, terutama anak-anak dan remaja yang dibutuhkan oleh bisnis rokok menjadi calon pelanggan tetap. Perusahaan <a href="https://theconversation.com/perusahaan-rokok-rayu-anak-muda-dengan-konser-musik-dan-media-sosial-94330">rokok menarget mereka</a> untuk menggantikan <a href="https://theconversation.com/disneyland-untuk-industri-rokok-aturan-yang-lemah-buat-generasi-muda-indonesia-kecanduan-rokok-97857">konsumen tua</a> yang meninggal akibat penyakit terkait merokok. </p>
<p>Makin banyaknya generasi muda yang terbuai dan terjerat oleh adiksi rokok adalah hal terakhir yang tidak kita inginkan dalam menyongsong generasi emas Indonesia 2045.</p><img src="https://counter.theconversation.com/content/207497/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Penelitian ini didanai oleh Bloomberg Philanthropies’ Bloomberg Initiative to Reduce Tobacco Use,
Grant No 125086.</span></em></p>Riset kami menjawab kelangkaan kajian yang menguak kandungan rokok berperasa di Indonesia secara komprehensif.Beladenta Amalia, Postdoctoral Fellow at the Institute for Global Tobacco Control, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2010262023-03-08T11:51:27Z2023-03-08T11:51:27ZGreat Mysteries of Physics 1: is time an illusion?<figure><img src="https://images.theconversation.com/files/513648/original/file-20230306-26-a3y2nz.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4200%2C3150&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/time-tunnel-161242013">andrey_l/Shutterstock</a></span></figcaption></figure><iframe src="https://embed.acast.com/638f4b009a65b10011b94c5e/63ff7a9ec60fff0011bc8567" frameborder="0" width="100%" height="190px"></iframe>
<p><iframe id="tc-infographic-807" class="tc-infographic" height="100px" src="https://cdn.theconversation.com/infographics/807/1668471fb1e76a459995c87bd439c36b04b754ac/site/index.html" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Without a sense of time, leading us from cradle to grave, our lives would make little sense. But on the most fundamental level, physicists aren’t sure whether the sort of time we experience exists at all. </p>
<p>This is the topic of the first episode of our new podcast series, <a href="https://theconversation.com/great-mysteries-of-physics-a-mind-blowing-podcast-from-the-conversation-200845">Great Mysteries of Physics</a>. Hosted by me, Miriam Frankel, science editor at The Conversation, and supported by <a href="https://fqxi.org/">FQxI</a>, the Foundational Questions Institute, we talk to three researchers about the nature of time.</p>
<p>Scientists long assumed that time is absolute and universal – the same for everyone, everywhere, and existing independently of us. It is still treated in this way in quantum mechanics, which rules the microcosmos of atoms and particles. But Albert Einstein’s theories of relativity, which apply to nature on large scales, showed that time is relative rather than absolute – it can speed up or slow down depending on how fast you are travelling, for example. Time is also interwoven with space into “space time”. </p>
<p>Einstein’s theories enabled scientists to picture the universe in a new way: as a static, four dimensional block, with three spatial dimensions (height, width and depth) and time as a fourth. This block contains all of space and time simultaneously – and time doesn’t flow. There’s no special now in the block – what appears to be the present to one observer, is simply the past to another. </p>
<p>But if that’s true, then why is our experience of time moving from past to future so strong? One answer is that entropy, a measure of disorder, is always increasing in the universe. When you run the numbers, explains Sean Carroll, a physicist at Johns Hopkins University in the US, it turns out that the early universe had very low entropy. “[The universe] was very, very organised and non-random and it’s been sort of relaxing and getting more random and more disorganised ever since.” This is likely to create an arrow of time for human observers.</p>
<p>We don’t know why the universe started out with such low entropy, however. Carroll suggests it it may be because <a href="https://arxiv.org/abs/hep-th/0410270">we are part of a multiverse</a> containing many different universes. In such a world, some universes would, statistically speaking, have to start out with low entropy. </p>
<p>Emily Adlam, a philosopher of physics at the Rotman Institute of philosophy at the University of Western Ontario in Canada, on the other hand, believes the mystery of why our universe started with low entropy is a problem that ultimately stems from the fact that physics is <a href="https://www.researchgate.net/publication/355367615_Determinism_Beyond_Time_Evolution">riddled with assumptions</a> about the time. </p>
<p>“I personally am very much on the side that says time does not flow,” she explains. “This is kind of an illusion that comes from the way in which we happen to be embedded in the world”. Her hunch is that, on the most fundamental level, everything happens all at once – even if it doesn’t appear that way to us.</p>
<p>Adlam argues the best way to understand time would be to remove it entirely from our theories of nature – to strip it out of the equations. Interestingly, when physicists try to unite general relativity with quantum mechanics into a “quantum gravity” theory of everything, time often disappears from the equations.</p>
<p>Experiments could also help shed light on the nature of time, helping to test various combinations of quantum mechanics and general relativity. Natalia Ares, an engineer at the University of Oxford, believes that studying the thermodynamics (the science of heat and work) of clocks <a href="https://journals.aps.org/prx/pdf/10.1103/PhysRevX.11.021029">may help</a>. “By understanding clocks as machines, there are things that we can understand better about what the limits of timekeeping are,” she argues.</p>
<p><em>You can also listen to Great Mysteries of Physics via any of the apps listed above, our <a href="https://feeds.acast.com/public/shows/638f4b009a65b10011b94c5e">RSS feed</a>, or find out how else to <a href="https://theconversation.com/how-to-listen-to-the-conversations-podcasts-154131">listen here</a>. You can also read <a href="https://cdn.theconversation.com/static_files/files/2550/MoP__Ep1_TRANSCRIPTION.docx.pdf?1678183921">a transcript of the episode here</a>.</em></p><img src="https://counter.theconversation.com/content/201026/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Natalia Ares receives relevant funding from the Royal Society, EPSRC, the Foundational Questions Institute Fund, a donor advised fund of Silicon Valley Community Foundation, and from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme (Grant Agreement No. 948932). She is CSO of a start-up company called QuantrolOx, which focuses on developing machine learning for quantum device control. Some of Emily Adlam's research was made possible through the support of the ID 61466 grant from the John Templeton Foundation, as part of the “The Quantum Information Structure of Spacetime (QISS)” Project (qiss.fr). The opinions she expressed are her own and do not necessarily reflect the views of the John Templeton Foundation. Sean Carroll has received funding from the Foundational Questions Institute, the US National Science Foundation, the US Department of Energy, the Sloan Foundation, the Packard Foundation and the Guggenheim Foundation.
</span></em></p>Physics makes a lot of assumptions about time that may be getting in the way of understanding the fourth dimension.Miriam Frankel, Podcast host, The ConversationLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1993982023-02-10T13:51:43Z2023-02-10T13:51:43ZCancer evolution is mathematical – how random processes and epigenetics can explain why tumor cells shape-shift, metastasize and resist treatments<figure><img src="https://images.theconversation.com/files/509265/original/file-20230209-14-qxpz1s.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2059%2C1454&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Stochasticity is everywhere -- and finding the order in disorder can unlock new ways to understand biology.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/colorful-and-fun-web-of-polygons-lines-and-small-royalty-free-image/1446137047">Erlon Silva - TRI Digital/Moment via Getty Images</a></span></figcaption></figure><p>Cancer is often seen as a disease that arises from genetic mutations causing cells to divide uncontrollably and invade other parts of the body. But the spread of cells away from their origins is actually a <a href="https://doi.org/10.1002%2Fcphy.c110012">normal process in some cases</a>. The embryo burrows into the uterus during early pregnancy. Immune cells spread from lymph nodes to sites of infection to attack the invading bacteria. And germ cells migrate to where the gonad will be during early human development. </p>
<p>Cancer is not a uniform disease. Rather, cancer is a disease of <a href="https://doi.org/10.1016/j.stem.2018.11.011">phenotypic plasticity</a>, meaning tumor cells can change from one form or function to another. This includes reverting to less mature states and losing their normal function, which can result in <a href="https://doi.org/10.1126/science.959840">treatment resistance</a>, or changing their cell type altogether, which <a href="https://doi.org/10.7554/eLife.26476">facilitates metastasis</a>.</p>
<p>In addition to direct changes in your DNA in cancer, a key driver of cancer progression is where and when your DNA is activated. If your DNA contains the “words” that spell out individual genes, then epigenetics is the “grammar” of your genome, telling those genes whether they should be turned on or off in a given tissue. Even though all tissues in the body have almost exactly the same DNA sequence, they can all carry out different functions because of chemical and structural modifications that change which genes are activated and how. This “<a href="https://doi.org/10.1056/NEJMra1402513">epigenome</a>” can be influenced by environmental exposures such as diet, adding a dimension to how researchers understand drivers of health beyond the DNA code inherited from your parents.</p>
<p>I’m a <a href="https://scholar.google.com/citations?user=tbj-LpcAAAAJ&hl=en&oi=ao">cancer researcher</a>, and <a href="https://feinberglab.jhu.edu">my laboratory at Johns Hopkins University</a> studies how the differences among normal tissues are controlled by an epigenetic code, and how this code is disrupted in cancer. In our <a href="https://www.science.org/doi/10.1126/science.aaw3835">recently published review</a>, colleague <a href="https://scholar.google.com/citations?user=1drUVwQAAAAJ&hl=en">Andre Levchenko</a> at Yale University and I describe a new approach to understanding cancer plasticity by combining epigenetics with mathematics. Specifically, we propose how the concept of stochasticity can shed light on why cancers metastasize and become resistant to treatments.</p>
<h2>What is stochasticity?</h2>
<p><a href="https://www.britannica.com/science/stochastic-process">Stochasticity</a> is a mathematical concept that refers to the idea that the randomness of the steps in a process affects the predictability of its outcome. <a href="https://doi.org/10.1002/andp.19053220806">Albert Einstein</a> famously studied this concept applied to the movement of particles suspended in a liquid or gas. Researchers can apply stochasticity to study the <a href="https://doi.org/10.1007%2Fs11538-022-01030-6">spread, resistance and evolution of COVID-19</a>, the behavior of the <a href="https://www.investopedia.com/articles/technical/073001.asp">stock market</a> and almost any <a href="https://doi.org/10.1007/978-1-4612-4002-0">game inside a casino</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/509269/original/file-20230209-16-63ou9e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Close-up of stock price chart lines" src="https://images.theconversation.com/files/509269/original/file-20230209-16-63ou9e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/509269/original/file-20230209-16-63ou9e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/509269/original/file-20230209-16-63ou9e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/509269/original/file-20230209-16-63ou9e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/509269/original/file-20230209-16-63ou9e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/509269/original/file-20230209-16-63ou9e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/509269/original/file-20230209-16-63ou9e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Stochastics is used as an indicator in stock prices.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/stock-chart-price-pattern-rebound-royalty-free-image/629027736">Saran Poroong/iStock via Getty Images Plus</a></span>
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<p>A key way to measure the stochasticity of a process is <a href="https://doi.org/10.1177/1687814019857350">entropy</a>, which quantifies the degree of uncertainty in an outcome. For example, a fair coin toss has an entropy of one, or low information, because there is no way to predict whether the coin toss will be heads or tails. But a weighted coin toss has an entropy of zero, or high information, as the outcome is already known and no new information will be gained by tossing the coin. </p>
<p>Researchers can use entropy to measure the amount of <a href="https://doi.org/10.1002/j.1538-7305.1948.tb01338.x">informational noise in telecommunications</a>. Entropy can also help players <a href="https://towardsdatascience.com/information-theory-applied-to-wordle-b63b34a6538e">beat the game Wordle</a>. The word with highest entropy and thus the largest expected new information after each guess would be your best bet.</p>
<h2>Epigenetics ties stochasticity and cancer together</h2>
<p>Incorporating stochasticity and entropy into biology allows researchers to better understand phenotypic plasticity in cancer. This could even reconceptualize development by including reversibility, or moving against “time’s arrow.” This departs from a more <a href="https://www.routledge.com/The-Strategy-of-the-Genes/Waddington/p/book/9781138998131">classic perspective of embryonic development</a> that views tissues as becoming progressively and irreversibly differentiated into their final state as they develop. </p>
<p>Experimental and computational biologists are using entropy to understand the underlying randomness in how cells are <a href="https://doi.org/10.7554/eLife.72707">internally organized</a>, respond to <a href="https://doi.org/10.1126/science.1204553">environmental signals</a> and <a href="https://doi.org/10.1371/journal.pcbi.1009305">mature and form tissues</a>.</p>
<p>Stochasticity in epigenetics is critical to how cancer evolves. For example, a condition called <a href="https://doi.org/10.1186/s13148-017-0409-4">Barrett’s esophagus</a> occurs when healthy cells in the esophagus develop features more like what cells lining the intestine normally have, which can ultimately lead to esophageal cancer. This is caused by progressive random changes in the epigenetic code, and this shift occurs more rapidly once it reaches a certain threshold. The stochastic nature of these epigenetic changes also leads to increased entropy in the function of those genes, and progression toward cancer.</p>
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<figcaption><span class="caption">Epigenetics is why twins sharing the exact same genome can develop in completely different ways.</span></figcaption>
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<p>By measuring the gene activity and epigenetic changes of individual cells, biologists and mathematicians can compare the entropy in cancer cells with the normal cells surrounding them. Scientists are now beginning to identify regions of the genome that mediate stochasticity in cancer. A study that has not yet been peer-reviewed found that entropy is related to <a href="https://doi.org/10.1101/2022.11.15.516549">how chromosomes are physically compacted</a> in the nucleus, another key <a href="https://doi.org/10.1016/j.gde.2016.03.008">epigenetic mechanism</a> for controlling gene activity in cancer.</p>
<p>There is a connection between entropy and aging as well. My colleagues and I found that <a href="https://doi.org/10.1038/ng.3811">human aging</a> is associated with an increase in epigenetic entropy in sun-damaged skin. Parts of the genome that have high entropy experience further loss of epigenetic information in sun-exposed skin, which can lead to cancer. Recently, researchers have identified <a href="https://doi.org/10.1016/j.cell.2022.12.027">DNA damage</a> as a cause for this age-associated entropy in mice. Thus, if epigenetic entropy increases in aging and is related to DNA damage, it might help explain why cancer risk starkly increases with age.</p>
<p>By identifying how epigenetic entropy triggers cancer, scientists might be able to better detect cancer at its early stages, and design drugs that reduce entropy and so decrease the risk of tumors spreading and becoming resistant to treatment.</p>
<p>And perhaps most importantly, epigenetic entropy shows that you can’t fully understand cancer without mathematics. Biology is catching up with other hard sciences in incorporating mathematical methods with biological experimentation.</p><img src="https://counter.theconversation.com/content/199398/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Feinberg receives funding from Johns Hopkins University, Bloomberg Philanthropies, the U.S. National Institutes of Health, the U.S. National Science Foundation, and Bristol Myers Squibb. He is an inventor on a pending US patent related to this work (“Detecting cancer through generalized loss of stability of epigenetic domains,” US20210071262A1, EP2707506B1). He is affiliated with the Democratic Party where he was a science advisor to the Obama and Biden campaigns. </span></em></p>An epigenetic model of cancer that incorporates the concept of stochasticity could also explain why cancer risk increases with age and how biological development can be reversible.Andrew Feinberg, Professor of Biomedical Engineering, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1908142022-12-08T13:33:02Z2022-12-08T13:33:02ZWhite teachers often talk about Black students in racially coded ways<figure><img src="https://images.theconversation.com/files/492368/original/file-20221028-13-t8n33a.jpg?ixlib=rb-1.1.0&rect=7%2C68%2C5084%2C3427&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Educators stereotype Black students in subtle ways.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/fourth-grade-girls-on-computers-royalty-free-image/608899871?phrase=black%20students%20classroom&adppopup=true">Jonathan Kirn via Getty Images</a></span></figcaption></figure><p>When a white Texas middle school teacher <a href="https://www.kxan.com/news/local/pflugerville/pflugerville-teacher-who-made-inappropriate-comments-no-longer-employed-by-district/">told his students</a> in November 2022 that he was “ethnocentric” and thought his race was “superior,” he attempted to explain his position by arguing that he was hardly the only person who held such a view.</p>
<p>“Let me finish …” the teacher is seen telling his students on a <a href="https://www.youtube.com/watch?v=uxMM-WwrNWs">now-viral video</a> as they began to push back against his remarks. “I think everybody thinks that; they’re just not honest about it.”</p>
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<figcaption><span class="caption">Texas teacher tells his students he is racist.</span></figcaption>
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<p>The teacher in question has <a href="https://www.thedailybeast.com/white-teacher-at-bohls-middle-school-in-pflugerville-benched-over-viral-rant-on-superior-race">since been fired</a>. His termination is hardly surprising given that he was captured on video making blatantly racist remarks in a public school classroom. But as we discovered while performing a study at a predominantly Black school with mostly white teachers, many of them – whether consciously or unconsciously – often harbor negative racial views and stereotypes about Black students and their families. The key difference is they <a href="https://doi.org/10.1177/00420859221119115">verbalize those negative views in less obvious ways</a> than the Texas teacher.</p>
<p>At the school we studied, the negative views were not isolated occurrences, but rather a part of a <a href="https://doi.org/10.1177/00420859221119115">culture of coded racial stereotypes</a>, which we argue encourages the disciplining of Black students at disproportionately higher rates.</p>
<p>Our findings were published in a <a href="https://doi.org/10.1177/00420859221119115">peer-reviewed study</a> that appeared in Urban Education in 2022. They are based on a study that began in 2015 when administrators at a predominantly Black high school asked our research team for help understanding why the predominantly white teaching staff was struggling to form positive relationships with the students. In the first part of our partnership with the school, we found that while Black students made up 89% of the student body, they represented 97% of all disciplinary infractions. Conversely, while white students made up 8% of the student population, they received only 1% of the disciplinary referrals. This early quantitative finding confirms studies from across the nation that showed that, even when controlling for rates of misbehavior and poverty, <a href="https://doi.org/10.3102/0002831214541670">Black students are still disproportionately</a> disciplined compared to their white peers.</p>
<p>We are education researchers who specialize in <a href="https://scholar.google.com/citations?user=PkC_OxQAAAAJ&hl=en">cultural</a> and <a href="https://www.researchgate.net/scientific-contributions/Olivia-Marcucci-2156367933">racial justice</a> issues. We believe our findings shine light on how often educators hold racial biases against the students they’ve been entrusted to teach.</p>
<h2>Stereotyping was prevalent</h2>
<p>The racial biases came to light as we conducted focus groups with teachers and students to ask them about their school’s culture and experiences with classroom discipline.</p>
<p>Of the teachers who participated in the focus groups, 84% were white. During focus group discussions, 36 out of 38 teachers voiced a stereotype at least once, though some did so up to 10 times. While some teachers pushed back against stereotypes they heard, and even more often acknowledged systemic racism in the lives of their students, the teachers still frequently used stereotypes when discussing their students and families.</p>
<p>In a series of focus groups, we asked educators from the school to reflect on their experiences in the school, interacting with students, and their thoughts on the school discipline practices. We were particularly interested in hearing their thoughts on the types of infractions for which students were disciplined and how specific punishments were decided on. For example, why were some students who disrupted class sent back from the office to the classroom immediately, but others received 10 days of in-school suspension? </p>
<p>The majority of the focus group questions were not focused on race explicitly. Even so, we still noticed an undercurrent of racially coded stereotypes as the teachers reflected on the statistical trends in school discipline and on their school culture as a whole. </p>
<p>For example, in one focus group, a white teacher notes that when the then-vice principal, a Black man, went to the school as a student, “we had a much more diverse student body. So, he had an opportunity to see different types of behavior. And I think a lot of these kids that we have, the chronic misbehaviors, they don’t have that option. They’re in a class, class by class where they’re all very similar socioeconomic background, and that really makes a difference, I think. Their parents are working and are unable to monitor them. Maybe they didn’t have such a successful high school experience, so they don’t have the tools that some of the other kids – we still have a few of them, fortunate to have a number in my classes.”</p>
<p>The teacher directly connects the presence of “chronic misbehaviors” with a change in the school’s demographics. The teacher opines that in the past, when the student body was nearly equally Black and white, that Black individuals, such as the then-vice principal, in his example, could observe better behavior in school. The teacher therefore communicates an anti-Black stereotype in a coded way, implying that Black students needed white students to “see different types of behavior.”</p>
<p>In a different example, two white teachers began talking about how parents at their school didn’t care about their children. At one point, they pretended to be parents, with one of the teachers even making a joke that one of the parents completely forgot they even had a child: </p>
<p>Teacher 1: Yeah, just somebody saying, ‘Hey, you know you have a baby, right?’
Teacher 2: I do?
Teacher 1: Yeah.
Teacher 2: Oh.
Teacher 1: Oh, wooord.</p>
<p>Nothing about this interaction is racially explicit. But the teacher’s joke invokes a stereotype of Black parents as disengaged from their children’s lives by using a stereotypical African American vernacular – “wooord.” When white teachers at a predominantly Black school make statements like these, they are upholding the stereotype that Black parents lack concern for their children – even if that is not the teachers’ intention.</p>
<h2>A way of bonding</h2>
<p>Using <a href="https://press.princeton.edu/books/paperback/9780691123899/interaction-ritual-chains">a theory</a> that measures the speed of bonding, we found that when teachers used anti-Black stereotypes, they often bonded with each other more quickly and effectively. Certain types of communication — often ones that happen nonverbally — can <a href="https://press.princeton.edu/books/paperback/9780691123899/interaction-ritual-chains">help individuals bond with each other</a>. These bonds then make individuals feel better about themselves and their community. In the data, teachers often used nonverbal communication or noises like “uh-huh,” laughter, and conversational rhythm, while stereotyping their students. </p>
<p>For example, in the “Hey, you know you have a baby, right?” joke, both teachers laughed as a result of the joke. Just as importantly, the rest of the teachers in the room also laughed. Laughter is an important display of bonding. In other interactions, teachers used verbalizations like “mhmmm” or “This is it” to support each other as they engaged in stereotyping their students.</p>
<h2>Reform through reflection</h2>
<p>Based on what <a href="https://www.guilford.com/books/Dual-Process-Theories-of-the-Social-Mind/Sherman-Gawronski-Trope/9781462514397/contents">social psychologist Russell Fazio</a> has found, if teachers are given time to reflect on their potential biases, they have a better chance of removing those biases from their teaching. Through <a href="https://eric.ed.gov/?id=ED521618">systematic and sustained professional learning</a>, teachers can become <a href="https://doi.org/10.1186/s40359-019-0299-7">aware of their implicit and explicit biases and how those biases may impact their behavior</a>. This type of professional learning must be coupled with structural reforms to <a href="https://doi.org/10.1080/17508487.2019.1579743">re-professionalize teaching</a> to achieve lasting, anti-biasing results. </p>
<p>Since our study was completed, the educators, school and district have sought to revamp their disciplinary policies and school culture, including deep discussions about how their biases might affect how they discipline students. The school has begun to use <a href="https://www.wested.org/wp-content/uploads/2019/04/resource-restorative-justice-in-u-s-schools-an-updated-research-review.pdf">restorative justice practices</a>, an alternative approach to discipline that focuses on humanizing individuals and repairing harm after a wrong occurs. The school hired a full-time staff person to support restorative justice. According to the current principal, in the year following, suspensions dropped by 47% in one year and chronic absenteeism dropped by 7%.</p><img src="https://counter.theconversation.com/content/190814/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>ROWHEA ELMESKY received an internal university grant which helped fund this study. </span></em></p><p class="fine-print"><em><span>Olivia Marcucci does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Though difficult to pinpoint, white educators often put forth stereotypes when they discuss Black students among themselves, new research has found.Rowhea Elmesky, Associate Professor of Education, Arts & Sciences at Washington University in St. LouisOlivia Marcucci, Assistant Professor of Education, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1952732022-12-05T13:26:14Z2022-12-05T13:26:14ZA judge in Texas is using a recent Supreme Court ruling to allow domestic abusers to keep their guns<figure><img src="https://images.theconversation.com/files/498785/original/file-20221204-16605-8lpn7f.jpg?ixlib=rb-1.1.0&rect=0%2C9%2C3008%2C1985&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Taking guns from abusers saves lives.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/gun-royalty-free-image/1007622020?phrase=gun%20law&adppopup=true">Kameleon007 via Getty Images</a></span></figcaption></figure><p>For a large part of the history of the United States, <a href="https://www.indiebound.org/book/9781635570977">domestic abuse was tolerated</a> under the nation’s legal system. There were few laws <a href="https://doi.org//10.1353/eam.2007.0008">criminalizing</a> <a href="https://doi.org//10.1086/449151">domestic violence</a>, and enforcement of the existing laws was rare. </p>
<p>It was only in the <a href="https://jaapl.org/content/38/3/376">past few decades</a> that laws criminalizing domestic violence came to be widespread and enforced. But now, the U.S. is in danger of backtracking on that legal framework precisely because of the <a href="https://doi.org//10.1086/449151">nation’s historical legacy</a> of turning a blind eye to domestic violence.</p>
<p>On Nov. 10, 2022, a <a href="https://storage.courtlistener.com/recap/gov.uscourts.txwd.1177458/gov.uscourts.txwd.1177458.55.0.pdf">judge in the Western District of Texas</a> struck down the federal law that prohibits access to guns for people subject to domestic violence protection orders. He did this based on a 2022 U.S. Supreme Court ruling, <a href="https://www.oyez.org/cases/2021/20-843">NYSRPA v. Bruen</a>, which held that, to be constitutional, a firearm restriction must be analogous to laws that were in existence when the country was founded. In other words, disarming domestic abusers violates the Second Amendment because those types of laws didn’t exist at the founding of the country.</p>
<p>In a separate, but related, case, the 5th U.S. Circuit of Court of Appeals on Feb 1. sided with the Texas judge, ruling that the <a href="https://www.cnn.com/2023/02/02/politics/domestic-violence-guns-fifth-circuit/index.html">federal ban was unconstitutional</a>. The Justice Department has indicated that it will appeal.</p>
<p>We <a href="https://sph.umich.edu/faculty-profiles/zeoli-april.html">study the link between gun laws</a> <a href="https://publichealth.jhu.edu/faculty/240/shannon-frattaroli">and domestic violence in the U.S.</a> and know that backtracking on laws that prevent the perpetrators of domestic violence from getting their hands on guns will put lives at risk – the <a href="https://pubmed.ncbi.nlm.nih.gov/20363814/">research </a>has proved this time and time again. </p>
<h2>Putting lives in danger</h2>
<p>At present, <a href="http://disarmdv.org/">federal law</a> prohibits persons subject to final – rather than temporary – domestic violence protection orders from purchasing or possessing firearms. In addition, 39 states and the District of Columbia have similar prohibitions on their statutes, with many expanding the restrictions to include individuals under temporary, or ex parte, orders prior to a full hearing.</p>
<p>Ruling that these laws are unconstitutional will put mainly women and children in danger. <a href="https://pubmed.ncbi.nlm.nih.gov/31245255/">More than 50%</a> of women who are murdered are killed by intimate partners, and <a href="https://psycnet.apa.org/record/2019-14080-005">most of those homicides</a> are committed with guns. A 2003 study found that when an abusive man has access to a gun, it <a href="https://doi.org//10.2105/ajph.93.7.1089">increases the risk</a> of intimate partner homicide by 400%.</p>
<p>Women constitute the <a href="https://ucr.fbi.gov/crime-in-the-u.s/2019/crime-in-the-u.s.-2019/tables/expanded-homicide-data-table-10.xls">majority of victims</a> of intimate partner homicide, and almost <a href="https://pubmed.ncbi.nlm.nih.gov/28630118/">one-third of children under the age of 13</a> who are murdered with a gun are killed in the context of domestic violence. </p>
<p>Moreover, <a href="https://injepijournal.biomedcentral.com/articles/10.1186/s40621-021-00330-0">68% of mass shooters</a> have a history of domestic violence or killed an intimate partner in the mass shooting.</p>
<p>Enforcement of <a href="https://pubmed.ncbi.nlm.nih.gov/20088664/">gun restrictions is spotty</a>, with further research needed as to how systematically they are ordered and whether restricted individuals relinquish firearms they already possess. Nonetheless, research shows that firearm restrictions on domestic violence protection orders save lives. <a href="https://doi.org//10.1093/aje/kwy174">Multiple studies</a> conclude that these laws are associated with an <a href="https://doi.org/10.1177/0193841X06287307">8%-10% reduction</a> in intimate partner homicide.</p>
<p>Specifically, there are <a href="https://pubmed.ncbi.nlm.nih.gov/30383263/">statistically significant reductions</a> in intimate partner homicide when the firearm restriction covers both dating partners and those subjected to temporary orders. This decrease is seen in total intimate partner homicide, not just intimate partner homicide committed with guns, nullifying the argument that abusers will use other weapons to kill.</p>
<p>Moreover, these laws have broad support across the country – <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7859883/">more than 80%</a> of respondents to two national polls in 2017 and 2019 said they favor them.</p>
<p>Americans – whether male or female, gun owner or non-gun owner – tend to agree that domestic abusers should not be able to purchase or possess firearms while they are subject to a domestic violence protection order. Most seem to realize that such reasonable restrictions serve the greater good of keeping families and communities safe. </p>
<h2>A disregard for data</h2>
<p>The ruling in Texas was based on an originalist legal argument rather than the data. Under the judge’s interpretation of the Bruen decision, because colonial law – written before a time when women could vote, let alone be protected in law from violent spouses – didn’t restrict domestic abusers’ gun rights, then it simply isn’t constitutional to do so now. In effect, the ruling, should it stand, would mean the U.S. is unable to escape the nation’s <a href="https://doi.org//10.1086/449151">historic legal disregard for domestic violence</a>.</p>
<p>It also disregards the harm that allowing domestic abusers to keep hold of guns does. Multiple studies demonstrate that domestic violence firearm restriction laws are <a href="https://doi.org//10.1136/ip.2009.024620">effective </a>and <a href="http://doi.org//10.1093/aje/kwy174">save</a> <a href="https://doi.org/10.1177/0193841X06287307">lives</a>.</p>
<p>That research shows that, should the Texas ruling stand, people who suffer abuse at the hands of an intimate partner are at greater risk of that abuse being deadly. </p>
<p><em><a href="https://www.linkedin.com/in/lisa-geller">Lisa Geller</a>, director of state affairs at the Johns Hopkins Center for Gun Violence Solutions at the Johns Hopkins Bloomberg School of Public Health, contributed to this article.</em></p>
<p><em>Editor’s note: This story was updated on Feb. 3, 2022 to include the ruling from the 5th Circuit Court of Appeals.</em></p><img src="https://counter.theconversation.com/content/195273/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Research shows that removing guns from violent abusers saves lives. But laws doing just that are at risk of being ruled unconstitutional, following a landmark Supreme Court guns case.April M. Zeoli, Associate Professor of Public Health, University of MichiganShannon Frattaroli, Professor of Health Policy and Management, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1950622022-11-21T21:28:17Z2022-11-21T21:28:17ZRed flag laws and the Colorado LGBTQ club shooting – questions over whether state’s protection order could have prevented tragedy<figure><img src="https://images.theconversation.com/files/496558/original/file-20221121-14-tvq6qg.jpg?ixlib=rb-1.1.0&rect=0%2C175%2C7340%2C5165&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Flowers at a memorial near Club Q </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/people-leaves-flowers-and-other-items-at-a-memorial-near-news-photo/1443134730?phrase=colorado%20shooting&adppopup=true">RJ Sangosti/MediaNews Group/The Denver Post via Getty Images</a></span></figcaption></figure><p><em>The killing of five patrons <a href="https://apnews.com/article/shootings-colorado-springs-e098d88261db6bcfc0774434abbb7a8f">in a Colorado LGBTQ bar on Nov. 19, 2022</a>, is the latest mass shooting to garner headlines in the U.S.</em></p>
<p><em>Police have said they have <a href="https://www.reuters.com/world/us/colorado-springs-police-probe-motive-lgbtq-nightclub-shooting-2022-11-21/">yet to determine a motive</a>. But one thing that has emerged is that the suspect had a history of violent plans, having <a href="https://www.npr.org/2022/11/21/1138197437/colorado-springs-shooting-suspect-red-flag-gun-law">allegedly threatened to attack his mother with a homemade bomb</a> more than a year before the attack at Club Q.</em></p>
<p><em>It has led to questions over why that earlier alleged incident did not trigger <a href="https://leg.colorado.gov/bills/hb19-1177">Colorado’s “red flag” law</a> – something that may have prevented him from acquiring the AR-15-style semi-automatic weapon that police say was used in the Club Q attack. The Conversation asked Alex McCourt, an <a href="https://publichealth.jhu.edu/faculty/3794/alexander-mccourt">expert on gun laws at Johns Hopkins University</a>, to explain how red flag laws are supposed to work – and why they weren’t triggered in this case.</em></p>
<h2>What are red flag laws?</h2>
<p>Red flag laws – also know as <a href="https://www.jhsph.edu/research/centers-and-institutes/johns-hopkins-center-for-gun-violence-prevention-and-policy/research/extreme-risk-protection-orders/">extreme risk protection orders</a> – allow for judges to make a ruling that results in firearms being taken away temporarily from a person who is deemed to be at high risk of harming themselves or others. They also prevent that person from purchasing guns for a set period of time.</p>
<p>They are aimed at protecting against the actions of individuals who have made violent threats or may be going through some sort of crisis.</p>
<p>The way they work is that specific people can petition a court to issue an order when someone is deemed to be behaving dangerously or making violent threats.</p>
<p>The categories of individuals who can petition in this way vary from state to state. But all the states that have enacted such laws – <a href="https://theconversation.com/red-flag-laws-saved-7-300-americans-from-gun-deaths-in-2020-alone-and-could-have-saved-11-400-more-185009">19 plus the District of Columbia</a> – include law enforcement officers among those who can petition the court to have a red flag order imposed.</p>
<p>Household and family members are also commonly listed. And in <a href="https://health.maryland.gov/bha/suicideprevention/Documents/ERPO_Brochure%20PRINT%20Version.pdf">Maryland</a>, <a href="https://www.hawaiinewsnow.com/2022/06/17/hawaiis-red-flag-law-how-file-gun-violence-protective-order/">Hawaii</a> and the <a href="https://oag.dc.gov/public-safety/dcs-red-flag-law-removing-guns-potentially">District of Columbia</a>, health care officials can petition the court should they be concerned over the behavior of a patient. In California, Hawaii and New York, <a href="https://www.edweek.org/policy-politics/let-school-officials-seek-gun-limits-for-potentially-violent-students-feds-suggest/2021/06">teachers or school administrators are included</a> in the list of people who can petition the court.</p>
<p>Typically, if the court finds there is sufficient evidence of risk of violence, a judge will issues an ex parte – or temporary – order. These cover a very short period until a hearing can take place. At that subsequent hearing the potential subject of the order can provide an argument that they aren’t dangerous.</p>
<p>If the court decides there is indeed a risk, it will deliver a longer-term order. In most cases it covers a period of up to a year. The subject of the gun ban may be able to petition for the order to be ended early, should they be able to prove, for example, that their moment of mental crisis is over or that they have sought sufficient treatment. The petitioner can also ask for the order to be renewed at the end of the year.</p>
<p><iframe id="W8RK4" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/W8RK4/3/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Does research show that red flag laws work?</h2>
<p>The first thing to note is that the laws are relatively new – most have come in over the past decade. So researchers are still evaluating the data. But studies have shown that they can be effective in preventing mass shooting events and possibly suicides.</p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/31426088/">Research from 2019</a> found that, among a group of cases in which guns were removed from individuals who made threats of mass shootings in California, none of the individuals went on to carry out mass shootings. A <a href="https://pubmed.ncbi.nlm.nih.gov/36265579/">2022 study</a> evaluated extreme risk protection orders in six states. It found that all the states being observed were issuing orders on the basis of mass shooting threats – 20% of these cases involved threats toward schools and 15% toward intimate partners or family members.</p>
<p>Though these laws are relatively new, <a href="https://scholarship.law.duke.edu/cgi/viewcontent.cgi?referer=&httpsredir=1&article=4830&context=lcp">research</a> <a href="https://pubmed.ncbi.nlm.nih.gov/30988021/">analyzing</a> the legislation suggests that they may help prevent suicide.</p>
<p>So there is enough evidence to say they can be used to prevent deaths. But these measures are so new, we need to know more about how well they are being implemented by states. So far, research suggests that public awareness of <a href="https://pubmed.ncbi.nlm.nih.gov/35977171/">extreme risk protection orders is low</a> and that efforts to <a href="https://pubmed.ncbi.nlm.nih.gov/36099263/">educate the public and facilitate filing of petitions might</a> help.</p>
<h2>How well are red flag laws implemented across states?</h2>
<p>Connecticut and Indiana both had early versions of red flags laws, in place in 1999 and 2006 respectively, but the policy was really developed after the <a href="https://apnews.com/hub/sandy-hook-elementary-school-shooting">Sandy Hook shooting of 2012</a>. Since that incident – in which 20 children and six adults were killed by a gunman – a further 17 states and Washington, D.C., have added extreme risk protection orders to their statutes. Most have come in since the Parkland school shooting of 2018.</p>
<p>One of the areas in which more research is needed is on implementation of red flag laws. There appears to be wide variation – both state by state, but also within states that have laws in place. </p>
<p>Spotty implementation might be the result of a combination of factors. As they are quite new, there is a knowledge gap – that is, would-be petitioners might not know that a red flag order is an option, or how to go about filing for an order.</p>
<p>But it is also true that there has been a fair amount of <a href="https://www.pbs.org/newshour/politics/red-flag-laws-get-little-use-even-as-mass-shootings-gun-deaths-soar">pushback</a> from certain counties and sheriffs who have said that they won’t enforce these laws out of Second Amendment concerns. This appears to be the case more in rural areas. But that has not been systemically studied to date.</p>
<h2>Any chance of a federal red state law?</h2>
<p>There has been some discussion among advocates about trying to <a href="https://www.politifact.com/article/2022/jun/10/ask-politifact-what-are-red-flag-gun-laws-and-do-t/">pass federal legislation</a>. But to date, the main actions taken at the federal level are to make it easier for individual states to adopt red flag laws. The Biden administration has pushed for their adoption, and the Justice Department has issued model legislation that states can use.</p>
<p>Meanwhile, the <a href="https://www.whitehouse.gov/wp-content/uploads/2022/06/Bipartisan-Safer-Communities-Act-SAP-1.pdf">Bipartisan Safer Communities Act</a> passed in June 2022 allows for the distribution of funds to states for crisis intervention programs, including the rollout of extreme risk protection orders.</p>
<h2>What was in place in Colorado?</h2>
<p>Colorado’s <a href="https://leg.colorado.gov/bills/hb19-1177">red flag law</a> was enacted 2019. It allows for law enforcement and family or household members to file a petition to a court. If it is approved, a court can order that an individual’s guns be removed for up to one year.</p>
<p>A <a href="https://injepijournal.biomedcentral.com/articles/10.1186/s40621-021-00353-7">2021 study</a> of the first year of implementation of Colorado’s law found that in 85% of cases it was law enforcement that initiated proceedings, and in 15% of cases it was household or family members that petitioned.</p>
<p>There has been slower uptake in Colorado than in some other states. But there have been some questions over whether that is over the timing of the law – it was implemented just before COVID-19 pandemic began, so for a large chunk of the first year it has been in operation, people were under stay-at-home orders.</p>
<p>Nonetheless, the study found there were a significant number of sheriffs and counties that said they would not enforce the law. There is no real legal basis for them to do this; it is more of a symbolic or political stance. But it does have implications for red flag laws, as law enforcement officers may not have the training or inclination to pursue red flag orders.</p>
<h2>Why was it not triggered in this case?</h2>
<p>There hasn’t been an awful lot of detail released on why a red flag order was not imposed on the Colorado shooter. Early reporting suggests that this appears to be a classic example of someone who made a threat, in this case threatening his mother with a homemade bomb – and as such would qualify for an order. But there is <a href="https://www.npr.org/2022/11/21/1138197437/colorado-springs-shooting-suspect-red-flag-gun-law">reportedly no public record</a> indicating that law enforcement or any family member acted on that threat and petitioned the court.</p>
<p>Experts can only speculate about why this might be the case. But one point of note is that it occurred in a county where the sheriff has <a href="https://www.koaa.com/news/covering-colorado/2019/03/07/sheriff-elder-explains-opposition-to-the-red-flag-bill/">expressed</a> opposition to Colorado’s law and has previously said that his officers <a href="https://www.epcsheriffsoffice.com/red-flag-bill">will not petition</a> for an order except under “exigent circumstances.”</p><img src="https://counter.theconversation.com/content/195062/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alex McCourt receives funding from The Joyce Foundation, The David and Lucille Packard Foundation, the Centers for Disease Control and Prevention, Missouri Foundation for Health, and the National Collaborative on Gun Violence Research.</span></em></p>Colorado is one of 19 states that have laws in place to prevent individuals believed to pose a threat from obtaining guns. But a preventive order needs to be petitioned before it can be issued.Alex McCourt, Assistant Professor of Health Policy and Management, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1944952022-11-15T13:23:19Z2022-11-15T13:23:19ZGuns on the ballot: How mixed midterm results will affect firearm policy<figure><img src="https://images.theconversation.com/files/495177/original/file-20221114-15619-a0gj3p.jpg?ixlib=rb-1.1.0&rect=0%2C139%2C5491%2C3268&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">One in 10 American voters listed guns as their top concern.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/many-torn-voting-campaign-buttons-with-handgun-as-royalty-free-image/1334515999?phrase=gun%20vote&adppopup=true">iStock / Getty Images Plus</a></span></figcaption></figure><p>The U.S. midterm elections took place on the backdrop of <a href="https://www.pbs.org/newshour/show/what-is-behind-the-rise-in-gun-related-violence-in-the-u-s">surging gun violence</a> and in a year scarred by high-profile <a href="https://www.nytimes.com/article/mass-shootings-2022.html">mass shootings</a>.</p>
<p>And though <a href="https://www.washingtonpost.com/politics/2022/11/08/exit-polls-2022-elections/">exit</a> <a href="https://www.nbcnews.com/politics/2022-election/inflation-abortion-lead-list-voter-concerns-nbc-news-exit-poll-finds-rcna56258">polls</a> indicated that abortion rights and inflation were the top motivating issues for voters, views toward guns also played a significant role. Indeed, a survey by Edison Research found that around <a href="https://www.reuters.com/world/us/inflation-abortion-top-issues-us-voters-casting-midterm-ballots-exit-poll-finds-2022-11-08/">1 in 10 voters</a> listed gun policy as their top concern.</p>
<p>That guns were in the mind of many voters should not be too much of a surprise. In 2020, <a href="https://publichealth.jhu.edu/sites/default/files/2022-05/2020-gun-deaths-in-the-us-4-28-2022-b.pdf">there were a record</a> number of gun deaths, and <a href="https://www.cdc.gov/mmwr/volumes/71/wr/mm7140a4.htm?s_cid=mm7140a4_w">data for 2021</a> shows a continuing increase. Disparities in gun violence widened – in 2020, the firearm homicide rate for young Black men was <a href="https://publichealth.jhu.edu/sites/default/files/2022-05/2020-gun-deaths-in-the-us-4-28-2022-b.pdf">over 20 times</a> greater than the rate for young white men. The midterms were also the first national vote since the tragic <a href="https://www.texastribune.org/series/uvalde-texas-school-shooting/">mass shootings in Uvalde, Texas</a>; <a href="https://www.cbsnews.com/news/buffalo-reflects-mourns-6-months-after-tops-shooting/">Buffalo, New York;</a> and <a href="https://www.chicagotribune.com/suburbs/lake-county-news-sun/ct-lns-victims-memorial-st-1112-20221111-4zpx5bbhujbhxirjbf7f7ly7cy-story.html">Highland Park</a>, Illinois.</p>
<p>The midterm elections offered voters the opportunity to affect gun policy in two ways. First, it gave voters the chance to elect local, state and national officials who will have a say in which gun violence strategies are considered and implemented. And second, in two states – Iowa and Oregon – residents voted on gun rights and gun violence initiatives. The mixed results in these initiatives, in particular, reveal much about the state of gun policy in the United States. </p>
<h2>State ballot initiatives</h2>
<p>In the two states in which guns appeared explicitly on ballots, voters approved measures that moved state gun laws in opposite directions. <a href="https://www.desmoinesregister.com/story/opinion/columnists/rekha-basu/2022/11/13/iowa-more-lax-on-guns-amendment-vote/69636745007/">Iowa passed a constitutional amendment</a> that enshrined a right to bear arms and specified a standard for judicial review of gun laws, while <a href="https://www.oregonlive.com/politics/2022/11/oregon-measure-114-one-of-strictest-gun-control-measures-in-us-too-close-to-call.html">Oregon voters passed</a> an initiative that requires a permit to buy a firearm and bans large capacity ammunition magazines. </p>
<p>Around <a href="https://electionresults.iowa.gov/IA/115641/web.307039/#/detail/15500">two-thirds of Iowans</a> voted to add the right to bear arms to the state constitution. This amendment <a href="https://www.thegazette.com/government-politics/iowa-senate-passes-gun-rights-constitutional-amendment/">brings Iowa in line</a> with 44 states that have similar provisions. </p>
<p>Iowa’s amendment differs from most by also setting a strict scrutiny standard for evaluating gun restrictions. Under strict scrutiny, a state law will only be upheld by a court if it is narrowly tailored to further a compelling government interest. Researchers have not studied how these provisions affect gun violence, but this amendment is part of an overall trend in Iowa toward deregulating guns. <a href="https://dps.iowa.gov/hf756-iowas-new-weapon-permit-law">The state began allowing</a> the carrying of concealed handguns without a license and repealed its longstanding law requiring a permit to purchase a handgun. Research has found that both of these changes are associated with <a href="https://pubmed.ncbi.nlm.nih.gov/32816544/">increases in gun</a> <a href="https://publichealth.jhu.edu/2022/study-finds-link-between-dropping-permit-requirement-for-carrying-concealed-weapons-and-increase-in-officer-involved-shootings-with-civilian-victims">violence</a>.</p>
<p>Meanwhile, Oregon voters narrowly <a href="https://results.oregonvotes.gov/resultsSW.aspx?type=MEASURE&map=CTY">approved</a> an initiative adopting a permit-to-purchase law. Under Oregon Measure 114, all would-be gun buyers will be <a href="https://www.opb.org/article/2022/10/18/oregon-measure-114-gun-laws-permits-safety-class-magazine-limits/">required</a> to first acquire a permit from local law enforcement. To acquire a permit, applicants will need to be fingerprinted, pass a background check and undergo safety training.</p>
<p>Research has consistently shown that laws requiring a permit to purchase a gun are <a href="https://doi.org//10.2105/AJPH.2020.305822">associated with reductions</a> in <a href="https://doi.org//10.2105/AJPH.2015.302703">homicide</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/26212633/">suicide</a>, <a href="https://doi.org/10.1111/1745-9133.12487">mass shooting incidents</a> and other measures of gun crime.</p>
<p>Despite this evidence, only <a href="https://giffords.org/lawcenter/gun-laws/policy-areas/owner-responsibilities/licensing/">nine other states and Washington, D.C.</a>, have this policy, and Oregon will be the first state to adopt it since <a href="https://mgaleg.maryland.gov/mgawebsite/Legislation/Details/sb0281?ys=2013RS&search=True">Maryland in 2013</a>. In addition, the Oregon initiative institutes a ban on large-capacity magazines – those that hold more than 10 rounds and allow shooters to fire for longer periods before reloading. Bans of these devices have been associated with <a href="https://doi.org/10.1111/1745-9133.12487">reductions in mass shootings</a>.</p>
<h2>The impact of Supreme Court’s Bruen ruling</h2>
<p>The midterms were the first general elections since the Supreme Court set a new standard for evaluating gun laws under the Second Amendment. Under the <a href="https://www.oyez.org/cases/2021/20-843">Bruen</a> ruling, which came down in June 2022, courts must assess whether a gun law is consistent with the “historical tradition of firearm regulation” in the U.S. In <a href="https://supreme.justia.com/cases/federal/us/597/20-843/#tab-opinion-4600259">its opinion</a>, the court failed to provide an adequate framework for lower courts to use for this <a href="https://firearmslaw.duke.edu/2022/09/worrying-trends-in-the-lower-courts-after-bruen/">analysis</a>. Despite the lack of clarity, this standard will affect implementation of Iowa’s and Oregon’s new policies.</p>
<p>The fact that Iowa’s constitutional amendment requires analysis of state gun laws under a strict scrutiny standard creates a difficult situation for state judges, who may have to <a href="https://firearmslaw.duke.edu/2022/11/2022-midterms-gun-watch/">grapple with both</a> strict scrutiny and the historical tradition test from the Bruen ruling.</p>
<p>Laws requiring a permit to purchase are popular, but they will almost certainly be challenged either in Oregon or in one of the other nine states with such a policy. For the law to be upheld, a court would need to find that such a law was consistent with the country’s history and tradition of firearm regulation. Rigorous historical analyses have proved difficult for courts. </p>
<p>Despite the confusion created by the Supreme Court, the midterm election results indicate that gun violence remains an important issue for voters and elected officials. </p>
<p>At the state and local level, <a href="https://www.thetrace.org/2022/11/midterm-election-gun-reform-candidates/">young candidates</a> who ran campaigns centered on gun violence prevention were elected. Control of some state legislatures and executive branches shifted from one party to the other and, as of this writing, control of the U.S. House of Representatives will come down to several close contests.</p>
<p>The outcomes of these state and local elections will dramatically affect the likelihood that gun violence prevention legislation and programs are considered and implemented in the coming months.</p><img src="https://counter.theconversation.com/content/194495/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alex McCourt receives funding from The Joyce Foundation, The David and Lucille Packard Foundation, the Centers for Disease Control and Prevention, Missouri Foundation for Health, and the National Collaborative on Gun Violence Research.</span></em></p>Two states had guns directly on the ballot in midterm election initiatives. Voters moved state laws in opposite directions.Alex McCourt, Assistant Professor of Health Policy and Management, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1943542022-11-11T04:34:14Z2022-11-11T04:34:14ZKenya Standard Gauge Railway contracts: what released documents say, and what they don’t<figure><img src="https://images.theconversation.com/files/494686/original/file-20221110-14-qetkm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A freight train runs on the Mombasa-Nairobi railway track in July 2022.
</span> <span class="attribution"><span class="source">Photo by Dong Jianghui/Xinhua via Getty Images</span></span></figcaption></figure><p>A media frenzy has erupted in Kenya over the November 5, 2022 <a href="https://nation.africa/kenya/business/read-pdfs-of-sgr-contracts-released-by-murkomen-4010830">release</a> of three Chinese loan contracts signed between the Kenyan government and China Export Import Bank (Eximbank), to finance two phases of <a href="https://www.railway-technology.com/projects/mombasa-nairobi-standard-gauge-railway-project/">Kenya’s Standard Gauge Railway (SGR)</a>. </p>
<p>The 700-km railway runs between the port of Mombasa through Nairobi to Naivasha. It has been dogged by controversy from the start. <a href="https://www.dandc.eu/en/article/why-kenyas-ambitious-cross-country-railway-controversial">Concerns</a> range from procurement, its massive cost and the government’s reluctance to allow detailed scrutiny of the contracts underpinning Kenya’s largest infrastructure project since independence.</p>
<p>The release of the three contracts by Kenya’s new Transport and Infrastructure minister came nearly four years after <a href="https://www.theeastafrican.co.ke/tea/business/mombasa-port-at-risk-as-audit-finds-it-was-used-to-secure-sgr-loan-1408886">rumours</a> began circulating that Kenya had staked its valuable Mombasa Port as collateral for the initial US$3.6 billion railway project loans. The minister’s disclosure of the contracts was intended to clear the air. Instead, the air is <a href="https://nation.africa/kenya/news/sgr-the-dirty-details-transport-cs-murkomen-did-not-disclose-4013454">thick with scepticism</a> and claims of <a href="https://www.standardmedia.co.ke/national/article/2001460086/sgr-deal-cs-murkomen-publishes-load-of-hot-air">selective disclosure</a>.</p>
<h2>Our study</h2>
<p>In April 2022, a team of researchers at Johns Hopkins University published a <a href="http://www.sais-cari.org/s/PB62-Brautigam-Bhalaki-Deron-Wang-How-Africa-Borrows-From-China-V2.pdf">policy brief</a> and <a href="http://www.sais-cari.org/s/WP52-Brautigam-Bhalaki-Deron-Wang-How-Africa-Borrows-From-China.pdf">working paper</a> summarising nearly two years of investigations into the collateral rumour. The team was made up of academics and professionals with extensive practical expertise in commercial law, international project finance, and auditing. </p>
<p>Our team discovered that the collateral rumour originated in a critical mistake by Kenya’s auditor-general’s office. The government’s chief auditor had <a href="https://www.oagkenya.go.ke/wp-content/uploads/2021/09/Kenya-Ports-Authority-2017-2018.pdf">wrongly labelled</a> Kenya Ports Authority, owner of Mombasa Port, as a “borrower” responsible for repaying the China Eximbank SGR loans. </p>
<p>The ports authority was not a borrower, we <a href="https://static1.squarespace.com/static/5652847de4b033f56d2bdc29/t/62575fb9c92fbc7ddb334cd8/1649893307393/WP52-Brautigam-Bhalaki-Deron-Wang-How+Africa+Borrows+From+China.pdf">concluded</a>.</p>
<p>The recently released loan contracts confirm that the “the Republic of Kenya, represented by the National Treasury of Kenya” is the Borrower, and is “fully liable for the payment and repayment obligations” of the loan contracts. The contracts state that this obligation remains, whether or not Kenya Railways Corporation and Kenya Ports Authority perform their own obligations. </p>
<p>The newly published loan contracts support previous statements by the Kenyan and Chinese governments. Kenya’s government has pledged to repay this sovereign debt with government revenues, just as it repays Eurobonds and the World Bank. </p>
<p>In other words, these are sovereign loans, signed by the central government, not Kenya’s state-owned companies. </p>
<p>We also analysed the “Take or Pay Agreement (TOPA)” signed between Kenya Railway Corporation and Kenya Ports Authority. In that agreement, a copy of which was shared with us by colleagues in Kenya, Kenya Ports Authority had committed to ship a set amount of cargo on the railway each month or pay the shortfall to the Kenya Railway Corporation. These revenues were to be deposited by the corporation into an escrow account and used to help repay the Chinese loan. But the port authority’s legal responsibility under Kenyan law was to Kenya Railway Corporation, not to the Chinese bank.</p>
<p>Kenya’s SGR credit enhancements were carefully and creatively designed to enhance the bankability of a railway project that has significantly upgraded the Kenya Ports Authority’s competitive position in the region. Yet – like most large investments with significant environmental, safety and connectivity advantages – the benefits of this project will ripen over time, while the upfront costs are high. </p>
<p>Credit enhancements like TOPAs increase the bankability of projects, showing the government’s commitment to raise various revenues to repay the lender. But ultimately the debt is guaranteed by the sovereign. </p>
<p>Our research dealt only with the collateral accusation. It did not deal with concerns about procurement or corruption that may have taken place around this project. The other contracts have not been released. Nevertheless, the three loan contracts are sufficient for establishing that Mombasa Port was not in any way pledged as collateral for the Chinese loans.</p>
<p>Kenya’s auditor-general’s office is renowned for its integrity, and we commend the concern with which the office and its courageous leaders approach their task of protecting Kenyan taxpayers. Its officers appear to have ample reason to be concerned about corruption and mismanagement in the Kenyan government. That’s the light in which the auditor-general’s <a href="https://twitter.com/johngithongo/status/1075187915875971072">leaked letter</a> to Parliament must be understood. </p>
<h2>Sovereign immunity</h2>
<p>However, as we noted in our research, the auditor-general’s <a href="https://www.oagkenya.go.ke/wp-content/uploads/2021/09/Kenya-Ports-Authority-2017-2018.pdf">opinion</a> that Kenya’s government had “waived immunity” on the Kenya Ports Authority’s assets and “expressly guaranteed” that they could be used to repay the Chinese loan was incorrect. </p>
<p>Given that all sovereign governments have immunity from lawsuits under international law, they are routinely required to waive that sovereign immunity in international contracts. This is so that if a dispute arises it can be arbitrated. Waivers of sovereign immunity are general and relate to dispute settlement, and not to the specification of any particular asset as collateral. </p>
<p>Our conclusion therefore was that the waiving of sovereign immunity did not mean that Kenya Ports Authority’s assets were deliberately put at risk.</p>
<h2>Bitter experience</h2>
<p>The Kenyan auditor-general was also concerned that the loan contract specifies that dispute arbitration would take place at the China International Trade and Economic Arbitration Commission. It is “<a href="https://www.acerislaw.com/the-cietac-arbitration-rules-organization-and-key-developments/">one of the oldest and busiest arbitration institutions in the world</a>.” </p>
<p>It is normal for arbitration to take place outside of the borrowing country. Nevertheless, the auditor-general was not alone in worrying <a href="https://www.millercanfield.com/resources-320.html">about the neutrality</a> of a Chinese venue. Kenya can insist that the presiding arbitrator be selected by both sides from <a href="https://www.winston.com/images/content/1/2/v2/123726/Arbitration-Guidelines-Chinese-JUN2017.pdf">a neutral third country</a>. This should dispel some of the worries about fairness, should disputes arise.</p>
<p>However, our team of researchers suggest that two factors contributed to the auditor-general’s interpretation. First, through sometimes bitter experience, the auditor-general’s office did not trust the Kenyan government to protect the interests of Kenyan citizens. </p>
<p>Second, and just as importantly, the auditor-general’s office and Kenyans more generally, were likely primed to also be suspicious of the Chinese bank due to the widespread rumours of “Chinese debt traps”. This was sparked by the case of <a href="https://www.nytimes.com/2018/06/25/world/asia/china-sri-lanka-port.html">Hambantota Port</a> in Sri Lanka. There, the same Chinese bank was accused in the pages of The New York Times (<a href="https://www.theatlantic.com/international/archive/2021/02/china-debt-trap-diplomacy/617953/">erroneously, as it happens</a>) of seizing a loss-making port when Sri Lanka was facing balance of payments difficulties. </p>
<p>The geopolitically fraught accusation of deliberate “Chinese debt traps” and “asset seizures” is a distraction from a genuine problem: infrastructure, like natural resources, is prone to corruption. Yet Kenya faces risks in unilaterally publishing contracts for a single lender and company. Nearly 20 years ago, government, industry and civil society stakeholders came together in London to build the <a href="https://eiti.org/our-history">Extractive Industries Transparency Initiative</a>. </p>
<p>Governments join, commit to transparency, and Extractive Industries Transparency Initiative publishes the complex contracts. A similar global initiative for public infrastructure is clearly needed. Since the Kenyan taxpayers will ultimately shoulder the cost of the project, they have a right to know all the details. And they also have the right to have information debated fairly and professionally.</p><img src="https://counter.theconversation.com/content/194354/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This research was supported by the Carnegie Corporation of New York, Grant #129871. </span></em></p>Kenyan taxpayers will ultimately shoulder the cost of the project. They have a right to all the details.Deborah Brautigam, Bernard L. Schwartz Professor of International Political Economy, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.