Sex workers are at disproportionate risk of violence and sexual and emotional ill health, harms that have been linked to the criminalisation of sex work. We synthesised evidence on the extent to which sex work laws and policing practices affect sex workers’ safety, health, and access to services, and the pathways through which these effects occur.We searched bibliographic databases between 1 January 1990 and 9 May 2018 for qualitative and quantitative research involving sex workers of all genders and terms relating to legislation, police, and health. We operationalised categories of lawful and unlawful police repression of sex workers or their clients, including criminal and administrative penalties. We included quantitative studies that measured associations between policing and outcomes of violence, health, and access to services, and qualitative studies that explored related pathways. We conducted a meta-analysis to estimate the average effect of experiencing sexual/physical violence, HIV or sexually transmitted infections (STIs), and condomless sex, among individuals exposed to repressive policing compared to those unexposed. Qualitative studies were synthesised iteratively, inductively, and thematically. We reviewed 40 quantitative and 94 qualitative studies. Repressive policing of sex workers was associated with increased risk of sexual/physical violence from clients or other parties , HIV/STI , and condomless sex . The qualitative synthesis identified diverse forms of police violence and abuses of power, including arbitrary arrest, bribery and extortion, physical and sexual violence, failure to provide access to justice, and forced HIV testing. It showed that in contexts of criminalisation, the threat and enactment of police harassment and arrest of sex workers or their clients displaced sex workers into isolated work locations, disrupting peer support networks and service access, and limiting risk reduction opportunities. It discouraged sex workers from carrying condoms and exacerbated existing inequalities experienced by transgender, migrant, and drug-using sex workers. Evidence from decriminalised settings suggests that sex workers in these settings have greater negotiating power with clients and better access to justice. Quantitative findings were limited by high heterogeneity in the meta-analysis for some outcomes and insufficient data to conduct meta-analyses for others, as well as variable sample size and study quality. Few studies reported whether arrest was related to sex work or another offence, limiting our ability to assess the associations between sex work criminalisation and outcomes relative to other penalties or abuses of police power, and all studies were observational, prohibiting any causal inference. Few studies included trans- and cisgender male sex workers, and little evidence related to emotional health and access to healthcare beyond HIV/STI testing.Together, the qualitative and quantitative evidence demonstrate the extensive harms associated with criminalisation of sex work, including laws and enforcement targeting the sale and purchase of sex, and activities relating to sex work organisation. There is an urgent need to reform sex-work-related laws and institutional practices so as to reduce harms and barriers to the realisation of health. Lucy Platt and colleagues provide qualitative and quantitative evidence demonstrating the extensive harms associated with criminalisation of sex work. To our knowledge there has been no evidence synthesis of qualitative and quantitative literature examining the impacts of criminalisation on sex workers’ safety and health, or the pathways that realise these effects.This evidence is critical to informing evidenced-based policy-making, and timely given the growing interest in models of decriminalisation of sex work or criminalising the purchase of sex .We undertook a mixed-methods review comprising meta-analyses and qualitative synthesis to measure the magnitude of associations, and related pathways, between criminalisation and sex workers’ experience of violence, sexual  and emotional health, and access to health and social care services.We searched bibliographic databases for qualitative and quantitative research, categorising lawful and unlawful police repression, including criminal and administrative penalties within different legislative models.Meta-analyses suggest that on average repressive policing practices of sex workers were associated with increased risk of sexual/physical violence from clients or other partners across 9 studies and 5,204 participants.Sex workers who had been exposed to repressive policing practices were on average at increased risk of infection with HIV/STI compared to those who had not, across 12,506 participants from 11 studies. Repressive policing of sex workers was associated with increased risk of condomless sex across 9,447 participants from 4 studies.The qualitative synthesis showed that in contexts of any criminalisation, repressive policing of sex workers, their clients, and/or sex work venues disrupted sex workers’ work environments, support networks, safety and risk reduction strategies, and access to health services and justice. It demonstrated how policing within all criminalisation and regulation frameworks exacerbated existing marginalisation, and how sex workers’ relationships with police, access to justice, and negotiating powers with clients have improved in decriminalised contexts.The quantitative evidence clearly shows the association between repressive policing within frameworks of full or partial sex work criminalisation—including the criminalisation of clients and the organisation of sex work—and adverse health outcomes.Qualitative evidence demonstrates how repressive policing of sex workers, their clients, and/or sex work venues deprioritises sex workers’ safety, health, and rights and hinders access to due process of law. The removal of criminal and administrative sanctions for sex work is needed to improve sex workers’ health and access to services and justice.More research is needed in order to document how criminalisation and decriminalisation interact with other structural factors, policies, and realities  in different contexts, to inform appropriate interventions and advocacy alongside legal reform. Sex workers can face multiple interdependent health risks ,2. BetweQualitative literature demonstrates how social policies and structural factors shape the health and welfare of sex workers. The ‘risk environment’ concept, developed to understand drug-related harms  and adapBroadly, there are 5 legislative models used to manage, control, or regulate sex work  33]. Fu. Fu33]. The debate around sex work policy and legislation is highly polarised. Some argue that all sex work is itself gendered violence and should be repressed—a notion that underpins the criminalisation of sex workers’ clients ,40. OtheFollowing a protocol with pre-specified search terms, we searched MEDLINE, CINAHL, PsychINFO, Web of Science, and Global Health for public health and social science literature on studies that combined 3 search domains: (1) sex work, AND (2) legislation OR policing, AND (3) health  OR access to services . The complete search terms and review protocol are attached . Meta-anThree authors screened the sources for inclusion, discussing any uncertainties within the team; a second person re-reviewed relevant sources when necessary. Quantitative data were extracted and analysed by LP and JE, and qualitative data synthesised by PG and RM. For qualitative and quantitative studies, we defined quality-related criteria adapted from the Critical Appraisal Skills Programme (CASP)  that papWe included studies with sex workers of all genders who currently or have ever exchanged sexual services for money, drugs, or other material goods. We included research on all models of sex work legislation and used the following definition of the criminalisation of sex work: ‘a model of intervention in which the criminal law is used to manage, control, repress, prohibit or otherwise influence the growth, instance or expression of prostitution’ . We alsoWe included quantitative, qualitative, and mixed-methods studies published in English, Russian, or Spanish, and included data specific to the experiences of sex workers. We included papers that measured quantitative associations between criminalisation or decriminalisation of sex work, or repressive policing practices within these contexts, and the following outcomes: threatened or enacted violence, STIs, HIV, hepatitis B/C, overdose, stress, anxiety, depression, risk practices/management , and access to health/social care services . We also included studies that reported qualitative data on the relationships between experiences of criminalisation or decriminalisation and policing and sex workers’ experiences of violence, safety, health, risk management, and/or accessing health or social care services, from the perspectives of sex workers themselves.I2 statistic. We conducted sub-group analyses to describe differences in experience of violence and condom use by partner type (client versus intimate partner/other) and by type of violence . We conducted sensitivity analyses to look at overall associations between policing and our specified outcomes, excluding or pooling studies that did not adjust for confounders or reported only STI outcomes  or composite HIV/STI, and altering the priority choice of police exposure (from recent arrest/prison to other). We conducted a narrative synthesis of outcomes that were too heterogeneous to pool, including access to services (both mandatory and voluntary uptake of services), harms related to drug use, and emotional health. Studies that measured associations with registration at the municipal health department were also synthesised separately, since this policy was less comparable with all others that involved direct police action. All analyses were conducted using the metafor package in R version 3.4.1 and RStudio version 1.0.143  You never know who it is, right? And you can’t really see his face, can’t really see anything they could have a gun in their hand or. You know what I mean they could be a little drunk or something if you can’t really see them very clearly, you know. And you don’t you can’t say hi or whatever before you get in. You have to just hurry up before the cops come.’—cis woman, street, age unspecified, Canada Quote 4b: ‘Clients are worried about police. To avoid police they wanna move to a different area. I don’t want to go out of my zone right.…Once you get out there, like you know their turf so it’s harder for me cause it’s their comfort zone so they act differently, you know what I mean. Yeah it never ends up good’—cis woman, street, age unspecified, Canada Quote 5: ‘The ideal situation is where you…have a separate premises where you can work from, and share those premises…Because then you’ve got companionship, added security, there’s someone to interact with. Because of the legal situation you have to be very, very careful. Because obviously it’s running a brothel, which has…really dangerous consequences these days.’—cis man, independent, age unspecified, UK Quote 6a: ‘In the past, we just stay in the brothel and no one dared to hurt us or beat us because we are there in the brothel. But now [since police crackdowns] we cannot know where they take us to. Such as taking us to Prek Ho [a village 15 km from Phnom Penh] and hurt us. We don’t know in advance. There is no one to control us. So it is not safe for us.’—cis woman, formerly brothel-based, age 26 years, Cambodia Quote 6b: ‘Now some clients may force us not to use condoms but when we lived in the brothel we had more rights than clients and they dared not to force us because they come into our house.’—cis woman, formerly brothel-based, age 22 years, Cambodia Quote 7: ‘One of the staff caught one [a violent client]. He was a visitor in the house, and he came in as a date, and they called the police, and he got arrested.’—cis woman, indoor, age unspecified, Canada Quote 8: ‘And the police weren’t around as much . But when it got legalised the police were everywhere. We always have police coming up and down the street every night, and we’d even have them coming over to make sure that we were all right and making sure our minders, that we’ve got minders and that they were taking registration plates and the identity of the clients. So it was, it changed the whole street, it’s changed everything.’—cis woman, street, age unspecified, New Zealand Quote 9: ‘You stand outside the car and talk. Don’t get in the car and talk—it’s best to just get them to wind the window down, stand there, talk to them and judge them. Yeah.’—cis woman, street, age unspecified, New Zealand Quote 10: ‘There was this time when I was arrested by six policemen. They afterwards demanded sex from me. One of them threatened to stab me if I refused. I ended up having sex with all of them and the experience was so painful.’—cis man, sector unspecified, age 26 years, Kenya Quote 11: ‘It’s really pathetic taking money from us. I don’t know how they don’t understand I struggled for that. I sold my body. I worked. The man, for instance, pardon me, fucked me and everything, for the money. And they take the money. Why? I don’t know, but so they say it goes into some fund, what do I know?’—cis woman, street, age not specified, Serbia Quote 12: ‘Does the law limit how much they [police] charge [when fining sex workers]? Today, 500, tomorrow 300. Why the law does not limit…the charges for this amount? For gambling, 1000 charged, prostitution 500, isn’t there a limit? We don’t understand. I feel like the charges just depend on their [police] mood.’—cis woman, focus group, sector and age not specified, Thailand Quote 13: [In a case where a participant reported being attacked by a client and the case going to court.] ‘He ended up getting off even though I had photos of the bruises. This is likely related to the institutional attitude that women who sell sex deserve what they get from taking on a dangerous occupation—it’s such bullshit but so common! Also, I feared prosecution myself as a prostitute so I was unable to be completely truthful in court and my abuser was let off—even with the evidence’—cis woman, independent off street, age not specified, Canada Quote 14: ‘The police don’t look at us as victims when we’re raped and when we’re beaten and stuff like that. If we get into a physical altercation and we have to fight for our lives, we’re most likely to be jailed because of it.’—cis woman, sector not specified, age 40 years, US Quote 15: ‘They come to my door and, you know, ask for my ID and so forth so it’s like harassment…The third time it’s like, “We know what you’re doing, I mean, what you’re about. We’re going to go after your clients”…I make a living out of this, so I was really paranoid for a very long time after.’—cis woman, internet escort, age not specified, Sweden Quote 16: ‘One night a client went off with a girl, and after their encounter he beat her. The next day she recognised him in the bar and told the bar owner who told her to go to the police. When she got to the police station the officers didn’t believe her—they said she didn’t have any proof. The police don’t give us any help at all.’—cis women, working in a bar with registration, age not specified, Senegal Quote 17: ‘Once, I forgot to return [to the city clinic] for a health stamp. The police threatened to take me and nine other girls to jail, but they let us go with a warning and a 2,000 pesos fine [$220].’—cis woman, sector not specified, age 19 years, Mexico Quote 18: ‘Well it definitely makes me feel like, if anything were to go wrong, then it’s much more easier for me to get my voice heard. And I also, I also feel like it’s some kind of hope that there’s slowly going to be more tolerance perhaps of you know, what it is to be a sex worker. And it affects my work, I think…when I’m in a room with a client…I feel like I am deserving of more respect because I’m not doing something that’s illegal. So I guess it gives me a lot more confidence with a client because, you know, I’m doing something that’s legal, and there’s no way that they can, you know, dispute that. And you know, I feel like if I’m in a room with a client, then it’s safer, because, you know, maybe if it wasn’t legal, then, you know, he could use that against me or threaten me with something, or you know. But now that it’s legal, they can’t do that.’—cis woman, sector and age not specified, New Zealand Quote 19: ‘Now if I get caught to police people, they check pockets and all and take everything.…the police people will snatch it [money] away…Even if we find two hundred [rupees] a police person will come [and take it].’—trans woman (nachichi), street, age unspecified, Sri Lanka Quote 20: ‘They [police] started going wild, only on us transvestites. They let the girls go. They just pick us up, and go to the woods, and go wild on us…First, they beat us in the woods, and then they take us to the station. And then they tell us at the station “Hey, freshen up,” and they beat us up in the bathroom’—transvestite [author’s term], street, age unspecified, Serbia Quote 21: ‘Sometimes a man will take you and after fucking, he says, “You are gay, where can you report me? I’m not paying you and you can do nothing about it.”‘—cis man, focus group, sector and age unspecified, Uganda Quote 22: [After reporting being jailed on charges of prostitution and describing an incident with police involving forced gender behaviour] ‘I’m very scared of policemen of course.…They straight away tell.…“Go sing a song! sweep!” Talk to us like dogs.’—trans woman, street, age unspecified, Sri Lanka Quote 23: ‘Because it wasn’t a trial of rape, it was a trial of me being a heroin addict, me being on methadone. It got thrown out of court….’—cis woman, street, age unspecified, Canada Quote 24: ‘Since the new law was passed, fewer women access health care and prevention services because we live at different places nowadays and NGOs could not find us. In the past, women live in one place at the brothel. We also want to contact NGOs but we don’t know the location of the NGOs…So we could not access to prevention services…Since the brothel was closed I have never contacted it again.’—cis woman, brothel, age 22 years, Cambodia Quote 25: ‘Because the policemen crack down often we cannot earn money. We are sleepless, so we sleep at day time, so I am lazy to go to check my health. I have no feeling to go.’—cis woman, brothel, age 22 years, Cambodia Quote 26: ‘I think every month is stupid. It has to be every three months at least. Because it’s a pain for owners, it’s a pain for girls, for everyone, because like you can’t go to your family doctor and say, “Listen I need a certificate”. You have to go to a sexual health clinic and wait all day to see a doctor.’—cis woman, brothel and escort, age unspecified, Australia Quote 27: ‘[For] any insurance one of the questions is, “Have you been a prostitute?” Whatever, now if they pulled your health records and they saw how many tests you’d had, you can’t lie about that one and I think it should be totally illegal [insurance companies asking about sex work]. And I would like to see them do a bit of a study on girls in the sex industry who have worked, that aren’t on drugs and how many diseases they actually have, to see if this kind of discrimination is warranted, because it’s not.’—cis woman, sector and age unspecified, US Quote 28: ‘I worked in a legal prostitution setting in Nevada. I did that for a couple of weeks to see what it was like. The amount of controls and the lack of freedom was horrendous. You know, I don’t want someone else telling me how to work. And I don’t think it is necessary really. Yeah, I think decriminalization gives us the most freedom.’—cis woman, independent in-call and out-call, age 39 years, US We estimate that, collectively, lawful or unlawful repressive policing practices linked to sex work criminalisation  are associated with increased risk of infection with HIV or STIs, sexual or physical violence from clients or intimate partners, and condomless sex. The qualitative synthesis clearly shows pathways through which these policing practices and health risks are associated: enacted or feared police enforcement—targeting sex workers, clients, or third parties organising sex work—displaces sex workers into isolated and dangerous work locations and disrupts risk reduction strategies, such as screening and negotiating with clients, carrying condoms, and working with others. Specific policing practices, including confiscation of condoms or needles/syringes, are associated with increased odds of HIV, STIs, and violence by a range of actors. Repressive police practices frequently constitute basic violations of human rights, including unlawful arrest and detention, extortion, physical and sexual violence by law enforcement, lack of recourse to justice, and forced HIV testing—violations inextricably linked to increased unprotected sex, transmission of HIV and STIs, increased violence from all actors, and poorer access to health services ,29,134. Our findings build on previous reviews documenting the extent to which and how social and structural factors influence sex workers’ safety and vulnerability to HIV. They do so by showing how these factors interplay with criminalisation to further marginalise sex workers and deprive them of civil, labour, and social rights –137. FeaDespite including search terms relating to broader health outcomes, the majority of epidemiological literature focused on sexual health outcomes and, in more recent evidence, violence. We found few studies that focused on emotional health, but these show detrimental associations with repressive policing and criminalisation. Qualitative and quantitative studies demonstrate that police enforcement and its threat is a major source of anxiety ,141, wheFindings clearly show that criminally enforced regulatory models create major disparities within sex worker communities, possibly enabling access to safer conditions for some but excluding the large majority who remain under a system of criminalisation, including trans women, cis men, people who use drugs, migrant populations, and often sex workers operating in outdoor environments, who are at increased risk of HIV in many settings ,90,126. We were unable to examine the effects of different legislative models in the quantitative synthesis due to limited data, particularly for the models of decriminalisation and the criminalisation of the purchase of sex. Evidence included in our qualitative synthesis clearly shows that criminalisation of clients does not facilitate access to services, nor minimise violence. This is supported by the epidemiological evidence from Vancouver that showed that sex workers who were stopped, searched, or arrested were at increased risk of client violence despite the introduction of more severe laws against the purchase of sex introduced in 2014  . In addiThere are a number of limitations to this review. Findings from our pooled meta-analyses examining condom use and violence were limited by high heterogeneity, although effect estimates remained consistent across sensitivity analyses, suggesting we can be confident in their robustness. By limiting the search to literature written in English, Russian, and Spanish, we may have missed key studies. There was a lack of comparable quantitative data on outcomes such as access to services, drug-related harms, and emotional ill health, which precluded the use of meta-analysis. Similarly, few qualitative studies explored the emotional health effects of criminalisation and enforcement, and its effects on access to health and broader services received less attention relative to safety and health risks, within the rich body of evidence reviewed. Methodologically, some studies did not provide sufficient detail on sampling and analysis methods, and few included reflexive discussions on the position of the researcher. Although a growing number involve sex workers as researchers or advisors, few included discussion of the challenges and benefits of participatory approaches. We found few eligible studies that included trans female or cis male sex workers, who experience particular inequalities in relation to HIV, access to services, and—as the qualitative synthesis shows—police targeting and violence, limiting our ability to generalise findings to these populations. It is also possible that some studies may not have differentiated between trans women and cis men , or betwOur review focuses on the implementation of enforcement practices linked to 5 broad legislative models. While it is clear that sex work laws and enforcement practices are inextricably integrated and it is key to link practice to legal frameworks to inform policy-making and advocacy, our findings reinforce previous evidence ,38 that The public health evidence clearly shows the harms associated with all forms of sex work criminalisation, including regulatory systems, which effectively leave the most marginalised, and typically the majority of, sex workers outside of the law. These legislative models deprioritise sex workers’ safety, health, and rights and hinder access to due process of law. The evidence available suggests that decriminalisation can improve relationships between sex workers and the police, increasing ability to report incidences of violence and facilitate access to services ,95,96. CS1 Moose Checklist(DOC)Click here for additional data file.S1 Fig(TIF)Click here for additional data file.S2 Fig(TIF)Click here for additional data file.S3 Fig(TIF)Click here for additional data file.S4 Fig(TIF)Click here for additional data file.S1 Table(XLSX)Click here for additional data file.S2 Table(XLSX)Click here for additional data file.S1 Text(DOC)Click here for additional data file.S2 Text(DOCX)Click here for additional data file.S3 Text(DOCX)Click here for additional data file.S4 Text(DOCX)Click here for additional data file.


Workers in the road transport industry, and particularly truck drivers, are at increased risk of chronic diseases. Innovative health promotion strategies involving technologies such as social media may engage this “hard-to-reach” group. There is a paucity of evidence for the efficacy of social media technologies for health promotion in the Australian transport industry.This study analyzed qualitative data from interviews and focus group discussions to evaluate a social media health promotion intervention, the Truckin’ Healthy Facebook webpage, in selected Australian transport industry workplaces.We engaged 5 workplace managers and 30 truck drivers from 6 transport industry organizations in developing workplace health promotion strategies, including a social media intervention, within a Participatory Action Research approach. Mixed methods, including a pre- and postintervention manager survey, truck driver survey, key informant semistructured interviews, truck driver focus groups, and focused observation, were used to evaluate the social media intervention. We asked questions about workplace managers’ and truck drivers’ opinions, engagement, and satisfaction with the intervention. This paper focuses on qualitative data.Of the workplace managers who reported implementing the social media intervention at their workplace, all  reported satisfaction with the intervention and expressed a keen interest in learning more about social media and how it may be used for workplace health promotion and other purposes. Truck drivers were poorly engaged with the intervention because (1) many believed they were the “wrong age” and lacked the necessary skills; (2) the cost of smartphone technology was prohibitive; (3) they confined their use of social media to nonwork-related purposes; and (4) many workplaces had “no Facebook” policies.The use of social media as a health promotion intervention in transport industry workplaces has potential. Workplace interventions using social media can benefit from a Participatory Action Research approach. Involving managers and workers in the design of social media health promotion interventions and developing strategies to support and deliver the interventions helps to facilitate their success. The workers’ profile, including their age and familiarity with social media, and work, workplace, and family context is important to consider in this process. Much more research needs to be undertaken to better understand the effective use of social media to engage “hard-to-reach” groups. The road transport industry accounts for 2% of Australia’s workforce, employing 192,600 Australians ,4. WorkpThe use of social media and related technologies is increasingly popular for personal enjoyment , as a buA literature review suggests that truck drivers, in Australia and internationally, use social media and related technologies for a variety of purposes. Facebook is a popular social media platform and has been used by truck drivers for a variety of purposes, including to advocate for improved safety at work, report road accidents, identify and stop fatigued drivers, search for missing drivers, and socially connect with other drivers -27. OtheIn Australia, social media have been used in the transport industry for health promotion purposes in a limited capacity. Herbert  reportedQueensland Transport Industry Workplace Health Intervention was a settings-based, mixed-methods Participatory Action Research (PAR) project. The project identified health promotion interventions for transport industry workplaces to support truck drivers to improve their health knowledge and behavior  who gets on Facebook. They don’t get on Facebook. I mean, who does get on Facebook?TWP420Another workplace manager commented as follows:I don't think a lot of our drivers are on Facebook. I would say, out of our truck drivers, maybe twenty percent use social media...A lot of them would have mobile phones, for sure. But I'd say the ones that were 'tech savvy' and who would jump on social media, a very small group... A lot of them are over fifty years old.TWP620Workplace managers perceived their predominately middle-aged workforce was the “wrong age” to engage with social media. In a postintervention focus group, drivers discussed this issue, highlighting they were “too old” to be familiar or comfortable with social media. One workplace manager said:My drivers are the wrong age-group in most cases; they’re not young enough for it, they’re old ‘sticks-in-the-mud’… It’s technology they don’t use… [Most] of the guys are sixty-plus.TWP120This was reinforced by a truck driver, who commented:We’re all sixty years old; we don’t change our thoughts on much.BTPThere are a number of other barriers to drivers’ use of social media. The theme of “other barriers to social media use” can be organized into 2 subthemes—the prohibitive cost of smartphone technology and drivers’ tendency to confine the use of social media to nonwork-related purposes.The perceived cost of social media was identified by one workplace manager as a key barrier to the intervention. This manager commented:And how would you get on Facebook? You'd have to have a [smart]phone... but a lot of fellas wouldn't have those... They cost $700, a lot of drivers wouldn't have $700, you've got to remember that.TWP420Another key barrier to the intervention was many drivers confined the use of social media to nonwork-related purposes. In the focus groups, drivers reflected the primary use of social media technologies like Facebook was to connect with family and friends. For example, one manager explained why he did not “like” the page to add it to his Facebook feed:I keep my Facebook strictly for personal things.TWP120A number of workplace managers explained the implementation of the intervention and, specifically, their promotion of the Facebook page was limited by a “no-Facebook policy” at the workplace. Many workplaces had guidelines and policies about social media technologies, such as Facebook, at work and about posting work-related content on such sites. The managers at these workplaces felt the rules limited their capacity to promote the Facebook page to drivers. One workplace manager commented:No, we didn’t [promote it]… That was when we had a no-Facebook policy… Like a lot of places, there was too much rubbish getting on it, ex-employees and things like that... It becomes a bit of an issue, and there are also privacy issues.TWP220The workplace managers identified those drivers who did engage with social media technologies, such as Facebook, were most likely to do so using smartphones. The use of smartphones on the job is illegal while operating trucks. A number of workplace managers reflected on this problem. Additionally, when implementing the intervention, some workplace managers did report attempting to overcome the limitations associated with rules about the use of Facebook and phones in the workplace. One workplace manager said:I can’t stop them using Facebook in their private time. I’d encourage them to go on and say, ‘Listen, when you’re at home you might like to have a look at it.’TWP320Drivers were poorly engaged with social media, but their partners and friends were engaged. This was, particularly, true for drivers’ wives, who were identified as being responsible for connecting drivers with social media technologies such as Facebook. For example, one workplace manager said:There’s one [driver] - his wife runs his Facebook page for him. She just updates the photos of all the grandkids and that sort of stuff. He doesn’t have anything to do with it.TWP120Workplace managers reflected on the potential reach of a social media health promotion intervention. This included the potential to reach others in a truck driver’s social circle. One workplace manager commented:I think [Truckin’ Healthy] sort of worked because I said ‘like’ and then I pressed ‘share’… Even people that I’m associated with outside, that aren’t drivers, liked that… The message is still getting out there… If you want anyone to know anything, just put it on FacebookTWP520Another manager commented on the visual immediacy of Facebook for health promotion:You can see if people like Facebook…GBFFThe potential of social media in workplace health promotion was identified by many of the workplace managers. Some workplace managers demonstrated a keen interest in learning more about how the technology worked. For example, one workplace manager commented:My daughter’s got me on Facebook…I knew [the project team] were coming up and I said, “Show me what’s on there”…She said all the trucks have been on…all the pictures of the flood on the farm. I said, ‘You’re joking!’TWP420Some workplace managers reflected about new ways of using technology in workplaces, which may be harnessed for health promotion purposes. One workplace manager explained:We’re rebuilding our Web face and we’re going to do a lot more messaging over [that]. And we’re going to get some Windows tablets for the drivers to use in their trucks, so they’ll have an intranet in their trucks…From there we’ll link all the policies, procedures, all the internal information on the intranet pageTWP320The results of this project reveal a range of barriers to the use of social media as a health promotion intervention in transport industry workplaces. These barriers are (1) truck drivers believe they are the “wrong age” and lack the necessary skills; (2) the cost of smartphone technology is prohibitive; (3) truck drivers confine their use of social media to nonwork-related purposes; and (4) many workplaces have “no Facebook” policies. Other people around truck drivers, particularly partners, do use social media. Many workplace managers identified the potential for social media in workplace health promotion. This section will explore these complex, interrelated concepts in detail.The key barrier to the use of social media as a health promotion intervention in transport industry workplaces was that drivers do not engage with it for a variety of reasons including demographic constraints and the prohibitive cost of smartphone technology. Further complicating this problem is drivers who do use social media do so primarily for nonwork-related purposes. These issues were not identified during the PAR process undertaken at the beginning of the project. Drivers’ lack of engagement with social media is reflected in other similar studies of health promotion interventions in transport industry workplaces, including those in Australia. For example, Gilson et al  reportedThis project found drivers were poorly engaged with social media, but their partners and friends were engaged. This raises the novel possibility of reaching truck drivers through social media interventions targeted at partners and friends. The importance of family and peer support for positive health outcomes has been demonstrated by other studies on health interventions in blue-collar workplaces -48. ThisAnother key barrier to the effectiveness of social media in health promotion interventions in transport industry workplaces is workplace policy. Many workplaces had “no-Facebook” policies, implemented because of drivers’ inappropriate use of smartphones at work. The literature and popular media reveal these as common problems. For example, there are numerous reports of drivers’ dismissals after breaches of workplace social media policies ,49,50 anA number of other barriers have been discussed in the literature with regard to social media in workplace health promotion interventions. These barriers include a lack of knowledge and understanding of social media among workplace managers and workplace managers’ failure to accept new ways of thinking related to the use of social media . These bDespite considerable barriers, this project and the literature suggest there is great potential for social media in health promotion interventions in transport industry workplaces. Much more needs to be known about how to best use social media to engage with the target audience and, particularly, “hard-to-reach” groups such as truck drivers . Hudson The contextualization of interventions in this way is a fundamental aspect of the PAR process, which underpinned this project . The finIn addition to the contextualization of a social media workplace health promotion intervention, the contextualization of strategies to support and deliver this intervention needs to be considered. In this project, workplace managers used posters displayed in depots to advertise the Facebook page. Some mentioned the page in toolbox talks with drivers. Other studies using social media to engage “hard-to-reach” groups in health promotion interventions have used more rigorous advertising, which is integrated with other interventions, including posters, personal health messages, and public announcements . This deThere are a number of limitations to this project. First, the convenience sample of truck drivers may create self-selection bias. Second, the project relied on the self-reporting of data in interview and focus groups, which may have resulted in socially desirable responses. Lastly, the small sample size and highly contextual nature of the social media intervention limits the generalizability of findings. However, other organizations with a small-to-medium sized, blue-collar, mobile workforce may find them of relevance.Future projects investigating social media in “hard-to-reach” workplaces should consider a larger sample from a wider demographic, including rural and regional workplaces, to improve the generalizability. Consideration should be given to improving engagement with social media interventions by integrating these with other interventions that do not use social media, by using a variety of social media technologies and engaging workplace managers, workers, and their families in the intervention design. Furthermore, future workplace health promotion interventions should consider reaching truck drivers through social media interventions targeted at partners and friends.Transport industry workplaces, in Australia and other countries, are increasingly technology-centric, and truck drivers are engaging with social media in their workplaces on a day-to-day basis. This project found that truck drivers participating in a workplace health promotion intervention involving Facebook were generally poorly engaged because of their older age, lack of skills with social media, the cost of smartphone technology, or their workplace “no Facebook” policy. Truck drivers’ family and friends were engaged with this intervention, which suggests if social media interventions in older male populations are to be effective, it is important to consider—and, where possible, utilize—their family context. The findings showed a high level of engagement from workplace managers in developing local social media strategies, which attests to the potentially important role of managers in engaging “hard-to-reach” workforce in health promotion. Therefore, it is important to gain greater insights into social media in workplace health promotion interventions and understand the enablers and inhibitors to potential use in the transport industry.Despite some barriers evident in truck drivers, it is important to explore the potential of social media in workplace health promotion interventions in the transport industry. Much more needs to be known about how to best use social media to engage with “hard-to-reach” groups such as truck drivers. This can be achieved by methods of inquiry, such as PAR, which allow interventions to fit the sociocultural context of workplaces. Strategies for the contextualization include the involvement of occupational groups in the design of social media workplace health promotion interventions and strategies to support and deliver interventions. The context of workers themselves, including their age and familiarity with social media, and work, workplace, and family context is important to consider in this process. The “context matters” because it enables the development of more nuanced, integrated, and extensive Web-based networks, key aspects of engaging “hard-to-reach” groups in social media interventions for health promotion.


In recent years, discourses around “personalized,” “stratified,” and “precision” medicine have proliferated. These concepts broadly refer to the translational potential carried by new data-intensive biomedical research modes. Each describes expectations about the future of medicine and healthcare that data-intensive innovation promises to bring forth. The definitions and uses of the concepts are, however, plural, contested and characterized by diverse ideas about the kinds of futures that are desired and desirable. In this paper, we unpack key disputes around the “personalized,” “stratified,” and “precision” terms, and map the epistemic, political and economic contexts that structure them as well as the different roles attributed to patients and citizens in competing future imaginaries. We show the ethical and value baggage embedded within the promises that are manufactured through terminological choices and argue that the context and future-oriented nature of these choices helps to understanding how data-intensive biomedical innovations are made socially meaningful. The last few decades have seen a proliferation of academic publications and policy discourses around so-called “personalized,” “stratified,” or “precision” medicine. While definitions of these terms are often debated, they all broadly refer to the possibilities that are opened up by the translation of emerging modes of data-intensive biomedical research to the context of medical practice and healthcare delivery. This is contextualized by the so-called “digital era” of bioinformatics and “big data” which is enabling the collation of, and application of predictive modeling methods to, unprecedented quantities of biomedical data. The rise of these technologies is associated with hopes and aspirations of a revolutionary change in medicine that will enable new, transformed modes of healthcare delivery in the future. “Personalized,” “stratified,” and “precision” medicine each describe, in different ways, the kinds of future medicine and healthcare that these new methods promise to bring forth.The concepts of “personalized,” “stratified,” and “precision” medicine and the discourses associated with each are overlapping and future-oriented, characterized by diverse visions of possible, desired and desirable futures that are illustrated by the plurality of terms. These visions in turn are articulated in different ways in different political and epistemic contexts, by different actors with different interests and agendas. The meanings of “personalization,” “stratification,” and “precision” are emergent, without collectively agreed boundaries: they refer to overlapping phenomena and collate shared themes, but each has a different emphasis, which delineates what is and is not included under each term in practice. Each reflects different views of what the aims of emerging biomedical research modes are and should be in the context of healthcare, and positions patients and citizens differently with respect to health and biomedicine as well as in relation to governance and the state.Building on and contributing to existing literature on the sociology of expectations, our objectives in this paper are, firstly, to delineate key aspects of the negotiations and disputes attached to “personalized,” “stratified,” and “precision” medicine, in order to analyze the divergent and overlapping themes that structure the related discourses. We aim to unpack the various aspirations and epistemic agendas attached to them, and to show how and why different terms are mobilized in policy discourses as opposed to biomedical academic discourses. Second, we map the political, and economic contexts that structure different policy articulations of “personalized,” “stratified,” and “precision” medicine along the lines of US vs Europe differences and similarities, as the articulations have largely originated from and are advanced by US and European political actors. We show how politico-economic interests and cultural differences between the US and European policy contexts frame how different future promises are imagined. Third, we aim to show how the patients and citizen subjects that are the target of medical interventions and healthcare systems are configured differently within and through the competing discourses and imaginaries.By providing insight into how (the concepts of) “personalized,” “stratified,” and “precision” medicine are delineated and mobilized, we examine how the future-oriented content of the discourses is likely to shape the direction of biomedical innovation today. What aspirations do different politically, epistemically, and geographically positioned actors attach to new and emerging biomedical research modes? What role do these aspirations play in envisioning the future of medicine and healthcare? How are different visions of this future embedded within and shaped by broader contexts in which they are articulated? How are individuals and citizens being (re)positioned with respect to health, healthcare systems and biomedicine? Through charting this contested conceptual landscape, we explore how the dispute over labels and definitions reflects political, social, epistemological and ontological tensions that must be negotiated as part of making sense of techno-scientific and biomedical innovation. We argue that analysis of such innovation and its implications must account, not just for this diversity of terms and the contextual differences that underlie it, but also for the ethical and value “baggage” embedded with the future promises that are manufactured through terminological choices.et al. The emergence of data-intensive biomedical methodologies and predictive analytics is contextualized by the “digital era” of scientific and technological innovation that has exponentially increased computational processing power and enabled the development of complex digital and interactive communication systems and high-throughput technologies including genome sequencing and -omics disciplines. Digital data collection, collation and analysis tools have enabled new research modes that rely on “big data,” i.e. large quantities of varied, dynamic, and mobilizable data Kitchin . New poset al. These new technologies and methods have altered the focus of much biomedical research, giving rise to an epistemic and ontological emphasis on “systems” or networks. This is rooted in the emergence of so-called systems biology, focused on the dynamics of complex biological systems rather than individual parts or constituents of the system. The application of systems approaches to medical and clinical contexts has been termed “systems medicine.” Both entail an ontological and epistemological re-direction in biomedicine  for tailoring the right therapeutic strategy for the right person at the right time, and/or to determine the predisposition to disease and/or to deliver timely and targeted prevention. Personalised medicine relates to the broader concept of patient-centred care, which takes into account that, in general, healthcare systems need to better respond to patient needs  developed by the EU-funded PerMed project, and aimed at shaping Europe’s vision for personalized medicine. The SRIA called for “a paradigm shift for all citizens, researchers and national healthcare systems,” underlining the importance of patient participation and responsibility in the ownership and control of personal health data  … resulting in an unprecedented customization of patient care”  agendas in morally unacceptable ways. They contend that a shared understanding of the term is required to mitigate these problems, but also that adequate analytic criteria should be used to construct the definition to avoid arbitrariness. Consequently, they propose and apply several in reality, “tailoring means no more than stratification” (10). Several biomedical commentators have agreed: Abettan . That some (including the European Commission) have conflated personalized and patient-centered medicine demonstrates, for Schleidgen and colleagues, that stakeholders can misuse the conceptual ambiguity of the term by inflating it with optimistic meanings according to their own agendas when,  Abettan , 426, fo Abettan , 497 hasrealistically. Yet, rather than protecting “personalized medicine” from stakeholder bias, Schleidgen and colleagues effectively appoint one stakeholder group as the (only) legitimate delineator of what “personalized” medicine can be, to the extent that other stakeholders’ conflicting interests, including patient-centeredness, are classed as “misuse” of the concept. Indeed, Schleidgen and colleagues’ definition can be seen as privileging the biological and molecular interpretation of “personalization” as group-level treatment stratification, to the explicit and purposeful exclusion of patient-centered interpretations.The definition proposed by Schleidgen and colleagues , 10 is tSimmons and colleagues  have notRelatedly, Schleidgen and colleagues’ emphasis on what medicine can in practice deliver and their desire to disentangle personalized medicine from patient-centered care not only render the European Commission’s aspirations for personalized medicine as misuse of the concept, but also side-line the future-oriented motivations that foreground these aspirations. By excluding patient-centered care and more inclusive interpretations of personalization as unrelated to personalized medicine, their definition tends to foreclose possible futures where the boundaries of both “personalization” and “medicine” more comprehensively incorporate data from “systems” beyond the traditional focus of medicine; namely, the environmental and/or socio-economic. These broader notions of personalization and medicine are in part what shape related research investment in the European policy context, illustrating a disconnect between policy aspirations, and agendas advanced by Schleidgen and colleagues’ and other biomedical commentators. The disconnect derives from differently articulated priorities linked with different stakeholders’ agendas and values.et al. It is also noteworthy that while existing research on patients’ and publics’ perceptions of personalized medicine is limited, the research that does exist , for example, has argued that “stratification” more accurately “reflects the realistic effects of medicines at population level, while the term ‘personalized medicine’ reflects the possibly overambitious promise of individualized unique drug targeting and development” , 180. Siet al. Thus, while stratified medicine has also been used to denote visions of the future of healthcare promised by data-driven predictive or systems biomedicine, these visions have simultaneously been contrasted against the “misleading and segmented” nature of “personalization,” compared to which “stratification” has been taken as a concept that “better captures the hopes and aspirations of this new branch of medicine” Chataway , 732. “SA 2015 joint forum meeting co-organized by the UK AMS, however, concluded that the language of stratification was potentially problematic due to its exiting associations with social divisions – especially stratification along ethnic and socioeconomic lines – which could render the concept misleading or problematic when applied in public communication or engagement AMS . This waSimilarly, based on interviews and ethnographic research with stakeholders in the US, Juengst and colleagues  argue thTowards Precision Medicine report, the National Research Council (NRC) of the US National Academies encouraged “precision medicine” research, describing it as having the “ultimate endpoint” of enabling “the selection of a subset of patients, with a common biological basis of disease, who are most likely to benefit from a drug or other treatment”  in the US context. In January 2015, US president Barak Obama launched what came to be called the Precision Medicine Initiative (PMI), investing $215 million to realize the initiative’s mission of enabling “a new era of medicine through research, technology, and policies that empower patients, researchers, and providers to work together toward development of individualized care”  with the aim of recruiting one million volunteers to form a longitudinal cohort reflecting the demographic diversity of the US population. They hope to build a databank large enough to facilitate detection of “associations between genetic and environmental exposures and a wide variety of health outcomes” to enable “the exploration of biological, clinical, social, and environmental determinants of health and disease” NIH , 6–7. ThNotably, there is significant overlap between the definitions and conceptualizations of “personalized medicine” applied in the European policy context, and the definitions and conceptualizations of “precision medicine” applied within the PMI. Indeed, in launching the PMI, Obama seems to have taken the two terms quite synonymously: while opting for precision medicine, he noted that “in some cases people call it personalized medicine”  with other ethically complex and controversial research modes such as biobanking and data mining of electronic health records under the language of “precision.” It has associations with notions such as “precision equipment,” and even resonates with “military precision” and the appeal of phrases like “precision bombing” in contemporary American culture  play in broader contexts of healthcare and biomedicine. The aims that are stated, and those that are implicit, in each version of personalized, stratified or precision medicine that are articulated in policy and biomedical discourses reflect the interests and aspirations of the articulators, which relate not only to what the future should look like, but also to what matters in the present.In the policy context, shared aspirations to increase individuals’ capability to take control of their own health are centrally embedded in political discourses in both the US and Europe. Such control is promoted as empowering and desirable, highlighting patients’ and citizens’ agency and the value of increased health knowledge and capacity. However, these discourses also carry connotations of “responsibilization” and its possible implications.as medical and displace other valid goals, values and ways of understanding and tackling life” (320). Thus, “at stake is no less than a person’s own ability to state ‘I am well’ without having to consult a computational mirror image” . Indeed, some have taken this further to advance dystopia-like prophecies centered on medical surveillance and control penetrating into our every-day lives: the post-genomic era is “setting the stage for a digital panopticon” which will result in “an emptying or obliteration of life ”  are strongly embedded in the cultural value system. European welfare model-based public healthcare systems have been grounded on the assumption that risk of unforeseen illness is approximately equally shared and should therefore be pooled active and collaborative with healthcare and research professionals, policymakers and regulatory bodies. These discourses frame healthcare around a social contract model of benefits and obligations where taking responsibility over one’s health is enticed in exchange for personalized or precision (or stratified) healthcare  for an emerging biomedical research area, and as efforts to distinguish their epistemological and ontological approach to this area from other competing approaches. They can simultaneously be seen as efforts to delineate the “newness” of their approach from past research modes to secure public and policy interest and investment. Choosing and defining a term that is then claimed as et al. The open and fluctuating boundaries of “personalized,” “stratified,” and “precision” medicine reflect, then, the context-dependent nature of biomedical and techno-scientific innovation, and how they come and are made to matter for and by different actors and groups in different ways. The chosen terms and their definitions, as labels and boundary delineations, mirror different interests, agendas, and visions around big data integration, preventative and systems approaches to biomedicine, in ways that make the terms and definitions work as marketing tools especially around research investment (Powell The ongoing negotiations and contestations over the present meaning and future implications of personalized, stratified, and precision medicine derive from uncertainties around what new and emerging big data, predictive and systems biomedicine actually imply in practice, and what they can and should become. These open questions reflect how new biomedical technologies, innovations and approaches are socially navigated, contested, and delineated in the context of their emergence.In dispute when it comes to which term should be chosen to denote the potential of new and emerging big data, predictive, and systems approaches to biomedicine are the social ideals and values that the different terms carry as their associations: which terminology and definitions gain dominance, where, and why is a result of struggle over these ideals, values, and priorities. The terminological debates, then, and the related epistemic and ontological tensions around where focus is placed and how conceptual boundaries are drawn are a matter of struggle over what a desirable and realizable future does and does not, and should and should not look like. Each term taps into different interests and links to future imaginaries that can then be used to gather support for and investment in emerging research activities. The future visions that prevail or gain prominence in different contexts ultimately reflect the power of, and investment in, the future visions and promise that has been manufactured.Our aim has been to map how the contextual conceptual, terminological and definitional boundary work and the future-oriented temporality that characterizes it are a key aspect of how biomedical innovations are made meaningful. The diversity of concepts that invoke “hopes” and “truths” about various biomedical and healthcare futures that could or should materialize also shape whose interests will ultimately be served by biomedical innovation. How and by whom these futures are manufactured matters because the temporal and contextual nature of the discourses around personalized, stratified, and precision medicine are central to how they are conceptualized and understood.Existing analyses around the potential implications of big data, predictive, and systems focus in biomedicine – such as analyses focused on responsibilization, increased medicalization and surveillance that they can give rise to – are necessary and valuable, as are analyses focused on delineating the possible meanings and scope of “personalization,” “stratification,” and “precision.” However, rather than pinpointing which of these terms is the “correct” one or delineating the “true” meaning of each, to know how we should critically approach the concepts we need an awareness of the discursive contexts in which they are mobilized. This is because the context ultimately structures the social and ethical implications that “personalization,” “stratification,” or “precision” will have for medicine and healthcare systems, and for different stakeholders. As big health data, predictive and systems-level analysis are, themselves, emergent phenomena, the terminology applied in the discursive spaces around these new biotechnologies and approaches cannot be abstracted from their context. Rather, when we apply the “personalization,” “stratification,” and “precision” terms, we invoke particular associations, connotations, “hopes” and “truths” that are part of pre-existing epistemologically and ethically loaded discourses that reflect broader and weightier struggles over what is a good future.


From the dimly lit hospital ward window, I watched as the sun fell asleep, shielded behind the endless rolling hills of Rwanda. The trees held strong; black soldiers, standing in resilient rows. The fleeting colors of dusk began to fade, and the crimson skies illuminated the hospital bed next to me.Heather, a 64-year-old prisoner, was admitted for altered mental status. She had progressive multifocal leukoencephalopathy, a rare and often fatal complication of uncontrolled HIV. Her face was creased by suffering, weathered from a life of remorse. A medical student fervently advocated for a change to a newer, costlier, antiretroviral medication, despite knowing she may have played a part in the genocide against his family, the Tutsi people, 20 years earlier. Another prisoner, donning a cap with a red cross and a bright orange cotton outfit, acted as Heather’s caretaker.Next to Heather lay Joseph, a 53-year-old farmer. Earlier today, he arrived at the University Teaching Hospital of Kigali, Rwanda’s largest tertiary care facility, complaining of shortness of breath—no longer able to tend to his farm animals. I too had just arrived at Kigali, but from Connecticut, with a goal of medical education. University Teaching Hospital of Kigali serves all patients, including prisoners, although the hospital tends to be more frequented by those who cannot afford care at newer private facilities. Nurses are in short supply, and family members are tasked with the daily care of patients, from bathing and feeding their loved ones to obtaining and, oftentimes, administering medications.Rounding on Joseph this morning, 11 white coats marched toward his bed—three residents (including myself) and eight medical students. I led the pulmonary examination as the medical students helped translate. The university and Rwandan government recently expanded their capacity for medical students, quadrupling their numbers in the last 2 years. Hungry for knowledge, the students eagerly listened to Joseph’s lungs together; stethoscopes pressed against his body like being hugged by an octopus.Pseudomonas aeruginosa pneumonia, a so-called superbug. He only had two previous health-care interactions in his life.“Even the white man has come to help us,” Joseph’s sister said in Kinyarwandan, smiling and pointing to me. Smiling back, I told her it was nice to meet her. However, I did not know at the time that Joseph was dying. Later, he would have to be intubated for pan-resistant As we loomed over his bed, we assessed the pertinent findings: fevers, hypoxia, rhonchorous lung sounds, no swelling in the legs, no thrush in the mouth, and no obvious skin rashes. We hurried off to the light box to review his chest X-ray, passing by a poster on the entrance to the ward illustrating the signs and symptoms of Ebola—a reminder to always consider Ebola in our list of differential diagnoses. We talked pathophysiology as the Rwandan residents quickly showcased their fluency. An enthusiastic medical student blurted out multifocal pneumonia, noting the infiltrates were scattered throughout his lungs. I was quickly impressed by the level of discussion among the team and curious to see the patient’s treatment course and evolution. They discussed clinical trials in various countries around the world and cited guidelines from American societies, looking to me for expertise.my help. No, I am not this mythical American doctor who can cure all or even teach you everything. I am a part of you, I’m just like you, and I am learning with you. In the case of medical education, U.S. trained physicians are likely less proficient at bedside procedures, less accustomed to working with minimal or no supervision, and have limited firsthand experience with tropical diseases.There is an unspoken assumption in the United States that Americans go to Rwanda “to help Rwanda.” Yet, it became clear that the team was not in need of On rounds, the systemic differences from other visiting physicians were clear. “I’ve never seen a case of malaria before,” an American cardiology fellow muttered to me. “Back home, we would have gotten an magnetic resonance imaging (MRI) immediately,” he said with authority. Phrases like “this would never happen in the U.S.,” or “surgery would have been performed days ago” would be whispered out, highlighting the seemingly utopian U.S. health system and the otherness of outside systems. I worry that this line of thinking distances us from our Rwandan colleagues.My mind flashed back to a few months ago in New Haven, when a diabetic patient demanded to see a physician after the nurse denied him a second dinner. I thought about how I have seen a patient get eight blood cultures as part of a nosocomial fever workup and a 95-year-old woman get four head computerized tomography (CT) scans in 1 month for delirium. Despite more limited access to care, there is a resourcefulness here in Rwanda that is to be admired. If the patient cannot afford labs, the residents make decisions like whether a patient needs a transfusion based on their assessment of conjunctival pallor. Bedside ultrasounds oftentimes replaced the need for advanced imaging. As the family cares for the patient, physicians perform beside lymph node biopsies at no charge. Electrocardiogram (EKG) suction cups are cleaned and reused. Patients arrive by motorcycle, ambulance, or even wheelbarrow.Umuganda, when 1 day a month, citizens, including the president, gather together to weed their fields, clean their streets, and build homes for the poorest among them. Street crime is almost unknown. The government, working closely with outside nonprofits and American institutions, is rapidly increasing the country’s capacity to care for complex medical diseases, such as leukemia.Rwanda’s success is due, in part, to its leaders building modern institutions on traditional values. They breathed life back into a civic tradition of As every sunset brings a new dawn, the Rwandans also see a better tomorrow. I am learning from their forgiveness and reconciliation as they provide compassionate care to those who had done harm to them previously. Just 20 years ago, neighbors took up arms against each other in a country-wide genocide that took the lives of nearly one million people in only 3 months. Today, the legacy is still evident, with many in wheelchairs or ravaged by HIV, yet still able to greet me with a handshake of affection. I wonder if I would have the fortitude to be able to do the same back home.The medical wards here are dynamic with unpredictable landscapes layered with innovation and heroism from the medical staff. I heard their stories and they heard mine; I felt I became a better physician from their experience. So as I stand looking out of the window, admiring the sun’s full-blooded colors between the miles of Rwandan hills and sky, I realize that though I am helping teach these Rwandan health providers, they are also teaching me.