Peer violence was remarkably high at baseline. Among urban public school students, 94% of 6th-grade boys and 85% of girls reported being victimized by peers in the last 4 weeks. And 85% of boys and 66% of girls reported perpetrating such violence. Boys scored worse on a number of mental health measures. A cluster RCT is underway to evaluate a well-established school-based intervention using sports and games to reduce peer violence. Peer violence was remarkably high at baseline. Among urban public school students, 94% of 6th-grade boys and 85% of girls reported being victimized by peers in the last 4 weeks. And 85% of boys and 66% of girls reported perpetrating such violence. Boys scored worse on a number of mental health measures. A cluster RCT is underway to evaluate a well-established school-based intervention using sports and games to reduce peer violence. Violence against and among children is a global public health problem that annually affects 50% of youth worldwide with major impacts on child development, education, and health including increased probability of major causes of morbidity and mortality in adulthood. It is also associated with the experience of and perpetration of later violence against women. The aim of this article is to describe the intervention, study design, methods, and baseline findings of a cluster randomized controlled trial underway in Pakistan to evaluate a school-based play intervention aiming to reduce peer violence and enhance mental health.A cluster randomized controlled design is being conducted with boys and girls in grade 6 in 40 schools in Hyderabad, Pakistan, over a period of 2 years. The Multidimensional Peer-Victimization and Peer Perpetration Scales and the Children's Depression Inventory 2 (CDI 2) are being used to measure the primary outcomes while investigator-derived scales are being used to assess domestic violence within the family. Specifics of the intervention, field logistics, ethical, and fidelity management issues employed to test the program's impact on school age youth in a volatile and politically unstable country form this report.A total of 1,752 school-age youth were enrolled and interviewed at baseline. Over the preceding 4 weeks, 94% of the boys and 85% of the girls reported 1 or more occurrences of victimization, and 85% of the boys and 66% of the girls reported 1 or more acts of perpetration. Boys reported more depression compared with girls, as well as higher negative mood and self-esteem scores and more interpersonal and emotional problems.Globally, prevalence of youth violence perpetration and victimization is high and associated with poor physical and emotional health. Applying a randomized controlled design to evaluate a peer violence prevention program built on a firm infrastructure and that is ready for scale-up and sustainability will make an important contribution to identifying evidence-informed interventions that can reduce youth victimization and perpetration. Violence against children is a global public health problem, affecting 50% of youth worldwide each year.–Violence against children violates children's human rights and impacts their education, quality of life, and mental health and dramatically increases the probability of major causes of morbidity and mortality in adulthood.Evidence demonstrates that drivers of violence against children are found at different levels of the socioecological model within the child, family, community/school, and society.This article describes the methods of an evaluation that is being undertaken as part of the "What Works to Prevent Violence?" global program,This article describes the methods of an evaluation underway to assess the effectiveness of a peer violence prevention initiative.Right To Play is an international NGO that has worked with more than a million children in 20 countries using the transformative power of play to build essential life skills, enhance school retention, and prevent violence among children. Specific to violence prevention, the Right To Play objectives posit a change in social norms that contribute to violence against women and girls, especially attitudes that support gender inequities and subordination of girls and women. Additionally, the program aims to empower girls and boys to prevent interpersonal violence and simultaneously build the capacity of schools, teachers, education departments, and communities to reduce violence against women and girls. Right To Play is operating in many countries but has not previously been evaluated with an RCT.Red Ball Child Play that focus on 4 areas of youth development, including physical, cognitive, social, and emotional components.Right To Play's Positive Child and Youth Development program in Pakistan includes games and activities from the manual Red Ball Child Play and youth development activities are integrated into the school schedule through a 35–40-minute time period twice weekly. A monthly schedule for each game session is discussed within Right To Play's implementation team, the school head, and teachers. Depending on the need of the school or curriculum outcome, a game is selected and children are engaged in it by the Right To Play coach and/or teacher during these periods. For community-based programs, a mutually agreed upon timeslot is allocated to conduct these games at community settings. The Positive Child and Youth Development program has been delivered to more than 200,000 children in Pakistan.These This article outlines the methodology, issues, concerns, and essential processes of a cluster RCT to test impact on violence prevention outcomes of the Positive Youth and Child Development program that is being delivered to low-resourced children in public, urban school settings in Hyderabad, Sindh province, Pakistan.The primary objective of this RCT is to determine whether exposure to sport and play as practiced by Right To Play's intervention is effective in reducing experience and perpetration of violence among children and enhancing mental health among boys and girls in grade 6. The secondary objectives are to determine whether the exposure to the intervention is effective in improving school performance and attendance, reducing exposure to violence at home and corporal punishment at school, and changing gender attitudes, including attitudes toward violence, among boys and girls in grade 6.The study used a cluster RCT design with 2 arms. The intervention arm is receiving the full Positive Child and Youth Development program of Right To Play delivered over 2 years, beginning in January 2016 and ending in December 2017, while the control arm receives regular schooling.The study is set among 6th graders in 40 public schools in Hyderabad, Sindh province, Pakistan. We chose Sindh province for ease of access for the research team and because Right To Play has been active there for some years. Hyderabad is an accessible city , large enough to give the requisite number of clusters for the study, and one in which Right To Play had not previously worked.We selected the 6th grade for several reasons. Peak school-age perpetration and victimization occurs between the ages of 13 to 15 years.Peak school-age perpetration and victimization occurs between the ages of 13 to 15 years, so interventions to prevent peer violence should start during the pre-teens.Access to the schools for the research was given at 2 levels of educational administration: each individual school head Master or Mistress and the district-level administrator. We needed 40 fairly homogenous schools from which to randomize that met the criteria of having a play area where the program could be implemented and with school directors who were willing to participate and commit time during the school day, twice a week, to the intervention sessions. We identified 50 gender-specific schools that met all criteria and were willing to participate. We visited each school to assess willingness to participate, examine school facilities to assess a safe play area, and collect information on school attendance to ensure an adequate cluster sample size of youth from each school.Inclusion criteria for schools were thus to be single-gender public secondary schools with an outside playground or indoor space in which games could be played, and to have 35 or more students in the grade-6 class who would give consent to participate. To reduce contamination between arms, if there were more than 40 eligible schools we included only schools that were more than 1 kilometer away from the nearest other included school of that gender.The inclusion criteria for children were that they be students in grade 6 in selected schools, obtain consent for the study from their parents, and agree to participate themselves. The youth needed to read the national language Urdu or provincial language Sindhi competently, so they could self-complete the questionnaire. Where schools had fewer than 50 children in a grade-6 class, we approached all grade-6 classes to be in the study and accepted children who gave consent. If there were more than 50 grade-6 children, we randomly selected a grade-6 section (or 2 grade-6 sections) at the school to get a number as close as possible to 35 to invite for the study. All the children in grade 6 receive the intervention, but not all are part of the research.–The study has 3 primary outcomes: the mean score on a scale measuring victimization of violence among children over the past 4 weeks; the mean score on a scale measuring perpetration of violence among children over the past 4 weeks; and the mean score on a scale measuring self-reported child depression over the past 2 weeks. All outcomes will be measured at 24 months post-baseline. We recognize that in the past primary outcomes have tended to be more narrowly defined as single measures, but there is a well-established precedent when evaluating interventions that seek to achieve multiple results that are equally important to select a small number of primary outcomes.The study assesses outcomes at 3 levels: peer victimization, peer perpetration, and child depression.A priori power analysis was conducted to determine the minimum sample size and cluster sizes required to find significance with power set at 0.80, an alpha level of 0.05, and a small effect size of 0.20 (f).A cluster RCT was required for intervention testing at the school level. A literature review revealed a small expected effect size of 0.2 difference between the mean scores of youth peer victimization and perpetration scores between intervention and control arm schools, following effective violence prevention interventions.This sample and cluster size is adequate for binary and continuous dependent measures. Schools were randomly selected and then randomly assigned to either the treatment or control group. Since schools are segregated by gender, we needed 20 schools in the intervention group (10 boys' schools and 10 girls' schools) and 20 schools in the control group (10 boys' schools and 10 girls' schools). Student data were needed on a minimum of 1,000 students, 25 youths in each school, collected across 40 schools and measured yearly for 3 consecutive years to compose baseline, 12-month outcomes, and 24-month outcomes.We learned about 20% to 30% of 12-year-old youth drop out from school, usually to marry, migrate, or join the labor force, and would therefore be unavailable to complete a 2-year study. Allowing for up to 40% attrition, we added a minimum cluster size of 35 youth per school for a minimum sample size of 1,400.The intervention is being delivered to all children in the selected schools, even though not all students are included in the research. This is in keeping with a whole-school approach and best practices with regard to school interventions.Male and female coaches deliver the intervention. Criteria for coach selection include completion of an intermediate education, previous experience in working with children, a passion and willingness to participate in Right To Play's training, a positive attitude toward child protection, and living in relatively close proximity to the school where the coaches will work. The latter is advised due to scarcity and unpredictability of available public transportation. Coaches and project staff meet twice a month for discussion of issues and challenges and further training if appropriate. Coaches are also trained to identify and mentor junior youth leaders in the schools.Red Ball Child Play manual. For the age group of the study participants, there are 103 learning games (activities) in the manual, which will be imparted over 2-years' time through 130 learning sessions. The sessions are organized into 5 thematic groups   . Red MinThe games are designed for play with fairly basic equipment. Further, most can be played in an indoor room, which is a requirement in some schools for girls and essential at some times of year due to heat. However, all the schools included in the study have some form of outside area in which the games can be played. This ranges in practice from a large interior courtyard to a relatively small walled space on the roof of a school. Initially the games are led by the trained coaches and later by junior leaders selected from among the children. Junior leaders are given leadership training, and they participate as assistants to the coaches, for example, by leading warm-up exercises. Sixty junior leaders (30 boys and 30 girls) were trained in accordance with Right To Play's Junior Leader Facilitation Toolkit.Red Ball Child Play manual in its efforts to provide change through holistic engagement. There are also sports tournaments and thematic Play Days  held several times a year (each attended by about 400 people), and parents are invited to engage in these events. They serve to increase the visibility, in particular, of girls' engagement in sport. There is also selection of youth ambassadors (10 girls and 10 boys) for training on community sensitization and mobilization to prevent violence against women and girls. Youth ambassadors are the volunteer youth from the local communities who are passionate about bringing positive change in their communities and becoming active change-makers. They are provided with mentorship and leadership training by Right To Play in order to strengthen them in skills of leadership, gender equality, communication, action planning, team work, and the role of sport and play for youth development. After attending the training, these youth ambassadors go back to their communities, identify pressing challenges, and implement small-scale projects to tackle the ground-level issues, such as making safe areas for play.Right To Play's intervention goes well beyond the The school-based intervention also engages parents and the community at large through tournaments, events, and other activities.In addition, Right To Play has a network of community groups and holds quarterly awareness sessions with them, including parents, on child rights, gender equality, and positive discipline. Further, there is training of teachers on Right To Play's foundational resources, positive disciplining, and gender and child protection in order to create a safer environment in and around schools. For example, midway through the first year of the intervention, 2 summer camps were held (1 camp for boys and 1 camp for girls) with the theme "Inclusion, Friendship, Equality, and Peace." Right To Play worked closely with the District Education Office who participated in the event alongside teachers, parents, and local community-based organizations. More than 200 children aged 11–14 years (50% girls) attended the camps.The activities of Right To Play to which research participants will be exposed will continue on an ongoing basis between the start of grades 6 until the endline assessment. At that point, the intervention will then be delivered to control arm schools.A public randomization of intervention and control schools was conducted to build trust and increase transparency of the research project. We invited all officials in the school district to the draw and gave them time to introduce themselves, their role, and name their school and location. We then followed the presentations with the public random draw. All schools signed an agreement of participation. Understanding all schools might desire the intervention, we offered 6 months of the intervention to all control schools following the final outcome measures. Further, we mitigated the disappointment of being a control arm school by offering control schools a water tank as an incentive. We chose this after consulting with school partners and parents and learning that all public schools in the area had a pressing need for potable water. Many schools did not have a water tank, resulting in dehydration among some youth who could not bring their own drinking water to school and the frequent need to dismiss school early due to lack of potable water.Instruments were selected following data analysis for the formative phase and in alignment with the primary outcomes of reducing youth perpetration and victimization and the secondary outcome of improving child mental health. Toward this end, we chose Multidimensional Peer-Victimization and Peer Perpetration ScalesFollowing review and approval by the Ethical Review Committee of Aga Khan University and the Ethics Committee of the Medical Research Council of South Africa, we collaborated with Right To Play organization to identify fairly demographically homogenous public schools for girls and boys, who were ages 11–12 years and in the 6th grade, who would be receptive to pilot testing the instruments. The schools also had to be in a school district geographically distant from the main study site to avoid any potential for contamination. Schools with receptive school directors and willing teachers were identified. Children in the segregated girls' and boys' schools were given parental consent forms, which when returned with parent consent enabled the researchers to obtain assent from the youth. Over 90% of the parents signed consent forms and all youth assented to the questionnaire.The instruments were tested among 124 youth attending the 6th grade who were between ages 11 and 12. The instruments were intended to be self-administered using a paper-and-pencil version. Although the instruments were written to a 6th grade reading level, many children had difficulty reading the questionnaires. Consequently, the researchers read each question, resulting in a 2.5-hour administration period. The questionnaires were revised to reduce their length, and the interview protocol was revised so that questionnaires could be self-completed but with interviewer assistance by reading the questions aloud. This enabled the questionnaires to be completed within an hour.Data were collected at baseline during November and December 2015 and will also be collected 12 months after baseline (midpoint) and 24 months after baseline (endline). Data collection for the 40 schools, with 1 facilitator who read each question to a group of 4 children, required a team of 40 data collectors, each of whom was bilingual in the national language of Urdu and the local district language of Sindhi.Baseline data collection for the 40 schools was completed over a 60-day period, following receipt of parental informed consent and child assent. For the 40 schools, we sent home a total of 2,486 parental consent forms and received 1,858 affirmed parent consents for a return rate of 75%. Of the 1,858 forms signed and returned by the parents, 1,767 children assented for a rate of 95%. In general, more parents of girls consented than parents of boys . A total of 1,752 youth questionnaires were completed and entered into an SPSS database.Integral to any longitudinal study is participant retention. To minimize attrition, a contact list was formed following a protocol for retaining abused women.Our protocol for tracking loss to follow-up is that if children are unavailable for the 12-month or 24-month follow-up interview, we will try to learn why. First, we will ask the teacher if the unavailable children are currently absent but normally present at school. If teachers respond that the children are usually present, we will make up to 3 return visits to the school to complete missing interviews. If we are unable to find the children after 3 visits, we will note the children as absent but still in school. If children are not in school, we will need to determine if the absence is due to marriage or wedding preparations, whether the children are now out of school or have transferred to another school, or whether there is another reason, such as loss of interest or refusal to attend school due to violence. To discover the reason, we will first ask the teacher and then ask the relatives or neighbors, named on the tracking form. If all strategies fail, we will visit the children's home to ask their parents.The primary responsibility for monitoring the fidelity of the intervention delivery rests with the intervention organization, Right To Play. To ensure fidelity, Right To Play monitors logs that record the dates a coach goes to a school, the game(s) played with grade 6 students, and the number of children from grade 6 participating in the intervention. This information is reported quarterly. The information is compared with the planned intervention delivery schedule and deviations flagged and sent to Right To Play for correction.The research team is also conducting spot checks on the fidelity logs to ensure accuracy. Two research staff members are visiting each intervention school monthly on a randomly chosen day and independently collecting data on the work in the school over the previous month, including the number of days coaches came and the games played. To collect this information, research staff talk to a teacher and 3 randomly chosen grade-6 pupils.Potable water and basic sanitation are major challenges in Pakistan. The geographic area of the 40 schools is located in an arid and very hot area, where temperatures of 49°C (120°F) are common. Clean drinking water and toilets are scarce at the public schools. Additionally, the journey from the University where the researchers work to the intervention schools is 3 hours each way with meager facilities for water and sanitation in transit, requiring the researchers to transport ample potable water, food, and emergency supplies for the 6-hour road journey and 6- to 8-hour work day at the schools. The 12- to 14-hour workday requires us to maintain close vigilance on hydration and fatigue level of all personnel.For optimum safety, we follow the University safety protocol, which requires registering each trip with the University Department of Safety that assesses the level of terrorism daily and authorizes (or denies) each trip. It is not uncommon to plan and prepare for a data collection day only to be denied travel authorization, which requires cancellation with data collectors, schools, and community partners. Close adherence to health and safety was maintained throughout baseline data collection. We experienced no threats or known risks to personal safety and all staff remained hydrated.As mentioned previously, the Ethical Review Committee of Aga Khan University and the Ethics Committee of the Medical Research Council of South Africa approved this study. We used a multi-layer consent process. Each school principal was given an information sheet and asked to give written consent to the school's participation, including the randomization process.Following school selection and consent from the principal, the research team met with the teachers at the school and established a day to send notices home with selected students regarding the parent's consent for child participation. Students were asked to submit their parent consent forms prior to participation. Many parents were illiterate, but previous research from Aga Khan University has shown that there is usually a relative living in the home who is literate to grade 7–8 and can read an information sheet to parents and help them sign consent. In addition, when distributing the informed consent forms to children, the forms were reviewed with the children to ensure the child could assist with reading. The researchers acknowledge this as a limitation and not ideal. However, our resources prohibited individual home visits to read the consent forms to parents or to use audio-recorded devices to be taken to the home due to safety concerns. After sufficient parental consent forms were received for a school, the research team placed the students with parental consent in a room and provided information to enable written consent to be given by the grade-6 students. Consenting students were asked to complete the tracking form and then the questionnaire. All participants are given study codes and only these are used on the questionnaires.We recognize that the area of research on violence can generate an emotional response from research participants, possibly as a result of recalling their experiences of violence. Field staff was trained to provide immediate emotional support, and we provided back-up counseling from a psychologist if needed. The research protocol stated that should emotional responses  occur in the middle of a questionnaire, the questionnaire completion should be postponed. No compensation is given in the form of cash or gifts. However, refreshments  are served each time participants complete the questionnaire.In this study, we are particularly concerned about 2 serious adverse events: death and hospitalization for injury due to interpersonal violence. Our intervention is aimed at prevention of violence and so it is essential that we fully ascertain severe injury due to violence. We have asked schools to notify us if any of these occur to students at the study schools, and we will conduct a verbal autopsy on every death by having a trained nursing professional study team member visit the child's home. We will seek in the verbal autopsy any evidence that the death could have been linked to the intervention (in the intervention schools) or research. These events will be reported to the Ethical Review Committees of Aga Khan University and the Medical Research Council of South Africa as adverse events or serious adverse events indicating whether they are related or unrelated to study participation. Finally, and very importantly, our intervention partner Right To Play practices a child safeguarding policy that demonstrates its commitment to the welfare of children including treating all children equally, encouraging positive discipline strategies, and ensuring confidentiality .A validation check was conducted between the first baseline data entry and the second baseline data entry to observe possible discrepancies and to confirm them with actual item responses from the questionnaires. Once validation of the second dataset was complete, data preparation and assumptions testing was conducted.The analysis for the baseline study consisted of frequencies, percentages, and means and standard deviations of participant demographics and subscales stratified by gender in the intervention and control arms. Peer victimization and perpetration were also categorized using thresholds suggested by the U.S. Centers for Disease Control and Prevention (CDC) guidelines.Because this study used a randomized cluster design, sample design effects were taken into consideration when analyzing the data and the statistical analysis was treated accounting for school as a cluster. Standard errors (SE) for the means/proportions accounting for the sample design are presented in the subsequent tables. The analysis of the subscales provided comparisons of intervention and control groups by gender testing for significant differences between intervention and control to establish whether randomization was successful. A multivariate test of each of the subscales was conducted to observe the independent effects of gender, treatment, and their interaction using random effects linear regression to account for the cluster effect of school. This trial data will be analyzed to assess whether the intervention was successful in subsequent studies. Pairwise comparisons of marginal linear predictions were conducted to evaluate multivariate group comparisons of intervention and control arms within gender groups.Background characteristics of the full sample are outlined in t tests were conducted to observe the difference of means between intervention and control groups within gender. The results revealed that in most cases there was group equivalence across intervention and control groups within gender, all values of P<.05.Means and standard deviations of the primary outcome measures for the full sample are shown in Boys reported higher prevalence of peer victimization and perpetration than girls, as well as poorer scores on a number of mental health measures.The 94% of boys and 85% of girls reported 1 or more episodes of peer victimization, and 85% of boys and 66% of girls reported perpetrating at least 1 of the same behaviors.P<.05).Frequencies and percentages for specific types of peer victimization by gender are presented in P<.05).Frequencies and percentages for types of peer perpetration by gender are presented in P=.04) but not for any of the other 4 measures. There was no significant interaction of gender and intervention in this regression (P>.05). When comparing treatment and control groups, there was only one significant comparison: peer victimization between treatment and control groups for girls . Mean difference testing revealed that group equivalence existed between intervention and control and that the randomized cluster sample design was successful.The results of Although we identified no studies measuring both youth victimization and perpetration among school-age youth, ages 12 to 14, with which we could compare our results, our prevalence of 89% of youth reporting peer victimization far exceeds global estimates of 50%.For example, in the Global School-Based Health Survey for Pakistan completed in 2009 by the Ministry of Health in collaboration with the World Health Organization and the CDC, among students in grades 8–10 (slightly older than the youth in our study), overall prevalence of bullying victimization in the past 30 days was 41.3%.When 2,264 adolescents in Malawi were surveyed about bullying in a school health survey, almost equal percentages of boys and girls  reported being bullied.Irrespective of prevalence, all these studies found appreciably higher psychological problems, such as anxiety, worry, and eating and sleeping disorders, among youth reporting victimization. In our study, boys reported appreciably more depression compared with girls as well as higher negative mood and self-esteem scores and more interpersonal and emotional problems. These gender differences and associations with health and functioning will be explored in future papers.The study is designed to evaluate Right To Play's intervention, but we can only test the intervention in one of the many countries in which it is delivered. We cannot generalize our results to the whole of Pakistan, all school grades, or all Right To Play programs. However, the Pakistan program is very large and has been underway for over a decade, and so a rigorous evaluation is timely. This is an effectiveness trial and so we are monitoring fidelity to the intervention and report this information to the implementers, but in other respects we are not able to influence the fidelity of the intervention.Pakistan may be a particularly challenging setting for evaluating Right To Play's intervention. For example, there is a serious problem in Pakistan of children not being able to attend school regularly, which impacts all school-delivered interventions. We ask about attendance in the questionnaire and important reasons for lack of attendance are lack of money for transport and a need for the children to engage in income-generating activities. There are also some difficulties with play-based activities when it is very hot, as for some months of the year it is over 40°C. Lack of food and drinking water for children also influences participation and attendance, and some children, both boys and girls, leave school early due to lack of school toilets. Days are also often lost from school due to severe weather during the monsoon, and there is often a delay in return to school after holidays. There may also be teachers' strikes. These factors will have an impact on the dose of Right To Play intervention that is delivered, and therefore considerable caution will be needed in generalizing from the study findings.Children with disabilities are admitted to special public schools where their physical and/or emotional challenges can be accommodated and therefore are not part of this study. However, to learn if there are children with disabilities in public schools, we will ask in future interviews a series of questions related to disabilities.Our research methodology has limitations that it may under- or overrepresent victimization, perpetration, and the functioning outcomes of the child participants. The questions may miss some episodes of victimization or perpetration and incorrectly classify others, particularly with respect to the 4-week reporting period. Children may not accurately recall the timing and type of victimization or perpetration they experienced . The researchers acknowledge recall bias is operant in all questions.The questionnaire focuses on a small number of measures that we believe can be more accurately recalled and reported by children and more reliably measured. This results in our failing to collect information on other impacts of the intervention. Further, the choice of a 24-month endline prevents us from studying sustainability or attrition of effect post-endline. Finally, our participants were limited to Sindhi and Urdu speakers, although these are the languages of teaching in the participating schools.Despite these limitations, the researchers feel this study provides a framework for understanding impact of the Right To Play intervention and the most detailed and comprehensive data available on the frequency and severity of peer perpetration and victimization of grade-6 male and female children in urban public schools in Pakistan as well as associated gender attitudes and family life.,,Some 89% of 6th-grade youth attending public schools in an urban area of Pakistan reported peer victimization within the last 4 weeks and 75% reported they perpetrated violence within the same time period. Evidence confirms violence against children transfers to poor health and increased mortality in adulthood as well as use of violence against women.Violence against children transfers to poor health and increased mortality in adulthood as well as use of violence against women.More than 1 billion youth, 50% of the world's population, are victimized each year and more than one-third of all adult women experience violence.


Cardiovascular disease (CVD) is the leading cause of death around the world; however, many CVD events could be prevented if we focused on modification of the main risk factors.Increased salt consumption is estimated to have caused millions of deaths, mostly related to CVD, particularly stroke, which is the leading cause of death in Portugal.In our study, we aim to assess trends in the proportion of high blood pressure (HBP) in Acute Coronary Syndrome (ACS) patients as well as the trends in stroke and ACS in Portugal, especially after a set of public health initiatives were implemented to reduce salt intake.The monthly proportion of ACS patients presenting with previously diagnosed HBP and the monthly rate of CVD admissions into public hospitals in Portugal were calculated. CVD rates were stratified into ACS rate and stroke rates. Data were stratified by demographics variables. An interrupted time-series model was used to assess changes over time.Breakpoint analysis revealed an estimated breakpoint around the year 2013 for the proportion of HBP patients, the following year there was a decreasing trend, however it was not significant. Analyses showed the trend before 2013 was increasing and started to decrease after this year. This decreased in proportion of HBP patients can be translated into a reduction of 555 people per year presenting with HBP in the ACS population.We analysed trends for ACS and stroke and tested the significance for a breakpoint in the year 2013. Although none of the remaining trends were significant for ACS crude rates and stroke crude rate, a decreasing trend was observed.This research provides an indication about the impact a population-wide approach to CVD risk factors has on CVD trends themselves. Our results suggest that population-wide approaches can have an impact on the prevention and improvement of CVD control, reducing the number of CVD events, and eventually reducing premature death by CVD. As more restrictions on salt intake are being planned in Portugal in the next years, it is highly relevant to assess what is the current panorama and what further reductions we can expect. Cardiovascular disease (CVD) is the leading cause of death around the world . An estiIn 2010, high blood pressure (HBP) was the leading risk factor contributing to global disease burden, accounting for more than 15% of all health loss in adults , and resImplementing both population-wide and high-risk approaches to reduce blood pressure seems almost inevitable due to the large burden of HBP , 12. EveBy 2010 a set of public health initiatives were implemented in Portugal, namely a reduction in salt added to bread and mandatory salt labelling in pre-packed food. As these initiatives are meant to reduce salt intake we hypothesized that it could lead to a reduction in the proportion of HBP and CVD, namely ACS and stroke. Therefore in our study, we aim to assess the trends in the proportion of HBP in ACS patients, as well as the trends in stroke and ACS in the country, before and after these initiatives were applied. For the sake of clarity in our study we refer as salt for all sodium data.Two population sets were used in this study. Approval to access data was obtained previously. For both sets of data, participants included in the study were over 20 years old.The National Registry of Acute Coronary Syndrome (NRACS) . All datThis dataset has the advantage of being integrated into the Euro Heart Survey platform and, consequently, uses the Cardiology Audit and Registration Data Standards (CARDS) system. This system ensures that credible and comparable information is collected in several European countries over time as they use standardised information, both in terms of the definition and coding of variables, and in the form of measurement and collection of data. As this data is validated and standardised, it can be applied to and used to validate analyses in other larger populations, thus being able to obtain more robust results . HBP in The National database that collects data from all admissions into Portuguese public hospitals . Data from 2002 to 2016 were extracted for our study. This database uses the Diagnosis Related Group (DRG) system holding data on primary diagnosis and some demographic variables, such as sex and age, as well as the geographic region of admission . DRG codThe two datasets were analysed separately as there is no possible method to identify the participants in the dataset, thus the same participant can in fact be registered in both datasets, however as the outcomes studied are independent from each other we do not expect this fact to influence on the validity of the analysis. Similarly the fact that the two datasets used in our study are carefully monitored by the Portuguese Society of Cardiology, in the case of the NRACS, and the Directorate of General Health, in the case of the DRG data, ensures the validity of these data.Two main outcomes were analysed in our study, the monthly proportion of ACS patients presenting with previously diagnosed HBP and the monthly rate of CVD admission into public hospitals in the country. CVD rates were stratified into ACS rate and stroke rates.The proportion of ACS patients with HBP was obtained by dividing the number of monthly HBP diagnoses by the total ACS patients registered for month.We applied an interrupted time series design, implementing a segmented multiple linear regression model, in which the response variable was the monthly the proportion of ACS patients with HBP. These models are useful when the relationship between the response and the independent variables are piecewise linear, namely represented by two or more straight lines connected at unknown values, which are usually referred to as breakpoints. In our case, the breakpoint would be expected for any given year where there was a change in the trend of the proportion of patients with HBP.R “segmented” package was used to determine the presence of any breakpoints in the trends found.Crude event rates for ACS and stroke  were computed for each month, using the population of the country, restricted to the population resident in mainland Portugal, with ages over 20 years as the denominator. Crude rates were calculated as the number of events, for each outcome separately, divided by the Portuguese population for that month.As the effect of this type of population wide approaches might not be immediate , 20, takThe impact of the breakpoint estimated on the CVD trends, was assessed through a multiple linear regression model using standard methods for interrupted time series.We included one dichotomous variable that accounted for the main effect on hospital admissions of the estimated breakpoint for the proportion of HBP patients and an interaction between the breakpoint estimated and time, to evaluate changes over time following the breakpoint.This model was implemented in order to test whether there was a significant change in the number of events, and if there was any change in the proportion of HBP patients was observed.A month indicator covariable was introduced to adjust for seasonality in the outcomes admissions.All analyses were stratified by sex and age. Age was grouped into two categories < 65 and ≥ 65 years old. Autocorrelation between month estimates was incorporated adequately into the model, with the presence of short term autocorrelation applying a first order autoregressive - AR (1) - structure to the residuals. Models were fitted in R version 2.3.2 software.p-values, assuming < 5% as significant and 95% confidence intervals (CI) were calculated for each of the regression coefficients.Statistical significance was assessed through A total of 43,271 ACS events were registered in the NRACS over the last 14 years. The proportion of males presenting with ACS has been consistently higher than women, with around 69% of ACS events occurring in males. Mean age through the years of study has also been fairly steady, ranging from 65 to 66 years old . Analyses showed the trend before 2013 was, in fact, increasing and started to decrease after this year . Although zero is present in the CI for the slope after 2013, the change between both slopes (before and after 2013) is negative with a decrease of − 0.012 in the monthly proportion. Thus, the decrease estimated after 2013 is higher than the increase estimated before 2013. This decrease in proportion can be translated into a reduction of 555 people per year presenting with HBP in the ACS population , and zero was always included in the confidence interval.When further stratified data by sex and age, although no significant trends were observed, a decreasing trend for ACS was found in women but not in men. The largest decrease was found for people over 65 years old for both outcomes. Nevertheless, all these results should be interpreted with caution as none of the coefficients were significant (The seasonal pattern observed for ACS and stroke was consistent with that reported elsewhere , with hiOur results showed increasing trends in the proportion of HBP comorbidity in the ACS population until 2013, the following years the trends appear to decrease. This year was used as a breakpoint to test for differences in trends for ACS and stroke. Decreasing trends for both outcomes were also found, but were not significant.Although our results were not statistically significant, and thus must be interpreted with caution, it is encouraging to find decreasing trends, especially in the proportion of HBP patients in the ACS population, with a reduction of nearly 600 people per year, after the implementation of a major public health measure that was meant to reduce salt intake.Even a small reduction in the proportion of HBP in the ACS population, as the one observed in our study of 555 persons per year achieved through a population-wide approach, can have huge impacts , 23. ThiThe decreasing trend for ACS was observed for women but not in men, in fact salt intake have been previously link to higher risk of CV events in women but not in men , more paAs salt sensitivity is known to be greater in the elderly we hypothesized that if the salt reduction law could have some effect it would be greater for the elderly , 28. In Results from this type of population-wide approach were seen in the UK, where salt reduction campaigns showed significant results, achieving a 15% salt reduction from 2003 to 2011, which translated into about 6000 fewer deaths from CVD, saving about 1.5 billion pounds a year .The decreasing trends for all of our outcomes was not as great as we expected, however the fact that the starting of the decrease takes place after the implementation of these approaches, and the trend of HBP in ACS patients was steadily increasing before that, supports our hypothesis that this approach of reducing salt in bread and making pre-packed salt labelling mandatory can influence HBP prevalence in ACS patients as well as CVD trends.The fact that, salt intake levels have been decreasing in Portugal to the most recent value of 7.3 g/day in 2016  also supIn addition, BP levels have been declining in the Portuguese population, from a mean BP of 134.7/80.5 mmHg in 2003  to a meaFurthermore, several studies showed that bread is one important source of salt in Portugal , and conBesides the legislation in 2010, several initiatives have been carried in Portugal to reduce salt intake, such as: electronic tools, such as websites included in the National Program for the Promotion of Healthy Eating, to free distribution of books and brochures, by the creation of an animated series, and the creation of the National Food, Nutrition and Physical Activity Survey, aiming to collect nationwide data on dietary intake and physical activity .There is already evidence that reducing salt intake could reduce BP in the Portuguese population. One community intervention trial conducted in Portugal demonstrated that reducing salt intake in an entire village, including cooking and processed food, led to a significant reduction in the BP of the population .Policy interventions to reduce national sodium consumption have demonstrated to be highly cost effective in nearly every country in the world. These interventions could reduce millions of disability adjusted life years at low cost and be more cost-effective than pharmacological interventions , 33.Policy and system changes are critical to reduce HBP in populations, including legislation and public education to reduce dietary sodium and food pricing policies, to support prevention and management of CVD .Alternative public health approaches, such as reducing salt in processed foods and bread, and labelling of processed food along with the use of multiple fiscal and educational policies, have already been proposed by the WHO as the first-line approach for CVD reduction, when implemented on a wide scale , 34.In spite of several efforts being made in the country to reduce salt intake, there is still room for improvement, namely in food labelling , adjustiSimpler labelling systems already exist in other countries, such as labels that rely on the use of front-of-pack information such as logos with information on the overall healthiness of the food and traffic light and colour coding systems, which might help citizens make healthier choices. Countries such as Finland and the UK have already implemented some of these labelling systems. In Finland, food products with salt contents below the designated levels display a low-salt label to emphasise their lower-than-conventional salt levels . In the More restrictions are being planned in Portugal to further reduce salt intake, such as a taxes on products with more than 1 g of salt per 100 g of finished product such as: pre-packaged crackers and biscuits; pre-packaged cereal flakes and pressed cereals; and pre-packaged, dehydrated potato chips. A rate of 0.80 Euros per kilogram of finished product will be applied to these products.On the other hand, further reduction of salt content in bread, to a minimum of 1 g per 100 g of final product, was proposed to be achieved by 2020, with continuous reductions each year after 2018.Our study presents encouraging indications suggesting there have been reductions in the proportion of hypertensives among ACS patients after 2013, along with an annual decrease in the rates of ACS and stroke.However, we recognise some limitations of the study. Like any ecological study, it is not possible to prove causal relations, i.e. direct association between the initiatives to reduce salt implement in the country the reduction observed in the proportion of hypertensives ACS patients. However, our methodology was applied, using the same data to analyse the effects of the smoking ban legislation on ACS trends, and a significant reduction was found right after the ban .On the other hand, it might be too soon to notice great effects from salt reduction on CVD trends.The fact that until 2013, the trend for the proportion of hypertensives was continuously increasing, and right after 2013 a decrease in trend can be observed, suggests that the lack of statistical significance could result from the time period being analysed being too short to capture further reductions.Moreover, our study has some strengths, such as the fact that we used two well validated and standardised databases is a major strength as this allows for an easy comparison with other international studies mainly those developed in other European countries. As well as the availability of information on gender and age, this allowed us to assess the robustness of our findings among different subgroups. Also the time series method is preferred over the simpler pre- and post-proportion comparison method that does not take the pre-intervention trend into account, and also allows correction for autocorrelation .In conclusion, the fact that we found decreasing trends for both HBP in ACS patients and CVD outcomes after major initiatives to reduce salt intake were implemented in the country, suggests that this type of approaches, although hard to measure, can impact the trends of major public health outcomes. Thus, this research is relevant to the public health community because it provides an indication about the impact that a population-wide approaches can have on CVD risk factors, and CVD trends themselves. Our results suggest that population-wide approaches can have an impact on the prevention and improvement of CVD control, reducing the number of CVD events and eventually reducing premature death, morbidity, and disability by CVD. Our study also highlights the importance of measuring the impact of these types of initiatives. These findings stress the need for public health policy in CVD to improve the health of populations addressing, in the first place, the well identified risk factors for CVD.Undoubtedly, more studies are needed to assess the impact of such measures, not only for other diseases beside CVD, but also adding more years to the study would allow analysis of long terms effects of the public health initiatives. On the other hand, as more restrictions on salt intake are being planned in Portugal, in the next years it is very relevant to assess what is the current panorama and what further reductions we can expect.


Scomberomorus commerson) caught in the coastal waters of the state of New South Wales (NSW) on the east coast of Australia. Previously, documented cases of CFP in NSW were few, and primarily linked to fish imported from other regions. Since 2015, thirteen individuals were affected across four additional CFP cases in NSW, linked to fish imported from tropical locations. The apparent increase in CFP in NSW from locally sourced catch, combined with the risk of CFP from imported fish, has highlighted several considerations that should be incorporated into risk management strategies to minimize CFP exposure for seafood consumers.Between 2014 and 2016, five cases of ciguatera fish poisoning (CFP), involving twenty four individuals, were linked to Spanish Mackerel ( Gambierdiscus, common in the coastal reef environments of tropical and sub-tropical regions )The risk caused by ciguatoxins is not new. Traditionally, in tropical regions where incidence of CFP is high, there appears to be a general acceptance of the illness and its symptoms . Yet theMore than 90 species of fish have been linked to CFP, most of these species originating from tropical or sub-tropical locations . The NSWThere are insufficient data to determine the prevalence of ciguatoxins and the concentrations at which they pose a problem for human health ,13,38,39For this to happen community awareness of the increasing likelihood of CFP incidents needs to improve. This would include increased awareness that: CFP is not seasonal (illnesses investigated in NSW were reported at different times throughout the year); all age groups can be affected at different degrees of severity depending on consumption factors and each individual consumer’s overall health; and previous exposure to ciguatoxins of an individual can contribute to more severe effects. In addition, Health professionals’ awareness of CFP is key to early diagnosis. Two primary indicators found in the NSW cases were temperature dysesthesia and whether those symptoms were associated with consumption of the head or offal of the fish, particularly if it was cooked in a soup or stew .n = 1) and liver (n = 5) samples from 71 Spanish Mackerel caught in NSW coastal waters [While CFP can be misdiagnosed, potential cases can be identified and sample collection encouraged. One case reported taking samples to a hospital emergency department but these samples were not retained for testing. In addition, sampling could also be improved through innovative approaches to that problem. A recent citizen science driven project detected P-CTX-1B in flesh  in the State’s North . While aWhere the fish was caught;The species of the fish;What symptoms are reported;The concentration and distribution of the toxin in the fish;How the fish was processed and cooked;How the fish was eaten.The nine cases investigated highlighted that both imported fish from tropical locations and Spanish Mackerel caught in NSW are potential causes of CFP for NSW consumers. The investigative approach was the same for either source of fish. The strategies in place to manage ciguatoxin risk are dependent upon accurate information about the nature and extent of the risk. During the investigations, it was apparent that confirmation of diagnosis, fish species and origin was difficult, and often meal samples were not obtainable. Key information to be ascertained from a CFP investigation relates to:CFP is a concern for seafood consumers, industry and regulators. As regulators, the most desirable outcome is to establish a cost effective, reliable, routine test for ciguatoxins to protect both consumers and the seafood industry. In lieu of this, risk management is reliant upon regulators and industry working to improve existing strategies including communication campaigns for consumers, improved catch traceability, improved regulation of high risk catch sites and the support of targeted research to improve testing capabilities.In NSW, surveillance of foodborne illness is monitored by NSW Health and the NSW Food Authority. Nine CFP incidents occurred in NSW between 2014 and 2017. Where possible, each investigation involved a trace-back to supplier and catch locations, interviewing those affected to determine their symptoms, the amount of fish consumed, how the fish was prepared and consumed and whether there was a history of the individual being previously exposed to CFP ,16,17. T


Less than ten years ago, the asbestos industry enjoyed the support of every Quebec and Canadian political party. The Chrysotile Institute and the International Chrysotile Association, both located in Quebec, aggressively marketed asbestos around the world, claiming scientific evidence showed that chrysotile asbestos could be safely used. The industry created a climate of intimidation. Consequently, no groups advocating for victims of asbestos or campaigning for its outright ban existed in Quebec to challenge the industry. A campaign was launched to mobilize the scientific community to speak out. Working with scientists, activists, and asbestos victims around the world, a small group of Quebec scientists exposed the false arguments of the asbestos industry. They publicly and repeatedly challenged the unscientific and unethical asbestos policy of the government. By appealing to Quebec values and holding those in power accountable, the campaign won public support and succeeded against all odds in defeating the asbestos industry. Until recently, Canada was a major producer, exporter and propagandist for the asbestos industry. Other Western countries banned asbestos many years ago, but it was only in December 2016 that the government of Canada finally announced that it would ban asbestos by 2018 [In order to achieve an asbestos ban in Canada, it was critical to understand the political, economic, social, cultural, and historical factors that underlay Canada’s policy of supporting the mining, use, and export of asbestos. A key factor was that Quebec had for more than a century been the heart of the asbestos industry’s power. While asbestos mining had shut down in all other parts of Canada, asbestos mining continued in Quebec and the last two mines operating there—the Jeffery mine in the town of Asbestos and the LAB Chrysotile mine at the town of Thetford Mines—were moving forward in 2012 with plans to expand the mining and export of asbestos for the next twenty years. They had the full support of the Quebec and Canadian governments.In September 2012, a new minority Parti Québécois government was elected in Quebec. It cancelled a $58 million loan that the previous Jean Charest government had given in June 2012 to finance the expansion of the Jeffery mine. Thus, the political and financial support that, for decades, Quebec governments had given to the asbestos industry ended. Both asbestos mines closed down. All mining and export of asbestos ceased.The Quebec asbestos industry had historically enjoyed the support of every political party at the provincial and national level. By the 1980s, in the face of indisputable scientific evidence of asbestos harm and epidemics of asbestos-related deaths in industrialized countries, the asbestos industry faced a crisis. It foresaw that its traditional customers in the West would soon ban or stop buying asbestos.In order to save the asbestos industry, in 1984 the Canadian and Quebec governments, together with the owners of the Quebec asbestos mines and Quebec trade unions, established and financed the Asbestos Institute in Montreal. Its mission was to create new markets for asbestos in developing countries. In 1997, the Asbestos International Association, whose Directors represented asbestos mines in Quebec, Russia, Kazakhstan, Brazil, China, and Zimbabwe, as well as asbestos industrialists in India, Indonesia, Vietnam, Thailand, Sri Lanka, and Mexico, moved from France to Montreal to work hand in hand with the Asbestos Institute. In 2005, in a public relations move to avoid using the word “asbestos”, they changed their names to the Chrysotile Institute and the International Chrysotile Association.Because Canada has a good international reputation and is seen as a scientifically and democratically advanced country, Canada’s image was of enormous value to the global asbestos trade.As stated in the title of a renowned Quebec novel , Canada Until the asbestos industry was defeated in Quebec, there was no possibility of the Canadian government banning asbestos.Key stakeholders who would normally play a leading role in initiating a campaign to ban asbestos are asbestos victims organizations and trade unions. This was not a possibility in Quebec. No asbestos victims organization existed in Quebec nor was there a Canadian asbestos victims organization.The trade unions had joined the asbestos lobby. The most powerful trade union leader in Quebec, Clément Godbout, the former President of the Quebec Federation of Labour, became the President of the Chrysotile Institute and the International Chrysotile Association.The asbestos lobby was aggressive, had financial resources, and had political and social power. A climate of intimidation existed such that no one in Quebec would launch a campaign to ban asbestos. When efforts were made to create an asbestos victims organization and hold a meeting in Thetford Mines in 2008, they were met with ugly insults and threats. Federal, provincial, and local political leaders, together with trade union and business leaders and the asbestos lobby, held a press conference denouncing the “anti-chrysotile militants” and warning them to stay away or be met by a “special reception committee” .The group cancelled its meeting and ended its efforts to create a victims organization.The situation was thus dire. It was urgent to launch a campaign to defeat the asbestos industry. If Jeffery Mine and LAB Chrysotile succeeded with their plans to vastly expand their mining activities and make Quebec the second biggest exporter of asbestos in the world, it would be much more difficult to shut down these mines once workers had been hired and once production and export increased.To succeed, a campaign had to be launched and won in Quebec.A climate of silence and intimidation existed in Quebec regarding asbestos.The two asbestos mines were no longer owned by powerful, distant U.S. and English Canadian corporations, but by local businessmen who lived and worked in the two communities. The workers themselves were co-owners of Jeffrey Mine Inc. through a co-operative which bought 35% of the company shares to rescue the mine from bankruptcy in 2002.Quebec asbestos miners were historically and culturally held in high esteem because of the heroic strike by the miners at the town of Asbestos in 1949 against the U.S. Johns Manville Company that owned the mine. Although the striking miners failed to achieve their demands, the courage displayed by the miners, their wives, and families against appalling exploitation was a turning point in sparking a movement for self-determination, justice, and pride in Quebec [The town of Asbestos was a single industry town that grew up around the asbestos mine. Thetford Mines had succeeded in diversifying its economic base but was still vulnerable. The workers and local political, union, and business leaders were, as they saw it, fighting for their jobs and the survival of their community. It was critical to not disregard the plight of the workers and instead demand that the Canadian and Quebec governments provide funding to allow workers to retire with dignity or transition to other jobs and to launch initiatives for sustainable, economic diversity for a post-asbestos era.The political, economic and social power of the asbestos industry in Quebec was enormous. The asbestos lobby aggressively attacked anyone who opposed asbestos as being a crazy fanatic and being paid by hidden interests. The campaign against the asbestos industry had no financial resources and virtually no support in Quebec when it began.The Canadian and the international asbestos lobby organizations were based in Montreal. They had financial resources, employees, consultants, lawyers, and public relations companies to promote the asbestos trade. They paid scientists large amounts of money to publish distorted research claiming that amphibole asbestos is hazardous but that chrysotile asbestos can be safely used. Chrysotile asbestos is the only kind of asbestos traded in the world today. It represents 95% of all the asbestos sold over the past century. This false “safe use of chrysotile argument”, created in Quebec, is still today the major weapon used by the asbestos industry to market asbestos and to maintain its profits at the expense of human life.Among the difficult challenges to be addressed were the following:In order for French language and culture to survive while surrounded by an ocean of English power, a particular sense of solidarity and social justice has taken root in Quebec.Scientists and academics in Quebec take pride in believing that their work and their institutions meet first class standards and deserve international respect.Some political parties, some individual politicians, some trade union organizations, and some individual trade union leaders were publicly committed to progressive ideals of international solidarity, human rights, scientific integrity, and worker health. If publicly challenged, it would be difficult for them to justify why they were supporting the export of asbestos overseas, why they were being complicit with deadly, corrupt scientific arguments, why they were rejecting the appeals of the world trade union movement, and why they were betraying their commitment to social justice.Many journalists and media outlets in Quebec take pride in doing quality journalism. If clear evidence was put before them, showing that the information the government and the asbestos industry were putting forward was false, there was the possibility of getting media coverage to expose the wrongdoing and winning public support. Of particular interest to the media and to the Quebec public would be if Quebec was receiving international attention and its conduct internationally condemned.Because of Quebec’s historical experience of political, linguistic, cultural, and religious oppression and discrimination, the issue of Quebec identity and national pride and the enjoyment of international respect have a particular resonance.The key power of the Quebec asbestos industry lay in the fact that it had taken control over the scientific message. It claimed to be playing a positive role in helping developing countries by promoting “the safe, controlled use of chrysotile” and supplying a valuable product. The vast majority of the Quebec population had no understanding of the scientific evidence on chrysotile asbestos. It was therefore easy to create confusion and doubt. The asbestos lobby published glossy propaganda, bearing the official emblems of the governments of Canada and Quebec, stating that “recent scientific studies” demonstrated that chrysotile was not hazardous . They diIt was essential to challenge the misinformation disseminated by the asbestos industry, which was the foundation of its success. It is almost always more effective to challenge an issue when there is a concrete, real life event occurring, rather than putting forward a general, abstract challenge. Such a real life event was about to occur.In 2006, the Canadian government played the leading role in opposing the listing of chrysotile asbestos as a hazardous substance under the United Nations (UN) Rotterdam Convention. The Convention does not impose a ban; it simply requires exporting countries to obtain Prior Informed Consent from any country to which they wish to export the hazardous substance.The next meeting of the Rotterdam Convention was to take place in September 2008. This presented an opportunity to put the spotlight on the scientifically and morally indefensible role Canada was playing in sabotaging the recommendation of the Convention’s expert scientific body to put chrysotile asbestos on the Convention’s list of hazardous chemicals.World Call of Conscience to Canada’s Prime Minister Stephen Harper to Stop Obstructing the Rotterdam Convention [Call of Conscience stated that Canada’s sabotage of a basic human right provided by the Convention was endangering the Convention, was contrary to Canadian values, and constituted an ugly smear on Canada’s international reputation.In the lead-up to the meeting, an internet advocacy organization based in British Columbia, RightOnCanada.ca, drafted in French and English a nvention . The CalCall of Conscience were twenty-six health experts from Quebec universities, the city of Montreal’s health authority, and Quebec government health institutions. The President of Quebec’s leading human rights organization, La Ligue des droits et libertés, was also a signer.Efforts had been made to reach out to scientists in Quebec. Consequently, among the well over one hundred scientists from around the world who signed the Thus, the climate of silence and intimidation in Quebec was cracked open. Quebec scientists, as well as a Quebec human rights leader, had publicly challenged the Canadian government’s asbestos policy at the UN. The scientific expertise and status of the signers of the letter made it impossible for the asbestos lobby to attack the signers as crazy, ignorant fanatics.World Call of Conscience received much media attention. The Chrysotile Institute lobbied hard to persuade the Canadian government to once again play the lead role in opposing the listing of chrysotile asbestos at the 2008 Rotterdam Convention Conference of the Parties. Instead, the Canadian government was silent and refused to answer any media questions, thus losing credibility.The The letter was a first, brave step by Quebec health scientists to publicly challenge the government’s asbestos policy. The Statement appealed to scientific integrity, human solidarity, and international reputation—values that had a particular resonance in Quebec.The next action was again to challenge a concrete, current event—the $750,000 funding the Canadian government had announced it would give to the Chrysotile Institute. The Conservative government of Prime Minister Harper was particularly vulnerable on this issue as it promoted an ideological belief in free enterprise capitalism, which opposed government subsidies to industry lobby organizations.In January 2009, two Quebec health experts, together with five English Canada signers, sent a letter to Prime Minister Harper, calling on him to cancel the $750,000 funding for the Chrysotile Institute [The letter received wide media coverage. It was a shock to the Chrysotile Institute, the government, and the Quebec public that Quebec health experts were leading an attack on the Chrysotile Institute. Neither Prime Minister Harper nor the Chrysotile Institute were able to defend the scientific and moral wrongdoing the letter documented. Both suffered a serious blow in the court of public opinion.The momentum grew in September 2009, when fifteen prominent scientists from Quebec universities and health institutions published an Open Statement in La Presse, Quebec’s biggest circulation newspaper, challenging the Quebec government to respect scientific evidence, respect the lives of workers overseas, and stop mining and exporting asbestos . The StaThis marked a pivotal turning point. The asbestos industry’s claim that scientific evidence supported the “safe use” of chrysotile asbestos had been exposed as false in the most public way possible by Quebec’s own health experts. The scientists’ arguments focused on scientific integrity and human solidarity. “This infamy is no longer defensible”, said the scientists. “It is time to align ourselves with the truth”.For the first time, the people of Quebec were challenged by respected Quebec figures to act truthfully and honorably and stop Quebec’s mining and export of asbestos.The asbestos lobby had money, lawyers, public relations consultants, and political influence. The health experts who spoke up had none of these. Instead, they demonstrated integrity and courage in speaking truth to power. Their appeal resonated with Quebec values and culture. In the arena of public opinion, they brought a credibility that no money can buy.Over and over again, the campaign mobilized scientists to speak up to and call for public policy to be based on independent, reputable scientific evidence and to protect human life. This was not done in an abstract way but by engaging in real issues, naming names and holding people accountable.When the government of Quebec held parliamentary hearings on Quebec’s mining legislation, Quebec health experts gave a powerful presentation, stating that Quebec’s export of asbestos brought dishonour to Quebec and must stop .A complaint was submitted to the Quebec College of Physicians that Quebec’s Minister of Health, Yv Bolduc, was violating his Code of Ethics as a medical doctor in supporting the use of chrysotile asbestos .When Radio-Canada, Quebec’s public broadcasting commission, provided biased, inaccurate coverage of the asbestos issue, complaints were submitted to Radio-Canada’s Ombudsman. The complaints were upheld. Journalists who put forward asbestos industry misinformation learned they would be challenged and publicly discredited.The small group of scientists who first broke the silence and challenged the asbestos industry gradually won the support of other professional bodies. The Quebec Medical Association, the Quebec Association for Public Health, the Quebec Cancer Society, the Quebec Association of Physicians specializing in Community Health, the Lung Association of Quebec, the Quebec Association for Occupational Hygiene, Health & Safety, and the Quebec College of Family Physicians all now called publicly for an asbestos ban. Not a single health organization or reputable scientist supported the asbestos industry.In an extraordinary act of leadership, all sixteen of the Quebec government’s Directors of Public Health sent a letter stating that, if the government gave the $58 million loan to the Jeffery mine, the subsequent expansion of mining and use of chrysotile asbestos in Quebec would result in an increase in asbestos-related diseases among workers and the general population, creating social and financial costs. The Directors issued a press release and posted their letter on the Quebec government website ,12.The challenge of the asbestos industry was done in a public and transparent manner. Intense, prolonged media coverage put a spotlight on the asbestos industry. Sunlight is a powerful disinfectant. It became clear that the arguments of the asbestos industry lacked credibility and were rejected as nonsense by the scientific community. The industry’s use of ugly insults, calling the government health scientists “a little band of Taliban”, and calling those who opposed the asbestos industry corrupt liars no longer succeeded in intimidating anyone and was recognized as dirty tactics of a desperate, discredited industry.Editorial after editorial was published in Quebec condemning the asbestos industry and calling on the government to stop supporting it.In December 2009, Quebec and Canadian health experts, together with leading environmental and health organizations, including the Canadian Cancer Society, wrote a letter challenging Canada’s Minister of Health, Leona Aglukkaq, to respect scientific evidence, fulfill her duty to protect the health of Canadians and support a ban on asbestos .Criticism of asbestos has “been a taboo for quite a while in Quebec. We’re trying to break that”, stated Pierre Gosselin, professor in the faculty of medicine at Laval University and a researcher at the National Public Health Institute of Quebec, who signed the letter. This was the first time a federal health minister had been asked to take action on asbestos, and her reaction will be seen as a litmus test for her support of public health measures, the health experts told the media.The Minister refused to meet the health experts and could not answer their damning evidence. She was publicly exposed as failing to fulfill her duty to protect health.In January 2010, scientists around the world wrote to Quebec Premier Charest challenging Quebec to stop mining and exporting asbestos . The letCharest was at the time embarking on a trade mission to India, accompanied by Quebec asbestos exporter, Baljit Singh Chadha, and by Normand Paulin, Quebec’s Director of Occupational Safety.In India, asbestos victims, trade unionists, and health activists asked Charest to meet with them and learn directly about how Quebec asbestos was harming workers, their families, and communities in India. Charest refused a meeting, but the Quebec journalists accompanying Charest met with the asbestos victims. Trade unionists and activists met with Paulin, informed him how “safe use” of chrysotile asbestos was impossible to practice in India and called on him to act ethically and stop supporting the export of asbestos to India.The appeals of the Indian asbestos victims, trade unionists, and activists for Quebec to stop exporting asbestos and harming the lives of populations overseas received major coverage on Quebec television, radio, and print media, as did the challenge of Premier Charest by the international scientific community.The Quebec population thus received a powerful message that the international scientific community condemned Quebec’s export of asbestos as bringing dishonour on Quebec worldwide. The coverage of the protests by asbestos victims and activists in India brought home the reality of the human suffering being caused by asbestos. This coverage had a major impact on public opinion.Challenges were not only made to the Quebec and Canadian governments but were repeatedly made to every Quebec and federal political party. Parties that expressed commitment to social justice and international solidarity were challenged to demonstrate these values by ending their support of the asbestos industry. As a result, in April 2009, Canada’s left-wing political party, the New Democratic Party, called for an end to asbestos mining and export, the first political party in the House of Commons to do so. In February 2010, Amir Khadir, the leader of Quebec Solidaire, called for the mining and export of asbestos to stop, the first political party in the Quebec National Assembly to do so.Little by little, as a result of continuous, very public advocacy actions and growing public opposition to asbestos export, other political parties at first split on the issue and then eventually came on side to support banning asbestos. Finally, by 2012, the Conservative party in Ottawa and the Liberal party in Quebec were isolated as the only political parties supporting the asbestos industry. Each had a vested interest in supporting the asbestos industry. Charest represented the asbestos mining region. Harper was ideologically dedicated to mining interests. Unfortunately, these two political parties were the governments in power in Quebec and Canada.In December 2010 a delegation from Asia of asbestos victims, health activists and a trade unionist came to Quebec to make a direct appeal to Quebec to reject the proposal to give the asbestos industry a $58 million government loan to allow it to vastly expand its mining and export of asbestos for the next two decades.Supported by the leader of Québec Solidaire and a New Democratic Party Member of Parliament, as well as Quebec health experts, the delegation held press conferences in the Quebec National Assembly and the House of Commons. They met with political and union leaders, did media interviews, and held public events. Together with Quebec human rights and health activists, they held a demonstration outside the office of Premier Jean Charest.The Solidarity delegation brought a powerful human message to Quebec. The fact that the delegation was working together with Quebec political, health, and human rights leaders was an inspiring example of international solidarity.On the scientific and human level, the asbestos industry was increasingly discredited and losing the battle for public support.A public opinion poll, commissioned in January 2011 by the Canadian Association of Physicians for the Environment, showed that 76 percent of Quebecers opposed government financing of the Jeffrey mine.In March 2011, for the first time, a Quebec trade union confederation (CNTU) stopped supporting the asbestos industry. The monopoly of power that the asbestos industry had held for so long over political parties, unions, and the media was finally being broken.By early 2012, in the face of public pressure, the Canadian government ended its 24 years of financing the Chrysotile Institute. Without government support, the Institute closed down.On Friday, 29 June 2012, just before a special long holiday weekend and just two months before a provincial election, the Charest government gave a $58 million loan to the Jeffrey mine. While the government tried to bury the news, it was met with a storm of protest . The asbJust days before the election, the Parti Québécois announced that, if it was elected, it would cancel the loan . The parIn October 2015, after almost ten years in power, the Conservative government of Stephen Harper was defeated and the Liberal Party of Justin Trudeau took power. The asbestos industry was now closed down in Quebec, and political and public attitudes in Quebec had completely turned around on the asbestos issue. In June 2016, all four political parties in the Quebec National Assembly supported a motion awarding the medal of the Quebec National Assembly to Kathleen Ruff to honour the campaign that had been carried out to end asbestos mining in Quebec, ban asbestos, and protect the health of workers and Quebec citizens .In December 2016, the Trudeau federal government announced that it will pass legislation to ban asbestos by 2018 and will hold consultations to develop effective regulations and implementation.It was important to understand the political and social foundation of the asbestos industry’s power in order to challenge it effectively. This required winning the battle of public opinion in Quebec. The campaign was fought in as open and public a way as possible. Every opportunity was seized to get media coverage and reach the minds and the hearts of the public.The campaign was based on sound scientific evidence, but putting forward evidence in a general way is not sufficient. It was critical to carry out repeated advocacy actions that put a spotlight on concrete, current events that drew public attention, that resonated with Quebec values, and that held those who possessed political and social power publicly accountable.The asbestos industry and its key supporters, such as Premier Charest and Prime Minister Harper, would likely have never changed. This is the same in most struggles for social justice. The key wrongdoers rarely abandon their vested interests. However, unless it is a dictatorship, the wrongdoers depend on social complicity. Enormous wrongdoing succeeds only when societies permit it by their silence.Wrongdoing is enabled, in particular, by those who have a responsibility to defend the public good but fail to do so. By turning a blind eye, they hide the wrongdoing. The campaign did not allow leading figures to hide. It put the spotlight on political leaders, union leaders, prestigious health organizations, top public servants responsible for health, Quebec’s top two English-speaking universities, journalists, academics, and students. It challenged them to stop being complicit with wrongdoing and to speak out publicly to condemn the scientific deception and human harm caused by the asbestos industry.Many showed courage and integrity and stopped being complicit. Starting with just a small number—a tiny handful of scientists, just one or two academics, just one political leader, just one union leader, just one journalist—they started a movement that became unstoppable.Again and again, we see how vested interests—whether asbestos, tobacco, the fossil fuel industry, hazardous chemicals, the sugar industry—distort scientific evidence and corrupt public policy so that it serves industry profits instead of the public good. Industry lobby groups aggressively attempt to intimidate and silence independent scientists whose work is inconvenient for industry profits.It is essential that scientists not be silenced and fulfill their responsibility to defend scientific integrity and evidence-based public policy.The asbestos battle in Quebec demonstrates how a determined advocacy campaign involving international solidarity, the scientific community, activists, and asbestos victims succeeded, against all odds, in defeating the asbestos industry and changing public health policy in Quebec and Canada. As a result, instead of the planned expansion of asbestos mining and export, Canada is now in the process of legislating a ban on the mining, use, and export of asbestos. Instead of being a propagandist for the asbestos industry, Canada is now an ally in efforts to achieve a global asbestos ban.


President Reagan outlined a new Superconductivity Initiative at the Federal Conference on Commercial Applications of Superconductivity, Washington, DC, July 28–29, 1987. The primary purpose of this conference was to stimulate commercial enterprise in high-temperature superconductor technology. Various sessions summarized the scientific facts so far as they are known, described the existing superconductor technology and attempted to draw lessons from it, speculated on the possible scope of the new technology and the problems to be solved before it can be realized, and displayed the technical resources of the Federal laboratories and the ways by which entrepreneurs might avail themselves of them. The conference received top-level political attention: it was organized by Dr. William Graham, the President’s Science Advisor, and President Reagan himself gave a speech. The attendance was about 1500 people, including representatives of many Federal laboratories, universities, manufacturing companies, and a large number of consulting and market research companies.The conference opened with a session in which Angelica Stacy (UC Berkeley), Paul Chu (Univ. Houston) and Robert Schrieffer (UC Santa Barbara) told the now-familiar story of the processing, structure, characteristics, and theory of the new ceramic superconductors. They were followed by Sadeg Faris (Hypres) and Sibley Burnett (GA Technology), who described their experiences in bringing products of the “old” superconductor technology to market: a fast sampling oscilloscope and magnets for a magnetic resonance imaging system, respectively. They had shown in their own ways that it really can be done.President Reagan then gave the keynote address. He started by announcing some new progress in the nuclear arms negotiations in Geneva. Then he warmed to the subject of superconductivity, with apt quotations from Benjamin Franklin and Thomas Jefferson. He concluded by outlining the Administration’s Superconductivity Initiative. This includes modifications to the anti-trust laws, the patent laws, and the Freedom of Information Act, the establishment of four Superconductivity Research Centers (three at DoE laboratories and one at NBS-Boulder), and directions to various Federal scientific laboratories to increase their efforts in superconductivity. After his speech, the President toured the exhibits and the conference adjourned for lunch, at which Clayton Yeutter, the U.S. Trade Representative, gave a speech emphasizing the highly competitive nature of the potential international market and the formidable challenge from Japan.The conference then turned to speculation about possible directions that the new superconductor technology might take. Theodore VanDuzer (UC Berkeley) gave a tutorial on the Josephson effect and other aspects of superconducting electronics. Fernand Bedard (NSA) then took up the theme of speculating about the future. He started from the notion that those who ignore history are condemned to repeat it, and reviewed the successes and failures of the past and the lessons that could be learned from them. He saw particular promise in a hybrid superconductor/semiconductor technology: a computer might combine the advantages of superconductor logic and transmission lines with the more established technology of semiconductor cache memory, for example.Speculation on applications to transportation and electric power were then taken up by Craig Davis (Ford) and Narain Hingorani (EPRI), respectively. The two unfinished technologies in transportation are electric cars and magnetically levitated trains. Mr. Davis showed that even high temperature superconductors could not be expected to do much for electric cars, but felt there is more promise in magnetic levitation. In electric power systems, magnetic energy storage, underground transmission, and MHD generation all deserve careful consideration. To end the first day, Roland Schmitt (GE) and Mark Rochkind (Philips) reviewed activities in high temperature superconductor research in Japan and Western Europe.The second day opened with descriptions of two superconductor systems that are already established as medical diagnostic tools and could derive quick benefit from a high temperature superconductor technology. Sam Williamson (NYU) described remarkable achievements of magnetoencephalography, at first in medical research and more recently in diagnosis. He suggested that in the future people may want routine brain checks as part of their physical examinations. Then John Stekley (IGC) described magnetic resonance imaging, with examples of what it can now do.3 substrates, which are not compatible with semiconductor technology; they must be heat treated at 900°, which would destroy any nonrefractory layer in a circuit; and they are chemically very active, which will severely restrict the options for lithography. For large scale applications the present critical current density in the presence of even quite modest magnetic fields is too low by several orders of magnitude; the materials are too weak mechanically to sustain the stress from the Lorentz force; and the problem of electrodynamic stability is as yet completely unexplored. These problems are probably all soluble, but on a time scale of years, not months.After this glimpse of what is possible, John Rowell (Bell Comm) and John Hulm (Westinghouse) reminded the audience of some of the major problems that must be solved before we can realize that possibility. For all the talk of Josephson junctions, microstrip transmission lines and hybrid superconductor/semiconductor circuits, YBCO films as we know them are incompatible with microcircuit processing as we know it. They have been successful only on SrTiOThe Federal science laboratories are clearly a great national asset in getting a commercial superconductor technology launched. Eugene McAllister (White House) and Herman Postma (ORNC) discussed all the ways in which they are accessible to private companies. The desire of the Administration is to have private industry control the development of the new commercial technology, guided by market forces, and to use the resources of the Federal laboratories to the greatest possible extent.The formal sessions of the conference closed with an address by John Herrington, Secretary of Energy. In the afternoon there were workshop sessions for informal discussion of the topics raised at the conference. There were sessions on industrial collaboration; access to Federal laboratories; finances, venture capital and small business; advances in the science of superconductivity; and industry/university/government cooperation. With these the conference ended on the optimistic note that the present administration considers the development of a commercial superconductor technology as being a test of the ability of the U.S. free-enterprise system to compete with other nations where the government plays a more active role in commercial affairs.