Violence against sex workers can heighten their vulnerability to HIV and other sexually transmitted infections (STIs). Evidence suggests the risk of acquiring STI/HIV infections among female sex workers (FSWs) who have experienced violence to be almost three-times higher than FSWs, who have not experienced violence. Moreover, an experience of physical and sexual violence makes it difficult for them to negotiate safer sex with their partners and often act as a barrier to utilization of prevention services.This study utilizes data from 2785 FSWs aged 18 years and above who participated in a cross-sectional behavioural study conducted during 2013–14 in Thane district, Maharashtra. A probability-based two-stage cluster sampling method was used for data collection. This study assesses the effect of physical violence on self-reported STI symptoms (any STI and multiple STIs) and treatment seeking for the last STI symptom using propensity score matching method.About 18% of sampled FSWs reported physical violence at the time of the survey. The likelihood of experiencing such violence was significantly higher among FSWs who solicited clients at public places, engaged in other economic activities apart from sex work, had savings, and reported high client volume per week. FSWs experiencing violence were also inconsistent condom users while engaging in sex with regular partners and clients. The average adjusted effect of violence clearly depicted an increase in the risk of any STI  and multiple STIs  and reduction in treatment seeking .This study demonstrates a significant effect of physical violence on reporting of any STI symptom and treatment seeking. Findings call for the immediate inclusion of strategies aimed to address violence related challenges in HIV prevention program currently being provided at Thane district. Such strategies would further help in enhancing the access to tailored STI prevention and care services among FSWs in the district. Globally about 1.5 million people died from HIV/AIDS-related causes, and nearly 2.1 million new infections detected by the end of the year 2013. among alWorldwide, sex work has been considered as a primordial and widespread profession among females and there is a presence of about 40 million FSWs, including an estimated 870,000 FSWs in India., 7 Indiamadams (brothel owners) and police.[FSWs in India have experienced high levels of physical and sexual violence from clients, d police. Recent ed police. However,d police. Evidenced police.–13 Moreod police. Existingd police., 14–17madams and pimps (broker) for safer sex, and thus leads to higher chances of STI/HIV among them.[Violence against women can heighten their vulnerability to HIV and other sexually transmitted infections (STIs).–21 The rong them. Studies ong them.–28Maharashtra state, in western India, has a population of approximately 110 million and ranks among the top four state in India with regard to HIV epidemic severity with an estimated HIV/AIDS prevalence of 0.42% among general population , rates among FSWs have reached 6.89% by the year 2012. The DistThe HIV/AIDS Partnership: Impact through Prevention, Private Sector and Evidence-based Programming (PIPPSE) project, supported by United States Agency for International Development (USAID), is working since 2012 to deliver targeted HIV prevention intervention programs under District Network Model (DNM) in Thane District with active support from Maharashtra State AIDS Control Society, Government of Maharashtra., 32 FSWsConsidering potential adverse effects of physical violence on health status of FSWs, this paper aims at examining the net (true) effect of violence on the self-reported STIs and the treatment seeking behaviour among FSWs in Thane district. We investigate the extent to which the net difference observed in the outcome between treated and untreated groups of FSWs, i.e. those experienced violence versus those who did not, could be attributed to violence given that the potential covariates are matched appropriately. In the absence of information on sexual violence from the survey, only the effect of physical violence has been discussed in this paper.madam and bar owners after explaining the purpose of the study. FSWs were free to decline to participate in the study or not to answer questions they were not comfortable. No monetary incentive was provided to the respondents. FSWs in need of care were referred to the nearest health facility for the necessary treatment.The data used for the study comes from a site assessment survey conducted to gain the details on risks and vulnerabilities of FSWs by their location and typology covered under each FSW TI NGOs implementing the HIV prevention intervention program in the Thane District. According to the targeted intervention strategy of National AIDS Control and Prevention (NACP) program in India, each NGO implementing the TI programme are mandated to conduct this assessment before rolling out the intervention. This assessment helps to the TI NGOs in validating the broad mapping estimate and help them in understanding the details on prevailing HIV related risks and vulnerabilities of high-risk population in their intervention geography. The assessment instruments and methodology followed the similar guideline as described in the National Operational Guidelines for Targeted Intervention. No separate ethical approval was sought. However, written informed consent was obtained from each participant before initiating any discussion. Confidentiality and anonymity were strictly maintained. Before the interview of the brothel and bar based study participants, permission was obtained from the brothel The present study utilizes data from a cross-sectional behavioural site assessment carried out during 2013–14 in the Thane district. This study assesses factors that elevate the HIV-related risks and vulnerabilities among FSWs, identify their HIV-related needs and implementation gaps in the existing HIV interventions.Any female, 18 years or older who sold sex in exchange for cash at least once in the last one month was as an eligible FSWs for this assessment study. A probability-based two-stage cluster sampling method was used. At the first-stage, selection of sites was done using conventional cluster sampling for stable populations and conventional time-location cluster sampling for the mobile population. Stable population includes FSWs based at home, brothels, lodges, and Dhaba’s (road-side eating or drinking establishments), and the mobile population includes street-based FSWs. The respondents were selected systematically within each site, at the second stage. The overall sample selection was proportionally allocated to estimated proportion of sex workers of each typology in the district. The methodology was almost on the similar line as used in earlier bio-behavioural studies conducted among HRGs in southern states of India. The detailed sampling strategy for the previous bio-behavioural studies described elsewhere –37.In this survey a total of 3,200 FSWs approached and 2,785 completed the behavioural interview with a response rate of 87%. These FSWs belonged to 11 Targeted Intervention (TI) NGOs implementing HIV-prevention program and geographically spread across the Thane district. The FSWs were interviewed face-to-face using pretested structured questionnaire by the trained staff of the TI NGO, who were part of the local community, t in a private setting away from the solicitation site. Interviews were conducted either in Hindi or local language that respondents speak or understand.We used three outcomes variables, self-reported any STI symptoms, self-reported multiple STI symptoms, and STI treatment seeking behaviour defined as:Since biological samples (blood and urine) were not collected to test for syphilis or chlamydia infection, we considered any self-reported STI symptoms as the first outcome variable measuring risk behaviour among FSWs. Participants were enquired about suffering from any STI symptoms in the 12 months preceding the survey. The response categories for the above question were: genital/vaginal discharge, genital sore/ulcer, lower abdominal pain, burning sensation while urination, swelling in groin area, itching in genital areas, and pain during sexual intercourse. FSWs who reported any STI symptoms in 12 months preceding the survey were considered as ‘reporting any STI symptoms’.Participants suffering from more than one STI symptoms in 12 months period preceding the survey were considered as ‘reporting multiple STI symptoms’. FSWs reporting multiple STI symptoms were considered as having higher risk profile than those who suffered from a single episode.The third outcome variable of interest was treatment seeking behaviour for the last STI symptoms they had in 12 months preceding the survey. Participants sought treatment/medicine/advice for the last STI symptom from government or private hospitals/clinics, traditional healers, medical shops or through the help of NGO-run-clinics were categorized as treated for STIs whereas participants did not obtain any treatment, took home based remedy or the medicine that they had at home, and just consulted with their friends or relatives were clubbed into another group, i.e., not treated for STIs.goons , police, and others was the primary exposure variable of our interest. The questionnaire contained following question about violence: “In the past twelve months, have you ever been harassed or beaten up by regular partner/husband, clients, local leaders, police and local goons. Those who said yes were probed about the number of times each of these persons beat them. These two variables were used to compute an indicator of FSWs’ exposure to physical violence.An experience of physical violence at the hands of intimate partners, regular clients or the occasional clients including the stranger, local We explored the extent of similarities and differences between FSWs, who experienced physical violence versus those who did not, with regard to a number of background variables likely to influence exposure and outcome variables of interest. Background variables fell into three broad categories: socio-demographic, economic, and sex work related characteristics. Socio-demographic and economic variables included age of respondents, marital status , literacy status , current residence in the form of whether they belong to place of interview  or not , co-residents , and alcohol use . Two variables on economic status of respondents includes source of income other than sex work , and any savings .In order to assess the differential in experience of violence by sex work-related characteristics, we included variables representing age at first sex , duration of sex work , place of solicitation , weekly client volume , have a regular partner such as husband/boyfriend/lover, and exposure to any HIV prevention intervention . Other than these, two indicators on condom use, representing the sex work characteristics, were also included in the study. These were consistent condom use with regular partners and consistent condom use with regular/occasional clients.https://www.census.gov/population/international/software/cspro) software. All data were double entered to make it free of error at the data entry level. All statistical analyses were performed using the STATA version 12.0.[The customized database was prepared for the study using the Census and Survey Processing System version 4.1  method to examine the net effect of violence on STI prevalence (self-reported) and treatment seeking behaviour among FSWs. This approach allows assessing the true effect of exposure on desired outcomes through cross-sectional survey data.–42 PSM mPSM generates a set of “control” cases  corresponding to “treatment” cases  by matching a set of observational characteristics of respondents in treatment and control groups- in the form of predicted probabilities (propensity score)- estimated through logistic regression analysis. The fundamental assumptions of this approach are: i). Conditional on the propensity score, assignment to the treatment and control groups can be taken to be random, and ii). For each value of the covariate, there is a definite probability of being falling into treatment or control group (assumption of common support condition). If these assumptions are satisfied then the differences in outcomes between treatment and control groups can be directly compared to estimate the effect of “treatment”, known as treatment effect of treated (ATT)., 46 AddiThe radius caliper method with replacement was used for matching purpose. This matching approach uses all the possible comparison group members within the maximum distance from caliper to reduces the risk of using poor matches. To improOf 2,785 FSWs interviewed, little less than one-fifth of them (18%) experienced physical violence perpetrated by their regular partners (husband/boyfriend/lover) or their regular/occasional clients . While nDifferential in socio-demographic, economic and sex work related characteristics of FSWs by the experience of physical violence are presented in Differentials in sex work characteristics of FSWs by their violence experiences suggest that reporting of physical violence was comparatively higher among FSWs, who had entry into sex work at relatively later age (15 or above). In addition to that, significantly larger proportion of FSWs among those experienced physical violence were found to be soliciting for their clients in public places (34%), had 10 or more clients per week (22%), and reported having a non-paying regular partner (70%) than their respective counterparts who had not experienced physical violence either by their regular partners or occasional/regular clients. Corresponding estimates were 16% for place of solicitation and weekly client volume. About 53% FSWs who did not experience physical reported to have a regular partner at the time of survey . FindingThe proportion of FSWs reported STIs and seeking behaviour by their experiences of violence is presented in The study estimates the effect of physical violence on self-reported any STI symptom, multiple STI symptoms and treatment seeking behaviour among FSWs by the estimated difference in the outcomes, between the treated  and the matched control  groups using matching analysis. As mentioned before, due to its’ computing strengths, this method allows to analyze the actual impact of the treatment on outcomes very precisely. The potential effect of violence on the group of FSWs who did not experience violence, i.e., if they would have experience such violence what would be the effect on the outcomes, is also presented. The adjusted treatment effect of treated (ATT), i.e., effect of violence on the FSWs who experienced the same, demonstrated an increase in the risk of any STI by 11% (p<0.05), and on multiple STIs by 7.5% (p<0.10) whereas reduction in chances of obtaining the treatment by 10.3% (p<0.05). When we compared the average treatment effect on treated (ATT) and average treatment effect on untreated (ATU) , consideThe critical step in using matching methods is to diagnose the quality of the resulting matched samples. The quality of results was assessed on the five parameters, namely, common support (% of variables discarded due to unavailability of matched sample), balancing test (comparison of significance of mean differences between unmatched and matched sample before and after treatment), identification of substantial overlap of the propensity score distributions in the two groups (treated and control) mostly presented through bar diagram, assessment of the covariate balance in the matched groups, and assessment of overall significance of the model by comparing the significance of pseudo- R2 between treated and untreated groups., 50–522. [2 had become insignificant, indicating the fact that there is no systematic difference in the distribution of covariates between treated and untreated groups.To demonstrate the extent of overlap of the propensity score distributions in the two groups, a bar diagram above and below the lines (x-axis) shows the propensity score for treated and untreated FSWs, respectively . This gr2.  Table 6 This study aims to estimate the extent of violence faced by the FSWs and the differential in the characteristics of women experiencing violence as compared to those who did not report violence in Thane District. The study also attempts to comprehend the linkages between violence, self-reported STI symptoms, and treatment seeking behaviour by comparing the experiences of two groups of FSWs. Though, in the Indian context, evidence on this issue is fairly available, due to methodological limitations they often failed to estimate precisely the net effect of violence on desired STI-related outcomes. The robust matching approach was adopted to assess the impact of violence on STI and treatment seeking among FSWs in the intervention district (Thane) from where evidence on this issue is rarely available. Below sections present a detailed discussion of the study findings.This study demonstrated an association between physical violence and demographic indicators for FSWs. The FSWs, who reported a source of income other than sex work and had savings, were more likely to report the experience of violence. A randomized control trial among FSWs in Mongolia demonstrated how high levels of financial responsibility and limited bargaining power increase the risk for physical violence, and HIV/STIs. Study figoons, pimps and the police, who were the main perpetrators of violence.[Our study findings elucidate that those FSWs who solicit the clients from public places were more vulnerable to experience physical violence than those of their counterparts . Aastha programme, implemented in Thane during 2004–2009, also found that FSWs, who were soliciting sex with the clients at streets, were found to be more vulnerable to physical violence than the FSWs of other typologies. Street based FSWs mainly belonged to the lowest socio-economic strata and was at the mercy of local violence. Moreoverviolence., 56 Dataviolence.Research from India and South Africa demonstrated a strong relationship between intimate partner violence and women’s risk of contracting STI/HIV., 57, 58 Our findings also corroborate with above results that found associations between being a victim of violence and non-condom use; which could be related to women’s inability to negotiate safe sex with clients or regular partners leading to increased chances of experiencing STI and HIV. , 61–63 TWe acknowledge that, although, we made considerable efforts to analyze the relationship between violence and STI related outcomes of interest for a major geographic region of India carrying a significant potential risk of HIV spread; our study does have certain limitations. For example, while an attempt was made to ensure, as far as possible in a cross-sectional study, appropriate temporal ordering, we acknowledge its limitations in asserting causality. There is a need for more longitudinal studies or, at least, cross-sectional studies that are better equipped to provide histories of both violence as well as STI-related outcomes. Second, there might be under-reporting of physical violence, especially those perpetrated by the regular partners. Besides these, the information on sexual violence was not collected in the study. Therefore, the study could not demonstrate the overall level of violence among the FSWs in Thane district. As sexual violence has a relatively larger direct effect on the prevalence of STI, mostly through forced sex. The relaViolence has immediate effects on women’s health, which in some cases, could even be fatal. Physical and mental health consequences can also have a sustained effect even after the violence has stopped. The resuS1 Doc(PDF)Click here for additional data file.S1 FigFSWs reported physical violence was perpetrated by various perpetrators in Thane district. The key perpetrators of physical violence were regular partners (husband or boy-friend or lover), occasional or regular clients including the stranger, local goons , police, and others in Thane district.(TIF)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.


Trade and investment liberalization  can promote or harm health. Undoubtedly it has contributed, although unevenly, to Asia’s social and economic development over recent decades with resultant gains in life expectancy and living standards. In the absence of public health protections, however, it is also a significant upstream driver of non-communicable diseases (NCDs) including cardiovascular disease, cancer and diabetes through facilitating increased consumption of the ‘risk commodities’ tobacco, alcohol and ultra-processed foods, and by constraining access to NCD medicines. In this paper we describe the NCD burden in Asian countries, trends in risk commodity consumption and the processes by which trade liberalization has occurred in the region and contributed to these trends. We further establish pressing questions for future research on strengthening regulatory capacity to address trade liberalization impacts on risk commodity consumption and health.A semi-structured search of scholarly databases, institutional websites and internet sources for academic and grey literature. Data for descriptive statistics were sourced from Euromonitor International, the World Bank, the World Health Organization, and the World Trade Organization.Consumption of tobacco, alcohol and ultra-processed foods was prevalent in the region and increasing in many countries. We find that trade liberalization can facilitate increased trade in goods, services and investments in ways that can promote risk commodity consumption, as well as constrain the available resources and capacities of governments to enact policies and programmes to mitigate such consumption. Intellectual property provisions of trade agreements may also constrain access to NCD medicines. Successive layers of the evolving global and regional trade regimes including structural adjustment, multilateral trade agreements, and preferential trade agreements have enabled transnational corporations that manufacture, market and distribute risk commodities to increasingly penetrate and promote consumption in Asian markets.Trade liberalization is a significant driver of the NCD epidemic in Asia. Increased participation in trade agreements requires countries to strengthen regulatory capacity to ensure adequate protections for public health. How best to achieve this through multilateral, regional and unilateral actions is a pressing question for ongoing research. The rate of economic change in Asia over recent decades has been unprecedented. According to International Monetary Fund (IMF) data, for example, China’s share of Global GDP (PPP) rose from 2.2% in 1980 to 15.6% in 2013 . IndicatTrade liberalization can work for or against health. On the one hand, it can promote the transfer of goods, services, investments and technologies that promote health directly through for example expanding access to nutritious foods and essential medicines, or indirectly by stimulating economic growth and employment. On the other, the benefits for health remain contested with demonstrated disparities in trade and investment related economic growth between countries, exacerbated income inequalities within countries, and heightened economic and food insecurity –12. In tIn this paper we conceptualize trade liberalization as a driver of NCDs through two main pathways. First, it can facilitate the global diffusion of ‘risk commodities’ – tobacco, alcohol and ultra-processed foods – across borders. A key mechanism is transnational risk commodity corporations (TRCCs), those that manufacture, market and distribute such commodities on a global scale. Trade liberalization allows TRCCs to rapidly move investments, technologies, production capacity, raw materials and final products across borders and thereby drive risk commodity consumption transnationally –21. GrowSecond, trade liberalization can strengthen the intellectual property rights of transnational pharmaceutical corporations and TRCCs. As it relates to pharmaceuticals, this can potentially constrain access to medicines and technologies used in the prevention or treatment of NCDs. While patent-ownership is concentrated in firms located in the US, EU and Japan  the greatest need for NCD-related medicines is located in low- and middle-income countries . Trade rYet while the magnitude and implications of the NCD burden in Asia have been elucidated ,30,31, lThe countries included in this analysis, henceforth termed ‘Asia’, were the Association of Southeast Asian Nations plus three (ASEAN + 3) grouping of countries: Brunei Darussalam, Cambodia, Indonesia, Laos, Malaysia, Myanmar, the Philippines, Singapore, Thailand, and Vietnam (ASEAN), and China, Japan and South Korea (+3). These countries were chosen because of their participation in extensive trade and investment liberalization activities at the bilateral, regional and multilateral levels over the previous two decades. We also included India because of its large population size, economic and political importance, and because it is a significant source of patented generic NCD medicines for countries in the region. Countries were categorized by World Bank income status as high-income (H-IC), upper-middle income (U-MIC), lower-middle income (L-MIC) and low-income (L-IC). We conducted a semi-structured literature search of scholarly databases  and internet sources  using a combination of three categories of search terms Table  to identWe also searched institutional websites to identify relevant grey literature and sourced detailed market reports for tobacco, alcohol and processed foods from Euromonitor International for all countries except Brunei Darussalam, Laos, Cambodia and Myanmar. Data for descriptive statistics were sourced from the World Bank World Development Indicators, United Nations Development Programme (UNDP) Human Development Index, World Health Organization (WHO) Global Health Data Repository, and WHO NCD Country Profiles. Tobacco, alcohol and processed food consumption data were sourced from Euromonitor Passport Global Market Information Database, 2013 edition, covering 1998-2012 with projections to 2017. Data were extracted for H-IC, U-MIC and L-MIC countries. Data for Brunei Darussalam, Laos, Cambodia and Myanmar were not available .Economic growth in Asia is closely tied to the Asian epidemiological transition . EconomiAccording to World Bank data there is a 57-fold difference in GNI per capita (Atlas method) between Singapore and Cambodia. In India and Laos, more than two thirds of the population live on less than $2 per day, the World Bank’s measure of absolute poverty . Rapid dIn 2008, across the countries we include in this analysis, 17 million people died from NCDs accounting for 65% of total deaths . Of thesDifferences between countries reflect variations in population-level determinants of NCDs. These include ageing populations, levels of educational attainment, the characteristics of urban environments, cultural and societal norms, and the extent to which the political and policy environments are protective ,38,39. ATobacco use is the most significant preventable risk factor for CVD, chronic respiratory diseases and cancers of the lung, larynx, pancreas, stomach, bladder and cervix. Smoking prevalence differs significantly from 53% among males in Indonesia to 24% in Singapore. In the H-ICs cigarette consumption is declining, but expanding rapidly in China, Indonesia and Vietnam Figure . In ChinAll countries in the region have adopted tobacco control policies, and all except Indonesia are signatory to the Framework Convention on Tobacco Control (FCTC). In many countries including China, Thailand and Vietnam the state plays a significant role in the production, promotion and distribution of tobacco products . In ChinThese observations discount the combined role of trade liberalization and transnational tobacco corporations (TTCs) as consumption drivers in these countries. However, evidence suggests that TTCs may still promote consumption in state-dominated markets through stimulating more intensive competition (including price competition), facilitating illicit trade in foreign tobacco products and in some cases by aggressively lobbying against the adoption of public health control measures ,51–54. TThe excessive consumption of alcohol is a significant preventable risk factor for CVD, some cancers, cirrhosis of the liver, road traffic injuries and some neuropsychiatric disorders . AlcoholCountries are also at varying stages of ‘nutrition transition’, a dietary-shift from traditional diets rich in staple foods and vegetables towards less healthy diets high in ultra-processed foods such as biscuits, confectionary, savoury snacks, processed meats and soft drinks –66. As uSuch trends indicate the burgeoning commercial successes of alcohol, tobacco and food industries in the context of rapidly-growing economies and rising household incomes. When the social and economic externalities of NCDs are accounted for they also constitute market failures. Extensive macroeconomic losses can result from increased health care expenditures, reductions in workforce participation, productivity and consumer spending ,74–76. CThere are also significant microeconomic implications for individuals and families living below or at the poverty-line. The poor are more likely to die prematurely from NCDs because of more limited access to treatments and medicines but also because of ineffective or non-existent NCD prevention policies ,79. Deatprocesses and five mechanisms that link trade liberalization to NCDs through impacts on risk commodity consumption and/or access to medicines. The three processes of trade liberalization include: structural adjustment programmes and unilateral liberalization, the multilateral system , and bilateral and regional preferential trade agreements (PTAs). These processes can also be conceptualized as successive layers of an evolving global trade, investment and intellectual property regime that we will elaborate on in the following sections. As it relates to risk commodity consumption each of the three processes has been more or less important at successive time points and our analysis is therefore historical.In this next step we offer some explanations as to why risk commodity consumption has increased and why it might continue to increase across the region. From the literature we identified three a [The five mechanisms that are evident in all three processes of trade liberalization are as follows. First, trade liberalization reduces tariff and non-tariff barriers to trade and thereby facilitates imports and exports of risk commodity products or the raw materials (e.g. tobacco leaf or vegetable oil) used in their production. Second, it can reduce barriers to trade in services  and FDI thereby allowing TRCCs to outsource their operations to domestic corporations or to acquire them (and thus grow) through mergers and acquisitions, as well as to expand their product marketing and promotional activitiesa ,14,81.Third, trade agreements can, through strengthening intellectual property rights, constrain access to medicines, technologies and medical procedures used in NCD prevention or treatment, or constrain the capacity of governments to develop legislation pertaining to risk commodity advertising, labelling and composition ,82. Fourb act to constrict domestic ‘policy space’, the freedom, scope and instruments available to governments to develop policies and regulations that can mitigate NCDs [Five, through mandating processes managed by third parties (e.g. the World Trade Organization) to oversee implementation of trade agreements including dispute settlement and enforcement mechanisms, the sovereignty of nation states and their autonomy to make decisions regarding population health is diminished . The aboate NCDs ,86. And In the 1980s and 1990s trade liberalization accelerated with the emergence of a global neoliberal development agenda and the structural adjustment programmes (SAPs) imposed on many countries by the International Monetary Fund (IMF) and World Bank . These pIn India, for example, an early-1990s IMF bail-out package required the Government to undertake extensive economic liberalization that inadvertently resulted in transformations in the domestic soft drink market sector. Following the repeal of laws that prohibited the repatriation of profits to foreign countries, PepsiCo entered the Indian market in 1990 and engaged in heavy competition with Parle, a domestic company and owner of ‘Thums Up’, a cola brand with close to 85% of the soft drinks market share . After aAgricultural SAPs have also likely contributed directly to a ‘nutrition transition’, in particular a regional shift in vegetable oil consumption. These have pursued the development of export-orientated cash-cropping. Between 1968 and 1993 the World Bank, for example, loaned US$618 million for palm oil production projects in Indonesia and US$383 million in Malaysia .The second process facilitating trade liberalization has been the multilateral trade system. This accelerated in 1995 when the General Agreement on Tariffs and Trade (GATT), the set of rules facilitating the reduction of barriers to trade since 1947, was subsumed by the World Trade Organization (WTO). The WTO serves today as the central global trade negotiating platform, that unlike the GATT system preceding it, includes a dispute settlement system and legally-binding enforcement mechanism . A centrc of the sixty WTO agreements are highly significant to risk commodities. The General Agreement on Trade in Services (GATS) for instance opens countries to trade and investment in services, although countries can opt-in on a sector-by-sector basis. Services liberalization can potentially enable TRCCs to contract out or acquire key services at the global level, thereby integrating and establishing control over global value chains  [Eight➔ sales) ,97. Such➔ sales) . Some se➔ sales) .The Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) expanded intellectual property protections, requiring WTO members to allow patenting of pharmaceutical products and processes (mandatory patentability). Because the TRIPs agreement grants extensive patent rights to transnational pharmaceutical firms it can prevent the import or production of generic (i.e. non-branded) drugs in developing countries, thereby potentially increasing the costs or limiting the availability of essential NCD medicines ,99. The Under the Agreement on Agriculture countries are obligated to reduce agricultural tariffs, domestic agricultural supports and export subsidies . This maThe elimination of technical (non-tariff) barriers to trade was also broadened through the Agreement on Technical Barriers to Trade. This ensures countries do not adopt technical regulations  that create unnecessary barriers to trade. It recognizes the use of technical regulation for the protection of ‘public health or safety’ as a legitimate objective when it is consistent with international technical standards. These can include, for example, standards pertaining to food, alcohol and tobacco developed by relevant international organizations such as the WHO and Codex Alimentarius . HoweverUnder GATT articles XIV and XX the protection of human health is recognized as an interpretive principle allowing countries to adopt trade restrictive measures when it is ‘necessary to protect human, animal or plant life and health’ . HoweverThe first stage of multilateral liberalization with a bearing on NCDs occurred under the pre-WTO GATT system. While most countries included in this analysis were signatory to the GATT prior to WTO establishment, others, concerned with the protection of domestic industries from foreign competition, proceeded with a more cautious approach to determining the depth and timing of trade liberalization ,103. On In other countries, however, GATT-era trade disputes were significant in the liberalization of tobacco trade. Bilateral trade sanctions (non-GATT) were used as an initial mechanism. For example the US Cigarette Export Association, a tobacco industry lobby group, solicited support from the US government to threaten trade sanctions against South Korea, Japan, Taiwan and Thailand unless they opened their domestic markets to US tobacco products . In the The second stage of multilateral liberalization has resulted from accession to WTO membership. In order to join the WTO a nation must declare all domestic policies that have a bearing on the various WTO agreements and is often required to modify such policies before membership is granted. On these grounds the US challenged Vietnam’s accession to the WTO claiming that its alcohol taxation policies favoured domestic over foreign producers. China and Taiwan also faced pressure during their WTO accession negotiations to privatize their state-owned tobacco monopolies . BritishSome nations have made certain sectors and products exempt from their WTO accession commitments. This may have also influenced the scale of risk commodity consumption. In India, for example, multi-brand retail was excluded from its GATS commitments and has been closed to foreign investment except through minority joint ventures, resulting in very low levels of penetration by transnational supermarket retailers ,111. BecThe third stage of multilateral liberalization has been through the WTO’s Dispute Settlement System. WTO mediated trade disputes have opened multiple countries to trade in risk commodities. Table What is also evident, however, is that Western nations have even more frequently used WTO rules to promote access to Asian markets for food and alcohol producers. Tobacco appears to have been under-represented in WTO trade disputes, most likely because of GATT-era liberalization and bilateral sanctions we described earlier had already resulted in market entry by TTCs. Of the 26 claims made against Asian nations, 21 were made by the United States (US) and European Community (EC) alone and of these 9 were against L-MICs and U-MICs. To the contrary only 5 claims were made by L-MICs and U-MICs against the US and EC. These differences likely reflect asymmetries in markets sizes and therefore bargaining power, but also the resources available to nations to make or defend disputes which can involve often complex and costly legal proceedings . DevelopMost notably, the US, Canada and the EC have made claims against Japan, South Korea, the Philippines and India to reduce taxes on imported alcohol products. For example, the national treatment rule was invoked to remove Japan’s high taxes on imported alcohol products. This began with vodka as considered ‘like’ the traditional spirit shochu but would subsequently include gin, rum, whiskey, brandy and other spirits. Subsequently domestic liquor prices dropped , althougThe threat of a WTO trade dispute can also result in ‘regulatory chill’, the non-adoption of domestic policies arising not from a dispute, but from the threat of one. For example, with the aim of reducing consumption of processed snack foods Thai civil society groups advocated for a law requiring that products are labelled with a ‘Children Should Take Less’ message as well as a traffic-light labelling system to indicate the sugar, fat, sodium and energy content of products. Although considered by the Thai Food and Drug Administration this was abandoned in favour of an industry preferred Guideline Daily Amount thumbnail labelling system when several WTO members raised concerns about these policies during the Technical Barriers to Trade committee deliberations .The TRIPS agreement has a significant bearing on NCD mitigation as it can determine the availability and affordability of life-saving medicines. Under ‘TRIPS-flexibilities’ there are legal mechanisms, such as compulsory licensing, available to governments to allow the production and import of patented pharmaceuticals by domestic firms . Under tFirst has been through the interpretation and implementation of TRIPS-flexibilities, in particular by Thailand, Malaysia and Indonesia. Moon and Szlezak have described the actions taken by these governments in issuing compulsory licenses for HIV/AIDS drugs since the 1990s. Building off these developments Thailand more recently extended TRIPS-flexibilities to NCD drugs. In 2007 it announced a compulsory license to a domestic firm to produce Clopidogrel, a blood-thinning drug for hypertension patented by French firm Sanofi (under the brand name Plavix). In 2008, compulsory licenses were also announced for four cancer drugs: Erlotinbi, Docetaxel, Letrozole and Imatinib (the latter was not implemented due to intervention by Novartis) .The second is exemplified by India through its adoption of stand-alone national patent licensing legislation that gives significant weighting to public health protection. Most developing countries usually have small or non-existent pharmaceutical industries and must therefore import patented medicines from developed countries. This often contributes to large health-cost and balance of payments deficits . India iIn 1997 the US and EU bought complaints against India alleging that the absence of a patent protection system violated the TRIPS mandatory patentability rule. India used TRIPS-flexibilities and made full use of the transition period allowed for developing countries under WTO accession rules to develop its national patenting legislation. This scheme became fully operational in 2005 . Unlike As a result India has been the centre of a legal battleground that has broad repercussions for access to NCD medicines. Two cases pertain to cancer medication. In a first case the company Novartis was refused a patent for the leukaemia drug Imatinib, allowing Indian generic companies to supply the drug at almost one twentieth of the price (US$124-174 versus $2478 per month). In a second, although the company Bayer was granted a patent for its renal cancer drug Sorafenib (marketed as Nexavar), the Indian Government issued a compulsory license to an Indian company that allowed supply at more than one fortieth of the branded price (US$125 versus $5500 per month) ,117.The future of TRIPS and tobacco labelling policy in Asia appears to be untested in this space . However Asian nations such as Malaysia and Thailand continue as ‘observers’ of the recent WTO challenge to Australia’s plain packaging regulation bought by a number of tobacco producing countries that could set an important precedent for tobacco control in the region .The third process is the more recent proliferation of bilateral and regional preferential trade agreements (PTAs). While PTAs are often referred to as free trade agreements they are best described as ‘preferential’ trade agreements because they are never truly ‘free’, but rather provide signatories with more favourable  terms of trade than non-signatories. While bilateral investment treaties (BITS) have been numerically more common, particularly so during the 1990s, today regional PTAs with investment provisions are more economically significant. Thus the most significant contemporary trend in the global trade regime is best described as multilateralism with ‘regionalism on the rise’ .Regional and extra-regional economic integration in Asia greatly accelerated following the 1998 Asian Financial Crisis . PTAs inconsistent with the existing WTO agreements but also commitments that go beyond them, thus referred to as ‘WTO-plus’ . They also include commitments outside of the current WTO framework, referred to as ‘WTO-X’ including those on intellectual property rights, investment and competition [The second important trend is that PTAs are becoming increasingly ‘deep’ with commitments and concessions that go beyond those required by the WTO system . First tpetition . These apetition .The implications for public health have generated significant concern for a number of reasons. First, while the multilateral system provides flexibilities on public health and safety grounds these can be excluded from or highly restricted within PTAs ,28. SecoThe net effect is to not only further constrain the domestic public health policy mechanisms available to signatory governments (i.e. reduce their ‘policy space’), but to also greatly expand the power of TRCCs and representative governments to dispute policies enacted by governments to prevent or control NCDs. Restrictions on risk commodity advertising could, for example, be represented as barriers to cross-border trade in advertising services. Compliance costs and evidence requirements imposed on countries aiming to regulate advertising could also act as a deterrent. The South Korea-US PTA (KORUS), for example, contains stringent criteria on countries wishing to regulate the supply of services. This concern has been flagged as a potential threat to legislation targeting the marketing of foods and beverages to children ,115.The impacts of PTAs on NCD risk factor consumption can be significant. A recent analysis demonstrated that a PTA with the US was associated with a 63.4% higher soft drink consumption per capita compared to countries with no US PTA . This isSeveral PTAs are or will be notably significant to NCDs in Asia. The 2003 US-Singapore agreement eliminated tobacco tariffs and included an ISDS allowing investors to directly challenge government regulations . KORUS ist Century. The twelve negotiating countries include Australia, Brunei, Canada, Chile, Japan, Malaysia, Mexico, New Zealand, Peru, Singapore, the US and Vietnam. South Korea may later join the negotiations. Together these counties have an aggregate GDP of US$28 trillion , and were attributed to 27% of world exports worth US$6 trillion in 2011. The TPP is also significant because it serves as an interim arrangement prior to a more comprehensive Free Trade Area of the Asia Pacific (FTAAP) that may incorporate a greater number of countries [In economic terms the TPP has the potential to be the most significant trade policy of the 21ountries .The TPP constitutes a significant threat to public health policies targeting risk commodities in the participating countries of Asia ,121,126.Other key provisions of concern include those on regulatory coherence and transparency that require governments to consult industry and disclose information during domestic policy-making processes . Unlike Intellectual property rights (IPR) provisions of the TPP are also highly contentious. The US has pushed for a broad approach to IPR akin to the KORUS agreement on patents, copyrights, trademarks and trade secrets. This includes demands that animals, plants and medical procedures are subject to patent protection . US negoThere are several limitations of this analysis. It reviews the evidence as it applies to a selection of Asian countries, excluding many where risk commodity consumption is also exerting a significant health and economic toll. Nonetheless, we capture countries with the largest population sizes. The market data we have used to describe changes in risk commodity consumption are imperfect measures because these do not capture those commodities manufactured in the home or sold through informal (non-market) productions systems, nor for wastage. However unlike survey data these data are not subject to recall bias, and their abundance allowed for comparisons between countries over time . Most imDespite these limitations this article has provided a synthesis of the literature and presented data on the considerable health and economic externalities resulting from risk commodity consumption in the region. It has demonstrated how successive layers of the global trade regime have contributed to the proliferation of the tobacco, alcohol and ultra-processed food industries, and how they might constrain access to NCD medicines across Asia. The findings bring into play pressing questions for future research. How in the context of increasing trade liberalization can public health responses to risk commodity consumption in Asia be strengthened at the global, regional and national levels? We offer some directions for future work on strengthening NCD governance capacity in Asia.Political Declaration on the Prevention and Control of Non-communicable Diseases (UNPDNCD), the highest multilateral mechanism addressing NCDs [Framework Convention on Tobacco Control (FCTC) (adopted under Article 19 of the WHO constitution) is a legally binding treaty that may be used to uphold domestic tobacco legislation in trade dispute arbitration, as exemplified recently in arguments by Australia to defend its plain packaging legislation in response to WTO dispute arbitration, although a ruling has yet to be made [In 2011 the United Nations General Assembly adopted the ing NCDs . Althouging NCDs . Internaing NCDs ,133. The be made .Global Strategy on Diet, Physical Activity and Health, and 2010 Global Strategy to Reduce the Harmful Use of Alcohol respectively. The former states that no provisions in the recommendations should be construed as justification for trade restrictive measures while the latter recognizes the important role of trade as a determinant of alcohol consumption [. The feasibility and approaches for strengthening international standards to address ultra-processed foods and alcohol have been explored elsewhere, and may include the development of more selective mechanisms targeting particular products (e.g. soft drinks) or services (e.g. advertising) as well as standards set by other international organizations including Codex Alimentarius [For ultra-processed foods and alcohol, however, international agreements are non-binding recommendations (adopted under Article 23), the 2004 sumption ,136. Theentarius –139. We entarius ,141.Countries may adopt provisions in the aforementioned international agreements as domestic policies so long as they are consistent with international trade obligations – that is they do not arbitrarily or unjustifiably discriminate or act as disguised barriers to trade. Increasing participation in trade negotiations, however, requires countries to strengthen regulatory capacity in terms of monitoring trade agreements and ensuring compliance with international obligations, but also in terms of managing associated risks and ensuring adequate protections for public health ,142. AchGlobal Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020 (GAPNCD) recognizes the role of WHO in offering technical assistance to developing country governments to mitigate the impact of trade agreements on health. Such assistance may be critical to addressing the proliferation of risk commodity industries in Asia, especially in developing countries with limited regulatory capacity. The GAPNCD also calls on the FAO to ‘Support ministries of agriculture in aligning agricultural, trade and health policies’ and on the WTO to ‘…support ministries of trade in coordination with other competent government departments , to address the interface between trade policies and…noncommunicable diseases’ [The WHO iseases’ , p74. Aliseases’ . Researciseases’ . This aliseases’ .The potential opportunities at the regional level are under researched in the current literature. Despite the primacy they give to trade liberalization, ASEAN and the Asia Pacific Economic Cooperation forum have recently demonstrated increased commitment to addressing regional health issues, in particular infectious disease threats ,149. As Asia is also home to ‘light-house’ countries taking unilateral action to address risk commodity consumption. Thailand, for example, has one of the most comprehensive tobacco control regimes globally . This can result in ‘regulatory chill’ whereby the potential threat of trade sanctions or costly litigation can deter government institutions from initiating policy processes. Second, through limiting the availability of policy instruments available to governments (substantive constriction) including those pertaining to advertising restrictions, mandatory product labelling and product content disclosures. Third, by expediting a shift from public to private provision of goods and services that expands the economic and regulatory power of private relative to public sector actors  [riction) .cWTO trade agreements most relevant to risk commodities include: (i) General Agreement on Trade in Services (GATS); (ii) Agreement on Agriculture (AoA); (iii) Agreement on the Application of Sanitary and Phytosanitary (SPS) measures; (iv) Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS); (v) Technical Barriers to Trade (TBT) Agreement; (vi) Dispute Settlement Understanding; (vii) Agreement on Trade-Related Investment Measures (TRIMS); and, (viii) Agreement on Government Procurement (AGP) [nt (AGP) .


To quantify the independent roles of geography and Indigenous status in explaining disparities in Potentially Preventable Hospital (PPH) admissions between Indigenous and non-Indigenous Australians.Analysis of linked hospital admission data for New South Wales (NSW), Australia, for the period July 1 2003 to June 30 2008.Age-standardised admission rates, and rate ratios adjusted for age, sex and Statistical Local Area (SLA) of residence using multilevel models.PPH diagnoses accounted for 987,604 admissions in NSW over the study period, of which 3.7% were for Indigenous people. The age-standardised PPH admission rate was 76.5 and 27.3 per 1,000 for Indigenous and non-Indigenous people respectively. PPH admission rates in Indigenous people were 2.16 times higher than in non-Indigenous people of the same age group and sex who lived in the same SLA. The largest disparities in PPH admission rates were seen for diabetes complications, chronic obstructive pulmonary disease and rheumatic heart disease. Both rates of PPH admission in Indigenous people, and the disparity in rates between Indigenous than non-Indigenous people, varied significantly by SLA, with greater disparities seen in regional and remote areas than in major cities.Higher rates of PPH admission among Indigenous people are not simply a function of their greater likelihood of living in rural and remote areas. The very considerable geographic variation in the disparity in rates of PPH admission between Indigenous and non-Indigenous people indicates that there is potential to reduce unwarranted variation by characterising outlying areas which contribute the most to this disparity. There is overwhelming evidence that Indigenous Australians, like indigenous peoples worldwide, suffer profound health disadvantage. The life expectancy of Indigenous Australians at birth is around 11.5 years lower for males and 9.7 years lower for females, compared with non-Indigenous Australians The concept of the “potentially preventable hospitalisation” (PPH) provides policymakers and health care managers with a framework to identify admissions that may have been prevented if timely and adequate care was available to that individual outside of the hospital system Further, evidence from other countries indicates that ethnicity and rurality both contribute to disparities in health care, with rural ethnic minorities experiencing poorer access to health care Our study aimed to address these knowledge gaps.Approval for the study was given by the NSW Population and Health Services Research Ethics Committee, the Aboriginal Health and Medical Research Council of NSW Ethics Committee, and the University of Western Sydney Human Research Ethics Committee.Observational study using linked hospital admission records.2  New South Wales (NSW) is the largest state in the Commonwealth of Australia, with a population of 6,663,402 in 2006, and includes both highly urbanised and rural areas. While Indigenous Australians represent only 2.3% of the total population of NSW, 23% of all Indigenous people living in Australia reside in NSW The NSW Admitted Patients Data Collection (APDC) includes information about all separations  from NSW public and private hospitals and day procedure centres. Diagnoses are coded using the International Classification of Diseases and Related Problems, Australian Modification (ICD-10-AM), and procedures are coded using the Australian Classification of Health Interventions Sixth Edition APDC data were available for the period 1 July 2003 to 30 June 2008. As NSW did not have a unique patient identifier available during the study period, hospital separations associated with the same individual were identified using probabilistic methods by the NSW Centre for Health Record Linkage Indigenous people are known to be under-identified in the APDC We derived synthetic Indigenous population estimates for NSW SLAs using a combination of age- and sex-specific estimates of the total population for SLAs, age- and sex-specific estimates of the Indigenous population for NSW, and the estimated proportion of the population of each SLA that was Indigenous, from the 2006 Australian Census We identified PPH admissions according to the 2012 NHA performance indicator: Selected potentially preventable hospitalisations We calculated directly age-standardised admission rates for all PPH conditions and the broad PPH groupings, using events from the hospital data as the numerator and population from the synthetic population estimates as the denominator. The rates were standardised to the 2001 Australian Standard Population 2) was expressed as a median rate ratio, which was the median of the rate ratios of pair-wise comparisons of people with identical characteristics taken from randomly chosen SLAs. We also added a random slope for Indigenous status to see whether there was significant variation across areas in the Indigenous to non-Indigenous admission rate ratio. Using area-level “shrunken” residuals from the multilevel models that borrow information from the average to stabilise estimates We used multilevel Poisson models to compare admission rates between Indigenous and non-Indigenous people. All models were adjusted for age group and sex, with the exception of the pelvic inflammatory disease condition-specific model which was only adjusted for age-group, and all models included a random intercept for the SLA of residence. Variation at the SLA level  with their 95% confidence intervals (CI). All analyses were carried out using SAS 9.3 Over the 5-year study period, PPH diagnoses accounted for 987,604 admissions in NSW. Of these, 36,430 (3.7%) were for Indigenous people. The majority of admissions were for chronic conditions (57%), followed by acute (41%) and vaccine preventable conditions (2.4%), with this distribution being similar for Indigenous and non-Indigenous people .The overall age-standardised rate of PPH admissions for Indigenous people was 76.5 per 1 000, compared with 27.3 for non-Indigenous people , a ratioAfter adjusting for age, sex and SLA, the largest disparities in PPH admission rates were seen for diabetes complications , COPD , rheumatic heart disease , other vaccine preventable  and congestive cardiac failure  .Rates of PPH admission varied markedly according to SLA (p<0.001) (from the random intercept model) and the rate ratio of Indigenous to non-Indigenous admissions also varied significantly (p<0.001) (from the random intercept and random slope model). Average length of stay for PPH admissions in Indigenous people was slightly longer than for non-Indigenous people of the same age group and sex who lived in the same SLA , with this difference being statistically significant for acute  and chronic  but not vaccine-preventable  conditions. Including a random slope term for Indigenous status did not markedly alter our estimates of the disparity in Indigenous and non-Indigenous average length of stay (not shown).Ours was the first study to our knowledge to explore the independent roles of geography and Indigenous status in explaining differences in rates of PPH admission between Indigenous and non-Indigenous people. Our results demonstrated unequivocally that higher rates of PPH admission among Indigenous people are not simply a function of their greater likelihood of living in rural and remote areas where rates of PPH admissions are higher Our age-standardised rates of hospitalisation for PPH diagnoses in Indigenous people in NSW  were lower than those reported for Indigenous people in the Northern Territory  in the years 1998–99 to 2005–06 We found that after adjusting for age, sex and SLA of residence, rates of PPH admission in Indigenous people were significantly higher than those in non-Indigenous people across almost all conditions included in the PPH indicator. However, diabetes complications contributed around one-third of all PPH admissions in Indigenous people, and were also responsible for the largest disparity, with the rate of these admissions for Indigenous people being more than five times higher than for non-Indigenous people of the same age group, sex and SLA of residence. Large ethnic disparities in potentially avoidable hospitalisations for diabetes were also evident between New Zealand Māori and people of European descent We found that there was very considerable geographic variation in the disparity in rates of PPH admission between Indigenous and non-Indigenous people in NSW, presenting the potential to reduce disparities by characterising and targeting the sources of this variation. We identified more than 30 “high rate, high disparity” SLAs in NSW, mainly in regional areas, as well as three “low rate, low disparity” SLAs. However, using administrative hospital data alone, we were unable to identify the relative contributions of such factors as differences in underlying disease prevalence, disease severity, access to quality care, and admission practices to these variations in admission rates. While studies of ambulatory care-sensitive hospitalisations in the USA were able to account for underlying disease prevalence in their estimates of ethnic disparities We could not identify other studies that investigated how ethnic disparities in potentially preventable hospitalisation varied with geography. Findings for disparities in mortality have varied between settings. Studies in New Zealand have reported relatively little variation in disparities between New Zealand Māori and European/other populations in life expectancy A possible artefactual contributor to geographic variation in our study was inconsistency in the numerator  and denominator (population census) data that were used to calculate admission rates. For example, high mobility of Indigenous people Linkage of hospital data to other population-based data such as large-scale health survey data, disease registers or Medicare claims would go some way towards addressing the limitations of our study, by ensuring consistency between numerator and denominator data, and providing more detailed information about patient risk factors. Unfortunately such linkages are not presently available as part of the current National Aboriginal and Torres Strait Islander Health Survey, and processes for access to linked Medicare and other Commonwealth data for research, while currently being revised Although we urgently need more information to characterise the sources of geographic variation in PPH admission rates, evidence is starting to emerge about the types of interventions that might be successful in tackling these variations. These include chronic disease management interventions that place an emphasis on the Chronic Care Model Repeating our analyses using linked hospital data for the whole of Australia, when available, will allow exploration of inter-jurisdictional differences. It will also open up possibilities for applying novel evaluation methods using “natural experiments” Figure S1Map of Indigenous to non-Indigenous PPH admission rate ratio by Statistical Local Area, 2003/04 to 2007/08, adjusted for age group and sex.(TIF)Click here for additional data file.


In 1988, the Global Polio Eradication Initiative (GPEI) was established through a partnership between the World Health Organization (WHO), Rotary International, CDC, and the United Nations Children’s Fund (UNICEF). By 2012, the annual incidence of polio had decreased by >99%, compared with 1988, and the number of countries in which wild poliovirus (WPV) circulation has never been interrupted was reduced to three: Afghanistan, Nigeria, and Pakistan , the WorA key factor contributing to the success of the global smallpox eradication program in the 1970s was the deployment of international public health field staff to assist national programs with smallpox outbreak investigation, surveillance, and planning of vaccination activities in endemic countries . In 1999The initial objectives of STOP field assignments were to conduct and support acute flaccid paralysis (AFP) surveillance and to plan, monitor, and evaluate large-scale supplementary polio immunization campaigns. Field assignment objectives were expanded in 2002 to support accelerated progress toward measles mortality reduction and development of data management systems for disease surveillance. The objectives were further expanded in 2003 to support strengthening routine childhood immunization activities, a key GPEI strategic component; in 2006 to support polio program communications and social mobilization at UNICEF country offices; and in 2011 to support the management needs of immunization and eradication teams at country level.The STOP program recruits and deploys three types of volunteers: field staff and data managers who work with WHO country teams, and communications officers who work with UNICEF teams. Since 2009, an “enhanced” STOP program component has placed senior, experienced volunteers at the district level in the highest priority areas. All volunteers undergo 10 days of intense technical, security, and cross-cultural training at CDC in Atlanta before being deployed on field assignments of 3–5 months duration. Additional training beyond the 10 days is provided for communication and data management volunteers; volunteers assigned to Nigeria, Pakistan, and Democratic Republic of Congo receive special management training.From January 1999 through June 2013, a total of 1,563 volunteers were identified, trained, and deployed for 2,221 STOP assignments to 69 countries.In February 2013, a survey of 458 volunteers from STOP teams deployed at any time since February 2011 was conducted to assess activities conducted in field assignments. Among 312 (68%) volunteers who returned questionnaires, an average of 51% of their time deployed was reported to be spent on capacity-filling polio eradication activities, , and an average of 49% of their time was spent on capacity-building activities . The distribution of time spent on specific activities varied by country. For example, among 82 volunteers with field assignments in polio-endemic countries, an average of 68% of their time was reported to be spent conducting polio-related activities, 22% on routine childhood immunization strengthening activities, and 10% on other health programs. By comparison, among 230 volunteers with field assignments in nonendemic countries, an average of 54% of their time was spent on polio-related activities, 31% on routine immunization strengthening activities, and 15% on other health initiative activities.What is already known on this topic?Since the Global Polio Eradication Initiative (GPEI) was established in 1988, the annual incidence of polio has decreased >99%, and the number of countries in which wild poliovirus (WPV) circulation had never been interrupted has been reduced to three: Afghanistan, Nigeria, and Pakistan. The Stop Transmission of Polio (STOP) program was developed and initiated by CDC with the World Health Organization in 1999 to mobilize skilled personnel and technical resources to assist countries affected by WPV transmission.What is added by this report?The STOP program has become a large human resources deployment mechanism that has worked successfully for GPEI over an extended period. During 1999–2013, 1,563 volunteers were identified, trained, and deployed for 2,221 assignments as part of 42 STOP teams in 69 countries. The number and length of assignments has increased since the World Health Assembly declared the completion of polio eradication a programmatic emergency in 2012. The number of volunteers increased from 90–120 per year during 1999–2011 to 378 in 2013.What are the implications for public health practice?Polio Eradication and Endgame Strategic Plan 2013–2018. The STOP model has been replicated within Nigeria and Pakistan as a public health capacity-building mechanism; national field epidemiology programs have been recruiting, training, and deploying qualified national staff members to supervise and implement GPEI activities at country level. These staff members enhance national polio eradication programs overall, and particularly in areas that are not accessible to staff of international organizations because of security concerns.GPEI partnership will continue the STOP program throughout the period of eradication, certification, and progressive withdrawal of oral poliovirus vaccines, as outlined in the The STOP program has made an important contribution to the mission of GPEI by providing countries with critical technical support to strengthen polio eradication activities. In response to requests from countries and WHO regional offices, STOP was expanded to provide a broader range of technical support for immunization programs, and the number of volunteers was increased over time. The flexibility of the STOP program enables volunteers to fill human resource gaps or build local capacity as needed by the country in which they are working. The effectiveness of STOP field assignments might be further enhanced through management training of some STOP supervisors and consistent development of clear work plans by field supervisors, in collaboration with STOP volunteers.The STOP program concept has served as a model for training programs elsewhere. In Pakistan (since 2011) and in Nigeria (since 2012), for example, national STOP teams of local health professionals have been specifically trained to enhance the implementation of polio eradication activities. National STOP staff members aid national GPEI programs overall, and particularly in areas that are not accessible to staff of international organizations because of security concerns.Polio Eradication and Endgame Strategic Plan, 2013–2018 (The STOP program is a coordinated effort of multiple GPEI partners. During 2000–2012, the Canadian Public Health Association, funded by the government of Canada, collaborated with CDC to identify, recruit, and deploy French-speaking participants for the STOP program. Rotary International and the Bill and Melinda Gates Foundation have contributed to funding for STOP volunteer field assignments. WHO and UNICEF organize field assignments through their regional and country offices. In addition, partners assist during the Atlanta-based training, providing technical and logistical support. The GPEI partnership will continue the STOP program throughout the period of eradication, certification, and progressive withdrawal of oral poliovirus vaccines, as outlined in the 013–2018 .


Cannabis is a predominantly diecious phenotypically diverse domesticated genus with few if any extant natural populations. International narcotics conventions and associated legislation have constrained the establishment, characterization, and use of Cannabis genetic resource collections. This has resulted in the underutilization of genepool variability in cultivar development and has limited the inclusion of secondary genepools associated with genetic improvement strategies of the Green Revolution. The structured screening of ex situ germplasm and the exploitation of locally-adapted intraspecific traits is expected to facilitate the genetic improvement of Cannabis. However, limited attempts have been made to establish the full extent of genetic resources available for pre-breeding. We present a thorough critical review of Cannabis ex situ genetic resources, and discuss recommendations for conservation, pre-breeding characterization, and genetic analysis that will underpin future cultivar development. We consider East Asian germplasm to be a priority for conservation based on the prolonged historical cultivation of Cannabis in this region over a range of latitudes, along with the apparent high levels of genetic diversity and relatively low representation in published genetic resource collections. Seed cryopreservation could improve conservation by reducing hybridization and genetic drift that may occur during Cannabis germplasm regeneration. Given the unique legal status of Cannabis, we propose the establishment of a global virtual core collection based on the collation of consistent and comprehensive provenance meta-data and the adoption of high-throughput DNA sequencing technologies. This would enable representative core collections to be used for systematic phenotyping, and so underpin breeding strategies for the genetic improvement of Cannabis. Cannabis, an erect annual herb and member of the Cannabaceae family, is monotypic and characterized by a single species Cannabis sativa L.  with an estimated haploid genome of ~830 Mb , rice (Oryza sativa), maize (Zea mays), sorghum (Sorghum bicolor), and millet (Pennisetum glaucum) increase by 0.5–1% annually between 1960 and 2000  have high tensile strength, and were used for millennia as the predominant source of fiber for the production of rope  as high as 39.8% have been recorded from contemporary marijuana preparations , were employed  analysis of 195 accessions using 2894 single nucleotide polymorphisms (SNPs) inferred close relatedness and shared ancestry between contemporary fiber accessions, with the latter forming a separate clade  accessions identified selective sweeps associated with domestication events , where simple sequence repeat (SSR) genetic marker comparisons between native American germplasm and secondary domesticated groupings revealed a higher level of nuclear diversity in the African germplasm than that of the native collection, suggesting that non-native geographical regions can act as both source and sinks for genetic diversity over different historical periods  have origins within China , and a concerted effort to characterize ex situ genetic resource collections would have significant benefit to the research community and for the continued genetic improvement of this plant.Limited effort has been devoted to comprehensive characterization of currently available Ex situ Cannabis genetic resource collections have been partially characterized and reported within peer reviewed conference proceedings and other reports from public sector researchers, as well as in a variety of gray literature and online databases  germplasm collection was established in 1988  and dioecious, with male or hermaphrodite plants releasing large amounts of pollen during flowering , maize and common bean genetic resource collections , African cowpea , and modeling software , which provides a web interface between raw sequence data, pairwise alignments and metadata relating to provenance, phenotype, and experimental parameters  database, which is currently being developed by researchers at Southern Cross University in Australia to characterize candidate genes involved in cannabinoid and lignocellulose composition in Cannabis.The accumulation of high-throughput DNA sequence data requires systematic management of large datasets (Kilian and Graner, Cannabis genome and transcriptome data are currently scattered within a number of public depositories (see review Lange, http://www.ncbi.nlm.nih.gov/; Van Bakel et al., Cannabis (Dai et al., in silico discovery of complex gene-to-trait relationships, ultimately benefiting both the research community and plant breeders alike.Cannabis is a phenotypically and genetically diverse genus which has yet to benefit from the advanced level of breeding applied to other commercial crops. Coordinated and comprehensive conservation and characterization of ex situ Cannabis resources holds the promise of preserving genepool diversity and enabling cultivar development. However, the legal constraints imposed by international narcotics conventions over more than 50 years have been influential in the fractionation and erosion of publicly accessible Cannabis ex situ genetic resources. The restrictions on legal exchange of bona fide research materials continues to limit the establishment of physical and centralized ex situ core collections. Nevertheless, the advent of low cost high-throughput DNA sequencing technologies and user-friendly data and metadata online repositories, make it possible to develop a virtual Cannabis core collection to facilitate the in silico mining of trait diversity and to guide genetic improvement strategies. This approach not only has the potential to accelerate the introgression and stabilization of commercially valuable genes into desirable germplasm, but may also precipitate a Green Revolution for Cannabis and the renewed commercial exploitation of this multi-functional plant species.MW: Carried out detailed literature survey and prepared manuscript. TS: Contributed to literature review and background information. TR: Contributed to development of review topic, detailed review, and revision of manuscript. LL: Contributed to organization of manuscripts, along with review and revision. RS: Contributed to generation of image data and review of manuscript. GK: Conceived of review topic, detailed review, and revision of manuscript.MW, TS, and RS were sponsored by scholarships funded by Ecofibre Industries Operations Pty Ltd. TS is an employee of Ecofibre Industries Operations Pty Ltd.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The reasons of deaths in developing countries are shifting from communicable diseases towards non-communicable diseases (NCDs). At the same time the number of health care interventions using mobile phones  is growing rapidly. We review studies assessing the health-related impacts of mHealth on NCDs in low- and middle-income countries (LAMICs).A systematic literature search of three major databases was performed in order to identify randomized controlled trials (RCTs) of mHealth interventions. Identified studies were reviewed concerning key characteristics of the trial and the intervention; and the relationship between intervention characteristics and outcomes was qualitatively assessed.The search algorithms retrieved 994 titles. 8 RCTs were included in the review, including a total of 4375 participants. Trials took place mostly in urban areas, tested different interventions , and included patients with different diseases . Except for one study all showed rather positive effects of mHealth interventions on reported outcome measures.Furthermore, our results suggest that particular types of mHealth interventions that were found to have positive effects on patients with communicable diseases and for improving maternal care are likely to be effective also for NCDs.Despite rather positive results of included RCTs, a firm conclusion about the effectiveness of mHealth interventions against NCDs is not yet possible because of the limited number of studies, the heterogeneity of evaluated mHealth interventions and the wide variety of reported outcome measures. More research is needed to better understand the specific effects of different types of mHealth interventions on different types of patients with NCDs in LaMICs.The online version of this article (doi:10.1186/s12889-016-3226-3) contains supplementary material, which is available to authorized users. As a result of increasing life-expectancy and growing welfare in low and middle income countries (LaMICs), there is a steady shift away from communicable to non-communicable diseases (NCDs) –3. NCDs The ability of LaMICs to provide treatment and care for the increasing number of patients with NCDs is limited by insufficient health care infrastructure, especially in rural areas . At the The number of health care interventions using mobile phones  is growing rapidly . In partTwo reviews are available that have included studies analyzing certain aspects of mHealth interventions for NCDs in LaMICs: Beratarrechea et al.  evaluateThe aim of this study was 1) to systematically review the available evidence generated by randomized controlled trials (RCTs) of mHealth interventions for people with NCDs living in LaMICs, and 2) to assess the relationship between intervention characteristics and reported health-related outcomes. We focused on RCTs since they remain the gold standard for evidence of effectiveness of health interventions .The study reported results of an RCT, as defined by JN Matthews The trial took place in at least one country that was classified as an LaMIC as defined by the World Bank classification of country income groups The intervention involved the use of mHealth as defined by the Global Observatory for eHealth Trial participants were patients suffering from NCDs as defined by the WHO The study was published in English or GermanThe study was published before August 2015 (no limit concerning the start date)Studies were included for this review if they met the following inclusion criteria:An initial systematic literature search was performed between December 2013 and February 2014 in MEDLINE (PubMed), CENTRAL and Business Source Complete. An update of the search was performed in August 2015.After piloting appropriate search words, the terms were constructed around (1) “mHealth”, (2) “Low and Middle Income Countries” and (3) “Non Communicable Disease”. Search terms for the operationalization of NCDs were derived from WHO’s Global Burden of Disease Report. In addition to the medical terms specified in the Global Burden of Disease Report , we added more common terms such as heart or skin (for including interventions against skin cancer) to the search algorithm.The search conducted in CENTRAL is shown in the Additional file In addition, reference lists of included studies and identified existing reviews were screened for relevant titles.After removal of duplicates, the resulting list of titles  was screened and studies whose titles/abstracts clearly indicated that they were not concerned with mHealth intervention trials for NCDs in LaMICs  were excluded from further consideration.Full-text articles of 114 studies were retrieved and assessed, resulting in 8 articles included for this review. The screening process was conducted independently by two reviewers (VS and DO). Disagreements were discussed between authors and resolved by consensus.the study location ;the population ;the intervention characteristics, including information on the type of mHealth intervention , the data transmitted , interactivity of the intervention , and personalization ;the comparator (control) group intervention ; andoutcomes reported by the studies, including clinical outcomes, compliance, quality of life, costs and other outcomes.For each included study, information was collected on key characteristics of the RCTs concerning:In order to assess the relationship between intervention characteristics and outcomes, studies were categorized into one of four types of mHealth interventions as suggested by Howitt et al.  , and the reported outcome measures  made a meaningful analysis of pooled data impossible.Risk of bias was assessed qualitatively concerning selection bias , performance bias (blinding of participants and personnel), detection bias (blinding of outcome assessment), extent of loss to follow-up, reporting bias (selective outcome reporting), and other bias . We used the Cochrane Collaboration’s tool for assessing risk of bias and information on assessment were derived from the text . The fuln = 43), did not report results of an RCT (n = 25), did not take part in LaMICs (n = 13) or because of other reasons (n = 25). The final analysis included 8 studies, which met all inclusion criteria.Figure Table A total of 4375 participants were included in all eight studies, of whom 2095 received a mHealth intervention, 314 received an alternative landline-telephone based intervention, and 1966 were included in the control group. Trial size varied from 16 participants  to 2086 Table The most basic intervention in the category of remote monitoring & care support was an appointment-reminder system, where text messages were sent 24–48 h before the patients’ scheduled appointments .Four interventions required the patients to record key parameters of their disease, e.g., the Peak Expiratory Flow Rate (PEFR) for patients with Asthma , 29, theOnly one intervention fell into the category of clinical decision support systems . CommuniTable health promotion & awareness interventions targeted diabetic patients but none of the reported outcome measures was available from both studies. In the study by Balsa and Gandelman [The two andelman , where dandelman , where premote monitoring and care support, one study evaluated an interactive telephone-intervention for patients with diabetes [Out of the five studies evaluating tools for diabetes . PatientTwo studies evaluated interactive mHealth interventions for patients with asthma , 29, whePiette et al.  found thLiew et al.  found thThe only study of a decision support system by Tian et al.  found thcosts in terms of time and money for physicians and patients was observed by only one trial [The impact of mHealth on ne trial . It was This is the first review focusing specifically on RCTs of mHealth interventions against NCDs in LaMICs. Despite much enthusiasm about the ‘great potential’ of mHealth for addressing NCD needs in LaMICs and despite a growing body of literature on the topic, we found only eight studies that reported results of RCTs performed in LaMICs. Except for one study , these sNevertheless, our review provides a first glimpse of the slowly emerging evidence base on the effectiveness of mHealth interventions for NCDs and has important implications for policy-makers and researchers. First, it is remarkable that the evaluated mHealth interventions generally showed positive effects on reported outcome measures, including clinical outcomes, compliance, and quality of life. This finding is in line with findings from a much broader literature on communicable disease and maternal care, where many different kinds of mHealth interventions have been found to improve clinical outcomes and compliance of patients – although results have been shown to vary depending on the specific type of intervention –33.Second, our results suggest that particular types of mHealth interventions that were found to have positive effects on patients with communicable diseases and for improving maternal care are likely to be effective also for NCDs. For example, text message appointment reminders have been found to lead to higher pre-natal visit rates of pregnant women –36, and clinical decision support systems were identified during full-text screening [Third, our results show that there is very limited evidence on the effects of mhealth in low income countries as all included studies reported results of trials conducted in middle income countries. Furthermore, when considering the 4 broad categories of mHealth interventions that we defined at the beginning, i.e., interventions of 1) health promotion & awareness, 2) remote monitoring & care support, 3) disease surveillance & outbreak detection, and 4) decision support system, it is evident that available RCTs have focused mostly on mHealth interventions falling into category 2. Also Bloomfield et al.  concludecreening –43 but tcreening .An important limitation of our review is that we excluded all studies that did not report results of RCTs. Observational studies and non-randomized trials may provide important bits of information that are useful for understanding the effectiveness of mHealth. Nevertheless, we opted for excluding these studies as non-randomized trial designs carry a greater risk of being flawed as a result of multiple biases . AnotherOur review shows that there are only eight studies reporting results of RCTs of mHealth interventions for patients with NCDs in LaMICs. These have generally found positive results. However, a more detailed analysis of the specific effects of different types of mHealth interventions on different types of patients and a firm conclusion about the effectiveness of mHealth against NCDs is impossible because of the small number of studies and the heterogeneity of reported outcome measures.Nevertheless, our results indicate that some findings of the positive effects of mHealth interventions for patients with communicable diseases and for maternal care can be replicated by mhealth interventions for patients with NCDs. However, we can only repeat the conclusions of previous reviews , 16 thatCHWs, community health workers; DALYs, Disability Adjusted Life Years; FEV1%, Forced Expiratory Volume in 1 second; LaMICs, low and middle income countries; LMICs, lower middle income countries; mHealth, mobile health; NCDs, non-communicable diseases; PEFR, peak expiratory flow rate; RCTs, randomized controlled trials; UMICs, upper middle income countries