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Blockchain is a shared distributed digital ledger technology that can better facilitate data management, provenance and security, and has the potential to transform healthcare. Importantly, blockchain represents a data architecture, whose application goes far beyond Bitcoin – the cryptocurrency that relies on blockchain and has popularized the technology. In the health sector, blockchain is being aggressively explored by various stakeholders to optimize business processes, lower costs, improve patient outcomes, enhance compliance, and enable better use of healthcare-related data. However, critical in assessing whether blockchain can fulfill the hype of a technology characterized as ‘revolutionary’ and ‘disruptive’, is the need to ensure that blockchain design elements consider actual healthcare needs from the diverse perspectives of consumers, patients, providers, and regulators. In addition, answering the real needs of healthcare stakeholders, blockchain approaches must also be responsive to the unique challenges faced in healthcare compared to other sectors of the economy. In this sense, ensuring that a health blockchain is ‘fit-for-purpose’ is pivotal. This concept forms the basis for this article, where we share views from a multidisciplinary group of practitioners at the forefront of blockchain conceptualization, development, and deployment.

Objectives. To deploy a methodology accurately identifying tweets marketing the illegal online sale of controlled substances. Methods. We first collected tweets from the Twitter public application program interface stream filtered for prescription opioid keywords. We then used unsupervised machine learning (specifically, topic modeling) to identify topics associated with illegal online marketing and sales. Finally, we conducted Web forensic analyses to characterize different types of online vendors. We analyzed 619 937 tweets containing the keywords codeine, Percocet, fentanyl, Vicodin, Oxycontin, oxycodone, and hydrocodone over a 5-month period from June to November 2015. Results. A total of 1778 tweets (< 1%) were identified as marketing the sale of controlled substances online; 90% had imbedded hyperlinks, but only 46 were “live” at the time of the evaluation. Seven distinct URLs linked to Web sites marketing or illegally selling controlled substances online. Conclusions. Our methodology can identify illegal online sale of prescription opioids from large volumes of tweets. Our results indicate that controlled substances are trafficked online via different strategies and vendors. Public Health Implications. Our methodology can be used to identify illegal online sellers in criminal violation of the Ryan Haight Online Pharmacy Consumer Protection Act.

The Open Payments database reports payments made to physicians by industry. Given the potential for financial conflicts of interest relating to patient outcomes, further scrutiny of these data is valuable. Therefore, the objective of this study was to analyze physician-industry relationships by specialty type, payment type, geospatial trend, and longitudinal trend between 2014–2018. We conducted an observational, retrospective data analysis of payments from the Open Payments database for licensed United States physicians listed in the National Plan & Provider Enumeration System (NPPES). Datasets from 2013–2018 were joined using the Python programming language. Aggregation and sub-setting by characteristics of interest was done in R to calculate means and frequencies of reported general physician payments from industry across different specialties, locations, timeframes, and payment types. Normalization was applied for numbers of physicians or payments. Geospatial statistical hot spot analysis was conducted in ArcGIS. 51.73 million payment records were analyzed. In total, 50,047,930 payments were issued to 771,113 allopathic or osteopathic physicians, representing$8,702,631,264 transferred from industry to physicians over the five-year period between 2014 and 2018. The mean payment amount was $ 179, with a standard deviation of $12,685. Variability in physicians’ financial relationships with industry were apparent across specialties, regions, time, and payment type. A limited match rate between records in the NPPES and Open Payments databases may have resulted in selection bias of trends related to physician characteristics. Further research is necessary, particularly in the context of changing industry payment trends and public perceptions of the appropriateness of these relationships.

Social media use is now ubiquitous, but the growth in social media communications has also made it a convenient digital platform for drug dealers selling controlled substances, opioids, and other illicit drugs. Previous studies and news investigations have reported the use of popular social media platforms as conduits for opioid sales. This study uses deep learning to detect illicit drug dealing on the image and video sharing platform Instagram. The aim of this study was to develop and evaluate a machine learning approach to detect Instagram posts related to illegal internet drug dealing. In this paper, we describe an approach to detect drug dealers by using a deep learning model on Instagram. We collected Instagram posts using a Web scraper between July 2018 and October 2018 and then compared our deep learning model against 3 different machine learning models (eg, random forest, decision tree, and support vector machine) to assess the performance and accuracy of the model. For our deep learning model, we used the long short-term memory unit in the recurrent neural network to learn the pattern of the text of drug dealing posts. We also manually annotated all posts collected to evaluate our model performance and to characterize drug selling conversations. From the 12,857 posts we collected, we detected 1228 drug dealer posts comprising 267 unique users. We used cross-validation to evaluate the 4 models, with our deep learning model reaching 95% on F1 score and performing better than the other 3 models. We also found that by removing the hashtags in the text, the model had better performance. Detected posts contained hashtags related to several drugs, including the controlled substance Xanax (1078/1228, 87.78%), oxycodone/OxyContin (321/1228, 26.14%), and illicit drugs lysergic acid diethylamide (213/1228, 17.34%) and 3,4-methylenedioxy-methamphetamine (94/1228, 7.65%). We also observed the use of communication applications for suspected drug trading through user comments. Our approach using a combination of Web scraping and deep learning was able to detect illegal online drug sellers on Instagram, with high accuracy. Despite increased scrutiny by regulators and policymakers, the Instagram platform continues to host posts from drug dealers, in violation of federal law. Further action needs to be taken to ensure the safety of social media communities and help put an end to this illicit digital channel of sourcing.

Background: Pharmaceutical corruption is a serious challenge in global health. Digital technologies that can detect and prevent fraud and corruption are particularly important to address barriers to access to medicines, such as medicines availability and affordability, stockouts, shortages, diversion, and infiltration of substandard and falsified medicines. Objectives: To better understand how digital technologies are used to combat corruption, increase transparency, and detect fraud in pharmaceutical procurement systems to improve population health outcomes. Methods: We conducted a multidisciplinary review of the health/medicine, engineering, and computer science literature. Our search queries included keywords associated with medicines procurement and digital technology in combination with terms associated with transparency and anti-corruption initiatives. Our definition of 'digital technology' focused on Internet-based communications, including online portals and management systems, supply chain tools, and electronic databases. Results: We extracted 37 articles for in-depth review based on our inclusion criteria focused on the utilization of digital technology to improve medicines procurement. The vast majority of articles focused on electronic data transfer and/or e-procurement systems with fewer articles discussing emerging technologies such as machine learning and blockchain distributed ledger solutions. In the context of e-procurement, slow adoption, justifying cost-savings, and need for technical standards setting were identified as key challenges for current and future utilization. Conclusions: Though there is a significant promise for digital technologies, particularly e-procurement, overall adoption of solutions that can enhance transparency, accountability and concomitantly combat corruption, is still underdeveloped. Future efforts should focus on tying cost-saving measurements with anti-corruption indicators, prioritizing centralization of e-procurement systems, establishing regulatory harmonization with standards setting, and incorporating additional anti-corruption technologies into procurement processes for improving access to medicines and to reach the overall goal of Universal Health Coverage.

Background The U.S Congress initiated sanctions against Iran after the 1979 U.S. Embassy hostage crisis in Tehran, and since then the scope of multilateral sanctions imposed by the United States, the European Union, and the United Nations Security Council have progressively expanded throughout the intervening years. Though primarily targeted at Iran’s nuclear proliferation activities, sanctions have nevertheless resulted in negative public health outcomes for ordinary Iranian citizens. This includes creating vital domestic shortages to life-saving medicines, leaving an estimated 6 million Iranian patients with limited treatment access for a host of diseases. Sanctions have also crippled Iran’s domestic pharmaceutical industry, leading to the disruption of generic medicines production and forcing the country to import medicines and raw materials that are of lower or questionable quality. Discussion Countries such as the United States have responded to this medical crisis by implementing export control exemptions with the aim of easing the trade of humanitarian goods (including certain pharmaceuticals and medical devices). However, despite these efforts, pharmaceutical firms and international banking institutions remain cautious about doing business with Iran, leaving the country faced with continuing shortages. We conducted a review of key characteristics of the Iranian drug shortage that identified 73 shortage drugs that closely tracked with the disease burden in the country. Additionally, 44 % of these drugs were also classified as essential medicines by the World Health Organization. A vast majority of these drugs were also covered under export control exemptions that theoretically should make them easier to procure, but nevertheless will still in shortage. Summary Based on our review of the sanctions regulatory framework and key characteristics of the Iranian drug shortage, we propose policy intervention leveraging the recently negotiated P5 + 1 agreement that begins the process of providing Iran relief from the international economic sanctions regime. This specifically includes advocating for the application of “health diplomacy” in ongoing multilateral negotiations following commencement of “implementation day,” by advocating for an additional set of reform measures incorporated into this historic negotiation that will finally address the humanitarian and medical crisis of drug shortages in Iran.

From late 2014 through 2015, Scott County, Indiana faced an HIV outbreak triggered by opioid abuse and transition to injection drug use. Investigating the origins, risk factors, and responses related to this outbreak is critical to inform future surveillance, interventions, and policymaking. In response, this retrospective infoveillance study identifies and characterizes user-generated messages related to opioid abuse, heroin injection drug use, and HIV status using natural language processing (NLP) among Twitter users in Indiana during the period of this HIV outbreak. Our study consisted of two phases: data collection and processing, and data analysis. We collected Indiana geolocated tweets from the public Twitter API using Amazon Web Services EC2 instances filtered for geocoded messages in the immediate pre and post period of the outbreak. In the data analysis phase we applied an unsupervised machine learning approach using NLP called the Biterm Topic Model (BTM) to identify tweets related to opioid, heroin/injection, and HIV behavior and then examined these messages for HIV risk-related topics that could be associated with the outbreak. More than 10 million geocoded tweets occurring in Indiana during the immediate pre and post period of the outbreak were collected for analysis. Using BTM, we identified 1350 tweets thought to be relevant to the outbreak and then confirmed 358 tweets using human annotation. The most prevalent themes identified were tweets related to self-reported abuse of illicit and prescription drugs, opioid use disorder, self-reported HIV status, and public sentiment regarding the outbreak. Geospatial analysis found that these messages clustered in population dense areas outside of the outbreak, including Indianapolis and neighboring Clark County. This infoveillance study characterized the social media conversations of communities in Indiana in the pre and post period of the 2015 HIV outbreak. Behavioral themes detected reflect discussion about risk factors related to HIV transmission stemming from opioid and heroin abuse for priority populations, and also help identify community attitudes that could have motivated or detracted the use of HIV prevention methods, along with helping identify factors that can impede access to prevention services. Infoveillance approaches, such as the analysis conducted in this study, represent a possibly strategy to detect \"signal\" of the emergence of risk factors associated with an outbreak though may be limited in their scope and generalizability. Our results, in conjunction with other forms of public health surveillance, can leverage the growing ubiquity of social media platforms to better detect opioid-related HIV risk knowledge, attitudes and behavior, as well as inform future prevention efforts.

Background As the 2014 Ebola virus disease outbreak (EVD) transitions to its post-endemic phase, its impact on the future of global public health, particularly the World Health Organization (WHO), is the subject of continued debate. Criticism of WHO’s performance grew louder in the outbreak’s wake, placing this international health UN-specialized agency in the difficult position of navigating a complex series of reform recommendations put forth by different stakeholders. Decisions on WHO governance reform and the broader role of the United Nations could very well shape the future landscape of 21st century global health and how the international community responds to health emergencies. Discussion In order to better understand the implications of the EVD outbreak on global health and infectious disease governance, this debate article critically examines a series of reports issued by four high-level commissions/panels convened to specifically assess WHO’s performance post-Ebola. Collectively, these recommendations add increasing complexity to the urgent need for WHO reform, a process that the agency must carry out in order to maintain its legitimacy. Proposals that garnered strong support included the formation of an independent WHO Centre for Emergency Preparedness and Response, the urgent need to increase WHO infectious disease funding and capacity, and establishing better operational and policy coordination between WHO, UN agencies, and other global health partners. The recommendations also raise more fundamental questions about restructuring the global health architecture, and whether the UN should play a more active role in global health governance. Summary Despite the need for a fully modernized WHO, reform proposals recently announced by WHO fail to achieve the “evolution” in global health governance needed in order to ensure that global society is adequately protected against the multifaceted and increasingly complex nature of modern public health emergencies. Instead, the lasting legacy of the EVD outbreak may be its foreshadowing of a governance “shift” in formal sharing of the complex responsibilities of global health, health security, outbreak response, and managing health emergencies to other international structures, most notably the United Nations. Only time will tell if the legacy of EVD will include a WHO that has the full support of the international community and is capable of leading human society in this brave new era of the globalization of infectious diseases.

Background Advances in science and technology coupled with globalization are changing access to and utilization of reproductive health services. This includes the transnational phenomenon of families who use surrogate mothers to reproduce, with forms of altruistic and commercial surrogacy becoming more commonplace. Simultaneously, changes in law, regulation, and policy are necessary to protect surrogates, intended parents, and resulting children. These developments have been slow to adapt to challenges inherent to surrogacy arrangements, most specifically in low-and middle-income countries, including in South American countries. Methods We conducted an interdisciplinary non-systematic literature review and legal analysis of existing and pending policy, laws, and regulations related to commercial surrogacy arrangements in Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Paraguay, Peru, Uruguay, and Venezuela. The review focused on articles that discussed topics of domestic and international law, policy, regulation, and governance related to commercial surrogacy. We queried PubMed, JSTOR, and Google Scholar for Spanish and English-language articles limited to those published between 2000 and 2016. Results Our literature and legal review found a wide variance in how different countries address the issue, including two (Brazil and Uruguay) that have issued guidance attempting to clarify the legality of commercial surrogacy, others who have introduced surrogacy-specific legislation, and a final group with no specific legal mechanisms in place. Our extracted legal case studies also indicate that courts have a hard time interpreting existing law and its applicability to surrogacy. The influence of Catholicism also played a role in the adoption of surrogacy and other advanced reproductive technology (ART)-related legislation. Conclusions Changes in global infertility rates, the emergence of new family structures, and advancement of ART are factors that will influence future development of legal frameworks addressing surrogacy in South America. Despite a growing transnational market for commercial surrogacy in many of the countries examined, the current patchwork of policy does little to clarify what forms of surrogacy are legally permissible, nor do they adequately protect surrogates, intended parents, or the children themselves. This points to an urgent need for regional legal and policy harmonization specifically designed to align with public health and human rights principles.

Background After 7 years of increasing conflict and violence, the Syrian civil war now constitutes the largest displacement crisis in the world, with more than 6 million people who have been internally displaced. Among this already-vulnerable population group, women and children face significant challenges associated with lack of adequate access to maternal and child health (MCH) services, threatening their lives along with their immediate and long-term health outcomes. Discussion While several health and humanitarian aid organizations are working to improve the health and welfare of internally displaced Syrian women and children, there is an immediate need for local medical humanitarian interventions. Responding to this need, we describe the case study of the Brotherhood Medical Center (the “Center”), a local clinic that was initially established by private donors and later partnered with the Syrian Expatriate Medical Association to provide free MCH services to internally displaced Syrian women and children in the small Syrian border town of Atimah. Conclusions The Center provides a unique contribution to the Syrian health and humanitarian crisis by focusing on providing MCH services to a targeted vulnerable population locally and through an established clinic. Hence, the Center complements efforts by larger international, regional, and local organizations that also are attempting to alleviate the suffering of Syrians victimized by this ongoing civil war. However, the long-term success of organizations like the Center relies on many factors including strategic partnership building, adjusting to logistical difficulties, and seeking sustainable sources of funding. Importantly, the lessons learned by the Center should serve as important principles in the design of future medical humanitarian interventions working directly in conflict zones, and should emphasize the need for better international cooperation and coordination to support local initiatives that serve victims where and when they need it the most.