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Climate Change, Statelessness, and Digital Sovereignty: Safeguarding Island Nationhood
Full text linkAs climate change accelerates the existential threat facing Small Island Developing States (SIDS), the case of Tuvalu represents a profound legal and moral challenge to international law. Tuvalu has pledged to maintain its sovereignty “in perpetuity,” even if rising seas render its territory uninhabitable. This research interrogates a central question: How can international law accommodate a state’s sovereign continuity in the absence of physical territory, and what transformative legal frameworks are necessary to support post-territorial statehood in climate-vulnerable contexts? This inquiry situates Tuvalu’s constitutional commitment to sovereignty within broader debates on climate justice, environmental displacement, and the postcolonial dimensions of international law. This paper explores how climate-induced statelessness reveals structural inequities embedded in doctrines of statehood, territorial integrity, and recognition. The paper draws upon relevant international legal instruments, including the 1933 Montevideo Convention, the United Nations Convention on the Law of the Sea (UNCLOS), the Paris Agreement, and emerging jurisprudence from the International Court of Justice (ICJ), particularly the 2023 advisory opinion proceedings initiated by Vanuatu. The research also critically examines Tuvalu’s Future Now Project, a pioneering initiative that seeks to preserve Tuvalu’s cultural, legal, and governmental identity through a digitised state apparatus hosted on cloud infrastructure. This novel strategy challenges traditional understandings of sovereignty, legal personality, and state continuity. In doing so, it introduces the concept of “digital sovereignty” as both a technological and legal innovation aimed at resisting erasure in an international system slow to adapt to ecological collapse. Furthermore, the paper considers the decolonial implications of Tuvalu’s stance
Development of an Instrument for Measuring Diversity in Teaching Resources: The GRADES10©.
Full text linkBackground: Higher education institutions around the world have a responsibility to diversify their course content. This is an important consideration to ensure that students are prepared to serve a diverse population once they graduate, however, a lack of diversity representation in medical school curricula in particular, is reported in the literature. A paucity of reliable resources to support creating more inclusive content is also reported.
Methods: This study developed and validated a diversity measurement instrument, designed to look at representation in the areas of gender, religion, age, disability, ethnicity/race, sexuality, and socio-economic status. Early prototypes were sent to experts for validity testing and using their feedback, improvements and iterations were made to the instrument until the final instrument was agreed: the GRADES10©. The instrument was then applied to a variety of medical education resources to test for rater-reliability. An accompanying user guide was developed to support users with application of the GRADES10© in practice.
Results: Face validity was conducted by 10 experts on several iterations of the instrument from the early prototype (GRADESs7), until the final agreed GRADES10©. Rater-reliability was calculated by intraclass correlation coefficient (ICC) and Cronbach’s Alpha measure of internal consistency. The GRADES10© instrument was shown to have an ICC of 0.83% (SD 0.725 – 0.907) p=<.0001, and Cronbach’s Alpha of 0.97.
Conclusions: Overall, this study has shown that the validated GRADES10© instrument is able to measure diversity in medical teaching resources reliably. The GRADES10© has the potential to contribute to creating a more inclusive learning environment by allowing its users to apply a diversity metric to their educational materials, to identify gaps and areas for improvement. If applied by medical schools in future, the GRADES10© may impact the grassroots of medical education diversification which may have a knock-on effect on student attitudes, experiences and ultimately on patient care
Is there Gender Bias in Medical Resources used in Undergraduate Medical Education? A Content Analysis Using the Gender Bias 14 (GB14) Measurement Tool.
Full text linkBackground: Medicine has been conceived as a male led career for centuries, with 58% of higher trainee jobs in the national health service being occupied by men. Male gender biases and discrimination against women in Medicine have been found to contribute to women choosing certain specialties, such as General Practice rather than surgery. This is likely attributable to healthcare professional cultures, equipment and resources, as well as a lack of female role models in e.g., general surgery. What is not apparent from the literature is whether a gender bias exists at undergraduate level, especially within teaching resources, which may also be contributing to future career choices made by women in medicine.
Methods: This study was a content analysis of a selection of core medical education resources including 3 chapters of a single medical textbook and all year 1 reading lists. Using the GB14(c) genderness tool, these resources were quantitively measured for extent of gender bias within. The GB14(c) measures bias on a sliding scale, with male bias represented by a plus score (+) and female bias represented by a minus (-) score, therefore results are given as + or - respectively with both indicating gender bias in one direction or the other. The GB14© gives an overall outcome of low, moderate, high or extremely high bias, depending on the score.
Results: Results highlighted an overall moderate level male bias across the 3 chapters of the core medical textbook. The authors of the chapters within this book were also moderately male biased (+23). Chapter by chapter, there was male bias in all but reproduction as follows: Cardiovascular System = +37; Respiratory System = +26; Reproductive System = -193.
The six year-1 module reading lists proved to be highly male biased with 267/305(88%) authors being male. % male authors per module were: FHD module 46/56(82%); HLB 42/47(89%); NME 33/36(91%); NB 61/67(92%); RE 54/59(91%); and MIS 35/45(77%).
Conclusions: There are male gender biases within medical education core teaching materials which may have impacts on female medical students, who aren’t then exposed to female role models or female representation overall. This may impact women’s future career aspirations by leading women into specialities they are more represented in, such as family medicine or obstetrics, gynaecology, and reproductive medicine. This is likely attributable to historical dominance of men in medicine and science with a predominance of males writing these textbooks therefore leading to a general lack of available resources which are gender balanced. Recommendations are for medical schools to include a wider pool of gender balanced resources where possible, but for the medicine and STEM community to encourage more publications from women
Clinical audit regarding adherence to emergency CT imaging pathways in anticoagulated elderly patients with a post-fall head injury.
Full text linkBackground: Anticoagulating patients prone to falls is a complicated decision, given the risk of intracranial haemorrhage (ICH). However, the balance of literature potentially now contradicts the weight of this risk. Several articles were identified demonstrating that anticoagulation is generally weakly associated with ICH, and that other signs such as reduced Glasgow coma scale (GCS) or skull fractures are better predictors. Yet anticoagulation was a key criterion for CT scanning patients who have sustained a head injury (HI) under National Institute for Health and Care Excellence (NICE) guidelines (2014), which state that even in the absence of other risk factors, anticoagulated patients should have a CT head scan within eight hours of HI, or within the hour if presenting more than eight hours from injury. Given the literature findings, it would be reasonable to assume that clinicians may doubt the usefulness of such guidelines, and hence clinical practice may vary. A research question was therefore created- ‘Are emergency department (ED) clinicians appropriately CT scanning anticoagulated elderly patients with a post-fall head injury in accordance with local trust protocol?’
Methods: An audit was designed to answer this question, which involved retrospectively reviewing 50 anticoagulated patients aged 65 or over who had presented to the ED of a single secondary care Trust, over a three-month period due to a post-fall HI, to ascertain whether they had a CT scan in the recommended timeframe.
Results: The audit identified the department’s compliance with guidelines as 78%, though most non-compliance was linked to a subset of patients who required a scan within one hour of attendance as their injury occurred more than eight hours prior, and if this subset was excluded, compliance was 93%. The one-hour scan target was subsequently discussed as being potentially unrealistic given National Health Service (NHS) pressures. Upon further scrutiny, the department’s non-compliance can be divided into scans which were delayed, or not done, though it is important to note that none of these patients came to harm as a result.
Conclusions: This study was limited by the fact that during the course of the project, NICE altered their guidelines, firstly to include antiplatelet medications, and secondly to recommend that in the absence of other risk factors, CT scan need only be considered rather than automatically done. This had significant implications for the audit but enabled the data to be reinspected following the change. While this was a subjective analysis, it appeared that the guidelines had been changed in line with evidence from the literature review and this audit’s findings and highlighted that as clinicians become more familiar with the updated guidelines, significant time and money could be spared for this indication. This project has set a precedent for expanding the scope of this audit and evidenced where further research may be indicated
Public health response and challenges during COVID-19 in Nigeria: a systematic review.
Full text linkBackground: The COVID-19 pandemic brought unprecedented challenges to public health systems worldwide. Nigeria faced unique challenges due to its diverse cultural landscape and the influence this may have had on public health behaviour. This systematic review explored the effectiveness of the public health response and identifies the challenges encountered in Nigeria during the COVID-19 crisis by collating data from qualitative studies, especially focusing on the perceptions, experiences, and opinions of Nigerians towards COVID-19 management, including healthcare workers and internally displaced populations.
Methods: A total of eight papers were selected for systematic review. This systematic review followed the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines to ensure transparency and reproducibility. Critical Appraisal Skills Programme (CASP) checklist for qualitative studies was used to evaluate the validity and applicability of the research findings. Qualitative studies were deliberately included to communicate deeper insights into the beliefs, values, and motivations driving public behaviour during the pandemic. Thematic analysis was then applied to identify and form themes within the data.
Results: The thematic analysis revealed insights into Nigeria's public health response during the COVID-19 pandemic. Major themes included government response, public compliance, healthcare accessibility linked to socioeconomic status, community engagement, and health facility resources. Gaps were identified in support for vulnerable groups, efficient aid delivery, ensuring adherence to guidelines due to economic constraints and stigma, and addressing systemic issues like poverty, overcrowding, low literacy, and healthcare worker burnout. The importance of comprehensive, inclusive approaches tailored to cultural contexts and lived experiences was emphasised. Recommendations highlight strengthening community- healthcare partnerships, incorporating faith groups and local organisations, integrating technology, and tackling corruption.
Conclusions: The themes identified through this systematic review illustrated the challenges and complexities faced by Nigeria during the COVID-19 pandemic. They highlighted the necessity for integrated, inclusive, and adaptable public health responses that address the multifaceted impacts of the pandemic. This research stressed the importance of considering cultural, economic, and social factors in crisis response planning and implementation. Ensuring that public health interventions are culturally appropriate, economically feasible, and socially acceptable are essential aspects of future pandemic management
What are the lived experiences of ethnic minority women regarding maternity care in the United Kingdom? A systematic review.
Full text linkBackground: In the United Kingdom, ethnic minority women are significantly more likely to experience severe complications related to maternity care compared to their white counterparts, underscoring a critical need for targeted research into the systemic inequities affecting their healthcare outcomes.
Methods: This systematic review aimed to synthesise the existing literature to gain insights into ethnic minority women’s maternity care experience, focusing on its impact on their health outcomes and satisfaction levels.
Results: This systematic review of qualitative studies was conducted through searches in databases such as PubMed, Science Direct, MIDIRIS, and CINAHL. The focus of the search was based on the literature from 2016, considering the Better Births initiative. The inclusion criteria was all studies that touch on the antenatal, intrapartum, and postnatal care of ethnic minority women in the UK.
Conclusions: Findings have shown that individualised maternity care is one of the primary factors helping ethnic minority women increase their experience of receiving maternity services. Adapting maternal services and being flexible enough to respond to the diversity of needs will be valuable in avoiding inequity and improving the quality of care. Therefore, there is a need for an in-depth study to explore the impact of individualised maternity care on ethnic minority women
What anthropometric, psychological, and lifestyle factors influence endogenous pain modulation?
Full text linkBackground: The endogenous pain modulatory system in humans inhibits the sensation of pain throughout the body. Conditioned Pain Modulation (CPM) is an experimental technique used to measure the capabilities of this system in an individual. It is unknown which factors are most predictive of an individual’s ability to modulate pain endogenously, and which type of factors are most significant. Thus, this research aimed to discover the relationship between anthropometric, psychological and lifestyle factors and CPM in healthy adults.
Methods: Twenty-six adults (12 males, 14 females) attended two lab visits; their age, height, weight, BMI, and fat mass percentage presented as mean ± SD were 23 ± 3 years, 172 ± 8 cm, 68± 11 kg, 23.15 ± 3.98, and 24% ± 10.5% respectively. To measure CPM, participants first underwent test stimulus (on index finger of right hand) by pressing an algometer and reaching 0.5 out of 10 on the Cook Pain Intensity Scale. This was followed by the conditioning stimulus (above antecubital fossa of left arm) where a pressure cuff was inflated gradually to 7 out of 10 on the scale. Following this, the test stimulus was tested again. The outcome variable was the degree of change in pressure pain threshold before and after the conditioning stimulus. Psychological variables measured include positive and negative affect, pain expectation and confidence, and pain quality. Subjective and objective measures of physical activity were taken. Stepwise regression analysis was performed to identify which variables can form a regression model which can predict participants’ CPM. Significance testing was used to identify the variables that are significant independent predictors of CPM.
Results: The regression model included five variables which predicted 62.1% of the variance in CPM (R2 = 0.621, Adjusted R2 = 0.526, ΔR2 = 0.087) with a p < .001. These variables were negative affect at the present moment, pain expectation, objective walking data (hr/day), subjective vigorous physical activity (day/week) and walking data (day/week). The first three variables were negatively correlated with CPM, while the latter were positively correlated. Negative affect and pain expectation combined explained the most variance (31.6%) before the lifestyle factors. Significance testing revealed only the first three variables were significant independent predictors of CPM (p <.05), whereas the subjective physical activity measures were not (p >.05).
Conclusions: This study provides evidence for the importance of psychological and lifestyle factors in the efficacy of the endogenous pain modulatory system, highlighting psychological factors as more significant. Objective walking data is negatively correlated with CPM, while self-reported vigorous physical activity and walking help contribute to the accurate prediction of CPM but are not directly correlated with the efficacy of endogenous pain modulation significantly. The discovery of these five variables as key in predetermining CPM, and the endogenous analgesic system by extension, sets up key targets for promoting emotional well-being and physical activity as effective pain management strategies. The findings should lead future research to identify what interventions can improve these five variables the most effectively and improve endogenous pain inhibition
Trickster Methods for Decolonial Resistance or How the Cardinal turned Red
Full text linkThis essay operates through a trickster story as philosophy essay format, which focuses on the discussion of the nature of a kind of trickster decolonial resistance grounding in kinship with the Land. In this trickster story, Jisdu, the Cherokee rabbit trickster, visits the Vatican for a conference on happiness and well-being. While traveling through the Earth to reach the Vatican (Elohi), Jisdu is presented a lecture by Elohi regarding the meaning of kinship with Land and decolonial resistence. When Jisdu reaches the Vatican, he tries out these Earth lessons on an unsuspecting Cardinal. Lessons are learned, trickstering occurs, faces turn red, and laughs are had
Tsalagi Scholars: Land, Stories, Relations
Full text linkThis issue of Transmotion gathers essays from members of the Tsalagi Scholars collective, which consists of citizens from the Cherokee Nation, the United Keetoowah Band of Cherokee Indians, and the Eastern Band of Cherokee Indians. It also includes the Spring 2024 issue of the student lirerary journal from Cherokee High School on the land of the Eastern Band of Cherokee Indians
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