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The terminal Ediacaran Period is signaled worldwide by the first appearance of skeletonizing tubular metazoan fossils, e.g., Cloudina Germs, 1972 and Sinotubulites Chen, Chen, and Qian, 1981. Although recent efforts have focused on evaluating the taxic composition and preservation of such assemblages from the southwestern United States, comparable forms reported in the 1980s from Mexico remain to be re-examined. Here, we reassess the latest Ediacaran skeletal materials from the La Ciénega Formation of the Caborca region in Sonora, Mexico, using a combination of analytical methods: optical microscopy of extracted fossils, thin-section petrography, scanning electron microscopy and energy dispersive X-ray spectroscopy, and X-ray tomographic microscopy. From our examination, we conclude that the La Ciénega hosts a polytaxic assemblage of latest Ediacaran tubular organisms that have been preserved through two taphonomic pathways: coarse silicification and calcareous recrystallization preserving finer details. Further, these fossils show signs that their shells might not have been inflexible or completely mineralized in vivo, and that they might also record tentatively interpreted predation traces in the form of drill holes or puncture marks. This work, along with ongoing efforts around the world, helps to provide a framework for biostratigraphic correlation and possible subdivision of the Ediacaran Period, and further shapes our view of metazoan evolution and ecology in the interval directly preceding the Cambrian explosion.
The first section of this chapter looks at how the two terms ‘migrant’ and ‘refugee’ came to be defined as distinct from each other in the context of the modern state. The second examines how states define and categorise refugees through laws that seek to contain and limit their flow. The third section is concerned with the consequences of limiting the definition of a refugee, which has led to an unequal burden between developed and developing states. The final section will canvass the various options presented to reduce the present imbalance where the vast majority of the world’s refugees eke out an existence in refugee camps in developing countries. Ultimately, this chapter seeks to demonstrate that the choices made by states in border protection become the key determinants of how refugees will be accepted. Adherence to international refugee law will not necessarily address all the problems associated with refugees, but nor will seeing refugees as unwanted intruders in contrast to ‘desirable’ migrants.
Between 2016 and 2020 the Australian government established a regional health security diplomacy project, known as the Indo–Pacific Centre for Health Security. In light of the COVID-19 pandemic, the initiative looked prescient. Its roots, however, could be traced back to Australia’s engagement with health security in the early 2000s. Then, as now, the government aligned its foreign policy agenda with health – specifically emerging infectious diseases – as a ‘scaled up’ approach comprising diplomatic, aid, and research and development. To explain Australia’s evolving relationship with health security this chapter proceeds in four parts. First, health security is situated with the recent tradition of ‘non-traditional security’. The second part examines the establishment of health security as a core theme in Australia’s response to global challenges. The third part turns to the government’s strategy and especially the Indo–Pacific Centre for Health Security both before and during the COVID-19 era. Finally, the chapter examines how Australia conceptualised its leadership role in regional health security.
Understanding characteristics of healthcare personnel (HCP) with SARS-CoV-2 infection supports the development and prioritization of interventions to protect this important workforce. We report detailed characteristics of HCP who tested positive for SARS-CoV-2 from April 20, 2020 through December 31, 2021.
Methods:
CDC collaborated with Emerging Infections Program sites in 10 states to interview HCP with SARS-CoV-2 infection (case-HCP) about their demographics, underlying medical conditions, healthcare roles, exposures, personal protective equipment (PPE) use, and COVID-19 vaccination status. We grouped case-HCP by healthcare role. To describe residential social vulnerability, we merged geocoded HCP residential addresses with CDC/ATSDR Social Vulnerability Index (SVI) values at the census tract level. We defined highest and lowest SVI quartiles as high and low social vulnerability, respectively.
Results:
Our analysis included 7,531 case-HCP. Most case-HCP with roles as certified nursing assistant (CNA) (444, 61.3%), medical assistant (252, 65.3%), or home healthcare worker (HHW) (225, 59.5%) reported their race and ethnicity as either non-Hispanic Black or Hispanic. More than one third of HHWs (166, 45.2%), CNAs (283, 41.7%), and medical assistants (138, 37.9%) reported a residential address in the high social vulnerability category. The proportion of case-HCP who reported using recommended PPE at all times when caring for patients with COVID-19 was lowest among HHWs compared with other roles.
Conclusions:
To mitigate SARS-CoV-2 infection risk in healthcare settings, infection prevention, and control interventions should be specific to HCP roles and educational backgrounds. Additional interventions are needed to address high social vulnerability among HHWs, CNAs, and medical assistants.
Human milk improves neurodevelopment for preterm infants, but relationships between human milk and neurodevelopment for infants with critical CHD are unknown. We aimed to (1) explore associations between human milk/direct breastfeeding and neurodevelopment at 1-year and 2-year follow-up and (2) describe patterns of human milk (maternal, donor) and commercial formula during hospitalisation in the first year of life.
This retrospective cohort study included infants who underwent surgery for CHD < 6 months old. The primary outcome was neurodevelopment via Bayley Scales of Infant Development-IV. Analysis included adjusted linear regression for associations between exclusive human milk while inpatient during the first 6 months or any direct breastfeeding while inpatient during the first year of life and 1-year Bayley-IV scores. Models were adjusted for race, insurance type, genetic diagnosis, and length of stay.
Of 98 eligible infants, 40% followed up at 1 year; 27% at 2 years. There were differences in follow-up related to demographics (race, ethnicity) and social determinants of health (insurance type, distance from clinic). In adjusted models, infants who directly breastfed had 13.18 points higher cognition (95% CI: 0.84–25.53, p = 0.037); 14.04 points higher language (2.55–25.53, p = 0.018); and 15.80 points higher motor scores (3.27–28.34, p = 0.015) at 1-year follow-up. Infants fed exclusive human milk had 12.64 points higher cognition scores (−0.53–25.82, p = 0.059).
Future investigation into nutrition and neurodevelopment in the context of critical CHD is warranted. As neurodevelopmental follow-up becomes standard of care in this population, efforts are needed to mitigate disparities in access to this care.
This paper contributes to an increasingly critical assessment of a policy framing of ‘financial resilience’ that focuses on individual responsibility and financial capability. Using a participatory research and design process, we construct a ground-up understanding of financial resilience that acknowledges not only an individual’s actions, but the contextual environment in which they are situated, and how those relate to one another. We inductively identify four inter-connected dimensions of relational financial resilience: infrastructure (housing, health, and childcare), financial and economic factors (income, expenses, and financial services and strategies), social factors (motivation and community and family), and the institutional environment (policy and local community groups, support and advice services). Consequently, we recommend that social policies conceptualise financial resilience in relational terms, as a cross-cutting policy priority, rather than being solely a facet of individual financial capability.
To characterize residential social vulnerability among healthcare personnel (HCP) and evaluate its association with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection.
Design:
Case–control study.
Setting:
This study analyzed data collected in May–December 2020 through sentinel and population-based surveillance in healthcare facilities in Colorado, Minnesota, New Mexico, New York, and Oregon.
Participants:
Data from 2,168 HCP (1,571 cases and 597 controls from the same facilities) were analyzed.
Methods:
HCP residential addresses were linked to the social vulnerability index (SVI) at the census tract level, which represents a ranking of community vulnerability to emergencies based on 15 US Census variables. The primary outcome was SARS-CoV-2 infection, confirmed by positive antigen or real-time reverse-transcriptase– polymerase chain reaction (RT-PCR) test on nasopharyngeal swab. Significant differences by SVI in participant characteristics were assessed using the Fisher exact test. Adjusted odds ratios (aOR) with 95% confidence intervals (CIs) for associations between case status and SVI, controlling for HCP role and patient care activities, were estimated using logistic regression.
Results:
Significantly higher proportions of certified nursing assistants (48.0%) and medical assistants (44.1%) resided in high SVI census tracts, compared to registered nurses (15.9%) and physicians (11.6%). HCP cases were more likely than controls to live in high SVI census tracts (aOR, 1.76; 95% CI, 1.37–2.26).
Conclusions:
These findings suggest that residing in more socially vulnerable census tracts may be associated with SARS-CoV-2 infection risk among HCP and that residential vulnerability differs by HCP role. Efforts to safeguard the US healthcare workforce and advance health equity should address the social determinants that drive racial, ethnic, and socioeconomic health disparities.
The quenching of cluster satellite galaxies is inextricably linked to the suppression of their cold interstellar medium (ISM) by environmental mechanisms. While the removal of neutral atomic hydrogen (H i) at large radii is well studied, how the environment impacts the remaining gas in the centres of galaxies, which are dominated by molecular gas, is less clear. Using new observations from the Virgo Environment traced in CO survey (VERTICO) and archival H i data, we study the H i and molecular gas within the optical discs of Virgo cluster galaxies on 1.2-kpc scales with spatially resolved scaling relations between stellar ($\Sigma_{\star}$), H i ($\Sigma_{\text{H}\,{\small\text{I}}}$), and molecular gas ($\Sigma_{\text{mol}}$) surface densities. Adopting H i deficiency as a measure of environmental impact, we find evidence that, in addition to removing the H i at large radii, the cluster processes also lower the average $\Sigma_{\text{H}\,{\small\text{I}}}$ of the remaining gas even in the central $1.2\,$kpc. The impact on molecular gas is comparatively weaker than on the H i, and we show that the lower $\Sigma_{\text{mol}}$ gas is removed first. In the most H i-deficient galaxies, however, we find evidence that environmental processes reduce the typical $\Sigma_{\text{mol}}$ of the remaining gas by nearly a factor of 3. We find no evidence for environment-driven elevation of $\Sigma_{\text{H}\,{\small\text{I}}}$ or $\Sigma_{\text{mol}}$ in H i-deficient galaxies. Using the ratio of $\Sigma_{\text{mol}}$-to-$\Sigma_{\text{H}\,{\small\text{I}}}$ in individual regions, we show that changes in the ISM physical conditions, estimated using the total gas surface density and midplane hydrostatic pressure, cannot explain the observed reduction in molecular gas content. Instead, we suggest that direct stripping of the molecular gas is required to explain our results.
OBJECTIVES/GOALS: The purpose of this mixed methods project was to gain a comprehensive understanding and generate data on factors, including stress and inflammatory biomarkers, that may negatively impact glycemic levels in children aged 8-12 years with type 1 diabetes (T1D) from underrepresented backgrounds. METHODS/STUDY POPULATION: This study employed a two-phase sequential QUAN -> qual mixed methods design. Children and their parents were recruited from a pediatric endocrinology clinic in the southeastern United States. In phase 1 (n=34), we used quantitative methods to measure perceived stress, diabetes distress, cortisol, inflammation (IL-1b, IL-2; IL-6; IL-8; TNF-a; CRP), and glycemic level (HbA1c). Both children and their parent/guardian completed surveys, and children provided salivary and blood samples to measure cortisol and inflammatory markers. Phase 2 qualitative interviews in a subset (n=20) of children and parent/guardians from phase 1 are ongoing; preliminary findings will be included in the presentation. RESULTS/ANTICIPATED RESULTS: Mean age of children was 10.47 (sd=1.44), 67.6% were male, and 41.2% were black. HbA1c ranged from 6.8%-15% and only 2 (5.8%) children met ADA recommendations for HbA1c of 7% or less. HbA1c was associated with child reports of perceived stress (r = .403, p < .05), but not parent reports of child perceived stress (r = -.011, p > .05). Parent reports of perceived stress and diabetes distress in children were not significantly associated with child self-report of perceived stress (r = .11, p > .05) or diabetes distress (r = .018, p > .05). Exploratory models with PROCESS suggest that cortisol slope and IL-8 moderate the relationship between child’s perceived stress and glycemic control. DISCUSSION/SIGNIFICANCE: Stressors are emerging that are unique to this population and may help highlight disparities in care. While the study is ongoing, findings may help health professionals identify and mitigate stressors in children with T1D to help maintain optimal glycemic levels.
The World Health Organization (WHO) is tasked with the ‘attainment by all peoples of the highest possible level of health’, yet, it is widely struggling to meet this mandate, and COVID-19 has revealed significant limitations of the organisation. Despite clear guidance provided by the institution as to how best to respond to the pathogen, many governments departed from WHO's guidance in their response efforts. Is this a new crisis for WHO? Does WHO need to restore its legitimacy in the eyes of the global community? As renewed calls for changes to WHO emerge, in this perspective we lay out the obstacles WHO face to become the WHO ‘we’ need. The assumption is that UN member states need an empowered and well-funded organisation. Yet, many years of discussion of reform of WHO have failed to lead to meaningful change, and glaring challenges remain in its financing, governance and politics, which are considered in turn. The reality may be that we have the WHO that UN member states need – one that can provide guidance and advice, but also take criticism for health governance failures when states want to avoid blame or responsibility. We discuss this, by analysing three key areas of WHO'S challenges: mandate and scope; structure, governance and money and domestic vs international.
Worldwide type 2 diabetes (T2D) prevalence is increasing dramatically. The present study aimed to evaluate the association between dietary habits and T2D in an Iranian adult population using a cross-sectional analysis of the Shahedieh cohort study. Participants were adults aged 35–70 years (n 9261) from Zarch and Shahedieh, Yazd, Iran, who attended the baseline phase of the Shahedieh cohort study. Dietary habits including meal frequency, fried-food consumption, adding salt to prepared meals and grilled-food consumption were assessed by a standard questionnaire. T2D was defined as fasting plasma glucose (FPG) ≥126 mg/dl according to the American Diabetes Association. Multiple logistic regression assessed the association between dietary habits and T2D. Individuals who consumed a meal more than six times per day compared to three times per day had greater odds for T2D (OR 2⋅503, 95 % CI 1⋅651, 3⋅793). These associations remained significant in a fully adjusted model. There was a significant association between greater intakes of fried foods and prevalence of T2D (OR 1⋅294, 95 % CI 1⋅004, 1⋅668) in the adjusted model. No significant associations were observed between other dietary habits (adding salt to prepared meals and grilled-food consumption) and odds of T2D in all crude and adjusted models. In conclusion, we have highlighted the association between meal and fried-food consumption frequencies with risk of T2D. Large longitudinal studies in different ethnicities are needed to confirm these associations.
We aimed to examine how public health policies influenced the dynamics of coronavirus disease 2019 (COVID-19) time-varying reproductive number (Rt) in South Carolina from February 26, 2020, to January 1, 2021.
Methods:
COVID-19 case series (March 6, 2020, to January 10, 2021) were shifted by 9 d to approximate the infection date. We analyzed the effects of state and county policies on Rt using EpiEstim. We performed linear regression to evaluate if per-capita cumulative case count varies across counties with different population size.
Results:
Rt shifted from 2-3 in March to <1 during April and May. Rt rose over the summer and stayed between 1.4 and 0.7. The introduction of statewide mask mandates was associated with a decline in Rt (−15.3%; 95% CrI, −13.6%, −16.8%), and school re-opening, an increase by 12.3% (95% CrI, 10.1%, 14.4%). Less densely populated counties had higher attack rates (P < 0.0001).
Conclusions:
The Rt dynamics over time indicated that public health interventions substantially slowed COVID-19 transmission in South Carolina, while their relaxation may have promoted further transmission. Policies encouraging people to stay home, such as closing nonessential businesses, were associated with Rt reduction, while policies that encouraged more movement, such as re-opening schools, were associated with Rt increase.
Gathering honest feedback is challenging as trainees are often reluctant to do so due to the perceived impact on their reputation, future careers, and professional relationships. A lack of constructive feedback severely impacts future trainees and can prevent necessary improvements. There is considerable variation over collection of feedback. The aim of the project was to allow higher trainees and newly appointed consultants within two years of completing training, provide feedback on previous training posts in a confidential manner. The information obtained would be used to improve trainee experience, support a change in culture around feedback and highlight posts in need of input from Training Programme. Directors (TPDs).
Methods
Anonymised questionnaires were sent to higher trainees and newly appointed consultants using a survey monkey link left open for a month. Reminders were sent via Medical Education, text messages, chats, and informal conversations. There were three basic open questions asked with free-text boxes. The questions were: What things were good about this post? What things could be improved? Would you recommend this post to a colleague? The data collected were in quantitative and qualitative formats.
Results
We received 22 responses of 46 higher trainee posts within the scheme. The general themes from the project were that trainees wanted more focus on training rather than service provision, more independent working while still having good clinical support/supervision; based on their level of experience, better support to meet non-clinical Intended Learning Outcomes (ILOs) and ensuring a good balance of being busy while not finding it overwhelming. Trainees in community settings suggested allocation of selected cases focused on training experience, the opportunity to manage complex situations with supervision, being able to shadow and have joint reviews with consultants. The themes highlighted in the inpatient settings included having protected time to develop non-clinical ILOs, assuming greater leadership of clinical meetings, and having the opportunity to manage a patient from admission to discharge. A total of 4 posts were not recommended for reasons outlined above.
Conclusion
Clearly there is a balance to be made between appropriate levels of independence and supervision. The vast majority of training posts reviewed have got the balance about right, however there are still some posts that require improvements. Careful consideration by both trainers and trainees needs to be given to various aspects of training, to achieve required ILOs, as not everyone fits the mould. This highlights the importance of creating individualised frameworks for trainee support and supervision.
There are over 72 000 licensed IMGs in the UK who fill up crucial shortages in the NHS and provide diversity. In 2020 there were more IMGs than local graduates joining the General Medical Council register with over half (54%) identifying as Black and Minority Ethnic doctors. There are ongoing and extensive conversations about the best approach to tackle differential attainment between IMGs and local graduates. The aims were to identify what the perceived differences were between local graduates and IMGs in various domains and recognise what measures could be taken to improve the issues identified.
Methods
This survey utilised the Typeform survey software to ask 23 questions and was left open for 3 months. Participation in the survey was voluntary and anonymized and included feedback from both Core Trainees and Higher Trainees. Initial emails, texts and chats with the survey link and reminders were sent to the Medical Education departments and trainee groups. The qualitative and quantitative data from all 33 respondents were analysed.
Results
90.9% (30) of participants felt there were issues of differential attainment between IMGs and local graduates and felt that the gaps in differential attainment could be addressed by mentoring, networking, IMG lead roles, education of trainers and better support systems. 57.6% (19) of IMGs stated that they had felt bullied, undermined, treated unfairly, or intimidated; with only 29% (9) attempting to challenge this due to the fear of retribution, concerns about accountable, cultural and communication barriers. All respondents felt induction programmes, focusing on IMGs and cultural diversity would be helpful for all trainees, with 93.9% (31) of respondents recommending that more education was needed for trainers. 57.6% (19) stated that they had considered relocating outside the UK after training because they felt they would be better valued elsewhere. 90.9% (30) suggested that a book for IMGs would be a welcomed development. 87.9% (29) recommended that having IMG leads was important for offering well-being support, play a safeguarding role, offer pastoral care, and contribute to induction and education; with 68.8% (22) recommending the person was a College trainer.
Conclusion
These findings highlight several challenges IMGs training in the UK face and must navigate to be successful. A greater awareness of their hurdles is critical to maximising what potentials lie within. As the numbers of IMGs within the system continue to rise, there is an even greater need to support and address the concerns this survey underscores.
Due to the demand for increased flexibility of working there is an ever-increasing number of trainees working Less Than Full Time (LTFT). The Royal College of Psychiatrists supports LTFT training and careers within the specialty. However, applying for and working LTFT can be a challenging and at times overwhelming process to navigate. This project's aims are to improve written information provided to trainees when commencing LTFT training. To assess interest for a LTFT training educational event and to plan this event based on trainees preferences for content and timing.
Methods
Questionnaires via SurveyMonkey were sent to higher trainees in all regions of the Yorkshire and Humber Deanery in October 2021 by the Medical Education Departments. A covering email invited those working or interested in LTFT to complete the questionnaire.
Questions assessed the need for further written information on LTFT training in the region and interest in an educational event. Trainees already working LTFT were asked what they valued most out of support already in place.
Results
Of 40 trainees who responded, 100% stated when commencing LTFT training they would wish to receive more information. Respondents were asked which areas they would like included: practicalities (100% of respondents), LTFT mentor (85%), peer support (83%), weblinks to information (70%), recommended reading (53%). Those already working LTFT were asked what they had found helpful, the most common themes were mentoring, peer and supervisor support.
85% of trainees surveyed confirmed they would be interested in attending a LTFT focused educational event. Based on trainee preferences the areas to be included were job planning (78%), choosing a job (81%), clinical lead views (78%), finances (86%), Out Of Programme opportunities (61%) and emotional aspects (61%). Further questions clarified preferences for a virtual Vs face-to-face meeting and timing to maximise attendance.
Conclusion
There is a need for further information to be provided to trainees on LTFT training in the region. The content has been guided by trainees and will be incorporated into the Higher Trainee Handbook.
For those training LTFT the most helpful aspect has been mentoring, peer and supervisor support. We have subsequently linked with the established mentoring scheme and those new to LTFT are matched with an established LTFT trainee. We recommend 3 monthly LTFT peer and Training Programme Director meetings continue.
There is considerable interest in an educational event focused on LTFT working. This has been organised for May 2022 and the content guided by trainee's preferences.
The Women, Peace and Security (WPS) agenda and women's participation in peace processes are strongly supported by states. Yet financing to support the implementation of WPS has lagged behind overt international commitments to the agenda. WPS scholars and practitioners have highlighted the funding shortfalls for enabling WPS implementation and continued under-investment in gender-inclusive peace. In this article, we ask how much are donor states financially backing the implementation of gender-inclusive peace agreements which they promote? We use a high ambiguity-conflict model of policy implementation to explore the mechanisms of bilateral and multilateral financing for gender-inclusive peace. We trace to what extent international investments are supporting specific gender provisions in two progressive gender-inclusive peace processes, the 2016 Colombian Peace Agreement and 2015 Comprehensive Peace Agreement in the Philippines. In both case studies, we reveal a drastic gap between the international donor rhetoric and the funding. Patterns of financial investment do not follow nor support the life cycle of inclusive peace processes. We suggest key strategies for further research to address this policy and recommend that all gender provisions of peace agreements be monitored in-country and all gender-responsive investments be tracked and evaluated.
In response to annual outbreaks of human cercarial dermatitis (HCD) in Lake Wanaka, New Zealand, ducks and snails were collected and screened for avian schistosomes. During the survey from 2009 to 2017, four species of Trichobilharzia were recovered. Specimens were examined both morphologically and genetically. Trichobilharzia querquedulae, a species known from four continents, was found in the visceral veins of the duck Spatula rhynchotis but the snail host remains unknown. Cercaria longicauda [i.e. Trichobilharzia longicauda (Macfarlane, 1944) Davis, 2006], considered the major aetiological agent of HCD in Lake Wanaka, was discovered, and redescribed from adults in the visceral veins of the duck Aythya novaeseelandiae and cercariae from the snail Austropeplea tomentosa. Recovered from the nasal mucosa of Ay. novaeseelandiae is a new species of Trichobilharzia that was also found to cycle naturally through Au. tomentosa. Cercariae of a fourth species of Trichobilharzia were found in Au. tomentosa but the species remains unidentified.
Cultural representations of pandemics and other apocalyptic scenarios often encourage us to reflect differently on those things we take for granted in our day-to-day lives. Seemingly mundane and dependable items no longer appear so mundane, nor so dependable. ‘Money’ itself is one such entity, which has been the object of various reimaginings within fictional accounts of disaster and subsequent societal breakdown. In ‘Bartertown’, the fictional trading place in the Mad Max film, for example, we witness the total collapse of civilization and, with it, the entire monetary system; swapping and bartering are all that matter in such a place. Money is erased from a society in which violence dictates everyday life.
Thankfully, such fictional accounts appear not to reflect the reality of the COVID-19 pandemic; however, the crisis does still provoke important questions about the future of money and how we pay for things. Cash – our physical coins and banknotes – has moved from being a mundane and dependable thing to something that many view as a threat, another source of spreading the virus. Cash as a medium of ‘exchange’ has taken on a new meaning. As such, many retailers are strongly encouraging customers to pay by card, while the limit on contactless payments has been increased from £30 to £45 per transaction in the UK, with similar moves across Europe. Automated teller machine (ATM) withdrawal figures – which were already on the decline – have plummeted.
What just a few months ago might have seemed like fiction – a seismic shift in the way we pay for things – has now become reality. The future of cash is very much at stake, and in the discussion that follows we begin by exploring why this still matters. We then consider the effect of COVID-19 on access to cash, situating these changes in the broader context of digitization and pre-crisis trends. We conclude by reflecting what the pandemic can teach us about what we can do better moving forward, ensuring that no one is left behind.
Cash matters
Money has been integral to human history for thousands of years. Early coins in circulation across Asia and Europe enabled civilization and economies to evolve from bartering to the generalized system of exchange that continues to exist in modern capitalism.
The key populations who are most vulnerable to HIV – sex workers, people who inject drugs, men who have sex with men, transgender people – are criminalized in many countries, and often lead double lives, hiding in order to survive. This creates a data paradox, in which governments deny or minimize the existence of key populations, no research is done on their health needs, and lack of data reinforces official denialism. Criminalization of same-sex sexuality is statistically associated with implausibly low size estimates of men who have sex with men. Low size estimates can also contribute to implausibly high reported coverage of HIV testing among men who have sex with men, leading countries that are failing to reach key populations to mistakenly believe they are successful. In Kenya, a government effort to conduct a size estimation study of key populations, including gathering biometric data, faced resistance from those groups, who feared the data could expose them to risk of arrest and abuses. Working with Kenyan key populations advocates and human rights lawyers, the author documented this resistance, and growing demands by key populations that they play a leadership role in the design, implementation and evaluation of research about their health.