A precautionary approach to autonomous vehicles.

In this article, we defend an approach to autonomous vehicle ethics and policy based on the precautionary principle. We argue that a precautionary approach is warranted, given the significant scientific and moral uncertainties related to autonomous vehicles, especially higher-level ones. While higher-level autonomous vehicles may offer many important benefits to society, they also pose significant risks, which are not fully understood at this juncture. Risk management strategies traditionally used by government officials to make decisions about new technologies cannot be applied to higher-level autonomous vehicles because these strategies require accurate and reliable probability estimates concerning the outcomes of different policy options and extensive agreement about values, which are not currently available for autonomous vehicles. Although we describe our approach as precautionary, that does not mean that we are opposed to autonomous vehicle development and deployment, because autonomous vehicles offer benefits that should be pursued. The optimal approach to managing the risks of autonomous vehicles is to take reasonable precautions; that is, to adopt policies that attempt to deal with serious risks in a responsible way without depriving society of important benefits.

The Barriers and Enablers of Primary Healthcare Service Transition From Government to Community Control in Yarrabah: A Grounded Theory Study.

Introduction: Consistent with the aspirations of First Nations Australians for community control of healthcare services, 123/196 (63%) of Australia's First Nations-specific primary health care services are community-controlled. Yet despite policy commitment over 30 years, the transition of government-run First Nations' primary healthcare services to First Nations community control has been slow. This paper identifies the barriers and enablers to transitioning the delivery of primary healthcare services from Queensland Health to Gurriny Yealamucka community-controlled health service in Yarrabah. Methods: Grounded theory methods were used to select 14 Gurriny and Queensland Health (QH) personnel involved in the transition for interview and to analyse these interview transcripts and 88 Gurriny organisational documents. Results: Barriers and enablers to transition were identified at three levels: those internal factors within Gurriny, external factors directly related to the government handover, and broader structural and policy factors outside the control of either Gurriny or QH. Barriers at the Gurriny organisational level were an internal lack of experience and capacity, and varying levels of community confidence; enablers were leadership stability and capacity, community mandate, relationships with partner organisations, and ability to provide service continuity. Barriers in Gurriny's relationship with QH were a lack of certainty, transparency and prioritisation of the transition process; systemic racism; difficulties obtaining and maintaining the necessary workforce; limited resources including insufficient, unstable and inappropriate funding support; and problems with information sharing; enablers were performance frameworks to keep transition progress on track. Barriers in broad policy environment were an unsupportive Queensland government policy environment; government bureaucracy; and delays, conflicts and divisions; enablers were high-level government support and commitment. Conclusions: The evaluation of Yarrabah's transition process suggests that future such transitions will require planning and commitment to a long-term, multi-faceted and complex process, encompassing the required level of authorisation and resourcing. This case example of a transition from government to community control of PHC highlighted the ongoing power issues that are faced every day by community-controlled organisations that co-exist with mainstream health systems within a colonial power structure.

Leading with local solutions to keep Yarrabah safe: a grounded theory study of an Aboriginal community-controlled health organisation's response to COVID-19.

BACKGROUND: Pandemics such as COVID-19 are a serious public health risk for Australian Aboriginal and Torres Strait Islander communities, yet primary healthcare systems are not well resourced to respond to such urgent events. At the start of the COVID-19 pandemic, a federal government advisory group recommended a rapid, tailored Indigenous response to prevent predicted high morbidity and mortality rates. This paper examines the efforts of one ACCHO, which in the absence of dedicated funding, pivoted its operations in response to COVID-19. Gurriny Yealamucka Health Service (Gurriny) is the only primary healthcare service in the discrete Indigenous community of Yarrabah, Far North Queensland. METHODS: The research was conducted at the request of the Chief Executive Officer of Gurriny. Using grounded theory methods, thirteen Gurriny staff and five Yarrabah and government leaders and community members were interviewed, transcripts of these interviews and 59 documents were imported into NVIVO-12 and coded, and key concepts were compared, organised into higher order constructs, then structured into a theoretical framework. RESULTS: Gurriny responded to COVID-19 by leading with local solutions to keep Yarrabah safe. Four key strategies were implemented: managing the health service operations, realigning services, educating and supporting community, and working across agencies. These strategies were enabled or hindered by five conditions: the governance and leadership capacity of Gurriny, relying on the health taskforce, locking the door, "copping it", and (not) having resources. A year after the first case was experienced in Australia and on the eve of vaccine rollout to Indigenous communities, there have been no COVID-19 cases in Yarrabah. DISCUSSION: The success of the locally led, holistic, comprehensive and culturally safe response of Gurriny suggests that such tailored place-based approaches to pandemics (and other health issues) are appropriate, but require dedicated resourcing. Key challenges were the fragmented and rapidly changing government processes, poorly coordinated communication and resource allocation channels, and bottlenecks in hierarchical funding approval processes. CONCLUSIONS: The COVID-19 response in Yarrabah demonstrates the need for governance reform towards greater resourcing and support for local decision making by Aboriginal community-controlled health organisations.

Transitioning to Aboriginal community control of primary health care: the process and strategies of one community-controlled health organisation in Queensland.

BACKGROUND: Aboriginal Community Controlled Health Services (ACCHSs) play a critical role in providing culturally appropriate, accessible primary healthcare (PHC) for Aboriginal and Torres Strait Islander peoples in Australia. The success of many ACCHSs has led to increased policy support for their growth and development, including the transition of state government administered PHC services to Aboriginal community control in select communities. However, there is minimal published literature available which evaluates such transitions. This paper reports on an evaluation of one ACCHS (Gurriny Yealamucka Health Service)'s experience of transitioning local PHC services to community control in Yarrabah, Queensland, with a focus on the processes and strategies which were implemented to achieve successful transition. METHODS: Data was collected from interviews with key personnel involved in the transition and organisational documents from the evaluation period. Face-to-face or telephone interviews were conducted with 14 key stakeholders, audio-recorded and transcribed with written consent. Historical organisational documents were provided by Gurriny. All interview transcripts and documents were imported into NVIVO, coded and analysed using grounded theory methods. RESULTS: Gurriny's journey of achieving community control of PHC in Yarrabah entailed an almost 30 year process of building and demonstrating organisational capacity. The first stage (1986 to 2004) was focused on establishing and developing a community-controlled health service and the second stage (2005-14) on preparing for the transition. Formal handover occurred in June 2014. Stage one strategies included: addressing community social and emotional wellbeing; consulting the community; collaborating with researchers; and, strategically building services, organisation capacity and stakeholder trust. Stage two strategies were: communicating and engaging with stakeholders; ensuring strong governance; planning and developing the services and workforce; assuring quality; and, financial planning, management and modelling. CONCLUSION: Achieving successful transition to community control of PHC for Gurriny entailed a lengthy process of substantial, ongoing organisational growth and development. Gurriny's experience provides a framework for both governments and the ACCHS sector to inform future transitions of PHC services to Aboriginal community control.

Finding the breech: Influence of breech presentation on mode of delivery based on timing of diagnosis, attempt at external cephalic version, and provider success with version.

BACKGROUND: Breech presentation affects 3-4% of pregnancies at term and malpresentation is the primary indication for 10-15% of cesarean deliveries. External cephalic version is an effective intervention that can decrease the need for cesarean delivery; however, timely identification of breech presentation is required. We hypothesized that women with a fetus in a breech presentation that is diagnosed after 38 weeks' estimated gestational age have a decreased likelihood of external cephalic version attempted and an increased likelihood of cesarean delivery. METHODS: This was a retrospective cohort study. A chart review was performed for 251 women with breech presentation at term presenting to our tertiary referral university hospital for external cephalic version, cesarean for breech presentation, or vaginal breech delivery. RESULTS: Vaginal delivery was significantly more likely (31.1% vs 12.5%; P<.01) in women with breech presentation diagnosed before 38 weeks' estimated gestational age as external cephalic version was offered, and subsequently attempted in a greater proportion of women diagnosed before 38 weeks. External cephalic version was more successful when performed by physicians with greater procedural volume during the 3.5 year period of the study (59.1% for providers performing at least 10 procedures vs 31.3% if performing fewer than 10 procedures, P<.01). CONCLUSIONS: Results support the need for interventions to increase timely diagnosis of breech presentation as well as improved patient counseling and use of experienced providers for external cephalic version.