Ottersen, T., Hoffman, S.J. & Groux, G., 2016. Ebola again shows the international health regulations are broken: What can be done differently to prepare for the next epidemic?. American Journal of Law and Medicine , 42 (2-3) , pp. 356-392. PDFAbstract

Epidemics are among the greatest threats to humanity, and the International Health Regulations are the world's key legal instrument for addressing this threat. Since their revision in 2005, the IHR have faced two big tests: the 2009 H1N1 influenza pandemic and the 2014 Ebola epidemic in West Africa. Both exposed major shortcomings of the IHR, and both offered profound lessons for the future.

The objective of this Article is twofold. First, we seek to compare the lessons learned from H1N1 and Ebola for reforming the IHR in order to test the hypothesis that they are similar. Second, we seek to examine the barriers to implementing these lessons and to identify strategies for overcoming those barriers.

We find that the lessons from H1N1 and Ebola are indeed similar, and that opportunities to act on lessons from H1N1 were woefully missed. We identify many political barriers to global collective action and implementation of lessons for the IHR. On that basis, we describe strategies to overcome these barriers, which will hopefully be deployed now to reform the IHR before the policy window following Ebola closes, and before the inevitable next epidemic comes. The emerging threat of the Zika virus underscores that we have no time to waste.

Laxminarayan, R., et al., 2016. UN High-Level Meeting on antimicrobials—what do we need?. The Lancet , 388 , pp. 218-220. PDF
Hoffman, S.J., et al., 2016. Clinicians’ knowledge and practices regarding family planning and intrauterine devices in China, Kazakhstan, Laos and Mexico. Reproductive Health , 13 (7) , pp. 1-12. ArticleAbstract


It is widely agreed that the practices of clinicians should be based on the best available research evidence, but too often this evidence is not reliably disseminated to people who can make use of it. This “know-do” gap leads to ineffective resource use and suboptimal provision of services, which is especially problematic in low- and middle-income countries (LMICs) which face greater resource limitations. Family planning, including intrauterine device (IUD) use, represents an important area to evaluate clinicians’ knowledge and practices in order to make improvements.


A questionnaire was developed, tested and administered to 438 individuals in China (n = 115), Kazakhstan (n = 110), Laos (n = 105), and Mexico (n = 108). The participants responded to ten questions assessing knowledge and practices relating to contraception and IUDs, and a series of questions used to determine their individual characteristics and working context. Ordinal logistic regressions were conducted with knowledge and practices as dependent variables.


Overall, a 96 % response rate was achieved (n = 438/458). Only 2.8 % of respondents were able to correctly answer all five knowledge-testing questions, and only 0.9 % self-reported “often” undertaking all four recommended clinical practices and “never” performing the one practice that was contrary to recommendation. Statistically significant factors associated with knowledge scores included: 1) having a masters or doctorate degree; and 2) often reading scientific journals from high-income countries. Significant factors associated with recommended practices included: 1) training in critically appraising systematic reviews; 2) training in the care of patients with IUDs; 3) believing that research performed in their own country is above average or excellent in quality; 4) being based in a facility operated by an NGO; and 5) having the view that higher quality available research is important to improving their work.


This analysis supports previous work emphasizing the need for improved knowledge and practices among clinicians concerning the use of IUDs for family planning. It also identifies areas in which targeted interventions may prove effective. Assessing opportunities for increasing education and training programs for clinicians in research and IUD provision could prove to be particularly effective.

Keywords: Family planning, Intrauterine device, Global health, Knowledge translation, Health professionals, Medical education, Systematic reviews, Health systems, Health human resources
Hoffman, S.J. & Justicz, V., 2016. Automatically quantifying the scientific quality and sensationalism of news records mentioning pandemics: validating a maximum entropy machine-learning model. Journal of Clinical Epidemiology , 75 , pp. 47-55. PDFAbstract


To develop and validate a method for automatically quantifying the scientific quality and sensationalism of individual news records.

Study design

After retrieving 163,433 news records mentioning the Severe Acute Respiratory Syndrome (SARS) and H1N1 pandemics, a maximum entropy model for inductive machine learning was used to identify relationships among 500 randomly sampled news records that correlated with systematic human assessments of their scientific quality and sensationalism. These relationships were then computationally applied to automatically classify 10,000 additional randomly sampled news records. The model was validated by randomly sampling 200 records and comparing human assessments of them to the computer assessments.


The computer model correctly assessed the relevance of 86% of news records, the quality of 65% of records, and the sensationalism of 73% of records, as compared to human assessments. Overall, the scientific quality of SARS and H1N1 news media coverage had potentially important shortcomings, but coverage was not too sensationalizing. Coverage slightly improved between the two pandemics.


Automated methods can evaluate news records faster, cheaper, and possibly better than humans. The specific procedure implemented in this study can at the very least identify subsets of news records that are far more likely to have particular scientific and discursive qualities.


  • Health communication
  • Mass media
  • News
  • Pandemics
  • Machine learning
  • Validation studies
Hoffman, S.J. & Habibi, R., 2016. International legal barriers to Canada’s marijuana plans. Canadian Medical Association Journal , 188 (8) , pp. 1-2. Article
Hoffman, S.J., et al., 2016. Surveying the knowledge and practices of health professionals in China, India, Iran, and Mexico on treating tuberculosis. American Journal of Tropical Medicine & Hygiene , 94 (5) , pp. 959-970. ArticleAbstract

Research evidence continues to reveal findings important for health professionals' clinical practices, yet it is not consistently disseminated to those who can use it. The resulting deficits in knowledge and service provision may be especially pronounced in low- and middle-income countries that have greater resource constraints. Tuberculosis treatment is an important area for assessing professionals' knowledge and practices because of the effectiveness of existing treatments and recognized gaps in professionals' knowledge about treatment. This study surveyed 384 health professionals in China, India, Iran, and Mexico on their knowledge and practices related to tuberculosis treatment. Few respondents correctly answered all five knowledge questions (12%) or self-reported performing all five recommended clinical practices “often or very often” (3%). Factors associated with higher knowledge scores included clinical specialization and working with researchers. Factors associated with better practices included training in the care of tuberculosis patients, being based in a hospital, trusting reviews of randomized controlled double-blind trials, and reading summaries of articles, reports, and reviews. This study highlights several strategies that may prove effective in improving health professionals' knowledge and practices related to tuberculosis treatment. Facilitating interactions with researchers and training in acquiring systematic reviews may be especially helpful.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the decisions, policies, or views of the World Health Organization.

Danik, M.E., et al., 2016. Assessing the political feasibility of an international agreement on antimicrobial resistance S. J. Hoffman & L. Sritharan, ed., Ottawa: Global Strategy Lab. PDFAbstract

This report was commissioned by the Norwegian Institute of Public Health and focused on the political feasibility of an international agreement on antimicrobial resistance.  The major finding was that a comprehensive response to AMR would commit all countries to act simultaneously on access, conservation and innovation. However, such an agreement is not immediately politically feasible without additional incentives and supports; instead a core groups of specialized countries could act to create the basis of an agreement before inviting other countries to join.

Hoffman, S.J., et al., 2016. International law’s effects on health and its social determinants: protocol for a systematic review, meta-analysis, and meta-regression analysis. Systematic Reviews , 5 (64) , pp. 1-9. PDFAbstract
Background: In recent years, there have been numerous calls for global institutions to develop and enforce new international laws. International laws are, however, often blunt instruments with many uncertain benefits, costs, risks of harm, and trade-offs. Thus, they are probably not always appropriate solutions to global health challenges. Given these uncertainties and international law’s potential importance for improving global health, the paucity of synthesized evidence addressing whether international laws achieve their intended effects or whether they are superior in comparison to other approaches is problematic.

Methods: Ten electronic bibliographic databases were searched using predefined search strategies, including MEDLINE, Global Health, CINAHL, Applied Social Sciences Index and Abstracts, Dissertations and Theses, International Bibliography of Social Sciences, International Political Science Abstracts, Social Sciences Abstracts, Social Sciences Citation Index, PAIS International, and Worldwide Political Science Abstracts. Two reviewers will independently screen titles and abstracts using predefined inclusion criteria. Pairs of reviewers will then independently screen the full-text of articles for inclusion using predefined inclusion criteria and then independently extract data and assess risk of bias for included studies. Where feasible, results will be pooled through subgroup analyses, meta-analyses, and meta-regression techniques.

Discussion: The findings of this review will contribute to a better understanding of the expected benefits and possible harms of using international law to address different kinds of problems, thereby providing important evidence-informed guidance on when and how it can be effectively introduced and implemented by countries and global institutions.

Systematic review registration: PROSPERO CRD42015019830

Keywords: International cooperation Global health Social determinants of health Public policy Jurisprudence Treaties

Dutchak, M., et al., 2016. Learning from Ebola to improve humanitarian organizations’ legal preparedness for future epidemics. S. J. Hoffman & L. Sritharan, ed., Ottawa: Global Strategy Lab. PDFAbstract

This report provides options for navigating five key issues faced by humanitarian organizations when responding to an epidemic: training, communication of risk, insurance, medical evacuation and reintegration. Options focus on practices that a humanitarian organization ought to adopt when interacting with its employees, since employees are owed a legal duty of care that, when ignored, makes an organization vulnerable to legal action. The options were identified by studying the successes and shortcomings of the Ebola response, and are meant to equip humanitarian organizations with the tools necessary to respond to future epidemics in a way that is efficient and that mitigates their liability.

Copija, W., et al., 2016. Opportunities for Canada to Improve Global Access to Medicines S. J. Hoffman & L. Sritharan, ed., Ottawa: Global Strategy Lab. PDFAbstract

This report explores a number of drug development and delivery models for the Canadian government to consider implementing as it looks to improve access to essential medicines both domestically and internationally.The Office ofInternational Affairs for the Health Portfolio (OIA-HP) commissioned the research of four market-level case studies, which focus on innovative financing and collaborative initiatives, and one patient-level case study, which considers international legislation as a model to improve Canada’s purchasing power. The Innovative Medicines Initiative (IMI), the International Finance Facility for Immunization (IFFIm), Open Source Drug Discovery (OSDD), Drugs for Neglected Diseases Initiative (DNDi), and Australia’s Pharmaceutical Benefits Scheme (PBS) were specifically selected based on their relevance to Canada’s strong pharmaceutical industry, commitment to R&D and global aid, and domestic health needs.

Hoffman, S.J., et al., 2016. The UN Convention on the Rights of Persons with Disabilities and its Impact on Mental Health Law and Policy in Canada, Toronto: Lexis Nexis. BookAbstract

Mental health issues pose critical challenges for Canada's systems of justice and health care. Problems with mental health are common, but often neglected due to stigma and the vulnerability of those living with these conditions. This is evident within our legal system. Every day in our courts we see played out the struggle to protect the human rights and dignity of individual Canadians with mental health challenges, to access adequate mental health care and social support, and to provide genuinely helpful responses to criminal behaviour associated with mental health problems. Law and Mind: Mental Health Law and Policy in Canada provides a comprehensive analysis of the most important cases and key debates at the intersection of mental health law and policy.

Written by a group of Canada's leading experts on mental health law, this volume provides practitioners, researchers and policy-makers with valuable insight into this challenging and important area of the law.

Features and benefits
Law and Mind: Mental Health Law and Policy in Canada is an important resource for understanding the complexities of mental health law and related policy issues in Canada.

Law students, practising lawyers and policy-makers alike will benefit from the broad range of topics covered in this comprehensive text. Topics addressed include the law surrounding the funding and administration of mental health care in Canada, the principles of mental health law related to hospitalization and consent to treatment, the components of the criminal law of mental disorder, and mental health issues in the policing and correctional contexts. In addition, the authors offer focused treatment of mental health law issues facing specific populations, including children, the elderly, refugees and ethnic minorities.

This text is written by leading mental health law experts who bring years of practice, research and expertise to provide readers with a comprehensive resource which:

  • Presents the legal issues related to mental health in a comprehensive manner
  • Enables students and lawyers to learn this challenging subject matter quickly and effectively
  • Analyzes recent changes and developments in the law
  • Provides current information so lawyers can properly advise their clients
  • Discusses pressing and emerging mental health issues that are relevant to practitioners and their clients

Essential reading
This new release will be particularly useful for:

  • Health lawyers advising clients and in-house lawyers at health service providers as it is an up-to-date resource on mental health law and policy
  • Students looking for a comprehensive resource on mental health law written by leading academics
  • Government health workers and policymakers who need to consult a reliable reference volume
  • Law libraries that want to stock essential guides for lawyers and students
Gulati, N., et al., 2016. Using International Instruments to Address Antimicrobial Resistance S. J. Hoffman & L. Sritharan, ed., Ottawa: Global Strategy Lab. PDFAbstract

Antimicrobial resistance (AMR) is a global health concern that poses a serious threat to the control of infectious disease. A continuous increase in rates of AMR poses a challenge to the global community and impedes progress previously made in improving health outcomes. This report examines how AMR can be addressed using international instruments, and the appropriate role of the World Health Organization (WHO) in this task. It is recommended that global collective action on AMR be achieved by implementing a Treaty under Article 19 and a Regulation under Article 21 of the WHO’s Constitution. This suite of international instruments can be used to address the greatest proportion of issues that currently impede AMR’s resolution and can mobilize the most effective action. This report further establishes that the WHO has legal authority under its Constitution to create these international instruments to address AMR.

Fafard, P. & Hoffman, S.J., 2016. Health ministers must spend smarter and negotiate wiser. The Hill Times. Article
Groux, G. & Hoffman, S.J., 2016. Why Zika matters to Canada. The Toronto Star. Article
Årdal, C., et al., 2015. International cooperation to improve access to and sustain effectiveness of antimicrobials. The Lancet , 387 (10015). PDFAbstract

Securing access to effective antimicrobials is one of the greatest challenges today. Until now, efforts to address this issue have been isolated and uncoordinated, with little focus on sustainable and international solutions. Global collective action is necessary to improve access to life-saving antimicrobials, conserving them, and ensuring continued innovation. Access, conservation, and innovation are beneficial when achieved independently, but much more effective and sustainable if implemented in concert within and across countries. WHO alone will not be able to drive these actions. It will require a multisector response (including the health, agriculture, and veterinary sectors), global coordination, and financing mechanisms with sufficient mandates, authority, resources, and power. Fortunately, securing access to effective antimicrobials has finally gained a place on the global political agenda, and we call on policy makers to develop, endorse, and finance new global institutional arrangements that can ensure robust implementation and bold collective action.

Gopinathan, U., et al., 2015. Conceptual and Institutional Gaps: Understanding How the WHO can Become a More Effective Cross-Sectoral Collaborator. Globalization and Health , 11 (46) , pp. 1-13. PDFAbstract

Background: Two themes consistently emerge from the broad range of academics, policymakers and opinion leaders who have proposed changes to the World Health Organization (WHO): that reform efforts are too slow, and that they do too little to strengthen WHO’s capacity to facilitate cross-sectoral collaboration. This study seeks to identify possible explanations for the challenges WHO faces in addressing the broader determinants of health, and the potential opportunities for working across sectors.

Methods: This qualitative study used a mixed methods approach of semi-structured interviews and document review. Five interviewees were selected by stratified purposive sampling within a sampling frame of approximately 45 potential interviewees, and a targeted document review was conducted. All interviewees were senior WHO staff at the department director level or above. Thematic analysis was used to analyze data from interview transcripts, field notes, and the document review, and data coded during the analysis was analyzed against three central research questions. First, how does WHO conceptualize its mandate in global health? Second, what are the barriers and enablers to enhancing cross-sectoral collaboration between WHO and other intergovernmental organizations? Third, how do the dominant conceptual frames and the identified barriers and enablers to cross-sectoral collaboration interact?

Results: Analysis of the interviews and documents revealed three main themes: 1) WHO’s role must evolve to meet the global challenges and societal changes of the 21st century; 2) WHO’s cross-sectoral engagement is hampered internally by a dominant biomedical view of health, and the prevailing institutions and incentives that entrench this view; and 3) WHO’s cross-sectoral engagement is hampered externally by siloed areas of focus for each intergovernmental organization, and the lack of adequate conceptual frameworks and institutional mechanisms to facilitate engagement across siloes.

Conclusion: There are a number of external and internal pressures on WHO which have created an organizational culture and operational structure that focuses on a narrow, technical approach to global health, prioritizing disease-based, siloed interventions over more complex approaches that span sectors. The broader approach to promoting human health and wellbeing, which is conceptualized in WHO’s constitution, requires cultural and institutional changes for it to be fully implemented.

Keywords: World Health Organization, United Nations, Global governance, Global health governance, Global governance for health, Social determinants of health, Health in all policies, WHO reform, Cross-sectoral collaboration

Fafard, P. & Hoffman, S.J., 2015. Five Things Justin Trudeau Can Do On Day One. National Post. Article
Hoffman, S.J., 2015. It's Time to End Canada's Ebola Visa Restrictions. Huffington Post. Article
Belluz, J. & Hoffman, S.J., 2015. Let's Stop Pretending Peer Review Works. Vox. Article
Tan, C. & Hoffman, S.J., 2015. Overview of Systematic Reviews on the Health-Related Effects of Government Tobacco Control Policies. BMC Public Health , 15 (744) , pp. 1-11. PDFAbstract

Background: Government interventions are critical to addressing the global tobacco epidemic, a major public health problem that continues to deepen. We systematically synthesize research evidence on the effectiveness of government tobacco control policies promoted by the Framework Convention on Tobacco Control (FCTC), supporting the implementation of this international treaty on the tenth anniversary of it entering into force.

Methods: An overview of systematic reviews was prepared through systematic searches of five electronic databases, published up to March 2014. Additional reviews were retrieved from monthly updates until August 2014, consultations with tobacco control experts and a targeted search for reviews on mass media interventions. Reviews were assessed according to predefined inclusion criteria, and ratings of methodological quality were either extracted from source databases or independently scored.

Results: Of 612 reviews retrieved, 45 reviews met the inclusion criteria and 14 more were identified from monthly updates, expert consultations and a targeted search, resulting in 59 included reviews summarizing over 1150 primary studies. The 38 strong and moderate quality reviews published since 2000 were prioritized in the qualitative synthesis. Protecting people from tobacco smoke was the most strongly supported government intervention, with smoke-free policies associated with decreased smoking behaviour, secondhand smoke exposure and adverse health outcomes. Raising taxes on tobacco products also consistently demonstrated reductions in smoking behaviour. Tobacco product packaging interventions and anti-tobacco mass media campaigns may decrease smoking behaviour, with the latter likely an important part of larger multicomponent programs. Financial interventions for smoking cessation are most effective when targeted at smokers to reduce the cost of cessation products, but incentivizing quitting may be effective as well. Although the findings for bans on tobacco advertising were inconclusive, other evidence suggests they remain an important intervention.

Conclusion: When designing and implementing tobacco control programs, governments should prioritize smoking bans and price increases of tobacco products followed by other interventions. Additional studies are needed on the various factors that can influence a policy’s effectiveness and feasibility such as cost, local context, political barriers and implementation strategies.