What are some opportunities for amateur scientists to contribute to real scientific progress in their spare time?

Wild-life conservation and ornithology are two fields where amateur scientists already contribute. More amateur involvement could help transform more citizens into becoming better committed and engaged stewards of their local environments. Such contribution may even be vital in this era of massive climate change. Committed eyes and ears on the ground help every bit as much as professional researchers in mapping and quantifying how climate change is impacting flora and fauna.

The Amateur Scientist And Wild-life Conservation: The Example Of Chennai, India, Students And The Olive Ridley Turtle

By the Bay of Bengal, the South Indian city of Chennai is one of the largest metropolitan areas in the country. No surprise that population growth and economic development threaten its local ecology. One casualty has been the Olive ridley sea turtle. Globally they've steadily lost their nesting sites and are now considered endangered. Annually returning to the same beach where they hatched, female turtles lay their eggs in a process of synchronized nesting. Thus, every year like clockwork, from January until April, Olive Ridley turtles arrive at Chennai's southern beaches, from Neelankarai to Edward Elliot's Beach, a distance of ~ 7 kms. Turtle eggs are highly vulnerable to predation and of course to man-made depredations, inadvertent or otherwise. In what is possibly one of the most beautiful and touching examples of volunteerism or altruism or service for the greater good or call it what you will, since 1987, the Students Sea Turtle Conservation Network, a voluntary group of mainly students gathers every night from January until April. From 11PM until ~ 3 to 4AM, they walk the 7 km beach stretch, looking for newly laid turtle eggs. They collect and relocate them to a nearby hatchery. When hatchlings emerge 45 days later, the volunteers release them safely into the sea.

In their own words (1),

'The SSTCN was initially organized and operated by students, aged 16 to 25. While a few ‘non – students’ (lawyers, biologists, conservationists, business professionals, etc.) advised, the leadership, organisation and manpower were principally from this age group. Once students finish courses, they routinely leave Madras [now renamed Chennai] after participating in or leading the organisation for two to three years, so the SSTCN has seen a high turnover of both membership and leadership.

SSTCN’s activities include beach monitoring, hatchery management, protection of clutches left in the beach (‘in situ nests’), and education and awareness campaigns; the programme has continued from 1988 until present. Each season, the group establishes a hatchery at Neelangarai, and every night from end-December through mid-March, the same 7 km stretch of beach is patrolled. Some years, when there are enough volunteers, the patrolling extends an additional 5 to 10 km beyond Neelangarai to the north. Due to egg predation by feral dogs and people, most nests along this stretch are highly vulnerable.

Consequently, most egg clutches that can be found are relocated to the hatchery. At the hatchery, nests are monitored and a few days prior to expected emergence of hatchlings, they are enclosed with plastic or thatch baskets, to restrain the hatchlings from crawling on to the beach, where chances of predation are high. Hatchlings are released at the edge of the sea the same night of emergence, and the respective nests are excavated to evaluate hatching success.

Experiments with nest spacing and shading have been conducted to improve hatching success, which has remained over 80% during most years since 1992 (Shanker 1995, 2003). Average densities on the beach range from 10 – 15 nests with eggs per km, and the group has collected between 50 and 200 clutches per year (now totalling some 120,000 eggs) and released about 80,000 hatchlings over the past 15 years (Shanker 2003). Since 1988, the sstcn has also been conducting education and awareness programs.'

More information about this volunteer activity on their web-site, SSTCN. I urge interested readers to fully explore this simple and beautiful web-site. Detailing the kind of co-ordination and effort necessary, this is a wonderful example of a purely grassroots volunteer-driven conservation effort. Unsurprisingly, naysayers have questioned the utility of this project, which the volunteers have countered most persuasively and cogently. Rather than simply focus on numbers of turtles saved, this effort also educates the local population about these turtles and about wildlife conservation in general, and thus raises their general awareness about the importance of such measures. As well, in its years of existence, this volunteer program has inspired several to pursue careers in ecology and wildlife conservation.

In their own words again (1),

'Every weekend during the season, members of the general public and students from Madras accompany the SSTCN on ‘turtle walks’ when they are educated about sea turtles and conservation.

Why we do this a question that has often provoked heated debate both within and outside the group is the utility of such hard work and dedication just to release a few thousand hatchlings each year. This result comes after much effort in organisation, long nights walking beaches and never seeing a turtle, and sacrifices to time that could be otherwise spent in studies, with family, or in more conventional hobbies, not to mention the expenses often incurred to each participating student. When the problems that face the hatchling are seemingly insurmountable – it has been suggested that one in 1,000 or less survive to reach maturity – it is often questioned if all the effort is really helping the turtles. SSTCN’s success lies in its role as an outreach program rather than strictly as a wildlife conservation program (something that many members of the group, but not all, do realise).

Thanks to the students’ network, thousands of people in the Madras area have been on a turtle walk; many have seen hatchlings – which are indisputably amongst the most charismatic ambassadors of conservation, and a few have even had the fortune of seeing a nesting olive ridley. Many student members have been motivated to pursue careers in ecology, ecotourism, wildlife management and conservation.

Even if they are doomed, and sea turtles on the Madras coast do not survive the coastal development, fisheries and other threats, these turtles (and hatchlings) still help conservation through their singular contribution to education and outreach programmes.

They help motivate and shape young ecologists and conservationists who might go on to save turtles or other species of wildlife elsewhere. Though nesting along the Madras coast has been extremely low in some years (2.5 nests/ km), there does not appear to have been an overall decline over the last fifteen years. While the long term conservation program may have prevented a drastic decline thus far, the intensity of threats has increased. The main threat to adult sea turtles along much of the Indian coast is fishery related mortality, with about 10 – 20 dead ridleys washed ashore every season on the northern coast of Tamil Nadu. Fishing villages dot the entire coastline of the state, and opportunistic egg poaching by members of the fishing community and other communities living on the coast, as well as depredation by feral dogs are major problems.

Furthermore, as residential, middle class colonies spread along the coast, beachfront lighting and subsequent disorientation of hatchlings is becoming a serious problem along a greater stretch of this coast each year.'

The Amateur Scientist And Ornithology: The Example Of Migrant Watch, India's First Citizen Science Effort To Collect Ecological Information About Bird Migration

Every year from July to December, >300 bird species touch down in India on their way further south from Africa, China, Europe and Russia. A citizen science effort now called eBird India, Migrant Watch was funded by the Bangalore based National Center for Biological Sciences. According to Sahel Quader, Migrant Watch's founder (2),

'Arrival and departure dates are an effective way of measuring the effects of climate change on bird migration...Citizen science can tell us about global warming just by arming people with a pair of binoculars and a little training'

'In India just two years of citizen science have transformed shy homemakers, geeks and retirees into skilled outdoor scientists. They are marching out into the great outdoors, taking on the classic pose of nature watchers, feet planted on earth and necks craned up to identify the flutterer between leaves and swooshers in the skies.

Early walkers are certainly getting the birds. Aniket Bhatt, an infotech consultant, was the first to log on to Tracking bird migration across India in August 2007. He says, “All I could identify were seven rosy starlings in Ahmedabad.” Since then, over 800 volunteer watchers have documented 195 migrant species, landing, living and leaving India, with their sharp-eyed sightings and swift keystrokes. Helping them along are identification markers and pictures on this ‘open access’ online database.

Ramit Singhal, a shy 19-year-old, knows about the birds and the bees as well as everything about birds called bee-eaters. Right from their distinguishing black-eye-stripe to how they feed on wasps without feeling the sting.

Despite being colour blind and a birding novice 18 months ago, this soft-spoken engineering student has recorded 378 bird species across India. Though he can’t tell green from orange, he doesn’t confuse green bee-eaters with brown laughing doves. Size, call and patterns are enough. Quader calls Ramit “a citizen science superstar”.

Walking about in the highly polluted Okhla Bird Sanctuary in Noida, Uttar Pradesh, a wetland stopover for migrant birds where methane bubbles up from the waters, Ramit casually picks out gliding black kites, yellow-bellied prineas and striated babblers on reeds. It’s only the beady gaze of a red-necked falcon that turns him into a gawking teenager, who ogles this awesome raptor loudly exclaiming: “Oh man! This is my first one.”

“Initially, we chose nine species,” says Uttara Mendiratta, coordinator, MigrantWatch. These were picked out for commonness, wide distribution and identifiability. Or, birds outside our windows like barn swallows—the first migrants in Jul —and rosy starlings, their entire global population winters in India.

With birds from wetlands, grasslands and forests making marathon migrations here, “We’re uniquely positioned to get good information about the mysteries of migration and climate change,” says Gopi Sundar, India research associate for the International Crane Foundation.

The late Indira Gandhi was perhaps our most prominent citizen scientist. Each year when she sighted a black redstart, she’d mail an exultant letter to Salim Ali, the late ornithologist. Snigdha Kar, a Delhi-based climate activist is following in Mrs Gandhi’s tracks. “I’m looking everywhere for the pied-crested cuckoo,” says the young hobby birder. The arrival of this stark black-and-white bird from Africa coincides exactly with whimsical monsoon winds which lift it to our shores'

So there you have it, two spectacular examples of amateur science in action.

Bibliography

1. Students Sea Turtle Conservation Network History. History

2. Waiting for Godwits. Open magazine, Pramila N. Phatarphekar, August 8, 2009. http://www.openthemagazine.com/a...

https://www.quora.com/What-are-some-opportunities-for-amateur-scientists-to-contribute-to-real-scientific-progress-in-their-spare-time/answer/Tirumalai-Kamala

How significant are Apple's medical apps to its future as a technology company?

Wearable devices (WD), mobile apps, other electronic systems, all these are new health monitoring tools, falling under the umbrella term mHealth (mobile health). They create new types of patient data called Patient Generated Health Data (PGHD). According to Shapiro et al (1),

'PGHD are health-related data, created, recorded, gathered, or inferred by or from patients or their designees (i.e., care partners or those who assist them) to help address a health concern'

According to Michael Fardis (2), PGHD include health and Rx history, symptoms, biometric data, lifestyle choices and other information. Main difference from traditional health data is patients record PGHD and are responsible for sharing it with those responsible for their care. According to Chan et al (3), over the coming years, mHealth in general and WD in particular could become indispensable in improving chronic disease monitoring. Systems monitored would be cardiovascular, nervous and respiratory, and chronic diseases covered would include cardiovascular diseases, Chronic obstructive pulmonary disease, diabetes, epilepsy, Parkinson's, autoimmune diseases such as Multiple sclerosis (MS), Rheumatoid arthritis (RA), to mention just a few obvious ones (for more possibilities, see table below from 2).

Thus, mHealth could fundamentally change chronic disease management and indeed biomedical research itself. Multiple sclerosis is a case in point. As Simpson et al state (4),

' Social media such as Twitter, mobile phone-based applications (apps), or even more pedestrian technology such as web based surveys or email, may provide a mechanism to more reliably track relapses. One could imagine an app that quickly queries relapse symptoms each day, and which automatically alerts investigators to follow up when a participant reports any level of symptoms indicative of relapse. Alternatively, a more participant-driven method like tweeting or emailing investigators about potential relapse symptoms could be utilised, avoiding the need to keep a study nurse on hand at particular hours to receive calls, and being sufficiently quick and simple to do that participants might be more likely to make that contact than if they were immediately having to do a phone assessment with a study nurse'

At its core, mHealth offers the following possibilities,

• That more frequent health monitoring could trigger behavior change.
• That it could help in better managing chronic diseases.
• That it could help improve medical research.

However, thus far the way mHealth has evolved creates a binary that mirrors the mutually antagonistic forces that currently drive it, namely, commercial market value of customer-generated health data versus improving chronic disease management and biomedical research by helping develop Precision medicine. Thus, mHealth essentially divides into two non-overlapping features,

1. Everyday health monitoring for the healthy.
2. Precision medicine for the chronically ill and for medical research.

Reason these are non-overlapping goals is because they target different population segments and serve different purposes. This difference in kind is a conundrum because the medical value is unclear for #1 while being obvious for #2. Everyday Health Monitoring ≠ Precision Medicine (see figure below). 

1. Healthy people frequently tracking some easily quantifiable health measurements (heart rate, pulse, blood pressure, sleep patterns, step tracking, posture, even pelvic floor health) raises the obvious issue of relevance. While its immediate medical value is ill-defined, it offers immediate commercial value for mHealth companies. Just sell WDs or apps to customers. Even if a customer doesn't share their data with their doctor or other healthcare advisers, there's always the possibility the device/app maker would sell it. Such user-generated health data is of obvious commercial value to health insurance companies, employers, affiliates, etc. Data may not be shared when the customer signs up for the service but there's no guarantee it will stay that way. For e.g., a 2015 Buzzfeed report by Ann Helen Petersen stated that Moves 'quietly modified its privacy policy to allow for sharing of data with “affiliates” after being acquired by Facebook in April 2014' (5). Issue of privacy is also an ever-present concern. Data may be anonymized when the customer signs up for the service but there's no guarantee it will stay that way.
2. OTOH, applied to chronic diseases and medical research, mHealth could help improve patient segmentation, symptom tracking and assessment, and thereby help develop more precise medicine, i.e., better fulfill the promise of precision medicine in short. Its medical value is thus clear and immediate but commercial value is long-, not short-term. This is because value-added input of mHealth in existing health care management and medical research can only be discerned over time through trial and error.

Apple's 2-pronged approach, Healthkit targeting customers, and Researchkit targeting medical research, epitomizes this essential conundrum in mHealth technologies. Conundrum as in commercial value of Healthkit data generated by healthy users versus Researchkit helping develop precision medicine in chronic disease and biomedical research. Clearly a difference in kind.

How to de-link the profit motive from collecting and selling health data generated from WDs and other health-monitoring apps from its potential to help develop precision medicine? If past is any predictor of the future, this won't happen without a fight followed by government stepping in to regulate this space. As for Apple, its future and future legal wrangles in mHealth will probably be shaped by which of these two mutually exclusive paths, Healthkit versus Researchkit, it decides to prioritize.

Bibliography

1. Patient-Generated Health Data. White Paper. Michael Shapiro, Douglas Johnston, Jonathan Wald, Donald Mon. April 2012. https://www.healthit.gov/sites/d...

2. Investigation of Models for the integration of Patient Generated Health Data within Swedish Multiple Sclerosis Quality Register. Michael Fardis, Master's Thesis. 2015. http://ki.se/sites/default/files...

3. Chan, Marie, et al. "Smart wearable systems: Current status and future challenges." Artificial intelligence in medicine 56.3 (2012): 137-156. https://www.researchgate.net/pro...

4. Simpson, Steve, Bruce V. Taylor, and Ingrid Van der Mei. "The role of epidemiology in MS research: Past successes, current challenges and future potential." Multiple Sclerosis Journal 21.8 (2015): 969-977. Past successes, current challenges and future potential

5. Big Mother Is watching You. Anne Helen Petersen, BuzzFeed News, Jan 1, 2015. Big Mother Is Watching You: The Track-Everything Revolution Is Here Whether You Want It Or Not

https://www.quora.com/How-significant-are-Apples-medical-apps-to-its-future-as-a-technology-company/answer/Tirumalai-Kamala

What kind of impact will allowing women to own land under their own names have on India?

Undoubtedly, along with education, economic self-sufficiency is the cornerstone for a woman's emancipation and autonomy, be it in India or anywhere else. However, in India at least two powerful obstacles stand in their way. One, all too often prevailing local cultural practices trump laws. Two, rural landholding sizes are shrinking fast in India. Since most Indians are still rural, this adversely impacts women's emancipation through land ownership.

In India, All Too Often Local Cultural Practices Trump Laws

Dowry laws prove this all too unambiguously. Bridegroom and/or his family demanding dowry from the bride's family remains a mainstay in many parts of India (Dowry system in India). Obviously commoditizing women, the dowry system constitutes systemic, structural abuse. When dowry's deemed insufficient, women are physically and psychologically abused, threatened, terrorized (1), even killed (2). Given the pernicious effects stemming from its systemic prevalence, the Indian Parliament passed the Dowry Prevention Act in 1961 (3). Neither demands for dowry nor dowry deaths abated so much so that the law was amended in 1983 (4) with a view to strengthening it. Did dowry demands and deaths stop? A decided no. The National Crime Records Bureau is the government agency that maintains records of all reported cognizable crimes in India. Their data show that ~1 woman is killed over dowry every hour (see Table 5(A) in 5). To top it, we have no way of knowing how accurate these data sets even are, and given dowry represents subjugation, under-reporting is more than likely.

Indian Rural Landholding's Shrinking Fast

Most Indians are still rural. For e.g., in 2011, ~833 million Indians (~69%) lived rurally compared to ~377 million in cities (6). Yet, individual rural landholding plot sizes almost halved in India since 1992 (See figures below from 6, 7, 8).

Rather than helping empower women through landholding, this trend disfavors them by increasing competition for land in an enormous, decidedly male-dominated culture.

Available data bear out both these concerns. ~400 million Indian women are rural. Almost 80% of them work in agriculture or related work, and are responsible for ~70% and 90% of food and dairy production,respectively. Yet <13% own the land (9) even as agriculture contributes 14 to 15% of India's GDP (10, 11). Glance at random at an Indian news piece about agriculture. Without fail, men are described as farmers. Women? As agricultural workers. Extent of gender-based disenfranchisement is so deep it casually pervades even the frame the highly educated use to examine salient issues.

Irony is India's Constitutional Fundamental Rights guarantees equality of opportunity and rights to all citizens (12). As well, the Hindu Succession Amendment Act 2005 was a landmark progressive and pro-women piece of legislation in a ~1.3 billion population where~80% are Hindu. However, cultural practices all too easily subvert and/or thwart laws allowing Indian women to own land under their own names. Prevailing culture ingrains subservience in women from an early age so lack of awareness and information is a major impediment.Women are thus easily pressured/coerced into writing off their property in favor of their brothers or other male relatives. Dowry's still prevalent so a woman's not considered eligible for more share post-marriage even when she patently is under the law.

Data suggest such socio-cultural practices severely limit Indian women's access to land ownership (9). For e.g., in West Bengal state, the government land title document, patta, had space for only one name. Even when meant to give joint ownership to husband and wife, practice was to write the husband's name as the family head. Only recently has the patta been re-designed to provide joint land titles to both husband and wife. Even when the patta is in their names with their photographs, as in the states of Andhra Pradesh and Karnataka, women typically never see it and believe their husbands have the title. Research in Odisha state uncovered that >30 year old single men, but not women, were considered a household. Such women weren't counted and thus denied access to government welfare schemes including land allocation. Only after this was uncovered did the state government start a program to count such single women in a few districts, and start allocating them homestead plots (9).

Despite such steep barriers, women landholders are a barely perceptible but growing segment in different parts of rural India.

How Landholding Could Help Indian Women's Empowerment

A 2005 Indian study showed women who owned land were 60% less likely to be subjected to domestic violence (13).

A 2007 Nepalese study showed landholding women have greater decision making power at home and their children are less likely to be severely malnourished (14).

A 2008 Ethiopian study showed landholding men and women invest twice as much time on its soil and water conservation (15). Implication? Ownership makes people better stewards of their land and environment.

Case studies of Indian landholding women reveal (see photos below from 16, 17).

• Their living standards and confidence improve.
• They command their community's respect.
• They garner greater decision making in their families.

All too easily overlooked barring an occasional news report, the impossibly slender shoulders of extraordinarily strong women like Chandra Subramanian carry an inordinate burden (photos below from 18). Following local tradition, she was married to her aunt's son at16. Husband and wife worked in a hosiery factory in Tiruppur, the knitwear capital of India. At 24, her father was killed in a road accident. Her husband committed suicide 40 days later. Such twin blows would prostrate the ordinary, not Chandra. This plucky mother's story reveals a person of remarkable strength, wit, and resilience (18). Chandra's mother inherited a 12 acre property on her husband's death and split it equally between her three children. Now 28, on her 4 acre share, Chandra grows vegetables, paddy, sugarcane, corn. Working almost 16 hours a day, she's up at 4 AM performing household chores and fixing her children's lunch. After harvesting vegetables, she walks her kids to school, then heads back to the fields until lunch. On market days, she packs her vegetable sacks on her moped and rides the 15 kms to the nearest town, Sivaganga, to sell her fresh produce. The photos documenting Chandra's life are a tonic. They declare in no uncertain terms that the truly intrepid can just buck up and keep going, no matter what.

That her mother inherited her father's land is the 1st critical emancipating event in this saga. Next, that Chandra inherited an equal land share from her mother is the 2nd critical emancipating event. So much else that's essential for a woman's emancipation is invisible and needs must be gleaned from reading between the lines. That a single woman alone on a farm is likely safe in this part of India. Implies a fully functioning local law and order machinery. That the local culture accepts financially independent single women. The astounding can-do spirit of Chandra and her ilk represent the best humanity offers but it can only blossom when laws aren't mere lip-service but actually implemented in deed. This is where there's many a slip between cup and lip in India.

Bibliography

1. Bloch, Francis, and Vijayendra Rao. "Terror as a bargaining instrument: A case study of dowry violence in rural India." The American Economic Review 92.4 (2002): 1029-1043)
2. Dowry Murder: The Imperial Origins of a Cultural Crime. Veena Talwar Oldenburg. Oxford University Press, 2002. http://www.amazon.com/Dowry-Murd...
3. http://ncw.nic.in/acts/THEDOWRYP...
4. http://www.498a.org/contents/ame...
5. https://www.google.co.in/url sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0ahUKEwiUuKLu7evLAhXCVyYKHQIkCawQFggeMAE&url=http%3A%2F%2Fncrb.nic.in%2FStatPublications%2FCII%2FCII2014%2Fchapters%2FChapter%25205.pdf&usg=AFQjCNHw2-Wo1JnDhbYTPbZqqLKBNuv2MQ
6. Chandramouli, C. (15 July 2011), Rural Urban Distribution Of Population (PDF), Ministry of Home Affairs (India). http://censusindia.gov.in/2011-p...
7. Agricultural Land Holdings Pattern in India. NABARD Rural Pulse, Issue - 1, Jan-Feb, 2014. https://www.nabard.org/Publicati...
8. The Hindu, Rukmini S., Dec 17, 2015. http://www.thehindu.com/data/rur...
9. Anisa Draboo, Yojana, November 2013. http://iasscore.in/pdf/yojna/Wom...
10. Agriculture Census in India. U.C. Sud, Indian Agricultural Statistics Research Institute, New Delhi, India. http://www.iasri.res.in/ebook/TE...
11. How Land Rights Can Strenghten And Help Accomplish The Post 2015 Development Agenda: The Case Of India. Anisa Draboo. 2015 World Bank Conference On Land And Property. Washington D.C., March 23 to 27, 2015. https://www.google.com/url?sa=t&...
12. Rao, Nitya. "Women’s access to land: An Asian perspective." Expert paper prepared for the UN Group Meeting ‘Enabling Rural Women’s Economic Empowerment: Institutions, Opportunities and Participation’. Accra, Ghana. 2011. http://www.un.org/womenwatch/daw...
13. Panda, Pradeep, and Bina Agarwal. "Marital violence, human development and women’s property status in India." World Development 33.5 (2005): 823-850. https://www.amherst.edu/media/vi...
14. Allendorf, Keera. "Do women’s land rights promote empowerment and child health in Nepal?." World development 35.11 (2007): 1975-1988. http://www.ncbi.nlm.nih.gov/pmc/...
15. Deininger, Klaus, Daniel Ayalew Ali, and Tekie Alemu. "Impacts of land certification on tenure security, investment, and land market participation: evidence from Ethiopia." Land Economics 87.2 (2011): 312-334. http://www.umb.no/statisk/ncde-2...
16. In pictures: How the right to own land transformed the lives of these five women. The Scroll, Anisa Draboo, March 8, 2016. http://scroll.in/article/804799/...
17. Landesa, Rural Development Institute. http://www.landesa.org/resources...
18. Small farmer, big heart, miracle bike. The Hindu, Aparna Karthikeyan, March 8, 2016. http://www.thehindu.com/news/nat...

https://www.quora.com/What-kind-of-impact-will-allowing-women-to-own-land-under-their-own-names-have-on-India/answer/Tirumalai-Kamala

Why do women make up a majority of live organ donors but not of organ recipients?

Several Studies Do Find Women Predominate Among Living Organ Donors

Studies ranging from Germany (1) to Oman (2) find that among medically suited living donors, women tend to donate more than men.

Kidney: In 2005, 59.2% of living US kidney donors were women while 58.2% of kidney recipients were men (3). Predominance of female kidney donors is seen not just in the US but also in Brazil (4). Global estimates for living kidney donors is ~65% female with ~65% of kidney recipients being male (3). Spousal differences are more striking compared to generic estimates. A University of Michigan study found 69% of spousal donations were female (5).

Liver: In 2005, 58.3% of living US liver donors were women while 58% of living liver segment recipients were men (6). Again, spousal differences are more striking compared to generic estimates. A Canadian study found 36% of women suitable for donating to their husbands were willing to do so while only 6.5% of suitable husbands were willing to be donors for their wives (7).

Examination of published literature suggests a combination of

• Different solid organ disease prevalence rates between men and women,
• Greater cultural pressure on women to carry the burden of caregiving,
• Gender selection bias in the healthcare system,

all of these factors contribute to why women predominate in living organ donations and yet receive fewer organ transplants.

Different solid organ disease prevalence rates between men and women

Several studies have documented pronounced gender bias in transplantation. However, while examining these, onus is on us to account for gender-based disease prevalence rate differences, especially where the rates are higher in men.

Kidney: Renal disease tends to be more common in men compared to women (8). Mortality rates of men on dialysis is also higher compared to women (9). Speculation is baseline creatinine clearance is better in elderly women compared to men.

Heart: In 1996, 81.2% of US heart transplant recipients were men and this only decreased to 76.8% by 2005 (6). Part of this has to do with greater preponderance of coronary artery disease in young men compared to young women. Even among those aged 55 to 64 years, congestive heart disease rates in US men are twice those in women.

Liver: Liver disease rates are higher among US men (10).

Greater cultural pressure on women to carry the burden of caregiving

Studies suggest women may offer kidneys more often from a greater drive to alleviate suffering and/or a greater inability to resist subtle pressures (11). Some authors speculate preponderance of bearing the burden of caregiving in a family may extend the woman's role to becoming a living kidney donor (12). Some studies support this conclusion (13). In fact, women are considered more vulnerable and more easily persuaded/pressured to donate (14). This is the reason the multi-disciplinary living donor assessment process in Australia and the US focuses on the living kidney donor's autonomy and decision making in the absence of coercion (15). Cultural differences may also play a role. Even today, in many societies the woman is the main caregiver with the man the breadwinner. When a woman undergoes transplantation, the man would need to take time off work to take over household management. Some authors (3, 12) speculate transplant centers may inadvertently reinforce such gender roles in the manner they offer, discuss and foster women's access to transplantation.

Gender selection bias in the healthcare system

Studies find men are often preferentially placed on transplant waiting lists (16, 17).

Kidney: A French study on 9497 men and 5386 women on dialysis found that women had both a lower probability of being registered on the waiting list and waited longer after starting dialysis before being registered (18). This study found older, unemployed and diabetic women were more likely to be victims of such disparities. A large southeastern US study found women were less likely to be perceived suitable for kidney transplants compared to men, and this was independent of medical factors (19). Gender bias favoring men was found in other US studies as well (20, 21).

Heart: Of US heart transplants in 2005, 52.3% of heart transplant recipients in 2005 were aged 50 to 64 years and 10.3% >65 years. With age, especially >65 years, coronary artery disease rates between US men and women are similar (22). Yet, gender bias persists even among this older age group of heart transplant recipients (3). Studies show that women decline heart transplantation at greater rates compared to men (23). One reason proffered for this implies surgeons prioritizing vanity over vocation, i.e., women presented with this option in a manner inclined to discourage them for the simple reason that post-transplant mortality rates tend to be higher for women compared to men, and heart transplant surgeons may be motivated by concern for their success rates (3).

Liver: One US study found women were less likely to get liver transplants (24) while another one found twice as many men as women get liver transplants (25) even though disease rates aren't twice higher.

According to JoAnn Grif Alspach (26), gender bias in medical care can thus be the unintentional product of implicit, insidious bias in the culture of medicine itself. She then lists the following implicit cultural biases as possible reasons,

'• Underestimating or misunderstanding a woman’s risk for health problems or complications 8

• Differences in the way women experience (cardiac) symptoms 30

• Differences in the way women perceive themselves and their illness 30

• The most likely explanations are at the patient level, the physician level, or both. Patients may have misperceptions of indications, risks, or benefits of surgery.

• One factor may be the differences in style that women and men use to describe their symptoms or injuries to the physician. Women tend to describe what they experience as a more personal, narrative commentary compared to men, who typically describe symptoms in a more straightforward, factual manner with fewer comments. 49 Women’s narrative presentation style reportedly contributed to physicians making more diagnostic errors in their evaluations of chest pain in women. 50

• Unconscious prejudices among physicians—social stereotyping 29

• Overt discrimination based on sex. Some physicians take women’s symptoms less seriously, attribute symptoms to emotional rather than physical causes, and refer women less often than men for specialty care, even women with a relatively greater degree of disability. 29

• Cultural biases, especially among older male physicians 51

• Women thinking of stroke and heart disease as men’s diseases 51

• Perceived differences in injury severity or perceived benefits of trauma center care, or from subconscious gender bias 48'

Ironically, transplants in women have also often been pioneering.

• In August 1966, Dr. Michael E. DeBakey implanted the 1st extracorporeal left ventricular assist device in a 37-year old woman who couldn't be weaned from bypass following a double valve replacement (27). The pump was successfully removed after 6 days and she survived for 6 years with good cardiac function only to tragically die from an automobile accident.
• The 1st pancreas allograft occurred on December 17, 1966 at the University of Minnesota when Drs. William Kelly and Richard Lillehei simultaneously transplanted a kidney allograft plus a duct ligated segmental pancreas into a 28 year old woman (28).

Gender Bias Matters Medically Because Gender Mismatch In Transplants Is Often Counter-Productive

Gender mismatch between donors and recipients is often counter-productive. Specifically, men with allografts from women have greatest risk of long-term allograft failure (29). This is especially true for kidney transplants (30).  Risk also runs both ways. In donations after circulatory/cardiac death (DCD), transplanting a male liver into a female recipient is a risk factor for primary non-function (31). Female recipients of male hearts is a risk factor for acute cellular and antibody-mediated rejection of heart transplants (32, 33, 34, 35, 36). Studies suggest gender matching may protect against heart transplant rejection (37).

Bibliography

1. Decker, Oliver, et al. "Between commodification and altruism: gender imbalance and attitudes towards organ donation. A representative survey of the German community." (2008): 251-255.

2. Mohsin, N., et al. "Donor gender balance in a living-related kidney transplantation program in Oman." Transplantation proceedings. Vol. 39. No. 4. Elsevier, 2007.

3. Csete, Marie. "Gender issues in transplantation." Anesthesia & Analgesia 107.1 (2008): 232-238.

4. Lima, Daniel Xavier, Andy Petroianu, and Heather Lynn Hauter. "Quality of life and surgical complications of kidney donors in the late post-operative period in Brazil." Nephrology Dialysis Transplantation 21.11 (2006): 3238-3242. Quality of life and surgical complications of kidney donors in the late post-operative period in Brazil

5. Kayler, Liise K., et al. "GENDER IMBALANCE IN LIVING DONOR RENAL TRANSPLANTATION1." Transplantation 73.2 (2002): 248-252.

6. US Department of Health and Human Services. "2008 Annual Report of the US Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients: Transplant Data 1998-2007." (2008).

7. Zimmerman, Deborah, et al. "Gender disparity in living renal transplant donation." American Journal of Kidney Diseases 36.3 (2000): 534-540.

8. Reyes, Daisy, Susie Q. Lew, and Paul L. Kimmel. "Gender differences in hypertension and kidney disease." Medical Clinics of North America 89.3 (2005): 613-630.

9. Lindeman, Robert D., Jordan Tobin, and Nathan W. Shock. "Longitudinal studies on the rate of decline in renal function with age." Journal of the American Geriatrics Society 33.4 (1985): 278-285.

10. Kim, W., et al. "Burden of liver disease in the United States: summary of a workshop." Hepatology 36.1 (2002): 227-242. https://www250.safesecureweb.com...

11. Biller-Andorno, Nikola. "Gender imbalance in living organ donation." Medicine, Health Care and Philosophy 5.2 (2002): 199-203.

12. Gordon, Elisa J., and Daniela P. Ladner. "Gender inequities pervade organ transplantation access." Transplantation 94.5 (2012): 447-448. https://www.researchgate.net/pro...

13. Mohs, Anja, and Gundula Hübner. "Organ donation: the role of gender in the attitude–behavior relationship." Journal of Applied Social Psychology 43.S1 (2013): E64-E70. https://www.researchgate.net/pro...

14. Dobson, Roger. "More women than men become living organ donors." BMJ: British Medical Journal 325.7369 (2002): 851.

15. Spital, Aaron. "Ethical issues in living organ donation: donor autonomy and beyond." American Journal of Kidney Diseases 38.1 (2001): 189-195.

16. Alexander, G. Caleb, and Ashwini R. Sehgal. "Barriers to cadaveric renal transplantation among blacks, women, and the poor." Jama 280.13 (1998): 1148-1152. http://citeseerx.ist.psu.edu/vie...

17. Bayat, S., et al. "Individual and regional factors of access to the renal transplant waiting list in France in a cohort of dialyzed patients." American Journal of Transplantation 15.4 (2015): 1050-1060.

18. Couchoud, Cécile, et al. "A new approach for measuring gender disparity in access to renal transplantation waiting lists." Transplantation 94.5 (2012): 513-519.

19. Soucie, J. Michael, John F. Neylan, and William McClellan. "Race and sex differences in the identification of candidates for renal transplantation." American journal of kidney diseases 19.5 (1992): 414-419.

20. Thamer, Mae, et al. "US NEPHROLOGISTS’ATTITUDES TOWARDS RENAL TRANSPLANTATION: RESULTS FROM A NATIONAL SURVEY." Transplantation 71.2 (2001): 281-288. https://www.researchgate.net/pro...

21. Segev, Dorry L., et al. "Age and comorbidities are effect modifiers of gender disparities in renal transplantation." Journal of the American Society of Nephrology 20.3 (2009): 621-628. Age and Comorbidities Are Effect Modifiers of Gender Disparities in Renal Transplantation

22. Young, Lynne, and Maureen Little. "Women and heart transplantation: an issue of gender equity?." Health care for women international 25.5 (2004): 436-453.

23. Aaronson, Keith D., et al. "Sex differences in patient acceptance of cardiac transplant candidacy." Circulation 91.11 (1995): 2753-2761. Sex Differences in Patient Acceptance of Cardiac Transplant Candidacy

24. Myers, Robert P., et al. "Gender, renal function, and outcomes on the liver transplant waiting list: assessment of revised MELD including estimated glomerular filtration rate." Journal of hepatology 54.3 (2011): 462-470.

25. Thuluvath, P. J., et al. "Liver transplantation in the United States, 1999–2008." American Journal of Transplantation 10.4p2 (2010): 1003-1019. https://deepblue.lib.umich.edu/b...

26. Alspach, JoAnn Grif. "Is there gender bias in critical care?." Critical care nurse 32.6 (2012): 8-14. Is There Gender Bias in Critical Care?

27. DeBakey, Michael E. "Left ventricular bypass pump for cardiac assistance: clinical experience." The American journal of cardiology 27.1 (1971): 3-11.

28. Kelly, W. D., et al. "Allotransplantation of the pancreas and duodenum along with the kidney in diabetic nephropathy." Surgery 61.6 (1967): 827-837.

29. Kittleson, Michelle M., et al. "Donor–recipient sex mismatch portends poor 10-year outcomes in a single-center experience." The Journal of Heart and Lung Transplantation 30.9 (2011): 1018-1022.

30. Gratwohl, Alois, et al. "HY as a minor histocompatibility antigen in kidney transplantation: a retrospective cohort study." The Lancet 372.9632 (2008): 49-53.

31. De Vera, M. E., et al. "Liver Transplantation Using Donation After Cardiac Death Donors: Long‐Term Follow‐Up from a Single Center." American Journal of Transplantation 9.4 (2009): 773-781. http://www.custodiol.com/hansjb/...

32. Kobashigawa, J. A., et al. "Pretransplantation risk factors for acute rejection after heart transplantation: a multiinstitutional study. The Transplant Cardiologists Research Database Group." The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 12.3 (1992): 355-366.

33. Jarcho, J., et al. "Influence of HLA mismatch on rejection after heart transplantation: a multiinstitutional study. The Cardiac Transplant Research Database Group." The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 13.4 (1993): 583-95.

34. Lones, Mark A., et al. "Clinical-pathologic features of humoral rejection in cardiac allografts: a study in 81 consecutive patients." The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 14.1 Pt 1 (1994): 151-162.

35. Kubo, S. H., et al. "Risk factors for late recurrent rejection after heart transplantation: a multiinstitutional, multivariable analysis. Cardiac Transplant Research Database Group." The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 14.3 (1994): 409-418.

36. Michaels, Paul J., et al. "Humoral rejection in cardiac transplantation: risk factors, hemodynamic consequences and relationship to transplant coronary artery disease." The Journal of heart and lung transplantation 22.1 (2003): 58-69.

37. Patel, Nishant D., et al. "Impact of donor-to-recipient weight ratio on survival after heart transplantation analysis of the United Network for Organ Sharing database." Circulation 118.14 suppl 1 (2008): S83-S88. Impact of Donor-to-Recipient Weight Ratio on Survival After Heart Transplantation

https://www.quora.com/Why-do-women-make-up-a-majority-of-live-organ-donors-but-not-of-organ-recipients/answer/Tirumalai-Kamala

Why are "housing first" homeless shelter programs so effective?

My one and only brush with accidental homelessness unforgettably sensitized me to this issue. Newcomer to the US, focus on my science made me choose a basement apartment off the NIH campus in Bethesda, Maryland. Landlord an elderly widower retired from the NIH, a safe dwelling I surmised, little knowing that just a few months later, he'd trigger a short circuit in his house and it would go up in flames. Happening the day after Thanksgiving, both at home, we were both lucky to get out alive. Once the hubbub of firetrucks, police cars and ambulance chasing clean-up specialists cleared, he drove us to a downtown Bethesda hotel, promising I'd be back in my apartment within two weeks. The weeks passed with no progress. Meantime, thanks to those clean-up specialists, I'd been left standing in the clothes I wore. Sheer accident that I rushed out wallet in hand. Everything else packed and sped off for 'smoke damage clean-up'. Sheer luck a colleague looking to sub-let got me into another place within a month. All this to say that even though my experience was positively luxurious compared to the truly homeless, I can well appreciate the hell that is to be homeless.

Where to sleep, to bathe, to go to toilet, get a meal. We take these essential basics of daily living for granted when we have a home to call our own. And that's not all. Situation's incalculably worse for those homeless even more unlucky to not be in the tropics. For such, staying warm through bitterly cold days and nights for weeks and months on end is yet another imperative on a long list of others we 'homed' take for granted and we still aren't done with the imperatives. A homeless woman has an additional imperative, how to stay safe and unmolested at all times of day and night. Sounds like a surefire recipe for insanity, no? Shocking then that it took an outsider to divine that rather than carrots and sticks, having a roof over one's head is the most essential first step for a homeless person to get on the track back to relative normalcy, maybe even permanently.

The radical visionary who divined this is Sam Tsemberis, founder of Pathways to Housing. The radical aspect of Tsemberis' solution stems from giving homes without preconditions to people with all kinds of serious and chronic problems ranging from addiction to other serious mental health problems. This is in direct contrast to how social policy traditionally addressed homelessness in the US, i.e., a reward system. It went somewhat like this. Let's say homeless person issues are x, y, z while the bureaucrat's carrots are 1, 2, 3. Social policy dictated to the homeless you solve issue x, say addiction, we'll give you reward 1, say counseling. A trained psychologist, his stint doing outreach with the mentally ill in New York City in the early 1990s revealed to Tsemberis his epiphany about the homeless. It also reveals the blinkers even the most well-intentioned can harbor. Paternalism is deeply ingrained in the conventional understanding of the homeless. The homeless are perceived to lack ability to function. However, submerging himself in the world of the homeless taught Tsemberis that on the contrary, the homeless are enormously resourceful.

I too got the same insight from watching someone at close quarters. During my time at the NIH, I met a brilliant researcher working in the building next to mine. Diagnosed with a mental disorder and forcibly institutionalized, having then managed to partially extricate herself, some years later she re-surfaced as a homeless person in the neighborhood. At unpredictable moments, she'd show up in the lab late at night as I harvested a thick stack of cell culture plates. She'd lean on a nearby counter and recount her experiences living on the street. Which intersections were best for panhandling. What time was best to panhandle at the intersection between Old Georgetown Road and Democracy Boulevard. How she negotiated with other panhandlers to gain a corner at this busy intersection. Which supermarket dumpsters were best for bread and other baked goods. Where years earlier, we'd discussed the latest paper on Toll-like receptor structure, now she'd regale with her varied and rich insights about life on the street. Not to mention I never found out how she even managed to get onto campus, let alone into the lab. I thought exactly the same as Tsemberis. What amazing resourcefulness!

Equipped with the insight that the homeless are nothing if not resourceful, Tsemberis created a team peopled by outsiders that included a recovering heroin addict, a former homeless, a psychologist and a poet survivor of incest (1). Team in hand and with a $500000 in federal funding,  Tsemberis started a pilot project with 139 chronically homeless his team immediately housed and offered counseling. The results? A retention rate of ~85%, far better than the 60% that was the then best metric. All this way back in 1997. When Tsemberis published his findings in 2000 in Psychiatric Services (2), a fairly respectable peer-reviewed journal, predictably, old hands in the homeless services community looked askance at this rude short shrift to conventional wisdom and by an outsider to boot (3, 4, 5, 6).

However, as the years passed, empirical data by others who implemented/pilot tested Housing First (7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17) bolstered support for it. Even the US federal government found it dramatically shrank addiction and health care costs (18). Success has been inconsistent when the local administration's commitment has been likewise, as in Washington D.C. Pilot projects in other countries such as Germany (19) showed promise. Homeless services researchers in the UK propose Housing First deserves serious consideration there as well (20, 21, 22) even as there's considerable resistance to the idea (23, 24, 25). Several studies in Canada find in favor of Housing First (26, 27, 28, 29, 30, 31, 32, 33). It also finds favor in Australia (34).

Analysts attribute the success of Pathways to Housing and its ascent to orthodoxy as Housing First to the juxtaposition of key individuals with unique gifts and qualifications. Dennis Culhane, a researcher who works closely with policy makers and is 'unusually adept' at translating research findings to policy positions (35), the charismatic Sam Tsemberis, founder of Pathways to Housing, and policy maker Phil Mangano (36). Sold by Mangano to local mayors as a consumer choice model rather than a coercive measure (37), Housing First appealed to politicians keen to erase visible signs of capitalism's failure and what could be a more compelling sign than the chronically homeless visibly sleeping in city parks.

Pathways to Housing and Housing First aren't interchangeable. However, both assert right to housing as a fundamental right. This is the reverse of beliefs that have historically shaped US welfare, namely, people have to first prove themselves worthy of government benefits or have earned it. However, there are unique aspects to what Pathways to Housing did in New York City. That blueprint isn't fully fleshed out even by its architects and already the model is being exported all over the US and even elsewhere. Several dangers are inherent to such an approach. Other policy makers may not have the same goals and commitments. Elsewhere, Housing First could easily become a tool for enforced gentrification of minority-dominated inner city blocks. It could be used as a cosmetic cover to relocate the chronically homeless to city outskirts without investing the corollary efforts necessary to get them on the path to autonomy and self-sufficiency (38). In other words, out of sight, out of mind could be a critical weakness of Housing First that could be easily exploited by less scrupulous policy makers keen to wall-paper a serious social problem that's also very embarrassing to leaders and policy makers in what's undoubtedly the wealthiest country in the world.

Bibliography

1. Terrence McCoy, The Washington Post, May 6, 2015. Meet the outsider who accidentally solved chronic homelessness

2. Tsemberis, Sam, and Ronda F. Eisenberg. "Pathways to housing: Supported housing for street-dwelling homeless individuals with psychiatric disabilities." Psychiatric services (2000). http://ps.psychiatryonline.org/d...

3. Shinn, Marybeth, Jim Baumohl, and Kim Hopper. "The prevention of homelessness revisited." Analyses of Social Issues and Public Policy 1.1 (2001): 95-127. https://www.researchgate.net/pro...

4. Bassuk, Ellen L., and Stephanie Geller. "The role of housing and services in ending family homelessness." Housing Policy Debate 17.4 (2006): 781-806. https://www.researchgate.net/pro...

5. Culhane, Dennis P., and Stephen Metraux. "Rearranging the deck chairs or reallocating the lifeboats? Homelessness assistance and its alternatives." Journal of the American Planning Association 74.1 (2008): 111-121. http://repository.upenn.edu/cgi/...

6. Kertesz, Stefan G., et al. "Housing first for homeless persons with active addiction: are we overreaching?." Milbank Quarterly 87.2 (2009): 495-534. http://www.coloradocoalition.org...

7. Siegel, Carole E., et al. "Tenant outcomes in supported housing and community residences in New York City." Psychiatric Services (2006). http://ps.psychiatryonline.org/d...

8. Walsh, Adam, Jennifer Vaughn, and D. F. Duncan. "The Cost Effectiveness of Supportive Housing Teams at Eighteen Months." (2009). http://www.unc.edu/~dfduncan/pap...

9. Meschede, Tatjana. "Accessing housing: Exploring the impact of medical and substance abuse services on housing attainment for chronically homeless street dwellers." Journal of Human Behavior in the Social Environment 20.2 (2010): 153-169

10. Rogers, E. Sally, et al. "Systematic Review of Supported Housing Literature 1993–2008." (2010). http://dcommon.bu.edu:8080/bitst...

11. Collins, Susan E., et al. "Exploring transitions within a project-based Housing First setting: Qualitative evaluation and practice implications." Journal of health care for the poor and underserved 23.4 (2012): 1678. https://depts.washington.edu/har...

12. Brown, Molly. "Effectiveness of Housing First for Non-chronically Homeless Individuals Who Are High Utilizers of Inpatient Psychiatric Treatment." (2012). http://via.library.depaul.edu/cg...

13. Collins, Susan E., Daniel K. Malone, and Seema L. Clifasefi. "Housing retention in single-site Housing First for chronically homeless individuals with severe alcohol problems." American journal of public health 103.S2 (2013): S269-S274. https://www.researchgate.net/pro...

14. Montgomery, Ann Elizabeth, et al. "Housing chronically homeless veterans: Evaluating the efficacy of a Housing First approach to HUD‐VASH." Journal of Community Psychology 41.4 (2013): 505-514.

15. Clifasefi, Seema L., Daniel K. Malone, and Susan E. Collins. "Exposure to project-based Housing First is associated with reduced jail time and bookings." International Journal of Drug Policy 24.4 (2013): 291-296. https://www.researchgate.net/pro...

16. Hwang, Stephen W., and Tom Burns. "Health interventions for people who are homeless." The Lancet 384.9953 (2014): 1541-1547. http://bibliobase.sermais.pt:800...

17. Davidson, Clare, et al. "Association of Housing First implementation and key outcomes among homeless persons with problematic substance use." Psychiatric Services (2014). https://www.researchgate.net/pro...

18. Burt, Martha R., and Brooke E. Spellman. "Changing homeless and mainstream service systems: Essential approaches to ending homelessness." Toward Understanding Homelessness: The 2007 National Symposium. Vol. 4. 2007. https://aspe.hhs.gov/sites/defau...

19. Fichter, M. M., and N. Quadflieg. "Intervention effects of supplying homeless individuals with permanent housing: a 3‐year prospective study." Acta Psychiatrica Scandinavica 113.s429 (2006): 36-40.

20. Atherton, Iain, and Carol McNaughton Nicholls. "'Housing First' as a means of addressing multiple needs and homelessness." (2008). http://dspace.stir.ac.uk/bitstre...

21. Price, Sian. "Housing related support interventions: a rapid review of the evidence." Pridobljeno dne 2 (2010): 2013.

22. McNaughton Nicholls, Carol, and Iain Atherton. "Housing First: Considering components for successful resettlement of homeless people with multiple needs." Housing Studies 26.5 (2011): 767-777.

23. Johnsen, Sarah, and Lígia Teixeira. "‘Doing it already?’: stakeholder perceptions of Housing First in the UK." International Journal of Housing Policy 12.2 (2012): 183-203.

24. Tsai, Jack, Alvin S. Mares, and Robert A. Rosenheck. "A multisite comparison of supported housing for chronically homeless adults:“housing first” versus “residential treatment first”." Psychological Services 7.4 (2010): 219. http://www.homelesshub.ca/sites/...

25. Tsai, Jack, and Robert A. Rosenheck. "Considering Alternatives to the Housing First Model." European Journal of Homelessness _ Volume 6.2 (2012). http://feantsaresearch.all2all.o...

26. Falvo, Nick. Homelessness, program responses, and an assessment of toronto's streets to homes program. Canadian Policy Research Networks Incorporated and Social Housing Services Corporation, 2009. http://cprn3.library.carleton.ca...

27. Fitzpatrick-Lewis, Donna, et al. "Effectiveness of interventions to improve the health and housing status of homeless people: a rapid systematic review." BMC Public Health 11.1 (2011): 1. BMC Public Health

28. Stergiopoulos, Vicky, et al. "Moving from rhetoric to reality: adapting Housing First for homeless individuals with mental illness from ethno-racial groups." BMC health services research 12.1 (2012): 1. BMC Health Services Research

29. Patterson, Michelle, et al. "Housing First improves subjective quality of life among homeless adults with mental illness: 12-month findings from a randomized controlled trial in Vancouver, British Columbia." Social psychiatry and psychiatric epidemiology 48.8 (2013): 1245-1259. https://www.researchgate.net/pro...

30. Somers, Julian M., et al. "Housing first reduces re-offending among formerly homeless adults with mental disorders: results of a randomized controlled trial." PloS one 8.9 (2013): e72946. http://journals.plos.org/plosone...

31. Patterson, Michelle L., et al. "Trajectories of recovery among homeless adults with mental illness who participated in a randomised controlled trial of Housing First: a longitudinal, narrative analysis." BMJ open 3.9 (2013): e003442. http://www.habitation.gouv.qc.ca...

32. Tan de Bibiana, Jason. "Housing first and emergency department utilization among homeless individuals with mental illness in Vancouver." Electronic Theses and Dissertations (ETDs) 2008+ (2013). https://circle.ubc.ca/bitstream/...

33. Russolillo, Angela, et al. "Emergency department utilisation among formerly homeless adults with mental disorders after one year of Housing First interventions: a randomised controlled trial." International Journal of Housing Policy 14.1 (2014): 79-97. http://summit.sfu.ca/system/file...

34. Johnson, Guy, Sharon Parkinson, and Cameron Parsell. "Policy shift or program drift? Implementing Housing First in Australia." AHURI Final Report 184 (2012): 1-21. http://espace.library.uq.edu.au/...

35. Stanhope, Victoria, and Kerry Dunn. "The curious case of Housing first: The limits of evidence based policy." International journal of law and psychiatry 34.4 (2011): 275-282. http://web.pdx.edu/~nwallace/AHP...

36. Shinn, Marybeth. "Waltzing with a monster: Bringing research to bear on public policy." Journal of Social Issues 63.1 (2007): 215-231.

37. Mangano, P. (2008). The impact of the federal initiative to end chronic homelessness in10 Years. Paper presented at the Center for Homelessness Prevention Studies Grand Rounds, Columbia University Mailman School of Public Health.

38. Hennigan, Brian Richard. "House Broken: The Functions and Contradictions of" Housing First"." (2013). http://surface.syr.edu/cgi/viewc...

https://www.quora.com/Why-are-housing-first-homeless-shelter-programs-so-effective/answer/Tirumalai-Kamala