Why do people believe that bottled water is better than tap water?

People may or may not have started out believing bottled water is better than tap water. However for >20 years now in the US, they've certainly been marketed to that way and consumption patterns suggest it worked.

In 1975, Americans hardly drank bottled water, just one gallon of bottled water per person per year on average. By 2005, it had grown to ~26 gallons per person per year (1). By 2012, touching 30 gallons per person per year (see figure below from 2), it had become the veritable 'superstar of the beverage industry' (3).

The US sociologist, Andrew Szasz offers an intriguing explanation for the explosion in bottled water consumption in recent decades. Calling it the phenomenon of 'inverted quarantine', modeled after quarantine, he characterizes it as a distinct consumer response to widespread threats, both perceived and real. In classic quarantine, the collective community and environment are deemed healthy and some discrete sources within it present a spreadable danger. The community then protects itself by isolating that source, i.e., the diseased individual(s). This reduces the chance that others will get exposed and spread the infection. What happens when the threat is perceived to be everywhere? When the surrounding environment itself is perceived to be toxic, dangerous? According to Szasz, in the US, many healthy individuals responded by isolating themselves from their disease-inducing environment. Healthy and relatively affluent. Hence 'inverted quarantine', a walling-off response to threats perceived everywhere, gated communities perhaps the purest expression yet of such impulses.

Contrasting it with past social movements which brought about change through collective action, Szasz characterizes choices to buy bottled water, and 'organic', 'natural', 'non-toxic' food, household and personal hygiene products as ultimate expressions of individualism. 'Assembling a personal commodity bubble for one's body' (3), an attempt to shop one's way out of trouble instead of banding together collectively to change the status quo. In the case of bottled water, it started with a long-perceived suspicion of tap water. Long before the tragic Flint water crisis, US residents reported their tap water mistrust in survey after survey (3, Chapter 3, reference 5).

'The 1999 National Consumer Water Quality Survey found that “about three -quarters [of American adults] have some concern regarding the quality of their household water supply” and “almost half are concerned about possible health-related contaminants.” Two years later, a follow -up survey found those numbers had grown bigger still. Eight -six percent agreed they had “concerns about their water,” and “51 percent worried about possible health contaminants.'

In other words, widespread perception of toxic industrial and agricultural chemicals polluting tap water. Once the beverage industry understood this was driving consumer interest in bottled water, it set about explicitly marketing it as a safer alternative to assuage precisely these concerns. While bottled spring water brands pitched the pristine purity of their bottled water (see some examples below from 3, chapter 3)...

Odwalla

'ANCIENT FRESHNESS™—The Odwalla water you are now meeting fell on the land as rain, snow, and glacial melt 16,000 years ago. When it began its circular journey deep into the earth, ecosystems were in balance, the air was clear, the landscape wild and primeval. It carried this prehistoric purity underground, where it has remained totally isolated from environmental changes. —This water is as pure as the day it fell to Earth 16,000 years ago.78'

Fiji Water

'water that has never been touched by pollution or dirtied by pollution because it was created hundreds of years before the industrial revolution and it’s been locked under the earth in an aquifer in Fiji . . . at the very edge of a primitive rainforest, 1,500 miles away from the nearest continent. . . . Far from pollution. Far from acid rain. Far from industrial waste. . . . when it comes to drinking water, “remote” happens to be very, very good.79'

...Brands sourcing their water from the public water system focused on the 'hypertechnological efforts' (3) to render the hitherto toxic pure (see some examples below from 3, chapter 3).

Big Sur Water Company

'goes through a carbon filter . . . then [it is] put through a vapor compression™ processor . . . then through a 1 micron . . . paper filter . . . [finally,] As the water then goes toward the filler, superoxygen in the form of ozone (O3) is injected into the water to assure our water will remain in a pure state after it is bottled.81'

Ionic

'The process used to purify and produce Aqua CoolR Pure Bottled Water involves the use of The Ionics ToolboxSM of technologies [that ToolboxSM has in it: Electrodialysis Reversal, Reverse Osmosis, Ultrafiltration, Adsorption] to obtain the complete removal of all dissolved and undissolved materials from the source water. The resulting highly pure water is then remineralized with a specific “menu” of minerals selected for taste and fortification.82'

Once such relentless, focused marketing succeeded and how (see an eyebrow-raising example below from Wikipedia), a virtuous positively reinforcing cycle came into existence. And it's a hard one to knock off. After all, the perceived threat is the subtle one of long-term consequences of ingesting low doses of 'toxic' pollutants present in tap water. Once beverage company marketers succeeded in convincing consumers of the superior safety of their product, it required less effort in expanding its appeal by pitching it to the health-conscious as a lifestyle choice. And thus, bottled water sales increase year on year.

Irony of choosing bottled water over tap water is it implicitly imbues beverage companies with saintly trustworthiness that may be just as unwarranted.

Bibliography

1. Beverage Marketing Corporation of New York, “News Release: Bottled Water Continues Tradition of Strong Growth in 2005,” April 2006, Consulting, Advisory Services, Trend Data and Market Reports for the Global Beverage Industry

2. Bottled Water Sales: The Shocking Reality. Peter Gleick, April 25, 2013.

3. Shopping Our Way to Safety: How We Changed from Protecting the Environment to Protecting Ourselves: Andrew Szasz: 9780816635092: Amazon.com: Books. Andrew Szasz, University of Minnesota Press, 2009.

https://www.quora.com/Why-do-people-believe-that-bottled-water-is-better-than-tap-water/answer/Tirumalai-Kamala

Are there any animals that actually enjoy being hugged by humans?

Question could be examined from at least three angles.

• How do animals react to a human's hug as in are there any physiological similarities between animal and human response to hugs?
• Do animals offer hugs to each other in their native habitats in social contexts plausibly similar to those among humans?
• Do animals offer hugs to humans?

Currently there seem to be scientific studies about the first two but not the last question.

How do animals react to a human's hug? Examples from Indirect Dog Studies.

What's a hug but a gesture of affection, consolation and/or support? If pet dogs expected such affectionate gestures from their human parents/owners as a matter of course, a logical extension would be that such expectations entail possessiveness expressed as jealousy when the dogs see those same gestures extended to others in their environment. So do pet dogs express jealousy in such situations?

I. A 2012 Plos One study on 36 dogs studied in their homes suggested they became jealous when they observed a rival for their affection (1). The study videotaped the dogs' reactions when their human parents/owners ignored them to instead pay attention to a stuffed animal, a jack-o-lantern pail or a pop-up book they read aloud. The stuffed animal consisted of a realistic-looking dog that barked, wagged its tail and whined. The authors chose not to include real rival dogs because such situations would be more difficult to control and would have yielded results much more difficult to interpret. The dogs in the study included a variety of breeds ranging from a Boston terrier, Yorkshire terriers, chihuahuas, mutts and a pug.

The study found a clear hierarchy of perceived affection deprivation

• 78% would push or touch the human parent/owner when they petted or sweet-talked the fake dog.
• 42% became upset when the human parent/owner gave attention to the jack-o-lantern pail.
• 22% became upset when the human parent/owner gave attention to the book.

Only a preliminary study so results can't be taken as conclusive and there are caveats as well. Study was small, only 36 dogs. The researchers didn't record the dogs' initial reactions to these new objects so we don't know if the dogs' reactions were to the objects per se or to human parents'/owners' interactions with them. However, the study does suggest that jealousy may not be solely a human construct nor based on sexual rivalry alone. Rather it may stem from 'the need to secure resources in all kinds of valued social relationships, be they sexual, parental, sibling, or just friendly' (2).

II. In a first of its kind study, animal cognition scientists at Eotvos Lorand University in Budapest trained dogs to lie still in an https://en.wikipedia.org/wiki/Ma... machine, and compared human (n=22) and canine (n=11) brain activity in response to different human and dog sounds such as voices, barks, and meaningful grunts and sighs that both species articulate (3). They found that happy sounds lit up the auditory cortex in both humans and dogs. According to Attila Andics, the neuroscientist and lead author of the study, dogs seems to be neurologically hardwired to pick up on their human companions' subtle mood shifts (4). This suggests they may welcome and appreciate hugs from their human parents/owners.

III. In another dog MRI study, Emory University also trained dogs (n=37) to lie still in an MRI machine and measured their neural responses to smells of familiar and unknown people using Functional magnetic resonance imaging (5). They found dog owners' smell triggered their brains' caudate nucleus, the brain's 'reward center'. This is extremely pertinent since dogs use their noses to navigate through the world. Study of how their brains process smell stimuli could improve our understanding of their social world, what's important, what's not, and how this process is similar or not to that in humans. In this case, smells of their human parents/owners seemed to be looped into their brains' reward circuits. Again, this suggests they'd likely enjoy being hugged by their human parents/owners. A follow-up fMRI study on 13 dogs found somewhat similar results in response to touch (6).

Caveats with these MRI studies is dogs were trained to sit motionless in the MRI machines using food rewards, i.e., essentially bribed to submit to such examinations (see photos below from 3). That definitely muddies the waters since it diminishes the dogs' autonomy in the experimental process (7).

Do animals offer hugs to each other in their native habitats? Example From A Chimpanzee Study.

If animals within a particular species are seen hugging each other, presumably they wouldn't mind hugs from humans either or at least from humans they're familiar with and perceive to be non-threatening. The former has indeed been documented in chimpanzees. In one of the largest studies of its kind and led by the acclaimed primatologist Frans de Waal, research showed two outdoor-housed groups of chimpanzees consistently and spontaneously consoled individuals with whom they were socially close, consolation defined as interaction 'in which an uninvolved bystander initiates friendly contact with a recent victim of aggression' (see photo below from 8).

Bibliography

1. Harris, Christine R., and Caroline Prouvost. "Jealousy in dogs." PloS one 9.7 (2014): e94597. http://journals.plos.org/plosone...

2. Dogs Get Jealous, Too. National Geographic, Jennifer S. Holland, July 23, 2014.

3. Andics, Attila, et al. "Voice-sensitive regions in the dog and human brain are revealed by comparative fMRI." Current Biology 24.5 (2014): 574-578. http://ac.els-cdn.com/S096098221...

4. Brain Scans Reveal What Dogs Really Think of Us. Science.Mic, Theresa Fisher, November 20, 2014.

5. Berns, Gregory S., Andrew M. Brooks, and Mark Spivak. "Scent of the familiar: An fMRI study of canine brain responses to familiar and unfamiliar human and dog odors." Behavioural processes 110 (2015): 37-46. Scent of the familiar: An fMRI study of canine brain responses to familiar and unfamiliar human and dog odors

6. Cook, Peter F., Mark Spivak, and Gregory S. Berns. "One pair of hands is not like another: caudate BOLD response in dogs depends on signal source and canine temperament." PeerJ 2 (2014): e596. https://peerj.com/articles/596.pdf

7. Dogs Are Not People. Boston Review, Colin Dayan, January 23, 2014.

8. Romero, Teresa, Miguel A. Castellanos, and Frans BM de Waal. "Consolation as possible expression of sympathetic concern among chimpanzees." Proceedings of the National Academy of Sciences 107.27 (2010): 12110-12115. http://www.pnas.org/content/107/...

https://www.quora.com/Are-there-any-animals-that-actually-enjoy-being-hugged-by-humans/answer/Tirumalai-Kamala

How widely accepted is the link between meat consumption and climate change?

 Logic dictates that if the link between meat consumption and climate change were widely accepted, industrial meat production would decrease, governments would push policies towards achieving such a goal, and per capita meat consumption rates would decline. But simple, straightforward logic isn't the only attribute to guide our actions, is it? Instead, notwithstanding the link between global meat production and climate change, the data show that meat production and consumption are on the rise globally as industrialization globalizes, industrial agriculture replaces traditional small-scale farming and hundreds of millions of humans are pulled out of poverty. Why does affluence tend to go hand in hand with meat consumption? Meat eating's a status symbol for the newly affluent the world over. A look at some of the obscene, shocking numbers suffices to convince we're far from global peak industrial meat production and consumption (see figures below from 1, 2, 3, 4).

Industrial meat production's much more inefficient in energy conversion and much more unsustainable in terms of deforestation and desertification, i.e., much more costly for Mother Earth.

• For e.g., massive forest cover's already been depleted in Brazil to make way for croplands needed to sustain food animal feed crops (soybean, corn).
• Land taken over for monoculture crop production for animal feed tends to become degraded faster.
• Industrial food animal production (IFAP) also requires massive freshwater use, this when increasing millions of humans the world over lack access to potable (safe drinking) water.
• Animal poop and pee from IFAPs heavily pollute nearby lands and waterways, working their way through the ecosystem.
• Also working their way through the ecosystem are the massive doses of antibiotics these hapless masses of animals are fed to accelerate their weight gain so they're ready for market that much sooner.
• Not to mention the sheer immeasurable pain and suffering of billions of food animals housed in soul-destroying inhumane conditions.

Rounding off such a perfectly dreadful litany of intractable problems associated with IFAP is its unmistakable contribution to global greenhouse gas (GHG) emissions.

So why, in the face of all the most compelling data advising otherwise, are meat production and consumption increasing globally?

• For one, IFAP's rise accompanies our increasing dissociation with the source of our food (2). It's not just food animal raising that's industrialized. So has their slaughter. The Brazilian company JBS is the world leader in animal slaughter. Its worldwide facilities can slaughter 85000 cattle, 70000 pigs and 12 million birds...every day. Following close on its heels is the US firm Tyson which can slaughter 170000 cattle, 350000 pigs and 42 million chickens...every week (2). And it isn't by accident that industrialized country IFAPs and abattoirs (slaughterhouses) are located far from cities in rural backwoods nor that they employ low-wage workers working in terrible conditions, i.e., captive labor market. Most industrial country consumers and increasingly, urban consumers in industrializing countries buy prettily packaged pre-cut slabs of meat in urban supermarkets, The Stepford Wives world far removed from the slaughterhouses with their rivers of blood, squeals, bulging eyes and sheer soul-chilling terror.
• For another, why change current habits when there's no immediate penalty for the status quo and no incentive for change? After all, governments haven't shown much inclination to curb meat consumption nor taken a stance against IFAPs and CAFOs (Concentrated Animal Feeding Operation) nor have citizenry successfully prevailed upon them to do so.
• Lastly, scientifically exploring the link between diet and climate change is of fairly recent vintage. It started in the late 1990s with Goodland saying 'diet matters' in the conversation about climate change (5). Since then many researchers have used life analysis and input-output models to estimate energy consumptions and GHG emissions of different foodstuffs (6, 7). Global meat production and climate change were first definitively linked in 2006 in a groundbreaking, massive (400 pages) study by Henning Steinfeld et al at the UN's Food and Agriculture Organization (FAO). This was the first study that clearly showed 'the livestock sector emerges as one of the top two or three most significant contributors to the most serious environmental problems' (8). They estimated global meat production contributes to 15 to 24% of total annual GHG emissions (5 to 7 X 109 tonnes per year).  Studies since show that meat and dairy production in particular are associated with disproportionately high GHG emissions (9, 10).

Since agriculture and related industrial activity are a massive part of the global economy, and directly and indirectly employ at least 1/7th of the global human population, there's been immediate and sustained pushback against the argument linking IFAP to GHG emission (see reference 8's wikipedia page for sources and their rationale). However, the conflict of interest inherent in the stance of such stakeholders renders their arguments weak and unconvincing.

Meantime, as the figures above show, meat production in places like China and Brazil has only increased even more steeply in the last few years. This means global meat production's contribution to GHG is only increasing, not decreasing and it will continue to do so unless and until governments intervene with specific policy changes. They could stop or curtail massive subsidies to agriculture for example so that we each pay the real price for our food. Pigs are likely to fly sooner. Yet if nothing changes, inevitable major environmental cataclysms from anthropogenic global warming (AGW) will likely hijack the agenda willy-nilly or IFAP-sourced pandemics will help wipe out a substantial chunk of global human population (11). Our pathetic history of collective problem solving shows these latter possibilities are far more likely than timely and wise government intervention, and when such eventualities inevitably come to pass, those humans unlucky enough to survive such apocalyptic catastrophes will perforce need to change their obscenely profligate abuse of Earth and domesticated animals. In fact, such survivors would likely no longer be able to dictate terms and the Earth will be all the more better off for it.

Bibliography

1. Growing greenhouse gas emissions due to meat production. UN Environment Programme (UNEP), 2012. http://www.unep.org/pdf/unep-gea...

2. Meat Atlas: Facts and Figures about the animals we eat. Heinrich Boll Stiftung, 2014. https://www.bund.net/fileadmin/b....

3. FAOSTAT

4. Thornton, Philip K. "Livestock production: recent trends, future prospects.” Philosophical Transactions of the Royal Society of London B: Biological Sciences 365.1554 (2010): 2853-2867. http://rstb.royalsocietypublishi...

5. Goodland, Robert. "Environmental sustainability in agriculture: diet matters." Ecological Economics 23.3 (1997): 189-200. http://www.is.cnpm.embrapa.br/bi...

6. Coley, David A., Emma Goodliffe, and Jennie Macdiarmid. "The embodied energy of food: the role of diet." Energy policy 26.6 (1998): 455-460.

7. Phetteplace, Hope W., Donald E. Johnson, and Andrew F. Seidl. "Greenhouse gas emissions from simulated beef and dairy livestock systems in the United States." Nutrient cycling in agroecosystems 60.1-3 (2001): 99-102. https://www.researchgate.net/pro...

8. Steinfeld, H., Gerber, P., Wassenaar, T., Castel, V., Rosales, M. and de Haan, C. (2006). Livestock’s long shadow: Environmental issues and options. Food and Agriculture Organization of the United Nations (FAO), Rome, Italy. Livestock's Long Shadow

9. Eshel, Gidon, and Pamela A. Martin. "Diet, energy, and global warming." Earth interactions 10.9 (2006): 1-17. http://www.environmentalcalculat...

10. Stehfest, Elke, et al. "Climate benefits of changing diet." Climatic change 95.1-2 (2009): 83-102. http://dels.nationalacademies.or...

11. Leibler, Jessica H., et al. "Industrial food animal production and global health risks: exploring the ecosystems and economics of avian influenza." Ecohealth 6.1 (2009): 58-70. http://are.berkeley.edu/~dwrh/CE...

https://www.quora.com/How-widely-accepted-is-the-link-between-meat-consumption-and-climate-change/answer/Tirumalai-Kamala

How can clinical trial enrollment be increased?

In this technocracy dominated era, there's no dearth of technological approaches to improve clinical trial (CT) participation. Ranging from alert systems linked to electronic health records (1) to online registries (2, 3, 4), the usual technology-based suspects have made their appearance on the scene to no avail. For e.g., available free to anyone online, ResearchMatch allows any US resident to register as a potential CT participant (volunteer). Hosted at Vanderbilt University and funded by the NIH, this registry launched in December 2008. Yet >7 years on, its name recognition is limited and <100000 volunteers have signed up (2).

Obviously, core of the problem requires a human, not technological, touch. Meantime, the general population gains the bulk of its knowledge about CTs from entertainment fare online or on TV and from news (5, 6, 7, 8). Obviously such sources are more likely to fuel and sustain misconceptions rather than anything remotely close to the truth about CTs. Essentially, the current CT ecosystem woefully under-utilizes two of its foundational pillars,

1) Referring physicians and other healthcare providers who lead patients to CTs (9, 10).

2) Current and previous CT participants, i.e., potential Patient Advocates.

Even more inexplicably, pertinent questions relating to the CT process remain unanswered

• What's the difference between healthcare providers who either do or don't participate in CTs, and between those who either do or don't refer patients to CTs?
• What are the recruiting strategies used by successful CTs (11, 12, 13)?
• Why don't organizers of successful CTs routinely record and report their recruiting strategies? Clearly trial funders should mandate their doing so.
• What level of engagement remains with CT participants after a trial's over? Do trial organizers and their staff stay in touch with them? While volunteers are enrolled in a trial, which can be for several months to even years, do trial organizers develop a rapport with at least their most enthusiastic participants, and teach and encourage them to advocate and recruit newer volunteers on their behalf within their families and communities (14, 15)? Given the current state of affairs, clearly not and yet wouldn't doing so set up a virtuous positively reinforcing cycle leading to cumulatively increasing CT participants? Instead, why is the system set up to recruit and forget once the trial's over? Isn't this an egregious example of re-inventing the wheel every time?

~70 years since the 1st double-blind, placebo-controlled randomized CT and with >210,000 ongoing registered CTs across the US and 193 other countries (see figure below from 16), it's scarcely believable but sadly true that such basic issues aren't well-studied nor their lessons freely available for others' benefit (17, 18).

Upon reflection, it's only to be expected that an inherently top-down and paternalistic enterprise like human biomedical research would under-utilize Patient Advocates. After all so insular is it that its very basics such as research ethics and regulatory oversight have been developed without seeking and incorporating the input of research volunteers (19), who are more frequently described condescendingly as subjects. Even peer-reviewed literature about woefully lacking CT participation rates is dominated by the voices of biomedical research aficionados. Where are the voices of CT participants? Why don't medical and scientific journals report their perspective, about their experiences and suggestions in their own words? Imbalance couldn't get starker than this (20). When was the last time the US FDA or the NIH convened meetings or town halls specifically inviting volunteer input into the CT process? Never. The current CT world is strikingly insular (21, 22).

'Findings concur with previous research suggesting that CT investigators rarely communicate about clinical research outside of specific, study-based recruitment messages, which are often only provided to current patients already familiar with the medical institution...Findings from the current study, however, show that CT teams rarely promote CT research outside of the medical setting or reach out to community organizations to serve as an important conduit between the medical institution ß and hard-to-reach populations...Although investigators rely heavily on local physicians to recruit patients into their studies, there may be limited communication between the investigators and local physicians [37] and between these local doctors and their patients [28].'

(8).

The funders and fund recipients, i.e., clinical researchers and their support staff working largely in academic medical centers, currently control the process. They hold endless rounds of meetings and write exhaustive white papers and reports filled with earnest recommendations. These current CT stakeholders haven't yet thought to expand their fold and bring into it the ones whose voices perhaps matter the most in CT participation and logistics, patients and volunteers who've participated in CTs, i.e., Patient Advocates. We all know new drugs and therapies can't get approved unless robustly tested on large pools of volunteers, and yet those same volunteers, the very heart of human biomedical research, have no say in how the process could be structured so their ranks stay filled, not depleted.

What Factors Deter CT Participation And How They Could Be Mitigated

Obvious ones are fears about unapproved medications and procedures, i.e., that one could be used as a 'guinea pig', as well as fears of side-effects, and that one could get a placebo instead of Rx due to randomization. Given such fears are likely pervasive among the population at large (23, 24, 25, 26), who could be more persuasive in convincing others to participate in CTs than those who've done so themselves? If previous trial participants aren't doing so, maybe there's something inherently discouraging about the process that urgently needs to be overhauled? While the medical and scientific aspects of CTs are rightfully the purview of clinical researchers and scientists, and should remain so, these patient-centric aspects are areas where Patient Advocates could help reshape the process to encourage others.

Studies also suggest local community-based sources of CT information are seen as more trustworthy. These include local doctors, TV and community health centers (7). As well, informal family and community networks, i.e., family and friends, and local church and faith-based organizations (26).

Cancer Clinical Trial (CT) Participation Rates Are High In Children Regardless of Race/Ethnicity But Very Low Among Adults. What Accounts For Such A Difference?

Poorly envisaged top-down policies often lack mechanisms to enforce their recommendations. In US biomedical research, one of the most prominent examples is the 1993 NIH Revitalization Act that mandates inclusion of racial and ethnic minorities in federally funded biomedical research (27). 23 years on, African Americans and Hispanics represent 12% and 16%, respectively, of the US population and yet constitute only 5% and 1% of CT participants (28) while whites are over-represented (29). Why is this so? Among US CT volunteers, blacks are supposed to mistrust medical research, and language and culture are supposed to be barriers to Hispanic participation while implicit bias among clinical researchers is supposed to disfavor minority participation in CTs. However, a crucial piece of data unerringly rebuts these oft-repeated myths because there's more than adequate participation among children regardless of race/ethnicity compared to dismal rates among adults.

In the US, only 3 to 5% of ~10 million adults with cancer participate in CTs (30). However, CT enrollment among <15 years old is anything but dismal. In the US, 60% of cancer patients aged <15 years are enrolled in CTs (31). That's not all. Proportion of minority pediatric cancer patients enrolled in cancer CTs (~10% blacks, ~12% Hispanic) ~matches their proportion in the population (32). This means neither do pediatric minorities systematically lack access to health research nor face systemic bias against CT enrollment. How to explain this huge difference between children and adult CT enrollment rates? What's different about the pediatric CT recruitment process? Undoubtedly, applying what works in recruiting children to CTs would hugely improve adult enrollment rates.

Crux Of The Problem: Huge Gap Between Eligible And Actual Adult Clinical Trial (CT) Participants

Real gap in adult CT enrollment is ~10X. For e.g., in the US, ~20% of cancer patients are typically eligible to participate (33, 34) but only 3 to 5% of them do so (30). This huge gap between eligible and actual participants is the critical problem needing to be solved. Weakest link in the chain? Extremely poor inclusion of referring physicians and Patient Advocates into the CT recruitment process, i.e., we're back to square one, the need to expand the fold of current CT stakeholders to include patients and volunteers, and their physicians, and seek their input in improving CT participation and logistics. One approach could be to have CT participants access trial-related procedures and services closer to their home rather than exclusively at academic CT sites, which are often far from their homes.

Clinical Trial (CT) Location Matters Hugely To CT Participants

Travel distance to and lack of transportation to and from the trial site are major barriers in CT participation (35, 36, 37). Even in the US, arguably the wealthiest country in the world and unquestionable global CT leader, many if not most CT volunteers need to drive >1 hour each way to reach a CT site (see figure below from 38).

Bibliography

1. Embi, Peter J., et al. "Effect of a clinical trial alert system on physician participation in trial recruitment." Archives of Internal Medicine 165.19 (2005): 2272-2277. https://www.researchgate.net/pro...

2. Harris, Paul A., et al. "ResearchMatch: a national registry to recruit volunteers for clinical research." Academic medicine: journal of the Association of American Medical Colleges 87.1 (2012): 66. http://www.ncbi.nlm.nih.gov/pmc/...

3. Denicoff, Andrea M., et al. "The National Cancer Institute–American Society of Clinical Oncology Cancer Trial Accrual Symposium: Summary and Recommendations." Journal of Oncology Practice 9.6 (2013): 267-276. Summary and Recommendations

4. Tan, Meng H., Matthew Thomas, and Mark P. MacEachern. "Using registries to recruit subjects for clinical trials." Contemporary clinical trials 41 (2015): 31-38.

5. Kelch, Robert P. "Maintaining the public trust in clinical research." The New England journal of medicine 346.4 (2002): 285.

6. Len-Rios, Maria E., and Qi Qiu. "Negative articles predict clinical trial reluctance." Newspaper Research Journal 28.1 (2007): 24.

7. Tanner, Andrea, et al. "Communicating Effectively About Clinical Trials With African American Communities A Comparison of African American and White Information Sources and Needs." Health Promotion Practice (2015): 1524839915621545.

8. Tanner, Andrea, et al. "Promoting clinical research to medically underserved communities: Current practices and perceptions about clinical trial recruiting strategies." Contemporary clinical trials 41 (2015): 39-44.

9. Baer, Allison R., et al. "Engaging referring physicians in the clinical trial process." Journal of Oncology Practice 8.1 (2012): e8-e10. Engaging Referring Physicians in the Clinical Trial Process

10. Robinson, M. Koa, JoAnn U. Tsark, and Kathryn L. Braun. "Increasing primary care physician support for and promotion of cancer clinical trials." Hawai'i Journal of Medicine & Public Health 73.3 (2014): 84. http://www.hjmph.org/HJMPH_Mar14...

11. Lai, Gabriel Y., et al. "Effectiveness of strategies to recruit underrepresented populations into cancer clinical trials." Clinical Trials 3.2 (2006): 133-141. Effectiveness of strategies to recruit underrepresented populations into cancer clinical trials

12. Friedman, Daniela B., et al. "How are we communicating about clinical trials?: an assessment of the content and readability of recruitment resources." Contemporary clinical trials 38.2 (2014): 275-283.

13. Friedman, Daniela B., et al. "A qualitative study of recruitment barriers, motivators, and community-based strategies for increasing clinical trials participation among rural and urban populations." American Journal of Health Promotion 29.5 (2015): 332-338. https://www.researchgate.net/pro...

14. Friedman, Daniela B., et al. "Improving our messages about research participation: a community-engaged approach to increasing clinical trial literacy." Clinical Investigation 4.10 (2014): 869-872. http://www.future-science.com/do...

15. Tanner, Andrea, et al. "Barriers to medical research participation as perceived by clinical trial investigators: communicating with rural and African American communities." Journal of health communication 20.1 (2015): 88-96.

16. Trends, Charts, and Maps

17. Michaels, Margo, et al. "Impact of Primary Care Provider Knowledge, Attitudes, and Beliefs about Cancer Clinical Trials: Implications for Referral, Education and Advocacy." Journal of Cancer Education 30.1 (2015): 152-157.

18. Sriphanlop, Pathu, et al. "New York state health care provider participation in clinical trials: a brief report." (2016). http://www.vipoa.org/journals/pd...

19. Dresser, Rebecca. "What Subjects Teach: The Everyday Ethics of Human Research." Wake Forest Law Review 50 (2015): 301. What Subjects Teach: The Everyday Ethics of Human Research

20. Holzer, Jessica K., Lauren Ellis, and Maria W. Merritt. "Why We Need Community Engagement in Medical Research." Journal of Investigative Medicine 62.6 (2014): 851-855.

21. Comis, R. L., et al. "Baseline study of patient accrual onto publicly sponsored US Cancer Clinical Trials: an analysis conducted for the global access project of the National Patient Advocate Foundation." Philadelphia, PA, Coalition of Cancer Cooperative Groups (2006): 1-52.

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