key: cord-294320-4s6vxmy7 authors: depoux, anneliese; martin, sam; karafillakis, emilie; preet, raman; wilder-smith, annelies; larson, heidi title: the pandemic of social media panic travels faster than the covid-19 outbreak date: 2020-03-03 journal: j travel med doi: 10.1093/jtm/taaa031 sha: doc_id: 294320 cord_uid: 4s6vxmy7 nan metonymic principle, where the images directly related to the physical epicentres crisis (the archaic imagery of quarantine and confinement) were often associated to places and people connected with this archaic imagery: chinese restaurants, chinese tourists, goods from asia, etc. leading to widespread distrust and outburst of racism. 4 chineselooking residents who have never set foot in china were one of the first victims of such viral racism. who`s director general dr tedros calls this the fight against "trolls and conspiracy theories". misinformation causes confusion and spreads fear, thereby hampering the response to the outbreak. "misinformation on the coronavirus might be the most contagious thing about it", he says. the impact of media reporting and public sentiments may have a strong influence on the public and private sectors in making decisions on discontinuing certain services including airline services, disproportionate to the true public health need. travel restrictions are one example, and we need to unpack the influence of social media on such measures that carry a huge economic loss. the spatio-temporal variability in the discussions on social media, specifically twitter, is often not in line with the spatiotemporal occurrence and intensity of the outbreak. in addition to addressing the urgent need to scale-up public health measures to combat the outbreak, we need to combat the pandemic of social media panic. 5 to this end, it is important to conduct spatiotemporal analyses of the discourse and its association, or disassociation, with the epidemiological situation as this will allow spatiotemporal targeted communication and intervention campaigns to be executed by public health authorities. we need to rapidly detect and respond to public rumours, perceptions, for the current covid-19 crisis, we call for the development of a real-time information sharing system, drawing from data and analyses from a range of social media platforms, in multiple languages, and across the global diaspora. this will enhance the ability of public health bodies and relevant stakeholders to respond to and understand the social dynamics of the increasingly fast and evolving spread of information and misinformation about the coronavirus and the outbreak and control measures. it will also reduce community panic, and unhelpful measures disproportionate to the cause. contributions: all authors are part of cov-impact consortium, and contributed equally to this manuscript. conflict of interest none declared. the biggest pandemic risk? viral misinformation the h1n1 pandemic: media frames, stigmatization and coping travelers give wings to novel coronavirus (2019-ncov) mediating panic: the iconography of 'new' infectious threats mediating panic: the iconography of 'new' infectious threats tracking online heroisation and blame in epidemics isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus (2019-ncov) outbreak transnational quarantine rhetorics: public mobilization in sars and in h1n1 flu covid-19: fighting panic with information fairness and trust: understanding and engaging with vaccine trial participants and communities in the setting up the ebovac-salone vaccine trial in sierra leone key: cord-320924-tphlv442 authors: cheshmehzangi, ali title: 10 adaptive measures for public places to face the covid 19 pandemic outbreak date: 2020-08-06 journal: city soc (wash) doi: 10.1111/ciso.12335 sha: doc_id: 320924 cord_uid: tphlv442 nan by limiting access nodes/points of public places, we can monitor better the ins and outs as well as have a better overview of human circulation. this adaptive measure is for both indoor and outdoor public places, including those of a larger scale that may require the closure of certain access nodes (such as secondary access points or other designated areas). it is also important to provide the primary access node that is visible and easily manageable. the temporary closure of access point to public car parking areas is aimed to reduce transportation mobility to potential hotspots. this measure could be applied to all public buildings, public areas, and also to help limiting the access points to residential compounds. this is a temporary measure that could be effective in a long run. (source: the author's own) the temporary closure of access points to public places are effective to better monitor the ins and outs of public places. the multiple access points to outdoor public places were only limited to one or two points where they could be managed and monitored when it is needed. (source: the author's own) to enhance the management of populated public places (i.e. both indoors and outdoors), it is important to adapt a one-way mobility circulation. this means the allocation of one entry node and one exit point that could determine a potential route of access/entry, circulation, use, and exit. by learning from the broader topic of environmental determinism, it is feasible to adapt new arrangements in the physical environment, which could stimulate altered behaviors in the public place. in doing so, we are able to determine effects on the mobility as well as other behaviors (broady, 1971; haydn and temel, 2006) associated with the use of the public place. doi:10 .1111/ciso.12335 © 2020 by the american anthropological association. all rights reserved. adapted from effective mobility control measures, and in combination with the earlier two measures, it is also possible to allocate checkpoints for monitory and recording the mobility in and out of public places. this approach is effective for prevention and safety checks that may be relevant to a particular disease, such as temperature checks, registration of people's departure points, specific uses of the place, record of destination, etc. checkpoint allocation is only feasible if the earlier suggested management measures are in place. the management of checkpoint areas to shopping mall premises is important to monitor mobility and check for any potential cases. in this instance, as shown in the image, the person was not allowed to enter the premises and was instructed by the safety and prevention team to follow the regulations before entering the premises (source: the author's own) under any circumstances, it is crucial to maintain the safety and viability of the city and society. hence, it is also important to address these at the social space level from the spatial dimension. the adaptive measures depend on contextual matters, such as density, cultural and social attributes, socio-economic opportunities, critical infrastructures, physical layout (or urban configuration), community setting, etc. the provision of safe social spaces should be doi:10.1111/ciso.12335 supported by regular disinfection procedures, high-level hygiene, and considerable waste management and cleansing methods. for instance, we can make use of urban parks and communal parks, without making them into over-crowded hotspots. they should then be regularly checked, monitored, and managed to ensure they are disinfected, facilities are monitored, and physical distancing guidelines are maintained. with the availability of large screens and other augmented methods in the public place (cheshmehzangi and ornsby, 2018) , there is an opportunity to transform public places into the main nodes in the city where people can see relevant information such as prevention measures, safety procedures, guidelines, regulations, etc. the informative characteristic of public places could represent the effective role of public places for public interests and uses. with the flexibility of contemporary public places, it is possible to transform them into other essential uses, or to utilize them for the support of essential sectors. this is likely to be more applicable for larger public places (both indoor and outdoor) that are expected to be underused (or completely unused) during the outbreak event. for instance, such transformative or adaptive approach could turn a public place into a place of food distribution, or for other potential uses, such as medical support, emergency services, supply production, temporary healthcare services, etc. by understanding the temporariness of such uses, it is possible to transform empty public places in to effective and dynamic supporting nodes in the city. hence, the dynamism of the public place should not be forgotten. during the pandemic outbreak, shared facilities and shared uses could speed up the community disease transmission (cheshmehzangi, 2020) . particularly for indoor public places, we suggest restrictions on shared facilities and uses, such as the use of elevators/lifts, crowded retail units, temporary food stalls, etc. it is also suggested to restrict the use of shared devices, such as centralized cooling and heating systems, large cooling fans, etc. by applying these restrictions in public places, we can minimize the potential spread of the disease through shared facilities/units, services, uses, and devices. in warmer climates, these measures are even more difficult to be adapted in practice. hence, it is recommended to minimize the use of such places as much as possible. it is important to categorize public places into primary and secondary uses. those that fit in to the category of non-essential public places are suggested to be closed until the recovery (i.e. through full containment of the disease outbreak) is reached. such public places could also include certain public buildings that offer public use and activities. during the pandemic outbreak, the city and society are more dependent on essential urban systems and primary services. hence, it is important to reduce the pressure on secondary services and public facilities (including secondary public places) that may cause more problems than solving doi:10.1111/ciso.12335 anything. apart from secondary communal spaces, the other secondary public places and public services (including public buildings, such as library, museum, gallery, cinema, religious building, etc.) are identified as non-essential; and hence, they must remain closed during the outbreak progression until the recovery stage. the temporary closure of secondary public places, especially those that are less likely to be easily manageable during the pandemic outbreak event, is a major measure to promote only the use of primary and essential public areas. this temporary closure could last for a longer period until the full recovery is reached (source: the author's own) doi:10.1111/ciso.12335 © 2020 by the american anthropological association. all rights reserved. 8 figure 6 -the temporary closure of public activities, such as artificial beach areas as shown in the image, are important to reduce overpopulated areas in the city that faces any sort of disease outbreak. in this instance, the impacts are expected to be on the primary social activities of the city, but it is important to keep the society safe than to risk increasing community transmissions through popular and populated places of the city. (source: the author's own) in higher infected areas or places with higher risks, it is suggested to have designated community-level areas that are identifiable as key public places for various uses. these can be community-level parks, community healthcare services, community food supply, goods collection points, etc. the provision of such essential services and supplies with the use of public places would help to empower the role of communities and support the city and society more effectively. this also promotes community-oriented or people-oriented approaches to doi:10.1111/ciso.12335 support public place uses. usually, public places offer a wide range of activities or opportunities for multiple functionalities and use. their inclusiveness for the city and society is a major factor that requires careful attention during the pandemic outbreak. while public places are primary nodes to attract people for specific social uses and activities, they could also be places where larger groups of people could become infected and/or transmit the disease at a faster pace. hence, temporary regulations are essential to monitor and restrict certain activities in public places. such activities include group gatherings, intermingling in clustered areas, high-level interactions, and overcrowded events. such regulations are only temporary but are adaptive enough to make a significant impact on the use of public places. to summarize briefly, i emphasize the importance of adaptive measures for public places during the pandemic outbreak (or other disease outbreaks of different scales). amid all uncertainties, the role of public place could be enhanced during the pandemic outbreak. the empty scenes of decaying public places around the globe are certainly upsetting images for those who know the values, meaning, and memories of such imperative and dynamic nodes in our cities. nonetheless, the contingencies that could be offered through the power of public places should not be underestimated. the above recommendations of adaptive measures may seem intimidating at first, questioning issues of privacy and undermining the role of public places. nevertheless, it is important to consider them under these special circumstances, which could not be simply handled through the operations of business-as-usual practices (cheshmehzangi, 2020) . these are temporary solutions for a period that requires extra attention and health and safety of the city and society. with many successful examples of adaptive approaches in public places around the globe, one can only recognize the importance of such hubs/nodes in the city. undoubtedly, public places are playful for our society but are also vital for the enhancement of city's resilience and management during the outbreak events. by reflecting on some of these examples, these 10 adaptive measures suggest opportunities for the better use of public places in cities and communities around the globe. doi:10.1111/ciso.12335 adaptive planning people and buildings: social theory in architectural design temporary urban spaces: concepts for the use of city spaces the city in need: urban resilience and city management in disruptive disease outbreak events augmented locality: the utilisation of urban screens in public place as new networks of the it is, therefore, vital for us to understand and value these adaptive measures to ensure our public places are safe, our cities are supported, and our society is healthy. key: cord-354434-bi409a6o authors: benjamin, georges c. title: ensuring health equity during the covid-19 pandemic: the role of public health infrastructure date: 2020-05-29 journal: rev panam salud publica doi: 10.26633/rpsp.2020.70 sha: doc_id: 354434 cord_uid: bi409a6o the covid-19 pandemic has significantly stressed public health systems around the world and exposed the gaps in health care for underserved and vulnerable populations. in the context of the social determinants of health, focusing on health system preparedness is paramount for protecting the health of all of society. faced with old threats (e.g., re-emergence of measles), disruptive new technologies (e.g., electronic cigarettes), increased challenges (e.g. drug-resistant organisms), and new threats (e.g., the current pandemic, climate change, politicized misinformation), our health systems must be robust and resilient. the response must include those who now suffer disproportionately—the poor and the vulnerable. current world health organization priorities call for infrastructures capable of detecting, monitoring, and responding to health emergencies, such as covid-19, and the health impacts of climate change in the context of health for all. health care infrastructure can be better prepared and more equitable if systems are strengthened by building on core competencies and following the recommendations made for leadership, stakeholder involvement, accreditation, data collection, and funding resources. ensuring health equity in a pandemic requires robust and resilient public health infrastructure during normal times. on 29 december 2019, officials in the people's republic of china identified four cases of individuals with severe pneumonia linked to a wholesale seafood market. shortly afterward, several other cases were reported, and within weeks an epidemic had engulfed wuhan, the capital city of the hubei province in china. this outbreak of what was a novel coronavirus was the beginning of a worldwide pandemic of sars-cov-2, the virus that we now know causes covid-19. the pandemic has stressed public health services around the world and has shown the importance of having robust, well-structured, and well-resourced health systems in place. the current pandemic demonstrates the challenges that we must overcome as a global community to ensure equitable health care access, economic security, and public health protections for vulnerable communities. in the united states, the practice environment for public health has changed in many ways, much like that of public health contexts in other nations (1) . we are in a globalized world, possibly a plane ride away from a major disaster. globalization changes the way we manage health threats-it has closely integrated commerce, transportation, economics, and all forms of communication. the internet and social media have actively democratized information, doing good in many ways when they serve as a major source of factual information. but misinformation and disinformation are also commonplace and create an enormous threat to public health by spreading inaccurate and deceitful material. in addition, the speed at which information now moves around the world is staggering, compounding the difficulties of advancing factual information during a public health emergency. the competition for goods and services has also intensified worldwide and becomes problematic when multiple nations must vie for limited resources in a crisis. given that about 80% of what makes one healthy occurs outside of the clinical setting, public health systems are working diligently to address the social determinants of health. issues around enhanced social supports, policy changes to encourage healthier choices, improved education, safe transportation, and healthy housing and other improvements to the built environment are some ways public health is addressing the fundamental reasons for health inequities. because of uneven access to resources in underserved and poor communities, social determinants play an over-sized role in undermining health equity. these disparities are especially important when serving people across the lifespan in a changing world. new and disruptive technologies can bring back old threats. for instance, electronic cigarettes are bringing back the dangers of tobacco just when some countries were seeing substantial reductions in tobacco use. also, big tobacco companies in some countries continue incessant marketing and regulatory interference to promote the scourge of tobacco addiction. we have also seen the return of old infectious threats, e.g., measles and tuberculosis; an increase in sexually-transmissible diseases and drug-resistant organisms; and the emergence of new threats, such as ebola, west nile virus, and zika. these remind us that there is still much to be done to ensure a healthy society. we have also had some near successes-polio and chagas' disease, for example. but antivaccine activists who spew disinformation, those who distrust government, and ongoing armed conflicts continue to inhibit our ability to stamp-out many preventable diseases. in many countries, public health has become a political football, with politicians undermining sound public health policies to the detriment of the population. too often, scientific principles are being questioned by politicians and policy-makers solely for political gain and ideological reasons. we live in a dangerous world, with many health threats, among which climate change is paramount. our changing climate continues its dramatic impact on the planet's ecology and produces major threats to public health. the world health organization (who) has identified the health impacts of climate and environmental change as a priority area, reporting that over 12.6 million people die annually from unhealthy environmental conditions (2) . furthermore, the underserved are extremely climate sensitive and suffer disproportionately from climate change. another who priority is public health preparedness for health emergencies (2) . this priority addresses the scope of emergencies around the world that impact public health, from famine and armed conflicts to environmental disasters and infectious pandemics. the covid-19 pandemic is one such global health emergency. a robust public health system, one capable of detecting any new health threat and monitoring and responding to it, is an essential component of a resilient health system. in 1998, the institute of medicine of the national academies of sciences, engineering, and medicine authored a consensus report titled the future of public health (3) . it defined three core competencies of public health -assessment, policy development, and assurance-and 10 core competencies of effective health departments ( figure 1 ). these competencies are currently being reviewed by the public health accreditation board (phab) of the united states, the country's accrediting body for state and local governmental public health agencies. recently, the phab began to consider offering accreditation to non-u.s. agencies. a concept called public health 3.0 (4) was released in 2017 by a working group under the auspices of the united states department of health and human services, the federal agency that serves as the country's ministry of health. public health 3.0 lays out five recommendations for public health agencies that seek to meet the challenges of the 21st century (4). these are relevant for agencies in other country's health systems as well: strategist for all communities. this is a leadership role that works with all stakeholders to address the social determinants of health. it may be assumed by stakeholders in other sectors when appropriate, however all members of the leadership team should develop the competencies to support this system-wide leadership role. effects, and creating economic hardship as physical distancing forces the shutdown of many nations' economies for months at a time. tragically, underserved and vulnerable populations are being disproportionately affected, just as they are by most health threats. it is essential that we focus efforts on ensuring that vulnerable populations receive equal access to testing, community protections, and treatment when they get sick. in addition, economic burdens for this population can be overwhelming as many live from paycheck to paycheck during normal times and are dependent on a range of social supports for survival. during extraordinary times such as this, extraordinary levels of support are needed to alleviate food insecurity, strengthen health care systems, and protect human rights, especially the rights of women and children, who frequently experience domestic violence and social practices that harm them disproportionately. economic support is also essential because severe economic disruptions affect low-income workers the most. nations with weak health systems are at significant risk from this pandemic and will require significant support from other nations to prevent widespread morbidity and mortality. strengthening public health systems should be a global priority for addressing health equity. the covid-19 pandemic is imposing enormous strain on public health systems and is a tragic example of the need for strong systems to promote and protect health and ensure health equity. a well-resourced and properly-structured public health system that is accountable, properly resourced, and able to perform the 10 core competencies can meet the needs of vulnerable populations and ensure equity is achieved across the lifespan in all communities. disclaimer. authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the rpsp/pajph and/or paho. should ensure they have the leadership and collaborative skills to engage all relevant stakeholders across multiple private and public sectors. these collaborations should have shared governance that works to obtain adequate resources and collective action to achieve shared health promotion and disease prevention objectives. actions should produce equitable and resilient communities. 3. public health accreditation. public health agencies should seek accountability for their public health responsibilities. in the united states, this can be done by becoming phab accredited. accreditation has been shown to improve agency capacity and quality (5) . the recommendations of public health 3.0 are embedded in the appropriate phab criteria. currently, about 80% of the united states population is covered by an accredited health department (https://phaboard.org/2019/09/03/ benefits-of-phab-accreditation-reaching-more-communitiesas-covered-population-continues-to-climb/) and the goal is to achieve 100%. 4. improving data for decision making. public health agencies must have access to more secure, granular data (preferably at the sub-county or postal-code level) in a timely way to make actionable health decisions. today, health threats enter communities with great speed and the need to address them requires cross-sectoral data systems that allow for the ability to measure impact in a variety of ways. data systems must collect data in a way that allows health equity to be evaluated. 5. adequate public health funding. funding for public health has been inadequate, not only in the united states, but also in many industrialized nations, and especially those with weak health systems (1). public health 3.0 supports enhancing resources for public health systems to ensure adequacy and sustainability. development of new and innovative models to achieve this enhanced support are recommended, both for core activities and community-wide initiatives. funding is essential for achieving health equity objectives. covid-19, the pandemic that the world has feared, is here. it is ravishing the health of communities through its direct asegurar la equidad en la salud durante la pandemia de covid-19: el papel de la infraestructura de salud pública resumen la pandemia de covid-19 ha sometido a una gran exigencia a los sistemas de salud pública de todo el mundo y ha puesto de manifiesto las deficiencias de la atención de la salud de las poblaciones desatendidas y vulnerables. en el contexto de los determinantes sociales de la salud, es fundamental centrarse en la preparación del sistema de salud para proteger la salud de toda la sociedad. frente a las viejas amenazas (p. ej., la reaparición del sarampión), las nuevas tecnologías perturbadoras (p. ej., los cigarrillos electrónicos), los mayores desafíos (p. ej., los microorganismos resistentes a los medicamentos) y las nuevas amenazas -la pandemia actual, el cambio climático, la politización de la información y la desinformación sobre la saludnuestros sistemas de salud deben ser sólidos y resilientes. su respuesta debe incluir a quienes ahora sufren de manera desproporcionada, los pobres y los vulnerables. las prioridades actuales de la organización mundial de la salud requieren infraestructuras capaces de detectar, vigilar y responder a las emergencias sanitarias, como la covid-19, y a los efectos del cambio climático sobre la salud en el contexto de la salud para todos. si se fortalecen los sistemas de salud reforzando sus competencias básicas y siguiendo las recomendaciones formuladas en materia de liderazgo, participación de los interesados, acreditación, recolección de datos y recursos de financiación la infraestructura de atención de la salud estará mejor preparada y será más equitativa. para garantizar la equidad en la salud en una pandemia se requiere una infraestructura de salud pública sólida y resiliente en épocas normales. políticas, planificación y administración en salud; control de enfermedades transmisibles; poblaciones vulnerables; equidad en salud. equidade em saúde durante a pandemia da covid-19: o papel da infraestrutura pública de saúde resumo em todo o mundo, a pandemia da covid-19 tem colocado ênfase significativa nos sistemas públicos de saúde e exposto as lacunas nos cuidados em saúde para populações carentes e vulneráveis. no contexto dos determinantes sociais da saúde, o foco na prontidão dos sistemas de saúde é fundamental para a proteção de toda a sociedade. diante de antigas ameaças (por exemplo, o ressurgimento do sarampo), novas tecnologias disruptivas (por exemplo, cigarros eletrônicos), maiores desafios (por exemplo, organismos resistentes a drogas) e novas ameaças -a atual pandemia, as mudanças climáticas, a politização da informação/informação sobre saúde -os sistemas de saúde devem ser robustos e resilientes. a resposta desses sistemas deve incluir grupos que agora sofrem de forma desproporcional, os pobres e os vulneráveis. as prioridades atuais da organização mundial da saúde exigem infraestruturas capazes de detectar, monitorar e responder a emergências de saúde como a covid-19 e aos impactos das mudanças climáticas sobre a saúde no contexto da saúde para todos. a infraestrutura de saúde estará mais bem preparada e será mais equitativa se os sistemas forem fortalecidos com base em competências essenciais e seguirem recomendações com foco em liderança, envolvimento das partes interessadas, acreditação, coleta de dados e recursos de financiamento. garantir a equidade na saúde em uma pandemia requer uma infraestrutura pública de saúde robusta e resiliente, mesmo em tempos normais. palavras-chave políticas, planejamento e administração em saúde; populações vulneráveis; controle de doenças transmissíveis; equidade em saúde. committee on investing in health systems in low-and middle-income countries; board on global health investing in global health systems: sustaining gains, transforming lives institute of medicine (us) committee for the study of the future of public health. the future of public health public health 3.0: a call to action for public health to meet the challenges of the 21st century evaluating the impact of national public health department accreditation key: cord-285532-rknygv7u authors: fraser, michael r.; hardy, george title: astho at 75: celebrating the past and preparing for the future date: 2017-08-04 journal: j public health manag pract doi: 10.1097/phh.0000000000000629 sha: doc_id: 285532 cord_uid: rknygv7u nan support these state leaders, the s/thos at the time believed that their "sanitary and other public health laws and regulations was a responsibility that merited and could be best served through an autonomous organization." 1 of course a great deal has changed over the last 75 years, but the original purpose of astho has remained constant: to convene s/thos nationwide and educate members on current issues, discuss state and territorial public health priorities, address urgent health needs, and advocate for continued support for the governmental public health enterprise. the history of astho authored by nancy maddox (pages 524-530) in this special section provides an excellent overview of astho's past with a keen eye toward its future. as de tocqueville notes in the aforementioned quotation, a unique feature of american democracy is the formation of voluntary associations created to promote shared values, goals, and policy agendas. in this regard, astho is no different from the thousands of other trade associations and professional societies that cover the vast array of interests on behalf of their various constituencies in our nation's capital. but astho is unique: there is no other national association that represents and convenes the leadership of s/thos and is concerned with the wide variety of issues and policies that directly impact state and territorial health agencies. astho's core mission is future-focused and dynamic: astho exists to "transform public health within states and territories to help members dramatically improve health and wellness." 2 to accomplish its mission, astho supports the leadership and professional development of s/thos and their executive teams, it advocates for the work of member agencies, and it collaborates funding partners and public health stakeholders to build the capacity of state and territorial health agencies. over the last 20 years, astho's capacity-building work has led to the development of a substantial body of technical assistance and training support for state and territorial health agencies in the many programmatic and operational areas of agency performance. today, astho employs a professional staff of more than 130 public health professionals, manages an annual budget of $28 million, is active in all 59 states, territories, and pacific freely associated states, and relies on countless hours of volunteer leadership and subject matter expertise of current health officers, astho "alumni," senior deputies, and affiliated public health organizations and associations to carry out its work. astho, like many national public health associations, enjoyed rapid growth in the 1990s as federal grants and contracts created new opportunities for public health organizations to provide technical assistance and training on a variety of public health issues. the primary funding partners for these cooperative agreements were the agencies that worked most with state and territorial health agencies including the centers for disease control and prevention (cdc) and the health resources and services administration (hrsa). however, over time, programs with the office of minority health, the food and drug administration, the environmental protection agency, the substance abuse and mental health services administration, and the national highway and safety and transportation administration along with other agencies also built the capacity of the state and territorial health agencies and astho. these investments allowed astho to offer technical assistance and training as well as grow internal operational and organizational capacity for communications activities and policy work. main topic areas of these projects included addressing communicable disease, chronic disease, maternal and child health, environmental health, health systems change, health equity, and public health informatics and surveillance capacity. work to build the public health workforce and assess the capacity of local and state public health agencies was also started in the 1990s through agreements with the cdc, hrsa, and national philanthropic partners including the robert wood johnson foundation, the de beaumont foundation, and the w.k. kellogg foundation. the development of the state health leadership initiative (shli), funded by the robert wood johnson foundation, further catalyzed astho's growth and its abilities to communicate with and convene s/thos. the shli provided the opportunity for the astho executive director to visit new s/thos, supported s/tho leadership development through an executive leadership institute at harvard university's kennedy school of government, to offer experienced s/tho mentorships to new s/thos, and to convene annually in an s/tho-only strategic session. now in its 18th year, the shli has expanded to include both executive leadership development and multisector leadership training to develop s/thos' abilities to create a "culture of health" within their jurisdictions. similar workforce development investments have allowed astho to convene executive leaders in state and territorial health agencies, including senior deputies, legislative liaisons, and program leads in the areas of public health preparedness, environmental health, informatics, human resources, finance, and several others. the terrorist attacks of september 11, 2001, and the anthrax attacks that followed in october propelled astho to its next level of growth ( figure) . amid wide recognition that governmental public health is critical to emergency preparedness and response, large investments were made at the local and state levels in public health preparedness capacity nationwide. astho received federal dollars through cooperative agreements with the cdc and the assistant secretary for preparedness and response to convene state and territorial public health officers and preparedness directors, support state efforts to build preparedness and response programs, and assist in national disasters and emergencies as a response partner. the modern era of "public health preparedness" had begun as did a "new normal" in public health that required active involvement in homeland security efforts on a basis of 24 hours, 7 days a week. discussions around how federal dollars for preparedness should be allocated at the state and local levels led to the development of the astho-naccho (national association of county & city health officials) joint council. convening health officers to discuss coordinated emergency response efforts to hurricane katrina, the gulf of mexico oil spill, the h1n1 outbreak, and severe acute respiratory syndrome outbreak laid the groundwork for astho's role in supporting state and territorial health agencies and federal partners during public health disasters. working collaboratively with nac-cho, the astho-naccho joint council also became an increasingly important factor in policy formulation and advocacy for governmental public health. in the early 2000s, the executive directors and staff of astho, naccho, nalboh (the national association of local boards of health), and apha, working with the iom (institute of medicine), asph (the association of schools of public health), and ceph (the council on education for public health), spent considerable time debating and creating a framework for the accreditation of official governmental public health agencies. that effort grew into the local and state health department accreditation program incorporated by astho, naccho, apha, and nalboh, a new 501c3 named the public health accreditation board (phab) and on which astho has an ex-officio seat. as of 2016, a total of 22 state and territorial health agencies have received phab accreditation. 3 building on the response to the hiv/aids epidemic in the 1980s and 1990s, astho grew its infectious disease portfolio in the early 2000s and continued to represent the interest of s/thos on national advisory boards and committees including federal advisory committees such as the national vaccine advisory committee and several workgroups and committees of the national academy of sciences, engineering, and medicine. programs to address the growing burden of noncommunicable diseases also expanded in the 1990s and early 2000s as the united states witnessed large jumps in the rates of overweight and obesity nationwide. in 2005, astho was one of 4 founding members of the national forum on heart disease and stroke. astho also created the alliance to make us healthiest, a national certification program recognizing excellence in workplace wellness. in 2009, astho president judy monroe called on s/thos to "walk the talk" on obesity prevention and commit personally and professionally to increasing physical activity and lead efforts to promote healthier lifestyles. this effort began the astho "president's challenge" program, in which the astho president calls on peers to actively address specific public health issues or topics (table 1) . astho president's challenges have led to significant work on several priority issues at the local, state, and federal levels including major work on preventing premature birth and infant mortality. as astho moved into the new millennium, it continued to grow as a vocal and active advocate for state and territorial public health agencies. programs in the areas of performance improvement, public health informatics, public health systems and services research, the integration of public health and primary care, responding to novel pathogens such as h1n1, sars, west nile virus, and ebola virus, tobacco prevention and control, water and air quality, the impact of climate change on health, and other topical areas allowed astho to partner closely with state and territorial health departments and their leadership teams. astho also continues to cultivate the astho affiliate council: a group of other state and territorial health organizations with specific constituencies such as chronic disease directors, health care accreditation agencies, public health nurses, oral health directors, hiv/aids directors, maternal and child health program directors (table 2 ). in recent years, astho also built its tracking capacity to monitor state and territorial legislative activity pertaining to public health. astho maintains an active database of state and territorial legislative initiatives that relates to health and partners with peer associations including the national governors' association, the national conference of state legislatures, and national association of attorneys general. 4 today, astho continues to support the orientation and onboarding of s/thos through its shli. s/tho tenure has decreased from an average of 4.7 years in the 1980s to an average of 3.7 years between 2010-2017, making the need for s/thos to "hit the ground running" even more important. 5 the characteristics of tenured s/thos and factors influencing s/tho longevity in their role are described by halverson in this special section (pages 537-542). leadership competencies are now a core part of the program (table 3) . training s/thos in these competency areas is aimed at bringing newly appointed s/thos "up to speed" quickly in their leadership roles as chief health strategists in states and territories. research on the state and territorial public health workforce continues to be a signature product of astho, including the profile of state and territorial health agencies and most recently illustrated by the de beaumont foundation-funded public health workforce interests and needs survey (phwins). the passage of the affordable care act (aca) in march 2010 created new opportunities for state and territorial health agencies and for astho beyond the aca's core focus on expanding health insurance coverage to millions of uninsured americans. the maternal, infant, and early childhood home visiting program supported the scale and spread of evidencebased home visiting programs in many state and territorial health agencies' maternal and child health programs. new opportunities to prevent chronic diseases, unintentional injury, and other leading causes of morbidity and mortality were established in the nation's first ever source of dedicated funding for prevention: the prevention and public health fund. astho supports several prevention and public health fund programs including the million hearts initiative, tobacco use prevention, and initiatives to expand breastfeeding at the state and territorial levels. the aca also led to new challenges for astho and its members. questions about the public health agency role as a safety net provider were raised and threatened to lead to funding reductions because state health agency efforts were perceived of as duplicative of services covered by health insurers. while concerns that state immunization, std/sti prevention and control, breast and cervical cancer screening, infant mortality/ preterm birth prevention, hypertension, and child and youth with special health care needs programs would be eliminated by the aca have not been realized, there are lingering questions about why public health agencies are funded to provide the delivery of clinical services when the population traditionally served by state and territorial health agencies is now medicaid eligible or may obtain health insurance coverage through the federal health care exchange. astho has grown through the continued engagement of its members and funding partners, especially federal agencies such as the cdc and hrsa. as discussions over the federal budget and deficit spending continue in washington, district of columbia, many public health leaders believe that overall federal public health funding will be cut by congress in future federal budgets, having a profound impact on the work of state and territorial health agencies as well as astho. future work at astho to "make the case" for sustained investment in public health and defend against potential cuts builds on past efforts to illustrate the impact of funding reductions to public health. a new area of work at astho is activity to demonstrate the return on investment of many public health programs administered by astho members. astho's ability to lead in public health advocacy and policy will be even more critical in the years to come as efforts to prevent disease and promote health continue to increase and government funding for public health is potentially reduced. current debates over the aca have pushed prevention and public health into the limelight, as there is growing recognition that health insurance coverage alone is insufficient to create good health. state and territorial health agencies will continue to face challenges in ensuring access to care and prevention of those things that lead people to seek care in the first place. the role of public health in injury prevention, chronic disease prevention, communicable disease control, and environmental health is as important as ever. astho's work to support "health care transformation" in a brave new world of health care transformation and cost containment is an area of great opportunity in the future. much of the future work in public health will involve alignment, coordination, collaboration, and integration with the "nonhealth" sector, including housing agencies, transportation, economic development, and education. perhaps, most importantly, the future of astho is deeply connected to its past. the issues that drove those first health officers to form astho may be different today, but the need to convene and advocate for state and territorial public health programs is as important as ever. given the extreme partisanship and political discord in washington, district of columbia, and across the country, what the future holds for governmental public health is unclear. leaders of state and territorial public health agencies of the future, as described by fraser and castrucci on pages 543-551 of this special section, will need to have the capacity to synthesize vast amounts of data, solve complicated public health problems, and push for policy changes that have the most impact on addressing health equity and ensuring optimal health for all in an environment of resource constraint. while the future is unclear, what is certain is the continued need for astho and the work it carries out in the areas of leadership development, advocacy, and capacity building for state and territorial public health officers and teams and agencies they lead. historical roster of state and territorial health officials, 1850 to 1960 association of state and territorial health officials. about us. www. astho.org/about public health accreditation board. data on state and territorial health agencies accredited as of april 10, 2017. www.phaboard.org/ new-room/accredited-health-departments astho's state legislative tracking database. www.astho.org/ state-legislative-tracking high turnover among state health officials/public health directors: implications for the public's health key: cord-314808-ssiggi2z authors: pappas, g.; kiriaze, i.j.; giannakis, p.; falagas, m.e. title: psychosocial consequences of infectious diseases date: 2014-12-12 journal: clin microbiol infect doi: 10.1111/j.1469-0691.2009.02947.x sha: doc_id: 314808 cord_uid: ssiggi2z historically, there has been an exaggerated fear related to infection compared to other conditions. infection possesses unique characteristics that account for this disproportionate degree of fear: it is transmitted rapidly and invisibly; historically, it has accounted for major morbidity and mortality; old forms re-emerge and new forms emerge; and both the media and society are often in awe. because, in an outbreak, the patient is both a victim and a vector, and because there exists the potential for infringement of personal rights in order to control an outbreak, infection may be viewed (and has been depicted in popular culture) as a foreign invasion. during recent outbreaks, fear, denial, stigmatization and loss have been recorded in the implicated individuals. stigmatization and discrimination may further involve ethical correlations, and attempts to adress these issues through activism may also have unwarranted effects. public health initiatives can address the public's fears by increasing health literacy, which can contribute to reducing stigmatization. a man watches the news and starts feeling anxious. his hands feel sweaty and his heartbeat increases. he experiences a sense of agitation as he hears of a possible bird flu pandemic. the media puts before him scattered images of people rushing to buy flu vaccines, discussions on the utility and potential shortage of antiviral agents, journalists reporting the death toll of the previous influenza pandemics, the hundreds of millions of birds slaughtered in southeast asia, the hundreds of millions of human victims expected worldwide, the extraordinary expense of the control of past outbreaks and the anticipated expense apparently needed to enhance preparedness. the man feels overwhelmed by the amount of information. in a nearby hospital, a nurse in the emergency department thinks of asking for a long-term leave because she wants to be absent when an outbreak emerges; she is thinking of her family and feels she is unqualified to deal with, and not secured against, morbid infection. an infectious diseases specialist is on a plane, returning from an international congress on infectious diseases; several hours earlier, he attended a lecture about the then evolving severe acute respiratory syndrome (sars) outbreak. now, a chinese passenger sits in a nearby seat; the specialist is transiently overwhelmed by fears: what if this person is a carrier; what should one do if this fellow passenger coughs? later, he manages to reassure himself. these three individuals, among many others, experience levels of fear associated with infectious diseases in their everyday lives. they share the anxiety, the uncertainty, and the potential for irrational behavior due to fear of an unknown disease. they suffer from 'germ panic' [1] . infectious diseases have had a significant role in shaping human history, and are responsible for, through the great plagues of the past, more deaths than any other human pathology [2] ; these outbreaks have engraved an automatic response in our subconscious of a fear of infection. in an era of major scientific progress in battling, and even eliminating, certain infections, this fear may seem unwarranted. yet 'germ panic' consistently re-emerges, in contrast to the fear related to more burdensome entities, in terms of mortality, such as cardiovascular disease. why is it that infectious diseases cause the most significant psychological unrest, both in the public and in health professionals alike? infection is: (i) transmissible, (ii) imminent and (iii) invisible. moreover, the field of infectious diseases is ever-expanding. the risk of cardiovascular disease is a recognized entity with predisposing factors that have changed little over the years. on the other hand, numerous new major threats have emerged during the last three decades; the pandemic of aids, the sars outbreak, the ominous scenarios of an avian influenza pandemic, and the threat of biological weapons are just some examples explaining the concern among health authorities, the media, and the public. the evolution of the 'global village' further enhances the fear of contracting exotic diseases that can be imported into metropolitan areas (e.g. the chikungunya virus) [3] , diseases that can be transmitted in the context of air travel [4, 5] , or simply diseases that emerge in new areas as a result of nature's peculiar ways (e.g. the west nile virus new world epidemic) [6] . fear, in strict neuropsychological terms, is a normal reaction to an evolving threat, preparing the individual, both physically and mentally, for an acute response to possible harm. this reaction, however, is triggered both in the cerebral cortex, the outcome of a rational mental approach to the present situation, and by the amygdala, a process generated earlier than the cortical one, which is subconscious and potentially irrational, often crossing the barrier to panic. there are numerous exogenous factors that shape the nature of this subconscious response. the psychological response of both patients and the public to the threat of infection has been evaluated with respect to numerous circumstances in recent years, not only acute outbreaks such as sars, but also gradually evolving pandemics such as aids, threats with marginal risk for humans such as bovine spongiform encephalopathy (bse; mad cow disease), and even threats that are only theoretical such as avian influenza. moreover, inordinate psychological responses to infection have been recorded in the context of epidemics. for which an unidentified, readily transmissible agent with high mortality was responsible. fear, denial and frustration, which comprise three sequential stages of the rational response to fear, have been reported as predominant among patients or quarantined individuals during the sars outbreak in canada and amoy gardens in hong-kong [7] [8] [9] . loss and a conflict between duty to the patient and the will to be with one's family have been recorded in health care workers quarantined during the sars outbreak in canada [10] . anxiety extends (in the case of patients and exposed persons) beyond the physical consequences of infection, to social consequences such as stigmatization, with the latter even extending to asian populations of non-endemic regions such as new york's chinatown [11] . a similar case of stigmatization during an acute outbreak was also racially orientated: in the us 1993 hantavirus outbreak, the native american indians were stigmatized by the term 'navajo disease', a term which ignored the fact that non-navajos were also becoming ill; as a result, 'anti-indian racism mixed with fears of disease' emerged [12] . the potential effect of psychological reactions was also exemplified in the 1994 plague outbreak in surat, india, which led to an extended official and unofficial quarantine, with stigmatization being disproportionate to the extent of the outbreak [13] . in the case of an unknown agent, a lack of preparedness on the part of medical authorities and misleading information reproduced by the media may further aggravate these pathological psychological responses. in the sars epidemic, both these factors have been recognized, and media miscommunications and inconsistent health policies have been highlighted as factors amplifying stigmatization in hong kong [7] . medical authorities can also inadvertently augment a problem by initiating and recycling fear. apart from the awe-inducing isolation procedures, devices and uniforms (with the latter being reminiscent of astronauts and the concept of alien invasion), the medical disputes over preventive and therapeutic strategies may perpetuate fear when made public. 2 psychosocial reactions in gradually evolving epidemics: the case of aids: the aids pandemic was also attributed to a hitherto unknown agent, but significant differences contributed, in part, to shaping the psychological response of both patients and the public. the aids pandemic developed over a period of years, instead of days, and it was related to sexual practices, further influencing public response. the initial stages of the disease, however, were reminiscent of the 'navajo disease', in that a marginalized population was targeted and stigmatized. however, the history of aids highlights the fact that such discrimination continues to exist, and targeted populations are marginalized through germ panic. activism here acts like a double-edged sword; it fights discrimination and augments public health literacy, but may also enhance fear [1] . attempts to raise awareness of an issue may be subject to media misinterpretation; continuous discussion of an issue may raise awareness, but also may raise the sense of threat in individuals who are inadequately informed. although the psychological responses to some extent reflect the epidemic, the aids story exemplifies that responses also reflect the content of public education campaigns and public health efforts, as well as media and news coverage [14] . the surgeon general's aidsrelated campaign in the usa took place in 1988, comprising the first official nationwide effort to promote risk reduction or even explain the mechanics of hiv transmission. it is worth noting here that a pamphlet by callen and berkowitz entitled 'how to have sex in an epidemic', produced by several gay activists, was distributed in 1983, 5 years ahead of the surgeon general's campaign, to help sort through the confusing information concerning the new epidemic and the divergent theories regarding the cause of the syndrome [15] . as a result, the epidemic was better understood among the gay community, regardless of the officials' silence, which left the rest of the population uninformed for a protracted period. a similar observation was made in israel in a region that was affected by poultry avian influenza; the residents of this area had a significantly greater understanding compared to residents of the rest of the country [16] . awareness is a key issue, particularly when there is ample time for it to be enhanced. 3 fear of forthcoming epidemics: the case of avian influenza, mad-cow disease, and more to come: fear may be a physical response leading to individual protection, but, sometimes, protective measures undertaken according to public initiative can lead to increased morbidity because of the protective measures themselves rather than the threat against which they were supposed to be protective [17] . in the case of both bse and the, only now gradually subsiding, avian influenza pandemic scenarios, a common denominator was the climax of the threat, with the mass media capturing the public's attention, classically highlighting the subconscious, and memories of the great epidemics of the past (e.g. the 1918 spanish influenza pandemic). in the case of bse, fear rapidly extended to other countries [18, 19] and continents [20] [21] [22] , aided by coverage of the subject in well respected journals of medical and general interest; in the latter case, with eye-catching titles such as 'can it happen here?'. in one french study [19] , the perceived risk of bse (which is significantly different to the actual risk) modified the public's approach towards meat consumption, although this modification of the peoples' cognitive and affective responses to hazard peaked rapidly and subsided in approximately 1 year. in the case of avian influenza, a similar 'vaccination panic' that rapidly subsided was recorded in greece [23] , underlining the distorted ways in which the public reacts when overwhelmed by information. the psychosocial effect of misconceptions about the disease was also demonstrated in israel, where the public had a distorted perception of the dynamics of human-to-human transmission [16] . the way that the media and scientists present relevant information can also account for this effect [24] . 'scare statistics' and imaginary titles in the news all contribute to arouse the subconscious perception of threat; although some have proposed the use of fear as an educational tool, behavioral effects in this case have not been demonstrated [25] . regarding avian influenza, fear extends to hospital personnel and the public alike [26, 27] , and cannot be underestimated. a study conducted in hong kong showed that the majority of the public would expect panic or other forms of stressrelated responses to emerge [28] , as well as a potential for stigmatization [13] . 4 fear of infection in non-epidemic situations: people continue to use antibiotics, even when advised against doing so, for numerous respiratory tract infections of obvious viral origin. patients fear that they may develop pneumonia and overestimate the morbidity, even the mortality, related to their symptoms. infection is often considered as a social issue that indirectly leads to stigmatization, as in the case of brucellosis, where patients may express denial, because of a correlation of the infection with a lower socio-economic status (i.e. an indirect form of stigmatization) [29] . this has been the case also for outbreak-causing diseases in the aftermath of the outbreak, as with bse, where protective measures have been dismissed by many uk farmers as potentially stigmatizing individual farmers in terms of 'bad practicing' [30] . fear develops in public and refers to the society. its evolution is not a strict medical process of the nervous system, but the result of a complex interplay of medical and social factors and forces. fear of infection is not only engraved in our subconscious as a result of memories of former epidemics, but also because of fictional dramatizations of such potential threats. the way that infectious diseases are presented in the cinema is a typical example and can influence society's perceptions [31] . the concept of an unseen foreign invasion, the numerous apocalyptic views of the end of the world as a result of an unknown virus, and the scenes of panic, are all derived from public fears and they concomitantly, via feedback, shape these fears. mass media is another major factor that shapes the physical and psychological response of the public to an infectious disease threat, as depicted in numerous attack scenarios in the literature [32] [33] [34] . a simulation of a q fever outbreak in spain after deliberate release highlighted such potential: one journalist retrieved a medical report of person-to-person transmission of the disease; the public was already informed that such transmission is not possible; some journalists accused the scientists of hiding the truth; the public felt misinformed by the scientific community. and this was a scenario focusing on an agent of limited mortality [34] . it would be unfair to judge the public as a homogenous group; the public is a coalition of numerous subgroups of individuals, with vastly different social, educational and economical backgrounds. one would expect these subgroups to face threats of infection in different manners. for example, a higher educational background should theoretically be related to lower levels of fear; on the other hand, it may be related to increased access to information in general and to medical advice, and thus to increased individual participation in the development of the perception of 'threat'. these differences in the perception of disease in general, and infection in particular, among individuals of different social, economical and educational status have not been adequately evaluated. a series of ethical dilemmas applies to the control of infectious diseases, and these dilemmas further serve to enhance the fear of infection. the typical ethical dilemma is the conflict between feelings and decisions [35] ; in an outbreak, the patient is a victim, but also a vector, and isolation and quarantine practices may make stigmatization unavoidable. a recent statistical model has focused on the effect of individual psychological responses during the outbreak itself; fear induces a 'fight or flight' response, flight in this case predisposing to outbreak spread [36] . control of a large-scale infectious disease outbreak may often demand the infringement of individual liberties and civil rights [37] . these ethical dilemmas extend beyond the actual nature of the disease and its psychological consequences, and may implicate the means and content of public communications [38] , from authorities and the media, during an outbreak (i.e. how much actual information can the public handle without going into panic, and where does the thin line between the right to know and panic lie in this case). these recently observed psychosocial responses are not unique. we not only have re-emerging diseases, but also re-emerging responses to disease. the equivalent of the famous plague doctor mask of the 1600s in venice is the white surgical mask worn during recent epidemics. public health initiatives can address the public's fears by increasing education about a disease. enhanced health literacy, along with wide-ranging access to health information, can contribute to early case detection and may be useful in reducing stigma and decreasing levels of fear of an illness. the making of a germ panic, then and now emerging infections: a perpetual challenge cases of chikungunya fever imported from the islands of the south west indian ocean to transmission of infectious diseases during commercial air travel contact tracing of passengers exposed to an extensively drug-resistant tuberculosis case during an air flight from beirut to paris west nile virus the experience of sars-related stigma at amoy gardens fear and stigma: the epidemic within the sars outbreak risk perception and compliance with quarantine during the sars outbreak the psychosocial effects of being quarantined following exposure to sars: a qualitative study of toronto health care workers s chinatown: the politics of risk and blame during an epidemic of fear the coming plague: newly emerging diseases in a world out of balance stigma in the time of influenza: social and institutional responses to pandemic emergencies public health communication: evidence for behavior change fatal advice: how safe-sex education went wrong differences in public emotions, interest, sense of knowledge and compliance between the affected area and the nationwide general population during the first phase of a bird flu outbreak in israel suffocation from misuse of gas masks during the gulf war bse fears stir the swiss risk perception of the 'mad cow disease' in france: determinants and consequences fear of bse risks could hit us blood banks can it happen here? panic over mad cow had already infected europe. now it's our turn japan's first bse case fuels fears elsewhere reaction to the threat of influenza pandemic: the mass media and the public avian flu: the creation of expectations in the interplay between science and the media effects of episodic variations in web-based avian influenza education: influence of fear and humor on perception, comprehension, retention and behavior a crisis: fear toward a possible h5n1 pandemic survey of hospital healthcare personnel response during a potential avian influenza pandemic: will they come to work? perceptions related to human avian influenza and their associations with anticipated psychological and behavioral responses at the onset of outbreak in the hong kong chinese general population health literacy in the field of infectious diseases: the paradigm of brucellosis an exploration of the drivers to bio-security collective action among a sample of uk cattle and sheep farmers infectious diseases in cinema: virus hunters and killer microbes smallpox: an attack scenario attack scenarios with rickettsial species: implications for response and management q fever in logrono: an attack scenario are there characteristics of infectious diseases that raise special ethical issues? coupled contagion dynamics of fear and disease: mathematical and computational explorations ethics and infectious disease guilt, fear, stigma and knowledge gaps: ethical issues in public health communication interventions the authors state that there were no sources of funding for the present study. the authors have no conflicts of interest to declare. key: cord-310197-gwhb2e6q authors: khan, ali s; lurie, nicole title: health security in 2014: building on preparedness knowledge for emerging health threats date: 2014-07-02 journal: lancet doi: 10.1016/s0140-6736(14)60260-9 sha: doc_id: 310197 cord_uid: gwhb2e6q nan ideas, information, and microbes are shared worldwide more easily than ever before. new infections, such as the novel infl uenza a h7n9 or middle east respiratory syndrome coronavirus, pay little heed to political boundaries as they spread; nature pays little heed to destruction wrought by increasingly frequent natural disasters. hospital-acquired infections are hard to prevent and contain, because the bacteria are developing resistance to the therapeutic advances of the 20th century. indeed, threats come in ever-complicated combinations: a combined earthquake, tsunami, and radiation disaster; black outs in skyscrapers that require new thinking about evacuations and medically fragile populations; or bombings that require as much psychological profi ling as chemical profi ling. response requires up-to-date laboratories with genetic sequencing capabilities for infectious agents and rapid detection methods for chemical and radiological threats, nimble medical and epi demiological response units, and an alert and prepared workforce. these complex and interconnected problems have spurred innovation across government to create interconnected solutions. increasingly, the usa is building national capabilities to improve health security, which is defi ned as a state in which the nation and its people are prepared for, protected from, and resilient in the face of health threats. 1 to ensure a nation's health security entails preventing, protecting, mitigating, responding to, and recovering from all hazards that adversely aff ect health, requiring strengthening health and response systems at the local, state, and national levels. these capabilities are being built to address a wide range of hazards so that a strong base of readiness for any threat is developed. public health advances that have resulted in a more resilient and prepared nation and that have led to such system strengthening at all levels of government have been described, 2 and include improvement and coordination of public health infrastructure through the national incident management system (nims), expansion of the strategic national stockpile (sns), upgrading of medical care and countermeasures capabilities, and improvement of laboratory expertise and capacity. we describe continued progress in the ongoing commitment to keep people in the usa healthy and safe (panel 1). in an emergency, capabilities from all sectors are used to mitigate the acute event. however, the public health consequences of an event are not always visible, and health expertise has historically been conspicuously absent from emergency management. over the past decade, awareness has grown that health is part of almost every event; much progress has been made in emergency management to use public health expertise in planning, response, and recovery. this integration is core to national activities to promote health security. nims was established in 2004 as a comprehensive, systematic, principle-driven approach to management of emergencies of all causes and sizes. the department of health and human services (hhs) uses, supports, and promotes nims with local and state health departments through both the centers for disease control and prevention's (cdc) public health emergency preparedness programme and the offi ce of the assistant secretary of preparedness and response's hospital preparedness program to be used whether responding to daily incidents or natural disasters. 3 as seen in the boston marathon bomb attack on april 15, 2013, these investments and use of nims are very worthwhile. in boston, the city's public health commission oversees citywide emergency response, requiring close integration of emergency response and public health. immediately after the bombings, medical and health department personnel began treating more than 140 injured people, 4 and coordinated hospital transportation for 90 people-all within 30 min. boston's health authorities credited their quick response to robust exercise and planning, the city's strong interagency partnerships, and support from the state and federal government. this support included use of a capabilities-based approach to preparedness, with concrete measures of performance (panel 2). part of the city's training also included a seminar in 2009 with doctors from india, spain, israel, the uk, and pakistan-countries that had managed blast injury terror attacks. on the day of the boston marathon bomb attack, local hospitals were able to draw from lessons learned in those and other exercises to respond with great speed and success. additionally, hhs used a new mental and behavioural health concept of operations to deploy federal mental health responders. this mental health framework is an integral part of eff orts throughout hhs to identify, study, and facilitate activities that promote resilience and recovery in communities across the nation. public health information sharing has improved rapidly. so-called digital epidemiology has enabled practitioners and researchers to use electronic databases and information to enhance traditional surveillance methods. 5 in 2012, hhs launched its now trending developer challenge to create programmes for health departments to monitor social media during an outbreak. the challenge resulted in mappyhealth, a twitter monitoring programme now being piloted for digital health surveillance around the country, helping offi cials examine real-time events. digital surveillance was used by public health workers during the infl uenza a h7n9 outbreak to monitor chinese social media for events, myths, and concerns. 6 improvements in digital surveillance have also improved public communication. local health departments that can monitor twitter can give immediate feedback to correct dangerous mistruths that are contagious on social media. 7 cdc's @cdcemergency twitter feed, fi rst established during the infl uenza a h1n1 response, now reaches more than 1·5 million people with emergency health information. during the japan nuclear disaster response, twitter was used to correct the dangerous myth that healthy people in the usa should take potassium iodide to prevent harm from radiation. 8 these technological advances have been developed in parallel with diplomatic information sharing advances. who's international health regulations and multilateral collaborations, such as the global health security initiative, have provided a framework for international cooperation during public health disasters. improved capacity and the high priority placed on rapid information sharing led to china's timely reporting in 2013 of clinical and genetic information about infl uenza a h7n9 and early sharing of isolates, by contrast with the response to sudden acute respiratory syndrome (sars) a decade earlier, when information was slower to emerge. 9,10 cloud computing allowed for distribution of validated epidemiological and analytical programmes to the global community, while allowing china to share genomic sequences, providing the opportunity for immediate actions to analyse the viral genome and develop vaccine candidates. 6 the public health emergency medical countermeasure enterprise was established by hhs to coordinate federal eff orts and build new ways to respond to 21st century health threats-from discovery to deployment. the programme generated a government-wide strategic plan to build all-hazards capabilities and countermeasures throughout federal public health agencies. one cornerstone of the programme is the development of new medical countermeasures. since july, 2012, seven products for anthrax, botulism, and infl uenza have received approval from the food and drug administration. the sns contains substantial formulary to provide prophylaxis or treatment to address the deliberate dissemination of anthrax, plague, botulism, or tularaemia, and enough smallpox vaccine to immunise every person in the usa. botulism antitoxin, anthrax immune globulin, and vaccinia immune globulin are also routinely made available for distribution for routine public health indications as needed. sns materials can be delivered anywhere within the usa within 12 h. furthermore, the hhs medical care and countermeasures strategy-which includes a focus on development of the next generation of infl uenza vaccines, diagnostics, and novel antivirals-has also led to advances in vaccines for seasonal infl uenza, and better prepared the nation for the next pan demic. for example, the us government now has licensed cell-based and recombinant seasonal infl uenza vaccines and have stockpiled pre-pandemic cell-based vaccine. network and can test for biological agents. regional chemical laboratories are also able to measure human exposure to toxic chemicals through tests of clinical specimens. • the select agent regulations, updated in 2012, came into full eff ect in april, 2013. the regulations prioritised selected agents and toxins on the basis of risk to the public, established suitability standards for people with access to the most threatening (tier 1) agents and toxins, and established personal reliability measures to improve biosafety and biosecurity. • the national disaster medical system has improved how it organises and deploys more than 75 of its nationally distributed disaster medical assistance teams, mortuary response teams, and veterinary response teams, in addition to other specialised units that provide medical response surge during disasters and emergencies through on-scene medical care, patient transport, and the delivery of defi nitive care through its participating hospitals. • the biomedical advanced research and development authority (barda) is mandated to support the advanced development of medical countermeasures, and has built a pipeline of more than 150 novel drugs or diagnostics for chemical, biological, radiological, and nuclear threats and pandemic infl uenza. seven of these products have received approval from the food and drug administration. barda has provided 12 new products under project bioshield that can be distributed in a public health emergency. • the strategic national stockpile was authorised and expanded, ensuring the availability of key medical supplies. all states have plans to receive, distribute, and dispense these assets. increasingly, the usa seeks to develop products that can address countermeasure requirements and also day-to-day needs. as a result, these government investments in products such as next-generation antimicrobials for biological threats can be supported by the market to address routine public health problems, such as antimicrobial resistance. in addition to storing these medical countermeasures, the sns has established a nationwide readiness programme with 72 metropolitan areas in its cities readiness initiative. cities receive technical assistance in developing plans to receive, distribute, and dispense medical assets, and must plan to respond to a large-scale bioterrorist event within 48 h. this initiative refl ects the value of having all the components of the system work together: research scientists work alongside logistics experts to ensure that as they build new life-saving products, others are making sure that they can get them to the right place, under the right conditions, in the right amount of time. the ndms is made up of more than 5000 citizen responders, including physicians, mid-level providers, nurses, emergency medical service personnel, and leadership staff ; and 1600 civilian hospitals across the country that can support the defi nitive care for patients who are evacuated from an aff ected area of all kinds of hazards. federal medical stations, components of which are also stored in the sns, can be deployed and staff ed by the us public health service and ndms medical personnel. after hurricane sandy, these stations were deployed along with more than 20 mobile fi eld care sites to provide both human and animal care. these resources provided relief for overworked local medical responders and facilities, and helped community members maintain access to critical services. multidisciplinary medical teams were able to assess and treat both acute and chronic medical needs, and either discharge or transfer patients for further care as necessary, helping to relieve the medical surge that the local hospitals were experiencing. the teams also assisted responders who got sick or injured in going back to work quickly, strengthening community resilience. cdc and hhs have supported public health laboratories around the country since the mid-1990s, through epidemiology and laboratory capacity-building cooperative agreements and the laboratory response network (lrn). the 150-member lrn, founded in 1999, assures standardised equipment, reagents, and protocols for testing, quality assurance and quality control, and result messaging. funding has gone towards renovation of old state and local public health laboratory facilities, purchasing of state-of-the-art testing equipment, and paying for more than 400 laboratory worker positions each year. nowadays, lrn laboratories can undertake rapid tests for high-priority biological agents such as those that cause anthrax, smallpox, and plague. receipt of test results within hours, not days, is crucial in the event of a biological or chemical attack. state laboratories showed their response capacity and the benefi ts of these investments during the 2012 multistate fungal meningitis outbreak, during which around 750 people were infected and more than 60 killed by contaminated spinal and paraspinal steroid injections. 11 the tennessee department of health identifi ed and raised the alarm on the initial cluster of cases. the virginia department of health and state public health laboratory identifi ed a rare fungal pathogen, exserohilum rostratum, which contaminated the steroid injections-a critical discovery. the michigan department of community health identifi ed the fi rst case of a joint infection from the injections. these fi ndings aided the response in several ways. tennessee's actions to identify the cluster led to a nationwide patient notifi cation eff ort so that cases were quickly discovered and treated. by identifi cation of the fungus involved, time was saved in developing specifi c diagnostic, patient management, and treatment guidelines. the michigan discovery of the joint infection led to instructions for doctors to look for medical complications that were related to the injections. 12 the department of health and human services (hhs) identifi ed the following 15 public health and health-care preparedness capabilities (shown in their corresponding domains) as the basis for state and local public health and health-care preparedness. health-care coalitions supported by hhs helped states to assist hospitals in managing the surge of patients. these enhancements in our national public health laboratory system capabilities have helped to support the development of laboratories worldwide. in this interconnected world, fostering this and the other public health preparedness capabilities overseas is crucial to us health security. hhs has worked to build infrastructure and provide technical assistance with partner countries in asia, africa, and latin america. as a result, us partners are building the scientifi c capacity to detect, contain, and respond to novel threats before they become global threats. bioterrorism, pandemics, and other global threats to the nation's health security remain major concerns. we must ensure that lessons learned locally, such as those of the boston marathon bombing or response to hurricane sandy, are shared and implemented widely in us states and cities with adequate funding and support. much work remains to make the eff orts and improvements of the past few years integral components of routine health systems, addressing existing gaps in preparedness, and to duplicate these eff orts globally as part of the new international global health security agenda in support of the international health regulations. all this work has to be accomplished in the midst of substantial decreases in federal and state funding for public health and health-care preparedness. in view of the challenging fi scal environment, additional progress will need increased emphasis on a risk-based approach and focus on a very limited number of priorities. one of the most pressing priorities is meeting the needs of vulnerable populations who tend to have poor health outcomes during and after disasters. although some innovative eff orts have been launched at hhs to increase access to federal data to address the needs of vulnerable populations, this population is often not included in emergency planning processes despite their disproportionate vulnerability and numbers. they include a large part of society, not limited to children; elderly, poor, and disabled people; and those not fl uent in english. although the public health community is aware of this need and many important eff orts are being made across the country, [13] [14] [15] we need more strategies to locate, engage, and communicate with vulnerable populations and make them the focus of our preparedness planningnot the annex. addressing the needs of these populations and other related eff orts to foster better personal and community preparedness are concrete measures to create resilient communities. this shared responsibility for resiliency is implicit in the all-community approach to ensure us health security. previous major disasters and mass casualty events drew attention to continued stress points for health-care services including insuffi cient back-up emergency power and decision points for evacuating patients versus sheltering in place; shortages of emergency medical services and medical supplies and insuffi ciently trained staff ; and the inability to refi ll prescription medications. the cornerstone of eff orts to improve the health-care delivery system's ability to surge and be resilient has been to establish and sustain health-care coalitions. establishment of broad-based health-care coalitions are a solid beginning, but this approach will be successful only if we learn from and not just record lessons from previous disasters. eff orts should incorporate changes on the basis of these lessons, and include robust integrated planning and exercising of the health-care and public health systems that are coordinated with emergency management. we need to foster improved and expanded stakeholder engagement in health-care coalitions with increased inclusion of emergency medical services, public safety offi cials, and other crucial infrastructure partners such as the power and water sectors. information systems will be critical in helping these coalitions to work together, share information and resources, and coordinate a system-wide response. additionally, alternative models are needed for fi nancing both preparedness and response activities. other priorities include embracing new technology for disease monitoring and real-time information sharing; improving the evidence base; expanding preparedness principles to include climate disruption; and encouraging even more cross-sector integration between public health, health care, emergency management, and, especially, the private sector. these are just a few necessary eff orts across public health agencies that seek to make americans more resilient and prepared. building on this integrated and systematic approach to health security will strengthen us health security for decades to come. us department of health and human services. national health security strategy public health preparedness and response in the usa since 9/11: a national health security imperative public healthspecifi c national incident management system trainings: building a system for preparedness public health workers at center of boston bombing response: preparedness pays off during crisis digital epidemiology infl uenza a (h7n9) and the importance of digital epidemiology the dynamics of health behavior sentiments on a large online social network the h7n9 infl uenza virus in china-changes since sars arms race: getting ahead of killer microbes us centers for disease control and prevention. multistate fungal meningitis outbreak investigation the critical role of state health departments in the us fungal meningitis outbreak: 4 key eff orts asph/cdc vulnerable populations collaboration group preparedness resource kit applying community engagement to disaster planning: developing the vision and design for the los angeles county community disaster resilience initiative responding to the deaf in disasters: establishing the need for systematic. training for state-level emergency management agencies and community organizations both authors contributed equally to the writing and editing of this viewpoint, and approved the fi nal draft. we declare no competing interests. we thank vivi abrams siegel for research, drafting the initial outline, and editorial assistance, and kacey wulff for editorial assistance. key: cord-303468-95btvr1v authors: verran, joanna; jackson, sarah; scimone, antony; kelly, peter; redfern, james title: biofilm control strategies: engaging with the public date: 2020-07-30 journal: antibiotics (basel) doi: 10.3390/antibiotics9080465 sha: doc_id: 303468 cord_uid: 95btvr1v there are few peer-reviewed publications about public engagement with science that are written by microbiologists; those that exist tend to be a narrative of an event rather than a hypothesis-driven investigation. however, it is relatively easy for experienced scientists to use a scientific method in their approach to public engagement. this short communication describes three public engagement activities hosted by the authors, focused on biofilm control: hand hygiene, plaque control and an externally applied antimicrobial coating. in each case, audience engagement was assessed using quantitative and/or qualitative methods. a critical evaluation of the findings enabled the construction of a public engagement ‘tick list’ for future events that would enable a hypothesis-driven approach with more effective communication activities and more robust evaluation. it is increasingly being recognised by 'experts' that science literacy is of key importance for the public [1] . at a time where antimicrobial resistance (amr) continues to pose significant public health threats (or indeed, at a time of a global pandemic), an understanding of statistics, epidemiology and microbiology is even more desirable. as a subject, microbiology offers many topics with which we can engage non-experts, such as microbial diversity (including fungi, algae, protozoa and viruses as well as bacteria), beneficial microbes (for example, probiotics, fermented foods, the human microbiome), and messages that can influence behaviour in a positive manner (including vaccination, hand hygiene, antimicrobial stewardship) [2] [3] [4] . biofilms (an assemblage of microbial cells that are irreversibly associated with a surface-not removed by gentle rinsing-and enclosed in a matrix of primarily polysaccharide material [5] ) are of great importance to microbiologists, but also to many other professionals (such as engineers, biocide manufacturers, architects), and are found in a variety of environments (water distribution systems, industrial processing, hospitals). biofilm research is multi-disciplinary, extensive and significant, with many applications. there are several research centres which focus on biofilm, such as the us-based centre for biofilm engineering (http://www.biofilm.montana.edu/) and the uk-centred national biofilm innovation centre (https://www.biofilms.ac.uk/), and conferences about biofilm are regular and not uncommon. some individual researchers, research groups and research centres are keen to engage with external public audiences through outreach activities, although evidence of such activities (websites, articles, learning materials and other peer-reviewed outputs) is not easy to find. but why do we want the public to know about biofilms? and what does the 'public' need to know about biofilms? 'now wash your hands' was developed as part of a university faculty family fun day during national science and engineering week/healthcare science week in the uk. the aim was to raise awareness of effective handwashing, whilst also engaging the participants in a discussion about the skin microbiome/biofilm. this event guarantees an audience of predominantly families who are likely to have an existing interest in science. hand hygiene activities are well established as interactive learning activities with demonstrable public health impact (for example, as an intervention in reducing the spread of coronavirus [6] ). in this activity, demonstrators (academic staff and student volunteers) engaged audiences to demonstrate surface contamination and effective handwashing ( figure 1 ). thus, visitors at this activity (in a walkway area) had their hands 'contaminated' with a uv hand gel (www.hand-washing.com). this kit uses a fluorescent dye and ultraviolet light to illustrate the transmission of 'germs' from hands to other surfaces (and vice versa) and the importance of handwashing. in addition, the participants were invited to press their hands onto large agar plates for subsequent incubation to reveal the culturable microorganisms present on their skin. of course, they were unable to see the results of this work until after incubation, thus images of plates pre-inoculated with microorganisms present on hands and mobile phones [7] were available to view, and post-incubation images of their own plates were uploaded to flickr, a social media site that hosts images (http://tinyurl.com/howcleanareyourhands, figure 2 ). within a week from results going online, almost 100 downloads were recorded (the participants were provided with a card/web address), equivalent to the number of plates inoculated. from this, we deduced that visitors demonstrated interest and engagement with the activity. throughout the activity, conversations were ongoing. it was unfortunate that these interactions were not noted in some form: informal observations revealed points of interest from the participants such as their inability to clean hands effectively (especially the adults!) and amazement at the mobile phone contamination. the handprint technique has been used as an engagement tool for other events, such as an art installation called 'hands across the cultures' for registrants to a qualitative research conference and as part of the 'bioselfies' project (https://blogs.bl.uk/science/2020/02/introducing-bio-selfies-11-february-2020.html) initiated by the university of salford. flickr has been used for other events that require incubation of plates [8, 9] , and download numbers have on occasion exceeded the number of images posted, showing that the participants may have been sharing the findings with others. the fluorescent hand technique was used to illustrate person-to-person transmission by handshaking prior to a screening of the movie contagion (directed by soderbergh, 2011). one person 'contaminated' his/her hands, shook the hand of their neighbour, who shook her/his neighbour's hand and so on. thus, the passing-on of fluorescence was used to illustrate the transmission of infection through poor hand hygiene, reinforcing the message as to how the movie pandemic was initiated (hand contact). hand hygiene activities are common in microbiology engagement, the aim of the activity being primarily to inform, and hopefully to change, participants' behaviour so that effective handwashing hand hygiene activities are common in microbiology engagement, the aim of the activity being primarily to inform, and hopefully to change, participants' behaviour so that effective handwashing hand hygiene activities are common in microbiology engagement, the aim of the activity being primarily to inform, and hopefully to change, participants' behaviour so that effective handwashing techniques are employed. explanation regarding the presence or importance of the antibiotics 2020, 9, 465 4 of 12 skin microbiome/biofilm are likely rare (especially if the results are not available until a later date): the activity is inevitably more focused on the removal of temporary contaminants and on the importance of good handwashing. some discussion could take place regarding the hygiene-versus-cleanliness hypothesis [10, 11] . the flickr method used for posting images and monitoring downloads at least gives an indication of interest, but much more could be made of this activity. it would also be interesting to know if the 'good handwashing' messages are retained and employed in the future. however, longitudinal studies are rare in this type of public engagement, probably because of the significant advanced planning required in terms of gaining approval for personal data access (e.g., emails) and also because only short-term awareness raising tends to be the primary aim of the activity. the plaque biofilm is one of the best-known medical biofilms [12, 13] , and oral hygiene advertising frequently provides cartoons of plaque being removed to demonstrate the effectiveness of a paste, mouthwash or brush. it is known that good toothbrushing helps to remove plaque [14] and should be carried out regularly. different dentifrices claim varying activities, but virtually all formulations include fluoride (to 'strengthen the teeth') [15] , and many contain antimicrobial agents (to reduce the number of microorganisms, with claims around gum health) [16] . 'plaque attack!' was a laboratory-based activity designed for children and their parents, taking place during manchester science festival's family fun day at manchester metropolitan university. the aim of the event was to encourage good oral hygiene but also to captivate visitors with the components of the plaque biofilm as well as the laboratory and its equipment. being time-consuming and space-limited, the participants had to register for the event, were limited to 3 groups of 20 participants, be escorted to the laboratory, provided with appropriate clothing and instruction and supervised at all times. oral microbiology is a key research area in our laboratories, and the delivery team thought it would be valuable for visitors to encounter activity in a working (teaching) laboratory. the delivery team comprised phd students, technical staff and an academic. several activities were conducted as part of a 'round-robin' activity: sampling plaque (microscopy demonstration and take-home photo [zip mobile printer, polaroid]); disclosing plaque (using commercially available disclosing tablets), with photographs taken before and after cleaning teeth (in a wash area adjacent to the laboratory); looking at cultures of oral bacteria on agar plates; investigating biofilm structure/building a biofilm (using 'model magic' [crayola bedford uk], a white air-drying modelling clay) ( figure 3a ); and destroying a biofilm (using a water pistol to remove plaque (whose microorganisms were pre-constructed from fimo, a multi-coloured clay which can be hardened in the oven [www.staedtler. com]) hampered by plaque matrix (a translucent hair gel) [17] (figure 3b ). the participants were provided with a basic information sheet on plaque and oral hygiene, onto which they could attach their polaroid images. they were also given a bag containing complimentary toothbrush and toothpaste (courtesy of unilever [www.unilever.co.uk]). at the end of the activity, they were asked for free text feedback on what they thought of the event, and the information was coded into categories to allow for comparison [18, 19] (figure 4) . the participants were particularly engrossed in the microscopy demonstration, being able to see their own plaque at high magnification. they also clearly had fun 'destroying' the biofilm but were less interested in the more passive/less exciting activity (agar plates demonstration, building a biofilm). the free text provided by the participants (allowing more thorough insight compared to multiple-choice or leading questions such as 'give three things you have learned', or 'smiley face/sad face' evaluations [18, 20] ) gave valuable qualitative information that was used to inform subsequent activities. (a/top) participants at the 'plaque attack!' event were encouraged to create their own oral bacteria flora from modelling clay, which was assembled into the oral biofilm representation here shown. (b/bottom) participants were encouraged to 'destroy a biofilm' by removing bacteria (coloured plastic pieces) encased in biofilm extracellular matrix (hair gel) with a spray bottle filled with water. there was a total of 19 comments that were coded based on their focus-with each comment possibly being coded into more than one category. our research into titanium dioxide coatings included a range of laboratory-based studies that compared different titanium dioxide concentrations in paint formulations [21] . the work described . themes identified from 'plaque attack!' feedback. there was a total of 19 comments that were coded based on their focus-with each comment possibly being coded into more than one category. our research into titanium dioxide coatings included a range of laboratory-based studies that compared different titanium dioxide concentrations in paint formulations [21] . the work described in this paper was to see whether the effect of a photocatalyst in paint could be detected by the human eye. thus, as part of a phd project investigating the activity of photocatalytic surfaces, one of the external walls of the university was used to illustrate the effectiveness of titanium dioxide paints in terms of self-cleaning and reduction of the formation of biofilm on the wall material. photocatalytic material such as titanium dioxide can exhibit self-cleaning, anti-fouling and antimicrobial properties in the presence of light, which makes these materials excellent candidates for incorporation into urban buildings and infrastructure [22] [23] [24] . the self-cleaning properties stem from their superhydrophilic nature-as, for instance, that of a liquid (e.g., rain) rolling off the surface of a continuous body. this sheeting carries away dirt and debris, cleaning the surface in the process-as seen in the sydney opera house [25] . thus, biofilm formation on the surface is delayed or prevented. in our study, the wall, comprising concrete panels (smaller panels 190 cm × 76 cm, larger panels 406 cm × 76 cm) on a 1970s university building, was west-facing (location on chester street, manchester, uk m1 5gd). six of the panels were painted with a siloxane external paint formulation that contained or lacked the photoactive pigment (kindly provided by tronox, www.tronox.com). our aim was to inform the passing public about our research (an interpretation panel was affixed to the wall), and on occasion, we encouraged passers-by to participate in a longitudinal subjective assessment of the impact of titanium dioxide-containing paint on the perceived cleanliness of the panel. this engagement activity was done directly by interview and indirectly using photographs at specific times over a 44-month period. initially there was no apparent difference in the brightness of the painted panels (figure 5a ). members of the public attending a manchester science festival event (october 2014) were asked to rank the painted panels in order of cleanliness/whiteness, with 1 being most clean, and 6 being least clean (n = 18). the experiment was also conducted via a social media platform (facebook), with participants asked to assess whiteness using photographs (n = 48). the direct assessment was repeated after three years (n = 21). in all cases, the participants ranked two or three of the photocatalytic panels as the 'whitest'. in 2014, around 60% of the participants selected the three photocatalytic panels correctly. in 2017, this figure rose to 78%. after six years, the test-paint panels appeared whiter than the control panels ( figure 5b, may 2020) . the presence of the wall with its accompanying information panel at the side of the university science and engineering building provided a useful pointer to introduce visitors to some of the research ongoing in the faculty. the use of the public to assess the cleanliness of the wall proved unnecessary within a few months, when the impact of the test paint was apparent. the fact that almost all participants could discriminate between the panels after less than 12 months was also of interest. this approach might therefore be useful in the future for the assessment of test formulations. figure 5 . images of the wall at manchester metropolitan university used in the study of photocatalytic paint (panels labelled 1-6). panels 1, 3 and 6 were painted with photocatalytic paint, whilst panels 2, 4 and 5 were painted with paint that did not contain the photocatalytic agent. the image on the top (a) was taken in 2014, eight months following the application of the paint: whiteness/brightness difference between the two paint types is hard to distinguish. the lower image (b) was taken six years later (2020); panels painted with photocatalytic paint are visibly brighter compared to control paint panels. antibiotics 2020, 9, 465 9 of 12 much was learned from each event (as noted above), particularly through observation, in terms of what components participants like and engage with when discussing biofilm. in addition, quantitative evidence of engagement was derived from the 'now wash your hands' event; qualitative evidence of enjoyment and engagement was obtained from 'plaque attack', and the potential for acquisition of research data was indicated by the photocatalytic wall activity. these various outcomes informed how subsequent events for the public would take place, with more focus on design, delivery and evaluation. more recently, there has been increasing effort to ensure that these criteria for effective public engagement are met. microbiology has a particularly dynamic approach to public engagement, and many teams are now publishing the outcomes of their public engagement research in peer-reviewed journals, magazines or online. yet, in a review of public engagement activity around amr, a rich bedrock of activity was found only through personal contacts and communication rather than through a literature search [4] . it is even more important when talking to audiences about biofilms that intended messages are clear. thus, we describe in table 1 the planning of a hypothetical public engagement event designed to inform a large number of adults about biofilm and amr. our focus was on the combination of the two phenomena, which occurs, for example, when biofilms on medical devices present increased resistance to antibiotics [26] . in order to address this combined effect, it was first necessary to define the two phenomena separately. we particularly wished to avoid intrusive aspects of evaluation, relying instead on observation and other (subjective and objective) indicators from participants. we hope that this checklist may be useful for others who might wish to engage audiences with their biofilm/antibiotic research. the national biofilm information centre has recognised the importance of public engagement and is providing a hub for the dissemination of biofilm-focused outreach and engagement activities, which will enable, over time, ideas, expertise and outcomes to be shared and developed, in order to improve the effectiveness of engagement encounters for scientists and their audiences alike. we hope that our experiences in the area are of interest in this context. public engagement activities can be designed with clear aims that enable effective evaluation using both quantitative and qualitative methods. this is particularly important for complex phenomena such as biofilms and amr. the urgent need for microbiology literacy in society simfection: a digital resource for vaccination education practical microbiology in schools: a survey of uk teachers raising awareness of antimicrobial resistance among the general public in the uk: the role of public engagement activities. jac-antimicrob role of hand hygiene in healthcare-associated infection prevention the microbial contamination of mobile communication devices fitting the message to the location: engaging adults with antimicrobial resistance in a world war 2 air raid shelter spreading the message of antimicrobial resistance: a detailed account of a successful public engagement event rsph and ifh call for a clean-up of public understanding and attitudes to hygiene 99th dahlem conference on infection, inflammation and chronic inflammatory disorders: darwinian medicine and the 'hygiene' or 'old friends' hypothesis composition of in vitro denture plaque biofilms and susceptibility to antifungals dental biofilm: ecological interactions in health and disease power toothbrushes: a critical review comparison of the effect of fluoride and non-fluoride toothpaste on tooth wear in vitro and the influence of enamel fluoride concentration and hardness of enamel antimicrobial efficacy of different toothpastes and mouthrinses: an in vitro study blast a biofilm: a hands-on activity for school children and members of the public transforming a school learning exercise into a public engagement event: "the good, the bad and the algae refreshing the public appetite for 'good bacteria': menus made by microbes research methods in education photoinactivation of escherichia coli on acrylic paint formulations using fluorescent light. dyes pigment photoinduced reactivity of titanium dioxide photocatalytic construction and building materials: from fundamentals to applications effect of process parameters on the photocatalytic soot degradation on self-cleaning cementitious materials the authors declare no conflict of interest antibiotics 2020, 9, 465 antibiotics 2020, 9, key: cord-337120-irpm5g7g authors: lee, bruce y. title: the role of internists during epidemics, outbreaks, and bioterrorist attacks date: 2007-01-13 journal: j gen intern med doi: 10.1007/s11606-006-0030-2 sha: doc_id: 337120 cord_uid: irpm5g7g internists are well-positioned to play significant roles in recognizing and responding to epidemics, outbreaks, and bioterrorist attacks. they see large numbers of patients with various health problems and may be the patients’ only interaction with the medical community for symptoms resulting from infectious diseases and injuries from radiation, chemicals, and/or burns. therefore, internists must understand early warning signs of different bioterrorist and infectious agents, proper reporting channels and measures, various ways that they can assist the public health response, and roles of different local, state, and federal agencies. in addition, it is important to understand effects of a public health disaster on clinic operations and relevant legal consequences. during the past half decade, well-publicized events, including the anthrax mail attacks, 1 hurricane katrina, 2 and severe acute respiratory syndrome (sars) 3, 4 have reminded us that epidemics, disease outbreaks, bioterrorist attacks, and natural disasters can occur. although there is debate over when and how they may happen, there is little question that such events could have significant and far-reaching health, social, and economic consequences. moreover, smaller outbreaks, such as influenza and west nile virus, 5 occur with greater regularity. internists can play vital roles in identifying, responding to, and containing bioterrorist attacks and disease outbreaks if they understand their role in these events. internists may be among the first to recognize clues that a problem is occurring, especially as initial signs and symptoms may be subtle or mimic common disorders, prompting victims to contact their primary care physicians, rather than go to emergency departments. 6 furthermore, internists' broad range of medical knowledge, experience, and skills make them uniquely qualified to diagnose and treat a variety of potential health problems. internists are also well-positioned to work with various health care personnel and services during a disaster. therefore, internists must understand early warning signs of bioterrorist and infectious agents, proper reporting channels and measures, and ways that they can help contain and treat the consequences of epidemics, outbreaks, and attacks. during its initial stages, an attack, epidemic, or outbreak may not be obvious. depending on the agent and its mode of transmission, the population density, and the population's access to health care, it can be days or even weeks before anyone can recognize the problem. as the early response may be crucial in containing the problem and minimizing resultant morbidity and mortality, efforts have been made to develop biosurveillance systems to detect outbreaks and attacks. [7] [8] [9] these systems collect pertinent data (e.g., pharmacy drug sales, emergency department visit chief complaints, and air samples) and search for irregularities that suggest a problem is occurring. however, these systems are by no means foolproof because they only look for a finite set of clues, do not cover every part of the united states, and may provide equivocal information. moreover, there could be delays between the point that biosurveillance systems detect suspicious patterns and when the public health system responds. therefore, internists might be the first to become aware of a problem and pivotal in initiating the public health response. internists see large numbers of patients with various health problems and may be the patients' only interaction with the medical community for symptoms resulting from infectious diseases and injuries from radiation, chemicals, and/or burns. so they could be the first to report attacks or outbreaks and initiate public health response. indeed, there are examples of "astute" clinicians being the first to recognize epidemic or bioterrorist attacks (e.g., the 1999 new york city west nile outbreak, 5 the 2001 anthrax attack cases, 10, 11 and the 2003 sars epidemic in vietnam 12 ). in some cases, bioterrorist and infectious agents cause distinctive signs and symptoms. 13, 14 for example, of the 10 inhalational anthrax cases in the 2001 attacks, all had fever, chills, lethargy, and chest x-ray abnormalities. seven had mediastinal widening, and 8 had pleural effusions. all but 1 had elevated liver transaminases. a combination of these findings is highly suspicious for inhalational anthrax, especially in a young, otherwise healthy patient and/or when a patient initially experiences nonspecific influenza-like symptoms followed first by a brief period of apparent recovery, and then, by an abrupt resurgence of more severe symptoms. 15 however, in a majority of cases, early symptoms are vague and readily mistaken for more common upper respiratory infections (e.g., influenza, plague, tularemia, and staphylococcal enterotoxin b) or viral gastroenteritis (e.g., hepatitis a, cryptosporidium, and salmonella). therefore, in addition to looking for specific symptoms, internists should remain vigilant about general trends and patient flow in their clinics. 16 any of the following may be the only sign that an attack or outbreak has occurred 17 21, 22 and rabbits in tularemia outbreaks 23 ); 5. physicians or other clinic staff becoming ill after coming into contact with patients (e.g., the 2003 sars epidemic 4 ); 6. a patient's health rapidly deteriorates out of proportion to the presenting symptoms and diagnosis (e.g., a 30-yearold non-immunocompromised patient dying of pneumonia is rare); 7. an unusual number of patients fail to respond to treatments. an internist's index of suspicion should be even higher when bioterrorism or epidemic alerts are issued. internists must be prepared to address a wide range of physical, psychological, and social consequences of public health disasters. patients may be injured by either a public health disaster or the ensuing mass panic. in addition, internists may have to function as emergency physicians when emergency departments are overcrowded or unavailable. specifically, internists must be prepared to: 1. treat the exposed and infected. different organ systems can be affected (e.g., meningitis from inhalational anthrax, sepsis from typhoidal tularemia, and pneumonia from influenza), so complete examinations are important. websites providing extensive treatment and prophylaxis information include the center for disease control and prevention (cdc) (http://www.bt.cdc.gov/), food and drug administration (fda) (http://www.fda.gov/cder/drugprepare/default.htm), department of health and human services (http://www.hhs.gov/disasters/index.shtml), and national library of medicine (http://www.nlm.nih.gov/ medlineplus/biodefenseandbioterrorism.html); 2. administer prophylaxis to the exposed but not the infected. determining exposure can be difficult as patients may claim that they have been exposed. in a large-scale epidemic or attack, public health officials may set up temporary stations for mass vaccination and prophylaxis. however, many patients may still appear at clinics requesting prophylaxis; 3. triage who gets treated in a large outbreak/attack. internists will have to prioritize who should receive treatment, especially when necessary resources and skilled manpower are limited. knowing when and how to ration treatments can be challenging, particularly in chaotic conditions. although internists may feel compelled to acquiesce to every patient's needs, their primary responsibility in public health emergencies is the public. 24 while clear guidelines have not been established and rationing decisions are rather controversial, certain groups such as essential personnel (e.g., health care workers, police, fire fighters, and other individuals integral in responding to a public health disaster) should receive priority. essential personnel are needed to prevent more casualties and fatalities and could spread contagious diseases to many other people; 4. treat mental health consequences. public health disasters can result in significantly increased mental health problems including anxiety, depression, and posttraumatic stress disorders. [25] [26] [27] [28] evidence suggests that even people who witness, hear, or read about a disaster can be affected. 29, 30 shortages of mental health professionals in a disaster often require internists to handle patients' mental health issues. 31-35 5. treat comorbidity exacerbations. evidence suggests that undue environmental stresses can exacerbate comorbidities such as heart disease and respiratory disease. [36] [37] [38] [39] [40] [41] [42] [43] in addition, during public health disasters, patients with certain chronic diseases (e.g., diabetes and chronic obstructive pulmonary diseases) may not have adequate access to maintenance treatments. 44 proper reporting and the public health and law enforcement chain of command figure 1 illustrates the public health chain of command. internists suspecting an attack or epidemic should immediately inform the local or state health department and contain any possible threat in their clinics, especially if the agent is contagious. providing information to wrong people (especially news media) may cause mass terror and delay the public health system's response. therefore, internists must remain calm, understand how their words can be misunderstood and misconstrued, follow instructions from appropriate health, military and law enforcement officials, and allow properly trained public health officials to deal with the media. local authorities are responsible for the initial response to any public health emergency with appropriate state agencies providing additional support when necessary. depending on the nature and magnitude of the problem, local or state authorities may choose to involve federal agencies. unlike naturally occurring disease outbreaks, bioterrorist attacks are criminal acts and require intervention of law enforcement agencies. 45 when there is a risk of contagious disease transmission across state lines or state efforts are deemed inadequate, the federal government assumes authority. the president makes executive decisions. the cdc administers federal quarantine actions. implementation of order could involve the department of defense or the federal emergency management agency (fema). for travelers seeking to enter the united states, the cdc has the authority to enact quarantine. in areas where the cdc's division of global migration and quarantine personnel are not stationed, the immigration and naturalization service and the united states customs service personnel are trained to identify travelers with potential epidemic. it is essential that health care professionals adequately protect themselves. they are needed to care for both victims of an outbreak/attack and "regular" patients and can inadvertently spread communicable agents rather quickly, especially to vulnerable members of the population. 46, 47 one study examined clinicians' knowledge regarding proper infection control practices during a bioterrorist event and found numerous deficiencies. 48 standard precautions should be exercised for all situations. internists should wash their hands frequently and be careful when handling body tissues and fluids. certain diseases require additional precautions (table 1) . contaminated clothing should be removed promptly and placed in sealed plastic bags. soap and warm water can wash off most noncontagious agents. 49, 50 bleach is needed for chemical decontamination. any health care worker who receives a needle stick from a potentially bacteremic anthrax-infected patient should receive prophylactic antibiotics. although the words quarantine and isolation have been erroneously used interchangeably, quarantine means the separation and confinement of currently healthy people who may have been exposed to a contagious disease, while isolation refers to the separation and confinement of people known or suspected to be infected with the contagious disease. when an infectious disease is confined to a specific locale, the authority to order quarantines usually rests with local or state public health officials. when the event spreads across jurisdictional boundaries within the state, such authority usually is relinquished to the state. there is great variability in quarantine regulations from state to state. 51 clinic patient volume can increase significantly from ill patients and concerned healthy patients (the "worried well"). this "worried well" phenomenon was seen after the 2001 anthrax attacks. 52, 53 internists will have to offer reassurance to the "worried well," relay appropriate disease information, and direct them to the right public health agencies and relevant websites (e.g., fig. 1 and websites listed in "treatment and prophylaxis") for information and mass prophylaxis (if needed). 54 clinics should minimize potentially contagious patients' contact with health care workers and other patients by either temporal segregation (clustering potentially contagious patients later in the day) or spatial segregation (shunting potentially contagious patients towards specific rooms). therefore, clinic schedulers and telephone operators should be aware of the signs and symptoms that suggest a patient is contagious. 55 proper triaging is necessary. minor issues and complaints may have to wait, but urgent problems must be addressed. the clinic will not operate with normal efficiency. health care workers may become ill or be absent. running additional tests, notifying authorities, taking on and off personal protective equipment, rearranging the clinic, and decontaminating rooms will cause operational delays. clinics that routinely run at peak capacity could become overwhelmed, especially if the clinic staff themselves become ill. every clinic should have clearly established contingency plans and build an extra capacity that can handle unexpected surges in patients. 56 specifically clinics will need: 1. additional rooms to place and examine patients. clinics should identify other patient areas (e.g., procedure, radiology, and operating rooms) that can be converted into examination rooms. rooms not normally used for patients (e.g., offices or conference rooms) may be utilized if they meet basic requirements for patients who do not require isolation. mobile clinics and hospitals may be available 57 ; 2. additional health care professionals and staff. clinics should know where and how to reach additional personnel who are cross-trained to handle a wide range of responsibilities in an emergency; 3. diversion plans. when a clinic is overwhelmed, it must know when to close to additional patients and where to send them. anytime medical treatment is administered, legal concerns come into play. public health disasters are no exception. in a mass casualty setting, the ability to mount an adequate response may be hindered by the myriad of rules and regulations that govern the everyday practice of medicine. laws vary from state to state, so internists should be aware of their state's specific regulations. unfortunately, many states have not yet adequately addressed or clarified medico-legal issues and regulations in public health disasters. 45 some of these include: 1. licensing and admitting privileges. internists willing to provide assistance may not be licensed in that state, have appropriate admitting privileges, or have the time or means to complete the necessary paperwork before administering treatment. some states (e.g., colorado) have introduced statutes that ease some regulatory barriers by providing protection to health care workers during a public health disaster, such as allowing physicians to administer care even though they are not licensed in that state; 2. malpractice liability. while states do have "good samaritan" laws that offer some legal protection to physicians who aid strangers in "good faith," the extent of these laws varies from state to state and currently do not cover all potential eventualities. "good samaritan laws" may not apply when treatment is administered against a patient's will. 58 3. maintaining patient confidentiality. bioterrorist attacks and epidemics require physicians to quickly transmit patient and case information to other health care personnel and appropriate authorities. while such communication is paramount, efforts should be made to maintain patient confidentiality and transmit only necessary information. at present, it is unclear how health insurance portability and accountability act (hipaa) regulations would affect the public health and health care system response. in a public health emergency, the hipaa privacy rule does allow disclosure of the following protected health information (phi): for treatment by health care providers; to avert a serious threat to health or safety; to public health authorities for public health purposes; to protect national security; to law enforcement under certain conditions; and for judicial or administrative proceedings. 59, 60 however, during an emergency, misunderstandings of the privacy rule's requirements may hinder the flow of phi. 61 as internists could play a vital role in epidemics, disease outbreaks, or bioterrorist attacks, they must be knowledgeable, equipped, and prepared. in an emergency, potential legal and administrative barriers should be eased. clinics should have appropriate contingency plans. although the risk of large-scale attacks and epidemics seems low, the risk of smaller epidemics and local public health emergencies is much higher. preparing for large events will help prepare for such smaller events. potential financial conflicts of interest: none disclosed. death due to bioterrorism-related inhalational anthrax: report of 2 patients update on emerging infections: news from the centers for disease control and prevention. vibrio illness after hurricane katrina-multiple states but fast enough? responding to the epidemic of severe acute respiratory syndrome a major outbreak of severe acute respiratory syndrome in hong kong the outbreak of west nile virus infection in the new york city area in 1999 the public and the smallpox threat biostorm: a system for automated surveillance of diverse data sources data, network, and application: technical description of the utah rods winter olympic biosurveillance system role of data aggregation in biosurveillance detection strategies with applications from essence index case of fatal inhalational anthrax due to bioterrorism in the united states emergency preparedness and response accuracy of screening for inhalational anthrax after a bioterrorist attack anthrax as a biological weapon, 2002: updated recommendations for management bioterrorism and critical care nato handbook on the medical aspects of nbc defensive operations amedp-6 departments of the army, the navy, and the air force apic bioterrorism task force and cdc hospital infections program bioterrorism working group bioterrorism readiness plan: a template for healthcare facilities a massive outbreak in milwaukee of cryptosporidium infection transmitted through the public water supply an outbreak of hepatitis a associated with green onions crow deaths as a sentinel surveillance system for west nile virus in the northeastern united states dead crow densities and human cases of west nile virus tularemia transmitted by insect bites-wyoming clinical decision making during public health emergencies: ethical considerations symptoms of posttraumatic stress disorder and depression among children in tsunami-affected areas in southern thailand mental health problems among adults in tsunami-affected areas in southern thailand surveillance for world trade center disaster health effects among survivors of collapsed and damaged buildings media exposure in children one hundred miles from a terrorist bombing posttraumatic stress two years after the oklahoma city bombing in youths geographically distant from the explosion referral gridlock: primary care physicians and mental health services posttraumatic stress disorder in rural primary care: improving care for mental health following bioterrorism the impact of terrorism on brain, and behavior: what we know and what we need to know. neuropsychopharmacology incorporating community mental health into local bioterrorism response planning: experiences from the dekalb county board of health incorporating mental health into bioterrorism response planning behavioral and emotional triggers of acute coronary syndromes: a systematic review and critique sudden cardiac death triggered by an earthquake population-based analysis of the effect of the northridge earthquake on cardiac the impact of a catastrophic earthquake on morbidity rates for various illnesses triggering of acute coronary syndromes after a chemical plant explosion earthquakes in el salvador: a descriptive study of health concerns in a rural community and the clinical implications, part i earthquakes in el salvador: a descriptive study of health concerns in a rural community and the clinical implications: part iii-mental health and psychosocial effects earthquakes in el salvador: a descriptive study of health concerns in a rural community and the clinical implications-part ii tsunami induced hyperglycemia and diabetes mortality-two studies from south india preparing for a bioterrorist attack: legal and administrative strategies nosocomial transmission of influenza research gaps in protecting healthcare workers from sars and other respiratory pathogens: an interdisciplinary, multi-stakeholder, evidence-based approach clinicians' knowledge, attitudes, and concerns regarding bioterrorism after a brief educational program efficacy of selected hand hygiene agents used to remove bacillus atrophaeus (a surrogate of bacillus anthracis) from contaminated hands guideline for hand hygiene in health-care settings. recommendations of the healthcare infection control practices advisory committee and the hicpac/shea/apic/idsa hand hygiene task force. society for healthcare epidemiology of america/association for professionals in infection control/infectious diseases society of america controlling the resurgent tuberculosis epidemic. a 50-state survey of tb statutes and proposals for reform the impact of anthrax attacks on the american public the psychological impacts of bioterrorism terrorism from a public health perspective pathogen transmission and clinic scheduling impact of an outbreak of severe acute respiratory syndrome on a hospital in taiwan, roc mobile hospital raises questions about hospital surge capacity legal history of emergency medicine from medieval common law to the aids epidemic bioterrorism meets privacy: an analysis of the model state emergency health powers act and the hipaa privacy rule. ann health law guidance from cdc and the u.s. department of health and human services the hipaa privacy rule and bioterrorism planning, prevention, and response bioterrorism preparedness varied across state and local jurisdictions key: cord-284125-35ghtmhu authors: chua, kaw bing; gubler, duane j title: perspectives of public health laboratories in emerging infectious diseases date: 2013-06-26 journal: emerg microbes infect doi: 10.1038/emi.2013.34 sha: doc_id: 284125 cord_uid: 35ghtmhu the world has experienced an increased incidence and transboundary spread of emerging infectious diseases over the last four decades. we divided emerging infectious diseases into four categories, with subcategories in categories 1 and 4. the categorization was based on the nature and characteristics of pathogens or infectious agents causing the emerging infections, which are directly related to the mechanisms and patterns of infectious disease emergence. the factors or combinations of factors contributing to the emergence of these pathogens vary within each category. we also classified public health laboratories into three types based on function, namely, research, reference and analytical diagnostic laboratories, with the last category being subclassified into primary (community-based) public health and clinical (medical) analytical diagnostic laboratories. the frontline/leading and/or supportive roles to be adopted by each type of public health laboratory for optimal performance to establish the correct etiological agents causing the diseases or outbreaks vary with respect to each category of emerging infectious diseases. we emphasize the need, especially for an outbreak investigation, to establish a harmonized and coordinated national public health laboratory system that integrates different categories of public health laboratories within a country and that is closely linked to the national public health delivery system and regional and international high-end laboratories. infectious diseases have affected humans since the first recorded history of man. infectious diseases remain the second leading cause of death worldwide despite the recent rapid developments and advancements in modern medicine, science and biotechnology. greater than 15 million (.25%) of an estimated 57 million deaths that occur throughout the world annually are directly caused by infectious diseases. millions more deaths are due to the secondary effects of infections. moreover, infectious diseases cause increased morbidity and a loss of work productivity as a result of compromised health and disability, accounting for approximately 30% of all disability-adjusted life years globally. 1, 2 compounding the existing infectious disease burden, the world has experienced an increased incidence and transboundary spread of emerging infectious diseases due to population growth, urbanization and globalization over the past four decades. [3] [4] [5] [6] [7] [8] most of these newly emerging and re-emerging pathogens are viruses, although fewer than 200 of the approximately 1400 pathogen species recognized to infect humans are viruses. on average, however, more than two new species of viruses infecting humans are reported worldwide every year, 9 most of which are likely to be rna viruses. 6 emerging novel viruses are a major public health concern with the potential of causing high health and socioeconomic impacts, as has occurred with progressive pandemic infectious diseases such as human immunodeficiency viruses (hiv), the recent pandemic caused by the novel quadruple re-assortment strain of influenza a virus (h1n1), and more transient events such as the outbreaks of nipah virus in 1998/1999 and severe acute respiratory syndrome (sars) coronavirus in 2003. [10] [11] [12] [13] [14] in addition, other emerging infections of regional or global interest include highly pathogenic avian influenza h5n1, henipavirus, ebola virus, expanded multidrug-resistant mycobacterium tuberculosis and antimicrobial resistant microorganisms, as well as acute hemorrhagic diseases caused by hantaviruses, arenaviruses and dengue viruses. to minimize the health and socioeconomic impacts of emerging epidemic infectious diseases, major challenges must be overcome in the national and international capacity for early detection, rapid and accurate etiological identification (especially those caused by novel pathogens), rapid response and effective control (figure 1 ). the diagnostic laboratory plays a central role in identifying the etiological agent causing an outbreak and provides timely, accurate information required to guide control measures. this is exemplified by the epidemic of nipah virus in malaysia in 1998/1999, which took more than six months to effectively control as a consequence of the misdiagnosis of the etiologic agent and the resulting implementation of incorrect control measures. 15, 16 however, there are occasions when control measures must be based on the epidemiological features of the outbreak and pattern of disease transmission, as not all pathogens are easily identifiable in the early stage of the outbreak (figure 1 ). establishing laboratory and epidemiological capacity at the country and regional levels, therefore, is critical to minimize the impact of future emerging infectious disease epidemics. developing such public health capacity requires commitment on the part of all countries in the region. however, to develop and establish such an effective national public health capacity, especially the laboratory component to support infectious disease surveillance, outbreak investigation and early response, a good understanding of the concepts of emerging infectious diseases and an integrated country and regional public health laboratory system in accordance with the nature and type of emerging pathogens, especially novel ones, are highly recommended. traditionally, emerging infectious diseases are broadly defined as infections that: (i) have newly appeared in a population; (ii) are increasing in incidence or geographic range; or (iii) whose incidence threatens to increase in the near future. 6, 17 six major factors, and combinations of these factors, have been reported to contribute to disease emergence and re-emergence: (i) changes in human demographics and behavior; (ii) advances in technology and changes in industry practices; (iii) economic development and changes in land use patterns; (iv) dramatic increases in volume and speed of international travel and commerce; (v) microbial mutation and adaptation; and (vi) inadequate public health capacity. 6, 17 from the perspective of public health planning and preparedness for effective emerging infectious disease surveillance, outbreak investigation and early response, the above working definition of emerging infectious disease and its associated factors that contribute to infectious disease emergence are too broad and generic for more specific application and for the development of a national public health system, especially in the context of a public health laboratory system in a country. thus, in this article, emerging infectious diseases are divided into four categories based on the nature and characteristics of pathogens or infectious agents causing the emerging infections; these categories are summarized in table 1 . the categorization is based on the patterns of infectious disease emergence and modes leading to the discovery of the causative novel pathogens. the factors or combinations of factors contributing to the emergence of these pathogens also vary within each category. likewise, the strategic approaches and types of public health preparedness that need to be adopted, in particular with respect to the types of public health laboratories that need to be developed for optimal system performance, will also vary greatly with respect to each category of emerging infectious diseases. these four categories of emerging infectious diseases and the factors that contribute to the emergence of infectious diseases in each category are briefly described below. [18] [19] [20] [21] [22] [23] factors that contributed to the occurrence of emerging infectious diseases in this subcategory include population growth; urbanization; environmental and anthropogenic driven ecological changes; increased volume and speed of international travel and commerce with rapid, massive movement of people, animals and commodities; and deterioration of public health infrastructure. subcategory 1b includes known and unknown infectious agents that occur in new host 'niches'. infectious microbes/ agents placed under this subcategory are better known as 'opportunistic' pathogens that normally do not cause disease in immunocompetent human hosts but that can lead to serious diseases in immunocompromised individuals. the increased susceptibility of human hosts to infectious agents is largely due to the hiv/acquired immune deficiency syndrome pandemic, and to a lesser extent, due to immunosuppression resulting from cancer chemotherapy, antirejection treatments in transplant recipients, and drugs and monoclonal antibodies that are used to treat autoimmune and immune-mediated disorders. a notable example is the increased incidence of progressive multifocal leukoencephalopathy, a demyelinating disease of the central nervous system that is caused by the polyomavirus 'jc' following the public health laboratories in emerging infectious diseases kb chua and dj gubler 2 increased use of immunomodulatory therapies for anti-rejection regimens and for the treatment of autoimmune diseases. 24 examples of past emerging infectious diseases under this category are antimicrobial resistant microorganisms (e.g., mycobacterium tuberculosis, plasmodium falciparum, staphylococcus aureus) and pandemic influenza due to a new subtype or strain of influenza a virus (e.g., influenza virus a/california/04/2009(h1n1)). 9,32-35 factors that contribute to the emergence of these novel phenotype pathogens are the abuse of antimicrobial drugs, ecological and host-driven microbial mixing, microbial mutations, genetic drift or re-assortment and environmental selection. accidental or potentially intentional release of laboratory manipulated strains resulting in epidemics is included in this category. factors that lead to the spillovers and emergence of these novel pathogens are human population expansion, economic development, changes in land use patterns, modifications to natural habitats, and changes in agricultural practices and animal husbandry. human behavior, such as wildlife trade and translocations, live animal and bush meat markets, consumption of exotic foods, development of ecotourism, access to petting zoos and ownership of exotic pets, also plays a significant role in the transfer of pathogens between species. 19 [41] [42] [43] [44] [45] [46] examples of infectious diseases under category 4b are gastritis and peptic ulcers due to helicobacter pylori, kaposi sarcoma due to human herpesvirus 8 and chronic hepatitis due to hepatitis virus c and g. [47] [48] [49] [50] advances in scientific knowledge and technology have contributed substantially to the discovery of these infectious etiological agents. regardless of the category, with some exception for category 4b, effective early detection, identification, characterization, containment, control and ultimately prevention of the emerging infectious diseases will require a good, functional national public health surveillance system. the system needs to be well supported by a network of primary public health and clinical/medical diagnostic laboratories that are coordinated by a national public health reference laboratory with real-time and harmonious communication between the laboratories and epidemiological surveillance units. confronted with the great diversity of these emerging pathogens and the equally diverse mechanisms and factors that are responsible for their emergence, there is an urgent need to develop a network of diagnostic laboratories, especially in countries where epidemic infectious diseases are likely to emerge. this network should include local laboratories with basic clinical laboratory capabilities, provincial and national public health diagnostic laboratories with greater capability to diagnose known pathogens and support effective laboratory-based surveillance, and a centralized national reference laboratory that can provide laboratory training and quality control for diagnostic assays for the network of diagnostic laboratories in the country. ideally, the national reference laboratory should have state-of-the-art laboratory technology and be able to identify and characterize novel pathogens with specialized university laboratories and foreign institutes that can provide backup capability, but more importantly, the national reference laboratory should be able to conduct research for the development of new diagnostic technologies to detect and identify novel pathogens, especially those classified as category 4. the us system, which includes local and state public health laboratories that conduct diagnoses of known pathogens, the centers for disease control and prevention and university laboratories that provide research and reference activities, is a good model. disease or pathogen-specific public health diagnostic laboratories established to support world health organization (who)-specific disease surveillance programs and vaccine-preventable diseases, e.g., national influenza, poliovirus and measles laboratories, led to the 'compartmentalization' of laboratory diagnostic services, segregation of functions, and duplication of facilities and equipment. the situation is further complicated by the siting of various pathogen-specific diagnostic laboratories in different buildings or institutes or different locations within a country, thus preventing more cost-effective measures of sharing common equipment and reagents, clinical samples, information and human resources. finally, the problem is compounded by policy makers and laboratory managers lacking flexibility and not allowing these disease or pathogen-specific laboratories to adopt a more generic approach in the investigation of infectious disease outbreaks. past incidents have shown that misdiagnosis or delay in the diagnosis of epidemics can cause substantial economic losses and social disruption and prevent containment or control as a result of the implementation of inappropriate control measures or a delay in implementing the appropriate control measures. the proposed integrated system of public health laboratories is not entirely new; public health laboratories are already in existence in most countries, but most are poorly equipped and are not adequately funded or staffed with trained professional staff. moreover, a lack of knowledge and coordination has led to ineffective operation in the support of infectious disease surveillance. the basic concept of realigning and harmonizing public health laboratories to optimize their roles and functions can be drawn from the system of medical practices. due to rapid and vast expansion of medical knowledge, technology and demand of specialized skills and therapy, medical practices have evolved into a number of specialties and subspecialties, such as infectious disease, cardiology, gastroenterology, neurology, radiology, anesthesiology and oncology. an excellent aspect of the medical system is the continual retention of the general physician (family physician) or general pediatrician as the initial or first entry point for patients seeking consultation for any medical problem before being subsequently referred to the appropriate specialist, if deemed necessary. it is not uncommon for patients, especially older individuals, to have more than one disease or pathology at the time of presentation to the doctor. in a similar manner, in outbreaks of infectious diseases, 'background' endemic pathogens are often present that are capable of similar disease manifestations. thus, public health analytical diagnostic laboratories (both primary and clinical) should adopt a generic approach and serve as the initial or first entry point for the investigation of the causative pathogens in the event of an infectious disease outbreak or the occurrence of any fatal illness with clinical suspicion of infectious etiology. in addition, public health laboratories must have the capability to support the expanded scope and sophistication of public health activities brought about by a rapid increase in population and social, demographic and ecological changes, in addition to the factors mentioned above. despite the presence of several types of health laboratories, they can be classified into three main categories: (i) public health research laboratories; (ii) public health reference laboratories; and (iii) public health analytical diagnostic laboratories. public health analytical diagnostic laboratories can be further subcategorized into primary public health (community-based) and clinical/medical (hospital and clinic-based) analytical diagnostic laboratories. a proposed organizational model to establish an integrated system of public health laboratories within a country to coordinate and link health laboratories under different ministries and in both public and private institutions based on their functional roles is shown in figure 2 . the broken lines indicate the diagnostic laboratories that are not directly regulated by the ministry of health. a schematic flow chart illustrating the functional relationships and linkages between various types of public health laboratories in a country was described previously. 51 a defined and harmonious linkage and collaboration will not only avoid duplication and redundancy, but also enhance and complement the function and output quality of each laboratory. bearing in mind that not all countries in the world have similar resources (financial, man-power and expertise), demography, geopolitical structure, needs and commitment, the proposed model can be appropriately modified to tailor each country's immediate needs with a provision for future upgrading and expansion. ultimately, it is recommended that all countries establish an integrated system covering all three categories of public health laboratories, with a cohesive centralized national public health reference laboratory. in countries with limited resources, an interim centralized national public health diagnostic laboratory can take on some of the roles and functions of a national reference laboratory, especially in supporting laboratory training and quality assurance. for countries without such an idealistic centralized public health reference laboratory, an in-place system of networking should be developed to link to regional and international high-end laboratories or who collaborative centers to rapidly identify and characterize novel pathogens and provide other specialized laboratory diagnostic reagents, assays or validation. in addition, each region should have a regional center for reference public health laboratories in emerging infectious diseases kb chua and dj gubler 4 and research to help the national reference and/or diagnostic laboratories train and maintain laboratory quality control. the us centers for disease control and prevention is a major who collaborative partner and provides laboratory service not only for the american region, but also for many other countries in the world. investigations into the diagnosis of nipah virus, sars coronavirus, pandemic influenza a virus and hemorrhagic fever viruses are just a few examples illustrating its worldwide function. the placement of the centralized reference laboratory under the national center for disease control strengthens close communication and coordination among public health specialists, epidemiologist and laboratory personnel and serves as an important coordinating center to support the functions and activities pertaining to biorisk issues, centralized pathogen characterization and storage, laboratory-based surveillance and laboratory quality assurance, as shown in figure 2 . a national reference laboratory will also be able to play an important role as part of a regional laboratory network to strengthen regional public health laboratory capacity in providing specific referral functions for public health diagnostic laboratories in other countries that do not have a reference laboratory. the public health research laboratories within the research institutes of ministries of health and universities or even private research institutions are best suited and can play a crucial role in collaborating with the national public health reference and diagnostic laboratories to discover novel pathogens of many human diseases under category 4, especially in subcategory 4b. the proposed network scheme will provide more cost-efficient laboratory services and ensure a regular flow of laboratory work to maintain the competency of technical staff to produce quality output. because of the increased likelihood of epidemic diseases caused by novel pathogens, diagnostic laboratories serving as the primary entry point of investigation should be able to take a more generic approach in pathogen detection, isolation and identification. the traditional existing system of 'compartmentalization' of national disease/pathogenspecific diagnostic laboratories should thus be reviewed and integrated into the national public health infectious disease diagnostic laboratory system. this proposed model would improve cost-efficiency and allow a more appropriate approach to infectious disease outbreak investigation and control. we thank tikki pang, lee kuan yew school of public policy, national university of singapore, for useful comments and suggestions in the preparation of this manuscript. emerging infections: getting ahead of the curve emerging infectious diseases: a 10-year perspective from the national institute of allergy and infectious 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year surveillance programme ast infectious diseases community of practice. arenavirus and west nile virus in solid organ transplantation acanthamoeba keratitis: an emerging disease gathering importance worldwide? dynamics of antibiotic resistant mycobacterium tuberculosis during long-term infection and antibiotic treatment chloroquine resistance in plasmodium falciparum malaria parasites conferred by pfcrt mutations vancomycin heteroresistance is associated with reduced mortality in st239 methicillin-resistant staphylococcus aureus blood stream infections the crisis in antibiotic resistance ebola haemorrhagic fever in zaire the cercopithecus monkey disease in marburg and frankfurt (main) a morbillivirus that caused fatal disease in horses and humans the emergence of simian/human immunodeficiency viruses wildlife, exotic pets, and emerging zoonoses a newly discovered human pneumovirus isolated from young children with respiratory tract disease a newly identified bocavirus in human stool emerging respiratory agents: new viruses for old disease? a previously unknown reovirus of bat origin is associated with an acute respiratory disease in humans identification and characterization of a new orthoreovirus from patients with acute respiratory infections saffold virus, a human theiler's-like cardiovirus, is ubiquitous and causes infection early in life unidentified curved bacilli in the stomach of patients with gastritis and peptic ulceration identification of herpesvirus-like dna sequences in aids-associated kaposi's sarcoma isolation of a cdna clone derived from a blood-borne non-a, non-b viral hepatitis genome molecular cloning and disease association of hepatitis g virus: a transfusion-transmissible agent this work is licensed under a creative commons attribution-noncommercial-noderivative works to view a copy of this license key: cord-271892-cadjzw9h authors: ario, alex riolexus; bulage, lilian; kadobera, daniel; kwesiga, benon; kabwama, steven n.; tusiime, patrick; wanyenze, rhoda k. title: uganda public health fellowship program’s contribution to building a resilient and sustainable public health system in uganda date: 2019-05-23 journal: glob health action doi: 10.1080/16549716.2019.1609825 sha: doc_id: 271892 cord_uid: cadjzw9h background: low-income countries with relatively weak-health systems are highly vulnerable to public health threats. effective public health system with a workforce to investigate outbreaks can reduce disease impact on livelihoods and economic development. building effective public health partnerships is critical for sustainability of such a system. uganda has made significant progress in responding to emergencies during the past quarter century, but its public health workforce is still inadequate in number and competency. objectives: to reinforce implementation of priority public health programs in uganda and cultivate core capacities for compliance with international health regulations. methods: to develop a competent workforce to manage epidemics and improve disease surveillance, uganda ministry of health (moh) established an advanced-level field epidemiology training program, called public health fellowship program (phfp); closely modelled after the us cdc’s epidemic intelligence service. phfp is a 2-year, full-time, non-degree granting program targeting mid-career public health professionals. fellows spend 85% of their field time in moh placements learning through service delivery and gaining competencies in major domains. results: during 2015–2018, phfp enrolled 41 fellows, and graduated 30. fellows were placed in 19 priority areas at moh and completed 235 projects (91 outbreaks, 12 refugee assessments, 50 surveillance, and 60 epidemiologic studies, 3 cost analysis and 18 quality improvement); made 194 conference presentations; prepared 63 manuscripts for peer-reviewed publications (27 published as of december 2018); produced moh bulletins, and developed three case studies. projects have resulted in public health interventions with improvements in surveillance systems and disease control. conclusion: during the 4 years of existence, phfp has contributed greatly to improving real-time disease surveillance and outbreak response core capacities. enhanced focus on evidence-based targeted approaches has increased effectiveness in outbreak response and control, and integration of phfp within moh has contributed to building a resilient and sustainable health system in uganda. the burden of communicable and non-communicable diseases (ncds) in uganda is high. most major health outcome indicators fall well short of desired targets: 343 women die for every 100,000 live births, and 131 of every 1,000 children die before age 5 years. nearly one in three children under 5 years is stunted [1] . more than half of the disability-adjusted life-years lost in uganda are due to communicable diseases, in part due to the high hiv prevalence (6.2%) and tb prevalence (3/ 1000) [2] . the emergence of multidrug-resistant tuberculosis has spread countrywide, and the growing noncommunicable disease burden is of increasing concern [3, 4] as an ecological hotspot, uganda has infectious disease transmission belts for meningitis, yellow fever, and viral haemorrhagic fevers. the country is prone to emerging and re-emerging infectious diseases, most of which have occurred in epidemic proportions in recent times with significant cost implications. for example, the cost of responding and controlling the 2017 marburg virus disease outbreak in kween district, eastern uganda was approximately $1 million usd [5] . addressing all of these health challenges requires a resilient health system, if meaningful prevention and control is to be achieved. health system resilience comprises both health system strengthening and sustainability. health system strengthening refers to significant and purposeful efforts to improve the system's performance, while sustainability has been defined as the implementation and continuous use of new practices that are able to produce the intended outcomes over a long period of time [6] . the world health organisation (who) in 2007 developed a framework that describes health system strengthening in terms of six building blocks: service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership/governance [7] . health workforce challenges have been recognized as a critical bottleneck to the delivery of high-quality health services, including response to epidemics. the spread of ebola in west africa during 2013-2016 was compounded by weak-health systems characterized by lack of public health capacity for outbreak detection and control [8, 9] . while there is no doubt that new strategies are needed to respond to evolving systems challenges, even the current available human resources are not being used to sufficiently strengthen the performance of health systems. evidence-informed policy-making presupposes the availability of high quality, relevant information, and decision-makers may need support to assess what is already known or to articulate demands for specific new evidence. field epidemiologists respond to public health emergencies, including outbreaks, as well as conducting epidemiologic research, evaluating and improving surveillance systems, implementing public health programs, and publishing data to facilitate evidence-based decision-making. the shortage of field epidemiologists in uganda to address critical aspects of health in the public sector prompted the uganda ministry of health (moh), with support of key partners including makerere university school of public health (maksph) and us centers for disease control and prevention (cdc), to establish the uganda public health fellowship program (phfp) in 2015. phfp is an in-service, post-master's-degree field epidemiology training program (fetp) that attempts to address human resources for health needs. as part of the moh's long-term sustainability vision, phfp will exist as a directorate and capacity-building arm of the uganda national institute of public health (uniph); uniph is an initiative of the moh to create an integrated disease control centre, analogous to the us cdc. this paper describes the phfp, its development and organization, and its contribution to building a resilient and sustainable health system by training a critical mass of competent field epidemiologists in uganda. the phfp is a 2-year, non-degree-granting, full-time, competency-based fellowship program modelled after the us cdc's epidemic intelligence service (eis) program. the program is primarily funded by the us government through the president's emergency plan for aids relief (pepfar), the president's malaria initiative (pmi), and the global health security agenda (ghsa). the phfp trains midcareer professionals who have a master's degree (or higher) in a health-related discipline and who aspire to become public health leaders. during the two-year fellowship period, fellows are required to attain certain core competencies in domains that include public health emergency response, surveillance data analysis, surveillance system evaluation, applied epidemiologic study, cost analysis of outbreaks, quality improvement science, burden of disease estimation, and leadership skills. their attainment of these competencies is demonstrated by completing a portfolio of projects in each of these domains. phfp is integrated as an arm of moh, and, together with the integrated epidemiology and surveillance department (iesd), the public health emergency operations centre (pheoc), and other important public health programs in the moh, conducts investigations and studies that provide data for decisionmaking for the national task force (ntf). the ntf is an arm of the moh created to coordinate emergency health response, and is responsible for bringing partners together, providing strategic direction to response, and coordinating functions that contribute to prevention and control of public health emergencies. the phfp secretariat is the operational and administrative unit responsible for coordinating the program. its functions include: (a) coordination of phfp partner collaboration with moh, (b) organizing and supervising fellows' placements within moh, (c) performance review of fellows, (d) back-up mentorship for fellows and coordination of mentorship activities, and (e) development of strategic and operational plans for approval by the phfp steering committee (sc). the phfp secretariat comprises a field coordinator, two field supervisors, a scientific writer, a training manager, and an administrative assistant, based at the ministry of health. the cdc resident advisor, who provides technical and programmatic guidance, supports the secretariat, but is not a part of it. applications are solicited through the print media, the program website, the alumni association, and professional associations. short-listed candidates are required to undergo a rigorous interview process comprising an in-person interview, a power point presentation on a given relevant topic, and an essay on a selected topic. approximately 10 fellows are selected annually. the service-in-training program comprises two didactic courses of approximately six weeks in duration each (~15% of the program time): an introductory course at the beginning, and an advanced course towards the end of the first year. the remaining weeks (~85% of time), the fellows are placed at an moh host site, where they implement activities stipulated in their scope of work and work plans, tailored towards accomplishment of host site activities and fellowship deliverables. the hands-on-learning is anchored around intense continuous mentorship by mentors at the host site, the secretariat, and staff at makerere university college of health sciences. fellows' progress is monitored and performance appraised on a quarterly and annual basis. supportive supervision is offered to the host site to ensure prompt identification of problems and possible solutions. (table 1) . graduation: by january 2019, the first three cohorts of fellows had graduated. all graduates have been absorbed within the moh (53%) or are working with moh-affiliated or linked institutions or organisations [who, idi, afenet and africa cdc] (47%) ( table 2) . field projects: during the nearly four years of the program implementation, the 41 phfp fellows completed more than 235 applied epidemiology projects, of which 91 were outbreak investigations and 12 were emergency refugee health assessments. in addition, fellows have conducted 50 surveillance projects, including analysis of surveillance data or evaluation of a surveillance system, and completed 60 epidemiological studies, 18 quality improvement projects, and 3 cost analyses for outbreaks (table 3) . on average, each fellow implemented 8 projects. these field investigations have been conducted throughout the country (figure 1 ). communication outputs: phfp has submitted 63 manuscripts for publication in peer-reviewed journals; 25 were published as of december 2018. a total of 29 manuscripts are undergoing internal and cdc reviews. findings from some of the published manuscripts, such as risk factors for podoconiosis in kamwenge district, uganda [10] were widely covered in major national and international media outlets, including international national newspapers have also published articles from many fellows, written to inform the public about current public health challenges, such as outbreaks and tips on disease prevention. these publications have contributed to use of their public health recommendations on a wider scale nationally. contribution to building a resilient system: prior to phfp, there was no investigative arm for outbreak response at moh; the phfp created and now leads this arm, as part of the national rapid response team. outbreak reports prepared by fellows are routinely submitted to the pheoc and presented at the national task force for epidemic preparedness and response, which helps to guide outbreak prevention and control in the country. examples include field projects participated 33 62 59 81 235 outbreak investigations 18 15 27 31 91 emergency investigations 1 4 7 0 1 2 surveillance 9 16 15 10 50 applied epidemiologic studies 5 22 5 29 61 cost analysis of outbreaks 0 2 1 0 3 quality improvement 0 3 4 11 identification and investigation of a large typhoid outbreak in 2015, which affected over 10,000 residents in kampala, in which investigation findings helped to guide the successful control of the outbreak, early identification and investigation of a yellow fever outbreak in 2016, leading to a subsequent mass vaccination campaign by moh, and investigation of a meningitis (serogroup w) outbreak in an institutionalized population in 2016, with subsequent control efforts potentially preventing spread into the civilian population. phfp also provided epidemiologic support for nationwide outbreaks of cholera, malaria, measles and anthrax [13] . phfp fellows have also conducted emergency assessments and evaluations at several refugee settlement areas. implementation of recommendations from these investigations by moh and un agencies has potentially prevented outbreaks and improved the health of the refugees. the prompt epidemiologic investigations conducted by the phfp have resulted in shortened time to identify dangerous pathogens, and prevented potential spread of outbreaks. for example, due to timely investigation and prompt response, a yellow fever outbreak that occurred in 2016 was confirmed within 12 days and controlled within three weeks of the initial outbreak report. in comparison, the previous yellow fever outbreak in uganda in 2010 took 40 days to confirm and 3 months to control [14] . due to its achievements, phfp won the cdc director's award for excellence in public health and response at the 2017 eis conference [15] . phfp and the moh are also supported by a frontline fetp program, established by the moh in partnership with the cdc in 2016. frontline fetp augments disease surveillance and outbreak detection and response at the district level [16] . in just four years of operation, uganda's public health fellowship program has demonstrated the ability to address multiple gaps in the uganda health system. they have generated quality products, experienced adoption of recommendations from their projects, and received national and international recognition [17] . as an integrated and adaptive program, phfp has greatly improved uganda's capacity to respond to disease outbreaks and other public health emergencies, controlling them at their sources, in a timely and effective manner. much as established literature guides response to epidemics, we are aware that each outbreak is unique. before phfp, outbreak responses in uganda typically had only minimal epidemiological investigation [16] . the commencement of phfp brought systematic approaches to epidemiologic investigations in almost all outbreaks in uganda [18] [19] [20] . as a result, phfp has made the national rapid response team more focused and enabled the moh to control outbreaks in a shorter time period and at lower cost. the decisions taken by the national task force are now routinely informed by evidence generated by phfp. vertical moh programs have benefitted from having embedded fellows routinely analyse their data and ensure that alerts are generated promptly. because phfp is non-degree awarding and fellows are required to already have at least a master's degree on entry, fellows spend more time working on program-oriented projects that address national health needs, and less time in didactic courses. this is different from most fetps, in which residents earn degrees while in their programs [21] . this model allows the fellows to obtain wide range of experience at all levels of public health in uganda. fellows have also demonstrated this capability by producing more manuscripts and presenting a number of papers at national and international level within a short span of time. compared to the evaluation report of the fetp at chennai, tamil nadu, india whose fieldwork led to the production of 158 scientific communications presented at international meetings and to 29 manuscripts accepted in indexed, peer-reviewed journals in seven years. going by this trend, achievement of phfp will definitely be greater than most fetps [22] . beyond the health benefits to the country, phfp and similar programs almost certainly provide return on investment through early detection, investigation and control of outbreaks, improvement in surveillance system, and provision of urgently needed data for public health programs. the recent ebola outbreak in west africa cost the global community $3.6b to respond to and contain and an additional $2.2b in gdp loss to guinea, liberia, and sierra leone [23] . had a fraction of that sum of money been used to build an effective health workforce in west africa for early identification, investigation, and control of outbreaks, both the human and the massive economic toll of the ebola epidemic could perhaps have been averted. the importance of putting people at the centre of delivery of health services was apparent during the initial response, the early recovery phase, and long-term planning for resilience in the ebola response [24] . other recent outbreaks, including the 2012 middle east respiratory syndrome coronavirus and the 2015 zika virus outbreaks, have similarly underscored the need for strong, resilient public health systems to both address the outbreaks and implement containment measures. all fellows who have graduated have been absorbed either within moh or are employed by institutions that work closely with the moh. because the program secretariat and most host sites are in the moh, having graduates working in the different programs within the moh provides opportunity for mentorship of new fellows (table 2 ). increased retention of graduates within the ugandan government will facilitate sustainability of the program. presently, recruitment in ministry of health is the prerogative of the health service commission which derives its mandate from public service regulations. these regulations in its current form does not ring fence any positions for fetp graduates, however, discussion are on the table by all relevant stakeholders to incorporate a clause that will make it easier to recruit and retain fetp graduates in public service. it's important to note that government of uganda (gou) intends to have 3300 field epidemiologists trained to match the current population based on the who target of 1 epidemiologist per 200,000 population. based on the recruitment of 10 fellows per year and the current reliance on donor funding, it will definitely take a relatively long time to bridge this gap. however, gou's plan to have a fully functional uniph which is largely funded by government in the very near future will definitely help in addressing this challenge. in addition, makerere school of public health has produced 340 fetp graduates since inception in 1994. although phfp has made strides in contributing to building a resilient system, there are still some challenges. the use of evidence generated for disease prevention and control is still limited, partially due to the multiple layers of implementation existing in the ugandan system. even when evidence is available, poor dissemination, rigid mindset, poor coordination of partners, and inadequate resources may hamper its utilization. improved stakeholder engagement with the moh should be able to address this challenge in the long run. funding also has some challenges: although phfp is currently funded by the usa government, for full integration and institutionalization within the uganda moh system there must be domestic resource allocation to support this program. recognizing this need, moh has made phfp a key component of the proposed uganda national institute of public health (uniph) by designating it as a unique directorate [25] . once the uniph is formally established by the ugandan parliament, it will become an integrated disease control centre in the country and have diversified funding sources from the government, philanthropists, and the private sector, as well as grants and cooperative agreements from international organisations and foreign governments. phfp is intended to be its capacitybuilding component, which will provide a competent workforce of field epidemiologists and other health professionals to meet the public health needs of the country [26] . moreover, phfp alumni have formed an association called 'field epidemiologists without borders', which will work closely with uniph to champion some of the institute's objectives to ensure knowledge transfer and the building of a critical mass of field epidemiologists [27] . during its four years of operation, the phfp has contributed greatly to improving the real-time disease surveillance and outbreak response core capacities of the uganda ministry of health. the enhanced focus on evidence-based targeted approaches has increased effectiveness in outbreak response and control, and the integration of phfp within the moh has contributed to building a resilient and sustainable health system in uganda. highly indebted to dr. bao-ping zhu and dr. julie harris, us centres for disease control and prevention, for technical guidance during the entire implementation period of the program thus far. we would like to thank the african field epidemiology network (afenet) for availing us several opportunities and support to showcase our program contribution to building a resilient and sustainable health system in uganda. i thank all the advanced field epidemiology fellows who have made tremendous contributions to enable the program achieve greater horizons. ara -led the writing process after collecting program data, did analysis, interpretation, drafted and coordinated manuscript writing and wrote the first draft; lb, bk, dk, snk participated in data collection, analysis, writing and revision of many drafts; pt and rkw revisited the first draft critically for key intellectual content, read and gave approval of the final manuscript. no potential conflict of interest was reported by the authors. this an initiative of the uganda ministry of health, a joint program implemented in collaboration with us centers for disease control and prevention and makerere university school of public health. the authors of the paper are staff of the uganda public health fellowship program, who have been granted permission to access data and publish any works that may seem befitting to share with the global world. authority was granted through the office of the director general health services, ministry of health. paper context phfp has contributed greatly to improving the real-time disease surveillance and outbreak response core capacities of the uganda ministry of health within a 4-year span. the enhanced focus on evidence-based targeted approaches has increased effectiveness in outbreak response and control, and the integration of phfp within the moh has contributed to building a resilient and sustainable health system in uganda. http://orcid.org/0000-0003-0400-8635 uganda bureau of statistics (ubos) and icf. uganda demographic and health survey 2016: key indicators report. ubos and icf uganda population-based hiv impact assessment looking at non-communicable diseases in uganda through a local lens: an analysis using locally derived data national non-communicable diseases prevention and control policy uganda ministry of health. public health emergency operations centre mvd cost estimate report. uganda ministry of health the path towards healthcare sustainability: the role of organisational commitment world health organization maximizing positive synergies collaborative group. an assessment of interactions between global health initiatives and country health systems ebola in west africa: gaining community trust and confidence advancing the global health security agenda: progress and early impact from u.s. investment. global health security agenda risk factors for podoconiosis: kamwenge district elephantiasis linked to volcanic soils found in uganda volcanic minerals behind mystery elephantiasis outbreak in uganda global health protection and security: experts team up to tackle deadly anthrax across uganda overview, control strategies, and lessons learned in the cdc response to the 2014-2016 ebola epidemic cdc. fetp international night: award recipients frontline field epidemiology training programs as a strategy to improve disease surveillance and response strengthening global health security through africa's first absolute post-master's fellowship program in field epidemiology in uganda cholera outbreak caused by drinking contaminated water from a lakeshore water-collection site a prolonged, community-wide cholera outbreak associated with drinking water contaminated by sewage in kasese district, western uganda outbreak of yellow fever in central and southwestern uganda field epidemiology and laboratory training programs in sub-saharan africa from 2004 to 2010: need, the process, and prospects seven years of the field epidemiology training programme (fetp) at chennai, tamil nadu, india: an internal evaluation cost of the ebola epidemic improving the resilience and workforce of health systems for women's, children's, and adolescents' health health sector development plan strategy for uganda national institute of public health constitution of association of field epidemiologists without borders. uganda: fewb we give special thanks to the leadership of the ministry of health for offering the support that has enabled us make these great achievements. we thank the us-cdc for supporting the uganda public health program activities and makerere university school of public health for providing program leadership and management of the funds. we are key: cord-285397-rc65rv6r authors: comfort, louise; kapucu, naim; ko, kilkon; menoni, scira; siciliano, michael title: crisis decision making on a global scale: transition from cognition to collective action under threat of covid‐19 date: 2020-05-30 journal: public adm rev doi: 10.1111/puar.13252 sha: doc_id: 285397 cord_uid: rc65rv6r nan engage citizens in collective action to reduce risk (who 2017 ). yet, decades of diminished investment by constituent nations and corresponding charges of mismanagement have left the existing international governance mechanisms, such as who, office for the coordination of humanitarian affairs (ocha) and the office for disaster risk reduction (undrr), without the resources, personnel, monitoring systems or global operational networks necessary to mount an early and effective response. consequently, the mechanisms for credible search and exchange of valid information to inform decisions and action on multiple scales of operation at the level and speed needed to inform global decision making were limited, leaving nations to chart individual courses of action with widely varying results. drawing on research from decision making in complex, dynamic conditions (hutchins 1995; comfort 2007; kahneman 2012) , we examine four basic functions -cognition, communication, coordination, and control-that appear central to governmental decision processes in all countries as public officials grapple with how to recognize, respond, and recover from this deadly, invisible threat. we follow this discussion with comparative vignettes from three nations as they addressed the threat of covid-19, leading to strikingly different outcomes. we conclude with recommendations to invest in a global information infrastructure to enhance cognition as a first step in managing large-scale, multi-disciplinary threats to the health, economy, and sustainability of the world's community of nations. public leaders have quintessential responsibility for protecting the lives and livelihoods of their constituents. in routine times, they may follow time-honored procedures honed over decades of experience, confident that lessons from the past will guide them (kettl and fesler 2005) . for public leaders facing unknown risks, decision making is fraught with uncertainty and becomes an adaptive process that has four distinct components: (i) cognition, this article is protected by copyright. all rights reserved. (ii) communication, (iii) coordination, and (iv) control (comfort 2007) . under conditions of covid-19, how public leaders exercised these four functions proved critical in different contexts. cognition. in crisis management, cognition is the "capacity to recognize the degree of emerging risk to which a community is exposed and to act on that information" (comfort 2007: 189) . importantly, cognition provides the transition to action. it constitutes not simply the perception of risk to self, but also comprehension of the risk to others (fligstein and mcadam 2012) . that is, action taken may help oneself, but action not taken may irretrievably harm others. the fundamental component of empathy in cognition creates a human connection to others who share the risk and spurs collective action for the benefit of the community as a whole. public leaders had difficulty in recognizing the depth, scale, and lethality of covid-19. from the first slow, sobering discovery of the virus as it emerged in wuhan, china to the broad determination that ordinary methods of treating the novel coronavirus were ineffective, cognition came late to public leaders in individual countries as they searched unsuccessfully through old models of dealing with contagion. by the time public leaders recognized the lethality of covid-19, it was already spreading silently in their communities. while measures to suppress social interaction slowed the spread of the virus, they also created a cruel trade-off by shutting down schools, travel, commerce, and cultural activities that make societies function. communication is defined as a process that links sender and receiver in shared comprehension of messages (luhman 1989) . in doing so, communication creates shared meaning among actors with different roles. it is the means used to inform partner agencies in the global community as well as the public in different nations about the potential risk and rationale for evidence-based mitigation measures and the need for collective response. effective communication to explain covid-19 to the public as an invisible, novel, deadly threat requires strong leadership, timely, evidence-based information, and trust to build broad public consensus to support collective action (ansell, boin, and keller 2010; kapucu 2006) . coordination is defined by the degree to which organizations align their resources, tasks, and time to engage in interdependent functions to achieve a shared goal (comfort 2007) . in complex environments, coordination requires articulation of shared goals among diverse actors in response to shared risk. coping with the risk of covid-19, each nation faced decisions on how to align the components of their respective national response systems in ways that would slow or stop transmission of the virus, actions that would also contribute to the global goal. public leaders build trust with their constituents through timely, informed communication, enabling citizens to accept the validity of proposed actions for both self and community and to act, collectively, under the extraordinary constraints of crises. control is defined as the capacity to respond to an external threat and still maintain regular operations in the society (comfort 2007; 2019) . in reference to covid-19, control means achieving a reasonable balance between mitigating the spread of the infection, building healthcare capacity, and managing a safe level of economic and social activity. the global crisis generated by covid-19 requires coordination not only across jurisdictional boundaries within countries, but also across national boundaries to bring this massive pandemic under effective control. the following section briefly characterizes the policy actions taken by three countries in response to the threat of covid-19 but focuses on the function of cognition as the initial step toward building effective communication, coordination and control of the pandemic. this article is protected by copyright. all rights reserved. south korea's previous experience with mers in 2015 significantly increased the level of cognition of covid-19 as a severe risk for individuals as well as government agencies. the mers experience taught korean decision makers primary lessons regarding prevention and mitigation of community infection, especially at hospitals, clarification of the command center functions, which became the korean center for disease control and prevention (kcdc), and information sharing among ministries, local governments, and citizens utilizing advanced information technology (moon 2020). recognizing early the risk of community infection from the progress of covid-19 in china, the kcdc started to strengthen surveillance for pneumonia cases in health facilities nationwide from january 3, 2020. moving quickly, the kcdc began to develop analysis and testing methods for covid-19 on january 13. private medical companies such as seegene also started to develop the test kits on january 21. the kcdc issued emergency use authorization on february 12 within a week after the application for the approval of seegene. with rapid development of test kits, south korea reduced the time required for testing for presence of infection from 24 to six hours. controversies arose when the kcdc reported the first confirmed patient, a chinese national traveler who resides in wuhan. many citizens, as well as opposition parties, called for banning travelers from china and intensive preventive measures. the kcdc scaled the national alert level from blue (level 1) to yellow (level 2) but did not adopt the travel ban policy following the who recommendation on january 23. instead, the ministry of foreign affairs increased the level of travel-alert to level 2 and asked for high caution in traveling to wuhan. almost two weeks later (february 4). the korean government banned entry of travelers from wuhan, not all of china. also, the korean government checked the health status of entrants from overseas and used information and communications technologies (ict) to deliver information and to identify the contacts. this article is protected by copyright. all rights reserved. the second outbreak of covid-19 emerged on february 17 due to the shincheongji (religious cult group) community infection in daegu province. well aware of the risk of escalating the infection, the korean government raised its national alert level to the highest level (level 4) and tested all religious groups in daegu province. with the quick development of test kits, the kcdc could test more than 10,000 suspected cases every day and continuously increased the number up to 18,000 tests per day in early march. at the same time, the korean government and civil society began to coordinate limited medical resources. while the national health insurance program provides full access to medical services for all people regardless of income, the local government did not have sufficient medical staff and hospital beds. responding to the immediate challenge, local governments less affected by covid-19 took patients from daegu, and hundreds of doctors and nurses volunteered to take care of patients. private companies and hospitals provided their facilities as special units for taking light-symptom patients. more than 180,000 citizens volunteered to help patients and support local communities between january 20 -march 17. government agencies worked with pharmacies to distribute masks to the public (the government of rok 2020a). extensive information-sharing between local governments and citizens developed and maintained collective cognition of the disease as public risk. before mid-february, the kcdc traced contacts of infected people manually. in early february, the korean government quickly developed the covid-19 smart management system (sms), which analyzes data from 28 public as well as private organizations, such as credit card companies and smartphone companies. using this system, the kcdc could analyze any movement of infected patients within 10 minutes and share that information with citizens through cellphone text messages. the sms evoked the issue of privacy (park et al. 2020 on february 19, 2020, the first person from a small town 70 km south of milan was found severely ill from covid-19. the italian government recognized the severity of this discovery, but several problems affected its capacity to translate such understanding into decisions before issuing a total lockdown of the country. the italian health care system is very stressed and working to near capacity in ordinary conditions. the buffer for emergencies in intensive care units is practically non-existent (grasselli et al. 2020 ) and burdened by poor response capacity of peripheral hospitals and lack of emergency plans (villa et al. 2020) . timely cognition was hampered by the mixed patterns of communication to the public regarding measures to suppress the infection and the chaotic, puzzling debate they generated. this article is protected by copyright. all rights reserved. public leaders at all levels issued opposing opinions and statements. lombardia region proved to be the epicenter of the contagion, with 75,134 cases as of april 29 (manca 2020). by mid-may, the plan for reopening the country mainly consists of a calendar for gradual reactivation of businesses. confusion still persists regarding the many guidelines circulating within individual organizations and among regions that are not always consistent. information regarding reopening is provided late, as has occurred with all preceding decrees. decree 33 issued on may 16 provides indications regarding mobility within regions and internationally, but specific norms are not provided for businesses (dwyer 2020) . the report prepared for the italian government to support the entrance into reopening is not publicly available and only partial and fragmented elements of it have been reported by newspapers. still lacking is a strategy that connects economic rebooting, technical and financial support to enact the many restrictions that will impact business productivity, monitoring and surveillance indicators, and practical tools to be used for tracing new surges and mapping the epidemic through a testing plan. the us response to covid-19 was slow in comparison to other countries. only in mid-march 2020 did the federal government and the general public began to acknowledge the seriousness of the disease and act in accordance. cognition and the subsequent response were hampered by three interrelated issues. first, the trump administration downplayed the gravity of the situation. both through press conferences and through conservative media outlets, the early talking points were that the us had the virus under control and that it posed no more threat than the flu (leonhardt 2020) . second, the us capacity to identify and respond to global pandemics had been dramatically reduced over the past two years (sun 2018) . the white house national security council's directorate for global health security and biodefense was disbanded, and a key homeland security advisor focused on biodefense strategies against pandemics was removed (lopez 2020). these key actors in the pandemic response system have not been replaced. third, and most critically, the us lacked the testing capacity needed to understand the extent, and contain the spread, of the virus. initial concerns of community spread in the us were confirmed on february 29 when the first known us resident died. because the individual had not been exposed through travel, health officials feared that community spread was occurring across the country. despite these concerns, testing capacity lagged. by mid-march, us testing capacity ranked last among eight developed nations (resnick and scott 2020) . reasons for the lack of testing capacity in the us were numerous and include the initially faulty cdc tests produced in february. as testing capacity slowly became available, only those who traveled to china were eligible to be tested. despite ongoing community transmission, most citizens, even those experiencing symptoms, could not be tested under cdc guidelines. those guidelines were not updated to facilitate wider testing until march 4 (cdc, 2020). at that time, the us had conducted fewer than 2,000 tests; in comparison, south korea, a country one-sixth its size, had conducted 140,000 (meyer and madrigal 2020) . without adequate capacity to test, the disease spread relatively undetected and hampered cognition. the artificially low case count provided many public officials with false assurance that covid-19 was not a serious threat. on march 25, who indicated that the us, with roughly 65,000 cases, would become the global epicenter of the pandemic (quinn 2020). by early april, the country had over 250,000 confirmed cases and 5,000 deaths. the initial federal response focused on travel restrictions to china and europe but lacked a broader national coordinated effort to mitigate the spread. in mid-march, the cdc released guidelines advocating for all events of 50 or more people to be canceled and the this article is protected by copyright. all rights reserved. accepted article president advised people to avoid gatherings of 10 or more. given the federal structure of government, and without national stay-at-home orders, states varied considerably in the timing and extent of interventions used to combat the spread of covid-19 (science news staff 2020). by march 13, several states, including pennsylvania and michigan, announced plans to close their schools. on march 19, california became the first state to issue a statewide stay-at-home order. several states quickly followed, while others delayed decisions until april. eight states, all with republican governors, chose not to issue stay-at-home orders for all residents (john 2020 ). lack of federal-level interventions and mixed communication from the trump administration culminated in a patchwork of policies that varied from state to state and even within states. extreme differences in state policy response created confusion and frustration among the public regarding the risk posed by covid-19. protests were held in several states by citizens demanding that the stay-at-home order be lifted (bosman et al. 2020) . despite warnings by public health officials, several states decided to reopen their economies by the end of april, much earlier than recommended. public health officials as well as the who warned that reopening the economy and lifting stay-at-home orders early is likely to escalate infections (chiu 2020) . lack of federal interventions coupled with an absence of national testing and equipment sourcing strategies pushed states to coordinate response efforts on their own (science news staff 2020; segers et al. 2020 ). overall, the impact of the virus on the us economy has been devastating. in the first quarter of 2020, the us stock market experienced one of its worst declines. as the stock market plummeted, so too did employment rates. data from the us department of labor indicated that in a five-week period from march 14 to april 18, more than 26 million unemployment claims were filed. on march 27, the president signed a $2.2 trillion stimulus bill to assist families and companies suffering from the pandemic. by may 17, the number of this article is protected by copyright. all rights reserved. accepted article cases surged to over 1,474,127 with 88,898 deaths (jhu coronavirus resource center 2020). slow cognition of the risk led to mixed patterns of communication and lack of coordination at the national level, resulting in devastating losses in lives and economic costs. the dilemma between public health and economic functions remains at both global and national scales. the global pandemic unleashed on the world by covid-19 creates a fundamental test of public values for leaders and decision makers both within and between this article is protected by copyright. all rights reserved. nations. this harsh test reveals the collective responsibility that we share for self and others in uncertain situations of shared risk and the critical role of of leadership in decision making and mobilizing collective action. it demonstrates the critical role of cognition in precipitating action, as the three countries revealed very different patterns of performance after identifying their first cases of the disease. south korea already had plans in place after the 2015 mers threat and quickly devised new programs and policies to strengthen existing capacity in response to covid-19. italy identified the threat of the pandemic early but had several weaknesses in preparedness and healthcare capacity that did not allow its early recognition to translate into effective practical interventions. the united states faced a critical fragmentation in cognition between scientific experts and political leaders that delayed substantive action at the federal level for over two months, leading to exponential increases in both cases and deaths. these divergent degrees of cognition led to mixed patterns of communication at the federal level and fractured efforts at coordination across a large country, while leadership at state and municipal levels gained the trust and support of their citizens and the large majority, 70%, of u.s. residents, supported stay-at-home policies (wise 2020 ). the three cases show that cognition alone does not achieve collective action and control within countries in a global pandemic crisis. rather, cognition needs to be supported by a rigorous technical capacity and actionable management frameworks for national and international communication and coordination with respect to collecting data, sharing good practices, and monitoring levels of coping capacity. each nation has a responsibility not only to its own citizens, but also toward other nations in the global community by implementing preparedness plans and making investments to strengthen their health care systems and the system of international organizations. the covid-19 pandemic reveals a rare opportunity to redesign global and national systems for managing deadly risks, using science-based evidence and information communication technology, to identify, track, search, and share timely, valid data among nations, triggering innovation and collective action to build a resilient international community. bold redesign of existing international organizations -who, ocha, and undrrthat monitor and compare the status of global risk would reinforce cognition in facilitating effective crisis response across the globe by partnering with nations to work with their local communities. enhanced coordination and exchange of good practices among member nations of the global community would save not only hundreds of thousands of lives, but forego trillions of dollars in economic losses, anguish, and pain. it would mean expanding networks of research, collaboration, and knowledge sharing among the world's scientists, scholars, public managers, and students in shared exploration of means for identifying and reducing emerging risks. it would include building and maintaining a global information infrastructure to support continuous learning and adaptation to a changing environment for both professional practitioners and researchers. it would involve designing and implementing plans for a global health infrastructure and training the personnel who would staff and maintain it, with secure funding sustained by responsible international contributions and oversight. building a global information infrastructure to support timely, coordinated decision making and iterative learning in public health is not an easy task, but the world's nations designed the united nations, marshall plan, organization for economic cooperation and development, and security alliances after wwii. with insight gained from the precedentshattering experience of this pandemic and bold public leadership, nations of the world have a unique policy window for transforming global governance capacity to strengthen and maintain public health and, reciprocally, sustain the global economy. and overall situation day by day can be found on the site of the national department of civil protection also in english: http://www.protezionecivile.gov.it/home 2. data are reported to the johns hopkins university coronavirus resource center from multiple credible sources, including the who, and represent the best sources available. yet, the data likely include errors and undercount the extent of actual cases and deaths, due to inadequate reporting in separate nations and states. managing transboundary crisis: identifying the building blocks of an effective response system why these protesters aren't staying home for coronavirus orders. the new york times update and interim guidance on outbreak of coronavirus disease fauci warns states rushing to reopen: ‗you're making a really significant risk crisis management in hindsight: cognition, communication, coordination, and control italy plans to lift some travel restrictions early next month bollettino pandemia covid-19 day by day bulletin can be impact of non-pharmaceutical interventions (npis) to reduce covid-19 mortality and healthcare demand theory of fields government of the republic of korea. 2020a. tackling covid-19: health, quarantine and economic measures of south korea how korea responded to a pandemic using ict : flattening the curve on covid-19 critical care utilization for the covid-19 outbreak in lombardy cognition in the wild these eight states haven't issued stay-at-home orders to fight the coronavirus outbreak thinking: fast and slow interagency communication networks during emergencies: boundary spanners in multiagency coordination the politics of the administrative process. 3 rd ed a complete list of trump's attempts to play down the coronavirus. the new york times the trump administration's botched coronavirus response ecological communication dynamics of icu patients and deaths in italy and lombardy due to covid-19 analysis updated to 30-march, day #38 evening exclusive: the strongest evidence yet that america is botching coronavirus testing. the atlantic fighting against covid-19 with agility, transparency, and participation: wicked policy problems and new governance challenges information technology-based tracing strategy in response to covid-19 in south korea-privacy controversies‖ is the united states the cornavirus pandemic's new epicenter america's shamefully slow coronavirus testing threatens all of us the united states leads in coronavirus cases, but not pandemic response states move forward with coordinating coronavirus response after trump backs down top white house official in charge of pandemic response exits abruptly. the washington post the covid-19 pandemic preparedness or lack thereof: from china to italy. global health & medicine poll: more than 70 percent of americans support coronavirus stay-athome orders key: cord-333467-de2aimuj authors: revere, debra; nelson, kailey; thiede, hanne; duchin, jeffrey; stergachis, andy; baseman, janet title: public health emergency preparedness and response communications with health care providers: a literature review date: 2011-05-18 journal: bmc public health doi: 10.1186/1471-2458-11-337 sha: doc_id: 333467 cord_uid: de2aimuj background: health care providers (hcps) play an important role in public health emergency preparedness and response (phepr) so need to be aware of public health threats and emergencies. to inform hcps, public health issues phepr messages that provide guidelines and updates, and facilitate surveillance so hcps will recognize and control communicable diseases, prevent excess deaths and mitigate suffering. public health agencies need to know that the phepr messages sent to hcps reach their target audience and are effective and informative. public health agencies need to know that the phepr messages sent to hcps reach their target audience and are effective and informative. we conducted a literature review to investigate the systems and tools used by public health to generate phepr communications to hcps, and to identify specific characteristics of message delivery mechanisms and formats that may be associated with effective phepr communications. methods: a systematic review of peerand non-peer-reviewed literature focused on the following questions: 1) what public health systems exist for communicating phepr messages from public health agencies to hcps? 2) have these systems been evaluated and, if yes, what criteria were used to evaluate these systems? 3) what have these evaluations discovered about characterizations of the most effective ways for public health agencies to communicate phepr messages to hcps? results: we identified 25 systems or tools for communicating phepr messages from public health agencies to hcps. few articles assessed phepr communication systems or messaging methods or outcomes. only one study compared the effectiveness of the delivery format, device or message itself. we also discovered that the potential is high for hcps to experience "message overload" given redundancy of phepr messaging in multiple formats and/or through different delivery systems. conclusions: we found that detailed descriptions of phepr messaging from public health to hcps are scarce in the literature and, even when available are rarely evaluated in any systematic fashion. to meet present-day and future information needs for emergency preparedness, more attention needs to be given to evaluating the effectiveness of these systems in a scientifically rigorous manner. public health emergency preparedness and response (phepr) involves activities directed at preventing possible emergencies and planning to ensure an adequate response and recovery if an emergency occurs. the public health system itself is a complex network of organizations and individuals that work together for the benefit of the public's health. these entities include public health agencies at local, state and federal levels, public safety agencies, emergency managers, academia, business, communities, the media, and the healthcare delivery system [1] . as one component of the phepr system, information contributed by health care providers (hcps) to public health is aggregated, analyzed and used by public health agencies, in part, to inform early event detection and situational awareness [2] . figure 1 illustrates a simplified transfer of information from hcps to public health which is aggregated, analyzed and used to inform public health alerts and advisories which are sent to hcps. the importance of the transmission of hcp information to public health, particularly for notifiable condition reporting, has been well-documented [2] [3] [4] [5] . hcps serve a critical role in public health's recognition and control of communicable diseases as illustrated by west nile virus [6] and sars [7] ; influenza and influenza-like illness [8] ; foodborne illnesses [9] ; and illnesses associated with intentional release of biologic agents such as anthrax [10, 11] . in public health responses involving bioterrorism, hcps have an especially important role since they will likely report such cases of unexplained or unusual illness to state and local public health officials who, in turn, may be able to conduct investigations and identify specific epidemiologic patterns or characteristics potentially indicative of bioterrorism [12] . during an emergency situation health care providers (hcps) are depended on to prevent excess deaths, treat the injured, and mitigate suffering [13] . to do this, and given that individuals will seek medical care in multiple locations during an emergency, hcps need to be aware of public health threats and emergencies, issue guidelines and updates, and facilitate surveillance [14] . on september 11, 2001, when telephone and paging systems failed, the new york city department of health and mental hygiene successfully used email and fax to distribute public health broadcast alerts to all nyc emergency departments, commercial and hospital laboratories, infection-control programs, and select providers [15] . in an emergency, effective communication will not only depend on the information/message, but on the type of communication system or tool, the delivery format, and the robustness of the system. while timely, efficient, and effective communications between public health and hcps is an important part of public health emergency preparedness and response (phepr), most publications concerned with this exchange have emphasized the hcp-to-public health component. yet, it is well-established that the "return" of information to hcps is also significant. we conducted a systematic literature review to investigate the systems and tools used by public health to generate phepr communications to hcps, and to identify specific characteristics of message delivery mechanisms and formats that may be associated with effective phepr communications. three questions guided this literature review: what public health systems exist for communicating phepr messages from public health agencies to hcps? have these systems been evaluated and, if yes, what criteria were used to evaluate these systems? what have these evaluations discovered about characterizations of the most effective ways for public health agencies to communicate phepr messages to hcps? table 1 lists the subject terms and keyword terms identified for key concepts for the search. to ensure retrieval of different types of phepr messages we included both health alerts (messages of the highest level of importance that warrant immediate action or attention) and health advisories (messages that provides key information for a specific incident or situation, such as a guideline change, and might not require immediate action). we also included as search terms any system, communication method or device that facilitated these communications. public health literature is reported to be poorly indexed in bibliographic databases and dispersed across a wide variety of journals and other sources, as well as across many disciplines [16] . we included "grey" or non-peer-reviewed literature sources [17] to ensure wide coverage of less accessible materials such as government reports and conference proceedings ( table 2) . the exact search terminology used was tailored for each database as appropriate to its structure and thesaurus to ensure a high degree of sensitivity ( table 3) . the web of science ® database was used to conduct cited reference searches of relevant articles. in addition, we hand-searched (known as snowball sampling) the reference lists of relevant articles and the tables of contents of the following journals: journal of homeland security and emergency management, disaster medicine & public health preparedness, and american journal of disaster medicine. the review was limited to publications in the english language and to materials published between 01/2000 through 01/2011. all search strategies were recorded at each step. citations from database searches were downloaded into the endnote bibliographic reference program (http://www.endnote.com/) or manually entered as needed. duplicates were removed. figure 2 illustrates the identification, screening, eligibility and inclusion numbers, and rationale for excluded materials in our search and selection process [18] . articles were included if they described systems or tools for public health agencies to communicate phepr messages to hcps or included an evaluation of these systems or tools. data extracted from the articles included: purpose, location, organization or agency involved, hcp population, method(s) of communication, and type of evaluation performed, if conducted. if an evaluation was performed, the outcomes were extracted. of the initial set of 42 full-text articles assessed for eligibility, 11 were excluded once read as they only described systems that sent phepr messages to health departments (n = 6) or were opinion articles (n = 5). data extraction from the final 31 articles resulted in identification of 25 different systems, with one article describing more than one system. overall, the final 31 articles contained information on the purpose of the system or tool (100%), location of the system (100%), public health organization or agency involved (100%), targeted hcp population (100%), and method(s) used by public health to communicate phepr messages to hcps (100%). eleven articles (covering 9 systems) included a description of the evaluation used with the system. type of evaluations included comparative [19] , interviewing [20] , surveying [21, 22] , retrospective [23, 24] , formative [25] , and an assessment following a simulation exercise [26] . one article reported a causal relationship could be "inferred" between the dissemination of health advisories and hcp reporting and testing [27] and two reported receiving feedback but did not detail method [28, 29] . the remaining articles (65%) either did not mention an evaluation or did not contain enough information to determine if an evaluation had been conducted. of the 25 systems and tools documented, the majority (96%) were north america-based. the location of the systems included: 40% state-level, 32% city-level, 16% country-level, and 8% regional, with one international system (4%). only one tool was designed to provide phepr messages to veterinarians; the remaining targeted hcps in hospitals, emergency departments and/or outpatient clinical settings. the majority of systems used email (64%) to deliver phepr messages. systems also delivered messages by phone, including cellular (36%); fax (36%); pager (28%); sms text messaging (16%); handheld devices such as pdas or blackberry ® (16%); other devices such as radios (16%); messaging through an electronic medical record "public health" pandemic "health alert" or "public health alert" veterinarians preparedness "health advisory" terrorism "preparedness message" surveillance "preparedness communication" system (12%); and "social media" (4%). some systems also posted the phepr message to a web site (24%) for passive consumption. a majority of systems used more than one method (60%) for delivering messages. only 4 systems were described in sufficient detail to determine that each method was attempted sequentially as opposed to redundant messages being delivered through all devices and formats. table 4 (additional file 1 table s1 ) lists each messaging system or tool included in the final retrieval set and indicates type of evaluation conducted where applicable. after conducting a systematic search, we identified 25 systems or tools currently being used to communicate phepr messages from public health to hcps. of the 9 systems that reported an evaluation, only 2 provided sufficient detail of methodology used. during a q fever outbreak, two public health alert faxes were sent asking physicians to submit serum samples on any patient meeting a clinical case definition of q fever and an association with the area where the outbreak occurred. by examining laboratory reports, van woerden et al (2006) found a statistically significant difference between the number of patients tested for q fever in the target population after the alerts had been sent as compared to a comparable two-week period one year before [19] . another study retrospectively examined recommended public health agency actions communicated to hcps through a pop-up in an electronic health record in comparison with lab orders and treatment guidelines and found that a causal relationship "could be inferred" (although with no detail to document this inference) between the alert and a change in hcp behavior [27] . other system evaluations lacked adequate detail to determine the extent of evaluation activities. prior to developing germwatch, a system focused on communicating advisories regarding respiratory viral pathogens and pertussis, gesteland et al (2007) conducted a formative evaluation of the feasibility and sustainability of the system [25] . however, formative studies, though useful in the planning and early development phases of a system, need to be followed up with an evaluation focused on identifying changes in outcome or performance measures, results, or effectiveness criteria that can be confidently attributed to the system rather than other factors and conditions. while reports of retrospective evaluations of promed, a global outbreak surveillance system [23, 24] , the messaging tools used in conjunction with a topoff exercise [26] , and a survey of homeless service providers during the sars outbreak in toronto [20] identify problems and propose measures to counteract problematic communications issues between public health and hcps, the reports lacked the detailed methodology or results that are needed to assess the rigor of these evaluations. ("public health") and (doctors or physicians or nurses or pharmacists or veterinarians or "healthcare providers" or "health care providers" or surveillance) and (communication or "emergency communication" or "disease event" or "health alert" or "public health alert" or "emergency alert") and (emergency or disaster or terrorism or pandemic or preparedness or response or "disease outbreak") medline inspec ("public health" or "emergency services" or "emergency preparedness" or "emergency planning" or "surveillance activity" or "emergency response") and alert web of science ("public health" and (doctors or physicians or nurses or pharmacists or veterinarians or "healthcare providers" or "health care providers" or surveillance) and (communication or "response capacity" or "emergency communication" or "disease event" or "health alert" or "public health alert" or "emergency alert") and (emergency or disaster or terrorism or pandemic or preparedness or response)) snowball technique hand-searching article references, related records, tables of contents of pertinent journals ahrq "public health" and "emergency preparedness" and alert cdc "public health" and "emergency preparedness" and "emergency communication" gpo access "public health" and providers* and communication and emergency "public health" and terrorism and alert nlm gateway "public health" and "bidirectional communication" and "health alert" rand "public health" and disaster and providers* and alert one of the most widespread strategies in the u.s. for public health agencies to communicate to hcps on both national and local levels is through the cdc's health alert network (han) program which communicates information about infectious disease outbreaks and public health implications of national disasters within its health alerts, advisories, and updates [14, 29, 30] . given its wide coverage, we were surprised to find so few studies attempting to systematically verify that han messages are received, processed, and/or acted upon by the intended recipients outside of public health agencies. as a result, in part, of current studies of the 2009 h1n1 outbreak, we are now learning that phepr messages may not be reaching their targeted audiences. for example, results of a cross-sectional survey of health departments, physicians, and pharmacists in kentucky regarding information dissemination and receipt during the early h1n1 outbreak found that deficiencies exist in the effectiveness of public health phepr communications to hcps. while 81% of responding local health departments (lhds) rated their capacity to disseminate information to hcps as very good or excellent, only 52% of surveyed physicians and 16% of surveyed pharmacists reported receiving any information about h1n1 from a lhd. seventy-four percent of pharmacists were not aware of their lhd's emergency plan in the event of an influenza outbreak [31] . in conducting this review we discovered that there are multiple sources from which hcps may receive han communications. cdc not only sends messages to state and local public health agencies that then disseminate to hcps, but clinicians can also sign up to receive han messages directly through the cdc's clinician outreach communication activity (coca) as well as through any of the 176 coca partner organizations that pass on or post coca-generated notices of new and updated cdc information on emerging health threats [21, 22] . while any phepr situation presents challenges in communicating about uncertainties, collaborating across and within organizations, and communicating timely messages [32] , every additional messaging source raises the potential for redundant and conflicting information. coca disseminates updates bi-weekly (more frequently when there is emergency information or event-specific updates). excluding han alerts, a tally of messages disseminated through coca from 2008-2010 yielded 140 messages that each contain as many as 7 topical messages. avoiding the communication of multiple and redundant messages that can engender "alert overload" in hcps is important, especially in a public health emergency situation. the han system allows hcps to set a preference for receiving messages but, as mentioned above, if the hcp is receiving messages from different sources the redundancy potential increases. staes et al (2011) presented an objective analysis of communication between public health agencies, health care organizations, and frontline hcps during the 2009 h1n1 outbreak. the investigators conducted a cross-sectional survey to understand communication processes between public health and frontline hcps and found that hcps received redundant messages; were challenged to keep up with evolving and tailored messages from multiple organizations at a time when clinic volumes, patient concerns, and media exposure were increasing; and were overwhelmed by e-mail volume. the study suggests that phepr messages sent to hcps be concise and clearly identified [33] . we found there are numerous formats (email, fax, etc) in which to deliver phepr messages to hcps. when more than one format was available it was not clear if hcps were given a choice between different ways to receive messages as opposed to receiving redundant messages in different formats or through different delivery systems. allowing hcps to set preferences for receiving phepr messages might improve response. our review has three main limitations: 1) scope and search terms; 2) access to full-text articles; and 3) lack of data in the included articles. for practical reasons we limited ourselves to materials written in the english language. while we did not limit ourselves to u.s. systems or studies, it is possible that systems of phepr messaging to hcps developed in europe and asia may be written in other languages. it is also possible that our search strategy did not cast either a wide or targeted enough net to capture relevant literature. perhaps modifications to the terminology or concept operators would have yielded better retrieval sets. we were limited to resources accessible through our academic libraries and their inter-library partnerships so may have missed some material. another limitation is our elimination of articles missing or with uninformative abstracts. again, it is possible that this omitted key articles from our results. lack of data was an issue as many articles did not contain sufficient descriptive information. despite these limitations, our results show that detailed descriptions of phepr messaging from public health to hcps are scarce in the literature and, even when available are rarely evaluated in any systematic fashion. this review shows that little is known about the effectiveness of phepr communications from public health to hcps. we also found that by using multiple formats and delivery methods, current systems and tools may be increasing, rather than reducing, communication challenges for hcps with unnecessarily redundant messages; confusion due to messages that may reflect conflicting federal, state and local guidelines, information and concerns; alert "overload"; and lack of tailored preferences for receiving these important messages. much has been written about the "astute clinician" who noted an unusual clinical finding and set off the public health alarm concerning the first case of anthrax in palm beach county, florida in october 2001 [34] . given the importance of hcps in phepr, more research needs to be done to further investigate how public health can communicate effectively with hcps. there are numerous questions about these systems and tools that need to be answered, some basic, such as: have phepr messages been successfully delivered? were they read and, if yes, can the date or time of their delivery and their content be recalled? is there an optimal frequency for sending phepr messages? what components of a message are most important for the message to be perceived as credible, authoritative, complete? what impact do phepr messages have on hcp behavior, surveillance or reporting of suspected or confirmed events of public health interest or phepr knowledge? one example of new research being conducted in this area is the reach trial in which the authors are using a randomized, community-based trial method to investigate the effectiveness of various message delivery systems (email, fax, and sms) for communicating phepr messages from public health agencies to hcps [35] . the primary aim of reach is to determine the effectiveness of various message delivery systems (email, fax, and sms) for communicating phepr messages from public health agencies to hcps and to compare the effectiveness of communication methods between these two groups across diverse communities. this is however, only one effort. to meet present-day and future information needs for emergency preparedness, concentrated attention needs to be given to evaluating the effectiveness of phepr systems in a scientifically rigorous manner [36] . additional file 1: table s1 : literature selected. iom: the future of the public's health in the 21st century will the nation be ready for the next bioterrorism attack? mending gaps in the public health infrastructure the bioterrorism preparedness and response early aberration reporting system (ears) evaluation of reporting timeliness of public health surveillance systems for infectious diseases syndromic surveillance using minimum transfer of identifiable data: the example of the national bioterrorism syndromic surveillance demonstration program the west nile virus encephalitis outbreak in the united states severe acute respiratory syndrome (sars) and coronavirus testing-united states outbreak of swine-origin influenza a (h1n1) virus infection -mexico surveillance for foodborne disease outbreaks -united states emergency department visits for concern regarding anthrax-new jersey death due to bioterrorism-related inhalational anthrax: report of 2 patients the role of an advanced practice public health nurse in bioterrorism preparedness bioterrorism preparedness and response: clinicians and public health agencies as essential partners the health alert network: partnerships, politics, and preparedness new york city department of health response to terrorist attack expert searching in public health the use of grey literature in health sciences: a preliminary survey preferred reporting items for systematic reviews and meta-analyses: the prisma statement using facsimile cascade to assist case searching during a q fever outbreak homelessness and the response to emerging infectious disease outbreaks: lessons from sars the novel influenza a h1n1 epidemic of spring evaluation of promed-mail as an electronic early warning system for emerging animal diseases: 1996 to the internet and the global monitoring of emerging diseases: lessons from the first 10 years of promed-mail informing the front line about common respiratory viral epidemics terrorism preparedness: web-based resource management and the topoff 3 exercise using electronic health record alerts to provide public health situational awareness to clinicians local collaborations: development and implementation of boston's bioterrorism surveillance system novel h1n1 and the use of hit within the chicago department of public health exemplary practices in public health preparedness. technical revere et al. bmc public health communication efforts among local health departments and health care professionals during the 2009 h1n1 outbreak order out of chaos: the self-organization of communication following the anthrax attacks public health communication with frontline clinicians during the first wave of the 2009 influenza pandemic bioterrorism-related inhalational anthrax: the first 10 cases reported in the united states. emerg infect dis improving public health to provider messaging: the reach project. joint conference on health iom: research priorities in emergency preparedness and response for public health systems: a letter report pre-publication history the pre-publication history for this paper can be accessed here public health emergency preparedness and response communications with health care providers: a literature review the authors would like to thank the bmc public health reviewers for their insightful comments and suggestions. this work was supported by the centers for disease control and prevention, grant no. 5p01tp000297. its contents are solely the responsibility of the authors and do not necessarily represent the official views of the centers for disease control and prevention. authors' contributions dr conceived of and led the search, evaluation and synthesis components. kn participated in the database searches and retrieval set evaluation. dr authored the overall manuscript with contributions by kn, jb, as, ht and jd. all authors read and approved the final manuscript. the authors declare that they have no competing interests. key: cord-309118-810fmd8e authors: burkle, frederick m. title: political intrusions into the international health regulations treaty and its impact on management of rapidly emerging zoonotic pandemics: what history tells us date: 2020-04-13 journal: prehospital and disaster medicine doi: 10.1017/s1049023x20000515 sha: doc_id: 309118 cord_uid: 810fmd8e for a large number of health care providers world-wide, the coronavirus disease 2019 (covid-19) pandemic is their first experience in population-based care. in past decades, lower population densities, infectious disease outbreaks, epidemics, and pandemics were rare and driven almost exclusively by natural disasters, predatory animals, and war. in the early 1900s, sir william osler first advanced the knowledge of zoonotic diseases that are spread from reservoir animals to human animals. once rare, they now make up 71% or more of new diseases. globally, zoonotic spread occurs for many reasons. because the human population has grown in numbers and density, the spread of these diseases accelerated though rapid unsustainable urbanization, biodiversity loss, and climate change. furthermore, they are exacerbated by an increasing number of vulnerable populations suffering from chronic deficiencies in food, water, and energy. the world health organization (who) and its international health regulation (ihr) treaty, organized to manage population-based diseases such as influenza, severe acute respiratory syndrome (sars), h1n1, middle east respiratory syndrome (mers), hiv, and ebola, have failed to meet population-based expectations. in part, this is due to influence from powerful political donors, which has become most evident in the current covid-19 pandemic. the global community can no longer tolerate an ineffectual and passive international response system, nor tolerate the self-serving political interference that authoritarian regimes and others have exercised over the who. in a highly integrated globalized world, both the who with its ihr treaty have the potential to become one of the most effective mechanisms for crisis response and risk reduction world-wide. practitioners and health decision-makers must break their silence and advocate for a stronger treaty, a return of the who’s singular global authority, and support highly coordinated population-based management. as osler recognized, his concept of “one medicine, one health” defines what global public health is today. whereas the ihrs provide a vital governing framework to limit the spread of disease, serious deficiencies, omissions, gaps, and political resistance began to occur. gostin and katz described wide-spread noncompliance to the ihr detailing multiple needed textual and operational reforms, emphasizing that who and the ihr "erred at multiple levels during the ebola epidemic" and who failed "to mobilize adequate fiscal and human resources until the epidemic was spinning out of control." 3 in 2015, after the ebola epidemic, i wrote "the intent of the legally binding treaty to improve the capacity of all countries to detect, assess, notify, and respond to public health threats has shamefully lapsed," 4 and that global health security demanded both a stronger who and a stronger ihr treaty. the who, sponsored by the un, currently has two primary sources of revenue: assessed contributions expected to be paid by member-state governments, income, and population; and voluntary contributions provided by member-states and contributions from private organizations and individuals, the latter of which opens the who up to being influenced by the highest bidder. the who must exist solely as a treaty-based organization sanctioned by the un and all its members, not dependent on outside financial assistance to do its work. health care experts, as sir william osler described, must be in charge of all health decisions, monitoring, response, and operational research. they neither abdicate any responsibilities to individual nation-states nor be beholden to them for support. the bottom line is that the global community can no longer tolerate an ineffectual and passive international response system, nor tolerate the self-serving political interference that authoritarian regimes, nationalism, and populism demand. this remains a highly integrated globalized world when it comes to public health protections. the current coronavirus disease 2019 (covid19) pandemic experience leads to only one solution: the who must be restructured from top to bottom to remove individual countries from health and public health assessment, decisions, and management. without political pressure, who and the ihr treaty have the potential to become the most effective partners in crisis response and risk reduction. practitioners and health decisionmakers world-wide must break their silence and advocate for a stronger treaty and a return of who's singular authority. the majority of health care providers world-wide practice oneon-one care with their patients. population-based care has not been emphasized in their training. a major deficiency in global health and the entire ihr process has been the failure to recognize the importance of zoonotic diseases-those diseases that can be passed from animals to humans. world-wide, zoonotic diseases represent 61% of all diseases and an alarming 71% of new diseases. second only to war, zoonotic epidemics have killed more humans than any other disease. today, it is known that climate change, overuse of antibiotics, and more intensified farming are thought to also be increasing the rate of zoonotic diseases globally. 5 my first experience in zoonotic disease was in 1968 during the vietnam war. that year, south vietnam witnessed the largest bubonic plague epidemic of the 20 th century. indeed, that outbreak temporarily paused the war on both sides of the conflict and emptied small villages and larger city streets. it prompted me to educate myself on the massive influence zoonotic diseases have on the environment and public health. for many of my generation of physicians, sir william osler remains a crucial role model, famous for his writings and for taking the teaching of medicine out of the classroom to the bedside. few know that he taught at both medical and veterinarian colleges, advancing the basic knowledge of veterinary pathology and zoonotic diseases, or those that commonly spread from non-human animals to humans. osler's work advanced the understanding of today's infectious disease outbreaks, epidemics, and pandemics. it was a veterinarian, calvin schwabe, schooled under osler's teachings and now recognized as the father of veterinary epidemiology, who first coined the term "one medicine" as the science of health and disease in which "differences between humans and animals are not considered." 6 schwabe pointed out that most infectious diseases of humans have an animal origin that incorporated the "inclusion of environmental health, as opposed to simply medical treatment" 7 into the crucial management of major infectious diseases such as sars, h1n1, and today's covid19. in his 1906 book aequanimitus, osler emphasized that medicine is the "only world-wide profession following the same methods, actuating the same ambitions, and pursuing the same ends." he emphasized that this "homogeneity" or "solidarity" which physicians world-wide are witnessing today with the covid-19 pandemic is a quality "not shared by law" or politics, that "allows physicians to practice the same art amid the same surroundings in every country on earth." 8 this unity of effort is not seen in other professions, and is witnessed today with the wide support given by medical colleagues from other countries, all cooperating on essential clinical and public health research. sadly, osler died in 1919 at age the of 70 from spanish influenza while teaching at oxford (england). the spanish influenza was also called "swine flu" because it allegedly jumped from live pigs to humans, killing one-quarter of the world's population. 9 the capacity for swine flu to survive and to initiate a second pandemic in 2009 was possible because it thrived and spread as a new mix of genes from swine, birds, and human flu viruses. we now live in an age of epidemics and pandemics. predictably, and in its own time, the swine flu will reemerge once again. modern day scholars have taken the "one medicine" concept and advanced it into the "one health initiative," a movement that seeks to "forge greater collaboration between the health disciplines," advocating for multidisciplinary efforts to improve global health in general. it became a globally shared concept and world-wide strategy for expanding interdisciplinary collaborations and communications in all aspects of health care for humans, animals, and the environment. the synergism accelerated "biomedical research discoveries, enhancing public health efficacy, expeditiously expanding the scientific knowledge base, and improving medical education and clinical care." 10 when properly implemented, the "one medicine" concept would help protect and save untold millions of lives in present and future generations. 11 this concept eventually incorporated specific expertise in biohazard events, food and water safety, vector-borne diseases, established and emerging zoonotic diseases, herd health, foreign animal risks, and public health issues such as antimicrobial drug resistance. 12 this would come to define one health advocates and practitioners of the future, and today defines what we now refer to as the operational elements of "global public health." beginning in the 1970s, major economic and political changes occurred when economically leading western countries developed businesses in third world countries, a process referred to as "globalization." with it came the realization that the economy was a major force behind the setting of public policies, including health policies. increasingly, the process revealed that the power of governments to shape national policy was, in many cases, being considerably limited and diminished by an increasingly competitive international economy where some countries impacted by globalization either thrived or collapsed. 13 global health experts, and those focusing on humanitarian and crisis management, who were excluded from any cross-cultural economic debates, closely watched from afar how and where public health infrastructure and protections in water, shelter, food, and availability of health services would either benefit or suffer from globalization. too often, local public health and the global health priorities they impacted took a backseat to economic demands resulting in "weakening of life-supporting systems," specifically "altered composition of the atmosphere, land degradation, depletion of terrestrial aquifers and ocean fisheries, and loss of biodiversity." 14 these are elements known today that can lead to acquiring and spreading of epidemic infections such as sars, h1n1, and influenza. health and public health were never at the same globalization negotiating table, but were more often silently relegated to a catchup role that tried to mitigate the impact on health caused by increasing globalization. with increasing globalization and speed of transportation, infections rapidly began migrating across borders. yet who, now equipped with improved telecommunications, developed an increased capacity to readily detect emerging epidemics, a major improvement never before available with previous epidemics and pandemics. an encouraging aspect of globalization was the increasing number of the millennial generation who studied abroad and worked on various humanitarian missions. as a result, they began seeing themselves less as nationalists and more as global citizens. 15, 16 however, with the recent rise and dominance of authoritarian regimes and populism, globalization has essentially noticeably faded and is rapidly becoming a non-entity. both the word "globalization" and its concept have disappeared under a coordinated false narrative campaign promoted by autocrats and rising nationalist state movements. 17, 18 ghitia contends that "modern-day would-be dictators don't overthrow another government. what they do is take over the system of government." she emphasized that their methods are more gradual, "manipulating the democratic norms, wearing them down to a thin shell that contains only the wrecked remains of democracy." 19 by the time most people realize what happened, it is too late to push back. i talked to an investor once active in the globalization movement, asking what was going to happen with the large number of desperately needed public health infrastructure projects. his response was, "only if they can show us a profit." in past decades, human population densities were much too low for viral illnesses to widely occur and outbreaks were, more often than not, driven almost exclusively by natural disasters, predatory animals, and prolonged wars. globally, zoonotic spread occurred simply because the human population has grown in numbers and become more dense. the spread was enhanced and accelerated by rapid unsustainable urbanization, biodiversity loss, climate change, and its extremes. this has resulted in producing further viral engagement with an increasing number of a new vulnerable populations suffering from chronic deficiencies in food, water, and energy. the current sars covid-19 transmission that flourished in wet market animals, whether it be a bat or civet, spread easily to the human-animal, a perfect host. the chaos created by the rapid spread of covid-19 has created an unprecedented opportunity for state-sponsored disinformation. probably the most infamous infectious disease disinformation incident was the kgb's "operation infektion" in the 1980s, which blamed the united states for the creation and spread of hiv. although the union of soviet socialist republics (ussr) conceded in 1992 that the kgb had instigated and perpetuated the myth, considerable damage was done, most importantly global distrust of the "official narrative" which fed into claims that hiv does not cause aids and distrust that the anti-retroviral used to treat hiv was useless, resulting in more than 330,000 preventable deaths. 20 what continues today is a russian autocratic regime that still places greater emphasis on false epidemic narratives than solving its own fastgrowing global rates of hiv/aids and tuberculosis (tb). russia and china are exploiting both real-life mistakes and weaknesses in the information space to control and modify the narrative with impacts on geopolitics and national security. spreading conspiracy theories from china, russia, and the united states is rampant, all systems designed to deflect responsibility for their bureaucratic failures. china is now seeking to blame the united states for covid-19 claiming, "further evidence that the virus originated in the us" and was planted in china by the us army. russia is sowing divisions between and within western countries to undermine public confidence in government competence and integrity. 21 the who, despite having in-hand evidence to the contrary, failed to properly contain the covid-19 pandemic. china's gross denial and failure to investigate and alert other nations is inexcusable. moreover, its malignant behavior toward clinicians and researchers who warned the government of the outbreak, when the virus was first known as far back as october of 2019, is equally inexcusable. yet the february 16-24, 2020 "report of the who-china joint mission on coronavirus disease 2019" singularly praised china's response as the best source of medical technology to deal with the pandemic. china then declared that their singular success in controlling the pandemic should qualify them to take over the who. 22 while the european union and the united states struggle to control the covid-19 pandemic, who fully supports china's "one belt, one road" initiative across africa to improve the economy of the continent. however, the lessons from globalization prove that economic prosperity alone cannot be achieved when huge knowledge and capacity gaps exist in health systems, especially public health and health information systems. there is a need for public health initiatives aimed at strengthening the health systems beyond sovereign borders to influence global geo-economics. 23 whereas who has fully supported this initiative with claims that china is investing in "people's health outside its border," the deplorable cover-up, response, and management of covid-19 for many months before it was known to the world questions whether china is up to the public health challenges it claims in africa, or fully understands the vital connections economic development has with public health. china claims that ruling africa's economy is a necessary prelude to the "next phase of globalization." 24 ever since who first announced the presence of clusters of unknown pneumonia on december 31, 2019, an alarming concern has surfaced that who has become beholden to influential countries for funding support, giving wealthy un members, especially china, support and influence both before and during the coronavirus outbreak. for example, who's position regarding china has renewed a longstanding debate about whether who, founded 72 years ago, is sufficiently independent to allow it to fulfill its purpose. 25 critics raised questions concerning who's response over how "china's sway over the who is its success in blocking taiwan's access to the body, a position that could have very real consequences for the taiwanese people if the virus takes hold there." others cite that who "downplayed the harsh control of medical whistleblowers," and the critical delay in revealing covid's presence, and further argue that who is "overly bureaucratic, bizarrely structured, too dependent on a handful of major donors, and often hamstrung by political concerns." 26 with the covid-19 crisis, "the state of politics and geopolitics has exacerbated, not stabilized, the crisis." 27 this applies to many countries, especially china, the united states, japan, cambodia, iran, and south korea. authors cite former who consultant charles clift who observed, as have many former insiders, that who "is too politicized, too bureaucratic, too dominated by medical staff seeking medical solutions to what are often social and economic problems, and too timid in approaching controversial issues, too overstretched, and too slow to adapt to change." he added that who, being "both a technical agency and a policymaking body, that excessive intrusion of political considerations in its technical work can damage its authority and credibility as a standard-bearer for health." 25, 28 united states' president trump has not done better in what must be a coordinated world response. his idea of "america first and national populism" is against everything that we believe in global health. 29 in january 2019, china made available the "genome" of this mysterious new virus in hopes of producing the first diagnostic test for the disease, but the united states declined to use the who test even temporarily as a bridge until the us centers for disease control and prevention (cdc; atlanta, georgia usa) could produce its test. this action remains a perplexing question and the key to the trump administration's failure to provide enough tests to identify the coronavirus infection, needlessly slowing the critical domestic testing process and surveillance. 30 additionally, president trump's reliance on the validity of his "hunches," claimed who's mortality rate was "false," irresponsibly valuing his "best guesses over scientific analysis." this has led to a "false sense of security that endangers public health." 31 both china and the united states have public health infrastructure and service deficiencies that have gone unattended for decades. public health infrastructure in the united states makes up only three percent of health care spending focused on prevention and public health, while 75% of health care costs are related to preventable conditions. 32 china chronically suffers low public health standards in toilets, restaurants, hospitals, and meat markets; and the united states has 50 states and 55 very different health department ratings. 33 as an example, during the covid-19 pandemic, mississippi, which rates last in public health infrastructure, has created confusion with many of its mayors claiming the need for curfews and closing of businesses, only to be over-ridden by the state's governor. 34 the only solution the who must exist solely as a treaty-based organization sanctioned by the un and all its members. it cannot be dependent on outside financial assistance to do its work. the unique characteristics of propagating zoonotic diseases must be better known by both the medical profession and governmental decision makers. health care experts, as osler described, must be in charge of all health decisions, monitoring, response, and operational research. they cannot abdicate any responsibilities to individual nationstates nor be beholden to them or well-financed donors for support. current disaster taxonomy describes diversity, distinguishing characteristics, and common relations in disaster event classifications. the impact of compromised public health infrastructure and systems on health consequences defines and greatly influences how disasters are observed, planned for, and managed, especially those that are geographically wide-spread, population-dense, and prolonged. 35 the one health concept helps to set the path forward for a solution based on local grassroots coordination, and a bottomup capability driven by medical, veterinary, and public health practitioners. this must include rapid, networked information sharing and the use of multiple expert disciplines to mitigate an outbreak. lastly, public health and public health infrastructure and systems in developing countries must be seen as strategic and security issues that deserve international public health resource monitoring. this must cover the entire disaster cycle from prevention, preparedness, response, recovery, and rehabilitation. 36 all six who regional offices must have similar multidisciplinary professional assets in support of zoonotic sciences. as osler might declare today, "there is so much more we need to know!" world health organization. managing epidemics: key facts about major deadly diseases do we still need international health regulations? the international health regulations: the governing framework for global health security global health security demands a strong international health regulations treaty and leadership from a highly resourced world health organization types of zoonotic diseases from "one medicine" to "one health" and systemic approaches to health and well-being animals at your doctor's office? one health, one solution. lifeapps aequanimitas: with other addresses to medical students, nurses, and practitioners of medicine osler centenary papers: management of pleural infection: osler's final illness and recent advances investigating interdisciplinary collaboration: theory and practice across disciplines the growth and strategic functioning of one health networks: a systematic analysis the global one health paradigm: challenges and opportunities for tackling infectious diseases at the human, animal, and environment interface in low-resource settings comment: whose globalization? public health policy forum the changing global context of public health the 2015 hyogo framework for action: cautious optimism hyogo declaration and the cultural map of the world character disorders among autocratic world leaders and the impact on health security, human rights, and humanitarian care globalization is dead, but the idea is not dictatorship, 21st-century style. cnn: opinion notes & theories: aids and hiv. the guardian the us-china coronavirus blame game and conspiracies are getting dangerous. the washington post covid-19) china's belt and road initiative: incorporating public health measures toward global economic growth and shared prosperity discussion paper: china's role in the next phase of globalization. mckinsey global institute the coronavirus crisis is raising questions over china's relationship with the world health organization. us & world the coronavirus is exposing the limits of populism the coronavirus crisis is raising questions over china's relationship with the world health organization. cnn the coronavirus panic exposes the pathology of nationalism. common dreams how testing failures allowed coronavirus to sweep the us coronavirus death rate is 3.4%, world health organization says, trump says 'hunch' tells him that's wrong. usa today strengthen public health infrastructure and capacity 2f01%2f27%2fis-china-ready-this-major-global-health-challenge%2f& closing businesses amid virus could do harm. fox10 impact of public health emergencies on modern disaster taxonomy, planning, and response challenges of global public health emergencies: development of a health-crisis management framework key: cord-317477-h3c5kddj authors: de coninck, david; d'haenens, leen; matthijs, koen title: perceived vulnerability to disease and attitudes towards public health measures: covid-19 in flanders, belgium date: 2020-11-01 journal: pers individ dif doi: 10.1016/j.paid.2020.110220 sha: doc_id: 317477 cord_uid: h3c5kddj during the covid-19 pandemic, governments installed measures to contain the disease. information about these measures was disseminated through news media. nonetheless, many individuals did not abide by these guidelines. we investigated how perceived vulnerability to disease and personality characteristics related to support for public health measures. we analyzed survey data of 1000 flemish (belgium) adults, collected between march 17, 2020 and march 22, 2020. older age, low educational attainment, gender (female) and work situation (no telecommuting) were associated with greater perceived vulnerability. greater expectations of loneliness and more solidarity with our fellow men were associated with gender (female), younger age and work situation (telecommuting). greater perceived vulnerability to disease was related to a greater belief that public health measures protect the population, but also to a critical stance towards the belgian government's handling of the crisis. high agreeableness and high emotional stability were associated with respectively greater belief that health measures protect the population, and greater support for the government's crisis management. watching television news was related to a greater belief that public health measures are necessary, and specifically consuming public television news increased support for public health measures. we discuss the implications for handling the covid-19 pandemic. recently, the coronavirus disease 2019 (covid-19) has been rapidly expanding in europe, north america, asia, and the middle east. by march 22, 2020, the number of cases and deaths of covid-19 outside china had increased drastically and the number of affected countries reporting infections to who was 149 (who, 2020a) . based on alarming levels of spread and severity, and by the alarming levels of inaction, on march 11, 2020, the director-general of who characterized the covid-19 situation as a pandemic (bedford et al., 2020; who, 2020b) . in order to respond to this pandemic, many countriesincluding belgiumare combining containment and reduction activities aimed at delaying major surges of patients and leveling the demand for hospital beds, while protecting the most vulnerable from infection. bedford et al. state that "activities to accomplish these goals vary and are based on national risk assessments that many times include estimated numbers of patients requiring hospitalization and availability of hospital beds and ventilation support. national response strategies include varying levels of contact tracing and self-isolation or quarantine; promotion of public health measures, including hand washing, respiratory etiquette, and social distancing; and closing all non-essential establishments" (2020, p. 1016) . information about these new public health measures is disseminated through news media's almost non-stop coverage of the covid-19 crisis: traditional (television, radio, newspapers) and social media are the main platforms for disseminating information merchant & lurie, 2020) . despite this, many instances have been reported of people not abiding by these guidelines. some consider them to be excessive, others cite economic concerns and socio-psychological perceptions (especially among older people, the at-risk population of covid-19) (armitage & nellums, 2020; duan & zhu, 2020; smith, 2006) . (excessive) fear of covid-19 may lead to negative consequences of disease control as shown by early recommendations for the current crisis from china (dong & bouey, 2020) , but also from previous sars and ebola outbreaks (cheung, 2015; lin, 2020; person et al., 2004) . we aim to show how perceived vulnerability to disease, personality characteristics, opinion on news media coverage and consumption of news media, and socio-economic and socio-psychological perceptions are related to attitudes towards public health measures in the context of the covid-19 pandemic. with this study, we inform on three gaps in covid-19 research identified by bedford et al.: analysis of quarantine strategies and contexts for their social acceptability, determining best ways to apply knowledge about infection prevention and control, and enhance (or develop) an ethical framework for outbreak response (bedford et al., 2020) . we collected data through an online survey among a sample of the adult population aged 18 to 70 in flanders, the northern region of belgium (n = 1000). the survey was fielded from march 17, 2020 to march 22, 2020. the first restrictive governmental measures in belgium regarding social distancing and telecommuting were installed on march 14 and were tightened a few days later. on the day that fieldwork began, the belgian government ordered the closing of all non-essential establishments, cancelling all (mass) events, and only allowing citizens to go outside for a limited number of reasons (to work, to buy groceries or medicine, to provide urgent care to family). these measures were in place throughout the data collection. the polling agency gathered 1000 responses (response rate: 32%) from an opt-in online panel that used quotas by gender, age, education, and province to ensure the data were representative for these characteristics in flanders. respondents were contacted by e-mail, and the survey was distributed via the polling agency's own survey tool. the survey language was dutch, the official language of flanders. respondents were unable to skip questions, but some questions did have a 'no answer'-option. each question in the survey was presented on a different page, and there was no option to return to previous questions and change any answers. all respondents who recorded partial data were removed by the survey agency prior to delivering the final, fully anonymized, dataset. we used a 15-item self-report instrument to assess perceived vulnerability to disease. approximately half the items were reversely scored. participants responded to each item on a 7-point scale with endpoints labeled 'strongly disagree' and 'strongly agree'. this instrument was developed and validated by duncan et al. (2009) and has two subscales: one assesses beliefs about one's own susceptibility to infectious diseases (perceived infectability; eight items; cronbach's alpha = 0.85), the other emotional discomfort in contexts that connote an especially high potential for pathogen transmission (germ aversion; seven items; cronbach's alpha = 0.70). 1 after conducting a principal component analysis, the factor scores of both subscales were saved to be used in the analyses. 2 the factor scores that were produced have a mean of zero. we used a brief measure of the big five personality characteristics containing 10 items. each item contained a personality characteristic, and people were asked to indicate to what extent it applied to them (1 = does not apply at all, 5 = fully apply). the 10 items covered both poles of each personality dimension of the big five: extraversion, conscientiousness, agreeableness, openness to experiences, and emotional stability. we used a dutch translation of the version originally developed by gosling, rentfrow and swann jr. which "reached adequate levels in terms of: (a) convergence with widely used big five measures in self, observer, and peer reports, (b) test-retest reliability, (c) patterns of predicted external correlates, and (d) convergence between self and observer ratings" (gosling et al., 2003, p. 504; hofmans et al., 2008) . five of the ten items on the opposite pole of each personality dimension were reversely coded to obtain accurate scores for all dimensions. we assessed the public's socio-economic and socio-psychological perceptions regarding the covid-19 pandemic through three items: if respondents believe that the measures will result in an economic crisis (perception of economic crisis), whether they believe they will be lonely in the coming weeks (loneliness), and whether they will selfquarantine if they feel unwell (solidarity). participants responded to each item on a 5-point scale with endpoints labeled 'strongly disagree' and 'strongly agree'. we assessed the public's attitudes towards public health measures installed by the belgian government through two items, asking if they believe the measures are necessary to protect the population and if they believe that the belgian government is handling the current crisis well. again, participants responded to each item on a 5-point scale with endpoints labeled 'strongly disagree' and 'strongly agree'. the frequency with which respondents gathered information in the news (public television, commercial television, quality newspapers, tabloids) about the covid-19 pandemic over the past week was assessed using 5-point scales with endpoints labeled 'never' and 'multiple times a day'. opinion on news media coverage was assessed by asking respondents' opinion of the media's coverage of the crisis (1 = media coverage underestimates dangers, 2 = media coverage is accurate, 3 = media coverage overestimates dangers). respondents were asked to indicate birth year (recoded to age categories: 18-34, 35-54, 55-70), gender (1 = male, 2 = female), educational attainment (1 = higher secondary education or lower, 2 = higher non-university education or higher), whether their place of work had closed down due to public health measures (1 = no, 2 = yes), and if they were asked or forced to telecommute or work from home (1 = no, 2 = yes). in order to highlight individual sociodemographic differences (age, gender, educational attainment, work situation) in perceived vulnerability to disease and attitudes towards public health measures, we used independent samples t-tests and one-way anova. subsequently, we conducted stepwise linear regressions to investigate associations of perceived vulnerability to disease, personality characteristics, consumption of and opinion on news media, and socio-economic and sociopsychological perceptions, with attitudes towards public health measures during the covid-19 pandemic in flanders, belgium. in these regressions, we controlled for relevant socio-demographic characteristics. women reported significantly higher germ aversion (ga: m = 4.73) and perceived infectability (pi: m = 3.87) than men (ga: m = 4.39; pi: m = 3.57). age differences were found for germ aversion only: older age categories (m = 4.81) reported significantly higher germ aversion 1 1 items were translated from english to dutch by the authors. reported reliabilities refer to the dutch items and are in line with those from the englishlanguage scale (pi = 0.87; ga = 0.74) (duncan et al., 2009 ). than younger ones (m = 4.35). for both ga and pi, the highly educated reported significantly lower scores than the lower educated. people who were asked or forced to telecommute during the covid-19 crisis experienced significantly less ga and pi than those who were not asked to do so. respondents whose place of work closed, did not report significantly different scores for either ga or pi than respondents whose place of work did not close (table 1) . women reported significantly higher belief of a (future) economic crisis (m = 4.11 versus m = 3.98 for men) and loneliness (m = 2.96 versus m = 2.71 for men), and higher solidarity (m = 4.16 versus m = 4.05 for men) than men. age differences were found for perceptions of loneliness and solidarity: older age categories (respondents aged 55 to 70) reported significantly less perceived loneliness (m = 2.64 versus m = 3.10 for respondents aged 18-34) and higher solidarity (m = 4.21 versus m = 4.05 for respondents aged 18-34) than younger age categories. people telecommuting during the covid-19 crisis reported significantly more solidarity (m = 4.14) than those who were not asked to do so (m = 4.00). respondents whose place of work closed reported significantly higher perceived loneliness (m = 3.11) and higher solidarity (m = 4.26) than those whose place of work did not close. no significant differences were found by educational attainment (table 2 ). to answer our main research question, we conducted two stepwise linear regressions to investigate associations between on the one hand perceived vulnerability to disease (ga and pi), personality characteristics, opinion on and consumption of news media, socio-psychological and economic perceptions (independent variables), and on the other hand the belief that the current measures are necessary to protect the belgian population (dependent variable; table 3 ) and that the belgian government is handling the covid-19 crisis well (dependent variable; table 4 ). tables 3 and 4 indicate that perceived vulnerability to disease plays a significant role: people with high germ aversion (β = 0.07, p < 0.05) are more convinced that the public measures are necessary to protect the health of the belgian population. however, respondents with high perceived infectability are more critical of the belgian government's handling of the covid-19 situation so far (β = −0.07, p < 0.05). as for personality characteristics, people with high agreeableness are more convinced that public measures are necessary to protect the population's health (β = 0.10, p < 0.01), while those with high emotional stability are more supportive of public health measures (β = 0.06, p < 0.10). watching news about the covid-19 crisis is mostly related to attitudes through television news consumption: public television news consumption is positively related to the belief that the measures are necessary to protect the population (β = 0.09, p < 0.01) and that the belgian government is handling the crisis well (β = 0.08, p < 0.01). commercial television news consumption also relates positively to the idea that the measures are necessary (β = 0.06, p < 0.10), albeit with a smaller effect size than that of public television consumption. reading so-called 'quality' newspapers is related to more negative attitudes about the necessity of the measures (β = −0.12, p < 0.001). people's opinion on the media's coverage of the crisis is strongly associated with public health attitudes: respondents who believe that the media overestimate the dangers of the covid-19 believe less than respondents who consider media coverage to be accurate that the measures are necessary to protect the population (β = −0.31, p < 0.001), and that the government is doing a good job handling the crisis (β = −0.17, p < 0.001). furthermore, respondents who believe the media underestimate the crisis also believe less than respondents who consider coverage to be accurate, that the government is handling the crisis well (β = −0.28, p < 0.001). note. ga and pi measured on 7-point scale (1: strongly disagree, 7: strongly agree). df between 712 and 998. a f-scores presented for age. d. de coninck, et al. personality and individual differences 166 (2020) 110220 in terms of socio-economic or socio-psychological perceptions, we find that solidarity is strongly associated with attitudes towards the public health measures. respondents who indicate they will quarantine themselves when they feel unwell hold more positive attitudes towards the necessity of the measures (β = 0.20, p < 0.001) and are more convinced that the belgian government is handling the crisis well (β = 0.06, p < 0.05). perceptions of loneliness are positively associated with the idea that the belgian government is doing a good job in handling the crisis (β = 0.07, p < 0.05). perceptions of an economic crisis is not related to attitudes about public health measures. we find that older peoplewho, as indicated in table 1 , have a high germ aversionbelieve more than young people that the measures taken are necessary to protect the belgian population (β = 0.05, p < 0.10). in line with this, they are also more positive than young people about the way the belgian government has handled the crisis so far (β = 0.13, p < 0.001). finally, those with a tertiary or higher degree believe more than those with a secondary or lower degree that the belgian government is handling the crisis well (β = 0.08, p < 0.01). this cross-sectional study identified several determinants for perceived vulnerability to disease, socio-economic and psychological perceptions, and attitudes towards public health measures. older age, low educational attainment, gender (female) and not telecommuting during the covid-19 crisis were associated with greater perceived disease vulnerability. additionally, greater perceived loneliness and more solidarity with our fellow men were associated with gender (female), younger age and individuals whose place of work has closed during the covid-19 crisis. women also reported greater perceptions of an economic crisis than men. person et al. (2004) found "that during serious disease outbreaks, when the general public requires immediate information, a subgroup of the population that is at potentially greater risk of experiencing fear… will need special attention from public health professionals" (2004, p. 358). the current covid-19 pandemic, table 2 independent samples t-tests (gender, educational attainment, telecommuting, and employment situation) and one-way anova (age) on perceptions of economic crisis, perceptions of loneliness, and solidarity scores. note. perceptions measured on 5-point scale (1: strongly disagree, 5: strongly agree). df between 712 and 998. a f-scores presented for age. d. de coninck, et al. personality and individual differences 166 (2020) 110220 but also recent sars or ebola outbreaks, are classic examples of such an outbreak (person et al., 2004; weiss & ramakrishna, 2001) . this special attention for fearful subgroups and individuals is vital, since "exclusionary practices based upon the best available scientific evidence may be scientifically and ethically sound for one population, those same practices may not be sound for all populations" (person et al., 2004, p. 358; weiss & ramakrishna, 2001) . it may be because of this attention that we found that older respondents are less concerned about loneliness than younger respondents. in the weeks prior to the study, media frequently stressed the need to care for the elderly, as they were at risk for both covid-19 and loneliness. this increased attention may compensate for this concern among older respondents, while many younger table 3 stepwise linear regression with belief that public health measures are necessary to protect belgian population as outcome variable, and standardized betas (β) of predictors. stepwise linear regression with belief that belgian government is handling the covid-19 crisis well as outcome variable, and standardized betas (β) of predictors. d. de coninck, et al. personality and individual differences 166 (2020) 110220 respondentsan increasing number of whom are single and lost most of their daily face-to-face interactions by telecommutingreceived no special attention at this stage of the pandemic, which may have alleviated concerns regarding loneliness among this group. research indicates that older age groups experience higher mortality than younger age groups from covid-19, which has been widely reported and may explain why older age groups perceive themselves as more vulnerable to disease (zhou et al., 2020) . furthermore, telecommutingwhich has been highly encouraged by many governments to reduce the probability of disease transmissionis not possible for many lower educated individuals who work in low-skilled and 'essential' jobs, which may in turn increase their perceived vulnerability to disease. the fact that women report higher perceived vulnerability to disease than men is in line with previous research which found that women report higher fear of pathogens than men (díaz et al., 2016; duncan et al., 2009) . these findings are also supported by preliminary cross-country research regarding fear of covid-19 (perrotta et al., 2020) . in addition, when we relate these indicatorsalong with opinion on and consumption of news mediato attitudes towards public health measures, we find that perceived vulnerability is related to greater belief that these measures protect the belgian population, but at the same time also to a more critical stance towards the belgian government's handling of the crisis. this indicates that those who perceive themselves as vulnerable to disease find that the current measures of (self-)quarantine, social distancing, and closing all non-essential establishments, are not far-reaching enough to combat this pandemicand support stricter public health measures. this assumption is strengthened by the finding that people who believe that media coverage underestimates the current crisis, are more critical of the belgian government's handling of the crisis than those who believe media coverage overestimate the crisis. we found that high agreeableness and emotional stability (or low neuroticism) are related to higher support for public health measures, or more positively evaluate governmental efforts to combat the disease. it is not surprising that these two personality characteristics came to the fore, since previous research has found that both are significantly correlated with some measures of underlying general health (hengartner et al., 2016) . in line with their recommendations, we further advocate that a short big five inventory provides much valuable information for health practise and research. an "integration of personality in public health policy offers many benefits at almost no costs. a short personality assessment may easily and cost-effectively screen entire populations for increased risk for probable health-impairing behaviours" (hengartner et al., 2016, p. 49) . at the same time, watching television news (on commercial and public media) is related to a greater belief that public health measures are necessary to combat the pandemic, and specifically consuming public television news increases approval of the government's handling of the pandemic. this may be related to the public's trust in these media. eurobarometer data from 2018 indicate that radio and televisionand in belgium, particularly public television (de coninck et al., 2018) are the most highly trusted news sources, with trust in social media being the lowest (eurobarometer, 2018) . in such uncertain times, with a plethora of real and fake information being disseminated by media, it is likely that individuals will trust the information coming from their most trusted news source (in this case, public television news) and be more sceptical of alternative news sources. the knowledge that public television is the most 'important' medium (from the public's perspective) may be useful for policymakers and medical professionals when determining where and how to disseminate important information about infection prevention and control to the public (bedford et al., 2020) . feelings of solidarity (i.e. quarantining yourself right away if you feel unwell) are also related to higher support for governmental measures. after all, to self-quarantine is an act of solidarity. as ulrich beck stated, "it is the coincidence, the coexistence of not knowing and global risks which characterizes the existential moments of decision not only in politics and science but also in everyday life situations" (beck, 2016, p. 104) . to stay at home is to reduce the risk of spreading covid-19. stimulating solidarity is therefore stimulating support for public health measures. these findings indicate that feelings of solidarity can function as a cornerstone of possible ethical frameworks for outbreak responsein flanders -, as it proves to be an important predictor for support for public health measures (bedford et al., 2020) . (quarantine) strategies that emphasize solidarity between people will likely receive more support and be more socially acceptable than measures that would, for example, address perceptions of an economic crisis. this is illustrated by recent attempts at increasing opening hours of grocery stores in belgium, which was met with much resistance. this study has some limitations. first, due to the cross-sectional study design, we are unable to make causal claims, but are limited to reporting (sometimes small) associations between variables. it is also possible that some associations regarding support for public health measures may be mediated by factors not included in the analyses (e.g., personal opinion regarding the crisis). in order to better inform the scientific community of causal effects, longitudinal studies measuring perceived vulnerability, personality, and attitudes are required. second, we cannot generalize these results to other populations. although flemish social life has been significantly affected by the public health measures to combat the covid-19 pandemic, support for public health measures may evolve differently among other populations due to, for example, the communication strategy of the government, socio-demographic characteristics of the population, or the (perceived) preparedness of the country's health care services. we therefore encourage other scholars to build on our findings and provide more insights about this multifaceted but highly relevant facet of the current covid-19 pandemic, as it continues to spread. learning from this pandemic may inform future communication and governmental strategies to combat such pandemics in the future by discouraging panic, hoarding, and increase support for public health measures. covid-19 and the consequences of isolating the elderly. the lancet public health the metamorphosis of the world covid-19: towards controlling of a pandemic an outbreak of fear rumours and stigma: psychosocial support for the ebola virus disease outbreak in west africa forgotten key players in public health: news media as agents of information and persuasion during the covid-19 pandemic the relationship between media use and public opinion on immigrants and refugees: a belgian perspective perceived vulnerability to disease questionnaire: factor structure, psychometric properties and gender differences public mental health crisis during covid-19 pandemic psychological interventions for people affected by the covid-19 epidemic perceived vulnerability to disease: development and validation of a 15-item self-report instrument fake news and disinformation online a very brief measure of the big-five personality domains big five personality traits may inform public health policy and preventive medicine: evidence from a cross-sectional and a prospective longitudinal epidemiologic study in a swiss community is short in length short in content? an examination of the domain representation of the ten item personality inventory scales in dutch language social reaction toward the 2019 novel coronavirus (covid-19) social media and emergency preparedness in response to novel coronavirus behaviors and attitudes in response to the covid-19 pandemic: insights from a cross-national facebook survey fear and stigma: the epidemic within the sars outbreak responding to global infectious disease outbreaks: lessons from sars on the role of risk perception, communication and management stigma interventions and research for international health. paper presented at stigma and global health: developing a research agenda coronavirus disease (covid-2019) situation reports. situation report-61 who virtual press conference on covid-19 clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study the authors declare no conflict of interest. key: cord-322543-lo1ra50f authors: li, z.; xu, t.; zhang, k.; deng, h.-w.; boerwinkle, e.; xiong, m. title: causal analysis of health interventions and environments for influencing the spread of covid-19 in the united states of america date: 2020-09-29 journal: nan doi: 10.1101/2020.09.29.20203505 sha: doc_id: 322543 cord_uid: lo1ra50f as of august 27, 2020, the number of cumulative cases of covid-19 in the us exceeded 5,863,363 and included 180,595 deaths, thus causing a serious public health crisis. curbing the spread of covid-19 is still urgently needed. given the lack of potential vaccines and effective medications, non-pharmaceutical interventions are the major option to curtail the spread of covid-19. an accurate estimate of the potential impact of different non-pharmaceutical measures on containing, and identify risk factors influencing the spread of covid-19 is crucial for planning the most effective interventions to curb the spread of covid-19 and to reduce the deaths. additive model-based bivariate causal discovery for scalar factors and multivariate granger causality tests for time series factors are applied to the surveillance data of lab-confirmed covid-19 cases in the us, university of maryland data (umd) data, and google mobility data from march 5, 2020 to august 25, 2020 in order to evaluate the contributions of social-biological factors, economics, the google mobility indexes, and the rate of the virus test to the number of the new cases and number of deaths from covid-19. we found that active cases/1000 people, workplaces, tests done/1000 people, imported covid-19 cases, unemployment rate and unemployment claims/1000 people, mobility trends for places of residence (residential), retail and test capacity were the most significant risk factor for the new cases of covid-19 in 23, 7, 6, 5, 4, 2, 1 and 1 states, respectively, and that active cases/1000 people, workplaces, residential, unemployment rate, imported covid cases, unemployment claims/1000 people, transit stations, mobility trends (transit) , tests done/1000 people, grocery, testing capacity, retail, percentage of change in consumption, percentage of working from home were the most significant risk factor for the deaths of covid-19 in 17, 10, 4, 4, 3, 2, 2, 2, 1, 1, 1, 1 states, respectively. we observed that no metrics showed significant evidence in mitigating the covid-19 epidemic in fl and only a few metrics showed evidence in reducing the number of new cases of covid-19 in az, ny and tx. our results showed that the majority of non-pharmaceutical interventions had a large effect on slowing the transmission and reducing deaths, and that health interventions were still needed to contain covid-19. as of august 27, 2020 this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, the copyright holder has placed this version posted september 29, 2020. . https://doi.org/10.1101/2020.09. 29.20203505 doi: medrxiv preprint suresh, 2020; anderson et al. 2020) , airflow (priyadarsini and suresh, 2020) , and socioeconomics such as median income (coccia 2020; saadat et al. 2020 ). the most explored non-pharmaceutical public health interventions and digital technologies for curbing the spread of covid-19 include social distancing, case isolation and quarantine as well as closuring borders, schools travel restrictions, use of face-masks, and testing ( although association analysis is of great importance for curbing the spread of covid-19, association measures dependence between two variables or two sets of variables in the data, and use the dependence for prediction and evaluation of the effects of environmental, socialeconomic factors and public health interventions on the spread of covid-19 (altman and krzywinski 2015; sharkey and wood 2020). it is well recognized that association analysis is not a direct method to discover the causal mechanism of complex diseases. association analysis may detect superficial patterns between intervention measures and transmission variables of covid19 . its signals provide limited information on the causal mechanism of the transmission dynamics of covid-19 (steigera et al. 2020 ). association analysis has been a major paradigm for statistical evaluation of the effects of influencing factors and health interventions on the spread of covid-19 (li et al. 2020) . understanding the transmission mechanism of covid-19 based on association analysis remains elusive. the question to uncover the transmission mechanisms of covid-19 is causal in nature. reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, intervention measures are time series data. an essential difference between time series and crosssectional data is that the time series data have temporal order, but cross sectional data do not have any order. as a consequence, the causal inference methods for cross sectional data cannot be directly applied to time series data. basic tools in statistical analysis are the raw of large numbers and the central limit theorem. applications of these tools usually assume that all reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, the copyright holder has placed this version posted september 29, 2020. . https://doi.org/10.1101/2020.09.29.20203505 doi: medrxiv preprint moment functions are constant. when the moment functions of the time series vary over time, the raw of large numbers and the central limit theorem cannot be applied. in order to use basic probabilistic and statistical theories, the nonstationary time series must be transformed to stationary time series (johansen 1991). a widely used concept of causality for time series data is granger causality (granger 1969; eichler 2013). underlying the granger causality is the following two principles: (1) effect does not precede the cause in time; (2) the effect series contains unique causal series information which is not present elsewhere. the multivariate linear granger causality test will be used to test causality between the number of new cases and deaths from covid-19 and environmental, economic and intervention time series variables (bai et al. 2010). the proposed anms and multivariate linear granger causality analysis methods are applied to the surveillance data of lab-confirmed covid-19 cases in the us, umd data, and google mobility data from march 5, 2020 to august 25, 2020 in order to evaluate the contributions of social-biological factors, economics, the google mobility indexes, and the rate of virus testing to the number of the new cases and number of deaths from covidnonlinear additive noise models for bivariate causal discovery this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, where n is not necessarily equal to m . procedures for using the anm to assess causal relationships between two variables are summarized below (jiao et al. 2018). step 1. regress on using the training dataset and non-parametric regression methods: . (3) step 2. calculate the residual using the test dataset and test whether the residual is independent of causal to assess the anm . step 3. repeat the procedure to assess the anm . reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, the copyright holder has placed this version posted september 29, 2020. . https://doi.org/10.1101/2020.09.29.20203505 doi: medrxiv preprint step 4. if the anm in one direction is accepted and the anm in the other is rejected, then the former is inferred as the causal direction. there are many non-parametric methods that can be used to regress y on x or regress cleveland, 1979). in this paper, the smoothing spline regression method was used to fit the regression models. covariance can be used to measure association, but cannot be used to test independence between two variables with a non-gaussian distribution. a covariance operator that is a generalization of the finite dimensional covariance matrix to infinite dimensional feature space can be used to test for independence between two variables with arbitrary distributions. specifically, we will use the hilbert-schmidt norm of the cross-covariance operator or its approximation, the hilbert-schmidt independence criterion (hsic) to measure the degree of dependence between the residuals and potential causal variable and test for their independence the covariance operator can be defined as , where are any nonlinear functions and is the covariance operator and is an inner product in the hilbert space. the hilbert-schmidt norm of the covariance operator can be used as criterion for assessing independence between two random variables and is called the hilbert-schmidt independence criterion (hsic). the hilbert-schmidt norm of the centered covariance operator is defined as , reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, the copyright holder has placed this version posted september 29, 2020. in summary, the general procedure for testing independence between the average number of new cases or new deaths and the scalar factor or intervention measure is given as follows (mooij et al. step 1: divide a data set into a training data set for fitting the model and a test data set } for testing the independence. step 2: use the training data set and smoothing spline regression nonparametric regression methods (a) regress on : , reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, the copyright holder has placed this version posted september 29, 2020. . https://doi.org/10.1101/2020.09.29.20203505 doi: medrxiv preprint step 3: use the test data set and estimated smoothing spline regression nonparametric regression that fits the test data set to predict residuals: (a) , . step 4: calculate the dependence measures ) , step 5: infer causal direction: this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, the copyright holder has placed this version posted september 29, 2020. . https://doi.org/10.1101/2020.09.29.20203505 doi: medrxiv preprint defined as the proportions of the statistic (computed on the permuted data) greater than or equal to (computed on the original test data ). before performing multivariate linear grander causality test, we first need to transform nonstationary time series to stationary time series. consider an -variable var with lags: , where is a dimensional vector, the are coefficient matrices and dimensional residual vector, is assumed to have mean zero ( , with no autocorrelation where matrixes and are functions of matrices . when two non-stationary variables are cointegrated, the var model should be augmented with an error correction term for testing the granger causality (engle and granger, 1987). the vecm can be reduced to , where reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, the copyright holder has placed this version posted september 29, 2020. , and (3) both and and likelihood ratio tests for multivariate granger causality are given by the following. (1) the likelihood ration statistics for testing the null hypothesis: is , which is asymptotically distributed as a central under the null hypothesis . (2) the likelihood ration statistics for testing the null hypothesis: is , reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, the copyright holder has placed this version posted september 29, 2020. . which is asymptotically distributed as a central under the null hypothesis . ( the scalar variables tested for causation of the new cases and deaths from covid-19 in the us included the number of contact tracing workers per 100,000 people, percent of population above 60 years of age, median income, population density, percentage of african americans, reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, the copyright holder has placed this version posted september 29, 2020. . https://doi.org/10.1101/2020.09.29.20203505 doi: medrxiv preprint percentage of hispanic americans, percentage of males, employment density, number of points of interests for crowd gathering per 1000 people, number of staffed hospital beds per 1000 people, and number of icu beds per 1000 people. the number of new cases and deaths were averaged over time. each state was a sample. since the sample sizes were small, the p-value for declaring significance was 0.05 without bonferroni correction for multiple comparison. the pvalues for testing 11 scalar potential causes of the number of new cases and deaths from covid-19 in the us were summarized in table 1 . we observed from table 1 that population density (pvalue < 0.0002) and percentage of males (p-value < 0.03) showed significant evidence of causing the spread of covid-19. percentage of hispanic americans (p-value < 0.0575) was close to significance. percentage of african american (p-value < 0.024) and population density (p-value < 0.025) showed significant evidence of causing deaths due to covid-19. p-values of employment density (p-value < 0.059) and percentage of hispanic americans (p-value < 0.064) were close to significance level 0.05 for causing death. the second most significant demographic risk factor for the spread of covid-19 was percentage of males. we found higher covid-19 morbidity in males than females. however, we did not find higher covid-19 mortality in males than females. population density was an important risk factor for both the spread and death from covidthis preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, the copyright holder has placed this version posted september 29, 2020. . https://doi.org/10.1101/2020.09.29.20203505 doi: medrxiv preprint percentage of hispanic americans was a weak risk factor for both the spread and death fromcovid-19, while the literature showed stronger evidence that hispanic communities were highly vulnerable to covid-19 (calo et. al. 2020) . it was reported that higher covid-19 mortality in males than females can be due to the following factors (bwire 2020). the first factor was higher expression of angiotensin-converting enzyme-2 (ace 2; receptors for coronavirus) in males than females. the second factor was sexbased immunological differences due to sex hormone and the x chromosome. daily mobility and social distancing data from a covid-19 impacted the analysis platform, google community mobility reports, 2020). the total number of variables to be tested was 19. the p-value for declaring significance after bonferroni correction was 0.0025. however, although ca was most affected and the most populated state, all 19 metrics except reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, the copyright holder has placed this version posted september 29, 2020. . https://doi.org/10.1101/2020.09.29.20203505 doi: medrxiv preprint protest attendance showed a strong significance in causing rapid spread of covid-19 (table 2 and table s1 ). table 4 listed the most significant risk factor for the new cases of covid-19 in each of the 50 states in the us. active cases/1000 people, workplaces, number of tests completed/1000 people, imported covd cases, unemployment rate and unemployment claims/1000 people, mobility trends for places of residence (residential), retail & recreation, mobility trends for places like restaurants, cafes, shopping centers, theme parks, museums, libraries, and movie theaters (retail) reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, the copyright holder has placed this version posted september 29, 2020. . https://doi.org/10.1101/2020.09.29.20203505 doi: medrxiv preprint and test capacity were the most significant risk factors for the new cases of covid-19 in 23, 7, 6, 5, 4, 2, 1 and 1 states of the us, respectively. table 5 summarized the most significant risk factor for the deaths from covid-19 in each of the 50 states in the us. active cases/1000 people, workplaces, residential, unemployment rate, imported covid cases, unemployment claims/1000 people, transit, test done/1000 people, grocery, testing capacity, retail, percentage of change in consumption, percentage of working from home were the most significant risk factor for the deaths of covid-19 in 17, 10, 4, 4, 3, 2, 2, 2, 1, 1, 1, 1 states, respectively. we also observed that the number of protest attendees showed mild significant evidence to cause increasing the number of new cases of covid-19 in ky (pvalue < 0.00012), ks (p-value < 0.00026), nh (p-value < 0.00108), ma (p-value < 0.0016) and tn (p-value < 0.0024) or to cause more deaths from covid-19 in or (p-value < 5.11 e-05), tx (p-value < 0.00017), me (p-value < 0.00028), ks (p-value < 0.00061), mi (p-value < 0.0015), oh (p-value < 0.0021) and nc (p-value < 0.0023). to illustrate the causal relationships between the risk factors and the number of new cases and deaths from covid-19, we plotted figures 1 and 2 . figure 1 plotted the social distance index curves as a function of time from march 5, 2020 to august 25, 2020 in florida (fl) and rhode island (ri). figure 1 showed that the social distance index in fl was much higher than that in ri state, which resulted in the larger number of new cases of covid-19 in fl than that in ri. our data suggested that men were more vulnerable to covid-19 than women . however, our analysis did not conclude that more men than women were dying from covid-19. reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, the copyright holder has placed this version posted september 29, 2020. . https://doi.org/10.1101/2020.09. 29.20203505 doi: medrxiv preprint we also discovered that more black americans were dying from covid-19. the reasons for this were complex. black americans had higher rates of chronic disease conditions, including diabetes, heart disease, and lung disease, were poor and more easily exposed to the covid-19, and lived in the cramped housing. inequities in the social determinants of health affected mortality and morbidity of covid-19 for hispanic americans with much milder significance. states. therefore, workplaces should be considered as a very important risk mitigation measure to reduce the number of new cases and deaths from covid-19. tests done/1000 people was the second population intervention in the us. it was the significant cause of the new cases of reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, the copyright holder has placed this version posted september 29, 2020. . https://doi.org/10.1101/2020.09.29.20203505 doi: medrxiv preprint covid-19 in 46 states and significant cause of death in 47 states. virus test results in quick case identification and isolation to contain covid-19, and rapid treatment to reduce the number of deaths. imported covid cases were also a top significant risk factor for speeding the spread and increasing the deaths from covid-19. our results showed that the imported covid case metric was the significant causal factor for the new cases in 46 states and the significant causal factor for the deaths in 47 states. our results showed that the high numbers of cases and deaths from covid-19 were due to lacking strong interventions and high population density. we observed that no metrics showed significant evidence in mitigating the covid-19 epidemic in fl and only a few metrics showed evidence in reducing the number of new cases of covid-19 in az, ny and tx. our results showed strong interventions were needed to contain covid-19. although we tried to systematically and comprehensively analyze the data, this study has multiple limitations. first, we only analyzed the causal relationship between mobility patterns and the number of new cases or deaths and ignored the role of other potential mitigating factors (e.g, wearing face masks) that could also have contributed to the reduction of new cases or deaths from covid-19. when data are available, more metrics should be included in the analysis. second, we have not addressed the confounding bias issue. when confounding is unknown, adjusting for confounding methods cannot be applied to eliminate confounding bias from the causal analysis. unadjusted confounding bias will distort the inferred (true) causal relationship between the number of new cases or deaths from covid-19, and metrics for social distancing when these two variables share common causes. this will have substantive implications for reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, the copyright holder has placed this version posted september 29, 2020. . https://doi.org/10.1101/2020.09.29.20203505 doi: medrxiv preprint developing interventions to mitigate the spread of covid-19 and reduce the deaths from covid-19. however, removing confounding from causal analysis for covid-19 is complicated and will be investigated in the future. in summary, our analysis has provided information for both individuals and governments to plan future interventions on containing covid-19 and reduction of deaths from covid-19. hw deng was partially supported by nih grants u19ag05537301 and r01ar069055. momiao xiong was partially supported by nih grants u19ag05537301. the authors thank sara barton for editing the manuscript. reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, the copyright holder has placed this version posted september 29, 2020. reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, the copyright holder has placed this version posted september 29, 2020. . https://doi.org/10.1101/2020.09.29.20203505 doi: medrxiv preprint grocery: mobility trends for places like grocery markets, food warehouses, farmers markets, specialty food shops, drug stores, and pharmacies. parks: mobility trends for places like local parks, national parks, public beaches, marinas, dog parks, plazas, and public gardens. transit: transit stations, mobility trends for places like public transport hubs such as subway, bus, and train stations. workplaces: mobility trends for places of work. residential: mobility trends for places of residence. test rate: ratio of the number of individuals who have taken the virus test over the total population in the region. attendee: number of attendees in the protest. this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, the copyright holder has placed this version posted september 29, 2020. . https://doi.org/10.1101/2020.09.29.20203505 doi: medrxiv preprint this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, the copyright holder has placed this version posted september 29, 2020. . https://doi.org/10.1101/2020.09.29.20203505 doi: medrxiv preprint reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, the copyright holder has placed this version posted september 29, 2020. . https://doi.org/10.1101/2020.09.29.20203505 doi: medrxiv preprint reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, the copyright holder has placed this version posted september 29, 2020. . https://doi.org/10.1101/2020.09.29.20203505 doi: medrxiv preprint reuse, remix, or adapt this material for any purpose without crediting the original authors. this preprint (which was not certified by peer review) in the public domain. it is no longer restricted by copyright. anyone can legally share, the copyright holder has placed this version posted september 29, 2020. . https://doi.org/10.1101/2020.09.29.20203505 doi: medrxiv preprint time to use the p-word? coronavirus enters dangerous new phase factors influencing the epidemiological characteristics of pandemic covid 19: a tism approach the math behind why we need social distancing, starting right now understanding economic and health factors impacting the spread of covid-19 disease influencing factors of covid-19 spreading: a case study of thailand covid-19 pandemic: environmental and social factors influencing the spread of sars-cov-2 in the expanded metropolitan area of sã£o paulo a country level analysis measuring the impact of government actions, country preparedness and socioeconomic factors on covid-19 mortality and related health outcomes socioeconomic factors influencing the spatial spread clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study an empirical investigation of chronic diseases: a visualization approach to medicare in the united states covid-19 spread in the uk: the end of the beginning? environmental perspective of covid-19 estimating the effects of non-pharmaceutical interventions on covid-19 in europe school closure and management practices during coronavirus outbreaks including covid-19: a rapid systematic review digital technologies in the public-health response to covid-19 effectiveness of airport screening at detecting travelers infected with 2019-ncov applications of digital technology in covid-19 pandemic planning and response association, correlation and causation the causal effect of social distancing on the spread of sars-cov-2 causal analysis of covid-19 observational data in german districts reveals effects of mobility, awareness, and temperature difference-in-differences to identify causal effects of covid-19 policies. discussion papers of diw berlin 1870 multivariate analysis of factors affecting covid-19 case and death rate causal inference for covid-19 interventions dynamic causal modelling of covid-19 causal impact of masks, policies, behavior on early covid-19 pandemic in the u air transportation, population density and temperature predict the spread of covid-19 in brazil high population density in india associated with spread of covid-19 strong effects of population density and social characteristics on distribution of covid-19 infections in the united states racial demographics and covid-19 confirmed cases and deaths: a correlational analysis of 2886 us counties reaching the hispanic community about covid-19 through existing chronic disease prevention programs effect of non-pharmaceutical interventions to contain covid-19 in china. medrxiv key: cord-307303-9mzs5dl4 authors: barnett, daniel j.; balicer, ran d.; blodgett, david; fews, ayanna l.; parker, cindy l.; links, jonathan m. title: the application of the haddon matrix to public health readiness and response planning date: 2005-02-02 journal: environ health perspect doi: 10.1289/ehp.7491 sha: doc_id: 307303 cord_uid: 9mzs5dl4 state and local health departments continue to face unprecedented challenges in preparing for, recognizing, and responding to threats to the public’s health. the attacks of 11 september 2001 and the ensuing anthrax mailings of 2001 highlighted the public health readiness and response hurdles posed by intentionally caused injury and illness. at the same time, recent natural disasters have highlighted the need for comparable public health readiness and response capabilities. public health readiness and response activities can be conceptualized similarly for intentional attacks, natural disasters, and human-caused accidents. consistent with this view, the federal government has adopted the all-hazards response model as its fundamental paradigm. adoption of this paradigm provides powerful improvements in efficiency and efficacy, because it reduces the need to create a complex family of situation-specific preparedness and response activities. however, in practice, public health preparedness requires additional models and tools to provide a framework to better understand and prioritize emergency readiness and response needs, as well as to facilitate solutions; this is particularly true at the local health department level. here, we propose to extend the use of the haddon matrix—a conceptual model used for more than two decades in injury prevention and response strategies—for this purpose. sudden fever and dry cough, along with chills and muscle aches. despite these symptoms, after the flight he still managed to drive from dulles airport to anytown, maryland. within 2 hr of arriving at his apartment to his wife and two children in anytown, mr. smith's condition rapidly deteriorated, and he began to have difficulty breathing. his wife drove him to general hospital emergency department in anytown. mr. smith was admitted to the intensive care unit at general hospital on 8 march, with a suspected clinical diagnosis of severe acute respiratory syndrome (sars). three days later (11 march), doctors at one hospital in washington, dc, one hospital in baltimore, and general hospital in anytown admitted three patients each (total = 9 patients) with histories of acute onset of high fever (> 38°c) and dry cough followed by shortness of breath. upon taking a detailed travel history of these patients, physicians determined that seven of these nine patients (including the three new patients presenting to general hospital in anytown) had taken orioles airways flight 000 on 8 march 2004. two others had recently traveled to the united states from guangdong province, china. these developments were reported on a 24-hr cable media outlet before local, state, and federal public health officials had a chance to generate a formal press release. meanwhile, at general hospital in anytown, the condition of mr. smith steadily worsened despite aggressive treatment efforts, and he died of respiratory failure on the afternoon of 11 march. by 2000 hr on 11 march, local, national, and international media outlets had converged upon anytown, with a sea of television trucks and satellite equipment gathered outside general hospital. the 911 system became flooded with calls from anxious citizens throughout anywhere county, and cell phone networks were quickly overwhelmed by call volume. the mayor of anytown, maryland, and the local county health commissioner prepared to deliver a joint press conference with the state health commissioner at 2030 hr, followed by an address by the president to the nation on these developments at 2100 hr. by 13 march 2004, a total of 90 cases of sars were confirmed in maryland, pennsylvania, northern virginia, and the district of columbia. twenty of these patients had died thus far from respiratory failure. the news of these deaths brought added fear to the region and the nation. schools had been closed and unnecessary gatherings canceled in anytown and the rest of the affected region for the past 2 days. epidemiologic workup by the centers for disease control and prevention (cdc) in conjunction with state and local health departments revealed that most cases in this sars outbreak were traceable to mr. smith, the anytown businessman who had been exposed to sars while on business in taipei and who subsequently exposed fellow passengers on orioles airways flight 000 because of a faulty on-plane ventilation system. the remaining cases were traced to the two travelers to baltimore who came from guangdong province in china. questions. what are the hospital infection control issues associated with a sars outbreak, and what are the most effective approaches to address these issues? what type state and local health departments continue to face unprecedented challenges in preparing for, recognizing, and responding to threats to the public's health. the attacks of 11 september 2001 and the ensuing anthrax mailings of 2001 highlighted the public health readiness and response hurdles posed by intentionally caused injury and illness. at the same time, recent natural disasters have highlighted the need for comparable public health readiness and response capabilities. public health readiness and response activities can be conceptualized similarly for intentional attacks, natural disasters, and human-caused accidents. consistent with this view, the federal government has adopted the all-hazards response model as its fundamental paradigm. adoption of this paradigm provides powerful improvements in efficiency and efficacy, because it reduces the need to create a complex family of situation-specific preparedness and response activities. however, in practice, public health preparedness requires additional models and tools to provide a framework to better understand and prioritize emergency readiness and response needs, as well as to facilitate solutions; this is particularly true at the local health department level. here, we propose to extend the use of the haddon matrix-a conceptual model used for more than two decades in injury prevention and response strategies-for this purpose. of advance planning strategy could a local public health department use to identify the contributing factors to this public health emergency? what approaches could a local public health department use to deliver comprehensive public health prevention, intervention, and risk communication measures before, during, and after such an outbreak? it was late in the afternoon on a typically warm, humid, sunny 4 july afternoon in anytown, maryland. thousands were gathered at the anywhere county fairgrounds in anytown in preparation for that evening's upcoming parade and celebration, and the crowds were currently enjoying an outdoor concert and other festivities. police estimated the afternoon's crowd at the fairgrounds at approximately 10,000. there was a breeze blowing westward at 10 miles/hr, cooling the fairground crowd slightly and making them a little more comfortable. tens of thousands more were en route to anytown for the evening's celebration via the major highways, including i-95, i-495, and i-270. there was heavy freeway congestion at this hour outside downtown anytown. warnings from the department of homeland security had been issued for vigilance during the 4 july holiday weekend, but the nature of this terrorist threat had been nonspecific, and the nation had been at a u.s. terror alert level of code yellow on this 4 july holiday. it was estimated that 7,500 of the 10,000 people at the fairgrounds this afternoon were attending the concert. about 30 min into the show, a man driving a white van on any parkway suddenly stopped at the main entrance to the fairgrounds, about 50 yd from the concert venue. ten seconds later the van exploded in a massive fireball, the blast hurling fiery shrapnel into the crowd. the explosion killed 300 people instantly and injured 2,000 more in the adjacent crowd, and the blast could be heard over a 5-mile radius. smoke emanating from the resulting fire was visible to motorists on the congested freeways and roads leading to the fairgrounds. within moments of the blast, thousands of people began fleeing from the fairgrounds. motorists hearing the blast and seeing the smoke from area freeways and roads began to use their cell phones simultaneously by the thousands. cellular phone systems rapidly became flooded. on monday, 8 july, an associated press wire bulletin surfaced that three moisture density gauges-each containing 10 mci cesium-137-were first reported missing that morning from a construction site on maryland's eastern shore. the site manager said the gauges were last seen on 1 july, the day before the construction crew left the site for the extended holiday weekend. given this new information, public safety authorities had a high index of suspicion that this terrorist blast may have been caused by a "dirty bomb" containing the cesium-137 from the eastern shore construction site. environmental sampling revealed elevated radiation levels at the site of the explosion, consistent with this hypothesis. in the several weeks after the attacks, emergency rooms noted a surge in patients coming in for anxiety-related symptoms. area pharmacies were flooded with prescriptions for anxiolytic and antidepressant medications. community mental health services were being strained as anytown citizens attempted to come to grips with the horror of this terrorist attack. many residents of anytown stated they would never return to the city again because they believed the area would never be adequately decontaminated. questions. what are the potential environmental impacts of a dirty bomb? what can be done to prepare for and respond to such impacts? how would local, state, and federal public health and partner emergency response agencies work together in this scenario? what steps would be taken to distinguish a dirty bomb vs. from another type of explosion? what steps would be taken to evacuate, contain, and decontaminate the affected area? would evacuation involve all of anywhere county? who would take the lead in communicating timely, accurate information to the public on radiation terror before, during, and after this event? what would the crisis-and consequence-phase mental health service responses be to an attack on anytown by a "dirty bomb"? what steps, if any, could have prevented this attack from occurring or could have reduced the number of deaths and injuries? the haddon matrix. the field of injury prevention has long provided solution-oriented models for understanding threats to the public's health. industry and public health officials alike have applied these models to reduce morbidity and mortality from a variety of injury types. the haddon matrix, developed by william haddon, has been used for more than two decades in injury prevention research and intervention. the haddon matrix is a grid with four columns and three rows. the rows represent different phases of an injury (preevent, event, and postevent), and the columns represent different influencing factors (host, agent/vehicle, physical environment, social family and social support in aftermath of event environment). table 1 illustrates a basic application of the haddon matrix to pedestrian traffic safety. the host column represents the person or persons at risk of injury. the agent of injury impacts the host through a vehicle (inanimate object) or vector (person or other animal/organism). physical environment refers to the actual setting where the injury occurs. sociocultural and legal norms of a community constitute the social environment. the phases of an event are depicted on the matrix as a continuum beginning before the event (preevent), the event itself (event phase), and sequelae of the event (postevent phase). the terminology used for the factors of the matrix can be adapted for different contexts; for example, "agent" may be more appropriate than "vector" in certain cases, and "organizational culture" might be used in addition to or instead of "social environment" (tables 2-4) when focusing on an institutional context. through its phase-factor approach, the haddon matrix meshes concepts of primary, secondary, and tertiary prevention with the concept of the host/agent/environmental interface as a target for delivering public health interventions (runyan 1998) . each cell of the matrix represents a distinct locus for identifying strategies to prevent, respond to, or mitigate injuries or other public health challenges (runyan 1998) . by dissecting a problem into its dimensions of time and contributing factors, the haddon matrix can be applied as a practical, user-friendly interdisciplinary brainstorming and planning tool to help understand, prepare for, and respond to a broad range of public health emergencies (runyan 2003) . the haddon matrix and new readiness challenges for public health. as an integral component of homeland security in the post-11 september environment, the public health infrastructure faces new and significant challenges of recognizing and responding to article | haddon matrix and public health response planning environmental health perspectives • volume 113 | number 5 | may 2005 563 a broad range of intentional and naturally occurring large-scale threats. furthermore, since the anthrax attacks of 2001, the concept of public health emergency preparedness in the united states has evolved and expanded from a bioterrorism focus to an all-hazards readiness and response model. the all-hazards approach means that the infrastructure and skill sets used to prepare for and respond to a bioterrorism event can also be applied to a wide spectrum of current and emerging natural and intentional threats to the public's health, ranging from an infectious disease outbreak to a weather-related disaster. effective public health emergency preparedness and response requires appropriate preevent, event (crisis phase), and postevent (consequence phase) activities. in the context of emergency readiness, preevent activities include risk assessment, risk communication, and primary prevention efforts (e.g., preevent vaccination). event-phase public health activities involve crisis risk communication and community-based medical interventions such as postexposure prophylaxis and treatment, crisis mental health counseling, and isolation/ quarantine measures. postevent activities involve consequence-phase disaster mitigation and treatment of longer-term physical and mental health sequelae, along with ongoing risk communication and recovery efforts. table 2 presents a conceptual overview of public health emergency preparedness and response activities and competencies and how they might be illustrated using the haddon matrix. items with asterisks on table 2 are cdc-adopted emergency preparedness competencies for all public health workers developed by the columbia university school of nursing center for health policy (2002) . this highlevel view of the issues faced by those preparing for emergencies demonstrates the multidimensional flexibility of the haddon matrix. each phase of a public health emergency presents a unique set of demands on health departments in their readiness and response efforts. allocating resources for these phases is a significant challenge in the face of competing public health priorities and resource demands. these preevent/event/postevent phase challenges and the organizational flexibility requirements of an all-hazards response model can quickly become overwhelming for public health departments. by breaking a larger problem into smaller, more manageable components, the haddon matrix provides a practical, efficient decisionmaking and planning tool that health department leaders can use to better understand current and emerging threats, perform vulnerability assessments, prioritize and allocate readiness and response resources, and maintain institutional agility in responding to an array of public health emergencies. health department leaders can use the haddon matrix as a planning instrument to dissect the required preparedness and response requirements for any public health emergency scenario, and then strategize to meet these requirements using a "divide and conquer" approach. once the haddon matrix has been filled in for a given type of emergency, the cells of the completed matrix comprise specific preevent, event, and postevent task-oriented items that leaders can assign to appropriate staff to optimize their agency's readiness and response. some of these items within the completed haddon matrix may be more responsive than others to public health prevention and intervention, or may represent more pressing needs for a given community; this allows health department leaders to prioritize these assigned tasks based on the health department's unique demands and resources. the haddon matrix can also serve as a helpful after-action evaluation tool to assess a health department's performance in achieving the goals of a preparedness exercise, or in responding effectively to a real-life event. in this context, the tasks within each cell become items for performance evaluation that can contribute to an effective, comprehensive after-action report. a view of readiness challenges through the lens of the haddon matrix also promotes efficient use of public health resources, because the matrix can reveal strategies that allow multiple issues to be addressed by one solution. for example, the logistics of trying to anticipate every possible source of attack or emergency are staggering and impractical. the establishment of an effective incident command system and flexible emergency operations plan within a health department facilitates a more effective response regardless of the emergency. through the use of the haddon matrix, it becomes much more likely that public health departments will be able to maximize their readiness efforts, because policies and procedures that are identified as clearly beneficial in multiple scenarios can be developed ahead of less generalizable efforts. the haddon matrix also promotes efficient resource allocation by focusing on appropriate phase responses. because the matrix requires the user to follow issues across all of the phases of an event, problems that seem insurmountable during one phase might have ready solutions in a different phase. for example, the logistics of adequately sheltering a population upon the release of an infectious disease become much more manageable with a "preevent" educated population that understands the concepts of sheltering in place, emergency supply kits, and resources for additional trustworthy information. the model shows considerable flexibility as a tool to address threats-both intentional and unintentional-that face public health departments in their efforts to enhance public health readiness and response. from sars to dirty bombs, the haddon matrix reveals itself as a useful public health readiness tool for tackling difficult public health emergencies. of a naturally occurring public health epidemic that can be better understood and addressed via the haddon matrix. from diagnosis, to treatment, to infection control, to risk communication, sars is an infectious disease that exacts significant stress on multiple facets of the public health infrastructure (affonso et al. 2004; gostin et al. 2003) . a myriad of public health response issues surround a sars outbreak. table 3 shows an example of the haddon matrix as applied to one such issue: sars hospital infection control. this sars model of the haddon matrix views infectious disease as a form of injury affecting the population on a broad scale. the model allows its users to better understand the multidimensional nature of the epidemic and to identify targets for prevention, mitigation, and intervention. by identifying targeted points of intervention (noted with asterisks in table 3 ), we can discover potential measures to successfully mitigate the public health threat before, during, and after a sars event. considered in the event of an emerging infectious disease outbreak such as sars (loutfy et al. 2004; svoboda et al. 2004) . lessons on public health readiness are often learned painfully after large crises, as was the case during the sars outbreak of 2003 (campbell 2004; hearne et al. 2004 ). using the haddon matrix before an event occurs allows us to consider the interplay of variables that might otherwise have been missed (and were missed during the actual events associated with the sars outbreak). for example, in the preevent phase under physical environment, the haddon matrix reveals the importance of addressing the need for adequate personal protective equipment; this may seem obvious enough in hindsight, but this issue received insufficient attention before the sars outbreaks in 2003 (campbell 2004; reznikovich and balicer 2004) . equally important, the model is flexible enough to allow for big picture analysis of a situation, or a more focused analysis of the smallest units of study, including individuals. as a tool to understand, prepare for, and respond to sars, the haddon matrix thus reveals itself as a highly adaptable model. "dirty bomb" preparedness and response: a haddon matrix analysis. from a public health emergency readiness standpoint, the haddon matrix's adaptability also extends to environmental impacts of nonbiologic origin. radiation terror preparedness, for example, is a significant challenge in the emerging allhazards public health readiness framework, because the physical and mental health impacts of radiation terror on an affected area can be profound and long lasting. radiologic dispersal devices ("dirty bombs") are examples of radiation terror that present a challenge for homeland security because of their simplicity and relative ease of acquisition. dirty bombs are conventional explosives bundled with ionized radioactive sources, and remain a front-line terrorism preparedness concern in the post-11 september era (zimmerman and loeb 2004) . applying the haddon matrix to the threat of a dirty bomb illustrates the value of this injury prevention model as a public health readiness and response tool, even when focusing exclusively on environmental issues. table 4 shows how the haddon matrix can be applied to address environmental health issues related to dirty bombs. although the human, agent, physical, and social factors are numerous, a closer look reveals a more specific set of points for targeting environmental assessment and intervention (table 4) . like the haddon matrix for sars in table 3 , the haddon matrix for dirty bombs in table 4 reveals the host, social environmental/ organizational culture, and selected physical environmental dimensions as major points of impact for public health assessment and intervention (noted with asterisks). hazardous materials (hazmat) and other first-responder agency personnel would comprise the front lines at the scene of a dirty bomb event, rather than health department workers. nonetheless, a comparison between the dirty bomb and sars haddon matrix examples shows marked similarities in the importance of risk communication, mental health support, resource use, surge capacity, and effective surveillance as points of public health impact, consistent with an all-hazards readiness and response framework. table 4 reveals that from an environmental perspective, modifiable public health "impact" opportunities for dirty bomb preparedness and response involve mainly organizational culture/ social environment factors, as well as a few host and physical environment factors. the legal and regulatory aspects of environmental remediation after a dirty bomb are critical public health issues with significant economic implications (elcock et al. 2004) ; these are also reflected in table 4 as "impact" opportunities on the haddon matrix. collectively, these modifiable host, physical environment, and social environment/ organizational culture factors represent targets for streamlining readiness and response activities; addressing the safety, risk perception, and mental health needs of first responders and hazmat personnel; and managing the financial resource and response issues of a dirty bomball of which are critical pieces in dealing with the environmental impacts of a dirty bomb. the applied examples of sars and dirty bombs illustrate the utility and flexibility of the haddon matrix as a tool for understanding, preparing for, and reacting to a spectrum of intentional and naturally occurring public health threats. following the principle that "all disasters are local," the haddon matrix can provide a tool for public health agencies to address specific gaps and requirements that must be filled to meet their communities' unique readiness needs. additionally, the haddon matrix can serve as a helpful model for disaster preparedness and response in a variety of contexts, from public health readiness policy development to local public health practice emergency response planning. as an effective creative brainstorming and planning tool, it is ideally suited to facilitate tabletop preparedness exercises at health departments in cooperation with partner firstresponse agencies. it can assist in needs assessment efforts for public health agencies and their stakeholders. it also can serve as a valuable classroom aid in teaching public health readiness concepts at the secondary and graduate school levels, helping future public health leaders to develop critical problem-solving skills needed to tackle difficult readiness challenges. these examples and their potential applications highlight five essential features of the haddon matrix as a tool for public health emergency readiness and response. first, the haddon matrix provides a framework for understanding a terrorism incident in a temporal context, including its preevent, event (crisis), and postevent (consequence) phases. second, it can effectively dissect these temporal phases of a public health event into their contributing factors. third, it can aid in a public health agency's vulnerability assessment of its preparedness and response capacities. fourth, it can provide health departments with a useful framework for developing these capacities to deliver a prioritized, targeted approach to the public health dimensions of terrorism prevention and response. fifth, it is a sufficiently flexible analytic tool to aid health departments in addressing virtually any type of intentional or naturally occurring public health emergency. the dissection of sars and dirty bombs by the haddon matrix reveals how widely disparate public health challenges can be tackled by a user-friendly and efficient injury prevention conceptual model. a renewed look at the haddon matrix thus shows this tool to be a vital link between public health preparedness and injury prevention science. the urban geography of sars: paradoxes and dilemmas in toronto's health care the sars commission interim report: sars and public health in ontario bioterrorism and emergency readiness: competencies for all public health workers establishing remediation levels in response to a radiological dispersal event (or "dirty bomb") ethical and legal challenges posed by severe acute respiratory syndrome: implications for the control of severe infectious disease threats sars and its implications for u.s. public health policy: "we've been lucky the canadian experience with the sars outbreak-israeli lessons to be learned using the haddon matrix: introducing the third dimension introduction: back to the future-revisiting haddon's conceptualization of injury epidemiology and prevention public health measures to control the spread of the severe acute respiratory syndrome during the outbreak in toronto dirty bombs: the threat revisited. defense horizons 38 the development of this manuscript by johns hopkins center for public health preparedness was supported in part through a cooperative agreement u90/ccu324236-01 with the centers for disease control and prevention.the authors declare they have no competing financial interests. key: cord-253120-yzb8yo90 authors: popovich, michael l.; watkins, todd; kudia, ousswa title: the power of consumer activism and the value of public health immunization registries in a pandemic: preparedness for emerging diseases and today’s outbreaks date: 2018-09-21 journal: online j public health inform doi: 10.5210/ojphi.v10i2.9147 sha: doc_id: 253120 cord_uid: yzb8yo90 public health immunization registries and the immunization ecosystem have evolved over the past two decades to become significant population health data assets. clinical providers and pharmacists are reporting the immunizations given to their patients to public health registries in 49 states and all territories, creating consolidated immunization event patient records. most of these immunization events are reported through the provider’s electronic health record system (ehr), pharmacy management system (pms), online, or through data uploads. meaningful use and health data standards (hl7) became the drivers that accelerated reporting to immunization registries and significantly improved the quantity and quality of the data. the infrastructure supporting the immunization ecosystem (ie) has enabled real-time compliance reporting and, more importantly, real-time patient queries. the provider community now has online access to a patient’s immunization history in over three quarters of the states, and growing. this access includes a forecast of the patient’s immunization gaps provided by public health decision support tools based upon the most recent acip recommendations. this is creating an opportunity for the provider and the patient to work together to reduce their risk of suffering a vaccine-preventable disease. this ie and the data in an immunization information system (iis) are especially useful as pharmacies expand their immunization practices and create opportunities to reduce the adolescent and adult immunization gaps. in a few states, this provider-public health ecosystem has begun to extend to individuals by allowing them to access the iis online through the use of myir. myir provides them with the electronic version of their immunization "yellow cards," recommendations for immunizations due, and the ability to print official certificates. this emerging consumer engagement creates opportunities to empower individuals to be more proactive in their family’s health care. this paper builds upon early experiments to empower individuals in this ecosystem by leveraging the value of these public health data assets and trusted communications, illustrating the possibilities for engaging consumers to support reducing the impact of emerging diseases, outbreaks and the next pandemic. this paper will suggest the value of the ie and the role individuals can play within their own social networks to advance public health efforts to manage disease events. in turn, this social mission would encourage consumers to be more proactive in managing their own healthcare. most of these immunization events are reported through the provider's electronic health record system (ehr), pharmacy management system (pms), online, or through data uploads. meaningful use and health data standards (hl7) became the drivers that accelerated reporting to immunization registries and significantly improved the quantity and quality of the data. the infrastructure supporting the immunization ecosystem (ie) has enabled real-time compliance reporting and, more importantly, realtime patient queries. the provider community now has online access to a patient's immunization history in over three quarters of the states, and growing. this access includes a forecast of the patient's immunization gaps provided by public health decision support tools based upon the most recent acip recommendations. this is creating an opportunity for the provider and the patient to work together to reduce their risk of suffering a vaccine-preventable disease. this ie and the data in an immunization information system (iis) are especially useful as pharmacies expand their immunization practices and create opportunities to reduce the adolescent and adult immunization gaps. in a few states, this provider-public health ecosystem has begun to extend to individuals by allowing them to access the iis online through the use of myir. myir provides them with the electronic version of their immunization "yellow cards," recommendations for immunizations due, and the ability to print official certificates. this emerging consumer engagement creates opportunities to empower individuals to be more proactive in their family's health care. when asked what scared him the most and kept him up at night, tom frieden, the former director of the cdc, replied: "the biggest concern is always for an influenza pandemic." [1] a recent cnn article [2] outlined the world health organization's (who) review of potential public health emergency diseases that included the top 10 global concerns: crimean-congo haemorrhagic fever (cchf), ebola virus disease and marburg virus disease, lassa fever, middle east respiratory syndrome coronavirus (mers-cov) and severe acute respiratory syndrome (sars), nipah and henipaviral diseases, rift valley fever (rvf), zika, and finally disease x. currently there are no vaccines to prevent these. the who's disease x was included in this "list of blueprint priority diseases" [3] because the world does not know what pathogen can cause the next epidemic. globally, as well as in the u.s., epidemiologists and public health professionals work endlessly to ensure the risk and impact of existing and emerging diseases are minimized, and that neither turns into a pandemic. as the world increasingly becomes interconnected through travel and technology, timely information and accurate data become more imperative. early warning of disease occurrence and assessing the resulting impact on the public are paramount. early warning systems referred to as "syndromic surveillance," along with mandated notifiable disease reporting, capture data and electronically process the information to present public health with a view into future potential impacts. over the past two decades, new information systems have played a key role in improving public health's early warning and case management for disease outbreaks. as improved analytics are used to predict risk in populations, researchers and epidemiologists open new doors to disease cures, clinical research develops new medicines, and providers develop new care models. the role of technology and public health to support these efforts therefore becomes more valuable. health information systems are traditionally considered to be used for electronic medical record or payer billing systems. they are not paired with technology advancements that exist in the ojphi hands of consumers which could encourage patients to be more proactive with their healthcare. efforts today to link information and technology to engage consumers are championed by health plans and healthcare providers. engaging and empowering individuals to be proactive when presented with their medical records is not a simple problem to solve. it is not just a matter of making data available but making it actionable. actionable information may not achieve the desired success. but what if… this was augmented with another social mission? what if… the health community engaged consumers to help them fight disease outbreaks; what if… consumers become frontline activists to report occurrences and outcomes, and become "intelligent connections" to extend the right information in their social networks? this would encourage today's consumer technology to be better integrated with the clinical health information technology (hit). it would encourage continued investment in evolving and sustaining critical public health ecosystems. it would create opportunity to engage consumers, empowering each to be more proactive in supporting population health and their own healthcare. another large part of the health information system are immunization information systems (iis) where individuals who have received vaccines are documented in a confidential computer based system in a specific geographic area [4] . the iis can be used for disease surveillance purposes and provide valuable information to public health authorities [5] . as an extension of one of the existing iiss, myir was created where any state iis, pharmacy or provider can provide patients direct access to family state immunization records -regardless of the type of immunization information system used. providers can communicate to patients using myir to increase patient engagement. automated vaccine reminders can be sent using this system as well. during a pandemic, the need for accurate and timely information is vital. we propose that if there were direct public health agency communication channels to individuals -by building on existing immunization networks, the public would receive correct information quicker. furthermore, there is value that can be leveraged from social networks to advance public health efforts to manage disease events and in turn encourage consumers being more proactive in managing their own health care. one could envision a public-health-engagement-approach to empower consumers begins by offering individuals a challenge and a mission they care about. a mission that allows them to contribute to the social good with the added benefit of making them more attentive to their own healthcare. placing this mission in the palms of their hands through every cell phone is the first objective. the second is to create value for this phone's owner to become active in supporting the mission. the third objective is to provide a commonly understood health event that is a cornerstone component to this phone owner's health and welfare that helps launch them toward utilizing their complete health information profiles. universally the most significant public health event in the 20th century was the power of vaccines and applied immunizations to individuals and large populations [6] . online journal of public health informatics * issn 1947-2579 * http://ojphi.org * 10(2):e203, 2018 the most significant action an individual can take to reduce their risk of a vaccine-preventable disease is to become vaccinated and stay up-to-date on their immunizations. however, there is a significant gap between believing in the value of an immunization and in ensuring one's own (and one's family's) immunizations are current. how many individuals really understand what the immunization schedule recommends or are proactive in ensuring they have no immunization gaps? how many of these same individuals in an outbreak or with news of a new disease ask the question "is there a vaccine and what are my risks?" the challenge is how to engage individuals directly, empower them to be advocates for their own health and in an outbreak become sources of trusted public health messages as they communicate within their social network, effectively supporting the higher-level mission. the lesson learned from every outbreak? that the public demands accurate, timely, and transparent communication from the government. if this public health information is communicated directly to this new evangelistic network, there is the potential to expand to larger consumer networks. a few separate experiments were conducted using myir. the first experiment aimed to increase sustainment. the engagement project was to reach out in an effort to increase sustainment by contacting users who had not used myir and accessed their data from the iis in over 30 days. the baseline looked at number of users that were logging into myir more than once a month. the target was non-engaged users. in this category there were nearly 8,000 accounts. the second experiment aimed to engage the consumer for the flu shot. for this campaign, on november 21st, 2017, an email was sent to 7,772 users that asked them a simple question, "did you get your flu shot?" if they selected yes, they saw a funny meme and received positive affirmation. if they clicked no, the message was an encouragement to get their flu shot before thanksgiving 2017. in the third experiment, consumer engagement effort was initiated january 19, 2017. capitalizing on the popularity of new year's resolutions around wellness this engagement experiment created a healthy lifestyle page within myir. it featured an arizona food blogger, simple, sassy and scrumptious, who offers readers nutritious easy meal ideas. the fourth experiment focused on outreach efforts where louisiana targeted users who had failed to complete the two step process to fully enroll for access to their immunization histories. forty-nine states have established immunization information systems (iis) to capture and consolidate patient immunization events as reported by their clinicians or pharmacists [7] . hl7 is a set of standards for the transfer of clinical and administrative data between applications among the healthcare system's stakeholders. in nearly all these states, and soon all, secure hl7 data exchanges exist, allowing electronic health records (ehrs) and pharmacy systems to report a patient immunization event to the state iis in real time. furthermore, this infrastructure allows a clinician or pharmacist to review a patient's vaccine history and actionable immunization intelligence provided by public health decision support tools that using the latest advisory committee on immunization practices (acip) recommendations to identify immunization gaps and establish opportunities for closing these through communication at the patient point-of-care. the immunization ecosystem is based on what public health has spent the past quarter century developing. this is based on statewide population health environments consisting of key data assets and technical infrastructure for reporting, accessing and assessing immunization activity. additionally, these systems layer decision support, analytics, and communications across the entire population health environment. the value that the immunization ecosystem creates is the ability for all key "players" to integrate or connect. thus, a national immunization ecosystem exists today and, as it continues to evolve, the framework and platform are primed to impact the cost of health care and improve patient outcomes. the key is to fully extend the framework to the consumer, creating end-to-end communication channels between trusted health authorities and individuals. pandemic preparedness planning that takes advantage of iiss, their infrastructure and their players while engaging individuals to be consumer activists in an emergency response network, is potentially a new approach to accelerating individual health accountability while offering public health the ability to communicate valuable outbreak or pandemic information. by doing so, the outcome should influence day-to-day consumer behavior to mitigate the outbreak's impact on the population. the 2003 sars outbreak (with a 40-billion-dollar economic impact) [8] , the 2009 h1n1 pandemic, and the 2015 zika outbreak confirmed that the questions asked by the public in each of these events were: • is there a vaccine for this [ the ability for continued government and health authority responses to these questions is an important step toward managing the welfare of concerned populations while outbreaks are studied, and public health mitigation plans are put into place. the velocity of information, both accurate and inaccurate, cannot be controllable through current communication channels available to disseminate information to individuals, especially those most at risk. public health has an expectation and relies on their disease specific health education reaches at risk individuals, and is clearly understood and accepted. this reliability can be impacted by the social media and online consumer world today. much of the public's information and behavior during a pandemic will be influenced through these social media and online networks [12] . individuals will search for data they choose to believe [13] . once found, they will push this information to their family and friends and their social media sphere of influence [14] . information from social media can pose as a challenge to stability for the trusted information that public health wishes to deliver in order to inform and encourage those at risk to take action [15] . when a pandemic occurs, the need for accurate and timely information accelerates. if the odds of receiving accurate information during a pandemic are against you in the social media world, consider the opportunity if there were direct public health agency communication channels to individuals -by building on existing immunization networks. accurate communications would be the goal during a public health event. in washington and louisiana currently, over 35,000 consumers access their immunization records through real-time connections to the state iis through myir. the "players" in these states encourage individuals to enroll for access. once enrolled, an individual is connected to one of their health data attributes through the immunization platforms, which also establishes information access to trusted health agencies. it creates the opportunity to accelerate consumer engagement and activism in a pandemic or outbreak by layering digital communication to individuals to include those most at risk, and supporting the extension of this trusted communication through the individual's social network. 1. using existing infrastructure for immunization data exchange, establish communication links to trusted public health authorities supporting the following actions: a. inform and engage consumers by proactively alerting and notifying each individual of their immunization coverage gaps. b. identify the nearest locations capable of providing specific immunizations and antivirals to high risk populations. c. capture feedback and monitor outcomes or concerns of individual immunization events at their time of occurrence as well as over an extended period of time. d. capture surveillance of personal (family) health events, such as influenza or influenza-like illness. 2. integrate provider, pharmacy and laboratory patient influenza tests, public health influenza reporting, and overall tracking of the most recent outbreak. 3. integrate outbreak occurrences through alerts and visual displays (risk and outbreak maps). 4. provide social media exchanges to link immunization ambassadors and general social networks that can support the concept of "layering" to reduce the impact of an outbreak and to ensure a controlled, consistent and accurate dissemination of information. since 2016, a number of immunization consumer engagement campaigns have been undertaken by stc to explore the power of direct links to individuals who have enrolled and have access to their immunization records. in a 90-day period from mid-august 2016 to mid-november, the stc consumer tool myir had 15,000 total user visits to the state immunization registry. of these 23% were returning users. in that same period 3,200 users visited myir more than once a month. they spent an average of 5 minutes on the site each time and viewed seven different pages. typically, this included the initial login, requests for their immunization records, and reviewing the forecast or immunizations due or past due for each family member. in reviewing the individuals that enroll for user access to the immunization registry, they currently are from a specific demographic. the majority are within the ages of 25-44, with 72% being female. this suggests the people who see the most value in myir are likely to be women with a family. 27% of people opened the initial email and 3.6% of these individuals used myir within 30 days to access their immunization records. 9% answered the question with 80% of these saying "yes" they got their flu shot. as a result, 25 new immunizations were administered to these individuals within 60 days. one nine-month-old family member received a full series of age appropriate immunizations. a 7.1% increase in returning users were tracked and a 9.1% increase in engaged users, again defined as logging in more than once a month. there was also a 6.7% increase in average session duration. five hundred fifty-six emails were sent and a 30% open rate was achieved. the email contained a single step to finalize the enrollment and thus access to their immunization medical records. fifty of those who opened the email followed through and completed the process. respondents were asked: "did you get a flu shot this year? do you feel like you got the flu this year?" 78% responded they did receive the flu shot this year. of these 61.5% felt they got the flu this year which equates in this group to a 38.5% efficacy rate for this year's influenza vaccine. in february, cdc had determined the interim estimates for the effectiveness of the influenza were 36% [16]. these consumer engagements were early experiments. they initially targeted to increase consumer access and utilization of the information contained in a public health immunization registry. they have moved toward soliciting input from active users to test the concept of empowering advocates to support a larger public health mission and engage with trusted communications from government. they created the thought processes that lead to the concept of extending the ie to proactively engage individuals to support public health missions, notably outbreaks and the next pandemic. the data, technical frameworks and infrastructure of the iiss form the environment to engage and empower consumers to be field assets to support outbreak mitigation efforts and be instrumental within the social networks if a pandemic were to occur. our aim was to illustrate examples where public health agencies using direct communication channels to individuals -by building on existing immunization networks, could increase the efficacy of reaching the public with correct information. the illustrations used to demonstrate the ojphi consumer engagement potential were not designed to test the hypothesis that consumer activism and the value of public health immunization registries in a pandemic would prove effective. they do demonstrate the potential of engaging individuals that have enrolled to access their immunization records from public health registries. they demonstrate that a subset of these individuals will provide information requested from public health authorities. it was through these early experiments and the growing data assets in state immunization systems that create a framework and technical platform to accelerate the potential value of engaging individuals in response plans for pandemic preparedness planning and support of today's outbreak. the next step is to begin to engage individuals to establish those that would be willing to provide ongoing information to public health specific to immunizations and disease occurrences. this would include developing experiments that test a social campaign to engage these individuals over the course of a year to ensure they remain activists in this network and then initiate efforts to encourage them to be proactive in their health care. the impact would be monitored in order to begin to establish a model with key parameters that would allow scaling across states and different demographics of users. the experiments illustrated were not statistically tested or compared to other sources.they were not designed to collect specific and more detailed information in support of an outbreak to determine if it is possible to enroll advocates and ensure consumer activism. however, sufficient assets and a growing community of individuals with access to their online immunization histories suggest a specific demonstration project to test this hypothesis is warranted. the paper presents a concept of empowerment and a few example consumer engagement tests that indicate the possible opportunity for public health. the results of the consumer engagements were not measured against a specific research goal to determine their effectiveness. there were no comparisons to other public outreach and education methods that would established the potential. the consumer outreach efforts were not regional, culturally, or demographic specific and as such there was no intent to determine the true public health education to populations approach. these are all recommendations for next steps although there is some justification to simply begin to enhance and expand the current process and develop a stronger strategy to be tested. this is the start. the immunization ecosystem is a robust environment to build upon. consolidated immunization information systems and technology supported by public-private partnerships have reached the dynamic where data and information is available across wide networks of users, stakeholders, and consumers. while health plans, providers and pharmacists struggle to engage their networks, by encouraging patients to be proactive in their healthcare, public health immunization assets may be the tipping point to accelerate this movement since the single most common health event is an immunization, required from birth to death. furthermore, pandemic preparedness planning is primed to step beyond just response actions and traditional communication plans to reach directly into areas where outbreaks are occurring, ojphi soliciting consumer activism through this ecosystem to report disease occurrences and disseminate accurate information as public health works to mitigate the outbreak. the hypothesis can extend one step further: if you are active in supporting a higher cause and technology is the facilitator, the belief is this would not only reduce the risk of outbreaks and help mitigate the economic impact and costs, but also create momentum for more people to become proactive with all their healthcare. continued investment through government immunization programs, centers of medicare and medicaid services (cms) 90/10 match programs, office of national coordinator (onc) efforts supporting innovation, and consumer empowerment are essential to continue to evolve and sustain the immunization ecosystem and data assets. as these assets create added value to each stakeholder, the government investment begins to create a positive return. the private sector benefits also grow. their investment in this same ecosystem is necessary. today, opportunities to use this ecosystem to drive down healthcare costs and improve patient outcomes are unlimited. the value of this virtual ecosystem to the nation is untapped. being ready for the next pandemic through everyday practice is unique. we are in unique times. 2 players in this sense represent all key stakeholders that utilize immunization information and include public health, providers, pharmacists, payers, employers, school nurses, foster care, consumers, and more. 3 for example, feedback such as: did you receive this year's influenza immunization? do you feel like you have the flu? (the dollar cost of the flu on the u.s. economy, according to cdc health affairs 2016-17, was $5.8 billion.) in a pandemic with a new vaccine, the question might be: do you feel you had a reaction to the vaccine? 4 federal funding provided by onc has partially supported the expansion and testing of stc's myir since 2014. 5 sustainment of public health immunization registries and technical infrastructure is the subject of a separate stc paper, "sustaining the public health immunization ecosystem through public private partnerships." 6 the content and concepts of this paper are based upon stc's 25 years of working in the immunization registry sector, which includes implementing state public health iis, implementing electronic hl7 connections to every state iis from over 30,000 pharmacies and 10,000 providers, and using data and analytics to tell the story of the power of the ecosystem. chief talks about agency's successes-and his greatest fear. the washington post world health organization gets ready for 'disease x'. cnn [internet] list of blueprint priority diseases. world health organization about immunization information systems immunisation information systems -useful tools for monitoring vaccination programmes in eu/eea countries centers for disease control and prevention (cdc). 1999. ten great public health achievements--united states immunization information systems (iis) fundamentals:overview and development. centers of disease control and prevention estimating the global economic costs of sars learning from sars: preparing for the next disease outbreak: workshop summary pandemic (h1n) 2009: frequently asked questions centers of disease control and prevention (cdc). questions about zika. cdc frequently asked questions on severe acute respiratory syndrome (sars). who [internet the effects of media reports on disease spread and important public health measurements why facts don't change our mind. the new yorker news sharing in social media: the effect of gratifications and prior experience a new dimension of health care: systematic review of the uses, benefits, and limitations of social media for health communication. eysenbach g we would like to thank theresa munanga for her editorial assistance. we would also like to thank all stc employees, especially those who assisted with the myir studies. key: cord-288477-dojdlfrv authors: doerr, megan; wagner, jennifer k title: research ethics in a pandemic: considerations for the use of research infrastructure and resources for public health activities date: 2020-05-18 journal: j law biosci doi: 10.1093/jlb/lsaa028 sha: doc_id: 288477 cord_uid: dojdlfrv the number and size of existing research studies with massive databases and biosample repositories that could be leveraged for public health response against sars-cov-2 (or other infectious disease pathogens) are unparalleled in history. what risks are posed by coopting research infrastructure—not just data and samples but also participant recruitment and contact networks, communications, and coordination functions—for public health activities? the case of the seattle flu study highlights the general challenges associated with utilizing research infrastructure for public health response, including the legal and ethical considerations for research data use, the return of the results of public health activities relying upon research resources to unwitting research participants, and the possible impacts of public health reporting mandates on future research participation. while research, including public health research, is essential during a pandemic, careful consideration should be given to distinguishing and balancing the ethical mandates of public health activities against the existing ethical responsibilities of biomedical researchers. although public health research is undoubtedly essential during a pandemic, 1 the line between research and public health activities is tricky in the best of times and can blur quickly in a public health emergency. 2 elements common to both endeavors range from study design, to the collection and use of personally identifiable and protected health information, and to analysis techniques. many point to the a priori purpose of a given initiative as a way to distinguish between research and public health activities. 3 yet, even while public health practice focuses on assurance, assessment, and policy development, these activities might contribute to generalizable knowledge-the hallmark of research. for example, in 2010 following the deepwater horizon oil spill in the gulf of mexico, the u.s. centers for disease control and prevention (cdc) tapped into the national poison data system (npds) for the purpose of monitoring health impacts of people in the region (ie, surveillance as a public health activity). nevertheless, the cdc's utilization of the npds post-environmental disaster also demonstrated the database's utility for advancing scientific understanding of how oil spill exposures affect human health (ie a resources for potential public health research with the primary purpose of contributing generalizable knowledge). 4 additionally complicating the divide between research and public health activities 5 is the now widespread practice of banking of data and samples for secondary research use. during a public health emergency, research repositories are attractive, ready-made data resources and communication channels with large, and, ideally, diverse cohorts through which public health activities could be pursued expeditiously. given that emergency responses 'tend to be nonresearch,' 6 what risks are posed by repurposing research infrastructure for public health activities? the covid-19 pandemic has already provided case examples highlighting key questions about the public health activities that seek to leverage existing research infrastructure. for research participants and collected nasal swabs with the goal of improving detection, monitoring, and control of influenza outbreaks in greater seattle, washington. on march 10, 2020, the new york times 8 reported on sfs's ongoing efforts to assess retrospectively the prevalence of the 2019 novel coronavirus, sars-cov-2, 9 using nasal swab samples collected for research purposes during the 2019-20 influenza season. in early february 2020, sfs began petitioning the state, cdc, and u.s. food and drug administration (fda) officials for permission to use the sfs's existing sample bank to track covid-19 spread. sfs participants had consented to the testing of their swabs for influenza and 'other respiratory pathogens (germs)' and to receiving these research results back from the study team, as well as for the secondary use of their data for research purposes. through the consent process, sfs had alerted participants that washington state law requires reporting of infectious diseases, including influenza, 10 but did not discuss the use of sfs's research infrastructure, including data or samples, for other public health activities. 11 after about 2 weeks of rebuff, and within the context of undeniable national spread of the virus and inadequate testing for it, the sfs team decided to test the samples without the explicit approval of public health authorities or regulators. the sfs team promptly identified a sars-cov-2 positive result and alerted local public health officials. the sample was rerun in the washington state laboratory, where the positive result was confirmed, and the research participant was subsequently notified by public health officials. 12 despite this apparent successful use of existing research infrastructure for public health activities, 13 cdc and fda regulators ordered sfs to stop retrospective testing of their existing samples immediately but indicated that, with additional consent language clarifying the use of research study materials for public health activities, sfs could prospectively test participants for sars-cov-2. in the first few days of march, the university of washington's ethical review board determined that, given the public health emergency, sfs had an ethical obligation to test all samples for sars-cov-2, citing that sfs already had consent from participants to test for another communicable diseases and return those results and, therefore, was already engaged in both research and public health activities. on march 9, 2020, state regulators again shut down retrospective testing by sfs. 14 sfs eventually completed its retrospective testing of samples, identifying 25 positive results across 2353 participants, including the first documented case of community transmission of sars-cov-2 in the usa. 15 the back and forth between federal and state authorities, the research team, and the overseeing ethics board, which eventually culminated in the seattle flu study turning its resources toward a joint public health initiative announced march 23, 2020, 16 illustrates the complexity of the boundary between federally regulated research and public health activities 17 and highlights key concerns about the repurposing of research infrastructure and its use for public health activities. firstly, what are the points researchers must consider as they contemplate either mining already collected research data during a public health emergency, or, as in the case of the sfs, undertaking new analyses on already collected samples in the name of public health response? secondly, what are the considerations for reporting back to research participants types of information derived from public health activities not explicitly disclosed in the informed consent process? thirdly, given the uncertainty of risks and benefits posed by public health activities, are there any additional concerns raised by legal mandates to disclose information derived from research sources to public health authorities at different governmental levels? these questions are particularly worthy of contemplation given the number of large research initiatives' data and sample banks that could potentially be called upon by public health authorities during this pandemic-including, notably, the national institutes of health's all of us sm research program. most federally sponsored human subject research activities are governed by a set of regulations known as the common rule. 18 however, while public health research is governed by the common rule, public health activities 19 are among those deemed 'not to be research' and therefore entirely outside of common rule's reach. 20 this regulatory exception specifically acknowledges that public health activities may 'use information and biospecimens from a variety of sources,' including, presumably, from existing research studies or data repositories. section 46.104(d)(4)(iii) further clarifies consent is not required for secondary use of research data or biospecimens for public health activities. so regardless of whether the data used for public health activities are data that have been previously generated for research or novel data generated from research samples, public health activities are legally considered 'not research.' following from this exemption, the use of research data/specimens for public health activities does not require consent from the individuals to whom those data and samples originated. from this perspective, the sfs would not have needed additional consent of participants for sars-cov-2 testing had the sfs's sars-cov-2 testing been designated a public health activity. arguments in favor of research data use for public health activities highlight the difference between the profound physical and emotional harms wrought by historical antecedents, such as the notorious u.s. public health service syphilis study at tuskegee, and the potential dignitary harms caused by data or samples previously derived from consented research participants being used for public health activities. and if the primary risk posed to research participants by public health activity use of their data is dignitary harm, researchers should correspondingly consider the privacy rights of participants (outside of those mutually agreed upon in informed consent) before proceeding with these activities. the most influential health data privacy protections in the u.s. are codified by the health insurance portability and accountability act (hipaa) privacy rule. 21 all covered entities and their 'business associates' must follow the hipaa privacy requirements, which generally covers people/entities providing healthcare, health insurance, or related services. under hipaa, outside of their use for care delivery, anyone wanting access to a person's records must obtain their explicit consent with a few very specific exceptions. one of the exceptions that allows for no-signature release of protected personal health information is the request of a 'public health authority.' 22 within the regulations 'public health authority' is broadly conceptualized as a federal, state, or other territorial division's agency or authority (or their designee), whose mandate includes public health matters. notably, the u.s. national institutes of health (nih), the largest funder of biomedical research in the world, 23 is authorized by law to assist as a 'public health authority' based on u.s. department of health and human services (hhs) interpretation dating back to at least december 2002. 24 as a public health authority, one might argue that the entirety of the nih's research resources-whether nih-funded researchers or participants are aware or not-might be accessible for use in public health emergencies unless other restrictions would preclude such use. notably, the sfs, funded through the private brotman baty institute for precision medicine, 25 under nih's public health authority designation and was not designated as a public health activity by state authorities as it initially pursued sars-cov-2 testing. of further interest with regard to privacy protections, during a pandemic, certificates of confidentiality-which are shields protecting identifiable sensitive research information from disclosure-are potentially penetrable, as disclosures are permitted if required by laws regarding the reporting of communicable diseases, necessary for the individuals' medical care, or done with the individuals' consent. 26 although the human subjects research regulations are relatively clear-cut with respect to public health activities, the ethical considerations for the use of existing research infrastructure for public health activities might not be. past examples of unethical practice of public health research drove the development of the current regulatory structures intended to protect human research subjects. 27 almost two decades ago, dr nancy kass set forth an ethical framework for public health practitioners to assess the implications of public health activities, distinguishing biomedical ethics (which relies heavily upon individual autonomy) and public health ethics (which emphasizes justice, among other principles). 28 later lee, heilig, and white (2012) provided a compelling justification for the conduct of public health surveillance in the absence of explicit consent from individual patient-participants, 29 recognizing an ethical obligation to put any public health data collected to use and, similarly, the need to justify nonuse of data that has been collected ['to use the data we collect for public health benefit; not using the data for improving health must be justified' (at 42)]. as felice batlan highlights in her analysis of national security claims from the lens of public health emergency, 30 the power to define a 'public health emergency' and the ethical concerns raised by these powers are far from straightforward. these complexities are only compounded if individual researchers themselves-rather than designated public health authorities (such as the nih as a whole) who/which are, at least, politically accountable-take it upon themselves to engage in public health activities, as did the researchers of the sfs who quietly defied state and federal guidance to continue their testing program. 31 when research resources have been funded by public tax dollars (such as nih grants), even decisions regarding the well-intentioned donation of supplies and equipment (redirecting such items from research labs that were wound down as nonessential during the pandemic to support emergency medical 26 compromising individual rights and interests for public benefit has a fraught and contentious history. yet even the constitutionally protected right to privacy has long been recognized as not absolute but one that is (i) conditioned upon exercise of that individual right to privacy not interfering with another's enjoyment of the same right and (ii) subject to reasonable, proportional, and necessary constraints imposed by state and local authorities fulfilling their roles to ensure public health and safety and by federal authorities supplementing such public health responses when they are inadequate. 34 moreover, there is a compelling argument that, although not yet widely recognized, there exists a constitutional right to public health. 35 this argument builds upon an acknowledgment that health has individual and collective aspects, as individuals alone 'cannot achieve environmental protection, hygiene and sanitation, clean air and surface water, uncontaminated food and drinking water, safe roads and products, or control infectious disease.' 36 in any case, considering vertical conflicts between local, state, and federal authorities and issues regarding preemption is essential to reconciling researcher obligations that seem to be inconsistent or in conflict within public health law and ethics: a reader 2 (2nd ed. 2010)) (emphasis added). the interaction of and relationship between the right of privacy and right of public health are both interesting and important considerations; however, given such a discussion requires advanced legal analysis and involves complex legal theory, it has been left for discussion elsewhere. the specific context of a public health emergency. research repositories that cross jurisdictional boundaries could be particularly complicated in this regard when trying to ensure a uniform research experience as well as equitable distribution of risks and benefits. 37 another dilemma highlighted by the sfs case is the considerations of reporting back to research participants' information that is not explicitly described in the informed consent process. further complicating matters in the sfs's case was the fact that their sars-cov-2 test had not, at the time of their original proposal, undergone traditional regulatory review and approval. the majority of the sfs's laboratories, like many research laboratories, are exempt from the clinical laboratory improvement amendments of 1988 (clia) 38 and therefore generally are not authorized to return individual research results by the fda. the fda is the oldest consumer protection arm of the federal government and works to ensure that food, drugs, devices, biologics, and others are trustworthy. nevertheless, since its inception, the fda has been criticized for 'slowing the progress' of medical innovation 39 and for its perceived political bent. 40 an emergency use authorization (eua) under section 564 of the federal food, drug, and cosmetic act (fd&c act) allows for the special use of unapproved medical products during some types of emergencies. 41 these are sometimes called 'medical countermeasures' (and include, for example, in vitro diagnostic tests, personal protective equipment, antivirals, vaccines, and biological therapeutics) that can be used 'to diagnose, treat, or prevent serious or life-threatening diseases or conditions' when there are 'no adequate, approved, and available alternatives.' 42 for example, in the case of sars-cov-2, hhs secretary alex azar issued a determination on february 4, 2020, that covid-19 'is a public health emergency and that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of the novel coronavirus.' 43 on february 29, 2020, the fda issued guidance to 'accelerate the availability novel coronavirus (covid-19) diagnostic tests developed by laboratories and commercial manufacturers during the public health emergency.' 44 this guidance stressed the importance of test validation, limits of detection, accuracy, and inclusivity; recommended the inclusion of a transparency statement that the test has been validated but fda's independent review of this validation is pending on all results; and required laboratories to report positive results immediately to federal, state, and local public health authorities. 45 the return of research results has been a catch-22 for this reason. if researchers share information that turns out to be inaccurate or misleading, they might be held liable for the erroneous disclosure. alternatively, if researchers withhold information that could be considered clinically relevant, they might be liable for failing to disclose this information. expert panels 46 have recommended that research results be returned with clear disclaimers regarding their potential limited reliability and validity, but participants might not fully appreciate these limitations. liability concerns (at least those related to disclosing the information), however, seem reduced in the context of actions taken in immediate response to covid-19, given the liability immunity declaration issued by the hhs. 47 while this immunity declaration unequivocally includes testing for sars-cov-2 within its scope of covered countermeasures, researchers do not categorically fall within the scope of covered persons. for immunity protection to be applicable, researchers would need to be recognized as 'qualified persons.' 48 it is possible, but not a given, that nih-funded researchers could be within this category. additionally, when considering the return of unexpected research results derived from public health activities, what, if any, considerations should be given to participants right not to know, for example, in the case of sars-cov-2 antibody testing? while 'right not to know' considerations within the specific context of an oft-fatal infectious disease might seem a stretch, reporting such results might seem contrary to the 'no surprises' principle in biomedical research, (which essentially means that researchers should avoid data practices that fail to align with participants' understanding and expectations). 49 when asked, the many of participants from a variety of different types of research want and expect to receive results back from their research participation. 50 given these expectations, is it necessary to obtain consent to return research results? in the past decade, 'right not to know' has been supported primarily in terms of incidental findings on genetic assay. 51 for many genetic conditions, there are no treatments. however, in the case of results generated as the result of a public health emergency, an individual's right not to know might be supplanted by the public good of informing them. if research resources are later used for public health activities, a question not definitively answered and likely requiring a case-by-case determination is whether reporting of those results should be treated pursuant to research norms (which historically have required consent) or public health norms (which prioritize information access to control the spread of disease over individual preferences). although the return of results might seem like a minor consideration, as 'back to work' certificates are being contemplated by many governments, the implications of whether and which sars-cov-2 results are to be returned should not be summarily dismissed by researchers or policy makers. 52 such concerns underscore the need for a system of ethical board oversight or other structured consultation, to aid researchers in assessing the risks and benefits of using research resources for public health activities. finally, are there any additional reporting concerns raised by legal mandates to disclose to public health authorities at different governmental levels if consent has not been obtained specifically? public health reporting varies from aggregate, potentially anonymous data (eg, disease prevalence) to fully identifiable data (eg, contact tracing). because public health response toolkits include police powers and the ability to infringe upon individual civil liberties, there are understandable concerns regarding the numerous potential uses for research data that might be generated or seized during a public health emergency. for example, because of the immigration law implications (such as the inadmissibility on public charge grounds final rule), undocumented immigrants might be unwilling to risk seeking health care during the covid-19 pandemic regardless of public statements from u.s. citizenship and immigration services (within the department of homeland security) that seeking services to test, treat, or prevent covid-19 would 'not negatively affect' any individual in the public charge analysis. 53 the inclusivity of a research data set being contemplated for use as part of a response during a public health emergency might require careful consideration regarding whether doing so advances or impedes an equitable distribution of the benefits and risks not only of the public health surveillance itself but also (i) the actions taken and policies developed and implemented based on those results made possible with that research resource and (ii) the subsequent willingness to participate in research. 54 one example to highlight this dilemma is contact tracing. public health authorities in other nations have adopted contact tracing to identify networks of exposed people. 55 given that human subject research studies now commonly include connected devices which collect data that could be valuable in contact tracing, this is of particular concern. researchers themselves struggle with appreciating the scope and implications of privacy concerns raised by the scope of big data research, 56 leaving ethics review boards and the participants they serve at a loss. 57 in the public health emergency context, these powerful data might only further obscure variables in the delicate calculus of individual risk and public benefit, underscoring the benefit of establishing formal consultation and review processes for public health activities that would use research data. both the volume and granularity of data collected in research repositories are orders of magnitude greater than it has ever been. however, utilizing these data-as well as the research infrastructure that supports them-in the name of public health response is not without risk. the differing legal and ethical obligations for research and public health activities are worthy of researchers' careful consideration even in the face of a public health emergency imposing powerful urgency constraints on decision-making. to be clear, these tensions should not inhibit research from proceeding during a pandemic nor the transfer of research resources to public health activities per se. rather, it is incumbent upon the research community, including biomedical legal and ethical scholars and practitioners, to reflect upon the many tensions experienced during the covid-19 pandemic between public health initiatives (the infrastructure and support for which has been proven woefully inadequate in the u.s.) and biomedical research (the leveraging of which might be particularly useful in times of public health emergencies, regardless of the state of public health infrastructure) and consider the creation of a formal consultative process, so that, in the future, research infrastructure might be called upon both responsibly and swiftly to augment public health initiatives. further, as ever larger and more diverse datasets are amassed, the lines between research and public health activities-not to mention clinical care-will continue to blur. the current pandemic highlights the need for each of these communities-researchers, public health authorities, and clinicians-to reconsider the legal and ethical bounds of their mandates and critically examine areas of overlap. active engagement with policy makers is needed. finally, it would be particularly prudent for the research community, equipped with its robust resources and good intentions, to think critically about how to avoid the research enterprise being simply an enabler for the continued neglect of public health in the u.s. a lab pushed for early tests christening of new coronavirus and its disease name create confusion new coronavirus cases confirmed in snohomish, king counties scan: greater seattle coronavirus assessment network public health practice is not research, 104 participatory disease surveillance systems: ethical framework, 21 final rule: federal policy for the protection of human subjects. 82 fed. reg. 7149 office for human research protections, activities deemed not to be research implementing a universal informed consent process for the all of us research program how to demand a medical breakthrough: lessons from the aids fight, npr fda moves to rein in drugmakers' abuse of orphan drug law, npr § 301-392, as amended to add section 564 by the project bioshield act of 2004, pub. l. 108-276, and as amended by 21 st century cures act, pub. l. 113-5, 21 u.s.c. 360bbb-3, 360bbb-3a, and 360bbb-3b. for example, during the 2009 h1n1 pandemic, the fda issued an eua so an unapproved antiviral drug could be used as a treatment, but the drug was not ultimately approved until 2014. see authorization of emergency use of the antiviral product peramivir accompanied by emergency use information lexi white & sarah wetter, from (a)nthrax to (z)ika: key lessons in public health legal preparedness emergency use authorization of medical products and related authorities: guidance for industry and other stakeholders determination of a public health emergency and declaration that circumstances exist justifying authorizations pursuant to section 564 (b) of the federal food, drug, and cosmetic act, 21 u.s. c. § 360bbb-3 policy for diagnostic tests for coronavirus disease-2019 during the public health emergency: immediately in effect guidance for clinical laboratories, commercial manufacturers, and food and drug administration staff returning individual research results to participants: guidance for a new research paradigm declaration under the public readiness and emergency preparedness act for medical countermeasures against covid-19, 85 fed at 15201-2, as '(a) any person authorized in accordance with the public health and medical emergency response of the authority having jurisdiction...; (b) any person authorized...to perform an activity under an emergency use authorization...; and (c) any person authorized to prescribe, administer, or dispense covered countermeasures in accordance with section 564a of the fd&c act explaining the 'no surprises principle' as 'assert[ing] that an individual's personal information should never be collected, used, transmitted, or disclosed in a way that would surprise the individual were she to learn about it health research participants are not receiving research results: a collaborative solution is needed health research participants' preferences for receiving research results the right to know and the right not to know revisited: part one, 9 covid-19 'immunity certificates': practical and ethical conundrums privileges and immunity certification during the covid-19 pandemic immunity passports' could speed up return to work after covid-19, the gaurdian coronavirus: scientists publish advice to government undocumented u.s. immigrants and covid-19, new eng ethical and legal considerations for the inclusion of underserved and underrepresented immigrant populations in precision health and genomic research in the us, 29 ethnic israel unveils open source app to warn users of coronavirus cases, harretz travel log' of the times in south korea: mapping the movements of coronavirus carriers, the washington post singapore says it will make its contact tracing tech freely available to developers, cnbc privacy and security in the era of digital health: what should translational researchers know and do about it? detecting the impact of subject characteristics on machine learning-based diagnostic applications. 2 npj digit med reimagining human research protections for 21st century science the authors would like to express appreciation to kayte spector-bagdady for formative discussions that helped prompt the development of this manuscript and for constructive feedback on an earlier draft. the content of this article is the authors' responsibility and might not represent the official views of the authors' institutions, funding sources, or any other person or entity. the authors have no conflicts of interest to disclose. key: cord-258223-8dhtwf03 authors: chow, cristelle; shahdadpuri, raveen; kai-qian, kam; hwee, chan yoke title: the next pandemic: supporting covid-19 frontline doctors through film discussion date: 2020-09-05 journal: j med humanit doi: 10.1007/s10912-020-09662-2 sha: doc_id: 258223 cord_uid: 8dhtwf03 this paper describes an innovative just-in-time health humanities programme to educate and provide support to covid-19 frontline doctors-in-training. the programme incorporates small-group screening of the netflix documentary, the next pandemic from the explained series, followed by a one-hour facilitated discussion to explore themes surrounding the current pandemic and its impact on frontline doctors in a tertiary paediatric hospital in singapore. themes derived from the film included preparedness, blame, and the impact on healthcare workers and public, which were further discussed to include concerns regarding current local readiness levels given global connectivity, the need for international cooperation, and the effects of blame such as racism and prejudice. the association with culture; the current impact on healthcare workers, physician-patient relationships, and the public including the role of social media, the government and associated public reactions were also explored. these rich discussions demonstrate the pivotal role health humanities has in times of uncertainty such as an emerging infectious disease outbreak by providing timely pandemic education and supporting reflective learning. the term, "cinemeducation," coined by alexander, hall, and pettice (1994, 430) , refers to the use of movie clips to educate medical students and residents about the psychosocial aspects of medicine. films, because of their audio-visual nature, can both engage and enthral viewers with emotional and dramatic portrayals of individual struggles and challenging interpersonal relationships. when health conditions, whether physical or psychological, drive or are explored in the film's themes, viewers can gain a deeper appreciation of the illness experience (powley and higson 2005) . especially for individuals training in the healthcare professions, movies can engage learners in deeper discussion and promote active learning through cognitive and social constructivism. learners embed new knowledge acquired from the film onto pre-existing cognitive structures and construct knowledge through group discussions with other learners, reflecting upon their personal experiences along the way. a systematic review by darbyshire and baker (2012) provides insights into the various areas in which cinema is used in medical education, ranging from hard science topics like biology and virology to soft skills like professionalism and ethics. while movies can be used for the teaching of many aspects of medicine, the use of movies in providing education and support during acute outbreak situations has yet to be described, as the health humanities is often viewed as a component of "peace time" education. the uncertainty of an emerging infectious disease can have significant psychological impact on frontline doctors (tan 2020; lai et al. 2019) , and provision of the health humanities during this period could potentially help to provide just-in-time education and address perceptions of safety, threat and risk (rambaldini et al. 2005) . hence, as the world experiences the current covid-19 pandemic situation, this study aims to describe the use of a short film and post-film discussion to educate and support frontline doctorsin-training during an acute emerging infectious disease outbreak. this study also aims to broadly describe the discussion themes generated through this just-in-time intervention (table 1) . from 10 february 2020 onwards, the department of paediatrics in a tertiary women's and children's hospital in singapore assigned rotating groups of house medical staff and paediatric consultants into isolation wards designated for suspect and confirmed covid-19 paediatric cases. rotations for house medical staff were in two-week blocks including weekends and public holidays, in a twelve-hour shift system. dyads consisting of related paediatric and adult patients were also admitted to these wards. in mid-february 2020, singapore experienced an increasing number of covid-19 infected cases in the adult healthcare institutions. in our institution, we had admitted a dyad of infected infant and mother in our isolation unit by 10 february 2020 (kam et al. 2020 ). there was still significant uncertainty about the virus' transmissibility, virulence and potential to cause morbidity and mortality. all house medical staff posted to isolation wards, consisting of freshly graduated house officers, medical officers (in non-training positions), paediatric junior residents, senior residents and resident physicians were invited to the film screening during their shift hours. participation was voluntary, and all participants were informed that a post-film discussion with notetaking by the facilitators would be carried out. facilitators consisted of paediatric faculty from general paediatrics, intensive care and infectious diseases, and some facilitators were teleconferenced into the discussion due to the hospital's enforced modular system. the film was selected based on recommendations by baños and bosch (2015) . two faculty members (cc and rs) reviewed several pandemic-related films of varying durations to assess its suitability and relevance for this study. the decision was made to screen the short documentary from the original netflix explained series entitled, the next pandemic. it was selected due to its timely recent release (7th november 2019), directness, factuality, short runtime of just over twenty minutes, relevance to the current hospital climate, and feature of severe acute respiratory syndrome (sars) which significantly impacted singapore in 2003 (tan 2006) . the above-mentioned faculty members independently watched the film multiple times to determine its underlying themes, generate educational objectives and questions to be used in the post-film discussion. the educational objectives of the session were: (1) to know the significant historical pandemics that impact ongoing pandemic preparedness efforts, (2) to discuss the challenges associated with the current pandemic and (3) to reflect on the impact of the current pandemic on personal lives, healthcare workers and the general public. three questions were selected for post-film discussion: (1) how did the film make you feel about the current covid-19 situation? (2) how has frontline covid-19 work impacted your personal lives, your families and your relationships with your patients? (3) how do you feel about the public's response to the covid-19 pandemic? the session started with projection of the documentary to a small group of not more than twelve participants. this was followed by a post-film discussion facilitated by faculty members for approximately one hour. facilitators encouraged active participation using the prepared questions although new and more relevant issues emerged during the session. participants and faculty members interactively exchanged their opinions in a nonjudgemental and constructive way, using the film as the initial basis of discussion, then branching out into new discussion areas. during the session, facilitators took notes of the broad themes discussed, including relevant quotes from participants. notes taken by facilitators were thematically analysed by the study authors independently for recurring themes. this was followed by discussion among the authors, and the final themes that were mutually agreed were organized in relation to the pre-determined themes from the film. a total of six similar sessions were conducted between 10 february and 6 march 2020, involving a total of sixty-three participants and six faculty members. of the sixty-three participants, twenty-eight were paediatric senior residents and resident physicians, four were paediatric junior residents, fourteen were non-trainee medical officers, and fifteen were house officers. of the faculty members, three were paediatric infectious disease physicians, two were general paediatricians, and one was a paediatric intensivist. from the film, four issues in particular were depicted as the main themes for group discussion, which included the following: pandemic preparedness, the allocation of blame, the impact on healthcare workers and the impact on the general public. during the film discussion, these were further branched into other areas of discussion by the participants (table 1) . participants were asked the question of whether the country, hospital and the public were truly prepared for the pandemic. they reflected upon the film's depiction of sars, and how the authorities in affected countries had "let it pass" until there was a significant number of deaths. they questioned whether we had really learnt from the sars outbreak and expressed helplessness, fear, uncertainty and being overwhelmed by the possibility of an uncontrollable pandemic. these perceptions were more prevalent in the discussions that were held in mid-february 2020 when the outbreak had still not peaked. a few residents shared that their fear stemmed from the uncertainty of how lethal the virus was and that preparation, vaccine research, personal protective equipment and border controls may not be sufficient to control the spread of the virus should it be virulent and highly transmissible. in discussions held in late-february and early march, participants expressed less concern about preparedness despite the increasing number of suspect and confirmed cases, as no healthcare workers were infected, and mortality rates were lower than sars. some of them also mentioned their personal preparedness and comfort due to the presence of adequate personal protective equipment and training: "i don't think anyone is really fearful to be in the eid teamthat says a lot about our preparedness." many comparisons were made between sars and covid-19 with one of the largest differences being the current increased global connectivity of humans because of the affordability and availability of air travel. as singapore is an international transport, trade and travel hub, participants raised concerns about border control methods and whether they were timely or effective in controlling the spread of the virus to the local population. participants recognized the need for international cooperation as one resident shared that the film "makes us feel vulnerable… that we should unite as a human race as this virus transcends gender, race, socioeconomic status…." there were genuine concerns raised that the pandemic preparedness was "not high on the agenda of some governments" and that insufficient funding and resources were being designated for this purpose. participants lamented about the "rise of ultra-nationalism" and self-preservation that would only backfire, as international cooperation and putting aside political and social differences would be key to tackling this pandemic. just as the film subtly apportions blame of the sars epidemic to china (and its wet markets selling live and wild animals), some residents felt that since the start of the covid-19 outbreak, this blame was manifesting in some countries as racism and prejudice. several participants reflected upon the experiences of loved ones in western countries who were "looked at in a particular way" or treated differently due to being of chinese descent or asian ethnicity. the discussion with regards to the role of traditional wet markets was particularly lively as participants shared that southeast asian countries still have a thriving live wet market scene, which is still very much the cultural norm. it was acknowledged that while live wet markets where "the meat is fresh" are indispensable to many asian communities, the consumption of undomesticated wild animals was not widespread. in china, this practice has been typically associated with higher social status and deep-seated beliefs about the perceived nutrition value of exotic meats. hence, while the general public may be quick to blame others for being the source of the current pandemic, participants reflected that we should also look to our own practices and not be too quick to judge the culture and beliefs of others. while working on the ground, most participants felt safe wearing personal protective equipment (ppe) provided by the hospital. some even mentioned that they did not flinch when they were coughed upon by patients while wearing ppe, and one participant shared: "we're mask fitted, papr (powered air-purifying respirator) trained, and just this feeling that we are well taken care of." however, given initial reports about asymptomatic covid-19 carriers, some participants were concerned whether they were safe in public areas such as on public transport, as they perceived that they were "more likely to get covid in (trains) rather than from the ward because of the precautions that we take in hospital." participants had differing opinions on disclosure to their families about their hospital work. some participants, especially those who had family members who were also healthcare workers (hcw) , were open about their role in the isolation ward. some of them declared to their loved ones, "i'm dirty… i'm a potential centre for a new cluster" and voluntarily cancelled their social appointments for the period when they worked in the isolation wards. others had decided to "censor information," as they did not want their family members to fear for their well-being. one participant shared that it was "tiring reasoning with every patient then going home and reasoning with family." most family members were supportive of the participants' jobs especially if they were kept informed about the hospital environment and measures taken to minimise transmission to healthcare workers. family members who were also healthcare personnel tended to express more understanding and less paranoia around the fact that the participants were looking after potentially infected or infected patients. however, some participants shared that their family members were still anxious and fearful of contracting the virus from the participants. one frontline staff mentioned that his parents called him "a virus" and kept their distance from him whilst at home, while others provided anecdotes about family members refusing to meet them at social events especially if they were elderly or parents of young children. however, the participants respected the wishes of their loved ones, as one shared, "i can't blame them, they are not wrong, (the elderly person) is more likely to develop a more severe illness." while most participants did not personally experience any overt hcw discrimination, a few shared thoughts about news circulating on social media that made them concerned about this rising trend. it was reported that local nurses in hospital uniforms were chased off public transport and told to leave public eateries due to public fears about contracting the virus from hcw. one participant recounted an episode of a private hire car driver cancelling his ride to the hospital when the participant shared that he was a doctor going to work. in later sessions, participants noted that there were fewer reports of discrimination against hcw and that the public had started to show more support through notes of encouragement, as well as retail, food and beverage promotions and discounts from local businesses. communication with caregivers was deemed the most important task whilst working in the isolation ward. although it was time-consuming, participants felt that caregiver reassurance was key to ensuring adherence to hospital isolation policies and recommended treatment plans. one resident reflected the importance of "having a bit more of a personal touch… reassuring (caregivers) that measures are being taken and the reasons why isolation is as such." anxiety levels of caregivers in the isolation ward were felt to be higher compared to the other general wards, not only due to covid-19 concerns but also due to the heightened movement restrictions associated with isolation ward admissions. with the need for constant ppe use, there was more physical distance between physicians and patients, inability to see the hcw facial expressions and other non-verbal cues, some challenges in obtaining language interpreters, breathlessness with n95 masks and fogging of goggles resulting in physicians' discomfort and hence shorter-than-desired consultations. there were also discernible fears of some young children in seeing healthcare staff wearing "spacesuits" especially when obtaining nasopharyngeal specimens for viral testing, although participants tried to reduce patient anxiety through "waving from outside and walking in slowly." participants mostly felt that stepping up to the frontline during a disease outbreak was their duty and one of the reasons for entering the medical profession. in response to individuals who had reservations about working in isolation wards, one participant reflected, "we entered this profession for a reason… in a time of need, how can others refuse to do their duty?" there was heightened appreciation for non-medical healthcare workers, including nurses, who must "stay in the ward and wear the n95 throughout their shift," porters, lab technicians and ancillary staff such as the porters and cleaners. one participant described watching cleaners wearing n95 masks who were diligently detaching and disinfecting wheelchair components and was "very impressed by the effort." a significant difference between the time of sars and the current covid-19 pandemic is the widespread ubiquity and availability of social media (e.g. whatsapp, facebook, instagram). social media was viewed as a "double-edged sword"; on one hand, it provides the public with government-sanctioned information and updates, but on the other hand, it can spread fake news and fuels unwarranted rumours and panic. through social media, personal stories can surface, and different sides of the story can be publishedfor example, one participant shared the heart-warming posts of chinese citizens caring for each other during the wuhan lockdown, which contrasted with undercover videos of chinese hospitals dealing with throngs of patients. overall, social media was still viewed as a positive tool for information dissemination, as long as it was adequately regulated and the public was directed to appropriate and reliable sources of information. participants were collectively concerned about the "uninformed public," as reflected through panic buying and hoarding of daily necessities when the ministry of health escalated to a higher level of disease outbreak response system condition (also known as dorscon) from yellow to orange on 7th february 2020. controlling public reaction was viewed as a major challenge as participants felt that they could not influence members of the public who refused to abide to government recommendations -"if people do not buy in, (we) cannot force it down." however, participants recognized that as healthcare workers, it was also their responsibility to provide accurate information to the public, whether to concerned family members or doubting caregivers in order to increase public trust in government authorities and reduce irrational and selfish public behaviour. it was also agreed that healthcare workers should be consistent in their messaging and set good examples in following government advisories such as avoiding panic buying and hoarding behaviour and not wearing n95 masks in public places where it is not clinically necessary (as this would lead to over consumption of limited n95 supplies). one resident shared that healthcare workers were key to "educating the public to really filter through information that is coming through… and how to react to things when they happen." most participants felt that the government had built up public trust through decisive responses and transparent decision-making processes. they felt that they could trust the authorities to take the necessary steps, whether in border control measures, healthcare advisories or contact tracing efforts in order to protect the local population and reduce the virus' transmission within the community. however, there was some debate on whether the extent of disclosure of positive cases' personal information to the public domain was appropriate, as there was concern about the stigma experienced by positive cases and their family members. one resident shared a personal experience of a close family friend who had recently returned from wuhan, the first epicentre of the virus, and the discrimination that the family experienced despite being tested negative for covid-19. participants recognized the fine balance between government transparency and personal data protection, and that "there must be bodies in place to scale down and to decide on what is necessary and what is not," as this would also change as the pandemic evolves. although a handful of participants were initially sceptical about the public's demonstration of appreciation for the hcws, gestures including hand-written notes of gratitude, donation of food items and artworks were generally welcome. some participants also shared that caregivers of both positive and suspect patients had verbally expressed their appreciation to the healthcare team during ward rounds, and admitted children had drawn thank-you cards for nurses and doctors. these simple gestures served as positive motivators for the frontline team. our study demonstrates the feasibility of a short documentary film in generating reflective discussions about an ongoing pandemic and its impact on frontline workers. this health humanities intervention primarily uses the principles of reflection and experiential learning in medical education. reflection, the metacognitive process that creates greater understanding of self and situations to inform future action, has been used in various medical educational approaches (sandars 2009 ). in the health humanities, reflection is encapsulated in the studentcentred affective developmental approach, which focuses on the development of self-concept, insight and introspection through the exploration of feelings, attitudes and values (self 1993) . guided reflection through discussions, rather than reflective writing, was used in this intervention in order to provide participants a safe and supportive environment to make sense of their personal experiences, through non-judgmental questioning and acceptance of different opinions within the group (sandars 2009 ). incorporating the principles of the experiential learning cycle, reflection is the second phase after experience, followed by "abstract conceptualisation" (kolb 2014, 50) . in this manner, as participants watch the film, they reflect upon how the themes presented through the film relate to their personal experiences of working in the isolation wards during the covid-19 pandemic. as they share these reflections during the film discussion, they conceptualize new ideas about the ongoing pandemic including its impact on their personal lives, the healthcare system, government authorities and society. being a collaborative group discussion, aspects of social constructivism also contribute to the learning process, as the participants' knowledge is co-constructed through learning from each other's personal experiences and opinions (vygotsky 1978) . it is also hoped that this intervention provides peer support and encouragement to the participants, improving their mental wellness as they work in the high-risk areas during this pandemic. some of the themes that emerged from the discussion were similar to those reported in other studies that explored the impact of emerging infectious diseases on house staff or medical residents. for example, during the sars outbreak in toronto, medical residents expressed concerns about personal safety and the wellbeing of loved ones, their sense of duty to care, as well as feelings about social isolation (rambaldini et al. 2005) . while study participants felt confident about ppe and hospital infection control policies, they were also worried about asymptomatically passing on the virus to their loved ones as asymptomatic transmission of sars-cov-2 was a real possibility, in contrast to the sars virus. the impact of social isolation, whether self-imposed or imposed by others, could have a minimized impact on study participants compared to frontline workers during sars, due to the current widespread use of video chats and social media, which were not available in the early 2000s. during the middle eastern respiratory syndrome (mers) outbreak, medical residents reported concerns about personal and hospital preparedness and fear of disclosure about their frontline work to family members (aldrees et al. 2017) . although study participants did share that the film questioned the world's preparedness for the next pandemic, when it came to hospital infection control policies, personal protection and ppe training, the majority of study participants felt adequately prepared about working in isolation wards, and there was significant trust in the government's and hospital's management of the worsening outbreak. like medical residents in saudi arabia, some study participants chose to withhold information about their frontline work to family members. as a conservative asian society, it is still common practice to withhold information about personal health and safety risks from the affected patient, so as to not cause unnecessary worry and anxiety among family members, especially those who may be elderly or less educated. the responses of the participants evolved over the course of four weeks with initial fears and anxiety being replaced with more certainty about preparedness. this evolution was likely related to better understanding of the novel coronavirus, the local and global response to the virus, and the extent of control. participants also experienced the "normalization" of working in an outbreak settingas hcws gain acceptance of the crisis and with increasing positive cases, they would experience less apprehension as positive cases start to become the "norm." towards the last few sessions, it appeared that participants accepted that caring for suspect and positive cases would become the mainstay of their clinical work. however, without a heightened sense of vigilance, this "normalization" may result in a lapse in infection control measures. hence, it would be prudent to ensure that frontline workers are constantly provided with appropriate infection control and policy updates to ensure that vigilance and selfprotection are still maintained as the pandemic ensues. an additional pandemic-related theme that has not been previously reported is the apportioning of blame and its subsequent effects of racism and prejudice. in the film, the vivid and somewhat unsettling scenes of chinese wet markets selling live animals during the sars epidemic could have triggered unhappiness over the similarities to which the source of the sars and covid-19 outbreaks may have originated from. while there was frustration about how governments did not seem to learn from past mistakes, participants also had the opportunity to reflect upon the challenges that governments face in banning practices that are deeply rooted in the society and culture. the discussion enabled participants to also reflect on our own personal biases and not let them cloud our judgement of others and their actions. the doctor's role in the education of the public was also repeatedly discussed. participants saw themselves as representatives beyond the hospital setting as role models for the public to follow government advisories and to protect patient confidentiality. their ability to accept this additional responsibility likely stemmed from their reflection on current public behaviours and their considerable impact. this provided them with an opportunity to generate insight on how they perceived their role as healthcare professionals and allowed them to explore the rationale behind their behaviours and attitudes during this time of international crisis (ginsburg and lingard 2006) . while participants' responses on the transparency and actions of the government may be quite unique to this study's setting, exploration of this theme in other settings would also be a worthwhile endeavour in hospital pandemic responses, as trust in health and government authorities can have a significant impact on the mental wellbeing of healthcare staff. finally, it was heartening to see that participants were able to reflect upon the importance of appreciating all staff working in healthcare, and while the public may view the true "heroes" as being doctors and nurses, we need to be mindful of the other silent healthcare workers in our midst who are indispensable in combating this pandemic. this study is limited by the number of participants, but despite the small sample size, there was significant heterogeneity in the background and experiences which would have provided significant breadth in discussion. in fact, data saturation was reached by the last session as there were no further new emerging themes. further research is needed to determine if health humanities interventions can further impact participants beyond the sessions, especially in their responses to future pandemics and in their mental wellness as the pandemic continues to rage on locally and throughout the world. as the health humanities is gradually integrated into mainstream medical school and postgraduate medical curricula, just-in-time interventions have a role in providing healthcare professionals with education and support through the current worldwide pandemic. while the focus of this study was on the implementation of a timely film screening and discussion, the themes that emerged from the guided reflections were insightful and can inform future pandemic-preparedness efforts for frontline healthcare staff. medical residents' attitudes and emotions related to middle east respiratory syndrome in saudi arabia cinemeducation: an innovative approach to teaching psychosocial medical care using feature films as a teaching tool in medical schools a systematic review and thematic analysis of cinema in medical education using reflection and rhetoric to understand professional behaviours a well infant with coronavirus disease 2019 with high viral load experiential learning: experience as the source of learning and development factors associated with mental health outcomes among health care workers exposed to coronavirus disease the arts in medical education: a practical guide the impact of severe acute respiratory syndrome on medical house staff: a qualitative study the use of reflection in medical education: amee guide no. 44 the educational philosophies behind the medical humanities programs in the united states: an empirical assessment of three different approaches to humanistic medical education psychological impact of the covid-19 pandemic on health care workers in singapore sars in singapore -key lessons from an epidemic publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-308378-qnkqckvm authors: yang, li; sun, li; wen, liankui; zhang, huyang; li, chenyang; hanson, kara; fang, hai title: financing strategies to improve essential public health equalization and its effects in china date: 2016-12-01 journal: int j equity health doi: 10.1186/s12939-016-0482-x sha: doc_id: 308378 cord_uid: qnkqckvm background: in 2009, china launched a health reform to promote the equalization of national essential public health services package (nephsp). the present study aimed to describe the financing strategies and mechanisms to improve access to public health for all, identify the strengths and weaknesses of the different approaches, and showed evidence on equity improvement among different regions. methods: we reviewed the relevant literatures and identified 208 articles after screening and quality assessment and conducted six key informants’ interviews. secondary data on national and local government health expenditures, nephsp coverage and health indicators in 2003–2014 were collected, descriptive and equity analyses were used. results: before 2009, the government subsidy to primary care institutions (pcis) were mainly used for basic construction and a small part of personnel expenses. since 2009, the new funds for nephsp have significantly expanded service coverage and population coverage. these funds have been allocated by central, provincial, municipal and county governments at different proportions in china’s tax distribution system. due to the fiscal transfer payment, the central government allocated more subsides to less-developed western regions and all the funds were managed in a specific account. several types of payment methods have been adopted including capitation, pay for performance (p4p), pay for service items, global budget and public health voucher, to address issues from both the supply and demand sides. the equalization of nephsp did well through the establishment of health records, systematic care of children and maternal women, etc. our data showed that the gap between the eastern, central and western regions narrowed. however the coverage for migrants was still low and performance was needed improving in effectiveness of managing patients with chronic diseases. conclusions: the delivery of essential public health services was highly influenced by public fiscal policy, and the implementation of health reform since 2009 has led the public health development towards the right direction. however china still needs to increase the fiscal investments to expand service coverage as well as promote the quality of public health services and equality among regions. independent scientific monitoring and evaluation are also needed. over the past 65 years, the public health system in china has made significant progress to enhance health for the entire population. after the founding of the people's republic of china in 1949, the chinese government made various innovations for better delivery of public health services. for example, at the beginning of 1960s, china launched a village doctor training program to create a front-line workforce, providing public health services and essential medical services including clinical treatment and drugs [1, 2] . in addition, disease prevention and primary care were the two most important tools at that time and people were able to receive some basic vaccines to prevent infectious diseases. all of these interventions lead to great health outcomes in china [3] . however, the public health system was ignored due to the transition from the planning economy to the market economy in the 1980s and 1990s. the government funds in the public health sector declined, which led public health institutions to generate their own revenues (i.e. selling vaccines, providing more profitable services) [4] . some infectious diseases such as tuberculosis (tb), re-emerged as a result of poverty and health inequities [5] [6] [7] . fortunately, the chinese government eventually realized that issues in the health care system must be addressed (particularly public health) and made various corrections. after the 2003 severe acute respiratory syndrome (sars) pandemic, the chinese government paid more attention to public health and allocated more funds to public health sectors. in the 2009 health care reform policy, an essential public health package, including nine types of basic services and six types of catastrophic services, was launched. the pcis including community health care centers, township hospitals and village clinics provided basic services and the specialized public health institutions like centers for disease control (cdcs) provided catastrophic services. the government regulated the guideline for basic services and provided training for public health workers. the financial supports were shared by the central and the local governments. until 2015, the package included 12 types of basic services and seven types of catastrophic services. the budget per capita for basic services increased from 15 renminbi (rmb) in 2009 to 40 rmb in 2015. almost every chinese citizen has equal access to this essential public health package. by summarizing china's experiences and lessons learned during development of both public health service systems and financing strategies, especially with regard to improving universal access, the present study will provide significant policy implications for public health development and health systems strengthening in other developing countries. health equity analysis was often used to assess the improvement of healthcare or public health equalization, which is concerned with four focal variables: health outcome, health care utilization, subsidies received through the use of services and payments people make for health care [8] [9] [10] . the equity analysis methods include lorenz curves and gini coefficients, thiel index, the index of dissimilarity(id), the slope indices of inequality(sii), relative index of inequality(rii) and concentration index(ci) [8] . since the policy has been implemented for only 6 years, the process indicators instead of health outcomes will be mainly considered for effects measurement. because of data availability, we just measure the financing equity of essential public health services and summarize the experiences and lessons by using mixed methods. based on the theory of change, we formed a theoretical framework of public health financing. policy contents, including financing strategies for fund collection, management, and allocation, which could provide incentives for both the supply side and demand side and finally influence the outcomes and impacts. contextual factors will indirectly contribute to outcomes by affecting the policy contents (fig. 1 ). the review included studies concerning china' public health equalization in either chinese or english on databases of pubmed, medline, china national knowledge infrastructure(cnki), and wan-fang data. in addition, the review is confined to studies concerning financing strategies which improve access to public health and health outcome from 1959 to 2015 in china. the keywords are:" public health equalization" or "public health" or "primary healthcare", and "revenue collect", or"fund collect" or "revenue manage" or"fund manage" or "revenue allocate" or "fund allocate" or "financing mechanism" or "health finance", and "population coverage" or "coverage rate" or "service content" or "service package" or "service items" or "access" or "availability" or "cost sharing" or "out of pocket" or "financial risk protection" or "catastrophic spending". policy articles or other documents and reports on public health revenue collection, management, allocation, or financing strategies for improving access to public health for all were included. two reviewers identified titles and abstracts of all articles from the search, and retrieved the full text articles. finally, we obtained a total of 208 literatures studies after data screening. the following literature information has been collected from relevant studies including background, content, mechanism and effect of the policy interventions. the main results and conclusions in the reviewed studies have been extracted. we used mixed-method syntheses to summarize successful financing strategies to improve access to public health for all in the past 65 years especially since 2009 nephsp policy in china [11, 12] . we interviewed six experts in the public health field with semi-structured questionnaire, including two officials from china national health and family planning commission, two experts from national health account department at china national health development research center, one director from china community health association and one director from expand preventive immunization(epi) department in china cdc. 1.5-2 h were spent for each interview. the questions for interview include: (1) how long has you worked there? what was your duty at that department? (2) why did china implement the public health equalization policy? (3) what are the changes in public health? (4) how was fund collected, managed and allocated? (5) what were the provide side and the demand side's responsiveness on this policy? (6) what are experiences or lessons for the policy implementation, which aspects still need improvement? we recorded it, coded it and conducted qualitative content analyses. we collected data from china health statistics yearbook, 60 years of new china yearbook, national health service survey report, national health financial report, national health account report and global burden of disease (gbd) database by institute for health metrics and evaluation (ihme) at washington university in st. louis, united states. in addition, we searched secondary data on some non-governmental organizations (ngo) and government websites [13] . by collecting data from above statistic reports and websites, we could show evidences on equalization process for essential public health financing and health indicators improvement since 2009. we used gini coefficients through the slab method to assess the total financing equity for public health in china [8, 14] . and calculated the thiel index to assess the financing equity among different regions [8] . the results include three parts: 1) reviewing the three phrases of public health financing evolution from 1949 to 2015, 2) summarizing the experiences and lessons of financing strategies learned during development of essential public health equalization and 3) assessing effects on government public health expenditure, fig. 1 conceptual framework expanded services coverage and narrowed the gap of health indicators between the urban and rural area. we generated the first part mainly by literature review, the second part based on literature review and key informants interview, and the third part based on literature review and second data analysis. equal access to basic services is one principle in the public health system of china. one of core policies is the free provision of basic public health services to all residents. with the development of the policy over the past 6 years, china has achieved almost universal basic public health services coverage for its population of 13.73 billion with increased funding levels, expanded services, and enhanced financial equity. the experience from china can provide policy lessons for other developing countries. foundation for basic public health services: sustainable public funds as part of public health, public health financing should be responsibilities of various levels' governments. lacks of sustainable financing for public health will affect the access and equity of public health service. china has some lessons as well as experience in the past 65 years. from 1949 to the present, china's public health financing has undergone three phases. planned economy period after the founding of the people's republic of china (1949 china ( -1984 the central government collected funds to address major public health issues and launch the "patriotic health campaign", which effectively decreased mortality from infectious diseases and significantly improve health status for the entire population. the life expectancy at birth of the chinese people has been extended from 35 years in 1949, to 67 years in 1980, the world bank and the world health organization called it the "china model", characterizing this strategy as maximizing health benefits with limited costs, which could be applied across many developing countries [15] [16] [17] . after national government budget reforms favoring decentralization and tax redistribution, chinese local governments failed to take full responsibility for funding the public health system. the government contribution to total public health expenditures decreased sharply. this weakened the role of pcis for the provision of public health services. in addition, the emphasis of public health institutions shifted to clinical treatment instead of prevention. without consistent financial supports from central budgets, the pcis were incentivized to become self-financing entities. because of the stagnation or even decline of basic public health service provision, some infectious diseases such as tb re-emerged [4, 18, 19] . based on an idea of the "harmonious society", and people-centered political and social policies, the government plays more active roles in the public health system and attaches great importance to this sector again. expenditures for public health institutions and pcis are again funded by the national budget. in addition, the government has increased the overall investments in public health, enhanced the primary health care system, trained health workers, and promoted health development in rural areas [20, 21] . equalization of essential public health services means every chinese citizen, regardless of their gender, age, race, occupation, place of residence, and income level, can receive the same essential public health services, as mandated and supported by the government. in view of the differences in people's needs for public health services, vulnerable groups such as low income people are given more attention [22] . essential public health services are mainly provided by pcis including urban community health service centers (stations), township hospitals and village clinics free of charge [23] . the current public health system in china includes a network of 3492 disease surveillance centers, 1271 professional public health institutions (such as tuberculosis dispensaries), 27,215 hospitals and 912,074 primary care facilities [24] . in specialized public health institutions, government budgets fully cover staff salaries, construction and capital development, pooled general funds, and major public health campaigns such as control of acquired immune deficiency syndrome (aids), tb and endemic diseases. public hospitals undertake particularly required public health services that are publicly subsidized. as for pcis, the government allocates funds for human resources as well as construction and capital development by government budget. the government allocates operating funds by government purchasing service. before 2009, the construction funds for pcis were mainly from subsidies of the central government, and the operational costs and personnel expenses were mainly from local governments' usual appropriation and medical services revenue generated by pcis themselves. the usual fiscal appropriation was not enough to pay for personnel expenses. in sichuan province, for example, the annual fund in rural areas was only 0.5 rmb per capita [25] . the pcis lost money due to high services costs and these losses seriously affected their initiatives to provide more public health services [26] . in 2009, the new special funds for nephsp were added into the public health sector. the funds are managed by special transfer payments through china ministry of finance. cross uses between funds are not allowed any more by "earmarked" funding management system from top to bottom. the national, provincial, municipal and county governments allocate the funding to local fiscal sectors directly according to a per capita fund standard based on the total number of the resident population [23] and the local fiscal sectors pay the pcis for providing public health services based on mixed payment of fix salary, pay for performance(p4p) and capitation (fig. 2) . details of the financing strategies for basic public health services in fund collection, management and allocation are discussed below. in 2009, china launched the nephsp with nine items, including health records establishment, health education, immunization, child health, maternal health, geriatric health, hypertension and type 2 diabetes management, severe mental illness management, and the surveillance and control of infectious diseases and public health emergencies. the service package has been continually expanded. in 2012, health supervision and management was added. in 2015, a regulation of traditional chinese medicine and tb management was added into the public health service package, which currently included a total of 12 items (table 1 ) [27] [28] [29] . by service comparison we can see that not only the service items but also the coverage of essential public health services was expanded from 2009 to 2015. for example, the target services group for children's systematic care extended from 0-3 years to 0-6 years. national clarification about the minimum service coverage has promoted the targeted provision of public health services and facilitated the process of assessment. in addition, local governments can add other public health services into this basic national package according to their local financial capacity and public health conditions. a national funding level was set by a standardized cost formula of each service item. the minimum funding [23, 30] . the central government requires that every locality meets this minimum level, in order to guarantee implementation. province and municipality level governments can further supplement the funding level according to the content of their local basic public health service packages, cost of services and local financial capacity, which has helped to expand services in the package for many areas. for example, a study suggested that the cost of the package in beijing was 50 rmb (7.95 usd) per capita in 2010 based on survey in 17 sample centers and model estimation [31] . national, provincial, municipal and county governments in china share responsibility for funding basic public health services, and the national government allocates more money to less-developed middle and western regions by transfer payments. the proportions contributed by governments at different levels vary among regions, partially based on local socio-economic status. funds allocated from the central government via general or special transfer payments account for 80% of total basic public health expenditures in western regions, 60% in central regions, and only10-50% in the more prosperous eastern regions. this helps to alleviate funding disparities and gaps in western and central regions [32] (table 2) . similarly, the provincial governments can cross-subsidize counties by transferring funds from richer to poorer areas by transfer payments. taking the 2009 minimum public health funding level of 15 rmb per capita as an example, contributions to western regions from the national, provincial and local levels of government were 12 rmb, 2 rmb and 1 rmb respectively. by comparison, only 9 rmb was from the national government in central regions. in eastern areas, the majority of the 15 rmb minimum came from local governments [32] (table 3) . public health funds in china are managed as 'special financial funds' , which means they are managed as ringfenced budgets with unified accounting and strict allocation by capitation. this strong transparency in allocations can effectively reduce issues of payment delay or fund misappropriation. moreover, it can help improve direct supervision of public financial departments, ensuring that disbursements are not impeded and flow smoothly and securely in the health system. there are mainly two ways in the disbursement of funds for essential public health services. the first is that central and provincial project funds are directly appropriated by the provincial finance departments to municipal and county finance departments. the county finance departments allocated funds to pcis in accordance with the results of the performance evaluation. the second is the establishment of municipal finance centralized payment accounts. municipal finance departments directly allocated funds to pcis. take tianjin city as an example, municipal and district governments match funds that are then turned in to the municipal finance centralized payment accounts and allocated directly to community health service centers. municipal finance department keep accounts alone and do not adjust the use of funds. municipal and district health boards take the responsibility of supervision [33] . this can ensure funding allocation in place and in time. in order to avoid problems from the delay of disbursements and ensure the effectiveness of funding for basic public health services. a large proportion (50%) of public health funds are allocated by capitation at the beginning of each fiscal year. according to the performance assessment system, subsequent funds are linked to the facility's actual delivery of services, which includes organization and management, responsible use of funds, productivity in completed tasks, quality, timeliness, socio-economic benefits, sustainable impact, social satisfaction, and other metrics. these payments can therefore increase the incentives to provide basic public health services in primary health care facilities and ensure funds are spent as intended by policymakers. the special fund for essential public health services were allocated by government procurement. government procurement of public health services refers to the following two ways, government proposes specific tasks, objectives, requirements and assessment criteria, and pcis provide free essential public health services to people. the government allocated the public health fund in terms of seven kinds of financial payment methods [34] : capitation, line budget, salary, pay for performance [33, 35] , global budget [36, 37] , fee for service [38, 39] and public health voucher [14, 40, 41] . actually mixed payment methods were often used in practice. the government also purchase the public health services by signing a contract with the private sector such as village doctors and the latter receive a modest subsidy for providing public health services associated with the package. the willingness of village doctors to provide public health services has been improved since the introduction of the package and a minimum subsidy, although village doctors do not find the subsidy to be sufficient remuneration for their efforts [42] [43] [44] . government procurement of services and publicprivate partnerships (ppp) can improve incentives in the private sector and alleviate shortages of health workers in public facilities. before the current policy of essential public health service equalization, public funds were only available for staff salaries but not institutional management. as a result, strategic performance of the public health services suffered. after adoption of the policy, pooled government procurement of services has led to greater purchasing efficiency for public health services. health workers in pcis are additionally more motivated, because their compensations are linked to performance assessment. furthermore, the government can purchase services provided by private sector actors such as village doctors, in order to effectively alleviate public health workforce shortages. the evaluation system of nephsp policy can effectively evaluate, interpret and improve basic public health services. hu shanlian initially established the evaluation indicators for this policy by consulting with experts, relying on the conceptual framework of the health system financing [45] . yu yong combined the evaluation indicators with "national essential public health service standards" (2011 edition) to effectively evaluated current policies [46] . both process indicators and outcome indicators are used to evaluate nephsp policy. process indicators are mostly service utilization indicators, used to measure the process effects of resources allocation. outcome indicators are used to reflect the final outcomes of the resource allocation. since only 6 years for this policy implementation, process indicators are often used in current empirical studies [47] [48] [49] [50] [51] [52] . the improvement of government public health expenditure equity [53] . measured by the gini coefficient, we found that inequality in ghe fell from 0. 33 (2003) to 0.10 (2014), and inequality in gphe fell from 0. 25 (2008) to 0. 23 (2014) . measured by the theil index, the gap of ghe between eastern, central and western areas has narrowed sharply since 2009 (fig. 3) . in 2015, adoption of standard electronic health records has reached to more than 75%. systematic coverage rates of public health care for children under 3 years old and maternal women are above 85% (fig. 4) . the coverage rate for people over 65 years old remains at 65% while the immunisation rate among school-age children is above 90%. standard management of hypertension and diabetes has reached 86.27 million and 24.19 million patients respectively, in an equivalent to management rates of 35% and 30%. meanwhile, the standard management rate of registered patients with severe mental disorders has reached to 73% and 40% of patients covered by traditional chinese medicine health care. nine million tb patients, or 90% of total tb patients in china, are successfully managed. the hospitalized delivery rate among rural pregnant women has reached to 99% [54] . the narrowed gap of health outcomes between urban and rural area as to outcome indicators for systematic care for children under 3 and maternal women, the mortality for children under 5 and maternal women decreased sharply in 2005-2014, especially in rural area, after 2009. the gaps between urban and rural areas have significantly narrowed since 2009, as shown in fig. 4 . as to outcome indicators for systematic care of patients with hypertension and diabetes, the mortality of ischemic stroke and ischemic heart diseases increased in 2000-2013, except the mortality of haemorrhagic stroke has decreased since 2005, and mortality of diabetes increased slightly since 2005 (fig. 5) . as we know, the hypertension is the leading risk factor of haemorrhagic stroke (rr = 2.74) [52] . total cholesterol (rr = 2.7) and triglycerides(male: rr = 2.5, female: rr = 3.8) are more contributed to ischemic stroke compared with blood pressure (rr = 1.92) [55, 56] . considering the control of dyslipidaemia is not included in the nephsp, it's easy to understand that the mortality of haemorrhagic stroke this public funding is nevertheless not enough in pcis. current workforce shortages and weakness in capacity will affect the quantity and quality of services that can be offered [42, 57, 58] . in addition, local governments may lack the capacity to effectively assess performance in terms of productivity and/or quality. service coverage and financing mechanisms for china's migrant population (approximately 252 million in 2015) also need to be improved. although many studies proved that the causal association between the public health expenditure and infant or child mortality [9, 10] , some studies well summarized china's experience on public health in 1949-1984 [3, 16] and lessons in 1985-2002 [4, 17] , some studies assessed the effects of nephsp on service coverage and equity [14, [40] [41] [42] [43] [44] [45] [46] [47] [48] , very few studies described china's financing strategies and mechanisms for the nephsp [34, 35, 41, 43] . this study could be an important contribution to the exiting literature on evaluation of public health equalization in china. china's experience of different financing strategies for public health shows that the public health sector can develop stably and sustainably only if the responsibility of governmentespecially at the national levelfor financing is emphasised. in fact, the 2009 policy of basic public health services equalization was not a novelty, but rather the re-establishment of public financing responsibility and governance in china, in order to set a mechanism for equity in financial and service provision. developing countries that rely on the national budget and/or international aid to mobilise resources for health expenditures can learn from china's experiences [5, 6, 16] . however, it is worth noting that public health financing in china is influenced strongly by its unique national governance and public financial management. strengthening the government's leading role in public health financing the chinese national government has introduced a clear and basic service package and clarified the service content, standards, and minimum financing levels, which has led to better health sector accountability [59] . the national government plays the main role in public health financing, and local governments should continue to be clear about their financing responsibilities. financial equity across citizens and regions can be guaranteed by transfer payments facilitated by national or provincial governments [34, 35] . the national government sets policies for subsidy management, allocates central funds, and implements the management hierarchy across levels. integrated payment management to ensure full and timely funding is in place earmarked funding and allocation by capitation can increase transparency of funding levels, which can safeguard against the delay or diversion of funds [35] . top up disbursement for actual services according to recurrent expenditure management can improve incentives in pcis [37] . with this combination of preappropriation and later payments based on performance assessment, the process of disbursements can be accelerated to meet operational needs. moreover, government procurement of services can promote ppp, to improve incentives for private sector actors to provide public health services as a supplement to public institutions [36, 38, 39] . according to local conditions, in terms of funding criteria as well as implementation schedule and goals, it is essential to continuously improve the health system [36] . in a large country with significant regional diversity, the key point is to increase local governments' incentives to promote equity of basic public health services [37] . it has been only 6 years since the carry out of nephsp equalization policy in 2009, it is difficult to use the data to measure the improvement of health outcomes and health equity in the public health sector. we need to use longitudinal data to capture its effectiveness in future. however based on existing evidences we could find that many process indicators has improved since 2009 which may finally result in improvement of health outcomes based on many experimental studies [50, 51, 56] . financing strategies are essential parts in the public health equalization policy. public fiscal policies have a major effect on the delivery of essential public health service. in many middle or low income countries, people couldn't acquire or have equal access to basic public health services due to the lack of sustainable public financing, which result in major infectious diseases and endemic diseases spreading, high maternal mortality and mortality of children, finally preventing the realization of mdg. the chinese public health financing evolution proved that equalization of health outcomes depends on fiscal equalization, health financing equalization and equal access to public health services. and chinese experiences for nephsp could provide lessons for other developing countries. abbreviations aids: acquired immune deficiency syndrome; cdcs: centers for disease control; gbd: global burden of disease study; ghe: government health expenditure; ihme: institute for health metrics and evaluation; nephsp: national essential public health services package; ngo: non-governmental organizations; p4p: pay for performance; pcis: primary health care institutions; ppp: public-private partnerships; rmb: renminbi; rr: risk ratio; sars: severe acute respiratory syndrome; tb: tuberculosis transformation of china's rural health care financing state council of the people's republic of china. regulation on the practicing of village doctors good health at low cost' 25 years on: what makes a successful health system? london: lshtm china's public health-care system: facing the challenges health sector reform: lessons from china regulating health care markets in china and india expanding health insurance coverage in vulnerable groups: a systematic review of options analyzing health equity using household survey data a guide to techniques and their implementation the effect of private and public health expenditure on infant mortality rates: does the level of development matters? child mortality and public spending on health: how much does money matter? world bank policy research working paper protocol: a realist review of user fee exemption policies for health services in africa proposal: a mixed methods appraisal tool for systematic mixed studies reviews institute for health metrics and evaluations. global burden of diseases compare empirical study on the equality of public health service in china: analysis and evaluation of public health voucher in chongqing municipality thinking about 60 years of public health in new china public health in china-is the experience relevant to other less developed nations? socsci med financing reforms of public health services in china: lessons for other nations historical evolution and current situation analysis of the construction of rural public health system in china historic evolution and problems of public health service system in china china's rural public health system performance: a cross-sectional study historic evolution and problems of public health service delivery mechanisms in rural areas in china feasibility research on the national essential health service package in china national bureau of statistics. statistical bulletin of the national economic and social development in 2015 surveying the implementation of primary public health services in rural sichuan the analysis of regional equalization of public health services in china -based on the prospective of public health expenditure and public health resources national basic public health service specification national basic public health service specification national health and family planning commission. national basic public health service specification national health and family planning commission. notice on the national basic public health service project in 2015 a model to estimate the cost of the national essential public health services package in beijing opinions on promoting the gradual equalization of basic public health services" issued, the vice minister of finance proposed to grasp "the three outstandings implementation progress of equalization of essential public health services and its countermeasures study on the financial share and compensation mechanism of the basic public health services in chongqing fiscal policy of promoting the equal basic public health services. the journal of science and technology to become rich wizard policy analysis of government purchase of public health service at el. problems and countermeasures of basic public health special funds management of primary health care institutions payment method research of basic health services payment method research of the basic health services institutions study on equalization of basic public service in urban and rural areas. taxation and economy discuss of cost estimation and financial security mechanism in community public health service in hunan province factors influencing the provision of public health services by village doctors in hubei and jiangxi provinces china evaluation and mechanism for outcomes exploration of providing public health care in contract service in rural china: a multiple-case study with complex adaptive systems design health providers' perspectives on delivering public health services under the contract service policy in rural china: evidence from xinjian county indices of the equality of essential public health services in china construction of evaluation index system for equalization of basic public health services china's rural public health system performance: a cross-sectional study differences and determinants in access to essential public health services in china: a case study with hypertension people and under-sixes as target population public health in china: the shanghai cdc perspective essential public health services' accessibility and its determinants among adults with chronic diseases in china determinants of basic public health services provision by village doctors in china: using non-communicable diseases management as an example evaluation of health care system reform in hubei province, china national health and family planning commission progress report of the state council on deepening the reform of health system subtypes of hypertension and risk of stroke in rural chinese adults guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the challenges of basic public health services provided by village doctors in guizhou, china revisiting current "barefoot doctors" in border areas of china: system of services, financial issue and clinical practice prior to introducing integrated management of childhood illness (imci) research on the fiscal policies of equalization of basic public health services in hebei province dr. meng qingyue is the pi of this study and provides guidance and supervision to the study design, analysis and manuscript writing. the dataset supporting the conclusions of this article is included within the article. all authors read and approved the final manuscript.ethics approval and consent to participate not applicable. all authors jointly contributed to the design, analysis, and interpretations of results. all authors read and approved the final manuscript. the authors declare that they have no competing interest.• we accept pre-submission inquiries • our selector tool helps you to find the most relevant journal submit your next manuscript to biomed central and we will help you at every step: key: cord-306816-n0ggrp16 authors: gardiner, rita a.; fulfer, katy title: virus interruptus: an arendtian exploration of political world‐building in pandemic times date: 2020-07-06 journal: gend work organ doi: 10.1111/gwao.12510 sha: doc_id: 306816 cord_uid: n0ggrp16 building upon a series of blog posts and conversations, two feminist scholars explore how political community, trust, responsibility, and solidarity are affected by the covid‐19 pandemic. we explore the ways in which we can engage in political world‐building during pandemic times through the work of hannah arendt. following arendt’s notion of the world as the space for human togetherness, we ask: how can we respond to covid‐19’s interruptions to the familiarity of daily life and our relationship to public space? by extending relational accounts of public health and organizational ethics, we critique a narrow view of solidarity that focuses on individual compliance with public health directives. instead, we argue that solidarity involves addressing structural inequities, both within public health and our wider community. finally, we suggest possibilities for political world‐building by considering how new forms of human togetherness might emerge as we forge a collective “new normal.” that solidarity involves addressing structural inequities, within organizations, public health institutions, and the wider community. finally, we suggest possibilities for political worldbuilding by considering how new forms of human togetherness might emerge as we forge a collective "new normal." i remember that you asked a question during a talk at the aforementioned conference about the newness of the coronavirus. 1 you framed your question by contrast with the twentieth-century political theorist hannah arendt, who characterizes political action as beginning something new in the world that is boundless, uncontrollable, and unpredictable. for arendt (1958) , action, as the human capacity to initiate new beginnings, is the fundamental component of human freedom. action, which is rooted in what she (1958) calls "natality," has a potential to interrupt the status quo, since it is not limited by the intentions or goals of the actor. once an action is initiated, anything can happen. the coronavirus exhibits some features of action but, of course, is not an actor and not free in the arendtian sense of those terms. what made you ask this question? arendt's philosophical approach might best be described as an attempt to understand the diversity of human experiences, especially when people are confronted with new phenomena (e.g., totalitarianism, the atom bomb). she (1958; 1961) often describes her writing as an exercise in thinking; that is, as an attempt to understand the meaningfulness of events or "crises" that cause us to question familiar experiences. the virus has certainly interrupted our unreflective assumptions about the world, but it also has revealed opportunities for societies to step up and challenge societal ideas about business as usual. covid-19 has raised questions about how members of a political community relate to public space and build a world together in these uncertain and unfamiliar times. arendt (1958) describes "the world" as the space of human togetherness, contending: to live together in the world means essentially that a world of things is between those who have it in common, as a table is located between those who sit around it; the world, like every in-between, relates and separates men [sic] at the same time (p. 52). as the space for human togetherness, the world is not only comprised of diverse peoples and organizations, it is also concerned with how we, as members of a political community, shape the public space we share. for her, politics is not just about organizing society, it is about our experience of shaping the world together. how do we engage in political world-building in pandemic times? "virus interruptus" has disrupted the familiarity of our world in so many ways. in virtually all diverse western countries, many public spaces have been closed and movement, both domestically and internationally, is restricted. for example, both of us are canadian immigrants with family who live in other countries (england, usa) whom we cannot visit due to travel restrictions. in canada, since mid-march, we have been unable to gather together with friends, neighbours, loved ones, coworkers, or even strangers. and this has led to feelings of lack, or missing out. more than i miss the weekly happy hour with colleagues, i also miss the ease of walking into a crowded grocery store to buy a simple item that i forgot i needed to prepare a meal. for those less privileged, however, the unfamiliarity of the public realm is less about feelings of loss, and more about feelings of potential danger. food service, grocery, and warehouse workers might not have thought about their jobs as dangerous prior to their occupations becoming deemed essential work. latour (2020) contends that, instead of acknowledging links between human actions, climate change, and the virus, we continue to think in nineteenth-century biopolitical terms that privilege statistical ways of thinking about the world. speaking about biopolitics in relation to the coronavirus, in late february, giorgio agamben (2020) provocatively claimed that the virus was no more serious than the seasonal flu. his comment was challenged quickly, and the comparison he drew between the coronavirus and the flu has proven to be false. but agamben's political concern was about government regulation of public and private life. justified in the name of public health, he viewed the kinds of restrictions imposed by the italian government to be an extension of state power that will not disappear when the pandemic ends. in response, roberto esposito (2020) suggests that agamben's argument proceeds too quickly, and fails to distinguish the ways in which government control has been increasing slowly with the need to respond quickly to a pandemic that could kill an unfathomable number of people. according to esposito, to talk of "risks to democracy" due to isolation protocols is misplaced -these protocols are about saving lives and supporting healthcare infrastructure. conversely, drawing on foucault and other theorists of biopolitics, paul b. preciado at the beginning of the stay-at-home directives, many people lamented the loss of having dinner with family and friends. but now families experience the pain of grieving for loved ones without the ability to visit them in long-term care homes or in hospitals, or even to mourn them at a funeral. lynne f. baxter (2020) has illustrated how much caring for the elderly is a feminist issue, both personally and politically. across the world, we see how those in care homes have suffered greatly from the lack of adequate care, despite the best of intentions from carers who are often women who are underpaid and overworked in an extremely demanding job. returning to berkowitz, he invites us to reflect upon what it means for human relationships when physical life becomes privileged. berkowitz (2020a) states that "the near total shutdown of social, political, and public life are also consequences of our increasing inability to value political and spiritual facets of human life." furthermore, feminist scholars, such as ai (2000) , baxter (2000) , and enloe (2000) encourage us to think about how issues of gender and power can be obscured by political discussions on the virus. cynthia enloe (2020), for example, contends that one of the problems with the language used by politicians to describe covid-19 is its militaristic overtones. this militarism serves not only to masculinize the pandemic, but also ignores how two thirds of the workers most affected across the globe are women (enloe, 2020) . what is necessary, she maintains, is the demilitarizing of language in favour of language that emphasizes social solidarity. perhaps these considerations might be a way to think about "world-building." specifically, in the wake of such a threat to physical life, how do we think about our social and political togetherness? if there is a risk to democracy in berkowitz's view, it is that as citizens and residents we will become complacent with the loss of political community. drawing on feminist scholarship, we suggest an additional risk is that democracy may be undermined if we do not change the system in ways to make political togetherness more inclusive. in "personal responsibility under dictatorship," arendt (2003a) contends that the term obedience is a misnomer; yet that misnomer is at the heart of the political system of rulers and ruled. she writes that, since the time of plato and aristotle, every body politic has consisted of rulers and ruled, the former give out orders while the latter obey those dictates. but, arendt argues, it is wrong to suggest that adults obey leaders, and merely go along with whatever is asked. rather what a reasonable adult does is offer up their consent. she (2003a) maintains that the word obedience should be stricken from our language, arguing "[m]uch would be gained if we could eliminate this pernicious word "obedience" from our vocabulary of moral and political thought" (p. 48). living in the aftermath of the second world war, and the horrors of the shoah, it is not surprising that arendt would make this claim. but, in this time of fear caused by the virus, does obedience have any place? social distancing protocols and their effects. what i am getting at here is that it is responsible to obey the law, which strictly speaking is not a law but a strongly-suggested request. in any event, i need to feel able to trust that politicians are acting in my best interests. indeed, we might articulate the concerns about government regulation in terms of trust. when we comply with government (or public health directives), we often presume that our governments are concerned with flattening the curve, and with saving lives. but government directives and public health guidelines are not always aligned. in addition to your questions about why ontario took so long to release models, baxter (2020) relates how with the scottish government's reporting on deaths in seniors' homes, information was slow to be shared with the public (p. 6). a lack of political transparency serves to erode public trust. but, this trust is not just about politicians; it is also about trusting our neighbours. yet we have all seen people not practicing social distancing which, health officials tell us, is one important way to combat the virus. many countries have first asked and then ordered their citizens to remain in their homes. here, in canada, it seems a good thing to do what we are told, and comply with the public health officials' orders, but what if this compliance is a mistake? or rather, when does compliance turn into obedience? what would arendt say in such a crisis? she might argue that such unthinking obedience negates our responsibility to judge for ourselves (gardiner, 2018) . but would arendt keep to her idea that for adults to obey is ludicrous or would she perhaps consider that, upon reflection, there may be times where obedience to some government edicts is in the best interests of the public realm? it seems to us that there are times when, for the health of the public sphere and those who act within it, it is necessary to comply with government decrees. and yet such compliance raises ethical issues about how much compliance is too much. self-isolation means those of us deemed non-essential workers stay in our homes, and stay away from our friends and family that do not live with us--if we are privileged enough for this to be a possibility. but are we thinking for ourselves when we decide to comply with government and medical requests to self isolate? or does such self-isolation represent a lack of thought on our part, a willingness to go along with what we are being told, without spending enough time reflecting upon whether what we are both told is the right thing to do? complying. reporting on neighbours who do not "toe the line" may seem like our civic responsibility. but who is to say that those snitch lines will not be used in other ways at other times? and will some groups of people be targeted more than others? which raises the question: what is our personal responsibility in a democracy? is it different in a pandemic? rather than obedience to the state, simona forti (2020) describes voluntary selfisolation as an act of solidarity. this relational emphasis is not only important for our political community, it is also important to think about organizational ethics in a relational and embodied way (pullen & rhodes, 2015) . the political and the organizational come together in thinking about public health ethics. similar to forti, health journalists (picard 2020 ) and bioethicists (baylis 2020) urge us to think of physical distancing, staying at home, and wearing non-medical masks as expressions of solidarity. according to feminist bioethicists nuala p. kenny, susan sherwin, and françoise baylis (2010) , "pandemic ethics" has been defined narrowly as a personal health care issue rather than broadly as global public health, and has focused on the traditional bioethical pillar of personal autonomy. however, an individualistic approach will not adequately conceptualize or address public health goals. as a corrective, kenny, sherwin, and baylis articulate a relational public health ethics, grounded in the recognition that individuals are embedded in social and political communities. autonomy, justice, and solidarity need to be envisioned through a relational lens, one that is cognizant of gender and other intersectional aspects of identity. responsibility during a pandemic, then, does not only require trust between people and the government, it also requires us to consider our experience with one other in our political communities. snitch lines suggest that we are fearful of our neighbours, rather than "in this together," a phrase we often hear in public media. the "us" of the political community is really, or should be, an "us all" (kenny, sherwin, and baylis 2010, p. 11 ). calls to stay at home or wear masks thus align with how kenny, sherwin, and baylis (2010) describe relational solidarity: "what matters in public health is a shared interest in survival, safety and security -an interest that can be effectively pursued through the pursuit of public goods," such as scientific evidence and ways of managing infectious diseases (p. 11). while the relational approach to public health ethics is helpful, thinking about responsibility and solidarity during the pandemic becomes difficult for me because of the loss of public space. what kind of togetherness emerges by staying at home? i cannot join with others in public space, if i am complying with orders to stay at home. in an essay originally published in 1957, arendt (1968) says that technology has brought the world together in a kind of solidarity, but it is a negative solidarity based on fear of the atomic bomb and the destruction of life. this solidarity, she argues, "does not in the least guarantee a common future" (p. 83). on the one hand, bonnie honig (2020) argues that social isolation can encourage togetherness and is not a turn towards the private. she states, "social isolation is social, unlike isolationism, which is anti-social. social isolation is collaborative and neighborly. anti-social isolation is competitive, seeks to survive above all else, and wants to 'win.'" on the other hand, what concerns us about thinking about solidarity during the pandemic is less a need to win, and more of a concern with focusing on one's own security at the expense of others. (1968) , must be connected with political responsibility. as we mentioned previously we don't think theorizing "staying at home" as a form of solidarity is misguided. what we want to claim, however, is that it is a narrow, limited mode of solidarity. when i think about compliance and obedience, i worry that we focus on our individual behavior and pay less attention to the world. one of my students told me yesterday he received a warning for reading (alone) on a bench in a public park. i have also heard stories of unhoused people in my community receiving such warnings or even fines. and, from the united states, in new york and florida, black people are being attacked by police officers (who are not always wearing personal protective equipment) for allegedly violating social distancing protocols (democracy now! 2020d; henderson 2020). this is business as usual, using the pandemic as a justification for continued violence against segments of the population. it seems like the new normal is just like the old in some respects. i wonder: does an over-emphasis on isolation and how we must all stay at home encourage us to ignore the ways in which the public realm is still a dangerous place? but what if it is home that is the unhappy place; early reports suggest domestic violence is increasing as a result of the pandemic (taub, 2020) . even if home is a happy space, do we ignore the injustices that occur for essential workers who cannot stay at home? for arendt (2003a), responsibility is not only about accounting for one's actions, it is also about being accountable to other members of one's political community and for our shared world. thus, you can be responsible for actions you did not do. to return to a previous question about personal responsibility in a democracy: it seems as if personal responsibility during covid-19 requires us to challenge the ways in which inequities emerge or are being exacerbated by the pandemic and governmental responses to it. in canada, for example, in the provinces of ontario and quebec, serious inequities have emerged concerning care in long-term homes. close to 80% of deaths from the pandemic are seniors in these homes. many of the homes where the deaths occurred are profit-making centres, rather than government-led spaces. care and profit do not mix well, leading instead to structural injustices that affect those who are most vulnerable in society. a recent report from the military, some of whom were sent into several long-term health care homes in ontario and quebec has shocked many canadians. the deplorable conditions that some elderly residents were in is distressing, reaffirming the idea that when profit is a motivator care is at risk. but this is not just a health problem; this is also a gendered issue. many of the older residents of these homes are women; similarly, most of the carers are women who work in poorly paid jobs, many of which are part-time. successive governments have ignored calls to change this system. what is our collective responsibility to deal with this situation? the crisis in care homes in ontario is not the fault of a singular government or individual, even though the actions of certain individuals may bear significant responsibility for the situation (malek, 2020) . to address the disparities that are being uncovered between the quality of care in for-profit and not-for-profit care homes requires a structural lens. to accomplish this task, iris marion young's (2006) social connection model of responsibility is especially helpful for thinking about collective responsibility. influenced by arendt, young argues that we can be responsible to those with whom we are connected, albeit in dispersed ways, through social structures. in seeking to achieve one's goals or plans, young maintains, a person interacts with diverse organizations and diverse others in a myriad of ways. these interactions take place through the web of social processes and connections. structural injustices occur when hierarchies are created whereby one group is under a threat of domination or has restricted opportunities for action, and another group receives social benefits or enhanced opportunities for action. because of the messy interactions and processes involved, structural injustice can occur even when some agents are acting with good intentions and according to accepted norms. and this system will continue to perpetuate injustice unless there is systemic change. more concretely, when we order food delivery (la times editorial board, 2020), purchase meat (harris, 2020) , or utilize online businesses such as amazon (levin, 2020) to get household necessities without leaving the house, we are staying at home. but we are also part of a web of relations whereby essential workers who work for these companies are often denied a safe working environment. your point is powerfully demonstrated in an article i read recently. it was about a railway worker in london, england; she and her colleague were spat on by some passenger who told them he had covid-19. both women became sick; one of them died from the virus. this story is all the more tragic because the woman who died, belly mujinga, had repeatedly asked her employer for ppe equipment, which was not forthcoming (weaver and dodd, 2020) . what young describes as "social structural processes," such as those bureaucratic processes that prevent precarious workers from having the ppe they need, enable some bodies to flourish while constraining others. politicians and public health officials should be examining systemic inequalities that affect the health of various groups, especially those which are vulnerable or marginalized socially (baxter, 2020; kenny, sherwin, & baylis, 2010 ). yet, as judith butler notes (2012), we do not get to choose the people with whom we share the world. she talks about two senses of vulnerability (or "precarity," in her terms). the first is an existential claim about the human condition, and the second is produced by social conditions and processes. butler states: "so as soon as the existential claim is articulated in its specificity, it was never existential. in this sense, precarity is indissociable from that dimension of politics that address the organization and protection of bodily needs" (p. 148). the virus seems to have brought our existential vulnerability and interdependence to the fore. thus, it alerts us to a paradox; that is, our physical health is vulnerable to the new virus, while our mental well-being is vulnerable through increased isolation. while it seems that many are grappling with this paradox of vulnerability, our argument is that the virus and this paradox should also alert us to pay attention to our social connections with others, to take responsibility for structural injustices that occur in the workplace, and to recognize how they affect diverse working lives. in particular, what this pandemic has brought to the fore is the gender, race, and other intersectional inequities that can be erased behind our politicians' calls for a collective and dutiful response on the part of citizens (ai, 2020) . in this spirit, legal scholar kimberlé williams crenshaw (2020) critiques the language of "we're all in this together" for ignoring racial inequities in the united states. as she highlights, "majority-black counties faced three times the covid-19 infection rate, and nearly six times the mortality rate from the virus, than majority-white counties did." when crises fail to take account of historical and existing power dynamics, solutions might ignore or worsen inequities, such as the us congress' legislative attempts to alleviate economic hardship during the pandemic. 2 crenshaw traces the government's "color blind" pandemic response as stemming from intersectional racism in economic policy in the great depression, through the 1960s civil rights era, to responses to disasters such as hurricane katrina in 2005. for both arendt and young, if a person or an organization contributes to structural injustice, they have a responsibility to remedy harm. thus, a positive view of solidarity in pandemic times must move beyond compliance with government or public health directives. togetherness is not just a feeling of mutuality, but a call to action. to return to the question you raised at the conference: does the coronavirus begin something new in the world? while the virus is not a beginner, we might shift the question to consider whether new forms of human togetherness have emerged in its wake. would we call this togetherness "solidarity" or "responsibility"? take, for instance, those who come together in a public space to critique government action, but do so in a menacing way, such as when members of the michigan militia took over the michigan state capitol to protest against the covid-19 restrictions. these restrictions of the right to gather in public space were, they argued, counter to their democratic rights. although the protest did not lead to harm, the way that the militia used assault rifles to guard the door of the assembly suggested violence could erupt in the political arena. and violence, as we know from arendt (1958; 1969) , is anathema to politics, since it closes down the dialogue and debate that is the essence of the arendtian polis. and yet, the militia protest seemed motivated by some kind of shared political concern for freedom, even if their action looks suspect to many of us. arendt's distinction between freedom and liberty may be helpful in thinking through the michigan militia protest. freedom, in arendt's (1958; 1965) thought, refers to our ability to share public space, to speak and act with our peers. in contrast, liberty is being free from the necessities of life that enslave us and prevent us from enacting our freedom. these necessities could be the mundane activities of daily living: eating, sleeping, caring for dependents, or persistent conditions such as poverty. for arendt, one can be liberated from poverty and still not be free, that is, still not be part of a political community. the militia's protest seems more about liberty than freedom, about protecting individuals' rights to do and go as they please rather than about concern for others. ultimately, the michigan protests do not seem to aim at protecting the public realm from disappearing, but rather seek to ensure individual liberty to pursue one's own security. although kenny, sherwin, and baylis (2010) emphasize social justice and solidarity in their relational account of public health ethics, we contend there needs to be more interaction between how these conceptual pillars are articulated by feminist scholars. in our view, solidarity in public health must extend beyond "a shared interest in "survival, safety and security" (kenny, sherwin, & baylis, 2010; p. 11) to promote an inclusive and accessible political community. we need to closely integrate social justice concerns with solidarity in public health ethics. such an integration is well-illustrated by baxter's (2020) weaving together personal narrative about caring for her aging father with factual information about long-term care in the uk. according to baxter, we cannot understand the challenges her father faced in receiving adequate care as he was moved between various institutions during the pandemic unless we also attend to structural factors. these factors include the gendered demographics of unpaid care for elders within families, federal defunding of local health supports, a sufficient number of staff in care homes, the poor pay and precarious conditions of (predominantly women) care workers, and even corporate tax havens. in sum, despite an emphasis on relationality in public health ethics, when solidarity is framed in terms of shared interests such as survival, safety, and security, then liberty can still be privileged over freedom thereby diminishing the ability of all members of the community to flourish. if we are correct in reading the michigan militia protest as people coming together around private interests, it seems as if the protest is not an exemplar of arendtian solidarity. rather, as lisa disch (1996) notes, arendt's conception of solidarity is about a common purpose rather than a common interest. and here, "purpose" must be something that is worldly and not private. perhaps new forms of togetherness are emerging with the caravan protests, where people drive or bicycle through empty city streets, such as what took place in washington dc (democracy now!, 2020a). similar expressions of solidarity with front line workers and calling for better worker protections, racial justice, and environmental justice, happened across europe. in san juan, puerto rico, people demanded more testing and supplies from the government (democracy now! 2020b). on the face of it, these actions seem to be about the private sphere or economics. yet these global actions also affirm the world as a space humans share, as our political home. the covid-19 crisis brings into focus an enduring challenge for political worldbuilding. as the virus interrupts the familiarity of daily life, it has also revealed that our political home can be enhanced or destroyed by the actions of politicians and by inequities produced through structural matters, such as healthcare funding. indeed, it seems as if many societies are at a serious juncture where we have the potential for making new choices about how we want to live together. the covid-19 crisis has also shown us that we too have a choice in that we can live our lives in fear and isolation, or we can start to trust one another again as we move back to our public spaces. establishing trust will be important in helping people learn to adapt to the new normal in organizational spaces and other public places. public trust in our previous version of normal was waning, because of injustices in the workplace and elsewhere. across the globe, the world was facing serious issues, borne out of neoliberal injustice as well as climate denial. could it be that this virus has made us think again about what matters? and, if so, what will that mattering look like? it has been an anxious time for sure, but it has also been a moment where many people have had the opportunity to reflect on what matters to them. an arendtian politics is concerned with how we share the world in such a way that it becomes a place of belonging, not just for a few, but for humanity. in this paper, we have examined ways in which "virus interruptus" offers an opportunity to rethink how we build a political home. as mcmurray and pullen argue (2019), arendt shows us how "rationality, probability, regulation, institutionalisation and quantification serve to limit space for individuality and difference as we are imprisoned by industrialisation, capitalism and marketisation" (p. 2). as we have illustrated, the temptation to view our pandemic crisis in statistical terms risks obscuring some important structural injustices. addressing structural injustices will require organizational change. bloom (2018) asks how can we create the conditions for organizational politics to flourish. that is, how can we envisage new ways of organizing that offer space for diverse ways of being in the world? an arendtian way of thinking about organizational action, he states, is not concerned with "a logic of means and ends but rather revel in the joy of simply acting to create the potential for something new to exist" (p. 78). as you mentioned earlier, questions about world-building presume a community already exists, when for many it does not, at least not in the robust way arendt views world-building as central to politics. the problem for political world-building is that structural injustices work to exclude some people, such as our elders or front line workers, from mattering. on her account, political community emerges through our acting and speaking together (arendt, 1958) . along these lines, solidarity establishes a community (arendt, 1965) . our everyday social interactions may be fleeting and may disappear as soon as the business of "normal" life resumes. yet, it seems as if some people have found time for reflection during the pandemic; such reflection may have awoken a realization that, for humanity to flourish, everyone needs rights to have a home, have meaningful and safe work, and to have enough food to sustain them. the argument we have begun here could be extended in future work to consider solidarity in pandemic times alongside arendt's (1951) conception of "the right to have rights." arendt uses this term to expose a contradiction in the way human rights are applied to stateless people; what has emerged during the pandemic is the need to reconsider how individual rights (and which individuals' rights) are undermined or ignored as a result of structural injustice in the workplace, and elsewhere. in addition, perhaps some of us have learned through this pandemic that small, everyday interactions, such as conversations between neighbors and colleagues, have the ongoing potential to not only offer us a recognition of our shared space but also highlight the importance of making human connections. there is this potential, at the least, for diverse forms of community to emerge from these moments. perhaps, in a small way, the joy of acting together that bloom (2019) describes, and the potential for community-building that we have explored, is akin to the kind of public happiness that arendt (1965) talks about as emerging in times of revolutionary change. this public happiness captures the existential component of striving to build a political community together, being able to have an impact in one's community, and being motivated to act to protect the community as a space where people can gather. yet, such public happiness is fleeting. part of the task of revolution, according to arendt, is to build a more stable home for it. what a political home looks like for pandemic times is as yet uncertain and up to us, together, to build. we have not prescribed any particular response to covid-19, but rather sought to highlight the urgency of attending to structural injustices that affect health and also limit the ways in which people can exercise their freedom. there is no doubt we are living in new times, but how these new times will turn out depends upon all of us having trust in one another. our politicians can only do so much; it is up to us, collectively, to begin the process of rebuilding our public spaces, as best we can. as bonnie honnig (2020) explains, "[t]he virus can make us go private, or it can lead us to a renewed democratic appreciation of public things, like public health services coordinated by dedicated experts." the task is to think through political world-building in an ecological, ethical, and relational manner. to address structural injustices, we need more world-building conversations about how to envisage our society in the future. a return to the old normal is not the way forward; yet what our new normal looks like depends on the conversations we have together about the ethical dimensions of a new ecological and equitable politics that embraces all of us. finally, as mcmurray and pullen (2019) note, arendt's work has been rarely taken up in organizational studies, although this lacunae is beginning to change (bloom, 2019; gardiner, 2018; gardiner & fulfer, 2017) . as feminist scholars whose work engages with arendt across a range of organizational topics, we encourage other researchers to consider how thinking with arendt can help us to reflect upon our interdependence not only with each other, but with the world. the invention of an epidemic digital surveillance in post-coronavirus china: a feminist view on the price we pay. gender, work & organization. 1-5 between past and future collective responsibility origins of totalitarianism 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worker dies of coronavirus after being spat at while on duty. the guardian responsibility and global justice: a social connection model key: cord-342939-b7qn6ynk authors: baillie, l.; dyson, h.; simpson, a. title: dual use of biotechnology date: 2012-01-03 journal: encyclopedia of applied ethics doi: 10.1016/b978-0-12-373932-2.00430-0 sha: doc_id: 342939 cord_uid: b7qn6ynk this article addresses issues that are central to the dual use of biotechnology, such as the public perception of risk and the need for physical containment to prevent the release of potentially dangerous microorganisms. it also examines the public and media perception of the scientists who handle and manipulate these pathogens and discusses the controls that are currently in place to ensure that scientists engaged in defense-related dual-use medical research act in a transparent and ethical manner. finally, the article discusses what can be done by scientists to allay the fears of their fellow citizens. research in the area of life sciences and biotechnology has the potential to bring great benefit to humankind. in a relatively short period of time, the life sciences have evolved from a simple cataloguing exercise of the diver sity of nature to a position in which researchers are adding to that diversity through the construction of modified and potentially novel life-forms. the vast majority of this activity has had a positive impact on the quality of life of at least some of the human race. indeed, the past 150 years have seen major advances in the fields of micro biology and biochemistry, and these have been followed by the emergence of the disciplines of immunology, molecular biology, and genetics. in practical terms, this has resulted in the introduction of sewers and clean water, the development of antibiotics and vaccines capable of eliminating infectious diseases such as smallpox, and the ability to create genetically modified organisms able to synthesize production-scale quantities of human hor mones such as insulin. indeed, on a daily basis biomedical researchers manip ulate microorganisms in an effort to understand how they produce disease and to develop better preventative and therapeutic measures against the infections they cause. the efforts of plant and animal biologists using similar techniques to improve agricultural yields have resulted in the development of disease-resistant crops and transgenic animals. some of these species have transitioned from the confines of the laboratory into mainstream agriculture in countries such as the united states and india. on first disclaimer: any views expressed are those of the authors and do not necessarily represent those of dstl, ministry of defence, or any other uk government department. inspection, these emerging technologies hold enormous potential to improve public health and agriculture, strengthen national economies, and close the develop ment gap between resource-rich and resource-poor countries. however there is also a potential dark side to this benign picture. throughout human history, every major new technology has been used for hostile purposes, and thus it would be naive to believe that the life sciences might not be similarly exploited for destructive purposes by state-sponsored biological warfare programs or by individual terrorist or doomsday groups. research with the potential to be misused for illicit purposes is said to be 'dual use.' simply stated, the techniques needed to engi neer a bioweapon are the same as those needed to pursue legitimate research. there are also concerns that rapidly advancing technological possibilities could enable the creation and production of unforeseen new biological threats with uniquely dangerous but unpredictable characteristics. a key challenge faced by regulatory authorities is the need to balance legitimate public concerns over the mis use of life sciences against the enormous potential that they have to benefit humankind. getting this balance right will be central to ensuring that governmental actions do not impose blanket restrictions and cumbersome rules on scientists that stifle legitimate research and reduce industrial competitiveness while having little impact on real security. it could be argued that any new regulations specific to dual use of biological technologies would be largely inef fective because they would only affect scientists working in government-funded laboratories, who already follow very stringent rules. indeed, even if new regulations were implemented, it is debatable as to how effective they would be. the anthrax attacks in 2001 in the united states are thought to have been undertaken by a 'regu lated' lone u.s. government scientist working in a government-controlled facility. does this mean that we need new regulations, or does it suggest that regulations alone are likely to be ineffective? it is also a fallacy to believe that life science research is limited to government-regulated facilities; indeed, the technology has reached a stage at which an individual with a graduate-level education, access to the internet, and a credit card can set up a garage laboratory anywhere in the world. the emergence of organizations such as diybio is a testament to this new movement. this spon taneously formed community of more than 2000 individuals is in the process of establishing community laboratory spaces in major cities throughout europe and the united states to enable their members to carry out their own 'hobby research.' how can these free spirits be assisted or regulated to ensure that both their own safety and that of the community in which they live and experi ment remain secure? an approach proposed by a number of advocates has been to encourage life scientists to take the lead in tack ling the issue of dual-use technology. indeed, some have stated that these scientists have a moral obligation to prevent the misapplication of their research because they are believed to be in the best position to understand the potential for misuse. although the validity of this argument is debatable, it is also extremely unlikely that the average research scientist will have more than a hazy comprehension of the factors important in developing an effective bioweapon. this view does, however, point to the need for life scientists to move more to center stage and proactively engage with both the public and the security and regulatory communities to ensure that the control systems that are ultimately adopted are both proportionate and likely to be relevant in the real world. it should not be forgotten that the reason for these control measures stems from a desire to protect the well being of the general public. although it is highly unlikely that they will understand the intricacies of the research, it is important that they support the outcome that the researchers are trying to achieve. indeed, the support and tacit consent of the general public and their elected representatives is essential in the development of propor tionate regulatory systems. unfortunately, scientists in general, and particularly those engaged in defense and industry-funded research, have a poor track record in communicating the impor tance of their research to fellow citizens. this is primarily due to the constraints imposed on them by their parent organizations, but it also flows from a lack of understand ing of science among the media industry generally, and particularly the popular press, which often results in incomplete and inaccurate reporting. as a consequence, this perceived lack of openness has created an atmosphere of suspicion in which conspiracy theorists, the media, and hollywood thrive, routinely conjuring up lurid images of evil scientists working on government-funded frankenstein projects to destroy the world. it is thus perhaps not surprising that public perception of scientists and their motives may not be as positive as it once was. this article addresses issues that are central to this theme, such as the public perception of risk and the need for physical containment to prevent the release of potentially dangerous microorganisms. it also examines the public and media perception of the scientists who handle and manipulate these pathogens and discusses the controls that are currently in place to ensure that scientists engaged in defense-related dual-use medical research act in a transparent and ethical manner. finally, this article discusses what can be done by scientists to allay the fears of their fellow citizens. although microorganisms capable of causing disease are widespread in the environment, medical, technological, and economic advances have, to a large extent, shielded individuals in the developed world from their adverse effects. notable examples include the reduction in the incidence of (1) puerperal fever and surgical sepsis in the nineteenth century following understanding of the modes of transmission of bacterial infection, (2) enteric fevers due to improvement in sanitation, and (3) food poisoning due to better education and food preparation practices. while there are still intermittent outbreaks of food poisoning in the united kingdom, the real concern is that the overuse by the farming industry of powerful antibiotics to promote animal growth could result in the emergence of multi-drug resistant pathogen bacteria making them increasingly difficult to treat. the importance of a society's organizational and tech nological status in mitigating the effects of disease is well demonstrated by the contrasting fortunes of new zealand and haiti following earthquakes in 2010. although the earthquake that hit south island at 04.35 local time on september 4 was of a similar magnitude (7.1 compared to 7.0) to the one that struck haiti at 16.53 on january 12, the outcomes for the two populations have been remarkably different. there were no fatalities in new zealand (only two people were admitted to hospital in the immediate aftermath), and there have been no epidemics, despite disruption of sewage and water supply systems. this contrasts with a high initial death toll (230 000), many injuries (300 000), catastrophic disruption of haitian society (1 million people made homeless), and an epi demic of cholera in the displaced population. aspects of a society that determine its resilience to major disasters include the general health and education of its popula tion, its technological infrastructure, the state of readiness of its societal organization to respond to the event con cerned, and its political and governance structures. new zealand and haiti appear to be at opposite ends of the spectrum for all of these criteria. a particular infection of a certain severity may have widely different impacts on an individual depending on the person's general health and specific circumstances. thus, an enteric infection in an undernourished child in the medical center of a refugee camp outside port-au-prince could well prove fatal (particularly because the child is likely to be only one of many), whereas a similar infection in a healthy child in christchurch might be overcome with little more than good nursing care from the child's parents at home. perception of the risks of such infection also varies considerably according to a society's recent experience; childhood deaths from enteric infec tions are an accepted fact of life in many poor areas of the world, whereas in richer, technologically advanced areas they are not. typically, as the prevalence of infectious disease decreases over time in a society, concern regarding rare and particularly novel infections increases. thus, fre quent but relatively mild infections (e.g., the common cold) may inflict a significant overall burden on a society in terms of general ill-health, use of health services, and loss of economic activity without arousing much outcry from the general population. in contrast, a rare but severe treatable infection such as methicillin-resistant staphylococcus aureus may cause much consternation in the media but actually inflict a much smaller overall burden on society. novel or emerging infections (e.g., severe acute respiratory syndrome (sars) and swine flu) may have major economic and societal impacts worldwide, with an actual disease burden that is a minute fraction of that caused by well-known diseases such as malaria and tuberculosis. perhaps counterintuitively, the fear engendered by rare diseases in a society appears to be inversely related to the actual disease burden that they impose. this fear will clearly be modified by experience of the disease; thus, sars was rightly to be feared and swine flu less so. by extension, an unknown infection can cause disproportion ate fear in a population, exaggeration by the media, and the risk of overreaction by the authorities. the 2001 anthrax letters episode in the united states was an exam ple of a major response to a relatively small overall disease burden (20 infected and 5 deaths in a country of 311 million people), but it demonstrates the fact that a society's response to an unexpected human-originated event may have a much greater impact on the society than the event itself. media-dominated, internet-connected, technologically advanced, economically developed areas of the world are therefore more prone to exaggerated responses based on fear of a horrifying unknown than are those areas that are less privileged. the controversies in europe regarding genetically modified (gm) crops (feared in europe for ideological reasons but welcomed by more pragmatic societies in india and the united states for the increased yields they bring) highlight the fact that advanced societies may, for cultural reasons, have different views of the risks associated with certain technologies. although all advanced societies would be expected to have a marked fear of the sequelae of a deliberate release of infectious organisms, those with an already heightened fear of biotechnology might be more prone to extreme reactions. deliberate release of harmful biological material would provoke a number of emotions, including fear of the unknown, the ancient fear of plague or conta gion, anger and fear of malicious human action, anger directed at law enforcement agencies for failing to prevent the event, and anger at politicians for possibly provoking the event. a release of dangerous biological material from a research laboratory would provoke many similar emotions, although anger would be direc ted more at the incompetence of those operating the laboratory and at the relevant authorities for failing to prevent it. so what is the real risk of an accidental or deliberate release of dangerous biological material in the united kingdom? fortunately, escape of infectious material from laboratories is very rare; examples include a small pox outbreak in birmingham in 1978 and the foot-and mouth disease outbreak associated with faulty drainage at the animal health facility at pirbright in 2007. the root cause of such accidental releases was a breakdown in containment (the physical control measures put in place to prevent microorganisms escaping to the environment). in fact, containment technology and practices have improved dramatically during the past 50 years, with significant improvements often being identified by analy sis of accidents or near-misses. at the porton down site, which houses both ministry of defence and department of health microbiological containment laboratories, there have been only two cases of laboratory-acquired infec tion; these occurred in the 1960s and both were the basis for considerable improvements in procedures. in the united kingdom, there have been no known deliberate releases of biological material. there have been deliber ate releases of infectious material in other countries -the rarity of such events has probably contributed to their celebrity status. given the extreme rarity of such events, why are they so feared? it is instructive to compare the annual inci dences of certain other commonly accepted events using headline statistics relating to work-related ill-health and accidents in the united kingdom during 2009-10: • ill-health: 1.3 million people who worked during this period were suffering from an illness (long-standing as well as new cases) that they believed to be caused or made worse by their current or past work. a total of 555 000 of these instances were new conditions that started during the year. an additional 0.8 million former workers (who had last worked more than 12 months previously) were suffering from an illness caused or made worse by their past work. a total of 2249 people died from mesothelioma in 2008, and thousands more died from other occupational cancers and diseases. • injuries: 152 workers were killed at work -a rate of 0.5 fatalities per 100 000 workers. a total of 121 430 other injuries to employees were reported -a rate of 473 per 100 000 employees. a total of 233 000 reportable injuries occurred, according to the labour force survey -a rate of 840 per 100 000 workers. • working days lost: 28.5 million days were lost overall (1.2 days per worker), 23.4 million due to work-related ill-health and 5.1 million due to workplace injury. thus, real risk is very different from perceived threat, which may sometimes appear greater the rarer the event (and hence the lower the probability of actually experi encing that event). data for england and wales for 1989 indicated that the more common avoidable causes of death (e.g., cardiovas cular disease due to smoking and obesity) carried a risk of 1 in 190 compared to a risk of 1 in 700 000 for spectacular events, such as railway accidents, that generally attract media attention. these risks were calculated retrospec tively from the reported causes of death during that year. the risk of dying in england and wales from infection due to bioterrorism in that year was zero (as it was in 2009). however, when looking forward into an uncertain future, many more factors than likelihood affect the per ception of threat, and it may be that the very rarity of an event adds to its perceived impact, making it more inter esting to society at large and therefore much discussed in the media. it is clearly the case that if these rare events remained unreported, the public would not dread them so much, but such censorship would not be acceptable in a democratic society, and the media should take a respon sible approach to explaining real risks and suggesting appropriate and proportionate precautions to mitigating them. although past experience suggests that release of danger ous biological material, whether accidental or deliberate, from facilities is extremely rare, it is important that we consider how such an event could occur in the future. the most likely routes of escape are following an accident in a laboratory (hospital, academic, government, or commer cial research) or as a consequence of defective physical containment processes or equipment as occurred at pirbright in 2007 when foot-and-mouth virus was released to the outside world. the mainstay of preventing release of dangerous bio logical material rests on principles of biosafety, biocontainment, and biosecurity. biosafety covers the procedures needed to work safely with hazardous organ isms. biocontainment includes the measures (facilities, equipment, and apparatus) within which work on these organisms can be carried out safely without danger of release into the environment. biosecurity is the process of ensuring that the whereabouts of hazardous organisms are known and tracked and that access to them is restricted to appropriately authorized personnel. these principles actually apply more widely to other human activities, including hygienic preparation of food, supply of clean drinking water, safe processing of sewage, sterile procedures in surgery, and safe operation of hospital microbiology laboratories, as well as the more obvious situations of microbiological research laboratories. welldesigned facilities and procedures both facilitate the con duct of good science and minimize the opportunities for accidental misuse. unfortunately, although good engineering can reduce the physical risk of pathogen release, it cannot stop a researcher from deliberately removing material for his or her own use. the motives for such an action could include ideology (extremist apocalyptic, islamist, or ani mal rights philosophies), blackmail by members of an extremist group, disorders of perception (mental illness or desire for revenge against society following some real or imagined disadvantage), or severe disaffection with employers or colleagues. the 2001 u.s. anthrax mail attacks represent just such a case, in which anthrax spores alleged to have been deliberately removed from a u.s. government defense research facility by a government scientist were used to carry out indiscriminate attacks against the general population. although extremely rare, this event is likely to have had a major impact on the public perception of scientists engaged in defense-related research and their motivation. scientists have an image problem. the charming and charismatic scientist is not an image that permeates popu lar culture. although it is common for the entertainment industry (and news media should be included in this category) to portray professions such as medicine, law, and journalism as exciting and glamorous, scientists are often depicted as unattractive, reclusive, socially inept white men or foreigners working in dull, unglamorous careers on projects that could destroy the world. indeed, there is evidence that this impression may be imprinted in childhood and once established is difficult to modify. the reasons for this stereotyping are complex but can be broken down into two main areas: a failure to grasp the nature of the scientific process on the part of the public (education) and a failure to present their message in an accessible manner on the part of scientists (communica tion). these tendencies are compounded by an understandable desire on the part of the entertainment industry to produce content that is popular and profitable. the issue of how our children are taught basic science is an area of obvious concern, as highlighted by the observation that approximately 70% of adult americans do not understand the scientific process and have to depend on others to help them understand the signifi cance and consequences of scientific advances. in the advanced economies, the major source of information is television, whereas the internet (another unregulated environment) is increasingly used to research specific scientific issues. given the importance of these media in 'educating' and shaping public opinion, how good are scientists at ensuring that their message is getting across? it is safe to say that whatever they are doing, it is not having the desired effect. part of this failure is due to the inability or reluctance of practicing scientists to engage with the media in such a way as to convey their story in a form that is understandable by their fellow citizens. a survey com missioned and funded by the wellcome trust found that the majority of scientists believed that the public saw them as detached, poor at public relations, secretive, and uncommunicative. furthermore, they identified a lack of knowledge and/or interest in science within the general public as a major barrier to communicating concepts and ideas. most of those questioned believed that they were insufficiently trained to deal with the media; more impor tantly, the majority of scientists surveyed distrust the role of the mass media in communication of their results. the role of the mainstream media and popular press is primarily to entertain their customers and make money. in that light, it is not surprising that there is a tendency to focus on stories and issues that seize public attention. all journalists know that scares make good stories and fre quently generate a momentum of their own that does not require any facts to keep them moving forward. for example, in recent years we have seen the emergence of numerous scare stories in the media (flesh-eating bacteria, falling sperm counts, chlorofluorocarbons, bovine spongi form encephalopathy, harmful gm foods, etc.), many with little in the way of scientific evidence to support them. it is perhaps not surprising, then, that a climate has been created in which the ordinary person regards scientific developments with suspicion, having the under lying assumption that he or she is being put at risk by reckless scientists operating in an uncontrolled manner in their ivory towers. this perception is not helped by hollywood, which provides a seemingly endless diet of disaster films in which dastardly government scientists are either blowing something up or pursuing genetic experiments in a top secret government laboratory to produce new species that could escape and destroy the world. when was the last time a blockbuster film was released in which a dedicated scientist carried out an experiment that did not involve a chiseled-jawed hero saving the day? a further element that may contribute to the public distrust of science is the rise of pseudoscience, which includes topics such as astrology, alternative medicine, yogic flying, and ufos. indeed, it has been suggested that the entertainment industry (e.g., the popular x-files series) is partially responsible for the large numbers of people who now believe in astrology, esp, alien abduc tions, and other forms of pseudoscience that contribute to the scientific illiteracy of the public. against such a cultural backdrop, it is not surprising that the public has little problem in believing that government scientists employed in defense-related research are not to be trusted. as a consequence, scientists, particularly those engaged in research considered dual use, find themselves in an almost impossible position when trying to explain their research and allay understandable fears harbored by the public. so why are members of the public concerned about research sponsored by the defense community? many nations view research into the development of medical countermeasures (mcms) against biowarfare agents as an essential element of risk reduction. although civilian and military populations are equally susceptible to the same biological agents, the relative risk of exposure differs markedly. thus, although there is considerable common ality in the research priorities of each group, some biological threats, such as anthrax and plague, are cur rently seen as being more relevant to the military. in addition, the nature of the work undertaken by the mili tary and the environment in which it operates are likely to influence how and when mcms are administered. for example, the military may consider immunizing troops with a new vaccine prior to deployment as the most effective means of protecting individuals and ensuring operational effectiveness in a high-risk environment. in contrast, the civilian authorities are more likely to treat with antibiotics after an outbreak has occurred rather than vaccinate large numbers of the public against a disease with a very low likelihood of a deliberate release (albeit very high impact), such as anthrax. thus, differences in the relative risk of exposure of each target population are a major driver of the research undertaken by defense scientists. to develop mcms capable of dealing with biothreat agents such as anthrax, there is inevitably a requirement to handle and manipu late these dangerous pathogens, which in turn generates concerns, rightly or wrongly, about the possibility of their inadvertent release or potential misuse (dual use). indeed, these concerns derive partly from the fact that the government-sponsored organizations currently devel oping defensive mcms were engaged many decades earlier in the development of offensive biological weap ons. although this research was discontinued in the 1960s in the united kingdom, there are still concerns, in some quarters at least, regarding the potential for this type of work to be resurrected. when the public's mistrust of politicians and scientists is added to this mix, it is not difficult to understand why people are willing to believe the worst. indeed, the perceived lack of 'public visibility' of defense research further stimulates the public imagination despite the fact that the results of this research are widely disseminated through peer-reviewed journals and at international conferences. the nature of modern research is such that it is rare to find a project that does not require collaboration with academic and/or industry-based part ners, thus ensuring at least some degree of scientific visibility. in addition, the regular inspection of defense research facilities by national regulatory agencies or under the auspices of international treaties is an attempt to alleviate some concerns. openness, combined with inspection by independent scrutinizers, is an important tool in tackling dual-use concerns. if one accepts that defense-related research is war ranted, then how does one justify the development of a new medical countermeasure costing millions of dollars to protect against an event that may never happen? this is particularly important given that any new mcm must first undergo clinical trials in human volunteers to demonstrate both safety and efficacy. this will require the exposure of healthy individuals to an experimental treatment that carries with it the risk of adverse reactions. given that this is a man-made risk, how can this be justified? fortunately, in countries such as the united kingdom, these decisions are taken out of the hand of the defense scientists. indeed, investigators conducting clinical trials need to justify their study to an independent research ethics committee, which determines if any potential health risks to trial participants are justified. a key element in the committee's deliberations is to determine if there is a real-world justification for the new mcm; thus, the committee represents an important reality check. once the study has received approval, it is subjected to further scrutiny at the national level in the united kingdom by the medicines and healthcare products regulatory agency (mhra). each of these layers of control has the power to stop a clinical trial if it is concerned that an ethical breach has occurred and thus plays a key role in preventing inappropriate research. although regulatory scrutiny is vital to prevent harm to volunteers, a further level of protection is provided by the financial realities of drug development. the cost of bringing new mcms to market is considerable, amount ing to hundreds of millions of dollars, and as a consequence, the engagement of the pharmaceutical industry is essential. drug companies are focused on making money and given the relatively small size of the military market will only invest significantly in the devel opment of mcms that could also be used to protect civilian populations. thus, any mcm derived from mili tary research will undergo intensive public scrutiny on route to being licensed and, as a consequence, will be exposed to intense public and financial scrutiny. even when an mcm has been approved for human use, there are still questions regarding its administration to service personnel. for example, should immunization with biodefense-specific mcms such as the anthrax vac cine be mandatory as it is the case for the u.s. army? this raises issues of military governance and consent to treat ment, which can only be dealt with by the relevant law in each country. if new mcms are being developed, there needs to be consideration of the target population in advance of likely use. it would be wasteful for defense research to develop new drugs that would not be accep table to service personnel and would therefore be effectively unusable. public concern regarding dual-use issues and the ethics of performing defense-related research has led to the instigation of a range of checks and balances in the united kingdom designed to reduce risk to a minimum. the effectiveness of these measures is rightly open to public debate, and it is hoped that future scientists, as well as members of the public, will be encouraged to make a full and active contribution to this debate to ensure that future regulatory decisions are based on evidence rather than driven by popular misconception. biological material with the capacity to cause harm can be found in a range of different institutions (hospital, aca demic, pharmaceutical, and government establishments, both civilian and military). potentially, such organisms could be released into the environment following unfore seen accidents, due to negligence, or by deliberate intent. however, experience to date shows that the actual like lihood of human infection as a result of deliberate or accidental release is vanishingly small, particularly com pared to that of contracting infections naturally or suffering harm from other types of accidents or being the victim of a criminal or terrorist assault of some kind. the disproportionate fear that the threat of such infec tions arouses in the general population reflects a lack of understanding of the nature of risk, hazard, and proba bility, coupled with an understandable tendency of the popular media to exaggerate the impact of rare or ima gined spectacular events. the research undertaken in organizations in which microorganisms can be found has produced results of enormous benefit to human society in terms of improving health outcomes (better sanitation, advances in medicines, and vaccines) and increasing safety and efficiency of food production. future developments in biotechnology hold the promise of major benefits to humanity in such diverse fields as mitigating the impact of climate change, improv ing agricultural yields in poor areas of the world, synthesis of novel materials on an industrial scale (e.g., biofuels), and the discovery of cures for major scourges such as tuberculosis and malaria. how do we balance the enormous potential for good that biotechnology offers against concerns regarding its misuse? in the united kingdom, the vast majority of microbiological research is performed in civilian organi zations, with only a very small fraction being conducted by defense laboratories. research activities in defense and civilian facilities in the united kingdom are carefully regulated by a number of statutory bodies such as the health and safety executive, which monitors studies involving genetically modified organisms, and the home office, which oversees experiments involving animals. clinical trials involving human volunteers are regulated by the mhra and are overseen by research ethics com mittees (which are themselves approved by the uk ethics committee authority). however, more regulations, such as intrusive psychological profiling of staff working in microbiological laboratories or heavy-handed, overbear ing, rigid assessment programs of scientific staff to 'ensure' reliability, are unlikely to further reduce the probability of an already extremely unlikely event. rather, they are more likely to alienate well-motivated staff, thereby sti fling research and the development of products and techniques that could bring major benefits to the united kingdom and humanity as a whole. indeed, fostering a supportive community among well-rewarded and appre ciated scientists and staff would make it much easier to detect early signs of unhappiness, social problems, or the unacceptable behavior of individual researchers. such an approach would also be expected to produce better scien tific outcomes. the role and responsibility of scientists is central to minimizing misuse of technology, and thus it is vital that life scientists are encouraged to take ownership of this problem and in doing so assume a more proactive role in regulating, communicating, and explaining their activities to the wider public. unfortunately, to date, the majority of scientists have demonstrated a marked reluctance to fill this role for the reasons outlined previously. it has been suggested that improved education of scientists, the media, and the public would go some way toward addressing this issue. improving the aware ness of scientists could take many forms, such as the inclusion of teaching material covering biosecurity and dual-use issues into the curriculum of all life science undergraduates and in seminars, conferences, and pub lications dedicated to the subject. scientists, particularly those engaged in areas of research that have the potential for misuse, must be encouraged to communicate the nature of their research as widely as possible to their fellow citizens. the most obvious vehicle through which to achieve this aim is the mass media, which is in a position to be a creative and positive influence in bring ing scientists and the public together around these issues. it has the capability to improve communication and understanding, reducing unwarranted fears and sensa tionalist reactions to imagined threats. how we achieve this utopian dream in the face of the economic realities of a 24/7 multimedia society is a question beyond our powers. the committee for skeptical inquiry uk -the health and safety executive les baillie is a professor of microbiology within the welsh school of pharmacy of cardiff university. prior to joining the university in 2007, he was director of the biodefence medical countermeasures department based at the naval medical research center in washington, dc. in this role, he led a multidisciplinary team developing novel therapeutics to combat the threat posed by biothreat agents. this research built on previous experience gained at dstl porton down, where he led a research team working on anthrax. having worked in both government defense and academic laboratories on two conti nents, he has a unique insight into the challenges faced by life scientists engaged in research in this area.dr. hugh dyson is a principal medical officer at dstl porton down. he has previously worked in the national health service and academia, holding posts in renal medicine and pharmacology.dr. andrew simpson is a clinical microbiologist at dstl porton down. he has previously held posts in the national health service and academia, and he worked for many years in thailand at the mahidol oxford tropical medicine research unit. key: cord-259247-7loab74f authors: capps, benjamin title: where does open science lead us during a pandemic? a public good argument to prioritize rights in the open commons date: 2020-06-05 journal: cambridge quarterly of healthcare ethics : cq : the international journal of healthcare ethics committees doi: 10.1017/s0963180120000456 sha: doc_id: 259247 cord_uid: 7loab74f during the 2020 covid-19 pandemic, open science has become central to experimental, public health, and clinical responses across the globe. open science (os) is described as an open commons, in which a right to science renders all possible scientific data for everyone to access and use. in this common space, capitalist platforms now provide many essential services and are taking the lead in public health activities. these neoliberal businesses, however, have a problematic role in the capture of public goods. this paper argues that the open commons is a community of rights, consisting of people and institutions whose interests mutually support the public good. if os is a cornerstone of public health, then reaffirming the public good is its overriding purpose, and unethical platforms ought to be excluded from the commons and its benefits. for some, the ongoing severe acute respiratory syndrome coronavirus 2 (sars-cov-2) pandemic has "reaffirmed the urgent need for a transition to open science." 1 "the real antidote to epidemic is not segregation, but rather cooperation," 2 so that open science will accelerate societal and economic progress. 3 across the globe, open science (os) is enhancing evidence-based nonpharmaceutical measures, and equitably contributing to scientific and clinical responses to the pandemic. 4 although os has come to mean many things, 5 this paper is a critique of the concept that all scientific knowledge resides in an "open commons." 6 os is preferable to a competitive, secretive, and proprietary scientific culture; 7 however, the veneration of data idealism under the "new" commons obscures potential abuse of os, too. 8 first, the pandemic has become a false panacea for os in the unprecedented application of big data and fast science, leading to hurried and expedient publication, rather than prudent protocols, to support public health. critics, however, point out that much of the information is not vetted, noisy, and can be socially and politically distorting. os's chaotic application is contributing to negative social determinants of fairness and equitability, in respect to whom the data is about, who can use it, and ultimately who controls it. 9 second, os has become an end-in-itself, so its purpose to support the public good has morphed into surveillance that bleeds into social control and profiteering. of these requires obligations to use it ethically. focusing on the question of markets (rather than surveillance), this paper attempts to keep os as a cornerstone of public health, and therefore reaffirms the public good as os's overriding purpose. during this pandemic, os has become central to sharing data about the sars-cov-2 and clinical nature of covid-19. this exponential growth of real-time information has been used directly to justify public health policies. os is not new to this pandemic, however, and its narrative has a distinct ideology which could have an impact on how we emerge from this time. the contemporary idea of os comes from a nebulous background: it has origins in history, 18 social convention, 19 jurisprudence, 20 and ethics. 21 these ideas represent different heritages about what constitutes favorable conditions for social innovation. today, os is principally positioned as a response to the unprecedented production of data-too quickly to be contained and too much to be constrained by solitary users-and a realization that misuse of proprietary models can discourage socially valuable innovation. 22 os, therefore, began the gradual normalization of open access journals as a benchmark for scientific dissemination, and has since become a movement to advocate for a new "open commons" to underpin all parts of the research process. colloquially, os is about removing barriers to scientific knowledge, and, as such, it has supported creative models that prioritize better and faster access to science for anyone who wants to use it. os is meant to remove structural obstacles to reporting and dissemination, and thereby optimize socially valuable practices (e.g., "open access," "open data," and "open source"). 23 numerous funding agencies and governmental institutions stipulate ethical conditions like transparency and fairness, confident that opportunities stemming from os will be socially equitable. 24 some industry-based individuals and institutions have integrated os into their work ideology. 25 it is also anticipated that publics, such as users, research participants and patients, will share their data too. 26 to this end, os is interconnecting all domains of scientific record-keeping, archiving, discovery, and innovation, and has taken root in the community ethos underlying citizen science and crowdsourcing. primarily, os maximizes efficiencies in the knowledge economy by reducing proprietary claims on intellectual property and promoting co-created knowledge. doing so enhances international and interjurisdictional cooperation on fair data creating, access and use. there is evidence that os benefits researchers through recognition, partnerships, and enhanced data access. it ensures critical review and reproducibility, and opens up scientific culture to social scrutiny and thereby reinforces the scientific method (i.e., advocating holistic creation and stewardship of knowledge). 27 os may become a cornerstone in clinical practice, enabling diagnostics and cures using patient records across vast places and time. 28 in public health, realtime data analytics enables rapid and equitable responses to pandemics. 29 although os culture may be a result of compromises, paradoxes, and surprises, it now seems to be the latest bandwagon; yet the reasons to jump on it may not always be compelling. in the context of this paper, os raises concerns about the contexts it creates for excessive scope for monitoring 30 and control (e.g., classification, profiling, and ultimately manipulation). 31 os-premised on big data-also opens up many other controversies 32 : the data is messy, noisy, and often irrelevant, and where does open science lead us during a pandemic? 3 creates ideal conditions for creating falsehoods and misleading perceptions to influence public policy. that raises further challenges for legitimate evidence, especially in situations where rapid publication compounds long-standing problems such as effective peer review and scrupulous communication of science. 33 by necessity, technology-based sociality (the online world) forces us to leave our digital footprints everywhere; these can be (falsely) incriminating or exonerating, embarrassing, and harmful-if-known. it is difficult to hide or cover those tracks, and the millions of data points they reveal are easily harvested 34 and assimilated into research without consent. 35 patients lose control of data, as it is sequestered under conditions that refuse further access, and patients are denied use of, or exploited for access to, end products. 36 bona fides scientists may be held responsible for disingenuous use of their data, and experience the backlash when someone else openly gets it wrong. 37 the conditions for os can theoretically preclude ethical scientists opportunities if they are concerned about specific circumstances of how data will be used; moreover, the imperative to take part denies researchers control over their hard worked-for data, and also makes them obedient to signals from the market. this milieu simultaneously undermines and celebrates "experts" and displaces scientific professionalism and the scientific method: experience and qualifications can be replaced by familiarity with particular forms of social criticism and popular debate, and therefore scientific authority and professional responsibility are won or lost depending on ideology. strategic promotion of the "citizen scientist" also makes a mockery of their years of training, and questions experts' claims to have authority. 38 finally, in the open commons, as we shall see, data created under ethical conditions for the public good, such as medical health records, can be acquired under a social pretext, capturing its benefits for traditional and novel market economies. 39 these possibilities erode the ethos of communal science. 40 the capitalist platforms seemingly leading this are knowingly impacting on public health: their acquisition of data relies on freeriding the open commons, using os to create a competitive advantage, but then implementing proprietary rules to protect their interests. in the earliest of at least three phases, os emerged as a movement to maximize practical conditions for fruitful collaborations and enhanced sharing. proponents talked about unprecedented knowledge generation and imagined that incredible transformative discoveries were imminent. 41 this new way of doing science would be transformative, so it became necessary to define ethical conditions for data deposit, access, and use. one of the key challenges became the tension between maximizing innovation, on the one hand, and respecting autonomy, on the other. the argument turned out to be comparable to the utilitarian reasoning underlying primitive ideas about public health, where collective wellbeing (a good in itself) may conditionally trump rights. 42 thus, os proponents appealed to "the public interest" to explain an innovation-based critique of autonomy that justified rescinding rights for the greater good. 43 in this respect, proponents may acknowledge the problems of the unproven os research paradigms practiced by capitalist platforms, but nevertheless remain positive about the capacity for society and jurisprudence to evolve an appropriate balance, that is, in respect to promoting innovation, but still having expectations about privacy and confidentiality. they argue that research benjamin capps 4 participants and patients must adapt to this sea change too, despite the risks to their rights, because on balance they benefit from the innovative opportunities of os. 44 this view, however, shares the commercial function of "capitalist platforms," and therefore cannot stop economies from undermining the communities they claim to serve. "social openness," illustrated by uninhibited social media use, has increasingly normalized capitalist platforms. 45 all the while, these platforms have gained further footholds in providing essential social services, often changing them into devices of capitalism. within os, there have been few questions raised as to whether these business models provide the most efficacious approach to data management in public health circumstances, 46 and some have forsaken concerns about the ethical appropriateness of private interests taking part in providing public goods. 47 os, in fact, creates a self-sustaining context for limitless data, and that data has become extraordinarily valuable now that the mechanisms for extraction and exploitation are in place: big data is a naturally, freely, and effortlessly self-propagating good, requiring little more than strategic mining. 48 the "new oil" has become ascendant as a unit of capital for market engines. 49 in this respect, the "extreme concentration of wealth means an extreme concentration of power," so that the capitalist platforms have become extraordinarily influential. 50 as our wellbeing has increasingly shifted online, that space has become a progressively attractive one for enhancing entrepreneurial freedoms, extending beyond core businesses (social networking and e-commerce) into providing basic services such as health care. meanwhile, there has been a global capitulation to neoliberal values, presenting an opportunity to keep the state in a subservient role of merely preserving institutional frameworks appropriate to market practices. 51 free market capitalists therefore imagine os supports laissez-fairism: it lacks government interventionism (i.e., strict control over data) so is conducive to the kinds of liberalization that promotes capital generation. 52 os also organizes society through voluntary and community activity, cooperation, civicness, networking, and social capital: these are easily exploited for their production of vast and free data. so, if there is any truth to a sociological view that "privacy is dead," 53 then os is an ideally "lawless" space to capture the public good. 54 the social work is freely done, allowing the platforms siphon off a rent from every transaction they facilitate. this neoliberal ruse is exemplified in a critique of "surveillance capitalism" 55 or "dataveillance" 56 : the "unexpected and illegible mechanisms of extraction and control that exile persons from their own behavior." 57 although many remain wary of the surveillance narrative (what will health apps be used for after the pandemic?), we seem less concerned with those who opportunistically clearcut the public good through its capture, using an "inherent political asymmetry …[and] in fact a posteriori private expropriation." 58 os risks opening the door to exploitative practices, 59 conflicts of interest, 60 and poor data security, 61 under a vague conjecture about the public interest. 62 the potential consequence of doing so takes us further down the path to dystopia: we become imprisoned but "happy consumers"-homo datus or data avatars, content (perhaps) to be counted, analyzed, and surveyed. 63 big data, bioinformatics, and ai combine to create artificial identities, replacing our dignity with a price to know everything about us. in this form, persons have insufficient knowledge about what is known about them and little ability to control how it is used. 64 the problem is not necessarily the monolith of state or the forces of innovation, but them acting together in a neoliberal adaptation of the role of public health. in so doing, public health now serves a public interest in strong economies. where does open science lead us during a pandemic? 5 seen this way, os makes communities more surveilled and potentially less free, paradoxically at odds with the intent of the open commons. 65 perhaps as a result of the blurring of public health and capitalist agendas, in the second phase of os, proponents have organized the movement into an "open commons." 66 the open commons has become more than the aggregation of data; it shifts os arguments from "intellectual property or confidentiality restrictions," to the "fundamental shared nature of the genomic commons." 67 given the right context, there is an ethical obligation to take part in these communities situated in both research and healthcare contexts. however, we are permanently connected through our household economies, education, work, use of the health system and social services, and all our real and virtual socializing. these circumstances perhaps entertain a contemporary "right to the internet," especially when the circumstance of a pandemic befalls a society. the open commons therefore signifies a continual connection between our being and with very large data, both created spontaneously (i.e., by social media use, as well as other nonprofessional activities) and by structured initiatives such as health care, biobanks and specific analytic websites, for example, genetic and virological. the data is shared between traditional networks of local, regional, and international research infrastructure and hubs, 68 as well as real-time database apps, platforms, and archives. 69 thus, following elinor ostrom, the open commons has become a massive "common pool resource" rather than a public good; data is a resource that may be decreased through consumption, and exclusion is possible, necessitating complex (and ethical) rules for deposit, access and use. 70 this "new commons" still presupposes a community coopted for the good of science, but its people are compelled to give up some of their interests without expecting immediate gains or fearing instantaneous harms. 71 this may be explained by an antecedent view-which contains elements of robert merton's "communism"-that a culture of sharing underlies all fruitful collaboration and equitable transfer of legitimate goods between citizens and scientists. for example, the total aggregation of accessible genomic data (across many institutions and resources) is referred to as the "genomic commons" 72 : that is a community of liberal citizens and public scientists working with their industrial counterparts, who are equally committed to the values of os. 73 in this respect, os fosters behavioral change in those who habitually conceal their data. in reality, these relationships require "tiered access" that assesses individuals or organizations, and grants them specific data-use conditions. 74 the commons, however, has become a place to influence social and political discourse. for example, the case may be made that if the open commons is in the "best interests" of people, 75 then it also creates a space for the specific interests of a sector that stands to profit from exploiting its co-inhabitants. 76 however, neoliberalism also applies to the kinds of entrepreneurial "experiments" currently undertaken in the open commons. a particular example is the emergence of "open research"often bypassing ethics scrutiny 77 -that blurs principles of research integrity with the social and economic critiques of big data. big data research not only uses data voluntarily provided (sometimes) and spontaneously harvested (with or without persons' consent), but its researchers have no qualms about using data that is secretively or disingenuously gathered, because there is an competitive advantage in doing so and it comes with few penalties (and powerful advocates). 78 in the background to these researches, there is an unfettered market where neoliberals may opportunistically capture public resources: commodification transforms a market economy into a market society, in which the solution to all manner of social and civic challenges is "the market" itself. 79 that is more worrisome, because the os consensus generally falls on publics to be players, and public institutions to support it, rather than being obligatory or reciprocal on the private sector. 80 in that regard, production of data has complex, mostly public but sometimes private origins, so that os idealism may be used to deliberately weaken those institutions operating "for the public good." doing so creates ideal circumstances to generate public bads that prospectively obstruct or reduce social opportunities: captured goods may become disruptive commodities. 81 in the current narrative of os, privacy may not be the only right we stand to lose by the subversion of the commons, 82 as access and use of both legitimately and surreptitiously obtained data 83 not only affect persons' freedom and wellbeing, but may undermine the commons by promoting illegitimate interest. these possibilities stoke criticisms about the corporate abuses of data, 84 which could weaken our response to the covid-19 pandemic and ultimately reduce the effectiveness of public health. in this third phase, proponents have attempted to move away from utility-based arguments, to define a more complex ethical environment that frames os as a "human right to benefit from the fruits of scientific research." 85 significantly, our existence in the commons is both essential (as sociable, cooperative beings) and unavoidable (as perpetually online beings), so that its moral governance requires a rights framework. in this respect, the "right to science" includes an untrammeled obligation to share, and a social contract involving trade-offs that are neither necessarily mutual or correlative, so that the open commons becomes critical, as well as supportive, of the conditions for freedom and wellbeing. 86 finding out where that right sits between autonomy and the public interests requires tracing it back to its roots in international conventions, where we find that right is anchored to equal dignity, self-realization, and substantive freedoms. thus, the right to science must include the right to consent to scientific experimentation. that right is fundamental to the integrity of science, and the development and diffusion of ethical technologies; that is, it protects persons from science misuse. 87 the "right to science" is simultaneously a veneration of good knowledge as a "public good"-a resource for the realization of human rights 88 -and also limited by fundamental obligations to "human dignity." 89 the correlation of the public good and dignity inevitably creates a tension between "the public interest" and autonomy; but since recognizing the atrocities of mid-20th century committed by doctors and scientists, autonomy has been clearly favored over the public interest. without that correlate, the right to science, as a disambiguation of an obligation to share, yet lacking stable protections of freedom and wellbeing, is on shaky ground. 90 the ground becomes firm only if the right to science is within a hierarchy of obligations. foremost there is the protection of basic rights (as formulated, e.g., in the nuremberg code), which later evolved to include a right to receive reasonable technological benefits. the basic rights create a correlative obligation to a prima facie positive right to privacy as well as a negative right to be "left alone." 91 next, the public interest promotes rights in the sense of general welfare-that is what tells us what is good where does open science lead us during a pandemic? 7 about the commons-and promotes opportunities to enjoy second tier rights, proportional to the tension between diminished freedom and prospectively enhanced wellbeing. 92 last, there is a right to engage in ethical science. although we may all "enjoy the benefits" of science, it is clear that citizens, whether they take part in its creation or revel in its progress, also have a choice in both respects; that choice is a freedom from an unjustified public interest. 93 what i have just described in brief terms is a "community of rights," in which an egalitarian conception of solidarity promotes os as mutual and cooperative, rather than secretive, manipulative or competitive. 94 therefore, the kinds of research conducted in this space must be bona fides, which excludes activities that prospectively obstruct or reduce social opportunities (i.e., public bads) and precludes capture of public resources. the ethical commons, therefore, is conditional on the technical examination of "the public interest" in terms of the public good and legitimate rights. 95 there can be no duty to take part in os without careful consideration of the public good; and, as such, we can reasonably opt out of taking part in research that foreseeably harms us. 96 moreover, the public interest creates obligations for institutions: innovation is an ability to make use of new scientific knowledge, but also a capacity to put it to use creatively and ethically to help solve broadly social problems. in general, candidate institutions must first commit to a normative principle of institutional responsibility. 97 this principle stipulates that they observe the meaning of the public interest as an "indirect" form of a social contract to promote the public interest in welfare. 98 such an application of rights theory means that they are practically as committed to equally respecting equally the rights of people in the commons as they are to their shareholders. responsible institutions protect rights and interests jointly by including procedural requirements for ethical associations and partnerships and establishing instrumental governance. 99 all this requires a regulatory response focused on the os sector as a whole, since it is not always easy to separate research or practice into distinct private, public or not-for profit forms. institutional responsibility also requires that public-private industry occupancy of the commons be ethically symmetrical. the onus also falls on prospective partners to provide reciprocal openness, so that its intentions become transparent in respect to why it collects data and what it is used for. 100 ethically, participating private industries must contribute corporate data to the public good, too, just as legitimate public bodies do. private institutions should compensate the open commons, so as to preclude freeriding on costs incurred by other people; that premium can be adjusted in respect to their adherence to these conditions. finally, these conditions should be spelled out in specific "data collection" and "data use" rules that are externally enforced, and there should be oversight in respect to applying norms of research ethics. 101 we can learn a lot from nuanced approaches to os such as that of uk biobank: it stipulates that its purpose is for the public good, so that its stewardship over data is conditional. the data it contains is never truly open, but is accessible to all bona fides researchers, whether public or private, on the conditions that data is returned to the resource and "unreasonable" patents are precluded in any future invention. 102 like uk biobank, the open commons may exclude those who attempt to capture goods or create public bads. 103 alas, although there are industries volunteering to use this approach already, in general joining the commons for them likely requires a comprehensive sea change to alter course from a speculated social cataclysm of post-pandemic capitalism. 104 the current os narrative potentially underestimates the opportunities for surveillance capitalism during a pandemic. enthusiasm for innovation, the open commons, and the "right to science" continue to conflate ethical conditions for bona fides research with capital purposes. this mistake has become an opportunity to undo rights protections, as os proponents cannot set effective ethical conditions for data access and use: os avails all possible scientific data for anyone and everyone to access and use for any purpose. ethical os requires a far more cautious approach in respect to how society emerges from the pandemic: new data, as well as new technologies (i.e., ai) and tools (open source software), even if used ethically now, will become resources able to be used beyond the purposes, and protections offered by, public health. 105 despite trust in some legal safeguards, 106 os has also become an opportunity for capitalist platforms to provide many essential services based on public health's legitimacy of surveilling peoples' health. this paper, therefore, provides some evidence that the protections afforded to persons may be rolled back under the "new commons," and that could undermine the essential provision of public goods. if we begin to imagine os as simply knowledge generation qua innovation, without establishing ethical norms, as well as legal protections, the conditions for the public interest can quickly become ambiguous in respect to the public good. this conclusion may be resisted still, because there is likely little social appetite for returning to times when science was more of a proprietary activity. but it will not do to remain ambiguous or ambivalent to the influence of surveillance capitalism. the open commons is not only data. it is a patient's expectant diagnosis, a community that provides care and future welfare, and it is where worthwhile research is done to promote public health. it is also the social space where much of our lives has shifted to during the covid-19 pandemic. these activities are underpinned by the public good, which establishes fundamental obligations on individuals and institutions that, at times like these, are necessary for an effective pandemic response. 107 in the community of rights, the freedom of the commons is given to friendly participants, donors or altruists, and their exclusion from its benefits is unethical; people are free to come and go. the egalitarian response to a potential the tragedy of the commons, brought about by misplaced trust in capitalist platforms, is to exclude those that "follow strategies that destroy the very resource" itself; 108 and recognition that the threat from open data use is "so sweeping that its can no longer be circumscribed by the concept of privacy and its contests." 109 the worthy ambitions of ethical os need safeguarding by expanding the narrative to the existential challenges of our time; it has become evident that the emergent os ecosystem is not sufficiently equitable, and encourages activities that actively reduce socially valuable outcomes. past examples of the untrammeled use of data (most recently, in political campaigns) raise concerns about the extent of data held about persons, and how that data can be manipulated and in what ways and for what purpose. the current os narrative does not go to the root of these concerns about the breadth of information needed and available to make sophisticated predictions about people, and ultimately, the consequential decisions made that limit their freedom during a public health crisis and beyond. a new sense of solidarity in the open commons is one of the few reassuring things to have happened during this pandemic, and through experiencing degrees of alienation, illness, poverty and sadness during the pandemic, communities should not be exploited by entities compelled by old-fashioned, anti-community ideas of neoliberalism. covid-19-open science and reinforced scientific cooperation in the battle against coronavirus, humanity lacks leadership. time a new pharmaceutical commons: transforming drug discovery profile of a killer: the complex biology powering the coronavirus pandemic open science versus commercialization: a modern research conflict the genomic commons falling giants and the rise of gene editing: ethics, private interests and the public good griffin a. coronavirus contact-tracing app could make 'privacy and rights another casualty of the virus', campaigners warn. the independent covid tracing tracker. mit technology review delete your account: on the theory of platform capitalism these platforms see lax regulatory infrastructure, including rescinding privacy rights for mass surveillance (and unbounded data gathering), conducive to maximising further control by those best (and privately) positioned to do so screen new deal. the intercept the secrets of surveillance capitalism. frankfurter allgemeine privacy protective research: facilitating ethically responsible access to administrative data the science of this pandemic is moving at dangerous speeds the "fact that open science is proposed equally as a panacea for each and every one of these problems is what prompts the suspicion of snake oil the future(s) of open science we can argue about the details of this context (or commons) but it will include elements pertaining to our wellbeing (clean air and water, food, environmental integrity, and the like) and our freedom (security, an absence of fear and intimidation, and so on) the historical origins of open science: an essay on patronage, reputation and common agency contracting in the scientific revolution the sociology of science: theoretical and empirical investigations order without intellectual property law: open science in influenza how does one 'open' science? questions of value in biological research open science now: a systematic literature review for an integrated definition how open science helps researchers succeed your health data helps everyone descartes and the tree of knowledge genomic variant sharing: a position statement open-access science: a necessity for global public health revealed: facebook's global lobbying against data privacy laws. the observer changing the rules: general principles for data use and analysis a similar process, it should be noted, has left persons without control over cells and tissues taken from their body redefining property in human body parts: an ethical enquiry in the stem cell era waste in covid-19 research the right to erasure: privacy, data brokers, and the indefinite retention of data models of biobanks and implications for reproductive health innovation ebola blood samples taken from patients during the 2014-2016 epidemic in west africa: "while some ethicists argued that the public good that could emerge from a vaccine or cure outweighed researcher responsibilities to any of the patients, it reinforces a perception that patients-and particularly patients in the developing world-do not have any rights lerner s. big pharma prepares to profit from the coronavirus. the intercept latin: honesty or lawfulness of purpose) indicates a systematic, investigative, or experimental activity conducted in good faith for the purpose of acquiring (and sharing) knowledge. it includes veracity in one's good faith or genuineness, and evidence/testimony of one's qualifications, reputation and achievements the commodification and exploitation of fresh water: property, human rights and green criminology crackpots and active researchers: the controversy over links between arxiv and the blogosphere the funding of medical research by industry: can a good tree bring forth evil fruit? what can we salvage from care.data? public goods in the ethical reconsideration of research innovation introduction: the why and whither of genomic data sharing compare with, for example, the "community of equals creating a data resource: what will it take to build a medical information commons? will privacy rule continue to favour open science? annual report of the chief medical officer politeness and the boundary between theory and practice in ethical rationalism people have really gotten comfortable not only sharing more information and different kinds, but more openly and with more people privacy no longer a social norm, says facebook founder. the guardian location surveillance to counter covid-19: efficacy is what matters. lawfare assessing private sector involvement in health care and universal health coverage in light of the right to health performance of private sector health care: implications for universal health coverage regulating the internet giants: the world's most valuable resource is no longer oil, but data. the economist big data: a revolution that will transform how we live, work, and think the triumph of injustice: how the rich dodge taxes and how to make them pay a brief history of neoliberalism …skillfully exploited a lag in social evolution as the rapid development of their abilities to surveil for profit outrun public understanding and the eventual development of law and regulation that it produces big other: surveillance capitalism and the prospects of an information civilization is privacy dead? financial times the system of freedom of expression also: "…the prospects of 'surveillance capitalism' being exploited for ulterior motives are only just starting to be understood, often to the surprise and concern of the platforms themselves. such is the commitment to this guiding thesis that it has spawned a new doctrine: 'dataism', in which information flow is the 'supreme value' s covid-19 app fuels worries over authoritarianism and surveillance. the guardian uk government using confidential patient data in coronavirus response. the guardian google executive took part in sage meeting, tech firm confirms. the guardian vote leave ai firm wins seven government contracts in 18 months. the guardian the world's scariest facial recognition company is now linked to everybody from ice to macy's. vox the public interest, public goods, and third party access to uk biobank the surveillant assemblage 345-363 brownsword r. knowing me, knowing you-profiling, privacy and the public interest emerging problems in knowledge sharing and the three new ethics of knowledge transfer attitudes of publics who are unwilling to donate dna data for research open science takes on the coronavirus pandemic the authors describe the "genomic commons" (with similar characteristics shared with "scientific disciplines of all descriptions") as "the worldwide collection of genomic data that is generally available for public use sustainable governance of common-pool resources: context, methods, and politics global alliance for genomics and health. a federated ecosystem for sharing genomic, clinical data the promise of common pool resource theory and the reality of commons projects neo-liberalism and the end of liberal democracy but the data is already public": on the ethics of research in facebook tastes, ties, and time: a new social network dataset using facebook.com experimental evidence of massive-scale emotional contagion through social networks the phenomenon known as the tragedy of the commons will occur in highly valued openaccess commons where those involved and/or external authorities do not establish an effective governance regime polycentric systems as one approach for solving collective-action problems. working paper w08-6. bloomington: indiana university workshop in political theory and policy analysis commission staff working document; accompanying the document: commission recommendation on access to and preservation of scientific information {c(2018) 2375 final} brussels, 25.4 first amendment experts: downloading hacked clinton campaign emails not a crime the problem isn't cambridge analytica: it's facebook. forbes applied ethics in a troubled world towards an understanding of the right to enjoy the benefits of scientific progress and its application dignity" has become a conservative protest against controversial experiments (e.g., embryo research or human cloning), leading many to decry its too prohibitive reach although we should be rightly wary of the dignitarian's false claims, careful analysis of the function of dignity may also provide legitimating criteria for such experiments, too; brownsword r. bioethics today, bioethics tomorrow: stem cell research and the 'dignitarian alliance rights without trimmings privacy, rights and biomedical data collections informed consent for human genetic and genomic studies: a systematic review defining variables of access to uk biobank: the public interest and the public good this is underscored by the "privacy tradeoff fallacy" that runs counter to the claim that people are always happy to give up their personal data in exchange for perceived benefits the tradeoff fallacy: how marketers are misrepresenting american consumers and opening them up to exploitation. philadelphia: annenberg school for communications, university of pennsylvania big data for all: privacy and user control in the age of analytics zuckerberg says facebook is pivoting to privacy after a year of controversies. the guardian conflicts of interest in e-cigarette research: a public good and public interest perspective open source drug discovery: finding a niche (or maybe several) open source in biotechnology: open questions that project's efficacy relied on a new code that ensured a secure connection and tracked the researchers' actions. arguably, that permitted them to legitimately interrogate the public good, that is they accessed, without consent, the national health service health records of british patients as credible "public health servants" and subject to british law. the code that enabled them to do so has been made available as open source. opensafely collaborative. opensafely: factors associated with covid-19-related hospital death in the linked electronic health records of 17 million adult nhs patients how to restore data privacy after the coronavirus pandemic. world economic forum institutional arrangements for resolving the commons dilemma: some contending approaches acknowledgements: an early iteration of this paper was presented at "open science: what do we need to know to protect the interests of public and scientists?," a workshop jointly presented by the hugo key: cord-306393-iu4dijsl authors: rosenstock, linda; helsing, karen; rimer, barbara k. title: public health education in the united states: then and now date: 2011-06-12 journal: public health rev doi: 10.1007/bf03391620 sha: doc_id: 306393 cord_uid: iu4dijsl it was against a background of no formal career path for public health officers that, in 1915, the seminal welch-rose report(1) outlined a system of public health education for the united states. the first schools of public health soon followed, but growth was slow, with only 12 schools by 1960. with organization and growing numbers, accreditation became an expectation. as the mission of public health has grown and achieved new urgency, schools have grown in number, depth and breadth. by mid-2011, there were 46 accredited schools of public health, with more in the pipeline. while each has a unique character, they also must possess certain core characteristics to be accredited. over time, as schools developed, and concepts of public health expanded, so too did curricula and missions as well as types of people who were trained. in this review, we provide a brief summary of us public health education, with primary emphasis on professional public health schools. we also examine public health workforce needs and evaluate how education is evolving in the context of a growing maturity of the public health profession. we have not focused on programs (not schools) that offer public health degrees or on preventive medicine programs in schools of medicine, since schools of public health confer the majority of master’s and doctoral degrees. in the future, there likely will be even more inter-professional education, new disciplinary perspectives and changes in teaching and learning to meet the needs of millennial students. decades, tensions between the evolving fields of medicine and public health continued to be reflected in discussions about the future of public health. by the 1950's, growth in the number of sph had stalled (there were only 12 by 1960), and economic challenges of schools were large, dominated by inadequate funding to pay faculty salaries, obtain necessary facilities and purchase needed equipment. schools increasingly turned to the national institutes of health (nih) for research funding. 10 there was growing interest in building departments of preventive and community medicine within medical schools-many of these would prove forerunners of subsequent independent sph, but that future was uncertain and unplanned at the time. the first major government investment in public health education came in 1960 with the hill-rhodes bill which provided funds for training and project grants for public health. this was the beginning of a period of renewed interest in public health as applications to sph increased. 7 schools began to thrive, with growth from 12 sph in 1960 12 sph in to 20 in 1975 . concomitant with the growth in independent public health schools were important changes in the numbers and composition of formally trained public health professionals. during the 1960's teaching methods changed, with greater attention to problem-based learning, especially in medical schools. 9 support for public health professional education has been inconsistent over the decades, with a marked erosion of federal funding, beginning in the 1980's. this trend only reversed in the last few years but is again at risk in the wake of a serious recession. state government support also has been variable but significant; 34 of the current 46 schools are public institutions, with different levels of state assistance. most schools with state funding have seen that support eroded over the last few years, some very significantly. a recent article in the chronicle of higher education provided data about declines in state support for public universities. the average state cut was 0.7 percent, with at least four state cuts exceeding 11 percent. 11 today, sph train public health professionals at multiple levels, provide services to their local communities and beyond, and conduct research to prevent disease, disability and avoidable mortality at the individual, community and societal levels. schools also translate research into evidence-based policies and practices in communities, clinical care settings and governments, non-governmental organizations (ngos) and private organizations. research in sph ranges from basic laboratory research (e.g., to explain molecular signatures for particular viruses, cancers and other diseases) to applied research in communities as well as policy research. in fact, it is this continuum from basic research to translation of research into practice and policies that makes sph especially relevant and skilled in solving problems. public health researchers often collaborate with faculty in schools of medicine, pharmacy, dentistry, nursing, and others. they conduct bench and clinical research as well as communication research, comparative effectiveness studies, clinical effectiveness research and translational research, frequently with community-based research components. these varied roles reflect, in part, the fact that public health is not just a profession, 10 but also a professional culture and commitment. 12 sph educate undergraduate, master's, doctoral, postdoctoral, and certificate students. schools also provide continuing education to public health professionals within and beyond their geographic reach. the us centers for disease control and prevention (cdc) funds training centers within sph charged with developing leadership skills among certain groups of health professionals (e.g., those from underserved groups). similarly, the cdc has funded preparedness centers that focus on training particular kinds of professionals within assigned geographic regions. 13, 14 this training and related concepts enabled schools to provide direct responses to training needs of first responders and health department personnel, in response to the events following september 11, 2001 and outbreaks such as severe acute respiratory syndrome (sars) and influenza a (h1n1). since september 11, 2001 , public health students and many practitioners are trained to understand concepts and language of biosurveillance, health risk communication, and the critical roles government agencies and nongovernment partners play in responding to public health emergencies. 14 the landmark 1988 institute of medicine (iom) report, the future of public health, criticized sph for being overly research intensive and disconnected from practice. 4 in response, many schools made administrative and policy changes that institutionalized the means by which practice communities can access academic public health expertise and also increased opportunities for academicians to connect with communities. despite some successes in addressing acknowledged deficiencies in practice, there still are many challenges to create permeable boundaries between academic public health and practice. for example, the need to demonstrate publication productivity may cause many younger faculty members to choose professional focus areas that have quicker timelines to publication than those required to build relationships and consensus with practice communities. some schools have modified their appointments and promotion guidelines to reflect the importance of practice, but this varies from school to school. within sph, students pursue their education with an extraordinarily interdisciplinary range of faculty, including biomedical scientists, medical care professionals, behavioral and social scientists (e.g., economics, sociology, politics), epidemiologists, biostatisticians, information scientists, lawyers, health service researchers and health educators, among others. as a result, sph are well-positioned to be university leaders in collaborations with other schools, organizations and within the communities they serve. increasingly, there are collaborations with schools of journalism, social work, and regional and city planning. this reflects, in part, recognition of the complexity of health and healthcare and the forces that influence them. the association of schools of public health (asph) was founded in 1941 by a group of seven sph concerned about the growth of public health education programs. 6 asph worked closely with apha to develop standards and definitions for sph. from 1945 to 1973, apha conducted accreditation of graduate professional education in public health, at first centered almost exclusively in sph, but later including other college and university settings. in 1974, the independent council on education for public health (ceph) 15 was established by apha and asph. responsibility for evaluation of sph was transferred to ceph, which initially limited its focus to school accreditation. in the late 1970s, ceph responded to requests from practitioners and educators to undertake accreditation of community health/ preventive medicine programs and to a request from apha to assume additional responsibility for community health education programs. in 2005, these separate programmatic categories were combined into a single category of public health programs. ceph is the accrediting body for sph, but other organizations accredit particular programs within sph. these include the commission on accreditation for dietetics education (cade) and the commission on accreditation of health management education (cahme). asph started as an association "representing university faculties concerned with graduate education of professional personnel for service in public health; to promote and improve education and training of such personnel, and to do such other things as may improve the supply of trained personnel for all phases of public health activity." 16 over time, asph became the national organization whose members are ceph-accredited sph, not just in the us but internationally with inclusion of an accredited school in mexico and an associate member school in france, which is in the process of accreditation. asph membership includes all cephaccredited member schools, 46 in 2011 ( figure 1 ), 16, 17 which together, graduate over 8,000 students each year. growth of schools and students in the most recent period has been dramatic ( figure 2 ). 17 additionally, six associate member schools are scheduled to become fully accredited sph within the next two years, and others have indicated intent to become fully accredited. 15, 16 growth of schools is expected to continue as states and private institutions recognize their value, and student interest grows. ceph accredits about 75 public health programs in a variety of kinds of institutions, e.g., mph programs in medical schools. some programs are not ceph-accredited. estimates gathered from 2007 (association for prevention teaching and research; unpublished survey) indicate that less than 1,300 graduates/year come from ceph-accredited programs. 15 the number of graduates from unaccredited schools and programs is unknown. several large, for-profit, online universities also offer public health programs and degrees. there is considerable concern about the growth and quality of these programs. in an effort to establish public health as a recognized, certified profession, asph, apha, the association for prevention teaching and research, the association of state and territorial health officials and the national association of county and city health officials established the national board of public health examiners (nbphe) in september 2005. nbphe's purpose is to "ensure that students and graduates from schools and programs of public health accredited by ceph have mastered the knowledge and skills relevant to contemporary public health." nbphe is an active, independent organization that develops, administers and evaluates a voluntary certification exam once every year. 18 graduates of cephaccredited schools and programs are eligible to take the exam. as of this writing, the number of examinees each year is small (about 1,000) but growing. it is not known what the ultimate effect of the exam will be on job availability, selection, salaries or on the quality of the public health workforce. ceph's focus is improvement of health through assurance of professional personnel who can identify, prevent and solve community health problems. 15 the council has several objectives, including to: promote quality in public health education through a continuing process of self-evaluation by schools and programs that seek accreditation. assure the public that institutions offering graduate instruction in public health have been evaluated and judged to meet standards essential for the conduct of such educational programs. encourage-through periodic review, consultation, research, publications, and other means-improvements in the quality of education for public health. to achieve this mission, ceph reviews sph resources, structure and programs through its established criteria, which are updated periodically. accredited sph must offer coursework in at least the five core areas of knowledge basic to public health: biostatistics; epidemiology; environmental health sciences; health services administration; and social and behavioral sciences. 15 the core, broad knowledge areas form the basis of how schools structure curricula. however, schools are not limited to these disciplinary areas. some schools have added departments of genetics, maternal and child health, nutrition and other areas. nothing precludes expansion of the five core areas, but all students must get sufficient exposure to core public health disciplines (table 1) . 15 over the last several years, asph has developed competencies in a number of areas, such as undergraduate education and master of public health programs, and identified cross-cutting areas, such as cultural competence, public health biology and health informatics which augment the disciplinary focus of the core areas. review of competencies shows the richness of subject matter area included under disciplinary areas, such as epidemiology. across schools, it is expected that students gain skills in a variety of areas and also emerge with understanding about the multiple determinants of health, using the kind of social ecologic model identified in the iom report, who will keep the public healthy? 6 the accreditation process is based on peer review, in which a site visit team visits each school and evaluates their self-study and the processes behind it. according to the ceph website 15 , site visitors must: be a senior academician (e.g., dean, associate dean, department chair or senior faculty member); or a senior public health practitioner (i.e., primarily employed by a public health department, non-profit organization, healthcare organization, etc. with preferably at least 10 years of experience in public health); and have at least a master's degree (practitioners) or a doctoral degree (academicians); and possess strong writing, communication and analytical skills. ceph is responsible for selecting site visit teams, chairs and assuring that guidelines are followed throughout the accreditation process for each school (table 1) . 15 in 2005, ceph amended and strengthened accreditation criteria for schools. sph now are required to have at least five full-time faculty members for each of the five core areas of study (minimum of 25 faculty members) and must offer at least three doctoral degrees in three distinct programmatic areas. again, they are not restricted to this minimum, and most mature schools have many more programs. some also offer joint degrees with schools of social work, medicine, dentistry, nursing, city and regional planning, law, business, information and library sciences and other areas. accreditation requirements are a floor and not a ceiling. • environmental factors including biological, physical and chemical factors that affect the health of a community. • planning, organization, administration, management, evaluation and policy analysis of health and public health programs. • concepts and methods of social and behavioral sciences relevant to the identification and solution of public health problems. schools must be independent, with status similar to other professional schools at their universities. that aside, the perceived value of sph undoubtedly varies across universities and is likely to be affected by a school's rankings, success in obtaining grants and contracts and other issues. criteria for programs are similar to those for schools, with some differences. each degree program and area of specialization must have clearly stated competencies that guide development of educational programs. these define what a successful learner should know and be able to do upon completion of a particular program or course of study. asph developed master's degree core competencies in 2006 to serve as a resource and guide and continues to develop competencies in several other priority areas, such as preparedness. accreditation has both advantages and disadvantages. from the perspective of students and the field, accreditation assures a minimum level of quality in relation to established criteria. specifying core disciplines that must be represented and taught, identifying core competencies and clearly specifying relationships between goals, learning objectives and student outcomes is a strength of the process. but such a process also carries threats to innovation if criteria are interpreted too narrowly and do not permit new developments in format, methods and content of training programs. there also is more emphasis on teaching and service aspects of schools and less on research which, for research universities, is an important part of the mission. in addition, costs of accreditation, both direct and indirect, have grown as the complexity of the process has grown. lengthening the time period between reviews might be appropriate in view of this. fifty years ago, the profile of a public health student was a white physician or nurse who pursued an mph in order to practice at a health department or other similar setting. today, about eight percent of public health students have medical degrees. 19 current public health students are younger, with less work experience, and more varied in the academic disciplines and the perspectives they bring to the profession. they also are more diverse in terms of ethnicity, race, age, socioeconomic backgrounds and culture and related characteristics. 20, 21 students' and trainees' characteristics vary as much as diversity of the schools themselves. in 2009, over 25,000 students were enrolled in accredited sph (table 2) ; about one third of students were part-time, and many were trained in online programs with limited in-person classroom contact hours (distance education offered at 19 schools). in 2009, females represented 72 percent of graduates. minorities (including asians) received 32 percent of graduate degrees awarded to us students. sixty percent of graduates received mph degrees. doctoral degree recipients were dominated by phds, about 15-fold more often than doctor of public health graduates. international students, despite small dips in enrollment in recent years, continue to grow and now constitute 17 percent of graduates. in 2009, across all accredited sph, there were over 4,700 faculty members. 20 overall, program areas with highest concentrations of graduates are health services administration (20%), epidemiology (17%) and health education/behavioral sciences (12%). "other" program areas included 12 percent of graduates, despite efforts to categorize degree classifications into one of the ten categories in asph's annual survey. 20 this may reflect diversity of offerings, as well as efforts to adapt to new priority areas and other emerging areas of focus, such as health equity, health systems modeling, public health preparedness, health implications of climate change, and chronic disease prevention. graduates from public health accredited schools and programs conduct research and teach in universities, international bodies and nonprofit organizations, manage healthcare and health insurance systems, work in the private sector and for foundations, are public health leaders in state, local and federal health agencies, and work globally and locally in many different roles. in the us, academic public health continues to grow in size and stature. the scope of public health education is expanding to new collaborations among health professions and other professional degree programs and includes college and even high school students. broadening public health education as a core body of knowledge for students, not just in other health professional schools but well beyond, was augured by the iom's 2003 report, who will keep the public healthy? 6 specifically, the report called for a dramatic upsurge in master's level training in public health for medical professionals, citing the need to train as many as half of all medical school students at this level. inter-professional education extends far beyond more traditional medicine and public health training. for public health, it is seen when multiple professions' disciplines collaborate to advance the knowledge and skills of professionals and students. public health schools have a long history of collaboration with other schools and colleges within their own universities. these include formal dual degree opportunities. some of the most common joint degrees include mph/md degrees, but also degrees joint with law (mph/jd), dentistry (mph/dds), social work (mph/msw), nursing (mph/msn), business (mph/mba) and veterinary medicine (mph/dvm). several schools offer dual degree training with schools of communications, journalism, information and library science, public policy, city and regional planning, education and international affairs. these combinations allow students to integrate curricula towards their particular interests. there is no conceptual limit to potential joint and dual degree programs; they are likely to increase in the coming years. for many years, a small number of schools offered undergraduate study of public health including public health majors. recently, public health has emerged in a broad spectrum of undergraduate programs amidst growing interest in public health. in 2008, the american association of colleges and universities surveyed their membership and found that 167 institutions offered undergraduate majors, minors or concentrations in public health. 22 universities with sph clearly dominate the playing field, with 15 schools offering public health as a major area of concentration, and 14 offering a minor concentration, accounting for nearly 3,000 under graduate students in 2008. a recent front page washington post story captured this interest, in an article entitled "for a global generation, public health is a hot field." 23 public health as a field has an increasingly wide appeal for students concerned with what the 21 st century holds for the world's population, and some potential applicants would like to be able to enter the field with less time in school. additionally, there is also increased attention to opportunities at the community college level for public health education. 24 applicants' interest in sph is growing at a remarkable rate, eclipsing other health professional fields, such as medicine. there was a 75 percent growth in the number of applicants between 1998 and 2008, from about 20,000 to 35,000/ year. 20 despite annual healthcare costs in the neighborhood of $2 trillion usd/ year, the us ranks 46 th in life expectancy and 42 nd in infant mortality among the world's 192 nations. 19 the us invests less than two percent of each heathcare dollar on prevention while spending 75 percent of that dollar treating preventable diseases. 25 such an imbalance defies peer-reviewed findings that show prevention activities in most instances are far more costeffective in improving health than medical treatment. 25, 26 unlike medical schools, sph do not receive core federal funding for education [beyond a small pool of students], such as is received through medicare funding for medical residents or core federal funding for research and service/care available through the veterans administration for faculty effort. while the nih bench science model drives much of the highly valued research at sph, progress has been made in garnering nih and foundation support for applied research in epidemiology, behavioral sciences, health policy, and environmental health. limited fiscal resources, however, often make it difficult to mobilize and sustain research articulated by the practice sector and communities of need. funding for sph comes from a variety of sources, which include: tuition and federal sources: health resources and services administration (hrsa), cdc and nih funding of students; research supported by federal, state, city and not-for-profit organizations (~$764 million in 2009), and foundation, corporate and philanthropic support. state and city universities and colleges often receive support from the relevant governmental level. the amount of this support varies, and has in general been significantly declining in recent years. for example at uc berkeley and ucla, core support has eroded to about 10 percent. funding at sph ebbs and flows depending on current governmental priorities. as mcginnis and foege observed, "one of the most difficult challenges is that the urgent does not crowd out the important. in health, this challenge is especially difficult, because urgent matters can be so riveting…" 27 examples of interventions with known major impacts on individual health include tobacco control and injury prevention activities. however, as colgrove et al. stated, "the current funding system for sph is piecemeal and largely reactive and constrains the ability of sph to meet essential societal needs. we argue that the federal government should invest significant and sustained financial support for this work through a dedicated funding stream." 28 this would be a milestone for a field that lacks support to carry out its essential functions. several programs at sph contribute to the nation's health through provision of effective, up-to-date public health training to public health workers via a network of regional centers. to successfully carry out their charge, these centers have formed formal partnerships, particularly with local and state health agencies. in late 2010, hrsa funded 27 public health training centers (phtc), 23 of which are located at sph, nearly doubling the previous network of 14 training centers. phtcs aim to develop the existing public health workforce as a foundation for improving the infrastructure of the public health system. phtcs are based on collaborations with health departments and foster close advisory roles for academia and practice partners in their geographic areas. cdc-supported centers for public health preparedness (cphp) which began in 2000 and funded schools to prepare frontline public health workers to respond to bioterrorism and infectious disease outbreaks. 13 in 2010, these centers were redesigned, and new preparedness and emergency response learning centers (perlc) were funded at 14 schools. these centers support workforce development needs by offering assistance to their state, local and tribal public health partners and are developing consistent curricula using public health workforce competencies. in 2008, cdc funded nine schools to establish preparedness and emergency response research centers (perrcs). centers connect public health researchers with scientists involved in business, engineering, legal, and social sciences and conduct research that will evaluate the structure, capabilities, and performance of public health systems for preparedness and emergency response activities. the cdc prevention research centers (prc) program 29 funds 37 prevention centers, the majority of which are housed in sph. the prc program is an effective model for applied population-based prevention research. community and research partners collaborate to develop programming and identify successful aspects of research projects that can be disseminated to other communities. prcs play a leading role in translating bench and clinical research findings into practice in complex and diverse community settings. this kind of research, which adapts, refines, and demonstrates the effectiveness of community interventions, is contributing to understanding mechanisms for improving the health of populations. prcs are integrally related to public health education, not just through interactions with community public health professionals but also through opportunities for involvement of students. examples of other research and training centers in sph include: education and research centers (niosh), which conduct research and training and make recommendations for the prevention of work-related illnesses and injuries; centers of excellence in health statistics (nchs), which improve data collection systems to help develop and evaluate prevention programs; injury prevention centers (ncipc), which fund and monitor research in three phases of injury control: prevention, acute care, and rehabilitation; centers for genomics and public health (nceh), which study all elements of our human genome and how they relate to human health and disease; public health research and education centers (phrecs) within the veteran's administration, which conduct research, education and outreach on health promotion and disease prevention activities for veterans; and, centers of excellence in environmental health (nceh), which partner with state and local health departments, to develop state-of-the-art environmental health programs based on the 10 essential public health services. in addition to these examples, there are many other centers and institutes within sph. public health professionals have been forced over an extended period of time to do more with fewer people, a problem greatly exacerbated by the recent global recession. "given the increasing complexity of public health science, meeting these challenges means training many more specialists in the many sub-disciplines of public health. as well, the availability and capacity of a global public health workforce needs to be significantly expanded." 21 although for some time, there has been widespread recognition that the us has a shortage of well-trained public health professionals, no quantitative estimates of projected needs had been taken prior to 2007. 31 at that time, a taskforce of the asph set about quantifying public health workforce needs projected for 2020. 6, 30, 31 we summarize below the findings and implications of the workforce report and related subsequent efforts. 21 as shown in table 3 , "in 2000, there were 50,000 fewer public health employees than in 1980. 32, 33 the workforce ratio in 1980-220 public health workers for every 100,000 us residents-although a likely underestimate of need, was used as a benchmark. 21 given population increases, a total of 600,000 (vs. the 450,000 available) would have been necessary in 2000 to maintain the workforce ratio that existed two decades earlier. in 2020, a public health workforce of more than 700,000 would be needed to achieve the 220:100,000 ratio. that creates a need for some 250,000 more workers than are available today." 21 table 3 public health workforce to us population ratios even that number is undoubtedly conservative, since public health departments across the us absorbed substantial personnel cuts during the recession of 2008-2010. extrapolation of these data to projected shortages by state is demonstrated in figure 3 . these estimates also do not take into account the large potential retirement effects of an aging worker cohort. although some retirements may be postponed due to the economic recession, by 2012, more than 110,000 us public health workers in government-24 percent of an estimated 450,000-person workforce-will be eligible to retire. in addition, the estimates are supply-based and do not attempt to quantify need or demand or the serious issue of geographic distribution and discipline-specific projects (e.g., laboratory workers vs. epidemiologists). several other organizations (e.g., apha 35 , trust for america's health, 36 association of academic health centers (aahc) 37 ) and efforts have addressed specific disciplines. for example, the american association of medical colleges (aamc) has reported a shortage of 10,000 public health physicians, recommending a doubling of public health physicians currently in practice. 38 moreover, there are demonstrated racial and ethnic disparities and significant geographic gaps in the public health workforce as the sullivan commission on diversity in the healthcare workforce concluded. 39 "today's physicians, nurses, and dentists have too little resemblance to the diverse populations they serve, leaving many americans feeling excluded by a system that seems distant and uncaring. the fact that the nation's health professions have not kept pace with changing demographics may be an even greater cause of disparities in health access and outcomes than the persistent lack of health insurance for tens of millions of americans." sullivan commission on diversity in the healthcare workforce. 39 public health workforce shortages are even more critical in much of the developing world. for example, sub-saharan africa has 11 percent of the world's population and 24 percent of the global burden of disease-yet it commands less than one percent of the world's health expenditures. 40 the world health organization has said there is a "major mismatch" between population needs and the available public health workforce in terms of overall numbers, relevant training, practical competencies and sufficient diversity to serve all individuals and communities. 39, 41 events and population health changes of the last few decades, have shown that countries do not exist in isolation and are increasingly interdependent. 9, 42, 43 health professionals move from one country to another in a permeable manner. similarly, health conditions know no borders. 9, 42 an epidemic that starts in the us, africa or thailand may become worldwide for non-communicable conditions as well as communicable diseases. tobacco companies found global markets after they became stymied in the us. a similar phenomenon is occurring with regard to availability of processed foods and obesity. the internet has made global communication instantaneous and accessible to more and more individuals regardless of country. burgeoning funding for aids through the us president's emergency fund for aids relief (pepfar) provided support for many public health researchers to conduct global research. older us sph have undertaken global activities for many years, although in the past, the area was referred to as international health. in dreaming of a time, 44 korstad described the global travels and sanitation consultation of faculty in environmental sciences and engineering at the university of north carolina in the 1950's and 1960's. in other departments, faculty members and students traveled around the world as they worked on health projects. participation of americans in leading roles in international health, such as outlined in the preface to this edition by donald henderson, 45 was not uncommon. however, except in a few schools with organized departments of international health (such as harvard and johns hopkins), systematic attention to international/global health was inconsistent. asph is leading an effort to develop global health competencies, and individual schools have been engaged in this effort as well. 46 to many, global health and public health are indistinguishable. 42 both global health and public health share many characteristics, including an emphasis on population-level policies, as well as individual approaches to health promotion. the commission on education of health professionals for the 21 st century 9 said that "maintaining a comparative global perspective can enrich existing curricula, thereby reducing the demand for extra time and space." the current focus on global health, separate from international health, is broader and not solely about developing countries. the us is approaching 100 years of formalized public health professional education. some features present at the outset remain today, notably, recognition of a distinct field that is science-based across a broad spectrum of activities, from the laboratory to bedside to communities, both domestically and globally. there continues to be some tension about the relationship between medicine and public health, with some holding to distinct boundaries, and others claiming the need for better integration. however, with broad research collaborations across schools and growing numbers of medical students receiving public health training, old dichotomies between medicine and public health are breaking down. even the term has come under review, with an increasing number of cited references referring to population health as a better descriptor of the field conventionally known as public health. much has changed; with change has come evolution in the structure and functions of public health education. globalization has spared little, and certainly not the health arena. as recognition of the importance of global health has grown, and with it, attendant economic resources, the area of global health -which an increasing number would define as synonymous with global public health -has caught on with great interest, capturing the increasing attention of the medical education and care communities as well. 42, 43 public health schools and training programs have responded to the growing interest of students and have flourished as they couple this interest with longstanding activities of their own faculties. perhaps most dramatic over the past 100 years is growth in numbers of students and their diversity. this trend promises to continue despite economic challenges created by recession. our field is exciting and better understood than it has been throughout most of its history. the importance of public health education should continue to grow, not only as its own distinct field but in the context of increasing interprofessional education, team-based learning and increasing opportunities to link research and education to didactic learning and practice, in the us and globally. over the last few decades, there has been greater attention paid to building the evidence base for public health, adapting a model that originally was built for medicine and operationalized in the us preventive services task force (uspstf). the cdc's task force on community preventive services is the us body charged with assessing evidence for public health interventions. 47, 48 focus on building the evidence base for public health is an important trend. this review has not focused on changes in healthcare delivery and payment that accompany the patient protection and affordable care act. 48 expansion of health insurance coverage for millions of americans is accompanied by a number of central issues relevant to public health education, including a central emphasis on the importance of prevention and public health, with recognition of the importance of workforce development and funding. moreover, there is a large role for sph in conducting comparative effectiveness research to answer important questions about which public health and healthcare interventions are most effective in practice. 49 we look forward to major opportunities to improve and innovate in public health education as a result of the passage of this historic legislation. as we enter a new decade, well-trained public health graduates are needed more than ever before. we face huge global threats, such as lack of safe water, emerging infections, wars, global income inequality, climate change, global obesity epidemic and changing demographic patterns associated with global aging. new technologies have potential to ameliorate some of the divide between rich and poor, developed and developing countries by providing access to information and tools to use information for improving the health of individuals and societies. as globalization makes the world smaller, public health graduates from the us and other countries are needed to strengthen health systems around the world. the complexity of these problems requires that students be trained, not in disciplinary silos but in interdisciplinary environments where they learn how to discover, find, synthesize and use information for health improvement. the commission on health professionals for a new century, 9 an ambitious agenda for health professional training in the new century concluded, "the next generation of learners needs the capacity to discriminate vast amounts of information and extract and synthesize knowledge that is necessary for clinical and population-based decision making." new skills, like data mining and visualization, will become increasingly important as we face terabytes of data that require sense making. research synthesis and health informatics also are likely to be increasingly important. some schools have begun to integrate teaching of the core disciplines, on the assumption that most students will work in interdisciplinary settings, and that the silo approach to disciplines is no longer appropriate. over time, it is likely that there will be more integrated teaching and learning across disciplines, because the amount of content is growing at an enormous rate, beyond what can be absorbed into courses conducted in isolation. inter-professional training should become more frequent, as well. we look forward with great interest and enthusiasm to changes that are likely to come in sph as our students increasingly demonstrate that they learn and communicate very differently than their predecessors. the millennial generation of students and teachers is expanding conventional teaching with their use of new media and their skills for information search and synthesis. 50, 51 we anticipate that, coupled with additional technological advances, these factors will drive significant changes in the way we educate future generations of public health professionals. for example, future classrooms are likely to offer global connections to facilitate hybrid learning, with students from different countries participating in discussions. students increasingly view themselves as global citizens, and that bodes well for the future of public health. 51 need for stable core funding for schools of public health. changing patterns of teaching and learning for new generations of students. integrating global and domestic missions of public health. integrating academic and practice missions. accommodating the tremendous knowledge explosion within the context of accreditation expectations. dealing with new problems, (e.g., climate change), and new disciplinary areas, (e.g., neuroscience). need for more inter-professional education among health sciences schools. accredited schools of public health have grown and continue to grow in number, depth and breadth. despite growth of programs, there is widespread recognition that the us has a shortage of well-trained public health professionals. accredited sph train professionals at multiple levels, provide service to local and global communities, and conduct and translate research at the individual, community and societal levels. despite many successes in addressing public health practice contributions in academia, there remain many challenges (e.g., most schools lack consistent funding mechanisms that are not research-oriented). with globalization and increased complexity involved in strengthening health systems around the world, today's students must be trained, not in disciplinary silos but in interdisciplinary environments. institute of hygiene: a report to the general education board of rockefeller foundation professional education for public health in the united states evolution of public health and preventive medicine in the united states the future of public health. institute of medicine of the national academies the future of the public's health in the 21st century who will keep the public healthy? educating public health professionals for the 21st century. institute of medicine of the national academy of sciences disease and discovery: a history of the johns hopkins school of hygiene and public health medical education in the united states and canada: a report to the carnegie foundation for the advancement of teaching health professionals for a new century: transforming education to strengthen health systems in an interdependent world federal support of schools of public health state support for higher education continues to fall are schools of public health needed to address public health workforce development in canada for the 21st century? public health preparedness centers for public health preparedness program: from vision to reality asph: association of schools of public health asph: association of schools of public health. member schools map nbphe: national board of public health examiners changing demographics of public health graduates: potential implications for the public health work force association of schools of public health. asph annual data report asph policy brief -confronting the public health workforce crisis: executive summary liberal education and public health: surveying the landscape for a global generation, public health is a hot field. the washington post a call to action: public health and community college partnerships to educate the workforce and promote health equity association of schools of public health. asph policy brief -creating a culture of wellness: building health care reform on prevention and public health greater use of preventive services in the us health care could save lives at little or no cost the immediate vs. the important schools of public health: essential infrastructure of a responsible society and a 21st-century health system ga: the centers for disease control and prevention the public health workforce 2006: new challenges for the health-care workforce, a critical prognosis. the chronicle of higher education public health personnel in the united states 1980: second report to congress bureau of health professions. the public health workforce enumeration issue brief -the public health workforce shortage: left unchecked, will we be protected public health workforce shortages out of order, out of time: the state of the nation's public health workforce: a report by the association of academic health centers physician shortages to worsen without increases in residency training sullivan commission on diversity in the healthcare workforce. missing persons: minorities in the health professions taking stock: health worker shortages and the response to aids working together for health: world health report global health is public health towards a common definition of global health dreaming of a time: the school of public health: the university of north carolina at chapel hill, 1939-1989. chapel hill: the university of north carolina at chapel hill on the eradication of smallpox and the beginning of a public health career developing competencies for a graduate school curriculum in international health patient protection and affordable care act committee on comparative effectiveness research prioritization board on health care services. initial national priorities for comparative effectiveness research the future of learning institutions in the digital age teaching digital natives key: cord-315209-xpzqd0wk authors: kabamba nzaji, michel; ngoie mwamba, guillaume; mbidi miema, judith; kilolo ngoy umba, elie; kangulu, ignace bwana; banza ndala, deca blood; ciamala mukendi, paul; kabila mutombo, denis; balela kabasu, marie claire; kanyki katala, moise; kabunda mbala, john; luboya numbi, oscar title: predictors of non-adherence to public health instructions during the covid-19 pandemic in the democratic republic of the congo date: 2020-10-21 journal: j multidiscip healthc doi: 10.2147/jmdh.s274944 sha: doc_id: 315209 cord_uid: xpzqd0wk background: adherence to public health instructions for the covid-19 is important for controlling the transmission and the pandemic’s health and economic impacts. the aim of this study was to determine the associated factors of non-adherence to public health and social measures instructions. methods: this was a cross-sectional study conducted with 1913 participants in two provinces of drc, mbuji-mayi, and kamina. predictors of non-adherence to covid-19 preventive measures were identified using binary logistic regression analysis. p-value<0.05 was considered as a significant predictor. results: among 1913 participants (1057 [55.3%] male, age 34.1 [14.9] years), 36.6% were defined as non-adherents. non-adherence was associated with never studied and primary education level [adjusted odds ratio (aor)=1.63, ci=1.31–2.03], unemployed status [aor=1.29, ci=1.01–1.67], living in kamina (haut-lomami province) [aor=1.63, ci=1.31–2.03], female gender of head of household [aor=1.53, ci=1.16–2.03], no attending lectures/discussions about covid-19 [aor=1.61, ci=1.08–2.40], not being satisfied with the measures taken by the ministry of health [aor=2.26, ci=1.78–2.81], not been regularly informed about the pandemic [aor=2.25, ci=1.80–2.03], and bad knowledge about covid-19 [aor=2.36, ci=1.90–2.93]. conclusion: the rate of non-observance of preventive measures for the covid-19 pandemic is high, and different factors contributed. the government has to counsel the permanent updating of messages taking into account the context and the progress of the pandemic by using several communication channels. coronaviruses (cov) are zoonotic pathogens that can be transmitted via animal-tohuman and human-to-human interactions. they are known to cause diseases including the common cold and severe acute respiratory syndrome (sars). 1 originating from the city of wuhan, hubei province, china, the 2019 novel coronavirus (2019-ncov) is rapidly spreading to the rest of the world. the circumstantial evidence that links the first case of covid-19 to the huanan south seafood market that sells various exotic live animals suggests that the zoonotic coronavirus crossed the barrier from animal to human at this wet market. 2 it has since become a global public health emergency. 3 the world health organization (who) designated covid-19 a pandemic on march 11, 2020 . 4 the african region remains the least affected continent, with 99,433 cases and 3078 deaths, but the numbers are increasing. covid-19 is majorly affecting many countries all over the world, whereas africa is the last continent to be hit by the pandemic. many countries around the world are majorly affected by covid-19, but africa is the last continent to be hit by the pandemic. 5 the first case of covid-19 in africa was confirmed in egypt on february 14, 2020 , and nigeria reported the first confirmed case in sub-saharan africa, in an italian patient who flew to nigeria from italy on february 25, 2020. 6 the government response to the pandemic on the continent has not been without challenges. airport screening has been implemented and mitigation efforts such as hand washing, social distancing, and stay-at-home lockdown measures have also been adopted. however, in the longterm these measures are unsustainable due to the socioeconomic dynamics in most african states. 7 in the democratic republic of the congo (drc), the first covid-19 case was reported on march 10, 2020. 8 according to the latest report from the drc covid-19 taskforce and ministry of health, the numbers of infected people in drc reached 2660 on 27 may 2020, including 69 deaths. 9 since the first case of 2019-ncov was registered in the drc, no cases have been reported in mbuji-mayi and kamina. vaccine may not be available in the early stages of a pandemic. so, non-medical measures such as the promotion of individual protection (hand hygiene and face masks), imposing travel restrictions, and social distancing of possibly infected cases are essential to reduce the possibility for new infections. 10 the willingness of the general public plays an important and decisive role in achieving such measures recommended by public health authorities. 11 it remains the health issues to lead the population to observe unconditionally these recommended preventive actions. however, it remains difficult to motivate people to adopt preventive behavior. risk perception is identified as one of the factors contributing to an increase in public participation in adopting preventive measures. 12, 13 a high level of people's risk perception can influence the intention to adopt protective measures. effective risk communication is an essential element of outbreak management. receiving information through different origins such as the ministry of health, frontline workers, and social media can affect the public's knowledge about the risk perception and community engagement, thereby influencing their decision to adopt protective measures. 14, 15 it is therefore important to understand how the populations risk perception and their engagement. the best way to limit the spread of the covid-19 depends on public adherence to the public health instructions. the aim of this study is to identify predictors of non-adherence to public health instructions. an analytical cross-sectional survey was conducted in the towns of mbuji-mayi (kasai oriental province) and kamina (haut-lomami province) in drc, in may 2020. the target was the female or male population, aged at least 18 years living in both cities for at least 6 months. we included all participants who gave consent to participate in the study and were found at home at the moment of the survey. we excluded those who did not give consent for participation in the study and were not found at home at the moment of the survey. the sample size was calculated using the following formula: n≥(zα2.p.q)/d2, where the p represents the proportion of non-adherence to public health measures during the covid-19 pandemic (we assumed that p=50% because this proportion in the drc is unknown), q(1−p), z-value of the standard normal distribution corresponding to a significance level of alpha of 0.01 (2.58) and d the precision degree that we assumed to be 3% too. the minimal size computed was 1849 participants. a total of 1913 participants present in the health facilities were selected. data were collected with the use of a semi structured tablet-based questionnaire, which consisted of two parts: demographics and kap. demographic variables included age, gender of interviewee, gender of head of household, marital status, religion, current employment status, town, and the source information of covid-19 related knowledge. the second part included 23 questions regarding submit your manuscript | www.dovepress.com journal of multidisciplinary healthcare 2020:13 covid-19 related knowledge, and the last seven questions probing for observance to each of the instructions released to the public by the ministry of health. participants were assured that the information collected would remain anonymous. a correct answer was assigned 1 point, whereas an incorrect/unknown one was assigned 0 points. the total knowledge score ranged from 0-23, and a cut-off point for covid-19 related knowledge level was 13: individuals with a score <13 were considered as having poor knowledge, whereas a score of 13 or higher indicated good knowledge. the dependent variable, non-adherence to the instructions, was measured by seven questions probing for observance to each of the instructions released to the public by the ministry of health. the mean score on the non-adherence for each participant to the instructions scale was ≤4. ethical approval was obtained from the ethics committee of the school of public health (approval letter no unilu/ cem/225/2020), university of lubumbashi, and drc in accordance with the declaration of helsinki. participants were informed that participation was on a voluntary basis. informed, verbal consent was obtained from each study participant, which was approved by the ethics committee, and that this study was conducted in accordance with the declaration of helsinki. data were analyzed using spss 23.0 software. the continuous and categorical variables age, gender, marital status, level of education, religiousness, gender of head of household, city of residence, current employment status, exposure to media, heard about novel coronavirus, attended lectures/discussions about covid-19, satisfied with the measures taken by the ministry of health, are presented as frequencies and proportions. binary logistic regression analysis was used to identify the predicting factors of non-adherence to the instructions for the covid-19 pandemic. variables that appeared to be associated (p<0.10) in the unadjusted analyses were further adjusted for demographic factors (ie, age, gender, education) using stepwise logistic regressions. associations with a p-value<0.05 in the adjusted analyses were considered to be statistically significant. the overall data are described in table 1 . in summary, of the 1913 respondents, 44.0% were 25-45 years old and 21.7% were 46 years or older, 55.3% were men and 14.4% of head of household were women, 59.3% were married, 53.1% had a secondary education level, 87.6% identified as religious, 51.1% lived in mbuji-mayi, 21.5% were unemployed, and 92.6% were exposed to media. the majority of the participants (99.2%) had heard about novel coronavirus and only 10.7% had attended lectures/ discussions about covid-19. more than a third of the participants (36.6%) were consequently defined as nonadherents to the instructions of the ministry of health for the covid-19 pandemic. table 2 presents the analysis results for non-respect of the measures for the covid-19 pandemic by people. the following background variables predicted non-adherence: female gender, age lower than 25 years, never studied, and primary education level, unemployed status, living in kamina (haut-lomami province), female gender of head of household, non-media expose, not heard about novel coronavirus, no attending of lectures/discussions about covid-19, not been satisfied with the measures taken by the ministry of health, not been regularly informed about the pandemic, and bad knowledge about covid-19. table 3 presents the multivariate logistic regression analysis, the following variables predicted non-respect of the instructions for the covid-19 pandemic: never studied and primary education level, unemployed status, living in kamina (haut-lomami province), female gender of head of household, not attending lectures/discussions about covid-19, not been satisfied with the measures taken by the ministry of health, not been regularly informed about the pandemic, and bad knowledge about covid-19. the discriminant analysis shows that the values of the area under the curve (auc) indicate a predictive capacity on non-respect of the measures for the covid-19 pandemic of 0.75 or 75% (auc between 0.72 and 0.77) (figure 1 ). understanding characteristics of people who do not comply with covid-19-related public health measures is essential for developing effective public health campaigns in the current and future pandemics. to reduce the covid-19 transmission and impact, in the context of absence of vaccines or curative medical treatment, high adherence to public health measures is crucial. the success of this approach is best measured by the public's willingness to comply. a number of public opinion polls suggest that the public generally abides by these measures. 16 the study shows that non-respect of public health measures for covid-19 can be predicted by never studied and primary education level, unemployed status, living in kamina (haut-lomami province), female gender of head of households, no attending lectures/discussions about covid-19, not been satisfied with the measures taken by the ministry of health, not been regularly informed about the pandemic, and bad knowledge about covid-19. people's engagement to an effective public response to an emergency requires clear communication and trust. [17] [18] [19] in the epidemic context, there is no sufficient time for dialog or feedback because immediate actions are required. in such conditions, the communication for development is no more a required approach than the risk communication and the community engagement. in democratic and non-democratic societies, risk reduction measures such as social distancing and lockdown cannot be coercive. people must understand what is required and be persuaded of the need to comply with it. risk perception, behavioral changes, and trust in government information sources change when pandemics are progressing. 20, 21 gender, income, geography, or social interactions are important determinants of recommended public health behavior. [22] [23] [24] it should be noted that the population of kamina did not non-adhere to public health instructions. our study shows that not been regularly informed about the pandemic and bad knowledge about covid-19 are factors of non-adherence to public health instructions. while more information is available, the ministry of health has to update the messages to achieve effective risk communication in the outbreak context. this is essential not only to instruct and motivate the community to adopt preventive measures, but also to build trust in public health authorities and prevent misconceptions. emotional aspects like anxiety play a role in decision-making. health authorities have to recognize these emotional aspects and take them into account in their risk communication. concerning educational level, a person whom never studied and primary education level had non-respect of public health measures for covid-19. no link is established between the education level and the behavior to be avoided. in the uk, during the swine flu pandemic, research showed that people without a diploma were more likely to adopt diagonal segments are produced by ties. dovepress protective attitudes (for example, avoiding crowds or public transport), 25 while in hong kong, higher educated people have been shown to be more likely to avoid public places during the sars outbreak. 26 in australia, it was found that people with higher education were more likely to report expected compliance. 27 on the whole, the instruction allows the adoption of protective and avoidant behaviors, while some results have remained inconclusive. a strength of our study was represented by the fact that the survey was conducted quickly in the most critical period when health authorities recommended the compliance to various barrier measures anywhere and anytime. this study has also limitations. first, despite using probabilistic sampling so that personal characteristics of the sample broadly reflected those in the general population, we cannot be sure that survey respondents are representative of the general population in both provinces. second, the data presented in this study are self-reported and partly dependent on the participants' honesty and recall ability; thus, they may be subject to recall bias. in conclusion, the present study indicates factors related to non-adherence on public health measures during the covid-19 pandemic in the drc. the non-adherence to these public health instructions can increase risk for the transmission of the pandemic. effective risk communication and community engagement are important to protect the public during the covid-19 pandemic. based on the results, we recommend the permanent updating of messages taking into account the context and the progress of the pandemic by using several communication channels (radio, newspapers, tv, social networks, etc). during these times, we believe that frontline workers, community health workers, and students in medical sciences can be useful as effective and trustworthy human resources against this pandemic. the change in declared willingness to comply with public health measures in the pandemic concern is necessary for the successful response and containment of the disease. the authors report no conflicts of interest for this work. novel coronavirus (covid-19) knowledge and perceptions: a survey of healthcare workers (preprint) epidemiology of coronavirus covid-19: forecasting the future incidence in different countries public responses to the novel 2019 coronavirus (2019-ncov) in japan: mental health consequences and target populations critical supply shortages -the need for ventilators and personal protective equipment during the covid-19 pandemic covid-19 pandemic -an african perspective covid -19: a perspective on africa ' s capacity and response leveraging africa's preparedness towards the next phase of the covid-19 pandemic comment limiting the spread of covid-19 in africa -: one size 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disease: the importance of research public health measures during an anticipated in fl uenza pandemic: factors in fl uencing willingness to comply monitoring the level of government trust, risk perception and intention of the general public to adopt protective measures during the influenza a (h1n1) pandemic in the netherlands the dynamics of risk perceptions and precautionary behavior in response to 2009 (h1n1) pandemic influenza perceived risk, anxiety, and behavioural responses of the general public during the early phase of the influenza a (h1n1) pandemic in the netherlands: results of three consecutive online surveys demographic and attitudinal determinants of protective behaviours during a pandemic: a review social capital and health-protective behavior intentions in an influenza pandemic contextual and psychosocial factors predicting ebola prevention behaviours using the ranas approach to behaviour change in guinea-bissau public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey a tale of two cities: community psychobehavioral surveillance and related impact on outbreak control in hong kong and singapore during the severe acute respiratory syndrome epidemic pandemic influenza in australia: using telephone surveys to measure perceptions of threat and willingness to comply the journal of multidisciplinary healthcare is an international, peerreviewed open-access journal that aims to represent and publish research in healthcare areas delivered by practitioners of different disciplines. this includes studies and reviews conducted by multidisciplinary teams as well as research which evaluates the results or conduct of such teams or healthcare processes in general. the journal covers a very wide range of areas and welcomes submissions from practitioners at all levels, from all over the world. the manuscript management system is completely online and includes a very quick and fair peer-review system. visit http://www.dovepress.com/testimonials. php to read real quotes from published authors. key: cord-001038-91uj6sph authors: mirza, nabila; reynolds, tera; coletta, michael; suda, katie; soyiri, ireneous; markle, ariana; leopold, henry; lenert, leslie; samoff, erika; siniscalchi, alan; streichert, laura title: steps to a sustainable public health surveillance enterprise a commentary from the international society for disease surveillance date: 2013-07-01 journal: online j public health inform doi: 10.5210/ojphi.v5i2.4703 sha: doc_id: 1038 cord_uid: 91uj6sph more than a decade into the 21(st) century, the ability to effectively monitor community health status, as well as forecast, detect, and respond to disease outbreaks and other events of public health significance, remains a major challenge. as an issue that affects population health, economic stability, and global security, the public health surveillance enterprise warrants the attention of decision makers at all levels. public health practitioners responsible for surveillance functions are best positioned to identify the key elements needed for creating and maintaining effective and sustainable surveillance systems. this paper presents the recommendations of the sustainable surveillance workgroup convened by the international society for disease surveillance (isds) to identify strategies for building, strengthening, and maintaining surveillance systems that are equipped to provide data continuity and to handle both established and new data sources and public health surveillance practices. online journal of public health informatics * issn 1947-2579 * http://ojphi.org * vol. 5 in 2002, the institute of medicine (iom) reported that the public health system in the united states had a multitude of deficiencies that impact the ability to effectively conduct public health surveillance. these included outdated and vulnerable technologies; a public health workforce lacking training and reinforcements; lack of real-time surveillance and epidemiological systems; and ineffective and fragmented communications networks. 1 while considerable headway has been made since the iom report was published, there is still evidence of a need for further improvements. a recent report by trust for america's health, for example, found that there are persistent gaps in the ability of state and local public health agencies to respond to events ranging from bioterrorist threats to natural disasters and disease outbreaks. 2 the question is-how can we reduce these gaps? nationwide and globally, rapid changes in health information systems, cloud computing technologies, communications, and global connections are catalyzing a re-examination of disease surveillance as an enterprise that needs coordinated and integrated system elements. sustainable surveillance, which we define as ongoing data collection, analysis, and application, coupled with a capability to respond to novel demands, is needed to ensure that public health agencies can perform reliably regardless of shifts in public health funding and priorities. the isds sustainable surveillance workgroup identified the following steps to maintain and advance the public health surveillance enterprise: 1. recognize systematic and ongoing public health surveillance as a core public health function that is essential for population health, economic stability, and national security. 2. create and support funding mechanisms that reinforce enterprise (i.e., integrated systems), rather than categorical (i.e., disease or program specific) surveillance infrastructures and activities in order to reduce inefficient silos, leverage resources, and foster synergies. 3. oppose further cuts to spending for surveillance activities. 4. invest in surveillance workforce development to build competencies and improve organizational capacity to utilize technological advances in surveillance practice. 5. advance a rigorous surveillance research and evaluation agenda that will deepen the understanding of community health, identify best practices, and provide evidence for decision-making. public health surveillance is defined as, "the systematic and ongoing collection, management, analysis, interpretation, and dissemination of information for the purpose of informing the actions of public health decision makers." 3 in addition to providing information about the health status of our communities, surveillance is a foundation of emergency preparedness, food safety, infectious disease outbreak prevention and control, chronic disease assessments, and other key areas that protect the health, economy, and security of the public. while public health surveillance policy and practice have been indicated as priorities for policymakers at the national and global levels, [4] [5] [6] [7] questions remain about how to move forward from planning to implementation, especially in a time of critical cuts to federal funding. progress in health information technology (it) and the increased use of electronic data and new data streams offer great potential for innovation in surveillance science and practice. for instance, the self-reporting of health information through social media (e.g., twitter), as well as crowdsourcing projects such as flu near you (www.flunearyou.org) offer new options for collecting timely data. in addition, the health information technology for economic and clinical health (hitech) act, 8 legislated as part of the american recovery and reinvestment act (arra) of 2009, is fueling the adoption of electronic health record (ehr) systems in the u.s. 9 in return for financial subsidies to implement ehr systems, hospitals and doctors are required to share data for public health purposes 9 with the intent to improve both population health outcomes and the quality of clinical practice. sustainable surveillance systems have the potential to advance both of these goals. 10 the value of public health surveillance 1. recognize systematic and ongoing public health surveillance as a core public health function that is essential for population health, economic stability, and national security. public health surveillance data is the foundation of public health programs and is required for a number of purposes, including: to demonstrate the size and impact of the public health problem being addressed by a program; to identify the population groups to which additional prevention efforts should be directed; to determine whether the problem is growing in size or abating; to provide feedback to data providers; and as part of an overall program evaluation strategy. the significant health impacts and economic costs of disease outbreaks illustrate the critical importance of effective public health surveillance and rapid response, as well as the cost of inaction. 11 table 1 provides examples of the health and financial burdens posed by some naturally occurring and intentional infectious disease outbreaks. the values reported in table 1 do not fully reflect additional indirect costs of diseases and their potentially crippling effects on a community, nor do they address costs that are underreported/ unreported due to lack of data. higher rates of illness, for example, can lead to lower worker productivity, 11 while premature mortality can reduce the size of the labor force, both of which have economic ramifications. there is growing evidence that these economic and societal costs can be mitigated by surveillance systems that are stable; a stable system provides the best foundation for identifying whether the problem being addressed is getting bigger or smaller or disproportionately affecting a section of the population, etc., while still allowing flexibility to provide useful information quickly about emerging issues. the optimum mix of stability and flexibility will depend on the purpose(s) of surveillance and the particular health condition under surveillance. for example, in ojphi the case of sars, an effective surveillance system has the potential to decrease the size of an epidemic by one-third and the duration by 4 weeks, with significant cost savings. 25 another study found that the early detection of an outbreak of highly infectious bacterial meningitis saved approximately $2 for every dollar invested in infectious disease surveillance. 26 yet another evaluation of surveillance practice found that technological improvements in a sentinel influenza-like illness (ili) surveillance system in virginia saved over $9,500 (1,992 hours) in staff-time during the 2007-2008 influenza seasons. 27 ongoing surveillance can also inform the design and evaluation of prevention and intervention programs in order to control the escalating costs associated with chronic diseases in the u.s. and abroad. 28 some experts forecast that chronic disease prevention programs could save up to $48.9 billion per year by 2030, 29 while others predict applying electronic medical record implementation and networking to the prevention and management of chronic disease will exceed the currently projected $81 billion in annual savings. 30 siloed surveillance systems are outdated, inefficient, and incapable of meeting today's demands for electronic data exchange and for the informatics capabilities needed to use the information for maximum benefit. integrated programs and collaboration, on the other hand, facilitate the efficient management of the complex, varied, and proliferating issues and information sources that exist today. the nature of public health surveillance also lends itself to multiple-purpose approaches in that strategies for preventing and controlling diseases, such as west nile virus, are to a great extent the same as for an influenza epidemic, a foodborne disease outbreak, or a bioterrorist attack. 31 technology that enhances communication and data sharing across disease programs, surveillance systems, and even across jurisdictions increases the ease of obtaining and disseminating useful information to a broad audience, including public health agencies, healthcare providers, policymakers, and the general public. 6, 32 this rapid information exchange not only facilitates timely response, but can also reduce emergency room visits, hospital admissions, and even costs of care. 33 however, many health departments currently have systems that are not flexible enough to respond to changing health it needs, which makes it difficult to deliver information when and where it is needed. 4 disease or program-specific funding also exacerbates program vulnerability to funding and budgetary cuts. for example, when funding is earmarked for specific purposes (e.g., emergency preparedness and associated surveillance systems), and then is reduced, such as has occurred for public health emergency preparedness cooperative agreement funding through cdc in the past seven years, 34 it can undermine and reverse efforts to establish sustainable systems that serve multiple crosscutting purposes throughout public health. by contrast, an enterprise approach provides a cohesive framework that will better equip public health practitioners to address the challenges of processing large volumes of electronic data, and the concomitant analytical and visualization requirements. specifically, enterprise funding supports a reliable, flexible infrastructure that can adapt to technological and information requirement changes, and allows for ongoing data collection and the integration of new data sources to advance all-hazard preparedness. a 2004 white house memo acknowledged how programmatic funding can lead to inefficiencies and redundancies in system acquisitions and usage and called for applying technological and human resources across programs. 35 by encouraging collaboration within and between departments, surveillance professionals can take advantage of shared platforms and resources to optimize data collection, analysis, storage, and dissemination, thus helping to reduce operational costs and improve efficiency. for example, collaboration could create opportunities for the effective integration of syndromic and reportable disease data for public health use. 36 a lack of consistent and sustainable funding is hampering the necessary expansion and improvement of public health surveillance systems at local, state, and national public health agencies. a 2010 survey of local health departments conducted by the national association of city and county health officials (naccho) found that 72% of local health departments reported insufficient funding as one of their major barriers to modernizing their it systems. 37 health data collection systems that take advantage of recent technological advances have proven to be more cost effective and sustainable in the long-term. 38 stable funding is essential to supporting the adoption of hardware and software systems as they become available, leading to a robust and sustainable public health surveillance infrastructure able to integrate, manage, and communicate the plethora of data necessary to generate actionable results. 39 the new age of disease surveillance requires a skilled public health workforce able to manage large volumes of increasingly complex electronic information, to understand the data flows, and to extract meaning from them. this calls for sophisticated and integrated competencies in public health informatics, epidemiology, statistics, and other areas, and the ability to present findings, draw conclusions, and make recommendations based on surveillance data. furthermore, in addition to needing people who can effectively operate existing surveillance systems and carry out tasks (such as the onboarding process for collecting newly available ehr data) there is also demand for people who can identify and assess new opportunities for surveillance and design new systems that take advantage of these opportunities. 6 online journal of public health informatics * issn 1947-2579 * http://ojphi.org * vol. 5, no. 2, 2013 attracting and retaining experts in these fields is especially challenging in light of the comparatively low base salaries allotted to public health workers compared to the salaries of technology-intensive positions in other sectors. 40 to align the surveillance workforce with new demands, the isds sustainable surveillance workgroup suggests the following approaches: • provide training programs for existing and prospective public health workers to equip themselves with the necessary expertise and skills to work in rapidly evolving it systems. • promote public health careers at the primary, secondary, undergraduate, and graduate levels across disciplines. • provide competitive salaries to recruit and retain a workforce skilled in public health surveillance and informatics. 5. advance a rigorous research and evaluation agenda that will deepen the understanding of community health, identify best practices, and provide evidence to inform decision-making. research and evaluation play an important role in connecting the processes of information collection, information use for decision-making, and translation of decisions to actions and measurable outcomes. research-based evidence and evaluation results can help to identify the limitations and benefits of different surveillance procedures for better decision-making and more effective resource allocation. investing in research and applying the rigors of science to public health surveillance questions leads to informed decisions on how best to direct efforts and resources. in addition, periodic evaluations of surveillance infrastructuresthe systems and people-are needed to assess return on investment and opportunities for quality improvement. effective and efficient surveillance systems are proven to save money and lives. the ability to detect and respond to known and emerging pathogens is central to protecting and maintaining population health. 41 the breakdown or absence of a stable public health surveillance infrastructure, on the other hand, can undermine efforts to mitigate disease outbreaks and other public health events. 31 public health surveillance systems built on a strong infrastructure of core workforce competencies, information systems, and organizational capacity, 42 and supported by consistent and enterprise-based funding, are essential if we are to understand and respond to the real and growing threats to population health. by providing political commitment and financial support to this issue, decision makers can play an active role in advancing the health of individuals, communities, and nations. the future of the public's health in the 21st century ready or not? -protecting the public's health from diseases, disasters, and bioterrorism international epidemiological association. a dictionary of epidemiology the white house public health surveillance and informatics program office blueprint version 2.0": updating public health surveillance for the 21st century sixty-fifth world health assembly: world health organization act enforcement interim final rule hitech. u.s. department of health and human services public health surveillance and meaningful use regulations: a crisis of opportunity improved diagnostic accuracy of group a streptococcal pharyngitis with use of real-time biosurveillance measuring and valuing productivity loss due to poor health: a critical review summary of probable sars cases with onset of illness from 1 estimating the global economic costs of sars learning from sars: preparing for the next disease outbreak: workshop summary investigation of bioterrorism-related anthrax total decontamination cost of the anthrax letter attacks epidemiology: infectious diseases: preparing for the future avian influenza: economic and social impacts officials warn of pertussis outbreak. abc news local health department costs associated with response to a school-based pertussis outbreak california west nile virus website economic cost analysis of west nile virus outbreak health department releases costs of salmonella probe. bismarck tribune global epidemics and impact of cholera. world health organization geneva: world health organization different epidemic curves for severe acute respiratory syndrome reveal similar impacts of control measures analysis of the value of local public health operations spending. public health -muskegon county cost-effectiveness of influenza-like illness sentinel surveillance in virginia. virginia department of health world bank return on investments in public health: saving lives and can electronic medical record systems transform health care? potential health benefits, savings, and costs strengthening the nation's public health infrastructure: historic challenge, unprecedented opportunity mission creep: public health surveillance and medical privacy fast access to records helps fight epidemics. the new york times state-by-state update report on preparedness and response white house office of management and budget. omb circular a-87 revised. the white house integration of syndromic surveillance data into public health practice at state and local levels in north carolina the status of local health department informatics. results from the 2010 naccho informatics needs assessment. national association of city and county health officers replacing paper data collection forms with electronic data entry in the field: findings from a study of community-acquired bloodstream infections in pemba, zanzibar design and operation of state and local infectious disease surveillance systems the public health enterprise: examining our twenty-first-century policy challenges the public health infrastructure and our nation's health public health's infrastructure, a status report to the u.s. senate appropriations committee key: cord-011700-ljc5ywy2 authors: hamaguchi, ryoko; nematollahi, saman; minter, daniel j title: picture of a pandemic: visual aids in the covid-19 crisis date: 2020-06-12 journal: j public health (oxf) doi: 10.1093/pubmed/fdaa080 sha: doc_id: 11700 cord_uid: ljc5ywy2 as a global crisis, covid-19 has underscored the challenge of disseminating evidence-based public health recommendations amidst a rapidly evolving, often uncensored information ecosystem—one fueled in part by an unprecedented degree of connected afforded through social media. in this piece, we explore an underdiscussed intersection between the visual arts and public health, focusing on the use of validated infographics and other forms of visual communication to rapidly disseminate accurate public health information during the covid-19 pandemic. we illustrate our arguments through our own experience in creating a validated infographic for patients, now disseminated through social media and other outlets across the world in nearly 20 translations. visual communication offers a creative and practical medium to bridge critical health literacy gaps, empower diverse patient communities through evidence-based information and facilitate public health advocacy during this pandemic and the ‘new normal’ that lies ahead. the covid-19 pandemic is rapidly becoming the greatest public health crisis of the new millennium. while frontline clinicians and innovative researchers continue to work tirelessly, effective management of this pandemic requires engagement of the public if we are to curb further rises in cases and safely enter a 'new normal.' however, despite the unprecedented connectedness that we are afforded in 2020, disseminating useful, accurate public health information has emerged as a major challenge-one exacerbated by the exponential growth of unverified covid-19-related information on social media platforms. 1 critical health literacy gaps further threaten the equity of information access among racial minorities and other vulnerable communities, which are already being disproportionately affected by the pandemic (e.g. 36% of african americans aged 16-64 in the lowest literacy bracket). [2] [3] [4] in this piece, we propose that simple, validated pictorial presentations of data, or infographics-situated at a unique intersection of the arts and public health-can be effective tools to deliver medical information during this pandemic. visual aids and graphics are a powerful medium and have a long history in the broader field of education research, which suggests that the combination of words and simple images into a unified model enhances learning and information retention. 5 during the current covid-19 pandemic, visuals have emerged as a particularly powerful vehicle of information dissemination. perhaps, the best-known example is the '#flattenthecurve' graphic, a widely circulated image showing the anticipated effects of social distancing efforts. however, there remains a need for simple illustrated resources that consolidate key public health messages and validated clinical evidence into compact visual aids-especially those that can be seamlessly disseminated through social media outlets to reach diverse patient communities. we addressed this need by creating a single-page infographic designed to educate the public about essential covid-19-related content (fig. 1 ). evidence-based information, ranging from mechanisms of transmission and risk factors to comparative epidemiological statistics between influenza and covid-19, was compiled and reviewed. we distilled this information into a simple infographic with the goals of (i) informing a layperson reader and (ii) guiding providers through a typical conversation about covid-19 with a loved one, curious patient or the larger public. in order to cater toward a diverse range of health literacy levels, overly complex medical terminology was avoided (i.e. replacing 'shock' with 'severely low blood pressure'), and each graph was annotated with simple interpretations of the data in accessible language to guide interpretation and circumvent potential 'numerical overload.' the final piece underwent rigorous peer review by a team of physicians, including experts in infectious disease, public health and medical education. in the first week following its release on social media, the infographic reached more than 120 000 people, with nearly 600 readers sharing it among usa and international medical schools, residency and fellowship programs, local municipal governments and even networks of professional comic and graphic artists. to better reach vulnerable communities at risk of limited access to information, the infographic was shared specifically with physician leaders and organizations focused on eliminating racial and ethnic disparities in healthcare. while virtual validation and increased social media visibility cannot be directly extrapolated to public health impact, they do underscore the synergy between social media and effective infographics in promoting rapid transmission of information across interdisciplinary sectors and bridging disparities in access to health information. importantly, there appears to be a global appetite for simple infographics such as the one we piloted. we received direct requests from readers in multiple countries for non-english language versions, as well as offers from international healthcare professionals and students to assist with these translations. we formed an organized coalition of providers, translators, peer reviewers and dedicated illustrators to assist with the production of versions in nearly 20 languages. each of our translators, many of them dedicated providers and advocates for diverse communities domestically and abroadhas disseminated our infographic with a breadth and speed made possible through the networks of social media and the digitally portable nature of a simple visual. our haitian-creole version has been disseminated to patient communities in haiti, and our spanish version was utilized in a spanishlanguage news broadcast targeting the working-class, spanishspeaking communities of los angeles and san diego. such experiences fuel our hope that this developing multilingual library-made possible through the unprecedented connectedness afforded by social media-will serve to further close linguistic barriers that alienate patient communities amidst the english-dominated flow of covid-19-related literature released each day. we have combined medical expertise and creative communication to create a validated, accessible and simple public education tool about covid-19. as our understanding of this disease continues to evolve, it will be important to clearly identify the areas of uncertainty in order to mitigate the propagation of misinformation and to reflect new evidence in revisions published in all available languages. in the weeks and months to come, we hope to translate the insights from audience feedback and serial revisions into experience-based recommendations on the design, communication and continual improvement of online visual resources in times of public health crises. as dr. danielle ofri expressed in the inaugural article for this section of the journal, '[a]rts and humanities have the potential to serve as a bridge to connect the population and the individual'. 6 the humanities offer a creative medium in the field of public health, which calls for the unconventional integration of seemingly disparate factors of disease-from the microbiology of epidemics to the complex sociopolitical fabric that shapes health on a population level. the visual arts offer an untapped trove of tools to not only reimagine critical issues, such as patient education and global dissemination of public health information, but also engage in important questions about responsible stewardship of graphic data amidst a modern social media landscape that is increasingly uncensored, rapid and visual. covid-19 has not only caused great human suffering but also shed light on a rapidly evolving information ecosystem that demands creative solutions for equitable, accessible public health communication. amidst this chaos has emerged a unique role for providers-one combining the identities of physician, translator and information liaison, as well as advocate within the broader public health arena. with this new responsibility comes a fresh canvas to engage the power of visual language as a valuable and versatile currency to facilitate public health advocacy, close critical health literacy gaps and inspire socially responsible action among all patient communities. this work was supported by no additional funding sources. social media and emergency preparedness in response to novel coronavirus piaac proficiency levels for literacy hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease 2019 -covid-net, 14 states trends and issues in instructional design and technology rh, sn and djm have no additional contributors, prior presentations of this work or conflicts of interests or disclosures to report. rh, sn and djm have no conflicts of interests to report. key: cord-341616-ts98sfxx authors: yang, yang; su, yingying title: public voice via social media: role in cooperative governance during public health emergency date: 2020-09-18 journal: int j environ res public health doi: 10.3390/ijerph17186840 sha: doc_id: 341616 cord_uid: ts98sfxx with the development of the internet, social networking sites have empowered the public to directly express their views about social issues and hence contribute to social change. as a new type of voice behavior, public voice on social media has aroused wide concern among scholars. however, why public voice is expressed and how it influences social development and betterment in times of public health emergencies remains unstudied. a key point is whether governments can take effective countermeasures when faced with public health emergencies. in such situation, public voice is of great significance in the formulation and implementation of coping policies. this qualitive study uses china’s health code policy under covid-19 to explore why the public performs voice behavior on social media and how this influences policy evolution and product innovation through cooperative governance. a stimulus-cognition-emotion-behavior model is established to explain public voice, indicating that it is influenced by cognitive processes and public emotions under policy stimulus. what is more, as a form of public participation in cooperative governance, public voice plays a significant role in promoting policy evolution and product innovation, and represents a useful form of cooperation with governments and enterprises to jointly maintain social stability under public health emergencies as a positive extra-role behavior, voice has attracted extensive interests from scholars and gained substantial attention in the organizational behavior literature [1] [2] [3] . public voice is a new type of voice behavior that refers to the behavior of citizens who share opinions on social media to improve the social status quo or prevent harmful practices [4] . as a pro-social behavior, public voice is vital for advancement and betterment of society [4] , and it is believed that public voice plays an important role in the cooperative governance of government and other organizations (e.g., enterprises, non-profit organizations) under a public health emergency. considering that public participation in public administration and policy formulation is beneficial to government performance, governments attach much importance to the public's role in policy-making, especially in the areas of environmental governance, public health, and sustainable development [5] [6] [7] [8] . in the face of extraordinary development problems, such as economic recession, public opinion in policy-making is extremely important [9] . thus, to ensure the timeliness and efficiency of policy in the case of public health emergencies, the value of public voice, along with technical support from enterprise, should not be underestimated. in the covid-19 epidemic, many governments have begun to cooperate with high-tech enterprises to formulate epidemic prevention and control policies such as the health code in china, covidwise in virginia, and corona-warn in germany [10] [11] [12] [13] . public voice on social media has effectively promoted the evolution of epidemic control policy and tracking applications developed by enterprises, making an outstanding contribution to social stability. thus, it is necessary to study public voice in public health emergencies in relation to the implementation of government policies and the promotion of enterprises' product innovation. public voice is also of great significance in further realizing cooperative governance. voice behavior refers to the extra-role interpersonal communication behavior in which organizational members actively make constructive suggestions to the organization for the purpose of improving work or organization status quo [14] . previous studies on voice behavior have mainly focused on employee voice and customer voice within organizations; public voice in a broader context has received little attention. the importance of employee voice and customer voice for the sustainable development of enterprises suggests that the role of public voice in social improvement should not be underestimated, and is worthy of in-depth discussion [4] . given that public voice can have wide ranging influence in terms of social change, this research focuses on its effect on the evolution of policy implemented under public health emergencies. public voice in public health emergencies has several important characteristics: first, the target of public voice is more extensive. the targets of employee voice and customer voice are employees inside the enterprise and customers who have cooperative relationships with the enterprise, respectively. they often offer advice to the enterprise as a single identity. however, for public voice, the target is the general public, who have dual identities as policy participants and enterprise customers. second, under cooperative governance, multiple subjects participate in policy-making, so the targets and content of public voice are also diverse. for example, voice to a government may relate to the implementation of policy, while that to an enterprise may focus on product improvement. third, the channels for public voice are more diverse. employees mainly voice to supervisors face-to-face or make suggestions through the internal social networks of an enterprise, and most customer voice occurs through the virtual community created by the enterprise. as social networking sites provide a more convenient platform for people to voice their concerns and make their voices heard, the public can voice through a variety of social networking sites [4] . finally, the effect of public voice is more significant. public health emergencies prompt the public to respond to the policy more actively and provide timely feedback [15] , which forces the governments and enterprises to absorb public opinion as soon as possible to improve policies and products. overall, research on public voice behavior is still in its infancy. the factors driving public voice and the mechanism of its action on government policies and enterprise product innovation are unclear. the purpose of this study is to address this gap and further explore the role of public voice in promoting cooperative governance under public health emergencies. the main contributions of this paper are threefold. first, it extends the literature on voice behavior. most studies on voice behavior have focused on employee voice and customer voice. under cooperative governance, the public is a participant in government policy as well as a customer of enterprises, yet the mechanisms for the influence of public voice on policy and product are not clear. this paper focuses on the dynamic role of public voice in policy-making and evolution and product innovation. second, it constructs a dynamic model of public voice to promote policy implementation under public health emergency. studies of public participation have mainly focused on its effect on environmental projects and decision, as public participation is seen as highly valuable and necessary to achieve the goal of environmental pollution control [8, 16, 17] . however, the voice behavior of the public in the formulation and evolution of policies in public health emergencies is unknown. finally, this paper extends the literature on cooperative governance in a public health emergency and attaches more importance to the role of public voice in the process of collaborative. this research uses china's health code policy under covid-19 as an example. this is an epidemic prevention policy whose implementation relies on a health rating system developed by alibaba, tencent, and other firms. the system uses opaque algorithms and individuals' data, such as physical condition and contact with an infected person, to make judgments about the infection risk of system users [18] . the system then generates a qr code corresponding to this risk level that is used as a passport. based on the evolution process of health code policy, this paper downloads comments about the health code policy to do research. this study uses the qualitative research method of grounded theory to explore the factors driving public voice and reveals the dynamic mechanism of its influence on policy formulation and product innovation. further, this research provides support for cooperative governance involving government, enterprises, and the public under public health emergencies. the concept of voice was first proposed by hirchman in the field of economics. it has been further developed in the field of organizational behavior [19] . currently, voice behavior is divided into employee voice, customer voice, and public voice. most research on voice behavior has been in the field of organizational behavior and mainly aimed to explain employee voice within organizations. van dyne and lepine define employee voice behavior as a positive extra-role behavior focused on improving existing working methods and procedures through constructive suggestions; they emphasize the 'promoting' role of employee voice for the organization [14] . van dyne et al. further expand the concept, pointing out that voice includes not only suggestions for improvement, but also concerns about the organization [20] . on this basis, liang et al. clearly divide voice behavior into promotive voice and prohibitive voice [21] . promotive voice refers to innovative ideas or suggestions put forward by employees to improve the overall operation of the organization, while prohibitive voice refers to employees' attention to work practices, and events and employee behaviors that are not conducive to the development of the organization [21] . employee voice is widely considered a valuable and positive extra-role interpersonal communication behavior, a kind of organizational citizenship behavior that plays an important role in the team and organization. scholars have conducted in-depth research on the influential factors and outcome variables of employee voice. previous studies indicate that personal characteristics, leadership, and organizational climate can influence employee voice, which will be beneficial to organizational betterment [2, 3, [22] [23] [24] [25] [26] [27] [28] [29] . additionally, the approaches of employee voice are also optimized due to the development of the internet [30] . with the aggravation of market competition, customer participation becomes crucial for the product and service innovation of enterprises, and enterprises have created brand virtual communities to gather customers' ideas and opinions. research on voice behavior has also expanded from the internal voice of the organization to the field of consumer behavior. on the connotation level, griffin and hauser regard customer requirements as customer voice, holding the view that customers would sort their needs according to importance and convey them to enterprises [31] . enterprises can then develop new products based on customer requirements. lee et al. expand the connotation of customer voice and define it as a description of customers' needs and expectations or preferences and dislikes, including the pursuit of rights and interests, suggestions for new products and services, and complaints about previous use experience. earlier definitions of customer voice are based on customer needs, but with advances in research on employee voice within organizations, scholars have begun to redefine customer voice from the perspective of role orientation. ran and zhou clearly define customer voice as the extra-role communication behavior in which customers actively make suggestions or express opinions to improve the status of enterprises; this kind of behavior belongs to the category of customer citizenship behavior [32] . at the dimension level, most previous studies on customer voice divide it into two categories: customer satisfaction and customer complaint [33] . with the deepening of research, scholars find that customers not only express dissatisfaction regarding product and service providers, but also express satisfaction and praise, and make their own suggestions. therefore, with reference to the classification of employee voice by liang et al., customer voice can be divided into promotive voice and prohibitive voice [21] . promotive voice refers to the innovative ideas and suggestions of customers regarding improvements to the efficiency of enterprises, while prohibitive voice refers to the expression of opinions on actual and potential problems within the products, services, or management of an enterprise that are harmful to the enterprise or its customers. as the input behavior of customers to enterprises, customer voice can urge enterprises to innovate products and services to meet the needs of customers, thus improving customer satisfaction and maintaining customer loyalty. it can also help enterprises correct errors, provide solutions to problems, and improve enterprise performance [33, 34] . with the rapid development of social media, people can express their views on social issues more directly and conveniently, and research on voice behavior has been further extended to a broader social life context. public voice behavior refers to citizens sharing opinions on social media to improve their social status quo or prevent harmful practices. it is essentially a pro-social behavior [4] . public voice channels have begun to focus on social media, because in the modern world, social media presents extensive information; people express their concern about education, security, the environment, work-life balance, and many other issues online. moreover, the diversity and openness of social media provides a broad platform for public expression. the public can conduct online voice behavior through third-party social media and public participation is increasing. however, research on public voice based on social media is still in its infancy and is uncommon. bhatti et al. explore the mechanism of the effect of individual moral identity and proactive personality on public promotive voice and prohibitive voice based on self-consistency theory [4] . research on voice behavior as discussed above has several characteristics. first, the research field has shifted from intra-organization to a broader social background. second, the voice subjects present a change trend of 'employee-customer-public'. third, the targets of voice behavior change from organizational practice to general social phenomena. fourth, the form of voice presents the evolution trend of "face-to-face-virtual community-social media". citizen participation in the formulation and consultation of public policies is an important way to strengthen and support modern democracy [35] . regarding the influence of public participation on policy, most research reveals extensive interest in environmental protection and pollution control, as public participation can help decision makers recognize public concern and demands, and handle environmental conflict in a more flexible manner [36, 37] . fu and geng explore the influence of public participation and regulation compliance on 'green development' with panel data from 30 provinces in china from 2004 to 2014, finding that public participation can lead enterprises to improve compliance and thus promote green development [8] . regional environmental quality (req) is a comprehensive indicator of emissions of waste gas, waste water, and waste solids, and its improvement requires coordination between governance and public participation. public participation can be coordinated with governance to effectively improve req effectively, and further promote the optimization of environmental governance system [38] . the arrival of the internet era has changed the method of public participation. as a branch of e-government, e-participation has been widely examined by scholars. considering that public participation is a voluntary activity, whether the public is willing to participate is the decisive factor affecting the success of e-government platforms. scholars consider that in addition to demographic differences, willingness to use an e-participation system is affected by system technical factors, personal incentive factors, and social capital factors. based on the unified theory of acceptance and use of technology, planned behavior theory, social capital theory, and other information system theories, previous studies have explored the willingness of the public to use the e-community to participate in policy-making and provide strategic suggestions for governments to improve e-government platform [39, 40] . product innovation is an important focus in the innovation research field and is key for enterprises to obtain sustainable competitive advantage. at present, there is no unified definition of product innovation in academia. katila and ahuja define it as change in design attributes-such as technology, appearance, quality, and structure-relative to the existing products of an enterprise. this is also known as technological innovation or design innovation [41] . the organization for economic co-operation and development defines product innovation as the process leading to a new or significantly improved product or service [42] . various scholars' definitions of product innovation, identify two aspects: entity product innovation and service-related innovation. according to the different degree of innovation, product innovation can be divided into radical innovation and incremental innovation [43] . rapid change in the external environment drives enterprise innovation; enterprises can only achieve long-term development by constantly producing more competitive products according to the needs of users. as an external innovation resource, customer voice can be regarded as a gift given by users to enterprises to help them carry out product innovation based on the collective wisdom [44] [45] [46] . customer voice provides valuable information for enterprises, which can help product designers and engineers to understand customers' needs and preferences, and turn them into key objectives of product improvement by making targeted adjustments to products and services to meet the needs of users [47] . further, customer voice can help enterprises identify the product attributes to which customers pay most attention and focus on product improvement and new product development [48] . governance refers to processes and structures in public decision making and may involve the participation of multiple agents, such as governments, corporations, and the public, with the aim of carrying out a public purpose that cannot be accomplished by single force [49] . cooperative governance is not limited to formal government-initiated arrangements, but involves diverse kinds of multi-partner governance related to a wide range of fields [49] . for example, because of the production of pollution, enterprises take the greatest responsibility for environment contamination control. however, as it is difficult for governance goals to be achieved through the actions of a single enterprise, so governance among enterprises is indispensable [50] . with regard to cooperative governance among governments, zhang et al. find that superior government should supervise heterogeneous local governments and increase penalties for non-cooperative parties to improve the efficiency of haze pollution control [51] . further, cooperative governance can provide guidance for participatory governance by the public [4] . studies of cooperative governance involving public participation have focused on environmental governance and sustainable development. when making local energy decisions, local governments should be given more autonomy and sufficient capacity to strengthen public participation. what is more, public opinion ought to be taken into consideration when developing policy [52] . studies show that policy-making style presents convergence to the cooperation among government, public and non-profit organizations. as the government may lack the necessary resources to deal with issues, they rely on other subjects to provide support to ensure policy utility [53] . to summarize, there are several problems needing to be solved: first, research on public voice is not mature and more studies are needed to clarify its antecedents as well as its effects on policy implementation and social development. second, it is undeniable that the public plays a crucial role in environmental governance, but the role of public voice behavior in policy-making and implementation under public health emergencies is still unclear. third, the role played by public voice in cooperative governance and how this happens deserve exploration. at the beginning of 2020, the outbreak of covid-19 brought great impact on people's life and work. in order to contain the spread of novel coronavirus and speed up the normalization of production and life, on 7 february 2020, yuhang first launched the yuhang health code. and on 11 february 2020, hangzhou launched the hangzhou health code to implement "green code, red code, yellow code" three-color code dynamic management [18] . the implementation of this policy has aroused widespread concern of the people all over the country, and local governments have followed up and implemented a local version of code in few weeks [18] . the implementation of health code policy is assisted by the qr rating health code system developed by alibaba, tencent, or other firms. when registering, individuals should provide their names, id numbers, phone numbers, and answer a series questions about physical health conditions and travel trajectory to get the initial rating [54] . in addition, the rating changes according to individual real-time data, which consists of individuals' travel history, directly related health information, overall medical test results, and overall risk assessment from individuals' reports, information from gps (global positioning system), telecommunications supplier, consumption record, qr code usage record, etc. the system assesses individual's infection risk and generates green, yellow, or red codes according to individual's data [55] . people with green codes have a very low probability to be infected and can move around freely, while people with yellow codes have a risk to be infected to some extent and should be quarantined for a week. people with red codes are at great risk of infection and need to be quarantined for 2 weeks. during the quarantine, if people with yellow or red codes check in on the app every day, the codes will turn green at the end of quarantine periods. and if the real-time information shows that people with green codes have gone to a high-risk area or been in contact with an infected person, the code will turn yellow or red as well [10] . up to august 2020, the tencent health code covers a population of 9 hundred million people, more than 400 cities and counties, and more than 5100 villages in china, with a cumulative total of 42 billion visits [56] . with the evolution of the health code policy, the effective circulation of personnel from all over the country has met the needs of residents' normal life and enterprises' resumption of work and production. at present, residents only need to provide a real-time qr code generated in a mini-app embedded in alipay (alibaba, hangzhou, china) or wechat (tencent, shenzhen, china) to the guard, they can move around [54] . in the health code policy implementation process, the high-tech enterprises not only provide technical support to develop the health code system, but also participate in the formulation of policy standards and establishment of policy platforms. for example, alibaba and tencent have been fully involved in the formulation of national standards for the personal health information code series [57, 58] . besides, during this process, the public is actively voicing on the implementation and evolution of the health code policy as well as improvements of health code application on social media. in the official weibo of people's daily, tweets about the health code policy get plenty of comments and followers, most of which are advice for policy implementation and system improvement. for example, the tweet about the hangzhou health code has 7227 comments and 79,547 followers. the government press conference and reports about enterprises confirm the public voice does play an important role in the evolution and promotion of health code policy and the voice is fully considered and adopted by government and enterprises when making decisions. on the joint prevention and control conferences of covid-19, the government spokespersons provided response to public concern and the governments also instructed local government and related enterprises to take measures to meet public voice. in addition, the enterprises responded to public voice as well. in the government affairs strategy conference, yuepeng qiu, vice president of tencent, said that they had updated the system more than 50 times. this study adopts a dynamic research perspective, and takes the dynamic evolution of health codes policy as an example, focusing on exploring how public voice promoted the improvement of products by enterprises and the implementation of policies by the government under a public health emergency. the core of grounded theory emphasizes the process of collecting and analyzing original data. in the data collection stage, the researcher takes the evolution process of the health code policy as the time axis, and collects public comments under the official microblog of the people's daily as the research object. data analysis included the following stages: firstly, open coding is used to identify phenomena, define concepts, and discover categories from the original data. secondly, axial coding is carried out to further analyze to get the main category. thirdly, selective coding is used to find the core category, and systematically connect it with other categories to construct a logical relationship. in the whole coding process, researchers keep supplementing the material. finally, the selective coding is analyzed and theoretical construction is carried out, and the density, variation, and high integration of theoretical concepts are adjusted to form a theoretical framework. the qualitative analysis software nvivo 11.0 (qsr international, melbourne, australia) was used for the analysis of this study. open coding is to analyze the original data word by word, so as to summarize the initial concepts and categories in the original data. following the process of "tagging-conceptualizationcategorization", the researchers analyzed the collected data word by word and refined the semantics of the data to obtain the corresponding concepts and categories. examples are shown in table 1 . it's much more convenient than running around to apply material this is not only efficient to reduce the burden of screening personnel, but also can record personal travel the purpose of axial coding is to explore the potential logical relationship between categories and develop main categories. this study classifies different categories according to their relationship at the conceptual level, and concludes eight main categories, which are divided into three classifications. the main categories and their corresponding classifications and relations are shown in table 2 . there is a risk of information leakage when the product collects too much user information there is a risk of abuse of rights when enterprises assume part of government responsibilities on the basis of axial coding, selective coding excavates the core category from main categories and analyzes the connection relationship among them. as shown in figure 1 , the dynamic mechanism of public voice behavior to promote policy implementation and evolution in public health emergencies is as follows: first, under the guidance of the government, enterprises participate in the development of policy and design products to assist policy implementation with advanced technologies. second, in response to the government policy, the public will use enterprise products in their daily life and work. and through judging whether the policy can effectively solve the current problems and guide the future development of the society to form the policy effectiveness perception. third, public's perception of the effectiveness of policies will trigger public emotions. different perceptions of policy effectiveness can lead to positive or negative emotions. then, emotions can induce public voice behavior, including voice for government policies and for enterprise products. finally, the government and enterprises will give feedback to the public voice and improve the policies and products accordingly. as a new external stimulus, the improved policies and products also have an impact on the public's perception of policy effectiveness, forming a dynamic mechanism of public suggestions to promote policy evolution and product innovation, as shown in figure 1 . induce public voice behavior, including voice for government policies and for enterprise products. finally, the government and enterprises will give feedback to the public voice and improve the policies and products accordingly. as a new external stimulus, the improved policies and products also have an impact on the public's perception of policy effectiveness, forming a dynamic mechanism of public suggestions to promote policy evolution and product innovation, as shown in figure 1 . based on the results of grounded theory and cognitive appraisal theory of emotion, this paper constructs a driving mechanism of public voice behavior: "stimulus-cognition-emotion-behavior" model. the model shows that there are causal relationships among cognition, emotion, and behavior. according to the cognitive appraisal theory of emotion, under the stimulation of external events, the external information obtained by individuals first enters the perceptual system for compilation and processing, forming specific cognitions. cognitions trigger the individual's emotional response, and finally produces specific behavioral tendency [59] . based on the results of grounded theory and cognitive appraisal theory of emotion, this paper constructs a driving mechanism of public voice behavior: "stimulus-cognition-emotion-behavior" model. the model shows that there are causal relationships among cognition, emotion, and behavior. according to the cognitive appraisal theory of emotion, under the stimulation of external events, the external information obtained by individuals first enters the perceptual system for compilation and processing, forming specific cognitions. cognitions trigger the individual's emotional response, and finally produces specific behavioral tendency [59] . public policy is the political and technical approach to solve problems, fundamentally, it is pragmatic [60] . under the cooperative governance, the government is no longer the only decision-maker, but the main participant plays a guiding role [49] . with the advent of the new internet era, the impact of big data, cloud computing, and other technologies on policy formulation and implementation cannot be ignored. first of all, the internet can optimize the link of policy-making, and the process of it can be completed with the help of the internet, thus making policy-making more efficient. secondly, big data can provide a wider range of data sources for policy evolution. through data mining and analysis, it can provide big data support for policy evolution, making policy formulation and implementation more reasonable. finally, the open data system can further broaden the channels for the public to participate in policy discussions and make policy-making more democratic. due to the immature application of big data by the government and lack of professional talents, enterprises are required to provide technical support. the technical support of enterprises is more important for the formulation of policies under public health emergencies. as public health emergencies tend to be urgent, destructive, and uncertain, putting forward higher requirements for the timeliness, scientificity, and effectiveness of policies. in this case, it is very necessary for the government to cooperate with enterprises to formulate policies. the government is responsible for policy formulation and implementation, while enterprises take technological advantages to provide products or services to assist policy implementation. according to the cognitive appraisal theory of emotion, when individuals encounter the external stimuli, they will experience two-stage cognitive appraisal processes: primary appraisal and secondary appraisal. in addition, through the appraisal, people can assess the relevance of external stimuli to themselves and whether the resources they have can cope with the situation [61] . in public health emergencies, the policy launched by government-enterprise cooperation is an external stimulus for the public. additionally, public appraisal mainly focuses on whether the policy can achieve policy purpose and effectively solve specific public problems, that is, perceived policy effectiveness. under the policy stimulation, the public will use the cognitive system to make evolution of it [62] . the perception of policy effectiveness reflects the individual's judgment of the correlation between the policy and himself and is an important way for policy to act on public behavior. a high level of perceived policy effectiveness indicates that the public believes the policy is beneficial to their daily life, while on the contrary, they consider that the policy has no significant positive impact or may pose a threat. policy is the action route or method to guide the current and future decision-making, and its role should not be limited to solving the current problems, but also should be instructive for future development of society [63] . according to the results of analysis, the policy effectiveness in public health emergency includes crisis resolution and social normalization. in the case of public health emergencies, the first problem to be solved by policies is to reduce the adverse impact of emergencies, that is crisis resolution. on the premise that the crisis is under control, policies should also have effects of accelerating the social normalization and promoting economic recovery, that is, the social normalization function. taking the health code policy as an example, if the public thinks that the health code policy cannot effectively control the spread of covid-19, or cannot speed up work resumption, the public's perceived effectiveness of health code policy will be low. otherwise, the perception will be high. emotions are the products of an individual's appraisal of the person-environment relationship and of great diagnostic value to help an individual identify what is important under a specific situation. additionally, emotions vary with the change of appraisals [61] . the public's emotional response to policy is formed on the basis of perceived policy effectiveness. according to the cognitive appraisal theory of emotion, emotion intuitively shows the public's evolution of external stimulus perception, and its core is evaluative cognition. almost everything will stimulate people to produce emotion, no matter if it happens or not [62] . however, emotion cannot be aroused by external stimulus directly; the appraisal process of relationship between person-environment is necessary to evoke emotion. when individuals are in a certain situation, they will evaluate it, be satisfied or dissatisfied, beneficial or harmful, and make corresponding emotional reactions [59] . if perceived policy effectiveness is high, the public will have a positive emotion, or vice versa. taking the health code policy as an example, different perceptions of public policy effectiveness will stimulate different emotions. when the public perceive that the health code policy can effectively control the spread of covid-19 or accelerate economic recovery, they will generate positive emotions. otherwise, they will hold negative emotions. examples of comments about health code policy are as follows. comment 1: as i am from hubei province, i didn't go back to my hometown, so i couldn't enter the market for 20 days. after having the health code, i entered the market for the first time without being stopped. it is easy to use and it's really convenient, give it a thumb up! comment 2: i'm in fuyang, and i'm not even allowed to go to my husband's hometown in the countryside. i haven't left fuyang for nearly a month. i haven't even gone to downtown or move around fuyang. what the hell is this code? i don't understand. i'm so angry! according to the cognitive appraisal theory of emotion, the cognition and appraisal of external environment will stimulate special emotions. then, the emotion will motivate coping behaviors to prevent harm or to improve the prospects for benefit [64] . public voice behavior is generated under the influence of public emotions. according to cognitive appraisal theory of emotion, emotional response will lead to an individual's specific behavior tendency to regulate the emotion (emotion-focused coping) or change for the better the problem (problem-focused coping) [61] . on the basis of the public perceived policy effectiveness, the emotional reaction is finally transformed into the driving force to improve the effectiveness of the policy, which urges the public to put forward a constructive voice or point out the problems existing in the policies and products. when the public believe the policy can effectively defuse the current crisis and benefit future development, they will hold positive emotions and employ behaviors that can maximize the policy benefits. however, when the public think that there are some defects in the process of policy implementation undermining the policy effectiveness, they will generate negative emotions and take actions to reduce potential harm. after analysis, it is found that public voice can be divided into two dimensions: policy voice and product voice. according to the content of voice, policy voice can be divided into policy evolution and policy implementation. policy evolution voice is promotive voice and usually occurs when the public is in positive emotion, referring to the public's suggestions on the promotion and unification of policies across the nation. policy implementation voice refers to the voice made by the public for the actual implementation process of policies. in a public health emergency, policy implementation voice is mainly in the form of pointing out defects in the process of policy implementation, and it usually happens when the public is in negative emotion. public voice on products can be divided into product utility and potential risk. product utility voice refers to the public's suggestions on improving product efficiency and it includes both promotive voice as well as prohibitive voice. while potential risk voice is prohibitive voice, referring to the public's concern about the negative effects caused by enterprise's products. the examples of the health code policy are shown below. comment 3: now in many provinces, the biggest problem is that people are not allowed to enter the community! not even people with health codes! this is too unreasonable! if a policy is made, it is to be implemented. what good is policy if the implementation problem at the grassroots level is not solved? comment 4: the health code really gives me a great convenience in my life. it's easy to go out with it. i hope it can be promoted nationwide. in conclusion, the formation process of public voice behavior conforms to the "stimulus-cognition-emotion-behavior" model of cognitive appraisal theory of emotion. policy stimulus leads to the public's cognition of the effectiveness of policy, which arouses public emotion response and further leads to public voice behavior. the formation and evolution of policy is a dynamic and continuous process. previous studies have paid more attention to the impact of public participation in the policy-making stage [65, 66] . however, this study finds that after policies are made, public voice also has a great impact on the evolution and implementation of policies. based on the results of grounded analysis, this paper divides the process of policy evolution into three stages: policy formation, policy promotion, and policy optimization, and constructs a dynamic mechanism of public voice to promote policy evolution and product innovation, as shown in figure 2 . the policy is formed in accordance with the rigorous policy-making process in order to solve specific public problems. as the output of the political system, the main function of policy is to solve social public problems effectively. as public health emergencies often pose a major threat to social security and public order, as well as the safety of citizens' lives and property, the policy under public health emergencies aims to resolve the crisis state timely and effectively and restore the normal life order as soon as possible [15] . as an external stimulus, the formation of policies will lead to the public's perceived policy effectiveness. at this stage, citizens' cognition of policy effectiveness mainly focuses on crisis resolution. whether the policy can effectively alleviate the adverse impact of public health emergencies is an important factor affecting public emotion. when policy is implemented, the public will form the perception of whether the policy can resolve the crisis effectively. when perceived policy effectiveness is high, the public will have positive emotion and tend to conduct promotive voice. as the construction of national emergency management system follows the basic principles of "ability-standard" and "center of gravity down", the local government is in the front line when dealing with public health emergencies and bears the main responsibility. therefore, the policies under public health emergencies are often formulated by the local government, and the superior government selectively promotes the policies according to the evolution of the applicability. so the public will suggest to promote policy across the country if they think the policy is effective enough. besides, the public will provide promotive voice to improve product utility in a state of positive emotion. when the public perceive the policy is not effective enough, they will have negative emotion and tend to conduct a prohibitive voice. public health emergencies prevent policy-making from following a strictly procedural process. the government needs to complete the implementation of the policy in a limited time, and it is difficult to guarantee the implementation of the grassroots administrative staff in a short time [15] . therefore, the prohibitive voice mainly focuses on pointing out the problems existing in the implementation of the policy at the grassroots level. in the policy formation stage, as the implementation of enterprise's product auxiliary policy, the public's requirements for its effectiveness are more stringent. therefore, the public will be more active in pointing out problems in the use of products. through the evolution and adoption of public voice, the government improves the policy and the policy is formed in accordance with the rigorous policy-making process in order to solve specific public problems. as the output of the political system, the main function of policy is to solve social public problems effectively. as public health emergencies often pose a major threat to social security and public order, as well as the safety of citizens' lives and property, the policy under public health emergencies aims to resolve the crisis state timely and effectively and restore the normal life order as soon as possible [15] . as an external stimulus, the formation of policies will lead to the public's perceived policy effectiveness. at this stage, citizens' cognition of policy effectiveness mainly focuses on crisis resolution. whether the policy can effectively alleviate the adverse impact of public health emergencies is an important factor affecting public emotion. when policy is implemented, the public will form the perception of whether the policy can resolve the crisis effectively. when perceived policy effectiveness is high, the public will have positive emotion and tend to conduct promotive voice. as the construction of national emergency management system follows the basic principles of "ability-standard" and "center of gravity down", the local government is in the front line when dealing with public health emergencies and bears the main responsibility. therefore, the policies under public health emergencies are often formulated by the local government, and the superior government selectively promotes the policies according to the evolution of the applicability. so the public will suggest to promote policy across the country if they think the policy is effective enough. besides, the public will provide promotive voice to improve product utility in a state of positive emotion. when the public perceive the policy is not effective enough, they will have negative emotion and tend to conduct a prohibitive voice. public health emergencies prevent policy-making from following a strictly procedural process. the government needs to complete the implementation of the policy in a limited time, and it is difficult to guarantee the implementation of the grassroots administrative staff in a short time [15] . therefore, the prohibitive voice mainly focuses on pointing out the problems existing in the implementation of the policy at the grassroots level. in the policy formation stage, as the implementation of enterprise's product auxiliary policy, the public's requirements for its effectiveness are more stringent. therefore, the public will be more active in pointing out problems in the use of products. through the evolution and adoption of public voice, the government improves the policy and policy evolution enters the policy promotion stage. as a new external stimulus, the improved policy continues to act on public cognition. more than that, the focus of perceived policy effectiveness begins to shift from crisis resolution to social normalization. under the control of the government, the grassroots implementation has been further improved, and the effectiveness of policies to solve current problems (i.e., crisis resolution effectiveness) has been effectively played. however, the effects of policies cannot limit to provide methods to solve the current problems, but also play a guiding role in the future development of society [63] . public health emergencies make society change from normal state to emergency state, which has a great impact on public life and work [15] . therefore, on the basis of effective resolution of the crisis, whether the policy can further promote the recovery of social normality has been widely concerned by the public. under the influence of public emotion caused by the cognition of policy utility, voice behavior emerges. in the stage of policy promotion, public promotive voice is policy unification. government policy-making under public health emergencies emphasizes the local government's ability of 'territorial management'. however, with the promotion of local policies across the country, the problem of compatibility between policies begins to emerge. the inconsistency of policies in different regions will bring many inconveniences to the public. therefore, in order to improve the effectiveness of policies, the public suggests that policies should be unified across the country. at this stage, with policy promotion, the audience range of the product is constantly expanding, the public's attention to the product utility is also increased. improvement suggestions to enhance the effectiveness are still the focus of voice. however, in addition to the utility of the product, the public also began to pay attention to the use experience of the product, pointing out the problems of the system in the use process. under the influence of public voice, the government and enterprises constantly improve the policies and products, and the policy evolution enters the optimization stage. at this time, with the public health emergency in the rehabilitation stage, the effectiveness of the policy has been played out to a greater extent; the public urgently need to return to normal life and work state, so the focus of perceived policy effectiveness is social normalization. public voice is still affected by the emotional response based on cognition, and the content of public voice has changed further. considering the adverse impact of public health emergencies, with the purpose of preventing the recurrence of the public health emergency, the public suggest that the policy should be normalized. policy normalization can predict the occurrence of public health emergencies in the early stage and minimize the loss. in addition, the public begin to pay attention to the coverage of the policy, pointing out that the omission of the population covered by the policy may have a negative impact on the fairness. with regards to the products of enterprises, the public voice focuses on the risks of long-term use of products. products are tools for enterprises to participate in cooperative governance and used to supply policy implementation. with the help of products, enterprises take part of the responsibilities originally belonging to the government, which will cause public concern. to sum up, public voice plays an important role in the evolution of policies. first, public opinion provides the widest source of information for policy feedback. public health emergencies require the government to formulate effective policies in the shortest time based on the least information and resources, and the effectiveness of the policies is uncertain [15] . the public voice gives quick feedback to the policy, which provides the basis for the government to evaluate the effectiveness of the policy. second, the public voice expresses the public interest demands and promotes the policy to be more democratic and efficient [67] . in order to gain more and more public support in the process of policy-making, public voice is an important consideration for the government in the process of formulating and implementing policies. finally, public voice behavior also plays an important role in product improvement and innovation. it can be seen from the analysis, that in the policy of government enterprise cooperation, due to the particularity of the product, the public's requirements are more stringent. voice for product improvement aims at making it more suitable to assist policy implementation, and it will provide an important reference for enterprise product innovation. this study reveals the driving mechanism of public voice behavior and enriches the literature on voice behavior. first, based on the results of qualitative research, this paper employs the cognitive appraisal theory of emotion to explain the process of formation of public voice behavior under public health emergencies, via the stimulus-cognition-emotion-behavior model. unlike voice within an organization, public voice on social media is a kind of self-motivated behavior free from the pressure of peers and organizational climate [4] . what is more, as the purpose of public voice is to improve social status quo, the cognitive appraisal theory of emotion is eminently suitable for explaining the formation of public voice behavior. as an external stimulus, a policy will have an impact on the public's cognitive processes, and prompt them to evaluate whether the policy can resolve a current issue and play a guiding role in the future development of society. when the public perceives the policy to be highly effective, they will have positive emotions; otherwise, they will have negative emotions. take the health code policy as an example, if the public think that the policy can effectively contain the spread of the novel coronavirus and speed up the resumption of the normal activities, they will experience positive emotions, and vice versa. in accordance with the cognitive appraisal theory of emotion, emotional response will stimulate behavioral tendencies. the public's positive emotions will lead them to employ a promotive voice to expand the effectiveness and coverage of the policy, whereas the public has the tendency to use prohibitive voice to reduce the possible negative effects of a policy when they are not satisfied with its effectiveness. this result is consistent with previous studies that make a clear distinction between promotive voice and prohibitive voice, where the former is positive in tone and the later negative [68] . in this study, members of the public feeling positive emotions will voice to promote a policy and establish uniform standards throughout the nation, whereas those experiencing negative emotions will identify deficiencies such as implementation at the grassroots level. second, this study clarifies the objects and types of public voice. compared with employee voice and customer voice, the coverage of public voice is more extensive. thus, for different problems, the objects of public voice are also different, which require separate analysis in each situation. under this circumstance, the objects of public voice include two main bodies involved in policy-making: governments and enterprises. for the health code policy, the objects of public voice are the government, alibaba, and tencent. with regard to voice type, there is some similarity with the other two kinds of voice-public voice can also be divided into promotive voice and prohibitive voice. finally, through qualitative research, this paper has attempted to reveal the role of public voice in policy evolution and product innovation, clarifying the promoting effect of public voice on societal improvement. the study emphasizes the importance of public voice via social media, suggesting that both government and enterprises ought to attach more significance to public voice when making decisions. taking china's health code policy under covid-19 as an example, this paper has constructed a dynamic mechanism for the effects of public voice on policy evolution. the study focused on the promotion of public voice for policy improvement and evolution in the late stages of policy-making. public opinion contains information about demands and aspirations which is very valuable for decision makers. to absorb more public opinions and take into account public aspirations or priorities before policy formulation, previous research has paid much attention to the impact of public opinions at the pre-policy-making stage [65, 66] . no studies have examined the impact of public voice on policy after its implementation. the development of social media not only provides a wider source of information for the public, but also builds a more convenient platform for the public to voice their opinions at any stage of policy formulation or implementation, thus having effect on policy. this study shows that after a policy is implemented, public voice is still of great value for policy evolution. however, this study divides policy evolution into three stages: policy formation, policy promotion, and policy optimization. it introduces changes in public policy utility perception and public voice content at different stages, and constructs the dynamic mechanism of the effect of public advice on policy improvement based on the government's adoption of public advice to promote policy evolution and implementation. to some extent, this study provides support for cooperative governance research. cooperative governance has different connotations in different situations, and there are also some differences among participants. the formulation and evolution of policies under public health emergencies is an important practice of cooperative governance. faced with a public health emergency, the government, enterprises, and citizens should form an open overall system to jointly govern social public affairs. the government, enterprises, and individuals play their own roles, participate and cooperate with each other to effectively reduce the negative impacts of a crisis and maintain the stable development of society. in this process, governments, enterprises, and the public are in a more equal position, and multi-agent participation is truly realized. faced with covid-19, yaowen wang, deputy director of shenzhen municipal government service data management bureau, said the epidemic situation was a great challenge to the government's governance ability and level. in addition, the fundamental problem was laid in whether the whole society could be quickly mobilized and organized to participate in the prevention and control in a short period of time. as an organ of power, the government is responsible for the formulation and implementation of policies. enterprises participate in the formulation of policies, and provide products and services with technical advantages to assist with policy implementation. as for the public, in addition to regulating their own behaviors under the guidance of policies, they also provide feedback and voice on policies and enterprises' products and services. take china's health code policy as an example, the government is responsible for the formulation and implementation of the policy. alibaba and tencent are committed to the development and updating of the health code system and participate in the formulation of the policy standards. the public need to move around in strict accordance with the policy guidelines and actively provide voice. under a public health emergency, public voice is an important way for public to participate in cooperative governance. it provides real-time feedback for policy, helping government and enterprises to make decisions as quickly as possible and set aside more time to fight against emergencies. further, public voice can facilitate the promotion of effective policy, improving prevention efficiency. as a universal way of participating in cooperative governance, public voice via social media deserves more attention in the future. although this research makes several contributions, there are still some limitations. first, we studied the influence of public voice only on policy evolution and specific product innovation. as public voice is social-oriented, it will affect almost all social affairs and phenomena. future research can explore the influence of public voice behavior in other respects. second, this study revealed the generative mechanism of public voice behavior from the perspective of emotional cognition. as a self-oriented behavior, public voice may be triggered by other internal processes. future research could explore the antecedents of public voice from different perspectives. third, this study was conducted under a public health emergency, covid-19. as public emergencies take several forms, the results differ in different situations. future research might examine public voice in other contexts. fourth, although many countries and regions have formulated corresponding policies in the context of public health emergencies, results from the study of china's health code policy under covid-19 may not be fully applicable to other nations, and future research should be conducted in different cultural contexts. author contributions: y.y. conceived the idea of this study, y.s. collected and analyzed data and wrote this paper. all authors have read and agreed to the published version of the manuscript. speaking up when water is murky: an uncertainty-based model linking perceived organizational politics to employee voice leadership behavior and employee voice: is the door really open? acad leader personality traits and employee voice behavior: mediating roles of ethical leadership and work group psychological safety constructive voice behavior for social change on social networking sites: a reflection of moral identity does performance management relate to good governance? a study of its relationship with citizens' satisfaction with and trust in israeli local government. public perform the snakes and ladders of 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deliberation in an age of direct citizen participation servant leadership and follower voice: the roles of follower felt responsibility for constructive change and avoidance-approach motivation this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflict of interest. key: cord-347877-px8e0hhi authors: liu, tao; li, jixia; chen, juan; yang, shaolei title: regional differences and influencing factors of allocation efficiency of rural public health resources in china date: 2020-08-14 journal: healthcare (basel) doi: 10.3390/healthcare8030270 sha: doc_id: 347877 cord_uid: px8e0hhi in the face of increasingly growing health demands and the impact of various public health emergencies, it is of great significance to study the regional differences in the allocation efficiency of the rural public health resources and its improvement mechanism. in this paper, the game competition relationship is included in the evaluation model, and the game cross-efficiency model is used to measure the allocation efficiency of the rural public health resources in 31 provinces of china from 2008 to 2017. then, the theil index model and the gini index model are applied in exploring the regional differences in the allocation efficiency of rural public health resources and its sources. finally, the bootstrap truncated regression model is used to analyze the influencing factors of the allocation efficiency of the rural public health resources in china. the results show that, first, the total allocation efficiency level of the rural public health resources in china from 2008 to 2017 is relatively low, and it presents a u-shaped trend, first falling and then rising. second, the changing trend of the allocation efficiency of the rural public health resources in the eastern, central, and western regions of china is similar to that in the nationwide region, and it shows a gradient trend that “the allocation efficiency in the eastern region is high, the allocation efficiency in the western region is low, and the allocation efficiency in the central region is at the medium level”. however, the gap among the three regions is continually narrowing. third, the calculation results of the theil index and the gini index show that intra-regional differences are the major source of the regional differences in the allocation efficiency of the rural public health resources in china, and the inter-regional differences demonstrate an expansion trend. finally, the improvement of the education level and the social support level will generally improve the allocation efficiency of the rural public health resources in china and its three regions. the increased governmental financial support and urbanization level will reduce the allocation efficiency of the rural public health resources in china and its three regions. the economic development level, the living conditions and the population density are the important influencing factors of the allocation efficiency differences of the rural public health resources in the three regions. therefore, on the basis of ensuring the increase of the total supply of the rural public health resources, more attention should be paid to the improvement of the allocation efficiency. moreover, on the basis of continually narrowing the inter-regional differences among the eastern, central, and western regions, more attention should be paid to the intra-regional differences of the allocation efficiency of the rural public health resources among the different provinces. the various economic and social policies should be constantly optimized to jointly improve the allocation efficiency of the rural public health resources. people's health is an important symbol of national prosperity. with the rapid development of china's economy, the people's demand for health services is growing continually. to meet the demand, there must be a high-quality public health service system. as a developing country, china has a large rural population. the data from national bureau of statistics of the people's republic of china indicates that the rural population of the chinese mainland was 564 million at the end of 2018, accounting for 40.42% of the total population. however, the per capita health expenditure of the rural residents was only 2477 yuan, accounting for only 41.31% of the per capita health expenditure of the urban residents. several main indexes reflecting the public health situation in the rural areas, such as the total service amount of the public health, the diagnosis and treatment person-time, the utilization rate of hospital beds, and the number of beds in the township hospitals per 1000 person, showed a downward trend [1] . according to the statistical information of national health commission of the people's republic of china, in recent years, with the continuous deepening of the poverty alleviation strategy, the proportion of poverty caused by diseases has not decreased, but increased from 42.2% in 2013 to 44. 1% in 2015. this shows that diseases have become one of the main reasons for the increase of poverty [2] . the economist banerjee won the nobel prize in economics in 2019 for his contributions to global poverty alleviation through experimental methods. his research found that investment in the health of rural poor groups can improve their health level and then reduce the poverty caused by diseases [3] . therefore, in consideration of the current urban and rural public health resource situation and the poverty alleviation, the rural public health career must be the top priority of the whole public health career development and therefore great importance should be attached to this. in addition, owing to the change of climate and environment as well as the increasingly frequent cross-border movements, the spread of infectious diseases has become ever more serious, such as the frequent occurrence of influenza including h1n1 and h7n9 in recent years and the attack of "dengue fever". in particular, the corona virus disease 2019 (covid19) incident, which began at the end of 2019, has brought a severe challenge to the rural public health service system of china. in the face of the increasingly growing health demand of the people and the impact of various public health emergencies, it is of great significance to study how to improve the allocation efficiency of the rural public health resources and ensure the effective supply of the rural public health resources. public health has always been the focus of attention in countries around the world. how to improve the effective allocation of the public health resources is the major problem facing most countries in the world [4] . at the same time, it has also attracted the extensive attention from academia, and a large number of studies of the effective allocation of the public health resources have been carried out. some scholars have discussed the evaluation method of the hospital efficiency. for example, varabyova et al. [5] and xu et al. [6] comparatively analyzed the application of ratio analysis (ra), stochastic frontier analysis (sfa), and data envelopment analysis (dea) in the hospital efficiency evaluation. mitropoulos et al. [7] and rouyendegh et al. [8] respectively combined the dea method with bayesian analysis and fuzzy analytic hierarchy process (fahp) method to evaluate the hospital efficiency. due to the complexity of the public health resource supply, a single index cannot fully reflect its allocation efficiency. the dea method can be used to evaluate multiple input and output indexes, has become the first choice for scholars. at present, many scholars use the dea method to analyze the allocation efficiency of the public health resources from different angles, mainly including the following two aspects below. first, the hospital efficiency in different countries or regions is discussed by using the classical dea method from the microcosmic level. kawaguchi et al. [9] , sohn et al. [10] , chowdhury et al. [11] , gholami et al. [12] , flokou et al. [13] , blatnik et al. [14] , campanella et al. [15] , and fuentes et al. [16] respectively evaluated the hospital efficiency of developed countries or regions, namely japan, south korea, the united states, ontario, greece, slovenia, italy, and murcia of spain. jat et al. [17] and gimenez et al. [18] assessed the hospital efficiency of the developing countries india and colombia. other scholars have evaluated the hospital efficiency in china and some areas. hu et al. [19] used the undesirable output dea method to evaluate china's regional hospital efficiency. cheng et al. estimated the efficiency of 48 rural township hospital in xiaogan city of hubei province, china from 2008 to 2014 [20] . zheng et al. evaluated the relative efficiency of the public hospitals in china after the implementation of new medical reforms [21] . li et al. analyzed the determinants and differences of the township hospital efficiency among chinese provinces from 2003 to 2016 [22] . other scholars have further discussed the impacts of management and organization [23] , the medical reform [24, 25] , and the increasing geographic elevation [26] on hospital efficiency. second, the classical dea method is used to study the allocation efficiency of the public health resources among different countries and within a country from the macroscopic level. some scholars have evaluated and studied the efficiency of the public health systems in 171 countries worldwide [27] , the organization for economic co-operation and development (oecd) countries [28, 29] , the low-and middle-income countries [30] , and the asian countries [31] . other scholars have estimated the public health efficiency in greece [32] , india [33] , lebanon [34] , méxico [35] , and slovakia [36] . some scholars have deeply discussed china's public health efficiency, and respectively calculated and studied the chinese provincial community health service efficiency [37] [38] [39] [40] [41] [42] and the allocation efficiency of the public health resources in the coastal provinces of china [43] . a few scholars have preliminarily analyzed the allocation efficiency of the rural public health resources [44, 45] . after analyzing the allocation efficiency of the public health resources, some scholars further discussed the influencing factors. mitropoulos et al. and lee et al. assessed the impact of the public health policies on the health efficiency [46, 47] . han et al. [48] introduced such variables as population density, per capita gross domestic product (gdp), the residents' education level, the fiscal decentralization, and the healthcare system reform into the tobit model. zhang [49] and liu [50] incorporated fiscal decentralization, the medical and health system reform policies, per capita gdp, the residents' education level, the population density, and the urbanization level into the explained variables. guo et al. believe that the social, economic, and policy variables, such as the population density, the residents' education level, and the fiscal decentralization, are important reasons for the efficiency difference [51] . to sum up, the research results of scholars such as kawaguchi [9] , jat [17] , li [22] , liu [37] , and xue [45] on the measurement of the allocation efficiency of the public health resources and its influencing factors provide a great deal of experience as a reference for the study of this paper. compared with the existing studies, this paper has three main contributions. first, a comprehensive and systematic study on the regional differences and the causes of the allocation efficiency of the rural public health resources in china is conducted in this paper. although the existing studies cover multiple levels, they are less involved in the field of the rural public health, and there are even fewer studies that explore it from the perspective of regional differences. second, the game competition relationship is included in the evaluation model, and the improved game cross-efficiency model is used to replace the traditional dea model. this solves the problem of overestimating the allocation efficiency of the regional public health resources in the traditional dea model. third, when analyzing the influencing factors of the allocation efficiency of the rural public health resources, the traditional tobit regression model is replaced by the bootstrap truncated regression model. this solves the deviation problem of the classical tobit regression model when measuring the influencing factors of efficiency [52] . consequently, this paper uses the game cross-efficiency model and theil index model to evaluate and analyze the regional differences and the causes of the allocation efficiency of the rural public health resources in 31 provinces of china from 2008 to 2017, and uses the bootstrap truncated regression model to find out the influencing factors, so as to provide the policy basis for improving the allocation efficiency of the rural public health resources in china. the game cross-efficiency model is an improvement to the traditional dea model. in the evaluation process of the traditional dea models, such as the charnes-cooper-rhodes (ccr) model [53] and the banker-charnes-cooper (bcc) model [54] , each decision making unit (dmu) tends to give more weight to itself so as to result in the overestimation of its efficiency. in order to overcome this shortcoming, sexton proposed a cross-efficiency dea model [55] . based on the ccr model framework, the weight of mutual evaluation was added between dmus to correct the pure self-evaluation problem in the traditional ccr. however, as ccr and bcc models have more than one optimal weight, the cross-efficiency value is not unique. in order to solve this problem, liang et al. proposed a game cross-efficiency model. on the basis of solving the problem that the traditional ccr and bcc models cannot be effectively ordered, the game relationship between the evaluation units is introduced. while avoiding the secondary target selection of the cross-efficiency model, the strict assumption conditions of the traditional models are relaxed to make it more practical [56, 57] . the main operation process of the model is as follows: assume that there are n dmu, and each decision-making unit dmu j obtains s outputs through m inputs. the i input and the r output of dmu j ( j = 1, · · · , n) is expressed, respectively, as x ij (i = 1, · · · , m) and y rj (r = 1, . . . , s) . first, the efficiency value of any evaluation unit dmu d under the ccr model is obtained by solving the following linear programming problem: ω id x ij ≤ 0, j = 1, 2, . . . , n µ rd ω id ≥ 0, r = 1, 2, . . . , s; i = 1, 2, . . . , m. (1) in equation (1), ω id and µ rd are respectively the i input weight and the r output weight of the evaluation unit dmu d . second, equation (1) is used to solve the cross-efficiency e dj of dmu j taking dmu d as its weight: by solving equation (2), the n sets of optimal weights ω * 1d , ω * 1d , . . . , ω * md and µ * 1d , µ * 1d , . . . , µ * sd can be obtained. then, all results of the cross-efficiency e dj constitute the following cross-efficiency matrix: therein, the elements on the main diagonal, e dd , d = 1, · · · n, are the optimum solution of the ccr model, namely the self-evaluation efficiency value of the traditional dea model. the elements on the off-diagonal are the cross-efficiency value that the decision-making unit dmu j ( j = 1, · · · , n, and j d) obtains by using the weight of dmu d . then, the cross-efficiency value of the decision-making unit dmu j ( j = 1, · · · , n) is the arithmetic mean value of the corresponding j column in the matrix: it should be noticed that the optimal weight of equation (1) is not unique, and accordingly, the cross-efficiency value of the decision-making unit dmu d taking dmu d as its weight is not unique either. the final cross-efficiency is determined in the multiple optimum solutions by introducing the quadratic objective. meanwhile, because there is a direct or indirect competitive relation between each decision-making unit, the final efficiency value can be determined by game. it is assumed that there is a non-cooperative game relationship between participants and this relationship is reflected in the constraint conditions of the mathematical programming. suppose that the efficiency value of the participant dmu d is α d , and the remaining participant dmu j maximizes its own efficiency value while keeping the efficiency value of dmu d from being reduced. here, the game cross-efficiency value that dmu j obtains by using the weight of dmu d is defined as: in equation (4), µ d rj and ω d ij are the feasible weights of the model, while α dj is the game cross-efficiency of dmu j for dmu d , and can be calculated by the following linear programming: in equation (5), α d ≤ 1 is the parameter. its initial value is the traditional cross-efficiency value, and its subsequent value can be calculated through the iterative algorithm. in summary, the game cross-efficiency value of dmu j is defined as: this paper applies the advanced maxdea uitra8.0 software to solve the complex linear programming problem in the game cross-efficiency model. theil index model was originally proposed by theil to measure the differences between samples, and can effectively measure the contribution of the intra-and inter-group gaps to the total gap [58] . this paper uses theil index model to measure the regional gap of the rural public health resource allocation efficiency in china. because of the additivity of theil index, the total regional differences are decomposed into the intra-regional differences and the inter-regional differences. first of all, the total regional differences of the allocation efficiency of the rural public health resources are measured by the total theil index (tl), and the methods of decomposing the theil index and its structure by bourguignon, cowell, and shorrocks are used for reference [59] [60] [61] . thus, the calculation formula is tl = 1 n n i=1 y i y log y i y . the intra-regional differences are measured by the intra-regional theil index, and the calculation formula is tl w = m k=1 n k n y k y tl k . the inter-regional differences are measured by the inter-regional theil index, and the calculation formula is n k n y k y log y k y . in the above formulas, y represents the allocation efficiency of the rural public health resources in each province, n represents the number of provinces, n k represents the number of provinces in k region. in addition, the ratio of the intra-regional theil index to the total theil index, namely, tl w /tl, represents the contribution rate of the intra-regional differences to the total regional differences. similarly, the ratio of the inter-regional theil index to the total theil index, namely tl b /tl represents the contribution rate of the inter-regional differences to the total regional differences. the gini index model proposed by dagum (1997) [62] is used to analyze the differences in the allocation efficiency of the rural public health resources in china and its three regions. according to the gini index and its subgroup decomposition method proposed by dagum, the gini coefficient of the allocation efficiency of the rural public health resources in china can be defined as: thereinto, y hi (y jr ) is the allocation efficiency of the rural public health resources in h(j) region, y is the mean value of the allocation efficiency of the rural public health resources in each region, n is the number of provinces, k is the number of regions, n h (n k ) is the number of provinces in h(j) region, g is the total gini index, h and j are the different region division, and i and r are the different provinces in the region. according to the gini index decomposition method proposed by dagum, g = g w + g nb + g t . the regional difference of the allocation efficiency of the rural public health resources can be accordingly divided into three parts: g w represents the intra-regional difference contribution of the total differences of the allocation efficiency of the rural public health resources, g nb represents the inter-regional difference contribution of the total differences of the allocation efficiency of the rural public health resources, and g t represents the contribution of the intensity of transvariation of the inter-regional allocation efficiency of the rural public health resources. the specific calculation formula can be seen in the literature of dagum [62] . the value range of the allocation efficiency of the rural public health resources is (0, 1], and it belongs to the truncated data. if the least squares method is directly used for the regression analysis, the results will be biased and inconsistent. simar and wilson proved that the classic tobit regression model for processing the truncated data is not suitable for testing the influencing factors of efficiency, and accordingly proposed the bootstrap truncated regression model that can minimize the uncertainty of data and the statistical noise to overcome this limitation [52] . the expression is as follows: in the equation (8), θ i is the explained variable, β is the regression parameter, z i is the explanatory variable, and ε i obeys the normal distribution of n(0, δ 2 ), i = 1, 2 , . . . , n. (1) input index: the input index of the public health resources usually includes three main categories, that is, the health human resources, the health material resources and the health financial resources. in the design of the specific indexes, the number of doctors, nurses and beds are generally selected as the input indexes [17, 25] . according to the statistical data of the health departments in china, considering the representativeness and accessibility of the input index, the number of personnel in the rural health institutions (the total number of doctors and nurses) is selected as an alternative index of the labor input, and the number of beds in the rural health institutions is selected as an alternative index of the material input. meanwhile, considering the fact that health institutions are the important spatial carrier for carrying out the health activities, the number of the rural health institutions is also used as another alternative index of the material input. although drugs are an important variable of the material input, they are mainly suitable for the hospital efficiency evaluation level. because it is difficult to obtain the regional data of drugs, they are not considered here. the rural medical and healthcare expenditure can provide the financial support for the rural health activities, and so it is selected as an alternative index of the financial input. (2) output index: the final output of the public health resource input is the improvement of the population health. however, because of the complexity of the health improvement measurement and the difficulty of the data acquisition, some process indexes are usually used to replace it [5] . according to the statistical data of the health departments in china, considering the representativeness and accessibility of the output index, the rural diagnosis and treatment person-time, the rural number of people receiving hospitalizations and the rural average hospitalization days are selected as the output indexes of the rural public health resources. see table 1 for details. this paper applies maxdea uitra8.0 software and selects the ccr model and the game crossefficiency model, and measures the average situation of the rural public health resource allocation efficiency of 31 provinces in china from 2008 to 2017 under the two dea models, and calculates the efficiency variance value of the two models, as shown in figure 2 . through the comparison between the ccr model and the game cross-efficiency model, it can be found that the efficiency value measured by the ccr model is obviously higher than that of the game cross-efficiency model. from the perspective of the national level, the efficiency value (0.804) measured by the ccr model is higher than that (0.578) of the game cross-efficiency model, which is 28.1% higher on average. from the perspective of the eastern, central, and western regions, the efficiency value measured by the ccr model is respectively 0.868, 0.703, and 0.820 and is higher than that (0.597, 0.592, and 0.553) measured by the game cross-efficiency model, which is 31.2%, 15.8%, and 32.6% higher, respectively. from the perspective of each province, the efficiency value measured by the ccr model is higher than that of the game cross-efficiency model, and the higher range is slightly different. this paper uses the deviation to measure the range that the ccr model is higher than the game cross-efficiency model. as shown in figure 2 , the deviation in tibet is the highest, and the efficiency value measured by the ccr model is 1. however, after it is proofread by the game cross-efficiency model, the actual efficiency value is only 0.365 and the deviation is as high as 63.5%. generally speaking, if the game relationship between each region is not taken into consideration, the measured efficiency value of the rural public health resource allocation in each province will be exaggerated, and is not consistent with the actual situation of the rural public health resource allocation. in order to solve this problem, this paper uses the game cross-efficiency model to measure the allocation efficiency of the rural public health resources in 31 provinces in china, and truly reveals this paper applies maxdea uitra8.0 software and selects the ccr model and the game cross-efficiency model, and measures the average situation of the rural public health resource allocation efficiency of 31 provinces in china from 2008 to 2017 under the two dea models, and calculates the efficiency variance value of the two models, as shown in figure 2 . through the comparison between the ccr model and the game cross-efficiency model, it can be found that the efficiency value measured by the ccr model is obviously higher than that of the game cross-efficiency model. from the perspective of the national level, the efficiency value (0.804) measured by the ccr model is higher than that (0.578) of the game cross-efficiency model, which is 28.1% higher on average. from the perspective of the eastern, central, and western regions, the efficiency value measured by the ccr model is respectively 0.868, 0.703, and 0.820 and is higher than that (0.597, 0.592, and 0.553) measured by the game cross-efficiency model, which is 31.2%, 15.8%, and 32.6% higher, respectively. from the perspective of each province, the efficiency value measured by the ccr model is higher than that of the game cross-efficiency model, and the higher range is slightly different. this paper uses the deviation to measure the range that the ccr model is higher than the game cross-efficiency model. as shown in figure 2 , the deviation in tibet is the highest, and the efficiency value measured by the ccr model is 1. however, after it is proofread by the game cross-efficiency model, the actual efficiency value is only 0.365 and the deviation is as high as 63.5%. generally speaking, if the game relationship between each region is not taken into consideration, the measured efficiency value of the rural public health resource allocation in each province will be exaggerated, and is not consistent with the actual situation of the rural public health resource allocation. in order to solve this problem, this paper uses the game cross-efficiency model to measure the allocation efficiency of the rural public health resources in 31 provinces in china, and truly reveals the actual situation of the allocation efficiency of the rural public health resources in each province of china. next, the game cross-efficiency model will be used to analyze the allocation efficiency situation of the rural public health resources in china in detail. from the perspective of the regional comparison, it shows a gradient trend that "the allocation efficiency in the eastern region is high, the allocation efficiency in the western region is low, and the allocation efficiency in the central region is at the medium level", and this conclusion is similar to the research results of jiang et al. [25] . however, the gap among the three regions is continually narrowing. the efficiency value in the eastern, central, and western regions from 2008 to 2017 is respectively 0.597, 0.592, and 0.553, and presents a state that "the efficiency value in the eastern region is the highest, the efficiency value in the western region is the lowest, and the efficiency value in the central region is at the medium level" as a whole. from the perspective of different years, the gap among regions is continually narrowing. in 2008, the eastern region with the highest efficiency value was 0.072 higher than the western region with the lowest efficiency value. the gap between the two regions had been continually narrowing since then, and the eastern region was only 0.003 higher than the western region in 2017. the allocation efficiency value of the rural public health resources (aev) in 31 provinces of china is divided into three grades: high-efficiency (aev > = 0.800), medium-efficiency (0.800 > aev > = 0.600) and low-efficiency (aev < 0.600). on this basis, gis10. from the perspective of the regional comparison, it shows a gradient trend that "the allocation efficiency in the eastern region is high, the allocation efficiency in the western region is low, and the allocation efficiency in the central region is at the medium level", and this conclusion is similar to the research results of jiang et al. [25] . however, the gap among the three regions is continually narrowing. the efficiency value in the eastern, central, and western regions from 2008 to 2017 is respectively 0.597, 0.592, and 0.553, and presents a state that "the efficiency value in the eastern region is the highest, the efficiency value in the western region is the lowest, and the efficiency value in the central region is at the medium level" as a whole. from the perspective of different years, the gap among regions is continually narrowing. in 2008, the eastern region with the highest efficiency value was 0.072 higher than the western region with the lowest efficiency value. the gap between the two regions had been continually narrowing since then, and the eastern region was only 0.003 higher than the western region in 2017. the allocation efficiency value of the rural public health resources (aev) in 31 provinces of china is divided into three grades: high-efficiency (aev ≥ 0.800), medium-efficiency (0.800 > aev ≥ 0.600) and low-efficiency (aev < 0.600). on this basis, gis10.2 software is used to draw the spatial distribution map of the allocation efficiency of the rural public health resources in china in 2008, 2011, 2014, and 2017, as shown in figure 4 . in 2008, the allocation efficiency of the rural public health resources showed an obvious aggregation effect of "the high-efficiency province aggregation and the low-efficiency province aggregation" [40] . in terms of high-efficiency, there are 13 provinces with high-efficiency, including six provinces in the eastern region, three provinces in the central region, and four provinces in the western region. in terms of low-efficiency, there are 14 provinces with low-efficiency, accounting for 45% of 31 provinces. these provinces with low efficiency are mainly concentrated in the central and western regions, including seven provinces in the western region, three provinces in the central region, and four provinces in the eastern region. there are four provinces with medium efficiency, that is, shanghai, hubei, hunan and yunnan, and their distribution is relatively scattered. in 2008, the allocation efficiency of the rural public health resources showed an obvious aggregation effect of "the high-efficiency province aggregation and the low-efficiency province aggregation" [40] . in terms of high-efficiency, there are 13 provinces with high-efficiency, including six provinces in the eastern region, three provinces in the central region, and four provinces in the western region. in terms of low-efficiency, there are 14 provinces with low-efficiency, accounting for 45% of 31 provinces. these provinces with low efficiency are mainly concentrated in the central and western regions, including seven provinces in the western region, three provinces in the central region, and four provinces in the eastern region. there are four provinces with medium efficiency, that is, shanghai, hubei, hunan and yunnan, and their distribution is relatively scattered. because of the unbalanced development of china's economy, the supply of the rural public health resources in different provinces showed an unbalanced state in 2011, and accordingly resulted that the allocation efficiency of the rural public health resources presented an obvious unbalanced trend of "the high-efficiency province reduction, the medium-and low-efficiency province expansion". the number of the high-efficiency provinces shrank from 13 to six, with hebei in the eastern region becoming a low-efficiency province and six provinces becoming the medium-efficiency provinces, namely, zhejiang, fujian, and shandong in the eastern region, anhui and henan in the central region, and guangxi in the western region. with this change, the number of the low-efficiency provinces increased to 16 and the number of the medium-efficient provinces increased to 9. in 2014, because of the implementation of the regional coordinated development strategy, the supply of the rural public health resources tended to balance, and the unbalanced trend of "the high-efficiency province reduction, the medium-and low-efficiency province expansion" presented by the allocation efficiency of the rural public health resources was eased. the number of the low-efficiency provinces had no changes and was still 15. the number of the medium-efficiency provinces shrank to seven. the number of the high-efficiency provinces had an obvious increase, from six to nine. although the regional coordinated development strategy has been continuously deepened, the allocation efficiency condition of the rural public health resources in 2017 is the same as that in 2014. in short, the unbalanced problem of the rural public health resource supply is still noticeable. there is a long way to further reform the allocation of the rural public health resources. in order to further explore the source of the regional differences in the allocation efficiency of the rural public health resources in china, the theil index model and gini index model are used to measure the regional differences and their sources in the allocation efficiency of the rural public health resources in china. figure 5 presents the total theil index and the total gini index of the regional differences in the allocation efficiency of the rural public health resources in china from 2008 to 2017. the total theil index is slightly higher than the total gini index, and they show the same change rule. the regional differences in the allocation efficiency of the rural public health resources in china show an inverted u-shaped development trend, first rising and then falling as a whole. specifically, the total theil index of the allocation efficiency of the rural public health resources was the lowest in 2008, and was only 0.0479. then it was in a rising condition from 2009-2014 and rose to 0.0613 in 2014. this is because china launched the rural medical and health system reform in 2009, but the impact of the financial crisis led to the different promotion speed of the rural medical and health system reform in different provinces, and then resulted in an increasingly expanding total theil index of the allocation efficiency of the rural public health resources among different provinces. the rural medical and health system reform of different provinces had entered a stable period after 2014, and the policy effect was beginning to gradually appear. the total theil index of the allocation efficiency of the rural public health resources was tending to shrink and had fallen slightly after 2015, and rose slightly in 2017. through the comparison, it is found that the changing trend of the intra-regional and inter-regional differences in the allocation efficiency of the rural public health resources are basically consistent with that of the total regional differences. table 2 presents the theil index decomposition and the gini index decomposition of the regional differences in the allocation efficiency of the rural public health resources in china from 2008 to 2017. from 2008 to 2017, the average contribution rate of the intra-regional differences measured by the theil index is 98.67% and much higher than that of the inter-regional differences (1.33%), while the average contribution rate of the intra-regional differences measured by the gini index is 65.26% and also much higher than that of the inter-regional differences (17.34%). this shows that the intraregional differences have become the major source of the regional differences in the allocation efficiency of the rural public health resources in china. this is because, since 2008, the chinese government has attached great importance to the equalization of the inter-regional rural public health resource supply, and has put forward a new round of regional coordinated development policies, such as western development, the overall revitalization of the old industrial bases in the northeast china, and the rise of the central china, especially increasing support for the ethnic minority areas, the border areas, and the poor areas, and has fully implemented a series of health poverty alleviation policies. those play an important role in promoting the optimal allocation of the regional rural public health resources. as the complex natural geographical situation, economic conditions, and social background among provinces within different regions, there is a great difference in the improvement degree of the allocation efficiency of the rural public health resources. the intra-regional differences become the major cause of the regional differences in the allocation efficiency of the rural public health resources in china. china's economy has gradually recovered from the financial crisis after 2013, but the recovery degree varies in different regions. the economically developed eastern region is recovering faster than the central and western regions. the contribution rate of the inter-regional differences of the allocation efficiency of the rural public health resources had presented a sustained rising state after 2013, and the inter-regional theil index and gini index rose to 2.56% and 18.8% separately in 2017. the result shows that if the inter-regional differences in the allocation efficiency of the rural public health resources are allowed to expand, it will not only deviate from the coordinated development goal of the regional rural public health resources, but also increase the difficulty of the coordinated development of the regional rural public health resources. table 2 presents the theil index decomposition and the gini index decomposition of the regional differences in the allocation efficiency of the rural public health resources in china from 2008 to 2017. from 2008 to 2017, the average contribution rate of the intra-regional differences measured by the theil index is 98.67% and much higher than that of the inter-regional differences (1.33%), while the average contribution rate of the intra-regional differences measured by the gini index is 65.26% and also much higher than that of the inter-regional differences (17.34%). this shows that the intra-regional differences have become the major source of the regional differences in the allocation efficiency of the rural public health resources in china. this is because, since 2008, the chinese government has attached great importance to the equalization of the inter-regional rural public health resource supply, and has put forward a new round of regional coordinated development policies, such as western development, the overall revitalization of the old industrial bases in the northeast china, and the rise of the central china, especially increasing support for the ethnic minority areas, the border areas, and the poor areas, and has fully implemented a series of health poverty alleviation policies. those play an important role in promoting the optimal allocation of the regional rural public health resources. as the complex natural geographical situation, economic conditions, and social background among provinces within different regions, there is a great difference in the improvement degree of the allocation efficiency of the rural public health resources. the intra-regional differences become the major cause of the regional differences in the allocation efficiency of the rural public health resources in china. china's economy has gradually recovered from the financial crisis after 2013, but the recovery degree varies in different regions. the economically developed eastern region is recovering faster than the central and western regions. the contribution rate of the inter-regional differences of the allocation efficiency of the rural public health resources had presented a sustained rising state after 2013, and the inter-regional theil index and gini index rose to 2.56% and 18.8% separately in 2017. the result shows that if the inter-regional differences in the allocation efficiency of the rural public health resources are allowed to expand, it will not only deviate from the coordinated development goal of the regional rural public health resources, but also increase the difficulty of the coordinated development of the regional rural public health resources. table 2 . theil index decomposition and gini index decomposition of regional differences and their sources of allocation efficiency of rural public health resources in china from 2008 to 2017. gini index source of differences contribution rate (%) total g source of differences contribution rate (%) intra-regional inter-regional intra-regional inter-regional note: g w is the intra-group differences, g nb is the inter-group differences, and g t is the differences of the intensity of transvariation; g = g w + g nb + g t . in addition, the gini index also provides the specific decomposition of the regional differences in the allocation efficiency of the rural public health resources in china, as shown in table 3 . from the perspective of the inter-regional differences, the differences between the eastern and western region are the largest, followed by the differences between the eastern and central region, and the differences between the central and western region are the smallest. from the perspective of the change rule, with the implementation of strategies such as western development and the rise of the central china, the differences between the central and western region are narrowing. however, due to the agglomeration effect and policy advantages of the economic development in the eastern region, the differences between the eastern and central regions and the differences between the eastern and western regions have been maintaining a very high level. from the perspective of the intra-regional differences, because the economic development level and the location characteristics are very similar, the gini index of the regional differences in the allocation efficiency of the rural public health resource among provinces in the central region is the smallest, and the gap is generally narrow during the research period. there are great differences in each province within the eastern and western regions and their gini index has been maintaining a very high level, and the gap is generally expanding during the research period. table 3 . gini index decomposition of regional differences in allocation efficiency of rural public health resources in china from 2008 to 2017. year inter-regional gini index intra-regional gini index through the calculation result of the allocation efficiency of the rural public health resources in china, it is found that the allocation efficiency of the rural public health resources in china is relatively low and the interregional differences are noticeable. next, this paper will further study the major factors that affect the change of the allocation efficiency of the rural public health resources in china. drawing on the research results of the existing literature, this paper indicates that the allocation efficiency of the rural public health resources is mainly affected by the economic and social factors, as follows in detail: (1) economic factors. according to the relevant literature, this paper mainly investigates the three economic variables including the economic development level, the living conditions, and the governmental financial support. first, the economic development level is expressed by the per capita gdp (yuan). it is generally believed that the economic development of a region can provide the strong support for the rural public health expenditure. second, the living conditions are expressed by the per capita disposable income of rural residents (yuan). it is generally believed that the higher the living standard of rural residents, the higher the cognition and demand for the public health resources. third, the governmental financial support is expressed by the proportion of the public health expenditure to the total fiscal expenditure. it is generally believed that the higher the public health expenditure, the more likely to cause the waste of funds and the lax management, resulting in the low allocation efficiency. (2) social factors. according to common practice of the existing literature, the social factors affecting the public health expenditure are mainly considered from four aspects: the population quantity, the population quality, the population structure, and the social support level. first, the population quantity reflects the demand degree for the public health resources, and then affects the governmental public health expenditure and the allocation efficiency of the public health resources. it is measured by the population density index and is expressed by the number of people per square kilometer in the rural areas. second, the population quality in an area is mainly reflected in the education level of population. the lower the education level of residents, the lower the cognition and demand for the public health resources, resulting in a lower allocation efficiency of the rural public health resources. the education level is concretely expressed by the proportion of illiterate persons to the rural population aged 15 and above. third, the population structure will affect the demand for the public health resources and the fiscal expenditure. the larger the urban population in a region, the more public health resources need to be invested in cities, and then the supply and management of the rural public health resources are ignored, resulting in the decline of the allocation efficiency. the population structure is measured by the urbanization level and is concretely expressed by the proportion of the urban population to the total population. fourth, the social support level reflects the major demand groups of the rural public health resources in a region. it is expressed by the proportion of the rural children, youth, and the elderly population to the total population. the higher the social support level, the higher the demand for the rural public health resources, which will lead to the improvement of the allocation efficiency. next, this paper takes seven aspects as the influencing factors of the allocation efficiency of the rural public health resources, that is, the economic development level, the living conditions, the governmental financial support, the population density, the education level, the urbanization level, and the social support level. according to the regional classification standard of the eastern, central, and western regions, the target samples are selected to construct a quantitative model between the allocation efficiency and the influencing factors of the rural public health resources, so as to quantify and analyze the influence of each factor on the allocation efficiency of the rural public health resources in china and its three regions. because the value range of the allocation efficiency of the rural public health resources is (0, 1], this paper uses the bootstrap truncated regression model that can minimize the uncertainty of data and the statistical noise to estimate the parameters. stata16 software is used in the regression process. through calculation, it can be seen that the r-squared value and the adj r-squared value of the four models are bigger than 0.6, and the overall goodness of fit of models is good. the estimation results are shown in table 4 . (1) there are the regional differences in the impact of the economic development level on the allocation efficiency of the rural public health resources. the eastern and western regions have passed the 1% significance test, and the regression coefficient is respectively 0.313 and −0.212. this indicates that the variable promotes the allocation efficiency of the rural public health resources in the eastern region and hinders that in the western region. for the eastern region, the improvement of the economic development level enables more rural residents to enjoy the fruits of the economic development and obtain more public health resources. for the western region, although the economy has developed, the city-centric unbalanced development strategy will make the government invest more resources in the urban development. not only is the supply of the rural public health resources insufficient, but the allocation efficiency is also low. the nationwide and the central regions have not passed the significance test. (2) there are the regional differences in the impact of the living conditions on the allocation efficiency of the rural public health resources. the living condition variable in the nationwide, eastern, and western regions has all passed the 5% significance test except for that in the central region, and the regression coefficient is respectively 0.094, −0.138, and 0.283. this indicates that the variable promotes the allocation efficiency of the rural public health resources in the nationwide and western regions, and hinders that in the eastern region. as a developing country, china has a large proportion of rural residents with poor living conditions. with the implementation of the national poverty alleviation strategy, the living conditions of rural residents have been improved and the demand for the public health resources has increased, and then the allocation efficiency of the rural public health resources has been improved. the improvement of the living conditions has greatly increased the demand for the public health resources and has a bigger improvement effect on the allocation efficiency of the rural public health resources, especially in the western region with the relatively low per capita disposable income of rural residents. however, the per capita disposable income of rural residents in the eastern region is very high, and they pay more attention to their own health and are less likely to get sick. the further improvement of the living standards reduces the allocation efficiency of the rural public health resources instead. 098, and all of them have passed the 5% and below significance test except for that in the central region. this shows that with the increase of the total financial inputs into the public health in china, the rural public health expenditure is also increasing year by year. however, the system and mechanism problem of the public health management gives rise to the spatial imbalance of the public health resource supply, and accordingly leads to the mismatch between supply and demand and distorts the allocation efficiency of the rural public health resources. (4) the population density plays a promotion role in improving the allocation efficiency of the rural public health resources in china. the population density variable in the nationwide, eastern, and western regions has all passed the 5% and below significance test except for that in the central region, and the regression coefficient is respectively 0.065, 0.060, and 0.052. this is mainly because the high population density brings the scale efficiency to the utilization of the rural public health resources, and then improves the allocation efficiency of the rural public health resources. (5) the education level plays a promotion role in improving the allocation efficiency of the rural public health resources in china. the regression coefficient of the education level variable in the nationwide, eastern, central, and western regions is respectively −0.003, −0.011, −0.018, and −0.013, and all have passed the 10% and below significance test. this indicates that the higher the illiterate person rate in rural residents, the lower the allocation efficiency of the public health resources. with the higher education level of villagers, the greater the demand for the public health resources. this is conducive to the effective allocation of the rural public health resources. resources. therefore, the higher the rural social support level, the higher the demand for the rural public health resources, and the more fully the rural public health resources may be utilized. and then improve the allocation efficiency of the rural public health resources. note: z value is expressed in brackets; * represents 10% significance level, ** represents 5% significance level, *** represents 1% significance level. bootstrap method is used to set the sample number of 1000 times. in this paper, the game competition relationship is included in the evaluation model, and the game cross-efficiency model is used to measure the allocation efficiency of the rural public health resources in 31 provinces of china from 2008 to 2017. then, the theil index model and the gini index model are applied in exploring the regional differences in the allocation efficiency of the rural public health resources and its sources. finally, the bootstrap truncated regression model is used to analyze the influencing factors of the allocation efficiency of the rural public health resources in china. the major conclusions are as follows: (1) the total allocation efficiency level of the rural public health resources in china from 2008 to 2017 is relatively low, and it presents a u-shaped trend of first falling and then rising. (2) the changing trend of the allocation efficiency of the rural public health resources in the eastern, central, and western regions of china from 2008 to 2017 is similar to that in the nationwide region, and it shows a gradient trend that "the allocation efficiency in the eastern region is high, the allocation efficiency in the western region is low, and the allocation efficiency in the central region is at the medium level". however, the gap among the three regions is continually narrowing. (3) because of the unbalanced development of china's economy, the supply of the rural public health resources in different provinces showed an unbalanced state, and accordingly resulted that the allocation efficiency of the rural public health resources presented an obvious unbalanced trend of "the high-efficiency province reduction, the medium-and low-efficiency province expansion". with the continuous deepening of the regional coordinated development strategy, the supply of the rural public health resources tended to balance, and the unbalanced trend of the allocation efficiency of the rural public health resources was eased. however, the unbalanced problem of the rural public health resource supply is still noticeable. (4) to judge from the source of the regional differences, from 2008 to 2017, the average contribution rate of the intra-regional differences measured by the theil index is 98.67% and much higher than that of the inter-regional differences (1.33%), while the average contribution rate of the intra-regional differences measured by the gini index is 65.26% and also much higher than that of the inter-regional differences (17.34%). this shows that the intra-regional differences have become the major source of the regional differences in the allocation efficiency of the rural public health resources in china. however, the contribution rate of the inter-regional differences had presented a sustained rising state after 2013, and it cannot be ignored. (5) the improvement of the education level and the social support level will generally improve the allocation efficiency of the rural public health resources in china and its three regions. the improvement of the governmental financial support and the urbanization level will reduce the allocation efficiency of the rural public health resources in china and its three regions. the economic development level, the living conditions and the population density are the important influencing factors of the allocation efficiency differences of the rural public health resources in the three regions. the above research results can provide the policy basis for improving the allocation efficiency of the rural public health resources in china. first, the health poverty alleviation project should be deeply implemented to ensure that the rural poor population enjoys the basic medical and health services, and prevent the poverty caused by diseases. the prices of the rural public health products should be continuously reduced, and the government should provide the corresponding free health preventive services, or subsidize families who take the initiative to take the health preventive services, so that the rural population can get the health preventive services as easily as possible. by constantly perfecting the national poverty alleviation strategy and policy system, the organic connection between the health services and the poverty alleviation can be realized, and the incidence of the rural poverty can be greatly reduced. second, the healthy china strategy should be further pushed forward, and more attention should be paid to the improvement of the allocation efficiency on the basis of ensuring the growth of the total supply of the rural public health resources. on one hand, the city-centric supply mode of the public health resources should be changed, the public health resources should be constantly pushed forward to tilt to the rural areas, and the system reform of the new rural cooperative medical insurance should be deepened. the hierarchical diagnosis and treatment system reform of china should be actively pushed forward, and it should be ensured that the high-quality medical resources can enter the rural areas to make the rural residents share the public health and economic development fruits. on the other hand, the system and mechanism reform of the rural public health resource supply should be deepened, restructuring of the rural grass-roots medical institutions should be pushed further forward, and the medical community should be established. a large information sharing platform of the urban and rural medical systems should be established to achieve the continuous records of the electronic health archives and the electronic medical records of the rural residents as well as the information sharing among different levels and types of medical institutions, so as to improve the accessibility of the high-quality medical resources and the total medical service efficiency. third, on the basis of continually narrowing the inter-regional differences among the eastern, central, and western regions, more attention should be paid to the intra-regional differences of the allocation efficiency of the rural public health resources among the different provinces. on one hand, the regional rural public health coordinated development strategy should be thoroughly implemented, and the mechanism and system reform of the rural public health resource supply within the region should be coordinated and pushed forward, so as to constantly promote the spatial balanced development of the rural public health resource supply. on the other hand, the regulatory mechanism and the accountability mechanism of the rural public health funds should be established and perfected, and efforts should be made to establish an efficiency-oriented regional rural public health resource supply mechanism, so as to constantly narrow the regional differences in the allocation efficiency of the rural public health resources and realize the effective match for supply and demand of the rural public health resources. fourth, various economic and social policies should be constantly optimized to jointly improve the allocation efficiency of the rural public health resources. first of all, each region should increase the investment in the rural education and constantly improve the education level of rural residents, so as to improve their demand for and utilization rate of the rural public health resources. secondly, each region should follow up and pay attention to the rural unoccupied village phenomenon caused by the improvement of the urbanization level, and duly adjust the layout of the rural public health resource supply, so as to avoid the efficiency loss caused by the idle rural public health resources. thirdly, the rural revitalization strategy should be accelerated. each region should promote the transformation of the unoccupied villages into the gathered 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smith, maxwell j.; bensimon, cécile m.; perez, daniel f.; sahni, sachin s.; upshur, ross e. g. title: restrictive measures in an influenza pandemic: a qualitative study of public perspectives date: 2012-09-01 journal: canadian journal of public health doi: 10.1007/bf03404439 sha: doc_id: 4195 cord_uid: msqvb97f objectives: recent experiences have demonstrated that restrictive measures remain a useful public health tool during infectious disease outbreaks. however, the use of restrictive measures is not without controversy, as there is no agreed-upon threshold for when and how to invoke restrictive measures. the objectives of this study are to solicit perspectives from canadians on the ethical considerations of using restrictive measures in response to influenza pandemics, and in turn, to use public views to contribute to a better understanding of what is considered to be the justifiable use of restrictive measures. methods: a series of town hall focus groups with canadian residents from june 2008 to may 2009, in three canadian regions, in order to achieve broad public engagement (n=3 focus groups with a total of 17 participants). results: two key themes emerged from all town hall focus groups: 1) create an environment for compliance through communication rather than enforcement, and 2) establish the delineation between individual rights, community values, and the greater good. conclusion: while there is a need for a decision-making authority and even a mechanism for enforcement, our data suggest that a more tractable approach to restrictive measures is one that enables individuals to voluntarily comply by creating an environment to compel compliance based on communication. this approach requires restrictive measures to be a) proportional to the threat, b) implemented along with reciprocal arrangements provided to those affected, and c) accompanied by open and transparent communication throughout all stages so that citizens can both understand and participate in decision-making. the team conducted three town halls in three major canadian urban settings (vancouver, bc; winnipeg, mb; saint john, nb) between june 2008 and may 2009. canadian residents aged 18 and over who spoke fluent english and who had no relationship with study investigators were recruited from the general public using local newspaper advertisements and social networking websites. in addition, study collaborators (i.e., local contacts who assisted in organizing town halls) used snowball sampling to recruit participants in their local areas. a total of 17 participants attended: 5 in vancouver, 6 in winnipeg, and 6 in saint john. data were collected through day-long facilitated discussions using case scenarios and focus group guides (appendix a), which were developed collaboratively by the research team. at each town hall meeting, participants were randomly divided into groups of five to eight people and asked to deliberate on the ethical issues concerning an assigned scenario (see appendix), in this case restrictive measures. groups met in the morning and afternoon (for a total of approximately eight hours) and were both given new details on the case and asked a new set of questions as deliberations progressed. at the end of the day, the four scenario groups met to debrief and share the key issues raised and discussed in their small groups. this paper reports only the results from the restrictive measures group. group discussions were facilitated by a member of the team while another member took notes. town halls were audio recorded, transcribed verbatim, and verified by team members. we conducted a thematic analysis of each transcript within and across town halls according to standard qualitative analysis procedures. thematic analysis progressed via the following four steps: 1) each author coded each transcript independently, one town hall at a time; 2) a shared coding framework for each town hall meeting was developed collectively based on each individual's independent codes; 3) codes were collapsed into themes for each town hall, repeating the process for all three town halls; and 4) themes were generated across town halls. trustworthiness of our analysis was ensured through analyst triangulation, prolonged engagement with the data by research team members both individually and as a group, and a series of peer consultation and debriefing sessions. 12 members of the research team met at each stage of analysis in order to discuss the interpretation of the results and consider the emerging themes. we also presented and discussed our results with the larger canprep research team. finally, we kept detailed team notes at each stage of analysis as to what codes were added, removed or collapsed, in order to establish an "audit trail." 13 the study received ethics approval from the university of toronto. participants were informed of confidentiality and privacy, possible benefits and risks, and the ability to withdraw from the study. all participants provided written consent. participants' responses were organized into two main themes that emerged from all three town halls: a) compliance through communication, and b) delineation between individual rights, community values, and the greater good. the issue of compliance was a pervasive theme. many participants categorically stated that absolute compliance with restrictive measures is not achievable, even when measures are made mandatory: the truth of the matter is, if we're going under the assumption that we can make people do what we want them to do, that's just false. the media is reporting that the world health organization has officially determined that an avian influenza ("bird flu") pandemic is now underway. the public health agency of canada has confirmed person-to-person spread in several canadian cities including [town hall location city]. some deaths have been reported, but no one knows how serious the problem may be because there is no information as yet on the extent of the outbreak. little is known about the actual virus at this point. vaccine development is underway; however, large-scale public vaccination programs are not expected to be available for 6 to 8 weeks. public health officials are strongly recommending the immediate implementation of some restrictive measures to help slow the spread of the infection. this includes the closing of community centres and the cancelling of all large public gatherings. one family whose 2 daughters, 24-yr-old amandeep and 16-yr-old marpareet, were killed in a car accident just as this information was released did not hear this information because it was disseminated in the english media and they do not watch tv or listen to the radio in english. sponsored by amandeep to come to canada, marpareet, her brothers, rajinder and darshan, and her parents had arrived from india less than a year ago and speak little english. the family holds a large memorial service for family and friends the following day. few people do not show up because most of them, although they had heard the order by authorities, think that the cancellation of large public gatherings means cancelling social events, not a funeral, which is a sacred rite to honour the passing of a loved one. moreover, the tragedy of this untimely loss overshadows everyone's concern about an outbreak, the actual seriousness of which no one really knows. there have been no reported deaths caused by influenza in their immediate community. over 200 people attend the funeral. • what are your initial thoughts and feelings about this situation? • what do you think were the most important considerations for the family in making their decision? • what are the features of this case that you find most compelling? public health authorities issue an order requiring everyone who attended the funeral to stay home for a period of 7 days, even though there is still little information about the virus or the extent of the outbreak. rajinder wonders whether this is feasible as his family depends on his income. he decides to go to work stocking shelves at canadian tire, in spite of the order, while the rest of his family stays home. • what do you think of rajinder's decision? • do you think people should face consequences if they don't follow an order of quarantine? if yes, what sort of penalties do you think would be fair? • is there anything compelling about this development? the [town hall location province] government has now declared a state of emergency. three people who attended the funeral are showing symptoms of influenza and one person has died from it. although rajinder is aware that the outbreak has now hit home, he can't see how it would be possible for him not to go to work. after his failing to heed the order, public health officials detain rajinder, meaning that the family is left with no income and stranded at home with little food. • have your responses to the situation changed in light of this new information? • what do you think of public health's decision to detain rajinder? • do you think society has obligations to those ordered into quarantine? • is there anything compelling about this development? • how do you feel about the use of detention in the event of an outbreak? • who should make these kinds of decisions? • how should these kinds of decisions be made? • in the absence of consensus, how should these decisions be made? thus, the question that invariably emerged was, "how do you compel compliance?" while participants explored several options ranging from voluntary compliance to enforcement, it was widely thought that creating an environment for voluntary compliance through communication, rather than employing a punitive model centered on compliance through compulsion, is both essential and desirable for the successful implementation of restrictive measures: allowing the public to decide whether they should do it is fair, instead of saying it has to be done as a moral or social issue. you've got to constantly have communication between medical and public and just get as much information as you can get out there and help get people onside. open and transparent communication was thought to foster voluntary compliance by engaging people in understanding what and why measures were needed. along with that, participants felt that it was preferable, indeed more appropriate, to communicate uncertainty rather than to give inconsistent estimates or assessments of the situation. that said, communicating uncertainty was not thought to preclude communicating with clarity and decisiveness. one of the most common themes identified as an element of pandemic response was the need for consistency and coherence in the messages that public health authorities and community leaders communicate to the public, both as a means to foster voluntary compliance and to engage the public in decision-making processes. participants suggested that, in order to create an environment for voluntary compliance, the principles of proportionality and reciprocity must be proactively operationalized. the notion of proportionality served as the foundation for much of the discourse regarding planning and response efforts. proportionality requires that restrictions to individual liberty and measures taken to protect the public from harm should not exceed what is necessary to address the actual level of risk or critical needs of the community. 11 participants stressed that, in order to create an environment for compliance and to justify the use of restrictive measures, measures must be proportional to the risk that is perceived by the public. furthermore, participants expressed that the actual risk that exists (according to experts) must be balanced with the potential impact of using restrictive measures: i would have to weigh the amount of risk vs. the potential for panic and for there to be a backlash against the kinds of rules that are being instituted. in sum, many participants agreed that restrictive measures must not create a disproportionate impact on those affected by such measures compared to what is strictly necessary to control an outbreak. reciprocity, which requires that society support those who are burdened by complying with restrictive measures, was presented as both fair and integral to the implementation of restrictive measures. that is, participants were broadly supportive of using even the most restrictive measure, quarantine, provided it is applied equitably and with appropriate support mechanisms in place. indeed, participants felt that an obligation exists to provide social and material support to persons affected by restrictive measures, including being assured that they will not be unnecessarily penalized for following orders or recommendations (e.g., not losing their job): for me, this raises the question of interactive societal responsibility. if society deems it necessary for [someone] to stay at home to protect society from the spread of infection…then society must, in turn, be responsible to him to ensure he is well provided for and will not suffer the results of his patriotic duty. while consequences such as fines and community service were found to be important for those who do not comply with restrictive measures, participants agreed that there ought to be no consequences in the absence of reciprocal arrangements, as in such cases individuals may be put in a position where they have no choice but to not comply with restrictive measures. participants suggested that, without reciprocal arrangements, individuals may resort to breaking quarantine, effectively being "forced to spread the disease". although priority was given to incentivizing compliance by promoting voluntariness, participants felt overall that the context in which restrictive measures are required creates very limited options for individuals ("you can have black or you can have black"). that is, even though individuals may comply with restrictive measures, it does not necessarily mean that they accept the justification for implementation of the measures. the common distinction between balancing individual rights and the greater good was broadened by participants to include the notion of what is good for the community. that is, participants introduced notions of community values as being distinct from the individual or the greater good or as a different kind of greater good: the greater good is the community or the policy, following the policy is the greatest good or is the most important thing than yeah, you'd be doing wrong but if individual autonomy is making your own decisions, that your family is the most important, your community, your immediate community is more important. what freedom do we give communities to deliberate about the ethical sort of nature of these decisions within their own system of meaning? in several discussions, participants expressed that there should be allowances to determine what is deemed to be an acceptable risk at the community level; for example, holding a funeral (see appendix a), which may be detrimental for the greater good but actually beneficial for the community. further, participants indicated that there are fundamental values that may not be within the scope of an individual's rights or the greater good (as it is conventionally viewed) that are important to, and define, a community -such as the right to assemble, obligations to one's family, and the view that religious rites trump the risk of mortality. a dominant theme that emerged from the data is that of compliance, or, more specifically, questions focusing on how to create an environment that compels compliance. participants strongly favoured the use of rewards -the "carrot" -or suasion -the "sermon" -rather than punishments -the "stick" -in order to create an environment for compliance. it was thought to be more acceptable to use reciprocal arrangements and effective risk communication as reinforcement tools rather than using threat of punishment to compel compliance. this finding supports results from a recent qualitative study on individuals who had been quarantined during sars, where effective risk communication was found to help individuals understand the precursors and consequences of diseases, which was ultimately linked to participants' reported compliance. 14 this is an interesting finding that collides with the compulsive and coercive authority that public health has traditionally used in law to justify intervention, particularly in infectious disease cases, like quarantine and border control. 15, 16 indeed, the method of compelling individuals to comply is largely based on the "stick", stemming from the theoretical and largely traditional view that infectious disease control measures must be compulsory in order to be effective. 17 our data suggest, however, that while participants recognize a need for a decision-making authority and even a necessary mechanism for enforcement, a more tractable approach is one that enables individuals to voluntarily comply. this finding supports the conceptual and empirical claims that public health must rely on persuasion rather than force when considering the use of restrictive measures. 8, 18 our data also go so far as to suggest how this approach can be achieved. this approach requires restrictive measures to be a) proportional to the threat, b) implemented along with reciprocal arrangements provided to those affected, and c) accompanied by open and transparent communication throughout all stages so that citizens can both understand and participate in decision-making. with regard to the provision of reciprocal arrangements, these findings support the claim made elsewhere that reciprocity plays a vital role in establishing restrictive measures as a morally legitimate means to prevent or contain effects of infectious diseases, and ultimately helps motivate support and compliance with legitimate restrictive measures. 4 another important finding is that a third consideration exists when implementing restrictive measures: the community. this consideration challenges the common dichotomy made in public health between the individual and the greater good. this suggests that important substantive nuances exist between what is deemed to be the greater good and what is deemed to be a community good, which has largely been viewed as one and the same by public health. indeed, attention must be paid to the role that community clusters play, particularly during a public health emergency, where measures such as the cancellation of social gatherings may benefit the greater good but may actually be detrimental to what participants understood to be community goods. these findings contrast, for instance, with the responsibilities outlined in the american model state emergency health powers act, which makes explicit distinctions between the common good and individual rights, but does not consider the good of the community as described in our findings. 19 we recognize that the views expressed by study participants may or may not be generalizable and that study participation was unevenly distributed across canada. however, this is consistent with standards of sampling in qualitative research, which aims to evaluate the theoretical representativeness of participants by describing the range of views, rather than quantitative or demographic representativeness. in this study, we elicited canadians' perspectives about the use of restrictive measures during an influenza pandemic. our analysis contributes a better understanding of public views on the acceptability of using restrictive measures as a means to stem the tide of influenza. prior studies utilizing public engagement demonstrate that the public can make coherent and sophisticated recommendations about regulatory issues pertaining to health and can provide invaluable "local knowledge" relevant to the policy-making process. [20] [21] [22] public engagement enhances accountability, especially in government decision-making, [23] [24] [25] and as has been argued extensively, improves the legitimacy of decisions taken. [26] [27] [28] [29] [30] with this in mind, what participants deemed to be the requirements for using restrictive measures, e.g., proportionality, reciprocity, and consideration of community goods, can further inform and give legitimacy to policy development efforts on pandemic planning and response. public health measures to control the spread of the severe acute respiratory syndrome during the outbreak in toronto world health organization working group on prevention of international and community transmission of sars. public health interventions and sars spread reducing the impact of the next influenza pandemic using household-based public health interventions your liberty or your life: reciprocity in the use of restrictive measures in contexts of contagion infectious disease ethics: limiting liberty in contexts of contagion modeling the worldwide spread of pandemic influenza: baseline case and containment interventions delaying the international spread of pandemic influenza public perceptions of quarantine: communitybased telephone survey following an infectious disease outbreak evidence and effectiveness in decision-making for quarantine communicable disease control in the new millennium: a qualitative inquiry on the legitimate use of restrictive measures in an era of rights consciousness stand on guard for thee: ethical considerations in preparedness planning for pandemic influenza naturalistic inquiry competing paradigms in qualitative research risk perception and compliance with quarantine during the sars outbreak principles of public health practice legal foundations of public health in canada public health or clinical ethics: thinking beyond borders bioterrorism, public health, and human rights the center for law and the public's health at georgetown and johns hopkins universities. a draft discussion of the model state emergency health powers act public perspectives on the new genetics: the citizens' jury experiment the new genetics and health: mobilizing lay expertise knowledges in context challenges of citizen participation in regional health authorities enhancing public input into decision making: development of the calgary regional health authority public participation framework limits to health care: fair procedure, democratic deliberation, and the legitimacy problem for insurers liberal democracy and the limits of democratization toward a deliberative model of democratic legitimacy public deliberation: pluralism, complexity and democracy deliberation and democratic legitimacy discursive democracy: politics, policy and political science objectifs : des expériences récentes ont montré que les mesures restrictives demeurent un outil de santé publique efficace durant les éclosions de maladies infectieuses. toutefois, le recours à ces mesures est controversé, car il n'y a pas de seuil communément accepté qui indique quand et comment s'en prévaloir. les objectifs de notre étude étaient de sonder l'opinion des canadiens sur les considérations éthiques qui soustendent l'emploi de mesures restrictives en réaction aux pandémies d'influenza, et en retour, d'utiliser les résultats de ce sondage pour mieux comprendre ce qui justifie le recours à des mesures restrictives aux yeux du public.méthode : nous avons organisé une série de discussions publiques avec des résidents canadiens entre juin 2008 et mai 2009 dans trois régions du canada pour obtenir une vaste mobilisation populaire (n=3 groupes de 17 participants en tout).résultats : deux grands thèmes se sont dégagés des discussions publiques; il faudrait : 1) créer un climat de conformité par la communication plutôt que par des mesures coercitives et 2) délimiter les frontières entre les droits individuels, les valeurs collectives et le bien commun. on aurait besoin d'un pouvoir décisionnel et même d'un mécanisme d'application, mais nos données montrent que l'on peut aborder les mesures restrictives avec plus de doigté en permettant aux gens de se conformer volontairement en créant un climat qui favorise la conformité par la communication. une telle approche exige que les mesures restrictives soient a) proportionnelles à la menace, b) appliquées en même temps que des accords de réciprocité avec les personnes touchées et c) accompagnées par des communications ouvertes et transparentes à chaque étape pour que les citoyens puissent à la fois comprendre les décisions et participer au processus décisionnel.mots clés : santé publique; grippe humaine; pandémies; bioéthique; recherche qualitative; quarantaine key: cord-297216-1b99hm1e authors: sariola, salla; gilbert, scott f. title: toward a symbiotic perspective on public health: recognizing the ambivalence of microbes in the anthropocene date: 2020-05-16 journal: microorganisms doi: 10.3390/microorganisms8050746 sha: doc_id: 297216 cord_uid: 1b99hm1e microbes evolve in complex environments that are often fashioned, in part, by human desires. in a global perspective, public health has played major roles in structuring how microbes are perceived, cultivated, and destroyed. the germ theory of disease cast microbes as enemies of the body and the body politic. antibiotics have altered microbial development by providing stringent natural selection on bacterial species, and this has led to the formation of antibiotic-resistant bacterial strains. public health perspectives such as “precision public health” and “one health” have recently been proposed to further manage microbial populations. however, neither of these take into account the symbiotic relationships that exist between bacterial species and between bacteria, viruses, and their eukaryotic hosts. we propose a perspective on public health that recognizes microbial evolution through symbiotic associations (the hologenome theory) and through lateral gene transfer. this perspective has the advantage of including both the pathogenic and beneficial interactions of humans with bacteria, as well as combining the outlook of the “one health” model with the genomic methodologies utilized in the “precision public health” model. in the anthropocene, the conditions for microbial evolution have been altered by human interventions, and public health initiatives must recognize both the beneficial (indeed, necessary) interactions of microbes with their hosts as well as their pathogenic interactions. the anthropocene marks the end of a period characterized by the human triumph of nature, and nowhere is this more prominent than in public health. the heroic era of microbiology made pasteur, koch, lister, and fleming household names, and few have done more for humanity [1] [2] [3] . the lifespan of a newborn parisian was 45 years in 1900; and a century later, a newborn parisian could expect to live another 80 years [4] . much of this increase in life expectancy (as well as the expectation to be healthy) has been due to the ability of public health measures-proper sanitation, food surveillance, antisepsis, and anti-viral vaccination-to remove humans from sources of microbial infection. however, our relationship with microbes and their evolution has changed dramatically since the discovery of antibiotics, and the conquest of polio and other endemic viruses in the 1950s and 1960s. the first part of our changing relationship to microbes involves the western world's manufacturing an environment that is increasingly sterile and characterized by the removal of unplanned and unplannable nature [5, 6] . indeed, nature is no longer our "state of nature." rather, we have continually separated ourselves from nature, separating the "who" of human lives from the "what" of other lives. and immune systems of plants and animals and (2) the microbes' ability to transfer dna horizontally from organism to organism. this article attempts to map out a holobiont perspective to public health. it is important to determine how these new views of microbial evolution-lateral gene transfer and mutualistic symbiosis-might be integrated into public health initiatives. it seems that present initiatives ignore or marginalize these phenomenon and that public health might be served better if they were made more central. two pertinent public health paradigms that have received much publicity in recent years are the "precision public health" (pph) paradigm and the "one health" (oh) paradigm. neither of these appear to take seriously our new appreciation of microbial evolution. precision public health (pph) is the application of genomics technology for population health benefits [34, 35] , and it is the attempt to make public health into a genomic science. pph began in 1997, when the office of public health genomics of the cdc was formed to "transform" population health care into a genomic science "by identifying, evaluating, and implementing evidence-based genomics practices to prevent and control the country's leading chronic, infectious, environmental, and occupational diseases" [36] . pph claims that it would be able to analyze one's genome and then prescribe the appropriate drugs and dietary regimens. however, the original promises that genomic science would find common alleles for common diseases were not fulfilled [37, 38] . genome-wide association studies (gwas) for cardiovascular disease showed that that genes played a negligible role in predicting heart attacks and that human genetic variation accounted for roughly 3% of the variation in blood pressure [39] . moreover, the prediction that a patient would have a heart attack was better made by the number of pushups a patient could do than by genomic analyses [40] . the genes thought to be associated with depression were "lost" when large trials were done [41] ; and deficiencies of the gut microbiome may provide a better account of causation [42] . worse, for any genomic model of public health, was when the genome of the founder of the human genome project, james watson, was analyzed. his dna sequences predicted him to be deaf, blind, growth retarded, and mentally deficient [43, 44] . genes work differently in different people. "phenotypic heterogeneity," wherein the same mutant allele causes different phenotypes in different individuals carrying it, is a well-known phenomenon in medical genetics [45, 46] and a gene that is "normal" in one generation can cause disease in another [47] [48] [49] . nevertheless, the pph got a shot in the arm (to use an old public health metaphor) by the "all of us" project begun at the usa's national institutes of health [50] . its website proclaims this to be a big genome, big data approach to public health, whereby "taking into account individual differences in lifestyle, environment, and biology, researchers will uncover paths toward delivering precision medicine..." pph is getting a shot in the other arm from pharmacogenomics, the study of how responses to drugs are influenced by the genetic makeup of the person receiving the drug. according to kapoor et al. [51] pharmacogenomics, is "one of the cornerstones of precision medicine" and furthermore, is a "significant innovation in health care that possesses the potential to change the paradigm in the practice of medicine, not solely in the way drugs are prescribed, but also in the way drugs are discovered and developed." indeed, precision pharmacogenetics is being touted as a paradigm for third-world health care [52] . however, this population-centered model of genomic healthcare delivery has been criticized [37] as being a salvage attempt to rescue something of value from the numerous extremely expensive genome projects that had been the scientific rage of the late 20th and early 21st centuries. reardon and others [37, 53, 54] claim pph is most likely dangerous fantasy, exacerbating global economic differences, taking the "public" out of "public health," and shifting responsibility for health onto the individual citizen [55, 56] . pph has also been criticized for not recognizing the contributions of the symbiotic microbial genomes [38] . symbiotic relationships with microbes, as will be discussed below, provide essential metabolic pathways for phenotype production (including those for drug metabolism) and over ten-fold the number of different genes than the zygote-derived genome. whereas precision public health works from one privileged level-the genome-up to humans and human communities, the one health paradigm is consciously interdisciplinary and multi-species-it attempts to envision people, animals, and environments as partners in each other's health on several levels [57, 58] . as gibbs [59] (p. 49) notes, "one health is the collaborative effort of multiple disciplines-working locally, nationally, and globally-to attain optimal health for people, animals, and our environment." the one health paradigm, according to friese and nuyts, provides a theoretical basis for research involving nonhumans in public health and used to re-organize relationships between human medicine and animal veterinary medicine so that these two fields communicate in both knowledge and practice [60] . with contributions from such disciplines as ecosystem services and soil microbiology, one health approach also recognizes the role of environments and ecologies in how human and animal health is shaped. these contributions see ecosystems (including symbiotic microbiomes) as providing economic infrastructure benefits that can be calculated as part of any managed change to the environment [61] [62] [63] . however, overall, the implementation of one health is still fixed on protecting humans from zoonotic infections [60] . indeed, the cdc, who, ama, and avma websites stress zoonoses and the fact that most infectious diseases are spread by animals. the environment gets short shrift in these sites, and this deficiency has not gone unnoticed. numerous investigators have documented that the environment does not receive attention or funding in most one health networks [64] [65] [66] [67] . thus, the three components of the one health model are not equal, and the framework is still used to prioritize protection of humans from zoonotic diseases. while the importance of this goal is made obvious in this coronavirus-infused decade, the anthropogenic deterioration of the environment by humans-such as mountain-top coal removal, anthropogenic deforestation, soil microbial deterioration, and reef depletion-are crucial in and of themselves as well as can have enormous effects on public health and do not appear on the one health agenda. only recently have there been calls to put microbes and global climate change under the one health umbrella [68, 69] . some of these initiatives have come under the planetary health [70] , which emphasizes how critical such ecological perspectives are for human health. the planetary health perspective, however, concentrates on the important issues of politics and economics of global health care in the anthropocene, but it does not address the issues the changes in how we perceive microbes. in contrast to the precision public health and one health paradigms, a recently proposed theory holds that microbes such as bacteria are primarily beneficial symbionts of the human body, and their presence is both expected and necessary for normal human health. while pathogenic microbes can cause enormous damage, they are a distinct minority, and public health needs to recognize the other arm of symbiosis-mutualism. this approach, which could revitalize the community-based one health perspective to public health by using the techniques of the molecularly based pph model, is based on the hologenome theory [71] . this model has recently received support by private funding, most notably from the bill and melinda gates foundation [72, 73] . the hologenome theory [74, 75] recasts the individual animal or plant (and other multicellular organisms) as a consortium ("holobiont")-the host plus all its symbiotic microbes. during the past two decades, advances in microbiome research have clearly shown that most animals cannot normally develop, function, or reproduce without the vast numbers of microorganisms that inhabit their bodies [28, 76] . microbes are essential for normal animal development and physiological functioning. for instance, bacteria acquired at birth from the female reproductive tract are critical to the construction of the gut capillaries and epithelia in several vertebrates [77] [78] [79] [80] [81] as well as being critical for the normal development of the vertebrate enteric and cerebral nervous systems [82] [83] [84] . pediatric geneticist barton childs [85] postulated that each person's genetic endowment constitutes a "biochemical individuality" conferred upon us by our genes. patterson and turnbaugh [86] have used the same term to designate the properties of the "hologenome"-the genes we inherit from our parents and our microbes, our germ cells and our germs. while we inherit some 22,000 genes from our parents, we inherit about 8 million different genes from our parents' bacteria [87] . indeed, in some instances, the gut microbiome appears to be critical in drug metabolism. digoxin, cyclophosphamide, and numerous other drugs are each metabolized differently by different populations of microorganisms [88] [89] [90] , giving each person an assortment of genes (and drug-metabolizing phenotypes) that can change with each meal [91] . even the human immune system, so critical in public health, is a holobiont property, and not merely the agency of the host [92] [93] [94] [95] [96] . microbes enter into the body at birth, prior to the maturation of the immune system, and they induce the formation of lymphoid tissues [97] [98] [99] . moreover, these lifelong immune activities are well-regulated only in the continuous presence of microbes, which in turn, constantly regulate the microbes that can stay with the animal [100] [101] [102] [103] [104] [105] [106] . the immune system is a continuously co-constructed property of the holobiont. holobiont public health recognizes that microbes may be pathogenic or beneficial, and that deficiencies in bacteria can cause developmental, immunological, cognitive, and physiological ailments. for instance, kwashiokor, long seen as a protein deficiency disease, manifests as a wasting and anorexic pathology only when certain bacteria are absent [107] . asthma and allergies are also seen to be due to the absence of protective bacteria, which normally are present to be induce anti-inflammatory regulators [108, 109] . in these studies, hanski and colleagues [110] explicitly link environmental health, microbial diversity, and human health. indeed, a new field of dysbiosis is now emerging, including not only infection, but also other conditions that may be caused by deficient or aberrant microbiomes. here, the normal symbiotic relationships that maintain physiological or developmental continuity, have been abrogated. in recent years, science has traced these networks from associations to specific causal changes that can be tested. while many of these experiments have been performed in mice, the same pathways are known to be present in humans. these non-contagious diseases include asthma and allergy [111] , kwashiorkor [107, 112] , obesity [113, 114] , diabetes [115] , ulcerative colitis [116] , depression [42, 117] , and parkinson's disease [118, 119] . these "microbial deficiency diseases," constitute a new and possibly important category of illness. this is not to say that dysbiosis is the only cause of these conditions, but that it is a public health concern that should be investigated. an important conceptual barrier was recently crossed when the gut microbiomes of pregnant mice were demonstrated to be critical for the intrauterine development of the fetus. short-chain fatty acids (such as butyrate and propionate) are products of the gut microbiome's digestion of cellulose. as no mammalian genome contains genes for cellulose digestion, the breakdown of plant material is almost totally accomplished by enzymes produced by microbes. kimura and colleagues [120] demonstrated that propionic acid, derived from the breakdown of fiber by maternal gut microbes, was critical for the normal development of the insulin-producing pancreatic beta cells, the sympathetic neurons that project to the heart, and the gut enteroendocrine cells. without the microbe-derived propionic acid, the adult offspring developed a metabolic syndrome characterized by glucose intolerance, obesity, and insulin resistance. since diet can control the prevalence of microbes, the holobiont model can explain the mechanism whereby eating low-fiber, high-calorie diets during pregnancy predisposes offspring to have metabolic syndrome later in life [121] . to understand the importance of a symbiotic approach to public health, one has to first appreciate the new biological notion of the human body. each of us is a functional entity that includes our zygote-derived cells as well as hundreds of species of microbes. the body is both an organism and a biome containing several ecosystems [28, 76, 101] . once the amnion breaks, and the fetus passes through the birth canal, the newborn becomes colonized by their mother's bacteria [87] . furthermore, mothers' milk contains a special set of nutrients to promote the survival and growth of those bacteria that are important for symbiosis [122] [123] [124] . these symbiotic bacteria will produce short-chain fatty acids and sphingolipids necessary for intestinal peristalsis and homeostasis, peptidoglycans necessary for normal neuron function, lipopolysaccharides necessary for the actions of the immune system, the tripeptides necessary for cardiac physiology, and the digestive enzymes necessary to metabolize plants [28] . remarkably, a third of the small metabolites in the blood are produced or induced by bacteria [125] . nearly all of our peripheral serotonin is induced by gut microbes, where it regulates the maturation of the enteric nervous system and regulates peristalsis [83, 126] . even more remarkable is that such critical symbioses are not only present within humans. rather, the development of most organisms appears to be predicated on interactions between hosts and their symbionts. as mentioned in the above section 1, without microbial symbionts, mice do not form their gut capillaries, their gut-associated lymphoid tissues, their t-and b-cell repertoires, or the proper synaptic connections in their guts and brains. moreover, no vertebrate contains genes that make the enzymes necessary for digesting plant material such as cellulose, hemicellulose, and pectins [127] . these genes are provided by symbiotic microbes in our guts. in mammalian evolution, the entire family of ruminants is made evolutionarily possible by the ability of gut bacteria (acquired at birth) to build the rumen of the stomach and then to ferment grass and grains [128] [129] [130] [131] . thus, symbiosis is a paradigm-changing idea in physiology. we are no longer seen as being "individuals." we are holobionts, and our anatomy, development, immunity, and physiology are intimately linked with that of our microbial components. the importance of the holobiont perspective for public health is that absences of particular microbes may cause dysbioses throughout a population. martin blaser and colleagues [6, 132] have warned that we may need particular microbes for particular functions, and that our obsession with exterminating microbes may be inadvertently killing those bacteria that we need to survive. their data indicate that microbes that used to be prevalent (those, for instance, in barnyards and horse stalls) are becoming rarer. if these microbes are necessary for normal organ, immune, or cognitive development, we will be impaired. rhesus macaques that are bottle-fed, rather than breast-fed, acquire a different population of gut microbes, and this population is not as adequate to develop a functioning immune system that can repel opportunistic infections [133] . in zebrafish, a relatively rare species of bacteria is essential for permitting the expansion of insulin-producing pancreatic cells, thereby protecting these fish against diabetes [134] . this absence of specific bacteria (or their genes) may be crucially important for explaining the increases in allergies and asthma since world war i, and especially, after world war ii. throughout human history, we had constant exposure to barnyard microbes. it was only in the 20th century that they were displaced. the barnyard was not just an attribute of farms. the nineteenth century city, according to raulff [135] (p. 36) "consisted of rows and rows of urban stables." mid 19th c. boston had some 367 stables, each having around eight horses. in contemporary america, only 6% of amish children, whose homes are often adjacent to their barns, have allergy and asthma. about 20% of the genetically similar hutterites, whose farms are not located close to their homes, have allergies, roughly the same as the american population in general [136] . similarly, finnish studies have shown that proximity to the barn is a factor in combatting allergies. a recent study shows that children living in urban homes with barnyard bacteria have much less asthma and allergies than those children living in urban homes with urban bacteria [109] . indeed, two of the bacterial types found in the "rural" homes and missing in "urban" homes were brevibacterium and ruminococaceae, bacteria found in horses and cattle. although the severity of microbiome diversity loss might be most discernable in urban populations [137] , the importance of soil microbiomes for the maintenance of healthy human intestinal microbiomes has recently been emphasized in studies [138] showing that even in rural areas, farming techniques have severely reduced soil microbiome biodiversity. bacterial displacement due to urban living and the absence of animals is only one of the ways that anthropogenic microbial displacement can affect public health. caesarian sections disrupt one of the pathways of maternal kinship. babies receive a protective set of symbiotic microbes from mothers when they pass through the birth canal. in caesarean sections, this transmission is abrogated. babies delivered by c-section were found to be deprived of those microbes that otherwise colonize the infant gut. instead, there were the hospital dwelling microbes that included a substantial number of opportunistic pathogens. moreover, a substantial set of these microbes contained genes associated with antimicrobial resistance [139] . not only were the species of microbes different, but so were their functions. the caesarean-delivered infants had less ability to mount immune responses to common antigens [140] . this may have strong public health implications concerning elective c-sections. the microbes of our gut are critical for "basic neurogenerative processes such as the formation of the blood-brain barrier, myelination, neurogenesis, and microglia maturation." [141] . if this is indeed true, then could microbes also be critical for mental health? what if, in addition to protection against allergies and asthma, bacteria were protecting us against mental health conditions such as schizophrenia, bipolar disease, and autism? several studies now indicate that gut microbes appear to be critical for normal brain development and behaviors in mice [82, [142] [143] [144] [145] [146] [147] [148] . first, mice born from germ-free mothers and who are themselves without microbes have a syndrome that includes obsessive self-grooming and asocial behavior [149] . this behavior is possibly due to the failure of oxytocin-releasing signals from the vagus nerve, and it can be reversed by providing the germ-free mice with lactobacillus reuteri or with microbes from normal mice or from normal humans [141, 150] . germ-free mice given microbes from autistic humans do not show improvement of their symptoms. although human cognitive and affective behaviors cannot be extrapolated for those of mice, a pilot uncontrolled fecal transplant study in humans showed that after two years, the acquisition of normal bowel microbes by autism patients significantly improved their symptoms: from 83% severe autism to 17% severe autism [146] . similar studies in mice and humans have shown that the gut microbiome may be critical in protecting humans from depression [42, [151] [152] [153] . there is therefore reason to test the hypothesis that removal or depletion of normal environmental microbes may be responsible for the increasing percentage of the population diagnosed with cognitive dysfunction. while studies of the effects of microbes on mental health lag behind those studies of microbial involvement in physical health, the relationship of symbiotic microbes to cognitive and affective health and disorder is an area that cannot be ignored. public health must acknowledge that we are not monogenomic individuals. we are consortia of dozens of species per person, integrated together in a complex and dynamically changing network that forms who we are at any given moment. this network is altered by the food we eat, by the food our mother ate, the toxins and medications we are exposed to, and by our daily interactions with other holobionts. our health depends upon other species, making the "one health" perspective more than metaphor. the symbiotic networks of the human holobiont are enmeshed in larger symbiotic networks that sustain the planet. public health would be severely affected if any of the many life support systems on which we depend-including pollinators, soils, and bacteria-fail. indeed, symbiosis is the signature of life on earth. the nitrogen in our soil and atmosphere is made available for protein synthesis by symbioses between rhizobacteria and legumes. the interactions of plant roots and mycorrhizal fungi are critical for plant growth, while endophytic fungi are often necessary to protect the plants against dessication [154] [155] [156] . the coral reef ecosystem is dependent on the symbiosis of algae and the ectoderm of corals, while the marine seagrass ecosystems are sustained by symbioses involving clams and their bacteria. reef-building corals survive through the photosynthesis of their algal symbiont, which enters into the ectoderm of its host and transports over 90% of its photosynthetically derived carbon compounds to the host cells [157] . however, these symbioses, the very symbioses that define the planet, are at risk. these are the analogues of the microbial displacement and extinction that affect human health. although public health is mainly concerned about "human" public health, one readily finds that we cannot separate ourselves from our ecosystems socially, politically, economically, or biologically. coral reefs, for instance, are thought to support 500 million people across 50 nations and contribute nearly a trillion dollars to the world's economy [158] . the great barrier reef, alone, brings 7 billion dollars annually to australian commerce. healthy coral reefs absorb over 95% of a wave's energy, thus protecting the shoreline, preventing nearly a hundred million dollars' worth of flood damage each year. however, the coral that form the critical structure of these reefs must be seen as a holobiont that exists only in a fragile symbiosis between the coral animal and single-celled zooxanthellae algae. the coral animal provides a sunlit, safe, and nutrient-containing environment for the algae; and the algae, living within the animal cells, provide the coral with the sugars it produces by photosynthesis. the coral holobiont can survive only when its symbionts are present to provide the food resources [157, 159] . under stress conditions such as high temperatures, the symbionts are expelled from the corals, leaving the corals "bleached" and undernourished. these corals usually die. as a result of global warming, massive bleaching events and coral die-offs have occurred [160, 161] . we are writing this essay not only in the coronavirus pandemic of 2020 but in the great barrier reef bleaching event of 2020 [162] . over half the corals in the great barrier reef have perished, and some entire reefs have collapsed. the mechanisms for the expulsion of the algal symbiont from its coral host are under investigation, and it appears to be a mutual breakdown of the symbiotic relationship [163] . one hypothesis is that heat disrupts the photosynthetic apparatus of the algae, causing them to produce dangerous hydrogen peroxide radicals. the coral cells defend themselves by expelling the algae or destroying them. another hypothesis is that warmer temperatures permit algae to get the organic nitrogen that allows them to metabolize their sugars without needing the coral, thereby forcing the coral to rely on their own meager carbon reserves [164, 165] . in addition to anthropogenic heating, humans are also affecting symbiosis through domestication. mycorrhizal symbiosis is critical to plant nutrition and, therefore, a necessity for sustainable agriculture. however, artificial fertilization of soil diminishes the mycorrhizal fungi and root symbiosis. martin-robles and colleagues [166] have linked the loss of symbiotic colonization with plant domestication. indeed, failure to colonize is common, making domesticated strains addicted to artificial fertilization [167, 168] . moreover, the lack of myccorhizal fungus may make the domesticated plants more susceptible to pathogenic fungi [169] . we are integrated into these webs, where our nutrition, oxygen, and environmental temperature depend on global symbioses, and microbes are at the base of each of them. the anthropocene has put these relationships in peril. as deborah bird rose [170] wrote, "relationships unravel, mutualities falter, dependence becomes a peril rather than a blessing, and whole worlds of knowledge and practice diminish. we are looking at worlds of loss that are much greater than the species extinction numbers suggest." the vectors of disease are following the sun and following airplane and sea lanes. wastewater, tourism, and trade are circulating microorganisms around the world in a scale never before seen [171] . moreover, global warming is predicted to introduce new microbes from melting permafrost as well as bringing many insect-borne diseases (dengue fever, malaria, lyme disease etc.) into new regions [69] . here, the vector spreads a pre-existing symbiont. these will undoubtedly cause major public health concerns. however, another mechanism of disease can be predicted: when organisms reach new lands, they are capable of finding new symbiotic partners. there is a new anthropogenic mingling going on. as an example, consider the red turpentine beetle, dendroctonus valens, a minor pest species that routinely infects pine trees that have been damaged by weather or fire. like other bark beetles, it is covered by fungi. these fungi digest tree bark, allowing the beetle to have a home and mate. the fungus associated with d. valens is usually leptographium procerum. however, this beetle was introduced from the pacific northwest of america to shanxi province of china in the 1980s. in china, it met other fungi, which are much more potent at digesting wood than the american fungi [172, 173] . these newly acquired fungi can degrade a major host defensive chemical [174] . as a result, over ten million pine trees have been killed by this fungus in china. american officials are worried about a "boomerang effect" [175] . the version of the beetle with its chinese fungi may have been re-imported into the usa. however, the public health services of the various states that might be affected claim they do not have the revenue to test whether this is so. organisms are holobionts, and public health must recognize the webs of symbioses uniting different species of organisms into a collective "individual" and uniting these different individual teams into complex ecosystems. symbiosis takes two major forms-mutualism (cooperative) and parasitism (pathogenic). the emergence of antibiotic drug resistance is the anthropocene effect on parasitic symbiosis. just as anthropogenic changes in the environment have changed the populations of microbes involved in mutualistic interactions with humans, so other anthropogenic changes have increased the prevalence and virulence of parasitic microbes. until the early 20 century, the leading cause of death, world over, was infectious disease. crucial to turning this around were sanitation of water, and the discovery of antibiotics. since their discovery in the 1920s, antibiotics have become the key tool against infections caused by microbes, used across different forms of medicine. by this definition, microbes are understood as pathogenic and parasitic, dangerous, dirty, and damaging the host that they reside in. bodies are seen to be 'at war' against harmful outside invaders and entire disciplines have been hinged on this notion-immunology, clinical medicine, and public health just to mention a few. antibiotics have been the miracle weapon that have been used to tackle the looming threats of bacteria and have been said to have developed contemporary medicine to be the success story that it is today [24] . antibiotics have magnificent power to alleviate symptoms and ensure sterile conditions; they play central roles in basic surgeries, cancer, cesarean birth, and in treating basic infections. they are prescribed against infections by doctors, nurses, pharmacists, dentists, and traditional healers, depending on the contexts, all across the world. there are very few communities left that have not incorporated the use of antibiotics into their basic methods of healing, and research on those communities is tapping to their 'untouched microbiomes' microbiome as an 'oasis' [176] [177] [178] [179] . literature about antibiotic prescription describes how requests for antibiotics reside on all sides of the patient-health care practitioner dyad: patients say that health care practitioners hand out antibiotics liberally and health care practitioners argue that patients demand them [180] [181] [182] . in addition, antibiotics are bought over the counter from pharmacies, and informal markets [183] . antibiotic use is a matter of concern as excessive or unregulated use of antibiotics is connected to the development of drug resistance and while there are few new antibiotics in the pipeline, there is a need to ensure the utility of existing ones [184, 185] . antibiotic use patterns offer insights into how central antibiotics are to public health, as well as the specific practices and contexts that rely on the use of antibiotics. understanding these dynamics also illuminates the effects of pathogenic thinking as well as the myriad ways in which reliance on antibiotics would need to change in order to make space for a holobiont practice of public health. global statistics about antibiotic use show differences between countries that often follow the guidelines of health system efficiency and general national income. since the 2000s, antibiotic use in low-and middle-income countries has considerably increased, while in high-income countries, particularly with those that rely on public rather than private health care, antibiotic use has been reduced. india, pakistan and china are among those countries where use has increased most [186] , while data is unavailable in most african countries [187, 188] . that said, despite the reduction in the high-income countries, antibiotic use in many european countries and the us is still considerably higher per capita than across many african nations [186, 188] . the increase of antibiotic use in low-income countries underscores the utility of antibiotics within lagging health care systems and/or in places where people cannot afford health care. especially in countries where health care access is precarious due to lack of access, poverty, or poorly operating health systems, antibiotics have come to play a central role in how short-term health goals are achieved. for example, work by denyer willis and chandler [189] shows how antibiotics function as a 'quick fix' for well-being. this fix operates on multiple domains: to ensure productivity of humans, animals and crops; hygiene in settings of minimized resources marked by lack of infrastructures; and good health in landscapes scarred by political and economic violence. in short, antibiotic use has come to stand for development and well-being. while use of antibiotics has played a crucial role in helping to increase life expectancy, implementing invasive surgical procedures, and stand in for health care systems where they are otherwise unavailable, the use of antibiotics has accelerated embodied and ecological havoc. a narrow characterization of microbes solely as parasitic and pathogenic enemies rather than as needed and helpful partners contributes to excessive use of antibiotics for humans and animals, where microbes 'refuse' to remain contained in bodies but shift their form by evolving resistance to antibiotics. the heroic narrative of antibiotics is beginning to crumble as microbes push back. mass scale attempts to eradicate bacteria with antibiotics in humans and animals has led to increase of antimicrobial resistance (amr), making it a quintessential anthropocene problem. indeed, the mass scale of antibiotic production, beginning in the 1940s, "quickly became infrastructural to the production of many other things at scale: more health, more meat, more fruit, more surgery, less death, more fertility, in everything from in vitro embryos cultured in antibiotics to fish farming. the scale of production is also the scale of resistance" [24] . the higher-than-expected levels of amr put western medicine in its current form-where antibiotics play central roles-at risk. with antimicrobial resistance, global health literature continues to frame microbes as a threat, now an incurable threat. the most comprehensive report about amr and its future impacts, the so-called o'neill report commissioned by the uk government and the wellcome trust, indicated that 7 million people will die due to complications associated with amr [190] . this report has evoked a flurry of research efforts, systemic interventions, stewardship programmes, and funding to tackle amr. health risks for humans have been extensively documented, with resistance spreading owing to both excessive use of antibiotics for human consumption and the use of antibiotics as part of animal feeding and in husbandry. a key route by which amr spreads is via environmental bacteria that serve as vectors for the resistant genes-lateral gene transfer-which is seen to become a problem when otherwise benign environmental bacteria contribute to the spread of resistance in pathogens [24, 191, 192] . robinson et al. state that this otherwise 'natural' quality of environmental bacteria is exacerbated, for example, by the influx of antibiotic residues from human and animal faeces, and run-offs from hospitals and pharmaceutical manufacturing [193, 194] . a global comparison of socio-economic determinants correlated with amr prevalence offers insights into the crucial roles that developmental and social inequalities play in anthropocene ecology. factors predicting high amr rates are not antibiotic consumption, but, rather, differential access to sanitation, education, and public investment in health care services, as well as the level of corruption in society [195] . the focus, therefore, cannot be simply on clinical bodies, but must broaden to encompass environments including animals and infrastructures on the one hand, and social practices and power on the other. we posit that the notion of plantationocene captures this complexity that transcends the human-more-than-human bodily boundary while taking power structures into consideration. as defined above, the plantationocene constitutes the coercive labor structures and extractive and hierarchical management of planetary resources to feed an ever-growing population [17, 18] . the plantationocene acts here both an analytical and a descriptive term. analytically, plantationocene points to transnational circulations of goods, domination and dominion of people over other people and people over nature, hegemonic colonial legacies, systematisation of farming. haraway et al. [196] point to the historical origins of the term and how relocations of the substances of living and dying around the earth as a necessary prerequisite to their extraction. the logic of the plantation system makes it more efficient to destroy the local labor and import labor from elsewhere. the plantation system is built on the relocation and control of any generative unit, whether plant, animal, microbe, or person [196] . indeed, plantations were the result of one of the most catastrophic public health events in world history-the columbia exchange. a major part of this exchange resulted in the elimination of a majority (perhaps 90%) of indigenous american people by the microbes-rubeola, variola, influenza, rubulavirus, rickettsia, salmonella and bordetella-brought across the atlantic ocean by the european settlers. the great migration of people and crops took place to bring workers to areas whose native populations had perished, especially in the caribbean, where the death rate of indigenous people was probably close to 99% [197] [198] [199] . intensive labour was needed to produce crops in north and south america, and the 'workers' at plantations were slaves shipped from west and central africa-now sites that have the least infrastructure to surveil and control amr, but have the most troubling evidence of amr prevalence [187, 200] . these were also sites of resource extraction as well as subjected to structural adjustments in the 80s by the world trade organisation to privatize health care and social welfare, resulting in poor health care and sanitation infrastructures and overall poverty that now are known to be key factors for the development of amr. the industrial agriculture of the plantationocene may also contribute to the spread of drug resistant microbes. the recent increase in resistant fungicides such as candida auris, that has caused tremendous concern among health practitioners and ecologists alike, is a resistant yeast that has contaminated entire hospitals [201, 202] . its spread has environmental vectors-resistance has developed in connection to the use of fungicides in monocropping [203] . environmental and agricultural practices are thus directly connected to public health concerns. amr with plantationocene underscores that public health needs to re-think its relationships with bacteria and antibiotics-it cannot bracket out environmental extraction, socio-economic injustices and the on-going need for health systems strengthening as factors that create the conditions for why excessive antibiotics are used that lead to antimicrobial resistance. amr by this definition is not an exemplary threat by microbes as is framed in global public health but should be seen as a result of the modernist, eradication approach towards microbes that requires rethinking. health is a negotiation between microbes and hosts. holobiont public health would do well to recognize both the parasitic and the mutualistic branches of symbiosis [204] it would also recognize the two major changes in our scientific knowledge of microbial evolution that have occurred in this century: (1) organisms are holobionts composed of several species, wherein microbes help maintain healthy physiology and resilience; and (2) bacteria can pass genes through horizontal genetic transmission, thereby facilitating the rapid spread of antibiotic resistance through numerous bacterial species. symbionts must be seen as partners and respected as agents with their own agendas. three recent examples of holobiont "management" for public health should be mentioned in this regard. the first concerns the public health against mosquito-transmitted diseases such as dengue, zika, and chikungunya by using wolbachia bacterium to infect aedes egypti mosquitos. wolbachia infects numerous insects, but not these species of mosquitos. however, wolbachia can become a symbiont in these insects, preventing the acquisition or replication of viruses inside their cells. scientists have been able to get wolbachia to grow inside aedes cells, and wolbachia-infected mosquitoes have been released into the wild. where this has happened, there has been significant drops (up to 76%) in reported cases of the vector-transmitted diseases [204] [205] [206] . the second holobiont-informed type of public health involves seeking alternatives to antibiotics and partnering with microbes capable of keeping pathogens in check. if symbionts help protect hosts from pathogenic bacterial infections, then symbiotic microbes would be a good place to start looking for new antibiotics. this is especially true of antibiotics for gram-negative bacteria. the antibiotics currently in use were developed in the 1960s, and several bacterial species have successfully been evolving resistance to them. certain nematode worms are susceptible to the same types of gram-negative bacteria as humans, so imai and colleagues [207] sought out the antibiotics made by the symbiotic strains of bacteria found in the nematode guts. by screening chemicals made by these symbionts, they have isolated darobactin, a modified and crosslinked 7-amino acid peptide. this antibiotic acts by disrupting the cell envelope of the gram-positive pathogens and is largely non-effective in destroying human gut commensals. the experiments further show that this new antibiotic is effective at protecting infected mice given potentially lethal infections of gram-negative bacteria. the third approach recognizes the importance of microbes to the life cycles of parasites and seeks to kill the parasite by killing its symbionts. this approach has worked in eliminating schistosoma mansoni, a filariasis worm that has become resistant to the drugs traditionally used to kill these parasites. a newer treatment strategy has been to use antibiotics (such as doxycyline) against its symbiotic bacteria [208, 209] . once the antibiotic destroys the symbiont, the worms' cells undergo apoptosis and the worms die [210] . a similar strategy is being considered to eradicate the plague locusts that are now devastating east africa. here, a locust-specific fungus might be sprayed on the juvenile locusts as they develop their wings. this fungus would grow inside the maturing insect and consume it from within [211] . we need to be in symbiosis with bacteria on a social, as well as on a corporal level. like the body, we need to be able to distinguish mutualistic from pathogenic microbes and treat them differently. humanity has been given notice. a paper by the alliance of world scientists [212] "puts humanity on notice that the impact of climate change will depend heavily on the responses of microorganisms which are essential for achieving an environmentally sustainable future." public health must take note that we humans are never independent of nature and, therefore, must be expanded to preserve environmental health as well as human and animal health. resilience to perturbations is increased by 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declare no conflict of interest. key: cord-006130-x8kl9bx4 authors: lee, connal; rogers, wendy a. title: ethics, pandemic planning and communications date: 2014-05-27 journal: monash bioeth rev doi: 10.1007/bf03351458 sha: doc_id: 6130 cord_uid: x8kl9bx4 in this article we examine the role and ethics of communications in planning for an influenza pandemic. we argue that ethical communication must not only he effective, so that pandemic plans can be successfully implemented, communications should also take specific account of the needs of the disadvantaged, so that they are not further disenfranchised. this will require particular attention to the role of the mainstream media which may disadvantage the vulnerable through misrepresentation and exclusion. in this article , our focus is on the central role played by communication in a public health emergency such as a flu pandemic, and th e ethical issues that arise from communication in this context. the two main eth ical issues d iscussed here are the need for effective communication, in order to ensure compliance with and therefore successful implementation of flu plans , and the need for communication strategies that do not exacerbate existing inequalities in the community. we will argue that ethical communication must be both effective and just. a flu pandemic will pose major threats to health and safety and has the potential to disrupt normal life in a variety of ways . measures such as case isolation, household quarantine, school or workplace closure and restrictions on travel figure prominently in many flu plans.p these measures will be requir ed to reduce the risks of contagion, leading to limitations on citizens' usual liberties. compliance from the public is required for measures su ch as quarantine and social distancing to be effective . whilst there is debate about the level of compliance required for effective containment of infection. " there is th e ri sk that non-compliance with restrictive measures from very small numbers of individuals may spread infection . it has been predicted, for example, that border restrictions and /or october 2006 internal travel restrictions must be more than 99% effective if they are to delay spread of infection by more than 2 to 3 weeks. 4 given the types of liberty-limiting arrangements that a pandemic will bring, it is important to recognise the potential for pandemic plans to be undermined by individuals and groups failing to comply with directives . one manner in which this is likely to occur is through an illinformed populace. if people are unaware of what is to be expected and how to respond appropriately, then there is the risk that pandemic plans may be undermined by a lack of co-operation from the public. inadequate communication during the sars epidemic has been identified as one factor associated with the genesis of panic in the community and weakened co-operation and support from the public. 5 another manner in which non-compliance may occur is through some people and groups viewing directives and government orders as unrepresentative or illegitimate. measures such as quarantine may be jeopardised by a refusal to comply with directives seen to lack fairness or authority. therefore, effective communication with the public is important for ensuring, to the extent possible, that all individuals both understand what is required of them and see restrictive measures as legitimate and worth adhering to. international communication guidelines draw attention to the need for communicators to understand existing public beliefs, opinions and knowledge, thus contributing to the public's involvement, or sense of involvement, in the planning and implementation process. 6 effective communication alone, however, cannot guarantee that the public will comply with directives, as people may act in selfinterested ways not consistent with pandemic plans. effective and efficient communications should therefore be seen to be necessary but not sufficient for implementing pandemic plans. further, communications should not only be efficient and effective but also just. in the following sections, we argue for ethical pandemic communications that overcome barriers to accessing information and avoid inequalities imposed by current media arrangements. avoiding unnecessary harms caused by a lack of information can help to prevent greater disadvantage to the worst off. firstly, however, it is important to outline the role of communications in pandemic planning. communication can take many different forms . of these, the media has been recognised as having a key role to play in effective implementation of a plan in the event of a pandemic outbreak. the world health organisation, for example, specifically identifies the role of the media and draws attention to the need for public officials to utilize the press as a means of communicating with the public. 7 (1) public knowledge. communication strategies should aim at increasing public awareness about what is involved in a pandemic. the media should playa central role in informing the public of the content of pandemic plans, as well as contributing to the public's (4) public rationality. in terms of creating and maintaining a social climate of rationality , it will be important that media information regarding risks and potential rationing of resources is not overplayed or sensationalised and is proportional to the actual threat at hand, thereby avoiding unnecessary public alarm. as thomas may points out, developing a communications infrastructure designed to accurately convey information can go a long way to mitigating crises created through fear. 11 (5) equity. there will be an ethical imperative to recognise and address inequalities in communications. if inequalities in access to information are not addressed , then there is the concern that some groups and individuals will miss out on vital information . as it may take only one ill-informed individual to spread disease, reaching every available person should be a priority in the event of a pandemic. inequalities in control over the mainstream media pose a potential threat to pandemic plans. as we discuss below, exclusion, m isrepresentation and stigmatisation of groups and individuals by the press may lead to a climate of non-compliance , thereby jeopardising the welfare of the whole population. (1) inequalities in access to information. with regard to access to information, people vary both in their ability to receive information and to act on this. addressing inequalities in access therefore requires making information directly accessible for the public and ensuring that information is sensitive to the varying needs and interests of different individuals and groups in society so that it is information that people have the capacity to act on. we have identified three ethical issues that should be recognised and addressed in overcoming inequalities in access to information. these are: barriers to accessing information; voluntary versus involuntary lack of access to information; and provision of information that is relevant to people's capacities. (a) barriers to accessing information. many influenza plans are available on internet sites. this is inadequate communication from an ethical point of view, as it places the burden of responsibility on individuals to access information.p in planning for a public health crisis such as a pandemic, there needs to be more than a formal capacity to access necessary information. this should necessarily involve a concerted effort by governments and authorities to ensure that information reaches people in forms that are readily accessible.p including but not limited to the mainstream media. inequalities in access to information may be due to a range of factors such as geographic isolation, disabilities related to visual or hearing impairments, or decreased access related to long or irregular working hours . whilst these inequalities may not be in themselves unjust, they are inequalities that affect access to information and have the potential to jeopardise successful pandemic planning. there is a strong moral imperative to address and rectify inequalities in access that arise from involuntary circumstances. if some individuals are unable to comply with directives because their capacity to access information has not been considered, there is an ethical duty to ensure that people are not unnecessarily harmed when they could have been protected if given appropriate information. overcoming all inequalities in access may not be possible, however, if we include inequalities resulting from voluntary actions, such as never watching or listening to the news or reading mail delivered to the home. overcoming voluntary refusals to accept information may require significant, costly and overly burdensome interventions in people's lives, and therefore not be as morally justifiable as overcoming involuntary barriers. addressing the issue of access must also take into account what kinds of information are most important for individuals to receive. we suggest that this must involve adequate consideration of how capable people are of understanding and acting on directives. this requires a match between the content of the information, including instructions for action, and the resources and capacities of the recipients of that information. there is an ethical imperative to ensure that the varying information requirements of the population are adequately considered.vt during the build up to hurricane katrina, for example, the community received information advising them to leave new orleans or seek refuge in the superdome stadium. however, this information did not take into account the varying capacities of groups and individuals to act upon the directives given. this type of advice did not assist already vulnerable groups (such as people in poor health or with disabilities) who lacked the resources to abandon their property in the absence of insurance and assurances that they would be adequately taken care of. 15 in this case the information available to the less well-off in new orleans was neither relevant nor particularly useful given the realities of people's circumstances. perhaps more importantly, the effect was to widen inequalities, as those who were well enough off to comply fared better than those who were not so able. communication during a pandemic must be sensitive to how capable people are of acting on information important to their health and well being, and the likely compounding effects on existing inequalities. it could be argued that it was not the nature of information distributed in the case of katrina that was the problem; rather, it was the poor socio-economic circumstances of much of the population together with the lack of other necessary resources. however, it is important to note that in the subsequent media reports , there was stigmatisation of those who had not complied with the advice, with the implication that much of the ensuing human disaster was the fault of the victims themselves, rather than anything else such as lack of capacity to follow the advice. in situations like this, the lack of appropriate information for the disadvantaged is exacerbated by media communication that is not sensitive to the capacities of people to act on that information. we will now look at inequalities in control over media content and give a brief account as to why addressing these inequalities is necessary for achieving compliance and avoiding extra injustices in the event of a pandemic. (2) inequalities in control over media content. in the event of a pandemic, inequalities in access to and control over the media may cause a number of problems, limiting the successful implementation of pandemic plans . this is critical when, as for example in australia, media ownership is concentrated in the hands of a few whose interests do not overlap with the role of communication outlined above. not everybody in society has the freedom to engage in and influence media discourse. in terms of the ability of individuals and groups to engage in the public forum, rawls' theory of justice is helpful for making an important distinction between liberty and its value. liberty, according to rawls, is the complete structure of the liberties of october 2006 citizenship, whilst the worth of liberty is the value a liberty has for individuals and collectives depending upon their ability to advance their ends. 16 for example, the value of freedom of speech is worth more to a radio-based 'shock jock' with the means of advancing their point of view than to an unemployed person lacking the capacities and opportunities to advance their interests through the media. mainstream news favours the interests and values of those with a stake in the media business ahead of any competing ethical principle such as the public interest or reducing inequities. here we take stakeholders to include advertisers, audiences, and those who work directly for media firms . as a result, the content of news stories, particularly within the commercial press, is typically slanted towards the interests of stakeholders, with consequent disenfranchisement of non-stakeholders . there are two main ways in which the mainstream media can have a negative impact on those who lack power and influence over the press: misrepresentation and exclusion of nonstakeholders. (a) misrepresentation of non-stakeholders. in the event of an influenza pandemic, media misrepresentation of the interests and claims of nonstakeholders, in particular the least well -off sections of the community, may be problematic. there is a risk that individuals and groups who protest current arrangements may be presented to audiences as disruptive and unhelpful to the situation. this has the potential to weaken compliance levels during a pandemic. the misrepresentation of some groups may lead the public at large to view these groups as troublesome, leading to further marginalisation. if this occurs, then it is unlikely that these groups or individuals will embrace the notion of 'civic duty', which is an important aspect of accepting liberty-limiting arrangements."? it will be concerning from an ethical standpoint if misrepresentative media coverage facilitates discrimination against certain groups, as happened in canada where there was public boycotting of chinese business interests after the outbreak of sars was linked to a chinese national.l" thus it is not difficult to imagine that in the event of a pandemic, certain groups will be treated less than fairly by the media, such that the public will also treat these groups unfairly. overall this inequality in representation of points of view , claims and interests is likely to impact negatively on pandemic plans. the interests of non-stakeholders are not well represented in the mainstream media. this means that in a pandemic, their information needs may be largely ignored, and their interests unnoticed, by the wider society.t? the exclusion of some groups may lead to a lack of understanding about the legitimate claims of these groups. this will be damaging for pandemic plans, particularly if certain groups have justified claims. for example, it may be that arrangements for dealing with a pandemic are actually harmful for some individuals or groups.s? a greater likelihood of infection in communities that lack infrastructure could lead to demands for extra resources in the event of a public health crisis. if the claims and view points of these groups are excluded from the press, then wider society simply will not understand what those claims and views are and how they might contribute to more effective handling of pandemics. it is important to note here that we do not want to develop an account of how the media ownership model could, or in fact should, be restructured in order to overcome the problems that we have identified. rather, we see it as important to highlight the specific problems that arise with current media arrangements that will, in the event of a flu pandemic, harm the vulnerable, despite any public perceptions that a privately owned press is a free and independent press. it is of course possible that privately owned media may act out of self-interest to promulgate effective communication, or be persuaded to act with benevolence. however, we suggest that more concrete action from pandemic planners and governments will be necessary to ensure that communications are equitable. having outlined how mainstream media may undermine pandemic planning, we now look in more detail at the effect that media bias may have on disadvantaged groups and individuals. living conditions and community infrastructure both have a bearing on how susceptible to infection a given community may be, or how well prepared and equipped a given community is to deal with infection.v' situations of socio-economic disadvantage facilitate transmission of infectious diseases, as we have seen to date with the patterns of emergence and transmission of both sars and bird flu. 22 given the potential for increased burden of disease amongst the disadvantaged, it may be particularly harmful for the effective implementation of pandemic plans if less well-off sections of the community and vulnerable groups are not given a voice through the media. this increased vulnerability to infection places a disproportionate amount of responsibility on the disadvantaged to act in ways that will not spread illness, adding to the moral imperative to support these groups through equitable communications. the increased risk of infection faced by disadvantaged groups is likely to put them in a position whereby they become subjects of news. given the above concerns regarding the fair representation of disadvantaged communities in the media, a pandemic may create a climate of news coverage that misrepresents,stigmatises and excludes the disadvantaged or vulnerable. we already have experience of this, for example, with news stories regarding hiv/ aids in the 1980s that contributed to stereotypical and harmful perceptions of the homosexual community, as well as leading to a lack of understanding by society at large as to how the virus is contracted.v' the potential for a pandemic outbreak to make the worst off even more worse off must be a consideration in structuring an ethical approach to communications. as the main communicative force in our society, the media will playa central role in communicating the ethical underpinnings of arrangements and decisions; as such the media will contribute to and influence how the public perceives the fairness of measures such as priority vaccination and distribution of resources. as well, the press will influence the public's judgement of how well state directives protect or have protected the public from harm. however, inequalities in control over media content suggest that the public may well be given a biased interpretation of the effectiveness of a given plan in safeguarding the collective interests of society, with the risk that pandemic reporting will favour the interests of wealthier sections of the community. in the event of an influenza pandemic, already vulnerable groups and communities will not only be in a position of greater risk with regard to infection, existing inequalities in media communications and infrastructure will further compound their vulnerability. by addressing these inequalities, it is possible to identify an ethical approach for communications about pandemic plans. in tum, addressing inequalities in communications means that pandemic plans are less likely to be undermined by groups and individuals not complying because their information needs have been ignored and their interests and points of view have not been fairly represented. box 1 lists four features of ethical communications strategies. box 1: features of ethical communication strategies 1. equity in access to information 2. active redress of existing media inequities 3. decrease extra burdens on disadvantaged 4. increase information, legitimacy and trust taking these into account, we believe it is possible to implement pandemic plans with greater efficiency, effectiveness and compassion. we suggest that if policy makers and pandemic planners attend to inequalities in communication, this will help to avoid unnecessary disaster and spreading of disease, and also ensure that disadvantaged individuals and groups are not made more disadvantaged in the event of a public health crisis, as occurred in new orleans. endnotes earlier versions of this paper were presented at the 8th world congress of bioethics, beijing, china, august 6-9, 2006, and the australasian bioethics association annual conference, brisbane, july 28, 2006 . we are grateful for comments received at these conferences, and from the anonymous reviewers. monitored, especially with respect to prospects for providing fair benefits to , and avoiding undue burdens on, disadvantaged groups, so that corrective adjustments can be made in a timely manner". for example, see th e european un ion public health in flu enz a website that offers access to flu plans detailing containment strategies , including liberty limiting arrangements: http:j jec.europa.eujhealthjph_threatsjcomjinfluenzaj influenza_en.htm reducing the im pac t of the next in fluenza pandemic using household-based public health in terventions stra tegies for mitigating an in fluen za pandemic the public's response to se vere a cute respiratory syndrome in toronto and the united states world health organisation, outbreak communication guidelines medical countermea sures for pandemic influenza: ethics and the law see for example the who outbreak communication guidelines, op . cit. , p . 4, which emphasise the rol e of trust and transparency in successful implementation of pandem ic plans clin ical decis ion m aking d u ring public health emergencie s : ethical con si de rations public co m m u nication, risk pe rception , and the via bility of preventa tive vaccina ti on against co m m u nicable d is ease s preparin g for an infl uenza pandem ic com mu nicati ng the risk s of bioterrori sm and other eme rge ncies in a d iverse society: a case stu dy of special populations in north dakot a afte r the flood oxford uni versi ty pr es s it will be important for people to accept liberty-limiting arrangem en ts, and this ofte n in volve s the public viewing co m pliance a s a civic resp on s ibility or duty. see for example the tor onto join t centre for bioethics pandemic influenza working gr oup rep ort, stand on guard for thee -ethical co nside rations in pr ep aredne s s planning for pandemic influenza , tor onto see al so sc hram j , 'how po pu lar percep tion s of ris k fro m sars are fermentin g dis crimination exp loring jou rnalis m ethics , sydney: un ivers ity of new south wal es pres s the bellagio sta te me n t of principle s h ighligh t s the n eed to m ake available accurate, u p-to -date and easily und erstood in for mation about avian and huma n pa ndem ic infl uenza for d isa dvantaged gro u p s . in particula r , prin ciple v states key: cord-308095-mehmk49a authors: marks, jonathan h. title: lessons from corporate influence in the opioid epidemic: toward a norm of separation date: 2020-07-13 journal: j bioeth inq doi: 10.1007/s11673-020-09982-x sha: doc_id: 308095 cord_uid: mehmk49a there is overwhelming evidence that the opioid crisis—which has cost hundreds of thousands of lives and trillions of dollars (and counting)—has been created or exacerbated by webs of influence woven by several pharmaceutical companies. these webs involve health professionals, patient advocacy groups, medical professional societies, research universities, teaching hospitals, public health agencies, policymakers, and legislators. opioid companies built these webs as part of corporate strategies of influence that were designed to expand the opioid market from cancer patients to larger groups of patients with acute or chronic pain, to increase dosage as well as opioid use, to downplay the risks of addiction and abuse, and to characterize physicians’ concerns about the addiction and abuse risks as “opiophobia.” in the face of these pervasive strategies, conflict of interest policies have proven insufficient for addressing corporate influence in medical practice, medical research, and public health policy. governments, the academy, and civil society need to develop counterstrategies to insulate themselves from corporate influence and to preserve their integrity and public trust. these strategies require a paradigm shift—from partnerships with the private sector, which are ordinarily vehicles for corporate influence, to a norm of separation. the opioid epidemic has claimed the lives of more than 400,000 americans in the last two decades (cdc 2019a) . it has devastated families, destroyed entire communities, and drained the resources of social services. opioid addiction and deaths impose societal costs that, in the united states alone, are now measured in the trillions of dollars (cea 2017 (cea , 2019 , with many of these costs falling on underfunded local and state government agencies. in recent months, much evidence has emerged demonstrating the ways in which opioid companies' strategies of influence fuelled the crisis. companies built relationships with a variety of individuals and institutions: physicians, professional societies, patient advocacy organizations, research universities, public health agencies, and legislators. although the impact of these strategies has been most closely observed in north america, their reach is international. previous analyses of corporate influence in the pharmaceutical sector make clear that the opioid companies' strategies are not entirely novel (see, e.g., applbaum 2009 ). some of the leading case studies should have been cautionary tales because they also involved prescription medicines for the treatment of pain (see, e.g., steinman et al. 2006; ross et al. 2008) . a number of corporate strategies were honed within the drug and medical device sector-for example, hiring "medical education and communication companies" (or meccs) to shape the evidence required for the approval and promotion of new products and recruiting physicians as "key opinion leaders" (kols), a title designed to be psychologically rewarding, and paying them to deliver scripted promotional presentations to their peers (sismondo 2018; sah and fugh-berman 2013) . but many strategies were developed with the advice and guidance of the kinds of entities-public relations, management consultancy, and crisis management firmsthat were previously hired by tobacco companies and other industries to cast doubt on the harms caused by their products or commercial practices (see, e.g., michaels 2008; armstrong 2019; michaels 2020) . these strategies are both extensive and comprehensive, involving webs or networks of relationships with government, the academy, and civil society (marks 2019a) . although relationships are widespread at institutional levels, media attention tends to focus on individualsmost commonly, excoriating doctors and researchers for failing to disclose that they have industry-related financial conflicts of interest. the focus on "naming and shaming" individuals, even when warranted, threatens to downplay or ignore a systemic problem: institutional and societal cultures and practices that embrace partnership with industry and, wittingly or unwittingly, promote companies' products, increase brand loyalty, burnish corporate reputations, defuse support for the regulation of companies' products and marketing practices, and reinforce the framing of public health problems and their solutions in ways that are least threatening to the commercial interests of those companies (marks 2019a) . nowhere is this more evident than in the origins of and responses to the opioid crisis, where collaborative efforts to address pain management-an important and historically neglected problem in medicine and public health-have profoundly exacerbated another major public health challenge, addiction (see, e.g., meier 2018; macy 2018; mcgreal 2018) . opioid companies' strategies were designed to expand the prescribing of opioids from terminal cancer patients to a larger and more lucrative population: patients with non-cancer-related acute and chronic paindespite lack of evidence of efficacy in relation to the latter. companies promoted-some would say pushed-higher doses of opioids in order to increase profits further, while downplaying the risks of addiction and abuse. in addition, companies framed both doctors and patients as the problem. physicians who had legitimate concerns about the addictive properties of opioids were characterized as having "opiophobia." this term, coined by purdue pharma, the manufacturer of arguably the most well-known prescription opioid, oxycontin, later found its way into guidelines of the world health organization (who) (clark and rogers 2019) . these guidelines remained in effect for the better part of a decade until they were "discontinued" by the who in june 2019 in the wake of revelations of corporate influence (who 2019). patients who became addicted were, of course, not characterized as victims of an aggressive marketing and public relations strategy. when richard sackler was president of purdue pharma in 2001, he urged colleagues to blame and "hammer" patients, describing them contemptuously as "abusers," "culprits," and "reckless criminals" (zezima and bernstein 2019) . most of the media attention has focused on purdue pharma-and on members of the sackler family who are major shareholders. 1 however, it is important to keep in mind that this company was only one of several drug companies that promoted their opioids by building webs of relationships with a variety of public health agencies, academic institutions, and public health ngos, as well as thousands of individual health professionals. a recent trial in oklahoma shed light on the activities of johnson & johnson, a family of companies that has not only sold its own opioids but also supplied the active ingredients to several other opioid companies, including purdue pharma (hoffman 2019a (hoffman , 2019b . for that reason, johnson & johnson had an additional incentive to engage (and did engage) in the unbranded promotion of opioids. the criminal trial of the former executives of another company, insys, also shed light on its fraudulent marketing practices (emanuel and thomas 2019) . we know more about the "webs of influence" woven by these companies than about the strategies of other companies that have been more successful, thus far, at keeping evidence out of the public domain-often by settling cases before they go to trial. but there is clear evidence that aggressive promotion strategies were widespread, to varying degrees, across the opioid industry (horwitz et al. 2019) . building on other recent work (marks 2019a (marks , 2019b (marks , 2019c , i will 1 the sackler family's arts philanthropy has attracted much attention. i focus my analysis here on relationships with entities in health and policy spheres because they appear to have most directly contributed to the opioid crisis. but i recognize that arts philanthropy also merits ethical scrutiny that i cannot provide in the space permitted. tease apart some strands of the known webs of influence of the opioid industry before reviewing the cumulative effects and exploring the ethical and policy implications. arthur m. sackler died in 1987, long before purdue pharma's 1996 launch and subsequent aggressive marketing of its leading opioid brand, oxycontin. but the roots of pharmaceutical marketing to physicians go back seven decades (greene and podolsky 2009) , and sackler was a vital rhizome (podolsky, hertzberg, and greene 2019) . he may not have invented the practice of medical marketing but, as the medical advertising hall of fame put it: "no single individual did more to shape the character of medical advertising than the multi-talented dr. arthur sackler. his seminal contribution was bringing the full power of advertising and promotion to pharmaceutical marketing" (podolsky 2015, 25) . the extent and efficacy of opioid marketing in recent years has arguably gone far beyond sackler's wildest dreams or, more charitably, his worst nightmares. between 2014 and 2015, roughly one in seven physicians in the united states received opioid-related gifts from pharmaceutical companies (hollander et al. 2019 ); another analysis of a similar period puts the figure for family physicians even higher at one in five (hadland, krieger, and marshall 2017) . during this time, physicians wrote more than seventy opioid prescriptions per year for every hundred americans (cdc 2019b). unsurprisingly, studies have found the receipt of payments from opioid companies is associated with increases in physicians' prescribing rates (hadland et al. 2018; hollander et al. 2019) . that is, of course, the reason drug companies engage in such practices, and similar effects have been found in relation to a variety of other prescription drugs. but disturbing recent research reveals why, in the case of opioids, the resulting increase in prescribing is especially problematic. a study of 67,507 physicians in 2,208 counties across the united states between 2013 and 2015 concluded that drug companies' marketing of opioids to physicians was associated with not only increased opioid prescribing but also elevated mortality from overdoses (hadland, rivera-aguirre, and marshall 2019) . more troubling still, court documents recently filed by the attorney-general of massachusetts allege that doctors who met with purdue pharma drug reps were ten times more likely to have prescribed opioids to patients who later died of an overdose than physicians who prescribed opioids without having met the company's drug reps (attorney-general of massachusetts [a.g. mass.] 2019; joseph 2019a). in february 2018, purdue pharma said it would stop marketing opioids to physicians (poston 2018 ). but we should not derive any comfort from these kinds of voluntary commitments. first, the massachusetts court documents make clear that the company continued its aggressive marketing strategy for at least a decade after it pleaded guilty in 2007 to misleading physicians and patients by downplaying the risks of addiction and abuse of its leading brand, oxycontin (meier 2007) . that strategy was complemented by an insidious kickback scheme: purdue pharma paid a technology company to generate prompts in electronic health records (ehr) software encouraging physicians to prescribe more opioids (farzan 2020) . second, a consortium of companies known as mundipharma, also owned by members of the sackler family, has been making efforts to expand opioid markets internationally. while some of mundipharma's apparent practices in china go beyond what has been alleged in the united states, the broad strategy of downplaying the risks of addiction and abuse clearly resembles purdue pharma's north american strategies (kinetz 2019) . as former u.s. food and drug administration (fda) commissioner david kessler observed, "it's right out of the playbook of big tobacco. as the united states takes steps to limit sales here, the company goes abroad" (ryan, girion, and glover 2016, ¶9) . purdue pharma is just one of several opioid manufacturers that have been making payments to physicians (see, e.g., hollander 2019)-and it is not the only company to have engaged in the aggressive marketing of opioids (horwitz et al. 2019) . a u.s. senate report describes in some detail how another company, insys, engaged in similarly aggressive practices (homeland security and government affairs committee [hsgac] 2018b). the report revealed that executives emphasized to their sales reps the importance of "owning" physicians and of "holding the customer [that is, the physician] accountable" when they failed to sustain or increase sales of subsys, a fentanyl brand. the company's new ceo informed the senate committee that the company had learned from past mistakes and replaced most of its sales force. but in the wake of multiple indictments, congressional investigations, civil lawsuits, and much highly critical media attention (see, e.g., woodson 2019), this is too little too late. it remains to be seen whether the conviction of several former insys executives for fraudand the prospect of imprisonment for several yearswill change corporate cost-benefit analyses in ways that previous fines on companies have not (emanual and thomas, 2019; raymond 2019; thomas 2020) . influencing the academy: universities and academic medical centres remarkably, academic institutions continued to accept donations from and build relationships with purdue pharma after the company and several of its executives had pleaded guilty in 2007 to misleading doctors and patients about the addiction risks of oxycontin (meier 2007) . a recent independent review (commissioned by tufts) found "no evidence of any meaningful attempt by tufts to reconsider its relationship with, or distance itself from, the sacklers or purdue" in the wake of the guilty plea-or at any time prior to the publication in autumn 2017 of highprofile magazine articles severely criticizing purdue and members of the sackler family (yurko and remz 2019, 10; keefe 2017) . tufts was not the only academic institution to accept gifts from purdue pharma after the 2007 guilty plea. in 2010-2011, mgh received an additional $3 million gift for its pain centre. around this time, the company also made gifts to promote opioids in programmes at a dozen institutions in massachusetts alone. these gifts included five-figure sums to boston university, northeastern university, and massachusetts college of pharmacy (a.g. mass. 2019). the donations made sense from the donor's perspective-at a time when opioid companies were coming under greater scrutiny, these relationships gave purdue pharma opportunities not only to influence students and doctors but also to burnish the company's reputation. but these gifts were extremely perilous to the integrity of and public trust in the recipients-as well as patient health. contemporaneous documents make these perils strikingly clear. in 2014, when purdue's medical liaison staff succeeded in getting two "unbranded curricula" approved for teaching tufts studentsdescribed by the university as "the next generation of leaders in the field of pain"-the accounts team congratulated their colleagues for "penetrating this account" (a.g. mass 2019, ¶285). in 2015-2016, the tufts university school of medicine decided not to assign as the "common book" for all incoming medical students, sam quinones' dreamland (2006) , "in significant part" because the book criticized purdue pharma for its role in the opioid crisis and there was a "desire to avoid controversy" in the donor relationships with purdue pharma and the sackler family (yurko and remz 2019, 23) . the following year some students became upset after a lecture by a senior employee of purdue pharma with an adjunct appointment at tufts (who had been giving occasional lectures on opioids for a decade). they complained that he was "sweeping the opioid crisis under the rug" and was "an apologist for the pharma industry" (yurko and remz 2019, 20) . there are also thousands of pages of emails, memoranda, and other contemporaneous documentssummarized in the complaint of the attorney-general of massachusetts made public in 2019-that reveal how purdue pharma's relationships with academic institutions provided opportunities to influence research, curricula, speaker series, and other events. these opportunities were enhanced by the appointment of purdue executives and employees to faculty and advisory boards, as well as by regular contact with these individuals (a.g. mass. 2019). in addition, one recent estimate puts the total gifts from the sackler family and its foundations to universities in the united states, the united kingdom, and elsewhere in excess of $60 million during the last five years (ap 2019). 2 in public health, corporate strategies of influence tend to involve public health ngos, as well as academic institutions. and, perhaps unsurprisingly, the leadership of these institutions often overlaps. for example, one of the founders of the tufts pain initiative also served as president of the american academy of pain medicine (a medical professional association) and on the board of the american chronic pain association (a patient advocacy organization) (joseph 2019c). as a result, pharmaceutical companies could influence professional associations and advocacy groups without making additional financial contributions to those organizations. nevertheless, opioid companies also targeted civil society groups, and gifts to these entities were a central component of several opioid companies' strategies of influence. industry funding of patient advocacy organizations (paos), professional societies, and other health-related ngos more broadly has become widespread (mccoy et al. 2017; rose et al. 2017; aaron and siegel 2017) . these organizations often face tight financial constraints and, not surprisingly, pharmaceutical companies are more than happy to "help out." although a corporate donation may be a drop in the ocean of business revenues and profits, the gift can be the main-or onlything keeping the recipient afloat (marks 2019a) . the contributions of opioid companies to paos and health professional associations have been consistent with practices in the pharmaceutical sector more broadly. a u.s. senate report revealed that five opioid manufacturers gave $9 million to fourteen patient advocacy organizations and health professional organizations over the five-year period 2012-2017 (hsgac 2018a). purdue and insys were the largest donors by far, giving in excess of $4 million and $3 million respectively. while the u.s. pain foundation received more than any other organization-in excess of $2.9 millionseveral other groups were also dependent on funding from opioid companies. notably, the academy of integrative pain management received more than $1 million and, when this funding dried up in the wake of the u.s. senate report, the organization closed because it lacked sufficient funds to maintain operations (anson 2019). the american pain society received almost $1 million from opioid companies, and it also dissolved in 2019 after facing lawsuits for its role in exacerbating the opioid crisis (mcgreal 2019). it is notable that the organizations discussed in the report continued to accept opioid industry money after one of them, the american pain foundation, closed its doors in 2012 in the wake of an investigation revealing its dependence on opioid industry funding (ornstein and weber 2012) . groups that received money from the opioid industry subsequently engaged in activities-including participation in policymaking processes-that protected and promoted the interests of their donors. as a result, some patient advocacy groups and health professional societies have been characterized as "front groups" for industry (e.g., michaels 2020). but even when organizations are genuinely created to promote the interests of patients, they can be profoundly influenced by gifts from and relationships with corporate actors-as the ethnographic and behavioural science research on reciprocity makes clear. reciprocity need not involve an explicit exchange (often called a quid pro quo); on the contrary, gifts can give rise to subtle reciprocity-which often manifests as a general disposition toward helping another (marks 2019a) . companies understand and commonly exploit this to promote policies that protect their interests. a recent study concludes that corporations "strategically deploy charitable grants" to non-profit organizations so that the recipients will comment favourably in regulatory processes (bertrand et al. 2018, 1) . the authors also found that this strategy is effective at promoting regulatory discussions more closely aligned with the companies' perspectives and commercial interests. when the centers for disease control and prevention (the cdc) issued draft guidelines in 2016 recommending greater restraint in opioid prescribing, opposition was significantly higher among organizations that had received funding from the opioid industry (lin et al. 2017) . in addition, a number of groups that received opioid industry funding lobbied against legislation restricting opioid prescribing and produced their own guidelines downplaying the addiction risks (hsgac 2018a). recently released internal documents reveal that purdue pharma considered these kinds of guidelines to be "an effective tool for selling our products" (ross 2019, ¶19). influence on health-related ngos is especially important because of the ways in which these bodies may, in turn, influence policymakers, policymaking, and the resulting policies. a recent article in the bmj expressed concern that the national academies of science, engineering, and medicine (nasem)-an ngo established by federal statute with the express purpose of providing independent advice to the federal government in the united states-had received millions of dollars from several pharmaceutical companies (including opioid manufacturers), as well as gifts from members of the sackler family (schwab 2019) . the article also expressed concern that members of nasem panels, including one commissioned to advise policymakers on clinical practice guidelines for prescribing opioids, had received payments from opioid companies (in the form of research funding, consultancy fees, and advisory board retainers). representations from bodies that appear to be independent or-at the very least, that appear to be promoting the interests of patients-may be viewed with much less scepticism by public officials than representations coming directly from companies. but, once again, opioid companies left nothing to chance. just as they made direct payments to paos and health professional associations to bolster indirect influence arising from relationships with leading health professionals, companies also reinforced indirect influence of public officials, legislators, and policymakers by making contributions to political campaigns and public health initiatives. according to the center for public integrity (cpi) and the associated press, between 2006 and 2015, opioid companies spent $880 million on lobbying and campaign contributions-dwarfing the $4 million spent by groups advocating limits on opioid prescribing, and (more surprisingly) exceeding by a factor of eight the gun lobby's political spending (cpi 2016a (cpi , 2016b . the cpi found that the industry and its allies contributed to roughly 7,100 candidates for state-level offices, employing on average 1,350 lobbyists a year, covering all state capitals. another study examined campaign contributions to members of the u.s. house and senate committees charged with responsibility for leading the legislative branch's response to the opioid crisis. it found that, during the two-year election cycle ending in november 2016, almost 90 per cent of the members of the house committee (forty-nine of fifty-five), and close to two-thirds of the members of the senate committee (fifteen of twenty-three) had received money from political action committees (pacs) that were associated with firms under investigation by state and federal officials for exacerbating the opioid crisis (mccoy and kanter 2018). once again, while shocking, this was reasonably predictable. we should anticipate that opioid companies would try to influence legislators to the full extent that the law allows in their efforts to prevent legislators from undermining their commercial interests when responding to the opioid crisis. and we should also expect that these companies' strategies of political influence would not be confined to lobbying and campaign contributions. another key element in the opioid companies' strategies-consistent with corporate strategies in other sectors such as food and soda-is to engage in partnerships with government agencies. these are often termed "public-private partnerships" or, when academic institutions and public health ngos participate too, "multistakeholder initiatives" (marks 2019a ). sometimes, it is the corporate actors that initiate these relationships; at other times, the public bodies do so. in 2017, the national institutes of health (nih) launched a "public-private initiative" to address the opioid crisis. more than one-third of the participants at its first two meetings in june 2017 were executives of drug companies, device manufacturers, or other industry actors (nih 2019). they included representatives of purdue pharma and johnson & johnson-which, along with its subsidiary, janssen pharmaceuticals, was also a defendant in opioid litigation. notably, when the nih launched the partnership initiative, it made no mention of the role that its "private partners" played in creating or exacerbating the opioid crisis in the "special report" written by the directors of the nih and the national institute of mental health (nimh) and published in the new england journal of medicine (volkow and collins 2017) . on its website, the nih director used the passive voice to avoid pointing the finger at drug companies: "the belief that people with pain would not become addicted to opioids was promoted 20 years ago in the medical community" (collins 2017, ¶2) . this statement begs the question: promoted by whom? it is not hard to see why collins avoided that question. self-censorship is common among the recipients of gifts and among public bodies participating in partnerships (marks 2019a) . the nih clearly did not want to alienate the drug companies with which it wished to partner. while the nih considered purdue pharma a "partner," the company wanted to make sure that the broader public did so too. it ran full-page advertisements in the new york times (among others) that concluded with these words: "we want everyone engaged to know that you have a partner in purdue pharma. this is our fight too" (purdue pharma 2018, ¶5). at the same time, the company appears to have been engaged in a very different kind of battle-an internal debate about whether or not to continue disputing the claim that oxycontin can be addictive even when taken as directed. on july 19, 2018, purdue ran another full-page "advocacy ad" in the washington post stating that the company was "acutely aware of the public health risks opioid analgesics can create, even when taken as prescribed" (schulte 2018, ¶2, emphasis added). but less than a week later, when the company reran the advertisement, it deleted the words "even when taken as prescribed." in addition, while the company was being described by the nih as a "partner"-and while it was positioning itself as a partner-purdue pharma was also working on plans to expand the opioid market, including the market for therapies to treat opioid addiction resulting from the company's own aggressive opioid marketing strategies (a.g. mass. 2019). to be clear, the efforts of the opioid industry to influence policymakers and prescribers were not limited to the united states. investigative journalists have uncovered similar efforts to exploit international markets (ryan, girion, and glover 2016; kinetz 2019) . and these efforts appear to have increased as opioid prescribing came under increasing scrutiny in the united states. global promotion has been spearheaded by mundipharma, a consortium of companies with offices in more than 120 countries. a recent congressional report produced by the offices of two u.s. representatives outlined the ways in which this consortium appears to have successfully influenced at least two who policy documents related to opioid prescribing-including 2012 guidelines that address pain management in children (clark and rogers 2019; who 2011 who , 2012 . in several ways, these guidelines (which were discontinued by the who in 2019 in the wake of the congressional report) were remarkably consistent with purdue's marketing strategies. for example, they embraced purdue's characterization of doctors' concerns about prescribing opioids as "opiophobia." the guidelines also stated that there is no maximum dose for opioidseven in the case of children. (purdue pharma and other opioid companies pushed broadly for higher doses, as they are significantly more lucrative than lower doses.) the congressional report also highlighted the role of patient advocacy organizations, professional associations, and industry-favourable articles published in their journals as avenues for indirect influence on the who (clark and rogers 2019). although purdue pharma has received considerable media attention in recent months for the aggressive marketing of opioids, it is important to keep in mind that several companies are alleged to have engaged in such practices. the picture that emerges is one of multiple corporations making gifts to and partnering with a variety of public health agencies, academic institutions, and health-related ngos. these gifts and relationships were part of larger strategies that were intended to have, and did have, a number of interrelated effects-all of which served to increase the revenues and profits of the opioid companies. the strategies were designed to expand the base of patients who would be prescribed opioids from (often terminal) cancer patients to non-cancer patients experiencing either acute or chronic pain; to promote the acceptance of opioids as the drug of choice in such cases, despite the lack of evidence as to their efficacy (especially for chronic pain); to expedite the prescribing of opioids in place of other analgesics and pain therapies; to downplay the risks of addiction and abuse; to characterize doctors' concerns about addiction and abuse as "opiophobia"; to promote the view that opioids are not addictive when taken as directed; and to blame patients when they became addicted. the success of the opioid companies in these respects was the result of both independent and coordinated action. corporations may influence policymakers through both kinds of activity, and trade associations often play a major role in coordinating action to influence policy in the pharmaceutical sector. phrma (pharmaceutical research and manufacturers of america), the main trade association representing pharmaceutical companies in north america, has coordinated an industry response to the opioid crisis. as two new york times journalists recently put it, "phrma is trying to position the industry on the right side of a health crisis that many blame it for creating" (corkery and thomas 2018, ¶10) . the article in which that observation was made raised legitimate concerns about phrma providing funding to the patient advocacy organization, addiction policy forum. of course, the trade association's support of this advocacy group is not an isolated relationship; it is part of the concerted strategy intended to influence the perceptions of policymakers, physicians, and patients (among others). drug companies want us to see them as partners in developing solutions to the opioid crisis, rather than actors responsible for creating or exacerbating the crisis. mirroring statements made by the nih and the national institute on drug abuse (nida), phrma issued its own press release announcing that it was "working to establish a public-private partnership" designed to "accelerate the development of innovative new treatments and therapies" (phrma 2017). these are examples of what might be considered corporate coordination-collaborative efforts to influence policy and practice often mediated by a trade association. however, it is important to recognize that the independent actions of companies may also be highly influential, even when competitive. we saw above how five different opioid companies all made financial contributions to patient advocacy organizations and health professional associations related to pain management. to some extent, these activities might be regarded as concurrent-each company giving money with the intention of fostering an even more permissive attitude toward the use of opioids that would be reflected in the recipients' representations to policymakers. but some of these activities might be considered competitive to the extent that the company making the donation intended to generate more prescriptions for its opioids by "stealing" potential patients from its competitors. recent court filings in massachusetts, for example, provide evidence of the competitive strategies of purdue pharma (see a.g. mass. 2019). but whether concurrent or competitive, the effect of these contributions was the same: to influence the public statements and representations of civil society groups so that they too favoured the relaxation of prescribing guidelines and downplayed the addiction and abuse risks. competitive and coordinated corporate strategies of influence may occur simultaneously as well as sequentially. as manufacturers of opioids and suppliers of active ingredients to other opioid companies (hoffman 2019a), the johnson & johnson family of companies (which includes janssen pharmaceuticals) had an additional incentive to engage in both strategies. so, any counterstrategy intended to insulate governments, universities, and public health ngos from corporate influence should also address both strategies. the significance of these forms of influence becomes especially important when we consider the ethical challenges presented by public-private partnerships, which have become the dominant paradigm in public health. as i noted above, the nih launched a "public-private initiative" in response to the opioid crisis, bringing together representatives of dozens of pharmaceutical companies. policymakers often justify the practice of "engaging" with multiple competing corporations in a partnership initiative on the grounds that this ensures no single corporation receives preferential treatment. however, it is important to recognize the ways in which incorporating multiple powerful corporate actors from the same sector in a partnership can be ethically problematic. bringing together multiple pharmaceutical companies can transform their concurrent actions into coordinated action-thereby magnifying the companies' influence. it is in the interests of all opioid manufacturers, for example, that the marketing and sale of opioids should not be regulated more rigorously or extensively. it is also in the interests of all pharmaceutical companies, whether or not they are currently manufacturing or selling opioids, for public health agencies to focus on pharmaceutical responses to pain management and opioid addiction. the traditional lens for understanding and addressing corporate influence in medicine and public health has been conflicts of interest. the definition of conflict of interest most frequently employed in this context is the one adopted by the institute of medicine (now the national academy of medicine) in the u.s.: "a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest" (lo and field 2009, 46) . 3 but framing the problem of corporate influence as financial conflicts of interest tends to have two consequences. first, while conflicts of interest can be defined broadly to include institutional conflicts, attention is usually focused on individuals rather than institutions-for example, physicians who receive payments from drug companies, rather than academic medical centres or universities that might have equally problematic relationships with drug companies. notably, a recent independent review commissioned by tufts to explore the university's relationships with purdue pharma and the sackler family found that, while there were policies addressing individual conflicts of interest, the university did not have-and needs to establish-a comprehensive institutional conflicts of interest policy (yurko and remz 2019) . investigative journalism also tends to highlight individual physicians who have failed to disclose financial conflicts of interest arising from their relationships with corporate actors (e.g., ornstein and thomas 2018) ; less attention has been paid to institutional practices and cultures that might promote such behaviours. conflicts of interest at the institutional level tend to be poorly managed, if they are managed at all, and rarely are they eliminated (marks 2019a) . once conflicts of interest have been recognized as a problem, the most commonly touted policy solution is disclosure of the conflict. the physician payments sunshine act (ppsa)-part of the affordable care actplaces the responsibility on drug and device manufacturers to disclose their payments to physicians and teaching hospitals (richardson 2014) . section 6111 of the substance use-disorder prevention that promotes opioid recovery and treatment for patients and communities (support) act of 2018-entitled "fighting the opioid crisis with sunshine"-expands the scope of transactions covered by the ppsa to include payments to physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anaesthetists, and certified nurse-midwives-commencing in 2022. several scholars have also explored whether this requirement should be further extended to include payments made to patient advocacy organizations (e.g., mccoy 2018; kanter 2018) , and in october 2018, senator mccaskill introduced a bill to this effect shortly before she lost her seat in the u.s. senate. disclosure of financial conflicts of interest with corporate actors is necessary but not sufficient to address the systemic problem of corporate influence. it is the "ethical floor" as bachynski and goldberg (2018, 182) put it-the minimum, but far from all, that is required. disclosure and other measures to promote transparency help reveal the extent of the problem of corporate influence. but we cannot and should not rely on such approaches to neutralize corporate influence. when policies primarily promote disclosure of conflicts instead of their elimination, there is a danger that they may exacerbate the problem of corporate influence-particularly when they lead policymakers and the relevant publics to believe (mistakenly) that problematic influence has been addressed. several scholars have rightly expressed concern that disclosure, while necessary, might "crowd out" more effective measures to address corporate influence, including the elimination of relationships giving rise to financial conflicts of interest (e.g., cain, loewenstein, and moore 2005; loewenstein, cain, and sah 2012; chambers 2017; sah 2019; marks 2019a; kanter and loewenstein 2019; goldberg 2019; marks 2020 ). this concern is especially acute in the case of the opioid crisis-fighting the crisis will require more than simply expanding the categories of recipient whose payments from opioid and other drug companies are subject to mandatory disclosure. given the evidence of the impact of interactions with drug reps on physicians' opioid prescribing and on opioid-related deaths, there is a compelling case that the best way to protect patients and insulate physicians from such influence is to prohibit these interactions. disclosure rather than elimination of these relationships places the burden of addressing this systemic problem on patientsindividuals who are least equipped to tackle it and, worse still, are being harmed by it (see also kanter and loewenstein 2019) . notably, the vast majority of patients have not even begun to discharge that burden-they remain unaware of whether their doctors have received payments from drug companies, even though this information has been publicly available on the internet for several years . but even if patients access this information-or if it is provided directly to them by their physician or the physician's office (rose et al. 2019 )-we cannot assume they will understand why it matters. we should certainly not expect them to 3 for a thoughtful critique of this definition, see rodwin 2018. rodwin argues that the institute of medicine's 2009 definition of conflicts of interest "neglects the actor's compromised loyalty to the party or mission she is supposed to serve" (70) and that, by referring to conflicts between primary and secondary interests rather than conflicts between obligations and interests, this definition "diminishes the conflict's significance" (70). rodwin also expresses concern that "[e]fforts to include so-called intellectual or nonfinancial conflicts as conflicts of interest blur the concept" (75). be familiar with the relevant social science-including scholarship exploring the limitations and potential adverse effects of disclosure (e.g., cain, loewenstein, and moore 2005; lowenstein, sah, and cain 2012; sah 2019 ). yet another burden on patients resulting from disclosure is what some scholars call "insinuation anxiety"-although patients may want to act on the disclosure, they may be afraid to signal distrust to their physician (loewenstein, cain, and sah 2011; sah 2016; sah, loewenstein, and cain 2019) . and, even if patients are willing to act, they may not have the time or resources to find another physician they trust. this is a great deal to ask of any patient, let alone one in severe pain. disclosure of the opioid industry's relationships with universities, academic medical centres, and teaching hospitals, as well as individual researchers is also necessary, but not sufficient, if we are to address the influence of the opioid industry on medical research and education. we should bear in mind that many of the relationships were not a secret-for example, when purdue pharma gave a $3 million gift to massachusetts general hospital (mgh) in 2002, its centre was named the "mgh purdue pharma pain center." several metaanalyses have shown that industry funding of medical research tends to produce more favourable findings for the industry sponsor (see, e.g., lundh et al. 2017; bekelman, li, and gross 2003) . given that these analyses are based on studies that disclose their industry funding, it is clear that disclosure in this context does not serve to neutralize the bias. in addition to the impact on research findings and the interpretations of those findings, industrysponsored research influences the kinds of questions that researchers explore (and those they neglect or ignore) and the ways in which those questions are explored (marks 2019a, 75-78) . research agenda distortion-which is not eliminated by the disclosure of the relationships that contribute to the distortioncan be both subtle and profound. in the case of the opioid crisis, it triggered an expansion of the use of opioids to non-cancer patients, and it continues to lead to an emphasis on pharmacological solutions to both pain management and addiction. i am not suggesting that pharmacological solutions have no place. but, if we are serious about solving these public health challenges, we must be prepared to explore all potential solutions, including those that may be inimical to the commercial interests of pharmaceutical companies. it would certainly have been important for the cdc to know that many of the patient advocacy organizations and medical professional associations that were objecting to its draft guidelines (calling for more restraint on opioid prescribing) had received funding from opioid companies. this was significant information, whether or not the groups were dependent on industry funding (and some clearly were). lack of dependence is not the same as independence. 4 so the disclosure of patient advocacy groups' and medical professional associations' financial relationships is clearly necessary. but disclosure alone will not address the systemic problem that arises when, as is so often the case, most of the relevant public health ngos related to a particular health problem receive funding from industry actors with a vested interest in the solution to that problem. 5 policymakers are then left with the unenviable task of having to decide whether to ignore these entities' representations entirely or to accord them less weight-and, in either case, whether to do so across the board, or only when these groups' representations align with the interests of powerful corporate actors operating in the same space. and, more fundamentally, policymakers lack what they really need-access to the full range of views and interests of patients that are truly independent of the views and interests of industry. turning now to public health agencies and legislators, once again we see that disclosure of financial relationships is necessary but not sufficient to address the problem of corporate influence. some information on campaign contributions is already in the public domain. for example, the federal elections commission in the united states maintains a database of campaign finance contributions from political action committees (pacs). (this database, available at https://www.fec.gov, is the one on which mccoy and kanter 2018 relied to assess the industry ties of the house and senate committees charged with leading the 4 physicians are not dependent on drug companies for pens and mugs-they can afford to buy their own! but these small gifts influence them nonetheless. see, e.g., sah and fugh-berman 2013; lo and grady 2017. 5 although widely publicized investigations revealing opioid company payments to paos and health professional associations led to withdrawals of funding and, in a few cases, to the recipient organizations ceasing to operate, industry funding of patient advocacy groups remains pervasive. one recent study found that 83 per cent of the 104 largest groups received funding from drug, device, or biotechnology companies (mccoy et al. 2017 ). we should not expect disclosure alone to lead to the widespread elimination of these relationships, especially if the pervasiveness of these relationships reinforces the (problematic) view that they are acceptable or unavoidable. response to the opioid crisis.) we do not know the full extent of campaign contributions by opioid companies because hundreds of millions of dollars in campaign contributions are made via "superpacs" that shroud the origin of the funds. greater transparency in relation to "dark money" is clearly important, but campaign contributions and lobbying can still influence legislators even when they are disclosed-as congressional voting records make clear (see, e.g., the website of the center for responsive politics, https://www.opensecrets.org). the solution, of course, would be to take corporate money-including opioid industry funds-out of politics (see, e.g., lessig 2015) . a detailed consideration of campaign finance reform is, of course, beyond the scope of this paper. but i will address another powerful vehicle for corporate influence: close relationships between public health agencies and opioid companies. after the director of the nih announced the "publicprivate initiative" to address the opioid epidemic (discussed above), he commissioned a working group to explore the ethical issues. the working group based its recommendations on concerns about "real or perceived conflicts of interest" (nih working group 2018). the group stated that it was "preferable" that public funds be used from this initiative, but it only recommended a bar on industry funding where an opioid company was engaged in "litigation of concern" related to the opioid crisis. the advisory group recommended that, in other cases, money provided by industry actors should be "without conditions." even when companies are excluded from funding due to litigation, the working group said it would not only permit but encourage "in-kind" industry contributions to the partnership. in response to the group's report, the director of the nih said that he "fully embrace[d]" the recommendation that the nih should address the crisis with government, not industry, funds (collins 2018) . he also said that any partnerships in this initiative would be "done with the utmost transparency." these assurances, however, do not address all the ethical concerns. first, influence can occur when there are no formal conditions (or "strings") attached-in fact, reciprocity often makes such conditions entirely unnecessary. second, reciprocal effects are not confined to cash payments; they may be triggered by the receipt-or mere anticipation of the receipt-of "in-kind contributions," whether goods, services, or anything else of value (marks 2019a) . and third, transparent relationships may still be extremely influential. as i emphasized above, policymakers cannot and should not rely on transparency to eliminate corporate influence. in addition, such influence can distort policy agendas and reinforce the framing of two of our most pressing public health challenges, pain management and opioid addiction, in ways that are most likely to promote the commercial interests of the opioid industry and pharmaceutical companies more broadly (marks 2019a, 78-81) . this may explain the nih's emphasis on the development of new pharmaceuticals to address pain management and addiction (collins 2017 (collins , 2018 . it is tempting for public health officials to perceive an alignment of interests. at first glance, both the nih and pharmaceutical companies might appear to have a shared interest in the development of effective nonaddictive pain medications. but that apparent alignment warrants interrogation (marks 2019a) . even when a corporation engages in a business activity with the express aim of promoting health, its primary objective is the generation of profits from the sale of goods or services. the primary obligation of public health agencies is to protect and promote public health. divergence between these objectives is inevitable and, at times, acute. a drug formulated to promote health (for example, by alleviating pain) may turn out to be less effective than anticipated or to have dangerous side-effects. in such cases, public health agencies have an obligation to ensure, at the very least, that health professionals and patients are made aware of these concerns. however, the drug company will have a powerful economic incentive to exaggerate the benefits of the drug, downplay the adverse effects, and promote sales for as long as possible to protect revenues-especially when profits dwarf potential financial penalties. we have seen precisely this scenario play out in the opioid crisis, and policymakers should be at pains to avoid its repetition. partnering with the pharmaceutical industry to address the opioid crisis courts serious public health hazards. the threat to public trust in government, the academy, and civil society groups is now readily apparent, too (rose 2013; marks 2019a) . but there is another important reason for public health bodies to be wary of close relationships with the pharmaceutical industry: institutional integrity. a key component of institutional integrity is consistency-in particular, consistency among what an institution does (its practices), what it says it does (its mission), and what it is obligated to do (its purpose) (marks 2017 (marks , 2019a . public health agencies' and ngos' relationships with the opioid industry have clearly served to undermine their public health mission and purpose-and, in turn, their integrity. the crisis is yet another painful reminder of the perils of partnership with any entity whose mission, purpose, or practices diverge fundamentally from those of one's own institution (marks 2019a) . what the opioid crisis has also made clear, moreover, is that looking solely at the ethical implications of a single relationship between a public health agency, university, or public health ngo on the one hand, and a private-sector entity on the other, fails to take into account the systemic problem arising from corporate strategies that involve (as they almost invariably do) webs of influence with a variety of institutions in government, the academy, and civil society. corporations do not build individual relationships in isolation; they develop strategies to engage with all these actors. but when each of these actors considers the ethics of "engagement," they tend only to focus on their own proposed relationship. public health agencies, universities, and public health ngos contemplating partnerships should be as attentive to webs of influence as the corporations that weave them. of course, being attentive to the webs of influence and their ethical and policy implications is resource intensive, and it cannot be a one-off enterprise either. imagine you are the head of a public health agency. yours may be the first public health agency to partner with corporation x. but that corporation may be using its partnership with you as a pilot or test case that it will then use to "sell" the idea of partnership to another public health agency. your public health agency would need to continue to be attentive to the relationships that corporation x is weaving with other public health agencies, universities, and ngos-in addition to other private-sector entities (including trade associations and consultancy firms) with whom the corporation is collaborating in order to exercise influence. and your agency would need to be attentive to these relationships throughout its own relationship with the corporation. such constant (or, at least, periodic) vigilance would require considerable additional resources. but the full extent of the webs of relations may not be apparent until far too late-as in the case of the opioid crisis. the safer and far more advisable course of action is simply to avoid these relationships-to move from the corporate partnership paradigm to a new norm: separation, instead of collaboration. for years, courts sealed documents that would have revealed the role of corporate strategies of influence in the opioid epidemic (lesser et al. 2019 ). news outlets have been challenging this practice, and the courts are finally unsealing documents from earlier opioid cases (ross 2019 ). there has also been a plethora of new litigation against not only opioid manufacturers but also opioid distributorsincluding several high-street pharmacy chains as well as commercial distributors. in addition to thousands of civil cases against opioid companies (gluck, hall, and curfman 2018) , a few individuals have faced criminal charges (gonzales 2019) . several former executives of one opioid manufacturer, insys, were convicted of fraud, and recently received prison sentences (thomas 2020) . the verdict was swiftly followed by the company's agreement to pay $225 million to settle its own fraud charges (thomas 2019) . in oklahoma, a judgment of $465 million was entered against the johnson & johnson companies for creating a "public nuisance" that resulted not only from the group's promotion of its own brands of opioids but also from its promotion of opioids more generally and its supply of active ingredients to other opioid manufacturers (hofman 2019a, 2019b). purdue pharma and teva, which were also defendants in that case, settled shortly before the trial for $270 million and $85 million respectively (silverman 2019) . in order to avoid the landmark first federal trial, three commercial distributors and one manufacturer (again, teva) also agreed in october 2019 to pay two ohio counties $260 million (hofman 2019c). and in february 2020, mallinckrodt pharmaceuticals, the largest opioid manufacturer in the united states, announced a tentative agreement to pay $1.6 billion to settle lawsuits brought by state and local governments for its role in the opioid crisis (kaplan and hoffman 2020) . amid discussions of further settlements, two thousand cases wait in the wings (hoffman 2020b ). but we should not expect these cases and settlements to make good the economic losses resulting from the opioid epidemic (hoffman 2019d (hoffman , 2020a . purdue pharma and insys have already filed for bankruptcy (hals 2019a (hals , 2019b . the judgement against johnson & johnson will only cover one year of one state's abatement costs for an epidemic that will take decades to address. if efforts to reach a larger coordinated settlement are successful, they would be measured in the billions of dollars-far short of the trillions of dollars in the most recent cost estimates (hoffman 2019c; cea 2019) . and any settlement would, of course, not bring back the hundreds of thousands of americans who have died, nor would it restore the lives of the families and communities destroyed by the epidemic. if we are to prevent future loss of life, we need to supplement "backwardlooking" strategies based on establishing legal liability with some forward-looking ones (young 2011; marks 2017) . such forward-looking strategies must address the webs of relationships that served as vehicles for corporate influence and severely exacerbated the current crisis. if the opioid epidemic has taught us anything, it is that governments, intergovernmental organizations, the academy, and public health ngos need to be pre-emptive and proactive, developing comprehensive counterstrategies to insulate themselves from corporate influence. whatever metaphor we use to describe corporate strategieswhether we characterize them as "webs" (freudenberg 2014; gornall 2015; marks 2019a) or "tentacular" (joseph 2019c )-the implications are the same: in order for counterstrategies to be effective, they cannot address individual relationships with industry actors in isolation. the opioid epidemic makes clear that individual institutions-whether governments, universities, or public health ngos-are unlikely to be fully aware of the networks of relationships in which they are implicated until many years later. by that time, the damage may already have been done-as was undoubtedly the case with the opioid crisis. if we are to protect and promote public health, we will need a paradigm shift. in order to bring about such a shift, we must first recognize that medicine and public health were not always so heavily dependent on corporate funding. the influx of this funding has burgeoned in the last few decades, as corporations increasingly and understandably recognized the opportunities for the promotion of their commercial interests that this affords them. but the relationships with industry that are now the norm were once frowned upon. this may not be readily apparent to the current generation of policymakers, researchers, practitioners, and others in medicine and public health-it may seem as though things have always been this way. but we need only turn to the work of the late arnold relman, former editor of the new england journal of medicine, in the early 1980s to be reminded that this is not the case. drawing on president eisenhower's warning about the "military-industrial complex," relman expressed concern about the "new medicalindustrial complex," and cautioned that relationships with drug and device manufacturers had become "more pervasive, complex, and problematic" (relman 1980, 963; relman 1984 relman , 1182 . despite relman's warnings, that trajectory has only increased during the last four decades. but it is not too late to change direction. changing direction will require more than the withdrawal of donors' naming rights in response to criminal convictions, public outrage, or opprobrium (barry 2019; mcneil 2019) . first, public officials, academic administrators, and the leaders of public health ngos must recognize that corporate influence in public health is a systemic problem, and they must speak out about that problem. if it is difficult for individual public officials or academic administrators to speak out on their own, they can collaborate with others by making a joint statement-for example, an open letter to the new york times that makes clear why corporate partnerships are problematic and why more public funding to protect and promote public health is necessary. government agencies may also collaborate with each other, instead of collaborating with industry, to address public health problems (marks 2019a) . notably, the opioid litigation has involved considerable collaboration among states' attorneys-general. working together, public health agencies can not only collaborate on addressing individual public health challenges, they can also develop strategies to wean themselves from industry funding. the same may be said for the academy and public health ngos-including health professional associations (which have the power to influence norms and expectations for other institutions, as well as individual professionals). although these institutions may not be able to restructure their funding strategies overnight, it is not unrealistic to expect them to develop a five-or ten-year plan. many proponents of corporate partnerships argue that we cannot afford to tackle the major challenges in public health without industry funding. but the opioid epidemic was fuelled by these very relationships, and it has cost us trillions of dollars. given the human and financial toll, we simply cannot afford to carry on doing "business as usual" in public health. sponsorship of national health organizations by two major soda companies $3 million gift from purdue pharma to support mgh pain program pain management association shutting down. pain news network getting to yes: corporate power and the creation of a psychopharmaceutical blockbuster commonwealth of massachusetts v. purdue pharma l.p. et al. first amended complaint time out: nfl conflicts of interest with public health efforts to prevent tbi tufts removes sackler name over opioids scope and impact of financial conflicts of interest in biomedical research: a systematic review hall of mirrors: corporate philanthropy and strategic advocacy. nber working paper 25329 the dirt on coming clean: perverse effects of disclosing conflicts of interest politics of pain: drugmakers fought state opioid limits amid crisis the illusion of transparency statement from nih director on public-private partnerships as part of the nih heal initiative. nih.gov corporate influence: purdue and the who. offices of the 19-who-purdue-report-final council of economic advisors (cea). 2017. the underestimated costs of the opioid crisis top executives of insys, an opioid company, are found guilty of racketeering /health/insys-trial-verdict-kapoor.html a tech company gave doctors free softwarerigged to encourage them to prescribe opioids, prosecutors say lethal but legal: corporations, consumption, and protecting public health civil litigation and the opioid crisis: the role of courts in a national health crisis the shadows of sunlight: why disclosure should not be a priority in addressing conflicts of interest bioethical inquiry drug distributor and former execs face first criminal charges in opioid crisis. npr sugar: a web of influence keeping modern in medicine: pharmaceutical promotion and physician education in postwar america industry payments to physicians for opioid products association of pharmaceutical industry marketing of opioid products to physicians with subsequent opioid prescribing association of pharmaceutical industry marketing of opioid products with mortality from opioid-related overdoses oxycontin maker purdue pharma to pay states' lawyers, urged to help victims $260 million opioid settlement reached at last minute with big drug companies association between opioid prescribing in medicare and pharmaceutical company gifts by physician specialty fueling an epidemic-report two: exposing financial ties between opioid manufacturers and third party advocacy groups inside the opioid industry's marketing machine: unsealed court documents reveal how drug companies ramped up sales during the epidemic we owe much to the sackler family": how gifts to a top medical school advanced the interests of purdue pharma extending the sunshine act from physicians to patient advocacy organizations evaluating open payments effect of the public disclosure of industry payments information on patients: results from a population-based natural experiment mallinckrodt reaches $1.6 billion deal to settle opioid lawsuits the family that built an empire of pain fake doctors, pilfered medical records drive oxy china sales how judges added to the grim toll of opioids republic, lost: the corruption of equality and the steps to end it financial conflicts of interest and the centers for disease control and prevention's 2016 guideline for prescribing opioids for chronic pain conflict of interest in medical research, education, and practice payments to physicians: does the amount of money make a difference the limits of transparency: pitfalls and potential of disclosing conflicts of interest the unintended consequences of conflict of interest disclosure industry sponsorship and research outcome dopesick: dealers, doctors, and the drug company that addicted america caveat partner: sharing responsibility for health with the food industry opioid crisis shows partnering with industry can be bad for public health. the conversation beyond disclosure: developing law and policy to tackle corporate influence conflict of interest for patient advocacy organizations industry support of patient advocacy organizations: the case for an extension of the sunshine act provisions of the affordable care act campaign contributions from political action committees to members of congressional committees responding to the opioid crisis us medical group that pushed doctors to prescribe painkillers forced to close. the guardian ub renames structure "pharmacy building" after removing convicted alumnus' name. the buffalo news pain killer: an empire of deceit and the origin of america's opioid epidemic ethical considerations for industry partnership on research to help end the opioid crisis: draft report what these medical journals don't reveal: top doctors' ties to industry /health/medical-journals-conflicts-of-interest.html pharmaceutical research and manufacturers of america (phrma). 2017. phrma announces major commitment to address the opioid crisis in america. press release the antibiotic era: reform, resistance, and the pursuit of a rational therapeutics preying on prescribers (and their patients)-pharmaceutical marketing, iatrogenic epidemics, and the sackler legacy capping years of criticism, purdue pharma will stop promoting its opioid drugs to doctors we manufacture prescription opioids. how could we not help fight the prescription and illicit opioid abuse crisis? new york times dreamland: the true tale of america's opiate epidemic judge partly vacates convictions of opioid maker insys' founder, executives the new medical-industrial complex health policy brief: the physician payments sunshine act attempts to redefine conflicts of interest patient advocacy organizations: institutional conflicts of interest, trust, and trustworthiness patient advocacy organizations, industry funding, and conflicts of interest patient responses to physician disclosures of industry conflicts of interest: a randomized field experiment. organizational behavior and human decision processes purdue's richard sackler proposed plan to play down oxycontin risks, and wanted drug maker feared "like a tiger," files show guest authorship and ghostwriting in publications related to rofecoxib: a case study of industry documents from rofecoxib litigation oxycontin goes global-"we're only just getting started conflict of interest disclosure as a reminder of professional norms: clients first! physicians under the influence: social psychology and industry marketing strategies insinuation anxiety: concern that advice rejection will signal distrust after conflict of interest disclosure purdue pharma edits public service ad in washington post us opioid prescribing: the federal government advisers with recent ties to big pharma teva reaches $85 million settlement on eve of opioid trial in oklahoma ghost-managed medicine: big pharma's invisible hands narrative review: the promotion of gabapentin: an analysis of internal industry documents insys, the opioid drug maker, to pay $225 million to settle fraud charges the role of science in addressing the opioid crisis ensuring balance in national policies on controlled substances: guidance for availability and accessibility of controlled medicines web statement on pain management guidance responsibility for justice report and recommendations concerning the relationship of the sackler family and purdue pharma with tufts university hammer on the abusers": mass. attorney general alleges purdue pharma tried to shift blame for opioid addiction publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgments the author is extremely grateful to michele mekel and to all the student and faculty participants in the penn state bioethics colloquium for their invaluable feedback on an earlier draft. this article also benefited from the author's discussions with several colleagues at other institutions-among them, marc rodwin, sunita sah, genny pham kanter, susannah rose, and lisa cosgrove. he is also grateful to quinn grundy and another (anonymous) reviewer for their extremely helpful comments and suggestions. please excuse any errors and omissions-final revisions to this piece were made during the covid-19 pandemic. key: cord-017349-eu1gvjlx authors: koh, howard k.; cadigan, rebecca o. title: disaster preparedness and social capital date: 2008 journal: social capital and health doi: 10.1007/978-0-387-71311-3_13 sha: doc_id: 17349 cord_uid: eu1gvjlx the first decade of the 21st century has pushed the field of disaster preparedness to the forefront of public health. in a few short years, the world has witnessed the far–ranging ramifications of 9/11 and anthrax (2001), sars (2003), the indian ocean tsunami (2004), hurricane katrina (2005) and the looming threat of pandemic influenza. societies everywhere are responding to these developments with new policies that commit added resources for protection against future disasters. to date, literature relevant to social capital has focused largely on the value of existing social capital in disaster mitigation and recovery. for example, among environmental scientists, there is growing interest in the role of social capital and global climate change (adger, 2001; pelling & high, 2005) . in light of the causal link between global climate change and the increasing incidence of natural disasters such as hurricanes, tsunamis and floods, researchers have identified social capital as an important tool in disaster mitigation. for example, semenza, et al. (1996) found that during the 1995 heat wave in chicago, in addition to location (i.e., living on the top floor of building) and access to air conditioning, variables related to social contact and networks were also strong predictors of mortality. specifically, the authors found that individuals who participated in church or social groups had a significantly lower risk of death during the heat wave. it is clear from these findings that social networks and social capital are important tools in community coping with stresses, and serve to mitigate adverse outcomes of disasters and other events associated with climate change. similarly, existing social capital has served as a vital instrument in the recovery and rebuilding efforts following numerous natural disasters. nakagawa and shaw (2004) hypothesized that differing rates of post-disaster recovery following major earthquakes in kobe, japan and gujarat, india could be attributed to disparate levels of existing social capital in the two cities. in the immediate aftermath of the 1995 kobe earthquake, neighborhood groups (previously formed in the 1960s to protest polluting factories) quickly reconvened to assist with school evacuation, establish community kitchens, and help protect against looting. these actions accelerated response efforts and served to initiate rebuilding. following hurricane katrina in 2005, a number of observers (garreau, 2005; turner & zedlewski, 2006 ) attributed many of the barriers to rebuilding new orleans to the previously documented low social capital there (putnam, 2000) . nevertheless, exceptions were notable. for example, within a matter of weeks, select tight-knit groups such as the vietnamese enclave in east new orleans were already engaged in rebuilding efforts (hauser, 2005; shaftel, 2006) . many of the 20,000 vietnamese in new orleans had previously emigrated to the u.s. in the 1970-1980s and have since maintained strong social and cultural networks. using a church as headquarters, the vietnamese residents of east new orleans formed neighborhood teams to rebuild, repair, and decontaminate houses, prepare meals for families visiting to check on their property, and drive one another to work, church, and temporary housing. for the preparedness and response phases of preparedness, much of the current efforts are focusing on the process of creating new social capital. one poignant illustration is the dramatic volunteer convergence on new york city following the terrorist attacks on september 11th, 2001, documented to include over 15,000 individuals within two and a half weeks. a qualitative study conducted by lowe and fothergill (2003) found that the primary motivation for volunteering was a need "to contribute something positive and find something meaningful in the midst of a disaster characterized by cruelty and terror" (p. 298). the authors characterized the impact of such spontaneous volunteerism on both the community and the volunteers themselves, i.e., affecting both groups and individuals. one volunteer described the work as "honoring our commitment to the american public" (p. 303), implying a broad national community. individual impact was noted when "the volunteers found that by working with new groups of people. . . . . they experienced a sense of solidarity with different community members" (p. 303). in another example outside of the united states, an estimated 2 million volunteers responded to assist with search and rescue, medical aid, transportation, and provision of shelter following the 1985 earthquake in mexico city (dynes & quarantelli, 1990) . a major benefit of preparedness planning would be to strengthen local public health infrastructure which has been traditionally fragmented and severely underfunded. over a few short years, nascent efforts on preparedness have broadened the initial focus on training federal and state government leaders to include local officials and indeed all members of society. lessons from sars and hurricane katrina have underscored the message that every person has an opportunity and responsibility to protect themselves, their families and their communities. as a result, in the world of public health, emergency preparedness training now extends deeply to the local level with respect to planning, communication and training. in many parts of the united states, efforts have focused attention to regionalization of local public health, surge capacity planning, vulnerable populations, risk communication, and training through exercises and drills. all these efforts have the potential to boost local public health infrastructure and build a legacy of social capital and social networks in local communities. the remainder of this chapter will explain in greater detail how such preparedness efforts apply to dimensions of social capital at the local level, particularly with respect to pandemic influenza preparedness. the threat of pandemic influenza has sparked heightened planning worldwide. the world health organization (who) urges that each country and community develop and regularly update a pandemic preparedness plan. who guidance centers on issues such as surveillance, communications and prioritization of scarce resources. as of december 2005, 40 countries have completed such plans (uscher-pines, omer, barnett, burke & balicer, 2006) . the united states unveiled its national pandemic influenza plan in november, 2005, addressing areas such as domestic and international surveillance, vaccine development and production, antiviral therapeutics, communications and state/local preparedness. moreover, each of the 50 states has developed and publicized plans, as summarized on www.pandemicflu.gov. all nations understand the importance of priority setting in preparedness planning, although such plans currently vary by rationale of prioritization of antiviral agents, vaccines and other scarce resources (uscher-pines, omer, barnett, burke, & balicer, 2006) . as "all preparedness is local" however, such plans can only come alive through full engagement at the local level. both bonding and bridging social capital apply throughout such plans. 13.4.1.1. local/regional planning the current fragmented status of local public health in the united states has left few cities or towns (aside from the major metropolitan areas) capable of responding on their own. for the most part, local health departments lack the personnel, resources or capacity to respond to mass casualties without the support of surrounding communities. to address this challenge, many states have turned to regionalization of resources and services to build emergency preparedness capacity at the local level. a study of state public health preparedness programs conducted in fall, 2004 by the association of state and territorial health officials (astho) found that most states tended to subdivide their organizations into regions for preparedness purposes, with more than half of such regions created post-9/11 (beitsch et al., 2006) . massachusetts, nebraska, illinois, kansas and the northern capital region (greater metropolitan washington dc) are among the states that have done so. for example, massachusetts, a state of 6.3 m, traditionally had a highly decentralized local public health system with 351 autonomous cities and towns. nevertheless, after 9/11 the state reorganized into seven emergency preparedness regions and 15 subregions (koh, elqura, judge, & stoto, 2008) . in another example, the primarily rural state of nebraska of 1.7 m people has developed 16 regions in efforts to improve capacity. preliminary qualitative information suggests that regionalization has built social capital for groups and individuals. the national association of county and city health officials (naccho) notes that regionalization has promoted coordination (of local public health and partners in public safety and emergency medical services), standardization (of resources and emergency plans) and centralization of local emergency response capability (bashir, lafronza, fraser, brown, & cope, 2003; hajat, brown, & fraser, 2001) . in so doing, improved collective efficacy can be realized. analyses have noted that regionalization has served as a foundation for sharing resources, coordinating planning, conducting trainings and improving capacity. for example, in massachusetts, regionalization led to emergency local capacity essential for pandemics and mass casualties, such as establishment of 24/7 emergency on-call capacity for all local public health officials in the state (when none previously existed) and mutual aid agreements for over 60% of local public health departments (compared to none previously). in fact, in the few short years of its existence, regionalization has facilitated the efficient organization of hepatitis a immunization clinics in the face of food borne outbreaks, and coordination of seasonal flu vaccine distribution during the shortages of the 2004-2005 season (koh, shei, judge et al., 2006) . such examples reflect enhanced social capital within groups (e.g., nurses and allied health professionals) and bridging between groups (local health groups and state public health officials). most notably, regionalization has fostered communication and connections between multiple groups: public health and public safety, interested parties in neighboring towns, local and state leaders, and volunteers across the state. multiple parties that rarely worked together prior to 9/11 are now meeting regularly to plan joint responses and clarify roles and responsibilities. planning for pandemics and mass casualties requires ramping up the current national health care system to care for thousands of extra ill patients. building surge capacity in this way can generate bonding and bridging capital, mobilizing and unifying a vast array of societal resources. based on past pandemics, the u.s. department of health and human services (dhhs) has modeled its pandemic planning on scenarios ranging from moderate (such as the 1957 and 1968 pandemics) to severe (such as the 1918 pandemic). current models project as many as 90 m cases nationally, 50% of cases requiring outpatient medical care, and up to 9.9 m requiring hospitalization (hamburg et al., 2005) . the u.s. centers for disease control and prevention (cdc) has developed the software program flusurge, which provides hospital administrators and public health officials local estimates of the surge in demand for hospital-based services during the next influenza pandemic. the challenge of surge capacity remains enormous, as national trends over the past several decades reflect declining, not increasing, capacity. with this daunting backdrop, the united states is working toward increasing surge capacity, explicitly defined by the u.s. agency for healthcare research and quality (2004a) as "a health care system's ability to expand quickly beyond normal services to meet an increased demand for medical care in the event of bioterrorism or other large-scale public health emergencies" (p. 1). the u.s. health resources and services administration (hrsa) has offered surge capacity benchmarks with respect to staff, space and supplies, as shown in table 13 .1 (agency for healthcare research and quality, 2004b) . building staff can be viewed as an exercise in creating bonding capital, i.e., within the community of health care providers. additional personnel needed for deployment in a crisis would include, in addition to physicians (approximately 800,000 in the u.s.) and nurses (approximately 2.2 m in the u.s.), veterinarians, pharmacists, mental health professionals and a host of other allied health professionals. such providers would not only administer direct care to those who are sick but could also aid with mass prophylaxis efforts to the many more who may be exposed or at risk. to augment this national network, communities across the u.s. are engaging volunteers in emergency response. with respect to space, all hospitals have been charged by hrsa and other organizations to identify additional beds for use in pandemics and emergencies. in addition to staffed beds (beds that are licensed, staffed, and physically available), all acute care hospitals are ascertaining surge capacity by identifying other beds that: are licensed but not staffed, can be made available within 24 hours (by discharging patients and canceling elective procedures) or within 72 hours (through use of non-traditional locations such as hospital cafeterias, chapels, etc.). in the event that hospital capacity is still overwhelmed, professionals across the country are currently identifying other health care facilities such as community health centers (koh, shei, bataringaya et al., 2006) or even non-medical sites such schools, gymnasiums, armories, and convention centers. considerations for such facilities include dimensions such as bed capacity, sanitary facilities, food services, and security. the shortage of medical supplies has also prompted bridging outside the medical world to other parts of government and society to generate sufficient resources. many have argued that preparing for pandemic influenza first entails mastering the proper coordination of national vaccination efforts for annual seasonal influenza, which yearly leads to 36,000 deaths and 200,000 hospitalizations (thompson, shay, & weintraub, 2003 . in particular, the fragmented nature of the national seasonal influenza vaccine supply became starkly apparent during 2004-2005, when a national low of 61 m doses led to prioritization of risk groups for immunization for the first time. production for 2006-2007 is now estimated to reach a high of 115 -120m doses, however (fauci, 2006) . shortages of antibiotics and antiviral agents may require interaction with the federal strategic national stockpile (sns), managed by the cdc and dhhs. the sns contains prepackaged pharmaceutical agents that can be deployed to states at the governor's request. all states have prepared preliminary plans for the receipt and management of stockpile materials, and many have initiated planning for emergency dispensing at the local level. acquiring such resources and even determining the resources needed are a tremendous source of activity and controversy. one area involves personal protective equipment (ppe) where, for example, experts differ about recommendations regarding proper use of surgical masks, n 95 respirators and other equipment (institute of medicine board on health sciences policy, 2006). additionally, ventilators represent a critical limiting physical resource. there are approximately 105,000 ventilators in the u.s., with as many as 80,000 in use at any given time for medical care; and more that 100,000 required during a typical influenza season (osterholm, 2005) . in the event of a pandemic, the number of patients requiring mechanical ventilation would likely exceed this capacity in excess of 500% (hamburg et al., 2005) . all disasters expose disparities. as mentioned previously, hurricane katrina has been a recent disaster that has graphically highlighted vulnerabilities of special populations, the varying levels of social capital within those populations, and the need to ensure equity in preparedness. a survey revealed that 38% of those who did not evacuate before hurricane katrina were either physically unable to do so or had to care for someone who was physically unable to leave. 52% of evacuees reported having no health insurance coverage at the time of the hurricane (brodie, weltzien, altman, blendon, & benson, 2006) . national groups have redoubled efforts to address the needs of special populations, defined by the cdc (2006) as "groups whose needs are not fully addressed by traditional service providers or who feel they cannot comfortably or safely access and use the standard resources offered in disaster preparedness, relief, and recovery" (p. 4). they include, but are not limited to: 1) those who are physically or mentally disabled (blind, deaf, hard-of-hearing, cognitive disorders, mobility limitations); 2) limited or non-english speaking; 3) geographically or culturally isolated; 4) medically or chemically dependent; 5) homeless; 6) frail/elderly and children. such groups would need to bridge to resources currently not available to them. issues of trust in, and trustworthiness of, authorities charged to protect them further complicate this issue. planning for special populations has increased recently. such planning may differ dramatically for densely populated urban settings as opposed to more sparsely populated rural settings; each community with its own profile of risks and assets. examples of special populations planning include evacuation planning for elderly immobile populations in nursing homes, targeted risk communication strategies for non-english speaking populations, and coordination of services for people who are homeless, homebound, or medically or chemically dependent. such populations are particularly vulnerable to broader social forces affecting their communities. overcoming social isolation in these instances remains a daunting societal challenge. in a time of crisis, all members of society expect and deserve accurate information that is conveyed simply, clearly, and in a timely fashion. such information is critical not only for all to understand roles and responsibilities in times of crisis but also for how and when to access resources. in this regard, the who, cdc and other organizations have afforded considerable attention and resources to upgrading media plans, training of communicators, and message preparation and delivery. to a great extent, the responsibility for such risk communication will fall on government public health authorities through broad use of the media. this presents special challenges in the u.s., where recent surveys show that less than 50% of the general public trust government public health authorities "a lot" as a source of useful and accurate information about an outbreak, compared to significantly higher levels in other parts of the world, such as taiwan, hong kong and singapore . in particular, it is unclear exactly how much the public understands the concept of "pandemic influenza" and how it differs from the term "avian influenza". also, there are many other subtleties in communicating relevant information to the public and the press. for example, the uncertain efficacy of antiviral agents for pandemic influenza may not be well known. in chapter 12 of this book, viswanath explores the information disparities affecting populations in society. building public awareness now through regular communication can enhance trust and confidence in advance of any future pandemic. in preparing for a disaster, professionals and the public need continuous education and training. groups such as the federally funded academic centers for public health preparedness have been charged with exploring many such educational avenues, including face-to-face teaching, train-the-trainer initiatives (orfaly et al., 2005) , distance learning initiatives (moore, perlow, judge, & koh, 2006) and other modalities. recently, the public health community has moved aggressively into exercises and drills as a favored educational modality (cadigan, biddinger, & koh, 2006) . mounting a rapid, coordinated, integrated local response to mass casualty events such as pandemic influenza necessitates tight collaboration among a host of participants, including emergency management, public health, law enforcement, fire, emergency medical services, health care providers, public works, municipal government, and community-based organizations. exercises, defined as any event beyond the planning process that gathers people to test or improve preparedness (u.s. department of homeland security, 2004) , both teach and test such coordination for individuals and organizations. involving representatives from multiple agencies to exercise together in a regular fashion facilitates an iterative cycle of developing plans, training personnel, testing preparedness, and improving plans even further to clarify specific roles and responsibilities. both bonding and bridging capital can be enhanced in this way. for example, tabletop exercises are often organized around multiple tables, with each table representing one local municipality. key government officials from across various agencies work together at each table, while being forced to interact with other towns/tables as well as state agencies. resources can be enhanced by building bonding capital within each professional group, each agency, each town, as well as bridging capital across agencies, communities and between local and state officials. furthermore, since public health disasters are critical but rare, exercises serve the vital function of testing plans in a concrete and memorable fashion. use of local tailored scenarios provides exercise participants with a sense of urgency as well as concrete opportunities to understand the complex coordination involved in local emergency response. furthermore, respondents can test their understanding of the national incident management system and the incident command system. such active, experiential learning appears to have greater educational impact than more conventional, didactic lectures, particularly for rare events (streichert et al., 2005) . these exercises build social networks of responders. qualitative studies suggest that exercises improve communications with colleagues from other agencies, force participants to address inadequacies in communications systems and protocols, and promote strategies to ensure presentation of consistent messages. by convening with local/regional partners, participants realize potential opportunities to increase capacity by sharing resources with neighboring communities. bringing together participants from a range of disciplines enhances opportunity to learn about the unique services, skills, and expertise offered by others. an ongoing area of research is to quantify these outcomes in a standardized way that demonstrates enhanced preparedness. while we offer our ideas here on the ramifications of social capital on evolving public health preparedness work, much of this information is qualitative and/or preliminary. many observations noted here need verification and validation. furthermore, the intense current focus on community disaster preparedness is still relatively new. academic investigation should verify and extend these concepts, offer more quantitative assessments of social capital as applied to disasters, demonstrate their utility through more rigorous analyses, and ascertain whether initial societal changes found in qualitative studies will be enduring and sustained. moreover, we have presented concepts of social capital as being overwhelmingly positive in their nature when in fact research in other areas has documented possible negative ramifications noted elsewhere in this book. nevertheless, much of the current work regarding public health preparedness can enhance social capital through stabilization and growth of the current fragile public health infrastructure, i.e., workforce capacity and competency, information and data systems, and organizational capacity (cdc, 2001) . disaster planning has undoubtedly revived and accelerated community discussions about societal planning, obligations, and expectations in a time of crisis. regionalization of local health has generated new local capacity. attention to special populations has renewed emphasis on commitments to equity and raises key questions about obligations of community members to one another. efforts to enroll volunteers through mrc and other initiatives have revitalized discussions on expectations of service in a community. attention to surge capacity, resource shortages and the prospect of alternate sites of care during a mass casualty event has raised explicit discussions about obligations and expectations. agencies have advanced bridging in the common mission of protecting the public. inherent in all planning has been the importance of trust building, particularly in information sharing and risk communication. moreover, such investments may well be helping to build a more cohesive, integrated, prepared national and global community where all understand their interdependence in the midst of a crisis. in a time of social isolation where many are "bowling alone", disaster preparedness efforts may serve as a force that reverses this trend and contributes to a legacy of stronger local public health and a more revitalized society for the future. tyndall centre for climate change research -working paper no surge capacity-education and training for a qualified workforce optimizing surge capacity-regional efforts in bioterrorism readiness local and state collaboration for effective preparedness planning a state-based analysis of public health preparedness programs in the united states attitudes toward the use of quarantine in a public health emergency in four countries experiences of hurricane katrina evacuees in houston shelters: implications for future planning using regional multi-agency exercises to enhance public health preparedness social capital: dealing with community emergencies individual and organizational response to the 1985 earthquake in mexico city seasonal and pandemic influenza preparedness: science and countermeasures a sad truth: cities aren't forever. the washington post community organizing: building social capital as a development strategy a killer flu. trust for america's health institute of medicine committee on the future of emergency care in the united states health system reusability of facemasks during an influenza pandemic regionalization of local public health systems in the era of preparedness building community-based surge capacity through a public health and academic collaboration: the role of community health centers emergency preparedness as a catalyst for regionalizing local public health a need to help: emergent volunteer behavior after september 11th using blended learning in training the public health workforce in emergency preparedness social capital: a missing link to disaster recovery local public health agency infrastructure: a chartbook train-the-trainer as an educational model in public health preparedness preparing for the next pandemic understanding adaptation: what can social capital offer assessments of adaptive capacity? bowling alone. the collapse and revival of american community heat related deaths during the july 1995 heat wave in chicago the ninth reward: the vietnamese community in new orleans east rebuilds after katrina. the village voice using problem-based learning as a strategy for cross-discipline emergency preparedness training mrc reaches 500 mrc unit milestone influenza-associated hospitalizations in the united states mortality associated with influenza and respiratory syncytial virus in the united states after katrina: rebuilding opportunity and equity in new orleans priority setting for pandemic influenza: an analysis of national preparedness plans public health workbook to define, locate, and reach special, vulnerable, and at-risk populations in an emergency public health's infrastructure: a status report homeland security exercise and evaluation program, volume i: overview and doctrine avian influenza frequently asked questions key: cord-018254-v8syiwie authors: rotz, lisa d.; layton, marcelle title: case study – united states of america date: 2012-08-31 journal: biopreparedness and public health doi: 10.1007/978-94-007-5273-3_18 sha: doc_id: 18254 cord_uid: v8syiwie the united states (us) considers the intentional use of a biological agent a serious national security threat. over the last decade, federal, state, and local governments in the us have made concerted efforts to enhance preparedness within the public health, medical, and emergency response systems to address this threat. these activities span a wide range of areas from the enactment of new legal authorities and legislative changes to significant financial investments to enhance multiple detection and response system capabilities and the adoption of a national command and control structure for response. many of these investments, although prompted by the concern for bioterrorism, have served to strengthen public health, medical, and emergency response systems overall and have proven invaluable in responses to other large-scale emergencies, such as the 2009 h1n1 influenza pandemic. the intentional use of a biological agent is also something that the united states considers a serious threat and the federal, state, and local governments in the us have made concerted efforts to enhance preparedness and capabilities within the public health, medical, and emergency response systems to address this threat. in 2001, this concern became a reality for the us when several letters containing anthrax spores were sent through the postal system to individuals and organizations [ 14 ] . this resulted in 22 cases of anthrax (11 inhalational and 11 cutaneous) with fi ve deaths. although this event may not have been the type of "mass-casualty" situation most bioterrorism preparedness planning activities were targeting, it still resulted in signi fi cant response efforts and cost; over 10,000 individuals were offered antibiotic prophylaxis because of possible exposures, over one million clinical and environmental specimens were tested, and hundreds of millions of dollars were spent on decontamination of the buildings where the letters were processed or opened [ 12, 22 ] . although many infectious agents are capable of causing human illness, some are much more capable of causing signi fi cant morbidity and mortality if successfully used as a bioterrorism agent. in 2000, the centers for disease control and prevention (cdc) developed a process to prioritize biological threat agents based on evaluation of the following threat agent characteristics: (1) public health impact from ability to cause illness or death, (2) ability to be produced and delivered in a way that could expose a large number of people, (3) existing public perceptions of a biological agent that could contribute to heightened fear and panic, and (4) requires signi fi cant special preparedness efforts in order to diagnose, treat, or prevent illness [ 20 ] . based on these characteristics, biological threat agents were prioritized into three different tiers. category a (highest threat tier) included bacillus anthracis (anthrax), variola virus (smallpox), yersinia pestis (plague), francisella tularensis (tularemia), clostridium botulinum toxin (botulism), and the filo and arenaviruses (e.g., ebola and marburg virus) that cause viral hemorrhagic fevers. category b and c were lower threat tiers and included agents such as burkholderia mallei and b. pseudomallei , rickettsia prowasekii (category b), and emerging threats such as nipah virus (category c). following the release of homeland security presidential directive 10 (hspd10) in april 2004, the us department of homeland security (dhs) became responsible for issuing biannual assessments of biological threats in order to guide the prioritization of ongoing investments in research, development, planning, and preparedness [ 23 ] . the united states has made signi fi cant investments in terrorism preparedness and response coordination over the last two decades that includes the implementation of new policies, legislation, and legal authorities in addition to signi fi cant funding investments. in 1995, presidential directive 39 added a terrorism annex to the federal response plan and de fi ned responsibilities of federal agencies in responding to terrorism [ 25 ] . the homeland security act of 2002 established the department of homeland security (dhs), a new cabinet level of fi ce whose primary mission is to prevent or reduce vulnerability of the united states to terrorism at home; coordinate homeland security responsibilities between the federal government and state, local and private entities; and minimize damage resulting from attacks and assist in the recovery. in 2003, homeland security presidential directive 5 (hspd-5) established a nationwide system to coordinate responses to emergencies between local, state, and federal governments and responding organizations and to administer this all hazards national response plan through a national incident management system (nims) that provides for uni fi ed command and better multi-agency coordination [ 24 ] . other presidential directives and legislation enacted in the us since the world trade center and anthrax letter events in 2001 have provided stronger legal frameworks and public health capacity to prevent, prepare, and respond to intentional acts of biological terrorism. the 2002 public health security and bioterrorism preparedness response act (phsbpra) established new requirements for possession, use, and transfer of selected biological agents and toxins (select agent list) that could pose threats to human, animal, and plant health and safety as well as established other authorizations and appropriations necessary to carry out essential public health and medical preparedness and response activities [ 19 ] . this act authorized more than 1.5 billion us dollars in grants to state and local governments and healthcare facilities to improve planning, training, detection, and response capacity as well as funding to expand the federal strategic national stockpile of medications and vaccines and upgrade food inspection capacity and cdc facilities that deal with public health threats. the project bioshield act (july 2004) and pandemic and all-hazards preparedness act (december 2006) also speci fi cally provided for new authorities and funding to address signi fi cant gaps that existed for the development, acquisition, and utilization of medical countermeasures (e.g. antimicrobials, vaccines, chemical antidotes) for chemical, biological, radiological, and nuclear (cbrn) threats. in 2002, the cdc asked the center for law and public health at georgetown and johns hopkins universities to draft a model state public health law (the model state emergency health powers act or model act) for state and local jurisdictions to use in addressing either bioterrorism or naturally occurring disease outbreaks [ 9 ] . the model act (available at http://www.publichealthlaw.net/msehpa/msehpa. pdf ) outlines fi ve major public health functions to be allowed by law including preparedness, surveillance, management of property, protection of persons, and communication. in addition to ensuring suf fi cient authority to collect disease surveillance data, conduct contact tracing, and provide preventive measures to those at risk, public health laws must enable local health of fi cials to implement quarantine measures, if needed, to control a contagious disease outbreak with epidemic potential that could lead to severe morbidity or mortality (e.g. smallpox). this authority should be linked with speci fi c, scienti fi cally appropriate criteria that would be met before quarantine could be implemented. in addition, public health laws should provide for due process measures to protect those affected. ideally, quarantine strategies would be determined and operational procedures would be in place prior to an emergency. ongoing broad-based investments to improve response planning and coordination, surveillance, training, information systems, and communications have been made that serve to improve public health capacity for all threats and hazards. starting in 1999, the us government began providing funding to 62 state, local, and territorial health departments to build stronger capacity for surveillance and epidemiology, laboratory diagnostic capacity, communications, countermeasure distribution, and emergency response planning, exercise, and evaluation. the initial investment into these public health system upgrades started at 40 million us dollars per year with a primary focus on addressing bioterrorism threats. following the events of 2001, funding to support enhancements in the national public health infrastructure increased to approximately 1.5 billion per year. the current state of progress towards speci fi c preparedness goals identi fi ed for cdc funded preparedness and response activities in the 62 state, local, and us insular areas is provided in the "2010 report -public health preparedness: strengthening the nation's emergency response state by state" which can be found online at http://emergency.cdc.gov/ publications/2010phprep/ . additionally, more targeted investments have been made that address surveillance, detection, and illness prevention or treatment needs for speci fi c high priority threats. examples of these targeted initiatives include the laboratory response network (lrn), the strategic national stockpile (sns), and an environmental monitoring system called biowatch. in 1999, the cdc and other partners formed the laboratory response network (lrn) [ 3 ] . the lrn is a network of approximately 170 national and international public health, veterinary, agriculture, food, military, and environmental laboratories that have increased diagnostic capability for the rapid identi fi cation of multiple biological and chemical threat agents in multiple sample types. participation in the network is voluntary and these pre-existing laboratories work under a single operational plan and adhere to policies on safety, security, and bio-containment. lrn members agree to perform testing using lrn procedures and are provided training, equipment, rapid detection assays and reagents, protocols, and secured communication and data reporting systems to increase testing and laboratory response capabilities in a standardized and coordinated fashion. there are three types of laboratory designation within the lrn: national, reference, and sentinel. national labs have unique capabilities and resources that allow them to handle highly infectious agents and perform strain-level identi fi cation and other agent characterization testing. reference laboratories are mostly based at state and large city health departments and have the capability to perform rapid con fi rmatory testing for certain agents and toxins while sentinel laboratories (primarily hospital and commercial clinical laboratories) can perform routine clinical testing on patient specimens with additional training and protocols for noti fi cation and rapid referral of isolates in the event that they are unable to rule-out a biothreat agent. in addition to the central role the lrn played in detecting and responding to the 2001 anthrax letter event, the commitment to infrastructure support and standardized platform testing capacity within the lrn has also proven extremely bene fi cial in assisting with more rapid and broader deployment of tests developed in response to other emerging public health threats such as the 2003 severe acute respiratory syndrome (sars) and the 2009 h1n1 avian in fl uenza pandemic. lrn laboratories are also trained on chain-of-custody requirements and protocols which allow them to serve as a local testing resource for law enforcement linked samples where there is a concern for biological threat agents. approximately 90% of the us population lives within 100 miles of an lrn laboratory, which provides for more rapid access to con fi rmatory diagnostic testing to evaluate potential illness from or exposures to threat agents. the sns (formerly the national pharmaceutical stockpile) program began in 1999 to acquire and store a stockpile of medications, vaccines, and other medical supplies whose rapid availability is vitally important for response to a large-scale event involving certain biological, chemical, or radiological agents [ 4 ] . without a pre-purchased and stored stockpile, most of these medications and vaccines would not be readily available through other sources in appropriate amounts or in a timeframe that would allow for the prevention or effective treatment of illness. partnerships with storage and transportation companies have been created that provide strategically located storage facilities, allowing rapid delivery of sns materiel to any location in the us or its territories within 12 h of the federal decision to deploy. certain medical countermeasures may be eligible for the shelf-life extension program managed by the food and drug administration and the department of defense, which allows for expiration date extension based on potency and other test results. in addition, agreements with pharmaceutical companies and medication distribution partners have allowed for rotation of certain medications back into the commercial supply chain for use prior to their expiration in order to help mitigate replacement costs. although the sns was originally developed as a medical countermeasure response resource for intentional biological, chemical, and radiological emergencies, it has been deployed and used multiple times to support the medical needs of other public health emergencies, including hurricanes katrina and rita, the recent h1n1 in fl uenza pandemic, the 2001 world trade center and the anthrax letter attacks. the successful distribution of the sns is dependent on the capacity of state and local jurisdictions to rapidly dispense these countermeasures to the public. planning for the timely provision of antibiotics and/or vaccines to large populations requires the involvement of public health, emergency management, and the local medical community. mass prophylaxis plans need to consider the speci fi c challenges of potentially vulnerable populations, such as children, pregnant women, and those who are isolated and without resources and social supports, such as the homeless and homebound. contingency plans for setting up community-based points of dispensing (pods) for mass prophylaxis have been developed by most state and local jurisdictions, with a focus on ensuring suf fi cient staf fi ng resources, equipment and space requirements, and expediting patient fl ow. the capacity of health of fi cials to rapidly vaccinate the community was recently tested in the united states during the 2009 h1n1 pandemic and demonstrated the need for fl exibility and coordination in distribution of vaccine, including school-based programs, community health centers, pharmacies, and large health department sponsored vaccination clinics. multiple initiatives have been supported to further strengthen public health disease surveillance and reporting that include an emphasis on traditional disease reporting as well as the utilization of non-traditional data that may provide an earlier indication of community health events or more likely assist with situational awareness assessments during an identi fi ed event [ 8 ] . traditional public health surveillance for illness associated with potential bioterrorism agents relies on enhancing the medical and laboratory communities' familiarity with these agents, with the goal of improved reporting of suspected or con fi rmed illnesses, as well as reporting of unusual disease manifestations or illness clusters. most local and state health codes require that physicians, hospitals, and laboratories report a de fi ned list of noti fi able infectious diseases. state public health agencies have added cdc category a and b agents to their reportable disease lists. these lists are available at http:// www.cste.org/dnn/programs andactivities/publichealthinformatics/phistate reportablewebsites/tabid/1 36/default.aspx. in addition, recognizing the need to detect newly emergent diseases that are not yet listed on the health code, most states also require reporting of any unusual disease clusters or manifestations. early recognition of a bioterrorism-associated event depends in large part on astute clinicians and laboratorians recognizing one of the index cases based on a suspicious clinical, radiologic, or laboratory presentation (e.g. a febrile illness associated with chest discomfort and a widened mediastinum on chest radiograph in an otherwise healthy adult suggests inhalation anthrax). isolated cases presenting at separate hospitals will not be recognized as a potential outbreak unless they are reported promptly to the local health department, where the population-based aberrations in disease trends are more likely to be noticed. previous examples of astute clinicians recognizing and reporting unusual disease clusters or manifestations that led to the detection of a more widespread outbreak include an outbreak of hantavirus in the southwestern us [ 7 ] , legionnaires' disease associated with the whirlpool on a cruise ship [ 13 ] , an outbreak of cyclospora associated with contaminated raspberries imported from guatemala [ 11 ] , and the initial outbreak of west nile virus in new york city in 1999 [ 18 ] . similarly, the initial detection of anthrax in 2001 was due to a physician who recognized that large gram-positive rods in a patient's cerebrospinal fl uid could be b. anthracis [ 1 ] . by reporting this suspected case of meningeal anthrax, rapid con fi rmation was facilitated in a state public health lrn reference laboratory. weeks later, a suspected case of inhalation anthrax was recognized and promptly reported to and con fi rmed by public health authorities in new york city [ 17 ] . with the continued emergence of new zoonotic disease threats, including those related to bioterrorism, local, state, and federal public health agencies have taken steps to improve communication between human and animal health communities. noti fi able disease requirements have been expanded to include reporting by animal health specialists of suspected or con fi rmed illness in an animal that might be caused by a potential biothreat agent. because many medical providers and laboratorians in the united states have limited experience with most potential bioterrorist agents, early diagnosis may be delayed. therefore, the fi rst indication that a large-scale bioterrorist attack has taken place might be an increase in nonspeci fi c symptoms at the community level. surveillance for these increases in nonspeci fi c syndromes (e.g. respiratory, gastrointestinal, or neurologic) constitutes the cornerstone of syndromic surveillance used for emergency response purposes. many health jurisdictions have begun collecting and monitoring other types of health-related information such as symptom complexes presented during emergency room visits (e.g. lower respiratory tract illness, gastrointestinal illness, rash with fever), healthcare utilization information (e.g. emergency room visits, 911 calls), or other data that may be affected by a community-wide health event (e.g. school absenteeism, fl u or diarrhea over-the-counter medication sales) [ 10, 15 ] . though the approaches and cost for implementing syndromic surveillance vary, the tools and concepts for syndromic surveillance are adaptable and have been successfully implemented in both developed and developing countries to address routine surveillance, outbreak monitoring, and health security needs [ 6 ] . while initially conceived for early detection for bioterrorism, these systems also can be used to monitor natural infectious disease outbreaks and trends in noninfectious events of public health importance. information from syndromic systems has proven to be useful for detecting, monitoring, and characterizing seasonal outbreaks of in fl uenza, winter gastroenteritis (e.g. norovirus and rotavirus) and asthma. furthermore, syndromic systems were utilized extensively in the us during the novel h1n1 in fl uenza pandemic of 2009, along with other methods, to estimate the scale of community-wide in fl uenza transmission. an additional concept to speci fi cally improve early detection of an intentional biological agent release is the use of environmental monitoring systems. if an agent can be detected quickly following an aerosol release, response timelines can be signi fi cantly improved, allowing for more time to intervene and potentially prevent illness in a signi fi cant portion of the exposed population. in 2003, the united states implemented biowatch, an environmental monitoring system that consists of a network of samplers that collect air on a continuing cycle [ 21 ] . filters from the monitors are removed on a frequent basis and screened in a laboratory for the presence of several biological threat agents. biowatch is currently operational in multiple us cities. environmental monitoring in this fashion requires a signi fi cant fi nancial commitment and is a complex system to operate as experience with this type of system was limited prior to its implementation. natural environmental presence of the target organisms and/or very closely related organisms and the size of the area to be monitored present ongoing challenges for establishing system sensitivities and speci fi cities that appropriately balance the potential value of early detection of a bioterrorism attack with the risk of inappropriately responding to a positive test that is caused by naturally occurring organisms in the environment. a separate system of detectors has also been deployed that monitors the us mail system, the method of "dissemination" used in the 2001 anthrax letter attacks. the us postal biohazard detection system (bds) has been operational since 2004 [ 16 ] . unlike traditional disease and syndromic surveillance systems for human and animal health which monitor for both intentional and naturally occurring disease, these environmental systems are single purpose with the primary focus being early warning of bioterrorism. one of the more effective preparedness planning tools are tabletop and fi eld exercises, with involvement of representatives from key local, state, and federal agencies, as well as representatives from the local medical and laboratory communities. these exercises provide the opportunity to test assumptions in existing plans, and work out issues related to decision-making authority and respective roles and responsibilities among the various disciplines that would be involved in responding to a bioterrorist attack or other local emergency. post exercise debrie fi ngs should be conducted to highlight gaps in preparedness that can then be addressed through follow-up planning meetings and revision of written plans, if indicated, and re-evaluated with repeat exercises. depending upon the size and scope, responses to public health emergencies may involve resources and responsibilities that span multiple agencies at the local (city or county), state, and federal government levels. emergency events begin at the community level (single or multiple communities) and local personnel and resources (medical, public health, emergency services, police, fi re, etc.) provide the initial response. if local resources are overwhelmed or authorities require special assistance or resources that are not locally available, assistance from the state or federal level can be requested. this may be done through a direct assistance request to an agency or agencies (e.g. a request to cdc to assist with a food outbreak investigation or test samples) or through the formal declaration of an emergency that activates state and federal emergency support functions (e.g. declaration of state of emergency that activates the federal emergency management agency (fema) and other federal assistance as needed through the national response framework (nrf) and the associated emergency support functions (esf)). emergency responses and their coordination in the us primarily involve civilian agencies and authorities, with the military providing support as needed. central to the ability to successfully coordinate a response to a large-scale emergency is the ability to integrate information fl ow, resources, and personnel into an organizational structure that is similar across all responding agencies, whether the emergency is primarily public health in nature or due to some other cause. this incident management system or incident command system (ics) structure, has been used for many years by traditional fi rst responder agencies such as fi re and law enforcement and was formally identi fi ed as the national emergency response structure in 2003 [ 24 ] . ics has also been adopted and used to a much greater extent by federal, state, and local public health agencies responding to public health emergencies. cdc utilized the ics to coordinate its response to public health emergencies such as the 2009 h1n1 pandemic and multi-state foodborne outbreaks but has also bene fi ted from better integration of its response activities into larger-scale, multi-hazard emergency responses such as hurricane katrina and the recent haiti earthquake. the us department of health and human services (dhhs) has the lead for coordinating the federal public health and medical services support functions outlined in esf 8 ( http://www.fema.gov/pdf/emergency/nrf/nrf-esf-08.pdf ). these support functions include response activities in the following areas: (1) assessment of public health/medical needs, (2) health surveillance, (3) medical care personnel, (4) health/medical/veterinary equipment and supplies, (5) patient evacuation, (6) patient care, (7) safety and security of drugs, biologics, and medical devices, (8) blood and blood products, (9) food safety and security, (10) agriculture safety and security, (11) all-hazard public health and medical consultation, technical assistance, and support, (12) behavioral health care, (13) public health and medical information, (14) vector control, (15) potable water/wastewater and solid waste disposal, (16) mass fatality management, victim identi fi cation, and decontaminating remains, and (17) veterinary medical support. several agencies exist within dhhs that help carry out these activities, including cdc, the food and drug administration (fda), the national institutes for health (nih), and the substance abuse and mental health services administration (samhsa) among others. in addition, dhhs manages the national disaster medical system (ndms) which includes disaster medical, surgical, and mortuary response teams as well as veterinary response teams. in addition to providing medical response to a disaster area, ndms also coordinates patient movement into hospital care in unaffected areas for de fi nitive medical care with the support of the department of defense (dod). in addition to dod, multiple other agencies and departments provide support to dhhs for esf8 functions, including the department of agriculture (doa), dhs, fema, the department of transportation (dot), the department of veterans affairs (va), the american red cross (arc), and others. once a bioterrorist event is recognized and then con fi rmed by laboratory testing, there will be a need for large-scale mobilization of surveillance and epidemiologic investigations. the focus of these investigations will be (1) tracking the number of cases to de fi ne the scope of the incident and (2) performing epidemiologic investigations to determine the common source(s) and site(s) of exposure. this information will be most critical in the event of a covert bioterrorist event to determine where and when the attack occurred, and who else may have been potentially exposed (either at the event or due to downwind distribution of the aerosol) and thus require prophylaxis. as active surveillance would need to be initiated rapidly once a bioterrorist event is recognized, many local and state health departments have developed materials and plans to facilitate the ability to rapidly implement an investigation, including template surveillance instruments and protocols for urgently mobilizing and deploying active surveillance surge teams to hospitals in the affected area. response to public health emergencies that result from an intentional biothreat agent, such as the 2001 us anthrax letter attacks, have an added investigational and coordination complexity due to the necessary law enforcement component of the event [ 2 ] . if an event is known to be secondary to an intentional act, local law enforcement of fi cials and the federal bureau of investigation (fbi) have a greater leadership role in coordinating the investigation and communication, however, public health and other responding entities are still responsible for carrying out their usual surveillance and emergency response activities. in this scenario, activities such as interviewing victims to determine the common site and/or sources of exposure, specimen or sample collection and testing, and public messaging would be coordinated with the fbi or other law enforcement of fi cials in order to preserve evidence and investigative information that may be essential for attribution and conviction of the perpetrators. some activities such as sample collection or victim interviews may even need to be planned and conducted jointly by public health and law enforcement of fi cials. although law enforcement has the responsibility for conducting the criminal investigation, their primary mission is also the preservation of life and health and investigative activities are targeted towards accomplishing that goal in addition to obtaining the evidence needed to identify and convict those responsible. many local, state, and federal public health and law enforcement authorities in the us have recognized the investigation and communication coordination that would be required in a bioterrorism or other intentional chemical, radiological, or toxin induced event that affects the health of individuals or communities and have established working relationships for preparedness as well as formalized agreements for information sharing and joint investigative activities in this type of event. a model for a memorandum of understanding (mou) that can be used to create formalized working agreements between public health and law enforcement of fi cials was developed by a working group convened by the cdc and the us department of justice. this model mou has been distributed to state and local authorities and a copy can be requested through the cdc public health law practice website at http://www2a. cdc.gov/phlp/mounote.asp . the united states considers bioterrorism a serious threat to its national security and has made concerted efforts over the last decade to bolster public health and other response capacity capabilities. many of these efforts, though initially begun to address the needs for bioterrorism preparedness, have proven bene fi cial for public health in responding to other emergencies, including those due to naturally occurring disease threats such as pandemic in fl uenza. speci fi cally, efforts that focused on improving: (1) laboratory diagnostic capacity, (2) surveillance data sources, analysis, and reporting, (3) risk communication (4) emergency response planning and training, and (5) overall response coordination have proven extremely bene fi cial for supporting public health responses to all types of health threats. in most state and local health departments in the us, bioterrorism surveillance and response capacity is fully integrated into the general infectious disease and all hazards emergency response infrastructure. the same staff that surveil for and respond to both routine and emergency infectious disease outbreaks would be called upon to respond to a bioterrorism attack. this dual-use capacity is more ef fi cient and ensures that front line public health staff maintain and exercise the skills required to detect and respond to disease threats, regardless of whether intentional or natural. the 2009 h1n1 pandemic provided one of the best training opportunities for what might be encountered in the event of a large scale bioterrorist outbreak, including the need to implement enhanced surveillance to provide greater real time situational awareness, with the initial reliance on the public health laboratory system for reference testing, and the implementation of a large scale vaccination campaign. although bioterrorism is not accorded the same level of concern everywhere, investments that help build or support stronger public health and medical systems provide the foundation for responding to all health threats and are essential, should an unthinkable event such as a large-scale bioterrorism attack occur. index case of fatal inhalational anthrax due to bioterrorism in the united states collaboration between public health and law enforcement: new paradigms and partnerships for bioterrorism planning and response emergency preparedness and response: the laboratory response network partners in preparedness emergency preparedness and response: strategic national stockpile leading causes of death syndromic surveillance: adapting innovations to developing settings hantavirus pulmonary syndrome: a clinical description of 17 patients with a newly recognized disease encyclopedia of quantitative risk analysis and assessment the model state emergency health powers act: planning for and response to bioterrorism and naturally occurring infectious diseases overview of syndromic surveillance: what is syndromic surveillance an outbreak in 1996 of cyclosporiasis associated with imported raspberries anthrax bioterrorism: lessons learned and future directions outbreak of legionnaires' disease among cruise ship passengers exposed to a contaminated whirlpool spa investigation of bioterrorism-related anthrax implementing syndromic surveillance: a practical guide informed by the early experience responding to detection of aerosolized bacillus anthracis by autonomous detection systems in the workplace fatal inhalational anthrax with unknown source of exposure in a 61-year-old woman in new york city the outbreak of west nile virus infection in the new york city area in 1999 the public health security and bioterrorism preparedness and response act public health assessment of potential biological terrorism agents the biowatch program: detection of bioterrorism antimicrobial postexposure prophylaxis for anthrax: adverse events and adherence hspd-10: biodefense for the 21st century hspd-5: management of domestic incidents terrorism incident annex to the federal response plan key: cord-017463-repm1vw9 authors: ungchusak, kumnuan; heymann, david; pollack, marjorie title: public health surveillance: a vital alert and response function date: 2018-07-27 journal: the palgrave handbook of global health data methods for policy and practice doi: 10.1057/978-1-137-54984-6_10 sha: doc_id: 17463 cord_uid: repm1vw9 ungchusak, heymann and pollack address the critical global issue of public health surveillance. they describe how epidemiologists collect and use surveillance data to detect unusual events or outbreaks and to guide control programmes. drawing on their combined international experience, the authors explain the vital role that data play in alerting authorities to respond to outbreaks such as severe acute respiratory syndrome, ebola, zika virus and avian influenza. they point to the importance of sharing information globally while ensuring equal benefits to providers of data, coordinating surveillance activities across sectors, building capacity for surveillance and coordinating national surveillance activities. the authors emphasise the need for enhanced global cooperation to prepare for future public health emergencies of international concern. a three-month delay in identifying the outbreak of ebola virus in rural guinea in late 2013 resulted in its rapid spread to urban areas and to neighbouring liberia and sierra leone [1] . once local and international responders identified the virus, they took a year to interrupt its widespread transmission. by april 2016, ebola had accounted for more than 28,000 cases and over 11,000 deaths. people around the world watched with increasing alarm, as this tragic course of events played out, and with concern that air travel could enable the virus to spread across continents. this epidemic highlighted not only the inadequacy of local health systems to recognise and respond but also that international organisations were not ready to provide timely expertise and resources to control the situation and ameliorate the virus's spread through the region. had health officials identified ebola in west africa promptly, they could have minimised its impact on the lives and livelihoods of the populations of west africa by implementing appropriate control procedures. public health officials coined the term surveillance to describe systems they set up to watch out for and control occurrence of health threats. just as police, for example, set up closed-circuit television devices and community watch programmes to detect and prevent crime, public health surveillance systems engage all possible means to detect unwanted health events and prevent them from escalating and damaging population health. while public health surveillance originated to control spread of infectious diseases such as plague and cholera, it has evolved to include some non-communicable diseases, occupational health and injuries as well as surveillance of biological, behavioural and social determinants of these conditions. we start by reviewing the public health need for surveillance and the development by the international community of regulations to control infectious diseases and other public health emergencies of international concern (pheic). we describe how epidemiologists use surveillance data to detect unusual events or outbreaks and to guide control programmes, and we provide guidance about maintaining data quality. we examine networks that contribute to global surveillance systems and highlight the role of social media and information technology in providing data to monitor new events of international importance. we consider challenges facing epidemiologists responsible for surveillance and describe efforts to address them. public health surveillance is vital to the functioning of national and global health systems. policymakers and health administrators need surveillance information to set priorities to address population health problems, allocate resources and monitor progress of prevention and control programmes; they need surveillance systems to alert them immediately of public health threats. emerging infectious diseases, such as avian influenza of different subtypes, severe acute respiratory syndrome (sars) coronavirus, pandemic influenza h1n1 and the zika virus (zikv) have the potential to spread rapidly causing severe loss of life and to impact socio-economic activity, especially trade and travel [2] . the outbreak of sars in november 2002 highlighted the importance of every country having functioning and connected surveillance systems (see box 10.1). surveillance requires high-level government support, well-trained health workers, strong health information systems, well-functioning laboratories, effective communication systems and operational health facilities. to be effective, surveillance systems also require a strong legal framework to ensure that individual data can be shared while maintaining confidentiality as far as possible. global cooperation between countries, with up-to-date international health agreements to build and maintain these capacities, is essential to decrease risk of international spread of infectious diseases and contain the risk of bio-terrorism. sars originated in wildlife and spread silently among humans as atypical pneumonia in guangdong province, china, two months before officials became aware of it. authorities began surveillance to identify atypical pneumonia cases but this, and the containment response, were too late to stop sars spreading. a chinese urologist who was infected travelled to hong kong and spread sars to another 16 persons. within weeks, sars spread to 25 countries with more than 8,000 reported cases ( fig. 10.1 ) [3] . by the end of the epidemic in july 2003, sars had killed 774 people [4] . although unable to contain the outbreak of sars, the international community was able to bring the epidemic under control within six months-by collaborating across countries to identify and isolate all probable cases. nevertheless, the asian development bank estimated that the economic loss due to sars in affected countries was up to us $28 billion with us$ 5.8 billion on mainland china (approximately 1.2 per cent of its annual gross domestic product (gdp)) and us$ 6.6 billion in hong kong (approximately 4 per cent of its annual gdp) [5] . plague ravaged europe during the fourteenth century and although authorities had no cure, they realised it was important to swiftly identify and isolate cases to prevent and control this lethal condition. authorities understood that international spread of such diseases followed cross-border trade, pilgrimage and war; and so prevention of disease was a national security issue. in the city-state of venice, authorities instigated quarantine measures-keeping arriving ships in the harbour for 40 days before docking, and holding people in isolation for 40 days at land borders to prevent entry of plague [6] . in the mid-nineteenth century, recognising that quarantine measures were not enough, governments agreed international conventions aimed at stopping spread of plague and cholera-and two other infectious diseases, yellow fever and smallpox. the conventions required each country to report outbreaks of these diseases to all signatories of the convention, and permitted application of certain public health measures at international borders once a country reported of one of the diseases. in the early twentieth century, governments in the americas and in europe set up regional conventions called international sanitary bureaus. in 1951, the newly formed world health organization (who) led establishment of the international sanitary regulations (isr) to foster global cooperation in reporting and acting at international borders to guard against spread of cholera, plague, yellow fever and smallpox. in 1969, the who replaced the isr with the international health regulations (ihr) which required countries to report any cases of cholera, plague, yellow fever and smallpox to who [7] . if a country reported one of these diseases, other countries could apply pre-established control measures at international borders-such as a requirement of proof of vaccination against yellow fever of any passenger arriving from a country that reported yellow fever to who. some countries reported to who late, or not at all, because of lack of capacity for public health surveillance, or because of fear of stigmatisation and economic repercussions. after hiv spread across international borders before being identified in 1981, the international community realised that infectious diseases could not be stopped at borders. diseases often cross borders while still being incubated in humans, or in non-human hosts-insects, animals, and food and agricultural goods. in 2005, after the 2003 sars outbreak, who updated and revised the ihr as a legal framework to include more diseases, and developed real-time evidence-based recommendations for prevention and control of outbreaks. who evaluates each newly identified outbreak for its potential to become a pheic by the country in which it is occurring. the ihr 2005 mandate who member countries to report immediately the occurrence of a single case of four diseases (smallpox, poliomyelitis due to wild type poliovirus, human influenza caused by a new subtype, and sars) [8] . even though the world eradicated smallpox in 1980, the ihr still maintain it on the list to cover the risk of the virus escaping from a laboratory. each country has an additional list of diseases that it requires its health workers to report by law. diseases of greatest public health threat are reportable, meaning that health workers or laboratory technicians must report individual cases as they occur. reportable diseases include those required by ihr and, for example, anthrax, cholera, ebola, legionellosis, plague and the zikv. other conditions are notifiable, meaning that health workers should report the number of cases that have occurred in a given time period. the number, frequency of reporting and breakdown of reportable and notifiable diseases varies by country. diarrheal cases, influenza cases, tuberculosis, aids and other significant endemic diseases are usually required to be notified to local health authorities. in some countries the notifiable list can include non-infectious conditions such as maternal or infant deaths. the ihr 2005 require countries to develop core capacities in public health, including surveillance systems and epidemiology services, that can analyse and act on surveillance information to detect and respond to diseases where and when they occur so that their potential to spread internationally is decreased. the purpose of surveillance activities is to: (1) detect at an early stage, acute public health threats from all hazards-biological, chemical, radiation, natural disaster and deliberate acts-which require rapid investigation and response; and (2) guide control programmes by measuring disease burden, monitoring trends, describing disease distribution and evaluating public health programme effectiveness (see table 10 .1). the structure of government responsibilities for public health surveillance varies across countries. most often, countries set up dedicated early warning and rapid response surveillance teams that work with or complement surveillance activities of vertical control programmes such as malaria, hiv/aids or tuberculosis. surveillance and response teams detect early stage public health threats while control programmes gather disease (or condition) specific information to plan activities. control programmes share information with surveillance teams as required. a national network of public health laboratories, often linked to international reference laboratories, confirms etiologic agents, genetic strains and antibiotic resistance patterns. surveillance activities are said to be active when health workers pro-actively seek out cases and passive when the system relies on patients to report themselves to a clinic. using standard case definitions, health workers report individual cases of reportable and notifiable diseases to the local or national surveillance centre where staff aggregates reports, and clean and analyse the data. in cleaning the data, staff look for coding and classification errors, and for duplicate reports. epidemiologists analyse the data to determine how many new cases have occurred during the past day or week and their distribution in time, place and by person to see whether the magnitude and pattern of the disease under surveillance is changing. they note any changes in frequency, clustering or distribution and flag them for verification and explanation. box 10.2 illustrates how careful data analysis led to malaysia identifying nipah virus in 1999 [9] . reporting of specific information about cases or patients or behaviour of populations under surveillance produces indicator-based data, that is individual or aggregated data derived from patients diagnosed-by syndrome description, clinical or laboratory confirmation-and identified through routine collection or active case search. the surveillance unit will also use eventbased data about outbreaks, unusual events or changes in human exposure [10] . rather than wait for official reports, the surveillance team gathers information and rumours through the media, internet and unusual events reported by the community, and investigates these reports. the team captures abnormal health events in real-time and confirms potential outbreaks by triangulating these data with indicator-based data. epidemiologists responsible for surveillance use standard epidemiological methods to analyse trends, identify clusters and investigate suspected risk factors (see chap. 18 for an overview of epidemiological methods). for example, high numbers of reported cases of kaposi sarcoma among young men in new york and california during the early 1980s led to an investigation which showed a japanese encephalitis commonly occurs in school-age children of both sexes. there is a seasonal pattern of disease related to the rainy season when transmission and therefore disease occurrence, increases; there is no difference in occurrence between ethnic or religious groups. from september 1998 to april 1999, surveillance teams sent reports of 229 cases of febrile encephalitis (48 per cent fatal) to the malaysian ministry of health [9] . initially, the ministry considered japanese encephalitis virus to be the probable etiologic agent for this outbreak, and instituted conventional interventions of vaccination and insecticide to control mosquitoes. when they examined the surveillance data closely, the epidemiological pattern of encephalitis cases was different to what they expected-the disease occurred mostly among male adults of chinese ethnic origin whose occupations related to pig farming. the ministry sought a different cause and found the etiologic agent to be a new paramyxovirus, later named nipah virus. common risk factor of homosexual behaviour and its relationship with hiv/ aids [11] . using increasingly sophisticated technologies for data capture and analysis, surveillance teams can monitor real-time occurrence, in time and place, of unusual events such as cholera or legionella, or seasonal outbreaks such as malaria (see chap. 20 for an introduction to spatial and spatio-temporal techniques and to chap. 14 which discusses predicting climate-related health outcomes such as malaria). once epidemiologists have concluded their analyses (sometimes in realtime), they prepare reports which can trigger immediate action by a rapid response team to visit the site of the events, investigate the situation and contain the outbreak. the team also sends reports to clinicians in hospitals and to local and national programme managers. many countries publish weekly disease surveillance reports that are also available to the general public: for example, the us centers for disease control and prevention (cdc) publish the morbidity and mortality weekly report (mmwr) [12] , the european centre for disease control (ecdc) publishes eurosurveillance [13] , and the who publishes the weekly epidemiological record [14] . box 10.3 shows how epidemiologists associated microcephaly with zikv which led who to declare zikv a pheic [15] . public health surveillance guides control programmes by undertaking the following functions: in late 2015, zikv spread rapidly through latin america especially in brazil and el salvador. surveillance of birth defects in brazil identified a major increase in microcephaly during the period when zikv transmission increased. this alerted policymakers and epidemiologists to study whether the increase in birth defects was associated with zikv infection during pregnancy. who declared the suspected increase in microcephaly in association with zikv infection of pregnant women a pheic and recommended pregnant women to protect themselves from mosquito bites and to avoid travel to areas with known zikv transmission. the observation that men who travelled to areas with known zikv transmission could sexually transmit zikv to their partners led who to recommend practising safer sex or abstinence for a period of six months for men and women returning from areas of active transmission. its epidemiological patterns disease in humans results from interactions between the human host and causative agents or hazards of all types. the natural and socio-economic environment influences these interactions. diseases usually occur in the same pattern when there is no change in the causative agent (such as mutation), in the human host (such as vaccination) or in the environment (such as climate change). a surveillance system can closely monitor any changes in these dynamic factors and their consequences, as illustrated by the case of nipah virus in malaysia (box 10.1). public health surveillance must also address risk. for example, surveillance of annual per capita cigarette consumption in the us showed an increased trend from 54 cigarettes in 1900 to 4,345 cigarettes in 1963. researchers related this trend to advertising and an expansion in the number of cigarette companies. in 1998, after the first studies suggesting cigarette consumption was related to lung cancer, and the us surgeon general issued a warning, the annual per capita consumption decreased to 2,261 [16] . with surveillance information, epidemiologists can forecast an increase in lung cancer without intervention thereby providing evidence for policy to implement effective interventions such as taxation to prevent smoking. evaluating performance of control programmes after they have implemented interventions, health authorities use surveillance data to see if disease incidence declines. for example, when vaccine coverage increases, the number of cases of vaccine preventable diseases is expected to decrease. increasing taxes on cigarettes is one way to reduce consumption. surveillance data can document a correlation between increasing taxes and decreasing trends in cigarette consumption. to achieve these functions, programme managers collect data through patient records, surveys, programme records or informal sources. types of data include determinants of the condition, behaviours or risk factors associated with the condition, morbidity and mortality associated with the condition, programme responses, and abnormal or unusual events associated with the condition. table 10 .2 provides examples of these types of data for surveillance of an hiv/aids control programme. to ensure surveillance programmes have adequate resources and produce useful information, public health authorities regularly review their surveillance activities. in 1988, the us cdc issued guidelines to evaluate surveillance systems which, with some updating, are still widely used [17] . these guidelines focus evaluation of public health surveillance on three areas: (1) the surveillance system itself, describing the system, its structure, diseases under surveillance, sources of data, and how data are processed, analysed and disseminated; (2) the resources used to operate the system, including funding sources, adequately trained staff and information technology; and (3) the usefulness and quality of surveillance information, using the following indicators: usefulness of data do the data and information disseminated to data providers and users contain comprehensible facts and findings and useful recommendations to improve control measures and guide programme management? has the system detected outbreaks? how many of the detected outbreaks were investigated and controlled in a timely manner? timeliness of data and other information is data dissemination timely and regular? for example, epidemic prone diseases require weekly summary, while other diseases require only monthly or quarterly summaries. are these requirements met? validity and completeness of data much of the data come from clinical diagnoses that do not have laboratory confirmation. it is useful to conduct studies to determine the accuracy of diagnoses using standard laboratory confirmation testing. this helps in preparing estimates of the proportion of confirmed cases among all reported cases. when undertaking field investigations, investigators can compare the number of actual cases they find with the number of cases reported through the system. this provides an estimate of reporting completeness of the system. global public health surveillance is the collection, analysis and use of standardised information about health threats or their risk factors from more than one country, and usually worldwide. while surveillance mainly focuses on infectious diseases, global systems also seek to identify deliberate use of biological agents or toxins to cause harm. who leads the global public health surveillance system, gathering information from formal and informal sources working through its country and regional offices. who extends its reach through the global outbreak and response network (goarn) [18] which comprises over 120 national technical institutions that support who to detect public health threats and respond to outbreaks. who uses the information for risk assessment and analysis as part of its routine disease control and prevention programme activities. when requested by countries for support, who works with goarn institutions to recruit suitable experts. goarn includes regional networks of countries that cooperate independently to prevent and control infectious diseases occurring in their regions, for example, the east african integrated disease surveillance network (eaidsnet), [19] and the mekong basin disease surveillance network (mbds) [20] . who leads global networks that work to control specific diseases. these networks depend on cooperation of governments, public health workers and scientists to report cases, provide specimens and share information so that specific diseases can be controlled globally. these include: networks to support influenza control through vaccine development the global influenza surveillance and response system (gisrs) consists of national sentinel centres and national and regional laboratories which annually collect 200,000-250,000 nasal swabs from patients presenting with influenza-like illness. their analyses provide information about the distribution of strains circulating each year and enable scientists to recommend the influenza vaccine composition for the following year based on predominant sequences. gisrs also uses flunet, a public web-based data collection and reporting tool that tracks movement of influenza viruses globally and provides epidemiological data about influenza outbreaks [21] . initiative. clinical health workers and epidemiologists report all cases of acute flaccid paralysis (afp) in children under 15 years of age from whom they have collected stool specimens for isolation and identification of the poliovirus. through its network of national, regional and specialised laboratories, gpln determines whether polio was the cause of the afp, genetically sequences viruses and compares them to a global database to understand their geographic source. if a polio virus is found, gpln informs the national authority and who regional office for appropriate action. project on anti-tuberculosis drug resistance surveillance [23] is a common surveillance platform to which countries can provide data that are then used to monitor the evolution and spread of multi-drug resistant tuberculosis (mdr-tb) and extensively drug-resistant tuberculosis (xdr-tb). national laboratories provide susceptibility testing of tuberculosis organisms collected from patients, supported by a supranational tuberculosis reference laboratory network. the global project provides understanding of the prevalence and distribution of tuberculosis resistance worldwide. [24] . its goal is to develop a standardised strategy to collect, analyse and share clinical, laboratory and epidemiological data globally, assess the burden and support local, national and global strategies to control amr. until recently, surveillance systems depended on paper-based reporting, compilation and analysis of data. computers and electronic reporting have made compilation and analysis of data much easier, and the world wide web (www) and the internet improve the comprehensiveness of reporting. digital and internet-based technology can retrieve information from medical records on a daily basis-but this must be done without infringing personal privacy. hospitals, especially private ones, may refuse to provide patient information to the public health sector unless privacy issues are addressed. cell phone technology has extended the scope of informal and event-based surveillance while social media has transformed exploring rumours of new events. some ground-breaking examples of the use of information and communication technology include: electronic reporting of events the programme for monitoring emerging diseases (promed-mail) is a fully moderated internet-based listserv, that receives and publishes reports of public health events in humans, animals, wildlife and plants from its subscribers and other traditional and nontraditional information sources [25] . promed-mail uses information available on the www and from voluntary listserv reporters who actively search for and report public health events in realtime from the media, internet blogs and other sites. promed-mail editors and expert moderators review, analyse, evaluate and where possible validate reports, and then disseminate them to listserv members and post them on its website. using big data to identify events the subscription-based application global public health intelligence network (gphin) continuously scans the www gathering information from multiple source news aggregators in real-time [26] . gphin searches in nine languages for key words that could indicate infectious disease outbreaks, or environmental, radioactive and natural disasters. analysts identify new events and inform subscribers-who are governmental and non-governmental agencies with an established public health mandate. every 24 hours, analysts communicate new information to who which validates reports through its network of regional and country offices. who discusses events that it validates in confidence with health departments in the countries involved. mapping events in real-time healthmap, a fully automated application, utilises online informal sources for disease outbreak monitoring and real-time surveillance of emerging public health threats [27] . healthmap trawls www sources of information (in nine languages) including online eyewitness reports, expert-curated discussions such as promed-mail, validated official reports, for example from who, or the food and agriculture organization of the united nations, and news aggregation services such as google news. using open source software, healthmap displays the events by time, geographic location and aetiology. participatory flu tracking diseases and abnormal events happen all the time in the community. only some patients, especially those presenting with severe disease manifestations, seek medical care. flu near you invites anyone living north america, over 12 years of age, to report if they have an influenza-like illness [28] . once registered, participants are asked weekly by e-mail to complete a brief survey that seeks information on ten symptoms linked to influ-enza, and other information such as whether or not the registered participant has had an influenza vaccination. other countries, including the uk, have adopted similar participatory influenza surveillance systems, thereby adding a greater understanding of the epidemiology of influenza around the world. participatory onehealth disease detection (podd) chang mai university in thailand, with support from the skool foundation, developed this mobile application which connects 296 volunteers in 71 local governments. when volunteers notice an abnormal event such as poultry dying off or sickness in animals or humans, they use podd to notify local authorities who dispatch a surveillance and rapid response team to investigate and contain the event. after 16 months of implementation, podd has enabled the detection of 1,029 abnormal events, including 26 chicken high-mortality outbreaks, four cattle disease outbreaks, three pig disease outbreaks and three fish disease outbreaks, all of which were detected and controlled [29] . since revision of the ihr in 2005, outbreaks due to infections, including the middle east respiratory syndrome coronavirus and ebola virus, have highlighted continued weaknesses in public health surveillance and response capacities in most countries, with international spread causing disruptions in trade and travel, and negatively impacting economies. we present some challenges and suggest some solutions. most countries have established disease control programmes each with a surveillance component reporting from grassroots through provincial and national levels. national surveillance units may have sufficient staff for each disease control programme, but at lower levels of the health system, the same individuals often manage more than one programme and are heavily burdened by reporting requirements. there is also duplication of effort in reporting between programmes. who supports countries to coordinate surveillance activities across departments, programmes and administrative levels through integrated disease surveillance and response (idsr) [30] . idsr links surveillance with other health information activities and strengthens overall capacity of countries to maintain public health surveillance. the ihr 2005 obligates countries to develop comprehensive disease surveillance, detection and response when and where infectious diseases and other acute public health threats occur. in reality, national surveillance capacity in many countries is still not at expected and necessary levels. this may be, as the ebola epidemic demonstrated in west africa, that health systems are weak and under-funded, or that the surveillance system itself does not function efficiently. regular evaluation of the system, as we describe in sect. 4.3, can identify which components need to be strengthened. an over-riding issue is for the system to deploy and maintain enough professionals throughout the system with the required skills-understanding the nature and limitations of the data they are working with and able to interpret and draw important findings from the analyses of the surveillance data. approximately 75 per cent of newly identified human diseases are zoonotic in origin [32] and 70 per cent of these diseases have their origins in wildlife [33] . since the 1997 outbreak of h5n1 avian influenza in hong kong, animal surveillance and human surveillance units have begun to share information and alert each other of unusual events. environmental factors are also crucial to disease occurrence, for example, paralytic shellfish poisoning among people who consume shellfish affected by harmful algae growth in the sea [34] . the one health approach involves sharing information between multiple health sectors and working together to identify and resolve outbreaks [35] . during the 2005 avian influenza outbreak, who requested all affected countries to share the virus isolated from humans for further study and vaccine development. some governments expressed concern about potential negative economic consequences of sharing information and about possible inequities in the benefits of sharing. this led to the 2007 jakarta declaration on responsible practices for sharing avian influenza viruses and resulting benefits [36] . this declaration underlined need for continued open, timely and equitable sharing of information, data and biological specimens related to influenza; it also emphasised need for more equitable sharing of benefits for example in the generation of diagnostics, drugs and vaccines. the jakarta declaration led to the pandemic influenza preparedness framework (pip) under which manufacturers of influenza vaccines, diagnostics and pharmaceuticals that use gisrs information make annual financial contributions to who. who uses approximately 70 per cent of these contributions for pandemic preparedness activities and surveillance, and 30 per cent for pandemic response including purchase of vaccines and antivirals at the time of a pandemic for countries without access to these supplies. in may 2017, the chatham house centre on global health security, after a series of roundtable consultation with experts in public health surveillance, produced a guide on strengthening data sharing for public health surveillance. this guide facilitates both informal and formal data sharing. the guide proposes seven principles: building trust; articulating the value; planning; using quality data; understanding the legal context; coming to agreement; and evaluating. the guidelines help create the right environment for data sharing and to facilitate good practice in addressing technical, political, ethical, economic and legal concerns that may arise. the guidelines aim to ensure, to the greatest extent possible, that any benefits arising from use of the data are shared equitably [37] . similar to clinical or public health practice, institutions or agencies responsible for public health surveillance need a set of ethical principles to guide their operations. the 2017 who guidelines on ethical issues in public health surveillance proposed 17 guidelines [38] . these guidelines fall into three major groups: first, the mandate and broad responsibility of the agency to undertake surveillance and subject it to ethical scrutiny; second, the obligation to ensure appropriate protection and rights of individuals under surveillance; and third, considerations in making decisions about how to communicate and share surveillance data to pursue common good and equity of population without harm to individual. the west african ebola outbreak provided a costly lesson that policymakers must commit to establishing, maintaining and advancing public health surveillance systems to protect and promote population health. to prepare for the next major outbreak, the world needs to invest in a strong warning and response system led by a global institution with sufficient authority and funding to react swiftly [39] . who serves this role but is chronically underfunded. similar investment is needed in countries where a fully supported, well-functioning surveillance office or programme must coordinate different components of the surveillance system. surveillance information should be disseminated widely to alert the public and health programmes of outbreaks so that they can contain the disease at source before it spreads internationally. because the world urgently needs reliable and timely surveillance information, public health surveillance should continue to make innovative use of new technology to gather and share information strategically and fairly. â�¢ the 2014 ebola outbreak highlighted inadequacies of national and global surveillance systems to detect and respond to public health threats. â�¢ surveillance provides critical data and information to guide, improve and protect public health. â�¢ more trained staff are needed for effective and efficient surveillance especially in low-and middle-income countries. â�¢ innovative use of information technology and social media can aid detection of public health threats. one year into the ebola epidemic: a deadly, tenacious and unforgiving virus: world health organization emerging infectious diseases in 2010. 20 years after the institute of medicine report. mbio sars molecular epidemiology: a chinese fairy tale of controlling an emerging zoonotic disease in the genomics era the legacies of sars -international preparedness and readiness to respond to future threats in the western pacific region. western pacific surveillance and response journal sars economic impacts and implications. economic and research department policy brief no 15. asian development bank lessons from the history of quarantine, from plague to influenza a. emerging infectious diseases world health organization. the international health regulations world health organization early detection, assessment and response to acute public health events: implementation of early warning and response with a focus on event-based surveillance: interim version who/hse/gcr/lyo/2014.4 world health organization world health organization. who director-general summarizes the outcome of the emergency committee regarding clusters of microcephaly and guillain-barrã© syndrome achievements in public health, 1900-1999: tobacco use-united states updated guidelines for evaluating public health surveillance systems the global outbreak alert and response network. global public health east african integrated disease surveillance network mekong basin disease surveillance network global polio laboratory network world health organization. surveillance of drug resistance in tuberculosis global anti-microbial resistance surveillance system (glass) epidemic intelligence -systematic event detection podd: an innovative one health surveillance system preventing pandemics with animal origins training programs in epidemiology and public health interventions network risk factors for human disease emergence global trends in emerging infectious diseases woods hole oceanographic institution. harmful algae one health initiative. one health initiative will unite human and veterinary medicine jakarta declaration on virus sharing: a strategic step to more equitable and affordable avian flu vaccines distribution a guide to sharing the data and benefits of public health surveillance. london (uk): the royal institute of international affairs chatham house world health organization. who guidelines on ethical issues in public health surveillance the next epidemic-lessons from ebola key: cord-017721-5bp0qpte authors: gable, lance; hodge, james g. title: public health law and biological terrorism date: 2008-09-10 journal: beyond anthrax doi: 10.1007/978-1-59745-326-4_12 sha: doc_id: 17721 cord_uid: 5bp0qpte nan result in significant illnesses or casualties [9] [10] [11] [12] [13] [14] [15] [16] [17] . consequently, proactive preparations for bioterrorism, even more so than other types of terrorism, involve systematic planning, ongoing training, and redistributions of resources. the prospect of bioterrorism has galvanized widespread support for improved preparedness within federal, state, and local governments and the health care sector throughout the united states. these efforts have targeted a wide range of relevant and intersecting areas. strengthening the public health workforce, infrastructure, and capacity available to respond to an outbreak associated with biological terrorism, is critical. policy-makers have responded by increasing training and funding to these areas [18] [19] [20] . similarly, planners within the public and private sectors have established tactics and procedures to respond to various emergency scenarios. these plans frequently consider methods to improve communications between various emergency responders and others who must have sufficient capability to contact each other in an emergency situation. preparedness planning efforts targeting bioterrorism have occurred concurrently with initiatives to bolster public health infrastructure for other public health emergencies including natural disasters (e.g., hurricanes) and naturally occurring disease outbreaks (e.g., pandemic influenza). finally, preparedness planners have considered some of the ethical concerns raised by bioterrorism attacks and their potentially devastating consequences. a foundational component of these preparedness efforts has been the potential modernization of state and federal public health and emergency response laws. law is a critical component of a well-developed public health system [21] . public health law grants public health agencies powers to detect, track, prevent, and contain health threats resulting from bioterrorism and other public health emergencies. however, many existing public health and emergency response laws at the state and federal levels may not be sufficient to address biological terrorism. these laws often do not grant public health authorities the necessary powers to stop an outbreak. public health laws vary widely across different jurisdictions. as a result, the legal powers ascribed to public health officials may be different in scope and function in different locales. these laws are also commonly targeted to specific diseases or conditions that may not relate to emerging threats [22] . public health powers typically lie at the state and local levels of government. the federal government plays a more limited role for practical and legal reasons. public health falls within the state's police powers, an area of state power traditionally reserved to the states under the tenth amendment to the united states constitution [23] . the federal government will normally become involved in localized public health matters only at the request of the state or if the disease has the potential to cross state or international borders, or affect interstate interests. from a practical perspective, this gives state and local officials greater autonomy to enact laws and policies conducive to the needs of their communities, without interference from the federal government. responses to bioterrorism, however, will almost certainly involve the federal government, since an infectious disease will rarely be contained within the borders of one state. indeed, an outbreak may traverse international boundaries as well, which would clearly entail the input of the federal government. bioterrorism implicates additional concerns beyond public health, including national security and law enforcement considerations. federal public health and legal authorities may specifically respond to multiple components of a bioterrorism attack, as well as offer guidance and expertise to assist state and local governments in their responses. thus, responses to bioterrorism require sufficient legal powers at both the federal and state levels, in addition to a wellconceived plan for coordinating these powers to maximize public benefit. the debate around bioterrorism preparedness has raised salient questions about the role of law in responding to biological threats, highlighted by inherent tensions between protecting the public and upholding individual rights of liberty, privacy, and freedom of association [24] . balancing these goals requires difficult choices that are further complicated when public health laws are unclear, poorly drafted, or confusing. to assist state and local law-and policy-makers, public health law scholars at the center for law and the public's health at georgetown university law center and the johns hopkins bloomberg school of public health drafted two model state public health acts. the model state emergency health powers act (msehpa) was drafted quickly after september 11, 2001 , with input from the centers for disease control and prevention (cdc) and multiple national partner organizations [25, 26] . completed on december 21, 2001, msehpa has served as a valuable template for states to modernize their public health laws to address public health emergencies, including emergencies caused by bioterrorism. it provides a modern framework for public health powers, authorizing state and local authorities to engage in a range of activities to address a public health emergency. these measures may restrict temporarily the liberty or property of affected individuals or groups to protect the public's health [27] . to date, 44 states and the district of columbia have introduced bills based on some or all of the provisions of the msehpa, and 38 states and the district of columbia have passed their respective bills [28] . the turning point model state public health act (turning point act) (completed on september 16, 2003) provides a more comprehensive prototype for state public health law reform [29] . it covers a broad array of topics that extend well beyond emergency situations, including (1) defining and authorizing the performance of essential public health services and functions; (2) improving public health infrastructure; (3) encouraging cooperation between public and private sectors on public health issues; and (4) protecting the privacy of identifiable data acquired, used, or disclosed by public health authorities [29] . a third model law, the uniform emergency volunteer health practitioners act (uevhpa), as drafted in 2006 by the national conference of commissioners on uniform state laws, provides a further model for emergency public health governance, organized around the challenge of accommodating health professionals who show up spontaneously at the site of a public health emergency or nearby health facilities in order to provide emergency assistance [30] . the aforementioned model acts recognize that an effective public health response to a bioterrorism-related outbreak will demand strong and clear legal powers. in the following sections, we focus predominantly on two specific areas of public health powers authorized under law: (1) restrictions on personal liberty (quarantine, isolation, travel restrictions, privacy) and (2) restrictions on property (decontamination, use of supplies and facilities, disposal of remains). while other areas of law are also relevant to the legal framework needed to address bioterrorism, these two areas feature the most sustained debates and controversies. each of these powers will be considered in the following sections from a legal and ethical perspective. the release of a highly infectious disease into the population presents government officials with a difficult quandary. within the climate of fear that may surround such an outbreak, public health authorities must quickly and accurately assess the risk to the population and take measures accordingly to protect the public's health. under such circumstances, public health authorities may resort to liberty-limiting measures such as quarantine, isolation, travel restrictions, and privacy limitations. personally restrictive actions are particularly likely when the disease is readily communicable, exceptionally virulent, or is of unknown origin. restrictions on personal liberty to respond to a public health crisis are constitutionally permissible, but the scope of restrictions and attendant protections against their misuse varies significantly across different jurisdictions. quarantine and isolation are among the oldest of public health tools. their use predates modern scientific advances in disease testing and treatment, not to mention modern conceptions of civil liberties. they operate on the most basic principle of infectious disease control-keeping healthy individuals separated from those who have been exposed or infected. in modern times, the mass use of quarantine or isolation has faded as rapid medical tests and effective treatments have become available. when quarantine and isolation have been used, they have been directed predominantly at specific infectious individuals, for example, to control recalcitrant tuberculosis patients [31] [32] [33] [34] . nevertheless, for a disease of unknown etiology or a disease that poses a significant threat to a vulnerable population, quarantine and isolation may still be effective techniques to contain an outbreak. depending on the scope of the outbreak, largescale quarantine measures may have to be considered. modern logistics surrounding enactment of a large-scale quarantine would be complex and possibly unworkable [35] . the terms quarantine and isolation have engendered a great deal of confusion. the two terms are often used interchangeably, but in actuality represent distinct concepts. the term quarantine denotes a compulsory physical separation of an individual or a group of healthy people who have been exposed to a contagious disease to prevent transmission during the incubation period of the disease [21] . historically, quarantine restrictions were often imposed on travelers to insure that they did not introduce a contagious disease into a country or town. the word itself derives from the latin term quadragina and the italian term quarante, which refer to the 40-day sequestration period enforced on merchant ships during plague outbreaks [21] . the term isolation, by contrast, means the separation, for the period of communicability, of known infected persons so as to prevent or limit the transmission of the infectious agent [21] . precise usage of and differentiation between these terms is vital to insure that those subject to these powers receive appropriate treatment and protection. the current legal framework authorizing the use of quarantine and isolation in the united states stretches across multiple jurisdictions and levels of government. quarantine powers were first implemented at the local level, and later the state level, during the colonial period. the federal quarantine statute, first enacted in 1796, authorized the president to assist states in their use of quarantines [36] . the federal government subsequently took control over maritime quarantines [37] . this expanded federal role prompted a debate over whether the federal or state government should administer quarantines-a debate which continues to this day. as discussed below, states claim that their quarantine authority derives from their police power, while the federal government argues that its authority arises from its constitutionally -granted power to regulate interstate commerce. state and local jurisdictions have the primary responsibility for quarantine within their borders. the state quarantine power is derived from the state's inherent police power, reserved to the states under the tenth amendment of the united states constitution. most public health powers have traditionally been recognized as falling under the jurisdiction of state and local governments. the united states supreme court has found that the police powers of the state allow the state to enact regulations to protect the health and safety of its citizens [23] . the use of quarantine and isolation by state and local governments is therefore legally and constitutionally acceptable, provided that these powers are used appropriately to protect public health and safety. the specific scope of state and local quarantine authority varies considerably between jurisdictions. these differences are evident in the structural distribution of power between the state and local governments and the substantive criteria (or lack thereof) for placing an individual under quarantine. some states have a centralized public health system that retains most public health powers at the state level, including quarantine and isolation decisions. other states delegate these decisions to local public health agencies. in these states, quarantine will generally be under the jurisdiction of local public health officials when the disease is confined to a discrete local area. if the outbreak affects more that one community within the state, the state public health authority will usually have the power to implement quarantine or isolation orders. very few jurisdictions have articulated explicit procedures and policies to determine whether or not an individual should be subject to quarantine. both the msehpa and turning point act propose a systematic process for making this determination that considers the exigencies of the situation. furthermore, they allow for an appeal of the decision if possible under the circumstances [25, 29] . federal quarantine powers are much more limited than comparable powers at the state level. the federal government may only apply powers delegated to it under the constitution. pursuant to these delegated powers, federal authorities have the ability to prevent the introduction, transmission, and spread of communicable diseases between states and from foreign countries into the united states. the federal quarantine power stipulates that if there is a risk that disease transmission will cross state lines, the federal government has the authority to implement quarantine [38] . the federal government is additionally authorized to cooperate with state and local authorities to enact quarantine to contain an interstate disease outbreak [39] . the federal quarantine response is conducted by the cdc, with assistance from other agencies if necessary, including the department of homeland security (dhs), the department of defense (dod), and the department of justice (doj). federal law establishes a role for a number of federal agencies and departments in the execution of a quarantine order. the secretary of health and human services (hhs) has statutory responsibility for preventing the introduction, transmission, and spread of communicable diseases from foreign countries into the united states and within the united states and its territories/possessions [40] . regulations grant the cdc authority to detain, medically examine, or conditionally release individuals reasonably believed to be carrying a communicable disease [41] . the cdc's division of global migration and quarantine has the specific authority to quarantine individuals seeking to enter the united states. u.s. customs and border protection (cbp) (formerly the u.s. customs service) and officers of the u.s. coast guard are authorized to assist in the enforcement of federal quarantine orders [42] . personnel from the u.s. citizenship and immigration services (uscis) (formerly the immigration and naturalization service [ins]), the cbp, the u.s. department of agriculture (usda), and the u.s. fish and wildlife service (usfw) all assist the cdc in identifying travelers or other persons who may be infected with illnesses that pose a risk to public health [43] . federal quarantine authority only extends to specific diseases enumerated by executive order [44] . however, this list of diseases can be amended quickly when necessary (e.g., as with sars in 2003, and pandemic flu in 2005) [45, 46] . the federal quarantine power has rarely been used in modern times. therefore, it is unclear how widely it could be used to combat a bioterrorism outbreak. public health law experts have demonstrated concern that the existing legal structures for initiating and managing a large-scale quarantine are inadequate at the federal and state levels [35] . this is problematic because the imposition of a large-scale quarantine will almost certainly involve the use of federal and state powers. under these circumstances, there is the possibility of confusion and controversy over who is in charge. as past bioterrorism simulations and real emergencies like hurricane katrina have demonstrated, if the lines of authority are not clear to officials at all government levels, the public health response can be paralyzed and undermined [3, 4, 47, 48] . thus, in addition to improving the legal framework within federal and state/local jurisdictions, serious efforts should focus on establishing a coordinated public health response between these jurisdictions. when should public health authorities use quarantine or isolation to restrict individuals during a bioterrorism emergency? the response to this question requires the decision-maker to balance the need for restrictive intervention with the effect it may have on the civil liberties of affected individuals. modern commentary on the acceptability of quarantine asks whether the risk to the population posed by the disease justifies such a serious loss of liberty [21, 49, 50] . in addition to restrictions on liberty, imposing a quarantine temporarily deprives individuals of their economic livelihood, their right to travel or associate freely with others, and may subject them to stigma and discrimination. in a time of great crisis, public sentiment may strongly support such measures, but public sentiment alone is an insufficient justification to use quarantine powers. these powers may be warranted to prevent the continued transmission of a disease that presents a serious risk to the population. it is important, however, that restrictive powers are not used unnecessarily or as an artifice for discrimination [51] . past quarantines in the united states have led to violence [52] , increased disease transmission among the quarantined population [53] , and biased decision making [54] . in one case, a federal court invalidated a quarantine imposed on an area of san francisco comprised mostly of persons of chinese descent, finding that the public health officials had used an ''evil eye and an unequal hand'' in issuing their quarantine order [55] . restrictive public health powers such as quarantine and isolation should be used as a last resort to halt the spread of an infectious disease. the law can provide a useful normative framework for making quarantine decisions. the msehpa, for examples, sets out a list of criteria that should be considered when making a quarantine or isolation decision [25] . in many situations, particularly where the disease is readily diagnosable and treatable, other options may be more defensible from a medical and civil rights perspective. barbera et al. list three key questions to consider when evaluating a quarantine decision: ''(1) do public health and medical analyses warrant the imposition of large-scale quarantine? (2) are the implementation and maintenance of largescale quarantine feasible? and (3) do the potential benefits outweigh the possible adverse consequences? [35] .' ' gostin has outlined several criteria for exercising restrictive public health powers under modern constitutional law [21, 51] : compelling state interest in confinement. public health authorities must only resort to restrictive powers when there is a compelling interest that is substantially furthered by civil confinement. only truly dangerous individuals (i.e., posing a significant risk of transmission) can be confined. whenever possible, risks should be assessed through scientific means. targeted intervention. individually restrictive measures should be well targeted to achieving public health objectives. interventions that deprive individuals of liberty or equal protection without justification may be constitutionally impermissible. for example, placing everyone within a geographic area under quarantine is overinclusive if some members would not transmit infection. underinclusive interventions that confine some, but not all, potentially contagious persons may be found to be arbitrary or intentionally discriminatory. least-restrictive alternative. public health authorities should not implement extremely restrictive measures such as quarantine and isolation if they can accomplish their objectives through less drastic means (although it is not likely that they would be required to enact extreme or unduly expensive means to avoid confinement). safe and habitable environment. quarantine and isolation are intended to promote well-being rather than to punish. therefore, individuals being confined should have access to clean living conditions, food, clothing, water, adequate health care, and means to communicate with others outside the quarantine. procedural due process. individuals subject to confinement for public health purposes must be able to access some form of procedural due process depending on the nature and duration of the restraint. where possible, this process should occur before confinement. if emergency circumstances demand immediate confinement, individuals have the right to request a speedy hearing and counsel to contest their confinement. public health authorities may also take actions during a public health emergency that limit the right to privacy, including public health surveillance, reporting, and contact tracing. the ability to identify and track the spread of infection is a vital component of the public health response to an infectious disease outbreak. public health authorities need access to valid and useful information to accomplish these tasks. in this context, public health surveillance and case reporting are indispensable techniques. surveillance allows public health authorities to collect, analyze, and interpret health information to search for concentrations of disease [21] . a bioterrorism outbreak could be detected through monitoring large increases in purchases of certain medications from pharmacies, clusters of cases detected by emergency rooms or managed care organizations, or spikes in absenteeism from workplaces and schools. case reporting is a form of passive surveillance involving the routine submission of data to a public health agency by external sources such as health care professionals and laboratories, often pursuant to mandatory legal requirements [56, 57] . through disease surveillance and reporting, public health authorities may assess the magnitude of the outbreak and appropriately target resources and tactics [21] . surveillance and case reporting raise privacy concerns since the reports usually contain identifiable data, which could include a person's name or other identifying characteristics. while using anonymous data instead of identifiable information is preferable to protect privacy, personal identifiers may be necessary to effectively track cases in some circumstances. public health authorities responding to bioterrorism may also wish to engage in contact tracing. contact tracing uses identifiable information to identify and contact persons who have been exposed to potentially infected individuals [21] . surveillance and contact tracing efforts may be utilized in conjunction with quarantine and isolation measures. this permits public health officials to determine the scope of the outbreak and take necessary measures to reduce the risk of further transmission. activities such as public health surveillance, reporting, and contact tracing test the boundaries of the right to privacy. public health authorities must balance the rights of the individual to control information about their infected status with the rights of the public health authority to collect and use this information to protect others in the community. these tensions may be particularly acute when the biological agent is not well understood. persons who may have come into contact with the agent may choose to not cooperate with public health officials, fearing that the outcome of their cooperation will be a loss of privacy or liberty. they may also fear the stigma that often accompanies persons or groups subjected to coercive public health powers. the use of identifiable information in a public health response to bioterrorism is particularly controversial if public health authorities share information with law enforcement agencies. information sharing between public health and law enforcement agencies may be justified to facilitate a swift response to bioterrorism threats and to apprehend the perpetrators of the outbreak. however, access by law enforcement personnel to identifiable information gathered through public health surveillance further jeopardizes the privacy of these data [58] . members of the community may be less likely to cooperate with public health officials if they suspect that their data may be revealed to law enforcement officials for purposes unrelated to their health. furthermore, this type of data sharing may undermine the credibility of the public health system by calling into question its fundamental goals and the justifications for engaging in surveillance activities and data collection in the first place [59] . a bioterrorism outbreak may justify interventions subordinating privacy interests to the common good, but the state must meet several rigorous standards. it must demonstrate that the need for the information is necessary to serve a legitimate public health interest. also, it must attempt to use the least amount of information necessary to achieve this interest. finally, it must conduct its activities openly and transparently, and consult with the affected community. law must allow for public health authorities to use coercive powers to manage property under certain circumstances. there are numerous situations that might require management of property in a public health emergency-for example, decontamination of facilities; acquisition of vaccines, medicines, or hospital beds; or use of private facilities for isolation, quarantine, or disposal of human remains. during the anthrax attacks, public health authorities had to close various public and private facilities for decontamination. consistent with legal fair safeguards, including compensation for takings of private property used for public purposes, clear legal authority is needed to manage property to contain a serious health threat [25] . once a public health emergency has been declared, the msehpa and turning point act allow authorities the power to seize private property for public use that is reasonable and necessary to respond to the public health emergency. this power includes the ability to use and take temporary control of certain private sector businesses and activities that are of critical importance to epidemic control measures. authorities may take control of landfills and other disposable facilities and services to safely eliminate infectious waste such as bodily fluids, biopsy materials, sharps, and other materials that may contain pathogens that otherwise pose a public health risk. the model acts also authorize public health officials to take possession and dispose of all human remains. health care facilities and supplies may be procured or controlled to treat and care for patients and the general public [25, 29] . whenever health authorities take private property to use for public health purposes, constitutional law requires that the property owner be provided just compensation. that is, the state must pay private owners for the use of their property [21] . correspondingly, the acts require the state to pay just compensation to the owner of any facilities or materials temporarily or permanently procured for public use during an emergency. where public health authorities, however, must condemn or destroy any private property that poses a danger to the public (e.g., equipment that is contaminated with anthrax spores), no compensation to the property owners is required although states may choose to make compensation if they wish [25, 29] . under existing legal powers to abate public nuisances, authorities are able to condemn, remove, or destroy any property that may harm the public's health [21] . other permissible property control measures include restricting certain commercial transactions and practices (e.g., price gouging) to address problems arising from the scarcity of resources that often accompanies public health emergencies. the msehpa and turning point acts allow public health officials to regulate the distribution of scarce health care supplies and to control the price of critical items during an emergency. in addition, authorities may seek the assistance of health care providers to perform medical examination and testing services [25, 29] . while the proposed use of these property control measures is not without controversy, they may provide public health authorities with important powers to more rapidly address an ongoing public health emergency. the complex and unpredictable threat of bioterrorism demands a serious effort to comprehensively strengthen all areas of public health preparedness. ongoing changes in public health practice help improve preparedness. public health authorities at the national, state, and local levels must also be prepared to work together to build a stronger public health infrastructure, ensure adequate training for emergency responders and other necessary personnel, and use new and existing technologies to combat future outbreaks. moreover, these authorities must understand the role of public health law. laws are essential to the empowerment, and restriction, of authorities to act in the interests of protecting the public's health prior to, during, and following a bioterrorism event. public health law provides the necessary authority for government to engage in public health activities. likewise, it limits government authority to infringe individual rights related to liberty, privacy, and property. many existing public health laws do not sufficiently clarify the contours or extent of public health powers. thus, legal reformation is needed to reflect modern conceptions of public health practice and contemporary constitutional norms. the msehpa and turning point act provide templates for public health law reform. these acts present clear criteria for governmental actions during public health emergencies. they delineate the scope of government public health power, the limits on this power, and the relationships between governments and other actors in emergency response situations. the roles of federal, state, and local governments in utilizing public health powers during public health emergencies must be considered and solidified in advance to avoid confusion or redundancy. public health authorities need to be able to implement a full range of strategies to combat the spread of infectious diseases through bioterrorism while respecting civil liberties. revision of state public health laws consistent with this balance will support and strengthen public health responses to future acts of bioterrorism. outbreak of severe acute respiratory syndrome -worldwide anthrax as a biological weapon shining a light on dark winter a plague on your city: observations from topoff biological threats and terrorism: assessing the science and response capabilities: workshop summaries trust for america's health. ready or not: protecting the public's health in the age of bioterrorism general accounting office. bioterrorism: federal research and preparedness activities model state emergency health powers act 1-104(a) preventing the use of biological weapons: improving response should prevention fail the emerging threat of bioterrorism the looming threat of bioterrorism the specter of biological weapons what america needs to know to survive the coming bioterrorist catastrophe biological terrorism: legal measures for preventing catastrophe the national response plan: a new framework for homeland security, public health, and bioterrorism response anti-bioterrorism research post-9/11 legislation: the usa patriot act and beyond catastrophe: risk and response defense against weapons of mass destruction act public health law: power, duty, restraint the law and the public's health: a study of infectious disease law in the united states public health law in an age of terrorism: rethinking individual rights and common goods the model state emergency health powers act the organizations include the national governors association (nga), the national conference of state legislatures (ncsl), the association of state and territorial health officials (astho), the national association of city and county health officers (nac-cho), and the national association of attorneys general (naag) bioterrorism law and policy: critical choices in public health msehpa state legislative activity table uniform emergency volunteer health practitioners act the resurgent tuberculosis epidemic in the era of aids: reflections on public health, law, and society rights and quarantine during the sars global health crisis: differentiated legal consciousness in hong kong, shanghai and toronto use of quarantine to prevent transmission of severe acute respiratory syndrome -taiwan efficiency of quarantine during an epidemic of severe acute respiratory syndrome -beijing large scale quarantine following biological terrorism in the united states center for disease control and prevention. legal authorities for isolation and quarantine center for disease control and prevention. division of global migration and quarantine: field operations executive order 13295 executive order 13375 (amending executive order 13295 to include ''influenza caused by novel or reemergent influenza viruses that are causing, or have the potential to cause lessons from katrina: response, recovery, and the public health infrastructure the alphonse and gaston of governmental response to national public health emergencies: lessons learned from hurricane katrina for the federal government and the states the future of public health law aids and quarantine: the revival of an archaic doctrine ethical and legal challenges posed by severe acute respiratory syndrome: implications for the control of severe infectious disease threats confusion, controversy, and quarantine: the muncie smallpox epidemic of 1893 knocking out the cholera'': cholera, class, and quarantines a long pull, a strong pull, and all together'': san francisco and the bubonic plague searching eyes: privacy, the state, and disease surveillance in america when terrorism threatens health: how far are limitations on personal and economic liberties justified? key: cord-017733-xofwk88a authors: davis, mark title: uncertainty and immunity in public communications on pandemics date: 2018-11-04 journal: pandemics, publics, and politics doi: 10.1007/978-981-13-2802-2_3 sha: doc_id: 17733 cord_uid: xofwk88a this chapter examines uncertainty in the expert advice on pandemics given to members of the general public. the chapter draws on research conducted in australia and scotland on public engagements with the 2009 influenza (swine flu) pandemic and discusses implications for communications on more recent infectious disease outbreaks, including ebola and zika. it shows how public health messages aim to achieve a workable balance of warning and reassurance and deflect problems of trust in experts and science. the chapter considers how uncertainties which prevail in pandemics reinforce the personalization of responses to pandemic risk, in ways that undermine the cooperation and collective action which are also needed to respond effectively to pandemics. uncertainty is a central challenge for public communications on matters pandemic. recent efforts to respond to outbreaks of infectious diseases, such as pandemic (swine flu) influenza (world health organization 2009), ebola (green 2014; world health organization 2014) and zika virus (world health organization 2016) have been marked by the limits of what can be known ahead of time and the challenges of responding to the particular turnings of outbreaks as they happen. the 2009 pandemic influenza-the topic of research i conducted with colleagues in australia and scotland-is a pivotal example of this problem of responding to a pandemic in real time. the 2009 pandemic put huge strain on global, national and local health systems, affecting many individuals and especially pregnant women and people with specific vulnerabilities to respiratory infections. it was a prominent, perhaps dominant, health news story of the period. but the pandemic turned out to be nothing like as severe as it was first thought to be. moreover, there was insufficient take-up of the h1n1 vaccine (bone et al. 2010; galarce et al. 2011; white et al. 2010; yi et al. 2011) and it was observed that only minorities or small majorities reported that they intended to, or did, enact recommended social isolation to avoid transmission of the virus (kiviniemi et al. 2011; mitchell et al. 2011; rubin et al. 2009 ; van et al. 2010) . like the "swine flu affair" of the 1970s in the united states (fineberg 2008) , the 2009 pandemic raised questions for the public health system of how to shape public action in light of the significant uncertainties which are particular to influenza, and without jeopardizing trust in government and the scientific knowledge on which is built public policy. central, too, was immunity, in its medical and social senses. immunity is not simply an object of biomedicine, it is also deeply entwined with collective life and the interrelations that come with, specifically, contagious diseases. it is also important to recognize that these issues are by no means settled; how individuals conduct themselves in relation to others in time of pandemic is a central and enduring concern for public health systems. in 2009 in the uk, for example, advertisements featured images of travellers on public transport and the following text: if you could see flu germs, you'd see how quickly they spread. cold and flu germs can live on some surfaces for hours. always carry tissues with you and use them to catch your cough or sneeze. bin the tissue, and to kill the germs, wash your hands with soap and water, or use a sanitiser gel. this is the best way to help slow the spread of flu. protect yourself and others (nhs swine flu information). this advice addresses responsible individuals and asks them to help limit the spread of infection. the final part of the message 'protect yourself and others' captures the idea that an easily spread influenza virus requires significant cooperation and the internalization of the idea of action on health for the collective good, as well as for oneself. this reference to altruistic action on health indicated that the social response to the 2009 pandemic exemplified biopolitics (rose 2007) . individuals are expected and encouraged to internalize the idea that they can take action on themselves to sustain and better their health and reproductive futures. this self-subjectification applies to the advice given to members of the general public on the 2009 influenza pandemic. in addition to the advice noted above, individuals were encouraged to arrange a network of "flu friends" who could be called upon in the case of illness, to stay abreast of developments in the media, and adopt expert advice (national health service 2009). publics were also advised to stay home if they suspected they were ill and to contact nhs services online or by telephone and to not attend gp surgeries of a&e, unless instructed to do so. in this view, the communications of 2009 hailed pandemic citizenship fashioned around the imperatives of action to avoid and contain the spread of infection and to make oneself available to expert advice. in what follows i explore pandemic communications under conditions of uncertainty, as exemplified by the 2009 influenza pandemic and its resonances with other recent contagions. as we will see, uncertainty has the effect of accentuating personalized responses to expert advice. it also sponsors communicative action figured around seeking the "just right" balance of warning and reassurance and related implications for trust in expert knowledge and authority to govern. the events of 2009 foregrounded many of the strengths and weaknesses of public health systems across the globe. key among these was preparedness and capacity to cope with large scale containment strategies which were used to manage the emerging pandemic. the pandemic preparedness plans in place in 2009 required that in the early phases of the pandemic, efforts should be made to sequester infected individuals and to trace their contacts so that the spreading infection could be tracked down and curbed (world health organization 2011). probably a central lesson of 2009 was that such efforts were costly and apparently ineffective. in some settings public health professionals were asked to continue this method even when they were aware that the virus was spreading quickly despite their best efforts . the 2009 pandemic therefore revealed the importance of being able to quickly assess the biological characteristics and severity of the infection so as to be able to modify the application of resources. since 2009, public health systems have attended to the development of evidence-based measures to assess seriousness and the development of local and viable responses to a global pandemic threat (australian department of the prime minister and cabinet 2011). pandemic preparedness, therefore, has demonstrated a marked shift away from uniformity and top-down governance towards local, evidence-based, approaches. for example, australia's 2009 version of its preparedness plan adopted a traditional method of top-down transmission of expert knowledge and advice to publics. government in this view was mandated to: deliver consistent and accurate public messages nationwide in the event of a pandemic. governments will make every effort to provide timely and reliable advice to the public, media, businesses and industries. (australian department of health and ageing 2008: 34) by 2014, however, the australian pandemic policy instrument referred to the need for public communications which were "two-way" and "listening" to publics (australian department of health 2014: 63). this approach to feedback on the transmission of information was said to depend on in vivo market research, the monitoring of social media, and a q&a website where publics can pose questions and air their opinions (australian department of health 2014: 63). the policy also made reference to the need for specific and tailored messages for vulnerable groups. however, during 2009 pandemic public communications faced significant challenges, not all of which are obviously addressed in the revised policies and their emphasis on feedback loops, market research and social media. surveys conducted at the time of the onset of the pandemic in 2009 show that while publics largely endorsed government action on the pandemic, they underestimated risk of infection and only minorities reported that they had adopted recommended behaviours such as social isolation and coughing and sneezing etiquette (rubin et al. 2009 ). the findings suggest that individuals interpreted public health advice with some scepticism. research shows also that espoused trust in government was associated with self-reported compliance with public health advice (lin et al. 2014; rubin et al. 2009 ). as noted, populations across the globe adopted vaccination only in small proportions, insufficient to protect the entire population. this indication of weak public engagement with the pandemic may be explained by a more general effect of risk management. it is surmised that the repetition of warnings over the last few decades-for example, hiv, bse, avian influenza, hospital superbugs, sars, h1n1, ebola and zika, to name a few-leads to weariness on the part of publics (joffe 2011) . diminishment in public engagement with risk is also thought to be an effect of risk society preoccupation with the forecasting and management of risks (giddens 1998) . public weariness can be thought of as a manufactured risk in the sense that it arises through attempts to manage risk. it is also evident that news on current risks are often framed by established patterns of meaning used to depict previous or contiguous risks (ungar 2008) . it is possible, therefore, that publics have learned to screen out global health alerts and treat media on the topic with a degree of scepticism, a perspective supported by our own davis 2017 ) and similar research (hilton and smith 2010; holland and blood 2012) . implied also is that repeated global health alerts coupled with some scepticism on the part of publics may lead them to fall back on personal knowledge and resources. the individualization of responses to pandemic risk communications was supported by our own research. individuals in our interviews and focus groups endorsed expert advice regarding coughing and sneezing etiquette and social isolation, but they did not think that these strategies would be viable in the long run . some of our respondents did adopt forms of social isolation, but they also saw in these strategies some flaws and inadequacies. they appeared, in general, to recognize the ease with which infection could occur. for these reasons, many of the people we spoke with resorted to discourse on immunity as a means of coping with a more than likely infection. almost absent was discourse on personal action as a means of protecting all, apart from among those with severe respiratory illness who were used to dealing with the threat of infection posed by others. our respondents focused on matters such as the building of immunity through consumer products, rest and exercise, and spoke of the need to cultivate and educate their personal immune system, with some reference to childhood experiences of exposure to infection. individuals seemed to accept that interaction with microbial life was inevitable and important to health and that their immune systems were shaped by their own actions. this "choice immunity" was spoken of as managing one's body and those of dependent others in ways that resonated with the well-known notion of "choice biography" which is said to characterize reflexive modernization (beck and beck-gernsheim 2002) . there are other implications of this resort to choice immunity. ed cohen has shown how immunity is a conceptual framing of subjectivity that preceded modern day microbiology (2009). with its root in the latin munis-also the root for municipal and remuneration, for example-immunity referred to the suspension of one's civic and pecuniary obligation to collective life. cohen gave examples which include, duty, gift, tax, tribute, sacrifice, and public office (2009). immunity suspends the "bond of requirement," but also, therefore, reinscribes it (p. 41). it always and necessarily marks the power of the social obligation it refuses, including in matters of health. as cohen showed, microbiology, and specifically germ theory, appropriated and reconfigured the metaphor of immunity to help narrate the emerging science of cells, microbes and pathogenesis. in particular, the idea of immunity helped to explain how the immune system destroyed cells colonized by alien microbial life and bypassed uninfected cells of the body, although autoimmunity and microchimerism complicate this understanding of biological immunity (martin 2010) . combined with germ theory, immunity operates to produce a "milieu interieur;" an imaginary of the battle with microbial invaders inside the body (cohen 2009 : 239), a metaphor which accentuates the emphasis on the individual in relation to contagious health threats. emily martin has made a similar point that media depictions of immunity have often referred to the war within the body (1994). it is therefore no surprise that individuals resort to the practical and metaphorical properties of immunity when they are asked to contend with the risk of pandemic influenza, which creates uncertainties over which they otherwise have very little apparent control. these issues are reflected in consumer products, for example, the commercial marketing of probiotic foods and supplements (burges watson et al. 2009; koteyko 2009; nerlich and koteyko 2008) , which address individual consumers in terms of "choice immunity." probiotics also raise the idea that it is important to replace bacteria that have been killed off due to antibiotic treatment and/or the idea that "good" bacteria will outcompete illness producing bacteria. the scientific underpinning and marketing of probiotics, then, depend on a division of "good" and "friendly" bacteria from disease-producing bacteria. it is against this backdrop of immunity culture that public health institutions have to shape and circulate messages on how individuals ought to conduct themselves. as with the 2009 pandemic, agencies such as the who, regional who offices, and lead national public health agencies such as the cdc and public health scotland implement communication strategies and are key sources of expert commentary in worldwide news media. a central communication challenge is how to shape messages so that they are productive of desired action on the part of members of the general public, when it cannot be known absolutely how matters will transpire. it is clear from our research with public health professionals in australia and the uk that finding a balance of motivation and reassurance was paramount (davis et al. 2011 (davis et al. , 2013 . in this context, public health experts were concerned that publics should be advised and asked to prepare for the pandemic but not in ways that promoted anxiety or promoted panic, as reflected in, for example, runs on supermarkets, pharmacies and clinics. this meant that messages also had to be reassuring but not in a way that led publics to ignore advice, or worse, to become complacent. as briggs and nichter have pointed out, pandemic messaging was carefully styled around the notion of "be alert, not alarmed" (2009). they have identified this approach as the "just right" goldilocks method, that is, the production of alert, but not panicky, reassured, but not complacent publics. for example, in a newspaper article published on 27 april 2009, in the first few days of the pandemic alert, the chief health officer of australia was quoted to have said: we should be aware but i'm not overly alarmed at this point. we don't have confirmed cases in australia but i think there will be some cases in the future. we think the population should be alert, should be aware of travellers in their midst who have the flu. but not alarmed at this point, just aware. (robotham and pearlman 2009) in this way, pandemic communications help to constitute the expert-informed, life choices of individuals. less obvious are obligations to others which also make immunity possible, such as herd immunity and the related practice of altruistic vaccination to protect vulnerable others. it is also important to recognize that explicit reference to immunity is rarely a feature of this public health advice; it is nearly always implied. the 2009 pandemic raised some other problems related to the eventual character of the pandemic as mild for most, but not all. as noted, the 2009 pandemic was quickly found to be less severe than early indications portended, though some groups faced elevated risks and the pattern of morbidity differed from that typical for seasonal influenza (presanis et al. 2011) . it therefore became necessary to manage the communications turn away from alert, but without the cessation of cautionary messaging and continued advice for those who did face higher risk of severe disease. influenza is known to return, on occasion, in a second wave which has the potential to be more severe for all or some of those affected (presanis et al. 2011) . uncertainties like these meant that it was imperative to sustain a kind of watchful, just in case, attitude, until such time as an effective vaccine became available. this particular situation of a global alert followed by revisions of preparedness and response and growing evidence of a significantly less dangerous pandemic led to new communications challenges to do with explaining to publics what was happening and how they should therefore conduct themselves. this shifting in messaging across the period of the pandemic implied "the boy who cried wolf " parable (nerlich and koteyko 2012) , which teaches in narrative form the jeopardy of trust faced by raising a false alarm, too often. one effect of false alarm is that it may amplify the importance of choice immunity, that is, recourse to the self-reliant management of the body as the means to contend with an uncertain health threat. sociological perspectives on choice biography point out that under the conditions of neo-liberal economic and political order, individuals are forced to rely on themselves and their own decision-making capacities, since there is in the end, nowhere else for them to go (beck and beck-gernsheim 2002) . they nevertheless are bound to depend on expert advice, since no one person can be expert in all the considerations that pertain to health or any other of the major life decisions (ungar 2003) . false alarm destabilizes expert authority and leaves people doubly reliant on themselves. in this view, the tendency for individuals to fall back on their immunity is a rational response to the requirement to take action and because, in the face of the uncertainties which preside in the case of influenza, the body is one apposite arena in which people are able to exercise some control. our research shows also that the communication on the pandemic had the potential to divide publics according to their vulnerability, another way in which knowledge and questions played out in the 2009 pandemic. they showed awareness of the "boy who cried wolf" dilemma but also recognized the invidious situation in which public health experts found themselves. they spoke of the needless hype of the media on the pandemic, by which they meant the extent of the reporting on the progress of the pandemic (davis and lohm forthcoming). it is important to remember, also, that some groups and individuals were affected and profoundly so, for example, women who were pregnant in 2009. public communications on the risk of pandemic influenza, therefore, had a schismatic quality in the sense that the mildness of the virus needed to be explained to publics, while some remained at risk. like the universalism of pandemic preparedness, communications were also faced with the need for nuance and provisionality. this splitting of publics according to their vulnerability , was suggestive also of the coexistence of different modes of pandemic subjectivity. the "not at risk and in general unconcerned" could look upon news media and public communications as needless and hyped, particularly as the pandemic progressed. vulnerable groups, as we have suggested , at times had trouble recognizing themselves in these messages and once they had established for themselves awareness of their immunological vulnerability, they looked upon the hype as masking what for them was a real and visceral anxiety and set of practical issues of infection control and vaccination. this schism in public engagement accentuates the sense in which people have to make up their own mind on how to act in the context of what our vulnerable interviewees suggested were confusing, mixed messages. the communications challenges of emerging, changing pandemics are considerable. messages have to, at first, inform publics without frightening them, but also reassure them without producing complacency. as the example of the 2009 pandemic indicates, as the infection progressed and evidence emerged of the health effects of the h1n1 virus, public health systems had to explain that the pandemic was mild, though this situation could change. they also had to embed in this more general message information for minorities that they remained at serious risk. this changing, complex message risked provoking accusations of false alarm and therefore mistrust, as has happened in previous outbreak situations (fineberg 2008) . as i argued, too, the mixing of a general message of a mild pandemic which might change with messages that also some particular kinds of people were at risk, placed vulnerable people in the difficult situation of having to identify themselves in these messages and take action when others were sceptical and unlikely to be acting to protect themselves and those around them. when we asked people in our research to talk about h1n1 and specifically if it could be prevented, people acknowledged that infection was unlikely to be avoided and, accordingly, they were forced to reflect on the capacity of their body to cope with infection. as indicated, this resort to personal immunity was not quite the same as the science of cellular immunity discussed by cohen and others. it more closely resembled an acceptance of the possibility of the presence of the virus in the body and fashions an arena for volitional action on the body when other forms of action seem to have less practical value, as was the case in 2009. for example, social isolation and possibly vaccination, were endorsed but by and large not extensively taken up, particularly given that the virus was in general mild and easy to catch. because the h1n1 virus was observed to be so easily transmitted, the resort to personal immunity had doubled value. it may be for this reason that publics endorsed expert advice to self-isolate and vaccinate, but did not do so, that is, they fended for themselves and the pandemic turned into a mild one, anyway, though not for everyone. appeals to the collective good and altruistic vaccination on which depend public health efforts concerning pandemics, may miss the point that individuals are led to think of their personal immunity as an arena within which they can sustain themselves in the face of deeply uncertain threats which arise in communal life. if as cohen has suggested, immunity is fused with ideas of cellular action on microbial pathogens but it is also a metaphor for freedom from obligation. it seems, then, that a key lesson from 2009 was that freedom from the dangers of infection found in personal action on immunity also implied freedom from having to act in the interest of others; the more free one is from the dangers of infection-the stronger one's immunity-the less one needs to consider the dangers which others face, particularly under conditions of uncertainty. individualized ideas of 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public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey mobilising 'vulnerability' in the public health response to pandemic influenza misplaced metaphor: a critical analysis of the 'knowledge society global bird flu communication: hot crisis and media reassurance university life and pandemic influenza: attitudes and intended behaviour of staff and students towards pandemic (h1n1) australia's pandemic influenza 'protect' phase: emerging out of the fog of pandemic influenza vaccine uptake in pregnant women entering the 2010 influenza season in western australia world now at the start of 2009 influenza pandemic report of the review committee on the functioning of the international health regulations (2005) in relation to pandemic (h1n1) statement on the 1st meeting of the ihr emergency committee on the 2014 ebola outbreak in west africa world health organization predictors of the uptake of a (h1n1) influenza vaccine: findings from a population-based longitudinal study in tokyo acknowledgements this chapter is based on research funded by an australian research council discovery project grant on pandemic influenza (dp110101081). i would like to acknowledge the assistance of my colleagues from the pandemic influenza project, niamh stephenson, paul flowers, emily waller, casimir macgregor and davina lohm. i am also very grateful for the time and efforts of those who participated in the interviews and focus groups for the research. key: cord-004531-agvg719f authors: schröder-bäck, p.; sass, h.-m.; brand, h.; winter, s. f. title: ethische aspekte eines influenzapandemiemanagements und schlussfolgerungen für die gesundheitspolitik: ein überblick date: 2008-02-07 journal: bundesgesundheitsblatt gesundheitsforschung gesundheitsschutz doi: 10.1007/s00103-008-0449-1 sha: doc_id: 4531 cord_uid: agvg719f infectious diseases are among the major global health threats. although associated with these diseases there are vast ethical challenges, ethics has more focused on other health related issues – e.g. associated with rare diseases, embryo research, genetic diagnosis. nowadays we are facing a possible influenza pandemic caused by a new human influenza virus subtype. this article presents issues and ethical challenges of the pandemic threat. the authors argue that it is necessary to consider ethical implications of pandemic influenza preparedness early on and to include ethical reasoning when deciding on the measures for the pandemic management. bi sher behandelt die literatur, die sich mit gesundheitlichen herausforderungen auseinandersetzt und aus bioethik-fachzirkeln kommt, kaum infektionskrankheiten, sondern eher themen wie embryonenforschung oder gendiagnostik. auf der anderen seite hat sich public health, wenngleich intensiv mit infektionskrankheiten, so doch bisher wenig mit ethik auseinandergesetzt. dies ist erstaunlich, da die fülle an ethischen herausforderungen im kontext von bevölkerungsgesundheit und infektionskrankheiten sehr groß ist. immerhin sind infektionskrankheiten oft verhinder-oder behandelbar und töten doch jährlich millionen menschen [1] . in der bioethik beschränken sich die diskussionen über infektionskrankheiten auf die mikroebene -wie beispielsweise auf fragen zur behandlungspflicht von ärzten gegenüber infizierten patienten [2] . aus der perspektive der bevölkerungsgesundheit sind dies eher probleme von individualbeziehungen, die in der bioethik jedoch verhältnismäßig intensiv diskutiert werden. das bewusstsein, infektionskrankheiten und bevölkerungsgesundheit auch aus sozialethischer perspektive zu behandeln, entwickelt sich erst seit wenigen jahren. 2003 war sars plötzlich ein thema für die öffentlichkeit und eine weltweite herausforderung, auch in ethischer hinsicht. der mögliche ausbruch einer pandemie mit einem neuartigen influenza-a-virus (im folgenden kurz: influenzapandemie) beschäftigt public health, die öffentlichkeit und auch die politik in den letzten jahren vermehrt. eine gute vorbereitung auf eine pandemie beruht jedoch nicht nur auf einer guten epidemiologischen oder naturwissenschaftlichen basis [3, 4] . auch ethische aspekte spielen eine rolle, um humane regelungen und maßnahmen zur bewältigung einer pandemie zu entwickeln. der ehemalige who-direktor für ethik, alex capron, sieht die diskussion ethischer aspekte sogar im herzen politischer entscheidungsprozesse zur pandemiemanagementvorbereitung. ethiker helfen, wertkonflikte aufzudecken, und haben zudem die aufgabe, ethische überlegungen in die politischen entscheidungsprozesse einzubringen. für capron müssen ethiker vor allem darauf drängen, eine gesundheitspolitische planung transparent zu betreiben und in die bevölkerung zu kommunizieren [5] . dies korrespondiert auch mit den ethischen leitsätzen der us-amerikanischen centers for disease control and prevention (cdc) [6] . so kann das vertrauen der bevölkerung erreicht werden, und sie wird partner von politik und verwaltung. der operative wert einer solchen planung liegt darin, dass eine informierte, vertrauende bevölkerung im krisenfall besser mitwirken und mehr compliance zeigen wird als eine, die dem staat aufgrund fehlender informationen misstraut und jede anweisung als handlung gegen die bürger verstehen will. wie wichtig es ist, ethische aspekte in diesem kontext zu berücksichtigen, betonen auch thompson et al [5] . sie zeigen an der erfahrung ihrer heimatstadt to ronto, welche probleme es 2003 im zusammenhang mit dem sars-ausbruch gab, bei dem es im vorfeld keine öffentlichen ethischen diskussionen zum krisenmanagement gegeben hatte. sie beschreiben als folge einen verlust des öffentlichen vertrauens, ein niedriges verantwortungsbewusstsein der krankenhausmitarbeiter, konfusionen über zuständigkeiten bei den beteiligten und eine stigmatisierung vulnerabler gruppen. thompson et al. heben hervor, dass durch eine orientierung an ethischen leitgesichtspunkten einige unnötige kollateralschäden hätten vermieden werden können. mit anderen worten: eine pandemievorbereitung, die ethische aspekte nicht ausreichend berücksichtigt, könnte im ernstfall folgenschwere auswirkungen haben. eine pandemie könnte dann nicht nur in einer moralisch-menschlichen, sondern auch in einer gesundheitlichen katastrophe enden [7] . ziel dieses aufsatzes ist es, auf die zentralen ethischen herausforderungen hinzuweisen, die im rahmen eines influenzapandemiemanagements zu beachten und zu diskutieren sind. es ist unsere grundlegende these, dass eine frühzeitige erörterung dieser herausforderungen das pandemiemanagement verbessern kann. nur eine frühzeitige adressierung der ethischen und gesundheitspolitischen dilemmata und ihrer möglichen lösungswege bedingt gerechtfertigtes vertrauen der bevölkerung in das management einer krise. angesichts der bedrohung durch eine mögliche influenzapandemie wurden pläne zur vorbereitung und zum management einer solchen erstellt. sie sollen sicherstellen, dass im pandemiefall die gesundheitlichen schäden der bevölkerung gering gehalten werden und das öffentliche leben so weit wie möglich aufrechterhalten wird, sodass nach einer pandemie eine schnelle rückkehr in den geordneten alltag möglich wird. entsprechende pläne gibt es auf kommunaler, regionaler und nationaler ebene sowie auch für einzelne krankenhäuser [8] . eine effektive und ethisch akzeptable vorbereitung und durchführung eines pandemiemanagements ist eine große herausforderung. diese herausforderung potenziert sich, wenn man eine globale verantwor-tung zugrunde legt, die sich einerseits aus dem moralischen hilfsgebot in anbetracht der menschlichen würde aller personen herleitet und andererseits auch einen instrumentellen wert darin sieht, eine pandemie schnellstmöglich weltweit einzudämmen. durch eine schnelle globale eindämmung werden in positiver rückkopplung auch der eigene schaden gering gehalten sowie die infrastrukturmaßnahmen in entwicklungsländern nicht noch weiter zurückgeworfen. derzeit wird diskutiert, welche ethischen leitgesichtspunkte bei der pandemievorbereitung und dem pandemiemanagement als orientierung dienen können [9] . plausibel erscheint, dass man mit einem patientenzentrierten medizinethischen hippokratischen ethos oder den 4 bioethischen prinzipien (autonomy, beneficence, nonmaleficence, justice [10] ) kein hinreichendes ethisches instrumentarium zur verfügung hat [11] . singer et al. geben alternativ 10 ethische leitgesichtspunkte an. sie schöpfen ihre empfehlung aus den diskussionen, die dem sars-ausbruch in toronto 2003 folgten. diese leitgesichtspunkte sind: "individual liberty, protection of the public from harm, poportionality, reciprocity, transparency, privacy, protection of communities from undue stigmatisation, duty to provide care, equity, solidarity" [12] . auch von anderen autoren kommen vorschläge zur normen-und werteorientierung. schröder-bäck fokussiert auf die prinzipien "menschenwürde, gerechtigkeit, effizienz, gesundheitliche gesamtnutzenmaximierung und verhältnismäßigkeit" [13] . sass betrachtet die berücksichtigung der leitgesichtspunkte "sicherheit, erziehung, minimax, partnerschaft, effizienz und review" als essenzielle orientierungsmöglichkeiten im zusammenhang mit public health, notstand und ethik [14] . einige der hier angesprochenen ethischen probleme sollen im folgenden intensiver vorgestellt werden. [15] . die ethischen herausforderungen bei einer influenzapandemie liegen also vor allem darin, dass mögliche public-health-maßnahmen zum schutz der bevölkerung individuelle freiheiten einschränken können [16] . zu diesen maßnahmen gehören: offenlegung der erkrankung des einzelnen zwecks surveillance und monitoring gegenüber gesundheitsbehörden und sozialem umfeld bis hin zu zwangsuntersuchungen, impfungen und therapie (ggf. gegen den patientenwillen), isolierung, quarantäne, beschränkung der bewegungs-, versammlungs-und reisefreiheit [1] . hinzu kommen bei einer influenzapandemie ggf. noch verteilungsprobleme -z. b. von knappen medikamenten, vakzinen, krankenhausbetten oder beatmungsgeräten. verteilungsproblemen ist insbesondere zu beginn einer pandemie zu begegnen, weil in ihren ersten 3-6 monaten keine bevölkerungsweite impfung gegen ein neuartiges influenza-a-virus möglich wäre, da ein impfstoff erst nach ausbruch der pandemie entwickelt werden kann, wenn der erreger bekannt ist. gerade für diese übergangszeit ist die versorgung der bevölkerung mit speziellen antiviralen medikamenten (derzeit werden vor allem die sogenannten neuraminidaseinhibitoren als geeignet angesehen) von großer bedeutung. darüber hinaus kann symptomatisch mit anderen grippemedikamenten, antibiotika, schmerz-, und -beispielsweise bei gegebener situation -auch mit palliativmedikamenten behandelt werden, sodassneben einer bevorratung, verfügbarkeit und bereitstellung von neuraminidaseinhibitoren, atemschutzmasken etc. -auch diese mittel in den vorsorglichen plänen der verteilung und zuweisung berücksichtigt werden müssen. außer um organisatorische und finanzielle aspekte geht es also insbesondere darum, nach welchen kriterien die begrenzt, d. h. nicht für alle unmittelbar und sofort verfügbaren güter zu verteilen sind. die verteilung knapper ressourcen erfolgt (beispielsweise innerhalb von regionen ohne hinreichende bevorratung)sofern sie nicht willkürlich sein soll -auf der basis von prioritätensetzungen, die faktisch harten rationierungen gleichkommen können. für harte rationierung "müssen die kriterien klar und transparent sein und die grenzen scharf gezogen werden. spielraum für individuelle interpretationen darf es dann kaum noch geben" [17] . priorisierungsschemata müssen auf moralisch robusten fundamenten -dazu kann man kontextsensitive spezifikationen und abwägungen der prinzipien menschenwürde und gerechtigkeit zählen -stehen und transparent sein [18] . sie müssen vor eintritt der krise bekannt sein, von der öffentlichkeit mitgetragen werden und antizipativ sowie rekonstruk-zusammenfassung · abstract pandemic threat. the authors argue that it is necessary to consider ethical implications of pandemic influenza preparedness early on and to include ethical reasoning when deciding on the measures for the pandemic management. keywords influenza · pandemic · ethics · rationing · justice · trust bundesgesundheitsbl -gesundheitsforsch -gesundheitsschutz 2008 · 51:191-199 doi 10.1007/s00103-008-0449-1 © sprin ger me di zin ver lag 2008 zu sam men fas sung infektionskrankheiten gehören weltweit zu den größten gesundheitlichen bedrohungen. trotz der daraus auch resultierenden ethischen herausforderungen sind entsprechende diskussionen bisher eher im zusammenhang mit speziellen gesundheitsassoziierten themen geführt worden -z. b. zu seltenen krankheiten, embryonenforschung und gendiagnostik. nun droht aber die möglichkeit einer influenzapandemie in absehbarer zeit. im vorliegenden beitrag werden diese bedrohung und die sich daraus ergebenden ethischen herausforderungen diskutiert. die autoren vertreten die these, dass es erforderlich ist, sich frühzeitig, d. h. bereits in der vorbereitung auf eine pandemie, mit den ethischen implikationen einer solchen auseinanderzusetzen und ethisches urteilen bei der weiterentwicklung von maßnahmenkatalogen zu berücksichtigen. influenza · pandemie · ethik · rationierung · gerechtigkeit · vertrauen infectious diseases are among the major global health threats. although associated with these diseases there are vast ethical challenges, ethics has more focused on other health related issues -e.g. associated with rare diseases, embryo research, genetic diagnosis. nowadays we are facing a possible influenza pandemic caused by a new human influenza virus subtype. this article presents issues and ethical challenges of the tiv nach der krise -hier der pandemieethisch vertretbar sein. priorisierung ist kein gegensatz zu leitgesichtspunkten wie "gleichheit" oder "gerechtigkeit", sondern eine situativ bedingte sonderform: wie in einer triage müssen im sinne des allgemeinwohls die primär zu rettenden und zu schützenden personengruppen bestimmt werden. das sollten in diesem fall die in der krise essenziellen leistungserbringer (in einem umfassenden und nicht nur gesundheitlichen sinne) sein [19] . dazu könntenwas näher zu bestimmen und zu differenzieren wäre -mitarbeiter in strom-und wasserwerken oder im transport-und lebensmittelbereich, sicherheits-und ordnungskräfte, mitarbeiter in krankenhäusern, drogerien, apotheken und auch niedergelassene ärzte gehören. die verschiedenen von kotalik ausgewerteten pandemiepläne (aus kanada, dem vereinigten königreich (uk), australien und den usa) nennen alle beispielsweise als gruppen mit der höchsten priorität für impfungen die "health care workers". danach kommen die "providers of essen tial services", danach personengruppen mit einem hohem erkrankungs-bzw. übertragungsrisiko [20] . eine ähnliche priorisierung muss im ernstfall je nach bevorratungsgrad auch in bezug auf die antiviralen medikamente vorgenommen werden. die kanadischen und us-amerikanischen priorisierungsmodelle sehen vor, hospitalisierten patienten hier die oberste priorität vor kranken "health care workers" einzuräumen, danach kommen "highest risk outpatients" (usa) bzw. "ill high risk persons" in der kommune. beide pläne sehen einen vorrang der therapie vor der prophylaxe. prinzipiell erscheint es durchaus plausibel "health care workers" und "providers of essential services" zuerst zu versorgen bzw. zu impfen. dies geschieht in der absicht, den gesellschaftlichen interessend. h. allen bürgern -gerecht zu werden und mortalität und morbidität zu reduzieren. auch der deutsche nationale pandemieplan -der nicht explizit ethische kriterien, begründungen oder leitgesichtspunkte nennt -sieht vor, dass zuerst das personal im ambulanten und stationären medizinischen versorgungsbereich, dann die berufsgruppen, die der sicherstellung der öffentlichen ordnung und infrastruktur, also der allgemeinheit zuträglich sind, geimpft werden. weitere priorisierungen sollen im pandemiefall auf der basis konkreter epidemiologischer kriterien getroffen werden. dabei geht es dann darum, die allgemeinen komplikations-und mortalitätsraten zu reduzieren [21] . die beschreibung der moralischen und professionellen rolle, d. h. der rechte und pflichten der ärzte und -was noch wenig bearbeitet wurde -der apotheker [22] im pandemiefall ist eine große herausforderung. schon im vorfeld einer befürchteten pandemie sehen sich viele ärzte mit problemen konfrontiert, wenn patienten sie bitten, vorsorglich privatrezepte für antivirale medikamente auszustellen. diesem wunsch dürfte häufig stattgegeben werden, auch wenn er aus ärztlicher sicht oft von moralischen skrupeln begleitet sein wird [23] . das handeln des arztes und letztlich auch des apothekers ist in grenzen nachvollziehbar, falls der patientder sein auftraggeber ist und auf dessen wiederkommen er ökonomisch angewiesen ist [24] -den klaren diesbezüglichen wunsch äußert. die ärztliche expertise und der heilberufliche auftrag reichen allein nicht aus, den herausforderungen im falle einer befürchteten oder auch tatsächlichen pandemie zu begegnen und gesamtgesellschaftliche public-health-probleme zu lösen. hier kann nur eine generelle entlastung des arztes helfen, etwa indem man es ihm zumindest erschwert (beispielsweise über eine indikationsstellungs-bzw. begründungspflicht), spezielle antivirale medikamente privat zu rezeptieren. hier müssen kluge abwägungen getroffen werden, die mit der ärztlichen individualethik und mit sozialethischen ansprüchen vereinbar sind [25] . eine zentrale gesundheitspolitische frage, die diskutiert werden muss, betrifft die versorgungsverpflichtung von ärzten und weiterer im gesundheitswesen beschäftigter, sobald sie sich selbst einer erhöhten ansteckungsgefahr aussetzen. wie weit geht die standesverpflichtung des arztes, seinem patienten gutes zu tun? letztlich brauchen die wichtigen und un-verzichtbaren leistungserbringer -vor allem diejenige, die den kranken in der akutversorgung begegnen -ausreichende sicherheiten, damit sie ihre arbeit auch in der akuten krise wahrnehmen und nicht zu hause bleiben [26] . zudem kann man ihnen anreize oder kompensationen bieten (z. b. spezielle versicherungsfonds, die auch für andere berufsgruppen wie techniker oder bestatter gelten könnten [12] auf soziale ereignisse und kontakte ("social mixing") muss in fortgeschrittenen pandemiephasen ggf. verzichtet werdend. h. schulen und öffentliche plätze müssen geschlossen werden, öffentliche veranstaltungen sollten nicht mehr stattfinden [4] . es muss geklärt sein, wer die verantwortung und wer die befugnis hat, solche maßnahmen durchzusetzen und bei verstoß sanktionen zu erlassen und konsequenzen zu ziehen [27] . isolation und quarantäne sind weitere konzepte zur eindämmung von infektionen. die beiden begriffe werden fälschlicherweise oft als synonym verwendet. die isolation ist eine maßnahme, um infizierte personen zu separieren, die andere personen anstecken können. in der quarantäne schränkt man hingegen den aktionsradius gesunder personen ein, die expositionsverdächtig waren [28] . die quarantäne kann einzelpersonen oder größere gruppen betreffen. bei influenzapandemien spielen übertragungen im familiären bereich eine große rolle, was bei der pandemieplanung berücksichtigt werden muss [29] . besonders brisant wären distanzierungsmaßnahmen in haushalten und familien, weil diese kleinste gesellschaftliche einheit besonders geschützt ist und für sie grundsätzlich das prinzip der staatlichen nichteinmischung gilt. quarantänemaßnahmen können im pandemiefall ein mittel zum gesundheitsschutz der bevölkerung sein. allerdings muss hier deutlich differenziert werden: eine freiwillige quarantäne ist ethisch wenig herausfordernd, eine unfreiwillige wäre anwendung von zwang, der moralisch gerechtfertigt sein muss. eine unfreiwillige quarantäne wäre ethisch eher zu verantworten, wenn für die betroffene personengruppe therapeutika oder impfstoffe zur verfügung ständen. ist dies jedoch nicht der fall, wird die abwägung, eine quarantäne zu treffen, noch schwieriger. um unangemessenen reaktionen bis hin zur panik in einer krisensituation vorzubeugen, ist es sinnvoll, die bevölkerung rechtzeitig, d. h. im vorfeld, aufzuklären. erforderlich ist in diesem zusammenhang die verbreitung umfassender informationen über die krankheit selbst und auch über selbstverständliche hygienemaßnahmen sowie andere schutzmaßnahmen [30] . folglich sehen der deutsche nationale pandemieplan sowie die entsprechenden pläne von ländern und kommunen auch die verteilung bürgernaher informationen vor [21] . informationsmaßnahmen verbessern die mitwirkung des bürgers und erfüllen zudem seinen informationsanspruch [26] . in diesem sinne ist die bereitstellung umfassender gesundheitsinformationen aus ethischer sicht genauso wichtig wie die transparenz bei der pandemiemanagementvorbereitung sowie bei allokationsentscheidungen und den ihnen zugrunde liegenden ethischen kriterien. informationen und transparenz schaffen letztlich begründetes vertrauen [18] . die usamerikanischen cdc raten dringend zur transparenz, d. h., sie empfehlen, in einer allgemeinverständlichen sprache darzulegen, was die entscheidungskriterien in härtefällen sind. klarheit und offenheit ergibt sich aus dem ethischen gebot der achtung gegenüber individuen [4] . eine fachlich gute und ethisch akzeptable vorbereitung auf eine pandemie sieht vor, dass pandemiepläne auf die resultierenden herausforderungen realistische und in der kommune, region und nation erprobte handlungsansätze finden. zur erprobung können beispielsweise übungen, szenariendiskussionen oder simulationen durchgeführt werden. in diesen sollte man, auch aus ethischen gründen, von notstands-und triagesituationen, also von einem worst-case-szenario ausgehen [26] . denn gerade in diesen situationen können ethisch relevante aspekte und lösungswege am besten diskutiert und entwickelt werden. aufbauend [21] . das ecdc hat zudem auch den deutschen influenzapandemieplan evaluiert und mit den anderen influenzaplänen aus der eu verglichen [33] . bisher sind die spezifisch ethischen aktivitäten auf dieser ebene allerdings noch nicht sehr ausgeformt. es könnte aber eine aufgabe der eu und konkret des ecdcs sein, einen europaweiten ethischen diskurs mit anzustoßen. die globalisierung und die damit verbundene mobilität von menschen ermöglicht eine schnelle ausbreitung ansteckender krankheiten. global gesehen, stellt uns die pandemievorbereitung vor einige organisatorische und ethische herausforderungen. zu den organisatorischen zählen z. b. der aufbau funktionierender informations-und meldewege, von netzwerken aus epidemiologen und biologen sowie die erarbeitung von regeln für reisebeschränkungen. im ernstfall müssen reisewarnungen ausgegeben und es muss über ausbrüche in den betreffenden staaten berichtet werden, dies möglichst ohne stigmatisierungen hervorzurufen. zudem muss von behördlicher seite auf die beibehaltung eines schnellen und zuverlässigen kommunikationsflusses geachtet werden. beim sars-ausbruch lag beispielsweise eine große herausforderung darin, dass sich china nicht als ausbruchsland sah. daraus schließen singer et al.: "it is no longer acceptable for countries to hide health information that can protect others. sharing public health in-formation is part of maintaining the global public good of health protection, and should be encouraged and admired." [12] im bemühen, ethisch akzeptable antworten auf eine weltweite bedrohung durch eine influenzapandemie zu erhalten, stellt sich im weiteren sinne auch die frage, wie einzelne regierungen die pflichten ihrer eigenen bevölkerung gegenüber mit möglichen pflichten gegenüber anderer länder bevölkerungen abwägen [5] . ein besonderes augenmerk gilt dabei den entwicklungsländern. die bevölkerungen armer staaten haben wesentlich weniger möglichkeiten, gesundheitskompetenzen zu entwickeln, ihre ernährung und die hygieneverhältnisse sind schlechter, und sie haben einen deutlich schlechteren zugang zu impfungen oder zur gesundheitlichen versorgung im krankheitsfall [34] . prospektive quantitative analysen zeigen, dass entwicklungsländer mit hoher wahrscheinlichkeit die größte bürde einer influenzapandemie zu tragen hätten. murray et al. gehen davon aus, dass in den oecd-ländern aufgrund der vorhandenen symptomatischen behandlungsmöglichkeiten, von impfungen, der verfügbarkeit von antibiotika zur behandlung von sekundärerkrankungen wie lungenentzündungen sowie aufgrund des deutlich besseren gesundheitsstatus der bevölkerung die auswirkungen einer influenzapandemie weniger drastisch wären als in den entwicklungsländern. hinzu kommt, dass diesen eine umfassende vorbereitung auf eine pandemie nicht möglich ist [35] . eine besondere unterstützung für entwicklungsländer im vorfeld und fall einer pandemie ist nicht nur aus ethischer perspektive von relevanz, sondern auch politisch klug und vorausschauend [35] , um die eigenen interessen zu schützen (möglichst geringe auswirkungen auf die bevölkerungsgesundheit, die ökonomie und die globale stabilität). es wäre aber auch zu erörtern, welche ethischen verpflichtungen entwicklungsländer im rahmen ihrer möglichkeiten gegenüber anderen ländern haben. im rahmen der globalen kommunikation sind die "surveillance systeme" zu betrachten -sowohl in internationaler als auch nationaler perspektive, da es auch in deutschland hier noch verbesserungs-potenzial gibt. mckee und atun zufolge kann ein globales surveillancesystem -das in zeiten des h5n1-influenzavirus dringend benötigt wird, um die vorboten einer pandemie und ihre weitere entwicklung zu beobachten bzw. die bevölkerung schnellstmöglich schützen zu können -nur so gut sein wie das schwächste mitglied dieses systems. eine besondere herausforderung liegt hier -außer in dem möglichen problem, dass staaten einen ausbruch bewusst nicht meldenin den sogenannten nichtstaaten (nonstates), d. h. in rechtlich unsicheren und nicht weithin anerkannten territorien. deren public-health-systeme bzw. fehlende internationale einbindung hemmen den aufbau eines effizienten globalen surveillancesystems. im kaukasus ist beispielsweise eine public-health-surveillance kaum vorhanden, auch ist es international kaum eingebunden. das exportland taiwan besitzt zwar ein gutes system, steht aber politisch isoliert da. in nordzypern und palästina gibt es probleme aufgrund der politischen teilung. zu den nichtstaaten zählen auch transnistrien, der kosovo, abchasien, die republik bergkarabach und westsahara [36] . es besteht die notwendigkeit, diese schwächen der surveillance im eigenen sicherheitsinteresse in den blick zu nehmen. jenseits des umstandes, dass die versorgung der personen in nichtstaaten im pandemiefall suboptimal wäre, gibt es noch weitere ethisch relevante aspekte. die nichtanerkennung von personen oder auch von personengruppen bzw. von staaten ist ein prinzipielles moralisches problem, da es missachtung ausdrückt [37] . nichtanerkennung hat immer mit der nichtbeachtung einzelner personen als zweck an sich, als träger von menschenwürde zu tun [38] . es ist zu diskutieren, ob es unsere moralische pflicht gegen über diesen ländern ist, ihre situation zu verbessern und ihre anerkennung zu fördern. die verbesserung der surveillancesysteme könnte man ggf. als anlass nehmen, sich in diesen ländern vermehrt zu engagieren, um public health -auch in unserem sinne -sowie anerkennungsprozesse voranzutreiben. in bezug auf die pandemieplanung gibt es also einerseits generelle überlegungen im eigeninteresse eines staates. in diesem zusammenhang wird gefragt: wie koordinieren wir und wie bereiten wir uns vor, sodass uns eine mögliche influenzapandemie so wenig wie möglich (auch nachhaltig) im eigenen land schadet. andererseits gibt es die ethischen leitgesichtspunkte, die dritten gegen über -d. h. gegenüber den entwicklungsländern und nichtstaaten -zur unterstützenden handlung auffordern. die autoren votieren mit diesem beitrag für eine frühzeitige und philosophischsystematische auseinandersetzung der öffentlichkeit, politik und verwaltung mit den vielfältigen ethischen aspekten eines pandemiemanagements. im folgenden sollen einige initiativen vorgestellt werden, die diesbezügliche diskurse führen und einige der bereits genannten ethischen aspekte reflektieren. im sommer 2006 trafen sich in bellagio, italien, wissenschaftler und experten aus der gesundheitspolitik, um über gerechtigkeitsfragen im zusammenhang mit einer pandemischen influenza zu beraten. vertreten waren neben fachleuten aus den bereichen tiergesundheit, ökonomie, public health und virologie auch ethiker: der gerechtigkeitsphilosoph allen buchanan, der medizinethiker alex capron und die public-health-ethikerin ruth faden. ihre diskussion fokussierte sich speziell auf die situation und auswirkungen einer influenzapandemie auf die entwicklungsländer bzw. allgemein auf benachteiligte personen und populationen [39] . auf der tagung wurde ein statement verabschiedet, das ethisch relevante forderungen aufstellt, an denen sich sowohl regierungen als auch nichtregierungsorganisationen (ngos) im falle einer pandemie orientieren können. in dem statement, das 6 prinzipien expliziert, wird zunächst gefordert, dass alle -vor allem auch die unterprivilegierten -personen zugang zu qualitativ guten und verständlichen informationen über die pandemie und über maßnahmen zur eindämmung kollektiver und individueller gesundheitsgefahren erhalten [40] . wörtlich heißt es: "all people should have ready access to accurate, up-to-date and easily understood information about avian and human pandemic influenza, public policy responses, and appropriate local and individual actions. communications should be tailored to overcome obstacles that disadvantaged groups face in accessing such information." [39] ferner wird gefordert, alle relevanten stakeholdereinschließlich des privaten sektors -in die unterstützung benachteiligter gruppen zu integrieren. des weiteren sollen surveillancesysteme implementiert werden, die eine stigmatisierung oder diskriminierung benachteiligter gruppen ausschließen. entsprechend muss die effektivität von public-health-maßnahmen auch unter dem gerechtigkeitsaspekt gegenüber benachteiligten bewertet werden. das fünfte prinzip fordert, den entwicklungsländern zugang zu den verfügbaren wissenschaftlichen und sozioökonomischen daten zu eröffnen, sodass ihnen eine optimale vorbereitung auf bzw. bekämpfung einer pandemie ermöglicht wird. als letztes wird ein gerechter und gleicher zugang zu vakzinen und anderen medizinischen bzw. public-health-maßnahmen gefordert -sowohl innerhalb eines landes als auch zwischen ländern [41] . die who hat 1999 einen ersten pandemieplan "influenza pandemic preparedness plan" [42] herausgegeben, der grundlage für viele nationale influenzapandemiepläne war. gegenwärtig wird von der who ein projekt koordiniert, das sich mit den ethischen fragen der pandemievorbereitungen und des pandemiemanagements befasst. zu diesem "project on addressing ethical issues in pandemic influenza planning" existieren derzeit nur arbeitsgruppenpapiere, die als entwürfe kursieren, sowie eine öffentlich zugängliche tagungsdokumentation [32] . ein offizielles who-dokument mit dem titel "ethical considerations in pandemic influenza planning" befindet sich in der erstellungsphase. die tagungsdokumenta-tion gibt aber schon einblicke in die (vorläufigen) ergebnisse der arbeitsgruppen [32] . diese werden im folgenden vorgestellt. von der ersten arbeitsgruppe "promoting equitable access to therapeutic and prophylactic measures" wird die bedeutung der grundlegenden prinzipien effizienz, gleichheit und verantwortlichkeit für die erarbeitung von priorisierungsfestlegungen dargestellt. je nach ihrer gewichtung und ausdifferenzierung resultieren verschiedene priorisierungsschemata für die vergabe von medikamenten und impfstoffen. diskutiert wird u. a., impfstoffe gemäß dem effizienzprinzip vor allem denen zu verabreichen, die potenzielle überträger der viren sind (z. b. personen, die aufgrund ihrer tätigkeit im krankenhaus viel kontakt mit infizierten haben). die who-arbeitsgruppe "isolation, quarantine, border control and social-distancing methods" weist darauf hin, dass alle maßnahmen eines pandemiemanagements bürger-oder sogar menschenrechtsrelevant sein können. so ist es wichtig, einschränkungen von rechten anhand international akzeptierter kriterien vorzunehmen; beispielsweise immer aus den möglichen maßnahmen die am wenigsten restriktiven zu wählen und nicht zu diskriminieren. hier können ansätze der public-health-ethik helfen, in dilemmasituationen die richtigen abwägungen zu treffen. in der arbeitsgruppe "the role and obligations of health-care workers during an outbreak of pandemic influenza" wird erörtert, wie weit die verpflichtungen der beschäftigten im gesundheitsbereich angesichts der potenziellen risiken gehen, denen sie im fall einer pandemie ausgesetzt sind. in der arbeitsgruppe "issues that arise between governments when developing a multilateral response to a potential outbreak of pandemic influenza" werden die verpflichtungen diskutiert, die staaten einander gegenüber haben, um im falle einer pandemie die durchführung konzertierter aktionen zu ermöglichen. auch soll sichergestellt werden, dass einzelne staaten vulnerable minderheiten nicht als verursacher von pandemien darstellen können und diese damit zu "sündenbö-cken" machen, also sie stigmatisieren oder diskriminieren. zusammenfassend kann festgehalten werden, dass die who also gegenwärtig die ethischen aspekte diskutiert, denen sich einzelne staaten in nationaler und globaler perspektive stellen müssen. das von der who angestoßene globale konsultationsverfahren ist ein wichtiger schritt in der bewusstmachung ethischer aspekte der influenzapandemieplanung. es ist wünschenswert, dass diese diskussionen weltweit von gesundheitspolitikern auf allen staatlichen ebenen rechtzeitig wahrgenommen werden. eingangs wurde kritisch gefragt, warum sich die bioethik nicht hinreichend und verhältnismäßig mit den möglichen folgen und konsequenzen der bedrohung durch infektionskrankheiten befasst hat. natürlich kann man ethikern und angewandten ethikdiskursen nicht vorschreiben, welchen forschungsgegenstand sie wählen sollten. es ist unseres erachtens jedoch notwendig, einen eigenen diskurs zu diesen drängenden fragen anzustoßen. ethiker müssen für public-health-fragen sensibilisiert werden, andererseits muss public-health-wissenschaftlern und praktikern die möglichkeit gegeben werden, mit ethikern in einen interdisziplinären dialog einzutreten [43] . angestoßen durch die sars-ausbrüche und drohende pandemien, ist dies in ersten ansätzen erfolgt, es beginnt sich eine neue bereichsethik, die public-health-ethik, herauszuschälen. dieser beitrag und die weiteren aufsätze des vorliegenden themenhefts des bundesgesundheitsblatts wollen diesen diskurs auch im deutschsprachigen raum fördern, auf seine dringlichkeit aufmerksam machen und erste methodische und inhaltliche anstöße geben. public-health-ethik liefert einen anderen normativen referenzrahmen als bioethik, weil sich letztere eher individualethisch auf arzt-patient-bzw. forscher-proband-verhältnisse bezieht und hier unter der prämisse, patienten-und bürgerrechte zu stärken, entscheidungskri-terienberatung anstrebt. public-health-ethik hat demgegenüber einen anderen auftrag, andere akteure und netzwerke, andere ziele und methoden. sie liefert mit eigenen grundsätzen einen eigenen ethischen rahmen [13, 14] . es ist eine gesundheitspolitische aufgabe auch im sinne einer weit voraus gedachten prävention, public-health-ethik zu institutionalisieren (z. b. durch forschung und lehre an den gesundheitswissenschaftlichen fakultäten, eine eigene wissenschaftliche zeitschrift, fachgesellschaften und wissenschaftliche beiräte), um auch im zusammenhang mit drohenden gesundheitlichen gefährdungen von bevölkerungsgruppen ethische gesichtspunkte noch stärker als bisher in public-health-planungen einbeziehen zu können. weltweit bereiten sich regierungen und verwaltungen mit notfallplänen auf mögliche pandemien vor. dabei wird eine systematisch-philosophische auseinandersetzung mit ethischen aspekten allerdings erst in ansätzen praktiziert [44] . ein differenziertes bewusstsein über die ethischen herausforderungen und probleme im zusammenhang mit dem management von influenzapandemien ist erst im entstehen und bedarf der weiterentwicklung [27] . in einer aktuellen usamerikanischen analyse wird bemängelt, dass vorbereitungen und pläne zur bekämpfung von pandemien keine "ethische sprache" verwenden [45] , d. h. moralische dilemmata noch nicht überall hinreichend mittels ethischer methodiken aufgearbeitet wurden. auch in der neufassung des deutschen nationalen pandemieplans ist an keiner stelle das wort "moral/moralisch" oder "ethik/ethisch" erwähnt, wenngleich den fachlichen reflexionen implizit ethische kriterien zugrunde liegen. es ist notwendig, sich im rahmen der influenzapandemievorbereitung frühzeitig und bewusst auch mit den ethischen implikationen einer solchen explizit auseinanderzusetzen und ethisches urteilen bei der weiterentwicklung des maßnahmenkatalogs zu berücksichtigen. diese public-health-ethischen diskurse zielführend voranzutreiben und dabei die in diesem beitrag dargelegten herausforderungen zu adressieren und darauf antworten zu finden ist eine lohnende aufgaben im schnittfeld von gesundheitspolitik und katastrophenvorbeugung. kor re spon die ren der au tor dr ethics and infectious disease duty to treat or right to refuse? pandemic influenza preparedness: an ethical framework to guide decision making ethical guidelines in pandemic influenza -recommendations of the ethics subcommittee of the advisory 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(2006) differentialethik. anwendungen in medizin, wirtschaft und politik ethics of planning for and responding to pandemic influenza nationaler pandemieplan zur standesethik des apothekers. die deontologia pharmaceutica aus historischer sicht ethische aspekte des ökonomisierungsprozesses in der medizin: eine analyse des sich verändernden arzt-patient-verhältnisses aus sicht der doppelten prinzipal-agent-theorie medizinische ethik bei notstand, krieg und terror. verantwortungskulturen bei triage pandemic influenza: ethics, law, and the public's health ethical and legal challenges posed by severe acute respiratory syndrome. implications for the control of severe infectious disease threats large-scale spatial-transmission models of infectious disease how you can be prepared for a flu pandemic? individual and family handbook strategien und maßnahmen in vorbereitung auf eine influenza-pandemie global consultation on addressing ethical issues in pandemic influenza planning. summary of 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pandemic influenza plans key: cord-349348-9rnvawfa authors: cousineau, j; girard, n; monardes, c; leroux, t; jean, m stanton title: genomics and public health research: can the state allow access to genomic databases? date: 2012-05-31 journal: iran j public health doi: nan sha: doc_id: 349348 cord_uid: 9rnvawfa because many diseases are multifactorial disorders, the scientific progress in genomics and genetics should be taken into consideration in public health research. in this context, genomic databases will constitute an important source of information. consequently, it is important to identify and characterize the state’s role and authority on matters related to public health, in order to verify whether it has access to such databases while engaging in public health genomic research. we first consider the evolution of the concept of public health, as well as its core functions, using a comparative approach (e.g. who, paho, cdc and the canadian province of quebec). following an analysis of relevant quebec legislation, the precautionary principle is examined as a possible avenue to justify state access to and use of genomic databases for research purposes. finally, we consider the influenza pandemic plans developed by who, canada, and quebec, as examples of key tools framing public health decision-making process. we observed that state powers in public health, are not, in quebec, well adapted to the expansion of genomics research. we propose that the scope of the concept of research in public health should be clear and include the following characteristics: a commitment to the health and well-being of the population and to their determinants; the inclusion of both applied research and basic research; and, an appropriate model of governance (authorization, follow-up, consent, etc.). we also suggest that the strategic approach version of the precautionary principle could guide collective choices in these matters. "during the past century, achievements in public health have led to enormous improvements and benefits in the health and life expectancy of people around the world" (1). however, even now, at the dawn of the xxi st century, public health still faces important challenges. new zoonoses such as bovine spongiform encephalopathy (bse) (2) or west nile virus (wnv) (3) as well as new infectious diseases such as acquired immune deficiency syndrome (aids) (4) or severe acute respiratory syndrome (sars) (5) come easily to mind and provide good examples. moreover, the continuing and growing prevalence of chronic diseases such as cancer and diabetes also merits considerable attention. because many of these diseases are multifactorial disorders, the scientific progress in genomics and genetics must be taken into consideration in public health research (1, 6) this approach, integration of genomics into public health, requires that we: "assess […] the impact of genes and their interaction with behaviour, diet, and the environment on the population's health. the promise of public health genomics is to have practitioners and researchers accumulating data on the relationships between genetic traits and diseases across populations, to use this information to develop strategies to promote health and prevent disease in populations, and to more precisely target and evaluate population-based interventions" (7) . in short, "public health genomics uses population based data on genetic variation and geneenvironment interactions to develop evidencebased tools for improving health and preventing disease" (8) . thus, genomic databases will constitute an important source of information, on the one hand, in order to pursue research aiming to understand better the genetic susceptibility to a disease regarding certain individuals within a population, and on the other, to implement eventually public health interventions. consequently, from this viewpoint, it is important to identify and characterize the state's role and authority on matters related to public health, in order to verify whether it has access to such databases while engaging in public health genomic 1 (9) research. then, is the mandate of our public health authorities adapted to the actual expansion of the genomic research domain? to answer this question, we first examine the evolution of the concept of public health, as well as its core functions, using a comparative approach (e.g. who, paho, cdc, and the canadian province of quebec) 2 . following an overview of the essential roles of public health and an analysis of relevant quebec legislation, the precautionary principle is examined as another possible avenue to justify state access to and use of genomic databases for research purposes or, for the management of a pandemic. finally, we consider the influenza pandemic plans developed by who, canada, and quebec, which are key tools framing public health decision-making. they 1 public health genomics is defined as : "the responsible and effective translation of genome-based and technologies into public policies, programs and services for the benefit of population". 2 quebec is one of the ten canadian provinces. canada is a federal state where health is a shared jurisdiction. in public health matters, both the federal and provincial levels have some competencies. could illustrate the first steps in the evolutionary inclusion of genomics into public health. we think that this paper could help countries to examine their own definitions and legislations of public health to see if they contain provision that could form the foundation of the state powers to access genomic databases. the world health organisation (who) defines public health as "the art of applying science in the context of politics so as to reduce inequalities in health while ensuring the best health for the greatest number" (10). despite the fact that who is the lead agency in health, up to now, no definition of public health has yet produced a general consensus (11) . the notion is heterogeneous, depending on whether public health is defined in terms of objectives, methods, actors, or values. this can result in difficulties in assessing health in its collective dimension such as the contribution of various disciplines, of determinants of health and of various practices that are used in the development of health knowledge (12) . the current trend for western countries is to adopt a broad definition (13) . for example, the canadian institutes of health research define it as "the combination of sciences, skills, and beliefs that is directed to the maintenance and improvement of the health of all the people through collective or social actions" (14) . this definition illustrates the importance of the collective dimension of public health measures and puts forward the idea that the concept of public health is constantly evolving. the american institute of medicine's committee for the study of the future of public health reminded us that the very substance of public health has expanded with the passage of time. indeed: "early public health focused on sanitary measures and the control of communicable disease. with the discovery of bacteria and immunologic advances, disease prevention was added to the subject matter of public health. in recent decades, health promotion has become an increasingly im-portant theme, as the interrelationship among the physical, mental, and social dimensions of wellbeing has been clarified" (15) . for example, until quite recently, the vision of the quebec legislator concerning public health meant health protection and protection of the population's well-being. this observation is based in part on the evolving title of quebec legislation, which was changed from public health protection act (r.s.q., c. p-35; act abrogated april 1 2002) to public health act (16). in adopting the public health act, the quebec legislator chose to implement a proactive rather than a defensive approach in order to respond to society's evolution and to knowledge about health determinants and therefore to encompass prevention, promotion and surveillance in the expression "public health" 3 . along these same lines, article 1 states: "[t]he object of this act is the protection of the health of the population and the establishment of conditions favorable to the maintenance and enhancement of the health and well-being of the general population". in this context, well-being is to the social sphere what health is to the medical sphere. it is a positive concept that goes beyond the absence of social problems and resembles the concept of quality of life. in fact, health and wellbeing are often linked (13) . the who stresses that a growing understanding of various health determinants is transforming the assessment of public health (17) . thus, in order for a public health system to adequately fulfill its function and keep up with advances in the discovery of health determinants, it must adopt a global approach to public health and define its components. indeed, "[s]uch an approach will 3 when examining the bill 36 in november 2001, minister rémy trudel specified that more than just to ensure health protection in case of threat, the new law would also deal with prevention and promotions. help to ensure that the public health infrastructure covers all appropriate public health activities adequately and that it can function well in an increasingly complex and changing environment" (17) according to the canadian institutes of health research, "[t]here is a critical need to reach consensus on the core essential functions of the public health system. it will not be possible to assess and develop a system infrastructure if these are not defined" (14) . the study of essential functions of public health is helpful in understanding public health legislation, its functioning and the scope of its application; essential functions are "the set of actions that should be carried out specifically to achieve the central objective of public health: improving the health of populations" (18, 19) . in effect, "in january 1997, the who executive board recommended that work proceed on the concept as a tool for implementing the renewed [health for all] policy in the 21 st century" (20) . the regional office for the western pacific of who specifies that it is the responsibility of governments to define the fundamental missions of public health more precisely and systematically and to articulate them, without having the obligation to execute them and finance them (17) . definitions of the main functions of public health, unlike broader definitions, address the need for the clarification of roles and responsibilities in the public health domain (21) . in fact, a univocal definition of the field of public health is impossible; rather, referring to the missions and roles of the field would illustrate the actionbased character, the knowledge, and the areas of intervention in public health (12) . although many categories and definitions of essential functions have been suggested, these categories and definitions are constantly evolving (13) and are specific to each organization. interestingly, quebec's approach to public health, proposed in 1992 and still in force, refers to measures relating to the determinants of health and well-being at the population level and the systems, which govern them 4 (22) . these measures are delimited by the essential and the supporting functions of public health (23) . in order to better understand the fundamental concept of public health, we drew up a table of the categories used by the québec public health program and compared them to those of the who, the pan american health organization and the national public health. a similar analytical approach has been proposed in quebec (12) . according to lévesque and bergeron such a comparative analysis constitute an interesting basis for reviewing the roles of public health. the authors specify that the selected organizations seem to equate elements related to roles of public health (health promotion, prevention, etc.) with elements related to the type of intervention used (information, education, empowerment) as well as to the strategies used (social participation, partnership mobilization, legislation). furthermore, in terms of healthcare, they limit themselves to evaluating its quality and to the defense of access equality (12) . similarly, other authors indicate that various functions defined by the american program, the who and paho have much in common, even though they demonstrate some specificities. studying quebec legislation, we retain the public health functions adopted by the provincial government. these are listed and defined in the québec national public health program 2003 program -2012 . the program distinguishes core functions from support functions. thus, core functions include ongoing surveillance of the population's state of health; promoting health and well-being, prevention of disease, psychosocial problems, and trauma; health protection. as for supporting functions, they refer to the regulation, legislation, and public policies that can have an impact on health; to research and innovation; to the development and the maintaining of professional competencies. a more in-depth understanding of the functions of public health is susceptible to 4 this echoes the population-centered approach that must guide public health according to provision 5 of the public health act, r.s.q. c. s-2.2. provide a legal basis for public health legislation to allow access, by the state, to genomic databases for research purposes. the next section is therefore devoted to their definition. the ongoing surveillance function has two main objectives: to follow closely the evolution of the population's health status and of its determinants and to inform the public and those responsible for the planning, organization and evaluation of services, within and outside of the healthcare network of this evolution (26) . included in this function are measures that delimit access to information, as well as those needed for the description and analysis of the population's health status and then for the distribution of this information to each targeted public (26) . the ongoing surveillance function also encompasses vigilance, producing snapshots of health and well-being (sociomedical statistics), analysis of determinants, and finally, identification of vulnerable groups and of efficient interventions (13) . it accounts for observed variations and tendencies, detects emerging problems, and elaborates prospective scenarios of health status and well-being, taking into account the natural evolution of problems, interventions and the change of determinants. it also implies communicating information on the state of public health and well-being to the population itself (27) . ongoing surveillance thus differs from public health research. surveillance aims to support decision-making concerning the health and wellbeing status of a given population. research, as a source of new scientific knowledge is better characterized as a support function of public health (table 1) . public health legislation and regulations. strengthening of public health regulation and enforcement capacity. enforce laws and regulations that protect health and ensure safety. **regulation, legislation and public policies that have an impact on health. public health management. development of policies and institutional capacity for health planning and management. develop policies and plans that support individual and community health efforts. human resources development and training in public health. assure competent public and personal health care workforce. **skills development and maintenance. quality assurance in personal and populationbased health services. evaluate effectiveness, accessibility, and quality of personal and population-based health services. personal health care for vulnerable and high risk populations. evaluation and promotion of equitable access to necessary health services. link people to needed personal health services and assure the provisions of health care when otherwise unavailable. research in public health. research for new insights and innovative solutions to health problems. **research and innovation. social participation in health. mobilize community partnerships and action to identify and solve health problems. occupational health protecting the environment * core functions ** support functions prevention specifically targets chronic diseases, trauma, and social problems having an impact on the health of the population (suicide, violence, drug addiction, etc.) this includes reducing risk factors, vulnerability, and early screening (13) . prevention thus has a double objective: reducing risk factors for disease, psychosocial problems and trauma and detecting these problems before they become exacerbated (26) . prevention can be carried out among individuals and at-risk groups by bolstering existing aptitudes, developing the acquisition of new skills, and practicing preventive care, including screening (27) . protection refers to the collection, by public health officials, of information deemed necessary in preventing or responding to a dangerous situation; this information is to be collected from individuals, groups, and populations in the case of a real or anticipated threats to public health (27) . a threat to public health occurs as stated by article 2, when there is the "presence within the population of a biological, chemical, or physical agent that may cause an epidemic if it is not controlled" (16). in the case of a real or apprehended health threat, health authorities will act at the scale of either the entire population, groups, or individuals (26) . health protection measures apply to harmful situations and particularly to biological, physical, and chemical aggressors, including the battle against sexually transmitted diseases and aids, workplace health, and environmental health (13) . the compilation of information for epidemiological studies, in order to better determine the threat and implement measures to counter or assess the situation is authorized. medical observation by public health teams, established by article 2 of the quebec public health act (16) allows the discovery of threats to population health in real time (26) . for the québec national public health program 2003-2012 (22) , health promotion refers to actions supporting individuals and communities in their effort to exert better control over essential factors of health and well-being. these actions, while encouraging individual progress, emphasize social and political dimensions: supporting community action, developing public policies, and creating a (physical, cultural, social, economical, and political) environment that is favorable to health (27, 22) . this is in line with article 3 of the quebec public health act (16), in virtue of which measures provided by the act are geared towards "exerting a positive influence on major health determinants, in particular through trans-sectoral coordination". thus, its aim is, from an ecological perspective, to facilitate the development of conditions favorable to health in the social and economic environment as well as in individual and collective behaviors (13) . this includes interventions not only on lifestyle but also on the totality of health determinants and the development of conditions and environments that are favorable to health and well-being (13). according to the québec national public health program 2003-2012 (25) , this function involves identifying the problems and situations which call for a regulatory, legislative or policy-based solution in order to enhance or maintain the health of the population. it consists also in assessing the consequences of public policies for the population's health and recommending measures to reduce their negative effects on health; finally, it includes carrying out mandates related to the application of regulations, laws, or policies, which come under spheres other than public health in order to prevent certain health problems (26) . overall, this function illustrates the support needed for the elaboration and application of laws and regulations, which have an effect on the health, and well-being of citizens (27) . this support function demands the development and the maintenance of professional resources, expertise, and skills (27) . of course, it includes the importance of evaluating the program's training needs in order to offer continuing education (26) . as expected, "the research and innovation function includes all activities focused on the production, dissemination, and application of scientific knowledge as well as on innovation" (21) . in short, this element refers to research needed to maintain and develop expertise for the implementation and evaluation of public health programs (27) . if genomics research is a new tool in public health action, should not the research and innovation function be integrated into the core functions of public health as an important activity, thus enabling the state to achieve its public health objectives? in this respect, should state powers in public health allow access to databases for the purposes of genomic research? in this section of the paper, in order to understand the legislative powers and the possibility of research in genomics, the public health act (16) is firstly examined and, secondly, the act respecting institut national de santé publique du québec (28), which allows powers for public health research. an overview of the public health act is helpful to identify the powers of the state in the protection of public health. the act does not contain any specific provision regarding access to genomic databases for research purposes. it is nevertheless important to examine the different options laid out by the legislation. in fact, be it in the context of common practices related to public health, in an alert or in an emergency, the act establishes certain powers related to the collection or transmission of information necessary for exercising public health powers. within the framework of current practices related to public health, the public health act stipulates that public health authorities may collect information by means of registries or information and data collection systems. registries, which are established for the purpose of clinical preventive care or for protecting the health of the population, contain personal information on certain health services or health care received by the population (16). the best example is the vaccination registry described at article 61 (16). data and information collection systems administered by public health authorities are divided into two categories. the first category refers to the system established by the minister of health and social services for the compilation of sociological and health-related personal or non-personal information on births, stillbirths, and deaths (16). this system is not intended for genetic information. the second category refers to systems for the collection of data and personal and non-personal information on the prevalence, incidence, and distribution of health problems and in particular on problems having a significant impact on premature mortality and on morbidity and disability (16). these systems could be used to investigate the prevalence of infectious diseases. these collection systems have been implemented within the framework of the ongoing surveillance entrusted exclusively to the minister and to public health directors 5 (art. 34, par. 1). ongoing surveillance is carried out in order to: 1) "obtain an overall picture of the health status of the population; 2) monitor trends and temporal and spatial variations; 3) detect emerging problems; 4) identify major problems; 5) develop prospective scenarios of the health status of the population; 5 a copy of the opinion of the ethics committee must then be forwarded to the commission. public health act, r.s.q. c. s-2.2, art. 36, par. 2. 6) monitor the development within the population of certain specific health problems and of their determinants" (art. 33). undoubtedly, points 3, 4 and 6 could be perceived by some as legislative basis for the creation of a data collection system of genomic information; nevertheless, ongoing surveillance, as prescribed by the act, is surveillance of the "health status of the general population and of health determinants so as to measure their evolution and be able to offer appropriate services to the population" (art. 4, par. 1). ongoing surveillance does not apply "to research and knowledge development activities carried out in the sector of health or social services in particular, by the institut national de santé publique du québec" (art. 4, par. 2). in addition, although the act stipulates that "[p]eriodic surveys on health and social issues shall be conducted to gather the recurrent information necessary for ongoing surveillance of the health status of the population" (art. 39), the nature of such surveys leads us to believe that they cannot be used in the context of genomic databases. indeed, the act specifies that "[t]he carrying out of national surveys shall be entrusted to the institut de la statistique du québec created under the act respecting the institut de la statistique du québec (chapter i-13.011), which shall comply with the objectives determined by the minister" (art. 42, par. 1). conducting genetic susceptibility research is not equivalent to conducting statistical surveys. having established the lack of a legislative basis for genomic research by the state in the course of the normal practice of public health, and more specifically, in ongoing surveillance, would it be possible for other previously collected data to be used by the state for other purposes, such as genomic research? the public health act provides measures for monitoring public health and for ensuring proper transmission of information. four areas are outlined: reporting of unusual clinical manifestations associated with a vaccination (art. 69); mandatory reporting of intoxications, infections and diseases (art. 81-82); notification of the public health director in the case where a person who is likely suffering from a disease or infection, subject to mandatory reporting, is refusing or neglecting to submit to an examination (art. 86); alerting public authorities to health threats (other than those arising from a sexually transmitted biological agent) (art. 92-94). two areas outlined by the act are particularly relevant to our study: mandatory reporting of intoxication, infections, and diseases, and the alerting of public authorities to health threats. first, we ask ourselves if genetic susceptibilities should be included in the category of reportable intoxications, infections, and diseases pursuant to section. it is important to specify that "the list may include only intoxications, infections or diseases that are medically recognized as capable of constituting a threat to the health of a population and as requiring vigilance on the part of public health authorities or an epidemiological investigation" (art. 80) . thereby: "with respect to the list drawn up pursuant to section 79 of the act, the intoxications, infections and diseases that may be included for reporting to public health authorities must satisfy the following criteria : (1) they either present a risk for the occurrence of new cases in the population, because the disease or infection is contagious, or because the origin of the intoxication, infection, or disease may lie in a source of contamination or exposure in the environment of the person affected; (2) they are medically recognized as a threat to the health of the population, as defined in section 2 of the act, which may result in serious health problems in the persons affected; (3) they require vigilance on the part of public health authorities or an epidemiological investigation; and (4) public health or other authorities have the power to take action in their respect to prevent new cases, to control an outbreak or to limit the magnitude of an epidemic, through the use of medical or other means" (29) . genetic susceptibility does not satisfy these criteria; the above list enumerates diseases, rather than methods for the detection of disease akin to the detection of susceptible genes. secondly, government departments and bodies, local municipalities, health care professionals, directors of institutions must report threats, other than those that arise from a sexually transmitted infection, to the public health director (art. 92-94). given the current legislative framework, reporting "does not authorize the person making the report to disclose personal or confidential information unless, after evaluating the situation, the public health authority concerned requires such information in the exercise of the powers provided for" in the case of threat to the public health (art. 95). a threat to public health occurs when there is the "presence within the population of a biological, chemical, or physical agent that may cause an epidemic if it is not controlled" (art. 2, par. 2). therefore, in any situation where the public health director believes on reasonable grounds that the health of the population is or could be threatened, he may conduct an epidemiological investigation (art. 96). where required within the scope of an epidemiological investigation, the public health director may: 1) "require that every substance, plant, animal or other thing in a person's possession be presented for examination; […] 5) take or require a person to take samples of air or of any substance, plant, animal or other thing; 6) require that samples in a person's possession be transmitted for analysis to the institut national de santé publique du québec or to another laboratory; 7) require any director of a laboratory or of a private or public medical biology department to transmit any sample or culture the public health director considers necessary for the purposes of an investigation to the institut national de santé publique du québec or to another laboratory; 8) order any person, any government department, or any body to immediately communicate to the public health director or give the public health director immediate access to any document or any information in their possession; even if the information is personal information or the document or information is confidential; 9) require a person to submit to a medical examination or to furnish a blood sample or a sample of any other bodily substance, if the public health director believes on reasonable grounds that the person is infected with a communicable biological agent"(art. 100, 102). if certain authorities have powers to sanction the collection and transfer of biological samples or of personal information (held by a third party or by the individual concerned), is it conceivable that these powers could be used to sanction genomic research, for example research into genetic susceptibility to an infectious disease endangering the health of the population? in declaring a public health emergency, the government has extraordinary powers at its disposal. the declaration of a public health emergency in all or part of the territory of quebec will occur "where a serious threat to the health of the population, whether real or imminent, requires the immediate application of certain measures to protect the health of the population" (art. 118). the government or the minister (if he or she has been so empowered) may, notwithstanding any contrary provisions, order any person, government department or body to communicate or provide immediate access to any document or information held, even personal or confidential information or a confidential document, in order to protect the health of the population (art. 123, par. 1(3)). the state of emergency is considered so paramount that "[t]he government, the minister or another person may not be prosecuted by reason of an act performed in good faith" (art. 123, par. 2). unless such "emergency" information is available and workable, genomic research will not be possible due to time constraints; the research would take too long before results could determine which measures to adopt. if the government has extraordinary powers at its disposal, we consider that they are inappropriate in this research con-text. in fact, such information should already be accessible under these powers. not only does the public health act not expressly permit research in public health, but also, our analysis leads us to conclude that these provisions do not give appropriate powers to the state to access genomic databases for research purposes. on the other hand, because the act respecting institut national de santé publique du québec (28) already gives certain powers for research into public health, it seems appropriate to examine whether this act presents a new avenue to explore. the institut national de santé publique du québec (inspq) was established to contribute to the development, consolidation, dissemination and application of knowledge in the field of public health (art. 3, par. 2(1)) and also to develop and promote research in the field of public health in collaboration with the various research organizations and funding bodies (art. 3, par. 2(6), 21). a review published by the inspq also notes that research into the health and well-being of the population and its determinants seeking to produce, integrate, disseminate and apply scientific knowledge to the exercise of public health functions, belong to the field of public health research 6 (23). knowing this, could the inspq initiate fundamental research in genomics? this would present a challenge since the government of quebec prioritizes applied research over fundamental research in public health (22) . on this matter, the inspq states that basic research, the results and applications of which are not expected in the short or medium term have been excluded from 6 for example, are considered as public health research activities research related to the surveillance of a population's health status and well-being; on the relationship between a population's health status and wellbeing and its determinants; on intervention and on promotional, preventive and protective programs aimed at maintaining and improving the health and well-being of a population; on public policies related to a population's health and well-being the field of research in public health, while applied research was included (23) . if all legislative texts examined here do not create an explicit power to access and use genomic databases for research purposes, we can ask ourselves if it is possible to invoke the precautionary principle to legitimate a state power allowing this type of intervention. is there a clear definition of the precautionary principle? the framework for the application of precaution in science-based decision making about risk (30) outlines guiding principles for the application of precaution to science-based decision making in areas of federal regulatory activity regarding the protection of health, the environment, and the conservation of natural resources. the concept of precaution is presented as resting on the notion that the absence of full scientific certainty shall not be used as a reason for postponing decisions where there is a risk of serious or irreversible harm (30) . formalized in international environmental law, the precautionary principle was incrementally introduced into the domain of public health 7 . spe7 the precautionary principle has not been explicitly integrated in the provincial (quebec) and international public health legislations. see: loi sur la santé publique, l.r.q., c. s-2.2; international health regulations (2005), art. 12(4)d) and 17 c). however, both the programme national de santé publique (2003) (2004) (2005) (2006) (2007) (2008) (2009) (2010) (2011) (2012) , which identifies public action that provincial (quebec) authorities must put into place until year 2012, and the report of the review committee of the functioning of the international health regulation (2005) cifically, we can emphasize its use in food safety. its direct applicability was explicitly recognized by the european court of justice, notably in the case of the embargo on british beef during the mad cow crisis (31) . the principle has also been recognized as an important risk management tool in the context of pandemics. in france, as in canada, it was prominent in the reports of commissioners appointed to inquire into the tainted blood scandal and the sars crisis 8 (32) (33) (34) . three fundamental components of the precautionary principle are outlined: the lack of full scientific certainty, the risk of serious or irreversible harm and the need for a decision (30) . the first two elements are criteria for the application of the principle, whereas the third determines its normative scope. however, these application parameters establish standards that cannot be determined objectively, and are therefore subject to different interpretations. for example, concerning scientific uncertainty, the level, and threshold of scientific knowledge on potential risk, required to apply the principle, is unclear 9 . in the same line of thought, the severity or the irreversibility of the potential harm cannot always be evaluated solely by objective scientific criteria (35) . furthermore, the conceptual "the response of who and many countries to the pandemic was a reflection of this mindset. this was affirmed in the sentiments expressed by many member states to the review committee: in the face of uncertainty and potentially serious harm, it is better to err on the side of safety. public-health officials believe and act on this conviction. it is incumbent upon political leaders and policy-makers to understand this core value of public health and how it pervades thinking in the field". 8 to this effect, we cite the krever's report on contaminated blood as well as judge campbell's report on sars in canada, in addition to commissioner legal's report in france. 9 this question constitutes one of the most important problems faced by the doctrine with regards to the application of the principle. one can wonder whether theoretical knowledge is enough or if it is necessary to support the hypothesis of risk by empirical data. it is also important to question the degree of consensus needed within the scientific community, so that a scientific hypothesis is regarded plausible. framework of the third element, the need for a decision, does not anticipate the nature or the scope of the precautionary measures, leaving the authorities with a margin of discretion. different interpretations of the precautionary principle resulting from the articulation of these three key elements 10 have been developed and reviewed in the literature (36) . indeed, the precautionary principle is a concept of "variable geometry" (37) . it has a malleable character; the definition and its impact on the decision making process vary according to the context of application. there is no strict consensus on this issue. a typology of the precautionary principle permits an examination of interpretations in line with our primary objective, which is to legitimate a state power allowing access and use by the authorities of genomic databases for research purposes and to see if, for this end, it is possible to invoke the precautionary principle. the first two versions, "the institutional model" and "the cautious approach", can be qualified as antagonistic 11 . they are based on the proportionality and the severity of the precautionary measures adopted. the institutional model promotes early action that is proportionate to the potential risks. the cautious approach, instead, calls for the implementation of more demanding precautionary measures and favors eradicating risk. in its extreme form, the cautious approach constitutes the rule of abstention or prohibition. the institutional model was recognized by justice krever in the tainted blood report (32) . he stated that additional precautionary measures, such as heating blood products and screening of blood donors to reduce the risk of hiv transmission via blood products should have been taken at an earlier point in the crisis. the cautious approach, which favours eradication of risks, can be associ10 the articulation of these three elements leads to differences regarding the measures adopted, the precocity of the application of the principle, etc., as well as its normative character (ethical principal or legal etc.). 11 with the exception of antagonistic versions, it is possible for precautionary measures adopted by authorities to stem from different interpretations of the principle. ated with the implementation of quarantine measures once fatalities occurred (e.g. efforts to counter the threat of sars). the third and fourth versions of the precautionary principle, the "tactic approach", and the "strategic approach" deal with the timeframe of the enactment of precautionary measures. according to the tactic approach, precaution is a temporary and flexible instrument; uncertainty is thought to dissipate with knowledge. the tactic approach operates in the short and medium term. thus, measures are provisional and revisable, subject to change in response to increased knowledge. the tactic approach, used in the area of food safety, is associated with moratoriums, embargos, and all other reversible measures 12 (36) . in the specific context of pandemics, quarantine measures could also serve as an example of this particular interpretation. the strategic approach relates to the vorsorgeprinzip, a legal concept developed in germany, which inspired the creation of the precautionary principle. the strategic approach is premised on the notion that obtaining scientific certainties cannot always be done in time to allow for guidance of collective choices. its proponents argue that a policy of prevention based on medium and longterm objectives should be adopted. thus, attention should be shifted from advances in the understanding of risks, to understanding the evolution of the technological and economic resources available for risk prevention (i.e. the invention of new and substitute treatments, etc.) (36) . among the different versions discussed above, this final version, the strategic approach, could legitimate power authorities to use genetic databanks for research purposes and to utilize their findings in the context of public health interventions. the implementation of surveillance systems and pre-authorized procedures illustrate measures corresponding to this approach. recently, the possibility of a pandemic caused by the avian influenza mobilized the forces of many international and national public health bodies. various surveillance mechanisms were recommended. it would be particularly interesting to verify whether these governing bodies, in the elaboration of their intervention plan, intend to take advantage of the field of genomics, and if so, in which manner they plan to do it. our analysis of the pandemic influenza recommendations proposed by the world health organization, canada and quebec, all of which are important planning instruments, centers on the four principal functions of public health: monitoring, promotion, prevention and protection. the emergency issue is dealt with separately to accentuate the characteristics of this specific context. canada's and quebec's plans emphasize the responsibility of governments in the risk management of pandemic influenza. the world health organization's influenza preparedness plan (38) has had a significant impact on the design and on the implementation strategies of the canadian and quebec plans. the canadian pandemic influenza plan (39) can be studied in parallel with the new quarantine act (40) . the purpose of the act is to prevent the introduction and spread of communicable diseases (art. 4). it specifically addresses the screening of travelers or conveyances leaving and entering canada (art. 4). by definition, a pandemic affects several countries. public health measures at the borders will therefore be crucial in preventing and controlling outbreaks. precise details concerning various types of data to be collected and the roles and responsibilities of individuals at the local, provincial, territorial and federal levels can be found in the canadian plan, and specifically in the pandemic influenza surveil-lance guidelines (41) . the document also outlines the responsibility of canadian officials towards the world health organization. a number of factors are likely to influence the nature of surveillance measures. in addition to the various phases and periods of a pandemic, which shape the surveillance objectives and officials roles, the guidelines recommend considering changes in circumstances and new information ensued. this approach requires attentiveness to any development or variation in multiple areas. in particular, all aspects of a disease or of the epidemiology of the infection will require special attention: clinical manifestation (case definition and pathogenesis of influenza), virulence, mode of transmission, incubation period, period of transmissibility, and its effect on the population (distribution and frequency of the disease). could this latter aspect possibly include the need for population genomic data on gene-environment relationships? in addition to the recommendations of the pandemic influenza surveillance guidelines (41) , annex c of the canadian plan sets out recommendations concerning the virological monitoring and laboratory tests and procedures (42) . the annex c is not as explicit as the surveillance guidelines on the subject of research studies. nonetheless, annex c institutes a context of investigation and information updates for laboratories by addressing certain test protocols as well as communication between stakeholders. apart from citizens and health professionals, communication and health promotion tools are also intended for a third category of persons: politicians. any information regarding the influenza pandemic would certainly be valuable in guiding different public health authorities (public health directors, ministers, governments). the annex on communication in the canadian plan describes national objectives of communication in detail and according to pandemic periods (43) . the plan favors transparency and stakeholder responsibility in risk communication. the canadian plan thus strives to ensure that up-to-date information about a situation and risks for society are transmitted to the political authorities concerned (43) . a large portion of the canadian plan deals with functions linked to prevention and protection. for instance, guidelines on public health measures set out recommendations on education and communication of information to the population, community measures, such as school closures and public assembly limitations, and the care and services to be offered to persons infected by the new influenza virus and to their contacts (39) . our analysis of the annexes of the canadian plan concerning prevention and protection demonstrates two guiding ideas in the elaboration of recommendations: updating the information to be used for public health interventions, but also, in parallel, maximum use of existing expertise in devising scenarios and hypotheses of an influenza pandemic in canada. annex l of the canadian plan, entitled federal emergency preparedness and response system, outlines the federal government's responsibilities in the area of public health, particularly the powers conferred to the public health agency of canada and health canada. this annex does not include a definition of "emergency" per se, but the concept is elucidated by the examples provided. from these examples, we can infer that emergencies share the following characteristics: severity, need for immediate action, and a large number of people affected. the examples listed include sars, the ice storm of 1998, nuclear emergencies, pandemic influenza and "events or catastrophes of natural origin or deliberately caused". similarly, to its federal counterpart, the québec pandemic influenza plan -health mission (44) serves as a reference document in preparing for an influenza pandemic. its implementation will take into account new epidemiological knowledge of pan-demics and the overall evolution of the situation (44) . the québec plan proposes participation methods for all susceptible individuals in the event of a pandemic influenza, including decision-makers, citizens, informal caregivers, and workers. with respect to this participation, "three rules of governance" are provided as guiding principles: protection, solidarity, responsibility, and sound management. as the authors point out, the three rules of governance "are interdependent and have the common condition that everyone be vigilant as to their own state and the state of others and act accordingly" 13 (44) . the government of quebec, in partnership with political and health authorities, has a responsibility to protect the lives and health of the population, and more generally, its well-being (44) . the québec plan reflects this complex objective in distinguishing five broad facets of state intervention: "protecting the health of the population (public health); providing medical care (physical health); ensuring people's psychosocial well-being (psychosocial response); providing clear, relevant and mobilizing information (communication) […] [, and] keeping the network working (continuity of services)" (44) . our analysis of the québec plan continues in light of the public health ethics committee's study of this document. the public health ethics committee was created by the public health act. as mentioned, "scientific activity" plays a significant role in controlling pandemic influenza (45) . yet, although the need to obtain the best knowledge possible and to adopt the most effective measures is evident, other documents fail to mention scientific activity. 13 this acuteness with regards to knowing about ones own health status is now coupled with a traveller's duty to disclose their suspicion that they have or might have a communicable disease listed in the schedule or are infested with vectors as provided by law: quarantine act, s.c. 2005, c. 20, art. 15. this disclosure shall be done to a screening or quarantine officer while crossing the country's border and this without waiting to be questioned by the officer. we must point out; however, that "scientific activity" is an area that can have significant demands. these demands lead us to question whether the collection and analysis of genetic or genomic information can be pursued as a means of obtaining the best public health intervention strategies 14 . influenza control plans only refer to genetics under the label of "scientific information". for example, though the canadian plan mentions the impact of "information from the viral genome" (39) , no direct or indirect mention is made of genomic information as it relates to information concerning individuals or group of people. the same observation is true for the québec plan (44) , and that of the world health organization (38) . nevertheless, the obligation to protect the population in the event of a pandemic places an incumbent responsibility on different levels of government to implement measures to attain this objective. could genomic research programs be a part of these measures? after having examined different definitions and legislations regarding public health particularly in the canadian province of québec to see if they provide the basis to allow the state to access genomic databases, we offer the following conclusion. we must admit that genomics, or more specifically, genomic susceptibility to disease, offers interesting avenues for action in public health. in a not too distant future, genomics may well become a health determinant (46) . in fact, in quebec, biological and genetic predispositions, lifestyles and other health-related behaviours, living conditions and social settings; physical environment and finally, organisation of health and social 14 we note that the public health ethics committee opinion does not mention genetic nor genomic information. the consideration of its inclusion among scientific activities is ours. services as well as access to resources (22, 47) are considered health determinants. nonetheless, we have observed in the paper that state powers in public health, are not, in québec, well adapted to the expansion of genomics research. currently in canada, in the absence of emergencies, states powers to access genomics databases for research purposes are not explicitly and clearly established. however, to the extent that it can be shown that the genomic can be a very useful tool to respond more efficiently to a crisis in public health, should the state not take into account this new field of knowledge? the influenza control plans by highlighting the important responsibilities incumbent upon states to implement effective interventions in a pandemic, and by recognizing the contribution of knowledge and research, promote an open approach toward public health genomics. this leads us to make an important recommendation. in the future, the scope of the concept of research in public health should be clear and include the following characteristics: a commitment to the health and well-being of the population and to their determinants; the inclusion of both applied research and basic research; and, an appropriate model of governance (authorization, follow-up, consent, etc.). medium and long-term objectives should be adopted in relation to the possible future use of research results for public health interventions (public health promotion, prevention, and planning). therefore, we propose that the strategic approach version of the precautionary principle, based on premise that scientific certainties cannot always be obtained in a timely manner, could guide collective choices in these matters. as an autonomous discipline, public health deals with the global health of populations in all its curative, preventive, and social aspects; its objective is to develop systems and initiatives of health promotion, prevention, and treatment of illnesses, and rehabilitation of handicaps (48, 49) . as mentioned, the concept of public health is far from being static; it demonstrates a flexibility that guarantees a perpetual adaptation to new forms of risks attributable to the determinants of health. on the one hand, this flexi-bility is a consequence of the evolution of the notions of health, well-being, and illness, which are recognized as multifactorial phenomena. on the other hand, it is the result of developments in informational and biomedical technologies (50) . as such, the flexibility of public health may allow it to embrace new research tools, such as genomics. however, how can this innovative tool be utilized to reach the public health objectives of protection, prevention, promotion, and surveillance? in order to insure its appropriate use, it is essential to take into account the state's powers and responsibilities and to decide on the most suitable model of governance for this new biomedical research asset. interestingly enough, world health report 2012 no health without research (51) will discuss the impact of research in the elaboration of effective and efficient policy options, recognizing that, unfortunately, health policies are often not well-informed by research evidence. as stated, "the theme was selected in part to meet who's core function of stimulating the generation, translation and dissemination of valuable knowledge" (51) . keeping in mind that, in april 2010, the who department of research policy and cooperation established the who initiative on genomics & public health (52), it will be fascinating to find out the importance given to genomics. ethical issues (including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc) have been completely observed by the authors. getting ready for the future: integration of genomics into public health research, policy and practice in europe and globally understanding the bse threat mad cow update: risk now limited étude d'impact stratégique du plan d'intervention gouvernemental de protection de la santé publique contre le virus du nil occidental west nile virus: don't underestimate its persistence learning from sras -renewal of public health chemokine (c-c motif) receptor 5 -2459 genotype in patients receiving highly active antiretroviral therapy: race-specific influence on virologic success committee on genomics and the public's health in the 21 st century -board on health promotion and disease prevention -institute of medicine of the national academies 10 years of public health genomics at cdc 1997-2007 the path from genomebased research to population health: development of an international public health genomics network le risque comme problème politique: sur les obstacles de nature politique au développement de la santé publique. revue française des affaires sociales de l'individuel au collectif: une vision décloisonnée de la santé publique et des soins. ruptures, revue transdisciplinaire en santé la santé publique au québec à l'aube du xxi e siècle. santé publique the future of public health in canada: developing a public health system for the 21 st century committee for the study of the future of public health -division of health care services regional office for the west pacific, provisional agenda item 15 (document wpr/rc53/10): essential public health functions: the role of ministries of health, regional committee, fifty-third session, kyoto (japan) public health in the americas: conceptual renewal, performance assessment, and bases for action redefining the scope of public health beyond the year 2000 essential public health functions: results of the international delphi study les fonctions essentielles de santé publique : histoire, définition et applications possibles. santé publique québec public health program québec, institut national de santé publique du québec et ministère de la santé et des services sociaux pan american health organization national public health performance standards program -the essential public health services programme national de santé publique 2003-2012, version abrégée. québec, direction des communications du ministère de la santé et des services sociaux éthique et santé publique : enjeux, valeurs et normativité. les presses de l'université laval framework for the application of precaution in science-based decision making about risk uk/commission krever commission report, ottawa, public works and government services canada the sars commission -spring of fear: final report. government of ontario le développement durable contre le principe de précaution le principe de précaution comme norme de l'action publique, ou la proportionnalité en question. revue économique le principe de précaution dans le contexte du commerce international : une intégration difficile pandemic influenza preparedness and response: a who guidance document her majesty the queen in right of canada, canadian pandemic influenza plan for the health sector pandemic influenza surveillance guidelines in her majesty the queen in right of canada, supra, note 39, annex n (date of latest version pandemic influenza laboratory guidelines in her majesty the queen in right of canada, supra, note 39, annex c (date of latest version canadian pandemic influenza plan for the health sector: communications annex in her majesty the queen in right of canada, annex k (date of latest version quebec pandemic influenza plan -health mission volet santé publique du plan québécois de lutte à une pandémie d'influenza -mission santé, avis adopté à la 25 e séance du comité d'éthique de santé publique, le 16 juin les défis de la santé au xxi e siècle: approche législative des déterminants de la santé santé publique : santé de la communauté population health in canada : a systematic review. canadian policy research networks secrétariat du comité d'éthique de la santé publique -ministère de la santé et des services sociaux world health report the initiative on genomics & public health the authors want to thank genome canada, genome québec and the social sciences and con humanities research council of canada for their financial support. the authors declare that there is no conflict of interests. key: cord-006037-we1rp0pa authors: koh, howard k. title: leadership in public health date: 2009 journal: j cancer educ doi: 10.1007/bf03182303 sha: doc_id: 6037 cord_uid: we1rp0pa the modern public health model for leadership will unlikely be the omniscient figure with easy answers.51 rather the public health leader of the future may well be the transcendent, collaborative «servant leader»(50,52) who knits and aligns disparate voices together behind a common mission. they pinpoint passion and compassion, promote servant leadership, acknowledge the unfamiliar, the ambiguous, and the paradoxical, communicate succinctly to reframe, and understand the «public» part of public health leadership. by working between and above the levels of leadership of self, others and organizations, these transcendent leaders can ultimately shift the paradigm from «no hope» to «new hope» and create a renewed sense of community. such leadership will be vital as the 21st century progresses. beginning the journey to new hope may start by motivating underdogs who nurture the spirit, discover a passion to serve, cultivate interdependence, and create uncommon bonds. these emerging leaders can tap into their unique talents, passion, and compassion to promote a mission of «the highest attainable standard of health» for all, in every community. n an ideal world, all people would reach their full potential for health: long life and high-quality lives in healthy communities would allow everyone to reach optimal physical and emotional well-being. unfortunately, however, the harsh reality falls far short of this vision. 1 a dynamic and ever-expanding panoply of health threats poses a host of challenges. dangers range from traditional threats such as infectious diseases and the health needs of mothers and infants to chronic diseases such as cancer and cardiovascular disease, substance abuse, mental illness, hiv/aids (human immunodeficiency virus/acquired immunodeficiency syndrome), and diabetes. rising health care costs and growing numbers of the uninsured represent growing burdens for the united states. the 21st century has also seen greater emphasis on emerging infections and deadly pathogens that seem only a plane flight away. 2 meanwhile, throughout all areas, health inequities divide the richer and the poorer. 1, 2 stemming the tide of such daunting challenges in these volatile times will require a renewed commitment to public health leadership. in fact, recent years have seen a crescendo of calls to reinvigorate leadership education and training, because "today, the need for leaders is too great to leave their emergence to chance." 3-5 such leaders could help further social justice and the common good by promoting the values captured in the preamble to the constitution of the world health organization-"the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being." 6 to advance such training, the association of schools of public health has identified leadership as a core competency area in the master of public health competency model for 2007. this and other cross-cutting competencies should distinguish the public health practitioner of tomorrow. however, leadership in public health requires stretching the mind and soul in almost unimaginable ways. 1 a good example is dr. harold freeman, a leader who throughout his career has kindled new hope by making cancer prevention and control come alive. dr. freeman started his career as a young surgeon with a simple but profound passion to help people. he went on to attain many distinguished positions of note, including national president of the american cancer society, chairman of the us president's cancer panel, associate director for the national cancer institute center to reduce cancer health disparities, and chief architect of the american cancer society's initiative on cancer in the poor. the power of dr. freeman's remarkable career lies, however, not in his rich array of official titles but rather in his dedication to the broad vision of a world free from cancer. a descendant of a slave who became free and changed his name to "free man," harold refused to be typecast as a stereotypical surgeon. rather, he used his passion and compassion to promote prevention, merging the fields of clinical medicine and public health to do so. even as a young physician, he grasped the power of saving lives through early detection of cancerwhich currently carries a global disease burden of about 7 million deaths per year and is projected to become the leading cause of deaths worldwide by 2010. 7 throughout his career, he not only delivered care for underserved individuals but also promoted early detection for all. in struggling to treat many underserved patients who died of metastatic cancer, he also pioneered cancer control by starting with a fundamental issue, "what i really needed to know was: why do people come in too late for treatment; what are the reasons?" 8 to probe for the answers, dr. freeman employed an innovative public health lens. in 1986, he published a landmark report addressing the impact of income and poverty on cancer entitled "cancer in the economically disadvantaged." 9 this report urged the country to view cancer outcomes not just through a clinical viewpoint but also through the broader perspective of poverty. subsequent analyses have underscored his wisdom. for example, we now understand that in the united states, overall cancer survival decreases with increasing poverty level. for example, women in more affluent census tracts have a 63% overall 5-year cancer-specific survival rate, as opposed to 53% for those in less affluent census tracts; the same trends apply to males. 10, 11 other data indicate that those with private insurance have better long-term survival than those with medicaid (or who are uninsured) and that use of screening varies inversely by socioeconomic position. these findings, among others, led to landmark institute of medicine reports such as unequal treatment: confronting racial and ethnic disparities in healthcare. 12 dr. freeman fully grasped what nobel prize winner amartya sen would further explain, ie, that poverty impedes capability to choose one's own functioning in areas such as literacy, security, freedom of religion and expression-in short, the ability to live in a secure environment without discrimination and oppression. 13 dr. freeman not only offered fresh insights into viewing these challenges but also offered innovative ways to address them. he transcended the confines of clinical medicine to envision new areas for advancement in public health. a major contribution was pioneering the "patient navigator program" that was first created at harlem hospital. such programs, now commonplace across the country, are designed to help every individual, regardless of culture, language, or country of origin, receive the efficient, optimal, and compassionate care they deserve. 14 perhaps most noteworthy of all, however, has been harold's steady and gentle leadership style. a man of quiet passion, he led many initiatives with a dignified sense of service. his style of communication and decision-making always sets standards for professionalism, fairness, and humility. along the way, he has engendered fierce loyalty from everyone he met. dr. freeman represents a model of public health leadership worthy of our attention and respect. in the following sections, i explore both some of the special challenges and notable dimensions for leadership in public health. public health leaders must begin by acknowledging the extraordinary challenges of the discipline, not the least of which is the field's enormity of scope and goals. as opposed to clinical medicine, where health is generally regarded as a matter of one-on-one interaction between provider and patient, public health strives for the most lofty of aspirations, ie, "fulfilling society's interest in assuring conditions in which people can be healthy" 3,5 -or, as some have termed it, "saving of lives millions at a time". 1, 4, 15 reaching such expansive goals requires attention to an extraordinary range of areas, as outlined domestically in the healthy people (hp) 2010 16 objectives or globally in the millennium development goals (mdg). they include the hp 2010 10 leading health indicators (physical activity, overweight and obesity, tobacco use, substance abuse, responsible sexual behavior, mental health, injury and violence, environmental quality, immunization, and access to health care), as well as specific mdg areas (eg, reducing infant and child mortality, combating major communicable diseases, and eradicating extreme poverty and hunger). 1, 17 public health leadership also requires sophisticated understanding of the many dimensions which comprise the field. these include (1) a philosophy of social justice that raises provocative ethical questions about the distribution of resources; (2) a need to ground decisions in research when definitive data are often scarce; (3) a delicate link with government that may provoke tensions when public health interventions potentially limit personal rights on behalf of community needs; and (4) an orientation toward long-term prevention. 18 perhaps the greatest challenge of the field, however, lies in its nonhierarchical structure involving seemingly limitless numbers of stakeholders. the field encompasses a growing multiplicity of actors, representing a dizzying array of values and perspectives about ends, means, and responsibility. today, a "typical" public health meeting may feature doctors, nurses, occupational therapists, social workers, government officials, business leaders, advocates, payers, providers, researchers, media experts, sanitarians, and, of course, concerned members of the lay public. after 9/11, such meetings are also more likely to include police, fire, and emergency medical services personnel. this diversity of perspectives and values creates, on one hand, a rich, uncommon culture that links professionals from diverse backgrounds but also, on the other hand, a frequent "collision of worlds" 19 concerning ends and means. moreover, with its egalitarian and social justice roots, the field is much less hierarchical than sectors such as business and the military that have previously generated many traditional leadership paradigms. however, innovative successes can bloom when public health leaders galvanize people in coalitions that rally around a results-centered focus. 20, 21 strategic capacity blossoms with teams featuring heterogeneous perspectives, 22 broadening group identity while building upon the contributions of all the individuals involved. [23] [24] [25] in short, public health leadership starts with a foundation of science but ultimately requires social strategy, political will, and interpersonal skill. public health leaders assume the responsibility of navigating jarring juxtapositions among a diverse group of "ps": (1) policymakers, (2) penurious budget officials, (3) the press, (4) passionate advocates, (5) purchasers (public and private), (6) providers, and, (7) the public. the s13 relentlessly interdisciplinary nature of the public health challenges the leader to harness talents, advance the power of prevention, and deliver new hope to areas where previously there was no hope. 26, 27 defining and identifying appropriate frameworks for public health leadership can be an elusive task. to begin, although no consensus definition of leadership exists, the literature is filled with interesting proposals. president harry truman once offered, "a great leader is [one] who has the ability to get other people to do what they don't want to do and like it." 28 benjamin zander, the british conductor, has said, "the job of the leader is to speak to the possibility." 29 walter lippman has commented that "the final test of a leader is that he leaves behind in others the conviction and will to carry on." 30 authors kouzes and posner define leadership as the "art of mobilizing others to want to struggle for shared aspirations." 31 and of note, depree has observed, "the first responsibility of a leader is to define reality. the last is to say 'thank you.' in between, the leader is a servant." 32 in addressing these definitions, the literature also abounds with a panoply of leadership theories, models, and frameworks. although all of them are static representations of dynamic processes, many have potential relevance to public health. of these, the concept of transcendent leadership has gained recent attention. in this perspective, crossan and others argue that leadership studies have, to date, focused disproportionately on transforming others and organizations when instead the larger emphasis should primarily rest on leadership of self. 33, 34 doing so, in turn, fully enables leadership across the 3 overlapping levels of self, others, and organizations. transcendent leadership involves going within, between, above, and beyond these levels. 33, 34 as opposed to other classical leadership models that focus on followers, transcendent leadership theory shines special attention on self-awareness to understand one's own weaknesses and biases, and self-regulation to align values, intentions, and actions. 33, 34 such attention may be particularly relevant in today's environment where strong distrust of authorities in leadership positions spurs added attention to issues of honesty, integrity, morality, transparency of goals, and consistency of words and actions. moreover, these themes concern more than the collaborative egalitarian world of public health to include a growing number of other arenas in the 21st century, because, as author thomas friedman has observed, "everywhere you turn, hierarchies are being challenged from below or transforming themselves from topdown structures into more horizontal and collaborative ones." 35 moreover, it has been stressed that leadership is a choice and that one can lead at any age at any place, not solely in positions of authority or as heads of organizations. 36 transcendent leadership therefore has an emphasis on wholeness, involving associates and constituents in collective decision making and group consent processes to serve the will of the group. 33, 34 such leadership understands that ". . . we are all connected. if this could be taught and if people could understand it, we would have a different consciousness." 37 we can apply these dimensions of transcendent leadership to the global public health goal of "the enjoyment of the highest attainable standard of health" for all human beings. dr. freeman's story exemplifies a number of themes in public health leadership: pinpointing passion and compassion; promoting servant leadership; acknowledging the unfamiliar, the ambiguous, and the paradoxical; communicating succinctly to reframe; and understanding the "public" part of public health leadership. by working between and above the levels of leadership of self, others, and organizations, transcendent leaders can ultimately shift the paradigm from "no hope" to "new hope" and create a renewed sense of community. standing for something "so you don't fall for anything" begins the journey of public health leadership. in fact, the most successful examples of public health leadership are fundamentally rooted in pinpointing passions 38,39 discovered from a leader's profound journey into self. 40 the mission of preventing human suffering involves a deep understanding of one's values and spirituality, defined by reverend william sloane coffin as "living the ordinary life extraordinarily well." 39 in addition, however, embracing a broader purpose requires not only the ability to suffer-passion-but also the ability to suffer with-compassion. father henri nouwen has noted, "compassion . . . asks us to go where it hurts, to enter into places of pain, to share in brokenness, fear, confusion, and anguish . . . compassion means going directly to those people and places where suffering is most acute and building a home there." 41 certainly harold freeman's passion and compassion in the world of cancer control underscore nouwen's themes. often the best leaders are those who, after suffering greatly, have successfully transformed their pain into passion. indeed, so many leaders have endured and grown from indelible "crucible experiences," so named for the medieval vessel used by alchemists in attempts to turn base metals into gold. 42 leadership expert warren bennis has written that such crucible experiences are intense, often traumatic, and always unplanned transformations that force deep reexaminations of values and assumptions. often though, the leader emerges stronger and more sure-imbued with a heightened sense of purpose. 42 as hemingway has written "the world breaks everyone, and afterward, many are strong in the broken places." 43 public health leaders, therefore, can gain passion and compassion through such crucible experiences. so, for example, until recently, the bylaws of mothers against drunk driving (madd) required that their presidents be those who were personally touched by the tragedy of the field. one recent president was launched into activism through the suffering of her family's 3 separate drunk driving crashes. 44 similarly, the late actor, christopher reeve, who played superman in action movies until a riding accident reduced him to quadriplegic status, used the remaining years of his life to advocate for stem cell research and the rights of the disabled. in his wheelchair, he had, perhaps, as much power and impact as when he was portraying a superhero on screen. all these leaders used their shared experiences to unite people and ultimately effect collective change. nouwen has written that such individuals are "wounded healers," whose pain motivates them to prevent suffering for others. he relates the talmud parable of a wounded healer who can be found "sitting among the poor covered with wounds. the others unbind all their wounds at the same time and then bind them up again. but he unbinds one at a time and binds it up again saying to himself, 'perhaps i shall be needed: if so i must always be ready.'" 45 nouwen underscores the rich interconnections of pain, passion, and compassion by noting that "the great illusion of leadership is to think that man (and woman) can be led out of the desert by someone who has never been there." 45 the journey into self also means constantly revisiting the fundamental, and often painful, question "who tells you who you are?" 39 for too many, the answer lies outside in terms of titles, status, or external trappings. some even are defined by their enemies-that is, what they are against, as opposed to what they are for. 39 in government and other hierarchical structures, many who are defined solely by their unquestioning loyalty to authority figures scramble for perceived power through proximity. but coffin reminds us that if power is a requirement for self-identity, then loss of power leads to loss of self. 46 leaders may thus do better to focus on expressing, rather than proving themselvesnurturing the personal spirit and trusting the inner voice. 47 such an approach helps one bear the inevitable slings and arrows of service and, in the words of gergen, "absorb the punishment without surrendering your soul." 48 passion, although critical, is not enough. transcendent leaders humbly understand their own biases and that their driving passions can easily blind them to the passions of others. finding ways to connect passions and align their own spirit with that of others brings a leader closer to mobilizing people for a higher purpose. as has been written, that is the secret of the bond between spirit and spirit. 49 as with any area in public health, no single leader has all the requisite skills and resources necessary to confront the constellation of complexities. for these and other reasons, public health leaders must engage in intergroup collaboration to serve the mission of the whole. 50 in a stark contrast, then, to some classic leadership models portraying bold leaders directing passive followers, the public health culture favors a more collaborative, facilitative leadership that recognizes the value of complementary and synergistic leadership functions among multiple contributors. such servant leaders motivate and inspire individual and organizational commitment for change in a manner that is "insistent yet not domineering . . . credible rather than powerful . . . concerned with process as much as content." 40 this public health approach also differs markedly from that of the traditional medical leader. classic surgical leaders in an operating room, for example, practice their craft in a hierarchical manner, possessing all the requisite technical expertise and skill to direct a team. in contrast, the transcendent public health leader is more like the symphony maestro, capable of playing perhaps only an instrument or two but required to coordinate and blend the melodies of dozens more. the maestro and the public health leader strive to strike the right balance and dynamics and in doing so may oscillate from being the focus of intense attention to being rendered almost invisible. focusing on the product and not the self, s/he is content to set the tempo and tone, confident that the music will soon flourish and flow. harold freeman lived by all these principles. he was surgeon and servant, combining service and leadership in his quest for a cancer-free world. in short, the most effective public health leader is unlikely to be the ceo with ready answers. 51 rather "the servant leader" 52 can "manage the dream" 47,53 by knitting disparate voices together and fostering change through open collaboration. in doing so, transcendent leaders shape organizations, while heeding harry truman's observation that, "[you] can accomplish anything in life, provided you do not mind who gets the credit." 54 ideally, this transcendent leader will cultivate interdependence and oneness of mission, mobilizing individual commitment by inviting people in to build coalitions and share power. the traditional leadership trait of fierce independence gives way to a more valuable trait of fierce interdependence. such a leader first emphasizes creating that special interdependent team that can create synergy and ultimately results. author jim collins has written in his classic book from good to great, that good leaders often focus first on "who" and then on "what." as he noted, "good-to-great leaders first get the right people on the bus (and the wrong people off the bus) and then figure out where to drive it." 54 learning to accept chaos-the unfamiliar, the ambiguous, and the paradoxical event-is essential for leadership in public health. ambiguity always accompanies this field characterized by partial knowledge, shifting dynamics and uncertain outcomes. 19 rarely blessed with the luxury of rigorous academic studies with defined end points, public health leaders often find themselves intervening based on minimal or incomplete data. but intervene they must to begin the process of change. adding to the sense of chaos is the advent of an era where disasters have become the norm. today's public health leaders must be especially prepared to face the unfamiliar, including the fall 2001 anthrax attacks, the 2003 sars (severe acute respiratory syndrome), and hurricane katrina in 2005. 55 such unexpected crises can shake communities to the core, as ". . . one of the worst outcomes of a crisis is the collapse of fundamental assumptions about the world." 55 these new challenges have prompted painful reexaminations of what had been taken for granted. for example, the 2001 anthrax attacks forced an awkward merger of public health, emergency management, law enforcement, and postal service investigators into a new post-9/11 public health infrastructure. now, with the world nervously eyeing increases in human cases of h1n1 influenza everywhere, the next pandemic has exposed major gaps in worldwide surveillance, disease control, resources (such as vaccines and antiviral medications), and an overall lack of a sound life-saving public health infrastructure. an artful leader in public health thus must live within this web of complexity, and sense potential creative opportunities and innovations as hidden issues surface and ripen 19 to "raise one another to higher levels of morality and motivation." 56 such leaders, although not necessarily seeking a specific outcome, acknowledge chaos as a useful starting point for change. as has been written, "chaos is not a mess, but rather a primal state of pure energy to which the person returns for every true new beginning." 57 harvard leadership expert ronald heifetz has written about 3 types of work; an ambiguous environment requires adaptive work. 58 the first is technical work where the problem is clear and the solution requires involvement of an authority (eg, a patient's broken bone is set by a doctor). the second type of work is both technical and adaptive; the problem is clear, but the solutions require work shared by both the authority and the stakeholder (eg, a patient has heart disease, the doctor offers broad, lifestyle solutions to address the condition, and then the patient must change his way of life with respect to diet, exercise, cigarette dependence, or other areas). public health, however, usually finds itself wrestling with the third type of work, adaptive work, in which the problem definition requires learning, the solutions require learning, and the primary responsibility for the work lies more with the stakeholder than the authority. most of the major public health challenges facing our society fall in this third category. we look to authority figures for ready answers, when in fact, we need leaders without obvious, ready solutions who are, nevertheless, committed to embarking on the journey to define the problem and implement a solution. among the myriad public health challenges in today's world, such as creating health coverage systems for the uninsured, defining the appropriate parameters for genetic testing, eliminating homelessness, or preventing violence, leaders in authority face enormous pressure to ". . . offer more certainty and better promises." 19, 51 in response, such authorities may be tempted to "sometimes fake the remedy or take action that avoids the issue by skirting it." 19, 51 however, transcendent leadership in such instances may mean "giving the work back to the group." 19, 51 for example, sustaining programs through public health budget cuts, a regular exercise in these uncertain times, is one example of leadership involving "disappointing people at a rate they can bear." 51 managing expectations guides people committed to change to understand that it may not come overnight. in such circumstances, the effective leader may need to humbly acknowledge tolstoy's belief that "certain questions are put to human beings not so much that they should answer them but that they should spend a lifetime wrestling with them." 59 all leadership requires the ability to communicate and persuade. 48 for public health, the field's vast and hazy image necessitates succinct, concrete communication that can cut through the fog. communicating public health in conjunction with the mass media especially demands artful understanding of the different goals of the 2 fields. 60 the mass media generally aim to entertain or inform, whereas public health aims to promote social change. media usually address short-term personal concerns, whereas public health addresses long-term societal concerns. mass media gravitate to certain answers, whereas public health acknowledges uncertainty, realizing that conclusions can change. dr. freeman especially understood that communicating with the public often meant reframing to create new meanings. for example, he is credited with focusing attention on the critical disconnect between discovery and delivery. 61 simply coining the phrase "the discovery to delivery disconnect" prompted renewed national attention on the challenges of cancer and its unequal burden on society. others have urged similar attention on reframing in the field of health disparities. the official definition of health disparities ("the quantity that separates a group from a specified reference point on a particular measure of health" 62 ) can be viewed as dry and dispassionate. substituting instead the terms "inequalities" or "inequities" for disparities reframes the conversation closer to basic issues of unfairness-or even human rights-and in this way may thus capture the attention of an otherwise disinterested public. as noted communication expert lakoff notes, "frames are mental structures that shape the way we see the world. reframing is social change. reframing is changing the way the public sees the world. it is changing what counts as common sense." 63 leaders master the power of reframing, using "steadfast concentration on the same core message along with the flexibility in how it is presented and openness to the message being apprehended at a number of levels of sophistication." 28 by definition, both leadership and public health are public. hence public health leadership combines double doses of exposure and scrutiny. former college president nan keohane notes that, "the leader is always on duty, always on stage and anything she does is inescapably interpreted not as a private action, but as representing the organization itself." 64 leadership expert warren bennis also warns of the trials and tribulations of being "on stage," noting, "you have to learn how to do the job in public, subjected to unsettling scrutiny of your every word and act; a situation that's profoundly unnerving . . . like it or not, as a new leader you are always on stage, and everything about you is fair game for comment, criticism, and interpretation (or misinterpretation). your dress, your spouse, your table manners, your diction, your wit, your friends, your children, your children's table manners-all will be inspected, dissected, and judged." 53 such scrutiny can be especially intense in public health, where so many differing passionate factions clash under the watchful eye of the media. promoting change for many can represent costly loss for some. when, at the beginning of the hiv/aids epidemic in the 1980s, former us surgeon general c. everett koop mailed what many considered to be sensitive information about risk factors and transmission to every house in america, the largest public health mailing in history, he was greeted with heavy criticism from many quarters. he withstood the assault, understanding that critics may "go after your character, your competence, or your family" in the hopes of leaving the leader marginalized or neutralized. 19 in such times, leaders gain resolve from the words of david gergen who has commented, "the toughest steel goes through the hottest fire." 48 when transcendent public health leaders make public what had been personal, they regularly assume risks. tobacco-company-executive-turned-whistleblower, jeffrey wigand, was fired after trying to change the system from within, going public to expose that the industry had long known that its products were addictive. 65 along the way, he expressed regret for his time working for the industry. his story exemplifies that "real change comes from our willingness to own our vulnerability, confess our failures, and acknowledge that many of our stories do not have a happy ending." 21 a transcendent leader can find a sense of oneness in juxtaposing a vision with the imperfect reality and living in the creative tension represented by the space between them. in some ways, the core of public health leadership hinges on surmounting the odds to kindle new hope for those being served. shifting the paradigm from "no hope" to "new hope" 26, 27 in any setting may well be one of the most daunting human journeys of all. in these volatile times, many feel overwhelmed by the chaos of seemingly endless societal challenges. but "no hope" situations can give rise to underdog leaders, who successfully strategize, mobilize, transform, and rise above. such leaders fully recognize that "giant obstacles are brilliant opportunities-brilliantly disguised as giant obstacles." 46 one example of this is the life of public health leader dr. jim o'connell who founded boston health care for the homeless in 1985. in the 2 decades since, jim has nurtured both an organization and movement that now cares for the most vulnerable in our society. as a street doctor, he not only has built an organization that now boasts over 300 employees, but has also set a national standard for medical care for the homeless who routinely live on grates, under bridges, near racetracks, and propped up against public buildings. 66 his transcendent leadership style is marked by service, humility, gentle passion, and compassion. other effective public health leaders also learn to relish, not reject, the role of the underdog. many, almost by definition, enter the field for social justice reasons and welcome fighting for the underserved. such leaders often find themselves in david versus goliath situations to "afflict the comfortable and comfort the afflicted." 22, 47, 53 by challenging a goliath publicly, they work to create a "crack in the armor" and expose a soft underbelly. a major public health example of this lies in the creation of the world health organization (who) framework convention on tobacco control (fctc). the fctc is the first and only international public health treaty, now ratified by 161 countries that have joined forces to counter tobacco industry marketing worldwide. 67 hundreds of public health leaders in these ratifying countries have brought new hope by challenging a tobacco industry whose products are projected to cause a billion deaths in the 21st century. 7 such leaders reject the status quo, "entice through moral power" 21 and demand change. healthy people 2010 states "the health of the individual is almost inseparable from the health of the larger community and that the health of every community . . . determines the overall health status of the nation." 16 perhaps no theme more embodies transcendent leadership than the goal of creating a renewed sense of wholeness for self, others and organizations .the most enduring legacy of any public health leader springs from honoring and creating a renewed sense of community. on a practical level, public health leaders can unify people in coalitions and organizations to craft a new shared urgency of public purpose and compelling direction. 24, 68 for example, advocacy groups and their leaders in areas such as cancer, cardiovascular disease, substance abuse, and s17 hiv/aids can galvanize a new sense of collective purpose through new coalitions with shared commitment. 68 in these circumstances, it is essential to have leaders who begin with a sense of urgency, create a guiding coalition, develop a vision and strategy, communicate the change vision, empower broad-based action, generate short-term wins, consolidate gains and produce more change, and anchor new approaches in the culture. 68 definitions differ of what represents community. for some, the community is represented by a coalition. for others, it is a group of professionals or committed volunteers focused on a particular disease area (cancer, heart disease, women's health, or hiv, for example). for still others, a community may be one's neighborhood, city, town, state, country, or even the globe. for harold freeman, the community included anyone who cared about preventing human suffering from cancer. because these are times of declining social capital where people are often "bowling alone," 69 leaders can bring new meaning to many global communities for the future. the modern public health model for leadership will unlikely be the omniscient figure with easy answers. 51 rather the public health leader of the future may well be the transcendent, collaborative "servant leader" 50,52 who knits and aligns disparate voices together behind a common mission. they pinpoint passion and compassion, promote servant leadership, acknowledge the unfamiliar, the ambiguous, and the paradoxical, communicate succinctly to reframe, and understand the "public" part of public health leadership. by working between and above the levels of leadership of self, others and organizations, these transcendent leaders can ultimately shift the paradigm from "no hope" to "new hope" and create a renewed sense of community. such leadership will be vital as the 21st century progresses. beginning the journey to new hope may start by motivating underdogs who nurture the spirit, discover a passion to serve, cultivate interdependence, and create uncommon bonds. these emerging leaders can tap into their unique talents, passion, and compassion to promote a mission of "the highest attainable standard of health" for all, in every community. working papers of the center for public leadership institute of medicine. who will keep the public healthy?: educating public health professionals for the 21st century committee for the study of the future of public health. the future of public health committee on assuring the health of the public in the 21st century. the future of the public's health in the 21st century human rights from a u.s. state health department perspective the mpower package war on poverty. new york 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acknowledgments i am grateful to sarah massin-short and kirkpatrick tans for their help on the manuscript and to dr. claudia arrigg for unending encouragement and support. key: cord-001634-mi5gcfcw authors: davis, mark d m; stephenson, niamh; lohm, davina; waller, emily; flowers, paul title: beyond resistance: social factors in the general public response to pandemic influenza date: 2015-04-29 journal: bmc public health doi: 10.1186/s12889-015-1756-8 sha: doc_id: 1634 cord_uid: mi5gcfcw background: influencing the general public response to pandemics is a public health priority. there is a prevailing view, however, that the general public is resistant to communications on pandemic influenza and that behavioural responses to the 2009/10 h1n1 pandemic were not sufficient. using qualitative methods, this paper investigates how members of the general public respond to pandemic influenza and the hygiene, social isolation and other measures proposed by public health. going beyond the commonly deployed notion that the general public is resistant to public health communications, this paper examines how health individualism, gender and real world constraints enable and limit individual action. methods: in-depth interviews (n = 57) and focus groups (ten focus groups; 59 individuals) were conducted with community samples in melbourne, sydney and glasgow. participants were selected according to maximum variation sampling using purposive criteria, including: 1) pregnancy in 2009/2010; 2) chronic illness; 3) aged 70 years and over; 4) no disclosed health problems. verbatim transcripts were subjected to inductive, thematic analysis. results: respondents did not express resistance to public health communications, but gave insight into how they interpreted and implemented guidance. an individualistic approach to pandemic risk predominated. the uptake of hygiene, social isolation and vaccine strategies was constrained by seeing oneself ‘at risk’ but not ‘a risk’ to others. gender norms shape how members of the general public enact hygiene and social isolation. other challenges pertained to over-reliance on perceived remoteness from risk, expectation of recovery from infection and practical constraints on the uptake of vaccination. conclusions: overall, respondents were engaged with public health advice regarding pandemic influenza, indicating that the idea of public resistance has limited explanatory power. public communications are endorsed, but challenges persist. individualistic approaches to pandemic risk inhibit acting for the benefit of others and may deepen divisions in the community according to health status. public communications on pandemics are mediated by gender norms that may overburden women and limit the action of men. social research on the public response to pandemics needs to focus on the social structures and real world settings and relationships that shape the action of individuals. conclusions: overall, respondents were engaged with public health advice regarding pandemic influenza, indicating that the idea of public resistance has limited explanatory power. public communications are endorsed, but challenges persist. individualistic approaches to pandemic risk inhibit acting for the benefit of others and may deepen divisions in the community according to health status. public communications on pandemics are mediated by gender norms that may overburden women and limit the action of men. social research on the public response to pandemics needs to focus on the social structures and real world settings and relationships that shape the action of individuals. the re-emergence of infectious diseases is a leading public health problem. pandemics and epidemics [1] including avian influenza, sars, ebola, and pandemic influenzaand the rise of anti-microbial organisms [2] now threaten the health of populations around the globe. it has been argued that the re-emergence of these diseases marks the end of the golden age of medicine and the dawning of a period where health and security will be undermined by resurgent infectious diseases [3] . pandemic influenza stands out in this situation because: it spreads quickly around the globe affecting many millions of people; it is associated with, potentially, high mortality, and; the world experienced a highly publicised, though ultimately mild for most, pandemic influenza in 2009/10. it is believed that another, more serious influenza pandemic is inevitable, though no-one, as yet, can predict when it will occur. for these reasons, explaining infectious diseases threats to the general public and encouraging them to adapt their health behaviours is high on the public health agenda. in relation to pandemic influenza, public communications feature in preparedness and response planning which requires that members of the general public adopt measures during a public health emergency, including: hygiene (e.g., covering the mouth and nose when sneezing or coughing, washing hands, keeping surfaces clean, avoiding sharing personal items) and the avoidance of close contact with others [4] . understanding how populations respond is also crucial for the science that supports response planning. for example, mathematical models, which underpin pandemic response planning, factor in biological, psychological and sociological assumptions of how populations respond to infectious diseases [5, 6] . effective communications with the general public and understanding how they respond, therefore, have a pivotal role to play in the management of pandemic influenza, in particular, and in the area of emerging infectious diseases, in general. however, knowledge of how to best communicate on pandemics with the general public and how they take up these messages is an emerging field with some inconsistencies [7] . evaluations of the public health response to the 2009/10 pandemic influenza claim that public communications were largely successful in preparing and reassuring publics during the emergency [8, 9] . these findings need to be read against the fact that the pandemic was a short-lived and ultimately mild public health emergency for most people. there is a view, also, that members of the general public are resistant to pandemic risk messages. some commentary has suggested that the general population is increasingly resistant to public policy on global threats, including climate change and emerging infectious diseases [10] . surveyswhich dominate the social scientific view on public responsesconducted during the 2009 pandemic indicate that populations in the uk and australia were complacent with regard to h1n1 and reported insufficient behavioural responses [11] [12] [13] [14] [15] . broad brush, risk communication research has identified that material circumstances and symbolic framing of risk [7] , inequalities in education and access to media [16] , (mis)trust in media and governmental advice [17, 18] , all shape how members of the general public respond to communications on pandemics. close-focus, qualitative research offers the view that while the general public endorses governmental advice, in the circumstances of the 2009/10 pandemic they were also unlikely to act in the ways advised by governments [19, 20] . there are additional explanations for the apparent resistance on the part of the general public. for example, because they are bombarded with so many messages, including those pertaining to pandemics, members of the general public may by subject to 'health threat fatigue' [21] . this is not the same as resistance. it is, instead, a dulling of alertness seated in screening out of overwhelming and competing risk messages. members of the general public appear to digest and critically reflect on risk communications messages [22] , and tailor risk reduction strategies to their personal circumstances [23] . it is also argued that the general public is only too aware of the 'boy who cried wolf ' syndrome [24] , where too frequent assertion of danger leads publics to dismiss public health warnings. in addition, audience reception of communications on health is framed by the historic rise of individualism in society [25] and health systems [26] . individualism implies that members of the general public take on the view that responsibility for their health is a matter of personal volition and effort. this view is often utilised in health communications that call on people to take care of themselves, but it is a perspective that can obscure factors that are not within the control of the individual. it is also an approach to risk that has a moral loading and therefore a negative effect for those who are unablethrough choice or otherwiseto avoid health harms. exactly how individualism plays out in relation to pandemic influenza warrants further inquiry. because it is so vital that public health authorities communicate with members of the general public as effectively as possible and as there are competing explanations and routes of inquiry available in the literature, it is necessary to re-examine the apparent resistance to communications and advice on the part of the general public. a central challenge is to get beyond prevailing assumptions and build up a theory of public engagement informed by the life worlds of the general public [7] . understanding why populations fail to sufficiently enact precautions must involve taking account of how lives are lived and the meanings ascribed to the threat of infectious diseases. indeed, what might look like lack of precaution may turn out to be reasonable given the material and symbolic circumstances of affected individuals and populations. a related challenge, then, is re-examining how public health characterises the general public in research on pandemics and in the more general area of emerging infectious diseases. taking these steps is vital to ensure that the public health response and its communications with the general public are as resonant, meaningful and effective as possible. this paper, therefore, uses inductive, qualitative research methods to develop new knowledge on how members of the general population respond to pandemic influenza, set against the backdrop of the assumed resistance on the part of the general public and related critiques, including, health risk fatigue, the risk communication dilemma and individualism. the analysis poses the question: how do members of the general public respond to the threat of pandemic influenza and to the hygiene, social isolation and other measures proposed by public health? by addressing this question in the manner indicated, the paper offers an alternative framing of pandemic influenza perceptions and behaviours in an effort to contribute to the better health of individuals and populations facing risk of infectious diseases. the following analysis was generated in international research (australian research council discovery project dp1101081) focusing on the responses of members of the general public to the events of 2009 alongside interviews with researchers, clinicians and policy-makers [27, 28] and analyses of the public policy texts on pandemic influenza control [29] . this research has examined general public data in light of sociological and psychological perspectives on responses to pandemic influenza [23, [30] [31] [32] [33] . the present paper synthesises and builds on the research undertaken on the general public, in particular, and introduces new data analysis to address the public health challenge of effective communication and engagement with members of the general public. interview and focus group participants were recruited through community sampling in melbourne, sydney and glasgow. generating data in australia and scotland addressed the international dimension of pandemic influenza and the events of 2009. australia was closely observed by other nations as early stages of the global pandemic in 2009 coincided with the southern hemisphere influenza season. the pandemic quickly affected melbourne, which reported a high and early peak of known infections [34, 35] . the city, for a time was known as the 'flu capital of the world.' the first confirmed cases in the uk were in scotland among passengers on a flight from mexico to glasgow [36] . the uk and australia reported 457 [8] and 191 [37] deaths, respectively, associated with the 2009 h1n1 pandemic. our analysis of interview and focus group texts reveals more convergence than difference between melbourne, sydney and glasgow, perhaps because the pandemic was managed in those cities by public health professionals who were members of a global pandemic response network. the research aimed to identify how members of the general public respond to pandemic influenza so that public health communications can be designed to engage with how its audiences respond to risk messages and how they enact hygiene, social isolation and related measures. four purposive criteria were used to select respondents in each city: women who were pregnant during 2009 (or with a new baby); older members of the community (71 years of age and older); people with compromised immune systems and or respiratory illness such as asthma; and people who self-identified as being 'healthy' (e.g., no disclosed health problems) and who did not belong to one of the former categories. in addition, selection of participants was conducted to ensure: a balance of male and female participants and a range of ages from 18 years upwards. drawing on interviews and focus groups ensured depth and breadth. interviews explored in-depth discussion of personal experiences of living through the h1n1 pandemic, seasonal influenza and related concerns. focus groups examined social norms concerning precautionary behaviours regarding pandemic influenza. between april 2011 and may 2012, 116 people participated in the research (see table 1 ) in 57 interviews and ten focus groups (with 59 participants). interviews included people from the purposive criteria (pregnant = 14; 71+ = 3; hiv/respiratory illness = 17; healthy = 23); a gender mix (women = 34; men = 23), and; an age range of 18 to 71+ years. focus groups included people from the 71+ group (10); hiv/respiratory illness (37) and the healthy group (22); a gender mix (women = 36; men = 23), and; an age range of 18 to 71+ years. this pattern of participation reflects the challenges of recruiting women who were pregnant in 2009, the very elderly and men. seven respondents reported having been diagnosed with h1n1; none through a laboratory-confirmed test (a reflection of our community sampling). a further eleven interviewees reported that a relative, friend or other social contact had been diagnosed, clinically. it needs to be acknowledged, however, that, as influenza is not ordinarily diagnosed with a laboratory confirmed test [38] , public health professionals and members of the general public identify and manage the infection on the basis of symptoms. indeed, respondents noted difficulty determining whether they had had influenza participants were asked to speak about their experiences with influenza and the public health response to the 2009 pandemic. topics for discussion included: health background (including pre-existing medical conditions, other infectious diseases, influenza vaccination); influenza experiences (including knowledge of pandemic influenza, sources of knowledge, experiences with the 2009 pandemic and seasonal influenza, prevention of infection, caring for self and/or someone else with infection); public communications (including broadcast and electronic media, public health advice, advice from gps, workplace and schools). verbatim transcripts of interviews and focus groups were analysed using an inductive, theory-building method. all transcripts were open coded to generate themes for analysis. interpretive memoranda were generated which explained each theme and how it connected with existing perspectives on the general public response to pandemic influenza. the research team reviewed these themes and memoranda to ensure that the themes were understood and that they could withstand refutation. this discussion also provided the basis for an agreed coding scheme that was used to re-code all data. key themes were identified for subsequent, in-depth written analysis in the form of technical reports and draft manuscripts. our approach to coding, memo writing and in-depth analysis sustains a dialogue between theory (pre-existing categories derived from social science theory and the relevant literature) and data (inductively-derived themes). this approach avoids the traps of overly dataor theory-driven analysis and ensures that the research has relevance to the field. this paper, therefore, is based on in-depth, nuanced analysis of interview and focus group texts that offers new perspectives and propositions, which provide the basis for interrogating prevailing assumptions regarding the general public response to pandemic influenza. this approach is consistent with social inquiry of the highest standard [39] . the assumed complacency and resistance on the part of members of the general public was not in evidence in the narratives provided by our research participants. other factors, centred around health individualism and contextual factors such as gender and biomedical situation do appear to influence how people respond to the threat of pandemic influenza. in what follows, we focus on themes that establish and complicate the role of health individualism and its effects in the responses of members of the general public to pandemic influenza. the interviews and focus groups revealed a tension to do with self and other in relation to the threat of pandemic influenza. as we have discussed elsewhere, respondents endorsed the pandemic control measures advocated by public health authorities [23] . they agreed that hygiene control measures (coughing and sneezing etiquette) and social distancing were valuable. this endorsement held in australia and scotland. characteristically, however, respondents did not believe that pandemic influenza could be prevented in the long run. they believed that the influenza virus was easy to catch and that hygiene measures and social isolation were difficult given that social interaction was needed to sustain work, schooling, the family and daily life. for this reason, respondents focused on strengthening their immunity through, for example, taking vitamins and eating healthy food: i think if you're healthy, keep up your vitamins and eat the right foods, drink healthily, eat healthily and live healthily. exercise. you've got to do all those things. (heather, 71+, melbourne) this immunity boosting was seen as a prudent defence against the seemingly inevitable moment of exposure and a means of coping with infection when and if it occurred. importantly, this focus on one's body and immunity in the face of seemingly inevitable infection accentuated health individualism, encouraging members of the general public to focus on their body's abilities to resist and cope with infection. there was evidence that immune boosting has the status of a social norm as those who were seen to succumb to infection were sometimes judged as failing to adequately care for themselves, even though it was admitted that the virus was easy to catch. to some extent individualism is an asset for public health interventions that seek behaviour change at the individual level. however, an individualistic approach to pandemic risk may obscure factors that the individual cannot control and, as indicated by the judgement of those who acquired infection, health individualism may be moralising. health individualism was not the only factor influencing how members of the general public perceived risk for pandemic influenza and took action. respondents who had responsibilities for others (e.g., pregnant women, people in couples or caring for people with health problems, families with children) or who saw themselves as vulnerable to influenza (e.g., respiratory illness, immune disorders) focused on social units such as the couple, family and colleagues at work: well given that the flu broke out at xxxx street primary school and my son was three and he was at xxxx street childcare, i pulled him out. so when my husband picked him up that day i was at work. i said, 'take him home. give him a bath. wash his clothes.' yeah. i stopped sending him and i was one week off my maternity leave so i stopped work a week early … i didn't go to the supermarket, didn't really mix. (gill, pregnant, melbourne, 31 -40 years) it appears, then, that both health individualism and relationships with important others influence what people do. in this regard, social proximity appears to be important, that is, those others who are close to oneself in terms of social and emotional ties and living situation are factored into health precautions. this social proximity also showed up in the ways in which respondents saw geographical distance and low population density as protective. those respondents living further away from the populous 'epicentres' of infectioncentral melbourne, for examplebelieved that they were less likely to encounter someone with the virus. ' we're familiar with chest infections' one important way in which this tension between responsibility to oneself and to others came to light in interviews and focus groups related to differences between the responses of those with pre-existing conditions and those who identified as 'healthy.' those who faced increased risk of serious disease focused on their relationships with othersincluding strangers they might encounter in public spaceslargely in an effort to protect themselves. those with no vulnerabilities showed themselves to be archetypally focused on their individual health. for example, people with severe respiratory illness reported that engagement with the risks of influenza was a 'well trodden path' for them: as lung patients, we're, we're familiar with chest infections and, as joy says, we could, we could have a flu and not know it. and the gp checks us over. and the only way that i know that they'll know whether it's a chest infection or flu, or pneumonia, is for an x-ray. (arthur, lung disease, melbourne, 71+ years) people with pre-existing lung conditions, then, were commonly hyper-vigilant during the 2009 pandemic and their accounts were peppered with examples of how social interaction was imbued with risk for them and also some resentment that the healthy majority seemed to not understand the significant threat that influenza infection might pose to their health [33] . people with immune disorders in our sampleprimarily hivunderstood they needed to be vigilant but saw influenza as a lower priority than their hiv infection and its effective management. older respondents (71+) conveyed judicious vigilance tempered with an unwillingness to be seen to overreact. important in these accounts was awareness of the vectors of transmission and that one's health was to some extent dependent on those with whom one interacted. in contrast, the healthy majority of our respondents saw pandemic influenza as a personal, though distant, health threat. they saw themselves 'at risk' and possibly as 'a risk' to close family, but not as 'a risk' to unknown others (e.g. a person sitting beside them on public transport). this focus on the 'at risk' self to the exclusion of the self as 'a risk' to others underlines how health individualism manifests in the responses of the 'healthy' majority of the general public. this focus of the healthy on their own health risks (at the expense of others) surfaced in narrative on expectations of recovery from influenza: like you sort of just, you think, maybe you just think influenza as a common cold sort of thing. and it's like, 'it'll pass. i might go to the doctor's and get some, something to help me get through it, ' or something. but yeah, i don't know … it's just like, 'just ignore it and push through.' (chris, healthy, melbourne, 18 -30 years) this interview participant shows how a healthy individual engages with pandemic influenza as a commonplace and personal risk, in contrast to those with pre-existing conditions who have to take pandemic, and even seasonal, influenza seriously. this expectation that one can 'push through' reinforces the previous theme noted with regard to the focus on the capacity of one's body to deal with infection. it is also an orientation to influenza risk that sets the scene for individuals to determine that infection is a risk worth taking since recovery is likely. also, recovery expectations synergise with the belief that infection is difficult to avoid in the long run. this means that people may assume that, while non-pharmaceutical strategies of pandemic control are sensible, their limited utility is set against the likelihood of recovery. this nexus of risk calculation helps explain why segments of populations appear to be complacent in surveys, as noted above. they may in fact be making multi-layered risk assessments of the likelihood of infection, their health status and expectations of recovery. another important provision on health individualism was the gendered meanings of one's response to infection. particularly in domestic settings, the management of respiratory illness was largely feminised. women provided elaborate accounts of managing the respiratory infections of family members while men did not. importantly, the pejorative term 'man flu' was used to denote the over-inflation of mild symptoms to gain sympathy and respite from normal activities, with connotations of questionable masculinity: it's always a little difficult to tell when you're moving from, sort of, a cold through the man flu to proper influenza. (vincent, healthy, sydney, 41 -50 years) these findings imply that responses to pandemic influenza in real world settings areas with other health problemsassociated with gender roles which shape behaviour, for example, women may be expected to perform infection control and symptom management, while men are expected to not show their symptoms and 'soldier on' or face accusations of 'man flu.' the uniform implementation of social distancing and other protective measures may therefore be compromised. accentuating the role of gender in response to messages concerning pandemic influenza, pregnant women found themselves thrust into a position of particular risk during the 2009/10 pandemic, at a time when they were already taking responsibility for the well-being of their unborn child. in particular, the prospect of vaccination elicited varied, often emotion-laden, responses: well, (sigh) when you're pregnant everything is about the baby … you just want to try and make your baby as healthy as possible and you want to try and keep your baby safe. (rebecca, pregnant in 2009, glasgow, 31 -40 years) the imperatives of good motherhood and responsibility for their unborn children placed these women into the emotionally-charged position of having to make decisions regarding virus protection in circumstances of intense uncertainty [32] . some distress was apparent among the pregnant women respondents, but also great resilience and active use of public policy information to protect themselves and their babies. as rebecca's account, above, indicates, health individualism in tension with responsibilities to others, gender and one's life situation played out in engagements with vaccination. though recollection was variable, 64 respondents in the present research (55%) reported that they had had an influenza vaccination at some point in their lifetime and there was no evidence of 'in principle' resistance to vaccination. this is a notable finding given that participants were sought in community settingswhere those with anti-vaccine views are thought to be locatedand in light of commentary that members of the general public are resistant to the science and technology used to manage global threats. indeed, endorsement of public health measures and attempted compliance characterised the respondents' accounts, with the provisos on the practical value of non-pharmaceutical strategies of infection control and management, as already discussed. but, taking on vaccination was not always straightforward: i saw in the press releases about the vaccine and i remember ringing the clinic and they said,'well if we were to give it to you, you'd have to come to the hospital and that's gonna put you at risk of getting exposed to it so we'd rather you not come in for the, for the vaccine.' and i was thinking,'well that's a bit of a catch importantly, though, vaccination, like non-pharmaceutical infection control, was mostly discussed as a personal strategy of health protection. apart from those with pre-existing vulnerabilities, vaccination was not readily understood as a method for protecting others and therefore society. this individualistic focus on one's own health implies that efforts to promote 'herd immunity' may not accord with perceptions and behaviours of the healthy majority. the findings question the prevailing view that the general public resists risk communication with regard to pandemic influenza. nor do the related ideas of complacency and fatigue seem relevant. more salient was multi-layered risk management informed by health individualism and to some extent tempered by interpersonal responsibilities, one's personal circumstances, gender, expectations of recovery, and prior experiences with influenza. as others using qualitative methods have also suggested [19] , respondents did not reject what was done by governments in 2009. they show interest in pandemic influenza, though their mode of engagement with it varied. they indicated that they wished to be informed but reserved the right to interpret and apply advice according to their own situation. public health guidance on hygiene and social isolation was endorsed, though its utility was largely found to have practical, long-term limitations given that social interaction was fundamental to daily life and the transmission of the virus. resistance and the related notions of complacency and fatigue, then, appear to have limited value for explaining how members of the general public respond to pandemics. part of the reason for this inapt attribution of research results to public resistance concerns research approach. forced choice surveys produce measures of hypothesised variables thought to influence behaviour. in-depth interviews and focus groups yield a different picture, where general public perceptions of the dangers of pandemics are placed in the context of what appears to be endorsement of the efforts of public health, tempered with awareness of the practical difficulties of managing influenza on a local basis. personal experience narratives reveal members of the general public to be engaged and willing to apply guidance in real world settings, though also aware of limits on what might be possible in time of pandemic. going beyond the idea of resistance, our analysis offers an alternative framing of how members of the general public respond to pandemic influenza. health individualism complicated by life circumstances (family life, health status) and the gendering of the meanings and practices surrounding the experience of influenza and how to deal with it in real world settings, appear to be important. risk communications are likely to benefit by addressing these influences on risk management behaviours. in particular, emphasising individual responsibility in risk communication may amplify divisions between people with different biomedical vulnerabilities and encourage those who consider themselves healthy to think of themselves as 'at risk' but not 'a risk' to others. this is a major hurdle for public health, particularly when hygiene, social isolation and vaccination are likely to become more important methods for controlling the spread of re-emerging infectious diseases. the pejorative, gendered meanings of influenza, of which 'man flu' stands as exemplary, point towards the deeply inscribed gendering of responses to infectious diseases. the role of gender in social aspects of health care is no surprise, but fully-fledged gender analysis is yet to be acknowledged in the public health address to the general population with regard to pandemics. in particular, messages to enact hygiene and social isolation are likely to accentuate already feminised health care in the domestic sphere. further, it is not simply that women are burdened with the labour of influenza care and men not. if men do find themselves unwell they risk accusations of 'man flu' and may therefore avoid making themselves available for health care interventions, a dynamic which keeps men out of the gp clinic in general [40] . as recent reviews have indicated [7, 16] , the influences of social factors on responses to pandemics need to be foregrounded in the social research agenda for better public health. our research indicates that health individualism and gender need to be part of this new research agenda. our findings also point to several further, specific, challenges for risk communication: ideas of proximity to risk; expectations of recovery, and; vaccination. proximity appears to be a blind spot in risk communications. public health messages of emergency are filtered by perceptions of proximity to threat, consistent with psychological theory [41] and cultural constructs where the source of contagion is placed at a distance from self [42] . we found that these ideas of proximity did surface in the narratives of members of the general public. yet, we know that, for example, within six weeks of the infection being detected in australia, people in remote communities in australia were found to be infected [43] . risk communication needs to attend to these ideas of distance from risk and the related underestimation of the speed with which the influenza virus can travel in a hyper-connected world. expectations of recovery from influenza also appear to dominate narratives. as others have argued [44] , healthy respondents recognised influenza infection as severerequiring bed and restbut thought that they would eventually recover. this finding implies that members of the general public may interpret infection as a risk worth taking, that is, that they can cope with infection if prevention fails them, due to their own choices or otherwise. members of the general public appear to be actively engaged with manifold risks that they juggle and prioritise in real world settings. our findings also suggest that taking up vaccination is not a simple matter, even among those who endorse the use of the biotechnology. survey findings have found that approximately 42% of australians are concerned about general vaccine safety [14] and that australian [45] and worldwide [46] rates of h1n1 vaccination have been found to be insufficient, prompting concerns that the 'anti-vaccine lobby' and other detractors are influencing use of this biotechnology. as noted, a slight majority of our respondents reported that they had been vaccinated in their lifetime and none spoke of vaccination as dangerous, though, of course, some may have held these views and not revealed them or opted out of our community-based recruitment strategies. our research, however, points to more immediate and practical considerations that shape how and when people vaccinate, including considerations of relative risk and whether or not a new vaccine should be used in pregnancy. attending to these more immediate concerns may be beneficial for public health, though we acknowledge that public perception of vaccine technologies is also an important public health agenda. the analysis presented is retrospective as the interviews and focus groups were conducted after the end of the pandemic on 10 august 2010 [47] , and therefore when it was known that the mortality rate had at first been overestimated [48] . importantly, too, the respondents were volunteers selected according to purposive criteria, implying that the sample is not representative and that generalisations to populations are not strictly tenable. what the analysis offers, however, is the opportunity to drill down into how people make sense of pandemic influenza, therefore providing the basis for building theory on how members of the general public, think, feel and act in the contemporary era of efforts to manage global health threats. the perspectives identified here help situate what we know in social context and alert public policy to some dilemmas and alternative explanations of why members of the general public do what they do. for public health to shape the actions people take prior to and during a pandemic, we need to understand and engage with the perspectives of those acting. viewed from the outside, the behaviour of the general public has been cast as resistant. however, viewed from the perspective of ordinary people involved in anticipating and responding to infection, it is clear that public health has engaged its publics. this engagement is frequently informed by individualistic ways of assessing and responding to risk, social norms (e.g. gender roles), knowledge of the clinical uncertainties of influenza infection, and reasoned thinking about the limits of preventing influenza transmission. the current challenge for pandemic influenza preparedness and response is not so much to address public disinterest, but to acknowledge and engage with members of the general publics' experiences of influenza and how they make sense of, and act on, pandemics in real world settings. factors in the emergence of infectious diseases antibiotic resistance: long-term solutions require action now world 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the 2009-2010 influenza pandemic: effects on pandemic and seasonal vaccine uptake and lessons learned for seasonal vaccination campaigns world health organization. h1n1 in post-pandemic period: director general's opening statement a virtual press conference influenza a(h1n1): lessons learned and preparedness submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution submit your manuscript at www this research was funded by an australia research council discovery project grant (dp11010181) with additional funding from glasgow caledonian university. we are grateful to casimir macgregor for assisting with interviews and to everyone who agreed to participate in interviews and focus groups. the authors declare that they have no competing interests.authors' contributions md helped conceive of this research, drafted this manuscript, managed the data collection and analysis in melbourne and integration with all data, and is a grantholder. ns helped conceive of this research, contributed sociology of public health perspectives to the manuscript and edited it, managed data collection and analysis in sydney and integration with all data, and is a grantholder. dl collected and analysed data used in this paper, conducted a literature review used in this paper, and contributed to the draft manuscript. ew collected and analysed data used in this paper and contributed to the draft manuscript. pf helped conceive of this research, contributed health psychology perspectives to the manuscript and edited it, managed data collection and analysis in glasgow, and is a grantholder. all authors read and approved the final manuscript. key: cord-018384-peh5efat authors: merrick, riki; hinrichs, steven h.; meigs, michelle title: public health laboratories date: 2013-07-29 journal: public health informatics and information systems doi: 10.1007/978-1-4471-4237-9_16 sha: doc_id: 18384 cord_uid: peh5efat this chapter will review the multiple functions of public health laboratories (phls), including their differences to commercial clinical laboratories. for example, the types of samples submitted to phls differ from those submitted to commercial clinical laboratories. phls are critically important to population based healthcare; playing an essential role in the detection of disease outbreaks. this chapter will describe the hierarchical organization of the phl system in the unites states, as well as the networks that have been created to support diverse phl functions such as food safety testing and emergency response to terrorisms or natural disaster. it will briefly describe the standards used by phls and how the implementation of standards should further improve patient safety as a whole. in this chapter the reader will be introduced to phl informatics in the context of the laboratories operational workflow – from test ordering, interfacing with diagnostic instruments, quality control and result reporting and analysis. the reader will also understand the impact of phl informatics collaboration efforts and its effect on ongoing policy development. overview this chapter will review the multiple functions of public health laboratories (phls), including their differences to commercial clinical laboratories. for example, the types of samples submitted to phls differ from those submitted to commercial clinical laboratories. phls are critically important to population based healthcare; playing an essential role in the detection of disease outbreaks. this chapter will describe the hierarchical organization of the phl system in the unites states, as well as the networks that have been created to support diverse phl functions such as food safety testing and emergency response to terrorisms or natural disaster. it will briefl y describe the standards used by phls and how the implementation of standards should further improve patient safety as a whole. in this chapter the reader will be introduced to phl informatics in the context of the laboratories operational workfl ow -from test ordering, interfacing with diagnostic instruments, quality control and result reporting and analysis. the reader will also understand the impact of phl informatics collaboration efforts and its effect on ongoing policy development. public health laboratories (phls) play a vital role in protecting the public from health hazards. phls offer diagnostic testing for humans and animals as well as testing of environmental samples and products. these laboratories also provide laboratory confi rmation for special organisms, and are part of public health's (ph) disease surveillance enterprise, conferring accurate, timely identifi cation of infectious organisms or toxins during disease outbreaks. they are also critical components in disaster response and bioterrorism preparedness. phls often perform tests that are not commonly available learning objectives 1. illustrate how public health laboratory (phl) functions differ from clinical labs, either at hospitals or national commercial laboratories. 2. examine the full environment of the ph informatics domain; from the long term sustainability of an enterprise laboratory information management system (lims) to the universe of data exchange partners and networks. 3. demonstrate how the evolution of informatics has enhanced the phl workplace and its practice. elsewhere. the catalog of available tests at a phl varies almost as much as their organizational structures. some phls are multi-branch operations; others are university-affi liated laboratories, while others are an integrated part of a public health department [ 1 ] . the association of state and territorial health offi cials (astho) and the association of public health laboratories (aphl), in their publication "a practical guide to public health laboratories for state health offi cials," summarize these 11 core functions of the phl [ 2 ]: 1. enable disease prevention, control and surveillance by providing diagnostic and analytical services to assess and monitor infectious, communicable, genetic, and chronic diseases as well as exposure to environmental toxicants. 2. provide integrated data management to capture, maintain, and communicate data essential to public health analysis and decision-making. 3. deliver reference and specialized testing to identify unusual pathogens, confi rm atypical or uncommon laboratory results, verify results of other laboratory tests, and perform tests not typically performed by private sector laboratories. 4. support environmental health and protection , including analysis of environmental samples and biological specimens, to identify and monitor potential threats. part of the monitoring also ensures regulatory compliance. 5. deliver testing for food safety assurance by analyzing specimens from people, food or beverages implicated in foodborne illnesses. monitor for radioactive contamination of foods and water. 6. promote and enforce laboratory improvement and regulation , including training and quality assurance. 7. assist in policy development , including developing standards and providing leadership. 8. ensure emergency preparedness and response by making rapid, high-volume laboratory support available as part of state and national disaster preparedness programs. 9. encourage public health related research to improve the practice of laboratory science and foster development of new testing methods. 10. champion training and education for laboratory staff in the private and public sectors in the us and abroad. 11. foster partnerships and communication with public health colleagues at all levels, and with managed care organizations, academia, private industry, legislators, public safety offi cials, and others, to participate in state policy planning and to support the aforementioned core functions. phls exist at all levels of government -from local to state to federal, and even internationally. there are approximately 300 public health laboratories in the us [ 3 ] . local phls are an intrinsic part of the safety network in underserved populationsthey are highly integrated with public health departments (phds) clinics to provide routine diagnostic testing as well as screening tests for disease prevention. lead there are 54 state phls [ 4 ] ; they are found in every us state and territory as well as the district of columbia. state phls often offer and perform tests that no other labs perform -be it for clinical practice (e.g., a regional reference lab for salmonella serotyping) or environmental surveillance (e.g., well water testing). their work informs public health offi cials in state government, allowing for targeted disease surveillance, quicker response to disease outbreak and provides population based data that may lead to new guidelines or policies to protect their residents. where local phls are not available, the state phl supports locally-needed public health activities. state phls also have the power to regulate private medical laboratories [ 5 ] and operate quality assurance programs (e.g., air quality or clean water act). during surveillance activities, the state phl takes a leadership role through active collaboration with federal agencies, state epidemiologists, fi rst responders, and environmental professionals. within the us, the federal government operates several phls that act as reference labs for their state and local counterparts; they manage centers for public health program areas, and are liaisons to international organizations like the world health organization (who). these federal reference laboratories are located at the centers for disease control and prevention (cdc), the united states department of agriculture (usda), the food and drug administration (fda), and the environmental protection agency (epa). just like their state counterparts, they provide the federal government with information to help protect americans everywhere, and through global outreach they ensure laboratory capacity around the world [ 6 ] . at the typical clinical lab, human biological samples are sent in for routine testing, such as blood sugar level, presence of bacteria, or screening for cancers. at a phl, in addition to human samples, phls also perform testing on non-human samples and even inanimate objects. animal samples are received at the phl for a number of reasons including: rabies testing, west nile virus surveillance, as well as ensuring the safety of our food animals through feed testing. water samples are also tested at the phl for a variety of reasons, but most importantly the phl monitors both well water and public water systems. food, be it peanut butter or spinach, is tested on a daily basis to detect pathogenic bacteria. our soil, building materials and even cups and plates are tested to protect citizens from high levels of toxic chemicals such as lead. and fi nally; our phls work closely with fi rst responders and the federal government to test for agents of bioterrorism; these samples can range from "white powder" to human based samples. phls also perform regularly scheduled tests on samples collected from designated sentinel (guard) sites. samples come from animals that are more susceptible to a disease, are living in close proximity to people and are being tested regularly to gauge when a new disease can be expected. the monthly testing of samples from a chicken population for west nile virus is one example. chickens are more susceptible to west nile virus infections than people. when west nile virus is detected in the chicken population, it is a good indicator that human cases can be expected soon in the same area. while commercial laboratories do report the detection of certain infectious diseases to their respective public health departments, it is the phls that are at the frontline when an infectious disease outbreak occurs. phls provide support to the public health department in identifying the cause of the latest foodborne outbreak that may have been fi rst detected at a clinical laboratory. phls also spend a significant amount of time developing new test procedures for emerging new diseases; such as the detection of the newest infl uenza virus strain that may cause the next epidemic or even a pandemic, as we experienced in 2009. because of their effi cacy, some of these newly developed tests are adopted by commercial laboratories and offered to their customers at a later point in time. not all human samples arriving at a phl come from sick people. for example, every newborn is screened for a panel of genetic disorders to ensure early detection of issues that can sometimes save a child's life. these tests are almost exclusively performed at the phls [ 5 ] . clinical labs perform mostly diagnostic testing, but they also offer some screening tests for example the pap smear testing to screen for cervical cancer. phls have surge capacity agreements with partner laboratories to cover the increase in testing volumes during outbreaks: if one phl is overwhelmed by the volume of samples received during an outbreak, they can send some of the samples to a neighboring phl with whom they have such an agreement. these surge capacity partners will have to have identical, or at least similar, testing capabilities, hence they are mainly other phls. because phls are critical to the health of a population, they also have continuity of care agreements to ensure that, in the event one phl is affected by a natural disaster, the other partner will perform their duties. hurricane katrina put these agreements to the test, especially in the areas of newborn screening, where test requests were successfully transferred to partner phls, because babies don't wait to be born because of a disaster ( fig. 16 since the advent of computers, the laboratory, with its capacity to produce and manage important data, has been at the forefront of health informatics. what initially began as a database for local results, over time developed into a laboratory information management system (lims) that provides capacity for improved workfl ow management, inventory tracking, and most importantly, patient management. testing is often performed on stand-alone instruments. these results need to be incorporated into the lims, in order to be included in the fi nal result sent to the submitter. in the beginning the lims was capturing only those results that needed to be printed to be sent back to the submitter. with the improvement of informatics knowledge in the phls more and more of the instruments are being interfaced, using industry developed standards, improving the quality of data and making the workfl ow more effi cient. informatics practice certainly has transformed several laboratory workfl ows as organizations migrate from paper-based to electronic system-based tracking. being able to draw data from a database in an electronic format facilitates secondary use of this information for forecasting or event detection. this information can then be shared with partners in the public health laboratory system (e.g., the public health department, a regional taskforce, preparedness coordinators, policy makers and federal agencies). the capability of the laboratory and its public health partners to share data in the same format, through an electronic data interchange (edi), can greatly reduce communication delays between partners; resulting in faster, better outcomes for both patient and population based responses. all these functions are covered by informatics principlesfrom database design to queries as well as application of format and content standards. 6 . inventory and forms management 7. general laboratory reporting -is part of the general systems requirementsall electronic data management systems need to be able to create reports 8. statistical analysis and surveillance -provides value added to the test results to both the submitters of the sample as well as public health partners 9. billing for services 10. contract and grant management -unlike clinical laboratories, phls often are funded through grants to provide services free of charge to the submitter of the sample, so tracking funding amounts and requirements is important 11. training, education and resource management -to comply with regulations and to document capacity of laboratory personnel and equipment 12. lab certifi cations and licensing -phls, mostly at the state level, are responsible to ensure compliance in laboratories operating in their jurisdiction, which includes inspections of those laboratories 13. customer feedback tracking 14. quality control (qc) and quality assurance (qa) management -both involve audit functionality about the tests performed -qc tracks the parameters for each method and instrument at the test level and allows for over time analysis of the control parameters, while qa defi nes specifi c measures across all the tests performed to ensure accurate testing 15. laboratory safety and accident investigation 16. laboratory mutual assistance and disaster recovery to support surge capacity and continuity of care operations not all business processes apply to every lab, but across the spectrum of laboratories all of these business processes are relevant. this document describes interdependencies between the lab and outside partners and following informatics protocol decomposes each of the core business processes into their individual steps with related functional requirements for the system, based on detailed laboratory workfl ow analysis [ 8 ] . the publication of this requirements document has created a functional standard vendors can utilize to build more useful systems that are conformant with these requirements. although much variability between information systems still exists, this requirement document has provided a solid basis to better identify and pin-point these variations. the phls use several kinds of codes in their daily operations: codes for the tests they offer and perform, codes for pre-defi ned results, and codes for patient demographics. in order to make data comparable across locations, the phls map their local codes to national data standards. these data standards include the logical identifi ers names and codes (loinc ® ) [ 9 ] for the tests they perform, systematized nomenclature of medicine (snomed ® ) [ 10 ] to identify organisms and ordinal results, and codes from health level seven (hl7 ® ) [ 11 ] for patient demographics like gender, race, and ethnicity. to exchange standardized data between phls and their partners, the order and format of the data to be exchanged needs to be defi ned. for individual point to point exchanges, simpler formats can be agreed upon; for example, comma-separated fi les (csv) or excel spreadsheets can be exchanged, but in order to accommodate larger scale data exchange with multiple partners across multiple information systems standards such as hl7 ® messages (in version 2.x) or the xml-based clinical document architecture (cda) formats should always be considered as part of the normal business process. in addition to utilizing these standards, transport mechanisms need to be defi ned and agreed upon by electronic data interchange (edi) partners [ 12 ] . in order to support these critical public health functions, phls create support networks among themselves. these networks help group laboratories together that perform the same kinds of tests and exchange results within the same networks, usually under the guidance of a federal program. utilization of the requirements document among phls has advanced the application of informatics in the phl realm, and has made several of these networks quite successful. examples of functional phl networks in the us are summarized in table 16 .2 . unfortunately, at this stage each of these networks is using different data exchange methods. lrn and nahln use hl7 ® v2.x messages as data exchange standard, fern and erln use xml-based electronic data deliverables (edds). this forces the phl to support a variety of formats and vocabularies in order to properly report to the respective partners during an investigation. a signifi cant obstacle to the development of consistent data exchange deliverables is the sheer number of networks and reporting requirements. table 16 .3 shows what a laboratory must do, after discovery of a food-borne illness outbreak due to consumption of tainted hamburgers. the following barriers to effective electronic laboratory information exchange were identifi ed in the aphl-phdsc white paper, "assure health it standards for public health, part 1: health it standards in public health laboratory domain," [ 12 ] : barrier i -the incomplete and inconsistent adoption of existing standards by the wide array of laboratories responsible for reporting laboratory results as well as by the electronic health record systems (ehr-s) and public health information systems they report to. barrier ii -the lack of adoption of ehr-s [ 18 ] in clinical settings (i.e., test order senders and result receivers) preventing electronic communication between providers and lims. barrier iii -the use of proprietary, non-standardized information systems in public health preventing electronic communication between lims and public health programs (i.e., receivers of test results on public health threat conditions). barrier iv -the absence of a sustainable approach and funding to support the development of laboratory standards and their testing; and of certifi cation and adoption of standards-based it products in clinical, laboratory and public health settings. barrier v -the need for informatics-savvy personnel in phls to operate in a new hit and information communication environment. the association of public health laboratories (aphl) is a national non-profi t, member-based organization representing governmental laboratories of all levels in all aspects of operation. aphl is especially active as the primary advocate for phls network description lrn [ 13 ] the cdc manages the laboratory response network (lrn). this includes the cdc lrn-biological (lrn-b) and cdc lrn-chemical (lrn-c). the mission of the lrn is "to maintain an integrated national and international network of laboratories that are fully equipped to respond quickly to acts of chemical and biological terrorism, emerging infectious diseases, and other public health threats and emergencies." due to the sensitive nature of cdc's bioterrorism preparedness activities, details of lrn-b operations are protected against general public access and distribution. these details, designated as "sensitive but unclassifi ed," are maintained at cdc, and require coordination with the lrn lims integration team to obtain. the lrn provides specifi cations about the message format (hl7 ® v2.x) and data content, including standardized vocabulary (for example loinc ® and snomed ct ® ) erln [ 14 ] the environmental response laboratory network (erln) is managed by epa. the erln consists of federal, state, and commercial laboratories that focus on responding quickly to an environmental chemical, biological, or radiological terrorist attack, as well as natural disasters affecting human health and the environment. the erln provides an electronic data deliverable (edd), which can be either a spreadsheet or the recommended xml format and a data exchange template (det) with data element defi nitions and groupings. the erln also provides a web-based electronic data review tool that automates the assessment of edds by providing web access for upload by the laboratory and review by project personnel department of agriculture (usda)'s food safety and inspection service and the food and drug administration (fda). the primary objectives of fern are to help prevent attacks on the food supply through utilization of targeted food surveillance; prepare for emergencies by strengthening laboratory capabilities to respond to threats, attacks, and emergencies in the food supply; and to assist in recovery from such an incident. fern uses the electronic laboratory exchange network (elexnet) that allows multiple government agencies engaged in food safety activities to compare, communicate, and coordinate fi ndings of laboratory analyses nahln [ 16 ] the national animal health laboratory network's (nahln) purpose is to enhance the nation's early detection of, response to, and recovery from animal health emergencies. such emergencies might include bioterrorist incidents, newly emerging diseases, and foreign animal disease agents that threaten the nation's food supply and public health gisn [ 17 ] the who global infl uenza surveillance network (gisn) receives result reports and samples of isolates from participating state and municipal phls to monitor infl uenza disease burden, detect potential novel pandemic strains, and obtain suitable virus isolates for vaccine development by promoting workfl ow improvements and refi ning laboratory science operations within the laboratory. it provides a forum for member collaboration, education, and workforce development [ 19 ] . the fruits of this collaboration are evident in the success of aphl's informatics committee in identifying and subsequently improving many of the functions required of lims and in the domain of laboratory informatics in general. one such example is the effort to standardize lims functionality across vendors. aphl lims user groups provide ways to prioritize and consolidate development efforts among customers of a specifi c vendor, which in turn can be easily compared to overall standardization approach. in partnership with other ph organizations, under the umbrella of the joint public health informatics taskforce (jphit), aphl also infl uences national e-health policy. internationally, aphl helps to build laboratory capacity in developing countries, including the selection and implementation of information systems. as part of every implementation, validation testing according to test cases also employs informatics principles. having identifi ed the need to harmonize the adoption of standards across federal programs and phl functional areas, aphl is actively involved in national standards harmonization activities for laboratoryrelated use cases (information exchange standards for laboratory orders and results, reporting in clinical and public health settings, as well as functional standards for electronic health record system (ehr-s) interactions with phls). due to limited informatics funding at phls and the ongoing struggle for these laboratories to support informatics trained specialists, aphl provides hands on informatics technical assistance to phls and their partners. these services include project management, national standards implementation and technical architecture support. phls are continually providing expertise to support the standards development process. they were instrumental in creating an implementation guide for newborn screening; working alongside standards development organizations (sdos) like the regenstrief institute to develop the required vocabulary and to make sure the hl7 ® message contained all the data elements needed for proper newborn screening result reporting. aphl provides leadership for the laboratory and messaging community of practice (labmcop), assisting phls and partners in harmonizing terminology and related standardized vocabulary to properly describe the specimen submitted for testing. on a national scale, when the offi ce of the national coordinator for health information technology (onc)'s certifi cation process for commercial electronic health record products was announced, phl expertise was utilized by providing real-world testing scenarios to ensure that specifi c result formats are properly represented in this information exchange paradigm. by ensuring a basis in reality, this effort will ensure greater patient safety, and improve public health's response to emerging diseases, terrorism, and natural disasters. in summary, phls are a critical public health resource and service. they detect, identify and monitor infectious disease outbreaks, chemical or biological contamination in people, animals, food and the environment. they provide testing that other labs cannot provide and screen for diseases that haven't even shown symptoms yet (i.e. newborn screening). phl testing supports food and environmental safety law enforcement and their data contributes vital information to support local, state and federal health policies. phls are at the forefront of population based health threats due to bioterrorism, newly emerging disease and natural disasters and they continue to ensure quality service by inspecting and certifying other laboratories in their jurisdiction. information systems enable phls, or any laboratory for that matter, to more predictably forecast testing demand and assist with human resource utilization during an outbreak or response. auditing functionality help to monitor the quality of testing and this analysis can be used to improve laboratory workfl ow over time. data derived from these systems can assist with both state and federal efforts to forecast disease, help with outbreak management as well as health policy development. but to ensure the long term operational capacity of our phls to provide these services and remain relevant in patient and population care, informatics must be considered a pivotal core business function. the use of electronic test orders, communicating between disparate systems about order statuses and specimen results as well as contributions to both electronic health records and personal health records submitters all require use and continual development of national data exchange standards. the work in this fi eld has barely begun, yet the continual evolution of standards will drive greater collaboration and cooperation between all levels of phls -local, state and federal as well as their commercial partners. community-driven standards-based electronic laboratory data-sharing networks association of public health laboratories and the association of state and territorial health offi cials. a practical guide to public health laboratories for state health offi cials. silver spring: association of public health laboratories public health laboratories: analysis, answers, action. aphl, silver spring association of public health laboratories: member lab listings association of public health laboratories. defending the public's health. silver spring: aphl association of public health laboratories. defi nition of a state public health laboratory system. silver spring: aphl aphl -internal documentation public health informatics institute. requirements for public health laboratory information management systems: a collaboration of state public health laboratories. aphl logical identifi ers names and codes (loinc ® ). web health level seven about hl7 ® . web public health data standards consortium and aphl white paper. assure health it standards for public health part 1: hit standards in public health laboratory domain centers for disease and prevention. the laboratory response network, partners in preparedness animal and plant health inspection service, animal health, national animal health laboratory network who global infl uenza surveillance network (gisn), surveillance and vaccine development offi ce of national coordinator for health it. health it adoption. dhhs 2012 association of public health laboratories about aphl. aphl, silver spring association of public health laboratories 1. list at least 6 of the 11 core phl functions and discuss how each of them can be supported by informatics. 2. how does the workfl ow in a phl change when an emergency arises -for example a disease outbreak, a bioterrorism event or a natural disaster? 3. list the different partners of a phl and their importance for public health. 4. contrast the differences and similarities between a phl and a commercial clinical lab. key: cord-029261-6d9cjeec authors: d’alessandro, daniela title: urban public health, a multidisciplinary approach date: 2020-07-16 journal: urban health doi: 10.1007/978-3-030-49446-9_1 sha: doc_id: 29261 cord_uid: 6d9cjeec urban environment is a highly complex interactive socio-physical system, with competing expectations and priorities. public health interventions have always had a fundamental role in the control of diseases in cities. who considers urbanization as one of the key challenges for public health in the twenty-first century, since cities offer significant opportunities to improve public health if health-enhancing policies and actions are promoted. a multidisciplinary approach is required, but the basic differences existing between technical and health disciplines make the interaction difficult. the multidisciplinary collaboration is still at a very early stage of development, and needs to be further understood and planned. the author concludes stressing the need for a transversal training, but also for sharing knowledge, instruments and methods, involving all the actors in the planning process, to develop a real multidisciplinary approach. public health interventions have always had a fundamental role in the control of diseases in cities [1] [2] [3] . a growing body of research has documented that the action of urban environment in shaping health and disease is itself of interest. understanding which are the urban factors relevant for health can enrich the positive aspects of urban living and lead to develop appropriate behaviours and to identify preventive measures. this is also the pivotal topic in many documents produced by who [4] [5] [6] [7] [8] [9] [10] . actually, we know that the urban environment is a highly complex interactive socio-physical system, with competing expectations and priorities [11] . several factors, related to the built environment, are directly responsible for health impacts [12] . they include air quality, both indoor and outdoor, climate, water quality and quantity, noise and traffic-related injuries. much of the evidence concerning direct impacts is quantifiable and causal effects can precisely be attributed [12, 13] . other factors, including the ways in which built environment features and their design (housing, neighbourhoods, social environments, connectivity, density, land use mix, accessibility, amenities and decision-making processes), have an indirect impact, because they are able to influence the feeling and behaviour of individuals and population [12] . for most of these impacts in recent years several evidences have been collected, documenting their relationship with health and these results are fundamental in the definition of salutogenic cities [8, 9, 14] . this is nothing of new. in the past, the disciplines of public health and urban planning were tightly intertwined. with the introduction of a deeper knowledge of microorganisms, infectious diseases and vaccinations, however, the focus of public health moved away from community engineering and urban design and going towards a model based only on strict medical principles [15] . these discoveries opened the way to targeted medical interventions aimed at preventing and curing communicable diseases. it was thus possible to control most of them diseases, at least in developed countries [16] . consequently, from 1850 to 2000 infant mortality rate has been massively reduced. in italy, for example it dropped from 220 to 5‰. on the contrary, in the same period, life expectancy at birth passed from about 44 to 79.6 years and the natality rate decreased from 33‰ to 9‰ live births, with an acceleration of this decline after the early 1960s. the mortality from all causes decreased from 22‰ to about 10‰ (crude rates), with a cross between natality and mortality curves in 1993 [16] . the fall in mortality for communicable diseases and the exceptional life prolongation explain why chronic diseases became the predominant cause of death during the twentieth century. in fact, the incidence of this kind of diseases grows exponentially with age. at the same time, after smallpox, other epidemiologically important infectious diseases are close to disappearing, but new epidemics are occurring in recent years, mainly related to climate change and to instability, poverty and conflict in many parts of the world. both chronic diseases and new infections find the cities the place of their most expression. as argued by who [15] , following this shift, public health and urban planning became separated across the world. for long time, mainly during the period of economic prosperity and improvements in medical technology, the urban inequalities in health persisted, the divary increased and the dialog among them became more difficult, because objectives and interest felt far one from the other. those who mostly suffered this dichotomy and the health consequences (both chronic and communicable diseases) were the members of poorer social class and economically disadvantaged urban population [3, [17] [18] [19] [20] [21] [22] . in the 1988 the institute of medicine published the report "the future of public health", in which leaders in the field agreed that the nation's public health activities were in confusion and that the field needed to refocus its efforts to address growing inequalities in health across population groups [10, 17] . by the 1990s, public health researchers of some western countries began to reconceptualise the risk factors for the uneven distribution of diseases across populations in order to explain health disparities, energizing the field of social epidemiology [23] . this discipline, by emphasizing distribution as distinct from causation, pushed public health scholars to reconsider how and why poverty, economic inequality, stress, discrimination, and social capital become "biologically embodied" and help explain persistent patterns of inequitable distributions of disease and well-being across different population groups and geographic areas [24] . the commission on social determinants of health drew attention to how transport patterns, access to green spaces, pollution effects, housing quality, community participation, and social isolation were all structured by social inequality [3, 10, 17] . as already discussed in some previous papers [3, 17] , by the end of the twentieth century, a split emerged in public health between those emphasizing the biomedical model and focusing on fighting individual disease risk factors, and social epidemiologists, who emphasized the idea of improving neighbourhood conditions, eliminating poverty, and enhancing social resources for health. to find something similar, it is necessary to go back to the second half of the eighteenth century, when west european countries understood that better living conditions would have increased city residents' physical and mental health, but also boosted moral and economical status of the population [1, 26] . in the same period, in germany, rudolf virchow, having understood that poverty and hunger lead to epidemics and that, in order to avoid them, political reforms were necessary [26] , wrote "medicine is a social science, and politics is nothing else but medicine on a larger scale" [27] . at the end of the second half of the twentieth century the drop of mortality for cardiovascular and cerebrovascular diseases is a reality in most countries in the world, which may be ascribed to important improvement in prevention, diagnosis and therapy, but also to changes in lifestyle and environmental conditions. past that era, a lot of things have changed. today health can mean different things to different people. one of the most pertinent definitions of health is that from the 1948 constitution of the world health organization [28] . this statement is the evidence that 70 years ago, public health moved progressively away from the medical model-focused on the individual and on interventions targeted to treat diseaseback towards a social model, considering health as an outcome of the effects of socioeconomic status, culture, environmental conditions, housing, employment and community influences. today cities are energetic hubs of creativity and power, learning and culture. they are ecosystems that support growth and change, and are now home to more than half of the world's population-a proportion expected to reach two thirds by 2050 [4] . the who has identified urbanization as one of the key challenges for public health in the twenty-first century [5] , since cities offer significant opportunities to improve public health if health-enhancing policies and actions are promoted [6, 7] . however, as the world continues to become more complex, the challenge is to fight for a framework in which scholars from multiple disciplines can effectively work together with a common aim: creating healthy, sustainable and equitable cities. while it is true that health and urban planning were successful partners long time ago, this is more difficult to reach today, because rests on building a respectful relationship out of mutual understanding and practical engagement across these disciplines [29] . the theme of multidisciplinarity has been very much discussed along the last decade, since the complexity of problems and processes to be managed at various levels (e.g. research, local governance, policy), need a new approach and methods able to analyse more in depth the problems and to find integrated and effective solutions. in the research field, the importance of multidisciplinarity has been widely recognized. it occurred not only in emerging areas such as the new infectious diseases (e.g. hiv, ebola, sars-cov, studies), the nanotechnology applications, etc., but even in more traditional fields, such as physics or applied math. multidisciplinarity does not mean a simple cooperation for improvement, at least at academic level. zuo and zhao [30] , in order to evaluate whether a higher level of multidisciplinarity within an academic institution was associated with true internal collaborations, revised 90,000 publications by 2500 faculty members in over 100 academic institutions belonging to three multidisciplinary areas (information, public policy, and neuroscience). they observed that many multidisciplinary institutions were not necessarily practicing true collaboration, although they did feature collaborations that are more interdisciplinary. speaking about urban environment, it is to be underlined that cities around the world face many health challenges, including air, water and soil pollution, traffic congestion and noise, and poor housing conditions, and all these situations are caused and worsened by unsustainable urban development and climate change. a multidisciplinary assessment of these criticalities offers opportunities for integrated low carbon solutions in the urban environment, that can bring multiple benefits for public health [31] . for example, to achieve high walkability, it is crucial to involve town planners and health workers, but this is not enough; it is mandatory also to incorporate thoughts about health and health promotion into regulation plans, to stimulate cultural and commercial activities, and to ensure good maintenance and safety [8, 32, 33] . the efforts that combine the perspectives of different disciplines, that use quantitative and qualitative approaches when appropriate, are more likely to provide answers about both how and why the characteristics of urban living may affect health. quantitative and qualitative methods may help each other to minimize the a priori decisions; however, the typical interdisciplinary practice involves people with disparate backgrounds and, frequently, for them, the sense of words assumes different meanings depending on which discipline is involved; and researchers and practitioners, schooled in different academic traditions, have to face considerable challenges when working together [34, 35] . in particular, as argued by kent et al. [29] , health and built environment professionals do not need to become technical experts in each other's field, but they simply must work together to capitalise on each other's particular skill. this requires understanding, and the development of this understanding should be the focus of professional development, rather than the explicit development of a technical skill set. actually, there is little shared vocabulary among disciplines and this is a problem, because cities are multi-dimensional systems influenced by trends and processes operating at local, national or supranational levels [e.g. global initiatives that address urban issues, such as the sustainable development goals (sdgs)] [36] . it follows that health and environmental issues, like climate change or the growing populations, need to be addressed using "holistic" approaches that require the development of multidisciplinary research synergies focused on urban health, accompanied by multidisciplinary sustainable interventions. for example, urban energy systems have interactions and influence wherein the socio-technical sphere is expanded to political, environmental and economic spheres as well. in addition to the inter-sectoral linkages, the diverse agents and multilevel governance trends of energy sustainability in the dynamic environment of cities make the urban energy landscape a complex puzzle [37] . a basic difference among technical and health disciplines, that can make interaction difficult, regards the "evidences". for example, the nature of evidence that planners use to develop their policy is different from that used by public health workers (e.g. lack of standardisation in measurement of environmental and health variables). however, as noted by kent et al. [29] , "it must be recognised that the way people live and move around a place cannot be subject to the methods employed to produce the standard of evidence traditionally used to underpin health policy decisions….". a more comprehensive way to explore and understand the complex issues needs to be embraced, including the use of case studies, in-depth observations, environmental and social impact assessment, etc. lawrence [38] argues that interdisciplinary contributions highlight the difference between disciplines and suggests to apply a transdisciplinary approach. this kind of contribution crosses the boundaries of scientific knowledge, to account for other types of knowledge (professional know-how, tacit knowledge, etc.). transdisciplinary contributions create a knowledge domain broader than interdisciplinary contributions; they are based on the coproduction of knowledge by actors and institutions for socially accepted projects that are meant to impact on real world situations. in conclusion, the multidisciplinary collaboration is still at a very early stage of development, and needs to be further studied, understood and planned. as argued by grant et al. [39] , today public health needs to add a fourth arm to its traditional remit of "(a) protecting and promoting health, (b) preventing ill-health and (c) prolonging life": it has to actually "create health" by means of investigating and understanding how possible it is to create the conditions for good health and wellbeing and equitable access to them. this concept is central in health promotion activities and it is an integral part of the "salutogenic city" definition [14] . at the same time, urban designers are grappling with a similar concept when they start to define their term liveability. to face up to complex issues, whose causes lie beyond the traditional remit of the health sector, it is necessary to share knowledge from many sectors for obtaining that this fourth arm could realize its goals. nevertheless collaborative activities involving professionals trained in different cultural areas are still marginal. more transdisciplinary contributions [38] are required in order to address the complexity of health-related problems at urban scale and implement effective responses to real-world situations. these kinds of contributions offer a broad integrated perspective, which should be part of the training in universities and of the professional training in today's era of complexity. barton et al. [40] suggest that an ideal health-integrated planning system should have five key elements: (a) acceptance of interdepartmental and intersectorial collaboration to properly explore health implications and to integrate the solutions across institutional remits; (b) strong political support, to ensure a consistent approach and the resources needed; (c) full integration of health with other local policy: placing health at the heart of plan-making; (d) active involvement of stakeholders (e.g. citizens) in the policy process; (e) a planning approach that fully reflects health objectives and makes them explicit (quality-of-life monitoring, health impact assessment, strategic sustainability assessment, urban potential studies). as argued by ryden et al. [10] , improving health in cities implies to realize numerous small-scale interventions, selecting those effective, encouraging selforganization by citizen, and constantly modifying approaches as the system continually changes and adapts. obviously, the assessment of these various experiments is fundamental. such assessment should be based on observation, dialogue, discussion and deliberation, rather than on a technical exercise done by external experts. for example, a regeneration project aimed at increasing social cohesion, must consider the values and the priorities of local dwellers. it could be useful to ask their contribution-involving in vivo actors and stakeholders-to understand whether this project contributes to, or hinders the change. in-depth consultation, mediation, and deliberation are all processes that can be used to engage stakeholders in detailed and problem-orientated argumentation, to deliver potential solutions in the policy-making process. transdisciplinary knowledge production has to move beyond conventional research agendas, to address real world concerns, to address societal challenges in many domains that require collective understanding, political commitment, and innovative responses. as lawrence argues, speaking about housing and health [38] , today there is no shared understanding about an interdisciplinary and a transdisciplinary epistemology in this field. therefore the formulation and application of shared conceptual and methodological frameworks (for research and action) should be an objective of this field of inquiry in the immediate future. in conclusion, there is a transversal need of training, but also of sharing of knowledge, instruments and methods, for all the figures involved in the planning process, to develop a real multidisciplinary approach. the road is long, and we have just begun the journey. history of public health urban health: a new discipline public health and urban planning: a powerful alliance to be 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interdisciplinary of research collaborations in multidisciplinary institutions challenges and opportunities for urban environmental health and sustainability: the healthy-polis initiative how walkable is the city? application of the walking suitability index of the territory (t-wsi) to the city of rieti the pleasure of walking: an innovative methodology to assess appropriate walkable performance in urban areas to support transport planning facilitating interdisciplinary research urban health: evidence, challenges ad direction the framework of urban exposome: application of the exposome concept in urban health studies a complex approach to defining urban energy systems constancy and change: key issues in housing and health research cities and health: an evolving global conversation healthy urban planning in european cities key: cord-342386-t5b8wpe2 authors: falcone, rino; colì, elisa; felletti, silvia; sapienza, alessandro; castelfranchi, cristiano; paglieri, fabio title: all we need is trust: how the covid-19 outbreak reconfigured trust in italian public institutions date: 2020-10-02 journal: front psychol doi: 10.3389/fpsyg.2020.561747 sha: doc_id: 342386 cord_uid: t5b8wpe2 the central focus of this research is the fast and crucial impact of the covid-19 pandemic on a crucial psychological, relational, and political construct: trust. we investigate how the consequences of the pandemic, in terms of healthcare, state intervention and impositions, and daily life and habits, have affected trust in public institutions in italy, at the time when the contagion was rapidly spreading in the country (early march 2020). in this survey, addressed to 4260 italian citizens, we analyzed and measured such impact, focusing on various aspects of trust. this attention to multiple dimensions of trust constitutes the key conceptual advantage of this research, since trust is a complex and layered construct, with its own internal dynamics. in particular, the analysis focuses on how citizens attribute trust to public authorities, in relation to the management of the health crisis: with regard to the measures and guidelines adopted, the purposes pursued, the motivations that determine them, their capacity for involvement, and their effectiveness for the containment of the virus itself. a pandemic creates a bilateral need for trust, both in public authorities (they have to rely on citizens’ compliance and must try to promote and maintain their trust in order to be effective) and in citizens, since they need to feel that somebody can do something, can (has the power to) protect them, to act at the needed collective level. we are interested to explore how this need for trust affects the attributional process, regarding both attitudes and the corresponding decisions and actions. the most striking result of this survey is the very high level of institutional trust expressed by respondents: 75% of them trust italian public authorities to be able to deal with the covid-19 emergency. this is in sharp contrast with the relatively low levels of institutional trust characteristic of italy, both historically and in recent surveys. moreover, the survey allowed the discrimination of several potential predictors for trust, thus emphasizing factors that, during this crisis, are exhibiting an anomalous impact on trust. the great societal challenge presented by the covid-19 pandemic has prompted extraordinary efforts to meet such a challenge, from public authorities, civil society, and the scientific community. extreme policies for containment, mitigation, and co-existence with the virus have been implemented by the governments of most afflicted countries, as well as by relevant international institutions (e.g., the who and the eu). at the same time, scientific research worldwide has focused on tackling the many facets of this dramatic phenomenon, including its impact on social relationships and psychological well-being, as well as the key socio-cognitive factors in promoting effectiveness of the proposed countermeasures. several of these studies have highlighted the crucial and complex role of trust in dealing with the covid-19 pandemic. llewellyn (2020) puts it very succinctly and effectively: "in times of crisis, trust is the most important thing to consider if you want to communicate health advice." this blanket pronouncement is well-supported by previous evidence: in their systematic review on the importance of trust when preparing for and during a pandemic, siegrist and zingg (2014) found confirmation that "trust in health agencies positively influenced people's willingness to adopt recommended behavior." in addition, among the five recommendations for crisis communication highlighted by the authors' survey, two directly concern trust management: "the focus should be not only on trust but also on confidence, and establishing trust in health authorities before a pandemic occurs is important." this latter point is also stressed by lewnard and lo (2020) , with reference to the current pandemic: "the effectiveness and societal impact of quarantine and social distancing will depend on the credibility of public health authorities, political leaders, and institutions. it is important that policy makers maintain the public's trust through use of evidence-based interventions and fully transparent, factbased communication." it is worth noting that this emphasis on evidence and transparency, albeit crucial, describes only part of the relevant socio-cognitive dynamics that affect trust in public institutions: in particular, it collapses trust to confidence in information sources and their credibility, while a crucial problem is also trust in the institution's power to intervene, as well as trust in collective compliance with the proposed measures. finally, in specific circumstances, interesting inversions in cognitive causeeffect relationships can occur, as widely studied in cognitive sciences and social psychology (e.g., festinger, 1957; koller, 1988; kunda, 1990; epley and gilovich, 2016) . in fact, the relevance of trust for dealing with health emergencies is also linked to the limits of direct enforcement of the required behavioral change: without the active cooperation of the population, any drastic intervention is doomed to fail, because the desired behaviors (e.g., frequently sanitizing one's hands, wearing a facemask, and keeping a safe distance from others) cannot be effectively monitored on the required scale and with sufficient frequency. in a broad and comprehensive survey of social and behavioral results to support covid-19 pandemic response, van bavel et al. (2020) highlight how most measures needed to contain an epidemic are, by their very nature, difficult to enforce directly: this, in turn, makes trust in public authorities all the more relevant. based on scientific evidence gathered during previous outbreaks, van bavel et al. (2020) argue that "trust in institutions and governments (. . .) may play an important role." for example, trust in the liberian government was correlated with decisions to abide by mandated social distancing policies and utilizing clinics for care during the ebola outbreak. trust was also related to decisions to adopt preventive measures such as ebola vaccinations in the drc. conversely, a lack of trust in public health officials may lead to negative effects on utilization of health services. reliable information and public health messages are needed from national leaders and central health officials. however, local voices can amplify these messages and help build the trust that is needed to spur behavioral change (van bavel et al., 2020) . these expectations on the positive role of trust in promoting adherence and compliance with preventive regulations and guidance are finding ample confirmation also in recent studies on the ongoing crisis, both within and across various countries. in a nationally representative survey conducted in denmark during the covid-19 pandemic (n = 1782), olsen and hjorth (2020) measured the respondents' willingness to apply social distancing in order to reduce contagion: they found that both lower levels of political trust and lower generalized social trust are negatively associated with willingness to distance and that younger male respondents with the lowest levels of education and least political trust report lower willingness to distance. in a nationally representative survey of italian adults (n = 3452) conducted between the 18th and 20th of march 2020, barari et al. (2020) observed high levels of understanding and self-reported compliance with containment measures, and noted that "even those who do not trust the government, or think the government has been untruthful about the crisis believe the messaging and claim to be acting in accordance." trust acts as a precious commodity both for institutions and for scientists, both of which are crucial actors in the public response to the covid-19 pandemic. in a large-scale background analysis of european social survey data on 25 european countries (n = 47,802) focused on the covid-19 epidemic from january 22 to april 14, 2020, oksanen et al. (2020) found that institutional trust acts as a protective factor: countries with low levels of institutional trust prior to the outbreak (including italy) experienced significantly higher mortality rates during the crisis; moreover, their governments introduced restrictions against contagion later than countries with higher levels of institutional trust (calculated as the delta between the date when the restrictions came into effect and when the first confirmed covid-19 death was reported in that nation), which in turn contributed to the severity of their death toll. these results on the relevance of trust as a protective factor are in line with previous studies on other epidemics, e.g., ebola, showing how people with higher institutional trust are more likely to follow the advice and guidelines given by the health authorities (blair et al., 2017; vinck et al., 2019) , as well as investigating the interplay between scientific and non-scientific sources in modulating people's trust in healthcare information (falade and coultas, 2017) . as for trust in science, its role has been highlighted in a recent study by plohl and musil (2020) : using structural equation modeling (sem) on a sample of 525 international, english-speaking respondents, the authors investigated whether and how risk perception and norm compliance for the covid-19 pandemic may be affected by several constructs, i.e., religious orthodoxy, conspiracy ideation, intellectual curiosity, and trust in science, all measured with validated scales. their results indicate that trust in science is by far the most important factor in producing appropriate risk assessment and high level of norm compliance. at the same time, trust in science, as opposed to the tendency to believe in alternative non-official sources, has been observed to be deeply affected by polarization and homophily (bessi et al., 2016) . looking at the specifics of the covid-19 pandemic, so far the most insidious threat posed by the virus has been the combination of the rapidity of its spread with the high number of patients requiring treatment in intensive care, resulting in unprecedented strain on the healthcare system of affected countries. this in turn has prompted an increasing number of national governments to adopt extreme measures to limit the spread of the virus, often imposing very demanding limitations on citizens' basic rights (e.g., social isolation, lockdown, and quarantine) and with dire socio-economic consequences (e.g., job insecurity, rising unemployment, loss of revenues, and inequalities). in such a unique scenario, the relevance of studying citizens' trust in public institutions is manifold: on the one hand, the effectiveness of these measures and the collective ability to overcome their costs is conditional on the compliance of the population, which in turn is affected by trust in institutions; for this same reason, institutions actively seek to promote citizens' trust, as a means to achieve their prevention goals; on the other hand, the very nature of the current crisis is likely to affect and shape how citizens conceptualize trust, and such socio-cognitive impact of the covid-19 pandemic needs to be understood. indeed, the current crisis acts as a magnifying glass in highlighting the essential role of trust in our societies (trust as "vinculum societatis, " the bond of society, to borrow john locke's famous expression), both for the psychological well-being of individuals and for the effective functioning of institutions. the study presented in this paper contributes to this fastgrowing body of knowledge on the interplay between trust in institutions and the covid-19 pandemic, by discussing the results of a large scale survey (n = 4260) conducted on italian citizens between march 9 and march 14, 2020. at that time, italy had the most active outbreak of the virus worldwide, and its death count was growing at alarming rates; at the same time, extreme prevention measures were still relatively recent and rapidly changing in nature, sometimes from day to day (e.g., on march 11 new restrictions were introduced by the government, closing public places such as restaurants, pubs, and most shops). thus, our data offer insight into a time window in which the phenomenon was already in its acute phase in medical terms, yet still novel and unexpected for the population: this offers a privileged vantage point to observe how a pre-existing construct, trust in institutions, was affected by a sudden and profound change in the everyday functioning of the whole country, by a complete (albeit hopefully temporary) re-representation of one's role in society and in personal relationships, as well as in the relationship between citizens and institutions. the survey was theoretically inspired by the socio-cognitive model of trust developed by castelfranchi and falcone (2010) : we chose this theoretical framework because it provides a rich and nuanced description of various reasons for trust, thus allowing us to probe not only the degree by which italian citizens expressed trust toward the relevant public authorities engaged in the response to covid-19 but also on what grounds such attitude was based. our purpose, however, was not to look for direct validation of the theoretical model, but rather to collect as many detailed data as possible on the rapidly evolving italian response to the covid-19 emergency, from the standpoint of institutional trust: in this sense, this study was mostly intended as explorative. in particular, we wanted to compare our results with the welldocumented low levels of trust in institutions exhibited by italians before the onset of the crisis, which some have associated with tardiness in responding to the covid-19 emergency across various european countries (oksanen et al., 2020) : we intended to see whether such widespread distrust toward public institutions would be confirmed or subverted during the initial stages of the covid-19 outbreak in italy and to offer some insights and suggestions regarding the original and peculiar nature of any discontinuity in institutional trust that may be associated with the current pandemic. moreover, we intended to take a closer look at the cognitive and social factors responsible for trust toward public institutions in the face of pandemic threats: the survey was designed both to discriminate several potential predictors for trust, so that subsequent analysis would allow us to individuate the most relevant ones, and to facilitate comparison with the underlying theoretical model, thus emphasizing factors that, during this crisis, are exhibiting an anomalous impact on trust-either because they determine trust more intensely than usual (overcharged factors) or because their impact is minimal or non-existent (anesthetized factors). indeed, a key hypothesis that we wanted to test concerns the impact of covid-19 on the very nature of the institutional trust construct: not only the overall trust in public institutions is affected by the pandemic and how these institutions respond to it, but also the determinants of trust in institutions change and adapt to this crisis, in comparison with other situations. desperate times require desperate measures, and desperate measures induce a drastic reconfiguration of the cognitive underpinnings of trust in institutions. our survey was designed to collect data on such paradigm shift in how institutional trust was conceptualized by italian citizens during the early stages of the national response to the covid-19 pandemic. we used a snowball sampling method to determine the respondents: we collected a large sample (n = 4260, 57% women, mean age = 46 years, range = 18-85 years, sd = 13.42), relatively well-balanced in terms of geographical provenance (33% northern italy, 39% central italy, and 28% southern italy and main islands), with a significant portion of respondents (30%) residing in the regions most affected by covid-19 at that time (lombardy, veneto, emilia-romagna, marche, and piedmont) . the relatively uniform geographical distribution of the sample among the three macro-areas of italy, as well as the significant proportion of respondents from highly affected regions, allows interesting comparisons based on participants' residence. moreover, the introduction of more drastic restrictions by the italian government at the end of march 11, 2020, invites considering also this temporal dimension in analyzing the data: in this respect, it is important that a fairly large set of participants (n = 829) completed the survey after those new restrictions had been introduced. finally, it should be noted that the mean educational level of participants is very high: almost three quarters of respondents have a degree (38%) or postgraduate specialization (34%). the main characteristics of the sample are synthetized in table 1 . data were collected with a 57-item questionnaire, using a fivepoint likert scale for most items: an english translation of the whole questionnaire is available in the supplementary materials. the questionnaire was based on the socio-cognitive model of trust developed by castelfranchi and falcone (2010) and explored the questionnaire was administered online using the google forms platform. the questionnaire fully complied with ethical guidelines for human subject research and participation was conditional on the preliminary approval of an informed consent by each subject; the compilation took an average time of 10 min. data analysis was performed using the spss (version 22) statistical software: the collected data were first analyzed through correlation analyses (given the asymmetric distribution of most variables, we considered spearman correlation values); secondly, given the high number of items in the questionnaire, we conducted a principal component analysis (pca) on each subsection of the questionnaire prior to running regression analyses on the aggregated data. full details on descriptive statistics for each item in the questionnaire are included in the supplementary materials, differentiating also based on geographical factors (northern, central, and southern italy; more affected vs. less affected regions) and temporal boundaries (before vs. after the march 11 announcement of new restrictions by the national government). here, we report only the most relevant findings, prior to more in-depth analysis, and only in terms of aggregate data, since no significant differences emerged at this level between different areas and different dates (albeit some interesting patterns were detected via regression analysis, see section "regression analyses"). when asked to indicate which public authority is the most adequate to take decisions concerning the covid-19 emergency (item 14 in the questionnaire), 72.8% indicated the national government, 13.3% indicated the civil protection, 4.2% indicated the presidency of the republic, 3.6% indicated the regional government, 0.9% indicated the municipal authority, and 5.2% indicated others. hence, the overwhelming majority (90.3%) of respondents consider pandemics as a matter of national concern, which should be primarily addressed by national authorities. this should be taken into account while interpreting all other results, since most of the attitudes expressed by participants regarding features of public authorities (competence, intentionality, trust, etc.) should be understood with reference to national institutions, unless otherwise specified. moreover, it is remarkable that the presidency of the republic, which is mostly a moral authority, is seen as having a greater role than regional governments, in spite of their leading role in the healthcare system, which in italy is organized on a regional basis. equally significant is the fact that only 0.1% of respondents (within the broader category "others") indicated any kind of international entity, including the european union, as having a primary role in facing a pandemic outbreak. in short, at this stage of the covid-19 emergency, italian citizens strongly believed that this pandemic was not to be prominently addressed by either regional or international authorities, but was rather mostly a matter of national concern. when asked to rank their overall trust in public authorities for the management of the covid-19 emergency (item 33 in the questionnaire), 75% of respondents manifested either extreme (23.8%) or high (51.2%) levels of trust, 17.7% were non-committal, and only 7.3% expressed distrust (see figure 1 , left panel). as we will see in the section "discussion and conclusions, " these numbers are in sharp contrast, to say the least, with the average institutional trust reported for italian citizens prior to the covid-19 crisis, especially considering that the main target of this newfound trust was national public authorities (see above). the competence of public authorities was assessed as their ability in planning both the right prescriptive measures (e.g., lockdown) and the appropriate behavioral guidelines (e.g., personal hygiene recommendations). on both counts, the majority of respondents expressed a positive belief in the public authorities' competence (79.3% for measures, 82.7% for guidelines), whereas only a relatively small minority was either undecided (14.4% for measures, 11.4% for guidelines) or skeptical (6.3% for measures, 5.8% for guidelines). moreover, correlational analysis indicates that competence scores for measures and guidelines are strongly and positively related (r = 0.738, p < 0.0001), suggesting that respondents did not really discriminate between prescriptive measures and behavioral guidelines, at least with respect to trust in public institutions: for this reason, in subsequent analyses, we collapsed these two items into a single competence value, calculated as the mean response for each subject to items 2 (competence on measures) and 3 (competence on guidelines) of the questionnaire (these are also the data reported in figure 1 , central panel). other items in this section of the survey were designed to investigate the reasons behind participants' beliefs on the public authorities' competence: in summary, the overwhelming majority of the sample (91.8%) believed that it was the public authorities' proper prerogative to take action and issue containment measures against the pandemic (item 4), and most respondents (71.7%) positively evaluated the use of experts' advice by the public authorities during the covid-19 crisis (item 5); there was instead less confidence in the organizational capacity demonstrated by public authorities in the early stages of the emergency (item 7: 44.8% expressed a positive evaluation, 33.6% were undecided, and 21.6% were critical), and the majority of the sample (54.3%) agreed that institutional communication on the covid-19 presented some contradictions, either between different authorities or over time (item 6). in spite of these partial concerns, a significant majority of the sample (63.3%) did not express any skepticism on the competence of the public authorities in handling the emergency (item 8). as for the competence, we inquired on the intentionality of public institutions separately for prescriptive measures and behavioral guidelines, asking participants whether they believed either type of intervention was both actively and honestly aimed at containing the covid-19 pandemic. again, respondents expressed an overwhelmingly positive belief in the good faith of public institutions, both in promulgating prescriptive measures (90.2%) and in issuing behavioral guidelines (89.1%): only a small minority was either undecided (7.1% for measures, 8.1% for guidelines) or skeptical (2.7% for measures, 2.8% for guidelines). correlational analysis reveals again that intentionality scores for measures and guidelines are strongly and positively related (r = 0.794, p < 0.0001), further confirming that respondents did not really discriminate between prescriptive measures and behavioral guidelines, when it comes to assessing the public authorities' trustworthiness in this emergency: hence, these two items on intentionality were collapsed into a unique intentionality value in subsequent analyses, using the mean response for each subject to items 9 (intentionality on measures) and 10 (intentionality on guidelines). other items in this section of the survey were designed to investigate the reasons behind participants' confidence, or lack thereof, in the nature of the public authorities' intentions: in summary, we found confirmation of the fact that most respondents (72.1%) did not doubt that the intentions of the public authorities were consistent with their public statements (item 13), whereas a smaller majority (55.9%) considered the economic investment mobilized by the italian public authorities sufficient to fight the pandemic (item 11: notice that only 16.4% considered it insufficient, with a significant portion of the sample, 27.7%, remaining undecided). finally, asked whether other interests, e.g., political or economic, were at stake (item 12), the larger part of the sample (43.1%) answered in the negative, whereas 34.1% acknowledged the presence of such ulterior motives and 22.7% were unsure: as we will discuss further on, this question was probably easy to interpret in two markedly different senses-either negatively, as an accusation of having some hidden and problematic agenda, or positively, as the capacity to take into account all the key ramifications of the covid-19 crisis, including its political and socio-economic aftermath. overall, we registered strong confidence in the good faith of the intentions manifested by public institutions (figure 1 , right panel): this parallels the belief in the public authorities' competence, and together, these attitudes support the high levels of institutional trust expressed by this sample. part of the survey was focused on the measures issued by public authorities as a response to the covid-19 pandemic, in order to estimate both their perceived usefulness and the goal attributed to these interventions by the participants. the vast majority of our sample (85%) perceived these measures as being either useful (38.5%) or very useful (46.5%) in fighting the pandemic, whereas only a tiny minority was skeptical (2.6%), with the remaining 12.3% being undecided (item 15). when asked to assess the adequacy of the public authorities' intervention (item 32), a more abstract notion involving a counterfactual comparison with alternative strategies, the majority rated current measures as adequate (53.8%), 33.2% were undecided, and only 13% considered them inadequate. in terms of the motivations associated with these measures, we asked participants to express agreement on three potential, non-mutually exclusive aims: reassuring the population (item 16), curbing the spread of covid-19 (item 17), and creating unmotivated alarm (item 18). the vast majority (89%) agreed that the rationale of the public authorities' intervention is indeed to contain the pandemic, whereas only 16.9% attributed to the public authorities the goal of reassuring citizens, and even fewer respondents (6%) regarded the proposed measures as a way of spreading unnecessary panic. when rating the personal burden of the proposed restrictions on their own lives (item 19), 39% of participants expressed to feel a high level of impact, whereas 29.6% indicated little discomfort for the current situation and the remaining 31.4% reported medium levels of distress. however, regardless of the perceived impact on the public authorities' intervention, the overwhelming majority of respondents agreed that such sacrifices were crucially beneficial for themselves and their families (item 20, 92.7% of agreement), for the society as a whole (item 21, 95.3%), and for both (item 22, 94.7%). moreover, when asked to assess the usefulness of one's personal contribution to these preventive measures, since they were intended for the whole population (item 23, a question aimed at implicitly measuring any "free-riding inclination" in our sample), as many as 96.6% of the participants considered their personal role relevant for the collective effort. taken together, these data show that, albeit different people suffered more or less because of the containment measures, almost all agreed on their usefulness and on the necessity of personal sacrifice to deal with the pandemic: this suggests a mindset in which the shared goal of public safety trumps any individual concern, including personal discomfort, fear, and anxiety (an interpretation later confirmed by regression analysis, see section "regression analyses"). in terms of expectations on compliance with the sanitary restrictions by other fellow citizens (items 24-27), we observe a fairly varied pattern of response (see figure 2 ): the most widespread belief (48.6% of agreement) is that enough italian citizens, albeit not all, will comply with the regulations, thus making them effective (item 25); in contrast, there is skepticism both on the most optimistic scenario, i.e., full compliance (item 24, 36.9% of disagreement), and on the bleakest outcome, i.e., insufficient compliance (item 27, 56.9% of disagreement), although it is worth noting that pessimism is rejected much more strongly than optimism. the possibility that only few people will comply, and yet their efforts will be useful (item 26), is also rejected by the relative majority of the sample (46.9% of disagreement), yet interpreting this result requires caution, since it could either express skepticism on figure 2 | expectations on compliance by others. frontiers in psychology | www.frontiersin.org how many people will comply, or on the chances that limited compliance may indeed be useful. regarding the motivations useful to induce compliance, we asked participants to express agreement on four possible motivational triggers: the expectation that everybody else will follow the new regulations (item 28), a personal concern for dangers (item 29), a spirit of collaboration in the face of the emergency (item 30), and trust in the fact that public authorities are doing everything in their power (item 31). all four motivations engendered significant levels of agreement, with the highest being the feeling of a common cause against a shared threat (90%), followed by trust in maximum effort by the public authorities (83.8%), concern for the associated risks (80.6%), and expecting others to comply as well (79.2%). it is interesting to note that a motivation tied to the collaborative dimension of trust in civil society, i.e., being united in pursuing a common goal, shows more than 10 percentage points of distance from a motivation inspired instead by the sanctioning view of trust, i.e., being able to monitor compliance by others, possibly to punish free-riders, as well as from fear of personal harm: this suggests that emphasizing collaborative motives (a strategy employed quite consistently by the italian government in its public communications during the early stage of the covid-19 outbreak) may be more effective in promoting compliance than stressing individualistic goals. this section of the survey asked respondents to provide a metacognitive evaluation of the most relevant factors promoting their trust in how public institutions are handling the covid-19 crisis. of the eight factors explored, the type of measures adopted by the authorities was the most frequently cited as important (item 41, 80.2%), followed by the information received on the crisis (item 36, 71.4%), the capacity of public authorities to actually enforce protective measures (item 35, 52.2%), the respondent's profession (item 37, 46.9%) and his/her health condition (item 38, 40.6%), the opinions expressed by social relations such as friends and relatives (item 40, 37.3%) or colleagues (item 39, 35.9%), and the political connotation of the relevant authorities (item 34, 18.4%). later on, we will use regression analysis to investigate the extent by which these self-reported data correspond to the relative weight of the actual factors affecting participants' trust in institutions. for now, it appears that participants self-describe their theory of trust in fairly objective terms, giving priority to the factual nature of the proposed measures, the information they gathered (apparently with the exception of social channels; see below), and the extent by which public authority is able to enforce their recommendations; in contrast, relatively little weight is given to personal factors and social networks, and none at all to political partisanship. this last result suggests that the public response to the covid-19 crisis was initially perceived as a matter of shared concern of all political parties, which in turn prompted a temporary truce in the usual partisanship characteristic of italian politics; moreover, in their efforts to deal with the emergency, public authorities were regarded mostly for their institutional role, with little attention to their political affiliation (even when such authorities were the expression of certain political parties, as it was the case with the national government). this interpretation also helps to explain the extremely high level of trust in public institutions with respect to the covid-19 emergency during those few days, in a population well-known for its deep-seated distrust of politicians in general, and of political parties in particular: further analysis of this interesting anomaly will be presented in the section "discussion and conclusion." this section of the survey investigated both frequency of use (items 42-47) and perceived trustworthiness (items 48-52 and 54) of various types of information sources in relation to the covid-19 pandemic, to get a better sense of what channels were most influential in affecting participants' opinions on this topic; in addition, we collected data on the trustworthiness directly assigned to public institutions as information sources (item 53), which was high for 77.6% of the sample, average for 17.7%, and low only for 4.6% of respondents. with respect to other information channels, the data summarized in table 2 highlight four main findings: (i) official online channels, e.g., the website of the civil protection, and scientists are both frequently used and considered reliable as information sources; (ii) in contrast, traditional media, albeit often consulted, are regarded as reliable only by less than half of our sample; (iii) family physicians are in general considered trustworthy, yet they are rarely used as information sources; (iv), finally, both social relationships and unofficial online sources, e.g., social media, are neither frequently used, nor widely believed. the result on unofficial online channels is especially surprising: whereas the very low credibility associated to these sources is understandable and even commendable, the fact that only one respondent out of four admits to using them frequently is hard to swallow, especially at a time in which personal contact was severely limited in italy, thus making social media an even more attractive outlet for users. besides, recent national statistics on internet use in italy do not agree with the picture painted by these data: according to the 2019 global digital report 1 , compiled annually by wearesocial and hootsuite, in 2019, 58% of italian citizens were active social media users (with a growing trend with respect to 2018), and the average time spent on social media every day was a little less than 2 h per person. besides social desirability effects (respondents may have been reluctant to admit gathering information via unofficial channels on such delicate topics), a possible explanation for this anomaly is in a common misperception of the role of social media as gatekeepers: someone who finds on facebook a link to an article on a traditional newspaper, or is made aware by a post on twitter of the latest press release on the official website of the civil protection, may be inclined to disregard the role of the social media in bringing these information to the user's attention. yet, this is how we use social media as information sources, often without even realizing it: we take advantage (or succumb, depending on the circumstances) of their agenda setting algorithms, which allow these platforms to act as powerful information brokers, rather than information producers. expectations on long-term impact on trust the final section of the survey intended to probe participants' expectations on the long-term impact of the covid-19 crisis on trust relationships between citizens and public institutions (item 55), between citizens and the dominant economic model of development (item 56), between citizens and the scientific community (item 57), and among citizens as peers (item 58). here, the big winner is expected to be science: 72.8% of respondents believe that the current crisis will strengthen the trustworthiness of scientists as public figures. expectations on the impact of trust toward public institutions and among citizens are less triumphant, yet still positive: 54.4% predict an increase in institutional trust after the covid-19 pandemic, whereas 57% make the same prediction with respect to social trust, i.e., trust among peers. finally, on future trust in the dominant model of economic development, our sample is evenly divided: 34% think that we will trust it more than before, 33.6% are undecided, and 32.4% expect an increase in distrust toward that model. as a preliminary step before running regression analyses, we used pca to identify strongly correlated items in the data set and simplify the variables' structure, in order to avoid multicollinearity issues in our regression models. since the survey was theoretically motivated by the socio-cognitive model of trust (castelfranchi and falcone, 2010) , we performed separate pca on 10 subsets of items, to preserve relevant theory-based distinctions in the participants' responses. item 33, degree of trust toward public authorities in relation to the covid-19 pandemic, was not included in the pcas, since it was intended to act as the target of the regression models; we also excluded items 8 (doubts on public authorities' competence) and 13 (doubts on public authorities' intentions), since these were included in the survey merely as control questions for, respectively, items 2-3 and items 9-10; moreover, we kept separate from the pcas item 19 (personal discomfort associated with public authorities' measures), item 23 (usefulness of one's own personal contribution to the collective effort), and item 32 (overall adequacy of public authorities' measures), since we wanted to test their role as individual predictors in the regression models; finally, item 26 (expectation of very limited yet useful compliance by other citizens) was excluded for the pca and regression analysis, due to the ambiguity in its interpretation already mentioned in section "descriptive statistics." the remaining 49 items led to the individuation of 21 principal components, as summarized in table 3 (full details on the pcas methods and results are provided in the supplementary materials). in order to be considered satisfactory, each pca had to explain at least 50% of the cumulative variance, and further components were added only if they improved by more than 15% the explained variance. in order to test our main hypotheses, we performed a multivariate regression model on raw data using ibm-spss 22 software. the dependent variable to be predicted was the overall trust manifested by participants toward public authorities involved in the covid-19 response, i.e., item 33 in the survey. after some explorative iterations and based on theoretical considerations, we decided to include 22 independent variables in the final model: 15 principal components identified via pcas (indicated with an asterisk in table 3 ), 3 individual items that were conceptually independent from the other sections of the survey (personal discomfort associated with public authorities' measures, usefulness of personal contribution to the collective effort, overall adequacy of public authorities' measures), and 4 socio-demographic variables-age (coded as 1 = 18-40, 2 = 41-55, 3 = 56-85 years of age), educational level (coded as 1 = high school diploma or lower, 2 = university degree or higher), region of residence (coded as 1 = most affected regions, i.e., lombardy, emilia-romagna, veneto, marche, and piedmont, 2 = all other regions), and time of data collection (coded as 1 = before, 2 = after the march 11 new restrictions were announced). preliminary analyses indicated that the respondent's profession did not affect responses, so we excluded it from the model; as for gender, preliminary regressions showed no difference in the predictors of institutional trust between male and female respondents, so we excluded it from the final regression model and performed a separate set of analyses to assess its impact in our data (see section "gender effects"). we first run the regression analysis on the whole sample: the model had a good fit (r = 0.8) and explained 64% of the variance in the overall trust evaluation; 15 out of 22 independent variables were significantly correlated with trust (p < 0.05), and the most powerful predictors were positive indicators of competence of public authorities (β = 0.31, p < 0.001), perceived adequacy of the adopted measures (β = 0.174, p < 0.001), trustworthiness of official information sources (β = 0.145, p < 0.001), public authorities' intention to (56) the numbering used for items follows the order of presentation in the survey: the relevant items are from 2 to 58, since item 1 was the informed consent, whereas items 59-63 asked for demographic information. the asterisk (*) indicates principal components that were later used for regressions. contain the pandemic (β = 0.137, p < 0.001), and perception that public authorities' efforts were focused on public safety, with no other agenda (β = 0.101, p < 0.001). all other significant predictors had an absolute value of β equal to or lower than 0.05. the non-significant predictors were personal discomfort due to the adopted measures, perceived usefulness of personal sacrifice, expectation of sufficient compliance (but notice that expectation of universal compliance was positively correlated with trust, whereas expectation of insufficient compliance was negatively correlated with it, both p < 0.005, suggesting an "all or nothing" attitude toward compliance), individualistic reasons for compliance (while collectivist reasons for compliance were strongly and positively associated with trust, p < 0.001), educational level, time of data collection, and age (the last one showed a marginally significant negative correlation, β = −0.018, p = 0.06). we also applied the same regression model to subsets of participants, distinguishing first geographically (most afflicted regions vs. all other regions), then temporally (before and after the announcement of new restrictions by the italian government on march 11), in order to detect differences in how trust was processed depending on the severity of the sanitary emergency in various areas, and the strictness of the measures implemented by public authorities while the pandemic was still progressing. we already knew from descriptive statistics that no overall change in trust toward public authorities was observed across these contexts, yet we wanted to probe for more subtle differences, e.g., different predictors of trust, or different contribution of the same predictors, depending on region of residence and time of data submission. all β and p-values for the various multiple regressions are reported in table 4 ; in what follows, we will focus only on the most relevant results. applying the model only to participants from the most affected regions in italy at that time (lombardy, emilia-romagna, veneto, marche, and piedmont) revealed again a good fit (r = 0.825), explaining 68.1% of variance in trust assessment; the same model also had a good fit when applied only to participants from all other italian regions (r = 0.788, 62.1% of explained variance). in both cases, the strongest predictors remained the same as in the whole sample, and also their order of importance was identical across regions, regardless of current outbreak severity (p < 0.001 for all the following predictors): positive indicators of competence (most affected: β = 0.352; other regions: β = 0.289), adequacy of the adopted measures (most affected: β = 0.146; other regions: β = 0.184), trustworthiness of official information sources (most affected: β = 0.134; other regions: β = 0.149), pa's intention to contain the pandemic (most affected: β = 0.119; other regions: β = 0.146), and perception that public authorities' efforts are focused on public safety, with no other agenda (most affected: β = 0.113; other regions: β = 0.96). in spite of the substantial similarity in how trust in public authorities was attributed by respondents in different areas of the country, some fine-grained distinctions emerge looking at those factors that were significant in one context but not in the other-and also exercising due caution, since a difference in significance does not necessarily imply a significant difference. in the most affected regions, we observed eight non-significant predictors, whereas there were only six in the other regions: four of these factors were irrelevant across both contexts (personal discomfort, perceived usefulness of the sacrifices, individualistic reasons for compliance, and time of data collection), whereas negative factors affecting competence of public authorities, intention to downplay the emergency, impact of personal effort, and trustworthiness of unofficial information sources were immaterial for respondents from the most affected areas, whereas they acted as significant predictors (albeit weak ones) for participants from other regions of italy; in contrast, an expectation of sufficient compliance from other people had a significant negative correlation with trust in the most affected regions (β = −0.047, p = 0.02), whereas it had a marginally significant positive correlation with it elsewhere (β = 0.026, p = 0.05). taken together, these results suggest that participants living in areas that were currently experiencing very severe outbreaks of covid-19 had a more focused mindset when deciding whether to trust public authorities to deal with the emergency: less factors were considered relevant, and in particular, it was probably taken for granted that some inconsistency in public communication and intervention may occur, without necessarily jeopardizing trust (negative factors on competence), and that unofficial sources were not to be taken seriously when deciding whom to trust; at the same time, expecting that only a sufficient number of people would comply with the emergency measures had a negative impact on trust in public authorities, probably highlighting the fact that, in those regions, people believed that "enough is not enough"that is, either everybody cooperates in facing the crisis (universal compliance) or we will not be successful in overcoming it. this extreme mindset is confirmed by the fact that the relevance of one's own personal contribution did not affect trust attribution to public authorities in the most affected regions, whereas it did in other areas: this indicates again that collective compliance, not personal efforts, are perceived as the key to success by people currently facing the worst of the covid-19 pandemic. looking instead for short-term shifts in trust assessment over time, in relation to relevant public events (i.e., the introduction of new measures by the italian government on march 11), we divided our sample based on time of data submission: before or after the public press release when the prime minister giuseppe conte announced the new restrictions to be implemented nationwide, to contain the covid-19 outbreak. the model performed well across both time windows (before: r = 0.799, 63.8% explained variance; after: r = 0.806, 64.9% explained variance) and the strongest predictors remained the same, as well as their relative order of importance (p < 0.001 for all the following predictors): positive factors affecting competence of public authorities (before: β = 0.311; after: β = 0.293), perceived adequacy of the adopted measures (before: β = 0.171; after: β = 0.183), trustworthiness of official information sources (before: β = 0.149; after: β = 0.117), attributing to public authorities the intention to contain the pandemic (before: β = 0.143; after: β = 0.108), and the perception that their efforts were focused on public safety, with no other agenda (before: β = 0.103; after: β = 0.096). again, we observed substantial stability over time in how trust in public authorities was attributed, with minor differences emerging only by comparing the significance and direction of some secondary variables. in general, the introduction of more severe restrictions had the effect of simplifying the metrics used to assess trust toward public authorities: before the march 11 announcement, only four variables failed to correlate significantly with trust, whereas after it, the number of irrelevant predictors increased to 8, indicating a more narrowly focused mindset in assessing the trustworthiness of the institutions in charge of dealing with the emergency. in particular, intention to downplay the emergency, personal discomfort associated with the proposed measures, and trustworthiness of unofficial information sources became irrelevant for trust in public authorities; unfortunately, the expectation of universal compliance also became equally irrelevant (before: β = 0.043, p = 0.001; after: β = −0.006, p = 0.81), while the negative correlation between expectation of insufficient compliance and trust was much stronger after the march 11 announcement (before: β = −0.024, p = 0.04; after: β = −0.083, p = 0.001). this suggests a turn for the worst in people's expectations: before the new restrictions, trust was positively supported by expectation of universal compliance (the more i believe all others will behave responsibly, the more i trust the authorities), whereas after them, the influence of pessimistic fear became dominant (the more i doubt enough people will comply, the less i trust the authorities). as a possible reaction to this shift, it is worth noting that the positive correlation between impact of personal efforts in the covid-19 response and trust in public authorities became significant only after march 11 (before: β = 0.023, p = 0.09; after: β = 0.062, p = 0.03), suggesting that the new measures strengthened in italian citizens a sense of personal responsibility for the collective reaction to the virus. finally, region of residence was a significant (albeit weak) predictor of trust before, but not after, the announcement of new restrictions by the italian government (before: β = −0.035, p < 0.001; after: β = −0.01, p = 0.65): this shows a stronger tendency to trust public authorities in the most affected regions before march 11, whereas this was no longer true after that date. since overall trust in public authorities did not decrease after march 11 in the whole sample, this indicates a leveling in trust attribution across the country after the introduction of new measures, which in turn could be interpreted as a shift in the perception of the emergency: whereas in early march, a significant part of the italian population still believed the outbreak to be somehow contained to specific regions, and thus a local problem unlikely to affect everybody in the same way, the nationwide interventions announced on march 11 made it crystal clear to all that covid-19 was indeed a national concern. overall, these regression analyses show that, in italy, trust in the capacity of public authorities to deal with the covid-19 emergency was attributed in a fairly consistent manner during the time window of this survey (march 9-14, 2020) across different areas of the country, giving central prominence to positive indicators of competence in public institutions, assessing the adequacy of the proposed measures, verifying that proper intentions supported their application, and paying attention mostly to official information sources. all considered, this suggests a fairly reasonable and well-balanced judgment-making process for trust attribution, while the true anomaly remains the high levels of trust in public authorities recorded during the early stages of this emergency (see section "descriptive statistics"), which are in sharp contrast with both long-term trends and recent surveys on institutional trust in italy, prior to the covid-19 pandemic. at a more fine-grained level, region of residence and time of data completion did reveal some interesting shifts in trust assessment, yet these insights should be interpreted carefully, since they concern relatively minor changes in the significance of secondary predictors, within a regression model with a high number of independent variables. comparing male and female respondents, a χ 2 test revealed a small but significant difference (p = 0.004) in institutional trust in relation to the covid-19 emergency: in particular, men were more likely to express high levels of trust toward public authorities involved in contrasting the outbreak (76.1% men vs. 74.3% women), whereas women were more often neutral (19.1% women vs. 15.7% men). running the regression model described in section "regression analyses" separately on male and female respondents showed that, although the main predictors remained the same (positive indicators of competence, adequacy of the measures, trustworthiness of official information sources, public intention to contain the pandemic, and institutional focus on public safety), age and region of residence were significant predictors only for women and not for men (age: women β = −0.026, p = 0.05, men β = −0.009, p = 0.516; region: women β = −0.052, p < 0.001, men β = 0.001, p = 0.964). to further investigate this interaction between gender and other socio-demographic factors influencing institutional trust during the covid-19 emergency, we run a trivariate analysis on, respectively, gender × age × trust and gender × region × trust. the first analysis revealed that gender effects on institutional trust are significant (p = 0.038) only in the age range 56-85 years, which is also the most vulnerable to the virus: among respondents in this age range, the majority of those that expressed low levels of institutional trust were male (60%), whereas most of those neutral or highly trustful were female (59.4 and 53.8%, respectively). it is also worth noting that, after performing a bivariate analysis on the impact of age on trust, we found a highly significant effect (p < 0.001), with 86.1% of elderly respondents (56-85 years old) expressing high trust in public authorities, whereas this percentage drops to 69.6% for participants in between 18 and 40 years of age: this further confirms the role of vulnerability to the covid-19 virus in eliciting higher attributions of trust, and it is consistent with previous findings on a negative correlation between age and willingness to comply with social distancing measures during the covid-19 pandemic (wirz et al., 2020) . the second analysis showed that the relationship between gender and institutional trust is significant (p = 0.027) only in those regions that were most affected by the covid-19 outbreak: in these areas, most of the respondents that manifested distrust in public authorities were men (55.5%), while the majority of the neutral and trustful participants were women (60.1 and 55.4%, respectively). taken together, these results suggest that, whenever the situation was most critical (i.e., for the most vulnerable age range and in the most affected regions), men were overrepresented in the (small) group of people expressing distrust toward public authorities, whereas women were overrepresented among those neutral or trustful. although this may suggest an interesting gender effect on resilience under extreme stress (women seem more likely than men to suspend judgment or look on the bright side, precisely when the situation is the most dire), it is worth noting that, regardless of gender, only a small minority of respondents were expressing distrust toward public authorities, even in the most affected age range (men 6.7%, female 3.8%) and in the most affected regions (men 10.8%, female 7.1%). thus, these gender effects invite further investigation, but on their own, they do not justify any hasty conclusion on how different genders may react against health emergencies. the most striking result of this survey is the very high level of institutional trust expressed by respondents: 75% of them trust italian public authorities to be able to deal with the covid-19 emergency. this is in sharp contrast with the relatively low levels of institutional trust characteristic of italy, both historically and in recent surveys: according to the demos & pi 22nd annual report on "the italians and the state" 2 , based on a large representative sample (n = 1212) of italian citizens over 15 years of age interviewed in december 2019, only 22% respondents trusted the state, whereas both regional governments (30%), european union (34%), and municipal authorities (38%) fared better, while political parties were in the worst shape, with only 9 italians out of 100 willing to trust them; in fact, of the main national institutions, the only one with decent levels of trust was the presidency of the republic (55%, still in sharp decline with comparison to 10 years before, in 2009, when it was as high as 70%). also international estimates indicated relatively low levels of institutional trust: according to the eurofound report on eurofound (2018) , italians' trust in the national government has been declining in the last few decades and is now below 20%, while the more recent data of the eurispes report-italy 2020 3 , presented in february 2020, indicated trust in institutions at 14.6% (6.2 points lower than in 2019). institutional trust in italy in recent years is extremely weak not only in absolute terms but also in relation to other european countries: in their comparison of 25 eu states, based on data from the 2016 european social survey, oksanen et al. (2020) reported very low levels of institutional trust in italy, measured by respondents' trust in five institutions (parliament, politicians, political parties, the police, and the legal system); in fact, only cyprus, poland, slovakia, and bulgaria expressed stronger institutional distrust than italy. moreover, this trend toward widespread distrust of public institutions is not a particularly recent feature of italian politics: while in recent decades, it developed mostly against the backdrop of increasing tensions between populist movements and traditional political parties (urbinati, 2019) , massive erosion of public confidence in political figures was already ongoing in italy well before the recent resurgence of populism worldwidein the last decade of the 20th century, following the corruption scandals of tangentopoli and its media resonance (giglioli, 1996; vannucci, 2009) , and with the largely failed shift toward bipolarism during the berlusconi age (viroli, 2011) . even before that, a longitudinal analysis reveals that the confidence gap between electors and political institutions, characteristic of many post-wwii democracies, appeared in italy much earlier than in other countries (segatti, 2006 )-so much so, that already in the 1960s lapalombara (1965), a highly influential political scientist, described italians' attitudes toward politics with three emblematic words: alienation, fragmentation, and isolation. such a deeply rooted tradition of distrust in public institutions underscores the importance of the opposite trend registered in our survey, i.e., a sudden boost in institutional trust prompted by the covid-19 crisis-a significant result that is also supported by other data collected in this survey, as seen in the "results" section. moreover, insofar as this newfound trust is grounded on trust in the expertise of the scientific authorities involved, it is also at odds with the widespread anti-scientific sentiment considered to be on the rise at the global level, variously stigmatized as "the death of expertise" (nichols, 2017) and the crisis of epistemic deference (marconi, 2019) . surprising as it may be, there are several reasons to consider this finding on trust as reliable: (i) internal consistency: as discussed in section "results, " all other responses to the survey are consistent with a high attribution of trust to public authorities and indeed provide justification for such attribution. (ii) external validation: just a few days after data collection for this study was concluded, a survey on a representative sample of italian citizens (n = 1028, 16-17 march 2020) was conducted by the independent research center demos & pi 4 , providing substantial support to our main results: e.g., 71% trust both the italian government and the current prime minister, with 94% approval of the adopted measures, strong endorsement for the sanitary system (94%), the civil protection (88%), and the national government (82%), coupled with lower levels of confidence in political parties (none of them above 30% of approval) and a rising skepticism toward the european union (80% of respondents believe the italian response to the covid-19 emergency to be better than that of other eu countries, and only 35% consider the role played by the eu as positive in this crisis). (iii) low chances of social desirability effects: as demonstrated by the very low levels of institutional trust recorded in previous surveys, including recent ones, italians have no qualms expressing public distrust toward public authorities-quite the opposite, in fact. thus, there is no reason to assume that the current data on trust are inflated by social desirability effects. thus, there is a genuine phenomenon to be explained here: a veridical "trust boom" during the early stages of the covid-19 crisis in italy. the socio-cognitive theory of trust (castelfranchi and falcone, 2010 ) that inspired our survey provides the tools needed to craft a tentative interpretation of this remarkable fact, although the questionnaire itself was designed to record such a phenomenon, rather than explain it. thus, the speculative nature of our interpretation cannot be stressed enough: our study revealed a highly significant and surprising phenomenon, for which now we look for an explanation. the interpretation we favor is the one that, to the best of our knowledge, appears more adequate to account for the pattern of results obtained in this survey; later on, we will contrast it with other alternative explanations and argue in favor of its superiority. nonetheless, such interpretation remains tentative, and it is intended as a springboard and an inspiration for further studies that may either confirm or falsify it, rather than as something set in stone. with this in mind, let us focus on the fact that trust, at its cognitive core, entails the decision to delegate to someone else (the trustee) the realization of a goal that is important to the agent who is expressing trust (the trustor). as a result, being able to choose not to trust someone requires either having alternative means to achieve the desired goal (e.g., "i will do it myself " or "i will delegate it to someone else") or being ready to forsake that goal. however, neither of these options are available in the face of a pandemic: the relevant goal is personal and public safety, which is non-negotiable, i.e., it is not something we can decide to forget about, and the only course of action that offers reasonable chances of achieving it is to put our collective trust in public authorities, since there are no other available agencies we might appeal to (indeed, the only choice we have concerns the level of public authority we should confide in, and our sample clearly indicated the national level as the most pertinent one). in other words, a pandemic like covid-19 creates the preconditions for a collective case of necessary trust in public authorities, or institutional trust by force majeure: not in the sense that we are being manipulated by some hidden power, as some conspiracy theorists may be prone to believe, but because the very nature of the health crisis leaves us with no other option than to put our trust in public authorities (that is why we emphasize a need, a necessity for trust). it is worth noting that these pressures toward trust between citizens and public authorities in times of sanitary crisis are symmetrical: citizens have no alternatives to reliance in the relevant public institutions, yet these institutions themselves cannot help but trust in civic compliance to the proposed regulations, on pain of failure in containing the contagion, due to the limits of enforcement already emphasized in previous studies (siegrist and zingg, 2014; lewnard and lo, 2020; olsen and hjorth, 2020; van bavel et al., 2020) . necessary trust is a two-way street in health emergencies, for both citizens and public authorities. moreover, this two-way street is often cyclically traveled: in fact, the citizens themselves become fully aware (perceive the request and expectation) of the need for public authorities to receive the right degree of trust from citizens as a tool for achieving the common goal, and this awareness becomes one of the reasons for citizens to trust public authorities themselves. in other words, in the best-case scenario, this becomes a trust-based "alliance" toward a supreme common purpose. this civic alliance, or social pact, is grounded in a specific dynamic of trust: the trustor deliberately bestows trust on the trustee, even if partially skeptical of the trustee's qualities, in an attempt of motivating the trustee to "rise to the occasion" and become trustworthy. this is the sense in which trust breeds trust, as noted both by trust theorists (e.g., falcone and castelfranchi, 2001b) and by political economists (e.g., feld and frey, 2002) . in the context of the early stages of the covid-19 pandemic in italy, we suggest that italian citizens put their trust in public authorities in charge of facing the crisis as a way of opening up a "trust credit line" and thus putting pressure on such authorities to prove themselves worthy of that credit. similarly, public authorities frequently manifested full trust in citizens' compliance with regulations (a topos often belabored on public occasions by all institutional actors, including the prime minister, the president of the republic, and representatives of the civil protection), precisely for the same reason: by declaring their trust in the common sense and civic responsibility of italian citizens, they were putting pressure on citizens to actually demonstrate such qualities. clearly, the objective need for trust created by a pandemic does not automatically evolve in greater trust toward public institutions. that need may find different outlets, so that other, bleaker outcomes may be equally possible: for instance, an already vulnerable trust relationship between citizens and public authorities may be shattered completely by a sudden crisis, especially if such crisis (or its poor management) are blamed on those authorities, possibly leading to a severe governmental crisis, and maybe even a takeover by authoritarian forces, or, in another scenario, public trust toward central authorities may dissolve, with citizens taking a turn toward tribalism and trying to face the crisis at the local level. 5 while these options are certainly viable in general, our results suggest that neither of these paths was being seriously considered by most italian citizens in early march 2020: our survey revealed a sudden increase of trust toward public institutions, rather than its collapse or further erosion, and that trust was directed toward national authorities, not toward specific charismatic leaders or local powers. according to our findings, faced with an unexpected need for public trust, the italian people in early march 2020 opted for putting their trust (at long last) in their elected representatives at the national level, rather than turning to authoritarian figures or local authorities for solutions. beyond the evidence of our data, how the management of the pandemic unfolded over those weeks provides further support to this interpretation. the italian government consistently acted as a mediator between all the social forces affected by the crisis, repeatedly demonstrating high reliance on the indications of the experts in crafting every containment measure: in short, the national authorities acted as the very antithesis of an authoritarian leader. at the same time, local authorities at all levels were relying on the guidance of the national government for facing the pandemic and, in some cases, were actively asking for its direct intervention to solve a crisis that they were not equipped to deal with; more generally, there was widespread consensus, both in political debate and in the media, on the need for a national response to the covid-19 emergency (a need well understood by our participants, as seen in the section "results"). again, an attitude that stands in sharp contrast with any shift toward tribalism. thus, assuming that the need for public trust prompted the high levels of institutional trust manifested by participants, we propose to interpret their other responses within the broad framework of motivated reasoning (kunda, 1990) and cognitive dissonance theory (festinger, 1957) : as the chosen path to pursue the paramount goal of personal and public safety, trusting public authorities became in turn a necessary instrumental goal, thus coloring all other attitudes expressed by the respondents; more precisely, it prompted them to actively look for reasons to justify their (unavoidable) trust in public authorities, in order to minimize cognitive dissonance. indeed, the need for trust experienced by italian citizens during the covid-19 emergency was at odds with their widespread attitude of distrust toward the very same public authorities they now needed to rely upon in the face of the outbreak: this, we argue, produced a massive and sudden shift in their perception of those public authorities, to better accommodate the new reality they had to deal with. in this interpretation, the trust boom observed in the survey was not produced by any collective epiphany on the actual qualities of the public institutions involved, but rather by a cognitive realignment of individual attributions to the current needs citizens were experiencing. all of a sudden, italian citizens found themselves pressured to rely on some key public authorities in ways and to a degree never experienced before, at least since the worst days of world war ii. regardless of how well these authorities behaved in the first stages of the covid-19 crisis, italians opted to re-frame their attributional states in a way that made this novel institutional trust justified, thus flipping the usual causal connection involved in acts of trust: it is not a case of detecting the appropriate qualities in public authorities and therefore deciding to trust them, but rather an instance of having first the need to trust those authorities and then justify such trust by assuming that these authorities would manifest the qualities required to warrant that trust. this is also justified and supported by the implicit pact with which public authorities communicated the need for this responsible and trusted attitude toward them as decisive for the achievement of the common purpose. it is worth noting that our reliance on motivated reasoning to explain some of these survey data is very different from the most common use of this notion in recent studies on public opinion: although originally conceived in much broader terms (kunda, 1990) , motivated reasoning in recent decades has become more and more associated with political ideology, with several studies investigating how partisan affiliations affect and filter our beliefs on matters of public interest (e.g., redlawsk, 2002; slothuus and de vreese, 2010; kahan, 2013; bolsen et al., 2014) . in fact, the same approach has been applied, with mixed results, to the public reaction to the covid-19 pandemic, e.g., looking at how political partisanship affected people's ability to discriminate between reliable information and fake news (pennycook et al., 2020) , timeliness in the adoption of restriction measures (rosenfeld, 2020) , health behaviors (kushner gadarian et al., 2020) , and compliance with social distancing guidelines (rothgerber et al., 2020) and stay-athome regulations (goldstein and wiedemann, 2020) . while the relevance of politically grounded motivated reasoning provides an interesting perspective on public opinion dynamics, other predictors have been found to be more relevant in explaining some of the target phenomena (e.g., fake news vulnerability, see pennycook and rand, 2019) ; more to the point, this is not the type of motivated reasoning we are discussing here. on the contrary, our data show no effect of political partisanship on trust attributions toward italian public authorities in charge of coordinating the covid-19 response, including those that did have a clear political connotation, e.g., the national government. instead, we appeal to the notion of motivated reasoning in relation to a manifestly non-partisan goal, i.e., public safety, and the related need to trust public authorities to be able to ensure such goal: this is the kind of motivated reasoning we argue influenced responses in our sample, independently from the political affiliation of either the survey participants or the relevant public authorities. alongside the preservation of consistency in citizens' beliefs toward public authorities, there is also another, more emotional path through which a need for trust may generate broader shifts in public perception. as noted by many trust theorists (luhmann, 1979; gambetta, 1988; batson, 1991; hardin, 2002) and also described in the socio-cognitive model adopted here (falcone and castelfranchi, 2001a; castelfranchi and falcone, 2010) , a fundamental function of trust is to allow both individuals and groups to face uncertainty, to moderate it and deal with it. trusting someone or something immediately reduces the perception of risk; in this sense, trust offers the advantage of a subjective sense of safety, before and without being able to reach that safety objectively. it allows us to face the risk and take it, partially by giving us control over part of that risk, since trusting implies actively choosing to expose ourselves to a risk, i.e., the risk of having our trust betrayed (mayer et al., 1995) . this is why koller (1988) individuated risk as a key determinant of trust, in the sense that a risky situation may bias people toward trustworthiness when assessing potential allies in facing such risk: "to the degree that the individual fears the occurrence of an event of negative valence (...) he exaggerates the subjective probability of an event of positive valence, which implies that he expects the interaction partner to behave promotively" (koller, 1988, p. 275) . this is very much in line with the higher levels of trust we observed in the most vulnerable age groups and in the italian regions most affected by the covid-19 outbreak (see section "gender effects"). in the context of a health emergency such as the covid-19 pandemic, this subjective dimension of trust becomes particularly apparent: consider how physicians and nurses in italy turned overnight from marginalized workers in a distrusted field to the most revered national heroes. the individual and collective gain of this sudden change of perception is obvious: faced with the danger of contracting a deadly virus, the belief that your life will be in the hands of trusted professionals is incredibly valuable, not only for the unlucky few that will actually have to rely on those professionals, but for everybody, since it greatly helps in calming down their fear and anxiety. in this perspective, the trust boom recorded in our survey should be considered not only as a merely intellectualistic attitude but also as a response with deep emotional undertones: this is the type of trust that is not only cognitively justified, but also felt, insofar as it provides us with the calmness needed to remain productive under the extreme stress of a pandemic. it is worth noting that emphasizing the motivated nature of institutional trust during a pandemic is not the same as treating this newfound trust in italian public authorities as a fiction, just a desperate figment of the imagination of a population looking for solace from a terrible crisis. nothing could be farther from the truth: precisely because this institutional trust was experienced as a matter of necessity by the italian people, it is also genuinely (and dramatically) authentic. italian citizens, during those terrible days in early march 2020, truly believed that public authorities would prove themselves worthy of their trust-possibly for the first time after many decades of increasing institutional distrust. yet, it is a very fragile belief, because it is massively based on assumptions: should the public authorities subsequently fail to prove themselves equal to the task at hand, this huge "trust credit" would come due, producing an even bigger backlash in terms of the gap between citizens and institutions. this would indicate the clear failure of an "alliance" in which citizens have invested their trust in public authorities. on the other hand, an actual demonstration of trustworthiness by the public authorities during the covid-19 emergency may engender a more durable and long overdue step change in institutional trust in italy. as the nobel prize joseph stiglitz put it in a recent interview to the italian newspaper la repubblica 6 (30 april 2020), we should "not waste this crisis, " since it opens up genuinely new opportunities for rethinking the fabric of our societies. what is more, respondents in our sample were fairly optimistic on the future of trust relationships with their institutions, with scientists, and among themselves, while expressing reservations on the adequacy of the current economic model (see section "descriptive statistics"). however, optimism is, by its very nature, a delicate thing, so the danger of experiencing a "trust crack" right after the initial trust boom is as real as ever. indeed, other ongoing research on the relationship between institutional trust and public response to the covid-19 emergency may invite a bleaker outlook on how things will unfold: in their comparison of data from 25 european countries, oksanen et al. (2020) highlighted a negative correlation between institutional trust prior to the crisis and the delay in introducing restrictions to curtail contagion-the less trust was manifested in public authorities before the covid-19 outbreak, the more time passed after the first confirmed virus-related death and the introduction of containment measures. while we do not dispute the role of institutional trust as a protective factor against virus outbreaks (already well documented with ebola, see blair et al., 2017; vinck et al., 2019) , we are skeptical of the particular correlation observed by oksanen et al. (2020) , since it does not take into account the fact that different european countries were affected by the covid-19 outbreak at different times: in particular, italy, france, and spain [all "late intervention countries, " according to oksanen et al. (2020) ] were among the first countries to record severe outbreaks, and much of the measures later adopted by other countries were largely based on the evidence coming in from these first, unwilling testbeds for the public response to the virus. this is confirmed by the same data used by oksanen et al. (2020) : in terms of absolute dates, italy was among the first countries to endorse all the five types of interventions considered in their study, much earlier than many others that are instead regarded as "early adopters." moreover, the alleged correlation considers only the adoption of some form of interventions, without discriminating between countries that adopted all of them (like italy) or just a few, sometimes even only one (as in the case of sweden). this is probably why subsequent data do not seem to support the proposed correlation: for instance, sweden, one of the countries with one of the highest levels of institutional trust before covid-19, as of may 11, 2020 has a very high ratio to the number of deaths per million inhabitants (among the top six nations in the world); similarly, belgium, where containment measures were adopted much more promptly than in italy according to oksanen et al. (2020) , in early may 2020 had the world's highest number of covid-19 confirmed deaths per million inhabitants. for all these reasons, we are not persuaded that prior institutional trust was the main factor determining timely adoption of containment measures by public authorities: while early intervention remains critical in facing virus outbreak, in the case of covid-19, we believe that this was determined mostly by other factors, e.g., where the outbreak manifested sooner in europe. looking at the main predictors of trust highlighted by our regression analyses, respondents exhibited a matter-of-fact, evidence-based attributional strategy toward public authorities: consistently with the socio-cognitive model of castelfranchi and falcone (2010) , competence, intentionality, trustworthiness as information sources, and the perceived adequacy of the proposed interventions were the most relevant factors in justifying trust in public authorities. the relevance given to the role of public authorities as information sources is also consistent with the significant weight that information has in shaping participants' institutional trust, based both on their own self-report and on regression analysis (see sections "descriptive statistics" and "regression analyses"): this highlights the importance of feedback and control for trust. even when trust on public authorities is perceived as a necessity by citizens, they try to retain a measure of control over it, by monitoring the quality of institutional information channels. equally suggestive are some of the factors that failed to impact institutional trust in our sample: most notably, the amount of personal sacrifice imposed upon participants by the restrictions introduced by the government. significantly, this dimension did not affect citizens' trust in public authorities, contrary to what would be reasonable to expect under different circumstances: this, in turn, provides further support to our interpretation of the observed trust boom as a matter of necessity-insofar as public safety is the paramount goal, the severity of the necessary costs are immaterial in modulating institutional trust. this provides a nice illustration of the complex and context-dependent nature of feedback mechanisms on trust attributions: whether or not a certain observable feature of the situation (in this case, personal costs) will affect trust depends on its role within a broader attributional process, which cannot be oversimplified as a single feedback loop (for discussion, see falcone and castelfranchi, 2004) . finally, it is worth stressing that the main predictors of trust remained stable both geographically and temporally: nonetheless, controlling for region of residence allowed us to notice a more focused mindset for trust attribution in the most affected regions, whereas comparing responses before and after the new restrictions introduced in italy on march 11 highlighted a leveling effect of these measures, which made us realize the national character of the covid-19 crisis to everybody, including citizens living in areas with only minor outbreaks. this last point underscores a common pattern to many of our main results: a shift from the particular to the general in how institutional trust is granted and justified by citizens, apparently caused by the unique circumstances of the covid-19 pandemic. as we discussed in section "results, " the responsibility of dealing with this emergency was clearly assigned to the national government, whereas regional and local authorities were perceived as marginal; moreover, high confidence was granted to public institutions, largely ignoring their political affiliation, unlike what happened in other countries, e.g., the united states (goldstein and wiedemann, 2020; kushner gadarian et al., 2020) , and without concern for any further agenda they might serve (in fact, trust in public authorities was paralleled by distrust in the various political parties, including those currently in power); consistently with this mindset, collectivistic reasons for institutional trust trumped individualistic concerns, and the perception of a common effort toward shared goals overshadowed any personal sacrifice that may be required to individuals and groups (this also relates to the fact that personal health itself obliges to look and reflect primarily on collective health, on which the former strictly depends); finally, confidence in each other's compliance with general rules was high, and the future outlook on trust was positive for public institutions, science, and civic society, not so much for the overall model of development. in short, participants responded to this survey not as individuals calculating trust based on likelihood of personal gains or losses (the standard economic view of trust), but rather as members of a collective subject, jointly engaged in facing a problematic situation. this tendency to make common cause against a shared concern is one of the most valuable assets any society can leverage to fight a public crisis, so in this sense, our data paint a positive picture of how italian citizens responded to the covid-19 emergency, as far as trust in public authorities is concerned. however, as repeatedly stressed above, this asset is also incredibly delicate, especially in a country with a complex and thorny history of institutional distrust, like italy. hence, a crucial research priority for future research, both in the short run and in the long term, is to keep monitoring how trust dynamics between citizens and public authorities will be affected by the next stages of the covid-19 pandemic: in fact, while our data suggest a generally positive reaction in the early phases of the emergency, they provide no guarantee of the fact that such trend will continue in the same direction. on the contrary, as mentioned, things could either turn for the best, as our respondents chose to believe, or turn for the worst, should public authorities fail to live up to their citizens' high expectations. all datasets generated for this study are included in the article/supplementary material. this study complied with all the ethical guidelines and standards for online surveys with human participants, in accordance with the local legislation and institutional requirements. the participants provided their written informed consent to participate in this study and were free to quit the survey at any time. rf led the design of the survey. ec, as, and sf performed data analysis. rf and fp wrote most of the manuscript. all authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication. evaluating covid-19 public health messaging in italy: self-reported compliance and growing mental health concerns the altruism question: towards a social social-psychological answer homophily and polarization in the age of misinformation public health and public trust: survey evidence 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ideology and the outbreak of covid-19 in the united states politicizing the covid-19 pandemic: ideological differences in adherence to social distancing italy, forty years of political disaffection: a longitudinal exploration the role of public trust during pandemics political parties, motivated reasoning, and issue framing effects me the people. how populism transforms democracy using social and behavioural science to support covid-19 pandemic response the controversial legacy of 'mani pulite': a critical analysis of italian corruption and anti-corruption policies institutional trust and misinformation in the response to the 2018-19 ebola outbreak in north kivu. dr congo: a population-based survey the liberty of servants: berlusconi's italy self-reported compliance and attitudes about social distancing during the covid-19 outbreak the supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg. 2020.561747/full#supplementary-material key: cord-005385-hswyus24 authors: baehr, peter; gordon, daniel title: on the edge of solidarity: the burqa and public life date: 2012-08-21 journal: society doi: 10.1007/s12115-012-9584-2 sha: doc_id: 5385 cord_uid: hswyus24 dislike among european publics for the islamic full veil and the desire to ban it are often ascribed to nativist "islamophobia." this article questions that assumption. it argues that, in political terms, the wearing of the burqa and niqab is inconsistent with western norms of equality, the backbone of the citizenship ideal; and that, in social terms, the full veil erects a partition to interpersonal understanding and reciprocity. while the constitutional duty to protect religious freedom is a good argument in favor of tolerating the full veil, the practice of wearing it is at the edge of solidarity and injurious to the democratic public sphere. a matter of simple ignorance, or, far worse, evidence of rampant islamophobia. the obvious remedy is not to ban the burqa and niqab (henceforth n/b) but to enlighten the ignorant. puncturing double standards is a good place to start. the american philosopher martha nussbaum puts it this way: it gets very cold in chicago-as, indeed, in many parts of europe. along the streets we walk, hats pulled down over ears and brows, scarves wound tightly around noses and mouths. no problem of either transparency or security is thought to exist, nor are we forbidden to enter public buildings so insulated. moreover, many beloved and trusted professionals cover their faces all year round: surgeons, dentists, (american) football players, skiers and skaters. what inspires fear and mistrust in europe, clearly, is not covering per se, but muslim covering. 3 these analogies fail. pulling a scarf over one's mouth in the dead of winter is an expedient to deal with a temporary situation. once one is in the company of others inside a building, however, the scarf or hat is removed. the same is true for champion skiers or football players who are interviewed after their competition and who relish public attention. dentists and surgeons wear masks for reasons of hygiene that are deemed beneficial to professional and client alike. in contrast, the n/b is not a remedy for a particular occasion; it is a permanent social impediment in all four seasons. and far from having beneficial reciprocity in mind it is a stark expression of separateness. nussbaum's views are typical of those who believe that the full-face veil is not a problem in its own right. if the problem bears no rational relationship to the n/b itself, then it follows that the real problem is in the eye of the beholder. that is in good measure true, as we will show, but not for the reason nussbaum adduces: the fear that often goes by the name islamophobia. sociologists, of all people, should be skeptical of this question begging term. is durkheim forgotten? do we intend, in all seriousness, to explain social currents in terms of individual or aggregate phobias? doubtless, some people view the n/ b as an emblem of unwelcome immigration. doubtless, some people fear muslims for no good reason. but other peopleincluding some leaders of international human rights organizations; some leftist and green politicians; and some prominent muslim intellectuals-share none of these attributes yet still favor banning full veils. those who spoke in 2010 to the french national assembly's information committee on the burqa in favor of a ban included (anri 2010): -sihem habchi, the president of ni putes ni soumises (neither whores nor submissives, a feminist organization founded in 2002) -abdennour bidar, a philosopher and commentator on the koran -andré gerin, a member of the french communist party -patrick gaubert, the president of the ligue internationale contre le racisme et l'antisémitisme (international league against racism and antisemitism) nussbaum also believes, as many do, that n/b-wearing is at root a matter of conscience, a right that demands protection. but conscience cannot be assumed to be the universal motive or defense of covering. muslim women cover for many reasons: piety, pride, tradition, political ideology, and family pressure. oppositional excitement is another factor. as one of eva chi's tunisian subjects confided, "the forbidden is desirable, and the more the government controls the veil, the more it is tempting to challenge it" (2010: 44). besides, in many societies and sub-societies, failure to cover is a mode of deviance that can be and is severely punished. the same is true sometimes even in the west, where in the most dramatic cases facial exposure, the wearing of make up, and the dating of western boys has culminated in planned, orchestrated murder by the shamed family, so called "honor killing" (chesler 2009 (chesler , 2010 husseini 2009; wikan 2008) . one only has to observe women -muslim and infidel both-on international flights to tehran, kabul or karachi donning scarves on entry, and removing them on exit, to appreciate the full weight of customary expectations in covering practices. nussbaum, to be sure, deplores pressures on women to conform. she simply wishes that women who choose to veil be left alone to do so in peace and dignity. yet her sympathy towards traditional practices is one sided. privileging the conscience of the covered over established western norms places the whole burden of adaptation on to the host population. it shifts the requirement to respect tradition on to everyone but the n/b wearer. western conventions of clothing and salutation can be ignored as superficial or coercive. it also bears emphasis that post-colonial writers (nussbaum is not among them), who see the west as "an imaginary formation" (al-saji 2010: 878), fail to note a telling irony of their position: that the fiercest fighters for colonial liberation were adamant about the "uniqueness," "national originality," and "national vocation" of their own cultures. "cultural destruction" was an evil to be resisted. local traditions were at the heart of national identity. anti-colonial radicals, unlike their post-colonial successors, were no cultural relativists. 4 this article seeks to identify features of n/b antipathy that polemics and special pleading routinely obscure. two dimensions are paramount. politically, n/b wearing is by western standards an uncitizenly posture that undermines the twin practices of civic equality and reciprocity. sociologically, n/b wearing impedes cross-cultural understanding, social interaction and, a fortiori, social solidarity beyond the domestic unit. together these political and sociological features suggest that the n/b, whatever the various intentions of its wearer-religious devotion, identity statement, life-style choice, generational revoltmarks a person as a political and social outsider within a western environment. three caveats preface the argument advanced below. first, our focus on the n/b is exclusively on its public appearance on the street, in public buildings such as schools, hospitals and offices, in parliaments and so forth. the garb is typically removed in domestic, familial settings. second, we say nothing of substance about the hijab (headscarf) or the iranian chador, both of which reveal the face without serious impediment. in france and belgium, the issue of the full veil has been formulated as a problem separate from the problem of the headscarf. speaking to the french national assembly (anri: 592), the sociologist nilüfer göle, whose book the forbidden modern (1997) elicited sympathy for the headscarf, described the full veil contrastingly as "a regression or, at least, a very radical will to rupture with reciprocity and exchange." the third caveat is that our comments refer exclusively to n/b wearing in western societies where it is an unorthodox attire confronting folkways and sentiments different from those in, notably, the middle east. there, and in western enclaves where middle eastern people are in the majority, matters are entirely different; the n/b is an accustomed presence of everyday life. as such it mostly prompts no comment or curiosity. in its native milieu, full-face covering is acknowledged but little noticed, whereas discarding it would drastically increase the visibility of the woman who did so. vision, as we now turn to see, is influenced by powerful cultural traditions. 5 citizenship in western democratic regimes is based on ideals of equality. 6 whereas other spheres of life are particularistic, asymmetric or exclusive-the family of which one is a member, religious confession, how much money one makes, how good looking, clever, socially adept or athletic one is, and so forth-modern citizenship confers on adults in a political jurisdiction the same rights (for instance, to vote) and obligations (such as tax payment) irrespective of rank, class, gender, religion, ethnicity and family (weber [1917 (weber [ ] 1994 . 7 to be sure, the prerequisites of citizenship in western societies are heterogeneous (brubaker 1992; caldwell 2009: 148-154) . and it is evident that many people who reside in a country, such as immigrants, are not afforded full political protection and rights of participation. our concern in the present argument, however, is mainly with the norm of equality as a conceptual basis of citizenship. that this is an idealized picture of the modern constitutional polity need not detain us so long as the aspirational link between equality and democratic citizenship is accepted. idealization is, in any case, an important part of citizenship; it enables citizens to demand that states lives up to their ideals. more immediately pertinent is that citizenship equality is, in fundamental ways, integrally related in western traditions to citizens being visible to one another. this expectation is registered in theories of moral judgment (consider the role played by the "spectator" in adam smith and kant's theories of judgment) and in some of our most potent democratic terms and metaphors: enlightenment, openness, transparency, illumination, recognition, social legibility, accountability, "publicity" and, not least, public, to which we return in the next paragraph. the echo of biblical revelation and ancient greek thought in these notions is audible. for the eighteenth century philosophes, enlightenment substituted holy writ with "the great book of nature, open for all mankind to read." the heavenly city of the philosophes was a city of light surpassing in its rational luminosity even the splendor of the sun king (becker ([1932] 1964: 51, 105-6) 105-6). negating these images are opacity, the dark ages, the dark arts, dark times, heart of darkness, artifice, living in the closet, a shadowy realm, a troglodyte world (paul fussell's depiction of world war i trench warfare), cavelike illusion, stygian gloom, moral blindness, the id, concealment, inscrutability, subterfuge, murkiness, obscurantism, and backroom deals-notions which imply various states of ignorance, menace and deceit. in sharp contrast, liberals trumpet the virtue of the open society and liberalized marxists idealize the translucent speech-situation. socialists and radicals extol debunking, the heir of rousseau's ([1750 rousseau's ([ ] 1993 crusade to remove the "deceitful veil of politeness" which conceals "fear, coldness, reserve, hate, and fraud". true, prominent french intellectuals of the last century sought to demote vision's status in the pantheon of sensibility (jay 1994) , while conservatives still remain attached to the "decent drapery of life" (burke [1790 (burke [ ] 1999 ). yet these perspectives have done little to impede the centrality of seeing within the western, apollonian political aesthetic. invented in the ancient greek world, the concept of "public" has assumed since its birth a host of connotations: common property and the common good; a realm in which free and equal men are able to deliberate on and decide political affairs; a place of discourse rather than labor; the primacy of law over arbitrary rule; a domain in which the ruler is considered to be a kind of custodian or guardian of the commonweal rather than a seigneur or lord; a region in which citizens may find distinction and glory; an area accessible to the many; a vehicle of composite opinion; a community pursuing a joint purpose (habermas [1962 (habermas [ ] 1999 oakeshott 1975: 149, 207, 218.) each of these meanings has, in turn, taken on its own inflections; for instance, robert nisbet's (1982: 249-50 ) distinction between public opinion ("the sturdy filter of long-shared values and traditions") and popular opinion (the transient froth of mood and fashion). of special relevance for our enquiry is that by the mid-sixteenth century, public added to its modern meanings the sense of activities and events that are "manifest and open to general observation" (sennett [1974 (sennett [ ] 1992 . in the public sphere, unlike domesticity, we demand to see what is going on, we expect honest dealing, disclosure; hiding is an affront to that stipulation. hannah arendt (1958: 50-3) claimed that the word public evokes two "interrelated phenomena". first: everything that appears in public can be seen and heard by everybody and has the widest possible publicity. for us, appearance-something that is being seen and heard by others as well as by ourselvesconstitutes reality. compared with the reality which comes from being seen and heard, even the greatest forces of intimate life-the passions of the heart, the thoughts of the mind, the delights of the senses-lead an uncertain, shadowy kind of existence unless and until they are transformed, deprivatized and deindividualized, as it were, into a shape to fit them for public appearance…the presence of others who see what we see and hear what we hear assures us of the reality of the world and ourselves… the second referent of public is "the world itself, in so far as it is common to all of us and distinguished from our privately owned place in it." the world, in arendt's usage, comprises not the terrestrial globe or earth on which we stand and from which we derive our physical sustenance, but the sphere of created things that join and separate us, the sphere of human "affairs which go on among those who inhabit the man-made world together." this formulation suggests what is discordant about the n/ b's existence in the western political space. while for its bearer the n/b may be understood as a badge of tradition and piety, from the standpoint of a constitutional pluralist citizenry it is a mode of concealment incompatible with public recognition in which visibility of face is central. the n/b denudes facial and, to a degree, vocal recognition, debilities to which we shall return in a more sociological context later. it standardizes human features and hence contributes to the very stereotyping that n/b wearers themselves deplore. faces and voices are all different, evidence of human plurality. the n/b literally effaces these variations, with the partial exception of the eyes that may sometimes be seen. the n/b also symbolically ruptures the bond of citizenship reciprocity because while its wearer can see her real or potential interlocutor, can take advantage of the visibility of others, non-wearers are denied such access. the integral importance of reciprocity to "public reason" and, its corollary, deliberative democracy, is a leitmotif of john rawls's later work. rawls says that the role "of the criterion of reciprocity…is to specify the nature of the political relation in a constitutional democratic regime as one of civic friendship" (rawls 1999: 137) . in arendtian terms, n/b apparel is an obstruction to "appearance"-"something that is seen and heard by everybody and has the widest possible publicity." to this line of reasoning at least four objections can be anticipated. n/b-clad persons, it might be protested, do appear in public; they simply appear in a different way to those uncovered. that is true. indeed one might add that concealment of the face and other parts of the body is by no means the same as general inconspicuousness. on the contrary, in western societies the n/b wearer is more eyecatching than the non-wearer of it, more subject to the stare or, conversely, more prone to evoke the embarrassment that greets attire that is deemed bizarre or inappropriate. some (notably al-saji 2010: 886), sympathetic to veiling, claim that it is western attitudes themselves that are responsible for a bizarre combination of the seen and the unseen. hence "while the veil is hypervisible as an oppressive and repressive barrier [according to its critics], muslim women 'behind the veil' are not merely invisible to the western gaze, but are made invisible as subjects" by not being respected. yet uncitizenly comportment is not about appearance as such. it is about a precise type of appearance that, concealing the face, impedes mutual openness and repels interaction as equals. frantz fanon ([1959 fanon ([ ] 1965 , describing what he called the "phenomenology of encounters" between the colonized veiled woman and the colonist, amplifies the point: the woman who sees without being seen frustrates the colonizer. there is no reciprocity. she does not yield herself, does not give herself, does not offer herself. the algerian has an attitude toward the algerian woman which is on the whole clear. he does not see her. there is even a permanent intention not to perceive the feminine profile, not to pay attention to women… [in contrast, the] european faced with an algerian woman wants to see. fanon cheered on this lack of reciprocity, enjoying the aggravation it caused the powerful. the colonized woman seeks to frustrate the will of the colonial man. that is not our current situation. the colonial was an interloper, unwelcome in a foreign land, bending and breaking customs so that his will be done. today, in western societies, muslim citizens are afforded equal rights in law, which is to say they are accorded the same rights as non-muslims. yet one group still veils while another is visible. denial of reciprocity to occupiers of colonial societies is extended to citizens of post-colonial ones. a second objection to the argument that hiding the face is uncitizenly might run as follows. users of the internet are often obscured from view and no one assumes that their being invisible is uncitizenly. indeed, under some definitions of politics, the internet might be considered the quintessentially modern medium of political life: informing the public of political events, orchestrating voting, requesting or inciting people to participate in demonstrations, directing attention to abuses of rule, mobilizing citizens for collective action. search engines like google ever more assume traditional government functions. its engineers claim that the company's predictions of flu epidemics and employment trends are already more accurate than those of the centers for disease control and the bureau of labor statistics. better predictions of "crime, terrorism and political unrest" may be in the offing, prompting one journalist to predict in turn that the "line between google and government is destined to blur." 8 even so, the political effectiveness of the internet, especially in comparison with face-to-face encounters, is more dubious, or at least more complex, than it first appears. to those who claim that digital networks act "as a massive positive supply shock to the cost and spread of information, to the ease and range of public speech by citizens, and to the speed and scale of group coordination" (shirky 2011: 154) , others reply with considerable skepticism. the above statement may be true, they say, but "weak ties" rarely lead to "high-risk activism." the latter entails not only personal contact and hard graft in actually building a movement but also organizational hierarchy, even in the most democratic initiatives. loose networks are no substitute for the "precision and discipline" afforded by such centralized groups as the naacp during the civil rights' struggles of the 1950s and 1960s. "facebook activism succeeds not by motivating people to make a real sacrifice but by motivating them to do the things that people do when they are not motivated enough to make a real sacrifice"-for instance, giving on average nine cents a piece to the facebook save darfur coalition (gladwell 2010: 1-6) . this important debate is not, however, central to the n/b issues raised here and for a plain reason. in western societies the internet is an ancillary to public display not a substitute for it, a tool to expand communication, rather than an obstacle to constrict it. computer webcams are employed between interactants and in web chat rooms; interviews of foreign job applicants conducted via skype grow daily in popularity. and it is no coincidence that the world's most prominent social networking site is called facebook. moreover, where internet use takes place without face recognition (as with email or instant messaging) it typically does so reciprocally: both users are in the same position and hence issues of visibility imbalance and citizen asymmetry do not arise. a third objection to the claim that n/b attire in public places is uncitizenly turns the tables on the authors: it draws on the graeco-roman tradition itself, the origins of western notions of citizenship. in that tradition, being a public person was considered a kind of theatricality in which an agent adopts a persona, a mask. hobbes ([1651] 1996: 111-2) , before noting that "persona in latine signifies the disguise, or outward appearance of a man, counterfeited on the stage; and sometimes more particularly that part of it, which disguiseth the face, as a mask or vizard," observed: a person, is he, whose words or actions are considered, either as his own, or as representing the words or actions of an other man, or of any other things to whom they are attributed, whether truly or by fiction. when they are considered as his owne, then he is called a naturall person. and when they are considered as representing the words and actions of an other, then he is a feigned or artificiall person (hobbes's emphasis) the persona was and is, however, a metaphorical mask, not one of cloth. in hobbes' political theory, it was a means of expanding modes of public representation whereas the n/ b is a symbol of religious belonging and, in french parlance, a claustral "folding in" (repli communautaire) or a "closing off" (enfermement) (bowen 2007: 156. 177 ). in antiquity, the function of persona was not to conceal public visibility but precisely to do the opposite: to shine the light of the polis on the political actor, to dramatize the fact that the individual had entered the public stage and that, as such, had left the private world of intimacy so as to consort freely with his peers and deliberate on political affairs. the political persona was, then, an addition to, or rather a rupture with, private life, not a replication or extension of it, a vehicle of distinction, not a mantle contrived to expunge from public view the unique personality of the woman beneath its folds. 9 politics, in western traditions, entails a split within the being that engages in it, the construction of a second self: as an equal of others who are familial strangers bound together by the common tie of citizenship; a self able to cooperate with these strangers, to "see" things from multiple points of view and be seen seeing. more generally, the western political tradition is notable for its pronounced binary structure: oikos and polis, dominium and res publica, lordship and office, king and crown, natural persons and artificial persons 8 christopher caldwell, "government by search engine," financial times, oct. 15, 2010, http://www.ft.com/cms/s/0/a62be1dc-d897-11df-8e05-00144feabdc0.html#axzz1k1hbrfpp 9 arendt 1963: 106-9. (louglin 2003: 6, 21, 45, 55-7, 76-9) . superimposed on these bifurcations are other contrasts that impute to religion, and religious institutions, a separate sphere of engagement to that of the political: god and caesar, piety and justice, sacerdotium and regnum, church and state, soul and city, revelation and reason, sin and crime (scruton 2003:1-6, 23, 134-139) . the nb, however, is not a fictive mask designed to open up its wearer to the public recognition of peers acting in concert or in conflict; it is a carapace projected into the public space, a material mask that signals exclusivity, an emblem of segmental occlusion, of what durkheim ([1893 durkheim ([ ] 1997 , discussing the primacy of resemblance in tribal societies, called the politico-familial. as a badge of similitude, the n/b smacks of mechanical solidarity. nor is the n/ b artificial or dualistic. on the contrary, it signifies sharia's total claim on the individual in all her activities, the type of claim that the public-private distinction expressly repudiates. it transpires that the classical concept of the mask and the n/b have nothing substantively in common. finally, it might be objected that our argument about the uncitizenly nature of the n/b rests on an unduly restrictive notion of citizenship. after all, the meaning and practice of citizenship has expanded greatly over the past two centuries. citizenship today involves social and cultural dimensions, not simply political and juridical ones. it straddles a wide array of contents, types, conditions and arrangements (susen 2010) . that being the case it is strained to place, as this article does, such a burden on the political idea of equality and reciprocity to the exclusion of all other citizenship elements. yet while a political community of equals, obligated to one another, is no longer a sufficient aspect of citizenship in the west, it is nonetheless a necessary aspect of it. moreover, an inflationary conception of citizenship is not without major problems or incongruities, as a number of theorists recognize. simon susen (op. cit.: 273) , for instance, insists that the "extension of civil, political and social citizenship to a potentially infinite number of different forms …leads to the relativistic impoverishment" of "contemporary accounts of the political". for if any social group can claim citizenship on the basis of its own definition, the concept degenerates into a "mere identity game". richard bellamy (2008: 51, 98-9) agrees. citizenship, he says, is ever more defined as a series of global human rights. and these putative rights are constantly growing. a survey conducted by the polling organization globescan for the bbc, on a population of 27,000 adults in 26 countries, found that four in five respondents believe that internet access is a "fundamental right." 10 the "absence of a political dimension," however, suggests a "somewhat second-rate account of what being a citizen involves". and why is that? because the "idea of a political community of equals … lies at the heart of citizenship." bellamy (2008:114) also remarks that "citizenship involves a degree of solidarity and reciprocity between citizens" and that such citizens "need to see each other as equal partners within a collective enterprise." if that is true, the n/b is a negation of citizenship. disguising the face, and avoiding contact with the kafir, disables citizens from "seeing" each other as free and equal partners. we have been discussing the ways in which n/b effacement breeches norms of political equality and reciprocity, the backbone of the citizenship ideal. n/b wearing is further accompanied by a social impairment: the partition it erects to interpersonal understanding and solidarity. making sense of the conduct of others in face-to-face, real-time encounters requires us to pay attention to more than disembodied words. unlike reading a book, which is a cognitive, reflective endeavor, albeit informed by past experience and learned competences, inter-personal understanding draws on immediate, spontaneous and practical aspects of the interaction-situation itself. these aspects are both cognitive and somatic: emotional signals emitted by the face, the voice, and the body in general. as erving goffman (1963:34-5) remarks, "bodily idiom … is a conventionalized discourse. we must see that it is, in addition, a normative one." he adds ([1955] 1967: 33) : during direct personal contacts…unique informational conditions prevail and the significance of face becomes especially clear. the human tendency to use signs and symbols means that evidence of social worth and of mutual evaluations will be conveyed by very minor things, and these things will be witnessed, as will the fact that they have been witnessed. an unguarded glance, a momentary change in tone of voice, an ecological position taken or not taken, can drench a talk with judgmental significance. humans in their social transactions, goffman reminds us, are constantly engaged in "face work," a semiotic traffic in which proper deference is given and where the appropriate demeanor is supposed to be maintained. "good" demeanor "is what is required of an actor if he is to be transformed into someone who can be relied upon to maintain himself as an interactant, poised for communication and to act so that others do not endanger themselves by presenting themselves as interactants to him" (ibid: 77). probably the single most important sign-vehicle that humans possess, the chief corporeal building block of solidarity in situational encounters, is the face. people who look away when we are talking to them, scanning the perimeter, are apparently preoccupied with other matters; they are indicating a kind of inattentiveness that, in our culture, translates to distraction or rudeness. our response to their alienation is alienation of our own. more generally, signals of emotions-such as sadness, anger, surprise, fear, disgust, contempt, and happiness-have facial correlates that convey various kinds of information about their bearer. 11 what makes people angry, for instance, differs to some degree among persons and cultures; but the looks of anger are universal, and spontaneously understood, part of our evolutionary hard wiring and manifested in muscular movements that differ both in intensity (ranging from irritation to fury) and type (sullen anger, resentful anger, indignant anger and cold anger) (ekman 2003: 58) . even when we seek to manage or hide our emotions, it is common for them to leak out through facial signs, bodily gestures and tone, volume and pitch of voice. accordingly people who look at us can, with a fair bit of reliability, tell how we are feeling unless we suppress our expressions (ibid: 54-55) or hide them as the n/b does. (botox and other similar treatments, by giving the face a stony and shiny appearance, also reduce expressive capacity and viewer reception.) even if we can see the eyes of the facially covered, as with the niqab, we may not be able to see the frame that gives their glance meaning: the forehead, the eyebrows, the mouth and the cheeks that, in various combinations of muscular movement or fixity, impart emotional information to the viewer. when people have difficulty understanding one another, this does not mean that fellow feeling between them is impossible. non-muslims, or the habitually uncovered in any society, are likely to feel sympathy for the woman in a crowded airport whose outfit must, in many circumstances, make her hotter, more confined and generally more uncomfortable than she would otherwise be divested of a niqab. or so we are inclined to think. the truth is that we do not know for sure and, out of a sense of propriety, would not wish to enquire. adam smith notes that much of our sympathy for others is not an accurate reflection of how they feel but how we imagine we would feel if we shared their situation. to illustrate this point, he ([1759] 1976: 12-13) gives a consoling example: we sympathize even with the dead, and overlooking what is of real importance in their situation, that awful futurity which awaits them, we are chiefly affected by those circumstances which strike our senses, but can have no influence on their happiness. it is miserable, we think, to be deprived of the light of the sun; to be shut out of life and conversation; to be laid in the cold grave, a prey to corruption and the reptiles of the earth; to be no more thought of in this world, but to be obliterated, in a little time, from the affections, and almost from the memory, of their dearest friends and relations…. the happiness of the dead, however, most assuredly, is affected by none of these circumstances; nor is the thought of these things which can never disturb the profound security of their repose. time and again, smith reminds us that moral imagination is mediated by vision: seeing, gazing, looking on, looking upon, (his words) objects that, thereby, excites us to feel compassion, revulsion and a host of other emotions. the connection, he says, between the way we feel about a person's plight, and that person's situation, is our witnessing the former, and our "foresight" (again smith's term) into the implications of the latter. it follows that our ability to judge with confidence a person's situation is greatly limited if our seeing, gazing, looking on and looking upon, let alone our foresight, is obstructed. whether georg simmel recalled smith's comments on this matter is unknown. but he offers an intriguing gloss on them in the remark that of "the special sense-organs the eye has a uniquely sociological function. the union and interaction of individuals is based upon mutual glances. this is perhaps the most direct and purest reciprocity which exists anywhere." 12 to return to our example of the n/b clad woman in the crowded airport: sympathy may turn to pity and indignation on her behalf if we believe that her dress is a sign of oppression. or we may feel incredulity and confusion. when people "turn off" their emotional lights, they appear blank and lifeless. covering the face turns off emotional lights in the most direct and comprehensive way imaginable. its consequences for fellow feeling and the interaction it enables in western societies are significant. to understand with greater precision why this is so, it is useful to identify three kinds of attachment among strangers: political solidarity, social sympathy, and social solidarity. these modes are ideal-types that in reality are intermingled to a greater or lesser extent. the point of sketching them is to discern whether, and to what extent, they can be extended to sartorially sequestered persons. political solidarity is an action or series of actions derived from an obligation: the duty, as we believe it to be, to support those who share similar political or quasi-political values to our own. socialists are happy to stand by other socialists who are embattled, whereas they are happy to see an abundance of liberals and conservatives in total disarray; and vice versa. political solidarity is hence a union of like with like and it is confined to that likeness. we feel political solidarity for groups to the extent they embody beliefs that we consider vital-say, of fairness or dignity-or because their predicament reveals dangers to which we could ourselves one day be exposed. people committed to constitutional pluralism, for instance, believe that all non-violent groups of citizens that obey the law are entitled to rights of participation. when british and west european trade unionists supported the polish trade union and political organization solidarity, during the 1980s, they did so out of the conviction that workers should support one another when oppressed by the state (or employers). while political solidarity is limited to like supporting like, confined to helping people as citizens or protocitizens of a certain persuasion (e.g. liberals not fascists, political prisoners not political jailors, workers not employers), social sympathy is potentially boundless and, where it is not simply emotional, rests on the altruistic principle of assisting individuals as fellow human beings, irrespective of their political and other views. social sympathy is boundless because the suffering that prompts it is endless. and unlike political solidarity, social sympathy is deaf to political antagonisms, credentials and alliances. social sympathy is especially sensitive to individuals rather than groups; and the individuals for whom sympathy tends to be strongest are children. while political solidarity is principally a matter of adult responsibilities, nothing is more likely to trigger social sympathy than the sight of a bedraggled orphan, a crying stray, an emaciated child, or a young face ravaged by the horror of war. it is for good reason that humanitarian aid agencies use such images as their prime advertising tool. social sympathy, often shading into pity, is more affective, more immediate, less detached and less conceptual than political solidarity (arendt 1963: 88-89) . and while political solidarity flags a boundary or marker of exclusion (not everyone is our ally but only those who share our convictions), social sympathy is infinitely extendable. the sense of justice that inspires social sympathy is based not on the requirements of political similarity but on the fulfillment of personal charity, common decency and elite philanthropy. those to whom we tender political solidarity are comrades and political equals, real or imaginary; those who provoke social sympathy are the abandoned with whom we have nothing in common aside from our humanity. neither political solidarity nor social sympathy requires physical proximity. nor do they require symmetry and reciprocity. a and b may strike up an alliance to assist one another, generating a vitality that neither party possesses by itself. just as often, however, the solidarity afforded by a to b is never reciprocated by b (south african trade unions under apartheid; political prisoners in china and cuba) because a, being safe and secure, has no need of reciprocation, and because b lacks the resources ever to "repay". similarly, the gifts of social sympathy are unlikely ever to occasion gifts in return because their recipients are simply too poor, too powerless and too geographically distant to give anything back. the weak are neither expected nor in a position to shore up the strong. in sharp contrast, social solidarity derives principally from face-to-face encounters and it requires reciprocity and mutual respect for its very existence. sociology 101 still teaches introductory students to think of social solidarity as the socialization of norms and values that, where successful, permeate the reflexes of human beings, coordinating their behavior, and committing them to common moral standards. or solidarity is said to arise from increasing differentiation, the modern division of labor, whereby we become dependent on a manifold of people and services that provide conditions of our existence that we are incapable of providing for ourselves. these textbook descriptions are not so much wrong as imprecisely stated or at least stated in such a way as to mean something different from social solidarity as the term is used here. drawing on the durkheimian model, we can say that social solidarity is a mode of cohesion based on mutual recognition of worth and classificatory congruence. in turn, these properties emerge out of situations of a special type, namely those that enact interaction rituals in natural settings. these rituals, more often spontaneously slipped into than deliberately choreographed, are ever present in social relations and help create a common mood centered on common foci of attention. the more intense the attention, the more concentrated the intersubjective awareness of the ritual participants of their common bond; as awareness increases, so too, does the entrainment of the actors as they fall into a common rhythm of interactions, and share the "emotional energy" they generate (durkheim [1912 (durkheim [ ] 1995 and especially collins 2004) . human rituals require co-presence. they may span the smallest encounter between two people-a greeting at the office, a joking relationship with a colleague, a marriage proposal-or larger units such as a sports event or a political demonstration; during a major crisis, a whole city may briefly be caught up in the same set of rituals. in each case, those in contact with one another expect, and themselves cultivate, a demeanor of respect for the situation and its participants so as to allow the interaction to proceed smoothly. and ubiquitously, interaction rituals take place within boundaries of recognition that delineate outsiders in the very act of soliciting the chosen few and affirming their status. those boundaries are marked by totems such as wedding rings, flags, holy buildings, songs, coins, slogans and other representations of exclusiveness that remind ritual interactants of past deeds and past promises and arouse commitments to the interactant unit. despoilment of these totems, or betrayals of the rituals of group intimacy they signify, cause anger and aggression. as a local event, a bounded interaction among subjects who give each other face and by so doing find unity in their social commerce, social solidarity is thus also the occasion of conflict between those granted respect and those denied it, between those in the "pocket of solidarity," and those outside it, between those allowed access to the enclave of valued transactions and those denied admittance as pariahs or inferiors . in this context, one sees the difficulty of social solidarity emerging spontaneously for and with n/b clad women. 13 if is true that "eye-to-eye looks…play a special role in the communication life of the community, ritually establishing an avowed openness to verbal statements" (goffman 1963: 92) , then it is also true that n/b, as a materialized collective representation, is an avowal of closure to familial strangers, a sharp boundary. the covered woman's eyes may well be visible, but covering itself is a disincentive towards meeting the eyes; a glance must be especially furtive if is not to push "civil inattention" too far and become offensive. in goffman's (1963: 38, 92-3) lexicon, the n/b is an "involvement shield." as with all such shields, the result is a dilution of both "richness of information flow" and "facilitation of feedback" (ibid: 17). more generally, the inability to see potential interlocutors is a major impediment to drawing "emotional energy" from them. the sociological irony is that a garb that signifies the danger of contamination-the male gaze-may itself be deemed dangerous by strangers because it represents tribal notions of exclusiveness as contrasted to pluralist notions of far-flung reciprocity. along these lines, stefaan van hecke, a member of the belgian ecolo-green! party, stated in the chamber of deputies that his party had supported the headscarf but that the burqa "goes too far in our eyes" because it is "a wall that permits no communication." he was immediately supported by georges dallemagne of the democratic humanist center party. "it [the burqa] represents to us a rupture with the fundamental principle of our society which holds that communication, even of a minimal kind, among the members of society implies the possibility of seeing the face of the other" (crb2 2010: 23-25). notice, however, that it is not public covering as such that creates alienation; it is the meaning that the covering conveys, together with its permanence. cities that experience particularly dangerous epidemic diseases such as the sars outbreak in hong kong in 2003 witnessed omnipresent mask wearing. but "efface work" (baehr 2008: 159-167) in the hong kong case shows that while mask wearing was a signal of repulsion ("don't get too close to me") it acted also as a signal of common courtesy: less a prophylactic against catching the virus than a symbol of deference for the sensibilities of others, expressing the desire not to infect them. in this case distance served the purpose of reciprocity; it was a demeanor that flagged respect. mask wearing in these conditions was temporary; it was a response to crisis. it was also ubiquitous, rather than being exclusive to one group. when sars retreated, the masks were discarded. the n/b is entirely different. it is a permanent marker of a separation deemed normal. it is not irrational for muslims to wear the n/b where it is appropriate for a certain kind of life. nor is it irrational for such covering to provoke indignation in another ritual order with diverging norms of appropriateness. however, "diversity" consciousness-the idealization of multiculturalismfinds such legitimate and rational incommensurability hard to handle. if two ritual orders are in collision, one of them must be phobic. we know which one that is. this article's exploration of the n/b's appearance in the west is limited in many obvious ways. it represents neither the experiences of covered women in western lands nor offers an ethnography of covering practices and native responses to them-for instance, videotaped behavior of people in supermarkets, airports and streets. both tasks are valuable; the latter, in particular, would be able to test, qualify and refute some of the claims made above. equally this article offers no divination of public opinion polls (the pew survey referenced at the beginning of this article did not ask people why they support a burqa ban), nor does it argue on the basis of survey data or interviews conducted by the authors. we offer something else: an enquiry into the political and social frameworks that, even in the absence of hatefulness and prejudice towards muslims, make the n/b profoundly dissonant with western traditions. these traditions are no less weighty by being historically "constructed". they are the real frameworks, or shards of frameworks, within which people make sense of the world. as we have stressed, our principal concern is with what the n/b controversy reveals about western structures of thought and feeling rather than what is says about muslim women. another limitation of the foregoing is that it offers no definite public policy advice to governments regarding prohibition, no attempt at adjudication to parties involved in the dispute. this is not a debate on which a sociologist can deliver authoritative judgment. it is a matter of political argument, moral choice and, almost inevitably, conflict. nor can sociologists ignore legal traditions that play a major role in defining the rationality or irrationality of a ban. for french ultra-secularists, banning the n/b makes sense in 13 we are also unlikely to extend political solidarity to those whose idea of politics is so very different from our own. we are just as unlikely to feel social sympathy for people who are happy to be as they are, if they are indeed happy, or who do not request our aid. light of france's republican tradition and civil religion. it also makes sense given france's tradition of regarding the public space as a controlled sphere in which egalitarian mannerisms and citizenly gestures are not merely a polite choice but a civic duty, a necessity, backed in constitutional law by the doctrine of "public order" (gordon 2008: 47, 52-53, 63 note 53; baehr and gordon 2013; anri 2010: 556-558) . for most americans, by contrast, prohibition is largely unthinkable because a) it contradicts the first amendment of the constitution protecting "the free exercise" of religion; b) americans fear government regulation more than they do cultural diversity; and c) the american idea of "religion" is more generic and inclusive than that of the french. americans rush, in cross-religious solidarity, to faiths that are embattled, believing that infringement on the liberty of one confession is potentially a threat to them all (gordon 2008:48-51) . both the structure of american jurisprudence and american popular culture work against a burqa ban. logic and universal morality (moralität), on which philosophers and theologians pronounce, is different from situated ethicality (sittlichkeit) with which historians and sociologists are concerned. 14 underpinning that ethicality are legal systems and popular conceptions of constitutional freedom. if the burqa controversy reveals more about what is important to western traditions than it does about muslim women, it also raises vital questions. these are questions about the rights of groups to organize their own collective life; questions about the responsibilities of the state to protect individuals within groups who are oppressed by them; questions about the indispensable nature of basic forms of citizenly, face-to-face comportment in a democracy; and questions about whether the state can legitimately require citizens to be communicative and reciprocal with each other, or whether the minima of transparency are a matter of choice. the burqa is at the edge of solidarity. it may be deemed a symbolic harm to democracy, or as a basic civil right. but the burqa controversy is certainly more than an expression of islamophobia. it is a predicament requiring us to articulate our democratic conceptions with uncustomary precision. and no matter which policy we choose, to ban or not to ban, it requires us to recognize the antimonies of democratic existence, and to sacrifice some goods for the sake of protecting others. the racialization of muslim veils: a philosophical analysis rapport d'information au nom de la mission d'information sur la pratique du port du voile integral sur le territoire nationale the human condition on revolution reflections on little rock from the headscarf to the burqa: the role of social theorists in shaping laws against the veil caesarism, charisma and fate: historical sources and modern resonances in the work of max weber the heavenly city of the eighteenth-century philosophers citizenship. a very short introduction why the french don't like headscarves. islam, the state and public space citizenship and nationhood in france and germany reflections on the revolution in france. indianapolis: liberty fund reflections on the revolution in europe. immigration, islam, and the west are honor killings simply domestic violence worldwide trends in honor killings persistent orientalism and burdened souls: a critical reading of the hijab debate through the case of la rochefoucauld and the language of unmasking in seventeenth-century france compte rendu intégrale séance plénière 4th session, 52nd legislature, plenary session 151 how institutions think 1893) 1997. the division of labor in society. translated by w.d. halls, with an introduction by lewis a. coser elementary forms of religious life. translated with an introduction by emotions revealed explaining social behavior algeria unveiled tear off the masks! identity and imposture in twentieth-century russia the great war and modern memory small change interaction ritual. essays on face-to-face behavior behavior in public places. notes on the social organization of gatherings the forbidden modern: civilization and veiling why is there no headscarf affair in the united states? historical reflections the stuctural transformation of the public sphere. an inquiry into a category of bourgeois society. translated by thomas burger with the assistance of frederick lawrence 1821) 2002. the philosophy of right. translated by alan white the veil in their minds and on our heads: veiling practices and muslim women murder in the name of honor downcast eyes: the denigration of vision in twentieth-century french thought new tech, new ties. how mobile communication is reshaping social cohesion the idea of public law accommodating protest: working women, the new veiling and change in cairo phenomenology of perception. translated by beyond the veil. male-female dynamics in modern muslim society the veil and the male elite on the political prejudices. a philosophical dictionary beyond the veil: a response on human conduct niqab and burqas -the veiled threat continues the law of peoples the social contract pluralism and the personality of the state political hypocrisy. the mask of power from hobbes to orwell and beyond translated with an introduction by george schwab, foreword by tracy b. strong and notes by leo strauss the politics of the veil the west and the rest. globalization and the terrorist threat the fall of public man from innovation to revolution 1759) 1979. the theory of moral sentiments transparency and obstruction. translated by arthur goldhammer, with an introduction by montaigne in motion. translated by arthur goldhammer the transformation of citizenship in complex societies suffrage and democracy in america behind the veil in arabia honor of fadime. murder and shame. translated by anna paterson peter baehr is an international editor of society and professor of social theory at lingnan university, hong kong daniel gordon is professor of history and associate dean of the commonwealth honors college at the university of massachusetts amherst. he is also co-editor of the journal historical reflections key: cord-336142-jmetfa6x authors: macdougall, heather title: toronto’s health department in action: influenza in 1918 and sars in 2003 date: 2006-10-11 journal: j hist med allied sci doi: 10.1093/jhmas/jrl042 sha: doc_id: 336142 cord_uid: jmetfa6x this article compares the toronto health department’s role in controlling the 1918 influenza epidemic with its activities during the sars outbreak in 2003 and concludes that local health departments are the foundation for successful disease containment, provided that there is effective coordination, communication, and capacity. in 1918, toronto’s moh charles hastings was the acknowledged leader of efforts to contain the disease, care for the sick, and develop an effective vaccine, because neither a federal health department nor an international body like who existed. during the sars outbreak, hastings’s successor, sheela basrur, discovered that nearly a decade of underfunding and new policy foci such as health promotion had left the department vulnerable when faced with a potential epidemic. lack of cooperation by provincial and federal authorities added further difficulties to the challenge of organizing contact tracing, quarantine, and isolation for suspected and probable cases and providing information and reassurance to the multi-ethnic population. with growing concern about a flu pandemic, the lessons of the past provide a foundation for future communicable disease control activities. (sars) in mount sinai hospital in april 2003 exemplifies the fear and concern that outbreaks of infectious disease provoke in the families of frontline workers. 1 for historians, both the role of the media in highlighting the dangers of an epidemic outbreak and the response of health authorities recalled nineteenth-and twentieth-century reactions to cholera, typhus, yellow fever, smallpox, bubonic plague, and poliomyelitis rather than hiv/aids. 2 but what part was toronto's health department to play in an international health crisis? as the sars outbreak once again demonstrated, local public health organizations are the foundation for concerted community efforts to manage disease and control public panic. 3 by comparing and contrasting the way in which public health authorities in toronto managed the 1918 influenza pandemic and sars in 2003, we can see how a century of medical advances had conditioned the public and health care professionals to expect prompt control of communicable diseases, speedy development of a prophylactic vaccine, and effective exchange of information at the provincial, national, and international levels. but both outbreaks also demonstrated the power of negative ethnic and class stereotyping, the impact of the media in both educating and frightening the public, and the high cost in terms of human lives and devastation of the local and national economies. 4 in 1918 and 1919, the worldwide influenza pandemic is estimated to have killed between 20 and 40 million people. for european and north american nations who were just coming to the end of world war i, with its toll of 6 to 9 million dead and wounded, the flu seemed to be the fourth horseman of the apocalypse. 5 war, famine, pestilence, and death challenged canadians, americans, and their allies and foes both to respond to the immediate threat and to institute more formal national and international organizations to ensure that future pandemics were controlled before they could spread beyond their countries of origin. the great pandemic also gave further impetus to biomedical research that resulted in the discovery of the causative virus by british researchers in 1933. 6 as research continued, however, the complexity of influenza strains became apparent. but did public perceptions of the disease change? was it seen as a 4. in her study the gospel of germs: men, women, and the microbe in american life (cambridge, ma: harvard university press, 1998), nancy tomes presents a convincing argument about the impact of the "germ" theory on american attitudes to infectious disease and demonstrates how various groups adapted new behavior patterns and beliefs as a result. more recently, in "epidemic entertainments: disease and popular culture in early-twentieth-century america," am. lit. hist., 2002, 14, 625-52, she examines how contemporary problems such as the aids, ebola, and west nile viruses have been used by the media to create a climate of fear that prompts citizens to ignore significant public health threats by focusing on exotic and unlikely "risks." but her focus is on the way that advertising agencies used scientific discoveries in the mid-twentieth century to sell products by claiming to educate consumers in basic health principles. the use of radio and film for similar purposes is also analyzed to demonstrate the way that science becomes part of popular discourse and is, in turn, modified by popular perceptions. killer or simply as an annual nuisance that appeared in north america every fall and winter, after it had completed its attacks on the southern hemisphere and australasia? in 2003, the question for many epidemiologists and health authorities was whether sars was the feared new version of the 1918 strain or another type of disease. 7 lack of a readily available diagnostic test or specific symptomatology significantly hampered health authorities' response to the 2003 outbreak and prompted some officials to seek historical precedents for their containment efforts. by their very nature, epidemics reveal the strengths and weaknesses of the societies in which they occur. using toronto as a case study to examine the reaction of citizens and their health departments to influenza in 1918 and sars in 2003 provides an opportunity to probe into the changing role of local health departments and their staffs in two key crises. in 1918, toronto was a bastion of white anglo-saxon protestantism, with less than 10% of its population of neither canadian nor british origin. the city had undergone a wave of physical expansion through the amalgamation of newly developed suburbs prior to 1914 and was the focal point for industry and commerce in ontario. as the provincial capital, it not only housed the legislature, the provincial board of health, the principal university, and the leading medical facilities, but also administered a budget equivalent to that of the provincial government. overshadowing these characteristics was toronto's fervent support of the war effort; it was the most imperialistic of canadian cities in 1914, and for four long years, its 490,000 citizens provided volunteers for the canadian expeditionary force (cef), the canadian army medical corps (camc), and field hospitals in france, britain, and canada. civilians played their part and turned out munitions, food supplies, and clothing; bought war bonds; and planted victory gardens. 8 the arrival of a virulent strain of influenza with the returning soldiers added further stress to the final days of the conflict and challenged existing public health staff to organize to combat disease with limited numbers, limited medico-scientific knowledge, and limited resources. by 2003, the former city of toronto had been forcibly amalgamated with five surrounding municipalities to create a combined population totaling 2.5 million, nearly 50% of whom had not been born in canada. from 1945 on, the city had been a magnet for successive waves of refugees and immigrants seeking a better life for their children. by the 1980s, toronto was the dominant economic engine for the nation. 9 but as the federal and provincial governments adopted thatcherite and reaganite economic policies, the city lost much needed funding for its aging infrastructure and services. this did not bode well for toronto's health department, which relied on municipal taxes as well as provincial grants. furthermore, in 1997 the province updated the mandatory programs that local health units were expected to provide, and then changed the tax base to limit business taxes that toronto had used to fund innovative health and education programs. 10 was toronto ready for a possible pandemic? the arrival of sars demonstrated the devastation that disease outbreaks impose as businesses and public facilities close in response to local, national, and international fears of disease transmission. indeed, one of the most striking differences between the two outbreaks was the administrative complexity created by the presence of competing provincial and federal authorities in 2003. 11 in 1918, canada did not have a federal health department, provincial health departments were very small, and no international health agency 9. james lemon, toronto since 1918: an illustrated history (toronto: james lorimer & company and national museums of canada, 1985), 11-23, 92-94, 113-87. see also lila sarick, "visible minorities flock to city," globe and mail, 18 february 1998, a8. sarick stated that 1996 census data indicated that 32% of the greater toronto area's population was visible minorities. the story noted that toronto's services and language classes were provided in many different languages and that these were under threat because of provincial plans to reorganize the education funding system. 10. gay abbate, "toronto board of health defies order to cut budget," globe and mail, 30 july 1997, a5; john spears, "budget blueprint holds line on taxes," toronto star, 10 march 1998, b1. according to a tph budget fact sheet dated 10 march 1998, the department received 1.6% of the $5.9 billion-dollar gross budget for the city. the $44.2 million allocated for tph services in 1998 was 4.6% less than in 1997 and 9.4% less than in 1996. 11. in 1867 the british north america act, now known as the constitution act, 1982, divided legislative powers between the federal and provincial governments. health, education, and social services were allocated to the provinces, while the federal government was responsible for national economic policy, the military, criminal law, agriculture, immigration, and only minor health duties such as immigrant inspection, quarantine, and the care of sick mariners and aboriginals. equivalent to the world health organization (who) existed. 12 by comparing and contrasting the abilities of the two local medical health officers-drs. charles hastings and sheela basrur-to coordinate disease control efforts, develop and maintain sufficient capacity to respond to outbreaks, and communicate effectively with fellow citizens, the media, and external authorities, we will be able to gauge the impact of their activities during these crises. the parallels and differences in the two outbreaks demonstrate how the lessons of the past need to be deeply ingrained in both collective memory and public policy if present and future challenges are to be met with courage and effectiveness. 20-22, 93-96. had to be supported with economic arguments that demonstrated that spending on public health administration was an investment, not an expense. 16 starting with a staff of three public health nurses in 1910, hastings moved quickly to expand the health education component of his staff's work and in 1914 created a division of public health nurses. based in district offices shared with either the police force or social agencies, the public health nurses quickly became "guides, philosophers and friends" for the women and children in their areas. using a generalized system that stressed health education rather than curative services, toronto's department of public health (dph) devoted great attention to forging links with more than 200 local voluntary groups through the neighbourhood workers' association (nwa). 17 this reciprocal relationship intensified during world war i as many families received coordinated assistance from the dph and nwa as a greater emphasis on "scientific" social service developed. 18 thus the concept of teamwork was well understood and widely shared when warnings about a flu epidemic began to arise in the spring and summer of 1918. the influenza outbreak is thought to have begun at camp funston in kansas in march 1918, and to have accompanied american troops to france, where it spread to the combatant armies. 19 canadian soldiers began to fall ill during the spring, and the return of some troops during the summer of 1918 triggered the epidemic in canada. the federal government was responsible for military cases, but provincial medical officers and their municipal counterparts knew that they would be fighting the outbreak with limited resources since so many doctors, nurses, and inspectors were serving in the armed forces. on 19 september, the toronto world reported cases in a military camp in ontario. for toronto's medical officer and its local board of health (lbh), this presented a challenge, because influenza was not a reportable disease under the 1912 ontario public health act, and most doctors were hoping that the outbreak would be similar to the one in 1889-90 that had attacked primarily the elderly and apparently provided some immunity to those who survived. 20 these hopes were soon dashed. military doctors were well aware that the flu was killing soldiers between the ages of twenty and thirty-nine with great rapidity. 21 when the disease spread into the community, it devastated the workforce, made entire families ill, and left orphans and the elderly in its wake. but what could be done to stop it? communicable disease control was one of the main functions of municipal and provincial health departments in canada during the late nineteenth and early twentieth centuries, but in the past it had created opposition and imposed economic hardship on those who were quarantined in their homes or sent to municipal isolation hospitals. 22 should these conventional tactics be used against the flu? as english canada's leading health department, toronto had a well-established division of communicable disease, a municipal laboratory for testing tb and diphtheria samples, an isolation hospital, and a division of vital statistics to provide the data needed for decision-making. 23 but as hastings was well aware, the usual approach to controlling the spread of infectious disease was proving ineffective against influenza. articles in the october issue of the american journal of public health (ajph) and personal contact with health authorities in the united states made it clear to hastings, who was president of the american public health association (apha) in 1918, and his provincial counterpart, dr. john w. s. mccullough, ontario's chief medical officer, that there was much disagreement about the benefits of these approaches. 24 indeed, mccullough conducted a survey of provincial and state health officers on the merits of quarantine and isolation and found that the majority had concluded that "these measures are impracticable." 25 but mayor thomas l. church, the press, and most of the public expected such actions, and in cities such as milwaukee, they were apparently effective. 26 in toronto, however, quarantine and isolation were not implemented because the disease toll escalated so quickly as to render it ineffective on a case-by-case basis. in his capacity as president of the apha, hastings left toronto from 5 to 8 october to travel to boston, new york, and washington to see the ravages of the epidemic firsthand. 27 since flu was not a reportable disease, the statistics for its spread and virulence are suspect, but each of the communities that experienced an outbreak quickly recognized its propensity to overwhelm standard disease control measures and facilities. when the disease first appeared in toronto, the moh and military authorities appealed for calm, provided a detailed description of the symptoms, strongly recommended resting in bed, and exhorted the sick to call for medical assistance. 28 the first civilian casualty was a schoolgirl who died in toronto general hospital on 29 september 1918. in spite of growing public pressure for isolation and quarantine, hastings did not issue the order, because the bulk of cases were military men in the 24. the provincial board of health of ontario, "spanish influenza," pub. health j., 1918, 9, 478 . this item is followed on pages 482-85 by an article reprinted from chicago papers of 3 october 1918. chicago's health commissioner, john dill robertson, provided citizens with information from surgeon-general blue of the u.s. public health service that focused on the origin of the disease, its symptoms, and treatment. an editorial on page 495, entitled "influenza," reminded pub. health j. readers that there was ongoing controversy over pfeiffer's bacillus as the cause of influenza and noted that the connaught laboratories of the university of toronto were undertaking to study whether the causative agent was a filterable virus or b. influenzae and if a prophylactic vaccine were possible. base camp located in the city. but the child's death was a prelude to a typically rapid increase in cases and deaths; within a week, more than 10,000 students and staff out of the 66,000 students and 1,630 teachers were sick. 29 the impact on the city's hospitals was immediate and overwhelming. by 8 october, the toronto western hospital was full, and half the nurses at the grace hospital were ill. 30 toronto general, the city's newest and largest facility, had almost 50% of its 676 patients ill with flu by mid-october; eighty nurses fell ill, and three died. 31 as a result, surgery was canceled except for emergency operations. similar problems beset the 350-bed st. michael's hospital, but the situation was further compounded by the absence of medical staff on duty overseas. the sisters of st. joseph used student nurses, their own teaching staff, and teaching sisters from loretto abbey to keep the hospital functioning during the epidemic. 32 with a population of roughly 490,000 and the fear that 40% or more of the population would become ill if the european and american experience was repeated in toronto, the moh and his provincial counterpart moved swiftly to create additional hospital accommodation and train volunteers to care for the sick. two hotels were commandeered and turned into emergency hospitals. to staff them, the province issued a call for an ontario emergency volunteer health auxiliary that provided training to create a volunteer group known as the sisters of service. 33 women's groups, teachers, and other women whose jobs were eliminated when their workplaces were closed attended the three-lecture course on the care of the sick and the sickroom. 34 willing volunteers were then assigned to one of the six health department district offices or to the temporary hospitals. but as the staff at central neighborhood house, a settlement in one of toronto's slum areas, noted, few of the sisters of service were willing to serve in their part of the city. 35 this was especially problematic for the poor and non-english-speaking immigrants because "the assistance of neighbours, usually freely rendered during illness, was negligible owing to the contagious nature of malady . . .," and this required settlement house workers to provide nursing, housekeeping, and child care during the epidemic. 36 nevertheless, volunteer work was vital, as the public health nurses (phns) were working "to the point of exhaustion" dealing with the rapid increase in sick families. early in the outbreak, the moh informed the globe that the nurses were focusing their entire attention on assisting the sick, and that various inspectors had been put on twenty-four-hour duty to provide food, fuel, and other necessities to stricken families. 37 according to the anonymous author of an in-house history of the public health nursing division: "as much hourly nursing care as could possibly be arranged was given, but it did not begin to cover the need. there were very few days that the nurses did not come into the district offices and relate some unbelievably harrowing stories." 38 as the epidemic progressed, health department staff also caught the disease, and by 23 october, 54 of 319 staff were ill, including twenty-two nurses and four doctors. 39 to deal with the growing demand for nursing care and for food, fuel, and "bedding, night clothing, towels and even pneumonia jackets," the dph turned to the neighbourhood workers' association. using toronto's newspapers to publicize these needs, the nwa appealed to torontonians' patriotism and civic spirit by informing readers that any and all donations of soup, money, or volunteer time would be gratefully received and that the former would be delivered to stricken homes by boy scouts. 40 depots to receive these items were set up throughout the city as torontonians rallied to care for the sick. the same issue of the papers reported that approximately fifty people a day were dying of flu or bronchopneumonia. the moh had already ordered schools to close, and various organizations such as the canadian and empire clubs as well as masonic lodges were canceling their meetings. the lbh and mayor church were in agreement that other places should also close to help prevent the disease from spreading, so on saturday, 19 october, all theaters, moving-picture shows, pool and billiard rooms, and bowling alleys were closed for the duration. 41 further precautions included prohibiting the circulation of public library books while allowing the libraries to remain open, and persuading toronto's churches to hold only a single service on sundays-mass for catholics in the morning, and evening services for protestants. the university was closed, and fifth-year medical students were assigned to assist busy general practitioners in making home visits and to work in the newly opened temporary hospitals. 42 the health department also relied on the work of the victorian order of nurses and the st. elizabeth visiting nurses for bedside care of the sick. 43 during the epidemic, the health department staff made 17,108 visits to stricken households, and its records indicate that there were approximately 1,750 deaths in 150,000 cases. 44 the latter is probably an underestimate, given the extent to which the press of work prevented accurate reporting of cases and deaths. 45 as well, the military was compiling its own statistics in the base hospital located in the 41. ibid. 42. "university classes cancelled," the toronto world, 17 october 1918, 5. the news story stated: "all students in the faculty of medicine are asked to volunteer their services to fight the epidemic." 43. "victorian order of nurses," pub. health j., 1919, 10, 290. the von usually cared for maternity cases, but their small staff of eighteen volunteered to care for the sick during the flu epidemic. the st. elizabeth visiting nurses performed similar duties for catholic torontonians. 44. marion royce, eunice dyke: health care pioneer (toronto: dundurn press, 1983), 69-70. can. j. med. surg., 1919, 45, 212 states that toronto suffered 1,408 deaths from influenza and 1,307 from pneumonia, for a total of 2,715, which was 1,980 in excess of the normal october death rate of 735. 45. "the provincial board of health of ontario," pub. health j., 1918, 9, 542 noted that since influenza was not a reportable disease, "the only means we have of getting anywhere near the deaths caused by the epidemic is from returns made by undertakers . . . ." the result was an ongoing recalculation of the provincial morbidity and mortality rates as new information arrived. by 1919, mccullough had concluded that ontario had experienced roughly 40,000-50,000 cases, with 10,000 deaths. eastern part of the city and at the base camp at the exhibition grounds. whether these were included in the city's tally is unclear. but the impact of the epidemic was profound. the newspapers contained short items noting the deaths of many specific individuals, advertisements apologizing for delays in delivering bread and milk, news stories describing board-of-health meetings and the actions that resulted from its deliberations, and hortatory calls for more volunteers. the world also printed an impassioned plea arguing the benefits of gauze masks and asking that "[e]verybody wear a mask to work on saturday morning." 46 neither hastings nor mccullough felt that wearing masks in public was warranted, with the result that ontarians were not required to use them as were their counterparts in alberta and several u.s. states. the economic consequences of the epidemic were significant. munitions plants and other war industries slowed as workers became ill. the municipal firefighters and policemen took sick, as did trainmen and bell canada employees. the cold rainy weather added further stress to the epidemic when coal became difficult to obtain and fuel supplies for the sick and for industry diminished. 47 in a society that lacked unemployment insurance, the task of responding to the needs of the sick and their families fell on a populace that had already donated its time, effort, and money to winning the war and buying victory bonds. nevertheless, the toronto board of trade created an influenza fund and worked with the nwa and other community groups to distribute the proceeds. 48 by the beginning of november, the situation began to ease. the schools were supposed to open on 5 november, but the fuel shortage postponed the reopening for a week. sporting events resumed, hospitals began to report empty beds, and on 11 november the armistice was signed. 49 the celebrations that this unleashed may have contributed to another wave of the flu, but for charles hastings, the 1918 epidemic revealed a crucial lesson: we require the centralization of authority. whether that be a public health service, a local government board, a department of health, a ministry of health or a secretary of health, it matters little, but all authority should be centralized under one department, if we are going to have efficient results. every human body may be a battlefield against these invisible foes. consequently, every individual must be trained a fighter, and though we march apart, we must fight together under one command. 50 to his canadian counterparts, hastings was clearly calling for the creation of a federal health department, and in march 1919, legislation to this effect was introduced. the ravages of the flu epidemic were cited as one of the factors justifying the extension of federal involvement in an area of exclusive provincial jurisdiction. 51 but the real impact was at the provincial and municipal levels. in toronto, hastings and his staff had demonstrated the benefits of a well-organized department that had made links to other municipal services, local hospitals, and non-governmental organizations. their experience enabled them to move quickly to take command in a crisis situation. the role of provincial authorities was somewhat more complex. as chief medical officer (mo), lieutenant-colonel john w. s. mccullough had responsibility for all parts of the province that lacked permanent public health staff, but he was also deeply involved with his military duties. the solution was to allow hastings and his staff to demonstrate effective community engagement and then to use this model for the rest of the province. 52 when standard disease control measures proved ineffective at stemming the rising numbers of cases, hastings turned to prevention. lessons from history," in which she reminds her readers that we still do not have an effective treatment for influenza, and that we too should use early twentieth-century techniques of providing information and immediate closure of all but essential services to ensure that "when our time comes, we will be able to match the intelligence, energy, coordination and cooperation of our forebears." see www.cmaj.ca/cgi/content/full/172/8/965/ dc1 for the full text. he brought back a b. influenzae-based vaccine from his visit to the new york city laboratory to start flu vaccine production in toronto. most civilian and military health officers pinned their hopes for controlling the epidemic on either a preventive or a prophylactic vaccine. in 1914 the connaught laboratories had opened in toronto to produce diphtheria antitoxin, but it quickly became the main supplier of vaccines for the war effort. 53 during the flu epidemic, dr. r. d. defries, the acting director, undertook the production and testing of flu vaccine using eighteen strains of the new york source and additional ones from canadian soldiers at the base hospital. although he was impressed by the impact of the vaccine on "desperate cases," he was alert to growing evidence that the vaccine was ineffective because researchers were unable to demonstrate that the pfeiffer bacillus was the cause of the disease and indeed had begun to argue that it was a filterable virus instead. 54 defries later argued that "[t]he preparation and trial of vaccine was fully warranted by the existent knowledge of the disease and its etiology," while hastings commented in november 1919 that during the flu epidemic the medical profession was "severely censured for not having discovered a vaccine," indicating that the public too expected science to provide a preventive for the disease. 55 but as many of the reports published in canadian and american medical journals indicated, there was little clinical evidence that preventive or prophylactic vaccination made a difference. 56 and what about the citizens? one of the most striking features of the outbreak was the extent to which torontonians of all social classes suffered and yet sought to help each other. the middle class and well-to-do volunteered themselves and their cars to take food, medical and nursing supplies, and doctors and visiting nurses to their patients. 57 workers tried to maintain essential services while their customers faced a final round of privation prior to the end of the war. teachers, homemakers, and nursing, medical, and dental students volunteered their services in hospitals and in the community. settlement workers noted that the poor were so severely affected that they were unable to provide assistance to their neighbors-a breach of customary practice. and various immigrant groups were presented with additional challenges, as the information provided in pamphlets and local newspapers had to be translated into languages they understood. as the anonymous scribe who wrote about public health nursing noted: "the epidemic lasted approximately two months and it was an unforgettable experience for us all." 58 for the health authorities who had directed local and provincial or state efforts during the epidemic, the influenza outbreak provided a challenge to their authority and expertise that led figures such as sir george newman and victor c. vaughan to lament the inability of officials to either control or prevent the disease. 59 at the rescheduled annual apha meeting in chicago in december 1918, a committee was formed to prepare "a working program against influenza," which was published in the january 1919 issue of the apha journal. this comprehensive review of the strengths and weaknesses of the efforts to combat the disease justified its prescription for action by noting that health agencies "must act in light of present knowledge," even if that knowledge is limited or flawed. 60 but it is clear that there were many variables that affected the progress of the disease, and that finding the cause and an effective vaccine was high on the medical community's agenda. for local health officers, however, the extent of public cooperation during ironically, the support that toronto's health department had received in 1918 proved limited. as the city returned to "normalcy" in 1919, the mayor and board of control recommended budget cuts to municipal services, including the health department. the effective organizing and yeoman services that staff had performed during the flu epidemic were forgotten or ignored when a mild form of smallpox appeared in october 1919. anti-vaccination groups organized rallies attended by some city council members who objected to hastings's dynamic leadership and his demand that mandatory vaccination be instituted. this well-established preventive measure was condemned as "german born compulsion" and rejected as antithetical to the principles of liberty and democracy for which the war had just been fought. were the anti-vaccinationists reflecting concern at the inability of the medical profession to prevent the flu epidemic through immunization, or was their opposition to compulsory vaccination a postwar rejection of the social and moral authority of progressive experts and their domination of the war effort? 65 from 1919 to 2003, municipal and provincial health departments continued to be legally responsible for control of communicable disease. but with the development of vaccines against childhood diseases, the eradication of smallpox, and the use of antibiotics to treat tuberculosis and sexually transmitted diseases, the war on disease appeared to be won. as attention and staff interest shifted to behavior modification and encouraging community development, the financial resources and personnel devoted to disease surveillance, infection control, and isolation/quarantine diminished. 66 instead of tb sanatoriums, preventive measures, and mass chest screening and tuberculin testing, for example, the communicable disease control (cdc) unit in toronto was using directly observed therapy against a resurgence of tuberculosis in the late 1990s. 67 but would this client-specific approach prove effective against a future pandemic? what role would municipal health departments be expected to play in the event of such outbreaks? experts and pundits began to warn about the possibility of a worldwide pandemic of influenza during the 1970s and 1980s, in the wake of the 1957 and 1968-69 of tuberculosis, followed by human deaths from avian flu, was coupled with growing concern about environmental degradation. 68 in ontario, the 2000 pathogenic outbreak of e.coli as a result of water contamination in walkerton demonstrated the price that communities paid for failing to maintain basic services. a commission chaired by justice frank o'connor highlighted the effect of provincial government cuts to the ministry of the environment and noted that it had failed to share vital information with local and provincial health authorities. 69 during the harris regime from 1995 to 2002, the provincial government pursued tax cuts and reorganization of provincial services that focused on downloading duties to municipalities and regional governments. convinced that toronto and its surrounding cities-scarborough, north york, the borough of york, east york, and etobicoke-were duplicating services, the province compelled them to amalgamate in 1997. this meant that the toronto health department had to incorporate staff from the other five municipalities, determine whether its programs and services were appropriate to the new city, and try to find economies that would assist the new city's budget committee in dealing with its declining revenues. 70 the new moh, dr. sheela basrur, was a graduate of the university of toronto (m.d. 1982, mhsc. 1987) who had been the moh of the east york health unit, which had approximately fifty employees. in 1998 she became the leader of over 1,800 staff, serving a population that was significantly different from its historical roots. 71 in addition to expanding in terms of territory, the new city had a multi-ethnic population that included 14.7% east and southeast asians, 10.8% south asians, 1.9% west asians, 2.6% africans, 6% caribbeans, 19% north americans, 27.4% british, and 1% aboriginals. 72 fortunately, toronto health had been hiring community workers from the various ethnic groups since the 1980s in recognition of the need to provide culturally sensitive approaches to health education and preventive services. but would toronto public health, as the new entity was known, be able to maintain its national and international reputation for innovative community-responsive public health services in the face of the province's mandatory programs and limited funding? the 1995 election of the progressive conservatives led by mike harris compounded the financial difficulties already facing toronto public health as a result of the recession of the early 1990s. the harris regime was committed to cutting government spending and staff, dismantling publicly owned utilities, remaking the public education system, downloading as many social service and welfare activities as possible, and privatizing certain environmental and health services. for tph, staff cuts, program closures, and the pressure to reorganize and redefine future goals meant focusing on children, families, and specific "high-risk" groups such as hiv/aids victims and street people rather than expanding cdc activities. 73 in addition, the city's many acute-care hospitals and long-term-care facilities were struggling to maintain service levels because of funding shortfalls and declining numbers of staff. a widespread flu outbreak in the winter of 2002 had resulted in the deaths of several citizens who had not received prompt assistance in overcrowded emergency wards. as a result, the province introduced mass flu vaccinations in the fall of 2002. the immunization program was offered free to citizens through public clinics or their family physicians. but would this voluntary program be sufficient to protect torontonians from the feared pandemic? health canada had been attempting to develop a national flu pandemic program, but ontario was not supportive, preferring to develop its own approach, since the harris conservatives were engaged in an ongoing conflict with the chrétien liberals over which level of government had the authority to design health to alert them to this possible problem. by 13 march, however, the tuberculosis test was negative, more people were sick, and infection-control experts at other toronto hospitals were working with tph to identify the new disease. on 12 march, the world health organization had issued a global alert announcing outbreaks of atypical pneumonia in hong kong and hanoi, and this enabled tph and dr. allison mcgeer, an infectious-disease specialist at mount sinai hospital, to identify the mystery illness. 76 "in consultation with provincial and federal health officials, tph held a press conference on march 14, activated its emergency response plan, established a public information hotline and assigned staff full-time to the outbreak investigation." 77 this succinct statement fails to convey the sense of crisis that existed as all three levels of health authorities discovered the weakened state of communicable disease control measures. for more than fifty years, tph had not imposed quarantine on its citizens, and although the provincial health promotion and protection act contained provisions to do so, tph staff lacked recent experience. even more challenging was the lack of knowledge regarding the disease itself. what was its cause? how was it spread? where was it most likely to be contracted? what was the incubation period? how should it be treated? who should be responsible for informing the public, provincial and federal authorities, and the who about suspected and probable cases? the sars outbreak starkly revealed the lack of coordination between federal and provincial health officials, and this conflict added to the demands being placed on tph staff when they found themselves providing the same information to two different sets of officials. differences of opinion about the confidentiality of patient information further challenged tph containment efforts, since they needed names of contacts to determine who should undergo a tenday quarantine. 78 in contrast to 1918, when there had been a united front against influenza, the sars outbreak illustrated the gap between prevention at the community level and care in hospitals or other tertiary facilities. the situation was further complicated because of international air travel and the growing demand for preventive precautions at pearson international airport, located in mississauga, outside the bounds of tph's jurisdiction. with virtually no scientific information to guide them at the start, and confused lines of communication with senior governments, basrur and up to 700 of her staff began to track cases, monitor contacts, provide infection-control advice to long-term-care facilities and hospitals with sars patients, and respond to growing public concern about the extent and nature of the outbreak. in addition to its printed materials, the tph website posted descriptions of the symptoms as well as guidelines on hand-washing and quarantine procedures in fourteen languages. more than 200 staff did daily double shifts from 8 a.m. to 11 p.m. on the sars hotline, which received over 300,000 calls during the outbreak, 47,567 in a single day. although staff worked diligently, they were aware that the fragmentary information they provided early in the outbreak caused frustration for many callers. as justice campbell commented: "the problem was not lack of dedication and effort, but the fact that it was impossible in the middle of a rapidly expanding crisis to create the necessary infrastructure." 79 nevertheless, in recognition of the ethnic diversity of the city and the origins of the outbreak, tph worked closely with the chinese community, which had created a community coalition concerned about sars. this group trained chinese-, mandarin-, and cantonese-speaking volunteers to staff a 6180 hotline (the numbers sound like the chinese word for "i'm willing to help you"), produced and distributed chinese-language sars material, did promotional activities for hard-hit chinese businesses, and raised research money for sars studies. 80 during the course of the outbreak, tph's case management team was involved in 2,000 investigations that required consultation with infectious-disease specialists because the symptoms were atypical and no diagnostic test was available, even though the genetic sequence of the coronavirus was established by british columbia's michael smith genomic sciences centre on 12 april. 81 the lack of clear diagnostic criteria complicated control procedures because tph staff and their clinical colleagues were aware of the stigma attached to the disease and of the danger of missing a case. to compound their difficulties, technology failed at this critical moment. when the outbreak started, the only available diseasereporting system was a fourteen-year-old dos-based one known as rdis (reportable disease information system). it was quickly apparent that this disease-specific program would not work, and tph turned to paper files with post-it notes to keep track of cases and their contacts. within two weeks excel spreadsheets were also in use, but at no point was the technology sufficiently flexible to provide the type of information and analysis that would have enabled a clearer picture to emerge. 82 the challenge of contact tracing and quarantine supervision was immense, as over 23,300 people were identified as contacts in each of the two waves of the disease and 13,374 spent ten days isolated in their homes. while they were in quarantine, staff from tph phoned once or twice a day to see if they had any symptoms and to find out if emergency food supplies from the salvation army or canadian red cross were required. in spite of frustration caused by having to review their situation with each tph staff member who contacted them, very few torontonians refused to comply with voluntary quarantine procedures. only twenty-seven isolation orders were issued during the outbreak. 2004, 2, 265-72 , in which torontonians and health care personnel who had been quarantined reported that they had complied with quarantine requests "to reduce the risk of transmission to others," to protect community health, and because they saw it as their "civic duty." fear of legal consequences had little influence in the decision to undergo the hardship that ten days in isolation imposed. in a post-outbreak survey of health care workers and the general population who had been isolated, an american organization discovered that respondents cited "protecting others" as their main motivation for undergoing quarantine. this strong sense of personal and collective responsibility for community welfare mirrors the dedication of visiting nurses and volunteers during the 1918 flu epidemic. the good behavior by the general public may have stemmed in part from the growing recognition that sars was apparently a nosocomial infection. 84 the outbreak was confined mainly to hospital staff, patients, visitors, and family members who had close contact with the index cases. 85 but in response to growing concern about sars spreading more widely, the ontario government declared a state of emergency on 26 march 2003 and ordered all of toronto's hospitals to move to code orange emergency procedures. as in 1918, this resulted in the cancellation of all surgical procedures, limited emergency access, and the cancellation of appointments and elective procedures. all visitors were banned, including families seeking to care for dying relatives. four days later, this draconian measure was applied to the province in general to protect health care workers and to prevent the spread of sars into the general population. 86 by the middle of april, the number of new cases was declining and health authorities began to think that the worst was over. 87 85. chapter 2 of learning from sars describes the "quest for containment" between 8 april and 23 april, 10-12, and notes that the media highlighted each story about possible community spread, leaving the impression that tph and provincial authorities were not doing their jobs effectively. provincial officials and hospital spokespeople had issued daily reports on the number of actual, probable, and suspected cases and provided the media with information to calm public anxieties over the easter and passover holidays. as in 1918, religious groups were asked to use common sense and to avoid shaking hands, kissing, sharing common communion cups, and organizing large gatherings, including funerals. but as post-outbreak studies indicated, the mixed messages that the daily briefings provided did not convince external observers that the situation was under control. 88 april the ban was lifted, but the international publicity and the continuing cancellation of conferences and conventions meant that toronto's economy was suffering greatly. 91 the loss of jobs in the tourism and hospitality industries added to the stress, and the civic and provincial governments turned to marketing campaigns in an effort to reassure torontonians and visitors that the city was safe to visit. during late april and early may, staff from north york general hospital sought advice from tph regarding possible sars cases in the psychiatric ward and among elderly post-operative orthopedic patients. since none of these people could be linked epidemiologically to previous cases, the situation remained in flux until an icu nurse from north york general was admitted to the toronto western hospital with sars. in the interim, possible sars patients had been transferred to st. john's rehabilitation hospital and the baycrest centre for geriatric care. 92 the province announced publicly that a second wave of the disease had appeared on 23 may, and the criticisms of all the flaws and failures that external critics had been making about the city's inability to control the disease increased in volume. prime minister jean chrétien had already appointed a national commission led by dr. david naylor, then dean of medicine at the university of toronto, to investigate the outbreak, and now the ontario minister of health, tony clement, announced the creation of an expert panel on sars and infectious disease chaired by dr. david walker, dean of medicine at queen's university in kingston. and finally, on 10 june, ontario's then-premier, ernie eves, named justice archie campbell to head a judicial commission to take testimony from patients, families, health care workers, and their representatives. these reviews made sars one of the most intensively studied disease outbreaks in canadian history, and the naylor, walker, and campbell reports all stressed the lack of coordination, capacity, and communication that bedeviled federal/provincial/municipal relations in ontario during the crisis. on 30 june, the first nurse to die in the outbreak perished. her death was followed by that of a colleague on 19 july, and by that of a family physician on 13 august. out of the national total of 438 cases, toronto had 224, with 44 deaths. 93 twenty-nine nurses, fourteen doctors, and thirty other health care workers, including respiratory therapists, radiology and ecg technicians, paramedics, registered assistants, housekeepers, clerical staff, and security personnel, suffered from sars, and many are still trying to recover. 94 in comparison to the morbidity and mortality of the 1918 flu, these numbers may seem small, but a century of medical progress had conditioned the public and health care workers themselves to expect medical professionals to provide prompt diagnoses and effective cures. the apparent speed with which sars could spread and the 92. kylie taggart, "independent sars commission set up in ont.," med. post, 2003, 39, 5 . in this story, taggart notes that a ninety-six-year-old man who died at nygh was thought to be the index case for the second sars wave: a health care worker on the same floor may have contracted sars from her mother, who had been a patient in the scarborough grace hospital. 93. learning from sars, chapter 1, 1, 4. according to mark hume's article, "in search of a sars vaccine," china experienced 5,000 cases, with 349 deaths, and was leading in the race to produce a vaccine against sars. worldwide, the disease infected 8,500 people in 30 countries and killed 800, including the 44 in toronto. 94. terry murray, "health-care staff have a 'duty' to treat," med. post, 2003, 39, 6. lack of provincial laboratory support for diagnostic purposes left toronto health reliant on volunteers from other health units in ontario and medical researchers based in the city's hospitals for the information that it needed to determine whether individuals were at risk of contracting or spreading the disease. when experts like allison mcgeer became ill with sars, not only was there concern for her, but the experts with whom she had been consulting had to undertake ten days of quarantine during the height of phase one. 95 the colleagues who cared for them, as well as the public health staff who supervised quarantine activities for their families, will never forget the stress that this outbreak brought. and authority. 96 gradually, informal links with nearby health units emerged, as sars spread beyond toronto and york county into the peel and durham regions, but the shared sense of camaraderie that marked 1918 did not materialize, because there had not been the type of sustained contact and trust-building that had occurred in toronto from [1914] [1915] [1916] [1917] [1918] . both outbreaks demonstrated the logistical and political challenge that contagious diseases pose to local public health administrators. in 1918, hastings and mccullough knew that their plans would be overset by lack of personnel. but they also knew that they could call on willing volunteers for support, and that the mayor and local board of health backed them. almost a century later, toronto public health had 250 to 300 people working in its communicable disease control section, but they were dealing with an unknown disease that quickly uncovered the gaps in existing procedures for infection control in public institutions. although tph staff had worked with the seventy-eight long-term-care facilities in the city to ensure that their infection control practices were effective, they had not provided the same level of service to acute care hospitals, because of budget cuts and because there were supposed to be infection control officers and committees in place. 97 as a result, the trust that enabled hastings and mccullough to rely on their academic and hospitalbased colleagues for curative services did not exist, and tph moved to create effective relationships with toronto hospitals by establishing a communicable diseases hospital liaison unit. this was fully funded by the province from june 2003 to march 2004, with a commitment for 50% funding thereafter. but as the toronto star reported, city bureaucrats think that unless the province pays the entire cost, the city should scrap the unit. not surprisingly, tph has argued that this unit is a critical part of future disease control efforts if a seamless transition from preventive to curative services is to be provided. 98 in both outbreaks, communication was a vital part of the moh's role. in october 1918, hastings responded promptly to press queries, relying on his well-established ties with various newspapers to ensure that a message of calmness and fortitude was presented. the extent of the epidemic meant that many reporters, typesetters, and delivery boys were among the ill, with the result that the official view was rarely questioned. as well, stories about the final days of the first world war occupied many readers' attention. in 2003, the local press was initially very supportive and provided excellent summaries of existing knowledge regarding symptoms and where to seek help. 99 the nightly news included the daily press conferences attended by senior provincial officials, local infectious-disease specialists, and dr. basrur. her calmness throughout the crisis had an impact, according to one toronto hospital's administrative assistant: "when the medical officer of health gets on tv and says everything is ok, we believe her." 100 unfortunately, the information provided by hospital-based specialists and provincial authorities seemed to contradict the moh's steady confidence in her staff and their activities. 101 as the naylor, walker, and campbell reports suggest, this approach was ultimately perceived as indicating a lack of leadership and a possible attempt at covering up the extent of the outbreak. in retrospect, a single spokesperson would have been advisable, but there was little that any of the officials could do to overcome the voracious appetite of the media for information. the information and misinformation that was broadcast internationally undoubtedly contributed to the who travel advisory and to the decline in tourism and convention business. 102 as a result, politicians at the provincial and federal levels tried to demonstrate their faith in the disease control efforts by tph and its supporters by having widely publicized meals in chinese restaurants. gallant as these attempts to jump-start toronto's economy and promote solidarity with potential voters were, they did not mask the underlying tension between the two levels of government. tph was caught in the middle because it was the body that had to help people qualify for federal employment insurance, provide food and other necessities while they were in quarantine, and respond to all the calls for information that flooded the hotline. perhaps the most difficult ones to deal with were those asking for assistance in avoiding ethnic stigmatization. with its origins in china, sars provided critics of canadian immigration policy with a platform from which to vent their concerns. but the april outbreak among a charismatic filipino religious group meant that they too were treated with hostility and fear. 103 as previously noted, nineteenth-and twentieth-century epidemics were replete with racist critiques directed against the presumed human vectors of diseases such as cholera, typhus, and plague. even aids prompted a similar response because of the high morbidity rate within the haitian community. 104 but one of the striking features of the sars outbreak was the uniform condemnation of racist epithets by politicians, reporters, and concerned members of the public. and when it became clear that sars was predominantly hospital-based, health care workers also found themselves socially isolated. each of the official reports commented on the sense of "fear, anger, guilt and confusion" that health care professionals felt as they tried to protect themselves and their families from the disease and from the fear evinced by their fellow citizens. even more perturbing was the rift that appeared when provincial public health experts suggested that some of the in-hospital transmission occurred because of lack of hand washing, lack of proper use of n95 masks, and lack of common sense about staying home if symptomatic. 105 a team from the centers for disease control and prevention in atlanta was invited to toronto to adjudicate this dispute, but well after the outbreak was over, it was revealed that very few of the n95 masks had been properly fitted. little wonder that hospital-based nurses who appeared before each of the commissions of inquiry were vehement in their criticism of the way the outbreak was handled. 106 for these frontline workers, the sars outbreak demonstrated once again the gap between theory and practice in clinical settings and the continuing hierarchy that privileged medical rather than nursing and other staff. a century of evolution in professional identities and status expectations was laid bare by sars. in 1918, flu was a known disease whose virulence seemed unaccountably to have mutated to the point that it became lethal. sars was an unknown virus whose incubation period, degree of virulence, symptomatology, treatment, and sequelae were determined through experience and monitoring events in hong kong, singapore, hanoi, and other stricken centers. 107 in both instances, local public health agencies were the principal agents of the state because they provided the organization and staff to conduct casefinding home visits, arrange contact tracing and quarantine measures, and organize hospital accommodations for the seriously ill. these standard disease-control measures were overwhelmed by the magnitude of the 1918 epidemic, but the volunteer efforts of many citizens meant that the supportive care needed to prevent flu sufferers from succumbing to pneumonia and other sequelae was available. in 2003, the unity of purpose that had linked toronto's health department, city hospitals, and the neighbourhood workers' association no longer existed. the hospital sector dominated much of the press coverage, and the cleavage between provincial officials and nurses' unions became widely known as a result. 108 "name, blame, shame" replaced the deference to authority that had marked early twentieth-century news reports. nevertheless, the work of tph staff was recognized by international experts, and on 12 july 2004, mayor david miller presented dr. barbara yaffe, the acting moh, and frontline staff with the canadian public health association certificate of merit award for "their exceptional contribution in managing the sars crisis" by "controlling the outbreak and implementing one of the largest quarantines in modern history." 109 such recognition from peers and colleagues across the country is welcome confirmation that in spite of all the flaws and failures, toronto public health fulfilled its obligations. and in his second interim report, justice campbell argued for the primacy of local and provincial medical officers, stating that they "must have the lead role in public health emergency mitigation, management, recovery, coordination and risk communication." 110 when the sars outbreak began, reporters looked for parallels and historical models. the 1918 flu epidemic was cited by epidemiologists and historians as a possible parallel, largely, one suspects, because it has recently been the subject of renewed research and because it was worldwide. 111 but was there perhaps another reason? were reporters and newscasters seeking reassurance that all would be well and that civilization would survive? in the western media, attention was divided between the war in iraq and the sars outbreak. in the twenty-first century, death in combat seems somehow more comprehensible than death from disease. but as environmental degradation proceeds and species-jumping viruses and bacteria multiply, the certainties that pervaded twentieth-century western medicine are beginning to fade. in their place is increasing respect for the ability of microorganisms to mutate and a determination to use all available scientific tools to combat threats to human health. to date, three vaccines have been developed against sars; the sino-european project on sars diagnostics and antivirals has reported that cinanserin, a drug for schizophrenia, is a useful therapy; and dr. josef penninger's research team has demonstrated that the protein ace2 can be used to combat the fluid buildup that killed sars patients. 112 clarifying the clinical picture and finding effective medications may remove the fear that epidemic diseases create, but, as this review of disease control activities has demonstrated, age-old methods such as case identification, contact tracing, quarantine, and isolation are the first stage of containment and hopefully eradication. toronto's experiences in 1918 and 2003 demonstrate "the power of public health" as the bedrock of disease control efforts. but is it the historian's responsibility to point out the "lessons of the past"? if so, to whom should her observations be addressed? policymakers and public health administrators will be using the recommendations of the three reports as the foundation for change, and indeed, the federal government has already created a junior minister of state for public health, while ontario, under its new liberal government, has promised $41.7 million over the next three years to create the ontario health protection and promotion agency. dr. sheela basrur has been appointed the new chief medical officer of health, and the powers of the position have been expanded to enable future planning and better coordination. 113 does this signal the senior governments' recognition of the crucial importance of prevention? has the balance of power within the biomedical world shifted, or will the sars outbreak fade from memory as quickly as the events of 1918? these questions will challenge future historians to explain the long-term impact of epidemic disease on society and to analyze the role of local health departments in the ever-expanding war on disease. the modern conception of public health administration causes of poverty the policy, spirit and programme of the neighborhood workers association america's forgotten pandemic some observations on the recent epidemic ´enlightening the public': the views and values of the association of executive health officers of ontario, 1886-1903 plague: a story of smallpox in montreal state medicine in transition: battling smallpox in ontario the value of a credit balance in public health administration doing good: the life of toronto's general hospital for the least of my brethren: a centenary history of st. michael's hospital (toronto and the control of influenza in ontario crossed wires put toronto on hit list disease is damaging ontario's economy, cabinet officials say first, tell the real story cutbacks fed sars calamity, critics say public-health spending cuts went too far, critics say fear factor: so just how big a risk is sars? what made the statement more surprising is that pat green's husband was a toronto firefighter and her son, derek, was a toronto transit commission bus driver, indicating that all three of them were in occupations that would be at risk if sars had been spreading in the community the learning from sars report estimated that sars would cost canada two billion dollars, while the former ontario auditor, erik peters, stated that sars-related spending by the provincial government would cost $720 million, only $250 million of which would come from federal coffers. see justice campbell's 2004 interim report-sars and public health in ontario, appendix e: the economic impact of sars. 103 pestilence and restraint: haitians, guantánamo, and the logic of quarantine countless health care workers faced a fundamental conflict between self-preservation, and a professional obligation to serve the greater good nurses have long voiced concerns that their knowledge and experience is not taken seriously by senior decision makers. at north york general hospital, nurses alleged that administrators ignored their warnings of an impending second sars outbreak 39, 5, quotes dr. mark lipsitch of harvard university, who stated that "tph did a very good job under completely uncertain circumstances second interim report: sars and public health legislation killer viruses sars link to acute lung failure discovered in laboratory mice as a result of experience during the sars outbreak and growing concern about a future influenza pandemic, all three levels of canadian government have created pandemic influenza plans. see www.health.gov.on.ca for information on the ontario plan and its links to the federal plan key: cord-013405-68777jts authors: lu, wenze; ngai, cindy sing bik; yang, lu title: the importance of genuineness in public engagement—an exploratory study of pediatric communication on social media in china date: 2020-09-27 journal: int j environ res public health doi: 10.3390/ijerph17197078 sha: doc_id: 13405 cord_uid: 68777jts there is a growing need for the public to interact with pediatricians through social media in china, and genuineness is a crucial factor contributing to effective communication, but few studies have examined the relationship between genuineness and its effect on public engagement. this study developed a four-dimension framework including self-disclosure, genuine response, functional interactivity, and genuineness in chinese culture to investigate the effect of genuineness in the communication of chinese social media influencers in pediatrics on public engagement. content analysis was employed to examine these dimensions and the related public engagement in 300 social media posts on the largest microblogging site in china. the findings indicate that genuine response was positively associated with the number of comments and positive comments, while negatively related to the number of shares. functional interactivity made the site more appealing, resulting in likes and shares. genuineness in chinese culture was reflected in engagement through sharing posts by the public. this study is the first to develop an integrated framework to measure genuineness in online health communication and contributes to the understanding of the effect of genuineness on chinese public engagement in social media. child health and development has been one of the biggest issues in the world health organization. in recent years, chinese president xi jinping has put public health at the center of the country's policy-making agenda, clarifying the need to include public health in official government policy. "the healthy china 2030 planning outline", issued by the chinese state council, is the first long-term strategic plan of public health developed at the national level in china [1] . one of the aims in the plan is to enhance children's health and reduce children's mortality by the construction of pediatrics and the prevention of pediatric critical diseases [2] . as an important area of study in public health, children health advocates the prioritization of children healthcare in public health community as a basis for the improvement of national health [3] . concerning this great emphasis on children's health, sustainable investment and efforts have been put into relevant fields, especially online. chinese premier li keqiang once put forward a guideline named "internet+," aiming to integrate online resources with other domains including education, logistics, and health care. social media is of particular importance in disseminating health information and promoting health communication as china records the world's largest number of registered social media users [4] [5] [6] . of all the social media in china, sina-microblog (aka weibo) is one of the most popular platforms for health communication, with 516 million active online users at the end of 2019 [4] . in recent years, the number of doctors' the constituent parts of online messages to be employed when they attempt to engage the public in health conversations through social media. moreover, a better understanding of how people view doctors' online health communication would strengthen the value of the principles that guide good communication. among all the driving factors in health communication, genuineness has been suggested as a contributing factor in effective medical communication, especially in patient-centered psychotherapy [21] . norcross and newman [22] pointed out that health practitioners considered doctors' genuineness as "important for significant progress in psychotherapy, and, in fact, fundamental in the formation of a working alliance" (p. 104). likewise, therapists' characteristics, especially genuineness, authenticity and honesty can enhance their credibility which was essential for promoting therapeutic alliance and patients' trust [23] [24] [25] . genuineness has been widely studied in face-to-face communication between doctors and patients. little attention has been paid on the importance of genuineness on health communication in the context of social media. due to the absence of concrete operational dimensions in studying genuineness, we developed an integrated framework that included four dimensions-"self-disclosure", "genuine response", "functional interactivity" and "genuineness in chinese culture", for examining genuineness in social media communication based on previous studies in health communication, dialogic communication, and the study of chinese culture. the first three are universal dimensions that occur regardless of the cultural context while the fourth dimension is a cultural determined dimension which is essential to chinese communication. there is no universally agreed-upon definition of genuineness. however, the common features of genuineness focus on "self-dimension," referring to transparency, realness, and the authenticity of one's mind and behavior. in the medical field, landreth stated, "the most significant resource the therapist brings to therapy relationship is the dimension of self. skills and techniques are useful tools, but therapist's use of their personalities is their greatest asset" ( [26] , pp. 104-105). egan also specified that genuineness is "beyond professionalism and phoniness" ( [27] , p. 55). it refers to an attitude or behavior that can only be expressed if the doctor is self-aware [28] . similarly, studies have noted that doctors' genuineness could be conceptualized as being real, being their true authentic self, and getting rid of dishonest and false behavior [29] . nevertheless, how to concretely perceive genuineness via "self" has been understudied. previous studies once demystified the idea that "self-dimension" of doctors' genuineness could be identified by self-disclosure during the health care process [30] [31] [32] . self-disclosure is defined as being willing to consciously and intentionally reveal personal feelings, life experiences, and professional knowledge in the process of communication to establish a positive relationship [30] . self-disclosure has received extensive attention in medical research because of its benefits to patients' positive health practices and doctor-patient relationships [31] . previous research [30] [31] [32] found three main types of self-disclosure being preferred by the doctors, namely the disclosure of personal thoughts/feelings, disclosure of personal life, and disclosure of personal expertise (e.g., pediatrics, neurology and psychiatry). a study reported [31] that patients liked their doctors more when doctors disclose personal feelings and thoughts. patients viewed an act of expressing feelings and thoughts from doctors as friendly and helpful because it encouraged patients to participate in a dialogue and enhance patient's self-exploration [31] . another study suggested that when a doctor disclosed his/her own lifestyle (e.g., positive health behaviors or daily activities), patients considered the doctor to be more credible and approachable [32] . likewise, patients particularly valued when doctors disclosed the accumulated skills, experience, and specific expertise in the field [28] [29] [30] . expanded on the previous studies, our study aims at investigating these three types of self-disclosure exhibited in the smip communication, and how public responded to different types of disclosure. in addition to self-disclosure, prior studies [33] [34] [35] [36] confirmed that genuineness could be manifested when healthcare workers communicate consistently and provide expertise and emotional support to patients. in the health communication, a consistent response from doctor matters because it reflects "the degree to which one person is functionally integrated in the context of the relationship with another, such that there is an absence of conflict or inconsistency between their total experience, their awareness, and their overt communication in their congruence in the relationship" ( [34] , p. 12). a genuine response is not a response that simply expressed yes or no answer or a simple act of reaction (e.g., smile/cry). it emphasizes on the recognition of interlocutors' concerns, thereby providing professional and emotional support to address their problems [33] [34] [35] [36] . a genuine response to a patient's question or concern, is useful for building a positive therapeutic relationship [35] . yet, an absence of an analytical framework for examining genuine response was noted. as such, we have modified frameworks from previous studies [33, 36] on health communication studies and proposed three main sub-dimensions to measure genuine response: (1) consistency, (2) knowledge, skill, experience and treatment advice, and (3) facilitation of hopefulness. consistency emphasizes on whether patients' concerns are well understood, and the response is on the right track [33, 36] . van et al. [36] noted that healthcare workers often rephrase or repeat the patient's questions or concerns before providing follow-up treatment and explanation to demonstrate their understanding on patients' needs. bottorff et al. [33] pointed out that nurses who responded with expert knowledge, such as treatment and medical advice were able to reduce patients' anxiety and uncertainty. they suggested that such responses enable patients to make informed decision-making and be more actively involved in a dialogue [33] . moreover, previous research [33, 35, 36] indicated that nurses usually communicated emotional support through facilitation of hopefulness with patients during a therapeutic process. bottorff et al. [33] and van et al. [36] found that facilitation of hopefulness that nurses adopted in interactions contributed to reassuring patients and avoiding escalation of emotional instability, thereby leading to positive outcomes of treatment. in view of these, we intend to investigate and reveal genuine responses in smip messages by examining the three sub-dimensions adapted from previous studies on health communication [33, 36] . in addition to health communication studies, this study drew on insights from dialogic communication theory in public relation and communication studies where functional interactivity serves as one of the principle elements in creating a genuine and dialogic communication online [37] . functional interactivity refers to the interface's elements that allow an online user to interact with someone/an organization and build a dialogue between interlocutors [38] . such elements include hyperlinks, multimedia, live-chat rooms, and questions [39] . functional interactivity is of particular importance in social media communication where dynamic, two-way interactive communication is advanced by the proliferation of social media [40, 41] . for a genuine and dialogic communication to emerge [37, 40] , interactive functions including "generation of return visits," "conservation of visitors," and "dialogic loop" were deemed necessary. the "generation of return visits" emphasizes on the return visit of the public while the "conservation of visitors" highlights the importance of connecting the public to the smi. both "generation of return visits" and "conservation of visitors" could be achieved by providing external links and hashtags to engage the public [41, 42] . "dialogic loop" placed much attention on promoting dialogue between smi and the public where strategies including providing frequent responses, asking questions, and using multimedia are most employed [41, 42] . subsequently, this study examines the use of interactive functions for building genuine dialogue in smip communication and their association with public engagement. if the first three dimensions of genuineness are universal dimensions that occur regardless of the cultural context, the fourth dimension can be identified as a cultural determined aspect which is essential in chinese communication. in chinese culture, honesty and kindness are viewed as necessary components for developing genuine dialogue [43] [44] [45] [46] , and therefore, are of particular value to the chinese audience. honesty is the essence of confucianism and has a deep impact on the moral personality development [47] . kindness, along with compassion, care, friendliness, righteousness, and affection, is one of the confucian values about a "good person" in chinese culture [48] . a kind individual is positively related to excellent job performance [49] . zhang et al. [50] also illustrated that the kinder a nurse is, the more satisfied patients are. the genuineness in smip communication that attributes to the portrayal of a positive personality trait [46, 47] , could be measured by the use of lexical indicators for the expression of honesty and kindness [43] [44] [45] [46] . honesty in the chinese culture is denoted as the moral quality of being consistent in words and deeds; opposite to hypocrisy; loyalty and open-mindedness; no lying, no fraud, no exaggeration, no distortion of facts [51] . as such, we postulate that lexical indicators related to (1) reasoning and explanation (e.g., because, so), (2) personal sharing and views (e.g., i think, i contend, i prefer), and (3) truth/facts (e.g., in fact, the truth is, the evidence reveals) are important in expressing honesty. kindness in the chinese culture denotes personalities of being friendly, harmonious, kind-hearted and nice, and behaviors of altruistic, affectionate, righteous, and caring [52, 53] . in smip communication, we expected kindness to be expressed through the use of lexical indicators related to (1) caring (e.g., is that okay, are you satisfied, is this clear for you), (2) friendliness (e.g., hello, could you please, welcome), (3) gratitude (e.g., thanks, appreciate it), (4) blessing (e.g., wish you, no worries, everything will be fine), and (5) compliment (e.g., good question, you are right). in our study, public engagement refers to the public's responses to the content communicated via social media which reflects the public's cognition and attitude on a particular issue [54] . different level of public engagement on social media reveals their trust and relationship with involved members [20, 55] . previous research has studied public engagement in different contexts with varied definitions. in corporate-stakeholder communication, bruce and shelley defined public engagement as "the interaction between an organization and those individuals and groups that are impacted by, or influence, the organization" ( [56] , p. 30). in ceo communication, men et al. conceptualize public engagement "as a behavioral construct focusing on publics' interactions with ceos" ( [57] , p. 87). in government communication, public engagement refers to the involvement of citizens in public affairs [58] . in this aspect, public engagement aims to boost mutual understanding and build up a good relationship between the local government and the public [58] . in recent years, scholars have started to study public engagement and perception in an online context due to the arrival of global social media platforms [59, 60] , such as weibo, youtube, twitter, and facebook, which all include the common feature of real-time public interaction. social media includes a variety of functions to engage with the public (e.g., blogs, photo sharing, video sharing, live chatting, and co-generation of content), and offers the ability to express attitudes via reaction buttons, appearing at the bottom of the relevant content: like, share, and comment [60] . "like" is an indicator to express awareness and interest, which can be used to identify the popularity of messages [61, 62] . "share" provides the opportunity to connect the organizational message to one's social group, and "comment" enables direct dialogue with organizations [61] . these engagement indicators fall into different engagement levels. like is the lowest level of engagement as it requires less cognitive effort and commitment than other indicators [62] . share has a higher engagement level [63] , as it can be viewed not only as an important indicator of user recognition but as user recommendation. this indicates that sharing requires certain time to evaluate the post's value [64] . a comment is the highest level of public engagement, as it requires more effort by the public to figure out the meaning of posts and directly respond to the messages with words or descriptors [61] . the number of likes and shares may indicate an overall positive effect but analyzing constituting parts embedded in comments helps estimate outcomes more concretely and accurately [65] . for instance, fan [66] argued that how people perceive products could be revealed in the comments thread. by studying the comments, the organization will know the weaknesses and affordances of products. public perceptions towards the content can also be amplified or constricted by reviewing other users' comments [67] . therefore, comments can be quite persuasive on affecting public opinions [68] . the present research categorizes comments as the high, shares as the intermediate, and likes as the low level of public engagement indicators. beyond the three engagement indicators, we paid particular attention to the valence of positive user comments. kim and yang [63] found that positive comments towards an organization are more likely to affect how people remember the organization, and further influence the organization's reputation. in tourism, for example, positive e-comments on businesses strongly influence travelers who read e-comments when they decide to select a hotel [69] . in the health field, positive online comments were positively associated with the effectiveness of anti-smoking persuasion on the public's attitudes [70] . given the impact of smip on public views and boosting children's health, we aim to identify the effectiveness of genuineness, one of the most influential driving factors in health communication, in smip's online communication. the paper employs the coding framework of four genuineness dimensions generated from dialogic communication, health communication and chinese cultural studies to examine the association between genuineness and public engagement. further, it provides an in-depth understanding on the relationships between genuineness and public reception indicators (i.e., likes, shares, comments, and positive comments). for the first research question (rq), we aim to investigate the association between the four dimensions of genuineness and public engagement, therefore the following research question is put forward: rq1: what is the association between the four dimensions of genuineness ("self-disclosure", "genuine response", "functional interactivity" and "genuineness in chinese culture") and public engagement? to fully understand the relationship within sub-dimensions in each dimension and public engagement, our second set of research questions is formulated as follows: rq2a: what are the associations within the sub-dimensions of "self-disclosure" ("disclosure of personal life", "disclosure of personal thoughts and feelings", and "disclosure of personal expertise in pediatrics") and public engagement? rq2b: what are the associations within the sub-dimensions of "genuine response" ("consistency", "knowledge, skill, experience and treatment advice", and "facilitation of hopefulness") and public engagement? rq2c: what are the associations within the sub-dimensions of "functional interactivity" ("the generation of return visits and conservation of visitors", and "dialogic loop") and public engagement? rq2d: what are the associations within the sub-dimensions of "genuineness in chinese culture" ("honesty" and "kindness") and public engagement? first, we employed a self-developed python program programmed by our research assistant with a postgraduate degree in computational science to identify the top pediatricians based on their number of followers in weibo, one of the largest microblogging sites in china. the crawler is designed to search and identify verified pediatrician using the keywords "pediatrician" and the label "v-users". "v-users" referred to verified users where doctors need to submit their medical certificates to weibo to prove their authenticity. once approved, the letter "v" with a yellow badge will be assigned to these doctors' profile pictures. verified pediatricians are preferred in our study, as they are much more influential in the social media community than non-verified ones [71] . the identified pediatricians with the highest number of followers in march are recognized as social media influencers in pediatric (smip) in our study as they are well connected and persuasive in their field. as an exploratory study, we scrutinized the number of posts published by these top 10 smip for six months (from march 1 to august 31, 2019), to ensure that they are active communicators online. subsequently, we replaced two inactive users who published fewer than two posts/day on average with the next two smip on the list. table 1 presents the final list of top 10 smip. unlike twitter, weibo tends to change its open api at times for the purpose of data security and timely technical updates. moreover, weibo has a strict "restrictions on the api usage rate and unsolicited data requests" ( [72] , p. 597). therefore, we had to manually collect the smip posts, record the number of comments, likes and shares and analyze positive comments for our study. due to the complexity of the ten sub-dimensions embedded in the four dimensions of genuineness, we decided to code the sub-dimensions manually to ensure an accurate interpretation [54] on the use of genuineness in the smip posts. taking all these into considerations, we decided to harvest a sample size of 300 posts to represent the target population. we have employed the sample size calculator developed by the australian statistics bureau [73] to estimate a sample size of 300, giving a confidence level of 95%, a confident interval of 0.056, and standard error of 0.029. through systematic random sampling, we randomly sampled 30 posts from each smip's weibo account between march 1 and august 31 in 2019 for content analysis. content analysis was employed to examine the four dimensions of genuineness adopted in the 300 posts of the top 10 smip on weibo. content analysis is a widely employed method in the study of media communication [74] and can be applied to "virtually any form of linguistic communication to answer the classic questions of who says what to whom, why, how, and with what effect" ( [75] , p. 268). it is concerned with the context where the occurrences of words, signs, and sentences are examined to provide in-depth understanding [74, 76] . researchers could adapt and integrate framework from previous research for conducting coding in content analysis [74, 76] . in this study, we have drawn insights from health communication, dialogic communication and chinese cultural studies (see sections 1.2.1-1.2.4) to develop a four-dimension framework in genuine communication for pediatricians. a code book that includes the four dimensions of genuineness, the ten sub-dimensions, and descriptors to investigate the genuineness in smip's communication has been developed (see table 2 ). the coding procedure of each dimension is listed below: for the dimension of "self-disclosure", we coded the pediatrician's willingness to disclosure information related to his/her: (1) personal life, (2) personal feelings and thoughts, and (3) personal expertise in pediatrics [30] [31] [32] in the post on sentence basis. for the dimension of "genuine response", we coded to reveal if the pediatrician demonstrates: (1) consistency, (2) knowledge, skill, experience and treatment advice, and (3) facilitation of hopefulness in his/her response in comment thread on sentence basis [33] [34] [35] [36] . for the dimension of "functional interactivity", we coded the number of interactive elements (e.g., links, hashtag, multimedia, responses) used to facilitate: (1) "the generation of return visits and conservation of visitors," and (2) creation of "dialogic loop". refs. [37, 39, 41, 42] in the post and comment thread. for the dimension of "genuineness in chinese culture", we coded the number of lexical indicators that demonstrates pediatrician's personality: of (1) honesty, and (2) kindness [43, 45, 46] ; refs. [50] [51] [52] [53] in the post and comment thread. to ensure a high accuracy of analysis, a face-to-face meeting was held by the first author and the second author before the coding exercise. the authors identified the related descriptors, including lexical indicators and features in each dimension. relevant examples were retrieved from the database collected to guide the coders in the process of coding. the first author and a well-trained research assistant who possesses a ma in communication conducted the coding in this study. table 2 presents the four dimensions, ten sub-dimensions, and descriptors of the code book. the related examples extracted from the database could be found in appendix a. for the evaluation of public engagement, the number of shares, likes, comments, and positive comments were identified. beyond three engagement indicators, we paid particular attention to the valence of positive user comments, as positive comments can contribute to the excellent reputation of social media influencers and enhance public trust [65, 77] . online positive comments are characterized by the expression of compliment and affirmation, admiration and gratitude, usefulness and goodness [78] . in the corpus of this study, the comments, such as "thank you doctor," "beneficial advice," "great," and "feel the same way" were recorded. lexical indicators related to reasoning and explanation, e.g., because, so; lexical indicators related to personal sharing and views, e.g., i think, i contend, i prefer; lexical indicators related to truth/facts, e.g., in fact, the truth is, the evidence reveals expressions of care, e.g., is that okay, are you satisfied, is this clear for you; expressions of friendliness, e.g., hello, could you please, welcome; expressions of gratitude, e.g., thanks, appreciate it; expressions of blessing, e.g., wish you, no worries, everything will be fine; expressions of compliments, e.g., good question, you are right. the coding was conducted by the first author, the primary coder, and a well-trained research assistant who possesses a ma in communication. to ensure inter-rater reliability on the coding of "self-disclosure", "genuine response", "functional interactivity", "genuineness in chinese culture", and public engagement, the coders were highly trained on the coding scheme. any disagreement between the two coders was discussed in the coding process until the agreement was achieved. the measure of interrater reliability was based on the co-coding of 60 posts from the top two smip (20% of the total number of posts studied). for all categories, the average agreement was higher than 0.95, and the average cohen's kappa was greater than 0.9, indicating an almost perfect agreement [79] . please refer to table 3 for the interrater reliability of all categories. since the content in posts and responses in comment threads varied from two words to 140 words, all coded data have been standardized, especially the coding done on sentence basis. as such we have standardized the coding data of the sub-dimensions in "self-disclosure" and "genuine response" by dividing the number of sentences yielded in each sub-dimension in every post by the overall number of sentences in each post. as for the sub-dimensions of "functional interactivity" and "genuineness in chinese culture", we standardized the data by dividing the number of features harvested in each sub-dimension in every post by the total count of features in each post. as likes, shares, comments, and positive comments are count outcomes, poisson regression was employed for statistics analysis. however, we found overdispersion exhibited when testing for assumptions in poisson regression. then we decided to employ negative binomial regression to replace poisson regression as suggested in previous research [80, 81] . negative binomial regression (nb2) fits various types of data arising in communication research [81] , and "the negative binomial model is a more general model compared with the poisson regression model that relaxes the strong assumption that the underlying rate of the outcome is the same for each included participant" [82] (p. 3). moreover, negative binomial regression allows various information to be included [82] ; it is appropriate for the data in this study, especially in the presence of overdispersion. thus, rq1 and rq2 were examined via negative binomial regression in which likes, shares, comments, and positive comments were taken as dependent variables. for the examination of associations between the four dimensions and public engagement in rq1, standardized data in the sub-dimensions were summed up in the related dimension. for instance, the data in "disclosure of personal life", "disclosure of personal feelings and thoughts", and "disclosure of personal expertise" were combined to form the "self-disclosure". as for rq2, we used the standardized data in the sub-dimensions to examine if there was a significant association between sub-dimensions in each genuineness dimension and public engagement. in this section, we aim to reveal the association between the four dimensions of genuineness and public engagement and then identify different levels of impact of sub-dimensions in each genuineness dimension on public engagement. in response to rq1, the nb2 findings indicated the number of "genuine response" was positively associated with the number of comments and positive comments, but negatively related to number of shares. for every extra sentence on "genuine response", 1.344 times more comments were generated, a statistically significant result (p < 0.0001). similarly, there was a 16% increase in the number of positive comments for each extra sentence on "genuine response" (p = 0.0001). likewise, a positive association was found between the occurrence of "functional interactivity" and shares, whereas there was a negative correlation with comment and positive comments. a 19.8% increase in the number of shares is expected for every extra feature in "functional interactivity" found (p = 0.0001). in addition, the frequency of "genuineness in chinese culture" was positively related to the number of shares. for every extra lexical indicator in "genuineness in chinese culture", 1.122 times more shares were generated (p = 0.003). table 4 summarizes the negative binomial regression results on the four dimensions of genuineness and public engagement. the results above show that three sub-dimensions of genuineness, namely "genuine response", "functional interactivity" and "genuineness in chinese culture", have significant associations with public engagement on social media. therefore, we intend to further examine the association between the sub-dimensions in the four genuineness dimensions and public engagement. table 5 summarizes the negative binomial regression results on the sub-dimensions of "self-disclosure", "genuine response", "functional interactivity", "genuineness in chinese culture" and the number of shares, likes, comments and positive comments. in response to rq2a, we found that in the dimension of "self-discourse", "disclosure of personal life" had positive effects on the number of user shares and likes, while "disclosure of personal expertise in pediatrics" is positively associated with number of shares. for every extra sentence in "disclosure of personal life" and "disclosure of personal expertise in pediatrics", 1.23 (p = 0.003) and 1.13 (p = 0.005) times more shares were generated. for every extra sentence in "disclosure of personal life", 1.26 times (p = 0.0003) more likes were expected. however, the "disclosure of personal thoughts and feelings" was negatively associated with the number of comments. for every extra sentence in "disclosure of personal thoughts and feelings", 0.89 times (p = 0.033) fewer comments were expected (see table 5 ). regarding the sub-dimensions in "genuine response" (rq2b), our findings revealed that "consistency" had positive effect on the total number of likes, comments, and positive comments. 1.402 times more likes (p = 0.0003), 1.581 times more comments (p < 0.0001) and 1.347 times more positive comments (p = 0.001) were witnessed for every extra sentence on "consistency" provided. similarly, the sub-dimension of "knowledge, skill, experience and treatment advice" was positively associated with the number of comments and positive comments. for each extra sentence on "knowledge, skill, experience and treatment advice", 1.342 times more comments (p < 0.0001) and 1.166 times more positive comments (p = 0.013) were yielded. however, the sub-dimension of "facilitation of hopefulness" was negatively associated with the number of likes and shares. for every extra sentence on "facilitation of hopefulness", 0.55 times fewer shares (p = 0.001) and 0.742 times fewer likes (p = 0.023) were generated, as presented in table 5 . for the dimension of "functional interactivity" (rq2c), the "generation of return visits and conservation of visitors" had positive effects on the total number of shares and likes, whereas "dialogic loop" had a negative association with the number of comments and positive comments. p < 0.05 *, p < 0.01 **, p < 0.001 ***, p < 0.0001 ****. table 5 . negative binomial regression results on the sub-dimensions of "self-disclosure", "genuine response", "functional interactivity", "genuineness in chinese culture" and the number of shares, likes, comments and positive comments. p < 0.05 *, p < 0.01 **, p < 0.001 ***, p < 0.0001 ****. for every additional "conservation of visitors and the generation of return visits" included, the shares and likes increased by 43% (p = 0.001) and 22% (p = 0.018) respectively while comments and positive comments decreased by 84% (p = 0.005) and 88% (p = 0.015) for every extra feature of "dialogic loop" provided, as shown in table 5 . last but not least, "honesty" in the dimension of "genuineness in chinese culture" (rq2d) had a positive association with the number of shares, likes, and positive comments in contrast to kindness, which showed no significant association. for every extra lexical indicator on "honesty", 1.158 times more shares (p = 0.001), 1.106 times more likes (p = 0.0004), and 1.07 times more positive comments (p = 0.007) were generated, as presented in table 5 . our results revealed that a variety of genuineness dimensions was employed by the smip to communicate with the public on social media. the findings yielded insights into how the "genuine response" alongside "functional interactivity" and "genuineness in chinese culture" played an active role in engaging the public. corroborated with previous studies [33, 36, 83] , our findings revealed that responses with high level of consistency and expert knowledge were positively associated with public engagement (table 5) . a doctor responded by acknowledging the public's need helps develop a trustful relationship [84] , even in online doctor-public communication. furthermore, response with medical knowledge and treatment advice indicates the doctor's understanding of patient's concerns and his/her intention to address the issues [85] . this could be the reasons attributing to the positive association between "genuine response" and the number of likes and comments, especially the positive comments. "genuine response" that aimed to address patients' concerns created more opportunities for the public to express feelings (e.g., grateful, satisfied) in the comment threads, and allowed them to continually ask questions if their concerns were not fully addressed. the phrases "thanks, doctor," "beneficial advice," "learn a lot," "really appreciate your patient guidance" and "what i need to do in the next step" were frequently unveiled under the comment threads. in line with previous studies [37, 40, 42, 57] , our results also revealed the strong effect of "functional interactivity" on public shares (tables 4 and 5) . we found a range of interactive features, in the form of links/hashtags, such as "#simp name+topic#", "@+other online users name" and "link to other weibo pages", employed on the smip posts which foster the public's access to various and detailed information. hashtags lead users to daily hot topics where users can make synchronous conversations, discuss relevant issues with others, and share insightful ideas [57] . links enable users to return the site and increase the time of stay when reading messages [42] . owing to word limit on weibo, the smip messages may not explain the ins and outs of a health problem thoroughly. the offering of external links expands messages in greater detail and strengthens the usefulness of corresponding posts, thereby fostering information sharing. given that the act of sharing can potentially reach out to a large audience, online doctors can adopt interactive elements to express genuineness and extend their influences. noticeably, the sub-dimension "honesty" positively engendered public engagement of likes, shares and positive comments ( table 5 ). the expressions in honesty mainly involve verbs and adverbs related to explanation, personal views, and facts, such as "for instance," "include," "i think," "i suggest," "according to," and "the document shows." tuckett [86] specified that "honesty" is "perceived as truth-telling" (p. 500), and the extent to which truth-telling is preferred is highly related to culture and context. as noted in previous study [86] , "honesty" is a fundamentally ethical principle in doctor-patient relationships. the majority of patients in china demonstrate that they want truthfulness and authenticity about their illness, which could enable them to manage uncertainty and make decisions independently [50] . this might also explain the negative association between sub-dimension of "facilitation of hopefulness" in the "genuine response" and shares and likes. to some extent, expression of hopefulness is intended to comfort patients instead of telling the whole truth [33, 36] , and the truthfulness of such expressions often arises suspicion. also, the shared post represents the user [62] . a previous study [87] found that online self-presentation was a crucial part of impression management, in which the public carefully evaluated someone by how he presented himself. this suggests that sharing requires more cognitive effort [64] . given that "honesty is the traditional morality of chinese nationalities and is regarded as the basis of the making of a man" ( [88] , p. 177), it is not surprising to see the public's willingness in sharing "honest" so as to promote positive personality traits on social media. despite previous studies suggested doctor's "self-disclosure" may have a positive impact on patients' reactions and foster a stronger therapeutic relationship, our results reveal that "self-disclosure" has no significant association with any level of public engagement (table 4 ). beach et al. [89] argued that doctors' personal disclosure to patients have sometimes been regarded as a boundary transgression. doctors should be more careful about disclosing personal information [86] . "self-disclosure" has been viewed as a positive intervention in doctor-patient communication but it could also hinder effective communication and lead to negativity [90] . kelly and achter [91] found that patients concerned the helpfulness and benefits of the disclosure information from doctors for their decision on engagement. if they think the information would be useful for their situations, they are willing to further interact with doctors and listen to their suggestions [92] . however, given that "self-disclosure" messages in this study mainly involve personal life, opinions, and feelings that may not be relevant to the public's concerns and problems, a lower level of public engagement is expected. forest and wood [90] commented that it is not surprising that people may disapprove or doubt the information provided by therapists who share personal opinions and experience frequently. likewise, disclosure of personal expertise may involve the discouraging expressions [92] , which makes the public feel sad and stressful. in addition, mcdaniel et al. [93] found that the frequent statements about the doctor's personal life (e.g., family, habit) and professional information are, occasionally, of little value to impair the doctor-patient relationship because they may result in fewer opportunities for patients to express themselves. general information is prevalent in smip's posts on weibo as each post is limited to 140 words, but there are a variety of followers with different needs. in other words, the posts cannot meet everyone's demands even though smip want to provide detailed information. therefore, the public may not react to some information that is not tailored to their problems. academically, this study contributes to the research of health communication in the following aspects: (1) developed an integrated framework to conceptualize and measure genuineness in social media communication and (2) shed lights in the understanding of effect of genuineness on chinese public engagement in smip online communication. in terms of practical implications, this study provides insights to health information providers such as pediatricians in engaging public on social media communication. for instance, the use of "genuine response" could raise public awareness which in turn facilitates the fostering of a healthy lifestyle. this study also has strong social implications. in recent years, the chinese government has placed public health at the center of the country's entire policy-making agenda and initiated a national long-term strategic public health plan. one of the missions is to improve the well-being of citizens coding items examples genuine response 1. consistency rephrase public's question and concern no 1: mar.10, 06:00 user one: 你好医生, 宝宝9个月，能逗笑，会发妈妈的音，能抓玩具，能扶着腋窝 站立，不能独坐超过7.8秒，要东倒西歪的，趴几秒也要哭就把两只手放两边，请 问这种情况做康复能好吗？ literal translation: hello doctor, my baby is 9 months old. he can laugh, make the voice of "mommy", grasp toys, and stand by armpit, but can not sit alone for more than 7 or 8 seconds. he often comes to cry for a few seconds when he is prostrating. i wonder whether he would recover from this situation? pediatrician: "9个月，能逗笑，会发妈妈音，能抓玩具，能扶着腋窝站立，不能独 坐超过7.8秒，趴几秒也要哭就把两只手放两边。"据叙述，大运动发育落后。"能 扶着腋窝站立"这一定是家长扶着孩子站，不利于大运动发育，反而会有消极作 用。建议看神经康复科医生，是发育问题，还是家长养育问题。 literal translation: "nine months, can make you laugh, can make your mother's voice, can grasp toys, can stand by your armpit, cannot sit alone for more than 7 or 8 seconds, can cry even if you lie down for a few seconds." according to your illustration, it could be said that the development of large motor skills is backward. "can support the armpit to stand" indicates parents was helping the child to stand, which is not conducive to the development of large motor skills and will have a negative effect. i suggest you should consult a neurologist to see if it is a developmental or a parenting problem. provide treatment advice to address public's concern no 2: may.9, 23:11 user one: 您好 吖一岁15天 不吃奶瓶已经十天了 只吃亲喂 奶量肯定不够 什么缘 故？怎么办呢？ literal translation: hello, my son is one year and 15 days old and has not fed by bottle for 10 days. i think the amount of breast-feeding may not be enough. what is the reason and what shall i do? pediatrician: 可以杯子喂奶 同时试试奶酪和酸奶。 literal translation: you can try to feed him by a cup. at the same time, feed him with some cheeses and yogurt. literal translation: as long as the mother has no discomfort after perming and dyeing her hair, she would not affect her children through breastfeeding. just keep in mind that do not let the child lick his/her mother's hair. everyone has a desire for beauty. after giving birth to the baby, most mothers want to recover their body shape and bright skin as soon as possible. thus, hair dyeing, perm, fingernail dyeing can be carried out. mothers will take care of themselves. literal translation: my son has 2 teeth within 8 months. when he was one year and 3 months old, he only had 8 teeth; at present, he is one and a half years old but only with 4 teeth growing. we eat the food, e.g., cod liver oil filled with calcium everyday, so what is wrong? pediatrician: 只要有牙齿出就说明牙齿发育没有问题，耐心等待即可。放轻松。 literal translation: as long as you can see teeth out and growing, there is no problem with tooth development. just be patient and relax. link to the pediatrician's clinic/organization/own weibo page no.3: mar.31, 12:05 哺乳期妈妈生病就要扛吗？还可以喂奶吗？很多妈妈在哺乳期的时候，十分谨慎， 生怕自己生病后不能哺乳，从而影响宝宝生长。有的则是因为家里老人怪自己生 病，怕传染给孩子。这个问题，点击"《我的诊室》"了解更多，网页链接 literal translation: is it necessary for lactation mothers to endure illness with silence? can they still provide breastfeeding? many mothers fear that they may not be able to breastfeed when they are ill in case of affecting the growth of their babies. some concern that the child's grandparents will blame them for being sick and infecting their children. for this concern, click "my clinic" to learn more link to other social networks in which the pediatrician is present no.1: apr.21, 06:22 孩子出现喂养不适很可能与疫苗有关，但不应该是大问题。如果孩子没有新的不 适，家长耐心等待，1-2周会自然恢复。还要关注排便情况。#崔玉涛讲疫苗#。 literal translation: feeding discomfort in children is likely to be related to vaccines, but it is not a big problem. if the child has not emerged new discomfort, the parents need to wait patiently. the child will recover naturally in 1-2 weeks. also, you should pay attention to defecation. #cui yutao talks about vaccines#. healthy china 2030 (from vision to action) outline of healthy china china cdc's chief expert of maternal and child health guizhou province# <the first story of my experience with dongzhai children >, all the things we are insisting on are worthwhile healthy china 2030 (from vision to action) outline of healthy china china cdc's chief expert of maternal and child health weibo monthly active users reach 516 million and barriers to entry remain solid how the public uses social media wechat to obtain health information in china: a survey study a new dimension of health care: systematic review of the uses, benefits, and limitations of social media for health communication china health science popularization alliance officially established the impact of social media influencers on purchase intention and the mediation effect of customer attitude opinion leadership in a computer-mediated environment the network effect on information dissemination on social network sites exploring factors influencing chinese user's perceived credibility of health and safety information on weibo functional interactivity in social media: an examination of chinese health care organizations' microblog profiles social support on weibo for people living with hiv/aids in china: a quantitative content analysis. chin smoking prevention in china: a content analysis of an anti-smoking social media campaign when health information meets social media: exploring virality on sina weibo characterizing depression issues on sina weibo attention, attitude, and behavior: second-level agenda-setting effects as a mediator of media use and political participation let the talk count: attributes of stakeholder engagement, trust, perceive environmental protection and csr. sage open customer agility and responsiveness through big data analytics for public value creation: a case study of houston 311 on-demand services citizen participation, community resilience and crisis-management policy conceptual considerations regarding self-disclosure: a relational psychoanalytic perspective psychotherapy integration: setting the context the significance of therapist genuineness from the client's perspective therapist nonverbal behavior and perceptions of empathy, alliance, and treatment credibility perceived therapist genuineness predicts therapeutic alliance in cognitive behavioral therapy for psychosis therapeutic limit setting in the play therapy relationship the skilled helper: a problem-management approach interpersonal skills in nursing child-centered play therapy: a practical guide to developing therapeutic relationships with children the gift of therapy: reflections on being a therapist is psychotherapy more effective when therapists disclose information about themselves? physician disclosure of healthy personal behaviors improves credibility and ability to motivate comforting: exploring the work of cancer nurses good communication in psychiatry-a conceptual review nurses' perceptions of facilitating genuineness in a nurse patient relationship how activist organizations are using the internet to build relationships understanding interactivity of cyberspace advertising designing interactivity in media interfaces: a communications perspective social impact in social media: a new method to evaluate the social impact of research a study on dialogic communication, trust, and distrust: testing a scale for measuring organization-public dialogic communication (opdc) building dialogic relationships through the world wide web advocate traditional concept of honesty cultivate modern honesty spirit the factor structure of chinese personality terms a. i am, ergo i shop: does store image congruity explain shopping behaviour of chinese consumers? creative education: explanation of cultural philosophy-on cultural characteristics of creative education in primary school. theory pract on honesty of confucius and its modern sense measuring the personality of chinese: qzps versus neo pi-r the role of character strengths for task performance, job dedication, interpersonal facilitation, and organizational support the personality profile of excellent nurses in china: the 16pf chinese personality; structure and measurement processes and preliminary results in the construction of the chinese personality scale (qzps) grappling with the covid-19 health crisis: content analysis of communication strategies and their effects on public engagement on social media public engagement as a means of restoring public trust in science-hitting the notes, but missing the music? public health genom assessing stakeholder engagement social presence and digital dialogic communication: engagement lessons from top social ceos a typology of public engagement mechanisms pandemics in the age of twitter: content analysis of tweets during the 2009 h1n1 outbreak an exploratory study on content and style as driving factors facilitating dialogic communication between corporations and publics on social media in china the like economy: social buttons and the data-intensive web like, comment, and share on facebook: how each behavior differs from the other. public relat analyzing user retweet behavior on twitter the culture of connectivity: a critical history of social media staking reputation on stakeholders: how does stakeholders' facebook engagement help or ruin a company's reputation? public relat research on the external factors of consumers releasing online comments what do others' reactions to news on internet portal sites tell us? effects of presentation format and readers' need for cognition on reality perception word-of-mouth research: principles and applications the impact of positive and negative e-comments on business travelers' intention to purchase a hotel room effects of online comments on smokers' perception of antismoking public service announcements how" big vs" dominate chinese microblog: a comparison of verified and unverified users on sina weibo how ikea turned a crisis into an opportunity. public relat the practice of social research content analysis: a flexible methodology friendship expectations and friendship evaluations: reciprocity and gender effects suggestion analysis for food recipe improvement computing inter-rater reliability for observational data: an overview and tutorial interpreting poisson regression models in dental caries studies some applications of the negative binomial and other contagious distributions do alternative methods for analysing count data produce similar estimates? implications for meta-analyses a model of empathic communication in the medical interview development of the trust in physician scale: a measure to assess interpersonal trust in patient-physician relationships how does physician advice influence patient behavior? evidence for a priming effect truth-telling in clinical practice and the arguments for and against: a review of the literature strategic self-presentation online: a cross-cultural study historical origin of the morality of "honesty" and "honesty" education for college students what do physicians tell patients about themselves? a qualitative analysis of physician self-disclosure when social networking is not working: individuals with low self-esteem recognize but do not reap the benefits of self-disclosure on facebook self-concealment and attitudes toward counseling in university students to seek help or not to seek help: the risks of self-disclosure physician self-disclosure in primary care visits: enough about you, what about me? this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license exemplification of four genuineness dimensions and relevant expression identified in the corpus.coding items examples self-disclosure 1. disclosure of personal life no. 7: may.12, 20:36 上午带小七一起去仙林金鹰广场观看全民营养周启动仪式，仪式活动很棒，小七表 现也很棒，天很热，小七全程很认真地看完。午餐时饿了，吃哈密瓜，鸡翅，意大 利面，还吃了半块含有牛奶和鸡蛋甜点，本来知道她会过敏，不给她吃，抢着要 吃，不过吃了没有出现明显过敏症状。 literal translation: in the morning, i took xiaoqi to xianlin golden eagle square to watch the launching ceremony of national nutrition week. the ceremony was great. xiaoqi performed well. it was scorching, but xiaoqi watched the whole process carefully. i ate cantaloupe, chicken wings, spaghetti, and half of the dessert at lunch. i knew that she would be allergic, so i did not give the food to her. however, she insisted on eating them, and i had not found any obvious allergic symptoms with her after eating. literal translation: experts research shows that from the perspective of health economics, the early childhood investment is the highest ratio of human capital input to output in the whole life cycle. the early return on investment is more than 1:7, so the development of early childhood potential not only determines the development potential of individuals but also profoundly affects the competitiveness of our country's human resources. literal translation: good question! first of all, we should ensure the intake of vegetables for the kids. vegetables contain vitamin k, which is produced by healthy intestinal flora. eating green leafy vegetables has many advantages for both children and adults. there is a mixture of vitamin d3 and vitamin k2 for now. key: cord-016405-86kghmzf authors: lai, allen yu-hung; tan, seck l. title: impact of disasters and disaster risk management in singapore: a case study of singapore’s experience in fighting the sars epidemic date: 2014-06-13 journal: resilience and recovery in asian disasters doi: 10.1007/978-4-431-55022-8_15 sha: doc_id: 16405 cord_uid: 86kghmzf singapore is vulnerable to both natural and man-made disasters alongside its remarkable economic growth. one of the most significant disasters in recent history was the severe acute respiratory syndrome (sars) epidemic in 2003. the sars outbreak was eventually contained through a series of risk mitigating measures introduced by the singapore government. this would not be possible without the engagement and responsiveness of the general public. this chapter begins with a description of singapore’s historical disaster profiles, the policy and legal framework in the all-hazard management approach. we use a case study to highlight the disaster impacts and insights drawn from singapore’s risk management experience with specific references to the sars epidemic. the implications from the sars focus on four areas: staying vigilant at the community level, remaining flexible in a national command structure, the demand for surge capacity, and collaborative governance at regional level. this chapter concludes with a presence of the flexible command structure on both the way and the extent it was utilized. situated in southeast asia yet outside the pacific rim of fire, singapore is fortunate enough to have been spared from major natural disasters such as typhoons, floods, volcanic eruptions, and earthquakes. however, this does not imply that singapore is safe, or immune from being affected by disasters. singapore houses a population of 5.2 million, a ranking of the third highest population density in the world. about 80 % of singapore's population resides in high-rise buildings (asian disaster reduction center 2005) . a major disaster of any sort could inflict mass casualties and extensive destruction to properties in singapore. clearly, like its neighboring countries, singapore is also vulnerable to both natural and man-made disasters alongside its remarkable economic growth. the potential risks may result from its dense population, intricate transportation network, or a transnational communicable disease. moreover, singapore can be affected by the situations in surrounding countries. for example, flooding in thailand and vietnam may affect the price of rice sold in singapore. indeed, singapore in her short history of 47 years has experienced a small number of disasters. chief among these, the severe acute respiratory syndrome (sars) epidemic in 2003 was the most devastating. the sars outbreak brought about far-reaching public health and economic consequences for the country as a whole. fortunately, the outbreak was eventually contained through a series of risk mitigating measures introduced by the singapore government and the responsiveness of all singaporeans. it is important to point out that these risk mitigating measures, along with the public's compliance, were swiftly adjusted to address the volatile conditions-such as when more epidemiological cases were uncovered. in this chapter, we introduce singapore's all-hazard management framework as well as the insights drawn from singapore's risk management experience with specific references to the sars epidemic. to achieve our research objective, we utilized a triangulation strategy of various research methodologies. to understand the principles and practices of singapore's approach to disaster risk management, we carry out an historical analysis of official documents obtained from the relevant singapore government agencies as well as international organizations, literature reviews, quantitative analysis of economic impacts, qualitative interviews with key informants (e.g. public health professionals and decision-makers), and email communications with frontline managers from the public sector (e.g. the singapore civil defense force, the communicable disease centre) and non-governmental organizations. the authors also employed the 'cultural insider' approach by participating in epidemic control procedures against sars. 1 in particular, we use the method of case study to illuminate singapore's approach to disaster risk management. the rationale of doing a case study of sars along with singapore's all-hazard approach is that the case study can best showcase the contextual differences, those being political, economic, and social. this case study aims to highlight the lessons drawn from past experiences in a specific context and timeframe, through which we are able to focus more on the nature of the risks, and the processes and the impacts of the disaster risk management and policy intervention. we also examined relevant literature on risk mitigating measures against communicable diseases in order to establish our conclusions. we evaluated oral accounts provided by key health policy decision-makers and experts for valuable insights. this chapter offers empirical evidence on the role of the whole-of-government approach to risk mitigation of the sars epidemic. applying the approach to a case study, our research enriches the vocabulary of risk management, adding to the body of knowledge on disaster management specific to the region of southeast asia. indeed, the dominant perspective in this field holds that the state must be able to exercise brute force and impose its will on the population (lai and tan 2012) . however, as shown in our paper, this dominant perspective is incomplete as the exercise of authority and power from the government is not necessarily sufficient to contain the transmission of transnational communicable diseases. success in fighting epidemics, as most would agree, is also contingent on a concerted effort of partnership between governmental authorities and the population at large. as discussed in the first section of this volume, community and family ties along with government responses can mitigate disasters. this chapter has four main sections. following this introduction, we provide an overview of singapore's historical disaster profiles. second, we introduce the policy and legal framework, and budgetary allocations for risk mitigation in singapore. third, we detail a case study of singapore's experience in fighting sars, as well as the impact of sars on singapore in its economic, healthcare, and psychosocial aspects. in the fourth section, we discuss the implications for practice and future research in disaster risk management, followed by conclusions. singapore has experienced a small number of disasters since it was founded in 1965. in this section, we briefly provide an historical account of singapore's disaster risk profiles including earthquakes, floods, epidemics, civil emergencies, and haze. singapore has a low risk of earthquakes and tsunamis. geographically, singapore is located in a low seismic-hazard region. however, the high-rise buildings that are built on soft-soil in singapore are still vulnerable to earthquakes from far afield (asian disaster reduction center 2005) . this is because singapore is at a distance (nearest) of 600 km from the sumatran subduction zone and 400 km away from the sumatra fault both of which have the potential of generating large magnitude earthquakes. this geographic vicinity may produce a resonance like situation within high-rise buildings on soft-soil. recent tremors from the september 2009 sumatra offshore earthquake were experienced in 234 buildings located mainly in the central, northern and western parts of singapore. on the front of potential tsunamis, singapore has developed a national tsunami response plan which is a multiagency government effort comprising of an early warning system, tsunami mitigation and emergency response plans, and public education. though singapore does not suffer from flood disasters due to the continuous drainage improvement works by the local authorities, the country has a risk of local flooding in some low-lying parts. the floods take place due to heavy rainfall that aggregates over short periods of time. the worst floods in singapore's history took place on 2 december 1978. the floods claimed seven lives, forced more than 1,000 people to be evacuated, and the total damages reached sgd10 million (tan 1978) . the swift and sudden floods in 1978 were caused by a combination of factors including torrential monsoon rains, drainage problems, and high incoming tides. over the following years, singapore saw a series of flash floods hit various parts of the city-state. for example, 2006 for example, -2007 southeast asian floods hit singapore on 18 december 2006 as a result of 366 mm rainfall in 24 h. from 2010 onwards, singapore has experienced a series of flash floods due to the higher-than-average rainfall. one severe episode occurred on16 june 2010 that flooded shopping malls and basement car parks in its most famous shopping area-orchard road. as per the reported historical disaster data from the cred international disaster database, singapore has suffered only two disaster events caused by epidemics. in 2000, singapore experienced its largest known outbreak of hand-foot-mouth disease (hfmd) which affected more than 3,000 young children, causing three deaths. later in 2003, sars hit singapore and it was singapore's most devastating disaster to date. the sars virus infected around 8,500 people worldwide and caused around 800 deaths. in singapore, sars infected 238 people, 33 of whom died of this contagious communicable disease. in 2009, novel avian influenza h1n1 struck singapore, which affected 1,348 people with 18 deaths. civil emergencies are defined as sudden incidents involving the loss of lives or damage to property on a large scale. they include (1) civil incidents such as bomb explosions, aircraft hijacks, terrorist hostage-taking, chemical, biological, radiological and explosive (cbre) agents and the release of radioactive materials by warships, and (2) civil emergencies, for example major fires, structural collapses, air crashes outside the airport boundary, and hazardous material incidents. in singapore, the singapore civil defense force (scdf) is responsible for civil emergencies. since 1965, singapore has experienced several episodes of civil emergencies. for example, the greek tanker spyros explosion at the jurong shipyard in 1978 was singapore's worst industrial disaster in terms of lives lost (ministry of labor, singapore 1979) . in 1986, the six-storey hotel new world collapse was singapore's deadliest civil disaster claiming 33 lives. the collapse was due to structural faults. the scdf, together with other rescue forces, spent 7 days on the whole relief operation. after the collapse, the government introduced more stringent regulations on construction building codes, and the scdf went through a series of upgrades in training and equipment (goh 2004 ). singapore experienced its first haze in the period of the end of august to the first week of november 1997 as a result of prevailing winds. the haze in 1997, called the southeast asian haze, was caused by slash and burn techniques adopted by farmers in indonesia. the smoke haze carried particulate matter that caused an increase of acute health effects including increased hospital visits due to respiratory distress such as asthma, pulmonary infection, as well as eye and skin irritation. the haze also severely affected visibility in addition to increasing health problems. as a result, singapore's health surveillance showed a 30 % increase in outpatient attendance for haze-related conditions (emmanuel 2000) . apart from healthcare costs, other costs associated with the haze included short-term tourism and production losses. a study by environmental economists of the 1997 southeast asian haze indicated a total of usd$74.1 million in economic losses in singapore alone. singapore is actively involved in various regional meetings to deal with transboundary smoke haze pollution in order to reduce the risk (singapore institute of international affairs 2006). the singapore government adopts a cross-ministerial policy framework-a wholeof-government integrated risk management (wog-irm), for disaster risk mitigation and disaster management (asia pacific economic cooperation 2011). this is a framework that aims to improve the risk awareness of all government agencies and the public, and helps to identify the full range of risks systematically. in addition, the framework identifies cross-agency risks that may have fallen through gaps in the system. this framework also includes medical response systems during emergencies, mass casualty management, risk reduction legislation for fire safety and hazardous materials, police operations, information and media management during crises and public-private partnerships in emergency preparedness. the wog-irm policy frame work in singapore functions in peacetime and in times of crisis. it refers to an approach that all relevant agencies work together in an established framework, with seamless communication and coordination to manage the risk (pereira 2008) . in peacetime, the home team comprises of four core agencies at central government level. these four agencies are the strategic planning office, the home front crisis ministerial committee (hcmc), the national security coordination secretariat, and the ministry of finance at the policy layer. among them, the strategic planning office provides oversight and guidance as the main platform to steer and review the overall progress of the wog-irm framework. during peacetime, the strategic planning office convenes meetings quarterly for the permanent secretaries from the various ministries across government. in a crisis, the home front crisis management system provides a "ministerial committee" responsible for all crisis situations in singapore. in the wog-irm structure, the hcmc is led by the ministry of home affairs (mha). in peacetime, mha is the principal policy-making governmental body for safety and security in singapore. in the event of a national disaster, the mha leads at the strategic level of incident management. the incident management system in singapore is known as the home front crisis management system (hcms). under the hcms, the scdf is appointed as the incident manager, taking charge of managing the consequences of disasters and civil emergencies. reporting to the hcmc is an executive group known as the home front crisis executive group (hceg), which is chaired by the permanent secretary for mha. the hceg is in charge of planning and managing all types of disasters in singapore. within the operation allayer, there are various functional inter-agency crisis management groups with specific responsibilities, integrated by the various governmental crisis-management units. at the tactical layer, there are the crisis and incident managers who supervise service delivery and coordination. the singapore government holds relevant ministries accountable in accordance to the nature and scope of the disaster. among those ministries and government agencies, the scdf is the major player in risk mitigation and management for civil emergencies. now, let us look into the scdf in more detail. for civil security and civil incidents, the singapore civil defense force (scdf) 2 is singapore's leading operational authority-the incident manager for the management of civil emergencies. the scdf is responsible for leading and coordinating the multi-agency response under the home front crisis management committee. the scdf operates a three-tier command structure, with headquarters (hq) scdf at the apex commanding four land divisions. these divisions are supported by a network of fire stations and fire posts strategically located around the island. the scdf also serves the following pivotal functions. the scdf provides effective 24-h fire fighting, rescue and emergency ambulance services. the scdf developed the operations civil emergency (ops ce) plan-a national contingency plan. when ops ce is activated, the scdf is vested with the authority to direct all response forces under a unified command structure, thus enabling all required resources to be pooled. however, the wog-irm policy framework only came to existence when singapore encountered sars. the sars epidemic in 2003 was an institutional watershed for singapore's approach to risk mitigation and disaster management (pereira 2008) . prior to the sars epidemic, singapore's executive group 3 mainly focused on crises or disasters that were civil defense in nature. these emergencies were merely conceived to be well managed by a solitary incident manager, supported by other relevant agencies. a specific multi-sectoral governance structure was not considered necessary to handle the crisis. the sars epidemic challenged the prevailing home front crisis management structure as the epidemic transcended just managing civil defense incidents. the policymakers realized the necessity to adopt a comprehensive disaster management framework, an all-hazard approach that includes a mechanism for seamless integration at both the strategic and operational levels among various government agencies. to this end, singapore revamped its home front crisis management framework to produce the current inter-agency structure. the main legislation supporting emergency preparedness and disaster management activities in singapore are the civil defense act of 1986, the fire safety act of 1993, and the civil defense shelter act of 1997. the civil defense act provides the legal framework for, amongst other things, the declaration of a state of emergency and the mobilization and deployment of operationally-ready national service rescuers. provides the legal framework to impose fire safety requirements on commercial and industrial premises, as well as the involvement of the management and owners of such premises in emergency preparedness against fires; and the civil defense shelter act provides the legal framework for buildings to be provided with civil defense shelters for use by persons to take refuge during a state of emergency. to tackle disease outbreak, singapore had earlier promulgated the infectious disease act in 1977. this legislation is jointly administered by the moh and the national environment agency (nea). unlike most governments that make regular national budgetary provision for potential disaster relief and early recovery purposes, the government of singapore makes no annual budgetary allocations for disaster response because the risks of a disaster are low (global facility for disaster reduction and recovery 2011, p.24). however, the singapore government can swiftly activate the budgetary mechanisms or funding lines in the event of a disaster and ensure these lines are sufficiently resourced with adequate financial capacity. to illuminate singapore's approach to disaster management, we now use a case study of singapore's fight against sars to highlight policy learning and lessondrawing in a specific context and timeframe. this case study has three sections. we first introduce the epidemiology of sars in singapore. in the second section, we describe the impact caused by sars epidemics on singapore in the economic, healthcare, and psychosocial aspects. in the third section, we demonstrate singapore's risk mitigating management, and detail the government's risk mitigating measures to contain the epidemic. singapore is a small open economy. external shocks can result in high levels of volatility resonating across the domestic economy. these shocks in turn would bring about higher levels of risk and uncertainty in singapore. at the beginning of 2003, singapore's economic outlook was clouded by the iraq war and its impact on oil prices (attorney-general's chambers 2003). the unexpected outbreak of sars led to greater uncertainty in the singapore economy. singapore's financial markets were severely affected due to the loss of public confidence and reduced floor trading. the impact of sars on the stock market reflected in the straits times index (sti) (see fig. 15 .1). the market did not react well to the sars epidemic. in the first fortnight of the epidemic, the sti closed down 76 points. even though more cases were reported, the sti climbed progressively up 86 points over the next fortnight, eclipsing the earlier falls. this could be attributed to the strict measures which the singapore government introduced. the sti remained relatively stable over the immediate fortnight as new cases were reported. however, it started a downward plunge over the following fortnight as the number of cases peaked once more. the sti plunged 96 points. however, the resilience of the sti was shown when it climbed back up, surpassing the level reported at the beginning of the sars period. the volatility of the sti demonstrates the vulnerability of a small open economy from exogenous forces-in this case, the sars epidemic. sars was the one single activity which contributed to the volatility of singapore's gross domestic product (gdp) in 2003. the ministry of trade and industry (mti) revised the forecast for singapore's annual gdp growth down from 3 to 0.5 %. this forecast was later revised upwards to 2.5 %. there were a number of channels by which the sars epidemic affected the economy. the economic impacts will be discussed from the positions of demand and supply shocks. the main economic impact of the sars outbreak was on the demand side, as consumption and the demand for services declined (henderson 2003) . the economic consequence caused fear and anxiety among singaporeans and potential tourists to singapore. the hardest and most directly hit were the tourism, retail, hospitality and transportrelated industries, for example airline, cruise, hotel, restaurant, travel agent, retail and taxi services, and their auxiliary industries (see fig. 15 .3 and this had a direct impact on hotel occupancy rates, which declined sharply to 30 % in late april 2003. cancellation or postponement of tourism events increased by about 30-40 %. revenues of restaurants dropped by 50 % while revenues of the travel agents decreased by 70 %. sars had an uneven impact on various sectors of the economy. a four-tiered framework to assess the impact on the respective sectors showed that tier 1 industries, such as the tourism and travel-related industries were most severely hit. tier 1 industries account for 3.5 % of gdp. the tier 2 industries, such as restaurants, retail and land transport industries were significantly hit, which account for 7.5 % of gdp. the next two tiers were less directly affected by the sars outbreak. tier 3 industries include real estate and stock broking, which account for close to 19 % of gdp. the remaining 70 % of the domestic economy in tier 4 includes manufacturing, construction and communications. these industries were not directly impacted by the outbreak of sars. all in all, the estimated decline in gdp directly from sars was 1 %, equaling sgd875 million. singapore experienced a significant drop in tourist arrivals where visitors usually stay for up to 3 days and transit onto their next destination. the trend for visitor inflow is that visitor inflows fall sharply. this is especially true in the case of singapore, when visitor stays tend to be shorter and the high-end visitors stayed away. as a result, tourism and other related industries were nearly crippled due to a significant reduction in both leisure and business travel. visitors from around the world cancelled or postponed their trips to singapore, causing a drastic decrease of total expenditure from visitors. (see table 15 .2) plummeting visitor arrivals directly impacted hotel occupancy rates, which declined sharply to 30 % in late april (see table 15 .3). the hotel occupancy rate plummeted from 72 to 42 %, compared to the normal level of 70 % or above. the annual averages for hotel occupancy rates were 74.4 % in 2002, 67.3 % in 2003, and 80.6 % in 2004 . singapore's national carrier, singapore airlines (sia), faced a record-breaking low passenger capacity of 29 % in april and may 2003. sia cancelled approximately 30 % of its weekly schedules (henderson 2003) . sia laid off 414 employees, of which 129 were ground staff, as a consequence of a usd200 million loss in june 2003. the hospitality industry had to resort to cutting budgets, which led to a steep plunge in the number of employed in the service sector. out of a total of 12,100 made unemployed, hotels and restaurants went through the biggest cut, that being 5,800 employees. the breakdown of total job losses showed 47 % in the service sector, 28 % in construction, and 25 % in manufacturing. additionally, transactions in the retail sector were dropped by 50 %. the private property volume transactions for condominiums and private property price index are also good proxies on the impact of the economy from sars. based on quarterly figures between 2002 and 2004, the volume transactions dipped to a low in the first quarter of 2003. also, there was a corresponding decline in the price index. transactions recovered steadily by the third quarter boosted by confidence in market sentiments (see fig. 15.3) . the sti and private property price index seemed to display fairly similar trends, albeit with some observed lag. note also that there is a lagged effect of consumer's deferred purchases after the outbreak of sars in singapore. demand creates its own supply. therefore, a fall in demand of goods and services is likely to bring about a fall in the supply of such goods and services. also, the loss of consumer and business confidence would reduce the level of aggregate demand. these effects were observed as the manufacturing industry experienced supply chain disruptions as the singaporean economy and employment market continued to weaken. singapore was taken off the who's list of sars affected countries on 31st may 2003-one of the first countries to be removed from the list. with the "fear-factor" managed, normal daily activities slowly resumed. sars affected industries and sectors started to show signs of recovery towards the end of the second quarter in 2003. a more comprehensive analysis of the economic costs of sars will need to consider the direct impact on consumer spending and indirect repercussions of the shock on trade and investment (asian development bank outlook 2003). the economic costs from a global disease, such as sars, go beyond the immediate impacts incurred in the affected sectors of disease-inflicted countries. this is not just because the disease spreads quickly across countries through networks related to global travel, but also because any economic shocks to one country spread quickly to other countries through the increased trade and financial linkages associated with globalization. however, just calculating the number of cancelled tourist trips, the declines in retail trade, and some of the factors discussed earlier do not provide a complete picture of the impact of sars. this is because there are close linkages within economies, across sectors, and across economies in both international trade and international capital flows. thus, analyzing the tourism sector alone may not be sufficient in analyzing the overall financial impact of sars. sars inflicted a heavy toll on businesses and immediately impacted severely the viability of business. businesses lost employees for long periods of time due to factors such as illness, the need to care for family members and fear of infection at work, or retrenchment. as the workforce shrunk due to absenteeism, business operations, for example supply chain, flow of goods worldwide and provision of services, were all affected both locally and internationally. in terms of retrenchment, the job prospects of employees in affected companies appeared miserable. a survey performed during the sars period showed that the jobless rate increased more than 5.5 %, the highest for the last decade in singapore (ministry of manpower, singapore 2003) . in absolute numbers, overall employment diminished by 25,963 in the second quarter of 2003, the largest quarterly decline since the mid-1980s recession. unlike previous retrenchment that affected mainly blue-collar labor, sars also affected whitecollar employees too. the implementation of workplace sars control measures added to operational and administrative costs. for example, the policy of temperature taking was implemented at workplaces in the private sector. numerous private establishments installed thermal-scanners in their entrances from day one. however, such precautionary measures were necessary to contain the disease. this helped to restore business confidence and investment potential (a lower level of investments will lead to slower capital growth). but the reduction in an economy's capacity may linger on for a few quarters before it is restored to pre-sars levels. the loss of productive working days from quarantine, and implementation costs incurred to monitor movements of employees contributed to the reduction in the aggregate supply front. some of these economic effects may have worsened the public health situation if strategic planning was not in place. sars reduced levels of service and care in singapore's healthcare system as the system mobilized its medical resources to deal with the sars epidemic. the influx of influenza patients to hospitals and clinics crowded out many other patients with less urgent medical problems for treatment. this particularly affected those seeking elective operations that had to be postponed until the epidemic ended in singapore. sars also severely impacted singapore's healthcare manpower. during the peak of sars from mid-march 2003 to early april 2003, there was a shortage of medical and nursing professionals because (1) the demand for care of influenza patients substantially increased, and (2) the supply of healthcare manpower decreased as some were also affected by the epidemic. like other business sectors, hospitals, clinics and other public health providers also faced a high staff-absenteeism rate and encountered difficulties in maintaining normal operations. this resulted in a further reduction in the level of service capacity. psychosocial impact from sars was mainly caused by limited medical knowledge of sars when it began its insidious spread in singapore. such uncertainty of contracting a highly contagious disease actually deteriorated the fear of security breaches, and the panic of overexposure (tan 2006) . responding to the uncertainty of disease transmission, the singapore government instituted many draconian public policies, such as social distancing, quarantine and isolation, as risk mitigating measures. all of these control measures created an instinctive withdrawal from society for the general population. this brought about a behavior which resulted in the public avoiding crowds and public places with human interaction. on 24 march 2003, the moh invoked the infectious disease act (ida) to isolate all those who had been exposed to sars patients. after ida was invoked, on 25 march 2003, schools and non-essential public places were closed. public events were cancelled to prevent close contact in crowds. singaporeans with contact history were asked to stay home for a period of time to prevent transmission. harsh penalties, such as hefty fines of more than usd4,000 or imprisonment, were imposed on those who defied quarantine orders. in a drastic move reminiscent of a police state, closedcircuit cameras were installed in the houses of those ordered to stay home to monitor their compliance with the quarantine order (abc news online 2003). at the height of sars, 12,194 suspected cases were ordered to stay home, all of whom were monitored either by cameras or in less severe cases, by telephone calls. quarantine, regardless of its effectiveness, received strong criticism from the general public during the outbreak of sars due to the invasive nature of that measure (duncanson 2003) . impact of social distancing remains unclear, but who has recommended such control measures depending on the severity of the epidemic, risk groups affected and epidemiology of transmission (world health organization 2005). singapore's moh advocated the practice of social distancing during the outbreak of sars. the sole intention of social distancing was to limit physical interactions and close contact in public areas to slow the rate of disease transmission. additionally, social distancing measures in particular have a psychological impact. the practice of social distancing led to a social setback in businesses that suffered economic losses as a result (duncanson 2003) . the psychological impact of sars is longer lasting. the most immediate and tragic impact was the loss of loved ones. in this section, we detail singapore's command structure, legal framework in fighting sars, as well as risk mitigating measures in economic, healthcare, and psychosocial perspectives. one of the most important lessons the singapore government learned from the sars epidemic was the crucial role played by the bureaucracy in disaster management. the bureaucratic structure in place then was severely inadequate in terms of handling a situation that was both fluid and unprecedented; indeed, fighting sars required more than a medical approach because resources had to be drawn from agencies other than the moh. accordingly, a three-tiered national control structure was created in response to sars-these tiers were individually represented by the inter-ministerial committee (imc), the core executive group (ceg) and the inter-ministry sars operations committee (imoc) (tay and mui 2004) . the nine-member imc was chaired by the minister of home affairs (mha) and it fulfilled three major functions: (1) to develop strategic decisions, (2) to approve these major decisions, and (3) to implement control measures. 4 notably, the imc also played the role of an interagency coordinator overseeing the activities of other ministries and their subsidiaries. on 7 april 2003 (5 weeks after the first case of sars was reported), the ceg and a ministerial committee was formed. the ceg was chaired by the permanent secretary of home affairs and consisted of elements from three other ministries: the moh, the ministry of defense (mod) and the ministry of foreign affairs (mfa). in particular, the role of the ceg was to manage the sars epidemic by directing valuable resources to key areas. the imoc, meanwhile, was seminal in carrying out health control measures issued by the imc (see fig. 15 .4 below). the moh, at the operational layer, formed an operations group responsible for the planning and coordination of health services, and operation in peacetime. during sars, it commanded and controlled all medical resources and served as the main operational linkage between the moh and all the healthcare providers. on 15 march 2003, when the epidemiological nature of sars was still unclear, the moh initiated a sars taskforce to look into the mysterious strain. only 2 days later, after more sars cases were reported and a better epidemiological understanding of the strain was developed, the singapore government swiftly declared sars a notifiable disease under the infectious disease act (ida) (ministry of health, singapore 2003a) . in the case of a broad outbreak, ida made it legally permissible to enforce mandatory health examination and treatment, exchange of medical information and cooperation between healthcare providers and the moh, and the quarantine and isolation of sars patients (infectious disease act 2003). in particular, the government amended the ida on 24 april 2003 requiring all those who had come into contact with sars patients to remain indoors or report immediately to designated medical institutions for quarantine (ministry of health, singapore 2003b) . asa legacy of singapore's british colonial past, the singapore legislature is unique and well-known for passing laws in a swift and efficient manner. the uniqueness in singapore's legal framework allows singapore to tan (2006) swiftly amend the ida during health crises to suit volatile conditions, for instance when more epidemiological cases were uncovered and the virus was better understood. all in all, the ida played an adaptive role in terms of facilitating a swift response to the outbreak of this particular epidemic. on 22 march 2003, the ceg designated the restructured public hospital-tan tock seng hospital (ttsh) as the sars hospital (james et al. 2006; tan 2006) . that is, once a suspected sars patient was detected at a local clinic or emergency department, he or she would then be transferred to ttsh immediately for further evaluation and monitoring. the national healthcare system prioritized life-saving resources such as medicine and medical equipment to allocate manpower and protective equipment to the ttsh. to ease the flu-like patient influx into the ttsh, the government diverted non-flu patients away from ttsh so that the sudden surge in the number of flu cases at ttsh did not paralyze its service delivery. the full impact of sars on the economy by and large depended on how quickly sars was contained, as well as the course of the sars outbreak in the region and beyond. to mitigate sars impact on singapore's economy, the government took every precaution and spared no effort to contain the sars outbreak in singapore. two aspects of sars warranted government intervention to mitigate economic impact. first, the information that needs to be collected and disseminated to effectively assess sars displays the characteristics of public good. second, there are negative externalities related to contagious diseases in the sense that they affect third parties in market transactions. public good and negative externalities are typical areas where government action is needed (fan 2003) . there are three major factors which can explain why some economies are more vulnerable and susceptible to the effect of sars than others (asian development bank outlook 2003) . these factors are structural issues (e.g. shares of tourism in gdp and the composition of consumer spending), initial consumer sentiments, and government responses. as the research shows, the singapore government implemented a usd 132 million (sgd 231 million in 2003) sars relief package to reduce the costs for tourism operators and its auxiliary services. on the other hand, an economic relief package worth usd 131m (sgd 230m) was created to aid businesses hit by sars. 5 in addition, the government incurred usd$109m (sgd 192m) in direct operating expenditure related to sars, and committed another usd 60m (sgd105m) development expenditure of hospitals for additional isolation rooms and medical facilities to treat sars and other infectious diseases. the government's economic incentives worked when seeking cooperation of other healthcare providers (such as public hospitals and local clinics) so that they would absorb additional cases of non-flu illnesses. to help sars affected firms tide over the plight and minimize job losses, singapore's national wage council widely consulted the private sector, and recommended sars-struck companies adopt temporary cost-cutting measures to save jobs. 6 the measures adopted by the private sector included the implementation of a shorter working-week, temporary lay-offs and the arrangement for workers to take leave or undergo skills training and upgrading provided by the ministry of manpower and associated agencies. when these measures failed to preserve jobs, the last resort was temporary wage cuts. surveillance and reporting is critical in combating pandemics because it serves to provide early warning and even detection of impending outbreaks. the surveillance process involves looking out for possible virulent strains and disease patterns within a country's borders as well as at major border-crossings (jebara 2004; ansell et al. 2010; narain and bhatia 2010) . when sars first surfaced, the nature of this virus was largely unknown. as a consequence, health authorities worldwide were mostly unable to detect and monitor suspected cases. health authorities in singapore encountered this same problem. but with the aid of who technical advisors, singapore managed to establish in a timely manner identification and reporting procedures. furthermore, the moh also expanded the who's definitions for suspected cases of sars (to include any healthcare workers with fever and/or respiratory symptoms) in order to widen the surveillance net (goh et al. 2006) . as the pace of sars transmission quickened, the singapore parliament amended the ida on 25 april 2003 requiring all suspected sars cases to be reported to the moh within 24 h from the time of diagnosis. although these control measures were laudable, sars also exposed the weaknesses of singapore's fragmented epidemiological surveillance and reporting systems (goh et al. 2006) . as a major part of lesson-drawing in the post-sars era, a number of novel surveillance measures were introduced to integrate epidemiological data and to identify the emergence of a new virulent strain faster. one of the most notable was the establishment of an infectious disease alert and clinical database system to integrate critical clinical, laboratory and contact tracing information. today, the surveillance system has four major operational components that include community surveillance, laboratory surveillance, veterinary surveillance, external surveillance, and hospital surveillance. to limit the risk of transmission in healthcare institutions once the sars epidemic had broken out, the moh implemented a series of stringent infection-control measures that all healthcare workers (hcws) and visitors to hospitals visitors had to adhere to. the use of personal protective equipment (ppe) 7 was made compulsory. visitors to public hospitals were barred from those areas where transmission and contraction were most likely. the movements of hcws in public hospitals were also heavily proscribed. unfortunately, except for ttsh, these critical measures were not enforced in all healthcare sectors until 8 april 2003, and this oversight resulted in a number of intra-hospital infections (goh et al. 2006 ). in addition, the policy of restricting the movements of hcws and visitors to hospitals was taken further. more specifically, their movements between hospitals were now restricted. patient movement between hospitals, meanwhile, was strictly restricted to medical transfers. the number of visitors to hospitals was also limited and their particulars recorded during each visit. it is also important to point out that these somewhat draconian control measures required strong public support and cooperation. indeed, their implementation would not have been successful had these two elements been missing. public education and communication are two indispensable components in health crisis management (reynolds and seeger 2005; reddy et al. 2009 ). communication difficulties are prone to complicate the challenge, especially when there is no established, high-status organization that can act as a hub for information collation and dissemination. therefore, it is necessary to disseminate essential information to the targeted population in a transparent manner. during the sars outbreak, the moh practiced a high degree of transparency when it shared information with the public. indeed, the clear and distinct messages from the moh contributed significantly to lowering the risk of public panic. the moh worked closely with the media to provide regular, timely updates and health advisories. this information was communicated to the public through every possible medium. in addition to the media (e.g. tv and radio), information pamphlets were distributed to every household and the moh website provided constant updates and health advisories to the general public. notably, a government information channel dedicated to providing timely updates was created on the same day-13 march 2003-when the who issued a global alert. a dedicated tv channel called the sars channel was launched to broadcast information on the symptoms and transmission mechanisms of the virus (james et al. 2006) . the importance of social responsibility and personal hygiene was a frequent message heard throughout the sars epidemic. as an example, when tan tock seng hospital was designated as the sars hospital at the peak of sars epidemics, the government undertook many efforts in public communication and education to seek cooperation and support from other healthcare providers, such as public hospitals and local clinics, so that they would absorb the additional cases of non-flu illnesses. many organizations displayed prominent signs in front of their building entrances that reminded their staff as well as visitors to be socially responsible. school children were instructed to wash their hands and take their body temperature regularly. the public was told to wear masks and postpone non-essential travel to other countries. the moh advocated the practice of social distancing during the outbreak of sars. the sole intention of social distancing was of course to limit physical interactions and close contact in public areas thereby slowing the rate of transmission. as a result, all pre-school centers, after-school centers, primary and secondary schools, and junior colleges were closed from 27 march to 6 april 2003. school children who had stricken siblings were advised to stay home for at least 10 days. moreover, students who showed flu-like symptoms or had travelled to other affected countries were automatically granted a 7-day leave of absence and home-based learning program were instituted for those affected. extracurricular activities were also scaled down to minimize social contact. meanwhile, the moh also advised businesses to adopt social distancing measures such as allowing staff to work from home and using split-team arrangements. those who were most at higher risk of developing complications if stricken were moved and removed from frontline work to other areas where they were less likely to contract the virus. as mentioned earlier, the practice of social distancing also drew strong criticisms from those businesses that suffered economic losses as a result. apart from providing economic compensation, measures to mitigate psychosocial impacts are also important. the government's measures of public health control, as mentioned above, drew strong criticisms from businesses and the public during the outbreak of sars due to the invasive nature of those actions. besides these, the economic slowdown affected overall employment and personal income. some households required financial assistance. in response to the public complaints, authorities in singapore provided economic assistance to those individuals and businesses who had been affected by home quarantine orders through a "home quarantine order allowance scheme" (tay and mui 2004; teo et al. 2005) . at the same time, the moh worked together with various ministerial authorities to provide essential social services to those affected by the quarantine order. for example, housing was offered to those who were unable to stay in their own homes (because of the presence of family members) during their quarantine, ambulance services were freely provided by the singapore civil defense force to those undergoing quarantine at home to visit their doctors, as well as high-tech communication gadgets such as webcams, for those undergoing quarantine to stay in touch with relatives and friends. impacts on social welfare in large part relate to economic outlook, especially in the area of consumption patterns. all these risk mitigating measures were not only effective in containing the epidemic, but also valid for implications in disaster risk management. in this section, we draw on the lesson-learning from singapore's experience in fighting the sars epidemic, and discuss implications for future practice and research in disaster risk management. the implications are explained in four aspects: staying vigilant at the community level, remaining flexible in a national command structure, demand for surge capacity, and collaborative governance at regional level. it remains questionable that singapore's draconian health control measures may not be applicable or replicable in other countries, for example setting a camera to monitor the public's compliance during home quarantine. the evidence suggests that draconian government measures, such as quarantine and travel restrictions, are less effective than voluntary measures (such as good personal hygiene and voluntarily wearing of respiratory masks), especially over the long term. however, reminding the public to maintain a high level of vigilance and advocate individual social responsibility can be a persuasion tactic by an authority to influence and pressure, but not to force individuals or groups into complicity with a policy. therefore, promoting social responsibility is crucial in terms of slowing the pace of infection through good personal hygiene and respiratory etiquette in all settings. to achieve this goal, public education and risk communication are two indispensable components in health crisis management (reddy et al. 2009; reynolds and seeger 2005) . the community must be aware of the nature and scope of disasters. they have to be educated on the importance of emergency preparedness and involvement in exercises, training and physical preparations. at the community level, institutions and capacities are developed and strengthened which in turn systematically contribute to vigilance against potential risks. this is best illustrated in the singapore government's communication strategy to manage public fear and panic during the outbreak of sars (menon and goh 2005) . throughout the epidemic, the singapore government relentlessly raised the level of vigilance of personal hygiene and awareness of social responsibility. this, in large part, has to rely on public education and risk communication. to effectively disseminate the idea of vigilance across the public, political leaders were seen as doing and initiating a series of countermeasures to reassure the public. by showing the people that government leaders practiced what they preached, the examples served to naturalize and legitimize the public discourse of social responsibility for all singaporean citizens (lai 2010) . the need to stay vigilant is never overemphasized, but being vigilant does not equate to a panacea that ensures all government agencies work together. to be well prepared for the unexpected, we need a clear and swift national command structure that can flexibly respond to, and even more promptly than in the case of disease transmission, the changing situation. all local agencies responding to an emergency must work within a unified national command structure to coordinate multi-agency efforts in emergency response and management of disasters. on top of facilitating close inter-agency coordination, the strength of this flexible structure is in its ability to ensure a swift response to an epidemic outbreak by implementing risk mitigating measures more effectively and efficiently. structural flexibility involves swift deployment of forces to mitigate the incident at the tactical level, and to provide expert advice at the operational level, in order to minimize damage to lives and property. among other things, the flexibility endemic to this command structure facilitates the building of trust between the state and its people (lai 2009 ). this in turn ensures that government measures are quickly accepted by the general public. as shown in this chapter, the moh has been entrusted by the singapore government and pre-designated to be the incident manager for public health emergencies. when a sudden incident involves public health or the loss of lives on a large scale, the moh is responsible for planning, coordinating and implementing an assortment of disease control programs and activities. during the outbreak of sars, the singapore government established a national command and control structure that was able to adapt to rapidly changing circumstances that stemmed from the outbreak. specifically, the moh set up a taskforce within that ministry even when the definition of sars remained unclear. as more sars cases were uncovered and better epidemiological information became available, the government quickly created the inter-ministerial committee (imc) and core executive group (ceg)-both of which were instrumental in the design and implementation of all risk mitigating measures-to coordinate the operation to combat the outbreak (pereira 2008) . while this overarching governance structure is more or less standard worldwide ('t hart et al. 1993; laporte 2007) , the case of singapore is unique in that the city-state was able to overcome bureaucratic inertia and adapt this governance structure. from singapore's experiences during the sars crisis, we have learnt that the strength of a national command structure lies in its flexibility to link relevant ministries on the same platform. these linkages ensure a timely, coordinated response and service delivery. having a flexible structure was not the only reason behind the successful defeat of sars. in singapore's case, we also notice the success of containing an uncertain, high-impact disaster has to rely on surge capacity. in the context of this paper, surge capacity refers to the ability to mobilize resources (such as ppes, vaccines and hcws) to combat the outbreak of a pandemic. singapore's response to sars in 2003 illustrates the importance of being able to increase surge capacity swiftly to deal with an infectious disease outbreak. in the asia pacific region, this problem continues to hamper many countries' ability to combat infectious diseases (putthasri et al. 2009 ). for many public health organizations in asia, it is a matter of fact that they are unable to deal with pandemics because the resources to do so are simply absent (balkhy 2008; hanvoravongchai et al. 2010; lai 2012b; oshitani et al. 2008) . meanwhile, there are evidences which suggest that surge capacity alone is not the full answer. for example, during the sars outbreak, abundant resources contribute an important but not all-encompassing element in the fight against these pandemics. as it turned out, when different stakeholders brought to the task-at-hand their unique skill sets and resources, they actually complicated the fight due to their lack of synergy. in fact, abundant resources without synergy might even undermine collaborative efforts. therefore, it is essential that the ability to link up various stakeholders must be complemented by some type of synergy between them. such ability can be enhanced through close collaboration. this brings us to the third implication for disaster management: collaborative governance at regional level. the trans-boundary nature of the disasters calls for a planned and coordinated approach towards disaster response for efficient rescue and relief operations lai 2012a) . combating epidemics requires multiple states and government agencies to work together in close (webby and webster 2003) . therefore, it is clear that collaborative capacity of various stakeholders is central to the fight against transboundary communicable diseases (lai 2011; lai 2012b; leung and nicoll 2010; voo and capps 2010) . while member states that are of advanced economic development typically lead such efforts, the inclusion of other developing countries, non-traditional agencies, and organizations (including non-governmental ones) is necessary and ultimately, inevitable. indeed, major countermeasures such as border control and surveillance are often made possible with the aid of regional collaboration. take the association of southeast asian nations (asean) as an example. asean countries take regional, national and sub-national approaches to disaster risk management ). the asean committee on disaster risk management (acdm) was established in 2003 and tasked with the coordination and implementation of regional activities on disaster management. the committee has cooperated with united nations bodies such as the united nations international strategy for disaster reduction (unisdr) and the united nations office for the coordination of humanitarian affairs (unocha). the asean agreement on disaster management and emergency response (aadmer) provides a comprehensive regional framework to strengthen preventive, monitoring and mitigation measures to reduce disaster losses in the region. in recent years, singapore has been active in providing training and education for disaster managers from neighboring countries. singapore has an ongoing exchange program with a number of asia pacific nations and europe. for example, to partner with apec to increase emergency preparedness in the asia-pacific region, singapore's scdf provides shortterm courses on disaster management in the civil defense academy (asia pacific economic cooperation 2011). the world today is far more inter-connected than ever before. international travel, transnational trade, and cross-border migration have drastically increased as a consequence of globalization. no country is spared from being influenced directly or indirectly by disasters. singapore is no exception. singapore is vulnerable to both natural and man-made disasters alongside its remarkable economic growth. in response, the singapore government adopts an approach of whole-of-government integrated risk management, a concerted, coordinated effort based on a total national response. we have witnessed in the case study singapore's all-hazard management framework with specific references to the sars epidemic. in fighting sars, singapore's health authority was responsive enough to swing into action when they realized that the existing bureaucratic structure was inadequate in terms of facilitating close cooperation between various key government agencies to tackle the health crisis on hand. therefore, a command structure was swiftly established. the presence of a flexible command structure, the way and the extent it was utilized, explains how well an epidemic was successfully contained. flexibility actually enhanced organizational capacities by making organizations more efficient under certain conditions. epidemic control measures such as surveillance, social distancing, and quarantine require widespread support from the general public for them to be effective. singapore's experiences with sars strongly suggest that risk mitigating measures can be effective only when a range of partners and stakeholders (such as government ministries, non-profit organizations, and grass-roots communities) become adequately involved. this is also critical to disaster risk management. whether all of these aspects are transferrable elsewhere needs to be assessed in future research. nonetheless, this unique discipline certainly has helped singapore come out of public health crises on a regular basis. singapore's response to the outbreak of sars offers valuable insights into the kinds approaches needed to combat future pandemics, especially in southeast asia. singapore imposes quarantine to stop sars spreading. abc news managing transboundary crises: identifying the 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to coordinate emergency medical services and emergency department teams crisis and emergency risk communication as an integrative model collaboration in the fight against infectious diseases economic survey of singapore singapore's efforts in transboundary haze prevention singapore real estate, and property price annual report on tourism statistics annual report on tourism statistics annual report on tourism statistics singapore floods sars in singapore -key lessons from an epidemic an architecture for network centric operations in unconventional crisis: lessons learnt from singapore's sars experience. california: thesis of naval postgraduate school sars in singapore: surveillance strategies in a globalizing city influenza pandemic and the duties of healthcare professionals are we ready for pandemic influenza who guidelines on the use of vaccines and antivirals during influenza pandemics. geneva: word health organization acknowledgement the authors would like to thank the economic research institute for asean and east asia (eria) to initiate this meaningful research project, and four commentators-professor yasuyuki sawada (tokyo university), professor chan ngaiweng (university sains malaysia), dr. sothea oum (eria), mr. zhou yansheng (scdf) and all participants in eria's two workshops, for their insightful comments for an earlier draft of this chapter. key: cord-138627-jtyoojte authors: buzzell, andrew title: public goods from private data -an efficacy and justification paradox for digital contact tracing date: 2020-07-14 journal: nan doi: nan sha: doc_id: 138627 cord_uid: jtyoojte debate about the adoption of digital contact tracing (dct) apps to control the spread of covid-19 has focussed on risks to individual privacy (sharma&bashir 2020, tang 2020). this emphasis reveals significant challenges to ethical deployment of dct, but generates constraints which undermine justification to implement dct. it would be a mistake to view this result solely as the successful operation of ethical foresight analysis (floridi&strait 2020), preventing deployment of potentially harmful technology. privacy-centric analysis treats data as private property, frames the relationship between individuals and governments as adversarial, entrenches technology platforms as gatekeepers, and supports a conception of emergency public health authority as limited by individual consent and considerable corporate influence that is in some tension with the more communitarian values that typically inform public health ethics. to overcome the barriers to ethical and effective dct, and develop infrastructure and policy that supports the realization of potential public benefits of digital technology, a public resource conception of aggregate data should be developed. analyze the movements and behaviour of an individual diagnosed with an infectious disease to identify possible incidences of transmission. the virology of covid-19 creates two kinds of scaling challenges that make manual contact tracing unfeasible. the mode of transmission is respiratory droplet spread, with some evidence of transmission via indirect surface contact, and the potential for aerosolized transmission in limited circumstances (van doremalen et al 2020) . with a reproductive rate sufficient for exponential case growth, this creates a horizontal problem of resource scale, in the us alone it is estimated that over 100,000 full-time contact tracers (watson et al 2020) . the long period of infectivity, and in particular the period of asymptomatic transmission, creates a vertical scaling problem, where the amount of data required to conduct tracing for each individual is quite large, encompassing contacts with people and surfaces over a 14 day period. dct apps could mitigate the vertical problem by assisting recall, recording high fidelity data for each individual that can be retroactively queried to identify potential transmission, and the horizontal problem by automating much of the contact tracing process (ferretti et al 2020) . even without a vaccine, effective dct could allow public authorities to relax some of the severe restrictions that have been imposed, an important counterfactual when considering the justifiability of dct programs (mello & wang 2020 ). most dct proposals use bluetooth low energy (ble) radio networking technology present in smartphones, recording received signal strength indicator (rssi) measurements to determine when devices are close together, and for how long. a database of device pairings and rssi information is maintained on the device or a centralized server, and when one device is flagged as belonging to an infected individual, an algorithm can select from the database identifiers recorded while the individual may have been infectious, filter them by duration and signal strength, and produce a list of device ids that might be targeted for intervention of some type, such as testing or self-isolation. as a sociotechnical system, dct re-taxonomizes rssi data as predictions of disease transmission risk and mandates actions, backed by public health authority. justification for the ensuing actions depends in part on the reliability of the prediction. dct faces serious efficacy challenges with both prediction and coverage, summarized in the supplementary material. when the non-causal proxies for transmission are too weakly correlated with actual transmission risks, or the individual or population coverage is insufficient or uneven, dct can't perform the function of identifying infection risks effectively. while predictive problems might be mitigated by improving technology and aggregating additional data, coverage problems threaten the viability of dct directly, and are least amenable to post-hoc correction. they require populations be persuaded to use the dct app, and that hardware and software vendors cooperate with public health authorities to resolve barriers to adoption and usage, such as the need for software modifications to enable passive rssi measurement. the exercise of coercive authority in the interests of public health is typically justified by the harm principle (upshur 2002) , that the action be necessary to prevent harm to others. it is further limited by the principle of least infringement (childress et al 2002) , that interventions which undermine privacy or autonomy must be the least burdensome alternative necessary to support the public health objective independently justified by the harm principle. efficacy is therefore a necessary condition on justification, and any modulation of measures taken in response to other ethical concerns must maintain a level of efficacy consistent with claims that the intervention is a viable alternative (allen & selgelid 2017) . for example, evidence that the pervasive use of face coverings in public significant reduces inter human transmission of covid-19 (zhang et al 2020) might justify the exercise of state power to make them compulsory, a significant limitation on autonomy, but one that is relatively low in costs and restrictions, compared to alternatives such as mass shelter-at-home orders. the efficacy of the less-restrictive alternative is high enough that the marginally better results from dramatically more severe restrictions are offset. if responsiveness to ethical or legal requirements constrain implementation of dct in ways that weaken its expected efficacy, this in turn undermines justification for coercive measures to encourage adoption. this might indicate a fundamental problem with the proposed intervention. because dct often triggers actions that further impact individual autonomy, such as quarantine, with the predictions it makes, efficacy is particularly critical. moreover, because dct has the potential to generate knowledge of risks that could save lives, decisions that dilute their epistemic capacity are themselves ethically salient (dennett 1986 ). at a time of heightened public awareness of the privacy and security challenges presented by our digital data exhaust, dct has been subject to intense scrutiny on privacy grounds. there is a growing awareness that our data can be used in contexts that we would not consent to, and which could harm our interests. we might agree to let an app to track our music listening habits to recommend playlists, but be dismayed to learn it can be used to make inferences about our even where we might grant consent to use our data in one context of analysis, interpretation and action, such as infectious disease control, we might not be able to foresee functions the data might be used for within it. similar problems with informed consent arise in the context of genetic research (lunshof et al 2008) , where uncertainty about usage problematizes consent, a problem magnified under the socio-technical conditions in which digital data is collected and retained, which generates very little friction to such re-contextualization and re-taxonomization. in light of these concerns it is not surprising that many dct models have focused on privacy-bydesign, with strict minimization of data collected and transmitted, strong anonymization, a prohibition on the use of additional data sources (such as gps), and policies demanding regular deletion of data and restrictions on uploading data to central servers. privacy-preserving dct models have been extremely influential, as evidenced by the extent to which implementations have coalesced around privacy-preserving standards (chan et al 2020 , li and guo 2020 , tang 2020 ) such as mit's private kit (mit 2020), pepp-pt (pepp team 20202) and dp-3t (troncoso et al 2020) , and the extent to which technology platform providers and health institutions (world health organization 2020) have embraced this approach. because the design of mobile operating systems prevents the passive collection of bluetooth data, the cooperation of vendors is necessary to build effective dct apps. the dominant mobile operating system vendors, apple and google jointly and rapidly developed the "exposure notification api" (apple & google 2020) to support limited dct capabilities. access to the exposure api is tightly controlled, and only one app can be deployed in a country. the vendors can disable and remove the app at any time. the app cannot use any data source except bluetooth rssi data obtained via the exposure api. the app cannot transmit this data to a central server. the exposure api provides a methodology for the calculation of disease transmission risk which public health authorities configure by setting some pre-defined values. the structure of the exposure api expresses and enforces a policy perspective on the the relationship between public health authorities and citizens who use the products manufactured by apple and google. this treats data as private property, frames the relationship between individuals and governments as adversarial, entrenches technology platforms as gatekeepers and offers a conception of emergency public health authority as limited by individual consent and considerable corporate influence. this is an unconventional view -historically privacy is not signifiant constraint on manual contact tracing, and even strong legislation such as hippa recognizes the legitimate need for public health authorities access to protected health information (hippa 45 cfr 164.512) technology companies require a great deal of public trust to operate, as do governments and public health authorities. because of the need for cooperation with governments to build dct, vendors are exposed to highly publicized risks in the deployment of dct, in terms of maintaining trust and also in avoiding additional regulation. the privacy preserving model serves vendor interests, allowing them to cooperate with public health authorities, thus avoiding regulatory or coercive measures, by limiting the possibility that the use of dct apps breaks tacit or contractual agreements with their users that could damage already wavering public trust. (newton 2020) . critically, the exposure notification api prevents several actions that might be undertaken to improve the efficacy of dct. coverage problems that relate to contexts where smartphone ownership or physical possession is uneven could be partially remediated by aggregating other data, as could the predictive weaknesses of rssi. the aggregation of data, including gps, on central servers where it can be subject to further analysis and enrichment might also improve the epidemiological value of dct (mello & wang 2020) . some countries have political, demographic and cultural characteristics that might favour the use of multiple apps, and data preservation may have future epidemiological value. if privacy-maximizing constraints on dct undermine efficacy, this in turn can weaken justification to deploy dct at all. one might conclude that this is the correct outcome of ethical analysis of dct, that it cannot be used ethically, because requirements needed to generate the efficacy required for public health objectives are unjustifiably invasive or coercive. alternately, one might wonder if this suggests that privacy-maximizing analysis is problematic. it is somewhat dismaying that a public health intervention that we have the technical means to deploy, which would be a much less restrictive alternative to measures currently in effect, becomes unjustifiable because of the restrictions necessary to ensure minimization of privacy risks. concerns about security and mission creep are only accidentally supportive of privacy maximization. while there are legitimate reasons to think that the socio-technical infrastructure dct apps depend on are too insecure to trust, these are generally not inherent but are instead the results of implementation decisions, and in practice we are able to mitigate these to support many sensitive applications. there will be many examples of poorly implemented dct, such as qatar's which leaked personal data in qr-codes (amnesty international uk 2020), but this does not mean that secure dct is not possible. one might also worry that governments will misuse the data down the road, but emergency public health legislation enacted in most jurisdiction has strict limitations that we should trust to function as intended. even if we have upstream worries about the rule of law in some jurisdiction, this a distal problem, and not one that weighs in favour of the privacy-maximizing view generally. the problem of coverage efficacy is one of trust and influence as much as it is technicaladequate coverage and compliance depends in part on the public's willingness to cooperate. justify if a majority of the population did not support it. one of the reasons why anti-vaccination propaganda, which is often produced and amplified by hostile entities, is particularly dangerous is that it can erode democratic mandate for the very actions that would mitigate the damage. the paradox which arises for dct is that increasing privacy protection in order to overcome constraints on justification undermines predictive efficacy to an extent that weakens justification to deploy dct at all. but, to relax these protections to improve predictive efficacy conflicts with public sentiment (milsom et al 2020) , creating resistance to adoption that would exacerbate coverage efficacy problems, again weakening justification on efficacy grounds, but also increasing the justificatory burden because implementation against public sentiment raises the stakes in terms of autonomy impingement. the remainder of this article explores a route to resolve this paradox by examining the conditions that make the privacy objections so difficult to overcome. public sentiment against impingements on privacy necessary for dct is grounded in legitimate fears of pervasive security problems with the socio-technical infrastructure. the litany of security and privacy problems with dct applications that have already been deployed (privacy international 2020) reinforce this. however, this sentiment is also shaped by an increasingly prominent public discussion of technology ethics that is framed in a way that sits uneasily alongside the values that inform public health ethics. a dominant strain of technology ethics, as exemplified by legal expressions such as the eu's gdpr and california's ccpa and many ai ethics charters and codes of conduct (jobin & vayena 2019 ) resembles a format that, in bioethics, came to be known as "principlism" (beauchamp & childress 2001 , clouser & gert 1990 . this is the view that minimal set of principals, usually autonomy, non-maleficence, beneficence, and justice, supply the analytical machinery needed to approach ethical problems. it is criticized on the grounds that it does not specify an ordering, which instead is often inherited from the context of application, which tends to privilege the liberal individualist emphasis on autonomy, and which is unable to fully articulate principles such as beneficence beyond self-interest. (callahan 2003) . applied technology ethics has a tendency to generate trade-off dilemmas, such as that between innovation and precaution, or privacy and public goods, because, as with principlism in bioethics, it does not supply a decision procedure for conflict resolution. this is particularly challenging when institutions that produce technological artefacts and systems struggle with "...onboarding external ethical perspectives..." (metcalf & moss 2019 ) that conflict with tacit and explicit internal norms. our underlying moral interest in applied ethics demands more than compromise and consilience, rather, as callahan puts it "[s]erious ethics, the kind that causes trouble to comfortable lives, wants to know what counts as a good choice and what counts as a bad choice" (callahan 2003) . the "communitarian turn" in bioethics arose in part because capabilities emerging in genetic research created opportunities for public goods that could only be ethically realized once focus on individual interests yielded to more communitarian principles such as solidarity and public benefit. (chadwick 2011) . predictive genetic analysis that might benefit an individual, their family, and their community, now and in the future, exposes information that might be prejudicial to the individual's interests, for example, by interfering with their ability to acquire health insurance (fulda & lykens 2006 , launis 2003 the extended value of genetic data over long timelines and across unforeseeable applications problematizes the coherence and applicability of autonomy protections such as informed consent. an ethical framework that could motivate policy and regulation to enables the pursuit of these opportunities for public good required the integration of communitarian values. likewise, public health ethics introduces principles such as solidarity, proportionality, and reciprocity alongside the four core principles of biomedical ethics (coughlin 2014 , lee 2012 , schrã¶der-bã¤ck et al 2014 , communitarian values that reflect the fundamentally shared object of concern, and further expose the limits of analysis that privileges autonomy. communitarian and distributive considerations can help resolve some of the ordering problems principlist technology ethics inherits from the liberal individualist context it operates within, helping to resolve tradeoffs by giving greater weight to shared values and common goods. if dct cannot be deployed in a way that is ethical and effective, this is an unfortunate loss of a significant public health opportunity. the barriers to remediation run deeper than privacypreserving technical measures, and stem from the need to develop a conception of aggregate personal data as a public resource. the exposure notification api encodes and enforces a privacy and autonomy maximizing model of dct, essentially privatizing a public health policy concern. one justification for this is that corporations are enabling their users to protect their personal property, or adhering to a contractual obligation (taddeo & floridi, 2016) . traditional contact tracing treats our personal data as a potential public resource, with synchronous consent and access procedures triggered by the identification of transmission risk, whereas dct treats it as a de-facto public resource with aways-on consent and access. dct provides public benefits based on data collected from many individuals who might never have an elevated risk. its value is at the population level, and we would accept impingement on our privacy for the good of the community. although privacy is usually regarded as a paradigmatically individual concern, communitarian approaches to privacy (o'hara 2010 , floridi 2017 argue that groups can have privacy rights, and that privacy is fundamentally a common good, where its value and limits are in reciprocal tension with other community values. technology companies profit from the value they extract from aggregate data, which depends on pervasive access to individual data in ways that frequently compromise privacy. aggregate data is exponentially more economically and informationally valuable than that of the data of any one individual, and confers signifiant soft power to influence public sentiment, and hard power to control access to data and generate economic opportunities. but it is not clear that the equivocation between personal data as the private property of an individual, and aggregate data as the private property of the collector, is justified. napoli (2019) argues that "...whatever the exact nature of one's individual property rights in one's user data may be, when these data are aggregated across millions of users, their fundamental character changes in such a way that they are best conceptualized as a public resource" (napoli 2019) . if aggregate data is substantially and uniquely distinctive, this supports the application of public trust doctrine, which is based on the idea that "...because of their unique characteristics, certain natural resources and systems are held in trust by the sovereign on behalf of the citizens" (calabrese, 2001) , such a the public broadcast spectrum. the exploration of a communitarian approach to applied technology ethics and the articulation and assertion of a public resource rationale applicable to the data we generate by engaging with digital technology and services could enable policy and regulation that would directly address the barriers to effective and ethical dct. this could expand regulatory and policy measures to ensure the safe handling of sensitive data, foster the enabling conditions for the realization of opportunities to use aggregate data for public good, and help reverse the centralization of decisive power over public policy in the hands of multinational technology corporations. where policy and legislation such as the gdpr, especially through the dpia process, identifies and protects risks to individual interests, methodologies to identify and protect opportunities in the public interest lag behind, as the barriers to dct implementation illustrate. inherent efficacy challenges: the virology of covid-19, so far as it is understood, makes this re-taxonomization problematic, because the mode of transmission and infectivity is such that there is only a weak likelihood that any particular contact detected by dct results in transmission, whereas for disease such as tuberculosis or hiv/aids, it is easier to identify exposure events with high transmission probability. the contact/transmission link is also problematic due to the potential for transmission via indirect surface contact. there are socioeconomic confounds related to smartphone ownership and use that will skew representation and the ability to install and update dct apps. life patterns in some populations generate periods of contact with others when smartphone are not present, and some forms of employment generate a large number of contacts with others, which may or may not actually correspond to increased risks of transmission. evidence for nonnosocomial transmission in japan shows primary cases in several contexts where smartphones are frequently not on our persons or turned off, such as music events and gyms (furuse et al 2020) . bluetooth rssi as a proxy for exposure: there are efficacy problems with the core technology. rssi measurements map only weakly to transmission risk, because ble radio signals travel through walls and barriers used in public spaces to specifically to prevent droplet spread. rssi is stronger when we walk side-by-side than following one another, is weakened when phones are in pockets while sitting around a table, and is sensitive to many idiosyncratic features of indoor environment (leith & farrell 2020) . there are also considerable differences in rssi measurement for different devices and different mobile operating systems (bluetrace 2020), which introduces socio-economic confounds. security: efficacy can be further undermined by deliberate exploitation of security vulnerabilities (vaudenay 2020) and even simple circumvention such as the display of screen captures instead of running apps, as has been observed in india with mandatory aarogya setu app (clarence 2020) undermines the public health value of dct. at the population level, dct apps would have to be in use by 60% of a population (servick 2020) to be effective, a challenge that lead singapore to consider making their app mandatory, a proposal later abandoned due to implementation challenges (mahmud 2020) . various jurisdictions have considering opt-in, out-out, and incentivization schemes to encourage uptake. at the individual level, coverage involves the extent of the individual's activities and behaviours that are accurately captured by the dct app. aside from issues related to smartphone ownership and presence described above, mobile phone operating systems place limits on the ways apps can access bluetooth radios, often requiring apps be open and in use -even an individual who has installed the app and has their phone at all times would produce little useful dct data in this case. this problem is in fact a critical barrier to effective dct, and requires the cooperation of operating system vendors to remediate, and requiring users to keep their phones open and the apps on-screen is not viable. neo-muzak and the business of mood necessity and least infringement conditions in public health ethics qatar: 'huge' security weakness in covid-19 contact-tracing app exposure notifications: using technology to help public health authorities fight covid-19 contact tracing of tuberculosis: a systematic review of transmission modelling studies principles of biomedical ethics principlism and communitarianism pact: privacy sensitive protocols and mechanisms for mobile contact tracing the communitarian turn: myth or reality public health ethics: mapping the terrain aarogya setu: why india's covid-19 contact tracing app is controversial a critique of principlism how many principles for public health 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title: promoting universal coverage of basic public services among urban residents date: 2014-12-31 journal: annual report on urban development of china 2013 doi: 10.1007/978-3-662-46324-6_10 sha: doc_id: 18794 cord_uid: stcre6ol in 2012, china’s urbanization rate reached 52.57 % but, if we counted only people with urban hukous, this was only 35.29 %; there were 263 million migrant workers in china, where they have already been playing a leading role in urbanization. nonetheless, governments are still managing applications for new permanent urban residents’ registration, demanded by rural migrant workers, by using the long-established hukou-based public service policies. this has constituted a big obstacle to the citizenization of rural migrant workers in china, caused a great deal of problems with urban management, and is contrary to social justice. in 2013, it was made clear in the report on the work of the government that relevant authorities should accelerate reform of the household registration system and related institutions; that they should register eligible rural workers as permanent urban residents in an orderly manner, “progressively expand the coverage of basic public services in urban areas to include all their permanent residents and create an equitable institutional environment for freedom of movement and for people to live and work in contentment.” accordingly, in order to protect the rights of migrants and improve the quality of the process of social urbanization in china, the most significant tasks involve investigating the current status of basic public services in chinese towns and cities, especially the public services provided for potential new permanent migrant worker residents, and exploring methods to expand the coverage of these basic public services in urban areas to all their permanent residents. residents, and exploring methods to expand the coverage of these basic public services in urban areas to all their permanent residents. 'public services' is a concept corresponding to that of 'public good' in economics, but is not identical to the latter. public services rely on public fi nance support to satisfy public needs, and they include social services, policies benefi tting the public, and social security and public infrastructures. public services therefore relate closely to government functions and will vary with distinct levels of economic development and the needs of each society. basic, or core, public services are a function of basic registered city residents' rights to them, established by the basic needs of any society and the capabilities of governments to provide such services. 3 regarding the public service system, the chinese government has been paying closer attention to the concept of fairness since 2003. it has invested signifi cantly more money than before in public services for rural areas, such as compulsory education, the nrcmcs and support for the elderly; in urban areas, the provision of basic public services has expanded beyond that given to employees of state-owned organizations to cover those of non-state-owned organizations, urban residents and the low-and middleincome groups. in addition, as the number of rural migrant workers grows, migrant workers have come to represent the majority of industrial workers present in cities, and have made notable contribution to urbanization in china. consequently, these migrant workers demand access to relevant basic public services, which demand, as urbanization advances in china, is also receiving more attention. in spite of this, the provision of basic public services in urban areas to all residents remains clearly insuffi cient. an examination of basic public services follows: according to the new compulsory education law of 2006, the state government shall be responsible for funding compulsory education. it must be made available to everyone eligible free of charge, in the name of tuition or any other fee. this was achieved fi rst in rural areas, followed by urban areas starting 2007. regarding the provision of education services for the children of migrants, full-time public schools in host cities are playing a leading role, suggesting that local governments assume a larger share of the responsibility than before. in 2003, the general offi ce of the state council forwarded the opinions on further improving compulsory education for children of migrant workers in cities co-issued by ministries/commissions such as the moe, emphasizing that the children of migrant workers should receive the same treatment as that of other children. the drc research team discovered in a 2011 survey that, of all children who had migrated with their parents, 80 % were receiving compulsory education at public schools. local governments are working to address the issue of education for the children of migrant workers, depending on local conditions. for example, in the province of guangdong, which is the leading destination for non-local migrants, children of non-local migrant workers already represented 67 % of all students who were receiving compulsory education in 2008. since the number of non-local migrant workers is still growing, the demand for education services for all children with non-local hukou s is quickly exceeding what public elementary and middle schools can supply. by paying qualifi ed private schools for admitting children with non-local hukou s, the guangzhou municipal government, for example, is trying to increase the percentage of children with non-local hukou s who receive education in this city; some members of the cppcc guangdong provincial committee have proposed issuing "education vouchers" to let children with non-local hukou s. 4 since children who migrate with their parents will need to take exams for admission to higher-level schools after the end of compulsory education, the outline of the national mid-and long-term education reform and development program (2010-2020) proposes that measures for these children to take such exams in host cities be developed. in 2010, the moe issued the notice on organizing application for implementing pilot projects of the national education system reform , which included equal access by children who migrate with their parents to compulsory education and exams for admission to higher-level schools in host cities, as well as the inclusion of further reform of the national college entrance examination (ncee) or gaokao , system in the earliest pilot projects of education reform. 5 by the end of 2012, competent local authorities had all worked out schemes for students with non-local hukou s to take the gaokao in host cities (see table 10 .1 ). the chinese government has been assuming more responsibility for these services and has gradually been improving the basic healthcare system for urban areas since the sars crisis of 2003. a network in which community healthcare service organizations play a primary role, and work with public hospitals, has been built and performs such functions as ensuring urban residents have access to medical services near where they live, controlling medical costs and establishing immediate monitoring systems in 4 xu chen and lai nanhui: "guangzhou plans to buy admission for more children of migrant workers to receive free education", yangcheng evening news , august 29, 2008, http://www.chinanews.com/edu/zcdt/news/2008/08-29/1365019.shtml 5 guo shaofeng and liu chang: "the moe will conduct pilot projects for children of migrants to gain equal access to compulsory education", cnr, may 15, 2010, http://news.163. com/10/0517/06/66s728ag000146bd.html chongqing: on the school roll for 3 years + steady jobs (2013); hunan: on the school roll for 3 years + parents' residence permits (2013); heilongjiang: on the school roll for 3 years + parents' jobs and domicile (2013); hebei: on the school roll for 2 years + parents' jobs and residence permits (2013); henan: on the school roll + steady jobs and domicile (2013); jiangsu: on the roll of a local senior high school plus full schooling record + guardians' permanent domicile (2013); sichuan: on the school roll + residence (2014); ningxia: on the roll of a local senior high school + parents' steady jobs, domicile and social insurance premium payment for 3 years or more (2014); inner mongolia: on the school roll for 2 years + permanent domicile, both jobs and tax payment for 2 years or more (2014); guizhou: on the school roll for 3 years + parents' residence, jobs, residence permits and social insurance premium payment for 3 years of more (2014); shanxi: on the school roll + parents' steady jobs and permanent domiciles (2014); jilin: full schooling record at senior high school + parents' jobs, domicile and social insurance premium payment for 3 years or more (2013); tianjin: on the school roll for 1 year or more + evidence for tax payment by parents and social insurance premium payment (from 2013 increasing in a step-by-step manner); hainan: schooling experience + permanent domicile and steady jobs (2014); shaanxi: on the school roll for 3 years + either parent's residence permit for 3 years or more, and pension insurance premium payments for 3 years or more (2016); chongqing: on the school roll for 3 years + working parents (2013) hukou yunnan: the examinee's hukou has been transferred in for 3 years or more, and studies at a local high school for 3 years (2013); gansu: on the roll of a local senior high school for 3 years + the examinee and his/her parents received local hukou s at least 3 years ago (2013); xinjiang: study at a local senior high school for three consecutive years + the examinee and his/her parents received local permanent hukou s at least 2 years ago (2013); qinghai: the examinee must produce his/her household register and id card; examinees with non-qinghai hukou s may take exams in this province but will not compete with local ones for opportunities for going to university (n/a) transitional scheme beijing: all children, whether local or not, may register for entrance exams for local secondary or advanced vocational schools (from 2013 onward in a step-by-step manner); shanghai: in combination with the regulations on residence permits (from 2013 onward in a step-by-step manner); guangdong: in combination with the points-based hukou system (from 2013 onward in a step-by-step manner) source: http://www.eol.cn/html/g/ydgk/ . tibet has no relevant scheme at present the event of sudden disease outbreaks. this network contributes to equal access by all urban residents to public healthcare services. 6 regarding migrant workers as a huge sub-group of migrants as a whole, the moh issued a notice in 2010 to announce that it would conduct pilot projects as part of the migrant worker healthcare program in 65 selected counties/cities and city-administered areas in 29 provinces other than hainan and tibet. main tasks included: health education among migrant workers; creating health records for migrant workers and making timely updates; conducting tuberculosis prevention and control among migrant workers, and making plans for their children's immunization programs; conducting programs to protect migrant workers from exposure to the aids virus and to carry out occupational disease prevention and control. each task came with quantifi ed targets. the moh hoped to summarize experience from these pilot projects before rolling migrant worker health care out across china. 7 in 2011, the beijing migrant worker healthcare program was launched in the haidian and daxing districts as pilot areas. 8 china's urban social security system has gradually improved in recent years. in addition to basic pension insurance for urban workers, the basic medical and pension insurance systems for all urban residents have been established after the social insurance law was implemented. these social security systems exhibit the drive towards socialization, compliance, wide coverage and multiple dimensions of basic urban social security provision in china. 9 in addition, a social security system for nonlocal migrant workers is being put in place. nationwide, in addition to work insurance, the percentages of employers that bought insurance for their employees, or migrant workers who bought insurance for themselves, was increasing more rapidly table 10 .2 ). in 2012, the numbers of migrant workers covered by urban basic medical and work-injury insurance increased by 3.55 and 3.45 million people respectively, compared to 2011. 10 regional social security systems have also been established in east, central and west china. the percentages of migrant workers covered by both work-injury and medical insurance, in particular, are higher than those of migrant workers covered by other insurances, due to the nature of their jobs. also, from a sectoral perspective, the percentages of non-local migrant workers covered by relevant insurance in such sectors as manufacturing, wholesale/retail, transport/warehousing/postal service and residential services are higher than in others such as the building industry (see table 10 .3 ). in the 1990s, the workers laid-off from state-owned enterprises (soes) due to deepening reform measures, were naturally the primary focus for service provision from urban public employment organizations. the chinese government launched two rounds of proactive employment policies, with one round being centered on the notice on further improving work relevant to the reemployment of the laid-off and unemployed people issued at the national work meeting on reemployment in september 2002, and the other on gf [2005] no. 36 document, promoting the continuous development of local public employment services. registered unemployed urban residents and people laid off from soes could from then on all receive free job advisory services. employment support policies for university graduates as well as disadvantaged urban families and groups (e.g. families in which nobody has a job and people who have diffi culties in getting a job) have also been improved. 11 , 12 as the number of rural migrant workers keeps growing, host cities, who used to focus only on employment rights' protection, have expanded the employment services to include allowing these migrants to enjoy equal access to the whole range of public employment services. in january 2003, the state council issued the notice on providing employment management and services for migrant workers in cities , proposing to do away with unreasonable restrictions on farmers' migration into cities for work, to address late payment and underpayment of wages, and to provide appropriate training and management of these issues. later in 2003, six ministries/ commissions such as the moa jointly issued the training program for migrant workers across china, 2003 -2010 , which included provision for migrant worker training and tools for performance evaluation of government at all levels, with a view to improving the employment stability of migrant workers. 13 the central government reemphasized in its no. 1 document of 2004 that relevant authorities should remove administrative restrictions and unreasonable charges for farmers' migration into cities for work and should seek to protect their economic rights. it also required municipal governments to expand the provision of public services to migrant workers. the notice of the ministry of human resources and social security and the ministry of finance on issues regarding further improving the public employment service system issued in 2013 makes clear that the basic principle of public employment services is to provide basic public employment services in a sustainable and equitable manner across china by merging urban and rural labor markets and creating a long-term service mechanism that is geared to both urban and rural areas and that serves, in effect, all workers. 11 wen junping: "on equal access to public employment services and the approach to realizing it", the journal of shanghai business school 2010 issue 6. 12 li gongda: "on the public employment service system in china", labor security 2008 issue 10. 13 on the question of legal support, the labor contract law which became effective on january 1, 2008, together with the employment promotion law and the labor dispute mediation and arbitration law which were both issued in 2007, all stipulate basic legal support for all job seekers, including migrant workers, in terms of fair employment and rights' protection. furthermore, local governments now publish policy documents on an annual basis which highlight and review the problem of underpayment to migrant workers. they also make greater efforts in providing migrant workers, especially the new generation, with employment services such as training (see table 10 .4 ). improvements in public employment services are contributing to a steady increase in the quality of employment among migrant workers. housing assistance is an important part of public welfare. the housing market has been growing rapidly since the chinese government rolled out house trading amid the urban welfare reforms of the 1990s. to provide low-income urban households with housing assistance, the then ministry of construction issued the measures for managing urban low-rent housing specifi cally focusing on measures to help lowest-income households with permanent urban hukou s in 1999. nonetheless, the low-rent housing system has since developed slowly and has yet to be further improved. to address high housing prices and diffi culties facing urban low-income households in buying or renting housing, the state council issued the opinions of the state council on addressing diffi culties facing urban low-income households in buying or renting housing in 2007, requiring that relevant authorities establish or improve an urban low-rent housing system, and improve and regulate affordable housing. the state council also made clear in this document that relevant authorities should work to improve housing conditions for residents, including migrant workers, living in large slums or old residential areas. it is expected that, by the end of the 12th five-year plan period, the provision of affordable housing will reach at least 20 % nationwide across china, in order to solve the housing issue for urban low-and middle-income households. given the needs and spending limitations of low and middle-income groups in cities, relevant authorities have developed various forms of housing assistance, such as priority access to public rental and low-rent housing, and also to a range of other affordable housing schemes where public housing policies have brought about house/rental price limits or, for example, the accommodation of people from slum clearances, waiting to be reassigned housing. 14 applicants for affordable housing such as low-rent and price-controlled housing must have received urban hukou s in areas administered by this city for 1 year or more; the municipal government issued the interim measures for managing public rental housing in nanning city on october 15, 2012 to address the housing issue for low-and middle-income households (with hukou s, but no number of years of residence limitations) as well as for graduates and non-local migrant workers (with hukou limitations for neither group) jinan city the municipal government offi cially announced a public rental housing assistance standard on november 30, 2012: barriers to application for public rental housing were lowered, and income and hukou limitations were cancelled. on the question of housing allocation, two-bedroom apartments were to become available for non-locally recruited skilled workers, certain families of three or more members, or certain single-parent families with one child of the opposite sex; one-bedroom apartments were to be made available for certain families of no more than two members or certain single people with permanent hukou s in the six districts within this city; shared rental apartments were made available for non-local single employees, with at least fi ve square meters in usable fl oor space available to each tenant anhui province the provincial government's 2013 plan was to build 400,000 social apartment units and merge public rental housing and low-rent housing into a single system; the allocation of such units would be in favor of new employees and workers with non-local hukou s shenzhen city in 2013, the provision of affordable housing was expanded to middle-income people with no housing, and families of skilled workers with non-local hukou s that had diffi culty in buying or renting housing sichuan province in 2013, the provincial government conducted the housing assistance for migrant workers program specifi cally aimed at migrant workers who had steady jobs and had lived in urban areas for at least a certain number of years. it was considering the allocation of 20 % of all public rental housing to workers with non-local hukou s such as migrant workers, and the expansion of the hpf program to cover migrant workers source: ou qianheng and li gongyu: "nanjing: people from three groups may apply for public rental housing and are subject to looser hukou requirements than before", news.gxnews.com.cn, november 7, 2012; yu wen and wang jiguo: "jinan: applicants for public rental housing are no longer subject to income and hukou requirements; people with non-local hukou s become eligible for local housing assistance for the fi rst time", qilu evening news , december 3, 2012; wu liangliang: "400,000 social apartment units will be built in anhui province this year, and will be allocated in favor of new employees and workers with non-local hukou s", anhui provincial department of housing and urban-rural development, january 6, 2012; li gang: "people with non-local hukou s in shenzhen benefi t from local housing assistance, and affordable housing will phase out", the people's daily , january 25, 2013; wan yao: "sichuan: the housing assistance for migrant workers program will be implemented this year, and 20 % of all public rental housing will be allocated to migrant workers", the sichuan daily , february 18, 2013; the offi cial website of the mohurd, http://www.mohurd.gov.cn most migrant workers still live in dormitories provided by their employers or in rented houses in formerly rural areas reclassifi ed as cities but still basically under rural governances. in 2011, most non-local migrant workers lived in dormitories provided by their employers or in rented or co-rented houses; those who lived in dormitories represented 32.4 % of all such workers; those who received housing allowances from their employers only represented 8.8 %, according to relevant statistics from the national bureau of statistics (nbs). 15 we can therefore see that migrant workers who pay housing rents for themselves represent a large share of all such workers. the picture of the current coverage of basic urban public sector services shows that it has been gradually going beyond initial limitations caused by ownership systems, and it has extended provision to a larger number of low-income households, together with better quality of service. this public service system is available to nearly all permanent residents with local urban hukou s and is becoming increasingly well regulated. in addition, urban migrant workers' needs in terms of public services are increasingly being met. from a regional perspective, the provision of basic public services in eastern china is better than in central and western areas. this being said, there has been no substantial change in the overall institutional design of the basic urban public service system, which is characteristically based on hukou registration, management under the territoriality principle and the division of administrative responsibilities. new permanent residents and, in particular, rural migrant workers, have yet to be fully covered by basic urban public service provision. public elementary and middle schools in cities hosting migrant families already play a substantial role in providing compulsory education for migrant workers' children across china. nonetheless, there is wide variation in the degree of effort put into the inclusion of these children within local public urban educational systems. in the city of dongguan, for example, the children of migrant workers studying in public schools represented only 26.5 % of all such children in 2010. 16 migrant workers hope that their children can receive better education in cities, but their children have to return to their hometowns for the gaokao after the end of compulsory education, since the governments of most host cities have yet to make policies that integrate elementary, middle and high school education. we can easily see that local schemes for students with non-local hukou s taking the gaokao vary widely from place to place. western provinces such as yunnan still impose hukou restrictions on students who take the gaokao ; the leading destination cities of migrants in china, which are beijing, shanghai and guangdong, have similar transitional gaokao schemes for students with non-local hukou s. thus, "beijing scored zero points and shanghai also failed," as a critic put it. 17 in 2008, the moh conducted pilot projects for the migrant worker healthcare program. however, owing to the lack of any long-term mechanism for their inclusion in basic urban medical care service provision, migrant workers have not got equal access to other connected healthcare services: they have not been fully covered by the disease prevention and monitoring system; only a small number of the children of migrant workers are covered by the national immunization program; migrant workers have not been fully included in the urban family planning service system, and there are interregional system incompatibilities in terms of related services and allowances. 18 the social security system in urban areas tends towards fragmentation. 19 migrant workers, in particular, are a low percentage of those who are covered by social insurance, and there are additional institutional defi ciencies. firstly, premium rates for social insurance are on the high side, compared with the wages of migrant workers. the current rates demanded for migrant workers are 17 "a professor at peking university: when it comes to the ncee schemes for students with non-local hukous, beijing scored zero points and shanghai also failed", the people's daily overseas edition , january 10, 2013, http://gaokao.eol.cn/kuai_xun_3075/20130110/t20130110_892022.shtml 18 han jun: "how the citizenization of migrant workers relates to the innovation of the public service system", administration reform 2012 issue 11. 19 the drc research team: "the citizenization of migrant workers: the general trend and strategic orientation", china reform 2011 issue 5. higher than those for urban residents, since the average wage of the former is lower than that of the latter, and because the contribution base for migrants to be covered by urban social insurance equals 60 % of the average wage of urban employees in the previous year. most migrant workers are employed in sectors such as processing/ manufacturing and services, where the labor cost represents a large share of the total cost and most employers are unwilling to pay full amounts of premiums for the employed migrant workers. secondly, pension insurance presents problems of continuation. this is because migrant workers are highly mobile, and, even if they are not rejected by the urban pension insurance system for employees, continuity of contributions cannot be guaranteed in other places. thirdly, interregional settlements for medical insurance are impossible. in 2011, only 16.7 % of all employers of nonlocal migrant workers paid medical insurance premiums for these workers 20 ; migrant workers who have opted to enroll in the nrcmcs (overall planning of which is made at the county level) are still unable to get medical expenses reimbursed immediately after they receive medical services where they work. fourthly and lastly, migrant workers who have not been covered by social assistance systems in their host cities, are also ineligible for medical assistance and minimum living allowances. in 2011, migrant workers who had received non-agricultural professional skills training only represented 26.2 % of all such workers in china, according to monitoring statistics from the nbs. their survey revealed that most migrant workers had an educational level of junior high school and had received no suitable professional skills training, both of which adversely affected their profi ciency at work and, thus, their income levels. in addition, it was noted that fewer than half of non-local migrant workers, especially in the building industry, had signed labor contracts with their employers in 2011. a research report published by the state council summarized the current problems affecting migrant workers' employment rights as: generally low wages, different pay scales for urban and rural workers in the same job, non-compliant worker management practices, poor safety at work, and low levels of organization. a survey in 2009 showed that as many as 59.7 % of the surveyed migrant workers were dissatisfi ed with their wages. 21 not all chinese cities have included migrant workers in the local affordable housing systems. medium-and large-sized cities which are the major destinations of migrant workers are, indeed, acting more slowly than others in this regard. some municipal and provincial governments typically lift hukou -related restrictions in a selective manner -their policies tend to be in favor of those non-local workers who are more skillful or have steady jobs and have lived in host cities for a required numbers of years; such workers are already essentially the same as native city residents. most migrant workers still live in corporate dormitories. moreover, only a small number of migrant workers receive housing allowances; that is, most of them pay their housing expenses themselves. those who are covered by the urban affordable housing system merely represent a small percentage. in this time of rapid urbanization in china, the biggest problem with the current urban public service system lies in its failure to cover rural migrant workers (han jun 2012). the total number of migrant workers across china reached 263 million people in 2012, including over 163 million non-local workers. 22 in addition to this, there is a growing trend of whole family migration. however, although they work and live in urban areas, migrant workers cannot access the same public and welfare services as those available to native city residents. this has reduced opportunities for migrant workers and their children, and their capacity to develop in urban areas (chi fulin 2008) and is detrimental to the fundamental aim of improving the quality of urbanization. the provision of public services and welfare dependent on hukou registration has resulted in migrants having insuffi cient or no access to public services in urban areas. the problem of the fast-growing demand for public services for rural migrant workers and the limited availability of public funds to provide them in host cities, must be addressed; relevant authorities should also undertake to gradually improve the urban public service system and expand its coverage to all permanent residents including migrant workers, in order to embrace the principle of fair treatment and equal opportunities for improvement for all. to this end, it is fi rstly necessary to concentrate on the major objective of extending the provision of urban public services to all permanent residents, including all migrant workers. the promotion of equal access and improving the quality of public services offered should proceed at the same time. governments of host cities should assume more responsibilities to ensure the educational rights of migrant workers' children. the authorities should also assume more managerial responsibility and include educational services for the children of migrant workers when planning local educational fi nancial support. while providing such children with compulsory education mainly through local public elementary and middle schools, these governments should take additional measures to help them integrate into receptor cities. they should also subsidize private elementary and middle schools that participate in the provision of compulsory education and enhance their management. it is also necessary to improve preschool education for the children of migrant workers, in which kindergartens open to all children should play a leading role. in addition to local gaokao schemes for school students with non-local hukou s, relevant authorities should promote vocational education for the children of migrant workers and allow them to participate in entrance exams to local senior high schools and the gaokao. the authorities should seek to improve the migrant worker health information system using as a model the results from pilot projects carried out for the migrant worker healthcare program. in areas where large numbers of migrant workers live, the current community-level public medical and healthcare services should be gradually extended to cover all permanent residents, allowing migrant workers access to convenient, fairly-priced and safe community-level medical and healthcare services. it is necessary to enhance sanitation, disease prevention/control and children's immunization services in the aforementioned areas, to pay suffi cient attention to migrant workers' occupational health rights, and to ensure that migrant-worker couples have effective and convenient access to family planning services in their urban societies. firstly, since most migrant workers are in dangerous industries such as manufacturing and mining, relevant authorities should provide all migrant workers with industrial injury insurance as soon as possible. secondly, it is necessary to gradually improve the basic medical insurance system for migrant workers. thirdly, the extension of pension insurance to include all migrant workers is essential. fourthly, it is recommended that measures be undertaken that enable the interconnectivity between urban and rural social insurance systems, so as to build a large social insurance and security network in which all fi ve required insurances are managed in a unifi ed manner. this will ensure that migrant workers may select insurances and rates depending on their income and mobility levels. fifthly and lastly, it is advisable to implement fl exible transitional policies that allow for low insurance rates and to increase appropriate worker subsidies, given that migrant workers typically have low wages. firstly, it is advisable to promote employment by assisting in skills improvement. governments, companies, workers and training organizations should work together to promote vocational education and skills training for migrant workers, enabling them to get better jobs and higher incomes. secondly, relevant authorities should support employment by providing employment information. it is necessary to gradually establish a rural labor force registration system, to realize information sharing among regional public employment service organizations, and to enhance government guidance services, including the provision of public employment information, for the employment and migration of rural people. thirdly and lastly, it is necessary to ensure a steady wage increase. local governments should: continue to improve the minimum wage standard system to guide companies in properly increasing wages; allow trade unions to play a positive role in protecting workers' rights; establish a negotiation mechanism between employers and employees, and facilitate the creation of well-regulated labor relations; increase efforts in law enforcement and in monitoring employers' contractual signatures and observation of contractual obligations; increase workplace safety management, occupational health management and worker protection; and, fi nally, encourage ngos to provide migrant workers with legal assistance. firstly, given migrant workers' varying needs for housing, relevant authorities may encourage employers to build subsidized housing such as corporate dormitories for these workers. local governments should fi rstly expand access to the local public rental housing assistance system to include migrant workers who have steady jobs and who have lived in their host cities for a required number of years, before gradually serving more people, including migrants, and providing access to more types of affordable housing. it is advisable to develop a well-regulated housing rental market in urban areas to satisfy migrant workers' need for rented accommodation. secondly, relevant authorities could provide migrant workers with housing allowances and set up specifi c urban public housing funds as part of the housing assistance system; they could also think about the possibility of expanding the coverage of the urban housing provident fund (hpf) system to migrant workers who have steady jobs in cities, and could implement more fl exible policies. when it comes to tax policies, relevant authorities should grant certain tax incentives to individuals or organizations that build dormitories for migrant workers and/or provide housing rental services; they should also grant such tax incentives to migrant workers who are able to buy affordable and price-controlled housing. thirdly and lastly, relevant authorities should establish appropriate fi nancial and land supply systems which would favor the building of affordable housing for migrant workers, thereby gradually including these people in the urban affordable housing system available to all workers. on the diversifi ed supplies of public goods in china. a master's degree thesis at the graduate school of the cass the citizenization of migrant workers: government responsibility and public service innovation on equal access to basic public services vs. the issue of migrant workers key: cord-257821-y3fhubnc authors: maeshiro, rika; carney, jan k. title: public health is essential: covid-19’s learnable moment for medical education date: 2020-05-26 journal: acad med doi: 10.1097/acm.0000000000003517 sha: doc_id: 257821 cord_uid: y3fhubnc the covid-19 pandemic, an unprecedented challenge for this generation of physicians and for the health care system, has reawakened calls to strengthen the united states’ public health systems. this global event is also a “learnable moment” for medical education—an opportunity to decisively incorporate public health, including public health systems, through the continuum of medical education. although medical educators have made progress in integrating public health content into medical curricula, “public health” is not a phrase that is consistently used in curricular standards, and public health colleagues are not identified as unique and essential partners to improve and protect health. the covid-19 crisis has demonstrated how a strong public health system is necessary to support the health of patients and populations, as well as the practice of medicine. partnerships between medical and public health communities, through individualand population-based interventions, can also more effectively combat more common threats to health, such as chronic diseases, health inequities, and substance abuse. to achieve a more effective medicine–public health relationship in practice, curricula across the continuum of medical education must include explanations of public health systems, the responsibilities of physicians to their local and state governmental public health agencies, and opportunities for collaboration. medical education should also prepare physicians to advocate for public health policies, programs, and funding in order to improve and protect the health of their patients and communities. pandemic covid-19 demonstrates with laser focus that all physicians are part of public health systems and that public health content has a distinct and critical place across the continuum of medical education to prepare physicians to participate in, collaborate with, and advocate for public health systems. for the vast majority of us, the onset of the covid-19 global pandemic in early 2020 was the beginning of an unparalleled time of uncertainty for the health of the nation and the capacity of our health care system. in the past, colleagues have weathered regional natural disasters, outbreaks of emerging infectious diseases, and terrorist attacks. although the events were formidable and, at the time, the extent of their casualties unpredictable, the victims of september 11, 2001 , and the anthrax attacks, for example, were treated by a limited corps of providers and institutions. in contrast, covid-19 has affected all of us and its duration is unpredictable. the demands for a stronger public health system are echoing back from previous emergencies. 1 how the medical community will reflect and adapt in the wake of this pandemic is unknowable, but an early lesson for medical students, physicians, and educators is clear: public health content has a distinct and critical place across the continuum of medical education to prepare physicians to participate in, collaborate with, and advocate for public health systems. recommendations to secure a foundational position in medical education for public health, described by c.-e.a. winslow as "the science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals," 2 date back for generations and are included in the 1910 flexner report. 3 public health includes quantitative sciences (biostatistics, epidemiology); social, behavioral, and environmental sciences; the study of health systems (health policy, financing, and regulation); clinical and community preventive services; leadership and communication skills; and contemporary disciplines and issues (e.g., informatics, genomics, preparedness) that together emphasize an ecological model of health. medical education standards across the continuum of training, including policies and recommendations from the liaison committee on medical education, accreditation council for graduate medical education, and specialty boards, have begun to include public health content, such as the application of biostatistics and epidemiology to evidence-based practice and quality improvement, social and behavioral sciences in the context of determinants of health, and the study of health care systems. the phrase "public health" is not necessarily included in this guidance, and public health systemsparticularly the responsibilities and structure of the governmental public health systems in which physicians practice-are rarely mentioned. content areas such as population health, social medicine, and health systems science overlap with public health, but we hope that our experience responding to covid-19 will put to rest the instinct to dilute public health with alternative labels. in 2007, the institute of medicine (iom) reiterated winslow's perspective of public health by defining it as the covid-19 pandemic, an unprecedented challenge for this generation of physicians and for the health care system, has reawakened calls to strengthen the united states' public health systems. this global event is also a "learnable moment" for medical education-an opportunity to decisively incorporate public health, including public health systems, through the continuum of medical education. although medical educators have made progress in integrating public health content into medical curricula, "public health" is not a phrase that is consistently used in curricular standards, and public health colleagues are not identified as unique and essential partners to improve and protect health. the covid-19 crisis has demonstrated how a strong public health system is necessary to support the health of patients and populations, as well as the practice of medicine. partnerships between medical and public health communities, through individual-and population-based interventions, can also more effectively combat more common threats to health, such as chronic diseases, health inequities, and substance abuse. to achieve a more effective medicinepublic health relationship in practice, curricula across the continuum of medical education must include explanations of public health systems, the responsibilities of physicians to their local and state governmental public health agencies, and opportunities for collaboration. medical education should also prepare physicians to advocate for public health policies, programs, and funding in order to improve and protect the health of their patients and communities. pandemic covid-19 demonstrates with laser focus that all physicians are part of public health systems and that public health content has a distinct and critical place across the continuum of medical education to prepare physicians to participate in, collaborate with, and advocate for public health systems. "what we as a society do collectively to assure the conditions in which people can be healthy." 3 in the wake of the september 11 terrorist attacks and subsequent anthrax attacks of 2001, the iom articulated a vision for 21stcentury public health systems that have governmental public health as the "backbone"; include the health sector (health care delivery system, public health, and health sciences academia); and broaden participation to include communities (e.g., schools, organizations, religious congregations), businesses and employers, and the media. 4 medical educators have similarly emphasized the importance of community engagement and interprofessional education. we wholeheartedly support this holistic perspective of health education but ask that public health entities and professionals not be grouped into a broad category of "community partners." with shared primary missions to improve health, medicine and public health should be unique and consistent allies, working together with community partners to address society's health challenges. calls to enhance public health content in medical curricula typically increase after significant threats to public health. 5 a physician workforce that is knowledgeable about public health can better anticipate and contribute to public health interventions during a pandemic. the emergency preparedness and response capabilities for governmental public health agencies have been described in 6 categories: biosurveillance, community resilience, countermeasures and mitigation, incident management, information management, and surge management. 6 at the time of crises, physicians contribute to surveillance efforts and echo public health messaging to patients from clinics and hospitals. collaborating in public health emergency initiatives may also offer insights and experiences that promote physician resilience during emergencies 7 and help to meet the needs of their patients, practices, and communities. the medical and public health professions have not collaborated fully to meet health needs in the united states, in part due to differences in perspective and priorities. treatment versus prevention, "reductionist" biomedical models versus bio-social-environmental landscapes, pure science versus efforts to translate evidence into policies-these have been some of the generalizations that have described the differences between medicine and public health. cultivating meaningful partnerships between medical and public health communities to address more common threats to health through individual-and populationbased interventions would improve the prevention and management of chronic diseases, injuries, and substance abuse; strategies to catalyze improvements in social determinants of health and achieve health equity; and the formulation of health-focused approaches to address global challenges like climate change. to achieve more effective medicinepublic health relationships in practice, medical education across the continuum must include explanations of public health systems, the responsibilities of physicians to their local and state governmental public health agencies, and opportunities for collaboration. governing bodies that oversee each phase of medical education should ensure that public health systems are included in curricular requirements, beginning by building foundational knowledge in medical school, then exploring specialty-specific issues in residency and continuing education. with an enhanced appreciation of the relevance of public health to their practices, physicians are also more likely to seek out public healthrelated content-through informal channels and professional societies-and incorporate public health in their expectations of lifelong learning. while a full and systematic assessment of our preparedness and response to covid-19 will occur after this crisis, some conclusions are glaringly evident. delays in testing have resulted in missed surveillance opportunities through the timeline of the u.s. outbreak, and the coordination of the response capacity in hard-hit areas has fallen short. dangerous shortages of personal protective equipment have threatened the lives of health care and other essential workers. minority communities have been disproportionately impacted. public health agencies are frequent conveners of preparedness planning activities at local and state levels, when stakeholders identify and try to correct potential gaps in response capacities. unfortunately, u.s. public health systems remain dangerously underfunded 8 and frequently operate without the recognition and stature of the health care system. in many regions of the country, the public health infrastructure needs to be expanded to achieve the kind of coordinated testing, robust case identification, contact tracing, and follow-up to provide clinical guidance and inform policy decisions, such as loosening restrictions on daily life. medical education should also prepare physicians to advocate for public health policies, programs, and infrastructure that will improve and protect the health of their patients and communities. advocacy has been incorporated into medical curricular standards, 9 and credible physicians engender trust in science, even in the face of complex political environments. at a minimum, all physicians should be knowledgeable about policies that will affect the health of their patients, communities, and practices and consider them when they vote. governmental public health and health-related policy can be political, however, and some physicians may hesitate to become directly involved. at the turn of the 21st century, for example, physicians were less likely to vote than the general public. 9 still, specialty societies are facilitating advocacy efforts, not only to promote specialty-specific interests but also to educate and inform policymakers and the public about a broader scope of issues that impact health. this is a teachable and learnable moment for medical learners across the curriculum to become better acquainted with public health. medical educators, who are already innovating and collaborating on delivering instruction virtually, are encouraged to integrate public health into their efforts. academic medicine readers may enjoy brandt and gardner's clear and succinct narrative of the relationship between medicine and public health in this country 10 and frieden's description of the future of public health. 11 for brief, introductory presentations on specific aspects of public health, the centers for disease control and prevention's e-learning series, public health 101, 12 too often, the public health and clinical care systems and professionals operate in parallel rather than in synergy, but a key public health-related principle in flexner's report was that "collaborations between the academic medicine and public health communities result in benefits to both parties." 3 the iom identified 3 levels of physician engagement with public health: (1) "all physicians," because practices intersect public health; (2) physicians in practices or specialties with public health needs; and (3) physicians specializing in public health. 3 during this crisis, we have been reminded of what is "essential." we have witnessed that in addition to advising the public, workplaces, schools, and communities, public health plays a crucial role in health care delivery, providing data and giving guidance for infection control, testing, and clinical care in all settings, from laboratories to emergency medical services and home care. pandemic covid-19 provides all of us, whether we are on the frontlines of the response or are sidelined from our usual practice and finding ways to provide material and moral support to frontline colleagues, laser focus that "all physicians" are indeed part of public health systems and that the capacities of public health systems impact our patients, communities, and practices. widespread availability of public health content in medical education across the continuum can help facilitate solutions to daunting challenges like climate change, firearm injury prevention, health inequities that contributed to disparities in covid-19 morbidity and mortality, as well as pandemic preparedness, as we live and work in a global society. our collective challenge is to transform this teachable public health moment into a learnable moment for medical education. funding/support: none reported. other disclosures: j.k. carney receives royalties from a textbook, controversies in public health and health policy, jones and bartlett learning, 2015. approach to public health: neglect, panic, repeat. the new york times the untilled field of public health medical education for a healthier population: reflections on the flexner report from a public health perspective training physicians for public health careers planning and incorporating public health preparedness into the medical curriculum public health emergency preparedness and response capabilities beyond disaster preparedness: building a resilience-oriented workforce for the future the impact of chronic underfunding of america's public health system: trends, risks, and recommendations perspective: physician advocacy: what is it and how do we do it antagonism and accommodation: interpreting the relationship between public health and medicine in the united states during the 20 th century the future of public health national association of county and city health officials. the forces of change in america's local public health system association of state and territorial health officials. astho profile of state and territorial public health, volume four ethical approval: reported as not applicable. key: cord-025905-9k7owm1v authors: acton, michele; bayntun, claire; kirby, roger; wessely, simon title: coronavirus: reducing the impact of quarantine date: 2020-04-29 journal: nan doi: 10.1002/tre.737 sha: doc_id: 25905 cord_uid: 9k7owm1v on the 26th february 2020, a meeting was held at the royal society of medicine between key advisers in uk healthcare and law enforcement to discuss quarantine measures in response to the current covid‐19 outbreak. this article is a brief summary of the comments and questions raised at the meeting. • meeting report p rior to this outbreak of covid-19, there have been no recent precedents for the use of group quarantine measures in the uk other than case-by-case isolation of individuals for treatment, or while pending results of tests for notifiable infections. this is in contrast to other countries that have taken dramatic measures to quarantine people (for example, singapore's reaction to sars). however, with covid-19 we now find ourselves in a 'living laboratory of quarantine', with people quarantined in a range of countries, cities, villages, ships, hotels, etc, around the world. as such, lessons are being learnt about quarantine logistics including transfer and entry planning, media reaction, security, provision of supplies and standards of living for those who have symptoms, and quarantine discharge arrangements. 1 what are the legal issues? the key legal issue on quarantine revolves around individual versus societal rights. in the uk, the legal structure of quarantine powers are covered by domestic laws and the european convention on human rights (echr meeting report • quarantine includes frustration, boredom, anger and confusion. 2 some smaller studies also show that long-term impacts, such as ptsd symptoms, can be a result of quarantine -although they do not always necessarily meet criteria for ptsd diagnosis. 3 the key factors that influence the impact of quarantine on the individual are: its duration; an understanding of the risks; frustration and boredom; availability of supplies and activities; clarity and availability of information; financial loss and the inequity of financial impacts between individuals (for example, individuals who can work from home versus those who cannot); and social stigma (how people react to individuals who have completed their quarantine period). although quarantine may be successful from an epidemiological perspective in controlling transmission, it is important to remember that authorities have previously been accused of overreacting (such as with the h1n1 swine flu pandemic). usually it is the role of the police to protect the public in the domestic societal sphere; however, this is not realistic at such a significant scale. a self-policing public would help greatly, but the military could provide logistical and infrastructure support to help enable police powers. it will require broad cooperation between the public and enforcement agencies. continued public trust in government institutions, like the nhs, is vital. of equal importance is the role of news agencies and the impact of key opinion leaders on public opinion. science journalists, for example, have generally been well briefed in the uk during this outbreak; however, experience with zika virus has shown that countries can place different political steers on interpreting and implementing the scientific evidence. the challenge is to maintain public trust while coherently communicating a dynamic situation, providing clear correspondence about adapted public health guidance. equally important will be citizen-tocitizen trust (termed 'social trust'). public willingness to engage in protective behaviours, including hand hygiene 1. wash hands regularly with soap and water for at least 20 seconds 2. always wash hands: -after coughing and sneezing -after touching nose or mouth -after caring for the sick -before, during and after food preparation -before eating -after using the toilet 3. if soap and water are not available, use an alcohol-based hand sanitiser. this is particularly important after taking public transport • meeting report self-isolation, will depend on beliefs that others are doing so. as such, it is hypothesised that low social trust countries (such as in southern europe) will have more difficulty in containing a spread than high social trust countries (such as the nordic states). the uk is currently a mid-rank social trust country. 4 campaign activity that signals that members of the public are cooperating with behaviour guidance, and for altruistic reasons, will likely increase compliance. if the nhs has to turn patients with other clinical needs away due to increased service demand in response to the covid-19 outbreak, then the challenge would be to communicate how the nhs is shifting priorities while managing public perception that the nhs is not coping. increased support for digital technologies could successfully enable a higher uptake in consultations progressed online and by telephone. if managed appropriately, these could also offer long-term benefits for the sustainability of the nhs. communication with the public needs to offer clear, practical guidance that reflects up-to-date information. there is a need for more clarity on transmission risks so that questions can be addressed with clear advice; for example, 'should i wear gloves?'; 'if so, in what circumstances?'. advice will also need to be segmented -it will be different for those in hospital than for those self-isolating, and for the wider general public. when senior medical figures are speaking in the media, or when poster campaigns are being run, messages should aim to be clear. one useful example is to specify the situations in which individuals should wash their hands (following a journey, for example), with the bmj recently publishing a table to outline proper hygiene behaviours (see table 1 ). 1 the aim is to embed hygiene behaviours by encouraging people to build the practice into current routines. current data suggests that children are at low risk of serious morbidity and have low rates of mortality from covid-19. however, children may be a source of asymptomatic transmission of the infection. the decision for school closure has significant ramifications for societal functioning, not least with police and hospital staff needing to stay at home as carers, as well as impacting the life chances of individuals taking key examinations. there is limited evidence available to support general school closures as a public health measure. there are currently a range of social-distancing measures, such as banning large-scale gatherings like football matches and concerts, that are being considered by decision-makers. panic can be a societal response to trauma and crises, and should be differentiated from goal-directed behaviour (for example, stocking up on essential supplies or a desire to leave an at-risk area is not necessarily an irrational response to a situation). at present, most sections of the public seem more likely to underestimate the risks, and there are great efforts being implemented to encourage the public to develop improved infection-control hygiene related behaviours. horizon scanning to realise the short-, medium-and long-term opportunities that this crisis presents may be valuable. this could involve identifying the benefits of embedding new systems (such as effective systems for remote working for a wider range of activities, including phone/digitised clinics for the nhs for some outpatient interactions) and behaviours (such as reducing travel, while increasing the demand and supply of local resources). 5 behavioural science must be at the heart of the public health response to covid-19 psychological impact of the 2015 mers outbreak on hospital workers and quarantined hemodialysis patients the psychological impact of quarantine and how to reduce it does social trust increase willingness to pay taxes to improve public healthcare? cross-sectional cross-country instrumental variable clinical features of patients infected with 2019 novel coronavirus in wuhan, china this article has been published in coordination with the royal society of medicine, london. key: cord-018504-qqsmn72u authors: caron, rosemary m. title: public health lessons: practicing and teaching public health date: 2014-09-23 journal: preparing the public health workforce doi: 10.1007/978-3-319-07290-6_4 sha: doc_id: 18504 cord_uid: qqsmn72u the following four cases represent events that actually occurred at the local, statewide, national, and international levels. a general, succinct overview is provided of each case with references listed should the reader want to access additional resource materials. the concise format of these cases is intended to generate questions. following the general overview of each case, i examine the lessons learned from the practitioner and educator perspective and i list the skills necessary to address the issues in the case. the reader will note that there are skills that are essential for the public health practitioner to master, whether one is in an internship, entry-level position, or the director of a public health organization and so these skills are consistently listed. i encourage the reader to regularly keep abreast of the news locally and abroad and to set aside time before a staff meeting or supervisory group meeting, or use the first few minutes of a class to discuss these issues. ask your workforce or students, “are we ready to handle such an event if it were to occur here?”; “what resources would we need to have accessible?”; “have we partnered with the correct agencies in the community?”; “do we have an established, trusted presence in the community?”; “who else do we need on our team?”; “do we need training in a specialty area, e.g., emergency preparedness?”; “what skills have we mastered and what skills do we need to obtain?” the discussion-based questions are endless but one runs the risk of not being prepared, either individually, or in their agency, should they not discuss how public health events are occurring around us daily. i encourage you to adapt these selected cases to use in your organization and/or classroom. discussing these issues and reviewing the lessons learned will only help us to be better prepared public health practitioners and educators of public health students. prior to the 1978 federal ban on lead paint and the housing in the center of this city is of very poor quality (mhd 2013a) . manchester is the most racially and ethnically diverse community in the state. the city's designation as a refugee resettlement community contributes to this richness in diversity. manchester experiences disparity in socioeconomic status and health, similar to other larger urban communities: manchester, new hampshire represents an urban microcosm of the childhood lead poisoning problem. one-third of all childhood lead poisoning cases occur predominantly in the center of this urban community (mhd 2013a; nhdhhs 2006) . in 2006, 2.7 % of children in manchester who had been screened for lead poisoning had eblls, as compared to 1.3 % of the new hampshire total (nhdhhs 2006) . in 2007, approximately 25 % of the leadpoisoned children in the local health department's caseload were refugees or children of refugees. (mhd 2013b) sargent et al. (1995) previously examined clp in urban, suburban, and rural communities in massachusetts and reported that "…those children living in communities with high rates of poverty, single-parent families, and pre-1950s housing and low rates of home ownership were 7-10 times more likely to have lead poisoning" (p. 531). the center city of manchester reflects similar demographics and is a community at risk for clp. pediatric fatality: although fatalities due to clp are rare, the first pediatric fatality to occur in over a decade in the usa occurred in this community of manchester, nh. the fatality occurred in a 2-year-old sudanese refugee child who had resettled in 2000 to this community with her mother and siblings from a refugee camp in egypt. the family resided in an apartment in a tenement building that was constructed in the 1920s. approximately 8 weeks following resettlement, this child acquired an ebll of 391 micrograms of lead per deciliter of blood. the cdc's action level in 2000 was 10 micrograms per deciliter of blood. hence, this child's ebll was 39 times above cdc's action level at that time. an environmental and epidemiological investigation determined that due to the child's exposure to lead paint dust and chips in the apartment she lived in with her family and her underlying conditions of pica (a craving for nonfood substances) and malnutrition resulted in her acquiring an ebll in a short period of time. the child died as a result of complications triggered by the ebll (caron et al. 2001) . furthermore, despite the existence of federal regulations developed by the environmental protection agency (epa) that require property owners and managers to provide families with information about lead poisoning and any lead hazards in the home before its sale or lease, the investigation into this case revealed that this information was not communicated in a manner that was understood by the mother of this child (caron et al. 2001) . lessons learned: this tragic event underscored the need for attention to be paid to those public health problems that persist in the environment, i.e., those issues that the community may live with because there is no feasible solution to completely eliminate the risk. due to the older housing stock in the community that contains lead paint, the cdc named the community and its surrounding towns as a universal screening site. this means that every child at 1 and 2 years of age must be screened for exposure to lead ). this is a form of secondary prevention. the gold standard is primary prevention where exposure to lead would not occur in the first place, thus the risk is removed from the environment. to achieve primary prevention of clp, lead paint would need to be abated from every apartment unit in the city. however, this is a costly process that the municipality or property owners/managers are unable to afford. yet, there are many families with lead-poisoned children who would argue that the benefits of primary prevention outweigh the costs. this case also highlights the complexity of persistent public health problems, such as clp. for instance, this particular family, not unlike other african refugee families, was illiterate in english as well as their own language. in addition, the refugee resettlement process is designed in a declining model of support where the refugees are placed in available housing, which is often of poor quality, and offered health benefits for a limited period of time, and employment is the benchmark of resettlement success not acculturation, good health, or community engagement (caron and tshabangu-soko 2012) . this community was fortunate in that it already had a functional community coalition that was addressing the problem via policy development, distribution of resources, surveillance, and testing of at-risk children. yet, it is important to consider the multifactorial issues affecting this persistent public health problem in this particular community. selected issues are included below ): • non-english speaking, at-risk population. • public health system that views the problem as complex due to the continuing influx of refugees and the number of agencies involved in refugee resettlement. • multiple stakeholders who view the problem differently and who offer varied, uncoordinated solutions. • intersect of socioeconomic factors, housing policies, cultural practices, english proficiency, and native language literacy. • clp exemplifies the failure of policy development and implementation in the community. • competing demands for food, shelter, clothing, employment for at-risk populations. • exposure results in health effects that are not visible until an ebll is acquired. • providing education in a culturally competent manner. • distrust of community organizations by the at-risk african refugee population. • often, persistent public health problems "…possess no definitive resolutions…" so "…remediation must focus on how to best manage them" (caron and serrell 2009, p. 195) . if this tragic event occurred in your community, what questions would you ask? i offer the following questions for you to consider from a practitioner and educator perspective: 1. how could we prevent children from being poisoned by lead in our community considering that practical solutions are difficult to implement due to the high cost of lead-abatement measures? 2. are there primary and secondary prevention tools we could implement and evaluate in our community? how will we provide lead prevention education for families for whom english is not their first language? there are over 70 different languages spoken in the manchester, nh, school system (mhd 2013a). it is not feasible to provide translation services for every dialect. how would you educate about a serious public health issue, such as clp, for which there are no visible signs or symptoms until there is an ebll? 3. does the community have a plan to address this public health issue? has the community, who lives with the issue (i.e., refugees, "working poor"), been invited to participate with public health practitioners? is there a community coalition formed to work on monitoring the issue and connecting families with testing services? how would you establish such a community group if one does not exist? 4. how would you partner with an academic institution with public health expertise to assist with providing knowledge, expertise, and resources? 5. how would you partner with the local health-care system (i.e., community health centers, hospitals, physician practices) to assure that they are following cdc testing guidelines and to assist with consistent outreach and prevention education efforts? 6. are there refugee resettlement services developed by resettled refugees who can assist with contacting an often hard-to-reach population to offer peer education? how would you engage this social service agency? 7. what data should you be collecting? how will you access these data? who is the "keeper" of the data? how will you conduct surveillance of the public health issue? 8. what stakeholders in the public health system should be invited to address the problem? if a stakeholder refuses to come to the "table" to work on the issue because they believe the issue is either not under their purview or is too complex to address, how would you engage this key partner? 9. policies pertaining to lead paint in housing and occupancy vary from state to state. how would you amend the current (if any) lead housing policies in your community or state? would public health enforcement laws be necessary (i.e., citations for property owners who do not comply with the developed policy)? whom would you work with to develop and enact such policies? 10. this case demonstrates a very tragic, albeit rare, event. with so many competing demands on the public health system, and the fact that clp is a persistent public health problem that the community has lived with for generations, and the costly abatement measures-should clp be in the "top ten" of issues for communities, similar to manchester, nh, to be concerned about? why or why not? 11. if we addressed clp in the community, what other public health issues could potentially be lessened or mitigated? 12. how does the refugee resettlement process exacerbate clp? should the refugee resettlement process be redesigned? if so, how? 13. should communities with refugee children poisoned by lead request a moratorium for refugee resettlement until the community can provide quality housing that does not pose a health risk? what are the implications of a moratorium for the resettled refugees and the community? 14. how would you engage the refugee resettlement agencies, the social service agencies developed by refugees, and the refugees themselves in a coordinated effort to reduce clp? 15. how would you know what the newly resettled refugee concerns are and how they compare to their counterparts who have been living in the community for a period of time? the answers to many of these questions may include more resources, more expertise, and more community support. i agree with this assessment. however, often, the public health principles that guide us are challenging to implement "on the ground." clp is a very real issue for this community. the number of refugees affected by this public health problem is influenced by the type of refugee who is resettled in the community. for instance, refugee children of parents who speak english and have a secondary and/or postsecondary education tend to not experience an ebll. this community is not able to request from which country the "newcomers" will arrive. box 4.1 highlights selected public health tools that should be utilized by a competent public health workforce addressing clp among a refugee population in their community. these skills are not meant to be exhaustive but are important for public health practitioners and educators of the public health workforce to consider when working on this type of public health problem. • engage the community in the public health issue being addressed. community-based participatory research (cbpr) is one approach to involve the community in addressing the public health issue that they live with on a daily basis. cbpr "…in public health focuses on social, structural, and physical environmental inequities through active involvement of community members, organizational representatives, and researchers in all aspects of the research process. partners contribute their expertise to enhance understanding of a given phenomenon and to integrate the knowledge gained with action to benefit the community involved". (israel et al. 1998, p. 173) serrell et al. (2009) previously identified four core values that were important to progress when building community capacity to address clp: "…adaptability, consistency, shared authority, and trust as core values for such partnerships" (p. 58). the type of public health professional required to address this specific public health issue includes, but is not limited to, the following: • public health director • environmental health specialist • nurse case manager • build academic-community partnerships based on cbpr principles (see above). these partnerships do not require the presence of a local academic institution but could operate via distance technology so the correct expertise for the specific public health issue is accessed. it is important to note that it can take time to build operational partnerships. • collect data from screening facilities (e.g., local health department, primary care physicians, community health centers). these data may be centralized in a state clp and prevention program. • analyze the data for descriptive purposes to know the demographics of the affected population and the at-risk population. • implement primary prevention via culturally and linguistically appropriate educational methods. • implement secondary prevention via blood screening. assure screening is being conducted by communicating with screening facilities and engaging in medical record audits. • develop policy that will be protective of the resident and places the burden of care on the property owner/manager to abate lead from the dwelling. • consider the community's ecology (i.e., its social, cultural, economic, and political composition) and social context of risk. caron et al. (2013) proposed the following: …that communities are important determinants in health-related problems for refugee populations. each community has its own environment and public health system that interacts with each other to influence health risks and risk perceptions of its populations. (p. 660) • partner with others in the public health system (e.g., housing development, refugee resettlement agencies, property managers, etc.) and learn their barriers to the problem, as well as their perception of the public health issue so a feasible and equitable solution or management strategy may be developed. • evaluate progress by reviewing the data to determine whether or not there is a decrease in the number of children poisoned by lead. based on the data, which will tell the story, targeted or tailored approaches for the affected population may be warranted. for example, peer education efforts may be implemented, temporary removal of a family from a home with lead paint until the lead can be removed or covered to meet housing code approval, visual aids for education, nurse case management, environmental inspection of the dwelling, etc. background: "hepatitis c is an infection caused by a virus that attacks the liver and may cause liver damage, liver failure, and even cancer" (nhdhhs 2013, p. 8). specifically, hepatitis c arises as a result of a blood-borne infection. for the majority of those infected, the acute phase of the infection is asymptomatic. in addition, for some infected individuals, their immune system will clear the infection. however, there is a risk that many people infected with the hepatitis c virus (hcv) will develop an active, chronic infection and without therapy some will develop liver cirrhosis, liver disease, liver failure, and/or liver cancer (nhdhhs 2013). the cdc estimates that there are approximately 4.1 million people who have been infected with hcv and 3.2 million people with active infection in the usa (cdc 2013): risk factors for acquiring hepatitis c include injection drug use, tattoos with contaminated supplies, use of infected blood products or occupational needlestick injury, transmission during pregnancy, and sexual transmission (which is usually very uncommon). the risk of acquiring hcv from a needlestick injury with blood from an hcv-infected patient is approximately 1-2 %, but it depends on the level of virus in the blood and the nature of the injury. (cdc 2013) hcv can be treated with an antiviral drug regimen that is administered for a period of several months and is quite costly (nhdhhs 2013). for those who are eligible for therapy and have not been treated in the past, the likelihood of cure is very good in acute infection (80-90 %). with newer available agents, the response rate is very good in chronic infection as well (60-80 %). (nhdhhs 2013, p. 10) specific to the transmission of hcv in health-care settings, risk factors include the following: 1. reuse of syringes for more than one patient or to access medication containers used for more than one patient; 2. sharing of contaminated equipment, like point of care or podiatry equipment; and/or 3. drug diversion by an infected healthcare worker (hcw). transmission can occur when the infected hcw self-administers an injectable narcotic, intended for patient administration, fills the syringe with saline, and places the used syringe back into the circulation for patient administration. (nhdhhs 2013, p. 10) reportable diseases are those that "…hospitals, laboratories, healthcare providers, childcare centers, schools, and local boards of health are required to report diagnosis of certain infectious diseases to dphs" (division of public health services; nhdhhs 2013, p. 10): in new hampshire, hcv infection is not in and of itself a reportable disease. however, any suspected outbreak, i.e., the occurrence of illness or disease in a community at a rate clearly in excess of what is normally expected, is reportable to dphs under the mandatory reporting law, part he-p 301 communicable diseases. (nh general court 2008; nhdhhs 2013, pp. 10-11) reported infections are investigated by public health nurses and epidemiologists at the new hampshire dphs. the purpose of the investigation is to prevent additional illness in the population, which may be accomplished through a variety of methods, depending on the specific disease. some examples of how public health works to prevent additional illness include identifying close contacts to the infected person and recommending prophylaxis medication to prevent them from becoming ill (antibiotics, antivirals, vaccine, etc.), providing disease prevention recommendations (washing hands, covering cough, etc.), recognizing outbreaks, and identifying and controlling their source (healthcare-associated outbreaks, foodborne outbreaks, etc.). (nhdhhs 2013, pp. 10-11) investigation overview an outbreak of hcv was identified at exeter hospital in exeter, new hampshire, in 2012. of the initial four patients diagnosed with hcv, one of the individuals was a traveling medical technician in the cardiac catheterization laboratory of the hospital. further investigation by the new hampshire department of health and human services (nhdhhs) revealed that the cause of the outbreak was drug diversion ("…the stealing of narcotic pain medication intended for patients for self use"; nhdhhs 2013, p. 6) by the infected medical technician. the testing of potential patients was conducted based on the hospital units to which the medical technician had access, i.e., patients seen in the cardiac catheterization laboratory and those who were patients in the operating room and the intensive care unit. for these areas, 1200 patients who had procedures in the cardiac catheterization laboratory during a time period that overlapped the medical technician's time of employment were tested for hcv: of the 1,074 who were tested, 32 patients were identified with active hcv infection with the nh hcv outbreak strain. 27 additional patients had evidence of past hcv infection (and their virus could not be tested) and 9 of them were categorized as probable cases (n = 4) and suspect cases (n = 5) based on epidemiological information. (nhdhhs 2013, p. 6) to contact those who were patients in the operating room or intensive care unit during this same time period, nhdhhs partnered with local health departments and clinics to conduct rapid hcv testing on site "…for the first time in an outbreak setting" (nhdhhs 2013, p. 6). …2,679 patients were tested and…no additional cases of active hcv infection matching the outbreak strain were identified. additional investigation of other units in 4. the medical technician worked for a staffing agency that assigned him to 18 different hospitals in seven other states (arizona, georgia, kansas, maryland, michigan, new york, and pennsylvania) over a decade (seelye 2012 ). in addition, he had been fired four times over this time span for allegations of drug use and theft (associated press 2013). thus, the potential for exposure of patients in other states existed and resulted in a multistate outbreak investigation that was conducted by the cdc. "as of may 2013, 13 other cases of the nh hcv outbreak strain were identified and confirmed in two other states (kansas and maryland)" (nhdhhs 2013, p. 6). the traveling medical technician pled guilty to "…obtaining controlled substances by fraud… [and] tampering with a consumer product" (fbi 2013): …he devised a scheme to divert and steal the controlled substance fentanyl for personal use and abuse. fentanyl is a powerful anesthetic intended for patients undergoing medical procedures, among other uses. [he] admitted that he would surreptitiously take syringes of fentanyl prepared for patients, inject himself with the drug, and refill the syringes with saline, causing the syringes to become tainted with his infected blood. he then replaced the tainted syringes for use on unsuspecting patients. consequently, instead of receiving the prescribed dose of fentanyl together with its intended anesthetic effect, patients actually received saline that was tainted with the same strain of hepatitis c carried by [the medical technician]. (fbi 2013) at the conclusion of the investigation, the nhdhhs (2013) recommended the following action areas: • "increase regulation and improve information sharing regarding allied healthcare workers." • "strengthen healthcare systems to promote prevention and early detection of drug diversion." • "assure optimal response to healthcare associated outbreaks to protect patient safety." (p. 63) lastly, as of september 2013, the nhdhhs had partnered with the national association of drug diversion investigators (naddi) in maryland and honoreform, hepatitis outbreaks national organization for reform, a patient advocacy group based in nebraska to influence national policy regarding the regulation of medical technicians (associated press 2013). any criminal act involving a prescription drug. (national association of drug diversion investigators) inciardi et al. (2007) define prescription drug diversion as the following: …the unlawful channeling of regulated pharmaceuticals from legal sources to the illicit marketplace, and can occur along all points in the drug delivery process, from the original manufacturing site to the wholesale distributor, the physician's office, the retail pharmacy, or the patient. (p. 171) in 2012, the cdc declared that the overdose on prescription drugs had reached an epidemic status (cdc 2012a). to further illustrate this point: "in 2007, approximately 27,000 unintentional drug overdose deaths occurred in the united states, one death every 19 minutes" (cdc 2012a, p. 10). opioid analgesics are responsible for the increase in overdose-related deaths (cdc 2012a). regarding the demographics of the abuse of and deaths from opioid analgesic use, it is …highest among men, persons aged 20-64 years, non-hispanic whites, and poor and rural populations. persons who have mental illness are overrepresented among both those who are prescribed opioids and those who overdose on them. (cdc 2012a, p. 774) of those who are prescribed opioid analgesics, the populations of greatest concern are those who seek care from multiple physicians and potentially take advantage of the physician's sensitivity to the patient's pain management (cdc 2012a). it is this population that is estimated to not only comprise approximately 40 % of overdose cases on opioid analgesics but also are diverting drugs for self-use or providing them to others (cdc 2012a). thus, the cdc recommends that prevention efforts should focus on addressing the following target populations: patients who consume opioid analgesics in high doses and those who seek care from multiple physicians and receive high doses of opioid analgesics. this latter group is likely to be involved in drug diversion (cdc 2012a). inciardi et al. (2009) report that the primary populations involved in drug diversion include "…drug dealers, friends and relatives, smugglers, pain patients, and the elderly, but these vary by the population being targeted" (p. 332). due to the complexity of the issue, several comprehensive prevention strategies have been proposed by the cdc and the american medical association: • restrict the number of reimbursement claims for opioid analgesic prescriptions written by a physician and filled by a pharmacy. this restriction is important for low-income populations on public health insurance, such as medicaid, since this population presents as high risk for drug abuse (cdc 2012a). • monitor that the type and prescribed usage of the opioid medication aligns with the diagnoses (cdc 2012a). • develop and enforce legislation that prohibits "doctor shopping" for those physicians who will prescribe opioid analgesics in high doses; elimination of "pill mills" where controlled pain medicine is distributed with little to no medical oversight; and the requirement of a physical examination prior to receiving a prescription for an opioid (cdc 2012a). • provide medical education via evidence-based practice for general and specialist physicians regarding opioid use and risks, thus holding them accountable for their prescribing practice (cdc 2012a). • fund, at the national level, the national all schedules prescription electronic reporting act (nasper). nasper provides …physicians with up-to-date, patient-specific information at the point of care in order to support appropriate prescribing and to identify those patients who were abusing or diverting prescription drugs. (ama 2013, p. 1) nasper was intended to fund prescription drug monitoring programs at the state level (ama 2013). • develop locations that will take back unused or expired medications (ama 2013). • expand access to addiction treatment and recovery centers (ama 2013). • support naddi: …a non-profit organization that facilitates cooperation between law enforcement, healthcare professionals, state regulatory agencies and pharmaceutical manufacturers in the prevention and investigation of prescription drug diversion. (naddi 2013) lessons learned: if this unfortunate event occurred in your hospital, what questions would you ask? i offer the following questions for you to consider from a practitioner and educator perspective: • how could a medical technician with a suspect record be passed from hospital to hospital? why did the staffing agency not disclose the issues with this employee? did the hospital conduct a thorough background check? • what are our hiring processes? how can we see "red flags" before the individual of concern is hired? who should be involved in the hiring process? • is there a system in place for employees to report suspicious behavior to senior management and human resources? should there be incentives to report employees observed in negligent behavior? • do we have a policy to prevent drug diversion in the workplace? if so, how can we improve the policy? • should we implement mandatory, unannounced drug testing for all hospital employees who engage in patient contact? should termination of employment be implemented if an employee refuses to cooperate with this policy? • is there a reporting system in place so that other hospitals across the country could be notified about the infected individual's reason for termination? • should the penalty for engaging in drug diversion be suspension or removal of one's license or certification to practice their skill in a health-care setting? • what other partners in the public health system should be involved in this issue? how can we partner more effectively with law enforcement and drug rehabilitation centers, for example? • should a public registry for those health-care workers found guilty of drug diversion be created at the national level? should access to such a registry be limited to health-care hiring agencies? should the public also have access to this registry? • how can we do a better job in protecting our patients? • how is drug diversion a public health problem, as well as a health-care problem? box 4.2 highlights selected public health tools that should be utilized by a competent public health workforce addressing a hcv outbreak in their community due to drug diversion. these skills are not meant to be exhaustive but are important for public health practitioners and educators of the public health workforce to consider when working on this type of public health problem. • conduct an outbreak investigation. − confirm that there are more cases than expected. − consider whether there is ongoing transmission. − define an outbreak-related case. − confirm existing number of outbreak-related cases. − investigate existing number of outbreak-related cases by reviewing all available data (e.g., medical records, laboratory results, interviews). − determine the infectious period for the outbreak. − determine potential sites of contact in a facility and potential family and others who could be exposed. − determine the exposed cohort of people at each site who may have been present during the case's infectious period. − define the screening action plan (including eligibility, implementation, and follow-up). − create a media plan. − develop and implement recommendations to prevent future outbreaks for particular populations or settings. − evaluate the outbreak response including whether implementations were effective in stopping transmission. − identify lessons learned to prevent future outbreaks (cdc 2012b). • communicate with the affected patients, their families, and the public as soon as the act of negligence is realized. • improve communication between the public health system and the healthcare system professionals. • develop a policy that would serve as safety measures to protect patient populations from health-care workers engaged in drug diversion. examples of such policies could include the establishment of a public registry of health-care workers found to be guilty of drug diversion; mandatory, unannounced drug testing of health-care workers whose employment involves patient contact; coordination of care so the number of physicians prescribing pain medications is limited; continued reporting of mandatory conditions. • collaborate with public health system partners, such as local health departments and law enforcement to assist with drug diversion education initiatives, drug and disease testing, and drug diversion investigations. • support national initiatives, such as nasper and honoreform. • engage in ongoing surveillance of drug diversion in the health-care setting. • educate health-care employees on proper reporting of such adverse events. the type of public health professional required to address this specific public health issue includes, but is not limited to, the following: antibiotic resistance is rising for many different pathogens that are threats to health. if we don't act now, our medicine cabinet will be empty and we won't have the antibiotics we need to save lives. (dr. thomas frieden, director, cdc) overview of public health threat antibiotic use arises from the inappropriate use of antibiotics in humans and animals. for example, with humans, physicians often prescribe an antibiotic when one is not needed and/or the patient does not complete the entire course of antibiotic treatment. thus, "…up to 50 % of all antibiotics prescribed for people are not needed or are not optimally effective as prescribed" (cdc 2013a, p. 11). antibiotic resistance can occur both within and outside of health-care facilities, yet deaths related to antibiotic resistance are most common in the healthcare setting (cdc 2013a). furthermore, antibiotics are also commonly used in food animals to prevent, control, and treat disease, and to promote the growth of food-producing animals. the use of antibiotics for promoting growth is not necessary, and the practice should be phased out. (cdc 2013a, p. 11) antibiotic resistance is not only a public health problem in the usa but it also presents as a major public health problem on a global scale. the statistics that demonstrate the magnitude of this public health issue on a national scale are staggering: • "each year in the united states, at least 2 million people acquire serious infections with bacteria that are resistant to one or more of the antibiotics designed to treat those infections." • "at least 23,000 people die each year as a direct result of these antibiotic-resistant infections." • "many more die from other conditions that were complicated by an antibioticresistant infection." (cdc 2013a, p. 11) the cdc states that these figures most likely underestimate the magnitude of the problem since …the distinction between an antibiotic-resistant infection leading directly to death, an antibiotic-resistant infection contributing to a death, and an antibiotic-resistant infection related to, but not directly contributing to a death are usually determined subjectively, especially in the preponderance of cases where patients are hospitalized and have complicated clinical presentations. (cdc 2013a, p. 18) thus, these statistics could be significantly higher. moreover, the health-care burden this preventable public health issue creates is multifaceted and can include the following cost-related issues for the health-care system: …prolonged and/or costlier treatments, extend hospital stays, necessitate additional doctor visits and healthcare use, and result in greater disability and death compared with infections that are easily treatable with antibiotics. (cdc 2013a, p. 11) these health-care costs are estimated to be in excess of us$20 billion and societal costs due to a loss of productivity are estimated to be us$35 billion a year (roberts et al. 2009) . a further complication of antibiotic resistance is seen in those populations who have underlying disease, such as diabetes, asthma, and rheumatoid arthritis. these groups, in addition to those patients who may undergo chemotherapy, organ and bone marrow transplant surgery, joint replacement surgery, or end-stage renal disease are significantly dependent on antibiotic use to fight off infections (cdc 2013a). these subgroups represent a susceptible population to infection especially if antibiotics that are heavily relied upon do not work optimally for these patients. the cdc readily acknowledges the following significant areas of improvement in the body of knowledge regarding antibiotic resistance: • "limited national, state, and federal capacity to detect and respond to urgent and emerging antibiotic resistance threats….we do not have a complete picture of the domestic incidence, prevalence, mortality, and cost of resistance." • "currently, there is no systematic international surveillance of antibiotic resistance threats. today, the international identification of antibiotic resistance threats occurs through domestic importation of novel antibiotic resistance threats or through identification of overseas outbreaks." • "data on antibiotic use in human healthcare and in agriculture are not systematically collected. routine systems of reporting and benchmarking antibiotic use wherever it occurs need to be piloted and scaled nationwide." • "programs to improve antibiotic prescribing are not widely used in the united states. these inpatient and outpatient programs hold great promise for reducing antibiotic resistance threats, improving patient outcomes, and saving healthcare dollars." • "advancing technologies can identify threats much faster than current practice. advanced molecular detection (amd) technologies, which can identify ar [antibiotic resistance] threats much faster than current practice, are not being used as widely as necessary in the united states." (cdc 2013a, p. 27) chen et al. (2011) propose that rather than identify population groups at risk for ca-mrsa, diagnostic and preventive approaches should focus on addressing risk factors for ca-mrsa, including "…poor personal hygiene, transmission through contaminated environmental services, and care of non-intact skin" (p. 444). ca-mrsa infections typically occur in otherwise healthy people with no recent stay in a health-care facility. in contrast, hospital-acquired mrsa (ha-mrsa) is contracted by patients in a health-care facility and has been attributed to invasive surgical procedures and poor infection control practices (niaid 2013) . health-care providers are concerned about those ha-mrsa infections that are potentially brought into the community once the patient is discharged (johnson 2013) . the cdc's report titled antibiotic resistance threats in the united states, 2013, is an excellent resource on this topic and provides a comprehensive overview of specific, ranked antimicrobial resistance threats, including prevention measures. an abbreviated outline of prevention measures for ca-mrsa and ha-mrsa are presented here. the reader is encouraged to review the cdc's report on this topic for more extensive information. at the state and community level, it is important to: • "know resistance trends in your region." • "coordinate local and regional infection tracking and control efforts." • "require facilities to alert each other when transferring patients with any infection." (cdc 2013a) the north carolina department of public health proposes the following core activities for public health professionals to engage in when managing ca-mrsa as a public health threat: • "recognize outbreaks" − for example, "an isolated case on a wrestling team; several cases within the same prison unit in a month; more than one case in a child care classroom in a month" (ncdph 2013). • "react to community concerns" − "consider the risk factors for transmission; the 5 cs" − "contact (skin-to-skin)" − "contaminated items and surfaces (wrestling mats, weight room equipment)" − "comprised skin integrity (cuts and abrasions)" − "crowding (locker rooms)" − "cleanliness (absence)" (ncdph 2013) • "respond with public health control measures" − "active surveillance to determine scope of problem in specific setting" − "assure specific control measures for wound care and containment of drainage" − "stop any sharing of personal items and promote enhanced personal hygiene" − "consider exclusion from contact activities, especially with actively draining or packed wounds" − "achieve and maintain a clean environment" (ncdph 2013) selected examples of actions health-care administrators and providers can take include the following: • "require and strictly enforce cdc guidance for infection detection, prevention, tracking, and reporting." • "make sure your lab can accurately identify infections and alert clinical and infection prevention staff when these bacteria are present." • "prescribe antibiotics wisely." • "remove temporary medical devices such as catheters and ventilators as soon as no longer needed." (cdc 2013a) patients and their family members should: • "ask everyone, including doctors, nurses, other medical staff, and visitors, to wash their hands before touching the patient." • "take antibiotics exactly and only as prescribed." (cdc 2013a) carbapenem-resistant enterobacteriaceae (cre) is a hospital-associated infection that is difficult to treat because the bacteria, normally found in the gut, have become resistant to all antibiotics, including carbapenem, which is often considered a last resort type of antibiotic (cdc 2013c). according to the cdc (2013c), …cre infections most commonly occur among patients who are receiving treatment for other conditions. patients whose care requires devices like ventilators (breathing machines), urinary (bladder) catheters, or intravenous (vein) catheters, and patients who are taking long courses of certain antibiotics are most at risk for cre infections. additional risk factors for cre infections include a patient's functional status and a stay in the hospital's intensive care unit (schwaber et al. 2008) . research conducted by perez et al. (2010) suggests that acute care health facilities could be significant reservoirs for the transmission of cre infections. furthermore, cre infections "…can contribute to death in up to 50 % of patients who become infected" (cdc 2013c). approximately 9300 cre infections occur in health-care facilities in the usa. "each year, approximately 600 deaths result from infections caused by the two most common types of cre, carbapenem-resistant klebsiella spp. and carbapenem-resistant e. coli" (cdc 2013a). the incidence of cre infections is on the rise, increasing sevenfold over the past decade (mckinney 2013). the cdc reports that "about 4 % of u.s. short-stay hospitals had at least one patient with a serious cre infection during the first half of 2012. about 18 % of long-term acute care hospitals had one" (cdc 2013a). the cdc has a comprehensive "detect and protect" program for cre infections. the reader is referred to the following website which provides information about this program (http://www.cdc.gov/hai/pdfs/cre/cdc_ detect protect.pdf). an abbreviated outline of prevention measures for cre infections is presented here: state and local health departments are well positioned to lead cre control efforts because of their expertise in surveillance and prevention and their ability to interact among all the health-care facilities in their jurisdiction. (jacob et al. 2013, p. 167) thus, at the state and community level it is important to: • "know cre trends in your region"; • "coordinate regional cre tracking and control efforts in areas with cre. areas not yet affected by cre infections can be proactive in cre prevention efforts"; • "require facilities to alert each other when transferring patients with any infection"; • "consider including cre infections on your state's notifiable diseases list". (cdc 2013a) selected examples of actions health-care administrators and providers can take include the following: • "require and strictly enforce cdc guidance for cre detection, prevention, tracking, and reporting"; • "make sure your lab can accurately identify cre and alert clinical and infection prevention staff when these bacteria are present"; • "know if patients with cre are hospitalized at your facility, and stay aware of cre infection risks. ask if your patients have received medical care somewhere else, including another country"; • "follow infection control recommendations with every patient, using contact precautions for patients with cre. whenever possible, dedicate rooms, equipment, and staff to cre patients"; • "prescribe antibiotics wisely"; • "remove temporary medical devices as soon as possible." (cdc 2013a) • "tell your doctor if you have been hospitalized in another facility or country"; • "take antibiotics only as prescribed"; • "insist that everyone wash their hands before touching you." (cdc 2013a). [to address antibiotic resistance] "…will require expanded and coordinated action from clinicians, facility administrators, and public health officials." (jacob 2013) guh et al. (2013) reported that of 11 state health departments surveyed, all perceived emerging infections, such as cre, as a public health priority for prevention. yet, the extent to which these states can engage in prevention-oriented activities depends upon available resources and existing partnerships among their agencies, hospital administrators, and others in the public health and health-care systems. the cdc has developed core actions to help prevent the development of antibiotic resistance: • "preventing infections, preventing the spread of resistance"; • "tracking"; • "improving antibiotic prescribing/stewardship"; • "developing new drugs and diagnostic tests." (cdc 2013a, p. 31) lessons learned the main question is how do we, as public health practitioners and educators, work collaboratively with our partners in the health-care system to prevent antibiotic resistance in the health-care setting and the community? building upon the public health action plan set forth by the cdc, box 4.3 highlights selected approaches and tools to prevent infections, broaden our surveillance approach, and improve antibiotic stewardship. these skills are not meant to be exhaustive but are important for public health practitioners and educators of the public health workforce to consider when working on this type of public health problem. • cdc has several surveillance programs to monitor antibiotic resistance trends in the community: • "cdc's national healthcare safety network (nhsn) is used by healthcare facilities to electronically report infections, antibiotic use, and resistance" (cdc 2013, p. 32). the more hospitals that report to this database will enable cdc to track the level of antibiotic resistance in all bacteria, as well as track antibiotic usage. "this information will allow facilities to target areas of concern, to make needed improvements and to track the success of their efforts" (cdc 2013a). • "cdc manages the get smart program [http://www.cdc.gov/getsmart], a national campaign to improve antibiotic prescribing and use in both outpatient and inpatient settings" (cdc 2013a, p. 33). "one core activity is the development and implementation of the antibiotic stewardship drivers the type of public health professional required to address this specific public health issue includes, but is not limited to, the following: , a tool that provides healthcare facilities with a menu of interventions they can select from to improve antibiotic use" (cdc 2013a, p. 33). • "stewardship is a commitment to always use antibiotics only when they are necessary to treat, and in some cases prevent disease; to choose the right antibiotics; and to administer them in the right way in every case. effective stewardship ensures that every patient gets the maximum benefit from the antibiotics, avoids unnecessary harm from allergic reactions and side effects, and helps preserve the life-saving potential of these drugs for the future." (cdc 2013a, p. 41) • "…new antibiotics will always be needed to keep up with resistant bacteria as well as new diagnostic tests to track the development of resistance". (cdc 2013a, p. 44) and is believed to be spread via direct transmission. the case fatality rate is high in that approximately half of the people with the mers-cov infection have died. "however, the virus has not shown to spread in a sustained way in communities. the situation is still evolving" (cdc 2013 the severe acute respiratory syndrome (sars) pandemic was short lived but certainly tested the preparedness of our public health and health-care systems for a never-before-seen virus that was transmissible from animals to humans. mers-cov possesses some similarities to sars in that both are believed to be evolved from the bat coronavirus, affect the lower respiratory system, and are transmitted via an airborne route (breban et al. 2013 ). however, recent research has also indicated significant differences between these two coronaviruses. for example, assiri et al. (2013) reported that patients diagnosed with mers-cov tended to be older men with underlying chronic medical conditions, including diabetes, heart disease, and renal disease. in addition, these researchers noted that the progression to respiratory failure occurred faster compared to sars (zumla 2013) . furthermore, these authors observed, in contrast to sars, which was much more infectious especially in healthcare settings and affected the healthier and the younger age group, mers appears to be more deadly with 60 % of patients with co-existing chronic illnesses dying, compared with the 1 % toll of sars. (zumla 2013) lastly, the authors note that it is possible we are only detecting the most serious of the mers-cov cases, and there are milder cases going undetected in the community (zumla 2013) . it is these milder cases that also require a case definition: ultimately the key will be to identify the source of mers infection, predisposing factors for susceptibility to infection, and the predictive factors for poor outcome. meanwhile infection control measures within hospitals seem to work. (zumla 2013) public health emergency? although this is a new virus with a high case fatality rate and is of great concern to the public health and health-care communities, the world health organization (who)'s emergency committee of the international health regulations [unanimously decided in july 2013] …that with the information now available, and using a risk-assessment approach, the conditions for a public health emergency of international concern (pheic) have not at present been met. (who 2013) "while not considering the events currently to constitute a pheic, members of the committee did offer technical advice for consideration by who and member states on a broad range of issues, including the following: • improvements in surveillance, lab capacity, contact tracing and serological investigation • infection prevention and control and clinical management • travel-related guidance • risk communications • research studies (epidemiological, clinical and animal) • improved data collection and the need to ensure full and timely reporting of all confirmed and probable cases of mers-cov to who…." (who 2013) furthermore, there are no current travel bans to countries that have reported mers-cov cases. cdc's …travel notice is a watch (level 1) which advises travelers to countries in or near the arabian peninsula to follow standard precautions, such as hand washing and avoiding contact with people who are ill. (cdc 2013) similarly, who does not currently propose any travel or trade restrictions or special screening activities at points of entry into countries (hopp 2013) . public health preparedness cdc is actively monitoring the outbreak of mers-cov cases and working with international public health partners. to date, cdc has engaged in public health preparedness for this new virus in the following ways: • "…developed molecular diagnostics that will allow scientists to accurately identify mers cases." • "…providing mers-cov testing kits to state health departments." • "…developed interim guidance for preventing mers-cov from spreading in homes and communities to help protect people if there is ever a case of mers in the u.s." • "…offering recommendations to travelers when needed. cdc is also helping to assess ill travelers returning from affected areas." • "…provide advice and laboratory diagnostic support to countries in the arabian peninsula and surrounding region." (cdc 2013) research by breban et al. (2013) examined the transmissibility of mers-cov between humans which allowed them to estimate the potential for mers-cov to attain a pandemic status. the authors concluded "…that mers cov does not yet have pandemic potential" (breban et al. 2013, p. 694) . the authors recommend the following public health actions: "…enhanced surveillance, active contact tracing, and vigorous searches for the mers-cov animal hosts and transmission routes to human beings" (breban et al. 2013, p. 694) . knowledge gaps since this outbreak is still evolving, there are many gaps in our knowledge about the epidemiology of the infection, its clinical course, best diagnostic tools, patient management, and infection control. assiri et al. (2013) did an outstanding job in formulating the questions the public health and health-care communities should be addressing. i have highlighted a few of these questions here for discussion purposes. the reader is referred to the descriptive study of mers-cov in saudi arabia that was conducted by assiri et al. (2013) for further probing questions. • "what is the natural reservoir of mers-cov?" • "what is the source of exposure to mers-cov outside of the healthcare facility (e.g., animals, water, sewage, food)?" the type of public health professional required to address this specific public health issue includes, but is not limited to, the following: asymptomatic, mild, severe infection)?" • "what is the infection rate in the community?" • "what are the protective immune system mechanisms against mers-cov?" • "what is the excretion pattern of the virus?" • "what is the best clinical management of mers-cov?" • "is there a role for antiviral agents?" • "how stable is mers-cov under different environmental conditions (e.g., dry surface, in vomit, sputum or diarrhea)?" • "how can we efficiently disinfect against mers-cov?" • "is there a role for herd immunity against mers-cov? public health skills to address a novel disease outbreak • collaborate with public health partners at the local, state, federal, and international levels in the case of mers-cov, public health and health-care professionals and researchers are reviewing the similarities and differences between sars and mers-cov. reviewing how similar outbreaks were managed can help steer a similar • participate in videoconferences and conference calls sponsored by the cdc and who regarding the latest information and best practices pertaining to the epidemiology, prevention guidelines, clinical management engage in diligent surveillance activities to help develop prevention methods specific to your local community • evaluate these prevention efforts and adapt as necessary. • document the approaches implemented and their effectiveness as this may inform evidence-based practice for future disease outbreaks • be prepared, to the extent possible, with sufficient material and personnel resources to plan, respond, and evaluate prevention efforts inform and educate the public about their risk and prevention efforts via media outlets outbreaks of novel diseases can be unpredictable as the virus evolves. be prepared for changes in transmission, the target population, and disease management references local public health case: pediatric fatality in a refugee resettlement community agency for toxic substances disease registry case studies in environmental medicine: lead toxicity community ecology and capacity: keys to progressing the environmental communication of wicked problems environmental inequality: childhood lead poisoning as an inadvertent consequence of the refugee resettlement process fatal pediatric lead poisoning childhood lead poisoning in a somali refugee resettlement community in new hampshire accessed 18 sept. city of manchester, new hampshire health department (mhd) lead poisoning among refugee children resettled in massachusetts review of community-based research: assessing partnership approaches to improve public health new hampshire childhood lead poisoning prevention program: 2002-2006 blood lead level screening data childhood lead poisoning in massachusetts communities: its association with sociodemographic and housing characteristics an academic-community outreach partnership: building relationships and capacity to address childhood lead poisoning combating rx diversion, overdose and death-comprehensive public health strategies needed after hepatitis c probe, nh, groups push for better drug diversion prevention, detection core elements of an outbreak investigation former employee of exeter hospital pleads guilty to charges related to multi-state hepatitis c outbreak mechanisms of prescription drug diversion among drug-involved club-and street-based populations national association of drug diversion investigators new hampshire code of administrative rules new hampshire division of public health services, department of health and human services national public health case: antibiotic resistance centers of disease control and prevention community-acquired methicillin-resistant staphylococcus aureus skin and soft tissue infections: management and prevention. current infectious disease reporting assessment of public health perspectives on responding to an emerging pathogen: carbapenem-resistant enterobacteriaceae vital signs: carbapenem-resistant enterobacteriaceae hospital mrsa infections fall by more than 50 %, report shows superbug a 'triple threat' but cdc issues warning early to prevent spread north carolina public health management of ca-mrsa carbapenem-resistant acinetobacter baumannii and klebsiella pneumoniae across a hospital system: impact of post-acute care facilities on dissemination hospital and societal costs of antimicrobialresistant infections in a chicago teaching hospital: implications for antibiotic stewardship predictors of carbapenem-resistant klebsiella pneumoniae acquisition among hospitalized adults and effect of acquisition on mortality international public health case: middle east respiratory syndrome-coronavirus epidemiological, demographic, and clinical characteristics of 47 cases of middle east respiratory syndrome coronavirus disease from saudi arabia: a descriptive study. the lancet infectious diseases interhuman transmissibility of middle east respiratory syndrome coronavirus: estimation of pandemic risk middle east respiratory syndrome coronavirus (mers-cov) who statement on the second meeting of the ihr emergency committee concerning mers-cov fullest clinical report of saudi mers points to important differences with sars cases to date key: cord-015944-6srvtmbn authors: brown, david title: the role of the media in bioterrorism date: 2008-09-10 journal: beyond anthrax doi: 10.1007/978-1-59745-326-4_15 sha: doc_id: 15944 cord_uid: 6srvtmbn nan in many ways, journalism about bioterrorism is little more than a special case of journalism about science. even when a bioterrorism story involves some broad public policy issue, the subject invariably rests on a substrate of science and technical knowledge. consequently, understanding policy issues involving bioterrorism -to mention nothing of terrorist events themselves -requires knowledge of biological mechanisms, an appreciation of clinical decision-making in medicine, and a sense of how to conceptualize and evaluate relative risks. many science reporters are conversant with these subjects, but some aren't. in any case, many stories on bioterrorism are written, produced and edited by journalists unfamiliar, and often uncomfortable, with scientific subjects. scientists and policy-makers should keep this in mind at all times. like it or not, they need to realize that to make themselves clear they may have to conduct a running seminar on scientific methods, concepts and reasoning. it goes -almost but not quite without saying -that the sources of information need to be conversant in those areas themselves. of all nationally compelling news events, those involving science are the ones in which successful communication most depends on simple command of the facts. political, constitutional and national security crises may be well-served by the voice of authority, the reassuring (or beguiling) power of rhetoric, and even by the ability to deftly make a weak argument. but scientific crises -which are almost always health crises at some level -require expertise, first and above all. opinion counts for little when evaluating hazards to life, or devising a response to them. judgment and authority are useful tools only when wielded by people who know what they are talking about. this is a very hard lesson for policy makers to learn. but it is the first one they must if they want to increase the chance that the news media will do a good job. what is the importance of the news media doing a good job? of course, it is impossible to give a good answer to that. but it is possible to say how important the public thinks the media is at such times. two weeks after the first (and fatal) case of anthrax from a bioterrorism attack using the mail occurred in october, 2001, 78% of americans sampled in a poll reported they were following the news of it ''very closely''. this was a level of attention equal to that seen after the events of september 11 that year. fifty percent said the media was not exaggerating the danger of anthrax; 42% said it was [1] . in the 110 days after the first case, the office of communications at the centers for disease control and prevention (cdc), the government agency coordinating the public health response to the attacks, conducted 23 press briefings and 306 television interviews, wrote 44 press releases, and took 7737 calls from the news media [2] . (interestingly, 2½ times as many calls came directly from the public -17,986 in all). the value of a well-informed and well-treated press in such times can scarcely be overstated. even when people providing information about bioterrorism are knowledgeable about the scientific issues and experienced in talking to reporters, they would do well to keep two ideas consciously in mind. one a principle and the other an observation, these two ideas are part of the natural mental apparatus of biologists. their importance in helping guide investigations and solve problems -their heuristic value, in short -is largely unappreciated by nonscientists. a major task of any science communicator is to bring them into public consciousness and keep them there. the first is the principle (or law) of parsimony. ''one should always choose the simplest explanation of a phenomenon, the one that requires the fewest leaps of logic'' and ''the principle that entities should not be multiplied needlessly; the simplest of two competing theories is to be preferred'' are two definitions of this principle, each converging on the notion that simpler explanations are more likely to be true than complicated ones [3] . when this principle is invoked in scientific argumentation it is often called ''occam's razor'', after william of occam (1285-1349), a medieval english theologian and logician. occam (whose name is a latinized spelling of ockham, his birth village south of london) criticized what he considered the unwarrantedly complex (and therefore, he thought, likely to be false) writings of his contemporaries. he wrote that when it comes to explaining things, ''it is vain to do with more what can be done with less'' [4] . employing occam's razor is particularly important (although not infallible) in medical diagnosis, where a physician ideally should account for all the important signs, symptoms and test results presented by the case. the clinician wielding occam's razor assumes all newly appearing clinical phenomena are the result of a single disease, not the coincidental occurrence of two or more diseases. consequently, a single diagnosis that explains all the clinical findings should be exhaustively sought, and abandoned with great reluctance. parsimony has two other corollaries besides occam's razor. one is that events are likely to unfold in the future as they have in the past -that patterns and mechanisms tend to be stable and relatively unchanging over time. the other is that unusual diseases or presentations of diseases are, by definition, unusual and should not be readily invoked. this idea is captured in two admonitions nearly every physician is told at least once during his training: ''common things are still common,'' and ''when you hear hoof beats, don't think of zebras.'' in sum, the natural impulse of physicians to resist acting on wild or untested ideas runs deep -so deep, in fact, that its power may not be fully appreciated by physicians themselves. the second idea that has heuristic value in times of bioterrorism is the bell-shaped curve. it captures the observation that outcomes arising from the same events or conditions are not identical, but differ from one another in ways that can be depicted visually and understood intuitively. most outcomes are similar to one another. they inhabit the fat, or humped-up, part of the curve, and define the average. a small number, however, are quite different from the rest, either much less or much more by whatever metric is in use. those outcomes inhabit the two thin ends, or tails, of the curve. when this pattern is symmetrical on either side of the mean (or average) value it is called a ''normal distribution.'' normal distributions have specific mathematical properties; for one, the rarity of certain outcomes can be calculated. in that sense, the bell curve can be used to predict the likeliness of future events. not all biological events have a normal distribution, but many do [5] . these two ideas -parsimony and the bell curve -are constantly at play in biology and medicine. an intuitive understanding of how the concepts operate in widely divergent biological spheres -and the ability to employ them consciously when facing new or difficult issues -may be the chief benefit for journalists in taking more-than-introductory courses in biology. when it comes to bioterrorism, however, these two concepts are important for opposite reasons. bioterrorism dilutes the importance of parsimony. that's because bioterrorism is an unnatural event even if its components -viruses, toxins, organs, medicines -are each natural and at some level behaving in familiar ways. bioterrorism creates interactions that do not occur on their own. it produces conditions of unpredictable risk; it makes vulnerable people who aren't normally vulnerable; it alters highly evolved mechanisms of transmission, distribution, and protection. the doomsday scenario of a crop-duster laying down a cloud of anthrax spores on manhattan -an event modeled by inference, if not by name, in a recent journal article -falls entirely outside the natural history of anthrax spores, human beings and manhattan [6] . it is safe to say that previous experience with anthrax outbreaks is not likely to be very helpful in predicting the outcome of such an event, or in planning for it. unfortunately, it is hard even to predict how unhelpful the past is likely to be. on the other hand, bioterrorism tends to magnify the importance of the bell curve as an informative idea. because size of the dose, duration of exposure, mechanism of transmission, and numerous other variables are unknown and unnatural, physicians and public health officials can not easily estimate an individual's risk during a bioterror event. in particular, it is difficult to identify occupants of the left-hand tail of a bell curve that depicts exposure to a pathogen. it's hard to say with confidence who is at very low risk of becoming infected, so that tail tends to be ignored and its occupants mentally swept into the fat part of the curve for safety sake when it comes to decisions about clinical monitoring, prophylactic treatment and other interventions. however, the bell curve that represents the side effects of interventions presents a different story. the existence of the right-hand tail -occupied by the few people who suffer serious side effects of, say, a vaccination -is either tolerable or intolerable, depending on the probability of the threat being guarded against. if the threat is high, then people will tolerate side effects (or at least the risk of them). if the threat is low, they will find side effects burdensome or unacceptable. but if the magnitude of the threat is unknownis simply ''non-zero'' -then nobody can gauge whether the side effects experienced are worth the protection gained. this was the central conundrum posed by the federal government's recommendation of smallpox vaccination for certain hospital workers in 2003 [7] . it's useful for people who determine society's response to the threat of bioterrorism (or, needless to say, an actual act of it) to explain how the importance of different regions of the bell curve changes depending on circumstances. even if decision-makers do a good job of explaining this, however, they are likely to observe the operation of yet another bell curve -namely, the one that defines what is news and what is not. news is the noteworthy event. on any given day, this is more likely to be the odd and unusual event rather than the common and expected one. if dog-bites-man is the fat and uninteresting part of the human-canine interaction, then the two tails are where the news is: the cliche´d man-bites-dog in one tail, and the pack-of-dogs-maul-man in the other tail. in practical terms, this means that even if the balance of events is well explained, the press is always going to devote more attention to the unusual, the dramatic, the damaging. thoughtful communication with journalists (and, of course, good journalism itself) can keep this natural predilection from obscuring the larger, more subtle truth of events. so how do these three things -expertise, and the ideas of parsimony and bellshaped distribution of outcomes -come into play in actual news stories about bioterrorism? there is only been one bioterrorism event in the united states that is captured national attention in recent times -the anthrax attacks of the autumn of 2001. (the intentional contamination of food with salmonella by the rajneeshee cultists in oregon in 1984 was largely a local story [8] ). consequently, the examples in the rest of this chapter are drawn largely from that episode of recent history. the drama was long, with many unexpected turns of event. it captured nearly every important lesson about the media and bioterrorism that is likely to arise in the future. policy makers and public health officials (and even to some extent, private medical care providers) face a difficult task when biological terrorism threats become real. without warning they are called upon to describe events, provide advice, anticipate what may happen, and offer reassurance. these jobs are especially difficult when an event has no ''natural history'' experts can look back to for help. in the early hours and days when even the general trajectory of events is unclear, the tasks can be close to impossible. it is obvious that under such circumstances, well-meaning and well-informed may give contradictory answers and advice. in order to prevent that, authorities sometimes choose to suppress information, limit access to people who know the most, or simply avoid the press altogether. all three strategies, to varying degrees, were tried during the anthrax attacks. in terms of public confidence, one of the more damaging incidents occurred the day the outbreak became news, october 4 [9] . tommy g. thompson, who at the time was u.s. secretary of health and human services and the titular leader of most of the federal government's civilian health workers, held a news briefing at the white house after learning of the first case. a 63-year-old man in florida working as a photo editor at a tabloid newspaper was diagnosed with inhalational anthrax. he was described as an outdoorsman, and thompson mentioned that ''we do know that he drank water out of a stream when he was traveling through north carolina last week.'' several further questions established the man's age, home town, and a few other details. the press conference ended this way: it's little surprise that some listeners left the briefing with the impression there was a reasonably good chance the florida case was naturally acquired, and that drinking from a stream might have been the route of transmission. it seems quite unlikely that the medical experts believed the former even at this early stage. the latter was virtually impossible given that the patient had inhalational disease and no cases of gastrointestinal anthrax had ever been reported in the united states [11] . however, the reluctance on the part of lillibridge to provide a fuller explanation that might have appeared to erode thompson's authority -along with fleischer's abrupt termination of the briefing -guaranteed that misleading information would be reported, and that it would be attributed to a high administration official. (fleischer's unwillingness to extend the press conference may have been something akin to a reflex action. in his role as a political spokesman, leaving facts ambiguous and opinions uncertain is often the explicit goal of an encounter with reporters, and not an unfortunate outcome. however, this should never, ever be the case when the topic is scientific. science is relatively impervious to spin, and incomplete or misleading answers are easily exposed. even when there is no intention to deceive -and clearly there was none herestopping reporters from asking questions about a technical subject when they have many left to ask is done at great peril.) as it happens, news reports that day and the next generally overlooked thompson's remark about the stream. in this country, msnbc, cnn, united press international, the washington times, and the st. petersburg times appear to have been the only ones reporting it. outside the united states, the remark was noted in the times (london), the daily telegraph (london), the scottish daily record, agence france presse, and the spanish-language news service efe [12] . if people thought there was a good chance the florida man acquired anthrax by drinking stream water, most were probably foreigners! this curious result may have occurred because thompson made his statement at the white house, where foreign news outlets have correspondents but most american newspapers don't. however, it is possible some american reporters didn't mention the remark in their stories simply because they knew it made little sense. the associated press, for example, carried a story october 5 in which jeffrey p. koplan, director of the cdc, was paraphrased as saying ''the patient has no digestive symptoms that would indicate the anthrax came from drinking contaminated water [13] .'' within a week, however, many newspapers -including such influential ones as the new york times, the washington post, and usa today -had discovered thompson's statement about the stream. by then nobody found the stream-contagion theory credible, and there was no evidence thompson's remark had done actual harm. nevertheless, it was publicized widely. reporters cited it as evidence in stories whose theme was the federal government's confusing and incompetent performance in communicating with the public [14] . patricia thomas, a science journalist commissioned by the century foundation to analyze the interaction between government agencies and the press during the outbreak, observed: ''as the crisis worsened and spread, thompson never quite repaired the damage done by his off-the-cuff words about water [9] .'' thompson [15] .'' nevertheless, authority and candor (if that is, indeed, what it was) didn't trump credibility and expertise. while people in the bush administration apparently believed there was value in having thompson be the spokesman, he came to the event with little technical grasp of the issues -and demonstrated it immediately. as a main source of information, he was eventually moved aside in favor of various epidemiologists at the cdc, and anthony s. fauci, head of the national institute of health's national institute of allergy and infectious diseases. by then, however, considerable damage had been done in terms of public relations. the comment became one of the most memorable anecdotes of the entire outbreak. worse, it became the pocketportable symbol of what many people considered -rightly or wrongly -to be the federal government's early mishandling of the crisis. a year later, thompson's remark was still being cited, albeit indirectly, by a prominent medical journalist, lawrence k. altman of the new york times, in an article criticizing the federal government's press relations on an entirely different mattersmallpox vaccination [16] . if having thompson be a main source of information early in the outbreak had been the only government miscalculation, then the media's overreaction to his stream comment would be especially objectionable. it was not. the cdc's press office was barely functional in the first 2 weeks after the initial outbreak. part of this was simply the result of volume: the office counted 2,229 requests about anthrax and 287 about bioterrorism between october 4 and 18, which is likely to have overwhelmed resources under the best of circumstances [9] . however, there were many other problems, which thomas describes well in her monograph: ''those who got in touch with a press officer were likely to be referred elsewhere. if they asked about field investigations they were advised to call local officials in florida, new york, new jersey, or washington. (there, press officers in the field sometimes bounced inquiries back to the cdc in atlanta.) reporters who asked about the search for the perpetrators were told to contact the fbi, which released prepared statements about the investigation but was otherwise tight lipped. if reporters called to follow up on comments made by secretary thompson or to ask about policy issues, they were usually referred to the public affairs office at hhs. and, although they did not realize this was happening, many reporters then had to wait while their requests were vetted by hhs officials in washington [9] .'' the idea that cdc functions as a mere consultant to states and cities in outbreak investigations is little more than a sophistry under normal circumstances. in the anthrax outbreak, it was simply wrong. cdc was at least an equal partner everywhere it sent investigators, from the start. with the outbreak potentially national in scope and with so much attention on the federal government's response to it, for cdc spokespeople to argue that providing information naturally ''devolved'' to state and local authorities was nothing short of infuriating. (koplan believes this clarification of federal-versus-state roles in communicating with the media during emergencies is an especially important problem to solve [17] ). providing reporters efficient access to informed sources is a tall order in a crisis, especially when events are happening in several places and many government agencies are involved. nevertheless, providing such access is a priority whose importance can scarcely be overstated. reporters can hardly be expected to abandon a subject simply because they cannot get information on it. instead, they will turn to experts who are available, but whose knowledge of events is often second-hand or whose opinions may be colored by unstated agendas. furthermore, policies that produce highly controlled and incomplete delivery of information to reporters lead to hypercritical and retaliatory journalism when things do not go well. nearly every major news organization produced a story questioning the cdc's credibility and performance in communicating with the public [18] . regardless of how unfair some of the criticism might have been, this analysis rapidly became part of the accepted history of the event. before reflexively limiting information or routing it through a single, scripted source, government authorities should ask: to what end? what is the advantage of such regimentation? what are the hazards of letting epidemiologists, physicians and investigators speak freely and without supervision? the prime advantage (they are likely to answer) is that when only a few people are allowed to talk to reporters, the chance that contradictory versions of events, or interpretation of them, will emerge is reduced. the press seeks conflict and reports it as news; a difference of opinion is the most rudimentary and common form of conflict. however, forbidding a multitude of informed sources from talking to reporters does not eliminate conflict. it merely transforms the conflict to differences of opinion between taciturn officials and the independent experts, while simultaneously giving the public insufficient information with which to reach its own opinion -not a good combination. an excess of detail and analysis -some of it contradictory -is not likely to produce more public confusion and negative reporting (although, of course, it is impossible to say this with certainty). the second argument that officials will probably make in defense of controlling the flow of information is that such a policy does not waste the time of people who have other jobs to do. this is undisputedly true. but it is a false economy. in a true health crisis such as an attack with a biological weapon, an effective public health response and clear communication with citizens are equally important. any system that puts them in conflict or requires them to compete should be changed. reassurance, which requires little time or expertise to deliver, is no substitute for information. in fact, unaccompanied by information, or in the presence of events that continue to go badly, reassurance makes people feel isolated and suspicious. the excessive number of calming messages during the anthrax attack drew criticism even from sympathetic quarters. philip s. brachman, an epidemiologist and anthrax expert who was retired from cdc after three decades of service, was quoted in one newspaper report: ''we have an intelligent public in this country. don't treat them as children. [officials] in the beginning got up and said, 'don't worry.' that's nonsense. what i would do is say, 'we've got a problem, you have every right to be fearful, i'm fearful too, and here's what we're doing' [19] .'' giving the media more information than it asks for or can easily digest is a safer strategy than giving the media the minimum it will tolerate or only what it can understand with no help. like anyone engaged in acts of construction, reporters are happy to have more building materials than they need. authorities should not worry that too much information will confuse. in general, reporters will seek and use only the level of detail with which they are comfortable. bad journalism is almost never the product of too many facts. the prominent science writer laurie garrett put it well: ''if you build it, we will come. if you have a valid information source that is readily available and easy to get to, with openness and facilitation, it will be used. most reporters will not search for unreliable facts elsewhere [20] .'' at the very least, a free flow of information will disarm journalists of their principal complaint in times of crisis -namely, that the people in the know are hiding things. in a bioterrorism crisis, the cdc should consider designating a high official with scientific expertise -not a member of the communications staff -to function as a kind of rapporteur of agency deliberations. ideally, this person should have some sense of what constitutes news and a fully reported story. he or she would be relieved of regular responsibilities but would otherwise function fully as an insider in agency activities. agency officials would continue to brief the press in time-limited sessions. during the anthrax and sars outbreaks, this was done in daily or near-daily telephone press conferences lasting about an hour. however, there were almost always unanswered questions at the end. the rapporteur would remain on the line for an open-ended period to answer them, provide scientific context or background explanations, and generally seek to eliminate ambiguity and misunderstanding. this would enhance clarity and transparency. it would also require planning and institutional courage. the federal government eventually solved the problem of expertise in its communication with the press during the anthrax attacks. but the experts weren't able to end the press's -and the public's -relative lack of understanding about how the outbreak response was being conducted. over the course of the 7 weeks between the first diagnosed case (october 4) and the last (november 21), spokesmen for the federal government repeatedly made assessments and predictions that turned out not to be correct. from the press's perspective, this was perhaps the most memorable -the most ''thematic'' -aspect of the entire event. the illness in the florida man was initially declared an ''isolated case'' with ''no evidence of bioterrorism [10] .'' while indisputably true when uttered, these statements on the first day set a pattern of confident assertions overturned by events. in ensuing weeks, pronouncements that a letter containing anthrax spores had to be opened in order to release enough pathogen to cause inhalational anthrax [21] ; that postal workers were only at risk for cutaneous anthrax [21] ; and that ordinary citizens had nothing to fear from mail all turned out to be wrong [22] . the fact that each successive event inscribed a circle of risk with a wider radius (and with more people in it) did not help the credibility of the speakers or their agencies. a statement by steven wiersma, florida's state epidemiologist, after the first victim died was notably different in tone and content from so much that followed: ''i don't want to give anyone the slightest inkling that we know what caused this [23] .'' why did so many assertions turn out to be wrong? there's no certain answer. but my theory is that many smart and experienced people failed to anticipate events such as inhalational anthrax in postal workers and a nearly homebound woman because of an instinctive belief in parsimony. those things simply seemed so unlikely -without precedent, actually -that planning for them was unnecessary, and perhaps even irresponsible given the likelihood of unintended consequences and morbidities. the tracks of this thinking are evident in what several high officials said when they were queried by reporters (and others) about why they had not taken steps some believe might have saved lives. koplan, cdc director, described his and his colleagues' thinking quite clearly several times. in one of the earlier daily teleconferences with reporters, on october 25, he reviewed the entire sequence of events. it was a highly illuminating account of epidemiological thinking. back to this particular outbreak. i think people are somewhat surprised that we're learning things on a day-by-day basis, but that's really no different from any other investigation that we've done this year, 5 years, or over the last 50 years. the way the natural history of these investigations are, you always wish you knew on day 20-on day one what you know on day 20, and it's probably not going to be different here. we learn new things almost daily in this, and try to anticipate, of course, what's coming up the next day or the next week. it's obviously much more difficult when you've got a purposeful intent and someone malicious at the other end engaged in combat on this, and that is different from anything else we have done before. a little later he describes how the belief emerged that a letter had to be opened to cause inhalational anthrax, and that contact with unopened letters containing powdered bacteria could only cause cutaneous anthrax. the letters we had seen or had described to us-we didn't have the letter in hand, but the letters we had had described to us, both the one from the new york post in new york and then the next set in washington, d.c., the letter that was in the hart office building that had been addressed to senator daschle, were described to us as welltaped, meaning that the seams along that letter were taped in a way that would have minimized, if not eliminated, the ability of a powder to seep out through openings around the letter. you would have to open the letter. and, indeed, we were told that the letter that was sent to senator daschle had to be opened by a scissors because of how well it was sealed. so through this period of time we were still operating on the assumption that in order for a letter to convey this-the anthrax, it had to be either opened by someone who was opening mail, or in some way torn or disrupted in the sorting process, because the concept of a powder in a sealed letter was one that suggested that it would stay in that letter. and that was our epidemiologic experience with the cases we had seen so far. that construct obviously changed markedly with the report of inhalation anthrax in mail workers in the brentwood facility in washington where mail was not opened in the places where these individuals were exposed, or seem to have been exposed, and where the disease that they contracted was not cutaneous anthrax, which takes less spores, and is obviously less threatening than inhalational anthrax, and in which the physical characteristics are different. but to get a aerosolization of anthrax requires both air currents flowing around, and some larger quantity of smaller-sized spores to be present, and not easily explained at all by unopened mail. and with that, our current construct on the risk includes, obviously, letters that are unopened as well as letters that are open, that have had, been tampered with or have been maliciously placed in the mail with anthrax spores. [21] the next day's teleconference featured this exchange about the possible risk from ''cross-contaminated'' letters -pieces of mail that don't themselves contain anthrax spores but which have come in physical contact with ones that do: reporter: on the cross-contamination possibility... does that mean the public is more at risk, and besides the 200-some different substations, are you looking at expanding the prophylaxis to perhaps whole zip codes? dr. koplan: no, on that latter; just plain no. let's get back to this issue of crosscontamination versus, you know, prim-whatever we're gonna call them-primary source criminal letters, or mailings. that where you indicated that there is an inhalation case in the state department that's been reported, i think we all think that that would be highly unlikely to virtually impossible to occur, just by cross-contamination, and as well, without having these letters in hand, but based on what we've seen in other sites, there are probably multiple mailings that have gone out, and, you know, there may be several places in the federal government that have been deemed targets for these letters to go to. so i guess my own personal working hypothesis would be that this is not crosscontamination. it just wouldn't be enough material, infectious material from crosscontamination to do that. [22] the day after that, bradley perkins, the cdc's lead epidemiologist in the florida anthrax outbreak, was asked about why environmental sampling had not gotten down to the level of the ordinary household. reporter: can i follow up on the first part of those? what about the idea of homes? why aren't they being tested and people on cipro if they also get their mail from the same place? dr. perkins: to date the epidemiology suggests that the cases that have occurred have not occurred as a result of exposure in home settings. and that's why we're not focusing on them at the current time. if the epidemiology changes, we will-we will change along with that epidemiology. [24] these quotations are a useful peek into the minds of two highly skilled and experienced epidemiologists. they reveal parsimony at work. they also show the unreliability of parsimony in biological terrorism, as the latter two assertions -that cross-contaminated mail, and mail received in the home would not cause inhalational anthrax -would soon prove incorrect. although the route of exposure of a non-medical hospital employee in new york city was never found, it is likely to have been cross-contaminated mail, as no spores were cultured from her workplace or home. the anthrax source in the case of a nonagenarian woman in connecticut also remained obscure, but as she rarely left her home and no gross contamination was found in it, the best inference is that she was infected by a cross-contaminated letter carrying a small number of bacterial spores. a similar failure of intelligent and parsimonious thinking can be expected in any bioterrorism event for the reasons mentioned earlier -they have few or no precedents, and are likely to defy the natural history of the disease in question. public health officials can count on being wrong much of the time. the press is likely to focus on the wrongness, and on the ''meaning'' of the errors. why? because the press's only consistent specialty is political analysis, the divination of how events affect power. the journalist james fallows has described this phenomenon: ''no one expects cokie roberts or other political correspondents to be experts on controlling terrorism, negotiating with the syrians, or other specific measures on which presidents make stands. but all issues are shoehorned into the area of expertise the most prominent correspondents do have: the struggle for one-upmanship among a handful of political leaders [25] .'' this insight is most relevant for the media's handling of matters of foreign or economic policy, but medicine and public health are not immune. the top officials of the new jersey department of health and senior services noted this in their detailed account of the state's experience in the anthrax outbreak: ''as the situation continued, news reports focused on what decisions were made (e.g., the closing of a facility, use of antimicrobial agents) and how they were made. the media and public were interested in what the response to the event seemed to say about state decision making and readiness to address emergencies in general [26] .'' if a journalist doesn't really understand the medical, statistical, and biological substance of a disease outbreak, he can at least appear to be knowledgeable about the interaction of individuals and agencies, and how events are believed to be changing their power and image. much of this coverage is unavoidable. some of it is even justified and illuminating [27] . in general, though, the public is better served by reporting that tries to reveal the substance of complex events and decisions rather than interpret them. public health agencies are better served by this approach as well. there is only one way to keep attention on the substance and that is to reveal the process of decision-making to the press and public as it happens. the best chance of keeping wrong decision and incorrect inferences from becoming the main story is to vicariously allow the non-experts to experience the difficulty and uncertainty of responding to events as they unfold. this is not necessarily done by opening meetings and conference calls to the press (although letting reporters occasionally witness such events is a good idea). what public health officers and policy-makers need to do is simply describe to journalists how decisions were made. they should not wait until the decisions prove to be right or wrong before they describe the thinking that went into them. they should do it in something close to real time (which regular briefings, such as the cdc's daily teleconferences, offered). specifically, public health officials should review the choices they considered when facing a set of facts and uncertainties. they should describe what the arguments for each course of action were, directing reporters' attention to the evidence and logic that advocates for each position brought to bear. they should reveal, at least in general terms, the magnitude of disagreement and the steps that led to its resolution -if, in fact, resolution preceded decision. cdc officials did a fairly good job of describing the logic of their thinking and the process by which decisions were reached. it occurred, however, almost entirely after the fact. the prospect of following these suggestions probably would fill a public health official with horror. but it should not. people appreciate being spoken to candidly. transparency is increasingly expected in government operations. the public appreciates being treated as intelligent enough to follow a complicated process undertaken on its behalf. the press is less likely to focus on process if it is forced to face the substance in all its difficult and incomplete detail. observers of all types are less likely to invoke race prejudice, obtuseness, and bad faith -all mentioned at one point or other during the anthrax attacks -if they understand how those in authority made their decisions. furthermore, people are more tolerant of uncertainty than decision-makers believe. while officials should be reassuring and do what they can to prevent panic, they should not shield the public from disagreement or discussions of what may happen if things get worse. disagreement is likely to be uncovered soon enough, and many people's understanding of what constitutes a worstcase scenario is likely to be more frightening than anything the facts support. on the issue of the threat of public panic, the record of how people behave during mass casualty events may be instructive. the national science foundation funded a study in which epidemiologists systematically analyzed the public response to 10 disasters that occurred between 1989 and 1994. these included an underground gas explosion in guadalajara, mexico, that killed more than 200 people in 1992; the first bombing of the world trade center in new york in 1993; and the northridge earthquake in california in 1994. the findings were revealing. one of the researchers described a few of the more salient ones: overall, the evidence suggested that victims tend to respond effectively and creatively. what we saw repeatedly in disasters was that victims formed spontaneous groups that have roles, rules, leaders, and a division of labor. this is the phenomenon of emergent collective behavior talked about extensively in the literature on the social science side . . . the literature and our study show that panic is relatively rare. there's a lot of talk about panic, and there's a general assumption that the public would panic in a bioterrorism event. my question is, where does the data come from to support that? in the events we studied, we were amazed to interview victims and health care workers who commented repeatedly on the absence of panic, complaints, or irrational behavior. many emergency department workers said, ''gee, i wish things worked this smoothly all the time.'' most people talked about an eerie feeling of calm that came over people during life and death moments. panic happens in disaster movies but typically not in real disasters for reasons that probably are based in evolution. what we witnessed is that ordinary citizens are amazingly capable of avoiding deadly harm. [28] william patrick iii, a former biological weapons worker quoted in this article also told david brown of the washington post in late october, 2001 that he had not been contacted by government investigators or epidemiologists in the 3 weeks after the first anthrax cases. although this evidence is indirect, it suggests that if difficult decisions -and the hazards they create -are explained fully to the press and public, panic and irrational behavior are not likely outcomes. in fact, the usual assurances that things will probably be okay are more likely to seem believable if decisionmakers reveal why they feel that way and give at least a hint of how events nevertheless might prove them wrong. this strategy may improve the image of public health decision-makers during a crisis. but that is not the main reason for it. the chief benefit is that it gives the public a vicarious sense of control. knowledge tends to allay fears even when uncertainty and danger are part of the knowledge. as evidence of this, public health officials need look no farther than medicine itself. description and prognostication were what physicians chiefly did before they were able to cure -and people took great solace from that alone. it is also possible that the act of preparing to describe the logic of a just-made decision to the press may itself be a useful tool in clarifying thinking and bringing unquestioned assumptions into consciousness. one wonders, for example, whether the assumption that mail had to be opened to cause inhalational anthrax -the assumption that may have contributed to the fatal infection of workers at the brentwood postal facility -would have stood up had there been greater public scrutiny of the assumptions and arguments being made behind closed doors. after all, the first cases of inhalational disease, at the florida tabloid newspaper office, were not definitively associated with open mail, and in fact no spore-containing letter was ever found there. similarly, a somewhat more open discussion of the aerosolization potential of finely milled anthrax spores might have directed epidemiologists' attention to the researchers retired from the united states army's biological weapons program -the only people with first-hand knowledge of the issue -sooner rather than later [29] . but even if the people who deliver information to the press are well-informed and they describe their decisions transparently, that would not guarantee that what appears in the newspaper and on television does not contain misleading information. there are crucial concepts that are second-nature to scientists but which are barely understood by the press and public. it is the job of public health officials to give the press a crash-course in these concepts. the most important one, as earlier suggested, is the usefulness of the bell-shaped curve in understanding the probability of complicated events. reporters and readers like to have concrete answers to questions. one of the more persistent queries, raised after the first case, was: how easy is it to contract inhalational anthrax? the answer was frequently given in number of spores, as inferred from experiments on monkeys. the number 8500 was often quoted; so was a range of 2500 to 55,000 spores [30] . reporters considered this a rather imprecise answer to the question, and at some level it was. as cases of disease occurred without the recovery of infecting letters, the estimates were questioned widely in news stories, and offered as evidence of ''how little we know about anthrax.'' a knight ridder story of october 27, 2001 noted that an anthrax expert outside the government ''said that officials have overestimated the amount of anthrax necessary -a minimum of 8000 spores -to cause inhalation anthrax [31] .'' at the cdc teleconference of october 25, a reporter asked: ''are you all doing any work in the labs perhaps with animals to test the assumption that perhaps with this particular form of anthrax it could take less than 8000 spores to cause inhalation disease? [22] '' in fact, the estimates and the events were confusing and contradictory only if one believed there was an absolute threshold for infection. it was clear that most journalists though of infection as analogous to a light switch -a certain number of spores will exert sufficient force to turn the light on, and fewer will not. but this is rarely, if ever, the case with infections, and certainly not with anthrax. the spore numbers are estimates of the number of the dose sufficient to infect 50% of the people exposed -the infectious dose 50%, or id 50 . half the people exposed to it won't become sick and possibly die, so it is far from being the minimum dose necessary to cause infection. because there is no minimum dose, biologists use this mid-way dose as a measuring stick for the infectiousness of something. while the usefulness of the id 50 -and the bell-shaped distribution it implies -is not intuitively obvious at first, once it's grasped many things are easier to understand. first, it explains why precision isn't possible in describing infectious dose, and thus why imprecision of itself isn't terribly newsworthy. more important, it helps make the two most mysterious cases of the outbreak -the 61-year-old female hospital worker in new york city and the 94-year-old nearly home-bound woman in connecticut -somewhat less mysterious and frightening. that's because if there is an id 50 , there's also an id 1 -the dose of spores that will infect 1 out of 100 people. for that matter, there's also an id .1 -the dose that will infect 1 in a 1000 -and an id .01 -the dose that will infect 1 in 10,000. so if it turns out that spores can get out of an envelope and stick to other envelopes, and if a fraction of those spores can become airborne again, and if there are a lot of envelopes moving around putting up spores in whatever tiny dose is the id .01 -then it stands to reason that someone among the thousands of postal customers will get infected. in some sense, all those envelopes are out there probing the population for the rare person who's susceptible to such a small dose. the envelopes are looking, so to speak, for the person who occupies the tail of the bell curve -because someone does occupy it. so, it should be no surprise when such a person appears [32] . the new york city patient -a relatively healthy working woman who was not especially old -doesn't present any obvious reasons why she might have been susceptible to a small dose. but the 94-year-old connecticut woman clearly has the major risk factor of age and its relative immunosuppression. in addition, she had the habit of tearing envelopes in half after opening them, which would have helped reaerosolize spores deposited on the outside through cross-contamination. similar confusion surrounded the issue of whether exposed people should undergo a three-dose course of anthrax vaccine after completing a 60 day course of antimicrobials. the large outbreak of inhalational anthrax caused by the accidental airborne release of spores in sverdlovsk, soviet union, in 1979 recorded no infections more than 43 days after exposure [33] . evidence from monkeys, however, suggests that infection can occur after more than 60 days of latency [34] . consequently, public health authorities offered vaccine, to be given along with 40 more days of antibiotics, to a large group of people, but did not recommend that they take it. the decision, instead, was left to the exposed people themselves. this agnostic stance was widely criticized -perhaps with good reason -as being insufficiently clear and authoritative. a new york times editorial called it ''an unsatisfactory medical cop-out,'' and added: ''it is disappointing that officials who are in the best position of anyone to make sense of the admittedly sparse data on anthrax are throwing up their hands and leaving the decision to patients and doctors who have far less command of the subject [35] .'' however, the key piece of data informing any individual's decision was not in the possession of the experts. that piece was the individual's tolerance of risk. what to do depended on whether a person worried about being one of the few people (actually, monkeys) in the tail of the bell curve and wanted to do something about it, or whether he assumed he was in the fat part of the curve where most people reside and was willing to live with the slim chance he was wrong. it is a subtle point -but one that has the advantage of being a statement of reality. public health officials could have helped the press and public understand the ''unrecommended offer'' of vaccine better if they had explained it as yet another decision arising from an understanding of the bell curve -the orderly distribution of events in biological systems in which there are many more average events than exceptional ones. the suggestion that such a concept could be taught to dozens of reporters on the fly isn't entirely far-fetched. journalists are used to getting one-on-one telephone tutorials from experts; it's one of the chief privileges of the profession. daily teleconferences with scientists and public health officials -the only reasonable way to manage news distribution during a bioterrorism eventprovide the opportunity. the internet even makes it possible for someone announcing a decision to help explain it with a diagram or graphic. at the moment, using the internet to provide journalists with background information during a running news story such as the anthrax outbreak is almost entirely untapped. if there is another event like it, public health officials would be wise to at least post on an easily accessed site a dozen or so scientific papers that form the core evidence base for the disease in question. posting the core literature would have many advantages. it would show how information was acquired through observation, experimentation, and extrapolation. it would demonstrate how some interventions (such as the use of anthrax vaccine after human exposure to the bacterium), while ''experimental'' in a formal sense, is grounded in evidence and not likely to carry much of the uncertainty associated with experimental therapies as commonly understood. it also provides color. the description of the investigation into an anthrax outbreak at a dickensian goat-hair mill in manchester, n.h., in the 1950s was both fascinating and informative [36] . the fact that those epidemiologists swabbed anthrax spores off the factory president's desk -which one of the still-living investigators told me -revealed something about the cohabitation of man and spore at all levels of that industry. the relationship between medicine and the media has never been especially easy or sympathetic [37] . medicine values privacy and authority. the media seeks to publicize the private and is reflexively suspicious of authority. medicine values nuance and caveat in communication. the media relishes definitive statements and often cannot tolerate subtlety. medicine generally attempts to reassure. the media often seeks to present facts in the most arresting and frightening context that can be defended with claims of technical accuracy. the hostility between the two worlds is sometimes profound. the twentiethcentury embodiment of medicine's ideals, william osler, said with more than a little bitterness: ''believe nothing that you see in the newspapers -they have done more to create dissatisfaction than all other agencies. if you see anything in them that you know is true, begin to doubt it at once [38] .'' on the other hand, the media does not do a bad job. on promed-mail, the main public website for breaking news in infectious disease epidemiology, about 90% of the postings ''start with a raw newspaper article.'' in an analysis of 7 months of activity, 2.6% of outbreak reports from unofficial sources -mostly newspapers -turned out to be wrong. that compared favorably with a 1.7% rate of inaccurate reports from official health agencies [39] . as an independent and occasionally unruly force, the media also has an invaluable role in emergencies, including epidemics. this was noted by numerous observers during the outbreak of severe acute respiratory syndrome (sars). in china, where control of the disease had consequences for the entire globe, the world health organization provided important assistance to local authorities, but ''it was the press that kept the focus on and led to the resolute responses that occurred,'' according to one western observer [40] . the lessons from the anthrax outbreak were evident soon after it ended. for sandra mullin of the new york city health department, they were similar to ones another disease had just taught. the media blitz surrounding the anthrax situation in new york city and elsewhere has far surpassed the crush of 1999. nonetheless, west nile provided a drill of sorts for the challenge public health is now facing. we learned most importantly about the need to address perceptions of risk, to have credible communicators, and to get information out in a timely and consistent way. in the past few weeks, this has meant getting facts out to the public rather than inventing ways to reassure the public. it has also involved acknowledging the seriousness of bioterrorism, but at the same time pointing out that thus far the morbidity and mortality associated with it are far surpassed by preventable illnesses like influenza and human immunodeficiency virus (hiv). admitting when we do not yet have the answers has also been required. [41] they're likely to be the lessons learned next time, too. the pew research center for the people and the press, poll released oct box 13-1. communicating about anthrax: some lessons learned at the cdc the first definition is from principia cybernetica guides for the perplexed physician discussions of the bell-shaped curve and normal distribution can be found at numerous websites, including at the university of the sciences in philadelphia emergency response to an anthrax attack the former head of the global smallpox eradication campaign and now the bush administration's main adviser on smallpox matters, told the committee [advisory committee on immunization practices] that the risk of the disease's reappearance is no different now from what it was when the panel last met toxic terror: assessing terrorist use of chemical and biological weapons the anthrax attacks, the century foundation other corynebacterial infections, and anthrax, in harrison's principles of internal medicine 15 th edition accessed through lexisnexis with search terms: ''thompson'' and ''anthrax'' and ''stream'' and ''north carolina florida man in critical condition with rare form of anthrax, raising fears about terrorism government's anthrax muddle: many voices, few facts bioterrrorism: preparedness and communication, delivered sept at the health department, the messengers still stumble but there probably should be a more obvious federal presence earlier where your suspicion has gone up. if it's anthrax or q fever or plague, that would be examples. sure, you could have the state of florida officials taking questions, but also make sure that we make some comments from a national perspective terrorism challenges thompson; pilloried, praised for crisis handling, he's still determined terrorism challenges thompson; pilloried, praised for crisis handling, he's still determined understanding media's response to epidemics statements to this effect were made by both jeffrey koplan and julie louise gerberding of the cdc in the cdc teleconference florida man suffering from anthrax dies why americans hate the media, the atlantic lessons from the anthrax attacks of 2001: the new jersey experience ttrial and error: seven days in october spotlight weakness of bioterror response; health officials were slow to grasp anthrax hazard for d.c. postal workers; mad dash from brentwood the word ''emergent'' in the third sentence is used in its correct sense, meaning ''unexpected and suddenly appearing,'' and not to denote action done quickly and under emergency conditions experts' key lessons on anthrax go untapped; fort detrick's veteran researchers studied bioweapons for 26 years future cases of anthrax, clues from decontaminated letters will help investigators the anthrax trail: tracking bioterror's tangled course the sverdlovsk anthrax outbreak of 1979 industrial inhalation anthrax a muddled message on anthrax vaccine an epidemic of inhalation anthrax, the first of the twentieth century medicine and the media: a case study sir william osler: aphorisms from his bedside teachings and writings global awareness of disease outbreaks: the experience of promed-mail learning from sars: preparing for the next disease outbreak'' workshop sponsored by the institute for medicine public health and the media: the challenge now faced by bioterrorism key: cord-278074-cube7lfh authors: kim, ock-joo title: ethical perspectives on the middle east respiratory syndrome coronavirus epidemic in korea date: 2016-01-29 journal: j prev med public health doi: 10.3961/jpmph.16.013 sha: doc_id: 278074 cord_uid: cube7lfh ethical considerations are essential in planning for and responding to outbreaks of infectious diseases. during the outbreak of middle east respiratory syndrome coronavirus (mers-cov) in the republic of korea in 2015, serious challenges emerged regarding important ethical issues, such as transparency and the protection of privacy. the development of bioethics in korea has been influenced by individualistic perspectives applied in clinical contexts, leading to a paucity of ethical perspectives relevant to population-level phenomena such as outbreaks. alternative theories of public health ethics include the perspectives of relational autonomy and the patient as victim and vector. public health actions need to incorporate clear and systematic procedures founded upon ethical principles. the mers-cov epidemic in korea created significant public support for more aggressive early interventions in future outbreaks. this trend makes it all the more imperative for ethical principles and procedures to be implemented in future planning and responses to outbreaks in order to promote perceptions of legitimacy and civic participation. ethical considerations have been embedded in plans made throughout the world for outbreaks and pandemics [1] [2] [3] [4] . lessons from past epidemics warn that without ethical safeguards, public health measures can inadvertently encroach on human rights and values [5] . the incorporation of relevant ethical principles in pandemic planning can help enhance voluntary cooperation based upon public trust, and reduce the undesirable outcomes of public health measures [1] . however, the outbreak of middle east respiratory syndrome in korea, public health ethics is not an established field. bioethics was introduced to korea in the 1990s, mostly in the form of clinical ethics and research ethics programs in medical schools and hospitals. from the beginning, the principalism proposed in beauchamp and childress's principles of biomedical ethics [6] played a dominant role in biomedical ethics education in korea. with the four principles of respect for autonomy, nonmaleficence, beneficence, and justice, this liberal indi-vidualistic ethical frame was established for patient-health professional relationships based on the premise that patients are pure autonomous agents. korea legally codified considerations regarding research ethics within a very short period of time. enacted in 2005 to regulate genetic and embryo research, the bioethics and safety act of korea was revised in 2013 to mandate informed consent and ethics review for research on human subjects, including public health research. enforcement of the bioethics and safety act has promoted the awareness of individual rights and interests in research. although korea is a family-oriented, collectively-minded society holding strong communitarian values, the individualist libertarian approach imported from western societies has been dominant in the field of biomedical ethics. in contrast, public health professionals in korea, such as scholars, practitioners and policy makers, deal with populationlevel issues rather than individuals and have not generally been engaged in bioethical discussions. in policies and practice, they implicitly employ utilitarianism or consequentialism to advocate for the greatest good for the greatest number of people. with cost-benefit analysis and the concept of the quality-adjusted life year, public health policies and practice aim at maximizing human welfare or well-being given a certain investment of resources. it is unfortunate that the public health sector in korea has not sufficiently addressed ethical considerations in preparation for impending outbreaks, while other nations and international organizations such as the world health organization have addressed ethical issues as crucial components of their pandemic plans. international pandemic plans developed by states and international organizations after the 2003 severe acute respiratory syndrome (sars) outbreak incorporated ethical values [1] [2] [3] [4] . since pandemics engender uncertain, dangerous, and fearful situations, ethical issues inevitably arise with regard to public health measures against pandemics. regardless of whether public health leaders explicitly articulate the ethical values that inform their plans and decisions, international guidelines on ethics and pandemic planning strongly recommend that pandemic plans be clearly founded on ethical values shared and affirmed by the public [1] [2] [3] [4] . doing so allows plans to be carried out with greater trust and legitimacy, supported by voluntary participation of members of society. quarantine was the primary response to the mers-cov outbreak in korea, and upshur [7] identified four principles that must be met in order to justify this liberty-limiting practice. first is the harm principle, according to which it must be the case that clear and measurable harm to others will occur if exposure is not checked through quarantine or isolation. the second is the principle of proportionality, or of the least restrictive means. the least restrictive measures must be used to accomplish the goal of disease control. voluntary quarantine should be implemented before turning to more restrictive means and sanctions. the third principle is that of reciprocity. if individuals sacrifice their liberties for the common good of the society, the society has reciprocal obligations to provide those individuals with needs such as food, shelter, and psychological support, and to protect them from discrimination, damages, or penalties as a result of quarantine. the final principle is the transparency principle, which states that the public health authorities must communicate transparently and clearly the justification for their actions and provide a process of appeal. this procedural due process is the ethical justification for the use of quarantine. how can ethical considerations be incorporated into planning for outbreaks of infectious disease? an excellent example is the ontario health plan for an influenza pandemic made in collaboration with the toronto joint centre for bioethics [4, 8] . these guidelines present a discussion of the substantive and procedural ethical values at stake in "restricting liberty in the interest of public health by measures such as quarantine. " this part contains ethical reflections on the experience of the sars outbreak. for ethical decision making, the substantive values at stake are liberty, protection of the public from harm, proportionality, privacy, and reciprocity. five procedural values also must be implemented, according to which public health measures should be reasonable, open and transparent, inclusive, responsive, and accountable. based on these ethical values, these guidelines provide four concrete recommendations for governments and the health care sector: 1) the preparation of comprehensive and transparent protocols for the implementation of restrictive measures founded upon the above ethical principles; 2) ensuring public awareness of the rationale, benefits, and consequences of restrictive measures; 3) the implementation of measures to protect against stigmatization and to safeguard the privacy of those involved; 4) statements of the provisions and support services for those affected by restrictive measures and public discussions of the levels of compensation in advance. ethical issues have rarely been discussed in the korean mers-cov literature. lee [9] raised the question of whether ethical values were appropriately considered in the public health actions taken during the mers outbreak in korea. that paper addressed conflicts in which "difficult choices had to be made between public health needs and the protection of individual rights, which include privacy, liberty, and freedom of movement. " valuable as it might be in the context of the minimal attention devoted to ethical considerations in the korean mers-cov literature, lee's discussion centering on the rights and interests of individuals provided only a limited list of ethical values in the response to an outbreak. recently, critics of individualistic approaches to public health ethics have proposed alternative perspectives on the ethics of infectious diseases. one such framework draws on a relational approach to public health ethics [10] . it claims that public health ethics in the context of epidemic planning should differ from individualistic bioethics by placing the primary focus on the common good of the public. rather than simply identifying the tensions between individual interests and community safety, responses to outbreaks should draw on the various ways in which individuals' interests are inseparable from and interrelated with the interests of the community. claiming that personhood and autonomy are products of social relations, this approach focuses on relational personhood and relational autonomy, with the goal of working towards social justice and relational solidarity in public health [10] . another important approach to the ethics of infectious diseases is an ethical framework that considers the infectious disease patient as both victim and vector (pvv) [11] . the pvv perspective sees individuals as socially located, biologically vulnerable, and interconnected with other human beings. if infection becomes a central concern, as in an epidemic or an outbreak, individual interests are not distinct from the interests of society as a whole. with all human individuals seen as potential pvvs embedded in the web of infectious disease transmission, the pvv view upholds sharing burdens fairly, trust, community participation, and responsibility. the view also helps avoid stigmatization and scapegoating, and provides for the humane care of infected patients including end-of-life care [11] . have these ethical values been clearly discussed and considered with regard to the public health measures implemented by the korean government during the mers-cov outbreak in 2015? as lee [9] pointed out, ethical values did not receive full consideration either in public health actions or in the literature reflecting on the lessons from the experience, including government-issued white papers on the mers-cov outbreak. although these white papers dealt with problems, issues, and future tasks in preparing for coming outbreaks of emerging diseases, none clearly addressed ethical values and considerations. however, some ethical principles have been embodied tacitly, if not explicitly, by the korean government in public health policies and practices during and after the mers-cov outbreak. a salient example is the government compensation policy for those who were ordered to stay home to prevent transmission of the disease, and compensation for the funeral costs to the surviving families of the deceased. although the government was not able to have a public discussion of the appropriate levels of compensation in advance, the decisions about compensation and the procurement of financial resources for compensation were made in the middle of the outbreak, and were motivated by the discovery that those who were quarantined were faced with loss of income and employment, putting their livelihood at stake. food and basic necessities were provided during the period of quarantine, and financial compensation for the loss of income was subsequently made according to the size of the family. in july 2015, the infectious diseases prevention act in korea was revised to include clauses for the compensation of financial losses to those who were placed under quarantine, the hospitals that provided medical care for mers-cov patients, and the surviving family members of those who died from mers-cov. this compensation policy, formally recommended by the special committee of the korea national assembly for the mers-cov outbreak in july 2015 in the midst of the outbreak, reflected the reciprocity principle. if individuals sacrifice their liberties for the common good of society, society has reciprocal obligations to provide the individuals with needs such as food, shelter, and psychological support. a contrary example is the transparency principle. the public health authorities in korea failed to uphold this ethical principle from the beginning. secrecy and a lack of transparency from the government in the early stage of the epidemic, together with a failure to effectively contain the disease, worsened the public's mistrust of the government, and the spread of rumors through the internet caused considerable panic among the public. without transparency and clear communication, public trust cannot be won and voluntary public collaboration cannot be expected. furthermore, fear and stigma-tization of quarantined residents and even of the families of health care workers occurred frequently, and this was exacerbated by the public distrust about transparency. members of the public tended to seek their own safety at the cost of discriminating against certain groups within the community, in the absence of other information or guidance that they perceived to be trustworthy. ethical values and considerations should be incorporated into pandemic planning and in the responses to future outbreaks in korea. alexander capron stated, "the key to an ethically responsible and appropriate response is advanced planning, including communication. part of the communication is openly acknowledging the unavoidable reality of scarcity of life-preserving resources and thus the resulting need both for collective action and for personal responsibility" [1] . what korea needs now is to implement the advice of the pandemic influenza working group of the university of toronto joint centre for bioethics: "1. national, provincial/state/territorial, and municipal governments, as well as the health care sector, should ensure that their pandemic plans include an ethical component. 2. national, provincial/state/territorial, and municipal governments, as well as the health care sector, should consider incorporating both substantive and procedural values in the ethical component of their pandemic plans" [4] . it is highly likely that korea's planning for the next epidemic aims at extensive early quarantine and isolation, as several authors have suggested such plans [12, 13] . those involved with public health measures against the epidemic have almost unanimously agreed that precautions and aggressive reactions to prevent the spread of the epidemic are far better than potentially losing the opportunity to contain the epidemic. if we do not include ethical values and principles explicitly in pandemic planning in advance, the next response to an epidemic may result in widespread breaches of ethical principles, leading to deeper confusion and non-cooperation. public engagement and civic partnership with public health authorities to discuss ethical principles are essential to foster community participation, collaboration, and solidarity from the civil society. pandemic planning enriched with ethical principles will facilitate efficiency, voluntariness, and legitimacy. ethical and legal considerations in mitigating pandemic disease: workshop summary centers for disease control and prevention. ethical guidelines in pandemic influenza world health organization. global consultation on addressing ethical issues in pandemic influenza planning: summary of discussions stand on guard for thee: ethical considerations in preparedness planning for pandemic influenza law in the time of cholera: disease, state power and quarantines past and future principles of biomedical ethics the ethics of quarantine public health and ethical considerations in planning for quarantine costly lessons from the 2015 middle east respiratory syndrome coronavirus outbreak in korea a relational account of public health ethics the patient as victim and vector: ethics and infectious disease a new measure for assessing the public health response to a middle east respiratory syndrome coronavirus outbreak structural factors of the middle east respiratory syndrome coronavirus outbreak as a public health crisis in korea and future response strategies this work was supported by grant from the snubh incentive for education and research. the author has no conflicts of interest associated with the material presented in this paper. ock-joo kim https://orcid.org/0000-0003-4095-4768 key: cord-025744-pynqwj5t authors: van der linden, clifton; savoie, justin title: does collective interest or self-interest motivate mask usage as a preventive measure against covid-19? date: 2020-05-14 journal: nan doi: 10.1017/s0008423920000475 sha: doc_id: 25744 cord_uid: pynqwj5t the revised guidance on masks from public health officials has been one of the most significant covid-19 policy reversals to date. statements made at the outset of the pandemic, including those from the world health organization (who), the united states surgeon general, and the chief public health officer of canada, all actively discouraged asymptomatic members of the general public from wearing masks. however, on april 3, 2020, the united states center for disease control and prevention (cdc) issued new recommendations that called for nonmedical masks, such as cloth face coverings, to be worn in public settings where other social distancing measures are difficult to maintain (adams, 2020). canadian public health officials quickly followed with their own guidance for wearing nonmedical masks or face coverings when out in public; however, they have stressed that doing so is optional for asymptomatic persons and should be seen as a complement to existing precautionary measures such as physical distancing and hand hygiene, particularly in cases where physical distancing may not be feasible (public health agency of canada, 2020). emphasis was placed on nonmedical masks serving not to protect the wearer, but rather others who come within close proximity of the wearer. echoing her public statements on the matter, canada's chief public health officer tweeted that “[w]earing a non-medical mask in public settings has not been proven to add any protection to the person wearing it, but it can be an additional way to prevent spread from an infected person to others” (tam, 2020). the revised guidance on masks from public health officials has been one of the most significant covid-19 policy reversals to date. statements made at the outset of the pandemic, including those from the world health organization (who), the united states surgeon general, and the chief public health officer of canada, all actively discouraged asymptomatic members of the general public from wearing masks. however, on april 3, 2020, the united states center for disease control and prevention (cdc) issued new recommendations that called for nonmedical masks, such as cloth face coverings, to be worn in public settings where other social distancing measures are difficult to maintain (adams, 2020) . canadian public health officials quickly followed with their own guidance for wearing nonmedical masks or face coverings when out in public; however, they have stressed that doing so is optional for asymptomatic persons and should be seen as a complement to existing precautionary measures such as physical distancing and hand hygiene, particularly in cases where physical distancing may not be feasible (public health agency of canada, 2020). emphasis was placed on nonmedical masks serving not to protect the wearer, but rather others who come within close proximity of the wearer. echoing her public statements on the matter, canada's chief public health officer tweeted that "[w]earing a non-medical mask in public settings has not been proven to add any protection to the person wearing it, but it can be an additional way to prevent spread from an infected person to others" (tam, 2020) . findings from a multiwave study conducted by vox pop labs indicate that the prevalence of mask usage among canadians rose significantly upon the issuance of revised guidance on the matter from u.s. and canadian public health officials and has since continued its upward orientation (see figure 1 ). given the discursive framing of wearing masks as a common good rather than an individual benefit, we examine the extent to which the rise in mask usage is motivated by collective interest as opposed to self-interest. drawing on recent survey data, we find that the decision to wear a mask is in part a function of collective interest. specifically, the increased propensity among canadians to wear masks is to a limited extent driven by concern for the welfare of others as opposed to oneself. however, the effect of collective interest on mask usage is rather modest by comparison with regional, gender, and partisan dynamics. we find no evidence to indicate that priming self-interest has an effect on mask usage by individuals in the general population. mask usage serves as a useful example of how collective action operates in the context of covid-19. according to olson (1965) , individuals in a group behave as rational egoists and would thus be disinclined to wear a mask if does not offer them additional protection from personally contracting covid-19. even though wearing a mask may indirectly protect the wearer in that increased mask usage by the general public may reduce overall transmission of covid-19, olson's logic asserts that individuals would instead free ride based on the expectation that other group members would adopt mask usage. this view is challenged by theorists who argue that rational self-interest alone fails to appropriately capture the empirically observable dynamics of collective action (mansbridge, 1990) . ostrom (2000, p. 142) argues that a substantial proportion of the population is composed of so-called "conditional cooperators" who are generally willing to act in the collective interest as long as they see a sufficient degree of reciprocation by others. conditional cooperators would be willing to don a mask to protect others so long as they observe a sufficient number of people within their group doing the same. respondents were asked, "what changes, if any, have you made to your normal routine in response to the covid-19 pandemic?" "wearing a mask" was among the response options. respondents to the first three waves of the study were provided with the response options in a multiselect format and asked to select all that applied. subsequent waves transitioned to a binary scale in which respondents were asked to explicitly respond "yes" or "no" to each response option. to ensure that the revised format did not affect self-reported behavioural changes, respondents were randomly assigned either the multiselect or the binary scale for the fourth and fifth waves. as the differences in self-reported behaviours were not statistically significant, the binary scale was adopted for all respondents from the sixth wave onward. we employed data from the fourth wave of a rolling sample survey, which was fielded between april 3 and april 7, 2020 and completed by 2,194 respondents who currently reside in canada. the sample was drawn from the vox pop labs online panel (n ∼ 650,000) as part of its covid-19 monitor initiative, a 24-wave weekly survey on public opinion in relation to the covid-19 pandemic. the sample was pre-stratified according to age, sex, education, partisanship, and region. we tested whether canadians exhibit a higher propensity to wear masks in response to appeals to a sense of collective interest or self-interest. to do so, we designed a survey experiment in which respondents were randomly presented with one of three texts: a control, a collective interest treatment, and a self-interest treatment. the control text read as follows: going forward, how likely are you to voluntarily (i.e., without being required to do so) wear a mask or any sort of protective face covering out in public as a preventative measure against covid-19? the collective interest treatment included the following preamble prior to the control text: some countries have started asking their citizens to cover their faces when in public in order to avoid potentially transmitting the virus to others with whom they come into contact. the suggestion is that, by wearing a mask, you may be protecting others from infection. the self-interest treatment included the following preamble prior to the control text: some countries have started asking their citizens to cover their faces when in public in order to avoid potentially contracting the virus from others with whom they come into contact. the suggestion is that, by wearing a mask, you may be protecting yourself from infection. survey respondents were asked to indicate their response on an 11-point scale ranging from 0 to 10, where 0 meant "no more likely" and 10 meant "much more likely." the mean of this continuous variable serves as our outcome variable. we used linear regression to model the effects of each treatment on the likeliness to wear a mask going forward. the results of the study are summarized in table 1 . model 1 compares each of the two treatments (collective interest and self-interest) against the control group. the coefficients represent the respective averages of the control and each of the treatment groups on the 11-point response scale. in model 2, we include a series of sociodemographic regressors in order to allow for substantive comparison of the effect size of the treatments with those of other independent variables. model 1 indicates that the self-interested treatment is not statistically significant vis-à-vis the baseline control. suggesting that canadians should wear masks as a protective measure against contracting covid-19 does not appear to increase the probability that they will do so. however, we do observe a small but statistically significant effect when it comes to the collective interest treatment. when compared with the control group, the collective interest treatment increases the average respondent's inclination to wear a mask by 0.505 points on the 11-point continuous scale. though a five-percentage-point increase on an 11-point scale is modest, it is non-negligible. the finding is statistically significant when the control is set as the base category, but also when the self-interested treatment acts as the baseline (see the appendix). the results of model 1 demonstrate that canadians are more willing to wear masks as a measure to protect others from covid-19 rather than themselves. figure 2 displays the results of an ordered logit regression so as to examine the note: *p < 0.1; **p < 0.05; ***p < 0.01. distribution of responses across the 11-point scale for the control group and both of the treatments. we observe that the differences in the collective treatment and selfinterest treatments cluster at the ends of the scale, whereas there are similar proportions of respondents in the centre in every case. this suggests that collective interest primers reduce opposition and increase support for wearing masks at the extremes. model 2 adds additional categorical independent variables including sex, age group, region, highest level of educational attainment, and vote choice in the 2019 canadian federal election. the results observed in model 1 are robust to the inclusion of additional regressors included in model 2, both in terms of significance and effect size. though model 2 also serves in principle to support the argument that individuals can act in the collective interest under certain conditions, it behooves us to note both the significance and effect size of several of the included sociodemographic control variables. first, women are more likely than men to wear masks. the effect size is larger than that of the collective interest treatment. second, living in british columbia is associated with a higher likelihood of wearing a mask, while living in quebec is associated with a substantively lower likelihood of doing so. compared to the (alphabetically determined) baseline of alberta, the effect size for quebec is −1.041, which is the largest effect size of any of the variables included in the model and a difference of 1.665 points from bc on the 11-point response scale. further study is required to interrogate this difference, but these differences may be related to the mixed and controversial messaging around the use of masks from premier françois legault and national director of public health horracio arruda (boisvert, 2020; cardinal, 2020) . third, partisan differences have an effect on the adoption of masks insofar as we observe a substantive and significant effect on mask uptake by those who voted for the liberal party and new democratic party in the 2019 canadian federal election. liberal and ndp supporters are more likely to wear masks, whereas the result for conservative party, green party, and bloc québécois voters is not significant. there is likely an ideological dimension at play within these findings, with left-leaning canadians being particularly more receptive to the idea of wearing masks. although in substantive terms the effect size is relatively modest, the findings of this study demonstrate that canadians are significantly more likely to adopt maskwearing in public when doing so is seen as a means to protect others from covid-19 rather than as a means to protect themselves. indeed, at the time of writing, the dominant framing around the utility of wearing masks in public was to prevent the potential transmission of covid-19, rather than as means to prevent oneself from contracting the virus. the survey results suggest that this approach is more likely to induce compliance with directives to wear masks than either a generic appeal or one that speaks to self-interest. although this study focuses exclusively on the adoption of masks, its findings are potentially instructive in terms of framing broader public health advice in relation to covid-19 in such a manner as to elicit compliance. the findings also lend credence to theories of collective action that are critical of the idea of rational selfinterest as the ubiquitous and exclusive motivation of individuals within a group. table 1 reports the effect of the self-interested and collective treatment vis-à-vis the control baseline but does not explicitly compare both treatments. as a robustness check, table a1 contemplates the selfinterested treatment as the baseline. the collective interest treatment remains statistically significant. recommendation regarding the use of cloth face coverings, especially in areas of significant community-based transmission notre erreur sur les masques qu'attend quebec pour imposer le masque self-interest in political life the logic of collective action: public goods and the theory of groups collective action and the evolution of social norms considerations in the use of homemade masks to protect against covid-19 5/9 wearing a non-medical mask in public settings has not been proven to add any protection to the person wearing it, but it can be an additional way to prevent spread from an infected person to others. #protectdontinfect #covid19 #layerupcovid key: cord-018336-6fh69mk4 authors: yasnoff, william a.; o'carroll, patrick w.; friede, andrew title: public health informatics and the health information infrastructure date: 2006 journal: biomedical informatics doi: 10.1007/0-387-36278-9_15 sha: doc_id: 18336 cord_uid: 6fh69mk4 what are the three core functions of public health, and how do they help shape the different foci of public health and medicine? what are the current and potential effects of a) the genomics revolution; and b) 9/11 on public health informatics? what were the political, organizational, epidemiological, and technical issues that influenced the development of immunization registries? how do registries promote public health, and how can this model be expanded to other domains (be specific about those domains) ? how might it fail in others?why? what is the vision and purpose of the national health information infrastructure? what kinds of impacts will it have, and in what time periods? why don’t we have one already? what are the political and technical barriers to its implementation? what are the characteristics of any evaluation process that would be used to judge demonstration projects? biomedical informatics includes a wide range of disciplines that span information from the molecular to the population level. this chapter is primarily focused on the population level, which includes informatics applied to public health and to the entire health care system (health information infrastructure). population-level informatics has its own special problems, issues, and considerations. creating information systems at the population level has always been very difficult because of the large number of data elements and individuals that must be included, as well as the need to address data and information issues that affect health in the aggregate (e.g., environmental determinants of health). with faster and cheaper hardware and radically improved software tools, it has become financially and technically feasible to create information systems that will provide the information about individuals and populations necessary for optimized decision-making in medical care and public health. however, much work remains to fully achieve this goal. this chapter deals with public health informatics primarily as it relates to the medical care of populations. however, it should be emphasized that the domain of public health informatics is not limited to the medical care environment. for example, information technology is being applied to automatically detect threats to health from the food supply, water systems, and even driving conditions (such as obstacles on the roadway beyond the reach of visible headlight beams), and to assist in man-made or natural disaster management. monitoring the environment for health risks due to biological, chemical, and radiation exposures (natural and made-made) is of increasing concern to protecting the public's health. for example, systems are now being developed and deployed to rapidly detect airborne bioterror agents. although they do not directly relate to medical care, these applications designed to protect human health should properly be considered within the domain of public health informatics. public health informatics has been defined as the systematic application of information and computer science and technology to public health practice, research, and learning (friede et al., 1995; yasnoff et al., 2000) . public health informatics is distinguished by its focus on populations (versus the individual), its orientation to prevention (rather than diagnosis and treatment), and its governmental context, because public health nearly always involves government agencies. it is a large and complex area that is the focus of another entire textbook in this series (o'carroll et al., 2003) . the differences between public health informatics and other informatics specialty areas relate to the contrast between public health and medical care itself (friede & o'carroll, 1998; yasnoff et al., 2000) . public health focuses on the health of the community, as opposed to that of the individual patient. in the medical care system, individuals with specific diseases or conditions are the primary concern. in public health, issues related to the community as the patient may require "treatment" such as disclosure of the disease status of an individual to prevent further spread of illness or even quarantining some individuals to protect others. environmental factors, especially ones that that affect the health of populations over the long term (e.g. air quality), are also a special focus of the public health domain. public health places a large emphasis on the prevention of disease and injury versus intervention after the problem has already occurred. to the extent that traditional medical care involves prevention, its focus is primarily on delivery of preventive services to individual patients. public health actions are not limited to the clinical encounter. in public health, the nature of a given intervention is not predetermined by professional discipline, but rather by the cost, expediency, and social acceptability of intervening at any potentially effective point in the series of events leading to disease, injury, or disability. public health interventions have included (for example) wastewater treatment and solid waste disposal systems, housing and building codes, fluoridation of municipal water supplies, removal of lead from gasoline, and smoke alarms. contrast this with the modern healthcare system, which generally accomplishes its mission through medical and surgical encounters. public health also generally operates directly or indirectly through government agencies that must be responsive to legislative, regulatory, and policy directives, carefully balance competing priorities, and openly disclose their activities. in addition, certain public health actions involve authority for specific (sometimes coercive) measures to protect the community in an emergency. examples include closing a contaminated pond or a restaurant that fails inspection. community partners to provide such care. though there is great variation across jurisdictions, the fundamental assurance function is unchanged: to assure that all members of the community have adequate access to needed services. the assurance function is not limited to access to clinical care. rather, it refers to assurance of the conditions that allow people to be healthy and free from avoidable threats to health-which includes access to clean water, a safe food supply, well-lighted streets, responsive and effective public safety entities, and so forth. this "core functions" framework has proven to be highly useful in clarifying the fundamental, over-arching responsibilities of public health. but if the core functions describe what public health is for, a more detailed and grounded delineation was needed to describe what public health agencies do. to meet this need, a set of ten essential public health services (table 15 .1) was developed through national and state level deliberations of public health providers and consumers (department of health and human services (dhhs), 1994). it is through these ten services that public health carries out its mission to assure the conditions in which people can be healthy. the core function of assessment, and several of the essential public health services rely heavily on public health surveillance, one of the oldest systematic activities of the public health sector. surveillance in the public health context refers to the ongoing collection, analysis, interpretation, and dissemination of data on health conditions (e.g., breast cancer) and threats to health (e.g., smoking prevalence). surveillance data represent one of the fundamental means by which priorities for public health action are set. surveillance data are useful not only in the short term (e.g., in surveillance for acute infectious diseases such as influenza, measles, and hiv/aids), but also in the longer term, e.g., in determining leading causes of premature death, injury, or disability. in either case, what distinguishes surveillance is that the data are collected for the purposes of action-either to guide a public health response (e.g., an outbreak investigation, or mitigation of a threat to a food or water source) or to help direct public health policy. a recent example of the latter is the surveillance data showing the dramatic rise in obesity in the united states. a tremendous amount of energy and public focus has been brought to bear on this problem-including a major dhhs program, the healthierus initiative-driven largely by compelling surveillance data. 1. monitor the health status of individuals in the community to identify community health problems 2. diagnose and investigate community health problems and community health hazards 3. inform, educate, and empower the community with respect to health issues 4. mobilize community partnerships in identifying and solving community health problems 5. develop policies and plans that support individual and community efforts to improve health 6. enforce laws and rules that protect the public health and ensure safety in accordance with those laws and rules 7. link individuals who have a need for community and personal health services to appropriate community and private providers 8. ensure a competent workforce for the provision of essential public health services 9. research new insights and innovate solutions to community health problems 10. evaluate the effectiveness, accessibility, and quality of personal and population-based health services in a community the fundamental science of public health is epidemiology, which is the study of the prevalence and determinants of disability and disease in populations. hence, most public health information systems have focused on information about aggregate populations. almost all medical information systems focus almost exclusively on identifying information about individuals. for example, almost any clinical laboratory system can quickly find jane smith's culture results. what public health practitioners want to know is the time trend of antibiotic resistance for the population that the clinic serves, or the trend for the population that the clinic actually covers. most health care professionals are surprised to learn that there is no uniform national routine reporting -never mind information system -for most diseases, disabilities, risk factors, or prevention activities in the united states. in contrast, france, great britain, denmark, norway and sweden have comprehensive systems in selected areas, such as occupational injuries, infectious diseases, and cancer; no country, however, has complete reporting for every problem. in fact, it is only births, deaths, and -to a lesser extentfetal deaths that are uniformly and relatively completely reported in the united states by the national vital statistics system, operated by the states and the centers for disease control and prevention (cdc). if you have an angioplasty and survive, nobody at the state or federal level necessarily knows. public health information systems have been designed with special features. for example, they are optimized for retrieval from very large (multi-million) record databases, and to be able to quickly cross-tabulate, study secular trends, and look for patterns. the use of personal identifiers in these systems is very limited, and their use is generally restricted to linking data from different sources (e.g., data from a state laboratory and a disease surveillance form). a few examples of these kinds of populationfocused systems include cdc systems such as the hiv/aids reporting system, which collects millions of observations concerning people infected with the human immunodeficiency virus (hiv) and those diagnosed with acquired immunodeficiency syndrome (aids) and is used to conduct dozens of studies (and which does not collect personal identifiers; individuals are tracked by pseudo-identifiers); the national notifiable disease surveillance system, which state epidemiologists use to report some 60 diseases (the exact number varies as conditions wax and wane) every week to the cdc (and which makes up the center tables in the morbidity and mortality weekly report [mmwr] ). the cdc wonder system (friede et al., 1996) , which contains tens of millions of observations drawn from some 30 databases, explicitly blanks cells with fewer than three to five observations (depending on the dataset), specifically to prevent individuals with unusual characteristics from being identified. if there is no national individual reporting, how are estimates obtained for, say, the trends in teenage smoking or in the incidence of breast cancer? how are epidemics found? data from periodic surveys and special studies, surveillance systems, and disease registries are handled by numerous stand-alone information systems. these systemsusually managed by state health departments and federal health agencies (largely the cdc) or their agents -provide periodic estimates of the incidence and prevalence of diseases and of certain risk factors (for example, smoking and obesity); however, because the data are from population samples, it is usually impossible to obtain estimates at a level of geographic detail finer than a region or state. moreover, many of the behavioral indices are patient self-reported (although extensive validation studies have shown that they are good for trends and sometimes are more reliable than are data obtained from clinical systems). in the case of special surveys, such as cdc's national health and nutrition examination survey (nhanes), there is primary data entry into a cdc system. the data are complete, but the survey costs many millions of dollars, is done only every few years, and it takes years for the data to be made available. there are also disease registries that track -often completely -the incidence of certain conditions, especially cancers, birth defects, and conditions associated with environmental contamination. they tend to focus on one topic or to cover certain diseases for specific time periods. the cdc maintains dozens of surveillance systems that attempt to track completely the incidence of many conditions, including lead poisoning, injuries and deaths in the workplace, and birth defects. (some of these systems use samples or cover only certain states or cities). as discussed above, there is also a list of about 60 notifiable diseases (revised every year) that the state epidemiologists and the cdc have determined are of national significance and warrant routine, complete reporting; however, it is up to providers to report the data, and reporting is still often done by telephone or mail, so the data are incomplete. finally, some states do collect hospital discharge summaries, but now that more care is being delivered in the ambulatory setting, these data capture only a small fraction of medical care. they are also notoriously difficult to access. what all these systems have in common is that they rely on special data collection. it is rare that they are seamlessly linked to ongoing clinical information systems. even clinical data such as hospital infections is reentered. why? all these systems grew up at the same time that information systems were being put in hospitals and clinics. hence, there is duplicate data entry, which can result in the data being shallow, delayed, and subject to input error and recall bias. furthermore, the systems themselves are often unpopular with state agencies and health care providers precisely because they require duplicate data entry (a child with lead poisoning and salmonella needs to be entered in two different cdc systems). the national electronic disease surveillance system (nedss) is a major cdc initiative that addresses this issue by promoting the use of data and information system standards to advance the development of efficient, integrated, and interoperable surveillance systems at federal, state and local levels (see www.cdc.gov/nedss). this activity is designed to facilitate the electronic transfer of appropriate information from clinical information systems in the health care industry to public health departments, reduce provider burden in the provision of information, and enhance both the timeliness and quality of information provided. now that historical and epidemiological forces are making the world smaller and causing lines between medicine and public health to blur, systems will need to be multifunctional, and clinical and public health systems will, of necessity, coalesce. what is needed are systems that can tell us about individuals and the world in which those individuals live. to fill that need, public health and clinical informaticians will need to work closely together to build the tools to study and control new and emerging threats such as bioterror, hiv/aids, sars and its congeners, and the environmental effects of the shrinking ozone layer and greenhouse gases. it can be done. for example, in the late 1990's, columbia presbyterian medical center and the new york city department of health collaborated on the development of a tuberculosis registry for northern manhattan, and the emory university system of health care and the georgia department of public health built a similar system for tuberculosis monitoring and treatment in atlanta. it is not by chance that these two cities each developed tuberculosis systems; rather, tuberculosis is a perfect example of what was once a public health problem (that affected primarily the poor and underserved) coming into the mainstream population as a result of an emerging infectious disease (aids), immigration, increased international travel, multidrug resistance, and our growing prison population. hence, the changing ecology of disease, coupled with revolutionary changes in how health care is managed and paid for, will necessitate information systems that serve both individual medical and public health needs. immunization registries are confidential, population based, computerized information systems that contain data about children and vaccinations (national vaccine advisory committee, 1999). they represent a good example for illustrating the principles of public health informatics. in addition to their orientation to prevention, they can only function properly through continuing interaction with the health care system. they also must exist in a governmental context because there is little incentive (and significant organizational barriers) for the private sector to maintain such registries. although immunization registries are among the largest and most complex public health information systems, the successful implementations show conclusively that it is possible to overcome the challenging informatics problems they present. childhood immunizations have been among the most successful public health interventions, resulting in the near elimination of nine vaccine preventable diseases that historically extracted a major toll in terms of both morbidity and mortality (iom, 2000a) . the need for immunization registries stems from the challenge of assuring complete immunization protection for the approximately 11,000 children born each day in the united states in the context of three complicating factors: the scattering of immunization records among multiple providers; an immunization schedule that has become increasingly complex as the number of vaccines has grown; and the conundrum that the very success of mass immunization has reduced the incidence of disease, lulling parents and providers into a sense of complacency. the 1989-91 u.s. measles outbreak, which resulted in 55,000 cases and 123 preventable deaths (atkinson et al., 1992) , helped stimulate the public health community to expand the limited earlier efforts to develop immunization registries. because cdc was proscribed by congress from creating a single national immunization registry (due to privacy concerns), the robert wood johnson foundation, in cooperation with several other private foundations, established the all kids count (akc) program that awarded funds to 24 states and communities in 1992 to assist in the development of immunization registries. akc funded the best projects through a competitive process, recruited a talented staff to provide technical assistance, and made deliberate efforts to ensure sharing of the lessons learned, such as regular, highly interactive meetings of the grantees. subsequent funding of 13 states by cdc and the woodruff foundation via the information network for public health officials (inpho) project (baker et al., 1995) was greatly augmented by a presidential commitment to immunization registries announced in 1997 (white house, 1997) . this resulted in every state's involvement in registry development. immunization registries must be able to exchange information to ensure that children who relocate receive needed immunizations. to accomplish this, standards were needed to prevent the development of multiple, incompatible immunization transmission formats. beginning in 1995, cdc worked closely with the health level 7 standards development organization (see chapter 7) to define hl7 messages and an implementation guide for immunization record transactions. the initial data standard was approved by hl7 in 1997 and an updated implementation guide was developed in 1999. cdc continues its efforts to encourage the standards-based exchange of immunization records among registries. as more experience accumulated, akc and cdc collaborated to develop an immunization registry development guide (cdc, 1997) that captured the hard-won lessons developed by dozens of projects over many years. by 2000, a consensus on the 12 needed functions of immunization registries had emerged (table 15. 2), codifying years of experience in refining system requirements. cdc also established a measurement system for tracking progress that periodically assesses the percentage of immunization registries that have operationalized each of the 12 functions ( figure 15 1. electronically store data regarding all national vaccine advisory committee-approved core data elements 2. establish a registry record within 6 weeks of birth for each child born in the catchment area 3. enable access to vaccine information from the registry at the time of the encounter 4. receive and process vaccine information within 1 month of vaccine administration 5. protect the confidentiality of medical information 6. protect the security of medical information 7. exchange vaccination records by using health level 7 standards 8. automatically determine the immunization(s) needed when a person is seen by the health care provider for a scheduled vaccination 9. automatically identify persons due or late for vaccinations to enable the production of reminder and recall notices 10. automatically produce vaccine coverage reports by providers, age groups, and geographic areas 11. produce authorized immunization records 12. promote accuracy and completeness of registry data registries, the national healthy people 2010 objectives include the goal of having 95% of all u.s. children covered by fully functioning immunization registries (dhhs, 2000) . the development and implementation of immunization registries presents challenging informatics issues in at least four areas: 1) interdisciplinary communication; 2) organizational and collaborative issues; 3) funding and sustainability; and 4) system design. while the specific manifestations of these issues are unique to immunization registries, these four areas represent the typical domains that must be addressed and overcome in public health informatics projects. interdisciplinary communications is a key challenge in any biomedical informatics project-it is certainly not specific to public health informatics. to be useful, a public health information system must accurately represent and enable the complex concepts and processes that underlie the specific business functions required. information systems represent a highly abstract and complex set of data, processes, and interactions. this complexity needs to be discussed, specified, and understood in detail by a variety of personnel with little or no expertise in the terminology and concepts of information technology. therefore, successful immunization registry implementation requires clear communication among public health specialists, immunization specialists, providers, it specialists, and related disciplines, an effort complicated by the lack of a shared vocabulary and differences in the usage of common terms from the various domains. added to these potential communication problems are the anxieties and concerns inherent in the development of any new information system. change is an inevitable part of such a project-and change is uncomfortable for everyone involved. implementation of information systems. in this context, tensions and anxieties can further degrade communications. to deal with the communications challenges, particularly between it and public health specialists, it is essential to identify an interlocutor who has familiarity with both information technology and public health. the interlocutor should spend sufficient time in the user environment to develop a deep understanding of the information processing context of both the current and proposed systems. it is also important for individuals from all the disciplines related to the project to have representation in the decisionmaking processes. the organizational and collaborative issues involved in developing immunization registries are daunting because of the large number and wide variety of partners. both public and private sector providers and other organizations are likely participants. for the providers, particularly in the private sector, immunization is just one of many concerns. however, it is essential to mobilize private providers to submit immunization information to the registry. in addition to communicating regularly to this group about the goals, plans, and progress of the registry, an invaluable tool to enlist their participation is a technical solution that minimizes their time and expense for registry data entry, while maximizing the benefit in terms of improved information about their patients. it is critical to recognize the constraints of the private provider environment, where income is generated mostly from "piecework" and time is the most precious resource. governance issues are also critical to success. all the key stakeholders need to be represented in the decision-making processes, guided by a mutually acceptable governance mechanism. large information system projects involving multiple partners -such as immunization registries -often require multiple committees to ensure that all parties have a voice in the development process. in particular, all decisions that materially affect a stakeholder should be made in a setting that includes their representation. legislative and regulatory issues must be considered in an informatics context because they impact the likelihood of success of projects. with respect to immunization registries, the specific issues of confidentiality, data submission, and liability are critical. the specific policies with respect to confidentiality must be defined to allow access to those who need it while denying access to others. regulatory or legislative efforts in this domain must also operate within the context of the federal health insurance portability and accountability act (hipaa) that sets national minimum privacy requirements for personal health information. some jurisdictions have enacted regulations requiring providers to submit immunization data to the registry. the effectiveness of such actions on the cooperation of providers must be carefully evaluated. liability of the participating providers and of the registry operation itself may also require legislative and/or regulatory clarification. funding and sustainability are continuing challenges for all immunization registries. in particular, without assurances of ongoing operational funding, it will be difficult to secure the commitments needed for the development work. naturally, an important tool for securing funding is development of a business case that shows the anticipated costs and benefits of the registry. while a substantial amount of information now exists about costs and benefits of immunization registries (horne et al., 2000) , many of the registries that are currently operational had to develop their business cases prior to the availability of good quantitative data. specific benefits associated with registries include preventing duplicative immunizations, eliminating the necessity to review the vaccination records for school and day care entry, and efficiencies in provider offices from the immediate availability of complete immunization history information and patient-specific vaccine schedule recommendations. the careful assessment of costs and benefits of specific immunization registry functions may also be helpful in prioritizing system requirements. as with all information systems, it is important to distinguish "needs" (those things people will pay for) from "wants" (those things people would like to have but are not willing to spend money on) (rubin, 2003). information system "needs" are typically supported by a strong business case, whereas "wants" often are not. system design is also an important factor in the success of immunization registries. difficult design issues include data acquisition, database organization, identification and matching of children, generating immunization recommendations, and access to data, particularly for providers. acquiring immunization data is perhaps the most challenging system design issue. within the context of busy pediatric practices (where the majority of childhood immunizations are given), the data acquisition strategy must of necessity be extremely efficient. ideally, information about immunizations would be extracted from existing electronic medical records or from streams of electronic billing data; either strategy should result in no additional work for participating providers. unfortunately neither of these options is typically available. electronic medical records are currently implemented only in roughly 10-15% of physician practices. while the use of billing records is appealing, it is often difficult to get such records on a timely basis without impinging on their primary function-namely, to generate revenue for the practice. also, data quality, particularly with respect to duplicate records, is often a problem with billing information. a variety of approaches have been used to address this issue, including various forms of direct data entry as well as the use of bar codes (yasnoff, 2003) . database design also must be carefully considered. once the desired functions of an immunization registry are known, the database design must allow efficient implementation of these capabilities. the operational needs for data access and data entry, as well as producing individual assessments of immunization status, often require different approaches to design compared to requirements for population-based immunization assessment, management of vaccine inventory, and generating recall and reminder notices. one particularly important database design decision for immunization registries is whether to represent immunization information by vaccine or by antigen. vaccinebased representations map each available preparation, including those with multiple antigens, into its own specific data element. antigen-based representations translate multi-component vaccines into their individual antigens prior to storage. in some cases, it may be desirable to represent the immunization information both ways. specific consideration of required response times for specific queries must also be factored into key design decisions. identification and matching of individuals within immunization registries is another critical issue. because it is relatively common for a child to receive immunizations from multiple providers, any system must be able to match information from multiple sources to complete an immunization record. in the absence of a national unique patient identifier, most immunization registries will assign an arbitrary number to each child. of course, provisions must be made for the situation where this identification number is lost or unavailable. this requires a matching algorithm, which utilizes multiple items of demographic information to assess the probability that two records are really data from the same person. development of such algorithms and optimization of their parameters has been the subject of active investigation in the context of immunization registries, particularly with respect to deduplication (miller et al., 2001) . another critical design issue is generating vaccine recommendations from a child's prior immunization history, based on guidance from the cdc's advisory committee on immunization practices (acip). as more childhood vaccines have become available, both individually and in various combinations, the immunization schedule has become increasingly complex, especially if any delays occur in receiving doses, a child has a contraindication, or local issues require special consideration. the language used in the written guidelines is sometimes incomplete, not covering every potential situation. in addition, there is often some ambiguity with respect to definitions, e.g., for ages and intervals, making implementation of decision support systems problematic. considering that the recommendations are updated relatively frequently, sometimes several times each year, maintaining software that produces accurate immunization recommendations is a continuing challenge. accordingly, the implementation, testing, and maintenance of decision support systems to produce vaccine recommendations has been the subject of extensive study (yasnoff & miller, 2003) . finally, easy access to the information in an immunization registry is essential. while this may initially seem to be a relatively simple problem, it is complicated by private providers' lack of high-speed connectivity. even if a provider office has the capability for internet access, for example, it may not be immediately available at all times, particularly in the examination room. immunization registries have developed alternative data access methods such as fax-back and telephone query to address this problem. since the primary benefit of the registry to providers is manifest in rapid access to the data, this issue must be addressed. ready access to immunization registry information is a powerful incentive to providers for entering the data from their practice. in the united states, the first major report calling for a health information infrastructure was issued by the institute of medicine of the national academy of sciences in 1991 (iom, 1991) . this report, "the computer-based patient record," was the first in a series of national expert panel reports recommending transformation of the health care system from reliance on paper to electronic information management. in response to the iom report, the computer-based patient record institute (cpri), a private not-for-profit corporation, was formed for the purpose of facilitating the transition to computer-based records. a number of community health information networks (chins) were established around the country in an effort to coalesce the multiple community stakeholders in common efforts towards electronic information exchange. the institute of medicine updated its original report in 1997 (iom, 1997), again emphasizing the urgency to apply information technology to the information intensive field of health care. however, most of the community health information networks were not successful. perhaps the primary reason for this was that the standards and technology were not yet ready for cost-effective community-based electronic health information exchange. another problem was the focus on availability of aggregated health information for secondary users (e.g., policy development), rather than individual information for the direct provision of patient care. also, there was neither a sense of extreme urgency nor were there substantial funds available to pursue these endeavors. however, at least one community, indianapolis, continued to move forward throughout this period and has now emerged as an a national example of the application of information technology to health care both in individual health care settings and throughout the community. the year 2000 brought widespread attention to this issue with the iom report "to err is human" (iom, 2000b) . in this landmark study, the iom documented the accumulating evidence of the high error rate in the medical care system, including an estimated 44,000 to 98,000 preventable deaths each year in hospitals alone. this report has proven to be a milestone in terms of public awareness of the consequences of paperbased information management in health care. along with the follow-up report, "crossing the quality chasm" (iom, 2001) , the systematic inability of the health care system to operate at high degree of reliability has been thoroughly elucidated. the report clearly placed the blame on the system, not the dedicated health care professionals who work in an environment without effective tools to promote quality and minimize errors. several additional national expert panel reports have emphasized the iom findings. in 2001, the president's information technology advisory committee (pitac) issued a report entitled "transforming health care through information technology" (pitac, 2001) . that same year, the computer science and telecommunications board of the national research council (nrc) released "networking health: prescriptions for the internet" (nrc, 2001) which emphasized the potential for using the internet to improve electronic exchange of health care information. finally, the national committee on vital and health statistics (ncvhs) outlined the vision and strategy for building a national health information infrastructure (nhii) in its report, "information for health" (ncvhs, 2001) . ncvhs, a statutory advisory body to dhhs, indicated that federal government leadership was needed to facilitate further development of an nhii. on top of this of bevy of national expert panel reports, there has been continuing attention in both scientific and lay publications to cost, quality, and error issues in the health care system. the anthrax attacks of late 2001 further sensitized the nation to the need for greatly improved disease detection and emergency medical response capabilities. what has followed has been the largest-ever investment in public health information infrastructure in the history of the united states. some local areas, such as indianapolis and pittsburgh, have begun to actively utilize electronic information from the health care system for early detection of bioterrorism and other disease outbreaks. in 2003, separate large national conferences were devoted to both the cdc's public health information network (phin) (cdc, 2003) and the dhhs nhii initiative (dhhs, 2003 yasnoff et al., 2004 . while the discussion here has focused on the development of nhii in the united states, many other countries are involved in similar activities and in fact have progressed further along this road. canada, australia, and a number of european nations have devoted considerable time and resources to their own national health information infrastructures. the united kingdom, for example, has announced its intention to allocate several billion pounds over the next few years to substantially upgrade its health information system capabilities. it should be noted, however, that all of these nations have centralized, government-controlled health care systems. this organizational difference from the multifaceted, mainly private health care system in the u.s. results in a somewhat different set of issues and problems. hopefully, the lessons learned from health information infrastructure development activities across the globe can be effectively shared to ease the difficulties of everyone who is working toward these important goals. the vision of the national health information infrastructure is anytime, anywhere health care information at the point of care. the intent to is to create a distributed system, not a centralized national database. patient information would be collected and stored at each care site. when a patient presented for care, the various existing electronic records would be located, collected, integrated, and immediately delivered to allow the provider to have complete and current information upon which to base clinical decisions. in addition, clinical decision support (see chapter 20) would be integrated with information delivery. in this way, clinicians could receive reminders of the most recent clinical guidelines and research results during the patient care process, thereby avoiding the need for superhuman memory capabilities to assure the effective practice of medicine. the potential benefits of nhii are both numerous and substantial. perhaps most important are error reduction and improved quality of care. numerous studies have shown that the complexity of present-day medical care results in very frequent errors of both omission and commission. this problem was clearly articulated at the 2001 meeting of the institute of medicine: "current practice depends upon the clinical decision making capacity and reliability of autonomous individual practitioners, for classes of problems that routinely exceed the bounds of unaided human cognition" (masys, 2001) . electronic health information systems can contribute significantly to improving this problem by reminding practitioners about recommended actions at the point of care. this can include both notifications of actions that may have been missed, as well as warnings about planned treatments or procedures that may be harmful or unnecessary. literally dozens of research studies have shown that such reminders improve safety and reduce costs (kass, 2001; bates, 2000) . in one such study (bates et al., 1998) , medication errors were reduced by 55%. a more recent study by the rand corporation showed that only 55 % of u.s. adults were receiving recommended care (mcglynn et al., 2003) . the same techniques used to reduce medical errors with electronic health information systems also contribute substantially to ensuring that recommended care is provided. this is becoming increasingly important as the population ages and the prevalence of chronic disease increases. guidelines and reminders also can improve the effectiveness of dissemination of new research results. at present, widespread application of a new research in the clinical setting takes an average of 17 years (balas & boren, 2000) . patient-specific reminders delivered at the point of care highlighting important new research results could substantially increase the adoption rate. another important contribution of nhii to the research domain is improving the efficiency of clinical trials. at present, most clinical trials require creation of a unique information infrastructure to insure protocol compliance and collect essential research data. with nhii, where every practitioner would have access to a fully functional electronic health record, clinical trials could routinely be implemented through the dissemination of guidelines that specify the research protocol. data collection would occur automatically in the course of administering the protocol, reducing time and costs. in addition, there would be substantial value in analyzing deidentified aggregate data from routine patient care to assess the outcomes of various treatments, and monitor the health of the population. another critical function for nhii is early detection of patterns of disease, particularly early detection of possible bioterrorism. our current system of disease surveillance, which depends on alert clinicians diagnosing and reporting unusual conditions, is both slow and potentially unreliable. most disease reporting still occurs using the postal service, and the information is relayed from local to state to national public health authorities. even when fax or phone is employed, the system still depends on the ability of clinicians to accurately recognize rare and unusual diseases. even assuming such capabilities, individual clinicians cannot discern patterns of disease beyond their sphere of practice. these problems are illustrated by the seven unreported cases of cutaneous anthrax in the new york city area two weeks before the so-called "index" case in florida in the fall of 2001 (lipton & johnson, 2001) . since all the patients were seen by different clinicians, the pattern could not have been evident to any of them even if the diagnosis had immediately been made in every case. wagner et al have elucidated nine categories of requirements for surveillance systems for potential bioterrorism outbreaks-several categories must have immediate electronic reporting to insure early detection (wagner et al., 2003) . nhii would allow immediate electronic reporting of both relevant clinical events and laboratory results to public health. not only would this be an invaluable aid in early detection of bioterrorism, it would also serve to improve the detection of the much more frequent naturally occurring disease outbreaks. in fact, early results from a number of electronic reporting demonstration projects show that disease outbreaks can routinely be detected sooner than was ever possible using the current system (overhage et al., 2001) . while early detection has been shown to be a key factor in reducing morbidity and mortality from bioterrorism (kaufmann et al., 1997) , it will also be extremely helpful in reducing the negative consequences from other disease outbreaks. this aspect of nhii is discussed in more detail in section 15.5. finally, nhii can substantially reduce health-care costs. the inefficiencies and duplication in our present paper-based health care system are enormous. recent study showed that the anticipated nationwide savings from implementing advanced computerized provider order entry (cpoe) systems in the outpatient environment would be $44 billion per year (johnston et al., 2003) , while a related study (walker et al., 2004) estimated $78 billion more is savings from health information exchange (for a total of $112 billion per year). substantial additional savings are possible in the inpatient setting-numerous hospitals have reported large net savings from implementation of electronic health records. another example, electronic prescribing, would not only reduce medication errors from transcription, but also drastically decrease the administrative costs of transferring prescription information from provider offices to pharmacies. a more recent analysis concluded that the total efficiency and patient safety savings from nhii would be in range of $142-371 billion each year (hillestad et al., 2005) . while detailed studies of the potential savings from comprehensive implementation of nhii, including both electronic health records and effective exchange of health information, are still ongoing, it is clear that the cost reductions will amount to hundreds of billions of dollars each year. it is important to note that much of the savings depends not just on the widespread implementation of electronic health records, but the effective interchange of this information to insure that the complete medical record for every patient is immediately available in every care setting. there are a number of significant barriers and challenges to the development of nhii. perhaps the most important of these relates to protecting the confidentiality of electronic medical records. the public correctly perceives that all efforts to make medical records more accessible for appropriate and authorized purposes simultaneously carry the risk of increased availability for unscrupulous use. while the implementation of the hipaa privacy and security rules (see chapter 10) has established nationwide policies for access to medical information, maintaining public confidence requires mechanisms that affirmatively prevent privacy and confidentiality breaches before they occur. development, testing, and implementation of such procedures must be an integral part of any nhii strategy. another important barrier to nhii is the misalignment of financial incentives in the health care system. although the benefits of nhii are substantial, they do not accrue equally across all segments of the system. in particular, the benefits are typically not proportional to the required investments for a number of specific stakeholder groups. perhaps most problematic is the situation for individual and small group health care providers, who are being asked to make substantial allocations of resources to electronic health record systems that mostly benefit others. mechanisms must be found to assure the equitable distribution of nhii benefits in proportion to investments made. while this issue is the subject of continuing study, early results indicate that most of the nhii financial benefit accrues to payers of care. therefore, programs and policies must be established to transfer appropriate savings back to those parties who have expended funds to produce them. one consequence of the misaligned financial incentives is that the return on investment for health information technology needed for nhii is relatively uncertain. while a number of health care institutions, particularly large hospitals, have reported substantial cost improvements from electronic medical record systems, the direct financial benefits are by no means a forgone conclusion, especially for smaller organizations. the existing reimbursement system in the united states does not provide ready access to the substantial capital required by many institutions. for health care organizations operating on extremely thin margins, or even in the red, investments in information technology are impractical regardless of the potential return. in addition, certain legal and regulatory barriers prevent the transfer of funds from those who benefit from health information technology to those who need to invest but have neither the means nor the incentive of substantial returns. laws and regulations designed to prevent fraud and abuse, payments for referrals, and private distribution of disguised "profits" from nonprofit organizations are among those needing review. it is important that mechanisms be found to enable appropriate redistribution of savings generated from health information technology without creating loopholes that would allow abusive practices. another key barrier to nhii is that many of the benefits relate to exchanges of information between multiple health care organizations. the lack of interoperable electronic medical record systems that provide for easy transfer of records from one place to another is a substantial obstacle to achieving the advantages of nhii. also, there is a "first mover disadvantage" in such exchange systems. the largest value is generated when all health care organizations in a community participate electronic information exchange. therefore, if only a few organizations begin the effort, their costs may not be offset by the benefits. a number of steps are currently under way to accelerate the progress towards nhii in the united states. these include establishing standards, fostering collaboration, funding demonstration projects in communities that include careful evaluation, and establishing consensus measures of progress. establishing electronic health record standards that would promote interoperability is the most widely recognized need in health information technology at the present time. within institutions that have implemented specific departmental applications, extensive time and energy is spent developing and maintaining interfaces among the various systems. although much progress has been made in this area by organizations such as health level 7, even electronic transactions of specific health care data (such as laboratory results) are often problematic due to differing interpretations of the implementation of existing standards. recently, the u.s. government has made substantial progress in this area. ncvhs, the official advisory body on these matters to dhhs, has been studying the issues of both message and content standards for patient medical record information for several years (ncvhs, 2000) . the consolidated healthcare informatics (chi) initiative recommended five key standards (hl7 version 2.x, loinc, dicom, ieee 1073, and ncpdp script) that were adopted for government-wide use in early 2003, followed by 15 more that were added in 2004. in july, 2003, the federal government licensed the comprehensive medical vocabulary known as snomed (systematized nomenclature of medicine; see chapter 7), making it available to all u.s. users at no charge. this represents a major step forward in the deployment of vocabulary standards for health information systems. unlike message format standards, such as hl7, vocabulary standards are complex and expensive to develop and maintain and therefore require ongoing financial support. deriving the needed funding from end users creates a financial obstacle to deployment of the standard. removing this key barrier to adoption should promote much more widespread use over the next few years. another important project now under way is the joint effort of the institute of medicine and hl7 to develop a detailed functional definition of the electronic health record (ehr). these functional standards will provide a benchmark for comparison of existing and future ehr systems, and also may be utilized as criteria for possible financial incentives that could be provided to individuals and organizations that implement such systems. the elucidation of a consensus functional definition of the ehr also should help prepare the way for its widespread implementation by engaging all the stakeholders in an extended discussion of its desired capabilities. this functional standardization of the ehr is expected to be followed by the development of a formal interchange format standard (ifs) to be added to hl7 version 3. this standard would enable full interoperability of ehr systems through the implementation of an import and export capability to and from the ifs. while it is possible at the present time to exchange complete electronic health records with existing standards, is both difficult and inconvenient. the ifs will greatly simplify the process, making it easy to accomplish the commonly needed operation of transferring an entire electronic medical record from one facility to another. another key standard that is needed involves the representation of guideline recommendations. while the standard known as arden syntax (hl7, 2003; see chapter 7) partially addresses this need, many real-world medical care guidelines are too complex to be represented easily in this format. at the present time, the considerable effort required to translate written guidelines and protocols into computer executable form must be repeated at every health care organization wishing to incorporate them in their ehr. development of an effective guideline interchange standard would allow medical knowledge to be encoded once and then distributed widely, greatly increasing the efficiency of the process (peleg at al., 2003) . collaboration is another important strategy in promoting nhii. to enable the massive changes needed to transform the health care system from its current paper-based operation to the widespread utilization of electronic health information systems, the support of a very large number of organizations and individuals with highly varied agendas is required. gathering and focusing this support requires extensive cooperative efforts and specific mechanisms for insuring that everyone's issues and concerns are expressed, appreciated, and incorporated into the ongoing efforts. this process is greatly aided by a widespread recognition of the serious problems that exist today in the u.s. healthcare system. a number of private collaboration efforts have been established such as the e-health initiative and the national alliance for health information technology (nahit). in the public sector, national health information infrastructure (nhii) has become a focus of activity at dhhs. as part of this effort, the first ever national stakeholders meeting for nhii was convened in mid-2003 to develop a consensus national agenda for moving forward (yasnoff et al., 2004) . these multiple efforts are having the collective effect of both catalyzing and promoting organizational commitment to nhii. for example, many of the key stakeholders are now forming high-level committees to specifically address nhii issues. for some of these organizations, this represents the first formal recognition that this transformational process is underway and will have a major impact on their activities. it is essential to include all stakeholders in this process. in addition to the traditional groups such as providers, payers, hospitals, health plans, health it vendors, and health informatics professionals, representatives of groups such as consumers (e.g., aarp) and the pharmaceutical industry must be brought into the process. the most concrete and visible strategy for promoting nhii is the encouragement of demonstration projects in communities, including the provision of seed funding. by establishing clear examples of the benefits and advantages of comprehensive health information systems in communities, additional support for widespread implementation can be garnered at the same time that concerns of wary citizens and skeptical policymakers are addressed. there are several important reasons for selecting a community-based strategy for nhii implementation. first and foremost, the existing models of health information infrastructures (e.g., indianapolis and spokane, wa) are based in local communities. this provides proof that it is possible to develop comprehensive electronic health care information exchange systems in these environments. in contrast, there is little or no evidence that such systems can be directly developed on a larger scale. furthermore, increasing the size of informatics projects disproportionately increases their complexity and risk of failure. therefore, keeping projects as small as possible is always a good strategy. since nhii can be created by effectively connecting communities that have developed local health information infrastructures (lhiis), it is not necessary to invoke a direct national approach to achieve the desired end result. a good analogy is the telephone network, which is composed of a large number of local exchanges that are then connected to each other to form community and then national and international networks. another important element in the community approach is the need for trust to overcome confidentiality concerns. medical information is extremely sensitive and its exchange requires a high degree of confidence in everyone involved in the process. the level of trust needed seems most likely to be a product of personal relationships developed over time in a local community and motivated by a common desire to improve health care for everyone located in that area. while the technical implementation of information exchange is non-trivial, it pales in comparison to the challenges of establishing the underlying legal agreements and policy changes that must precede it. for example, when indianapolis implemented sharing of patient information in hospital emergency rooms throughout the area, as many as 20 institutional lawyers needed to agree on the same contractual language (overhage, 2002) . the community approach also benefits from the fact that the vast majority of health care is delivered locally. while people do travel extensively, occasionally requiring medical care while away from home, and there are few out-of-town consultations for difficult and unusual medical problems, for the most part people receive their health care in the community in which they reside. the local nature of medical care results in a natural interest of community members in maintaining and improving the quality and efficiency of their local health care system. for the same reasons, it is difficult to motivate interest in improving health care beyond the community level. focusing nhii efforts on one community at a time also keeps the implementation problem more reasonable in its scope. it is much more feasible to enable health information interchange among a few dozen hospitals and a few hundred or even a few thousand providers than to consider such a task for a large region or the whole country. this also allows for customized approaches sensitive to the specific needs of each local community. the problems and issues of medical care in a densely populated urban area are clearly vastly different than in a rural environment. similarly, other demographic and organizational differences as well as the presence of specific highly specialized medical care institutions make each community's health care system unique. a local approach to hii development allows all these complex and varied factors to be considered and addressed, and respects the reality of the american political landscape, which gives high priority to local controls. the community-based approach to hii development also benefits from the establishment of national standards. the same standards that allow effective interchange of information between communities nationwide can also greatly facilitate establishing effective communication of medical information within a community. in fact, by encouraging (and even requiring) communities to utilize national standards in building their own lhiis, the later interconnection of those systems to provide nationwide access to medical care information becomes a much simpler and easier process. demonstration projects also are needed to develop and verify a replicable strategy for lhii development. while there are a small number of existing examples of lhii systems, no organization or group has yet demonstrated the ability to reliably and successfully establish such systems in multiple communities. from the efforts of demonstration projects in numerous communities, it should be possible to define a set of strategies that can be applied repeatedly across the nation. seed funding is essential in the development of lhii systems. while health care in united states is a huge industry, spending approximately $1.5 trillion each year and representing 14% of the gdp, shifting any of the existing funds into substantial it investments is problematic. the beneficiaries of all the existing expenditures seem very likely to strongly oppose any such efforts. on the other hand, once initial investments begin to generate the expected substantial savings, it should be possible to develop mechanisms to channel those savings into expanding and enhancing lhii systems. careful monitoring of the costs and benefits of local health information interchange systems will be needed to verify the practicality of this approach to funding and sustaining these projects. finally, it is important to assess and understand the technical challenges and solutions applied to lhii demonstration projects. while technical obstacles are usually not serious in terms of impeding progress, understanding and disseminating the most effective solutions can result in smoother implementation as experience is gained throughout the nation. the last element in the strategy for promoting a complex and lengthy project such as nhii is careful measurement of progress. the measures used to gauge progress define the end state and therefore must be chosen with care. measures may also be viewed as the initial surrogate for detailed requirements. progress measures should have certain key features. first, they should be sufficiently sensitive so that their values change at a reasonable rate (a measure that only changes value after five years will not be particularly helpful). second, the measures must be comprehensive enough to reflect activities that impact most of the stakeholders and activities needing change. this ensures that efforts in every area will be reflected in improved measures. third, the measures must be meaningful to policymakers. fourth, periodic determinations of the current values of the measures should be easy so that the measurement process does not detract from the actual work. finally, the totality of the measures must reflect the desired end state so that when the goals for all the measures are attained, the project is complete. a number of different types or dimensions of measures for nhii progress are possible. aggregate measures assess nhii progress over the entire nation. examples include the percentage of the population covered by an lhii and the percentage of health care personnel whose training occurs in institutions that utilize electronic health record systems. another type of measure is based on the setting of care. progress in implementation of electronic health record systems in the inpatient, outpatient, long-term care, home, and community environments could clearly be part of an nhii measurement program. yet another dimension is health care functions performed using information systems support, including, for example, registration systems, decision support, cpoe, and community health information exchange. it is also important to assess progress with respect to the semantic encoding of electronic health records. clearly, there is a progression from the electronic exchange of images of documents, where the content is only readable by the end user viewing the image, to fully encoded electronic health records where all the information is indexed and accessible in machine-readable form using standards. finally, progress can also be benchmarked based on usage of electronic health record systems by health care professionals. the transition from paper records to available electronic records to fully used electronic records is an important signal with respect to the success of nhii activities. to illustrate some of the informatics challenges inherent in nhii, the example of its application to homeland security will be used. bioterrorism preparedness in particular is now a key national priority, especially following the anthrax attacks that occurred in the fall of 2001. early detection of bioterrorism is critical to minimize morbidity and mortality. this is because, unlike other terrorist attacks, bioterrorism is usually silent at first. its consequences are usually the first evidence that an attack has occurred. traditional public health surveillance depends on alert clinicians reporting unusual diseases and conditions. however, it is difficult for clinicians to detect rare and unusual diseases since they are neither familiar with their manifestations nor suspicious of the possibility of an attack. also, it is often difficult to differentiate potential bioterrorism from more common and benign manifestations of illness. this is clearly illustrated by the seven cases of cutaneous anthrax that occurred in the new york city area two weeks prior to the "index " case in florida the fall of 2001 (lipton & johnson, 2001) . all these cases presented to different clinicians, none of whom recognized the diagnosis of anthrax with sufficient confidence to notify any public health authority. furthermore, such a pattern involving similar cases presenting to multiple clinicians could not possibly be detected by any of them. it seems likely that had all seven of these patients utilized the same provider, the immediately evident pattern of unusual signs and symptoms alone would have been sufficient to result in an immediate notification of public health authorities even in the absence of any diagnosis. traditional public health surveillance also has significant delays. much routine reporting is still done via postcard and fax to the local health department, and further delays occur before information is collated, analyzed, and reported to state and finally to federal authorities. there is also an obvious need for a carefully coordinated response after a bioterrorism event is detected. health officials, in collaboration with other emergency response agencies, must carefully assess and manage health care assets and ensure rapid deployment of backup resources. also, the substantial increase in workload created from such an incident must be distributed effectively among available hospitals, clinics, and laboratories, often including facilities outside the affected area. the vision for the application of nhii to homeland security involves both early detection of bioterrorism and the response to such an event. clinical information relevant to public health would be reported electronically in near real-time. this would include clinical lab results, emergency room chief complaints, relevant syndromes (e.g., flu-like illness), and unusual signs, symptoms, or diagnoses. by generating these electronic reports automatically from electronic health record systems, the administrative reporting burden currently placed on clinicians would be eliminated. in addition, the specific diseases and conditions reported could be dynamically adjusted in response to an actual incident or even information related to specific threats. this latter capability would be extremely helpful in carefully tracking the development of an event from its early stages. nhii could also provide much more effective medical care resource management in response to events. this could include automatic reporting of all available resources so they could be allocated rapidly and efficiently, immediate operational visibility of all health care assets, and effective balancing of the tremendous surge in demand for medical care services. this would also greatly improve decision making about deployment of backup resources. using nhii for these bioterrorism preparedness functions avoids developing a separate, very expensive infrastructure dedicated to these rare events. as previously stated, the benefits of nhii are substantial and fully justify its creation even without these bioterrorism preparedness capabilities, which would be an added bonus. furthermore, the same infrastructure that serves as an early detection system for bioterrorism also will allow earlier and more sensitive detection of routine naturally occurring disease outbreaks (which are much more common) as well as better management of health care resources in other disaster situations. the application of nhii to homeland security involves a number of difficult informatics challenges. first, this activity requires participation from a very wide range of both public and private organizations. this includes all levels of government and organizations that have not had significant prior interactions with the health care system such as agriculture, police, fire, and animal health. needless to say, these organizations have divergent objectives and cultures that do not necessarily mesh easily. health and law enforcement in particular have a significantly different view of a bioterrorism incident. for example, an item that is considered a "specimen" in the health care system may be regarded as "evidence" by law enforcement. naturally, this wide variety of organizations has incompatible information systems, since for the most part they were designed and deployed without consideration for the issues raised by bioterrorism. not only do they have discordant design objectives, but they lack standardized terminology and messages to facilitate electronic information exchange. furthermore, there are serious policy conflicts among these various organizations, for example, with respect to access to information. in the health care system, access to information is generally regarded as desirable, whereas in law enforcement it must be carefully protected to maintain the integrity of criminal investigations. complicating these organizational, cultural, and information systems issues, bioterrorism preparedness has an ambiguous governance structure. many agencies and organizations have legitimate and overlapping authority and responsibility, so there is often no single clear path to resolve conflicting issues. therefore, a high degree of collaboration and collegiality is required, with extensive pre-event planning so that roles and responsibilities are clarified prior to any emergency. within this complex environment, there is also a need for new types of systems with functions that have never before been performed. bioterrorism preparedness results in new requirements for early disease detection and coordination of the health care system. precisely because these requirements are new, there are few (if any) existing systems that have similar functions. therefore careful consideration to design requirements of bioterrorism preparedness systems is essential to ensure success. most importantly, there is an urgent need for interdisciplinary communication among an even larger number of specialty areas than is typically the case with health information systems. all participants must recognize that each domain has its own specific terminology and operational approaches. as previously mentioned in the public health informatics example, the interlocutor function is vital. since it is highly unlikely that any single person will be able to span all or even most of the varied disciplinary areas, everyone on the team must make a special effort to learn the vocabulary used by others. as a result of these extensive and difficult informatics challenges, there are few operational information systems supporting bioterrorism preparedness. it is interesting to note that all the existing systems developed to date are local. this is most likely a consequence of the same issues previously delineated in the discussion of the advantages of community-based strategies for nhii development. one such system performs automated electronic lab reporting in indianapolis (overhage et al., 2001) . the development of this system was led by the same active informatics group that developed the lhii in the same area. nevertheless, it took several years of persistent and difficult efforts to overcome the technical, organizational, and legal issues involved. for example, even though all laboratories submitted data in "standard" hl7 format, it turned out that many of them were interpreting the standard in such a way that the electronic transactions could not be effectively processed by the recipient system. to address this problem, extensive reworking of the software that generated these transactions was required for many of the participating laboratories. another example of a bioterrorism preparedness system involves emergency room chief complaint reporting in pittsburgh (tsui et al., 2003) . this is a collaborative effort of multiple institutions with existing electronic medical record systems. it has also been led by an active informatics group that has worked long and hard to overcome technical, organizational, and legal challenges. it provides a near real-time "dashboard" for showing the incidence rates of specific types of syndromes, such as gastrointestinal and respiratory. this information is very useful for monitoring the patterns of diseases presenting to the area's emergency departments. note that both of these systems were built upon extensive prior work done by existing informatics groups. they also took advantage of existing local health information infrastructures that provided either available or least accessible electronic data streams. in spite of these advantages, it is clear from these and other efforts that the challenges in building bioterrorism preparedness systems are immense. however, having an existing health information infrastructure appears to be a key prerequisite. such an infrastructure implies the existence of a capable informatics group and available electronic health data in the community. public health informatics may be viewed as the application of biomedical informatics to populations. in a sense, it is the ultimate evolution of biomedical informatics, which has traditionally focused on applications related to individual patients. public health informatics highlights the potential of the health informatics disciplines as a group to integrate information from the molecular to the population level. public health informatics and the development of health information infrastructures are closely related. public health informatics deals with public health applications, whereas health information infrastructures are population-level applications primarily focused on medical care. while the information from these two areas overlaps, the orientation of both is the community rather than the individual. public health and health care have not traditionally interacted as closely as they should. in a larger sense, both really focus on the health of communities-public health does this directly, while the medical care system does it one patient at a time. however, it is now clear that medical care must also focus on the community to integrate the effective delivery of services across all care settings for all individuals. the informatics challenges inherent in both public health informatics and the development of health information infrastructures are immense. they include the challenge of large numbers of different types of organizations including government at all levels. this results in cultural, strategic, and personnel challenges. the legal issues involved in interinstitutional information systems, especially with regard to information sharing, can be daunting. finally, communications challenges are particularly difficult because of the large number of areas of expertise represented, including those that go beyond the health care domain (e.g., law enforcement). to deal with these communication issues, the interlocutor function is particularly critical. however, the effort required to address the challenges of public health informatics and health information infrastructures is worthwhile because the potential benefits are so substantial. effective information systems in these domains can help to assure effective prevention, high-quality care, and minimization of medical errors. in addition to the resultant decreases in both morbidity and mortality, these systems also have the potential to save hundreds of billions of dollars in both direct and indirect costs. it has been previously noted that one of the key differences between public health informatics and other informatics disciplines is that it includes interventions beyond the medical care system, and is not limited to medical and surgical treatments (yasnoff et al., 2000) . so despite the focus of most current public health informatics activities on population-based extensions of the medical care system (leading to the orientation of this chapter), applications beyond this scope are both possible and desirable. indeed, the phenomenal contributions to health made by the hygienic movement of the 19th and early 20th centuries suggest the power of large-scale environmental, legislative, and social changes to promote human health (rosen, 1993) . public health informatics must explore these dimensions as energetically as those associated with prevention and clinical care at the individual level. the effective application of informatics to populations through its use in both public health and the development of health information infrastructures is a key challenge of the 21st century. it is a challenge we must accept, understand, and overcome if we want to create an efficient and effective health care system as well as truly healthy communities for all. questions for further study: while some of the particulars are a little dated, this accessible document shows how public health professionals approach informatics problems can electronic medical record systems transform health care? potential health benefits a consensus action agenda for achieving the national health information infrastructure public health informatics: how information-age technology can strengthen public health public health 101 for informaticians public health informatics and information systems the value of healthcare information exchange and interoperability a consensus action agenda for achieving the national health information infrastructure public health informatics: improving and transforming public health in the information age what are the current and potential effects of a) the genomics revolution; and b) 9/11 on public health informatics? how can the successful model of immunization registries be used in other domains of public health (be specific about those domains)? how might it fail in others? why? fourteen percent of the us gdp is spent on medical care (including public health). how could public health informatics help use those monies more efficiently? or lower the figure absolutely? compare and contrast the database desiderata for clinical versus public health information systems. explain it from non-technical and technical perspectives make the case for and against investing billions in an nhii what organizational options would you consider if you were beginning the development of a local health information infrastructure? what are the pros and cons of each? how would you proceed with making a decision about which one to use? phi) involves the application of information technology in any manner that improves or promotes human health, does this necessarily involve a human "user" that interacts with the phi application? for example, could the information technology underlying anti-lock braking systems be considered a public health informatics application? key: cord-333599-hl11ln2r authors: tulchinsky, theodore h.; varavikova, elena a. title: planning and managing health systems date: 2014-10-10 journal: the new public health doi: 10.1016/b978-0-12-415766-8.00012-4 sha: doc_id: 333599 cord_uid: hl11ln2r health systems are complex organizations. they are often the largest single employer in a country, with expenditures of public and private money of 4–17 percent of gross domestic product. overall and individual facility management requires mission statements, objectives, targets, budgets, activities planning, human interaction, services delivery, and quality assurance. health organization involves a vast complex of stakeholders and participants, suppliers and purchasers, regulators and direct providers, and individual patients, and their decision-making. these include pyramidal and network organizations and ethical decision-making based on public interest, resource allocations, priority selection, and assurance of certain codes of law and ethical conduct. this chapter discusses how complex organizations work, with potential for application in health, and the motivations of workers and of the population being served. organization theory helps in devising methods to integrate relevant factors to become more effective in defining and achieving goals and missions. health systems are complex organizations and their management is an important concept in the new public health. health is a major sector of any economy and often employs more people in the industrialized countries than any other industry. health has complex networks of services and provider agencies, including funding through public or private insurance or through national health service systems. whether insurance is provided by the state or through private and public sources combined, skilled management is required at the macro-or national and the micro-or local level, including the many institutions that make up the system. management training of public health professionals and clinical services personnel is a requisite and not a luxury. planning and management are changing in the era of the new public health with advances in prevention and treatment of disease, population health needs, innovative technologies such as genetic engineering, new immunizations that prevent cancers and infectious diseases, prevention of non-communicable diseases, environmental and nutritional health, and health promotion to reduce risk factors and improve healthful living for the individual and the community. modern and successful public health also must address social, economic, and community determinants of health and the promotion of public policies and individual behaviors for health and well-being. the social capital and norms that promote cooperation among people are the basis of a "civil society" (i.e., the totality of voluntary, civic, and social organizations and institutions of a functioning society alongside the structures of governmental and commercial institutions). health systems are ideally knowledge-and evidence-based in using technologies available in medicine and the environment to promote the health and well-being of a population, including security against the effects of threatened terrorism, growing social isolation, and inequities in health. management in health can learn much from concepts of business management that have evolved to address the economic and human resource aspects of a health system at the macrolevel or an individual unit of service at the microlevel. the new public health is not contained within one organization, but rather reflects the collective efforts of national, state, regional, and local governments, many organizations in the public and non-governmental sectors, and finally efforts of individual or group advocates and providers and the public itself. the political level is crucial for adequate funding, legislation, and promotion of health-oriented policy positions and in public health management. the responsibility for health management is shared across all parts of society, including individuals, communities, business, and all levels of government. the new public health identifies and addresses community health risks and needs. planning is critical to the process of keeping a health system sustainable and adaptable and in creating adequate responses to new health threats. monitoring, measurement, and documentation of health needs are vital to design and adapt an effective program and to measure impact. data on the targeted issues must be accessible while protecting individual privacy. health is a hugely expensive and expansive complex of services, facilities, and programs provided by a wide range of professional and support service personnel making up one of the largest employers of any sector in a developed country. services are increasingly delivered by organized groups of providers. but all health systems operate in an environment of economic constraints, imposing a need to seek efficiency in the use of resources. how organizations function is of great importance not only for their economic survival, but also, and equally important, for the well-being of the clients and providers of care. an organization is two or more people working together to achieve a common goal. management is the process of defining the goals and making effective use of an organization to attain those goals. even very small units of a human organization require management. management of human resources is vital to the success of an organization, whether in a production or service industry. health systems may chapter 12 vary from a single structure to a network of many organizations. no matter how organizations are financed or operated, they require management. management in health care has much to learn from approaches to management in other industries. elements of theories and practices of profit-oriented sector management can be applied to health services even if they are operated as non-profit enterprises. physicians, nurses, and other health professionals will very likely be involved in the management of some part of the health care system, whether a hospital department, a managed care system, a clinic, or even a small health care team. at every level, management always means working with people, using resources, providing services, and working towards common objectives. health providers require preparation in the theory and practice of management. a management orientation can help providers to understand the wider implications of clinical decisions and their role in helping the health care system to achieve goals and targets. students and practitioners of public health need preparation in order to recognize that a health care system is more complex than the direct provision of individual services. similarly, policy and management personnel need to be familiar with both individual and population health needs and related care issues. health has evolved from an individual one-on-one service to complex systems organized within financing arrangements, mostly under government auspices. as a governmental priority, health may be influenced by political ideology, sometimes reflecting societal attitudes of the party in power and sometimes apparently at odds with its general social policy. following bismarck's introduction in germany in 1881 of national health insurance for workers and their families, funded by both workers and their employers, most countries in the industrialized world introduced variants of this national health plan. usually, this has been at the initiative of socialist or liberal political leadership, but conservative political parties have preserved national health programs once implemented. despite the new conservatism since the 1990s with its pre-eminent ideology of market forces, the growing roles for national, state, and local authorities in health have led to a predominantly government role in financing and overall responsibility for health care, even where there is no universal national health system, as in the usa. the uk's national health service (nhs), initiated by a labour government in 1948, has survived through many changes of government, including the conservative margaret thatcher period in which many national industries and services were privatized. health policy is a function of national (government) responsibility overall for health, but implementation is formulated and met at state, local, or institutional levels. the division of responsibilities is not always clear cut but needs to be addressed and revised both professionally and politically within constitutional, legal, and financial constraints. selection of the direction to be taken in organizing health services is usually based on a mix of factors, including the political view of the government, public opinion, and rational assessment of needs as indicated through epidemiological data, cost-benefit analysis, the experience of "good public health practice" from leading countries, and recommendations by expert groups. lobbying on the part of professional or lay groups for particular interests they wish to promote is part of the process of policy formulation and has an important role in the planning and management of health care systems. there are always competing interests for limited resources of funding, by personnel within the health field itself and in competition with other demands outside the health sector. the political level is vitally involved in health management in establishing and maintaining national health systems, and in determining the place of health care as a percentage of total governmental budgetary expenditures, in allocating funds among the competing priorities. these competing priorities for government expenditures include defense, roads, education, and many others, as well as those within the health sector itself. traditionally, there are competing priorities between the hospital and medical sector and the public health and community programs sector. a political commitment to health must be accompanied by allocation of resources adequate to the scope of the task. thus, health policy is largely determined by societal priorities and is not a prerogative of government, health care providers, or any institution alone. as a result of long struggles by trade unions, advocacy groups, and political action, well-developed market economies have come to accept health as a national obligation and essential to an economically successful and well-ordered society. this realization has led to the implementation of universal access systems in most of the industrialized countries. once initiated, national health systems require high levels of resources, because the health system is labor intensive with relatively high salaries for health care professionals. in these countries, health expenditures consume between 7 and nearly 18 percent of gross domestic product (gdp). some industrialized countries, notably those in the former soviet bloc, lacking mechanisms for advocacy, including consumer and professional opinion, tended to view health with a political objective of social benefits, and also as a "non-productive" consumer of resources rather than a producer of new wealth. as a result, budget allocations and total expenditures for health as a percentage of gdp were well below those of other industrialized countries (figure 12 .1). salaries for health personnel in the semashko system were low compared to industrial workers in the "productive" sectors. furthermore, industrial policy did not promote modern health-related industries, compared to the military or heavy industrial sectors. the former socialist countries of eastern europe which have joined the european union (eu) have gradually increased allocation to health from 5.44 percent of gdp in 1995 to 7.1 percent in 2010, while the pre-2004 members of the eu increased their expenditures from 8.5 percent of gdp to 10.6 percent. the average spend in the commonwealth of independent states (russia, ukraine, and others) increased from 5.6 percent in 1995 to 5.74 percent in 2010, and in the central asian republics (kazakhstan, uzbekistan, and others) from 4.8 percent in 1995 to 5.2 percent in 2010 (who health for all database, january 2013). however, russian health expenditure in 2011 was still only 6.2 percent of gdp and there is a lingering idea of health being a non-productive investment. the developing countries generally spend under 4 percent of gnp on health, because health is addressed as a relatively low political priority, and they depend very much on international donors for even the most basic of public health programs such as immunization. financing of health care and resource allocation requires a balance among primary, secondary, and tertiary care. economic assessment, monitoring, and evaluation are part of determining the health needs of the population. regulatory agencies are responsible for defining goals, priorities, and objectives for resulting services. targets and methods of achieving them provide the basis for implementation and evaluation strategies. planning requires written plans that include a statement of vision, mission objectives, target strategies, methods, and coordination during the implementation. designation and evaluation of responsibilities, resources to be committed, and participants and partners in the procedure are part of the continuous process of management. the dangers of taking a "wrong" direction may be severe, not only in terms of financial costs, but also in terms of high levels of preventable morbidity and mortality. health policy is often as imprecise a science as medicine itself. the difference is that inappropriate policy can affect the lives and well-being of very large numbers of people, as opposed to an individual being harmed by the mistake of one doctor. there may be no "correct" answer, and there are numerous controversies along the path. health policy remains more an "art" than the more quantitative and seemingly precise field of health economics. societal, economic, and cultural factors as well as personal habits have long been accepted as having an important impact on vulnerability to coronary heart disease. but other factors such as the degree of control over one's life, as suggested in studies of british civil servants, religiosity, and the effects of migration on families left behind are part of the social gradients and inequalities seen in many disease entities, with consequent excess morbidity and mortality in some contexts, such as in russia and ukraine. health policy, planning, and management are interrelated and interdependent. any set goal should be accompanied by planning how to attain it. a policy should state the values on which it is based, as well as specify sources of funding, planning, and management arrangements for its implementation. examination of the costs and benefits of alternative forms of health care helps in making decisions as to the structure and the content of health care services, both internal structures (within one organization) and external linkages (intersectoral cooperation with other organizations). the methods chosen to attain the goals become the applied health policy. the world health organization's (who's) 1977 health for all strategy was directed at the political level and intended to increase governmental awareness of health as a key component of overall development. to some degree it succeeded despite its expansive aspirations, and even after nearly 40 years, its objectives remain worthwhile even in well-developed health systems. within health, primary care was stressed as the most effective investment to improve the health status of the population. in 1993, the world bank's world development report adopted the health for all strategy and promoted the view that health is an important investment sector for general economic and social development. however, economic policies promoting privatization and deregulation in the health sector threaten to undermine this larger goal in countries with national health systems. in the usa, major steps are being taken to increase coverage of health insurance for all as the number of uninsured americans declined from 50 million people uninsured in 2010 to 48.6 million in 2011, edging down from 16.3 to 15.7 percent of the total population. further decline in the uninsured population is expected as the patient protection and affordable care act (ppaca, or "obamacare") comes into effect in the coming years, bringing many millions of americans into health insurance and meeting federal standards of fair practices such as eliminating exclusion for preexisting conditions by private insurers. the ppaca comes into effect on 1 january 2014 and will guarantee coverage for pre-existing conditions, and ensure that premiums cannot vary based on gender or medical history. it will subsidize the cost of coverage, and new state-based health insurance exchanges will help consumers to find suitable policies. it will introduce many preventive care measures into public and private insurance plans, and will promote efficiencies in the health systems including reduction in fraudulent claims and wasteful funding systems. all of this will require skilled management in the components of the health system (see chapters 10 and 13). in the new public health, health promotion, preventive care, and clinical care are all part of public health because the well-being of the individual and the community requires a coordinated effort from all elements of the health spectrum. establishing and achieving national health goals require planning, management, and coordination at all levels. the achievement of health advances depends on organizations and structured efforts to reach health goals such as those defined above, and more recently by the united nations (un) in the millennium development goals (mdgs) (see chapter 2), and requires some understanding of organizations and how they work. the study of organizations developed within sociology, but has gradually become a multidisciplinary activity involving many other professional fields, such as economics, anthropology, individual and group psychology, political science, human resources management, and engineering. organizations, whether in the public or private sector, exist within an external environment, and utilize their own structure, participants, and technology to achieve goals. for an organization to survive and thrive, it must adapt to the physical, social, cultural, and economic environment. organizations participating in health care establish the connection between service providers and consumers, with the goal of better health for the individual and the community. the factors for this include legislation, regulation, professionalism, instrumentation, medications, vaccines, education, and other modalities of intervention for prevention and treatment. the social structure of an organization may be formal (structured stability), natural (groupings reflecting common interests), or open (loosely coupled, interacting, and self-adjusting systems to achieve goals). formal systems are deliberately structured for the purposes of the organization. natural systems are less formal structures where participants work together collaboratively to achieve common goals defined by the organization. open systems relate elements of the organization to coalitions of partners in the external environment to achieve mutually desirable goals. in the health system, structures should focus on prevention and treatment of disease and improvement in health and well-being of society. the social structure of an organization includes values, norms, and roles governing the behavior of its participants. government, business, or service organizations, including health systems, require organizational structures, with a defined mission and set of values, in order to function. an organizational structure needs to be tailored to the size and complexity of the entity and the goals it wishes to achieve. the structure of an organization is the way in which it divides its labor into distinct tasks and coordinates them. the major organizational models, which are not mutually exclusive and may indeed be complementary, are the pyramidal (bureaucratic) and network structures. the bureaucratic model is based on a hierarchical chain of command with clearly defined roles. in contrast, the matrix or network organization brings together professional or technical people to work on specific programs, projects, or tasks. both are vital to most organizations to meet ongoing responsibilities and to address special challenges. some classic organization theory concepts help to set the base for modern management ideas as applied to the health sector. scientific management was pioneered by frederick winslow taylor . his work was pragmatic and based on empirical engineering, developed in observational studies carried out for the purpose of increasing worker, and therefore system, efficiency. taylor's industrial engineering studies of scientific management were based on the concept that the best way to improve worker productivity was by designing improved techniques or methods used by workers. this theory viewed workers as instruments to be manipulated by management, and assumed that efficient, rationally planned methods would produce better industrial results and industrial peace as the tasks of managers and workers would be better defined. time and motion studies analyzed work tasks to seek more efficient methods of work in factories. motivation of workers was seen to be related to payment by piecework and economic self-interest to maximize productivity. taylor sought to improve the productivity of each worker and to make management more efficient in order to increase earnings of employers and workers. he found that the worker was more efficient and productive if the worker was goal oriented rather than task oriented. this approach dominated organization theory during the early decades of the twentieth century. resistance to taylor's ideas came from both management and labor; the former because it seemed to interfere with managerial prerogatives and the latter because it expected the worker to function at top efficiency at all times. however, taylor's work had a lasting influence on the theory of work and organizations. the traditional pyramidal bureaucratic organization is classically seen in the military and civil services, but also in large-scale industry, where discipline, obedience, and loyalty to the organization are demanded, and individuality is minimized. this form of organization was analyzed by sociologist max weber between 1904 and 1924. leadership is assigned by higher authority, and is presumed to have greater knowledge than members lower down in the organization. this form of organization is effective when the external and internal environments, the technology, and functions are relatively well defined, routine, and stable. the pyramidal system (figure 12 .2) has an apex of policy and executive functions, a middle level of management personnel and support staff, and a base of the people who produce the output of the organization. the flow of information is generally one way, from the bottom to the top level, where decisions are made for the detailed performance of duties at all levels. lateralizing the information systems so that essential data can be shared to help staff at the middle and field or factory-floor levels of management is generally discouraged because this may promote decentralized rather than centralized management. even these types of organization have increasingly come to emphasize small-group loyalty, leadership initiative, and self-reliance. the bureaucratic organization has the following characteristics: l there is a fixed division of labor with a clear jurisdiction and based on assignments, which are subject to change by the leader. l there is a hierarchy of offices, with each lower functionary controlled and supervised by a higher one. employment is viewed as a tenured career for officials, after an initial trial period. the bureaucratic system, based on formal rationality, structure, and discipline, is widely used in production, service, and governmental agencies, including military and civilian departments and agencies. health systems, like other organizations, are dynamic and require continuous management, adjustment, and systems control. continuous monitoring and feedback, evaluation, and revision help to meet individual and community needs. the input-process-output model (figure 12 .3) depends on feedback systems to make the administrative or educational changes needed to keep moving towards the selected objectives and targets. organizations use resources or inputs that are processed to achieve desired results or outputs. the resource inputs are money, personnel, information, and supplies. process is the accumulation of all activities taken to achieve the results intended. output, or outcome, is the product, its marketing, its reputation and quality, and profit. in a service sector such as health, output or impact can be measured in terms of reduced morbidity and/or mortality, improved health, or number of successfully treated and satisfied patients at affordable costs. the management system provides the resources and organizes the process by which it hopes to achieve the established goals. program implementation requires systematic feedback for the process to work effectively. when targets are set and strategy is defined, resources, whether new or existing, are placed at the service of the new program. management is then responsible for using the resources to achieve the intended targets. the results are the outcome or output measures, which are evaluated and fed back to the input and process levels. health systems consist of many subsystems, each with an organization, leaders, goals, targets, and internal information systems. subsystems need to communicate within themselves, with peer organizations, and with the macro (health) system. leadership style is central to this process. the surgeon as the leader of the team in the operating room depends on the support and judgment of other crucial people on the team, such as anesthesiologists, operating room nurses, pathologists, radiologists, and laboratory services, all of whom lead their own teams. hospital and public health directors cannot function without a high degree of decentralized responsibility and a creative team approach to quality development of the facility. health systems management includes analysis of service policy, budget, decision-making in policy, as well as operation, regulation, supervision, provision, maintenance, ethical standards, and legislation. policy formulation involves a set of decisions made in pursuit of a course of action for achieving selected health targets, such as those in the mdgs or continuing to update healthy people 2020 health targets in the usa (see chapter 2). cybernetics, a term coined by norbert wiener, refers to systems or organizations which are dependent on each other to function, and whose interdependence requires flexibility of response. cybernetics gained wide credence in engineering in the early 1950s, and feedback systems became part of standard practice of all modern management systems. its later transformations appeared in operating service systems, as information for management. application of this concept is entering the health sector. rapid advances in computer technology, by which personal computers have access to internet systems and large amounts of data, have already enhanced this process. in mechanistic systems, the behavior of each unit or part is constrained and limited; in organic systems, there is more interaction between parts of the system. the example used in figure 12 .4 is the use of a thermostat to control the temperature and function of a heater according to conditions in the room. this is also described as a feedback system. cybernetics opens up new vistas on the use of health information for managing the operation of health systems. a database for each health district would allow assessment of current epidemiological patterns, with appropriate comparisons to neighboring districts or regional, state, and national patterns. data would need to be processed at state or national levels in comparable forms for a broad range of health status indicators. furthermore, the data should be prepared for online availability to local districts in the form of current health profiles. thus, data can be aggregated and disaggregated to meet the management needs of the service, and may be used to generate real targets and measure progress towards meeting them. a geographic information system may demonstrate high rates of a disease in a region due to local population risk factors, and thus become the basis for an intervention program. in the health field, the development of reporting systems based on specific diseases or categories has been handicapped by a lack of integrative systems and a geographic reporting approach. the technology of computers and the internet should be used to process data systems in real time and in a more user-friendly manner. this would enable local health authorities and providers to respond to actual health problems of the communities. health is a knowledge-based service industry, so that knowledge management and information technology are extremely important parts of the new public health, not only in patient care systems in hospitals, but also in public health delivery systems in the community, school, place of work, and home. mobilization of evidence and experience of best practices for policies and management decisionmaking is a fundamental responsibility of health leaders. the gap between information and action is wide and presents an ethical as well as a political challenge. regions with the most severe health problems lack trained personnel in assessment and exploitation of current state-of-the-art practices and technology in many practical public health fields, including immunization policy and in management of risk factors for stroke. knowledge and evidence are continuously evolving, but the capacity to access and interpret information is commonly poorly implemented in many countries so that very large numbers of people die of preventable diseases even when there are, overall, sufficient resources to address the challenges. international guidelines are vital to help countries to adopt current standards and make use of the available knowledge for public policy. political support and openness to international norms are crucial to this process of technology diffusion and building the physical and human resource infrastructure needed to achieve better population health with current best practices. development of health standards in low-income countries is progressing but is seriously handicapped by low levels of funding, lack of emphasis on training sufficient and appropriate human resource personnel and administrative support to promote measures which can save millions of lives. in high-income countries, the slow adoption of best international health standards can have harsh effects on population health, such as in the long delay in adopting national health insurance in the usa. in the european context, the eu has failed to adopt a harmonized recommended immunization program, which is badly needed for the new and potential members, as well as the older member countries. in countries of the former socialist bloc, mortality rates from stroke and coronary heart disease are slowly declining but remain two to four times higher than in countries of western europe (see chapter 5). systems management requires access to and the use of knowledge to bridge these gaps. adoption and adaptation of knowledge to address local problems are essential in a globalized world, if only to prevent the international spread of threatened pandemics or adoption of unhealthy lifestyles (diet, smoking, and lack of exercise) to middle-income countries, which are developing a growing middle class alongside massive poverty. the application of knowledge and experience that has been successful in leading countries can foster innovation and create experience that may generate a local renewal process. management is crucial to address the complex "strategy areas for improving performance of health organizations: standards and guidelines, organizational design, education and training, improved process, technology and tool development, incentives, organizational culture, and leadership and management" (bradley et al., 2012) . managing a knowledge-based service industry or facility relies on leadership, collaboration to realize the potential of technology, professional skills, and social capital to the address the health problems faced by all countries. the management of resources to achieve productivity and measurable success has been characterized and accompanied by the development of systems of organizing people to create solutions to problems or to innovate towards defined objectives. operations research is a concept developed by british scientists and military personnel in search of solutions for specific problems of warfare during world wars i and ii. the approach was based on the development of multidisciplinary teams of scientists and personnel. the development of the anti-submarine detection investigation committee for underwater detection of submarines during world war i characterized and pioneered this form of research. the famous bletchley park enigma code-breaking success in britain and the manhattan project, in which the usa assembled a powerful research and development team which produced the atomic bomb, are prime world war ii examples. team-and goal-oriented work was very effective in problem solving under the enormous pressure of wartime needs. it also influenced postwar approaches to developmental needs in terms of applied science in such areas as the aerospace and computer industries. the computer hardware and software industries are characterized by innovation conceived and developed through informal working groups with a high level of individual competence, peer group dynamism, and commitment to problem solving. thus, the "nerds" of macintosh and microsoft beat the "suits" of ibm in innovation and introduction of the personal computer. similar startup groups, such as google and facebook, successfully took the internet to startling new levels of global applications, showing the capacity of innovation from california's silicon valley and its counterparts in other places in the usa and worldwide. in the health field, innovation in organization developed prepaid group practice which became the health maintenance organization (hmo), and later the managed care organization (mco), now a major, if controversial, factor in health care provision in the usa. other examples may be found in multidisciplinary research teams working on vaccines or pharmaceutical research, and in the increasingly multidisciplinary function of hospital departments and especially highly interdependent intensive care or home care teams. the business concept of management by objectives (mbo), pioneered in the 1960s, has become a common theme in health management. mbo is a process whereby managers of an enterprise jointly identify its goals, define each individual's areas of responsibility in terms of the results expected, and use these measures as guides for operating the unit and assessing the contributions of its members. the common goals and then the individual unit goals must be established, as well as the organizational structure developed to help achieve these goals. the goals may be established in terms of outcome variables, such as defined targets for reduction of infant or maternal mortality rates. goals may also be set in terms of intervening or process variables, such as achieving 95 percent immunization coverage, prenatal care attendance, or screening for breast cancer and mammography. achievements are measured in terms of relevancy, efficiency, impact, and effectiveness. the mbo approach has been subject to criticism in the field of business management because of its stress on mechanical application of quantitative outcome measures and because it ignores the issue of quality. this approach had great influence on the adoption of the objective of "health for all" by the who, and on the us department of health and human services' 1979 health targets for the year 2000, later as healthy people 2010, and now, based on these experiences and new evidence, renewed as healthy people 2020. targeting diseases for eradication may contribute to institution building by developing experience and technical competence to broaden the organizational capacity. however, categorical programs or target-oriented programs can detract from the development of more comprehensive systems approaches. addressing the mdgs of reducing child and maternal mortality is at odds to some extent with targeting poliomyelitis for eradication and reliance on national immunization days, which distract planning and resource allocation for the buildup of the essential public health infrastructure for the basic immunization system so fundamental to child health. immunization and human immunodeficiency virus (hiv) control draw the major part of donor resources in developing countries, while education for strengthening human resources and infrastructure draw less donor attention. a balance between comprehensive and categorical approaches requires very skilled management. the mdgs agreed to by the un in 2001 as targets for the year 2015 provide a set of measurable objectives and a formula for international aid and for national development planning to help the poorest nations, with the wealthy nations providing aid, education, debt relief, and economic development through fairer trade practices. they are now being reviewed for extension to 2020 based on experience to date, with successes and failures, and recognizing the vital importance of non-communicable diseases as central to the health burden of low-and middleincome countries. management is the activity of coordinating and integrating organizational resources, including people, money, materials, time, and space. the purpose is to achieve defined/ stated objectives as effectively and efficiently as possible. whether in terms of producing goods and profits or in delivering services effectively, management deals with human motivation and behavior because workers are the key to achieving goals. knowledge and motivation of the individual client and the community are also essential for achieving good health. thus, management must take into account the knowledge, attitudes, beliefs, and practices of the consumer as much as or more than those of the people working within the system, as well as the general cultural and knowledge level in the society, as reflected in the media, political opinions, and organizations addressing the issues. management, like medicine, is both a science and an art. the application of scientific knowledge and technology in medicine involves both theory and practice. similarly, management practice involves elements of organizational theory, which, in turn, draws on the behavioral and social sciences and quantitative methodologies. sociology, psychology, anthropology, political science, history, and ethics contribute to the understanding of psychosocial systems, motivation, status, group dynamics, influence, power, authority, and leadership. quantitative methods including statistics, epidemiology, survey methods, and economic theory are also basic to development of systems concepts. comparative institutional analysis helps principles of organization and management to develop, while philosophy, ethics, and law are part of understanding individual and group value systems. organizational theory, a relatively new discipline in health, as an academic study of organizations, addresses health-related issues using the methods of economics, sociology, political science, anthropology, and psychology. the application of organizational theory in health care has evolved and become an integral part of training for, and the practice of, health administration. related practical disciplines include human resources, and industrial and organizational psychology. translation of organizational theory into management practice requires knowledge, planning, organization, mobilization of professional and other staff support for evidence-based best practices, assembly of resources, motivation, monitoring and control. health organizations have become more complex and costly over time, especially in their mix of specializations in science, technology, and professional services. organization and management are particularly crucial for successful application of the principles of the new public health, as it involves integration of traditionally separate health services. delegation of responsibilities in health systems, such as in intensive care units, is fundamental to success in patient care, with nurses taking increasing responsibility for the management of the severely ill patient suffering from multiple system failure. delegation or devolution of health care responsibilities to non-medical practitioners has been an ongoing development affecting nurse practitioners, physician assistants, paramedics, community health workers and others, as discussed in chapter 14. it is a vital process to provide needs not met by physicians because of shortages and inappropriate location or specialty preferences that leave primary care or other medical specialties unable to meet community and patient needs. elton mayo of the harvard school of business carried out a series of observational studies at the hawthorne, illinois, plant of the western electric company between 1927 and 1932. mayo and his industrial engineer, along with psychologist colleagues, made a major contribution to the development of management theory. mayo began with industrial engineering studies of the effect of increased lighting on production at an assembly line. this was followed by other improvements in working conditions, including reduced length of the working day, longer rest periods, better illumination, color schemes, background music, and other factors in the physical environment. these studies showed that production increased with each of these changes and improvements. however, the researchers discovered, to their surprise, that production continued to increase when the improvements were withdrawn. furthermore, in a control group where conditions remained the same, productivity also grew during the study period. these results led mayo to conclude that the performance of workers improved because of a sense that management was interested in them, and that worker participation contributes to improved production. traditionally, industrial management viewed employees as mechanistic components of a production system. previous theory was that productivity was a function of working conditions and monetary incentives. what came to be known as the hawthorne effect showed the importance of social and psychological factors on productivity. formal and informal social organizations among management and employees were recognized as key elements in productivity, now called industrial humanism. research methods adapted from the behavioral sciences contributed to scientific studies in industrial management. traditional theories of the bureaucratic model of organization and management were modified by the behavioral sciences. this led to the emergence of the systems approach, or scientific analysis to analyze complex structures or organizations, taking into account the mutually interdependent elements of activities, interactions, and interpersonal relationships between management and workers. some revisits to the hawthorne studies suggest that the data do not support the conclusions, and offer a different interpretation. one is that informal groups such as workers on a production line themselves set standards for work which assert an informal social control outside the authority system of the organization. the informal cohesive group can thus control the norms of the amount of work acceptable to the group, i.e., not "too much" and not "too little". others point out that the effects were temporary and that there were extraneous factors, but the added value of the hawthorne effect remains part of the history of and had a culturechanging effect on management theory. the hawthorne effect in management is in some ways comparable to the placebo effect in clinical research and health care practice. it is also applied to clinical practice, whereby medical care provided by doctors is measured for specific "tracer conditions" to assess completeness of care according to current clinical guidelines. review of clinical records has been shown to be a factor in improving performance by doctors in practice, such as in treatment of acute myocardial infarction, management of hypertension, or completeness of carrying out preventive procedures such as screening for cancer of the cervix, breast, or colon (see chapters 3 and 15). awareness of being studied is a factor in improved performance or response to an intervention. studies of clinical practice-based research or public health interventions need to consider whether different types of studies and outcomes are more or less susceptible to the hawthorne effect (fernald et al., 2012 ). abraham maslow's hierarchy of human needs made an important contribution to management theory. maslow was an american psychologist, considered "the father of humanism" in psychology. maslow defined a prioritization of human needs (figure 12 .5), starting with those of basic physical survival; at higher levels, human needs include social affiliation, self-esteem, and self-fulfillment. others in the hierarchy include socialization and self-realization; later revisions include cognitive needs. the survival needs of an employee include a base salary and benefits, including health insurance and pension; the safety and security needs include protection from injury, toxic exposure or excess stress; social needs at work include an identity, pride, friendships, union solidarity, company social activities and benefits; esteem and recognition include job titles, awards, and financial rewards for achievement by individuals, groups, or all employees; and self-actualization includes promotion to more challenging jobs with benefits, both financial and in terms of recognition. this concept is important in terms of management because it identifies human needs beyond those of physical and economic well-being. it relates them to the social context of the work environment with needs of recognition, satisfaction, self-esteem, and self-fulfillment. maslow's conclusions opened many positive areas of management research, not only in the motivation of workers in production and service industries, but also in the motivation of consumers. maslow's hierarchy of human needs contributed to the idea that workers' sense of well-being is important to management. his theories played an important role in application of sociological theory to client behavior, just as the topic of personal lifestyle in health became a central part of public health and clinical management of many conditions, such as in risk factor reduction for cardiovascular diseases. this concept fits well with the epidemiological studies referred to in the introduction, such as those showing strong relationships with sociopolitical factors as well as socioeconomic conditions. theory x-theory y (table 12 .1), developed by clinical psychologist and professor of management douglas mcgregor in the 1960s, examined two extremes in management assumptions about human nature that ultimately affect the operations of organizations. organizations with centralized decision-making, a hierarchical pyramid, and external control are based on certain concepts of human nature and motivation. mcgregor's theory, drawing on maslow's hierarchy of needs, describes an alternative set of assumptions that credit most people with the capacity for self-direction. traditional approaches to organization and management stress direction and external control. theory x assumes that workers are lazy, unambitious, uncreative, and motivated only by basic physiological needs or fear. theory y places stress on integration and self-control. this model provides a more optimistic leadership model, emphasizing management development programs and promoting human potential, assuming that, if properly motivated, people can be self-directed and creative at work, and that the role of management is to unleash this potential in workers with performance appraisal. many other theories of motivation and management have been developed to explain human behavior and how to utilize inherent skills to produce a more creative work environment, reduce resistance to change, reduce unnecessary disputes, and ultimately create a more effective organization. variants of the human motivation approach in management carried the concept further by examining industrial organization to determine the effects of management practices on individual behavior and personal growth within the work environment. they describe two contrasting models of workforce motivation. theory x assumes that management produces immature responses on the part of the worker: passivity, dependence, erratically shallow interests, shortterm perspective, subordination, and lack of self-awareness. in contrast, at the other end of the immaturity-maturity spectrum was the mature worker, with an active approach, an independent mind capable of a broad range of responses, deeper and stronger interests, a long-term perspective, and a high level of awareness and self-control. this model has been tested in a variety of industrial settings, showing that giving workers the opportunity to grow and mature on the job helps them to satisfy more than basic survival needs and allows them to use more of their potential in accomplishing organizational goals. this model became widely influential in human resource management theory of organizational behavior, organizational communication, and organizational development, and in the practical management of business and service enterprises. in the motivation to work (1959) , us clinical psychologist frederick herzberg wrote of his motivationhygiene theory. he developed this theory after extensive studies of engineers and accountants, examining what he called hygiene factors (i.e., administrative, supervisory, monetary, security, and status issues in work settings). his motivating factors included achievement, recognition of accomplishment, challenging work, and increased responsibility with personal and collective growth and development. he proved that the motivating factors had a substantial positive effect on job satisfaction. these human resource theories of management helped to change industrial approaches to motivation from "job enrichment" to a more fundamental and deliberate upgrading of responsibility, scope, and challenge of work, by letting workers develop their own ways of achieving objectives. even when the theories were applied to apparently unskilled workers, such as plant janitors, the workers changed from an apathetic, poorly performing group into a cohesive, productive team, taking pride in their work and appearance. this approach gave members of the team the opportunity to meet their human self-actualization needs by taking greater responsibility for problem solving, and it resulted in less absenteeism, higher morale, and greater productivity with improved quality. rensis likert, with mcdougal and herzberg, helped to pioneer the "human relations school" in the 1960s, applying human resource theory to management systems and styles. likert classified his theory into four different systems, as follows. l system 1 -management has no confidence or trust in subordinates, and avoids involving them in decisions and goal setting, which are made from the top down. management is task oriented, highly structured, and authoritarian. fear, punishment, threats, and occasional rewards are the principal methods of motivation. worker-management interaction is based on fear and mistrust. informal organizations within the system often develop that lead to passive resistance of management and are destructive to the goals of the formal organization. l system 2 -management has a condescending relationship with subordinates, with some degree of trust and confidence. most decisions are centralized, but some decentralization is permitted. rewards and punishments are used for motivation. informal organizations become more important in the overall structure. l system 3 -management places a greater degree of trust and confidence in subordinates, who are given a greater degree of decision-making powers. broad policy remains a centralized function. l system 4 -management is seen as having complete confidence in subordinates. decision-making is dispersed, and communication flows upward, downward, and laterally. economic rewards are associated with achieving goals and improving methods. relationships between management and subordinates are frequent and friendly, with a sense of teamwork and a high degree of mutual respect. case studies showed that a shift in management from likert system 1 towards system 4 radically changed the performance of production, cut manufacturing costs, reduced staff turnover, and increased staff morale. furthermore, workers and managers both shared a concern for the quality of the product or service and the competitiveness and success of their business. the health industry includes highly trained professionals and paraprofessional workers who function as a team with a high degree of cohesion, mutual dependence, and autonomy, such as a surgical or an emergency department team. the network, or task-oriented working group, is basically a more democratic and participatory form of organization meant to elicit free interchange of concerns and ideas. this is a more organic form of organization, best suited to be effective for adaptation when the environment is complex and dynamic, when the workforce is largely professional, and when the technology and system functions change rapidly. complexities and technological change require information, expertise, flexibility, and innovation, strengths best promoted in free exchange of ideas in a mutually stimulating environment. in a network organization, leadership may be formal or informal, assigned to a particular function, which may be temporary, medium term, or permanent, to achieve a single defined task or develop an intersectoral program. the task force is usually for a short-term specific assignment; a working group, often for a medium-term project, such as integrating services of a region; and a committee for permanent tasks such as monitoring an immunization program. significant advantages of this form of organization are the challenge and the sharing of information and responsibility, which give professionals responsibility and job satisfaction by providing the opportunity to demonstrate their creativity. members of the task force may each report within their own pyramidal structure, but as a group they work to achieve the assigned objective. they may also be interdisciplinary or interagency working groups to review the state of the art in this particular issue as documented in reports and professional literature, and to coordinate activities, review previous work, or plan common future activities. an ongoing network organization may be a government cabinet committee to coordinate government policy and the work of various government departments, or a joint chiefs of staff to coordinate the various armed services. this approach is commonly used for task groups wherein interdisciplinary teams of professionals meet to coordinate functions of a department in a hospital, or where a multidisciplinary group of experts is established with the specified task of a technical nature. network organizational activity is part of the regular functions of a health professional. informal networking is a day-to-day activity of a physician in consultations with colleagues and also a part of more formalized network groups. the hospital department must, to a large extent, function as a network organization with different professionals working as a team more effectively than would be possible in a strictly authoritarian pyramidal model. a ministry of health may need to develop a joint working group with the ministry of transport, the police, and those responsible for standards of motor vehicles to seek ways to reduce road accident deaths and injuries. if a measles eradication project is envisioned, a multidisciplinary and multiorganizational team, or a network, should be established to plan and carry out the complex of tasks needed to achieve the target (figure 12.6) . in a public health context, a task group to determine how to reduce obesity rates in school-aged children, or to eradicate measles locally, might be chaired by the deputy chief medical officer or senior health promotion person; if the project is reduction of obesity among school children, the lead agency may be the department of education, perhaps jointly with the local department of health; if reduction in road traffic deaths is the topic, the lead may be the police department with participation of emergency transportation and hospital emergency room lead personnel. members may include the chief district nurse, an administrative and budget officer, a pharmacist, the chief of the pediatric department of the district hospital, a primary school administrator, a health educator, a medical association representative, the director of laboratories, the director of the supply department, a representative of the department of education, representatives of voluntary organizations interested in the topic, and others as appropriate. most organizational structures are mixed, combining elements of both the formal pyramidal and the less structured network structure with a task-oriented mandate. it is often difficult for a rigid pyramidal structure to deal with parallel bodies in a structured way, so the network approach is necessary to establish working relations with outside bodies to achieve common goals. a network is a democratic functional grouping of those professionals and organizations needed to achieve a defined target, sometimes involving people from many different organizations. the terms of reference of the working group are crucial to its function as well as its composition, time-frame, and access to relevant information. the application of this concept is increasingly central in health care organization as multilevel health systems evolve in the form of managed care or district health systems. these are vertically integrated management systems involving highly professional teams and units whose interdependence for patient care and financial responsibility are central elements of the new public health. in the usa during world war ii, w. edwards deming, a physicist and statistician, developed a system of economic and statistical methods of quality control in production industries. following the war, deming was invited to teach in japan and moved from the university to the level of industrial management. japanese industrialists adopted his principles of management and introduced quality management into all industries, with astonishingly successful results within a decade. the concept, later called total quality management (tqm), has since been adopted widely in production and service industries. in the deming approach to company management, quality is the top priority and is the key responsibility of management, not of the workers. if management sets the tone and involves the workers, quality goes up, costs come down, and both customer satisfaction and loyalty increase. having their ideas listened to, and avoiding a punitive inspection approach, enhances the pride of the workers. it is the responsibility of leadership to remove fear and build mutual participation and common interest. training is one of the most important investments of the organization. the differences between traditional management and the tqm approach are shown in boxes 12.1 and 12.2. in societies with growing economies, the role of an educated workforce becomes greater as information technology and services, such as health, become larger parts of the economy and require professionalism and self-motivating workers. the tqm approach integrates the scientific management and human relations approaches by giving workers credit for intellectual capacity and expects them to use it to analyze and improve the tasks they perform. even more, this approach expects workers at all levels to contribute to better quality in the process of design, manufacture, and even marketing of the product or the service. the tqm ideas were revolutionary and successful when applied in business management in production industries. the tqm concept is much in discussion in the service industries. the who has adapted tqm to a model called continuous quality improvement (cqi), with the stress on mutual responsibilities throughout a health system for quality of care. the application of tqm and cqi approaches is discussed in chapter 15, including the external regulatory and self-development tqm approaches. in the health sector, issues such as prevention of health facility-acquired infections require staff dedicated to promoting a culture of cleaning, frequent and thorough hand washing, sterilization, isolation techniques, intravenous and intratracheal catheter and tube care technique, and immunization of hospital personnel. these and many other crossdisciplinary measures promote patient safety and prevent the costly and frequently deadly effects of serious respiratory or urinary tract injection acquired in hospitals or other health care facilities. human behavior is individual but takes place in a social context. changes to individual behavior are needed to reduce risk factors for many diseases. change can be threatening; it requires alteration, substitution, transformation, or modification of purposes, procedures, methods, or style. the implementation of plans usually requires some change, which often meets resistance. the resistance to change may be professional, technical, psychological, political, emotional, or a mix of all of these. the manager of a health facility or service has to cope with change and gather the support of those involved to participate in creating or implementing the change effectively. the behavior of the worker in a production or service industry is vital to the success of the organization. equally important is the behavior of the purchaser or consumer of the product or service. diagnosing organizational problems is an important skill to bring to leadership in health systems. even more important is the ability to identify and alter the variables that require change and adaptation to improve the performance of the organization. high expectations are essential to produce high performance and improved standards of service or productivity. conversely, low expectations not only lead to low performance, but produce a downward spiraling effect. this applies not only within the organization, but to the individuals and community served, l judgment, punishment, and reward for above-or belowaverage performance destroy teamwork essential for quality production. l work with suppliers to improve quality and costs. l profits are generated by loyal customers -running a company for profit alone is like driving a car by looking in the rearview mirror. whether in terms of purchase of goods produced or in terms of health-related behavior. people often resist change because of fear of the unknown. participation in the process of defining problems, formulating objectives, and identifying alternatives is needed to bring about changes. change in organizational performance is complex, and this is the test of leadership. similarly, change at the individual level is essential to achieve the goals of the group, whether this is in terms of the functioning of a health care service unit, such as a hospital, or whether it is an individual's decision to change from smoking to non-smoking status. the health of both an individual and a population depends on the individual health team member's motivation and experience. the behavior of the individual is important to his or her personal and community health. even small steps in the direction of a desirable change in behavior should be rewarded as soon as possible (i.e., reinforcing positive performance in increments). behavior modification is based on the concept that change of behavior starts with the feelings and attitudes within the individual, but can be influenced by knowledge, peer pressure, media coverage, and legislative standards. change involves a number of elements to define a current or previous starting point: change in behavior is vital in the health field: in the organization, in the community, in individual behavior, and in societal regulation and norms. the health belief model (chapter 2) is widely influential in psychology and health promotion. the belief intervention approach involves programs meant to reduce risk factors for a public health problem. it may require change in the law and in organizational behavior, with involvement and feedback to the people who determine policy, those who manage services, and the community being served. obesity in school-aged children is being fought by many measures including healthier menus and banning the sale of high sugar drinks on school property. high cholesterol is being fought on many fronts including dietary change and banning the use of transfats in food processing. deaths from bulimia are not uncommon and may stem from teenage identification of beauty with ultrathin body image. banning television and modeling agencies from using models with a very low body mass index is an intervention in advertising which encourages harmful practices that are a danger to health and life. banning cigarette advertising and smoking in public places promotes behavioral change, as does raising the taxes on cigarettes. gun control laws are meant to prevent disturbed individuals or political fanatics having easy access to firearms to commit mass murder. strict enforcement of drinking and driving laws can prevent drunk driving and reduce road traffic deaths (see chapter 15). in the 1980s, major industries in the usa were unable to compete successfully with the japanese in the consumer electronics and automobile industries. management theory began to place greater emphasis on empowerment as a management tool. the tqm approach stresses teamwork and involvement of the worker in order to achieve better quality of production. comparatively, empowerment went further to involve the worker in operation, quality assessment, and even planning of the design and production process. results in production industries were remarkable, with increased efficiency, less absenteeism, and greater searching for ideas to improve quality and quantity of production, with the worker as a participant in the management and production process. the concept of empowerment entered the service industries with the same rationale. the rationale is that improvements in quality and effectiveness of service require the active physical and emotional participation of the worker. participation in decision-making is the key to empowerment. this requires management to adopt new methods that allow the worker, whether professional or manual, to be an active participant. successful application of the empowerment principles in health care extends to the patient, the family, and the community, emphasizing patients' rights to informed participation in decisions affecting their medical care, and the protection of privacy and dignity. diffusion of powers occurs when management of services is decentralized. delegation of powers to professional groups, non-governmental organizations (ngos), and advocacy organizations is part of empowerment in health care organizations. governmental powers to govern or promote areas such as licensure, accreditation, training, research, and service can be devolved to local authorities or ngos by delegation of authority or transfer of funds. organizational change may involve decentralization. institutional changes such as amalgamation of hospitals, long-term care facilities, home care programs, day surgery, ambulatory care, and public health services are needed to produce a more effective use of resources. integration of services under community leadership and management should encourage transfer of funds within a district health network from institutional care to community-based care. such changes are a test of leadership skills to achieve cultural change within an organization, which requires behavioral change and involvement of health workers in policy and management of the change process. strategic management emphasizes the importance of positioning the organization in its environment in relation to its mission, resources, consumers, and competitors. it requires development of a plan of action or implementation of a strategy to achieve the mission or goal of the organization within acceptable ethical and legal guidelines. articulation of these is a key role of the management level of an organization. defining the mission and goals of the organization must take into account the external and internal environment, resources, and operational needs to implement and evaluate the adequacy of the outcomes. the strategy of the organization matches its internal approach with external factors, such as consumer attitudes and competing organizations. strategy is a set of methods and skills of the health care manager to attain the objectives of a health organization, including: policy is the formulation of objectives and priorities. strategy refers to long-range plans to achieve stated objectives, indicating the problems to be expected and how to deal with them. strategy does not identify all actions to be taken, but it includes evaluation of progress made towards a stated goal. while the term has traditionally been used in a military context, it has become an essential concept in management, whether of industry, business, or health care. tactics are the methods used to fulfill the strategy. thus, strategic mbo is applicable to the health system, incorporating definitions of goals and targets, and the methods to achieve them (box 12.3). change in health organizations may involve a substantial alteration in the size or relationships between existing, well-established facilities and programs (table 12. 2). a strategic plan for health reform in response to the need for cost containment, redefined health targets, or dissatisfaction with the status quo requires a model or a vision for the future and a well-managed program. opposition to change may occur for psychological, social, and economic reasons, or because of fear of loss of jobs or changes in assignments, salary, authority, benefits, or status. downsizing in the hospital sector, with buildup of community health services, is one of the major issues in health reforms in many countries. it can be accomplished over time by naturally occurring vacancies or attrition due to retirement, or by retraining and reassignment, all of which require skilled leadership. the introduction of new categories of health workers in hospitals such as phlebotomists, hospitalist doctors, and technicians of all kinds has improved hospital efficiency and safety. community health has benefited from home care and in many situations community health workers to assist and supervise patient care in remote rural villages and in urban centers, even in high-income countries, with health guides trained to help people to function with chronic illnesses and dementias (see chapter 14). the new public health is an integration or coordination of many participating health care facilities and health-promoting programs. it is evolving in various forms in different places as networks with administrative and financial interaction between participating elements. each organization provides its own specific services or groups of services. how they function internally and how they interact functionally and financially are important aspects of the management and outcomes of health systems. the health system functions as a network with formal and informal relationships; it may be very broad and loosely connected as in a highly decentralized system, with many lines of communication, payment, regulation, standards setting, and levels of authority. the relationship and interchange between different health care providers have functional and economic elements. as an example, an educated adult woman is more likely than an uneducated woman to prepare herself for the requirements of pregnancy by smoking and alcohol or drug cessation, folic acid intake, healthful diet, and attending professional antenatal care. a pregnant woman who is healthy and prepared for pregnancy physically and emotionally, and who receives comprehensive prenatal care, is less likely than a woman whose health is neglected to develop complications and require prolonged hospital care as a result of childbirth. the cost of good prenatal care is a fraction of the economic cost of treating the potential complications and damage to her health or that of the newborn. a health system is responsible for ensuring that a woman of reproductive age takes folic acid tablets orally before becoming pregnant, has had access to family planning services so that the pregnancy is a desired one, ensures that the space between pregnancies is adequate for her health and that of her baby, and receives adequate prenatal care. an obstetrics department should be involved in assuring or providing the prenatal care, especially for high-risk cases, and delivery should be in hygienic and professionally supervised settings. similarly, for children and elderly people, there is a wide range of public health and personal care services that make up an adequate and cost-effective set of services and programs. the economic burden of caring for the sick child falls on the hospital. when there is a per capita grant to a district, the hospital and the primary care service have a mutual interest in reducing morbidity and hence mortality. this is the principle of the hmos and district health systems discussed elsewhere. it is also a fundamental principle of the new public health. health care organizations differ according to size, complexity, ownership, affiliations, types of services, and location. traditionally, a health care organization provides a single type of service, such as an acute care hospital providing episodic inpatient care, or a home health care agency. in present-day health reforms, health care organizations, such as an hmo or a district health system, provide a populationbased, comprehensive service program. each organization must have or develop a structure suited to meet its goals, in both the internal and external environments. the common elements that each organization must deal with include governance of policy, production or service, maintenance, financing, relating to the external environment, and adapting to changing conditions. a functional model of an organization perhaps best suited to the smaller hospital is the division of labor into specific functional departments; for example, medical, nursing, administration, pharmacy, maintenance, and dietary, each reporting through a single chain of command to the chief executive officer (ceo) (figure 12.7) . the governing agency, which may be a local non-profit board or a national health system, has overall legal responsibility for the operation and financial status of the hospital, as well as raising capital for improvements. the medical staff may be in private practice and work in the hospital with their own patients by application for this right as "attending physician", according to their professional qualifications, or the medical staff may be employed by the hospital in a similar way to the rest of the staff. salaried medical staff may include physicians in administration, pathology, anesthesia, and radiology, so that even in a private practice market system many medical staff members are hospital employees. increasingly, hospitals are employing "hospitalists", who are full-or part-time physicians whose work is in the health facility, to provide continuity of inpatient and emergency department services, augmenting the services of senior or attending staff or private practice physicians. this shift is in part related to the increasing numbers of female physicians who run their homes and families as well as practice medicine and who find this mode of work more attractive than full-time private practice. this model is the common arrangement in north american hospitals. the governing board of a "voluntary", nongovernmental, not-for-profit organization with municipal and community representatives may be appointed by a sponsoring religious, municipal, or fraternal organization. the corporate model in health care organization (figure 12.8) is often used in larger hospitals or where mergers with other hospitals or health facilities are taking place. the ceo delegates responsibility to other members of the senior management team who have operational responsibility for major sectors of the hospital's functioning. a variation of the corporate model is the divisional model of a health care organization based on the individual service divisions allowing middle management a high degree of autonomy (figure 12.9 ). there is often departmental budgeting for each service, which operates as an economic unit; that is, balancing income and expenditures. each division is responsible for its own performance, with powers of strategic and operational decision-making authority. this model is used widely in private corporations, and in many hospitals in the usa. with increasing complexity of services, it is also employed in corporate health systems in the usa, with regional divisions. the matrix model of a health care organization is based on a combination of pyramidal and network organization. this model is suited to a public health department in a state, county, or city. individual staff people report in the pyramidal chain of command, but also function in multidisciplinary teams to work on specific programs or projects. a nutritionist in the geriatric department is responsible to the chief of nutrition services but is functionally a member of the team on the geriatric unit. in a laterally integrated health maintenance organization or district health system, specialized staff may serve in both institutional (i.e., hospital) and community health roles (figure 12.10) . the organizational structure appropriate to one set of circumstances may not be suitable for all. whether the payment system is by norm (i.e., by predetermined numbers of staff, their salaries, and fixed costs for all services), per diem (i.e., payment of a daily rate times the number of days of stay), historical budget, or per capita in a regional or district health system structure (see chapters 10 and 11), the internal operation of a hospital will require a model of organization appropriate to it. hospitals need to modify their organizational structure as they evolve, and as the economics of health care change. leadership in an organization requires the ability to define the goals or mission of the organization and to develop a strategy and define steps needed to achieve these goals. it requires an ability to motivate and engender enthusiasm for this vision by working with others to gain their ideas, their support, and their participation in the effort. in health care as in other organizations, it is easier to formulate plans than to implement them. change requires the ability not only to formulate the concept of change, but also to modify the organizational structure, the budgeted resources, the operational policies and, perhaps most importantly, the corporate culture of the organization. management involves skills that are not automatically part of a health professional's training. skilled clinicians often move into positions requiring management skills in order to build and develop the health care infrastructure. in some countries, hospital managers must be physicians, often senior surgeons. clinical capability does not transfer automatically into management skills to deal with personnel, budgets, and resources. therefore, training in management is vital for the health professional. the manager needs training for investigations and factfinding as well as the ability to evaluate personnel, programs, and issues, and set priorities for dealing with the short-and long-term issues. negotiating with staff and outside agencies is a constant activity of the manager, ranging from the trivial to major decisions with wide implications. perhaps the most crucial skill of the manager is communication: the ability to convey verbal, written, or unwritten messages that are received and understood and to assess the responses as an equal part of the exchange. interpersonal skills are a part of management practice. the capable manager can relate to personnel at all levels in an open and equal manner. this skill is essential to help foster a sense of pride and involvement of all personnel in working towards the same goals and objectives, and to show that each member of the team is important to meeting the objectives of the organization. at the same time, the manager needs to communicate information, especially as to how the organization is doing in achieving its objectives. the manager is responsible for organizing, planning, controlling, directing, and motivating. managers assume multiple roles. a role is an organized set of behaviors. henry mintzberg described the roles needed by all managers: informational, interpersonal, and decisional roles. robert katz (1974) identified three managerial skills that are essential to successful management: technical, human, and conceptual: "technical skill involves process or technique knowledge and proficiency. managers use the processes, techniques and tools of a specific area. human skill involves the ability to interact effectively with people. managers interact and cooperate with employees. conceptual skill involves the formulation of ideas. managers understand abstract relationships, develop ideas, and solve problems creatively". technical skill deals with things, human skill concerns people, and conceptual skill has to do with ideas. the distribution of these skills between the levels of management is shown in figure 12 .11. hospital directors in the past were often senior physicians, often called superintendents, without training in health management. the business manager ceo has become common in hospital management in the usa. during the 1950s, the ceo was called an administrator, and worked under the direction of a board of trustees who raised funds, set policies, and were often involved in internal administration. where the ceo was a non-physician, the usual case in north american hospitals, a conflict often existed with the clinical staff of the hospital. in some settings, this led to appointment of a parallel structure with a full-time chief of medical staff with a focus on clinical and qualitative matters. in european hospitals, the ceo is usually a physician, often by law, and the integration of the management function with the role of clinical chief is the prevalent model. over time, as the cost and complexity of the health system have increased, the ceo role has changed to one of a "coordinator". the ceo is now more involved in external relations and less in the day-to-day operation of the facility. the ceo is a leader/partner but primus inter pares, or first among equals, in a management team that shares information and works to define objectives and solve problems. this de-emphasizes the authoritarian role and stresses the integrative function. the ceo is responsible for the financial management of operational and capital budgets of the facility, which is integral to the planning and future development of the facility. budgets include four main factors: income, fixed or regular overhead, variable or unpredictable overhead, and capital or development costs, all essential to the survival and development of the organization. the key role of top management is to develop a vision, goals, and targets for the institution, to maintain an atmosphere and systems to promote the quality of care, financial solidity, and to represent the institution to the public. the overall responsibility for the function and well-being of the program is with the ceo and the governing board of directors. community participation in management of health facilities has a long-standing and constructive tradition. the traditional hospital board has served as a mechanism for community participation and leadership in promoting health facility development and management at the community level. the role of hospital boards evolved from primarily a philanthropic and fund-raising one to a greater overall responsibility for policy and planning function working closely with management and senior professional staff. this change occurred as operational costs increased rapidly, as government insurance schemes were implemented, and as court decisions defined the liability of hospitals and reinforced the broadened role of governing boards in malpractice cases and quality assurance. centrally developed health systems such as the uk's nhs have promoted district and county health systems with high degrees of community participation and management, both at the district level and for services or facilities. the role of local authorities, as well as state and national governments, is crucial to the functioning of public health in its traditional issues such as safe water supply, sanitation, business licensing, social welfare, and many others, as discussed in chapter 10. these functions have not diminished with the greater roles of state and federal or national governments in health. in healthful living environments the local authority functions are of continuing and indeed expanding importance, as in urban planning and transportation, promoting easy access to commercial facilities for shopping and healthy food sources for poorer sections as well as those available to prosperous members of the community. advocacy has always been an important part of public health. an illustration of this is seen in box 12.4 in changing the law banning birth control in massachusetts in the 1960s. the issue of birth control still casts a heavy burden on women globally owing to religious objections, so this example from the 1960s is still relevant as a political issue both in the usa and in many other countries. community participation can be crucial to the success of an intervention to promote community health. sensitivity to local, religious, or ethnic concerns is part of planning any study or intervention in public health. this does not mean that the national, state, and local health authorities must continuously canvass public opinion, but there is advantage in holding referenda on some issues compared to governmental fiat. the usa has higher rates of fluoridation than most countries, and this is implemented after referenda in each municipality (see chapter 7). in portland, oregon, the city council profluoridation vote in 2012 (new york times, 12 september 2012) was later rejected in the public referendum. portland is the only major american city without fluoridation (portland tribune, 21 may 2013). rationalization of health facilities increasingly means organizational linkages between previously independent facilities. mergers of health facilities are common events in many health systems. in the usa, there are frequent mergers between hospitals, or between facilities linked to hmos or managed care systems. health reform in many countries is based on similar linkages. governmental approval and alteration to financing systems are needed to promote linkages between services to achieve greater efficiency and improve patient care (see chapters 10 and 11). lateral integration is the term used for amalgamation among similar facilities. like a chain of hotels, in health care this involves two or more hospitals, usually meant to achieve cost savings, improve financing and efficiency, and reduce duplication of services. urban hospitals, both notfor-profit as well as for-profit, often respond to competition by purchasing or amalgamating with other hospitals to increase market share in competitive environments. this is often easier for hospital-oriented ceos and staff to comprehend and manage, but it avoids the issues of downsizing and integration with community-based services. vertical integration describes organizational linkages between different kinds of health care facilities to form integrated, comprehensive health service networks. this permits a shift of emphasis and resources from inpatient care to long-term, home, and ambulatory care, and is known as the managed care or district health system model. community interest is a factor in promoting change to integrate services, which can be a major change for the management culture, especially of the hospital. the survival of a health care facility may depend on integration with appropriate changes in concepts of management. in the 1990s, a large majority of california residents moved to managed care programs because of the high cost of fee-for-service indemnity health insurance and because of federal waivers to promote managed care for medicare and medicaid beneficiaries. independent community hospitals without a strong connection to managed care organizations (mcos) were in danger of losing their financial base. hospital bed supplies were reduced in the usa however, the article served to stimulate the legislature to revisit the law, leading to its repeal in 1966, thus allowing use of all methods of birth control. the controversy subsided and women were free to control their own fertility as a result of this advocacy. by diagnosis-related group (drg), rather than on a per diem basis. similar trends are seen in european countries, although in the commonwealth of independent states the number of hospital beds declined between 1990 and 2005-2011 but stabilized at high and inefficient levels (8 beds per 1000 population) compared to the number in western europe, which fell from 5 beds per 1000 in 1990 to 3.4 in 2011, and in some countries to 2 per 1000 population despite increased longevity and aging of the population. there was a shift to stronger ambulatory care, as occurred throughout the industrialized countries despite an aging of the population. these trends were largely due to greater emphasis on ambulatory surgery and other care, and major medical centers responded with strategic plans to purchase community hospitals and develop affiliated medical groups and contract relationships with managed care organizations to strengthen their "market share" service population base for the future. the new payment environment and managed care also promoted hospital mergers (lateral integration) and linkages between different levels of service, such as teaching hospitals with community hospitals and primary community care services (vertical integration). vertical integration not only is important in urban areas, but can serve as a basis for developing rural health care in both developed and developing countries. the district hospital and primary care center operating as an integrated program can provide a high-quality program. hospitalcentered health care, common in industrialized countries, has traditionally channeled a high percentage of total health expenditures into hospital services. over recent years, there has been a reduction in hospital bed supply in most industrialized countries, with shorter length of stay, more emphasis on ambulatory care, improved diagnostic facilities, and improved outcomes of care (see chapter 3). expenditures on the hospital component of care have come down to between 40 and 45 percent of total health expenditures in many countries, with a growing proportion going to ambulatory and primary care, and increased percentages to public health. this shift in priorities has been an evolutionary process that will continue, but requires skilled management leadership, grounded in health systems management training and epidemiological knowledge, and skilled negotiating skills to foster primary care and health promotion approaches both within the organization and in relation to outside services, especially preventive services. this shift in policy direction will be fostered in implementation of the ppaca (obamacare), discussed in chapters 10 and 13. managed care systems or accountable care organizations (acos) will integrate hospital and community care and try to limit hospital care by strengthening ambulatory and primary care, and especially preventive care. this will have both economic and epidemiological benefits, but will depend on skilled management to understand and lead in their implementation. much of the rationale for these changes is discussed in the literature and summarized in a 2012 report from the us institute of medicine, entitled "best care at lower cost". this report calls for overhauling the health system in a continuous evolution based on evidence and lessons learned from decades of innovative care systems and research into their workings. the health system needs to relate to other community services with a shared population orientation (institute of medicine, 2012). norms are useful to promote efficient use of resources and promote high standards of care, if based on empirical standards proved by experience, trial and error, and scientific observation. norms may be needed even without adequate evidence, but should be tested in the reality of observation, experience, and experiment. this process requires data for selected health indicators and trained observers free to examine, report, and publish their findings for open discussion among colleagues and peers in proceedings open to the media and the general public. normative standards of planning are the determination of a number per unit of population that is deemed to be suitable for population needs; for example, the number of beds or doctors per 1000 population or length of stay in hospital. many organizations based on the bureaucratic model used norms as the basis for planning and allocation of resources including funding (see chapter 11). this led to payment systems which encouraged greater use of that resource. if a factory is paid by the number of workers and not the number and quality of the cars produced, then management will have no incentive to introduce efficiency or quality improvement measures. if a district or a hospital is paid by the number of beds, or by days of care in the hospital, there is no incentive to introduce alternative services such as same-day or outpatient surgery and home care. performance indicators are measures of completion of specific functions of preventive care such as immunization, mammography, pap smears, and diabetes and hypertension screening. they are indirect measures of economy, efficiency, and effectiveness of a service and are being adopted as better methods of monitoring and paying for a service, such as by paying a premium. general practitioners in the uk receive additional payments for full immunization coverage of the children registered in their practices. a block grant or per capita sum may be tied to indicators that reflect good standards of care or prevention, such as low infant, child, and maternal mortality. incentive payments to hospitals can promote ambulatory services as alternatives to admissions and reduce lengths of stay. limitations of financial resources in the industrialized countries and even more so in the developing countries make the use of appropriate performance indicators of great importance in the management of resources. pay-for-performance is a system of paying for health services developed in the uk for paying general practitioners, with apparently satisfactory results. it is now widely used in the usa. it is defined as "a strategy to improve health care delivery that relies on the use of market or purchaser power. agency for healthcare research and quality (ahrq) resources on pay for performance (p4p), depending on the context, refers to financial incentives that reward providers for the achievement of a range of payer objectives, including delivery efficiencies, submission of data and measures to payer, and improved quality and patient safety" (agency for healthcare research and quality, 2012) . more than half of commercial hmos are using pay-for-performance. recent legislation requires the medicare and medicaid programs to adopt this approach for beneficiaries and providers. as commercial programs have evolved during the past 5 years, the categories of providers (clinicians, hospitals, and other health care facilities), number of measures, and dollar amounts at risk have increased. this method of payment is likely to be promoted in the affordable care act implementation to improve quality and control cost increases in us health care (see chapters 10, 11, and 13). payfor-performance has also been adopted in other countries trying to improve quality of care, such as macedonia (lazarevik and kasapinov, 2012) . social marketing is the systematic application of marketing alongside other concepts and techniques to achieve specific behavioral goals for a social good. initially focused on commercial goals in the 1970s, the concept became part of health promotion activities to address health issues where there was no current biomedical approach, such as in smoking reduction and in safe sex practices to prevent the spread of hiv. social marketing was based initially on commercial marketing techniques but now integrates a full range of social sciences and social policy approaches using the strong customer understanding and insight approach to inform and guide effective policy and strategy development. it has become part of public health practice and policy setting to achieve both strategic and operational targets. a classic example of the success is seen with tobacco reduction strategies in many countries using education, taxation, and legislative restrictions. other challenges in this field include risk behavior such as alcohol abuse through binge drinking, unsafe sex practices, and dietary practices harmful to health. philanthropy and volunteerism have long been important elements of health systems through building hospitals, mission houses, and food provision, and other prototype initiatives on a demonstration basis. this approach has been instrumental in such areas as improved care and prevention of hiv, immunization in underdeveloped countries, global health strategies, and maternal and child health services. during the late twentieth and early twenty-first centuries, a new "social entrepreneurship" was initiated and developed by prominent reform-minded former us president bill clinton, microsoft's bill gates, and the open society institute of george soros. the rotary club international has been a major factor in funding and promoting the global campaign to eradicate poliomyelitis. this has promoted integration and consortia for the promotion of acquired immunodeficiency syndrome (aids) prevention and malaria control in many developing countries. the global alliance for vaccine and immunization (gavi) is a us-based organization which links international public and private organizations and resources to extend access to immunization globally. it includes the united nations children's fund (unicef), who, bilateral donor countries, the vaccine industry, the gates foundation, and other major donors. gavi has made an important contribution to advancing vaccine coverage and adding important new vaccines in many developing countries and regions. these organizations focus funds and activities on promoting improved care and prevention of hiv, tuberculosis, and malaria, along with improved vaccination for children, reproductive health, global health strategies, technologies, and advocacy. these programs generate publicity and raise consciousness at political levels where resource allocations are made. a central feature of these programs is the promotion of "civil society" as active partners in a globalized world of free trade, democracy, and peace. specific initiatives included promoting improved largescale marketing of antiretroviral drugs for the treatment of hiv infection, including price reduction so that developing countries can offer antiretroviral treatment, especially to reduce mother-to-infant transmission. programs have branched out into the distribution of malaria-preventing bed nets, provision of low-cost pharmaceuticals, marketing drugs for the poor, desalination plants, solar roof units, lowcost small loans, and cell phones, mainly in africa. another form of social entrepreneurship that has gained support in the private sector is proactiveness in environmental consciousness to address issues raised by the environmental movement, and public interest for environmental accountability. the automobile industry is facing both public concern and federal legal mandates for improved gas mileage as opposed to public demand for larger cars. hybrid cars using less fuel have been successfully introduced into the market for low-emission, fuel-efficient cars, and electric cars are gradually entering the field. public opinion is showing signs of moving towards promoting environmentally friendly design, marketing, and purchasing practices in energy consumption, conservation practices, and public policy. public opinion and the price of fuel will play a major part in driving governments to legislate energy and conservation policies to address global warming and damage to the environment, with their many negative health consequences. however, such changes must work with public opinion because of the sensitivity of consumers to the price of fuel. in addition, when food crops, such as corn, are used to produce ethanol for energy to replace oil, then food prices rise and consumers suffer and respond vigorously. corporations adopt policies of environmental responsibility in part because of public relations and partly because of potential liability claims. much of the planning and financial costs of offshore petroleum and gas drilling is spent on safety measures to protect the environment. the explosion in 2010 at a british petroleum site in the gulf of mexico, off the coast of texas and louisiana, caused massive pollution and environmental damage, and resulted in the us government being awarded us$4.5 billion against bp for cleanup and damages. the reputation of the corporation suffered and some executive officers lost their positions. thus, corporate social responsibility can be seen as self-interest. new models of health care organization are emerging and developing rapidly in many countries. this is partly a result of a search for more economical methods of delivering health care and partly the result of the target-oriented approach to health planning that seeks the best way to define and achieve health objectives. the developed countries seek ways to restrain cost increases, and the developing countries seek effective ways to quickly and inexpensively raise health standards for their populations. new organizational models that try to meet these objectives include district health systems, managed care organizations (mcos) and accountable care organizations (acos), described in greater detail in chapter 11. critical and basic elements of a health system organization are shown in figure 12 .12. new initiatives are part of the growth and development of any organization or health service system, as needs, technologies, resources, and public demand change. identification of issues and decisions to launch new endeavors or projects to advance the state of the art, to address unmet needs, or to meet competition are part of organizational responsibility, in the public sector to meet needs, and in the private sector to remain competitive. in developing and developed countries, many ngos provide funding from abroad for essential services that a government may be unable to provide. such projects focus on issues directed from the head offices in the usa or europe of the funding source or management offices for specific vertical programs which are often not fully integrated with national priorities and programs. however, these need coordination and approval by the local national government agency responsible for that sector of public service. new projects run by ngos may run in parallel to each other, or to state health services as uncoordinated activities. governmental public health agencies have responsibility for oversight of health systems and can play a leadership and regulatory role in coordinating activities and directing new programs to areas of greatest national need. the public health agency may also seek funding to launch new pilot or specific needs programs. the agency may introduce a new vaccine into a routine immunization program in phases, pending government approval and funding to incorporate it as a routine immunization program based on evaluation of the initial phase. an example is the introduction of haemophilus influenzae type b vaccine in albania in 2006, which was funded by gavi for 5 years based on a study and proposal including a cost-effectiveness study (bino s, ginsberg g, personal communication, 2007) . proposals for health projects by ngos or private agencies need to be prepared in keeping with the vision, mission, and objectives of the responsible governmental agency, with ethics review and community participation. a project proposal should include why the project is important, its specific goals and objectives, available or new resources, and the time-frame required to achieve success (box 12.5). it should describe the means proposed to accomplish the goals, and how the proposed program will impact the community, providing recommendations for follow-up and/or further action. the introduction of the project proposal outlines the current state of the problem and the case for action. it should describe existing programs which address that issue, with proposed collaboration, and expansion or improvement of programs, but avoiding duplication of services. background information needs to relate the project to the priorities of the prospective funding organization. the objectives should follow the acronym "smart": specific, measurable, achievable, relevant, and time-based. this term, originally used for computer disc self-management, has been adapted as a current form of mbo from the 1950s and 1960s. the project objectives should be feasible and the expected results of the project should be based on the stated objectives. organizations: behavior, structure, process. new york: mcgraw-hill/ irwin; 2003. the proposed funding agency expects convincing evidence of how this program will be effective, efficient, practical, and realistic. this information is presented in the activities section, which also needs to address the resources that will be needed to implement the program such as the budget for staff, supervison, training, management, materials (vaccines, syringes, equipment, ongoing supplies and others), transportation, and costs of premises. after completing the activities section, a realistic and achievable work plan and time-frame are required. well-planned projects have monitoring and evaluation criteria. monitoring follows the performance of the program, documenting successes, failures, and lessons learned, as well as expenditures. evaluation guidelines of the program define the methods used to assess the impact of the project and whether the project was carried out in an effective and efficient manner, and may be required periodically throughout the life of the project. the most difficult issue is sustainability. a project funded by an ngo is usually time limited to 3-4 years and the survival of the program usually depends on its acceptability and the capacity of government to continue it. thus, evaluation becomes even more crucial for the follow-up of even successful short-term projects. harm reduction programs include tackling hiv in drug users, reducing maternal-child hiv transmission, tobacco control programs, and reducing levels of obesity in schoolchildren. sustainability and diffusion of positive findings to wider application are important challenges, especially to global health. even in high-income countries, diffusion of best practices is often slow and fraught with controversy and inertia. examples of this slow or non-diffusion of evidence-based public health include the failure of most european countries to harmonize salt fortification with iodine or total indifference to flour fortification with folic acid to prevent neural tube defects (see chapters 6 and 8). public health work within departments or ministries of health or local health authorities operates at a disadvantage in comparison with other health activities, especially hospitals, pharmaceuticals, diagnostics, and medical care. the competition for resources in a centrally funded system is intense, and the political and bureaucratic battles for funds may pit new immunization agents or health promotion programs against new cancer treatment drugs or scanners, and this is very often a difficult struggle. the presentation of program proposals for new public health interventions requires skill, professionalism, good timing, and the help of informed public and professional opinion. allocation of resources is decided at the political level in a tax-based universal system, while even in a social security (bismarckian) system where funding is through an employee-employer payroll deduction, additional funding from government is essential to keep up with the continuing flow of new modalities of treatment or prevention. public health is handicapped in portraying the costs and benefits of important interventions, leaving new programs with insufficient resources, including the staffing and administrative costs (e.g., office space, phone service, transportation costs), which are essential parts of any public health program. portraying the cost of the new proposed program should be based on the total population served, not just the specific target population for a new program; that is, it should be represented as a per capita cost. similarly, projected benefits should extrapolate the results from other areas, such as pandemic or avian flu or severe acute respiratory syndrome (sars), and the likely impact on the target geographic area and its population. public health has prime responsibility for monitoring the health status of the population as well as in preventing infectious and non-communicable diseases and injuries, preparing for disasters, and many other functions. this role requires an adequate multidisciplinary workforce with high levels of competencies. this topic is discussed extensively in chapter 14. canada's experience with the sars epidemic in 2003 led to a reappraisal of public health preparedness and standards. this, in turn, led to the establishment of the national public health agency of canada, which is mandated to develop standards and practices to raise the quality of public health in the country and especially to prepare for possible pandemics. the agency issued standards of competency for public health personnel and fostered the development of regional laboratories, and schools of public health were developed across canada. core competencies for program planning implementation and evaluation are seen in box 12.7. health care systems throughout the world are being scrutinized because of their growing costs in relation to national wealth. at the same time, techniques for evaluating health care with respect to appropriateness, quality, and resource allocation are being developed. these techniques are multifactorial since they must relate to all aspects of health care, including the characteristics of the population being served; available health care resources; measures of the process and utilization of care; measures of health care outcomes; peer review, including quality assessment of health care providers; consumer attitudes, knowledge, and compliance; care provided for "tracer" or sample conditions; and economic cost-benefit studies. evaluation in health care assumes that a health care system and the providers of health care within that system are responsible and accountable for the health status of the population. it must, however, recognize that health services are not the sole determinants of health status; social, economic, and cultural factors also play key roles. a comprehensive approach to evaluation in health care is described in chapter 3. many of the components that are available in health care systems exist, while others that remain to be developed are discussed. evaluation is an integral part of a comprehensive health care system, in that the components of evaluation must be built into any national system. as long as rationality is expected of health care, evaluation is an essential element of the overall system (tulchinsky, 1982) (see chapter 3). the purpose of management in health is the improvement of health, and not merely the maintenance of an institution. separate management of a variety of health facilities serving a community has derived from different historical development and funding systems. in competition for public attention and political support, public health suffers in comparison to hospitals, new technology and drugs, and other competitors for limited resources. the experience of successes in reducing mortality from both non-infectious and infectious conditions comes largely from public health interventions. medical care is also an essential part of public health, so that management and resource allocation within the total health sector are interactive and mutually dependent. the new public health looks at all services as part of a network of interdependent services, each contributing to health needs, whether in hospital care or in enforcing public health law regarding; for example, motor vehicle safety and smoking restriction in public places. separate management and budgeting of a complex of services results in disproportionate funds, staff, and attention being directed towards high-cost services such as hospitals, and fails to redirect resources to more cost-effective and patient-sensitive kinds of services, such as home and preventive care. however, reducing the supply of hospital beds and implementing payment systems with resources for early diagnosis and incentives for short stays have changed this situation quite dramatically in recent decades. the effects of incentives and disincentives built into funding systems are central issues in determining how management approaches problem solving and program planning, and are therefore important considerations in promoting health. the management approach to resolving this dilemma is professional vision and leadership to promote the broader new public health. thus, managers of hospitals and other health facilities need broad-based training in a new public health in order to understand the interrelationships of services, funding, and population health. managers who continue to work with an obsolescent paradigm with the traditional emphasis, regardless of the larger picture, may find the hospital non-competitive in a new climate where economic incentives promote downsizing institutions and upgrading health promotion. defensive, internalized management will become obsolete, while forward-looking management will be the pioneers of the new public health. this may be seen as a systems approach to improve population and individual health, based on strategic planning for immediate needs and adaptation of health systems in the longer term issues in health. examples of national planning that cut across health and social services include national insurance policies and the provision of new services to meet rising needs, as shown for alzheimer's disease, in france since 2001 (box 12.8) and in the usa since 2011 (box 12.9). health care is one of the largest and most important industries in any country, consuming anywhere from 3 to nearly 18 percent of gnp, and still growing. it is a service, not a production industry, and is vital to the health and well-being box 12.7 core competencies for program planning, implementation and evaluation management, from policy to operational management of a production or a service system. creative management of health systems is vital to the functioning of the system at the macrolevel, as well as in the individual department or service. this implies effective use of resources to achieve objectives, and community, provider, and consumer satisfaction. these are formidable challenges, not only when money is available in abundance, but even more so when resources are limited and difficult choices need to be made. modern management includes knowledge and skills in identifying and measuring community health needs and health risks. critical needs are addressed in strategic planning with measurable impacts and targets. public health managers should have skills gained in marketing, networking, data management, managing human resources and finance, engaging community partners, and communicating public health messages. many of the methods of management and organization theory developed as part of the business world have become part of public health. these include defining the mission, values and objectives of the organization, strategic planning and management, mbo, human resource management (recognizing individual and professional values), incentives-disincentives, regulation, education, and economic resources. the ultimate mission of public health is the saving of human life and improving its quality, and achieving this efficiently with high standards of professionalism and community involvement. the scope of the new public health is broad. it includes the traditional public health programs, but equally must concern itself with managing and planning comprehensive service systems and measuring their function. the selection of targets and priorities is often determined by the feasible rather than the ideal. the health manager, either at the macrolevel of health or managing a local clinic, needs to be able to conceptualize the possibilities of improving the health of individuals and the population in his or her service responsibility with current and appropriate methods. good management means designing objectives based on a balance between the feasible and the desirable. public health has benefited greatly from its work with the social sciences and assistance from management and systems sciences to adapt and absorb the new challenges and technologies in applied public health. the new public health is not only a concept; it is a management approach to improve the health of individuals and the population. for a complete bibliography and guidance for student reviews and expected competencies please see companion web site at http://booksite.elsevier.com/9780124157668 bibliography electronic resources glossary of managed care terms national association of public hospitals and health systems world health organization, the health manager's website pay for performance (p4p): ahrq resources dr. deming: the american who taught the japanese about quality achieving a high performance health care system with universal access: what the united states can learn from other countries improving the effectiveness of health care and public health: a multi-scale complex systems analysis framework for program evaluation in public health biological and chemical terrorism: strategic plan for preparedness and response. recommendations of the cdc strategic planning workgroup a framework for program evaluation. office of the associate director for program -program evaluation developing leadership skills patterns of ambulatory health care in five different delivery systems capacity planning in health care: a review of the international experience. who, on behalf of the european observatory on health systems and policies strategic management of health care organizations social media engagement and public health communication: implications for public health organizations being truly "social crossing the quality chasm: a new health system for the twenty-first century future of the public's health in the 21st century best care at lower cost: the path to continuously learning health care in america behavioral interventions to reduce risk for sexual transmission of hiv among men who have sex with men cd001230. available at the wisdom of teams: creating the high-performance organization social marketing: influencing behaviors for good the interaction of public health and primary care: functional roles and organizational models that bridge individual and population perspectives the powers and pitfalls of the payment for performance three skills every 21st-century manager needs total quality management as competitive advantage: a review and empirical study making the best of hospital pay for performance the public health approach to eliminating disparities in health public health systems and services research: building the evidence base to improve public health practice united states innovations in healthcare delivery a call to action: lowering the cost of health care reduced mortality with hospital pay for performance in england practical challenges of systems thinking and modeling in public health public health: essentials of public health health united states the funding organization will want to know what will be the expected product of the program in measurable process (e.g., immunization coverage) or outcome indicators (e.g., reduced child mortality). projections will be based on the intended activities and known outcomes of other past programs with similar goals in the same or other countries (environmental scan), and should be supported by a review of local and international literature on the topic. the activities section of a proposal should include a timeline of the intended actions and a description of activities based on best practices. the expected outcomes, monitoring and evaluation, and justification are all part of the presentation (box 12.6). the following utility standards ensure that an evaluation will serve the information needs of intended users: l identify and engage stakeholders, including relevant government agencies, people or communities involved in or affected by the evaluation, so that their needs and concerns can be addressed. l develop and describe the program. l focus the evaluation design with ethical standards and review requirements respected.l gather credible evidence -the people conducting the evaluation should be trustworthy and competent in performing the evaluation for findings to achieve maximum credibility and acceptance. information collected should address pertinent questions regarding the program and be responsive to the needs and interests of clients and other specified stakeholders.l justify the conclusions -the perspectives, procedures, and rationale used to interpret the findings should be carefully described so that the bases for value judgments are clear. l ensure sharing and use of information and lessons learned -evaluation reports should clearly describe the program being evaluated, including its context and the purposes, procedures, and findings of the evaluation so that essential information is provided and easily understood. substantial interim findings and evaluation reports should be disseminated to intended users so that they can be used in a timely fashion to encourage follow-through by stakeholders, to increase the likelihood of the evaluation being used.l standards of a project should focus on scientific justification, utility, feasibility, propriety, and accuracy. l a program in this context includes: -direct service interventions -community mobilization efforts -research initiatives -surveillance systems -policy development activities -outbreak investigations -laboratory diagnostics -communication campaigns -infrastructure building projects -training and education services -administrative systems and others. title page -name of project; principal people and implementing organizations; contact person(s); timeframe; country (state, region); target group of project; estimated project cost; date of submission.l introduction -provides project background including the health issue(s) to be addressed, a situational analysis of the health problem, the at-risk and target populations, and existing programs in the community; includes an international and national literature review of the topic with references. budget -estimated cost of expenditures, including human resources, activities, running costs, and overheads for project and evaluation. l monitoring and evaluation -what evidence will be used to indicate how the program has performed? what plan is recommended for periodic follow-up of project activities (including timeline and measures) to implement lessons learned from positive or negative outcomes, and use of resources? how efficient and effective is the project? l conclusions -what conclusions regarding program performance may be drawn? what conclusions regarding program performance are justified by comparing the available evidence to the selected standards? l reporting -report the project to the key stakeholders and public bodies; publication in peer-reviewed journal if possible.l justification -why is this project important and timely, and how will implementation benefit health of the community?core competencies are essential knowledge, skills, and attitudes necessary for the practice of public health. they transcend the boundaries of specific disciplines and are independent of program and topic. they are the building blocks for effective public health practice, and the use of an overall public health approach.generic core competencies provide a baseline for what is required to fulfill public health system core functions. these include population health assessment, surveillance, disease and injury prevention, health promotion, and health protection.the core competencies are needed to effectively choose options, and to plan, implement, and evaluate policies and/ or programs in public health, including the management of incidents such as outbreaks and emergencies.a public health practitioner is able to: l describe selected policy and program options to address a specific public health issue l describe the implications of each option, especially as they apply to the determinants of health and recommend or decide on a course of action l develop a plan to implement a course of action taking into account relevant evidence, legislation, emergency planning procedures, regulations, and policies l implement a policy or program and/or take appropriate action to address a specific public health issue l demonstrate the ability to implement effective practice guidelines l evaluate an action, a policy, or a program l demonstrate an ability to set and follow priorities, to maximize outcomes based on available resources l demonstrate the ability to fulfill functional roles in response to a public health emergency. of the individual, the population, and the economy. because health care employs large numbers of skilled professionals and many unskilled people, it is often vital to the economic survival of small communities, as well as for a sense of community well-being.management includes planning, leading, controlling, organizing, motivating, and decision-making. it is the application of resources and personnel towards achieving targets. therefore, it involves the study of the use of resources, and the motivation and function of the people involved, including the producer or provider of service, and the customer, client, or patient. this cannot take place in a vacuum, but is based on the continuous monitoring of information and its communication to all parties involved. these functions are applicable at all levels of an estimated 600,000 french people lived with dementia; half were diagnosed and one-third were receiving treatment; 75 percent of people with alzheimer's disease were living at home; 50 percent of all nursing home residents lived with some form of dementia; a day's care cost €60 while full-time residency in a nursing home ranged between €3000 and €4600. l identify the early symptoms of dementia and refer people to specialists. l create a network of "memory centers" to enable earlier diagnosis. "for millions of americans, the heartbreak of watching a loved one struggle with alzheimer's disease is a pain they know all too well. alzheimer's disease burdens an increasing number of our nation's elders and their families, and it is essential that we confront the challenge it poses to our public health. " on 4 january 2011, president barack obama signed into law the national alzheimer's project act (napa), requiring the secretary of the us department of health and human services (hhs) to establish the national alzheimer's project to: l create and maintain an integrated national plan to overcome alzheimer's disease (ad). l coordinate alzheimer's disease research and services across all federal agencies. l accelerate the development of treatments to prevent, halt, or reverse the course of ad. l improve early diagnosis and coordination of care and treatment of ad. l improve outcomes for ethnic and racial minority populations that are at higher risk for ad. l coordinate with international bodies to fight ad globally. the law also establishes the advisory council on alzheimer's research, care, and services and requires the secretary of hhs, in collaboration with the advisory council, to create and maintain a national plan to overcome ad. research funds are being allocated towards that end. education for health providers, strengthening of the workforce, for direct care and for public health guidelines for management of ad, education and support for caring families, addressing special housing needs for ad patients and many other initiatives are proposed in this comprehensive approach to a growing public health problem. enhancing public awareness is crucial to achieve the goals set out in this plan. key: cord-027695-ptp62krc authors: cavatorto, sabrina; la spina, antonio title: conclusions: still risking implementation gaps date: 2020-06-25 journal: the politics of public administration reform in italy doi: 10.1007/978-3-030-32288-5_6 sha: doc_id: 27695 cord_uid: ptp62krc continuity and differentiation elements in the administrative reform cycles are considered from the perspective of implementation, and its gaps. the reformist seasons of the last 25 years mostly shared the same principles, goals and weaknesses in their implementation phases. the vicious cycle of administrative reforms has not been defused: the widespread disagreement in the policy community against further waves of comprehensive reform is an indicator of a persistent low degree of practical implementation, and rather of the prevalence of contradictory effects with respect to reforming principles and goals, like the performance evaluation introduced by statute in 2009. creeping resistance within administrations is a constant presence, apparently unaffected by several waves of normative innovation. notwithstanding the recent call for “concreteness” of the five-star movement and league “government of change”, we find that the lack of empirical, in-depth organizational analysis gives the real measure of current complexity to be dealt with. public policies-including administrative reforms-are more and more influenced by several supra-national, cross-national and global factors which are not in control of nation states. some international organizations (such as the organisation for economic cooperation and development (oecd), the united nations, the world bank and the international monetary fund) can suggest or-under certain conditions-request certain reform paths. when among such institutions there is consensus about some contents of the reforms that are deemed necessary (as it was apparently the case on new public management (npm) in certain historical phases), the influence that they can exert is supposed to become stronger (la spina 2020) . private bodies, such as rating agencies or institutional investors, can also have an impact on domestic choices (although they are more interested in budgetary and economic policies). other ratings-like those of the doing business reports published by the world bank-are more focused upon the attractiveness and investment climate exhibited by each country, which are of course tied, among other things, to the functioning of public administrations (pas). international economic competition is a driver for change in regulation and public administration. domestic economies are dependent on the contingencies of global economic cycles. this is especially evident during downturns, which can offer unusual opportunities for certain reform packages concerned with structural adjustment. as we have seen in this book, such packages can cover administrative reforms. international epistemic communities, composed of scholars, think tanks and experts of a given field, can also be rather influential (haas 1992; la spina 2020) . policy options which are considered successful tend to be imitated abroad. ideas are relevant. "perhaps the single most important source of ideas and policy innovation are practices that prevail elsewhere. the fact that a policy has worked-or at least is perceived to have workedsomewhere can be a powerful reason to copy it" (rodrik 2014: 204) . certain public bodies (such as independent regulators) participate in international networks and therefore feel a pressure to conform to what is estimated normal or dutiful by their foreign peers. the same can happen with the directors of some ministerial departments. the most important exogenous influence, which often amounts to a constraint, is exerted by the eu. this happens through legislation, budgetary discipline, cohesion funds, action programmes and recommendations. for instance, the directives on public procurement were intended to have a direct impact on a crucial activity of public bureaucracies. the imposition of austerity as a response to the risks of default after the 2008 recession affected the size of public employment, salaries, performance pay, recruitment and collective contracts (di mascio et al. 2013; di mascio and natalini 2014) . cohesion policy addresses administrative modernization and capacity-building through the supply of dedicated financial resources (european commission 2017a, b). some eu action programmes, like the one on administrative burdens measurement and reduction, were also focused on administrative culture and innovation (european commission 2012). we might go on at length. what was sketched above is enough to show that also with regard to administrative reform certain salient sources, factors and decision-making powers are more and more exogenous to nation states. furthermore, it could be argued that, generally speaking, such external pressures push towards policy convergence, defined by knill (2005: 768 ; see also holzinger and knill 2005; drezner 2005 ) as "any increase in the similarity between one or more characteristics of a certain policy (…) across a given set of political jurisdictions (…) over a period of time. policy convergence thus describes the end result of a process of policy change". we can also suppose that the more some domestic policy is divergent from the exogenous accepted standard, the more forceful will be the pressure aimed at obtaining convergence. overall, when the emphasis is on the need to recover reliability and budgetary discipline, performance improvement could understandably become less central (kickert et al. 2013; di mascio et al. 2013) . it must also be said that reforms inspired by public management in certain countries were less successful than expected (de vries and nemec 2013; pollitt and bouckaert 2017; van dooren and hoffmann 2018) . internal resistances (also by professionals, see bezes et al. 2012 ) as well as domestic societal features can play a role in retarding or distorting convergence (jordan 2005; lenschow et al. 2005) , which cannot be complete and immediate. nevertheless, convergent policies in some of the most important sectors are increasing, in connection to the diminishing sovereignty of nation states. all the exogenous influences just mentioned-ranging from the oecd's recommendations to the contents of the merida convention, and of course to what was asked by the eu-played a role in the italian case. however, some of the developments that we have hitherto highlighted also tell a different story, as we showed in the various chapters of this book. with regard to anti-corruption, for example, convergence was actually absent until 2012. with regard to public procurement, eu legislation notwithstanding, the merloni law was first suspended and then superseded in 2006 by a code of public contracts which was much less convergent. the new code adopted in 2016 was not welcomed by everybody. then it has been partially revised and is undergoing other substantial changes. as far as public managers and performance evaluation are concerned, we have witnessed a gap between the official provisions of several legislative decrees and the real functioning of flesh-and-blood public bureaucracies. the "end result" of all these efforts is still far away from convergence. even when it was possible to use cohesion funds which had been earmarked for administrative modernization, they were sometimes granted on the basis of formal, extrinsic compliance (the official adoption of certain norms), without checking whether real administrative behaviours had been actually modified. this "taught" concerned bureaucrats a perverse lesson: that certain requirements could have been circumvented, that symbolic innovation was sufficient and that it was possible to get away with it, or even being rewarded for it (la spina 2007) . we can conclude that, at least with regard to administrative reforms, and more specifically to performance improvement, italian policymaking in the last three decades has exhibited an official endorsement of their need, but did not managed to guarantee the actual fulfilment of convergence. why? this is the question we continue to ask. it is precisely to the implementation failures that this conclusive chapter is devoted. the vicious cycle of administrative reforms in italy is also explained with a focus on the most recent developments from the 18th legislature (started on 23 march 2018). the commitment of the five-star movement and the league "government of change" to achieve the "concreteness" of existing regulation regarding the pa governance, instead of changing it in a comprehensive way, has been hence especially taken into consideration. the coalition agreed on an independent prime minister, although close to the five-star: the private law professor giuseppe conte, almost unknown to the public. yet, the same commitment to the "concreteness" of the implementation, in continuity with previous waves of comprehensive administrative reforms, was confirmed by the five-star-democratic party (pd) coalition, which unpredictably succeeded the sudden collapse of the conte i government (august 2019), letting prime minister conte survive in his role (conte ii). with regard to the pa, the "government of change" (1 june 2018-4 september 2019) intended first of all to intervene on the failure of implementing existing laws. in italy some administrations implemented innovations, but others did not. this is why the modernization rate of the italian pa as been judged low, because of the lack of homogeneity of implemented reforms, as well as the heterogeneity of the administrations themselves. the latter makes regulatory efficiency a complex problem per se. according to the new minister for public administration of the conte i cabinet, giulia bongiorno (a lawyer, centre-right mp from 2006 to 2013, elected in 2018 to the senate with the lega, but as an independent), no new "maxi" reform was needed, just the application of the "reasonable" and "shared" laws that already exist in italy: "i want to be an implementing legislator" 1 ; "some good things have been done, and i don't reject them because they were made by the left; instead, where i see gaps, i have to intervene". 2 hence the issue of putting norms into practice more clearly entered the policy agenda: since "practical implementation walks on the legs", the m5s-league government's "concreteness" law 3 has addressed the problem of pa's different speeds in the way it established a team of specialized subjects (unit of "concreteness", i.e. nucleo) for the improvement of pa organizational efficiency. on that account, the nucleo is now aimed at supporting the diffusion of best practices from "top-level" administrations-"that in fact there are"-to those in difficulty (ibidem). moreover, the nucleo is expected to act as a "tutor" who intervenes where needed to recommend organizational remedies. consequently, the nucleo's added value should first be on the side of organizational action: "the nucleo of concreteness has the sole purpose of helping, collaborating, 132 indicating corrective actions (…) it does not want to interfere, it wants to help" (ibidem). however, the "concrete" actions for the efficiency of public administrations have been not identified on a case-by-case basis. rather, they are expected to be described in a three-year action plan (i.e. the "plan of the concrete actions"), prepared, centrally, by the department of public administration. 4 anyhow, the information available has not allowed to clarify what the specific contents of this plan will be and how materially the activation of the nucleo will be realized. in addition, according to the current legislation, the same policy objectives must be already included in the "performance plan", which is to be drawn up by each pa (see chap. 5), obligation to which still not all pas fulfill. 5 besides, hardly same level of operational detail could be reached by a plan only elaborated at the central level. the nucleo's profile of organizational support risks then to be sacrificed within a top-down regime, which includes disciplinary-although presented as "not punitive"-actions. as a matter of fact, in order to overcome administrative inertia and contrast organizational inaction, in the minister's design "a managerial responsibility has to be triggered". afterwards, "it is right that those who do not comply (with the nucleo's recommendations), they will suffer the consequences", namely being registered in a "black list" of defaulting administrations (ibidem). at present, it is also worth mentioning that the compliance of the administrative action is (ex post) supervised by the "inspectorate for the public function", acting together with the financial guard (guardia di finanza), the military police force under the authority of the ministry of economy and finance ( fig. 6 .1 6 ). the nucleo should instead verify (in itinere, and consequently recommending corrective operational measures) the practical implementation of the provisions on organization and functioning, especially to promote transparency and digitalization, as well as on human resource management, in order to increase the efficiency of public administrations. but uncertainty about the boundaries of the two bodies' scope of intervention, due to risk of overlaps, was object of widespread criticism during the parliamentary examination, even from the institutional and stakeholders' hearings. 7 strong opposition was also expressed by the regions and the autonomous provinces in the unified conference, because of the perceived excessive interference in the organization of regional offices. 8 on the contrary, accompanying organizational actions have been widely welcome. 9 anyhow, on the nucleo's functions, the minister bongiorno spoke of "so much confusion in interpretation, at times perhaps wanted", and insisted that it differs from the inspectorate, with which it is albeit expected to cooperate. to "transfer" the organizational models, "we need someone surely doing the job" (idibem). yet, after all, nothing has been specified as for the expertise of the nucleo's components. not surprisingly, for the many critical issues raised, the new pa minister of the conte ii government, the 36-year old fabiana dadone (five-star), has announced that she does not exclude to put the profile of the nucleo under re-consideration. 7 see for instance the court of auditors' opinion (senate 26/11/2018). 8 extraordinary meeting 31/10/2018. 9 among the most recent participatory contributions, the "forumpa 2018 white paper on pa innovation" recommends a "legislative moratorium" in favour of forms of organizational change sustained by the digital transformation (https://librobianco-innovazione-pa2018-final.readthedocs.io/it/latest/). the fight against absenteeism likewise has become a confirmed political priority. at any rate, the connection between the "presence in service" of public employees and the effective improvement in the quality of administrative action is unlikely to be obvious. therefore, even though it was ascertained that the progressive introduction of biometric surveys and the video surveillance of accesses does not violate-but just under certain conditions 10 -the privacy policy, as the public discourse about the introduction of "fingerprints" in the public employment had also complained, the new rule does not cope with the issue of the effectiveness of pa organizational structure: without appropriate attributions of competences and a systematic performance evaluation by the top managers, that actually are critical issues, public employees should be "fixed" in their place to do what? on grounds of which motivations? 11 measures have been withal put in place so as to accelerate "targeted recruitments" in the following areas: digitalization, organization and administrative simplification, quality of services, structural funds management and investments, public contracts, audit and inspecting activity, public accounting and financial management. "if we make targeted, intelligent assumptions, it means restarting the pa, those offices that are sometimes deprived of personnel, as in the very crucial field of justice" (ibidem). accordingly, the generational turnover is confirmed, 12 as the renzi government already planned (see chap. 3), but within the new budgetary constraints established by the m5s-league executive, which imposed another block on recruitments (albeit defined as "technical", i.e. just for accounting purposes by reason of eu fiscal coordination) for the duration of almost the whole year 2019 (table 6 .1), aside from the following sectors: law enforcement agencies, the fire corps, school and health. 13 simplified procedures to speed up recruitments ( fig. 6. 2) have been also mentioned, making the public concorsi more frequent (yearly), thus abolishing the rankings of eligible candidates, to be called in the longer run. as 10 as made clear by the italian data protection authority (garante per la protezione dei dati personali), heard in the senate (26-27/11/2018). 11 the same minister admits that if "we let them in, we have to make them work; yet, in the meantime, we have not cut resources, but invested" (parliamentary hearing, joint chambers 13/2/2019). 12 the costs should cover 100% of retirements. 13 in the same areas, the 100% turn over's quota is not applied; sector regulations already in force prevail. already established by the madia reform, 14 the concorsi must be centrally managed by the department for pa, which is asked-now by the law, not "solely" by ministerial guidelines, which actually are said to be well functioning 15 -to provide a recruitment website (portale del reclutamento), with candidates' individual electronic pages (fascicolo del candidato). reasonably this rule, transparency oriented, has been relaunched by the new minister dadone. within certain limits, but again in great continuity with the existing norms (i.e. law 114/2014), mobility has been encouraged, both territorially and between public institutions, that operate at the international level 14 in april 2018, minister madia approved the "guidelines on recruitment procedures", published on the official journal-gazzetta ufficiale-on 12/6/2018. the minister's directive executed the legislative decree 75/2017, which modified the 2001 consolidate text on public employment (see chaps. 3 and 5). 15 as shown by a certain number of hearings during the parliamentary debate. too, or between the public and private sectors. a similar web portal was devoted in 2015 to the same purpose 16 ; however, it seems no more updated now. on the same point, we can conclude that if so many websites are launched but not systematically implemented, they for sure will increase a sense of fragmentation instead of transparency. in terms of implementation, one of the most significant effort, confirmed over time since the bassanini's reform cycle in the late 1990s, has been simplification. 17 by definition, as an institutionalized policy goal, simplification could-and should-be a never-ending story, featuring systemicwide challenges, now more intensively reframed through the digitalization imperative. "administrative simplification is an obscure activity (…), which will never be a topic for parliamentary debates, (…) or press coverage; yet, it must absorb the greatest energy nowadays, from central to local administrations" (ibidem). this component of madia's inputs, in continuity with the past, was explicitly shared by minister bongiorno and, after her, also agreed by minister dadone (see also table 6 .2). at the same time, the conte i executive continued on the path of legislative simplification passing "urgent provisions on support and simplification for businesses and the pa" through the decree-law 135/2018, then converted into law 12/2019, which was highly contested by the oppositions due to its prominent omnibus profile, for example even including a norm about the extension of the alitalia loan, strictly linked to the budget law approved shortly before. besides, always in connection with the 2019 budget law, on 28 february 2019, the council of ministers approved further ten delegating bills providing simplifications and codifications in a vast number of policy fields (public procurement, civil code and military order comprised). the scope of this legislative delegation was very ambitious and described a medium-long term perspective. being the parliamentary exam at the very beginning at the time of our analysis, it was too early to make assessments or forecasts. anyhow, it deserved to be pointed up that nearly all hearings during the parliamentary discussions relating to administrative reforms in the 18th legislature, along with the public discourse that emerged from most of the speeches in the 2019 forumpa-that is, the italian annual convention 16 https://www.mobilita.gov.it/home.php. 17 the monitoring of the "agenda for simplification 2015-2017" estimated that 98% of actions were realized (as reported by the economic and financial document, def, 2018). see also http://www.funzionepubblica.gov.it/semplificazione and http://www.italiasemplice.gov.it/. devoted, since 1990, to the topic of innovation in the public sector 18expressed scepticism towards any new legislative proposal that ignores a targeted and in-depth analysis of public organizations, as the madia law even established, again without adequate implementation so far. in her impetus towards concreteness, minister bongiorno extensively recognized that "the legislator's limit is the effectiveness of what is done inside (emphasis added) the offices: this is the public manager's job". 19 on that account, "the reform of reforms" still consists of innovating the top management profile and effectively working to redesign the public employees competencies and skills. "i want passionate managers, (…) making others grow, (…) soliciting, helping, rewarding, and sharing objectives" (ibidem). not a different attitude was expressed by the minister dadone in 18 in 2019, events were about "pa as a creator of public value" (https://forumpa2019. eventifpa.it/it/2019/02/13/forum-pa-2019-creare-valore-pubblico/). since a while, the forumpa narrative has been articulated along five keywords: digitalization, rejuvenation, simplification, communication and merit. the context of action is that of sustainability. 19 parliamentary hearing, joint chambers 13/2/2019. as known, the projects are co-financed: 75% by the eu and 25% by the member state source: http://www.pongovernance1420.gov.it/en/programme/action-strategy/documents/ the beginning of her mandate. she stressed -and soon realized -a more consultation-oriented approach aimed at "re-starting from the people, and the work organization". 20 under the necessary umbrella of digital transformation, 21 the search for convergent policy solutions in that no longer postponable direction makes us understand the attention that has been recently devoted, although in the "legalist" italian pa, to behavioural-oriented approaches. 22 actually, the effects of such a vogue require to be concretely monitored in the medium term, as the empirical science of administration would properly suggest. owing to the long politicization's tradition of italian pa, human resources management was the area where the gap between reform design and implementation has been larger (ongaro and valotti 2008) . 20 parliamentary hearing on the programmatic lines of the minister fabiana dadone (chamber of deputies 11/12/2019). the conte ii cabinet has inaugurated the first governmental italian digital platform devoted to public consultation and participation processes (https://partecipa.gov.it/). 21 pillars of this policy strategy have been granted by structural funds in the context of the operative programme (op) on "governance and institutional capacity" for the 2014-2020 period (http://www.pongovernance1420.gov.it/en/): the department of pa is responsible for the digital agenda and modernization processes, such as simplification or performance evaluation (for instance, the project riformattiva supports the implementation of innovative actions at the territorial level; cloudify noipa is focused on the digital transformation of human resources management at all level of government; the delivery unit is devoted to simplification and red tapes' cuts); the ministry of justice is especially delegated to the enforcement of civil justice, as also recommended by the european council (see chap. 2). 22 under the gentiloni government, a working group was formed at the presidency of the council of ministers with the purpose of developing a research plan to apply behavioural sciences in the management of administrative processes (secretary general decree of 13 september 2017). to confirm the perspective, the national school of administration (sna) began offering courses on modern "nudging" techniques to public civil servants and managers, and also funded university masters on that topic. furthermore, a course on "cognitive sciences and behavioral pa" has been launched as an action under the op governance 2014-2020 in the field of cohesion policy to promote "a better interaction between administrations and the beneficiaries of the interventions, with the final recipients, and among public employees involved in the management of the operational tools" (http://www.pongover-nance1420.gov.it/it/rafforzare-le-politiche-di-coesione-attraverso-il-behavioural-insights/). a central pillar of the madia reform was that on the top management, whose proposal was however rejected by a sentence of the constitutional court in 2016 (see chaps. 3 and 5), then not reformulated by the gentiloni government. why is this component of the pa reform so difficult to achieve? it is well known that large part of italian top executives did not agree on the new perspective, 23 for corporate, clearly defensive 24 reasons that the current government would seem to welcome more openly. 25 this means that bureaucratic politics consistently matters when reforms are at issue. for the time being, ten years after its introduction (legislative decree 150/2009, see chap. 5), the performance evaluation system has been widely considered "the" administrative reforms' failure. it is diffusely believed that "the reform of reforms" has to be restarted from there. again, the then minister bongiorno in front of the parliament: "the top management reform is one of those things that had no results so far. the effort now is to create evaluators who are third parties. (…) everyone will say that in some way we want to create a sort of control over the top management; (…) but the reform is not a punishment! (…) if the objectives are homemade, they do not make any sense; at the same time, if evaluations are mild, they cannot really help the pa; (…) if i had an excellent pa, then i would understand all these 100% (i.e. full score)" (ibidem). but this is not the situation. the problem of performance is thus first of all organizational, before than individual, having produced direct wage effects, hence having been 23 a joint document raising doubts about the draft of the madia law's implementing decree was-among others-presented in october 2016 to the committee for constitutional affairs of the chamber of deputies by two associations of public managers, together with the association nuova etica pubblica. particularly critical also a document published in july 2017 by nuova etica pubblica, which complains about the madia reform as a policy failure (https://www.eticapa.it/eticapa/documento-ufficiale-di-nuova-etica-pubblica-sul-fallimentodelle-riforme-amministrative/). 24 on "defensive bureaucracy", see battini and decarolis (2019) . an interesting research panel was carried out by fpa (may 2017) "burocrazia difensiva. come ne usciamo?" (https:// www.forumpa.it/riforma-pa/burocrazia-difensiva-come-ne-usciamo-una-ricerca-di-fpa/). 25 as it can be seen from the hearings realized at the beginning of the exam of the senate bill 1122 "delegation to the government for pa improvement" (april-may 2019): the professional associations expressed themselves in a quite auspicious way (http://www.senato.it/leg/18/bgt/schede/ddliter/51407.htm#). mostly-and ineffectively-characterized as self-referential. 26 on the contrary, a "competent" organization could encourage a clearer distinction between political direction and high-level managerial (i.e. technical) activity, although the two are in the field intricately linked. indeed, the historian of public administration melis (2015: 284-285) suggests that the privatization of employment relationships brings with it a direct and personal connection between managers and their political principals (see also battini and cimino 2007; antonelli and la spina 2010) . this tendency can be either accepted as unavoidable or curtailed (like the italian constitutional court did in the past). one of the objectives of new public management (npm) was that of "reasserting political control over the administration" (van de walle 2018: 2). therefore, in principle politicization of top managers is not incompatible with a rather high degree of managerial autonomy. pollitt and bouckaert (2017: 58-60) nevertheless argue that in some countries such as canada, new zealand, and the united kingdom (which used to be among the most well-known champions of npm), the careers of "mandarins" in ministerial departments most of the times are neatly separated and relatively insulated from politics. when explaining variation in european public sectors, van de walle (2018) found that in italy, as well as in spain and portugal, perceived managerial autonomy is the lowest, but he also confirmed that "(the lack of) managerial autonomy and politicization-i.e. regular political interference-are different concepts" (ivi: 13). 27 indeed, he found clear findings related to structural factors, such as organization's type and size, and the hierarchical position of the respondent, even in cases where the interaction frequency with the responsible minister is high. additionally, already ongaro and valotti (2008) added confidence to the fact that behavioural factors may influence differences in the implementation of public management reforms, although in turn influenced by 26 among others, a critical assessment of the current situation by enrico deidda gagliardo (member of the performance technical committee at the department of pa) taking part in the forumpa 2019, together with marco de giorgi (director general, office for performance evaluation, department of pa) (https://forumpa2019.eventifpa.it/it/ event-details/?id=8521). 27 the data set contains information on top managers in central governments (see the cocops project already mentioned in chap. 1: http://www.cocops.eu/). "managerial autonomy" refers to autonomy that managers perceive to have in making decisions about issues like budget allocations, hiring and firing, and contracting out (ivi: 3). the administrative tradition and the politico-administrative context dominating the country. according to melis (2015: 291-292) , administrative reforms in italy were often and mostly seen in terms of "personnel policy, systematically ignoring (…) organization, service productivity, relationships with citizens". moreover, in his view the choices made were frequently instrumental "to clientelistic, electoral and anyway contingent objectives": there are too much public managers, insufficiently shielded against political interferences, and de facto unaccountable with regard to objectives, results and merit. as we have seen in the previous chapter, all these topics were actually tackled several times, at least since 1993. however, it cannot be denied that the real functioning of italian public bureaucracies still exhibits the critical aspects mentioned by melis. particularism, inefficiency and resistance to change tend to coalesce, obstructing the path of performance improvement. as we have already shown, republican italy lacked for decades an anticorruption policy, which was launched and then strengthened in parallel with the creation and institutionalization of an independent authority. even when the given status quo is resistant and blocked, it is possible, under certain conditions, to imagine and actually use an exogenous lever for change. this does not necessarily mean that the changes produced will always be appropriate, or long-lasting, as suggested by the recent decisions concerning the code of public contracts and the relevant anac's competences. the planning of anti-corruption has many elements in common with the planning and evaluation of performance. nevertheless, as we have seen, performance evaluation was taken away from the authority for public administration. unlike what later became the anac, the civit had been initially established without powers. however, the same had happened in the past also in the cases of other independent bodies. over time they gradually grew stronger and enlarged their range of action. had the civit lived enough time, perhaps it could have gone through a similar path. for instance, it could have tried to homogenize the way similar public organizations design their performance plans, implement them and evaluate the ensuing results. such an approach would, among other things, relieve some of the burdens of performance planning and evaluation, so that the justified complaints of many administrations would be met. as we have seen, an attempt at homogenization was made through the creation of some central commissions for managerial appointments, but it was defeated. the independent bodies for performance evaluation (oivs) were expected to be a crucial lever for performance improvement. however, the way their members are chosen as well as the nature of the principals to which they owe their appointment are not necessarily conducive to independence and expertise. the relevant provisions remained mostly ineffective "because the introduction of performance evaluation tools is mostly left to spontaneous decisions of political echelons, without appropriate supervision, monitoring, and sanctioning in case of failed implementation" (merloni 2018: 92) . the oivs have to confront politicians, public managers, civil servants, endowed with resources that range from funds to legal powers, or political influence. if they were chosen by an independent authority and were directly answerable to it, this could enhance their level of both independence and technical competence, by shielding them vis-àvis some particularistic pressures stemming from the administrations that they are supposed to evaluate. it might even be discussed whether a new independent authority could also administer sactions and exert powers of direct intervention, like the avspp proposed in 2006. independent bodies as a policy tool have advantages and disadvantages. in some political systems, they enjoy a certain legitimization by public opinion and political elites. the opposite can be true for some other systems, at least in certain periods of their political history (la spina and majone 2000) . understandably, having to address the extremely resilient italian bureaucracies, an authority for public administration would need a robust and continued popular and political support, with regard to both its tasks and its independency. this used to be unlikely (although not impossible) in the past. on the one hand, it is very difficult to forecast whether such a support will be found in the future. on the other, the italian administrative system (like many others) was seriously shaken by the covid-19 emergency. this has had devastating consequences, but at the same time has increased and sharpened citizens' expectations towards the public sector. therefore, a favourable occasion has emerged for wideranging and impactful reforms, that could interrupt the long chain of mistakes made in the past. i dirigenti pubblici e i nodi del cambiamento la dirigenza pubblica italiana tra privatizzazione e politicizzazione. rivistra trimestrale di diritto pubblico l'amministrazione si difende. rivista trimestrale di diritto pubblico new public management and professionals in the public sector public sector reform: an overview of recent literature and research on npm and alternative paths austerity and public administration: italy between modernization and spending cuts the ghost of crises past: analyzing reform sequences to understand italy's response to the global crisis globalization, harmonization, and competition: the different pathways to policy convergence action programme for reducing administrative burdens in the eu-final report quality of public administration-a toolbox for practicioners quality of public administration: a toolbox for practicioners. some considerations on managing thematic objective 11 causes and conditions of cross-national policy convergence policy convergence: a passing fad or a new integrating focus in european union studies fiscal consolidation in europe: a comparative analysis introduction: cross-national policy convergence: concepts, approaches and explanatory factors politiche per il mezzogiorno e riforma amministrativa politiche pubbliche. analisi e valutazione lo stato regolatore when the birds sing. a framework for analysing domestic factors behind policy convergence fare lo stato per fare gli italiani costituzione repubblicana, riforme amministrative e riforme del sistema amministrativo. diritto pubblico public management reform in italy: explaining the implementation gap public management reform. a comparative analysis-into the age of austerity introduction: epistemic communities and international policy coordination when ideas trump interests: preferences, worldviews, and policy innovations explaining variation in perceived managerial autonomy and direct politicization in european public sectors the palgrave handbook of public administration and management in europe key: cord-278707-36rr56oe authors: tandon, ajay; cain, jewelwayne; kurowski, christoph; dozol, adrien; postolovska, iryna title: from slippery slopes to steep hills: contrasting landscapes of economic growth and public spending for health date: 2020-07-05 journal: soc sci med doi: 10.1016/j.socscimed.2020.113171 sha: doc_id: 278707 cord_uid: 36rr56oe identifying ways to increase public spending on health is critical for the achievement of universal health coverage. while policymakers and donors often look at available options for increasing public spending for health in the medium-term, examining trends and drivers of past growth can help countries elucidate important lessons and to anticipate changes in the future. this note analyzes trends in inflation-adjusted per capita public spending for health vis-à-vis economic growth within and across a sample of 150 countries over the 2000-2017 period. since 2000, per capita public spending for health across lowand middle-income countries has more than doubled. less than one-fifth of this increase, however, resulted from a higher priority for health in government budgets. the remainder was largely due to conducive macroeconomic conditions such as economic growth and increases in total public spending. furthermore, across most countries, a single time trend does not adequately capture the evolution either of economic growth or of per capita public spending on health. instability in growth rates is large for both indicators, revealing distinct episodic patterns. from slippery slopes to steep hills: contrasting landscapes of economic growth and public spending for health abstract: identifying ways to increase public spending on health is critical for the achievement of universal health coverage. while policymakers and donors often look at available options for increasing public spending for health in the medium-term, examining trends and drivers of past growth can help countries elucidate important lessons and to anticipate changes in the future. this note analyzes trends in inflation-adjusted per capita public spending for health vis-à-vis economic growth within and across a sample of 150 countries over the 2000-2017 period. since 2000, per capita public spending for health across low-and middle-income countries has more than doubled. less than one-fifth of this increase, however, resulted from a higher priority for health in government budgets. the remainder was largely due to conducive macroeconomic conditions such as economic growth and increases in total public spending. furthermore, across most countries, a single time trend does not adequately capture the evolution either of economic growth or of per capita public spending on health. instability in growth rates is large for both indicators, revealing distinct episodic patterns. financing; economic growth public financing is essential for making progress towards universal health coverage (uhc), a united nations sustainable development goal (sdg) policy commitment which emphasizes that everyone should have access to quality health services they need and that the use of these services does not expose individuals to undue financial hardship (world bank, 2017) . the focus on both effective service coverage as well as financial risk protection under uhc implies that how countries finance their health systems matters (kutzin, 2012) . financing for health in most low-and middle-income countries (lmics) is dominated by high levels of out-of-pocket (oop) spending, an inefficient and inequitable modality which contributes to foregone care among vulnerable populations and puts them at risk of impoverishment from illness-related catastrophic expenditures. low levels of government revenue generation and low priority for health in government budgets are two key factors contributing to low levels of public spending for health, which, in turn, is one of the primary reasons behind high levels of oop spending in lmics (world bank, 2019) . identifying ways to increase public spending on health is thus critical for the achievement of uhc. while policymakers and donors often look at available options for increasing public spending for health in the medium-term, examining trends and drivers of past growth can elucidate important lessons and help countries anticipate changes in the future. we analyze trends in inflation-adjusted per capita public spending for health vis-à-vis economic growth within and across a sample of 150 countries over the 2000-2017 period using publicly available data from the world health organization's (who's) global health expenditure database (ghed). since 2000, global levels of per capita public spending for health have increased by more than 60 percent (from us$431 in 2000 to us$708 in 2017) with an annual growth rate of 4.0 percent. this was higher than global economic growth of 2.5 percent, implying an income elasticity of per capita public spending on health of 1.6 (per capita gdp is used as proxy for income). this indicates that per capita public spending on health on average grew 60% faster than per capita gdp between 2000 and 2017. to understand the growth dynamics of public spending for health and explain why the income elasticity of per capita public spending for health has been greater than 1, we decompose contributions from three macro-fiscal drivers --economic growth, changes in total public spending, and reprioritization for health --exploiting a macroeconomic accounting identity that captures the relationship between these factors. on average, global comparative data show that both total public spending as well as priority for health increased with economic growth. across most countries, however, a single time trend does not adequately capture the evolution either of economic growth or of per capita public spending on health. instability in growth rates is large for both indicators, revealing distinct episodic patterns. per capita public spending on health was calculated by summing three major subaccounts of health expenditure from their revenue sources: transfers from government domestic revenue finally, countries with population below 600,000 were excluded from the analysis to minimize outliers in the data. public spending for health was converted to real per capita terms using population and inflation numbers derived from variables published in ghed. the total public spending share of gdp was also taken from ghed. the relative contributions to changes in public spending for health over time from a sub-set of factors were analyzed exploiting a key macroeconomic identity that, in any given year t, the following must hold true (tandon et al., 2018) where p is per capita public spending on health in constant local currency unit (lcus), h is health's share of total public spending, e is the total public spending share of gdp, and y is per capita gdp in lcus. taking the logarithmic difference in t+1 versus t (denoted by lowercase with 'hat') of p must mathematically equal the sum of the logarithmic growth rates in health's share of total public spending, of the total public spending share of gdp, and of per capita gdp: although mathematically this identity must hold exactly, empirically it will hold only approximately given data-related measurement errors. this implies that growth in per capita public spending on health ( ̂ ) over a given time period must be accounted for by changes in per capita gdp ( ), changes in the total public spending share of gdp ( ̂ ), and by changes in health's share of total public spending (ℎ ). furthermore, dividing each component of the equation by yields the elasticity of each component with respect to the relative percentage change in national income: this equation shows that the income elasticity of public spending on health ( , ) is 1 plus the sum of the income elasticities of both health's share ( , ) and of total public spending ( , ). hence, if income elasticity of public spending for health is estimated to be greater than 1, this can be due to an increase in prioritization for health and from an increase in the size of public spending either or both of which could themselves be a result of economic growth. following pritchett (2000) , shifts in per capita economic growth trends were estimated by finding the 'breakpoint' year (t * ) that minimized the sum of squared errors over all t: 2000, t is 2017, t * is the breakpoint year chosen subject to the constraint that each segment of the trend covers a minimum of three years (that is, t * -t 0 ≥ 3 and t-t * ≥ 3) and a and b are the intercept and time-trend slope, respectively, where the suffix 1 or 2 represents the estimates before and after the estimated breakpoint. the same method was also applied to capture changes in growth rates of p t across countries. based on this, trend patterns were classified into 10 distinct types depending on the pace of growth before and after break points (table 1) . source/notes: source: authors' classifications based on pritchett (2000) . note: index refers to constant per capita public spending on health using first year as the base year. given the relatively short time period over which cross-country data are available, the method allows for only a single break point. the choice of a minimum of three years is arbitrary and for illustrative purposes only. in country-specific applications of this analysis, where longer time series data may be available, additional break points could be considered. applying the decomposition methodology reveals that, globally, more than half of the increase in per capita public spending on health has been the result of economic growth. this finding is broadly consistent with others in the literature, such as those reported by the global burden of disease health financing collaborator network (2019) and saxenian et al. (2019) . for the remainder, increases in total public spending contributed more than reprioritization across lmics, whereas the reverse was true in hics by a very large margin ( table 2) . some of the largest increases in per capita public spending for health occurred among lmics in the eca and eap regions, including in countries such as armenia, azerbaijan, china, georgia, indonesia, and vietnam. reprioritization accounted for less than one-fifth of the change in public spending for health in lmics, less than half of its contribution among hics. although some countries experienced consistently steady linear growth in both per capita gdp and per capita public spending for health, most showed large shifts in trends often with statistically-identifiable break points that occurred primarily in 2008, the year of the global financial crisis, following which average growth rates declined significantly (table 3 ). figure 1 shows some country examples. a few countries such as ukraine, cote d'ivoire, and china showed the same trend patterns for both per capita gdp and public spending on health ( figure 1 ). however, many countries including madagascar, brazil, kenya, india, indonesia, thailand, and the united states, among others, changed trend patterns, sometimes significantly. for example, economic growth was negative in brazil following 2014, with a per capita gdp landscape that can be characterized as a 'cliff'. during the period, the country also experienced a decline in the total public revenue share of gdp. however, reprioritization efforts combined with a deficit-fueled rise in total public spending protected levels of per capita public spending for health from declining thus leading to a 'plateau' landscape. indonesia was an 'accelerator' for per capita gdp but a 'steep hill' for per capita public spending for health, primarily because priority for health increased in recent years especially after 2014 when a new administration took office. the trend in madagascar changed from being a 'slippery slope' for economic growth to a 'steep valley' for per capita public spending on health: economic growth was relatively stagnant from 2000 to 2017 leading to an almost flat landscape for per capita gdp. volatility in public spending for health prior to the break in trend was primarily a result of changes in priority; and a steady increase in health' share of total public spending is the reason for the 'steep valley' landscape for the latter post-2011. overall, close to 70 percent of all countries in the sample (105 out of 150) showed different trend patterns for per capita public spending on health vis-à-vis economic growth. these differences were due to the intermediating effect of changes in total public spending and prioritization for health. in some cases, the adverse impact of a decline or volatility in per capita gdp was offset by corrective action by both a rise in total public spending and a higher priority for health; in other countries, the impact of changes in income on per capita public spending on health were magnified due to same-direction movements in prioritization and total public spending on health. in general, if the landscapes are ordered by decreasing growth rates following break points as in figure 2 , countries tend to be more likely to lie below the diagonal suggesting some evidence of counter-cyclicity for protecting public spending on health. of the 105 countries with differing landscape patterns, close to two-thirds (70) fall below the diagonal. source/notes: source: authors' analysis using data from who global health expenditure database. note: chart shows concentration of countries per combination of per capita gdp landscape and per capita public spending on health landscape. larger circles indicate higher number of countries. yellow circles indicate countries with the same landscape for both per capita gdp and per capita public spending on health. taking a retrospective data-driven decomposition approach can help countries better understand where realizations in per capita public spending for health have come from --to assess both the potentially additive and 'cancelling out' effects of changes in income, prioritization, and total public spending --and to inform how future trends might be impacted. the decomposition results show that economic growth was the main driver of changes in public spending on health. while the tendency is for changes in per capita public spending on health to go in the same direction as changes in per capita gdp, intermediating effects of changes in total public spending and prioritization for health led to different landscapes between per capita public spending on health and per capita gdp for majority of the countries. such corrective action by both a rise in total public spending and a higher priority for health help mitigate the adverse impacts of a decline or volatility in per capita gdp. thus while country context matters, the importance of economic growth for public spending on health underscores the critical need to situate, integrate, leverage, and proactively manage health financing reforms within a country's overall macro-fiscal context and to emphasize the need for counter-cyclical policies to support per capita public spending for health during economic downturns. on the flip side, the relatively marginal role of changes in priority for increasing public spending for health is notable, especially given how much effort and advocacy has focused on this aspect (african union, 2001; tandon et al., 2014) . these lessons are now even more critical given the current global covid-19 pandemic. based on projections by the imf (2020), the current crisis is expected to result in greater declines in economic growth than the 2008-2009 global financial crisis. the impact on public financing for health will depend on the extent to which expansionary fiscal policies and health reprioritization occurs. it is during these periods that it is particularly important to ensure levels of public financing are protected and increased to maintain effective service coverage and financial risk protection towards uhc. another key point is the diversity of growth trajectories across countries and, especially, the volatility in trends over time. the implications are clear: capturing economic growth or per capita public spending for health with a single growth rate is not the best metric to characterize country experiences. changes in patterns are often in of themselves of interest to highlight reasons behind underlying breaks in dynamics of growth and in assessing potential impact on health systems and sustainability of reforms. further analysis is needed to determine the extent to which the breaks and different landscapes are associated with changes in service delivery and health systems outcomes, including oop spending for health. pritchett (2000) . note: index refers to constant per capita public spending on health using first year as the base year. african union past, present, and future of global health financing: a review of development assistance, government, outof-pocket, and other private spending on health for 195 countries anything goes on the path to universal health coverage? no. bulletin of the world health organization a system of health accounts understanding patterns of economic growth: searching for hills among plateaus, mountains, and plains a quantitative analysis of sources of changes in government expenditures on health intertemporal dynamics of public spending for universal health coverage: accounting for fiscal space across countries. hnp discussion paper reprioritizing government spending on health: pushing an elephant up the stairs? tracking universal health coverage: 2017 global monitoring report high-performance health financing for universal health coverage: driving sustainable, inclusive growth in the 21st century • public spending on health growth largely due to conducive macroeconomic conditions • reprioritization for increasing public spending for health has been marginal • counter-cyclical policies essential for public financing during economic downturns • single time trend not adequate to capture evolution of public spending on health key: cord-263659-9i5qws5h authors: zhao, y.; cui, s.; yang, j.; wang, w.; guo, a.; liu, y.; liang, w. title: basic public health services delivered in an urban community: a qualitative study date: 2010-12-08 journal: public health doi: 10.1016/j.puhe.2010.09.003 sha: doc_id: 263659 cord_uid: 9i5qws5h objectives: to understand the advancements in and barriers to the implementation of measures to improve basic public health services in an urban chinese community. study design: a qualitative study based on semi-structured interviews. interviews were audio-taped, transcribed and analysed using thematic content analysis. methods: in-depth interviews were undertaken with the directors of the management centres for community health services in 15 of the 18 districts in beijing from december 2008 to february 2009. content analysis of the data was completed in may 2009. results: fifteen types of free basic public health services had been delivered in beijing. some were supplied at a low level. an average of £2.38 per person per year was provided for inhabitants since 2008, but demand for funding far exceeded monies available. teams consisting of general practitioners, community nurses and public health specialists delivered these services. the number of practitioners and their low levels of skill were insufficient to provide adequate services for community residents. respondents gave recommendations of how to resolve the above problems. conclusions: in order to improve the delivery of basic public health services, it is necessary for beijing municipal government to supply clear and detailed protocols, increase funding and increase the number of skilled practitioners in the community health services. supplying free basic public health services (individual-based clinical preventive services and population-based public health services) in community settings is of great significance in improving quality of life and promoting social harmony. since 2005, the chinese government has promulgated a series of documents for developing basic public health services. 1e3 these reports mandated that basic public health services would be funded at all levels of governments and be delivered by the nationwide community health services (chs) organizations. 4 on 10 april 2009, the chinese government released a policy statement which enhanced the reforms of the medical and health systems, and which re-emphasized that governmental bodies will offer equitable access to basic public health services for both urban and rural residents. 3 as the centre of politics, economy and culture of china, beijing municipal government attaches extreme importance to and promotes advances in the development of basic public health services delivered in the community. over the past two decades, china has been undergoing a process of economic reform and has been relatively successful. the healthcare system, which had been reformed to suit the market economy, 5 faced multiple challenges: limited financial support from governments; high rates of catastrophic out-of-pocket spending and impoverishment through health expenses; inequalities in health and healthcare utilization; and limited financial protection even among those with insurance (a small minority of the population). 6 due to the above challenges, the old 'three-tiered' hospital system, which involved local neighbourhood hospitals, district-wide secondary hospitals and city-wide tertiary hospitals, was forced to rely on the sales of new drugs and technologies to boost income, which resulted in expensive and inefficient care and strained patientedoctor relationships. 7 the old public health system was the responsibility of dozens of disparate institutes, centres, agencies, bureaus and departments, which resulted in overlapping and sometimes conflicting mission statements and agency mandates. 8 with an increase in life expectancy, increased burden due to chronic diseases, and the challenges of emerging infectious diseases (e.g. severe acute respiratory syndrome in 2003), the chinese government re-examined the public health infrastructure and saw the need for a new public health system to address the many health issues associated with these changes. 5 to minimize overlapping of functions and to increase efficiency, the chinese government consolidated existing institutions into a new agency: the centres for disease control and prevention (cdc). the goal of the cdc is to provide a central public health organization with responsibility for both community and individual health needs. the development of the cdc strengthened the government's role in public health. 5 as public health and primary care share the common goal of improving the overall health of specific populations, it was decided to integrate the two systems by strengthening public health functions in primary healthcare settings. this approach could improve local public health surveillance and reinforce disease prevention and health promotion. 9 in order to resolve the problems of the increasing burden of healthcare expenses and limited access to health services, the chinese government initiated its chs programme in 1997. 4 the 'threetiered' hospital system was replaced by the current 'twotiered' chs centre system. the new system consists of ambulatory care in chs centres and inpatient care in referral hospitals. 7 the main roles of the chs centres are to provide high-quality, affordable, accessible primary health care and public health services to community residents. the scope of services of the chs centres is described symbolically by the chinese government as 'one body, six aspects'. the body is the chs centre. the six aspects consist of basic clinical services, prevention, health education, women and children's care, elderly care, immunizations and physical rehabilitation. 7 the centres integrate western and traditional chinese medicine. in the population-based public health services, there is collaboration between the community health centres and the local cdc. 7 local governments are the main sources of funding for the local cdc and chs centres. the core providers in the chs centres are general practitioners (family doctors), 10, 11 public health specialists and community nurses. these practitioners are responsible for the provision of basic clinical services and for maintaining the wellness of the residents, of all ages, in their communities. 4 in china, a general practitioner is a medical practitioner with recognized general training, experience and skills, who provides and co-ordinates comprehensive medical care for individuals, families and communities. 10, 11 two models are currently being used to train general practitioners in china. the first model is a 3-year general practice postgraduate residency training programme. the second model of education involves retraining the majority of the less-educated doctors currently working in local community health centres, and transforming them into general practitioners. completion certificates are awarded by different organizations, including the central ministry of health, provincial ministries of health and city-level health bureaus. 10, 11 general practitioners typically work in the clinics of chs organizations. when delivering population-based public health services, general practitioners often work in teams with public health specialists, community nurses and other providers. 10, 11 in 2007, in order to implement the chs more effectively, beijing management centre for community health services (mcchs) was established. it is affiliated administratively with beijing municipal health bureau. similarly, a district office of the mcchs is attached to each of the city's 18 district health bureaus. 12 the main responsibilities of beijing mcchs include writing regulations, establishing assessment standards, and organizing practices for the chs while, at the same time, supervising the work of the district mcchss. the district mcchss are responsible for planning, managing and assessing the work performed by all chs organizations in their respective districts. each director of a district mcchs must be familiar with the activities of the chs in his/her district. 12 fifteen types of free basic public health services have been delivered by the chs in beijing since 2006 13 (appendix 1). to date, no research has investigated the implementation of these services in beijing. due to an interest in understanding the status of and barriers to basic public health services in the beijing communities, the authors chose to design a study that would investigate the conceptual frameworks of these services. to that end, all 18 mcchs district directors were approached in order to ascertain their opinions of the quality of the delivery of basic public health services by providers in the chs. sampling consisted of all 18 directors from the 18 mcchs distributed in the 18 districts in beijing. after obtaining their numbers from the telephone book, initial contact was made with them. one director was away on business, one was too busy and declined to be interviewed, and one was unable to be reached, despite multiple calls. semi-structured, in-depth interviews were conducted with the remaining 15 mcchs district directors who were familiar with the work in the chs. interviews were usually carried out in the respondent's work offices. all participants were informed about the purpose of the study and were made aware that they could stop the interview at any point without giving a reason. written informed consent and an agreement for the use of anonymised quotes from the interviews were obtained from all participants. semi-structured, face-to-face, tape-recorded, qualitative interviews, lasting 60e90 mins, were conducted by trained professional interviewers from december 2008 to february 2009. interviewers took extensive notes, in addition to tape recording and transcribing the interviews. the transcripts were reviewed by the research team. analysis and interpretation were reached by consensus, using an iterative process in the research team meetings. the research team was a multidisciplinary group including two community-based medical researchers with qualitative and social research experience, one health administrator from a health bureau familiar with health policy, one family doctor familiar with the chs, two epidemiologists and one masters degree candidate with a family medicine degree. the variety of perspectives of the team ensured a depth of understanding critical to the design of the study and the validity of the results. an interview guide was developed on the basis of references and relevant government documents. the interview questions were open-ended and covered issues about basic public health services, the content of specific services being delivered, funding, types of providers, and general insights of the respondents. qualitative content analysis 14, 15 was used to analyse the data between march 2009 and may 2009. the data consisted of rich text files containing transcripts of the tape-recorded interviews. the team members read all the material through several times to obtain a sense of the whole, and then independently coded transcripts to identify themes by condensing and summarizing the contents. coding differences were resolved after thorough discussion in order to ensure that all perspectives on the themes were represented in the written results. the themes that emerged for the purposes of this report included the content of basic public health services, funding support, providers and recommendations. all of the interviews were included in the analysis; there were no disconfirming cases. the findings relate to three main themes: the content of basic public health services, funding support for basic public health services, and the providers who deliver basic public health services. fifteen types of basic public health services, including 78 specific services (appendix 1), were delivered at different levels in the various districts. among these services, most of the directors considered the establishment of health records, chronic disease management, childhood immunizations and care, maternal care, elderly care, disability and rehabilitation services, and health education to be supplied at high levels. however, the provision of mental health, ophthalmologic, oral health, pest control and endemic disease services were low and sporadic in some communities due to the low level of staff competency for these tasks. in community health information management, community needs assessments were one of the important jobs in the community. the 15 directors agreed that it was often necessary for community needs assessments to be undertaken with the assistance of a special research group due to practitioners' limited research skills in this area. the rates of creation of paper health records for all inhabitants were estimated to be high. at present, the governments have attached importance to the development of electronic health records, and the transformation from paper to electronic records is a slow, stepwise process in the communities: "paper health records have been established for 70% of people in our district, and we plan to complete this work for all our residents by 2010." "the municipal government required chs organizations to establish paper health records for all residents in beijing. a centre provides services to about 30,000e100,000 residents according to the size of a region. in fact, due to health workforce shortages and a small number of revisiting patients, only 30% of established paper records can be followed up and used continuously." "how to continuously and dynamically use these health records, especially those of healthy people, is a 'gordian knot'. a feasible method to resolve this problem may be by using an electronic health record information systems to reduce the time spent on paperwork. the first thing that the governments need to do is to establish the standards of electronic record systems and to make experiments in some districts." regarding the management of communicable diseases, most of the chs organizations' roles are limited to assisting the local cdcs with the completion of tasks such as finding, reporting and follow-up of cases: "however, for responses to emergent public health hazards, chs organizations are playing more and more important roles." the management of chronic, non-communicable diseases is an important job for chs organizations because of the high incidence and deleterious effects of these illnesses. providing optimal health care for persons with chronic conditions is a major concern in the community. beijing municipal health bureau has established a set of guidelines for the management of chronic diseases in community p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 3 7 e4 5 settings e including hypertension, diabetes, stroke and heart disease e and requires general practitioners to use these guidelines when managing chronic diseases. however, deficiencies in continuous professional development and a lack of evidence-based guidelines have created further problems in delivering cost-effective interventions for chronic disease prevention: "the rate of adherence to these guidelines is low due to poor understanding and co-operation. it is necessary to make recommendations for these diseases by means of a process of critical appraisal and consensus building." regarding maternal and child care, the interviewees said that chs organizations assisted local women's and children's health organizations in carrying out related programmes, such as health education and counselling, screening, followup and referral: "childhood immunizations were implemented at the highest rate. it is estimated to be 98e100%." "now, cost-free screenings for breast cancer and cervical cancer for adult women are delivered in some districts according to local government's regulations." when asked about geriatric care and care of persons with disabilities, all 15 directors replied that the instruction of self-care and the management of chronic diseases were emphasized for the elderly, and that exercise sites have been gradually upgraded by supplying physical rehabilitation equipment for disabled people. health education is delivered regularly in the context of supplying other health services. most of the respondents agreed that illness-oriented visits were the most important opportunities to deliver health habit counselling and education to patients, but that this was done less frequently during health maintenance visits. the directors agreed that tobacco cessation counselling and exercise advice were the most common health education topics covered by doctors and patients during illness visits. an average of £2.38 (at a conversion rate of 10.49 rmb to £1) per person per year was provided for basic public health services in beijing since 2008, and each district government supplied different amounts of money for basic public health services in its communities according to its economic level and population. however, basic public health services were often perceived as not being reimbursed proportionately to the amount of time expended, particularly when they were opportunistically added to illness visits. the 15 directors conveyed the opinion that funding for basic public health services was insufficient, and that most of the funds were spent on correlative public equipment and expendable items: "few financial incentives are paid to the individual health services.this may be an important reason why we can't motivate providers to deliver more and higher-quality basic public health services." "there is a higher percentage of migrants in some districts such as chaoyang, fengtai and haidian, but no exact budget support from beijing municipal government for migrants except immunizations. part of public health services, such as health education, communicable diseases management are delivered for migrants in some districts, financed only by local government. the municipal government needs to think over the problems brought by migrants." providers who deliver basic public health services teams consisting mainly of general practitioners, community nurses and public health specialists deliver basic public health services in the community. in addition to supplying medical care, general practitioners are required to delivery cost-free clinical preventive services for individuals and families, and population-based public health services (appendix 1). their roles include being exemplars for health; providing assessments; serving as educators, counsellors and evaluators; and making referrals when necessary. public health specialists, who serve as recorders of health data as well as health educators, are responsible for public health services for populations in their communities. community nurses mainly assist general practitioners and public health specialists. "basic public health services often were actually delivered by allied health professionals who may be more effective than physicians in initiating and carrying out many public interventions." due to the broad scope of basic public health services and limited financial incentives, providers felt that they were under great stress and harried by many competing demands for their time. it is unrealistic to expect that basic public health services would be improved by placing additional burdens on providers without removing other demands: "time constraints and the short supply of public health service providers are barriers to the delivery of prevention. furthermore, there are considerable gaps in knowledge and experience about public health among community providers. most of them don't realize the importance of delivering public health services for residents in community. individuals charged with making policy recommendations and increasing the delivery of basic public health services must acknowledge this fact." medical staff in community settings often complained that community members for whom they were responsible did not trust them as these clinicians had lower levels of knowledge and skill than specialists. as a result, community members are often reluctant to accept basic public health services: "young people especially, who seldom see general practitioners, do not know clearly which basic public health services are supplied by chs organizations. as a result, they often do not trust and refuse these community-based services, so patient noncompliance is one of the chief constraints to the improvement of basic public health services." the directors complained that some public health services, such as aspects of mental health care, pest control and endemic disease management, should have been supplied by other organizations but were passed off on the chs. as staff competency for these tasks is low, the quality of these services is low as a consequence. basic public health services delivered in the community should be creative, adaptive and responsive to local needs and expectations, including those of patients, community, local healthcare institutions, staff and doctors. 16 it is necessary for beijing municipal government to further elucidate the content of basic public health services and define the priorities in which services need to be delivered according to the needs of local practices, their patients and their communities: "certainly, it is difficult for medical staff in the community to deliver so many public health services with high levels of quality . the governments should prioritize the delivery of services according to patients' risk factors and preferences, practical considerations and financial budget." beijing municipal government is planning to increase funding for basic public health services to £4 per person in 2010. the 15 directors considered that this was still insufficient and advised that the municipal government should increase providers' salaries and subsidies. for example, an additional duty hour allowance scheme should be brought forward, under which health workers would be allowed to work extra hours and receive pay to augment their salaries: 17 "besides payment, of course, some changes in the process and organization of the providers' work are also part of the solution to the problem of the under-provision of basic public health services.a useful solution to attract more community residents to see general practitioners would be to increase the proportion of medical reimbursement for chs services." recruiting more competent medical staff there were 16.33 million residents and 5.55 million migrants in beijing in 2007. in 2008, the total number of medical staff in the entire beijing community was 24,740 (source: beijing statistical bureau, 2008). 33 of these, 3451 were general practitioners, 2299 were public health workers (including 765 public health specialists) and 4667 were nurses. staffing patterns differed from district to district. however, there was consensus among the directors that more medical staff need to be allocated to chs organizations. there is a large disparity between general practitioners and specialists in salary and opportunities for promotion. many doctors and nurses with better educational backgrounds or higher professional titles prefer to work in hospitals. 4 it is difficult to recruit competent medical staff in the community. the directors advised that the governments can attempt to attract better qualified doctors to work in the chs by raising salaries, providing more opportunities to participate in continuing medical education programmes and academic conferences, and shortening tenure periods for promotion to higher professional titles. in addition, emphasis was placed on the need to increase team work among chs workers or between chs providers and hospital-based specialists. china has made great efforts to improve the health of its huge population, and has had considerable success in this endeavour. for example, longevity has increased. compared with 35 years in 1949, life expectancy had increased to 73 years in both sexes in 2006 (source: ministry of health of china, world health organization, 2008). 34,35 however, excessive healthcare costs and inconvenient access to health care are still major healthcare problems in china. 4 in order to resolve these problems, china has initiated a new approach 3 which includes improving primary healthcare facilities and offering equitable access to basic public health services across the country. many provinces and cities have followed these regulations and are devoted to developing core communitybased public health services. accordingly, beijing municipal government has drawn up a series of protocols 18à20 to support basic public health services for its residents. as the tie that links district governments and chs organizations, the 18 district mcchss are at the front line of implementation of the plan to deliver basic public health services in community settings. this study found much valuable information by interviewing the directors of the mcchss. the chinese government is supplying nine types of basic public health services, including 21 specific services, at no cost for all people since 2009 according to its announcement. 3 since 2006, chs organizations in beijing have supplied more basic public health services for residents than those required by the national plan, and basic public health services are regarded as part of a core mission in general practice. however, the delivery of some of these basic public health services was at lower levels of quality than is desirable. this finding is consistent with the reports of other researchers about preventive services delivery in other countries. 16, 21 in general, locally tailored interventions are more likely to be adopted into the usual routines of practice than interventional approaches that are dependent on outside stimuli (such as financial incentives), 22 or which impose practice tools and approaches developed elsewhere. 23 it is imperative to undertake more research to find ways to make these improvements. 24 according to a 2009 policy statement, 3 the chinese government and local governments at all levels will provide financial outlays that are not less than £1.43 per person per year for basic public health services for all chinese people in 2009, and increase subsidies to achieve universal insurance coverage and to assure every citizen equal access to affordable basic health care. 25 year. the budget in beijing is £2.38 per person per year since 2008; however, beijing chs centres are required to deliver more basic public health services than their counterparts in other provinces. the deficiency in funding has become such a problem that some basic public health services cannot be implemented effectively in beijing. the municipal government is now assessing how much money should be devoted to basic public health services on the basis of its funding capability and the demands of stakeholders. in addition, migrants need to be recognized as a specific target group for health promotion, prevention and health care, 27 and the governments should provide additional funding for them. these findings are consistent with research 28 which points out that multidisciplinary practice teams are key to delivering basic public health services in community settings. successful teams are created through formulating inter-related goals, identifying measurable outcomes, systematizing routine tasks of care, defining provider tasks and roles explicitly, and providing appropriate training. 27 a document published by the state council of china in 2006 29 mandated that the allocation rate for medical staff working in the chs should reach the level of two to three general practitioners and nurses per 10,000 residents, and one public health specialist per 10,000 residents by 2010. in beijing, the allocation is one general practitioner per 3000 residents, one nurse per 25,000 residents and one public health specialist per 2000 residents. 20 in fact, the above allocation rates have not yet been met, especially since the demand for much of the scope and quality of public health services has increased. in addition, the low levels of chs providers' knowledge and skills 4 is a major problem. as a result, basic public health services are often only provided in response to patient requests or obvious needs in beijing; services thus tend to be reactive rather than proactive. it may simply be unrealistic to expect community providers to deliver a comprehensive package of basic public health services along with the many competing demands of providing direct clinical care. 21 in view of the reasons mentioned above, beijing municipal government is planning several programmes to improve the service capabilities of the chs providers. these include partial changes in the structure, roles and functions of the teams; incentives to attract more medical graduates to work in community settings; redistribution of tertiary hospital doctors to chs organizations; reemployment of retired doctors in the chs; and the provision of financial support and opportunities for younger doctors to get better continuing medical education. 4 the roles and experiences of both medical staff and their patients also impact on health promotion activities. the community resident/patient is not a passive participant in the process of receiving basic public health services, and many residents look to providers for guidance and direction in the prevention of diseases. 30 favourable interaction between providers and patients is critical to the effectiveness and efficiency of the delivery of basic public health services, because in some types of preventive services, the patient's contribution may ultimately be more significant than the provider's role (e.g. weight loss, smoking cessation, reduction of alcohol use, adherence to medical regimen). 30 people with insurance can access other services which are not free of charge in chs organizations. in fact, people with insurance prefer to visit doctors in hospitals to chs organizations. in order to attract more people to visit the chs, chs organizations are required to supply acceptable services by decreasing drug prices and increasing the proportion of medical reimbursement. 31 beijing municipal government is currently devoting significant funding to publicizing basic public health services in the community by means of various media, and is encouraging residents with common diseases to see general practitioners. this exploratory study provides in-depth examinations of the status and barriers of basic public health services provided in community practices. interviews were carried out and analyzed by a multidisciplinary group in order to maintain the validity and meaningfulness of the results. purposeful sampling was used to enhance external validity or transferability. 32 however, the findings must be interpreted in the context of the study's limitations. the data were crosssectional in nature. the possibility that the non-responding directors were different from the 15 interviewed directors can not be excluded. the study examined basic public health services from the perspective of supervisors, who do not themselves provide direct primary medical care. it did not examine the broader frame of basic public health services in the community and overall population levels. the fact that all the data for this study were collected in one city may call into question its generalizability to other locales. however, the choice of beijing as the site for data collection has particular significance to healthcare service delivery in china because the nation's capital was one of the first cities to comprehensively implement the chs reforms of 2006, and thus has had the longest experience with them. in addition, beijing has traditionally served as a national test site for reforms of the chs. accordingly, the authors recommend that further research should be undertaken on the delivery of basic public health services with larger sampling from community providers from other cities in china. this qualitative study suggests that the emphasis of beijing municipal government on the delivery of basic public health services in community settings is an important effort, but the specific parameters for these services should be clarified, the quantity and quality of staffing must be addressed, sufficient time for provision of services must be allowed, and sufficient funding must be provided. the authors believe that major reforms of the healthcare system in beijing and china are needed to address these problems. the state council of the people's republic of china. the guidelines of development of community health services in urban areas the state council of the people's republic of china. the 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analysis: an introduction to its methodology the content analysis guidebook online delivery of clinical preventive services in family medicine offices factors influencing resource allocation decisions and equity in the health system of ghana suggestions for promoting of community health services in beijing beijing municipal health bureau. the implementing suggestions of training the human resources in general practice the suggestions for strengthening human resource staffing in community health services organization direct observation of rates of preventive service delivery in community family practice a qualitative study in rural and urban areas on whether e and how e to consult during routine and out of hours sustainability of a practice-individualized preventive service delivery intervention public health in primary care trusts: a resource needs assessment china's health care reform: a tentative assessment department of the health care for women, children and communities, ministry of health of china challenges of change: a qualitative study of chronic care model implementation consequences of international migration: a qualitative study on stress among polish migrant workers in scotland ministry of health of the people's republic of china. the distribution standards of human resource staffing and community health services organization settings economic incentives and physicians' delivery of preventive care: a systematic review people's republic of china: ministry of labour and social security. the suggestions of encouraging people with health insurance to get chs services qualitative evaluation and research methods investigation reports of community health services in beijing 3 follow-up 10.4 intelligence, dental, hearing and vision screenings 10.5 growth and development assessment, monitoring and counselling 10.6 psychological development counselling 10.7 health status assessments 10.8 nutritional counselling 10.9 communicable diseases reporting and management in preschools 10.10 disinfection management in preschools 11. maternal care (women's care) 11.1 public awareness and professional education, providing health advice and support to young mothers 11.2 establishing records 11.3 examination of early pregnancy 11.4 perinatal high-risk management 11.5 follow-up of the prenatal and postpartum periods 11.6 prenatal/postpartum care 11.7 referrals 11.8 gynaecologic diseases, breast and cervical cancer screenings 12. family planning 12.1 education and consultation 12.2 provision of information on contraception 12.3 financing contraception 12.4 surgery for birth control 13 help people to develop their understanding and skills to improve their own health 15.2 raising public awareness of the early symptoms of diseases 15.3 reduction in inappropriate antibiotic use 15.4 multitopic health promotion campaigns 15 centre for disease control and prevention the authors wish to thank liguang sun for his help in coordinating work, gang liu for supplying some policy information for the interviews, min liu for sharing her expertise in the interview guide, qiongying wang for her help in organizing the data, and kenneth kushner and o. daniel smith for their astute editorial suggestions. the authors would also like to thank the participating directors for their contributions to this project and their commitments in the study. r e f e r e n c e s medical ethics committee of capital medical university. none declared. none declared. free basic public health services delivered in community health services organizations in 15 districts in beijing since 2006. key: cord-257571-4ujw0mn1 authors: price, alex; schwartz, robert; cohen, joanna; manson, heather; scott, fran title: assessing continuous quality improvement in public health: adapting lessons from healthcare date: 2017-02-17 journal: healthc policy doi: nan sha: doc_id: 257571 cord_uid: 4ujw0mn1 context: evidence of the effect of continuous quality improvement (cqi) in public health and valid tools to judge that such effects are not fully formed. objective: the objective was to adapt and apply shortell et al.'s (1998) four dimensions of cqi in an examination of a public health accountability and performance management initiative in ontario, canada. methods: in total, 24 semi-structured, in-depth interviews were conducted with informants from public health units and the ministry of health and long-term care. a web survey of public health managers in the province was also carried out. results: a mix of facilitators and barriers was identified. leadership and organizational cultures, conducive to cqi success were evident. however, limitations in performance measurement and managerial discretion were key barriers. conclusion: the four dimensions of cqi provided insight into both facilitators and barriers of cqi adoption in public health. future research should compare the outcomes of public health cqi initiatives to the framework's stated facilitators and barriers. this study examines the implementation of a public health accountability and performance management system featuring declared principles of continuous quality improvement (cqi) in ontario, canada. cqi is an approach to the management and improvement of organizational services and processes (dilley et al. 2012; nicolucci et al. 2010; radawski 1999) . the approach stands in contrast to quality control and assurance by virtue of its focus on identifying opportunities to improve work processes as opposed to identifying individualized problems and maintaining a status quo (dever 1997) . cqi relies heavily on performance measurement and analysis, as well as on the involvement of leadership and front-line staff in decision-making processes (kosseff 1992; mclaughlin 1987; radawski 1999) . the adoption of quality improvement approaches such as cqi in public health has been a recent and popular development (capacity review committee 2006; corso et al. 2010; dilley et al. 2012) . despite this phenomenon, there exists a limited body of empirical evidence on the impact of quality improvement approaches in public health settings (corso et al. 2010; dilley et al. 2012; mclees et al. 2014; riley et al. 2012) . moreover, valid and reliable frameworks for assessing the integrity and impact of such systems in public health are still emerging. in contrast, development of cqi in healthcare settings has been much more extensive, dating back to the late 1980s (chinnaiyan et al. 2012; radawski 1999; rex et al. 2002) . this study uses shortell et al.' s (1998) four dimensions of cqi as an analytical framework for assessing a public health quality improvement initiative in ontario ( figure 1 ). the four dimensions of cqi represent an assessment framework derived from systematic reviews of empirical healthcare research. in addition, shortell et al.' s earlier research on the cultures of high-performing organizations is used to augment the cultural dimension of the adapted framework (shortell et al. 1995) . for instance, developmental cultures featuring an emphasis on risk-taking, innovation and change, as well as group cultures with strong teamwork and participation, found the greatest success in supporting cqi initiatives. hierarchical and rational cultures that stress bureaucratic norms and narrow definitions of achievement were found to act as barriers. within clinical health research fields, the four dimensions of cqi have received empirical validation (bennett and crane 2001; forsner et al. 2008; solomons and spross 2011) . one example includes forsner et al.' s (2008) controlled study of evidence-based practice in swedish psychiatric care. the investigators examined the implementation of clinical guidelines and found that in the test group, in which the four dimensions of cqi were applied, the reported guideline compliance was significantly greater (p < 0.001) than in the control group. many of the key factors presented in the four-dimensions framework overlap with those emphasized in the public health quality improvement literature. for instance, in their qualitative study of 51 quality improvement initiatives in various public health departments in the us, riley et al. emphasized leadership and appropriate performance measures, which are also highlighted in the strategic and technical dimensions of cqi (riley et al. 2012) . resource inadequacy was a key barrier in mclees et al.' s (2014) study of 74 public health agencies involved with the national public health improvement initiative in the us, as it is in the strategic dimension of shortell et al.' s framework. the importance of training and education in quality-improvement concepts and techniques is also stressed in both the public health literature and the technical dimension (corso et al. 2010) . knowledge transfer and exchange, supportive organizational cultures and the influence of implementers in decision-making outlined in the structural, cultural and strategic dimensions were factors that did not appear to have extensive profiles in the public health literature. the public health system in ontario features several key stakeholders, including the ministry of health and long-term care (mohltc), boards of health and local public health units. the ministry provides provincial stewardship and 75% of core funding for the public health system and is also charged with upholding key legislation. boards of health are municipal and regional public health governing bodies that are responsible for overseeing their corresponding public health units and providing them with the remaining portion of core funding. public health units are the agencies that deliver programs and services in their respective jurisdictions. following the 2003 outbreak of severe acute respiratory syndrome (sars) in ontario, a major reform of the system was initiated by the minister of health (smitherman 2004) . this reform included the declarative adoption of cqi as a means of pursuing performance improvement (capacity review committee 2006; law et al. 2013; mohltc 2008 mohltc , 2011 . cqi adoption has taken the form of a system of accountability and performance management, currently undergoing implementation across 36 municipal and regional public health jurisdictions. the system is composed of (1) the ontario public health standards (ophs), conditions and processes that offer the greatest opportunity for improvement training and information systems needed for quality-improvement efforts mechanisms for facilitating learning through the organization and system which outline the program and service requirements for boards of health and public health units, as well as broad goals and outcomes across each area of public health; (2) accountability agreements between the ministry and boards of health and their public health units that establish specific performance indicators and targets related to areas of the ophs; (3) organizational standards that articulate management and governance requirements for boards of health and public health units; and (4) reporting requirements for the collection and analysis of performance measurement information (mohltc 2008 (mohltc , 2011 (mohltc , 2013 . a mixed-methods approach consisting of key informant interviews and a web survey was used to assess ontario' s public health accountability and performance management initiative. all data collection and analysis were conducted by the principal author with university ethics approval and editorial feedback from co-authors. this study used many elements of a case study approach, such as interview and survey methods and triangulating analysis, which have been used extensively in the field of implementation research (long and franklin 2004; mcdermott 2004; mischen 2006) . research conforming to case study characteristics has also been used to investigate public accountability and performance management (christensen and laegreid 2014; hildebrand and mcdavid 2011) . key informant interviews were conducted in three public health units (sites a, b and c). sample selection was conducted to reflect diverse implementation contexts characterized by both rural and urban service environments, as well as municipal and regional governance. in total, 20 semi-structured key informant interviews of ~1 hour in length were conducted. all interviews were tape-recorded and professionally transcribed in full. public health unit informants included executive, management and specialists in various areas of public health, such as chronic and infectious disease prevention and control. these groups of individuals represent the primary implementers of the province' s public health accountability and performance management intervention. four separate interviews with representatives of the mohltc were also conducted during the same period of data collection. these interviews also followed a semi-structured approach and included individuals directly involved with the development of the province' s quality improvement initiative. interview questions for both public health unit and ministry informants included specific and broad items relating to facilitators and barriers within the four dimensions of cqi. for example, ministry and public health informants were asked to choose characteristics of shortell et al.' s (1995) organizational cultures typology (i.e., teamwork, risk-taking, bureaucratic, efficiency-focused) that best reflected their work environment. broader items included questions asking informants to independently identify what conditions or factors were critical to the success of implementing ontario' s system of accountability and performance management. in addition to key informant interviews, a web survey of public health managers was conducted. targeting all public health managers in each of the province' s 36 health units, recruitment involved contacting each senior executive to seek approval and access to their organizations. in total, 12 public health units agreed to participate and provided contact lists of public health managers; 97 surveys were distributed; 53 questionnaires were returned, providing a response rate of 54.6%. this sample, while only covering one-third of all public health units, represented a near-equivalent distribution of rural, mixed rural and urban, and urban jurisdictions. survey questions, for example, asked about manager discretion, relating to stakeholder decision-making in the strategic dimension; resistance to the intervention, relating to barriers in the cultural dimension; familiarity with components of the initiative, as well as sentiment regarding performance measurement pertinent to the technical dimension; and prospective thoughts on the use (and usefulness) of collected information for performance management and quality improvement. directed content analysis was applied to qualitative data by using an initial coding frame informed by pre-existing empirical and theoretical literature (hickey and kipping 1996; hsieh and shannon 2005; potter and levine-donnerstein 1999) . strong, anomalous themes were then coded separately. established codes were then matched with facilitators and barriers of shortell et al.' s (1998) four dimensions of cqi and analyzed. quantitative data collected using keysurvey.com were recoded for descriptive and bivariate analyses using spss. two-sided fisher' s exact tests (p ≤ 0.05) assessed association because of the small survey sample (daya 2002) . findings from the survey supplement the qualitative data, and all presented findings did not feature missing data (n = 53). the findings in this study are presented across strategic, cultural, technical and structural dimensions and focus primarily on the facilitators and barriers in the four-dimensions framework. overall, evidence of both facilitators and barriers in each dimensional category related to ontario' s system of public health accountability and performance management was apparent. the strategic dimension emphasizes the importance of leadership, communication and inclusion of all stakeholders in decision-making. analysis of interview data found statements of strong leadership expressed by each public health unit. local-level leadership in quality improvement focused mainly on outcomes in priority populations, such as immigrants from countries with endemic infectious diseases. ministry informants identified leadership as a key driver of implementation efforts and acknowledged its strength within public health units, who they felt shared their interest in showing high performance. a site-b informant confirmed this leadership sentiment: "well, we have very strong leadership values of teamwork and participation and participatory management in most of our program areas. i think we are very strong that way." -site-b informant communication relating to the initiative was evident from interview findings identifying various forums for the development and conveyance of its elements. several public health unit informants noted that the province' s new system of accountability and performance management had prompted both internal and external dialogue, which has since increased their understanding of performance objectives and quality improvement more broadly. site-a stood out as a particularly strong example of this: "i think that changing conversations has actually motivated people, not just here in the health unit but even as i talk to people across the province. people like the fact that we are being asked to think about these questions and like the fact that we are going to be held more accountable for actually making a difference." similarly, a large proportion of survey respondents reported moderate or great familiarity with many components of the intervention, including accountability agreements (96%), performance targets (98%) and reporting requirements (94%). implementer inclusion in decision-making was mixed. although many public health unit informants cited participation in committees and working groups related to the cqi initiative, their influence over final decisions varied. in some cases, such as human papillomavirus (hpv) vaccination, public health agents were able to negotiate "more realistic" performance targets. 1 in other instances, local informants noted that the ministry took a hard line in making decisions despite concerns voiced by the field. for example, when a prescriptive ophs protocol for tuberculosis follow-up was challenged because of evidence of alternative best-practice, requests to change the protocol were denied by provincial decision-makers. one ministry informant corroborated this dynamic by stating their interest in the input provided by the field, but the decisions ultimately rested with those holding authority over legislation: so, yes, [consultation] is to enable conversations within a forum that in a sense the majority of the practitioners and the province have agreed to talk about. it' s supposedly a partnership. the province always has the upper hand. (laughing) he who controls legislation has the upper hand." -ministry informant informants in each of the three public health unit interview sites raised concerns over the narrow timelines for achieving targets. one ministry informant noted that many of the targets are set to 100%, matching with the ophs, and that even public health units with low baselines would be expected to meet targets within the first two years of implementation. divergence between the ministry and the field was expressed in terms of provincial and local health priorities. some informants argued that targets set by the ministry such as senior falls were not a priority in their jurisdiction or, generally, a major responsibility of public health because of small target populations and the many determinants outside of their control. although many public health unit informants acquiesced to the province' s quality improvement initiative, each of the local public health unit interview sites placed greater emphasis on internal systems of performance management to foster meaningful performance improvement. for instance, one site-a informant stated: "at this point i feel more confident in our organization' s capacity to demonstrate success in performance management than i do with the two indicators my team has been given within the accountability agreement system from the ministry of health and long-term care." -site-a informant despite the implied and explicitly stated opportunity cost created by misalignment in local and provincial priorities apparent in interview findings, 74% of survey respondents disagreed or strongly disagreed that an emphasis on provincial performance measurement and target achievement would interfere with the quality of program and service provision at a local public health level. resource inadequacy was often referenced in relation to the cost neutrality of the intervention and the current public health funding model, more broadly. while public health unit informants highlighted the quality of their agencies' human resources, some did not consider general resourcing to be adequate for achieving all targets -a phenomenon that was reflected by nearly one-third of surveyed public health managers. issues of increased burden on public health units to show compliance with provincial targets and fulfill local priorities were, in some cases, compounded by rapidly expanding local populations that the current public health funding model does not compensate for. for example, one site-b informant explained: "i think that both financial and human resources, i think for most if not all boards of health [our] reach is beyond our grasp … [our] population increases five to ten thousand a year. basically i' ve been getting base budget increases for the last few years. in other words very few if any new staff to service a population even over the last four years that would be in the order of twenty to forty thousand additional people." -site-b informant ministry informants acknowledged the need for greater equity in the public health funding model, although some were not convinced that public health performance improvement required additional funding, but rather greater efficiency. other barriers such as work overload did not have a strong profile in the data, although some public health unit and ministry informants speculated that smaller, rural health units may struggle with performance expectations related to intensive analytical tasks such as population health assessment. facilitators of the cultural dimension are distinguished by openness, collaboration, teamwork and learning. at the local level, all three public health unit interview sites exhibited at least assessing continuous quality improvement in public health: adapting lessons from healthcare some of the characteristics of developmental and/or group culture. site-a exhibited many characteristics of group culture, such as teamwork and participation. organizational hierarchy appeared fairly flat, and even front-line workers were said to be involved in program decisionmaking, collective priority-setting and performance monitoring. one site-a informant noted: "certainly i think we prided ourselves on teamwork and participatory management styles and participation of front-line staff into decision-making where that makes sense." -site-a informant site-b appeared to be an equally distributed mix of developmental, group and rational cultural types -emphasizing efficiency and achievement of ophs requirements. group culture was apparent in reference to the interdisciplinary team-based approach to program and service provision. leaders also regarded teamwork as an important value of their culture, as illustrated by instances of participative management in various program areas. developmental culture emerged in the context of the health unit' s internal, evidence-based approach to cqi planning, which allowed for informed innovation and risk-taking. a site-b informant expanded by stating: "… there has been a very strong undercurrent in my organization … that your programming is evidence-based and you have a method for reviewing it and each time trying to learn more about how it went and improve it. it' s a continuous cycle of implementation, reflection, evaluation, and review and kind of revision. so there is constant introduction of innovation as well as fine-tuning things as they go." -site-b informant site-c presented a dominant developmental culture. risk-taking and innovation were often regarded as very important aspects of the organization' s culture. these aspects of developmental culture were contextualized in terms of evidence-informed decision-making, which was paradoxically argued to reduce risk at the same time. risk-taking in the development of strategic plans and priorities and examples of innovative programming were highlighted as proof of the health unit' s commitment to a developmental culture. an example of one site-c informant reflecting on the health unit' s organizational culture explained that: "… evidence informed decision-making is a large component. it' s one of the strategic priorities in our health unit and so really having that … engaging in processes of informed innovation certainly informs decision-making and out of that what are the risks that we are taking to do things differently than other health units based on the evidence that we have found." -site-c informant resistance to change, unrewarded achievement, and hierarchical and rational organizational cultures are regard as barriers to the cultural dimension. in this regard, there was limited evidence of an approach for rewarding achievement and good performance related directly to the province' s cqi initiative. however, some public health unit interviewees argued that celebrating achievement of targets was important -something that their health units did internally when goals were achieved or improved upon. site-a provided an example of this: "i think setting targets and celebrating the reaching of the targets is the other part. part of our plan will be not just setting goals but also celebrating the achievement of the goals … what we look at when we set out goals for staff and within the organization, knowing that we are not going to achieve every goal every time but celebrate our achievements and keep us moving forward." -site-a informant moreover, there was some uncertainty about the level of support for facilitating factors and the presence of barriers such as hierarchical cultural norms. on the issue of whether the system was primarily intended to promote learning (a key characteristic of cqi), those surveyed in the area of chronic disease prevention were significantly more uncertain than respondents from other areas (p < 0.02). likewise, 84.3% of the survey sample agreed or strongly agreed that the initiative was primarily concerned with maintaining compliance with public health practice and performance expectations -resembling a quality assurance orientation. in addition, respondents in the area of emergency preparedness were more likely to disagree (p < 0.02) with the statement that data generated from the provincial initiative would be used to improve performance. training opportunities and the quality and availability of data are the primary facilitators in the technical dimension. in ontario, training in quality improvement, and cqi specifically, manifested mainly at the local level, with public health units providing instruction to staff on strategic planning. guidance in program and service provision was evident through provincial ophs protocols, but these materials did not relate specifically to quality improvement training. a site-a informant reflected on this gap: "i' m not aware of any kind of … the how stuff that' s come from the ministry other than just … okay your targets are now being established with an expectation we do something about them." -site-a informant gaps in training and data systems can be precursors to frustration and false starts, according to shortell et al. (1998) . guidance from the ministry on how public health units were to achieve performance targets or improve was limited. moreover, some guidance materials, such as the previously mentioned tuberculosis protocol, were criticized by site-c informants for not reflecting best available evidence and local expertise: "so we had examples where we are absolutely convinced that we should vary the standards or not conform exactly with the [tuberculosis] protocol. this is the ministry telling us how to practise public health where actually we know more about practising public health than they do … it always ends up the same way because their lawyers advise them to stick to the letter of the law. i don' t know. something to do with liability. this is not the best use of our resources." -site-c informant considerable concern with the quality of performance measurement information relating to the provincial initiative was raised by all parties. the choice of population health outcomes as measures of public health performance was identified as problematic because of externalities that made attributing public health outputs difficult. some performance indicators were perceived as unreflective of public health performance by health units. for instance, the tobacco use indicator was highlighted as one such problematic measure: "we only have one performance indicator that relates to chronic disease and that is the one about the number of youth who smoked a whole cigarette. i think it doesn't reflect in any way the work that we do but i understand the ministry' s need to show a tangible objective outcome and so we will do that and be happy with providing that information. i would say it has very minimal contribution to anyone understanding anything about what we do." -site-b informant ministry informants generally agreed that information systems needed to be improved and that this task was a difficult one. however, ministry informants also noted that where evidence was weak, best-practice information was used in place of causal linkages between ophs requirements and outcomes. one ministry informant explained: "so the real work is at the linkages between requirement, to short-term outcome, to medium-term, to long-term outcome … so wherever we made a link we found evidence to support that but where we couldn't, it was based on best practices and what was occurring in the field and the assumptions that were being made that had been integrated right at the beginning of the '98 standards all the way through." -ministry informant the structural dimension focuses on effective forums of communication for facilitating learning throughout an organization or system. in ontario, the cqi initiative is supported by several communication forums, such as accountability agreement working groups, committees and monthly teleconferences amongst public health specialists, leadership and the ministry. at a local level, several public health unit informants noted active lines of communication between themselves and other public health units pertaining to collaborative projects, research and other forms of knowledge production and exchange. in contrast, some ministry informants stated that public health units do not typically work cooperatively or collaboratively because of jurisdictional protectionism. this divergence in perspectives was reflected in informants' testimony: "the fact that none of them work cooperatively, the fact that there are turf wars and all that good stuff, i think is one of the challenges." -ministry informant "i think there is a lot of similarities between health units. we talked a lot." -site-b informant "we work really well with our partners so we can capitalize on limited resources and make the most of them so that again we can really accomplish the goals we set out for communities and make our communities healthier places to be. so we do a lot of collaborative work with other health units but also with our community partners as well in order to accomplish public health goals." -site-a informant within the structural dimension, the lack or limited use of communication mechanisms related to the quality improvement initiative fosters an inability to produce knowledge and diffuse it within systems. ambiguity relating to how information would be fed back to public health units and used for quality improvement was apparent and highlighted by local informants: "i don't know. i think that remains to be seen. i' m hoping it' s more to be used in a combination with evidence to make ongoing improvements to public health programs and policies." -site-c informant ministry informants stated that performance information would allow for "discussion" with public health units. some public health unit informants speculated that these discussions would include questions of what barriers to performance existed. one public health unit interviewee noted that performance information lacked the context to address why the results were the way they were. meanwhile, several other informants argued that their public health unit would have to provide additional, unsolicited information to explain their performance achievement. one site-b informant explained: "so, in my earlier interview with you i described some of the vehicles that you can use and that i voluntarily send to the ministry like our performance report, it' s rare that i would get an acknowledgement, let alone do they read it. so i don't think the ministry is all that interested in what we are doing apart from the information that we use to populate what i would call to be our financial reports." -site-b informant in contrast to the provincial initiative, all public health unit interview sites described specific internal processes of quality improvement such as balanced scorecards, evaluation, assessing continuous quality improvement in public health: adapting lessons from healthcare reporting and strategic planning elements. only 55% of survey respondents believed the province' s system of accountability and performance management had the intent of providing learning opportunities and improving performance. this study shows a mix of facilitators and barriers to cqi best-practice in ontario, according to shortell et al.' s (1998) four-dimensions framework. evidence of strong leadership interest and involvement in quality improvement at both local and provincial levels was clear. strong developmental and/or group cultures were also evident at public health unit interview sites, which reflected leadership efforts to foster high performance and provided additional insight into their cqi capacity. the importance of senior and managerial leadership engagement cannot be over-emphasized, as previous reviews of public health quality improvement initiatives have shown (dilley et al. 2012; randolph et al. 2012) . however, ontario' s quality improvement initiative also featured limitations placed on the meaningful influence of local leadership in decision-making by provincial stakeholders, which was reflected by misalignments in priorities, even though agreement on the principle of quality improvement was mutual. a part of this phenomenon may be because of the split emphasis that ontario' s system of accountability and performance management has between quality assurance and quality improvement. assurance of legislative and service requirements promotes top-down decision-making and control, whereas a focus on improving outcomes requires local leadership and discretion. similar misalignments were highlighted in the work of degroff et al. (2010) who argued that many of the challenges to applying performance measurement to national public health programs in the us were due, in part, to the competing interests of quality improvement and public accountability (degroff et al. 2010) . in addition, the availability of indicators that accurately reflect performance continues to be one of the greatest constraining factors to cqi in public health settings, as many have already pointed out, and one that sets it apart from healthcare (kahan and goodstadt 1999; scutchfield et al. 2009; weir et al. 2009 ). public health unit informants were adamant that performance targets indicated by population health outcomes, which are subject to numerous determinants outside of their control, were problematic. given that cqi relies upon the quality of performance measurement information for informed decision-making, developing public health metrics that are more attributable to service outputs should be a priority. this study is limited by its small public health unit sample, which, although offers valuable insight into a nascent quality improvement process, ultimately, cannot represent the broader set of units. also, while boards of health are acknowledged to be important stakeholders in ontario' s public health system, members were not included in this study because of unsuccessful recruitment. furthermore, this study offers a snapshot of an initiative in a fluid environment and in its very early stages. changes to the approach are expected, which have potential implications on the perceptions of informants. this also means that evidence of outcomes resulting from the presence of facilitators and barriers was beyond the scope of this study. this study illustrates the applicability of shortell et al.' s (1998) four dimensions of cqi as a framework for understanding public health quality improvement. the study also represents one of the first attempts to examine the implementation of a cqi initiative across a complex public health system using an empirically derived and validated framework from the healthcare field. insight provided by the framework relating to facilitators and barriers of cqi implementation has largely confirmed disparate public health research on the topic (corso et al. 2010; mclees et al. 2014; riley et al. 2012; shortell et al. 1998 ). this confirmation is a promising indicator that the framework may hold value as a tool for public health decision-makers developing and implementing cqi systems. finally, future research should test the four-dimensions framework in other public health environments and, more importantly, examine the linkages between the framework' s indicated outcomes and attributable facilitators and barriers. hpv vaccination in ontario is voluntary. target levels had previously been set at levels comparable to those of mandatory vaccinations, such as measles, mumps and rubella (mmr) correspondence may be directed to: alex price; e-mail: alex.price@mail.utoronto.ca quality improvement efforts in oncology: are we ready to begin? revitalizing ontario's public health capacity: the final report of the capacity review committee impact of a continuous quality improvement initiative on appropriate use of coronary computed tomography angiography. results from a multicenter, statewide registry, the advanced cardiovascular imaging consortium performance and accountability-a theoretical discussion and an empirical assessment the national public health performance standards: driving quality improvement in public health systems fisher exact test challenges and strategies in applying performance measurement to federal public health programs improving outcomes in public health practice: strategy and methods quality improvement interventions in public health systems: a systematic review an approach to measure compliance to clinical guidelines in psychiatric care issues in research: a multi-stage approach to the coding of data from open-ended questions joining public accountability and performance management: a case study of lethbridge, alberta three approaches to qualitative content analysis continuous quality improvement and health promotion: can cqi lead to better outcomes? continous quality improvement a primer on quality in public health: what's needed to advance cqi in ontario public health the paradox of implementing the government performance and results act: top-down direction for bottom-up implementation incentives, capacity, and implementation: evidence from massachusetts education reform learning from experience: lessons from policy implementation advances in public health accreditation readiness and quality improvement: evaluation findings from the national public health improvement initiative ministry of health and long-term care (mohltc) ministry of health and long-term care (mohltc) ministry of health and long-term care (mohltc). 2013. accountability agreements background for wdg board of health intraorganizational implementation research: theory and method four-year impact of a continuous quality improvement effort implemented by a network of diabetes outpatient clinics: the amd-annals initiative rethinking validity and reliability in content analysis continuous quality improvement: origins, concepts, problems, and applications lessons learned from building a culture and infrastructure for continuous quality improvement at cabarrus health alliance quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the u.s. multi-society task force on colorectal cancer developing a taxonomy for the science of improvement in public health public health performance assessing the impact of continuous quality improvement on clinical practice: what it will take to accelerate progress assessing the impact of continuous quality improvement total quality management concept versus implementation operation health protection: an action plan to prevent threats to our health and to promote a healthy ontario evidence-based practice barriers and facilitators from a continuous quality improvement perspective: an integrative review applying the balanced scorecard to local public health performance measurement: deliberations and decisions assessing continuous quality improvement in public health: adapting lessons from healthcare let's talk key: cord-260565-cdthfl5f authors: burkle, frederick m. title: declining public health protections within autocratic regimes: impact on global public health security, infectious disease outbreaks, epidemics, and pandemics date: 2020-04-02 journal: prehospital and disaster medicine doi: 10.1017/s1049023x20000424 sha: doc_id: 260565 cord_uid: cdthfl5f public health emergencies of international concern, in the form of infectious disease outbreaks, epidemics, and pandemics, represent an increasing risk to the worldʼs population. management requires coordinated responses, across many disciplines and nations, and the capacity to muster proper national and global public health education, infrastructure, and prevention measures. unfortunately, increasing numbers of nations are ruled by autocratic regimes which have characteristically failed to adopt investments in public health infrastructure, education, and prevention measures to keep pace with population growth and density. autocratic leaders have a direct impact on health security, a direct negative impact on health, and create adverse political and economic conditions that only complicate the crisis further. this is most evident in autocratic regimes where health protections have been seriously and purposely curtailed. all autocratic regimes define public health along economic and political imperatives that are similar across borders and cultures. autocratic regimes are seriously handicapped by sociopathic narcissistic leaders who are incapable of understanding the health consequences of infectious diseases or the impact on their population. a cross section of autocratic nations currently experiencing the impact of covid-19 (coronavirus disease 2019) are reviewed to demonstrate the manner where self-serving regimes fail to manage health crises and place the rest of the world at increasing risk. it is time to re-address the pre-sars (severe acute respiratory syndrome) global agendas calling for stronger strategic capacity, legal authority, support, and institutional status under world health organization (who) leadership granted by an international health regulations treaty. treaties remain the most successful means the world has in preventing, preparing for, and controlling epidemics in an increasingly globalized world. “honesty is worth a lot more than hope…” the economist, february 17, 2020. infrastructure, prevention, and preparedness, yet these protections remain far from being globally understood, available, practiced uniformly, or free of political control. what is increasingly common since the last one-third of the 20 th century is the thread of public health emergencies permeating, and often dominating, the consequences brought on by wars, conflicts, and large-scale disasters. 2 few are aware that wartime public health crises cause more deaths than weapons. 3, 4 consistently in war, the public health protective threshold is destroyed and not recovered or maintained. 5 recovery is purposely ignored, resulting in increasing post-crisis mortality and morbidity indices that are characteristically ignored or denied, especially if they negatively impact political, ethnic, or religious groups whose views are contrary to the newly installed autocratic regime. ruger reminds us that authoritarian regimes suppress political competition and tend to have an interest in preventing human development, because improved health, education, and economic security mobilizes citizens to advocate for greater participation and more resources. 6 public health protections are literally invisible to populations; they are often taken for granted and applauded as great successes serving as propaganda ploys in public speeches. 7 although there has been scant investment in public health infrastructure and protections in all parts of the world, those countries suffer the most under autocratic regimes, especially where they have failed to keep pace with population growth and density. 8 currently, both the urban and rural environment of the 21 st century are being defined by deficient dwellings, aged and inadequate infrastructure, and insufficient capacity to respond to crises, especially in ensuring access to safe water, food, sanitation, and energy. public health surveillance, the "continuous, systematic collection, and analysis of health-related data serve as an early warning system for impending public health emergencies, but compliance differs remarkably from one country to another." 6, 8 indeed, the direct and indirect mortality and morbidity resulting from these tragedies are the responsibility of the government in power, but are often the first to be ignored. ecological and environmental protections and preservations, such as the continuous surveillance mandated by the world health organization (who; geneva, switzerland) of wet markets in china that launched sars (severe acute respiratory syndrome) in 2008, is an example of a critical monitor that was ended prematurely. only the reporting of three diseases (yellow fever, plague, and cholera) are currently binding under the international health regulations, and then some countries are unwilling to notify who fearing economic and political consequences. 9 stable and unstable political systems the processes of political development, primarily as they apply to stable and unstable political systems and change, have always been dynamic, especially in crisis situations such as outbreaks of infectious diseases in less-developed countries. crisis situations test the stability of political systems in revealing ways, placing extraordinary demands on the political leadership and the existing public health structure and processes of the country. in the absence of early and effective preparedness, societies may experience social and economic disruption, threats to the continuity of essential services, reduced production, distribution difficulties, and shortages of essential commodities. the who emphasizes a "whole-ofsociety" approach that emphasizes significant roles not only for the health sector, but also by all other sectors, individuals, families, and communities, in mitigating the effects of a pandemic. 10 developing such capacities is at the heart of preparing the whole of society for a pandemic. i assert that it is the loss of the whole of society's concept, thinking, and participation that is systematically destroyed in autocratic regimes that contributes to why these political systems fail. they fail when citizens have no defined ownership, channels of communication, or are allowed to participate in any aspect of the disaster cycle (prevention, preparedness, response, recovery, or rehabilitation). they fail when citizens are not allowed a voice in the implementation of acceptable policies when the political system ceases to be viewed as responsive by individuals and groups making demands on it, and by what is considered inappropriate political behavior. infectious disease outbreaks have the uncanny capacity to question the status quo, catalyze smoldering unrest, and most importantly, reveal population-based public health imperfections. 11 the "whole of society" which depends on a form of collaborative governance, which complements public policy, disappears and is seen only as the dictate of one person. indeed, the negative influence on society, what i refer to a "societal mental health," is out of proportion to their representation in society. 12 the 2019 democracy index, compiled by the united kingdom's economist intelligence unit (london, uk) and published annually in the economist, ranks countries according to political and civic freedom using five criteria: whether elections are free and fair, whether governments have checks and balances, whether citizens are included in politics, the level of support for the government, and whether people have freedom of expression. nations are divided into "full democracies, flawed democracies, hybrid regimes [which include those exhibiting regular electoral frauds], and authoritarian regimes" where "political pluralism has vanished or is extremely limited." 13 the 2019 edition is considered as having the "worst average global score since the index was introduced in 2006, driven primarily by regressions in latin america and sub-saharan africa. 14 globally, this is the first time in the modern era where we have the fewest democracies. by ranking on how functional their political systems are, less than five percent of the world's population live in a "full democracy." 15 fewer countries can claim free and fair elections, checks, balances, and participation in their governments. fewer nations offer freedom of expression or political participation in established political cultures. rapidly established and increasingly prosperous autocratic regimes, many first drawn in by populist claims that enticed the masses of working-class and poor, are now firmly established by an economy ruled by dictators and oligarchs with unfettered political influence. the united states is now categorized as a "flawed democracy," experiencing both undeniable presidential claims for more authoritarian rule, a population that increasingly claims loss of traditional liberties, and low esteem in which us voters hold their government, elected representatives, and political parties. 15 characteristics of autocratic regime leadership autocratic leaders demonstrate personality and behavioral characteristics that are remarkably consistent across borders and cultures. 16 in great part, this is due to a common fault line from their adolescent development which becomes arrested cognitively and emotionally. while they may, at first glance, seems smart, they are not bright or capable of attaining abstract reasoning. 17 this type of reasoning is required to formulate theories and understand multiple meanings crucial for reasoning. it demands generalizations, ideas, the ability to identify the relationship between verbal and nonverbal ideas, and to understand the multiple meanings that underlie an event, statement, or object; an example often cited is: "the liberty bell is not just a piece of american history, but is a symbol of freedom." 18 concrete thinkers misinterpret many concepts like this and are compelled to reinterpret them in their own concrete manner in political speeches and legislative decisions. abstract thinking refers to a cognitive concept involving higherorder, or complex thoughts. to be able to think in an abstract manner implies that one is able to draw conclusions or illustrate relationships among concepts in a manner beyond what is obvious. 19 often the terms "abstract thought" and "concept formation" are used interchangeably. in the past, the term "fluid intelligence" has been used to refer to the ability to reason. the generation of concepts, or abstract ideas, indicates an ability to progress beyond concrete thinking. the concrete interpretation of a concept involves a focus on the salient, obvious characteristics. progressing beyond the tangible characteristics in order to conceptualize theoretical relationships between items or processes involves abstract thought. deeper meanings such as "freedom," "equality," "charity," "love," and "democracy" express ideas, concepts, or qualities that cannot be seen or experienced. 20 they are considered only in the concrete sense as it applies to autocratic thinkers. the us constitution would not be understood in the manner it was originally written as it is an example of a document that requires abstract thought and is either not read, understood, or interpreted concretely by a leadership that is completely self-serving. concepts such as freedom and equal rights interpreted concretely become self-serving. studies demonstrate that "persons with different value preferences apply different neurobiological strategies when facing a decision" and can help explain the fixed values that decisions are made that are independent of an actual situation. 21 this stubbornness of thought and action is reflected in shared personality disorders of autocratic despots. brain areas beyond those activated in actual moral dilemma situations were found to be involved. they are psychologically fixed, as illustrated by muammar gaddafi when he was being beaten to death by his own people, claiming up to the last minute: "but the people love me!" some of the well-known behaviors include cover-ups, exaggeration, and fabrication; fraud, omission, half-truth, perjury, and lies that come in various types, conveyed to exaggerate one's credentials or get the attention that reflects their universal narcissistic disposition and constant needs. in great part, these behaviors are witnessed between all despots of the world. despite the bad press lies get, and that many press agencies tally the daily lie numbers, most are ignored by political supporters in every country, particularly the ones that have spoken to avoid conflict, and as a show of collective support. operationalization of narcissism is "dispositional" which accompany a "grandiose sense of selfimportance, exhibitionism, entitlement, interpersonal exploitativeness, and a total lack of empathy." 22 autocratic leaders: [r]etain all power, authority, and control, and reserve the right to make all decisions; distrust their subordinate's abilities, closely supervise and control people under them; rarely delegate or empower subordinates; adopt one-way communication, do not consult with subordinates or consider their opinions; create a system of rewards and punishments; use threats and punishments and evoke fear; rarely concern themselves with developmental activities; and take credit for all the accomplishments. 23 in truth, once in positions of power, only the most emotionally healthy and resilient can avoid the slide into psychopathology. for those with some of the personality attributes of sociopathy or psychopathy, the descent into deeper pathology may be beyond their ability to resist. even their followers can become pathologically dependent. democracies characterized by individual freedom and liberty are rare. throughout history, autocratic governments and tyranny have been the rule. their lack of conscience and an inability to feel remorse are the underlying factors that are often viewed initially as charming, but soon reveal uncanny skills as master manipulators, skillful at lying and cheating. they have no capacity to feel guilt. despite an incidence rate of three percent to five percent within the general population, and 25% of prison populations, it sometimes seems that they already rule the most despotic and populated areas of the world. 24 part ii: pandemic status of countries under autocratic rule as of february 20, 2020, 26 nations have who-confirmed cases of covid-19 (coronavirus disease 2019) outside china. the global surveillance covid-19 database centralizes all covid-19 cases reported from outside china and is maintained at the who headquarters in geneva. their data analysis is conducted daily to: "follow the transmission of the disease between countries; describe the characteristics of human-to-human transmission within clusters of cases; describe the characteristics of affected persons and their exposure history; and support the evaluation of public health measures implemented in response to the epidemic." 25 this study focuses only on countries under autocratic rule and describes the current status of public health preparedness and current responses. this review includes all countries run by one person or party with absolute power. autocracy is a system of governance headed by a single ruler called an autocrat. decisions made by the autocrat are not subject to legal restraints and the autocrat exercised unlimited and undisputed power. 26 as of 2018, 50 nations are ruled by a dictator or authoritarian regime. admittedly, democracy remains unsure in many countries, especially africa, where dictators rising to power are increasingly likely. the study adds that: "europe is home to one dictatorship, while three of them can be found in latin america and south america. there are eight dictatorships in asia, seven in the eurasian region of the world, and twelve span territory from the northern parts of africa to the middle east." 26 china i cut my humanitarian teeth in china in the 1970s and 1980s when an unprecedented 83% of the population was suffering from poverty and malnutrition, one of the highest in the world. i was one of the few foreign physicians continually invited back under mao's repressive regime. this allowed me an unprecedented view of china's attempt to re-define what is the anthesis to the established global who requirements that guaranteed population-based public health protections. i taught basic public health management and reforms and helped establish emergency services to many hospitals. i was engaged in these activities while the government emphasized unprecedented industrial and economic development that contributed to rapid and "remarkable achievements" in the overall social and economic health of the population. the incidence of poverty in china in 1981 declined from 85% to 27% in 2004, a reduction of slightly more than 600 million people, primarily accomplished through targeting rapid industrialization and village-based poverty. 27 it also caused "twists and turns on the development of china's public health" requirements, which lagged vastly behind industrialization. public health was never given the same priority and failed to catch up with changes that required timely updating and adjustment of services. 28 while it took time to recognize that china was on a path to also politically and economically redefine public health protections, infrastructure, and development, warnings directed at china's new regional centers for disease control (cdc; beijing, china) fell on deaf ears. that same lack of coordination and collaboration remains evident today, placing china under a different microscope, one of greater scrutiny and judgment from the global community who sees their many poor health outcomes. many of these poor outcomes are especially related to air pollution in re-defining hazardous air by who standards as "acceptable," and prompting many in china and the world to ask "at what price?" 29 in 2010, there was water scarcity in two-thirds of china's 600 cities, 80% had no sewage treatment facilities, the food security program was unsustainable, 90% of groundwater was polluted, and major rivers had their downstream microorganism ecology altered by chemicals and fertilizers dumped by industry and cities into the water. this resulted in new and re-emerging diseases. 30 after identifying sars origin from a wet market civet source in august of 2016, president xi's economic address, tied to security concerns, called for "full protection of people's health, stressing that public health should be given priority in the country's development strategy." 31 an independent survey of the chinese citizenry two months later revealed that while the chinese public agreed with xi's need to promote china's more influential role in the world, they raised grave concerns about environmental safety, numerous high-profile scandals regarding unsafe medical and food products, and water and air pollution. 32 china's story mirrors that of other developing countries in asia, the fastest-growing region in the world, in that government spending on public health is inadequate and not focused on those who need it the most. studies in 2018-2019 confirm that 90 % of china's groundwater is contaminated; tap water is not safe due to water contamination by the continued dumping of toxic human and industrial waste, because oxygen levels have obliterated normal organisms in all major rivers and only algae continue to flourish. air quality remains "very unhealthy" and continues to have a major toll on public health, resulting in 350,000 to 400,000 premature deaths. 33, 34 it remains unclear whether china will ever meet its air pollution goals, let alone participate in global climate commitments to reduce carbon emissions. 34 no one in global public health was surprised to learn that once again a wet market animal, not suited for human consumption, was probably responsible for this year's covid-19 pandemic. however, chinese researchers now stress that the virus did not originate in the wet market, but was transferred from elsewhere, on december 8th and again on january 6th. 35 transmission could have begun in early december or late november, admitting the world-wide spread could have been limited had the earlier alerts been implemented. after sars in 2002, external pressure has also impacted on the development of china's public health. 36 during the sars outbreak, the who directly told the chinese government in its mission report in april 2003 that "[t]here was an urgent need to improve surveillance and infection control" in the country. 37 two years later, in a joint report issued by state development research center (beijing, china) and who, the chinese government officially admitted its health care system was failing, and it needed to improve its disease surveillance system at the local wet market levels if they were to be seen as a "responsible state." 38 in december of 2019, the first cases of covid-19 were diagnosed in wuhan, the capital of hubei province, and rapidly expanded. for two weeks, the existence of a novel rapidly expanding virus was known to president xi. unconscionably, china arrested, jailed, and punished physicians and journalists who defied government attempts to silence the truth of the virus. moreover, the government ceased to enforce the timely flow of crucial public health information, delaying both critical medical care, its obligations to the who, and the sacred paradigm of human interaction with a disease that collectively defines "freedom of speech." 39 andrew price-smith put the same point succinctly post-sars, stating that "while the sars epidemic may have generated moderate institutional change at the domestic level, it resulted in only ephemeral change at the level of global governance." 40 in other words, national sovereignty is still of paramount importance for the chinese leadership. because of its sensitivity to foreign interference into its internal affairs, the chinese government has not yet formally or officially endorsed the notion of "human security." 40 while china has embraced multilateral cooperation in a wide array of global health issues, its engagement remains "state-centric." 37, 38 the sars event not only exposed a fundamental shortcoming of china's public health surveillance system, as well as its singleminded pursuit of economic growth since the late 1970s, but also forced china to realize that, in the era of globalization, public health is no longer a domestic, social issue that can be isolated from foreign-policy concern. 37 having no tolerance in ceding its supreme authority, the central government has adopted a multifaceted attitude towards its civil society organizations. while beijing shows its willingness to cooperate with a wide array of actors inside china, it refuses to let its domestic nongovernmental organizations (ngos) and activists establish direct links with their counterparts overseas. 37, 41 china was openly accused of a cover-up with sars, and few professionals are confident that anything has changed. 42 chan maintains that while "it is still uncertain whether this sovereign concern will trump the provision of global public good for health. nevertheless, in a highly globalizing world, infectious diseases know no border. while china is seeking to adhere as much as possible to the underlying norms and rules of global institutions," reemphasizing that china after sars "perhaps [needs] to reframe health as a global public good that is available to each and every individual of the world, rather than merely as an issue of concern to nation-states." 37 in a rare openness, rarely seen before, the normally secretive xi admitted at a meeting to coordinate the fight against the virus that china must learn from "obvious shortcomings exposed during its response." yet given the second-guessing that always surfaces in these tragedies, "it cannot be denied that the chinese government tried to control the narrative, another sign of irrational hubris, and as a result, the contagion was allowed to spread, contributing to equally irrational fear." a china researcher for human rights watch (new york usa) noted: "authorities are as equally, if not more, concerned with silencing criticism as with containing the spread of the coronavirus. : : : repeating a pattern seen in past public health emergencies." 43 although less clumsy than with sars, the government kept all non-party groups that could have helped prevent the spread of the virus out of the loop. 44, 45 china's religious groups who "reflect the country's decades-long revival and feeling among many chinese that faith-based groups provide an alternative to the corruption that has plagued the government" are being ignored. 46 will this just be a temporary stay as it was post-sars, or is china capable of adopting, without conditions, the who public health requirements they have ignored to date? north korea, the most sealed-off country in the world, has literally shut down all borders and communications on covid-19, denying, according to their propaganda channels, the existence of any cases or deaths. this is unusual as it sits between china and south korea, which have recorded the largest numbers of cases. researchers state it is "unlikely that north korea is free of covid-19." south korean media reported that kim jong un, the north korean leader, had an official executed for violating the quarantine after the official returned from a trip to china. this may or may not be true since such reports have proved dubious in the past. north korea press outlets claim that "not one novel coronavirus has emerged;" yet south korea's unification ministry (seoul, south korea), in charge of inter-korean relations, reported to the who that north korea had tested 141 suspected cases of coronavirus and all came up negative. 47 nevertheless, south korean media, relying on anonymous sources, report cases of covid-19 in north korea, some of them fatal, according to john linton, head of the international health care center at severance hospital in seoul: "through private sources, they're asking for disposable gowns, gloves, and hazmat suits, which are undoubtedly lacking," he says. "so something is going on, otherwise they wouldn't be asking for this." 47 north korea relies on china for more than 90% of its trade. researchers admit that while health indicators have improved in the two decades since the country's 1990s famine, during which hundreds of thousands of people starved to death, 48 but there are still major problems. in the 1990s, amnesty international (london, uk) detailed a crumbling health care system in north korea, a nation unable to feed its population, and, in violation of international law. north korea refused to cooperate with the international community to receive food. levels of malnutrition, maternal health, and tuberculosis (tb) are chronic problems, but a lack of accurate data on hiv/aids and hepatitis b present cause for alarm. health indicators have improved in the two decades since the country's 1990s famine, but major problems still exist. whereas communicable diseases account for a large proportion of the disease burden, there are very few opportunities to better understand and control them. 49 while health infrastructure has improved, capacity is low and the health system is chronically under-resourced. north korea has allowed for united nation (un) interventions, primarily focused on sustainable development, but this has been on north korea's terms, a demand not unusual for autocratic regimes. 50 in 2014, the report of the un commission of inquiry on human rights in the democratic people's republic of korea (dprk) concluded that: "20 years after humanitarian agencies began their work in the dprk, humanitarian workers still face unacceptable constraints impeding their access to populations in dire need." 51 the report found that the dprk has "imposed movement and contact restrictions on humanitarian actors that unduly impede their access." the dprk has "deliberately failed to provide aid organizations with access to reliable data, which, if provided, would have greatly enhanced the effectiveness of the humanitarian response and saved many lives." the north korean government "continually obstructed effective monitoring of humanitarian assistance, presumably to hide the diversion of some of the aid to the military, elite, or other favored groups, as well as to markets." in summary, the report stated: in this tightly controlled political climate, international humanitarian staff often have to make compromises. some point out privately that it is unrealistic to try to uphold humanitarian standards in an environment as difficult as north korea's. they try hard to come up with ways to make their aid sustainable for the north korean people, but their plans are not always accepted. 51 although the knowledge of public health has improved in recent years, 18 million people are dependent on a public distribution system of food rations and more than 10 million are undernourished. 52, 53 iran early in the coivid-19 crisis, iran introduced containment measures that china had instituted placing tens of millions of people under lockdown. yet, iran has confirmed 43 infections and eight deaths, and appears to have entered the epidemic phase of the disease. pakistan and turkey announced the closure of land crossings with iran, while afghanistan said it was suspending travel to the country. four new covid-19 cases surfaced in tehran, seven in the holy city of qom, two in gilan, and one each in markazi and tonekabon. as of this writing, several reports from the cities in the south, west, center, and north of iran indicate cases testing positive for covid-19. the iranian minister of health stated that the origin of the virus was in qom, where infected chinese nationals and iranians who traveled to china during its pandemic were diagnosed. reports suggest that a minimum number of cases is between 1,000 to 1,500, with additional unofficial reports of deaths from hamedan, saveh, tonekabon, and tehran, suggesting that the government under-reports the number of positive cases. 53 the health ministry ordered the closure of schools, universities, and cultural centers across 14 provinces. all sport and cultural events were shut down for two weeks and all educational public exams were postponed. unfortunately, many health workers and physicians are among newly infected cases, including the deputy health minister. 53 the country suffers a lack of basic equipment such as masks and disinfecting materials, even in health care centers. people are in a panic due to a lack of access to protective materials and angry over the government cover-up. 54, 55 personal contacts in iran, unfortunately, report that: "there is a major concern of misinformation because people do not trust the governmental information, opening the doors for rumors and more misinformation." paul hunter, professor of medicine at britain's university of east anglia (norwich, england), said the situation in iran has "major implications" for the middle east. "it is unlikely that iran will have the resources and facilities to adequately identify cases and adequately manage them if case numbers are large." 56 as of this writing, turkey has not reported any covid-19 infections. the government has closed its border with iran, introduced health checks from iran, and are turning back travelers. yet travel from turkey to iran continues. turkey is strategic in its geographic position. it is bordered by eight countries, is the intersection point of asia, europe, and africa, making it one of the most strategic countries in the world. with its geopolitical position, turkey is a unique bridge between eastern and western civilizations and between all religions. 57,58 i bring up turkey because that nation also has one of the most autocratic regimes in the world, which has mastered control over the population and media. the government has a pattern of undercutting critic's claims, accusing the opposition of having ulterior motives, and systematically undercutting the independence of the rule of law. 57 recep tayyip erdogan's one-man rule-control all executive, legislative, and judicial functions by imprisoning critical journalists and destroying what was left of the free media. he has arrested teachers, police, and government workers. erdogan must be in control of the narrative on all issues, including health. 59 after the lessoned learned in china with one non-medical voice controlling all news on covid-19, a similar false narrative, seen with all dictators, may again occur. health differences with their northern european union (eu) neighbors were a concern that delayed accession talks for full membership in the eu in 2005. one-half the population is made up of secular and liberal turks who wish to restrain erdogan and his abuse of power. 59 african nations autocratic or authoritarian regimes-dictatorships-have been a dominant form of governance in africa for many years. in the second decade of the 21st century, one concern is that they may hinder the attainment of one of the un's crucial sustainable development goals. in the last three years, analysts say that african countries have registered an overall decline in the quality of political participation and rule of law. the british broadcasting corporation (bbc; london, uk) recently reported that "more and more elections are being held in africa." however, analysts dismiss many as being "lawful but illegitimate." although studies show a majority of africans still want to live in democracies, an increasing number are looking to alternative, autocratic models. 60 african countries, in the last three years, have registered an overall decline in the quality of political participation and rule of law; analysts say: "today there are almost the same number of defective democracies (15) as there are hardline autocracies (16) , among the continent's 54 states," nic cheeseman, professor of democracy at birmingham university (birmingham, england), concludes from his analysis of the last three years. 60 nigeria is among those listed as a "defective democracy," which underscores the importance of recognizing fragile political parties in africa. recent elections in nigeria illustrates this. 60 nigeria is seen as an emerging democracy often found in newly emerging states, and established democratic regimes existing in states with long traditions of uninterrupted sovereignty. 60 most critically, many autocratic african countries have been thrown into an inescapable political mix with china because of china's close economic ties with multiple african countries. this economic dependence on china has grown so fast that it has critical future implications. the rapidity in which china has launched its massive continent-wide initiatives has been lost on many. the covid-19 pandemic has awakened scholars to revisit its impact on africa, where the world's most powerful autocratic regimes exist. 61 as of 2012, the african continent was home to more than 1.1 million chinese immigrants. 62 from 2001 to 2017, china's africa strategy began to solve overpopulation, pollution, and the poor economy in africa and other developing countries. china offered sizeable loans to finance infrastructure projects, which incurred major debts for many third world nations, but especially africa. these loans have changed the cultural and ethnic landscape of many struggling nations. 63 the building of african ports, highways, and railways, all with chinese money, have primarily corporate-level intentions, not the daily welfare of the populations. on the surface, these sound infrastructure projects are what africa legitimately sees as necessary for progressing out of poverty. but on closer examination, they serve china's ambitions to write the rules of the next stage of what they define as "globalization." 64 of major concern is that these african countries are now defaulting on the loans, primarily funded by countries other than china, for daily external assistance and survival. the very predictable failures of the african countries to pay back the loans have entrapped african nations even further: "china, as the only major creditor in africa, won't be far away from taking hold of virtually every industry in africa." 65 according to the agreements set up by china, the african nations can repay loans with natural resources such as oil. yet, the defaulted loans made for constructing ports that were not productive are already owned by china. china's massive "belt & raid initiative" was designed to link up to 70 countries, all tied to china's multiple infrastructure contracts and investments. overland routes for roads and rail transportation guarantee that most countries involved will never be able to fully pay the loans and will remain dependent on china for their trade economies in the coming years. this receives very little attention in the western press. in 2017, forbes reported that china now owns international port holdings in greece, myanmar, israel, djibouti, morocco, spain, italy, belgium, cote d'ivoire, egypt, and about a dozen other countries. 66 in 2018, china took control of kenya's largest port after that nation defaulted on its unpaid chinese loans. china wants everything from africa-its strategic location, its rare earth metals, and its fish. this leaves african nations forever indebted to beijing. over one million chinese now work in africa, with one author citing that africa is "china's second continent," 67 but the actual long-term impact of these many transient workers on african's future is mixed. one author summarized that "on closer examination, china's ambition is to write the rules of the next stage of globalization. this suggests that beijing will not accept anything less than being the dominant landlord, one that is autocratic and mimicking the current authoritarian regime in china. china wants africa's resources and its maritime roads for beijing's large military presence." this is evident from the fact that chinese troops and weapons outnumber all other countries, especially the us, which is decreasing its military footprint. china formally launched its first overseas military base in djibouti, where it constructed strategic ports, an electric railway, logistics, and intelligence facilities. 68 but in all their projects, they focus on highways, ports, dams, and public networks, such as electric grids, not public health infrastructure. military might is their priority, a model taken from the us over the past two decades. while the us today is trimming down its military presence in africa, china is increasing theirs. from the outset, china and heads of state from 53 african countries met to implement eight major initiatives to strengthen the cooperation between china and africa. some of the initiatives included industrial, trade, and cultural promotion, with public health ranking as a top priority for the china-africa health cooperation plans. in 2017, there were 1,050 health professionals from china working in all 53 african countries, focusing on public health training and disease-control programs centered on emerging infectious diseases, malaria, hiv/aids, and health informatics, in collaboration with africa cdc (addis ababa, ethiopia), us cdc (atlanta, georgia usa), and other global partners. 69 what remains a contradiction is the strong health priorities of the china-african cooperation, which emphasizes many health initiatives that mainland china currently lacks. but china looks to the future and its survival. as they say in their next phase of "globalization," african economic dominance will be necessary for africa's survival. 69 what political regime will rule at that time is questionable, but will probably be autocratic across china, africa, and other countries that currently face a potential military takeover by china, such as cambodia and myanmar. in the meantime, who and other regional and country public health experts are concerned the "fragile" health systems in most african countries will not be able to cope if coronavirus takes hold on the continent. even china, with its larger pool of technical and financial resources, appears to be struggling to contain the virus. 70, 71 russia for all the advances in weaponry, including the first hypersonic missile, the poor-quality of public health directly "undermines the country's economic development." their aging population and declining birth rates contribute to the low overall health status and low life expectancy. more than two million russian men are considered to be hiv positive and extremely high multi-drug resistant tb persists. the direct connection between the public health crisis and russia's economic potential is clear. it is generally accepted that the highly productive educated soviets leave the country largely for reasons having to do with the deteriorating political freedoms in the country. failure to tackle russia's huge public health problems is likely to exacerbate the brain drain already underway. it is estimated that up to 2010, more than 1.25 million russians emigrated. that represents an even greater number than those who left after the collapse of the soviet union. 72, 73 russia reported its first two cases of covid-19 and said the infected people were chinese citizens who have since recovered. the first three russian citizens have also been infected with covid-19 onboard a quarantined cruise ship in japan. around 2,500 people arriving from china have been ordered/placed under quarantine for covid-19 and monitored by the russian capital's facial-recognition technology. 74 their quarantine measures have mimicked other nations and appear robust, but remain challenging to the economy and sustainability. the one achilles heel in russia's public health is the abominable rise of infectious diseases such as tb and aids. public measures for their control in russia are insufficient, mainly because of the lack of funding for treatment, vaccine prophylaxis, and health education. tuberculosis has become an epidemic in a country where it was once a rarity. immunity is down because of poverty, too little food, and difficult access to health care. russian doctors are worried that the tb epidemic could lead to epidemics of another disease. today, tb is endemic in russia, and there is a rising incidence of multi-drug-resistant strains of tb. 75 like other autocratic regimes, russia's "political model" of globalization that feeds transnational research and treatment of infectious diseases is seriously flawed and must take responsibility for the prevention of the spread of infectious disease beyond their borders accelerated by enhanced migration. 76 what this reveals are cautious doubts about whether russia, combined with shortages of medical supplies and inadequate standards that further highlights a number of public health challenges for the country, has the public health and political capacity to manage a serious covid-19 epidemic. the borgen project, which addresses poverty and hunger, focuses on the leaders of the most powerful nations addressing the need to deal with poverty as a consequence of their dictatorial rule. it is repeated here as it serves as an objective measure of the consequences of a despotic rule, as well as an indication of the physical and emotional state of populations that might not survive the additional insult of an infectious disease: 76 the united states, now designated a "flawed democracy," is showing increasing authoritarian rule and threats to basic health protections, especially in combatting communicable diseases. most concerning is the president's embrace of authoritarian leaders and the real possibility of major pandemic prevention funding, including the emergency reserve fund, which is designed to be "quickly deployed to respond to pandemic outbreaks." president trump has mimicked other autocratic leaders' positions in managing any serious outbreak. he has praised president xi's rulings and failed to comment on the chinese ruler's decision to punish physicians for grossly delaying international warnings and calling attention to the public health threat for which xi was totally responsible. trump's narcissistic personality will force him to be defensive and again lie to save face. peter navarro, trump's senior trade advisor, is quoted: "this delay allowed the virus to proliferate much faster than it otherwise would have and reach other countries that it might otherwise have not." 77 trump does not possess the knowledge base or intellectual capacity to be the spokesperson for any north american outbreak. most critically, trump has set up a narrative that will impair the us's ability to manage any serious outbreak. he has argued for cutting spending for the cdc, national institutes of health (nih; bethesda, maryland usa), and medicare directly related to communicable diseases and will directly hinder any public health response. he is oblivious to the current status of emergency medicine departments in all hospitals, rural and urban, which are currently overloaded and have no beds for influenza patients. patients must remain in emergency rooms until critical care beds open somewhere in the system, and that may take days. in no manner is our current health system capable of handling a serious outbreak, and the failure to begin a dialogue with practicing medical professionals is being ignored. lipsitch predicts that some 40%-70% of the world's population will be infected this year. 78 despite political claims, a vaccine is more likely seen within a year or two at best. 79 it is no longer realistic to expect the management of these gaps in infectious disease outbreaks, especially those that threaten to be epidemics and pandemics, are to be capably managed in their present state of willful denial and offenses by many countries, especially those that are ruled by authoritarian regimes. 80 despite resistance to globalization's health benefits that would markedly benefit the global community during these crises by authoritarian regimes, in 2015, i called for a new who leadership granted by the international health regulations treaty that has consequences if violated. i stated: the intent of a legally binding treaty to improve the capacity of all countries to detect, assess, notify, and respond to public health threats are being ignored. while there is a current rush to admonish globalization in favor of populism, epidemic and pandemics deserve better than decisions being made by incapable autocrats. during ebola, a rush by the global health security agenda partners to fill critical gaps in administrative and operational areas was crucial in the short term, but questions remain as to the real priorities of the global leadership as time elapses and critical gaps in public health protections and infrastructure take precedence over the economic and security needs of the developed world. the response from the global outbreak alert and response network and foreign medical teams to ebola proved indispensable to global health security, but both deserve stronger strategic capacity support and institutional status under the who leadership granted by the [international health regulations] treaty. treaties are the most successful means the world has in preventing, preparing for, and controlling epidemics in an increasingly globalized world. other options are not sustainable. given the gravity of on-going failed treaty management, the slow and incomplete process of reform, the magnitude and complexity of infectious disease outbreaks, and the rising severity of public health emergencies, a recommitment must be made to complete and restore the original mandates as a collaborative and coordinated global network responsibility, not one left to the actions of individual countries. the bottom line is that the global community can no longer tolerate an ineffectual and passive international response system. as such, this treaty has the potential to become one of the most effective treaties for crisis response and risk reduction world-wide. practitioners and health decision-makers world-wide must break their silence and advocate for a stronger treaty and a return of who authority. health practitioners and health decision-makers world-wide must break their silence and advocate for a stronger treaty and a return of who's undisputed global authority. 81 will china's unilateral decisions just be a temporary stay as it was post-sars, or is china capable of adopting, without conditions, the who public health requirements they have so far ignored? autocratic leaders in history have a direct impact on health security. dictatorships, with direct knowledge of the negative impact on health, create adverse political and economic conditions that only complicate the problem further. this is more evident in autocratic regimes where health protections have been seriously and purposely curtailed. this summary acknowledges that autocratic regimes are seriously handicapped by sociopathic narcissistic leaders who are incapable of understanding the health consequences of infectious diseases or their impact on their population. they will universally accelerate defenses indigenous to their personality traits when faced with contrary facts, double down against or deny accurate science to the contrary, delay timely precautions, and fail to meet health expectations required of nations under existing international health regulations, laws, and epidemic control surveillance. 82 kavanaugh's lancet editorial initially praised chinese tactics that reflected a level of control only available to authoritarian regimes. as days and weeks passed, it revealed a government that inherently became victims of their own propaganda based on "need to avoid sharing bad news." he concluded that authoritarian politics inhibited an effective response, and that openness and competitive politics favor a strategically fair public health strategy. 83 democratic nations in comparison to autocratic regimes recognize that public health fundamentally depends on public trust. 84 the who's china joint mission on coronavirus disease report has applauded china's eventual response capability and capacity with strict measures to interrupt or minimize transmission chains with extremely proactive surveillance, rapid diagnosis, isolation tracking, quarantine, and population acceptance of these measures, to implement the measures to contain covid-19 within the country. 85 it must not be forgotten that china's authoritarian rule "put secrecy and order ahead of openly confronting the growing crisis and risking alarm or political embarrassment," 86 arrested and compelled dr. li wenliang to sign a statement that his warning constituted "illegal behavior," all of which delayed a concerted public health offensive that led to his death. 86 this was an "issue of inaction" that would have contained covid-19 within china and remains a potent symbol of china's failures. 86 there is no evidence that the authoritarian regime has or will change to prevent this from happening again. 87 i suspect china's sophisticated censorship and propaganda systems will outlast any public health improvements. world health organization research priorities in emergency preparedness and response for public health systems: a letter report wartime public health crises cause more deaths than weapons, so why don't we pay more attention? new security beat civilian mortality after the 2003 invasion of iraq interference, intimidation, and measuring mortality in war democracy and health democracy matters for health care report on global surveillance of epidemic prone infectious diseases: types of surveillance roles and responsibilities in preparedness and response development and change in political systems whole of society and whole of government approach. health and healthcare in transition: dilemmas of governance the economist 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citizen journalist covering the coronavirus has gone missing in wuhan the coronavirus outbreak exposes the truth about socialism with chinese characteristics religious groups in china step into the coronavirus crisis. the new york times north korea claims zero coronavirus cases, but experts are skeptical north korea isn't ready for coronavirus devastation the crumbling sate of health care in north korea humanitarian engagement with north korea sanctions hurt but are not the main impediment to humanitarian operations in north korea public health in democratic people's republic of korea why is iran's reported mortality rate for coronavirus higher than in other countries? nbo news now coronavirus: iran's deputy health minister tests positive as outbreak worsens world is approaching coronavirus tipping point, experts say. the guardian xi says china facing "big test" with virus, global impact spreads healthcare in overview of turkey how dictatorships take root in the 21 st century a comparative analysis of the european union's and turkey's health status: how health-care services might affect turkey's accession to the eu is africa going backwards on democracy? bbc news june 12 is now democracy day in nigeria. why it matters chinese immigration to africa: an essay countries jumped tenfold in the last five years what china wants from africa? everything how large chinese loans are entrapping african nations china's seaport shopping spree: what china is winning by one million chinese in africa perspectives china says it will increase its military presence in africa public health priorities for china-africa cooperation africa prepares for coronavirus some african countries at risk for the new coronavirus aren't prepared. the verge: science/health public health challenges facing russia today cripple its potential for tomorrow. the globalist: rethinking globalization the sickness of a nation. the yale global health review coronavirus in russia: the latest news. the moscow times top diseases in russia 8 current dictators as of 2018. the borgen project the coronavirus outbreak could bring out the worst in trump. virology isn't politics harvard scientist: coronavirus pandemic likely will infect 40%-70% of world this year johns hopkins bloomberg school of public health usa: the international bank for reconstruction and development/the world bank global health security demands a strong international health regulations treaty and leadership from a highly resourced world health organization theme papers on global public health and international law authoritarianism, outbreaks, and information politics china's harsh response to the coronavirus has influential admirers, but western nations recognize that public health fundamentally depends on public trust report of the who-china joint mission on coronavirus disease as new coronavirus spread, china's old habits delayed fight. the new york times coronavirus weakens china's powerful propaganda machine. the new york times key: cord-005068-3ddb38de authors: meslin, eric m.; garba, ibrahim title: biobanking and public health: is a human rights approach the tie that binds? date: 2011-07-15 journal: hum genet doi: 10.1007/s00439-011-1061-2 sha: doc_id: 5068 cord_uid: 3ddb38de ethical principles guiding public health and genomic medicine are often at odds: whereas public health practice adopts collectivist principles that emphasize population-based benefits, recent advances in genomic and personalized medicine are grounded in an individualist ethic that privileges informed consent, and the balancing of individual risk and benefit. indeed, the attraction of personalized medicine is the promise it holds out to help individuals get the “right medicine for the right problem at the right time.” research biobanks are an effective tool in the genomic medicine toolbox. biobanking in public health presents a unique case study to unpack some of these issues in more detail. for example, there is a long history of using banked tissue obtained under clinical diagnostic conditions for later public health uses. but despite the collectivist approach of public health, the principles applied to the ethical challenges of biobanking (e.g. informed consent, autonomy, privacy) remain individualist. we demonstrate the value of using human rights as a public health ethics framework to address this tension in biobanking by applying it to two illustrative cases. at first blush, the ethical foundations guiding public health and genomic medicine are at odds: whereas public health practice adopts collectivist principles that emphasize utilitarian and population-based benefits, genomic (and especially personalized) medicine is squarely grounded in an individualist ethic that emphasizes autonomous decisionmaking for personal benefits. one definition of public health illustrates its breadth and focus: the promotion of health and the prevention of disease and disability; the collection and use of epidemiological data, population surveillance, and other forms of empirical quantitative assessment; a recognition of the multidimensional nature of the determinants of health; and a focus on the complex interactions of many factors -biological, behavioral, social, and environmental -in developing effective interventions (childress et al. 2002) . lawrence o. gostin (2001) further highlights the critical role of collective entities like communities and governments in ensuring the public's health because although individuals, given the means, can do many things to protect their own health, there are health benefits such as a healthy environment, safe roads, potable water and clean air that require ''organized and sustained community activities''. in short, public health programs deliver to populations health benefits that cannot be effectively secured on an individual or small group basis (childress et al. 2002) . in contrast, genomic medicine-sometimes conflated with personalized medicine-has been described as an endeavor that ''will provide a link between an individual's molecular and clinical profiles, allowing physicians to make the right patient-care decisions and allowing patients the opportunity to make informed and directed lifestyle decisions for their future well-being'' (ginsburg and mccarthy 2001) . it envisions medical care in which ''drugs and drug doses are made safer and more effective because they are chosen according to an individual's genetic makeup'' (lesko 2007) . others, such as the ickworth group (burke et al. 2010) , characterize personalized medicine as any medical ''care that is tailored to the individual or stratified by the population subgroup''. common to all of these definitions is the emphasis on customizing therapy to the individual patient. indeed, for as long as clinicians have been caring for patients, medicine has been personalized (ramsey 1961) , but it is the accelerant of genetic technology that has led some to think that today's medicine has the potential to be even more ''personalized'' than its historical predecessors. of course, with the benefit of further reflection, the contrast between personalized medicine and public health is not so stark. for instance, the collectivist approach of public health does not preclude a role for clinical interventions and choices at the individual level. moreover, the claim that the treatment of a sick individual improves the health of the population of which she is a member is all but tautologous. vaccination is an example that fits both conditions. seen this way, personalized medicine and public health are not mutually exclusive, but rather incompletely overlapping. the goals of public health practice certainly include the impact on the health of individuals, and included in the potential value of a genomic approach to medical care is its generalizability to the public's health, for example through better screening and prevention programs (burke et al. 2010 ). recognition of this potential for demonstrating the relationship between public health and genomics is evident in a new area of study complete with its own journal, public health genomics that hopes to address some of these very issues. it has been noted, for instance, that a better understanding of what lies between the genes that make up the genome, the role of the environment on gene expression and the role of the interaction between genes will help us to know why some individuals remain healthy while others are more susceptible to genetic diseases. this understanding will also benefit the public health sector where the prevention and expression of communicable and infectious diseases, for example, is related in part to understanding genetic susceptibility… ). the ickworth group recently examined the potential for genomics and personalized medicine to inform public health practice and concluded that much still needs to be done before the promise can be realized (burke et al. 2010) . in particular, they made six recommendations: 1. efforts to integrate genomics into public health and practice should continue. 2. an appropriate research infrastructure for generating an evidence base for genomic medicine needs to be established and maintained. 3. model public health genomics programs and clinical services need to be developed, implemented and evaluated. 4. international collaborations should be promoted. 5. appropriate genetic services and genome-based research should be fostered within low and middle income countries. 6. programs, research and strategies in public health genomics should be informed by accepted ethical principles and practices. such qualified support for the potential for genomic impact on public health is not surprising, as others have commented on the status of promises made and kept (evans et al. 2011; hall et al. 2010) . biobanking is a useful case study to unpack issues at the intersection of genomics and public health. the storied history of the many uses of biological materials that help to improve the understanding, clinical diagnosis and treatment of human disease is long and impressive with detailed reports of the clinical value of banked specimens dating to the early eighteenth century (ackerknecht 1967; korn 2000) . without access to stored specimens of blood, urine, tumors, body tissues, dna and other human biological materials, important advances in cancer, infectious disease, cardiovascular care and mental disorders would not have been possible (nat'l bioethics adv. comm. 2000) . for example, the pap smear would not have been developed (younge et al. 1949 ) and the nonsteroidal estrogen hormone, diethylstilbestrol (des), would not have been found to be carcinogenic (herbst 1981) . without the knowledge gained from autopsies of korean war veterans, science would have known less about the age of onset for atherosclerosis (enos et al. 1955) . moreover, the cdc would not have been able to isolate and understand the hantavirus (wrobel 1995) and researchers would not have been able to make progress on certain brain tumors . no doubt researchers hoping to understand the impact of radiation leaks on residents near the fukushima nuclear plant in japan will make use of the chernobyl tissue bank established in 1998 to study the effects from (until this point) the world's foremost nuclear plant disaster (http://www. chernobyltissuebank.com). the completion of the human genome sequence (and other genomes) greatly expanded the capacity of science to use and obtain greater value from both previously collected biological specimens and those still to be collected (meslin and quaid 2004) . for example, the international community, led by canadian researchers, was able to rapidly sequence the sars virus from obtained specimens (marra et al. 2003) . others used similar technology for the h1n1 virus (graham et al. 2011; zhang and chen 2009 ), dramatically shortening the time it took to understand the nature of the threat and prepare a public health response. moreover, the prospect of using genome technology on already stored specimens for enhanced genetic diagnostics, drug development, and even domestic and international security threat analysis (meslin 2003; bugl et al. 2007; atlas 2002 ) offers a glimpse into the future of a genetically-informed public health capacity for nation-states. indeed, it is the fortuitous combination of genomics and pharmacology that gives rise to the most promising example of personalized medicine-the field of pharmacogenomics (evans 2006; evans et al. 2004; desta and flockhart 2007) . just as the past benefits to human health from using banked human biological materials stand on their own merit, any future benefits will need to be assessed over time. for us, the important challenge is whether the ethical and legal basis for using banked materials is sufficient to support its expanded use in more areas of public health practice and research. in other words, while we acknowledge that the boundary between the two domains is by no means a stark one; the failure to appreciate what makes them different may prevent productive engagement between these two domains of health care to serve the health interests of society. several explanations have been offered for why public health approaches to health and disease differ from clinical medical approaches, each of which have ethical valence. one theory credits medicine's increasing focus early in the twentieth century on treating the biological causes of disease, and public health's contrasting occupation with the social and environmental causes of illness, resulting in efforts geared toward health promotion and prevention (khoury et al. 2007 ). the vectors of medicine and public health diverged further when schools of medicine and public health in the united states were officially separated in 1916 (khoury et al. 2007 ), in part due to the conflicting goals of professionals in the fields (porter 2006) . additional ideas include ''the rise of medical authority with the expansion of hospital-based specialist practices'' (porter 2006) as well as a corresponding split between individualist and collectivist modes of analysis in the social sciences (arah 2009 ). this disciplinary, professional and institutional dissociation between the two fields has been blamed for the current gap between personal medical care and public health (arah 2009 ). the public health approach presupposes that an exclusive focus on the treatment of individuals is not sufficient to protect, promote and sustain effectively the health of a population. this is evident in the work and writings of public health practitioners such as the sanitarians (susser and susser 1996a) , thomas mckeown (szreter 2002) , geoffrey rose (marmot 2001) , dan e. beauchamp (kass 2004) , marc lappe (kass 2004) , marvin susser (susser and susser 1996b) , ezra susser (march and susser 2006) , norman daniels (kass 2004) , paula braveman (braveman et al. 2004 ) and the world health organization (who) commission on the social determinants of health among numerous others (marmot 2005) . whatever the historical source of the ''schism'' between clinical medicine and public health (khoury et al. 2007 ), the gap between them translates directly into the ethical plane. the individuating drive of personalized medicine could make the breach felt all the more keenly, especially when values of individual and population health conflict. for instance, genomics research has focused on ''individually rare single gene disorders,'' prompting warnings that such investments redirect limited resources from ''efforts to address the social and environmental causes of ill health'' (khoury et al. 2007) . moreover, the challenge of ethical analysis is exacerbated by a disparity in the maturity of ethical frameworks governing medicine and public health. whereas early bioethics scholarship often focused on the individual patient receiving care and to ethical principles supporting this relationship, a similar comprehensive and widelyaccepted ethical framework for public health is yet to be established (nixon and forman 2008; mann 1998; callahan and jennings 2002) . tellingly, nancy e. kass (2004) observes that the language of public health was conspicuously absent among the early bioethicists, despite some achievements with implications for public health ethics. daniel callahan and bruce jennings (2002) likewise point out the focus in bioethics on novel medical technologies in clinical settings at the expense of social and economic inequities. another reason an individualist outlook has prevailed in bioethics is that some public health interventions are conducted on the individual rather than the population level. for instance, postwar antismoking campaigns in great britain set a trend that involved educating and influencing individual behavior and lifestyles (porter 2006) . the approach, later adopted to combat heart disease, obesity and cancer, helped solidify the individualist and behavioral model already prevalent in clinical medicine (beauchamp 1985; porter 2006) . hence, the population perspective implicit in public health ethics was at times at odds with the individualist methods employed to serve the public's health. a further rationale for the individualist bias of hum genet (2011) 130:451-463 453 bioethics is the backlash against the misuse of populationbased policies in the field of eugenics, resulting in an understandable suspicion of collectivist bioethical analysis (pernick 1997; kirkman 2005; lombardo 2011 ). these factors have combined to generate a rich framework for ethical analysis, but one that has remained individualist in orientation. the inadequacy of the framework was noted by bioethicists such as dan e. beauchamp who argued, against the prevailing political valorization of individual autonomy, that a framework that privileged ''individual interests'' and ''market justice'' was detrimental to public health (kass 2004 ). beauchamp suggested that public health might require its own ''ethic,'' a proposal taken up by marc lappé (1986) who differentiated medical ethics from public health ethics. as the new millennium unfolded, several efforts were undertaken to establish frameworks for public health ethics. among these was the american public health association's (apha) adoption of the public health code of ethics in early 2002. the apha was the first national organization to adopt the code (thomas et al. 2002) , which is based on the public health leadership society's principles of the ethical practice of public health. the code is relatively narrow in scope, catering primarily to an audience in traditional public health institutions such as public health departments and schools of public health (thomas et al. 2002) . moreover, it focuses on public health practice rather than research, and has in view the united states' public health system. meanwhile, efforts were underway to mainstream another and more comprehensive ethical framework for public health ethics in the form of human rights. the appeal and promise of human rights as an ethics framework for public health was articulated by the late jonathan mann: given that the major determinants of health status are societal in nature, it seems evident that only a framework that expresses fundamental values in societal terms, and a vocabulary of values that links directly with societal structure and function, can be useful to the work of public health. for this reason, modern human rights, arising entirely outside the health domain, and seeking to articulate the societal level preconditions for human well-being, seems a more useful framework, vocabulary, and template for public health efforts to analyze and respond directly to the societal determinants of health than any framework inherited from the past biomedical or public health tradition. (mann 1998) apart from the capacity of human rights to speak in ''societal terms,'' a crucial part of mann's argument was his identification of the goals of human rights as virtually inseparable from those of health, i.e., human well-being (mann 1997) . although a human rights perspective has the practical advantage over other frameworks of being realized in (mostly international) law, it also benefits from being rooted in an established and fertile ethical vision. human rights can be traced back to the ancient world, but we describe here the prevailing view, which has origins in the writings of such philosophers as hugo grotius, thomas hobbes, jean jacques-rousseau and john locke. modern human rights assume that all persons possess inherent dignity and certain inalienable rights by the simple fact of their being human. the words ''inherent'' and ''inalienable'' mean these things belong to them naturally and are not granted to them by any political authority. to advance their individual and common well-being, however, people give up certain rights to set up a government that serves their needs. a functioning human rights framework is based on the proposition that a government should not take more rights from people than people give to the government in the first place. on this view, the government exists to ensure the well-being of the individuals who give up certain rights in exchange for certain protections and benefits from the government. the same applies to the community they jointly establish. from this analysis, the traditional roles of government include such things as collective security, the administration of justice, the protection of property and, relevant for our purposes, the promotion of the public's health. seen in this way, a human rights perspective provides an ethical framework for describing the conditions under which the government can protect and promote both individual and community well-being. with the onset of the cold war, however, rights that were part of a single ethical vision in the universal declaration of human rights (1948) were gradually split into two categories. the two classes of rights reflected the ideological priorities of the contending sides and were enshrined in two separate treaties in the 1960s. the international covenant on civil and political rights (1966) (iccpr) reflected the capitalist and liberal emphasis on such rights as free speech, freedom of movement, freedom of religion, the right to vote and the right to privacy. these civil and political rights required governments to refrain from interfering with the liberties of their individual citizens. on the other hand, the international covenant on economic, social and cultural rights (1966) (icescr), spearheaded by the communist eastern bloc, focused on such priorities as the right to work, the right to housing, the right to education and the right to health-rights that require governments to take some kind of action for the benefit of the whole society. in part due to their being costlier than civil and political rights and also because of their questionable justiciability (i.e., their enforcement in courts of law) (tarantola 2008) , social and economic rights were not given the same priority as civil and political rights by governments. the main result of this focus on individualist civil and political rights is that many governments have not invested as heavily in addressing issues at societal or population level-issues such as housing, education and health. hence, human rights norms in the twentieth century have developed along broadly individualist rather than collectivist lines. roberto adorno (2009) describes the potential for human rights as a framework for biomedicine and public health in the global context. he notes that ''[a]s our world becomes increasingly interconnected and threats to the global public health continue to proliferate, it is hard to see how the global governance of health could be managed without assigning an integral role to human rights''. the reasons he provides in support of a human rights framework include the fact that much biomedical activity has clear human rights implications (e.g., the rights to life and physical integrity); human rights have developed into a transcultural ethical discourse with the potential for setting common standards; and there are few if any other viable mechanisms that can serve as a ''global normative foundation''. considering the then incipient unesco universal declaration on bioethics and human rights, t. a. faunce (2005) noted the increasing application of human rights to address challenges traditionally considered within the sole purview of bioethics and medical ethics. in the narrower context of genomics, knoppers (2000) has argued that benefit-sharing in the context of genetic research ''is an aspect of fundamental human rights and serves to counterbalance the effects of commercialization and patenting''. she has also proposed human rights as a compelling model for policy governing new genetic technologies (knoppers 2004) . these developments notwithstanding, commentators have been quick to point out the limitations of adopting human rights approach for public health and genome-based medicine. meier and mori (2005) criticize the ''limited, atomized right to health'' contained in the icescr, a provision that establishes neither a robust individual right to health nor an effective means of ensuring public health. similarly, adorno (2009) acknowledges the criticism ''that human rights are conceived as excessively individualist for non-western mentalities and lack a significant concern for personal duties and for the common interest of society''. with particular reference to the field of genomics, iles (1996) points to two specific shortcomings of human rights as an ethical framework, both of which are traceable to the individualist orientation of the current system. his first criticism is that such a framework pays inadequate attention to the structural and social effects of genetic information. he argues that because economic, racial, ethnic and power disparities already exist between groups in societies, genetic information used without ethical oversight can exacerbate these differences and result in discrimination and exclusion. iles infers that human rights may adequately protect individuals facing genetic profiling in employment or insurance contexts, but it is questionable whether the framework's individualist lens can monitor the effects of genetic information on relations between and among groups. iles' second criticism of the applicability of human rights as a foundation for ethical uses of genomics is that individual freedom of choice regarding the use of genetic information can have an aggregate population-wide effect. for example, the choice parents make to have a ''normal'' child rather than one with a ''comparatively inert and tolerable'' disorder is not only heavily influenced by society's values but also determines eventually the society's constitution (iles 1996) . a narrow focus on individual choice, therefore, may obscure the effects of the uses of genetic information on a society. the preceding discussion demonstrates that even human rights as a framework for public health ethics are not immune from the individualist approach that characterized early bioethics. toward the end of the cold war, however, there were renewed efforts to reintegrate the individualist civil and political rights with the community-oriented economic and social rights (meier and fox 2010) . we outline three of these developments below. the first development is the increasing recognition of a category of rights known as ''solidarity'' or third-generation rights (wellman 2000) . the phrase ''third-generation'' distinguishes solidarity rights from the more individualist civil and political rights (''first-generation'' rights) and the more collectivist social, economic and cultural rights (''second-generation'' rights). like the other two generations of rights, solidarity rights were a response to a particular set of problems facing the international community. these included ''securing peace after the first and second world wars, achieving freedom for colonial peoples, reducing the gross economic inequalities between developed and underdeveloped countries, and preserving a healthy environment when the technologies in one nation seriously damage an environment shared by all nations'' (wellman 2000) . solidarity rights, in other words, are aimed at conditions that can be addressed only by global efforts rather than the laws of any single country. the classic examples of solidarity rights are the rights to peace, development, a healthy environment, self-determination, humanitarian intervention, communication and ownership of the common heritage of humankind (wellman 2000; monshipouri et al. 2003) . apart from requiring the concerted efforts of all countries, solidarity rights have two other criteria: first, that the rights belong to peoples (i.e., groups), not just individuals; second, that obligations apply to all actors on the international scene, not just governments. more recently, solidarity has been described as a key ethical foundation for biobanks (chadwick and berg 2001) . from an ethical perspective, solidarity rights complement first-and second-generation rights. whereas firstgeneration rights protect individuals from the abuses of their governments (e.g., no torture or arbitrary arrests), and second-generation rights enable individuals to claim benefits from their governments (e.g., education, housing), solidarity rights recognize that individuals cannot reach their full potential without ''cooperative participation in the social life of the various communities to which they belong'' (wellman 2000) . hence, solidarity rights further establish in human rights the ethical principle that human well-being has a communal dimension that goes beyond an individual citizen's relationship with her government. the second development emphasizing a collectivist approach in human rights is growth in the area of indigenous peoples' rights. the united nations general assembly adopted the declaration on the rights of indigenous peoples in 2007. what makes this declaration unique is that it explicitly recognizes a category of ''collective'' rights. until the declaration's adoption, human rights were concerned primarily with ''the rights of the individual against the state, without much attention to the collective and associational dimensions of human existence beyond the state'' (anaya 2006) . in an historic shift, the declaration recognizes rights to indigenous peoples as groups rather than merely as individual members of their communities. it is a particular instance of the ethical principle underlying solidarity rights, which proposes that community is not an elective component of human well-being. this development, moreover, has significant ethical implications for the involvement of indigenous peoples in research and in access to health benefits, and exemplifies the relevance of indigenous perspectives on genomics research generally (dodson and williamson 1999) . the third and final development pertains to regional human rights instruments. the major global regions are encouraged to adopt their own treaties, thereby customizing global human rights norms to their particular situations for more effective implementation. of particular relevance is the african charter on human and peoples' rights (also known as the banjul charter), which was adopted by the organization of african unity (now the african union) in 1981, and which includes ''a mixture of all three generations of rights'' (shepherd 1985) . as its official title suggests, the banjul charter includes the concept of peoples' rights, which, like the collective rights of indigenous peoples, is a version of group rights. the banjul charter deliberately omits a definition of the term ''people,'' thereby leaving the term open to several interpretations, e.g., persons struggling to gain political independence, persons living in a territory and sharing certain characteristics, or simply all people living in a country (kiwanuka 1988) . whatever their precise legal definition, peoples' rights in the banjul charter are based on the african philosophical belief that a human being is not ''an isolated and abstract individual, but an integral member of a group animated by a spirit of solidarity'' (kiwanuka 1988) . the kinship between this african principle and the ethical norms undergirding solidarity rights and the rights of indigenous peoples discussed above is evident. they all recognize the importance of community to human wellbeing and reject an approach to human rights that focuses exclusively on the individual. these three developments demonstrate how human rights have been finding ways to complement the protection of individual rights with approaches that recognize the ethical importance of community. these attempts to expand the vision of human rights beyond the individual are analogous to the efforts of public health ethicists to develop a population perspective that transcends the clinical encounter between a single patient and her caregiver. this similarity makes the human rights framework a compelling candidate for analyzing the ethics of biobanking and public health. as with early debates in medical ethics and bioethics generally, much of the ethical and legal attention in biobanking has been individualistic, focusing on informed consent (beskow and dean 2008; brekke and sirnes 2006) , privacy protections (chen et al. 2011; evans 2009) , and risks of exploitation, especially in vulnerable populations (lo 2004; bernhardt et al. 2003; dodson and williamson 1999) . important as these topics are, some now believe the time has come to update the ethical/legal dialog about biobanks to accommodate broader social and political perspectives (meslin and cho 2010; kaye 2004; caulfield et al. 2007) . it is against this backdrop that our analysis is set. a human rights approach may offer two advantages over other potential public health ethics frameworks. first, it may avoid having to resolve the seemingly interminable debate about the proper approach to obtaining individual informed consent for research using human biological materials. in situations in which groups may be consulted, approached and from which permission to participate in biobanks may be sought, informed consent may be necessary but not a sufficient mechanism for engaging a community. second, it recognizes the institutionalization and application of human rights discourse at international forums by providing tools for discussing the values of public health across national borders. this is important in light of observations by recent commentators of a linguistic shift with both practical and ethical implications: the gradual transition of the term ''international health'' to ''global health.'' ''international health'' was used to describe a technical endeavor conducted jointly by developing countries and their partners in the industrialized world through such large institutions as the world health organization (who) and care international (elmendorf 2010) . it was useful in this context to distinguish between ''international'' and ''domestic'' health. in contrast, the term ''global health'' reflects an acknowledgment that intensifying interaction between countries through trade and travel renders national borders increasingly immaterial for health challenges (elmendorf 2010) . the shift in terms represents the change from health conceived as an issue for diplomacy and knowledge transfer between countries to health conceived as a common asset and concern of the international community. importantly, the terminological shift from ''international'' to ''global health'' is also reflected in the bioethics literature (chadwick et al. 2011) . a specific example of the application of ''global'' rather than ''international'' health is the ''one world, one health'' initiative, a framework that builds on efforts to contain the avian influenza outbreak (fao et al. 2008) . the initiative is built on the premise that infectious diseases have potentially national, regional and international effects, thus requiring approaches that are not only ''interdisciplinary'' and ''cross-sectoral'' but indeed global. the changes signified by the term ''global health'' have implications for biobanking in many ways (burke et al. 2010) . public health genomics research is becoming ''increasingly international and collaborative'' resulting from the need for larger and more diverse datasets to evaluate genetic differences within groups (ickworth 2010). aided by more robust bioinformatics, genotypic and phenotypic data will be employed with greater frequency to study the significance of genetic variation (mendoza 2010 ). this will involve the use of larger databases and the consolidation of samples from sites around the globe (meslin and goodman 2010; ickworth 2010) . this raises the obvious challenge of harmonizing norms concerning privacy and confidentiality across jurisdictions and, beyond that, consideration of the varied cultural norms guiding data sharing particularly when information moves between developed and lower and middle income countries (lmic) (chalmers 2007; holman et al. 1999; asslaber and zatloukal 2007) . biobanking in the global public health arena is also faced with the challenge of determining research priorities given the different health problems facing populations in developed and lmic. although both regions face the complex diseases of urbanization (e.g., cancer, heart disease, diabetes), environmental factors like climate change and resource scarcity are likely to affect lmic more profoundly than their developed country counterparts. this is especially troubling given that a research imbalance exists between the regions: although african populations are ''the 'root and branch of genetic variability''' the bulk of genomic research is conducted by developed countries and among european populations (ickworth 2010). fortunately, new initiatives such as h3africa may begin to redress this historic injustice (nordling 2011) . these challenges confirm the need for an ethical framework that can be understood and implemented at global forums. s. h. e. harmon (2006) echoes the need for global frameworks ''given the rise of predictive medicine (involving genetic research and clinical genetics), which is driven by private global operators, thereby suggesting a need for regulatory responses which are similarly global''. although a 2003 who report on genetic databases concludes that biobanks are based more on ''communal value'' than on ''individual gain,'' the reality is that the ethics of biobanking has been analyzed predominantly in the traditional individualist bioethical categories of confidentiality, autonomy and informed consent (knoppers and chadwick 2005) . the fact has not been lost on some commentators. garrath williams, for instance, discusses the daunting task of developing ethical principles for large-scale biobanks. he attributes the difficulty in part to an excessive focus on the individual research subject's right to informed consent, an emphasis he finds inconsistent with the inevitably collective nature of large-scale biobanking (williams 2005) . williams maintains that this conceptual incongruity obscures important ethical questions about how research priorities are set and how to accommodate the diverse motives of actors in health care systems. he warns that ignoring analyses that transcend individualist frameworks may, paradoxically, end up harming the interests of individuals (williams 2005) . human rights can make no original contributions to the ethics of biobanking if they are incapable of transcending their individualist biases. the second challenge of a human rights framework for biobanking involves developments in global politics. the observation by knoppers and chadwick (2005) that genetic research has compelled ''a public and therefore a political examination of personal and social values'' illustrates the close connection between politics and ethics in biobanking. therefore, ethical analyses of international biobanking and public health that omit the global political context will likely remain deficient. the developments in global politics that pose the greatest challenge to human rights as an ethical framework for biobanking are efforts, in the context of globalization, to entrench policies that entail an increasing delegation of governmental responsibilities to private actors. in a publication on health and human rights, who (2002) notes that [w]ithin the human rights community, certain trends associated with globalization have raised concern with respect to their effect on states' capacity to ensure the protection of human rights, especially for the most vulnerable members of society. located primarily in the economic-political realm of globalization, these trends include: an increasing reliance upon the free market; a significant growth in the influence of international financial markets and institutions in determining national policies; cutbacks in public sector spending; the privatization of functions previously considered to be the exclusive domain of the state; and the deregulation of a range of activities with a view to facilitating investment and rewarding entrepreneurial initiative. these trends serve to reduce the role of the state in economic affairs, and at the same time increase the role and responsibilities of private (non-state) actors, especially those in corporate business, but also those in civil society. this transfer of responsibilities from governments to private actors is critical because the operation of international law depends both on governments assuming legal obligations by signing agreements and on these governments being held accountable for fulfilling the responsibilities they undertake. generally speaking and despite recent changes in international criminal law, private actors are not accountable under public international law, the branch of international law to which human rights belong (jessberger 2010) . hence, the transfer of governmental responsibilities such as health provision to private actors removes a growing number of issues from the direct supervision of human rights. governments retain the duty to ensure that private actors such as transnational corporations do not violate human rights, but monitoring and enforcing the norms remains a major challenge (gruskin et al. 2007; tarantola 2008) . we conclude this discussion with two examples of key ethical issues raised by the prospect of expanding international biobanking: the first addressing differences in national laws governing biobanks, and the second addressing ethical obligations of transnational corporations operating in lmic. various commentators have discussed the problem for international biobanking arising from the absence of common regulations applying across country borders. the regulatory terrain has been depicted as ''a patchwork of national laws, regulations and ethics advisory body guidelines'' (maschke 2005) , and comparisons have proven ''laborious and defy generalizations'' (helgesson et al. 2007 ). the discrepancies in ethical rules governing such issues as consent and secondary uses raise obvious barriers to the principled collection of tissue samples and the development of personalized medicine. adopting human rights as a public health ethic is not an ideal guide for drafting specific rules governing individual focused biobanking issues such as consent, privacy and secondary uses. however, such an ethic can inform efforts to determine the general principles that should govern the activity of biobanking as a broader societal undertaking. human rights can do this by integrating three concepts: (1) collective rights (from international human rights); (2) global public goods (from economics); and (3) the common heritage of humanity (from international environmental law). we have discussed above the welcome and increasing recognition of community-oriented socio-economic rights as well as solidarity rights in international human rights toward the end of the cold war. we noted also how the change was reflected in the explicit recognition of ''collective'' rights in the 2007 united nations declaration on the rights of indigenous peoples. these rights ''operate at an international level to assure public goods that can only be enjoyed in common with similarly-situated individuals and thus cannot be realized through individual rights claims against the state'' (meier and fox 2010) . the premise grounding the recognition of collective rights is that the realization of some human rights is simply not reducible to their exercise by an aggregate of individuals. harmon (2008) writes that social solidarity has been incorporated, even if implicitly, into unesco's major instruments on genomic research, namely the universal declaration on the human genome and human rights (1997) and the universal declaration on bioethics and human rights (2005) . he maintains that the emergent notion of social solidarity mitigates the excesses of modern individualism and is ''grounded in the recognition that individuals are socially embedded''. his analysis of the unesco documents describes a solidarity based on the fundamental unity of all humans, a focus on ''the collective, the observance of duties and the creation and preservation, through personal and collective action, of a just and decent society''. the notion that the human genome is the ''common heritage of humanity'' has been eloquently defended (knoppers 2005a ), but has not avoided the disquiet among some commentators, some of whom suggest that the human genome be classified as a common resource rather than the common heritage of humanity (spectar 2001; resnik 2005) . developed in the context of international law governing the management of resources in outer space and the high seas, this concept is founded on three basic principles: ''(1) absence of private property rights i.e. the right [usually of governments] to use resources but not to own them; (2) international management of all uses of the common heritage; and (3) sharing of benefits derived from such use'' (white 1982) . also included in the concept is an obligation to use the resource in a peaceful and responsible way, keeping the resource accessible to all and considering the interests of future generations (knoppers 2005a) . in economic terms, a global public good is a good ''for which the cost of extending the service to an additional person is zero and for which it is impossible or expensive to exclude individuals from enjoying'' (nordhaus 2005) . a global public good is marked by two criteria: that the good be non-excludable and non-rivalrous. stated differently, ''[a] good is non-excludable if persons cannot be excluded from accessing it, and non-rivalrous if one person's use of the good does not diminish the supply of that good'' (chadwick and wilson 2004) . a classic example is a lighthouse that lights the sea and which is not diminished in its use by multiple sailors (chadwick and wilson 2004) . other examples include a global positioning system (gps) whose value is not compromised by multiple users, or the eradication of an infectious disease, the benefits of which cannot be diverted from any susceptible persons (nordhaus 2005) . it has been argued that both genetic information (knoppers and fecteau 2003; chadwick and wilson 2004) and public health (meier and fox 2010) should be classified as global public goods in this same way. these three concepts have been integrated by several commentators in efforts to develop ethics frameworks for public health and biobanking. meier and fox (2010) consider public health a public good and make a case for its recognition in international law as a collective right. knoppers (2005a) notes growing support in international normative documents for the human genome to be classified as the common heritage of humanity, and argues, as do chadwick and wilson (2004) , that genetic databases should be considered a global public good (knoppers and fecteau 2003; knoppers 2005b; chadwick and wilson 2004) . the combination of features from all three concepts can provide the basic constituents of a human rights public health ethic for international biobanking. first, collective rights, premised conceptually on the fact that certain rights can be protected only in groups, is virtually analogous to the population perspective of public health, which presumes that certain health challenges require society-wide, rather than individual, interventions. the kinship of the two perspectives is highlighted in the argument made by meier and fox (2010) that public health be recognized as a collective right. second, the classification of genetic databases as the common heritage of humanity, which precludes private ownership while requiring shared uses and benefits, buttresses the view that biobanks should be managed under principles that consider the whole of humanity rather than narrower interests, no matter how seemingly benign. again, these principles would share an affinity with the principles of public health that target the health of the whole population. third, the arguments for the status of genetic information as a non-rivalrous and non-excludable global public good also support an approach to managing biobanks that recognizes the public character of the resource. together, these features ground the management of international biobanking in a framework that keeps foremost the population perspective of public health. biobanking and developments in personalized medicine entail the involvement of private investors. commentators have pointed out the costs associated with this infusion of private funding. they raise concerns that such involvement may influence the type of research, distort the process by restricting the direction of research, prevent collaboration, and restrict the sharing of the raw data generated by the research. it also might prevent the results of the research being disseminated effectively or cause publication bias. most importantly, it may serve to reduce public trust in the research process. some evidence suggests that potential participants may be less willing to engage in research if this is privately funded (as they perceive themselves to be more exposed to potential exploitation) (ickworth 2010). the risks expand significantly when, as projected, biobanking expands globally. most lmics have vulnerable populations and lax to minimal research regulation. but even where lmic governments have the ability to regulate research activity, we have noted above the growing trend under globalization for governments to delegate traditional responsibilities to private actors. this constitutes a major administrative and ethical challenge in the regulation of biobanks because, as a rule, governments rather than private actors assume international obligations (ratner 2001). the situation requires an ethical framework for protecting vulnerable populations living under governments either unwilling or incapable of protecting their interests. in 2005, john ruggie was appointed the united nations special representative of the secretary general (srsg) on business and human rights for an initial term of 2 years. ruggie's primary charge was to clarify the human rights obligations of companies operating internationally and the responsibilities of host governments to regulate such businesses (u.n. comm. on human rights 2005). in extending the srsg's mandate another 3 years in 2008, the human rights council 1 observed that weak national legislation and implementation cannot effectively mitigate the negative impact of globalization on vulnerable economies, fully realize the benefits of globalization or derive maximally the benefits of activities of transnational corporations and other business enterprises and that therefore efforts to bridge governance gaps at the national, regional and international levels are necessary… (u.n. human rights council 2008) the appointment of the srsg underscores the ethical implications of international trade and politics. it also testifies to the potential of human rights as a framework for addressing global governance challenges. the srsg fulfills his mandate through research, consultations and workshops that lead to recommendations, standards and tools for the use of businesses and other stakeholders. in the course of his mandate, the srsg has developed a human rights framework for business in the global economy. the framework (known as the ''un framework'') has three pillars: the duty of governments to protect their citizens from human rights violations by third parties (particularly international businesses); the responsibility of businesses to respect human rights (typically contained in corporate codes of conduct); and the establishment of remedies for people whose human rights have been violated (u.n. spec. rep. of the sec. gen. 2008). the un framework provides a useful tool for helping mitigate the regulatory hazards associated with privatelyfunded biobanking enterprises in lmics. by further clarifying the responsibilities of both host governments and foreign investors, the un framework increases the chances that clear laws regulating biobanking will be passed by lmic governments. effective biobanking governance models (kaye and stranger 2009 ) are necessary if biobanking is to benefit public health as governments remain the primary actors in public heath practice. moreover, by ensuring the availability of remedies for violations, the un framework reduces the incentive of foreign investors to take advantage of weak and/or corrupt governments unwilling to implement existing biobanking regulations. the un framework was endorsed by the human rights council in june 2011, thereby enhancing its credibility as a global ethical standard for regulating international business activity. this endorsement ensures that the un framework will help guarantee that the projected extension of especially privately financed biobanking to lmics will take into account the public health interests of lmic populations. we have taken the view that one of the ethical challenges raised by genomic medicine reflects an enduring problem in public health: the appropriate balancing of individual and collective values, rights and interests. biobanking in the context of public health genomics reflects a unique case study in this classical problem because it must accommodate both individual and community interests (including multiple types of affected communities). while no single ethical-legal framework has been accepted to bridge 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projects 25 questions and answers on health and human rights serendipity, science and a new hantavirus a study of 135 cases of carcinoma in situ of the cervix at the free hospital for women possible origin of current influenza a h1n1 viruses key: cord-021105-6z619phm authors: sandler, todd title: regional public goods and international organizations date: 2006-03-09 journal: nan doi: 10.1007/s11558-006-6604-2 sha: doc_id: 21105 cord_uid: 6z619phm this article focuses on the provision prognosis for regional public goods (rpgs) and the role of international organizations in fostering supply in developing countries. all three properties of publicness—i.e., nonrivalry of benefits, nonexcludability of nonpayers, and the aggregation technology—play a role in this prognosis. the paper highlights many provision impediments, not faced by national or global public goods. when intervention is necessary, the analysis distinguishes the role of global, regional, and other institutional arrangements (e.g., networks and public-private partnerships). the pros and cons of subsidiarity are addressed. able benefits to people in two or more countries. 1 some tpgs provide benefit or cost spillovers globally-e.g., efforts to reduce ozone-shield-depleting chlorine and bromide substances improve the well-being of people worldwide. when spillovers are global, the associated good is a global public good (gpg). if, instead, the public good's benefits are confined to two or more countries in a given location, then the good is a regional public good (rpg), whose spillovers may be more confined than tpgs. in recent years, there is a growing interest in the study of gpgs and tpgs beginning with global challenges (sandler, 1997) and followed by other contributions (see, e.g., ferroni and mody, 2002; kanbur, sandler and morrison, 1999; kaul, grunberg and stern, 1999; kaul, conceiçã o, le goulven, and mendoza, 2003; sandler, 1998 sandler, , 2004 . some studies focus on rpgs and their associated collective action problems (arce and sandler, 2002; cook and sachs, 1999; estevadeordal, frantz and nguyen, 2004; sandler, 1998 sandler, , 2002 stå lgren, 2000) , while others analyze gpgs and their provision efforts to date. a primary concern is to distinguish tpgs for which nations have the proper incentives to contribute from those where incentives are perverse. another concern is to identify the role of diverse agents and international organizations-i.e., global (e.g., world bank, united nations) institutions, regional institutions, networks, public-private partnerships, and charitable foundations-in bolstering tpg provision in developing countries. in recent years, increased foreign assistance has been channeled in a bilateral and multilateral fashion to finance tpgs in developing countries. based on data from the organization for economic cooperation and development (oecd), te velde, morrissey and hewitt (2002: 128) show that aid-funded public good support more than doubled from 16.22% of assistance in 1980-82 to 38.19% in 1996-98. 2 much of this increase was in terms of npgs: in 1996-98, 29 .40% of official assistance funded npgs compared with 8.79% for tpgs (te velde et al., 2002: 126-127) . the current study has two essential purposes: to survey the current knowledge of rpgs and to push this knowledge frontier outward. in accomplishing the first goal, the modern study of public goods and collective action (olson, 1965; sandler, 1992 sandler, , 2004 is applied to assess the effectiveness of the support for rpgs in developing countries. all three properties of publicness-nonrivalry of benefits, nonexcludability of nonpayers, and the aggregation technology (i.e., how individual contributions add to the overall level for consumption)-indicate where to direct efforts in providing rpgs. blanket statements about rpgs must be resisted since these goods display a wide range of publicness properties and prognoses. once the prognosis is understood, the role of national and international institutions in promoting the supply of rpgs and gpgs in developing countries will be known. 1 benefits are nonrival when a unit of the good can be consumed by one agent without detracting, in the least, from the consumption possibilities still available for other agents from the same unit. benefits are nonexcludable when they are available to all would-be consumers once the good is supplied. 2 estimates by raffer (1999) indicate that support for public goods varied from 20% to 40% of official development assistance in the 1990s, depending on the classification of public goods used. the growth of aid-supported public goods is further documented in a recent study by mascarenhas and sandler (2005) . also see the world bank (2001) study, which distinguishes between complementary and core activities. complementary activities lay the infrastructure for developing countries to consume tpgs-the so-called core activity. the former require npgs that prepare the country to benefit from tpgs. for the second goal, we highlight the importance of the aggregation technology. the unique position of rpgs vis-á -vis npgs and gpgs is clarified for the first time. moreover, the article identifies the role of global and regional institutions in fostering the provision of rpgs in developing countries. the article also highlights the pros and cons of applying the principle of subsidiarity to the choice of jurisdiction and international organizations. finally, the article explores new institutional arrangements and participants-i.e., networks, public-private partnerships, regional trade pacts, and nongovernmental organizations (ngos)-to augment rpg provision where needed. this section explores the properties and classes of rpgs in regards to developing countries in order to identify the need for international organizations to bolster the provision of rpgs. in many instances, intervention may not be needed, but, when required, the form of intervention and the requisite institutional arrangement hinge on the publicness properties of the rpgs. hence, this taking stock of rpgs is essential. an rpg provides benefits to two or more nations in a well-defined region. a region is a territorial subsystem of the global system, whose basis may be geological (based on earth formations such as a plain or coastline), geographical, political, cultural, or geoclimatic. regional characteristics can influence the extent of spillovers from a public good-e.g., language can facilitate or limit spillovers, while natural barriers, such as mountain ranges, may also affect the range of spillovers. because agricultural research findings are specific to soil and climatic conditions, geoclimatic factors can be the prime determinant of the range of the resulting spillovers. thus, knowledge public goods can be regional in nature. diseases and pests may be indigenous to some regions so that defensive measures may yield rpgs. the two classic properties of a pure public good give rise to market failures that may require either government provision or some form of cooperation among the benefit recipients. nonexclusion results in a market failure because a provider cannot keep noncontributors from consuming the good's benefit. once the public good is provided, consumers have no incentive to contribute because their money can purchase other goods whose benefits are not freely available. thus, the public good will be either undersupplied or not supplied. benefit nonrivalry means that extending consumption to additional users results in a zero marginal cost. exclusionbased fees are inefficient because some potential users, who derive a positive gain, are denied access even though it costs society nothing to include them. purely public rpgs include cleansing a local ecosystem, curbing the spread of an infectious disease, curing a region-specific disease, and instituting regional flood control. for purely public rpgs, intervention by a global institution, regional organization, or other collective is required for provision. impurely public rpgs may, at times, have a more favorable prognosis. impurity can stem from partial rivalry or partial excludability. suppose that impurity is due to partial rivalry alone. an example is a common property resource, such as a regional fishing ground, where access is open to all nations in the region. rivalry applies because increased fishing effort by one nation limits the catch of other nations through crowding. to haul in the same catch, each nation's fleet must exert more effort as that of other nations increases. this problem can be addressed if a regional body restricts fishing efforts to account for the crowding externality. nations are not anticipated to reduce overexploitation on their own unless there is a nation with a sufficiently large stake in the fishery and/or the ability to impose restrictions on others. next, suppose that an rpg is impure owing to partial rivalry and partial excludability. partial rivalry means that extending consumption has a nonzero marginal cost owing to crowding (e.g., treating diseased patients, monitoring a disease outbreak, or cleaning up an oil spill), so that a crowding toll can be levied without necessarily implying inefficiency. the partial exclusion indicates that some of the users can be denied entry unless they pay the toll. the lack of complete excludability means that there will still be some free riders who will use the good, crowd others, and escape payment. thus, the good will be undersupplied and overutilized, which worsens as the degree of exclusion decreases. club goods are impure public goods whose benefits are fully excludable and partially rival. club rpgs include regional parks, power networks (e.g., central american electricity interconnection system (siepac)), 3 transportation infrastructure, crisis-management teams, satellite-launch facility, and biohazard facility. members can efficiently provide these club rpgs, financed through tolls. if exclusion is complete, then there will be no free riders and only members benefit. the toll charges each user the same fee, which equals the crowding costs associated with a standardized unit of use or visit. taste differences among members can be taken into account: members with a stronger preference for the club good will use it more frequently and will thus pay more in aggregate tolls. under a wide range of scenarios, the tolls collected will finance the efficient level of provision (cornes and sandler, 1996) . suppose that nations in a region jointly utilize a satellite-launch facility (e.g., alcâ ntara in brazil for latin america). each launch is charged the same fee, but countries that launch more satellites will pay more in total charges. such a club arrangement means that resources will gravitate to their most-valued use without the need for outside intervention. regional clubs can seek loans from global institutions, donor nations, or regional development banks to initially finance the club good. toll proceeds can subsequently repay the loan. members can be quite heterogeneous and include nations, private firms, and other organizations. intelsat is a global club that is a private consortium with diverse members that share a satellite-based communication network that carries most intercontinental phone calls and television transmissions. clubs represent a low-cost institutional arrangement for collective provision that can be member owned and operated or government provided. joint products arise when an activity yields two or more outputs that may vary in their degree of publicness. jointly produced outputs may be purely public, private, a club good, or something else. actions to preserve a rain forest not only yield local public goods (e.g., a watershed, ecotourism, and localized climate influences) but also gpgs (e.g., biodiversity and sequestration of carbon). eliminating a local insurgency not only provides rpgs in the form of fewer refugees and a reduced spread of diseases, but also a tpg from a smaller likelihood of a contagious conflict. regional peacekeeping may offer similar joint products. foreign aid is also associated with joint products. conditionality may provide donor-specific private benefits, while poverty reduction in the recipient country can create an altruistic gpg as the global community benefits from welfare improvements in poor countries. for joint products, the prognosis for effective collective action depends on the ratio of excludable benefits-e.g., contributor<specific and club good benefits-to total benefits. as this ratio approaches one, the share of excludable benefits grow in importance, thereby enabling markets and clubs to efficiently allocate resources to the activity_s provision. if, instead, this ratio approaches zero so that all jointly produced benefits are nonexcludable, then underprovision and/or overutilization will result and intervention is needed. since this ratio can assume any value between zero and one, many scenarios are possible. institutional design can endogenize this ratio so that collective action can be fostered by augmenting country-specific and excludable benefits to provide incentives to potential supporters. for example, tying voting privileges to a donor country's international monetary fund (imf) quota is a way to motivate greater support. the third property of publicness is the aggregation technology, which indicates how individual contributions to the public good contribute to the overall quantity of the public good available for consumption. this aggregator property influences the incentives that potential contributors possess and, hence, affects the prognosis of supply. each of the subclasses of public goods introduced above can be further subdivided by the aggregation technology to gain a better perspective on contributor incentives (sandler, 2003) . traditionally, the only aggregator assumed was summation where the overall level of the public good equals the sum of the agents' contributions to the good. in cleansing a local ecosystem, the level of cleanup equals the sum of the pollutants removed, where each agent's removal efforts adds in a cumulative fashion. the measure of the number of diseased patients treated equals their sum. in addition, the quantity of regional parks and/or rain forest preserved corresponds to the sum of hectares protected. a distinguishing feature of summation is that every contributor's efforts are perfectly substitutable for those of others; one nation's unit of provision has the same impact on the total level of the public good as a unit supplied by anyone else. without exclusion, free-rider incentives are then a prime concern because another nation's provision limits the need for the nation to contribute. when summation is associated with the two classic properties of pure publicness, an rpg has little likelihood of supply unless some outside party, such as an international organization, takes over. a less extreme form of summation is where the overall level of the public good equals a weighted sum of agents' contributions. thus, actions to curb the spread of an infectious disease may differentially depend on individual efforts where those taken to protect the most susceptible population have a greater payoff. when reducing sulfur deposits falling on a country, the influence of cutbacks abroad depends on wind patterns, the sites of emission sources, and the pollutants' airborne time. cutbacks in an upwind country can have a greater impact than the same cutback in another country, not in the pathway of the prevailing winds. with weighted-sum technology, provision is no longer a perfect substitute and so incentives to act may differ among nations. for example, a country that dumps more of its sulfur on itself or else receives relatively large amounts from other countries has strong incentives to sign treaties that mandate cutbacks. if a weakest-link aggregator applies, then the smallest contribution fixes the public good_s aggregate level. the effectiveness of actions to maintain the integrity of a network or to monitor a regional disease outbreak hinges on the least adequate measures. a network will fail at its weakest point; the ability to stem an outbreak depends on the least adequate intelligence. with a weakest-link public good, matching behavior is anticipated because there is no gain from providing beyond the smallest contribution level. contributions above this level utilize scarce resources but do not augment the overall amount of the public good. if all nations in a region have similar means and tastes, then nations are motivated to attain an acceptable standard of rpg provision. free-riding incentives are eliminated; contributing nothing means that the effective level of the good is naught regardless of the contributions of others. with diverse means or income, the poorer nations possess insufficient capacity to provide a level of the weakestlink public good acceptable to wealthier nations. the latter are, however, motivated to contribute in-kind to the rpg to achieve an acceptable level (vicary and sandler, 2002) . if all nations in a region are poor, then rich nations in other regions are motivated to give, provided that the public good has spillover benefits outside of the region. thus, even weakest-link rpgs may present an allocation concern for poor regions if the rpgs offer little to countries outside of the region. a less demanding form of a weakest-link rpg is a weaker-link rpg, for which the smallest contribution has the greatest impact on the good's aggregate level, followed by the second smallest contribution, and so on. applying prophylactic measures against a regional disease is a weaker-link rpg since action that exceeds the minimum level can achieve additional gains, though these diminish at the margin as the contribution rises (arce and sandler, 2001; sander, 1998) . with weaker link, there is less incentive for matching behavior because suppliers can somewhat make up for inadequate provision of others; thus, the necessity to bolster capacity is attenuated. there is, however, a need to coordinate which nation does more to make up for the shortfall of others. another aggregator is threshold where the benefits of an rpg are only experienced once the cumulative quantity of the good surpasses a certain level. for example, regional flood control may only be effective after a sufficient level of protective measures is deployed to handle an anticipated flood. similarly, forest fire suppression may have to exceed some threshold, depending on the conflagration, before any containment can be achieved. a threshold technology also characterizes regional peacekeeping and crisis-management squads, where insufficient provision is a recipe for disaster. when a threshold applies, there is a need to pool efforts. leadership by one or more nations can help meet the threshold. the threshold aggregator limits the incentive to free ride until the threshold is attained. a sixth aggregator is best shot where the largest contribution solely determines the good's overall level-lesser action is redundant. best-shot rpgs include curing a region-specific disease, uncovering geoclimatic-specific research, building a regional satellite-launch facility, and launching hurricane-tracking satellites. bestshot rpgs requires coordination so that effort is not wasted through duplication. coordination problems may be tricky in the presence of more than one best-shot candidate. in many developing regions, this is not a concern because there is, at most, a single country with the requisite capacity. a greater worry is that some regions may be devoid of any nation with the necessary capability. in these cases, the nations will either have to pool their efforts to provide the best-shot rpg or else seek assistance from outside of the region. with development trends, china and india will gain capacity to assume a leadership role in asia, while brazil will be able to do so for south america. better shot is a less extreme form of best shot, where the greatest contribution has the largest influence on the rpg's provision amount, followed by the second largest contribution, and so on. examples of better-shot rpgs include discovering effective vaccines, cleaning up an oil spill, providing biohazard facilities, and biospecting. in these instances, a second-best effort can still provide some benefits despite the presence of a greater effort. for example, a less effective vaccine may benefit those who cannot tolerate the more effective one. with better-shot rpgs, there is less need to coordinate and/or concentrate effort. in table 1 , a typology for rpgs is displayed along with examples of each of the 28 categories displayed. a number of implications are essential for understanding the provision problem posed by rpgs, associated with the three properties of publicness. first, nonrivalry and nonexcludability of benefits are insufficient to gauge the prognosis for rpg provision. this is aptly illustrated by a weakest-link purely public good, where the classic public good properties suggest a bad provision prognosis. when, however, these properties are coupled with weakest link, the supply outlook is promising if the agents have similar tastes and income. this follows because free riding is no longer an option. second, club rpgs can be efficiently provided by the members when tolls account for crowding. this efficient outcome holds for all aggregators except weakest link, for which externalities from undersupply or poor maintenance may not be fully internalized. third, joint products' rpgs can be adequately supplied whenever there is a large share of excludable benefits. this share can be raised through institutional innovation that engineer contributor-specific benefits (sandler, 2004: 90-97) . fourth, a weightedsum technology may support rpg supply whenever there is sufficient weight on the country's own efforts relative to other countries' efforts. fifth, weakest-link type aggregators highlight the importance of capacity, while best-shot type of aggregators (including threshold) underscore the importance of coordination and/or pooling of in some weakest-link situations, the added capacity may come in the form of an in-kind transfer intended to attain an acceptable provision standard. sixth, the primary concern arises when these weakest-link and best-shot rpgs hold little interest for rich countries in other regions. in these cases, there may be little choice but to rely on global and regional institutions, or new participants. in many ways, rpgs are in a unique position compared with npgs and gpgs. an understanding of this uniqueness is essential to prescribe the proper intervention and the appropriate international organization, if any, to assist. by benefiting residents, npgs provide adequate incentives for the recipient nation to assume a loan to underwrite the good-sufficient ownership exists. there is no free-riding issue among nations since, by their nature, these goods' benefits do not spill over to other nations. by supplying the social overhead capital required for development, npgs play a complementary role in setting the stage for developing countries to take advantage of tpgs (world bank, 2001) . gpgs and tpgs offer spillover benefits for donor nations outside of the recipient region. this last realization suggests that there are considerations that inhibit rpg provision when compared with gpgs. many researchers have solely emphasized the supportive factors that favor rpg provision over gpgs. 4 rpgs involve fewer nations than gpgs which can favor collective action at the regional level. by limiting uncertainty, spatial and cultural propinquity foster rpg provision compared with gpgs where all cultures are present. in recent years, the rise in regionalism has given birth to regional trading blocs as well as a greater regional identity (mansfield and milner, 1999) . these trading blocs supply some of the requisite infrastructure to facilitate rpg provision-e.g., trading blocs can offer collateral for loans, supply rpgs, or coordinate supply efforts. the european union (eu) has been instrumental in coordinating rpg provision in europe, where the eu spearheaded action to curb acid rain and other regional pollutants. in addition, many rpgs possess some favorable publicness properties that foster provision. for example, the underlying aggregation technology for curbing surface ozone is weighted sum in which nations experience the greatest share of their own pollutants, thereby motivating action. a final favorable influence is that of past and ongoing interactions among regional participants, which mean that defecting from an agreement can result in subsequent punishment. unlike the global level, nations are in constant contact at the regional level so that short-run gains from reneging on an agreement may not justify the long-term retribution. other factors inhibit rpg provision relative to gpgs. one rpg concern is the possible absence of a leader nation to coordinate action and to publicize the region's needs. with development, leader nations may eventually emerge-e.g., nigeria in west africa or china in asia. in some cases, regional rivalries have worked against a united stance on rpg needs. these rivalries have been fueled by neighborhood civil wars, whose economic consequences have adversely affected neighboring nations (murdoch and sandler, 2004) . since the late 1990s, civil wars have plagued many developed countries, thereby hampering growth and the support of rpgs (collier et al., 2003) . these civil wars not only destroy social overhead capital in war-torn countries but also induce peaceful countries to erect expensive firewalls to limit harmful consequences. such action curbs rpg supply. compared with gpgs, rpgs may experience greater uncertainty owing to insufficient information-e.g., many developing regions do not monitor emissions to track sources and recipients. the special problems of rpgs also arise from regional institutional considerations. there has been a lack of a global culture to support regional development banks, which has limited their capacity to support rpgs. donors have traditionally turned to the global institutions to channel some of their support to developing countries and their public good needs. this culture is changing as regionalism, a localized form of globalization, takes hold. if this transformation is to make a difference, then regional development banks must also change their practices. one study shows that these banks gave tiny percentages of their foreign assistance in the form of tpgs (which includes rpgs) during 1996-98: 4.18%, african development fund; 6.86%, asian development bank; and 1.97%, inter-american development bank (te velde et al., 2002: 126) . in contrast, these institutions gave large aid percentages to npgs during 1996-98: 34.73%, african development fund; 47.34%, asian development bank; and 69.15%, inter-american development bank (te velde et al., 2002: 127) . even more worrying is that the percentage of aid in support of tpgs has fallen since 1980-this is not encouraging for these institutions to bolster rpg support! in a subsequent study, mascarenhas and sandler (2005) establish that the regional development banks did not tailor their loan-grant mix to reflect the degree of publicness of supported activities. loans are more appropriate when recipientspecific benefits dominate, while grants are appropriate when regionwide benefits dominate. essentially, regional development banks applied a fixed percentage for the various functional areas-e.g., the environment, governance, and knowledgeunlike bilateral donors and global institutions that tailored this mix to publicness considerations. this is additional evidence that these banks must adjust their procedures if they are to warrant enhanced funding. these banks can perform an essential role to address another inhibiting factor of rpg provision-i.e., the absence of a clear entity to obtain loans, provide collateral, and promote a regional agenda. this role must be assumed by either a dominant nation in the region, if one exists, or a regional trading bloc. the regional development banks can then work together with one or both of these entities to fund rpgs. table 2 provides a summary of the factors that favor and inhibit support of rpgs, compared with their gpg counterparts. what must be emphasized is that rpgs face many impediments, despite their smaller set of nations, that do not confront gpgs. for rpgs, many difficulties stem from the lack of the necessary infrastructure and inexperience in supporting regionwide needs. merely giving more money to regional development banks will not fix the problem unless explicit action is taken to earmark funds to rpgs. measures are also needed to prepare regional trading blocs and organizations to represent the region's interest in supplying rpgs. subsidiarity indicates that the decision-making jurisdiction should coincide with a public good's region of spillovers. strict adherence to subsidiarity dictates that global institutions supply gpgs and tpgs, regional institutions provide rpgs, and nations support npgs. subsidiarity is modeled after the notion of fiscal equivalence (olson, 1969) . when the spillover range of the public good extends beyond the political jurisdiction, decision makers often fail to account for all who benefit and, consequently, the public good is undersupplied. if, instead, the political jurisdiction exceeds the public good's spillover range, taxes are then imposed on some people (nations) that do not benefit, thus resulting in an oversupply of the good. in an ideal world, regional institutions will coordinate its member nations to supply rpgs. when regions are too poor to support sufficient rpgs, regional development banks and other donors can underwrite these regional institutions to achieve subsidiarity. by matching political and economic domains, subsidiarity fosters efficiency because the rpg's marginal benefit (summed over regional recipients) is equated to its marginal cost. another benefit of subsidiarity is that it limits transaction costs by reducing the number of participants to just those with a stake in the decision. as these participants interact over time, incentives are fostered to abide by agreements, thereby reducing enforcement cost. repeated interactions also lessen asymmetric information and its associated transaction costs. localized regional benefits increase the evolution of regional institutions from shared culture, norms, concerns, experiences, and values (north, 1990) . as in a fiscal federal system, region-based provision may also lead to best-practice innovations that can be copied by other regional institutions. centralized provision at the supranational level inhibits such innovations. greater reliance on regional institutions avoids bmission creep^as global institutions have assumed an ever-wider array of activities. mission creep can impair the performance of these global institutions as organizational communication lines become complex. table 2 are rpgs harder or easier to provide than gpgs? rpgs have fewer participants than gpgs. spatial and cultural propinquity limit uncertainty with respect to rpg provision. new regionalism and the rise of trading blocs can provide the necessary infrastructure to facilitate regional provision. favorable characteristics of publicness-e.g., joint products, weighted sum, and excludable benefits. past and ongoing interactions among regional participants. absence of donor spillovers owing to regional specificity of benefits. absence, at times, of a leader nation within the region. regional rivalries, fueled by local conflicts. greater uncertainty owing to lack of information concerning some rpgs. lack of global culture in supporting regional development banks, which has resulted in insufficient capacity. poor past behavior by some regional development banks-i.e., not tailoring the loan-grant mix to public good considerations and not supporting rpgs. no clear entity to obtain loans, provide collateral, and promote a regional agenda. there are also considerations that detract from applying subsidiarity. economies of scale can justify having an rpg provided by an institution whose political domain exceeds that of the requisite region whenever the reduced unit cost offsets any lost efficiency. in a global institution, economies of scale may arise from fixed costs that can be spread over serving the needs of multiple regions. for example, peacekeeping would be more expensive per deployment than un peacekeeping if each region maintains its own peacekeeping forces and equipment. another factor that limits the application of subsidiarity are economies of scope associated with providing two or more tpgs in the same institution. economies of scope come from unit cost savings as common inputs (e.g., a communication network or administrative staff) are used to supply these tpgs. because the spillover range from two or more tpgs is unlikely to coincide, the common provision of multiple tpgs by a single institution is not expected to satisfy subsidiarity. as the number of jointly supplied public goods increases, the anticipated violation of subsidiarity strengthens. another obstacle to subsidiarity may involve the absence of the requisite regional institution or jurisdiction. for example, the available regional institution may not entirely match the rpg's spillover range. in the case of river blindness (onchocerciasis), the disease affected three different regions-latin america, africa, and the arabian peninsula. either a new jurisdiction had to be cobbled together by linking three separate regions or else one region has to take up the cause for the other regions. a public-private partnership (i.e., onchocerciasis control partnership) between merck, the world health organization (who), host countries to the disease, and donors formed to address river blindness, in which merck contributed ivermectin to control the disease and the other partners assisted in the drug's distribution. for some best-shot, better-shot, and threshold rpgs, the required effort may necessitate pooling resources beyond the jurisdiction identified by subsidiarity. this is relevant for actions against communicable diseases in those regions that lack sufficient research facilities and medical personnel. for the search of an hiv/aids vaccine, the requisite research infrastructure only exists in a few countries outside the most threatened regions. table 3 summarizes supporting and detracting influences on the application of the subsidiarity principle for the provision of rpgs. the new regionalism should over time result in more capable regional institutions, as it has in europe. as regional institutions are strengthened, subsidiarity can be applied to a greater extent; however, subsidiarity is not always desirable. when scale and scope economies are significant or pooled efforts are required owing to best-shot considerations, either global institutions must step in or else regional institutions must coordinate efforts across regions. there is an essential role that diverse institutions and innovative institutional forms must assume to further regional cooperation when subsidiarity fails as a guiding principle. in practice, the likely failure of subsidiarity in developing parts of the world is being addressed by myriad participants that foster rpg and gpg provision. at the regional level, regional development banks can provide funding. regional trade pacts serve two purposes: increase interregional trade and coordinate efforts to provide rpgs. when the pacts do not act to support rpgs, new regional organizationse.g., siepac in central america for power and the regional fund for agricultural technology (fontagro) in latin american for research-can be created. global organizations are appropriate when subsidiarity has too many roadblocks. such institutions can pool funds and coordinate responses for best-shot, threshold, and summation rpgs, or provide capacity for weakest-link rpgs. many of these organizations are geared to the three focus areas-e.g., world health organization (who) and un development program (undp) for communicable diseases, united nations for peace and security, and world bank for knowledgediscussed in the next section. when rpgs possess interregional spillovers and does not fit into a single region, networks-e.g., global environment facility (gep) and consultative group for international agricultural research (cgiar)-offer a novel institutional alternative. networks can pool effort for best-shot rpgs and bolster capacity for weakest-link rpgs. a network can limit transaction costs by keeping interregional links loose when little more than information and best practice need sharing; thus, linked organizations can operate quite autonomously. gep and cgiar can serve as role models for addressing health concerns and knowledge creation. another institutional innovation to facilitate rpg provision is a public-private partnership among diverse participants that may include firms, regional organizations, global institutions, and other entities. partnerships draw on the comparative advantage of their members and have been popular in providing health public goods. given their heterogeneous composition, partnerships are especially attuned to addressing problems that cannot be pigeonholed into a single region, such as river blindness, malaria, and hiv/aids. other institutions-charitable foundations, ngos, and nation-based organizations-bolster efforts to supply rpgs. charitable foundations and ngos provide inflows of new funds for health issues, the commons, knowledge, and other concerns that do not reduce standard funding sources. for communicable diseases, charitable foundations and nation-based organizations (e.g., the centers for disease table 3 supporting and detracting influences on regional subsidiarity supporting factors for regional subsidiarity fosters efficiency by equating the good's marginal benefits (summed over regional recipients) to its marginal costs. limits transaction costs by reducing the number of participants, augmenting repeated interactions, and curtailing asymmetric information. supports the evolution of institutions from shared culture, norms, concerns, experiences, and values. bolsters interregional innovations. avoids bmission creep^of multilateral institutions. detracting factors for regional subsidiarity economies of scale from reduced unit costs favor allocation by a larger jurisdiction. economies of scope from reduced unit costs encourage providing two or more regional public goods in the same jurisdiction. the requisite regional institution may not exist nor possess sufficient capacity. certain aggregation technologies favor jurisdictions beyond those identified by regional subsidiarity. control, national institutes of health, and pasteur institute) focus resources on bestshot rpgs or provided capacity for weakest-link rpgs. nation-based organizations are particularly interested in diseases that may threaten interests at home. ngos have wider interests and champion many global and regional concerns including refugees (e.g., red cross and medecins sans frontiè rs) and environmental issues (e.g., greenpeace). table 4 summarizes eight categories of institutions and how they promote rpgs. essential features of three important rpg sectors are now examined. some sectors have much better prognosis than others; efforts must be directed at those where incentives are unsupportive for regional or global collective action. these sectors differ according to public good properties, institutional capability, and provision prognosis. since the late 1960s the global incidence of civil wars increased until 1988, at which time it fell somewhat before leveling off at an elevated high level. conflict-torn countries are associated with refugees, trade disruption, poverty, low economic growth, diseases (e.g., hiv/aids and malaria), and financial instability. in terms of the latter, civil wars lead on average to a flight of ten percent of a country's capital (collier et al., 2003: 15) . reducing intrastate and interstate conflict is one activity that can simultaneously contribute to many rpg issue areas. conflict may not only spread from one country to the next, but may also generate a wide range of negative externalities, whose reduction represents rpgs. in a recent study, murdoch and sandler (2004) show that regional wars can reduce a nearby peaceful country's growth by about one half of a percentage point; thus, four regional conflicts will wipe out most countries' growth in the region. security concerns also arise from terrorism. although transnational terrorism has fallen since the early 1990s, each incident is now more likely to result in casualties (sandler and enders, 2004; enders and sandler, 2006) . the four hijackings on 11 september, 2001, (hereafter 9/11) underscore that a well-planned attack can have significant consequences in lives and economic losses. transnational terrorism is associated with a btransference externality^in which increased protection taken in one location transfers the attack to less secure venues in other countries or regions. this suggests that security against transnational terrorism is a gpg necessitating global coordination. for example, attacks against americans in the middle east and elsewhere motivate u.s. willingness to bolster defenses abroad if requested. since the rise of fundamentalist terrorism after 1979, there has been a shift of transnational terrorism to the middle east and asia (see enders and sandler, 2005) . this shift is quite dramatic after 9/11 and the subsequent upgrades to u.s. homeland security. other security risks arise from the proliferation of weapons of mass destruction (wmds)-e.g., pakistan and india-and organized crime. wmds pose a global problem since once available in a region, these weapons can get into the wrong table 4 role of institutions in fostering rpgs purposes/function provide funding for rpgs. this funding can be in the form of loans and grants depending on the degree of publicness of the supported activity. grants are more appropriate when public goods provide regionwide or interregional spillovers. coordinate action to promote regionwide financial stability. promotes trade within the region. these pacts can coordinate efforts to provide rpgs. in some instances, pacts can provide collateral for rpg loans. global multilaterals: world bank, undp, who, wto pool funds for best-shot, threshold, and summation public goods and bolster capacity for weakest-link public goods. can assist for all rpg areas with some global institutions specializing in a specific area-e.g., who in communicable diseases. global institutions can channel funds to regional institutions to augment their financial capacity. facility (gep), consultative group for international agricultural research (cgiar) link together interests within and among regions for providing rpgs and tpgs. for example, gef addresses regional and global commons issues, while cgiar focuses on knowledge. other networks are particularly suited for supplying tpgs that have interregional spillovers. they are also useful for weakest-link and weaker-link tpgs. partnerships: global fund, onchocerciasis control partnership, medicines for malaria venture draw on the comparative advantage of diverse participants. many partnerships concern diseases, but other partnerships can form to address other key areas. hands-e.g., the transfer of nuclear technologies to other countries by pakistan's top nuclear scientist. globalization involves both legal and illegal exchanges, so that organized crime in one region has consequences in other regions. in afghanistan, the defeat of the taliban resulted in a weaker government that has been unable to control poppy cultivation-an unintended global public bad resulting from antiterrorism action in the wake of 9/11. thus, security actions in one region cannot necessarily be isolated from consequences in other regions. proactive measures against transnational terrorism, wmd proliferation, and organized crime represent a best-shot public good. even if the action is regionspecific, the associated threat is mobile and so such measures constitute gpgs rather than rpgs. in contrast, defensive actions to forestall the spread of terrorism, weapon proliferation, or crime is a weakest-link public good. defensive measures also have global implications owing to transference of terrorists or criminals to safe havens and their attacks to soft targets. most regions do not possess the military prowess to act proactively; hence, regions generally resort to venue-shifting defensive actions. at some point, the world must realize that much of today's security threats must be addressed on a worldwide scale by global institutions and powerful alliances when there is a sufficient consensus to legitimize a proactive response. shoring up weakest links often creates new ones as terrorists or criminals identify new targets of opportunity. furthermore, actions to shore up weakest links offer free-riding incentives. a regional approach to transnational terrorism or organized crime is not going to end these threats as terrorists and criminals move their base of operations. the usled attacks against al-qaida in afghanistan after 12 october, 2001, reduced transnational terrorism in the short-term, but such attacks are now increasing sandler, 2005, 2006) . for wmd proliferation, a nation or alliance must come forward with the power to eliminate a proven wmd. the bbest shootern eeds a mandate from the global community to act. in many regions, there is currently insufficient capacity to confront a powerful nation determined to acquire wmds. some form of global coordination is required. unlike the other security threats, civil wars can, at times, be addressed at the regional level. in the case of east timor, australia took a lead role in peacekeeping. reliance on regional entities for peacekeeping, however, presents some concerns. first, the peacekeeping country must bring peace without pursuing its own agenda and gain. second, the region must contain a capable peacekeeping country or a sufficiently strong alliance to bring peace. third, regional peacekeeping must be economically sensible compared with such action by the united nations or nato. putting too much reliance on regional alliances for localized peacekeeping can result in wasteful duplication of forces, which can increase the unit cost of peacekeeping. since the end of the cold war, nato has assumed peacekeeping missions in europe, while the united nations has taken on these missions in most other places. this distribution of effort has worked even though there is no formal agreement. a more formal arrangement will be difficult to frame because nato's articles mandate that any military deployment must be unanimously approved by its allies. knowledge is the quintessential best-shot or better-shot public good, where breakthroughs come from concentrating effort and building up research centers of excellence. best-shot and better-shot aggregation also means that a coordination of action is required; thus, research for region-specific knowledge needs efforts to be orchestrated and funded by a global or regional institution. once discovered, knowledge also represents an intergenerational public good that provides nonrival benefits to the current and future generations. because benefits conferred to future generations are unlikely to be fully taken into account by the provider, knowledge will be undersupplied in an intergenerational sense even under the best of circumstances. to provide incentives for knowledge production, governments issue patents that confer monopoly rights for a set period to the creator. these patents imply an interesting tradeoff: restricted use in the near-term in return for a larger number of discoveries. the optimal patent period must balance welfare losses from restricting short-run consumption with the long-term gain of more discoveries. knowledge presents some interesting rpg issues. first, there is a marked tendency for rich nations to pursue knowledge that primarily furthers their interests. in health, this is known as the 90/10 gap in which less than 10% of u.s. annual spending on health-related research and development addresses the health concerns of 90% of the planet's population (who, 2002: 23) . similar gaps hold for all forms of knowledge creation. second, knowledge reflects increasing returns in production where a substantial effort must be attained before payoffs are realized. third, many developing regions must acquire complementary npgs to take advantage of the knowledge created elsewhere-e.g., sub-saharan africa and central america. fourth, many regions have limited capacity to conduct research on the requisite scale. fifth, owing to specific diseases, geoclimatic conditions, and other regionspecific circumstances, the rpg needs of some regions provide little or no spillover benefits to other regions, so that these regions must produce their own knowledge or get funding and other assistance from global institutions, charitable foundations, networks, partnership, or ngos. to address these unique region-based problems, a planned sequence of actions is required. the global community must first provide the complementary npgs, including improving educational attainment, for poor regions. networks can then be relied upon to pool resources and expertise across regions to achieve best-shot breakthroughs and surpass required thresholds. regional development banks and regional trade pacts can provide a source of funding; shortfalls can be made up by global institutions (e.g., the global fund is financing vaccines and other healthrelated knowledge searches for malaria and hiv/aids). region-based research institutions are essential if region-specific needs are not to be ignored. interregional cooperation can foster scale economies regarding similar research questions. regional communicable diseases may or may not present a concern to the global community. in those cases, such as sars or bird flu, where a worldwide epidemic may occur, actions to monitor and isolate a regional outbreak constitute gpgs. obviously, rich nations and their institutions (e.g., cdc, nih) are motivated to offer help to raise capacity to address such diseases. for those regional diseasescommunicable or otherwise-where rich nations are not in harm's way, there is less interest to augment a region's healthcare ability. curing, monitoring, and/or ameliorating a region-specific disease is an rpg with little apparent spillover to the global community. in fact, kremer and leino (2004) view most public goods associated with communicable diseases as npgs and rpgs. this viewpoint, however, misses some indirect links and subtleties. nation-specific and regionspecific infections weaken a host population and make it more vulnerable to other communicable diseases that can travel to other venues. plane travel facilitates rapid dissemination of acquired diseases. similarly, an inadequate health infrastructure makes a population more susceptible to diseases that can spread worldwide. the ability to eradicate a disease through inoculation hinges on achieving sufficient immunity. costly vaccinations must be administered worldwide until herd immunity is attained; hence, rich countries experience an externality unless a disease is completely eradicated. inadequate healthcare responses in any region can have global spillovers. communicable diseases are associated with a host of public goods: educating people about transmission, finding a cure, limiting the spread, eradicating a disease, isolating a bacterium or virus, developing a vaccine, establishing best treatment regime, and others. many of these public goods are either of a weakest-link or bestshot variety. for weakest link rpgs, building capacity is the key because the least effort by a nation in the region determines the regionwide public good level achieved. thus, an inadequate prophylactic by one nation permits the disease to spread and jeopardize the whole region. for poor regions, this enhanced capacity must come for bilateral donors, global institutions, or the regional development banks. if the region does not possess the proper infrastructure to use funds to provide the weakest-link rpg, then the aid must be in-kind with the donor supplying the good directly. at the regional level there is also a need for assistance to provide disease-related best-shot and better-shot public goods. the need is particularly acute for regionspecific communicable diseases that present little concern to rich countries. as with weakest-link rpgs, capacity is an issue that must be supplied by others working either alone or in partnerships. in recent years, foreign assistance to the health sector has increased. 5 another concern is that developed and developing countries have different needs with respect to diseases. for hiv/aids, developed countries benefit from the development of more effective treatment regimes for those infected. developing countries gain more from a vaccine that prevents the disease owing to the high rate of new infections and the limited funds for costly treatment regimes. rich countries are more interested in noncommunicable diseases, such as heart disease and cancer, than developing countries, and thus direct more of their research budget to ailments that pose less risk to the latter, whose population's life expectancy is shorter. pharmaceutical companies heighten this asymmetry by developing drugs for lucrative markets with an emphasis on noncommunicable disease. this difference in orientation means that disease-related discoveries and treatments in rich countries have fewer spillovers to developing countries. thus, best-shot health-related public goods are not going to come very frequently from rich countries. this emphasizes the need for assistance that account for the special health needs of the developing regions-e.g., funds for prevention of hiv/ aids, tuberculosis, and malaria. many public goods associated with communicable diseases provide intergenerational spillovers of benefits. once a disease is cured or a virus is isolated, benefits are conferred on the present and future generations. these intergenerational benefits mean that undersupply will be significant as both interregional and intergenerational spillovers are ignored when allocation decisions are made. a key conclusion is that rpgs pose many collective action difficulties, not associated with gpgs. nations have proper incentives to finance npgs due to direct gains, while rich nations possess incentives to underwrite gpgs owing to spillover benefits. neither individual nations nor the world community may have the right motives to fund rpgs. this is consistent with recent empirical work that shows bilateral donors, global institutions, and regional institutions strongly favor npgs and gpgs over rpgs (mascarenhas and sandler, 2005; te velde et al., 2002) . thus, there is a growing need to focus foreign assistance on creating a more adequate supply of rpgs. to achieve this goal, regional development banks must be given greater financial capacity. these banks must, however, change some practices by supporting more rpgs and tailoring the loan-grant mix to the underlying publicness properties of the supported activity. in order to facilitate loans for rpgs, regional trade pacts and other regional institutions need to represent regional interests and provide collateral for loans. the publicness considerations of rpgs must assume an enhanced role in tailoring support and institutional design. for example, club rpgs can be privately provided by member-owned collectives that fund the shared good from tolls that account for crowding. thus, an interregional highway or power grid can be supported in this fashion. clubs are underutilized at the regional level and should be increased to promote regional infrastructure. the aggregation technology is also an essential consideration. for weakest-link rpgs, a variety of participants are needed to boost capacity so that an acceptable level of these goods is attained regionwide. this added capacity can be provided by global institutitions, partnerships, charitable foundations, and regional institutions. for best-shot and threshold rpgs, these same institutions must step in or pool efforts to supply the good. the subsidiarity principle should not be blindly followed. as shown, there are offsets to subsidiarity that may require an imperfect match to take advantage of other gains such as scale or scope economies. when tpgs involve interregional spillovers, networks and partnerships of participants from multiple regions are appropriate for supplying the good. combining interests from multiple regions may also be necessary for some best-shot and threshold rpgs. in such cases, the global institutions can serve an important coordinating function to ensure sufficient investment and the absence of duplication of efforts. the three focus sectors for public goods have diverse policy recommendations. for most of today's security challenges, a global approach is recommended because proactive measures require a response that most regions cannot, or will not, mount. moreover, defensive regional responses merely divert the threat to another region. as a best-shot rpg, knowledge creation is associated with effort levels that require assistance from global institutions or rich countries. unless poor regions build up their knowledge infrastructure through outside assistance, their knowledge needs will be increasingly ignored. rpgs associated with communicable diseases adhere to weakest-link and best-shot aggregation technologies. the former requires assistance-funded capacity upgrades, while the latter means that global institutions and rich nations must increase effort. best-shot actions to cure region-specific communicable diseases will require help from global institutions, charitable foundations, rich nation-based institutions, and public-private partnerships. a selective survey of regional public goods in latin america transnational public goods: strategies and institutions regional public goods: typologies, provision, financing, and development assistance. stockholm: almqvist and wiksell international for expert group on development issues supplying international public goods: how nations can cooperate 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the principle of ffiscal equivalence_: the division of responsibilities among different levels of government oda and global public goods: a trend analysis of past and present spending patterns. ny: office of development studies background paper, united nations development program collective action: theory and applications global challenges global and regional public goods: a prognosis for collective action financing international public goods assessing the optimal provision of public goods: in search of the holy grail global collective action an economic perspective on transnational terrorism regional public goods and the future of international development cooperation: a review of the literature allocating aid to international public goods weakest-link public goods: giving in-kind or transferring money global development finance: building coalitions for effective development finance coordinates 2002: charting progress against aids, tb and malaria acknowledgments sandler is the robert r. and katheryn a. dockson professor of international relations and economics. the author has profited from the comments provided by three anonymous reviewers. key: cord-016387-ju4130bq authors: last, john title: a brief history of advances toward health date: 2005 journal: understanding the global dimensions of health doi: 10.1007/0-387-24103-5_1 sha: doc_id: 16387 cord_uid: ju4130bq three major discoveries determined the health and history of the human species. the first occurred almost a million years ago, when our hominid precursors discovered how to use fire to cook the meat they had hunted. they found that cooked meat tasted better, it didn’t go bad so quickly, and eating it was less likely to make them ill. our understanding of nutrition, a basic tenet of public health science, and the art of cooking have been improving ever since. as humans grew fruitful and multiplied, so did the variety and number of their diseases. permanent human settlements transformed ecosystems, and abiding by epidemic theory, the probability of respiratory and fecal-oral transmission of infection rose as population density increased. ecological and evolutionary changes in micro-organisms account for the origins of diarrhea , measles, malaria, smallpox, plague, and many other diseases. micro-organisms evolve rapidly because of their brief generation time and prolific reproduction rates. many that previously had lived in symbiosis with animals began to invade humans, where they became pathogenic. some evolved complex life cycles involving several host species, such as humans and other mammals, humans and arthropods, and humans and freshwater snails. these evolutionary changes in host-parasite relationships occurred at least several millennia before we had created written histories. our oldest written records that have a bearing on health date back about 4,000 years. the code of hammurabi (c. 2000 bce) contains ideas indicative of insight into the effects on health of diet and behaviour. it also suggests rewards and punishments for physicians who did their jobs well or poorly. information about the impact of diseases, especially of epidemic diseases, from those ancient times has come down to us in myths and biblical accounts of pestilences and plagues, although we cannot reliably identify the nature of the epidemics that afflicted ancient populations. the greek historian thucydides provided a meticulously careful description of an epidemic that struck the athenians in the second year of the peloponnesian war in 426 bce, from which the forces of athens perhaps never fully recovered. modern infectious disease specialists have puzzled over this epidemic. was it typhus, a virulent form of epidemic streptococcal infection, that is, a variant form of scarlet fever, or something completely different? similar questions have been raised about other ancient epidemics, for instance the sweating sickness that recurred many times in mediaeval europe then vanished, never to be seen again, almost 1,000 years ago. there has been debate too about the exact nature of the black death, the terrible pandemic that devastated asia minor and the whole of europe in 1347-1350. this is usually attributed to the plague bacillus, yersinia pestis, but revisionist historians and epidemiologists have raised the possibility that other pathogens, for instance, the anthrax bacillus, might have been responsible. here, as with the plague of the athenians, the plague of justinian, the medieval sweating sickness, the accounts of apparent fulminating epidemic syphilis (that may really have been another sexually transmitted disease or may have been caused by a highly virulent variant of the causative organism of syphilis, treponema pallidum, which has slowly lost its extreme virulence and infectivity), and, indeed, as with all other great epidemics of historical times before the rise of modern microbiology, we can only speculate about the exact aetiology and pathogenesis. this is a rather sterile, albeit fascinating, quest. it is more productive and useful to focus on what we know with reasonable certainty, and it is simplest to describe this knowledge in relation to some of the heroic figures who have contributed to advances in our understanding of epidemics and other diseases that have helped to shape history. this account therefore concentrates on a handful of the heroes of public health through the course of written history. hippocrates , the father of medicine, was also the father of public health. he practised and taught in a school of medicine at the temple of asklepios, near epidaurus in greece, and alone or with members of his school, laid the foundations of rational clinical medicine with careful descriptions of diseases and common sense ideas about ways to manage them. the hippocratic writings contain rich medical wisdom based on careful observation of sick and healthy people and their habits and habitats. epidemics is a series of case records of incidents of diseases, many of which we now know to be caused by infectious agents. the accounts of tetanus, rabies, and mumps, for instance, could have been written by a modern clinician. airs, waters, places outlines environmental health as it was understood two-and-a-half thousand years ago. the relationships of environment, social conditions, and behaviours to health and sickness is made explicit in the timeless advice of the opening paragraph: whoever would study medicine must learn of the following. first, consider the effect of each of the seasons . . . and the differences between them. . . . study the warm and cold winds . . . and the effect of water on health . . . when a physician comes to a district previously unknown to him he should consider its situation and its aspect to the winds . . . and the nature of its water supply . . . whether the land be bare and waterless or thickly covered with vegetation and well-watered, whether in a hollow and stifling, or exposed and cold. lastly, consider the life of the inhabitants-are they heavy drinkers and eaters and consequently unable to stand fatigue, or being fond of work and exercise, eat wisely but drink sparely. in short, study environment and life style, which are very modern concepts. for well over a thousand years after hippocrates' lifetime, human communities were afflicted with ever-present respiratory and gastrointestinal infections that cut deeply into the lives of everyone, and most deeply, as a rule, into the lives of young children who all too often died before they reached adolescence, carried off by measles, scarlet fever, diphtheria, bronchitis, croup, pneumonia, gastroenteritis, or typhoid. from time to time, this steady drain on long life and good health was punctuated by great and terrifying epidemics-smallpox, typhus, influenza, and, most terrible of all, the plague, or the "black death." the causes of these periodic devastations, the contributing reasons to why they happened, were a mystery. many at the time believed they were god' s punishment for sin, or the work of evil spirits. ideas about contagion were rudimentary, even though it had been dimly understood since antiquity that leprosy, perhaps the least contagious of all the infectious diseases, was associated with propinquity and uncleanliness. the 16 th century italian monk, fracastorius, recognized some ways infection can spread. his conclusion, that disease could pass by intimate direct contact from one person to others, was easy to draw because he saw the dramatic epidemic of syphilis that was so obviously spread by sexual intercourse. he described this in a mock heroic poem, syphilis, sive morbis gallicus (1530) about the swineherd syphilis, and how he got and passed on to others the "french disease" then raging in europe. his anti-hero, of course, gave us the name of the disease. fracastorius' s other concepts, contamination by droplet spread and by way of shared contaminated articles, such as clothing and kitchen utensils, were published in de contagione in 1546. fracastorius is important because he made a conceptual breakthrough-he brought about what thomas kuhn calls a paradigm shift in understanding of infection and some ways to control it. after fracastorius, the pathfinders on the road to health became numerous, but mention here will be made of only a handful of public health heroes: paracelsus, john graunt, antoni van leeuwenhoek, bernardino ramazzini, james lind, edward jenner, johann peter frank, john snow, ignaz semmelweiss, and louis pasteur. the swiss alchemist theophrastus bombastus von hohenheim, known as paracelsus (1493-1541), occupies the junction of medieval alchemy with scientific chemistry, pharmacy, medicine, and environmental health. he was a colourful character, a foul-mouthed drunkard who insulted and sometimes fought those who disagreed with him, whom he considered superstitious nincompoops. he recognized the relationship of goitre to cretinism, the fact that inhaled dusts caused lung disease, and that some common mental disorders were diseases, not caused by witchcraft or 'possession' by evil spirits. he experimented with chemical remedies containing compounds of mercury, lead, and other galenicals, observed their effects, and, thus, could be considered also a founding figure of pharmacology. john graunt (1620 graunt ( -1674 , a london merchant haberdasher, was an amateur scientist and an early fellow of the royal society. he was interested in the impact of epidemics, especially the plague, and how plague outbreaks caused the numbers of deaths, and the age at death, to vary from one year to another. for over 100 years before his time, parishes had kept records of baptisms and deaths, and what was then understood about causes of death was inscribed in the bills of mortality. graunt collected and analyzed these bills of mortality. he demonstrated statistical differences between males and females, between london and rural areas, and the ebb and flow of epidemics of plague. he published his work in natural and political observations ... upon the bills of mortality (london, 1662). this work was the foundation for the science of vital statistics. john graunt demonstrated the importance of gathering facts in a systematic manner, to identify, characterize and classify health conditions of public health importance. the diagnostic categories in the bills of mortality tell us what was understood 400 years ago about the variety of human ailments and their causes. the nature of diseases caused by things not visible to the naked eye was long a mystery that began to unravel when antoni van leeuwenhoek (1632-1723), a dutch linen draper and amateur lens-grinder in delft, perfected the first functioning microscopes, with which he viewed drops of water, vaginal secretions, feces, his own semen, and the detailed structures of plants and insects. he lacked any formal scholarly training but in a series of 165 letters to the royal society of london, he described accurately and in detail all that he saw. he did not suggest that the tiny creatures he was the first to see with his microscope were capable of causing diseases, but he is nonetheless regarded as the first of the 'microbe hunters' who sought and identified the pathogenic micro-organisms responsible for many diseases. bernardino ramazzini (1633-1714) was an italian physician who observed and classified workers in many occupations, and reported his observations and conclusions about the diseases to which workers in each of these were vulnerable in de morbis artificum diatribe (on the diseases of workers, 1713). it is a tour de force, a masterly account in the form of sweeping generalizations, and although the evidence supporting these generalizations was often flimsy, ramazzini introduced a new way of thinking about ways in which work conditions can affect health. james lind (1716 lind ( -1794 was born and educated in edinburgh. he was apprenticed to a surgeon when he was 15, and spent nine years as a naval surgeon, during which time he saw many cases of scurvy, a disease that disabled and often killed sailors on long ocean voyages. lind thought this disease might be caused by a diet lacking fresh fruit and vegetables. he conducted an experiment, giving different diets to each of several pairs of sailors. this was the first clinical trial ever conducted-although the sample sizes were very small, there was no random allocation, and no informed consent was obtained from the sailors. the two sailors who received fresh oranges and lemons recovered rapidly from the scurvy, the others did not, or got worse. lind also initiated the first effective measures aimed at enhancing hygiene in the british navy, but he is best known for his work on scurvy, reported in a treatise of the scurvy (1753). not only was this the first reported clinical trial, it also was proof that a dietary deficiency can cause disease, that a well-balanced diet is essential for good health. thus lind, like fracastorius, was responsible for an important paradigm shift in the understanding of causes and control of disease. johann peter frank (1745-1821) studied medicine in heidelberg and strasburg, was a professor of medicine at göttingen and pavia, and taught in many other centres of learning including st petersburg, before he ended his career in vienna where he was professor of medicine at the allegemeines krankenhaus. early in his career he began writing system einer vollständigen medicinischen polizey, his great work on ways to improve population health. this appeared in a series of nine volumes from 1779 to 1827. it was, as the title indicates, a system dealing with every then-known way to protect and preserve good health, including community hygiene, personal health protection by cleanliness, and a suggested set of laws and regulations to govern the control of conditions in lodging houses and inns, medical inspection of prostitutes, and so on. edward jenner (1749 jenner ( -1823 was an english family doctor who practised throughout his life in the village of berkeley, gloucestershire. in his days, smallpox was a ubiquitous threat to life and health. in severe epidemics, it killed up to a quarter of all it attacked. when it did not kill, it often left disfiguring facial pockmarks and if it infected the eyes it caused blindness. the practice of variolation, inoculation into the skin of dried secretions from a smallpox bleb, was invented in china about 1000 years ago and spread along the silk route, reaching asia minor in the 17 th century. lady mary wortley montague, wife of the british ambassador to constantinople, described the practice in a letter dated april 1, 1717, and imported the idea to england when she came home. by the time jenner was a child, variolation had become popular among educated english families as a way to provide some protection against smallpox. jenner knew the popular belief in gloucestershire that people who had been infected with cowpox, a mild disease acquired from cattle, did not get smallpox. he reasoned that since smallpox in mild form was transmitted by variolation, it might be possible similarly to transmit cowpox. a smallpox outbreak in 1792 gave him an opportunity to confirm this notion. in 1796 he began a courageous and unprecedented experiment-one that would now be unethical, but that has had incalculable benefit for humankind. he inoculated a boy, james phipps, with secretions from a cowpox lesion. in succeeding months, until the summer of 1798, he inoculated others, most of them children, to a total of 23. all survived unharmed, and none got smallpox. jenner published an inquiry into the causes and effects of the variolae vaccinae in 1798-perhaps the most influential public health treatise of all time. the importance of jenner' s work was immediately recognized and although there were sceptics and hostile opponents, vaccination programs began at once. the frequency and ferocity of smallpox epidemics began to decline early in the 19 th century, but the disease remained a menace until the mid-20 th century. in 1949, the american epidemiologist donald soper worked out the strategy of containment, in other words, vaccinating all known contacts of every diagnosed case. in 1966, who embarked on a global campaign to eradicate smallpox. the last naturally occurring case was a girl in somalia in 1977. in 1980, the world health assembly proclaimed that smallpox, one of the most deadly scourges of mankind, had been eradicated. at the beginning of the new millennium, samples of smallpox virus are preserved in secure biological laboratories in several countries, but, thanks to edward jenner, this terrible disease need never again take a human life-unless it is used illegally in biological warfare. john snow (1813-1858) was a london physician, and a founding father of modern epidemiology. (he was also a pioneer anesthetist who invented a new kind of mask to administer chloroform, which he gave to queen victoria to assist at the births of her two youngest children.) snow' s work on cholera demonstrated fundamental intellectual steps that must be part of every epidemiological investigation. he began with a logical analysis of the available facts, which proved that cholera could not be caused by a 'miasma' (emanations from rotting organic matter) as proposed in a theory popular at that time, but must be caused by a transmissible agent, most probably in drinking water. he confirmed the proof with two epidemiological investigations into the great cholera epidemic of 1854. he studied a severe localized epidemic in soho, using analysis of descriptive epidemiological data and spot maps to demonstrate that the cause was polluted water from a pump in broad street. his investigation of a more widespread epidemic in south london involved an inquiry into the source of drinking water used in over 700 households. he compared the water source in houses where cholera had occurred with that in others where it had not. his analysis of the information about cases and their sources of drinking water showed beyond doubt that the cause of the cholera outbreak was water that was being supplied to houses by the southwark and vauxhall water company, which drew its water from the thames downriver, where many effluent discharges polluted the water. very few cases occurred in households supplied with water by the lambeth company, which collected water upstream from london, where there was little or no pollution. john snow reasoned correctly that the cholera must be caused by some sort of agent in the contaminated water supply. this was a remarkable feat, completed 30 years before robert koch identified the cholera bacillus. snow published his work in a monograph, on the mode of communication of cholera (1855). this book has been reprinted in modern editions and is still used as a teaching text. the hungarian physician ignaz semmelweiss (1818-1865) was a great but tragic figure. working in the obstetric wards of the allgemeines krankenhaus in vienna, he tried to transform traditional but ineffective treatment methods by using logic and statistical analysis to demonstrate the efficacy, or lack of it, when he compared treatment regimens. he believed in the germ theory of disease and was convinced that the terrible death rates from puerperal sepsis must be caused by germs introduced into the raw uterine tissues by birth attendants who did not disinfect their hands. he carried out a meticulous comparative mortality study in his own wards, where he insisted that all birth attendants must cleanse their hands in a disinfectant solution of bleach, and other wards run by senior obstetricians where hand-washing was not routine. his senior colleagues regarded his findings as a gross insult to their professional competence. semmelweiss' s rather abrasive nature and his jewish origins in the anti-semitic atmosphere of 19 th century vienna made matters worse for him. he was hounded out of his hospital post, and ended his life in a mental hospital. his belatedly published comparative statistical analyses of the death rates from puerperal sepsis in his own and other wards of the allgemeines krankenhaus are a model of how to conduct such studies, but, unfortunately, no one in vienna heeded him and young women continued to die of childbed fever for another generation. medical science advanced rapidly in the second half of the 19 th century, applying the exciting discoveries of a new science, bacteriology, which transformed public health. the great bacteriologists of the late 19 th century identified many pathogenic bacteria, classified them, developed ways to cultivate them, and, most important, worked out ways to control their harmful effects, using sera, vaccines, and "magic bullets" such as the arsenical preparations that ehrlich developed to treat syphilis. it would be useful to discuss each of them, but i will focus on just one, louis pasteur (1822-1895). this french chemist evolved into a bacteriologist, and was a towering figure of 19 th century bacteriology and preventive medicine. in 1854, he had recently been appointed professor of chemistry in lille, and was invited to solve the problem of aberrant fermentation of beer that caused it to taste bad and made it undrinkable. he showed that the problem was caused by bacteria that were killed by heat. in this way he invented the process for heat treatment to kill harmful bacteria, first applied to fermentation of beer, then to milk-the process known ever since as pasteurization that has saved innumerable children from an untimely death. he went on to study and solve many other bacteriological problems in industry and animal husbandry. he developed attenuated vaccines, first to prevent chicken cholera, then, in 1881, to control anthrax, which was a serious threat to livestock and, as well, occasionally to humans. before this, in 1880, he began experiments on rabies, seeking a vaccine to control this disease, which without treatment is invariably fatal. as a result of the success of the anthrax vaccine, he believed that an attenuated rabies vaccine could be made. this, of course, was many decades before the virus was visualized. he prepared and successfully tested his rabies vaccine in 1885 on a boy, joseph meister, who had been bitten by a rabid dog. pasteur became not just a national but an international celebrity. born in the same year as louis pasteur, the austro-hungarian monk gregor mendel (1822-1884) was another amateur scientist, a botanist. experimenting with varieties of garden peas, he cross-pollinated them and observed and recorded the results. unfortunately, he published his findings in an obscure journal where they remained un-noticed for many years, but when they were unearthed about 15 years after his death, gregor mendel was retroactively honoured as the father of a new science, genetics, which soon found many applications in clinical medicine, with the recognition of the fact that many inherited diseases were caused by genetic disorders. almost 100 years after mendel' s death, other discoveries with great public health relevance include development of genetically modified sterile insect vectors of disease, genetically resistant strains of rice, wheat, and so on, and applications of genetic engineering to limit and even control and prevent some recessive inherited disorders. pasteur, henle, koch, virchow, and, soon after, battalions of bacteriologists and pathologists firmly established the fact that micro-organisms caused many diseases-the germ theory was a proven fact, not theory. however, many germ diseases require much more than germs before they can cause their worst damage. tuberculosis is caused by the tubercle bacillus acting in conjunction with poverty, ignorance, overcrowding, poor nutrition, adverse social and economic circumstances, and other enabling and predisposing factors. the diarrheal diseases, including cholera, are caused by various microorganisms, but these get into the gut when ingested with contaminated water or food, that is, they are really caused by poor sanitary and hygienic practices. by late in the 19 th century, many of these factors had been clarified. the stage was set for the health reforms that included the sanitary revolution, the beginnings of a social safety net, provision of immunizations, nutritional supplements for school children, prenatal care for pregnant women, and other essential public health functions we take for granted 100 years later. it required a dedicated army of public health workers to achieve all this. i have singled out and mentioned a mere handful of the public health pathfinders on the road to good health. many others could be added, but that would turn this brief chapter into a weighty monograph. often the physician−pathfinders used their own patients as experimental subjects for their path-finding discoveries. lind' s sailors, jenner' s 23 young friends starting with james phipps, pasteur' s patient joseph meister, and all others known and unknown by name who provided the material for the great discoveries of robert koch and other members of the austrian and german schools of bacteriology, should be remembered and honored too. many others belong in their company: the great german pathologist rudolph virchow recognized that political action as well as rational science are necessary to initiate effective action to control public health problems; edwin chadwick and lemuel shattuck reported on the appalling sanitary conditions associated with the unacceptably high infant and child death rates that prevailed in 19 th century industrial towns; william farr established vital statistics in england as a model for other nations to follow. and so the list grows from a handful of public health pathfinders to whole armies. more was needed than scientific discoveries. such discoveries had to be applied, and this often required drastic changes in the established social and economic order. so, other pathfinders appear on the road to health. they include politicians, administrators, journalists, creative writers, performing artists, and cartoonists. the journalists, creative writers, and artists who transmit the scientific concepts of public health to the general public and to the politicians are indispensable partners in the team that makes it possible for us to advance up the road to better health. the process continues in modern times with investigative journalism and tv documentaries. i have identified five essential ingredients of the processes that brought about the public health reforms called the sanitary revolution of the late 19 th and early 20 th century, and have shown that these five features are essential for the control of all public health problems. 1. awareness that the problem exists. john graunt began this process with natural and political observations. others consolidated his conceptual breakthrough, and it was applied to great effect after the establishment of formal national vital statistics in england and wales under the inspired leadership of william farr. by farr' s time, widespread literacy, the proliferation of daily newspapers, and word of mouth helped to enhance awareness among thoughtful people everywhere that there were massive public health problems in society at that time. modern computer-based record-keeping and effective health information systems with instantaneous worldwide notification of contagious disease outbreaks with public health significance continue to enhance the process. 2. understanding the causes. in the second half of the 19 th century, understanding rapidly increased, as epidemiology and bacteriology, and nutritional and environmental sciences explored previously unknown landscapes of aetiology and pathogenesis. the new mass media-daily newspapers-propagated this understanding among literate people throughout the country. from the middle of the 20 th century, news magazines and tv have ensured that knowledge of causal connections-smoking to cancer, diet and lack of exercise to coronary heart disease, alcohol-impaired driving to traffic fatalities, and many more-are very widely disseminated. this, however, has not necessarily led to effective control measures. 3. capability to control the causes. with astonishing speed, once the initial breakthroughs had occurred, sera and vaccines were developed to control many of the lethal microbial diseases that had plagued earlier generations. improved dietary practices, pasteurization of milk, improved personal hygiene and, above all, environmental sanitation to rid drinking water of polluting pathogens, all advanced rapidly in the final quarter of the 19 th century and the first few decades of the 20 th century. thus many ancient infectious disease scourges have been controlled, most dramatically being, perhaps , the eradication of smallpox. unfortunately, new infectious pathogens including the human immunodeficiency virus, viral tropical haemorrhagic fevers, the coronavirus of severe acute respiratory syndrome, and a score or more of others, have emerged to take their place . . . this is an essential prerequisite to the determination to act upon the problem. it is the most fascinating and challenging aspect of the essential features. this belief is the moral imperative that drives public health reforms. geoffrey vickers described the history of public health as a process of redefining the unacceptable-an endless process of identifying conditions, behaviors, and circumstances that individuals, communities, and cultures must no longer tolerate. throwing the contents of the chamber pot into the street, clearing one' s nostrils on the tablecloth, coughing and spitting on the living-room floor, all became unacceptable in the late 19 th century. many people outside the boundaries of traditional medical science and public health practice played a role in this process. in the era of the great reforms of the 19 th century, they included social reformers like edwin chadwick, journalists like henry mayhew and charles kingsley, novelists like charles dickens, cartoonists in punch and other periodicals-all of whom were aided by the rise of literacy in that period. collectively, they inspired a mood of public outrage that became an irresistible force for reform. in the second half of the 20 th century, this sense of moral outrage found new targets-lighting a cigarette without permission in someone else' s home, carrying infant and child passengers in a car without safety equipment, dumping toxic industrial waste where it harms others, and more. yet, much else remains to be done. 5. political will. there is always resistance to change, there are always interest groups-often rich and powerful withal-who will do whatever it takes to obstruct necessary improvement. in the era of the sanitary revolution, it was the owners of water companies, factories, and tenement housing who resisted most vigorously. since the 1950s it has been tobacco companies and a host of manufacturers of toxic petrochemical and other dangerous compounds released into the air and water. legislation and regulation are almost always necessary, and inevitably generate opposition. nevertheless, when the other four features-awareness, understanding, capability, and values-are in place, the political will to bring about reforms gathers momentum and usually succeeds eventually. these five essential ingredients required for public health reforms apply to several public health problems that have waxed and waned over time: tobacco addiction, impaired driving, domestic violence, child abuse, irresponsible domestic and industrial waste disposal, and so on. lately, mountainous barriers-of our own making-to maintaining our public health have appeared. the most formidable is a cluster of human-induced changes to global ecosystems and the global commons-the atmosphere, the oceans, wilderness regions, and stocks of biodiversity-that threaten all life and health on earth, not just the life and health of humans. another barrier is perhaps an inherent flaw in the human character that leads many individuals and national leaders to believe that disputes can be settled by violent means. currently, we have so many terrible weapons that violence done by them can and does cause immense suffering, innumerable deaths (80% or more of these deaths, as well as a similar proportion of permanent maiming and disability, are among non-combatants), and appalling damage to ecosystems, the environment, and the fabric of society. sadly, this is rarely recognized as a public health problem. the very first essential ingredient, awareness of the problem, is lacking. both these massive public health problems, in my view, are linked to the insatiable human craving for petroleum fuels, an addiction far more pervasive and dangerous to mankind and the earth than addiction to tobacco. so far in our only partially sentient and insightful civilization, this particular addiction is not even recognized as a public health problem. one public health problem that has been recognized is a worldwide pandemic of tobacco addiction and its many adverse effects on health and long life. recognition of this problem led the delegates to the world health assembly of 2002 to approve the framework convention on tobacco control. another universally recognized public health problem is the global pandemic of hiv/aids. tobacco addiction and the hiv/aids pandemic are both associated with the values of modern life and social behavior, including the marketing practices of transnational corporations. surmounting these barriers to health will require social, cultural, and behavioral changes and political action. i am an optimist. i believe that the pace of scientific advances will be maintained in the future, and that values will continue to shift in favor of essential changes towards global ecosystem sustainability. i do not know whether those who follow us will ever reach the ultimate summit or idealized who vision of halfdan mahler' s "health for all," but i am confident that they will continue to climb towards it. de contagione et contagiosis morbis et eorum curatione, libri iii natural and political observations mentioned in a following index and made upon the bills of mortality with reference to the government, religion, trade, growth, air, diseases and the several changes in the said city an inquiry into the causes and effects of the variolae vaccinae a treatise of the scurvy hippocratic writings. harmondsworth: penguin a green history of the world; the environment and the collapse of great civilizations the greatest benefit to mankind; a medical history of humanity from antiquity to the present a history of medicine, 1. primitive and archaic medicine on the mode of communication of cholera key: cord-277246-24u9e4wr authors: thomas, james c.; miller, reid title: codes of ethics in public health date: 2016-10-24 journal: international encyclopedia of public health doi: 10.1016/b978-0-12-803678-5.00079-5 sha: doc_id: 277246 cord_uid: 24u9e4wr ethics in public health were distilled into a professional code relatively recently, with adoption of a code by the american public health association (apha) a little more than 10 years ago. in that short time, however, the code has influenced standards for public health practice and education. a few organizations representing disciplines within public health, such as the society for public health education (sophe) and the american college of epidemiology (ace), have written ethical guidelines specific to their professions and consistent with the apha code of ethics. codes related explicitly to public health ethics in countries other than the us have yet to be written. in 1974, an experiment conducted by the american public health service was ended after a whistle-blower revealed what was widely considered as unethical conduct. the experiment, named after the local collaborator, the tuskegee institute, withheld known cures from low-income, undereducated black men infected with syphilis. following this and other instances of unethical medical experimentation, the federal government issued the belmont report, providing ethical guidelines for the conduct of research on human subjects (the belmont report, 1979) . the belmont report served as a starting point for ethics in the era of twentieth-century medical technologies. some of those technologies, such as vaccines to prevent infections and antibiotics to prevent their transmission, are used in public health. but public health differs from clinical health care in a number of significant ways. in medicine, it is the interaction between the care provider and the patient that leads to the most ethical issues. in this interaction, medical ethics seeks to protect the autonomy of the patient. in public health, however, most ethical issues arise from the interaction between an agencysuch as a city health departmentand the population it is serving. a public health agency is often protecting some people within a population from others. for example, it may need to isolate an infectious person in order to prevent transmission to others. in so doing, the autonomy of the infected person is constrained in the interest of the community. because of these fundamental differences between medicine and public health, the belmont report, and policies subsequently derived from the report, do not adequately address a number of important issues in public health. epidemics of highly pathogenic organisms in recent years have underscored the need for ethical guidelines in public health. they include epidemics of severe acute respiratory syndrome (sars), ebola, and the highly anticipated but not yet realized h5n1 influenza pandemic (gostin et al., 2003; hsin-chen hsin and macer, 2004; ovadia et al., 2005; singer et al., 2003; who, 2007; thomas and miller, 2015) . common ethics challenges have included the distribution of scarce resources for curing or preventing infection, protection of populations without unnecessarily infringing on individual rights, ensuring that health-care workers fulfill their duties when they and their families are at risk, and ensuring that health-care organizations fulfill their obligations to employees who are taking risks. codes of ethics in public health are a recent development. while the american medical association (ama) approved its first code of ethics in 1847, the american public health association (apha) approved its code in 2002 (thomas et al., 2002) . the late emergence of a code of ethics in public health may reflect that, until recent years, many public health institutions were led by physicians who would naturally recognize medical codes of ethics. moreover, for centuries, physicians were regarded as the overseers of all health-related matters. only in the past few decades have nonclinical health professionals begun to assume more authority in health care and prevention. the landmark, 1988 institute of medicine (iom), report on public health set the tone for the writing of the u.s. public health code of ethics. it focused on strengthening federal, state, and local government agencies in their mission of protecting and promoting the health of the public. the impetus for developing a public health code of ethics originated within a group of public health practitioners, including providers of public health services, staff of public health nonprofit organizations, government officials, and academics. they had come together for leadership training by the public health leadership institute. as a leadership exercise, they sought to identify ethical principles that aligned with the issues they were encountering in their work more closely than the common principles of medical ethics. the group began by identifying typical ethical challenges and responses that had surfaced over time from their experiences in public health. from these, they identified principles, such as the use of scientific data for making decisions. these principles led in turn to an initial draft of the code. three professional perspectives were represented in the drafting of the public health code of ethics: law, philosophy, and public health practice. when confronted by an ethical dilemma, such as the use of quarantine to limit transmission of a highly pathogenic infection, lawyers typically reflect first on what the law allows and on the precedents in case history. philosophers typically expand on the situation to explore all the philosophical threads and identify what various schools of philosophical thought would have to say about the ethical conundrums. public health practitioners are relatively pragmatic. they commonly seek to minimize the number of people harmed by the epidemic. although they may not name the philosophy, this perspective is closely aligned with utilitarianism, which seeks the greatest good for the greatest number of people. in some instances, public health practitioners also appeal to human rights, another ethical school of thought, which acts as a counterbalance to a utilitarian calculus that can sideline a minority of the population; for example, the few placed in quarantine for the benefit of the community have a right to have certain basic needs met while in quarantine. lawyers and philosophers familiar with public health weighed in on early drafts of the code developed by the public health practitioners. input on the next draft was sought during an open meeting at an annual conference of apha. the final code was officially endorsed by apha in 2002 (table 1) . reflecting the key interaction between an agency and the population it serves, noted above, the public health code addresses the actions of agencies rather than individuals. most other codes of ethics address the actions of individuals within the profession. of the 12 principles of the public health code of ethics, 9 state obligations of public health institutions and 3 state ethical principles of public health policies and programs. for example, the 11th principle in the code states, "public health institutions should ensure the professional competence of their employees." a few constituent disciplines of public health have their own codes of ethics. each narrows in on particular concerns within the profession. in doing so, they enumerate more principles than does the code for public health. the society for public health education (sophe) code of ethics consists of 38 sections or principles categorized into six articles or responsibilities. the responsibilities are to the public, the profession, employers, the delivery of health education, research and evaluation, and professional preparation. as an example of the level of detail, the first section of the third article (pertaining to responsibilities to employers) states, "health educators accurately represent their qualifications and the qualifications of others whom they recommend." the american college of epidemiology (ace) ethics guidelines addresses 11 topics, such as the professional role of epidemiologists, providing benefits, and protecting confidentiality. the code of ethics of the american college of healthcare executives (ache) consists of 39 principles grouped into six responsibilities: to the profession, to patients, to the organization (i.e., an employer), to employees, to the community, and to report violations of the code. other traditional disciplines within public health either refer to the public health code of ethics or the codes of related fields. none of the principles in the three codes for constituent organizations (sophe, ace, and ache) disagree with the public health code of ethics. each affirms accountability, equity, confidentiality, professional competence, and more. one potential area for disagreement between the guidelines for epidemiologists and the public health code of ethics relates to advocacy. some epidemiologists assert that advocating for certain groups or needs compromises scientific objectivity. yet, the public health code states that "public health should advocate and work for the empowerment of disenfranchised community members." ace avoided this controversy by stating both sides of the issue: "in confronting public health problems, epidemiologists sometimes act as advocates on behalf of members of affected communities. advocacy should not impair scientific objectivity." a few principles in the public health code of ethics are not addressed in the other codes. the public health code, for example, emphasizes the importance of prevention and addressing the fundamental causes of disease. it also speaks clearly of the need to allow communities to have input into policies affecting them and for collaboration among institutions and organizations. the absence of these principles from the other codes does not represent a disagreement. rather, it highlights the value of a code that transcends the perspectives of the constituent disciplines within public health, one that maintains a broader, interdisciplinary perspective. the agreement and complementarity of the codes demonstrate that one code does not supersede another. a professional needs both the global perspective of the public health code and the particularity of the code of his or her narrower profession. the codes of ethics cited above were written for american professional organizations. codes related explicitly to public health ethics in countries other than the us have yet to be written. instead, one can find lists of values and principles that are often invoked in the context of a particular public health threat. pandemic influenza planning provides one example. the world health organization project on addressing ethical issues in pandemic influenza planning divided themselves into four working groups: 1. equitable access to therapeutic and prophylactic measures; 2. ethics of public health measures in response to pandemic influenza; table 1 the u.s. public health code of ethics 1. public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes 2. public health should achieve community health in a way that respects the rights of individuals in the community 3. public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members 4. public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all 5. public health should seek the information needed to implement effective policies and programs that protect and promote health 6. public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community's consent for their implementation 7. public health institutions should act in a timely manner on the information they have within the resources and the mandate given to them by the public 8. public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community 9. public health programs and policies should be implemented in a manner that most enhances the physical and social environment 10. public health institutions should protect the confidentiality of information that can bring harm to an individual or community if made public. exceptions must be justified on the basis of the high likelihood of significant harm to the individual or others 11. public health institutions should ensure the professional competence of their employees 12. public health institutions and their employees should engage in collaborations and affiliations in ways that build the public's trust and the institution's effectiveness and should obtain the community's consent for their implementation 3. the role and obligations of health-care workers during an outbreak of pandemic influenza; 4. issues that arise between governments when developing a multilateral response to a potential outbreak of pandemic influenza (who, 2006) . the working group addressing public health measures identified four values: (1) public health necessity (a government should exercise its public health police powers on an individual or group only if the person or group poses a threat to the community such as the likelihood of spreading an infection), (2) reasonable and effective means (the methods by which a threat is addressed should have a reasonable chance of being effective), (3) proportionality (the human burden imposed by a public health regulation should be proportionate to the expected public health benefit), and (4) distributive justice (the risks, benefits, and burdens of public health action should be fairly distributed, thereby precluding the unjustified targeting of an already socially vulnerable population). in addressing the tension between the rights of individuals and the good of the community, this group noted the siracusa principles, which are internationally recognized limitations on human rights established at a meeting in siracusa, italy (united nations economic and social council, 1985) . they are as follows: l the restriction is provided for and carried out in accordance with the law. l the restriction is in the interest of a legitimate objective of general interest. l the restriction is strictly necessary in a democratic society to achieve the objective. l there are no less intrusive and restrictive means available to reach the same objective. l the restriction is not drafted or imposed arbitrarily, that is, in an unreasonable or otherwise discriminatory manner. other lists of values in public health ethics are on website in the section titled relevant websites, below. principles and rules for research ethics have developed along a path separate from codes of ethics. they have evolved out of recommendations resulting from high-profile research abuses such as nazi war crimes and the tuskegee study of untreated syphilis. the principal concerns in research ethics are informed consent and the protection of vulnerable individuals such as prisoners and minors. to ensure compliance with prescribed procedures in federally funded research, there exists an institutional infrastructure reaching from the federal government to individual institutions such as universities. institutions found not to comply with the prescribed procedures can lose their license to conduct federally funded research until they are found to be compliant once again. codes of ethics for the practice of public health do not have the enforcement structures seen in research ethics. rather, the codes are aspirational, articulating the values and expectations of the profession. they are a means of being transparent and enabling the public they serve to hold them accountable for their actions. in addition, they serve as a tool for identifying and addressing ethical issues. for example, ethical issues in the application of genomics to public health were identified by considering genomics in light of each principle of the public health code of ethics in turn . since its creation, the code has served as a resource principally to public health practitioners. as their respective disciplines would rightfully demand, the main reference for public health lawyers remains public health law and regulations; and the main reference for those trained in philosophy remains philosophical schools of thought. public health practitioners, however, have proceeded to build on the foundation of the code. although written under the auspices of the society of public health leadership, soon after it was completed in 2001, the code was officially adopted by the apha and the national association of county and city health officials (naccho). naccho incorporated the code into its ethics training for local public health officials (naccho, 2015) . the code of ethics also became a resource for academic public health. in its 2003 report on education in public health, the iom included a section on public health ethics and mentioned the code (iom, 2003) . the report recommended the development of core competencies to guide the education of future public professionals. the association of schools and programs of public health (aspph) then developed core competencies for masters in public health degrees. the ethics competencies incorporated in leadership skills were informed by the code of ethics (e.g., "use collaborative methods for achieving organizational and community health goals") (aspph, 2006) . a few schools of public health have developed an oath of public health professionals that is read at graduation ceremonies. the oath of the university of georgia college of public health is modeled after the principles in the public health code of ethics (university of georgia, 2011). since the public health code of ethics was first drafted, a multitude of online platforms have been created that could help to further disseminate the public health code of ethics and host a community space for discussion on ethics in public health including twitter, which may be particularly suitable for connecting public health practitioners on the issue of ethics in public health. the american public health code of ethics is barely a dozen years old, but it has shaped the guiding principles of national public health organizations and is influencing the training of future public health professionals. as the teaching of public health ethics continues through degree programs and mechanisms, such as online modules and naccho's ethics training, the impact will continue to grow. even so, there are least three particular challenges to the growth in impact: 1. as previously mentioned, the ethical principles in the code are intended for organizations rather than individuals. while this accurately reflects the primary relationship between agencies and populations, which makes it difficult for individual practitioners to understand their role as stewards of the code. public health oaths, such as the one written by the university of georgia college of public health, may mitigate this limitation of the code. 2. public health is as much a consortium of constituent disciplines as it is a field unto itself. a person working at a water purification plant may identify more with the discipline of environmental science than with public health at large. this challenge is perhaps met in part by codes of ethics written by disciplines within public health, as noted above. we encourage those disciplines to reflect on the broader code of ethics as they write or revise their own, to ensure consistency and coverage of the full range of concerns to address. 3. the code has served as a resource primarily for public health practitioners. however, philosophers and lawyers are more likely to write text books on public health ethics. thus, the texts for teaching public health ethics may not appeal to future public health practitioners. we encourage public health practitioners who have one foot in academics, perhaps by being an adjunct professor, to develop ethics teaching resources that incorporate the processes of everyday life in various aspect of public health. this might include, for example, how decisions are made and communicated in the context of public health emergencies. the effectiveness of public health institutions depends heavily on the trust of the populations they serve. distrust results in passive and in some cases active resistance to policies and programs. a code of ethics reminds an institution of what it must do to maintain public trust. in the 2015 annual meeting of apha, the ethics section voted to update the code in light of its use and public health experiences since it was created. keeping the code up-to-date and relevant is an important step toward ensuring ethical practices that are worthy of public trust. see also: ethics and health promotion; ethics of immunization; ethics of infectious disease control. master's degree in public health core competency development project ethical and legal challenges posed by severe acute respiratory syndrome heroes of sars: professional roles and ethics of health care workers the future of the public health the future of public health education; ethics. national association of city and county health officials better late than never: a reexamination of ethical dilemmas in coping with severe acute respiratory syndrome ethics and sars: lessons from toronto ebola: the ethics of thinking ahead a code of ethics for public health genomics and public health ethics siracusa principles on the limitation and derogation provisions in the international covenant on civil and political rights the public health professional's oath ethical considerations in developing a public health response to pandemic influenza world health organization project on addressing ethical issues in pandemic influenza planning, draft paper for working group two: ethics of public health measures in response to pandemic influenza further reading public health ethics: the voices of practitioners the role of professional codes in regulating ethical conduct an ethics framework for public health ethics in health administration: a practical approach for decision makers skills in the ethical practice of public health science and social responsibility in public health aspx -european centre for disease prevention and control doc -national ethics advisory committee of new zealand. ethical values for planning for and responding to a pandemic in new zealand-a statement for discussion -public health code of ethics and accompanying documents pdf -university of toronto joint centre for bioethics. stand on guard for thee: ethical considerations in preparedness planning for pandemic influenza key: cord-018316-drjfwcdg authors: shephard, roy j. title: building the infrastructure and regulations needed for public health and fitness date: 2017-09-19 journal: a history of health & fitness: implications for policy today doi: 10.1007/978-3-319-65097-5_22 sha: doc_id: 18316 cord_uid: drjfwcdg 1. to recognize the importance to the maintenance of good health of adequate public health regulations and an infrastructure that provides clean water and appropriate waste management. 2. to see the lack of such amenities over many centuries, but the progressive development of public health bureaucracies dedicated to provision of an appropriate infrastructure for healthy cities, beginning during the victorian era. 3. to observe how responsibility for the provision of adequate housing for poorer city dwellers has been shared between government, benevolent entrepreneurs and charities. 4. to note the new challenges to public health presented by such current issues as the abuse of tobacco and mood-altering drugs, continuing toxic auto-emissions, the epidemic of hiv/aids, a decreased acceptance of mmr vaccinations, and the ready spread of infectious diseases by air travel. opportunities for the spread of communicable diseases have increased with the growth in size of cities. the success of urban living has depended in great part on governmental ability to maintain population health through the building of an adequate infrastructure to provide clean water and to dispose of waste, as well as the enactment of appropriate regulations to control the prevent the spread of infectious diseases. in this chapter, we will look at success in meeting these objectives in various communities from early history through the classical era, the arab world, mediaeval europe, the renaissance, and the enlightenment to the victorian era, concluding with some comments on current challenges to public health. in the hey-day of the persian empire, heat, cold, dirt, stench, old age and anxiety were all thought to contribute to ill-health. cyrus the great (590-530 bce) thus taught his soldiers not to urinate or spit into running water. dead matter was also carefully removed from water-courses, and the clothing of dead people was systematically burnt. during the mediaeval era, interest in public health was much more advanced in the islamic world than in northern and western europe. ali ibn-rabban (838-870 ce), a well-respected physician living on the south coast of the caspian sea, wrote in his seven-part medical work paradise of wisdom that: "no one should live in any country which does not have four things: a just government, useful medicaments, flowing water and an educated physician." in the eleventh century, the arabic biographer al-mussawir emphasized that the main duty of a monarch was the preservation of health and well-being in his subjects. thus, islamic legislation required physicians to pay regular visits to army units, prisons and people living in outlying areas. the practice of medicine was regulated through a religious office, the hisba, headed by an official called the muhtasib with some of the powers of a modern ombudsperson. one function of the muhtasib was to act as the city medical officer of health. he prevented people with elephantiasis from using the public baths, regulated the cleanliness of public places such as markets, and ensured that garbage collectors did not handle food. one interesting example of applied hygiene was the method used to determine an appropriate location for construction of the main hospital in baghdad (chap. 16). the merits of various sites were compared by hanging up pieces of meat, and noting the location where decomposition proceeded the most slowly. the city of córdoba under moorish rule further illustrates the infrastructure typical of the arab world during the tenth century ce. among other facilities, the city boasted 300 public baths. in northern and western europe, public health infra-structure such as aqueducts and sewers fell into disrepair following departure of the roman garrisons, and during the mediaeval era the sanitary conditions in most cities were appalling. positive developments were the development of quarantine procedures and the re-emergence of a few public baths. food inspectors were appointed, and some cities also introduced zoning regulations, requiring malodorous trades such as tanning to be undertaken outside the city walls. water supply and sewage disposal untreated waste was thrown directly into the rivers of london and paris, and travellers were advised: "wise men go over bridges, and fools go under them." in 1349 ce, king edward iii ordered the mayor of london to: "cause the human faeces and other filth lying in the streets and lanes in the city top be removed with all speed to places far distant, so that no greater cause of mortality may arise…" a fourteenth century ordinance prohibiting the emptying of latrines into a creek near london's city wall remained largely ignored, so that in the fifteenth century the stream was buried underground. substantial populations of hogs and cattle roamed the streets of many large cities, adding to the urban stench. uncontaminated water was a rarity, and a lack of refuse disposal encouraged rat infestations. infrequent bathing and unwashed woolen clothing led to a proliferation of fleas and other insect vectors of infection. during the mid-fourteenth century, two thirds of the european population was killed by the flea-borne bubonic plague (the "black death", 1340-1348 ce). many doctors deserted their patients during this epidemic, and others proposed preposterous remedies. guy de chauliac wrote: "so contagious was the disease…. that no one could see or approach the patient without taking the disease…for self-preservation, there was nothing better than to flee the region… to purge oneself with pills of aloes, to diminish the blood by phlebotomy and to purify the air by fire and to comfort the heart with senna and things of good odor and to soothe the humours with armenian bole and resist putrefaction by means of acid things." chauliac unwittingly kept the rats and fleas away from pope clement vi, by surrounding his bedside with charcoal burners. a few years following the black death, observant physicians hypothesized that ships arriving from overseas were contributing to the recurring epidemics of plague. at first, hostels for sick townsfolk and newly arrived visitors were set up outside the city, but this was not entirely effective in containing infection. thus in 1377 ce, a trentino (30 days) of isolation on an uninhabited island was required at many european ports of entry. subsequently, the isolation period was extended to 40 days, perhaps because of an ancient greek doctrine that a contagious disease became manifest within 40 days. in britain, recently arriving travellers were quarantined on guardships, anchored in the thames estuary ( fig. 22 .1). most of the roman baths in northern europe had been abandoned by the mediaeval era, in part because of the high cost of heating the bath water, and in part because the church considered public bathing as a common prelude to venal sins. the church also had concerns about reinforcing belief in the supposed healing powers of celtic water deities (chap. 14). nevertheless, as prosperity increased in the latter part of the middle ages, public baths were built or reopened in various parts of europe. in britain, the king's bath was built over the sulis minerva temple in the city of bath, and paris had established 26 public baths by the thirteenth century. in germany, the tradition of river bathing had persisted from celtic times, and a growing number of new public bath-houses were constructed during the 14th and 15th centuries. admission to a bath-house was expensive, and poorer germans considered the payment of "bath money" a great blessing. the full luxury package of a spa treatment included washing, scouring and slapping of the body with a sheaf of twigs, a steam bath, rubbing to induce perspiration, swatting the skin with wet rags, scratching, hair washing, cutting and combing, lavendering, and blood letting. unfortunately, some of the baths subsequently became the scene of debauchery, prostitution and infection, and by the sixteenth century, many were closed for fears of spreading syphilis, leprosy and plague ( fig. 22 .2). personal hygiene substantial quantities of soap were traded during the mediaeval era, but this was used more for the washing of wool than for cleansing of the skin. monasteries boasted laundry rooms, and many women listed their trade as "laundry woman." however, the laundering of clothes was an infrequent luxury for poorer people, and indeed many had no spare set of clothing, so that fleas flourished in the poorer households. food inspection basic foodstuffs such as wine, beer, bread, meat, fish and salt were frequently adulterated in mediaeval times. to counter such abuses, several european governments appointed food inspectors. in britain, in 1266, the assize of bread and ale regulated the price of these staples in relation to the price of corn. occasional renaissance scholars expressed some interest in health promotion. the english diplomat and scholar thomas elyot (c. 1420-1546) wrote a book entitle the "castell of health," summarizing the latest medical knowledge for those unfamiliar with greek, and the venetian nobleman luigi cornaro (1464-1566) wrote a book on the art of living a long life. santo santorio (chap. 27) also sought to put hygiene on a mathematical basis. most of renaissance society showed little interest in public health or hygiene, as shown by the outbreak and management of the great plague. however, boards of public health were set up in some cities. two small advances in personal hygiene were the introduction of cotton clothing and a growing use of toothbrushes. diligent housewives adopted a few other simple changes in household management to preserve the health of their families, and cambridge university insisted on a direct control of its food supply, the great plague the london "plague" of 1665 ce was one in a series of european epidemics of bubonic plague dating back to the "black death." the great plague claimed at least 70,000 lives in central london, this being about a half of the population who had not fled from the city. indeed, the death count was probably underestimated, since publically appointed street monitors were open to bribery by those who did not wish to disclose that their house had become infected. samuel pepys commented that the prevalence of the disease was such that corpses could not removed during the hours of darkness ( fig. 22 .3). people were confined to their homes if one family member was infected, thus virtually ensured the death of the entire household. two watchmen were posted at the doors of infected homes for 40 days, at a cost of 16d per house per day, and the victims received a public stipend of 8d per day to pay for food, fuel and medicaments. believing that the disease was conveyed by miasmata, the college of physicians recommended using bonfires to displace the infected air. there was probably some incidental benefit from these fires, since the smoke tended to drive away the flea-ridden rats that were vectors of the disease. the epidemic was eventually checked by the great fire, which consumed both the rats and the plagueinfested slum dwellings. in europe, local boards of public health were established; they adopted various measures for the containment of epidemics and the provision of social support to the community. in some cases, they designated specific physicians to attend plague victims, and in florence, local doctors prepared a public information booklet that summarized current knowledge on plague prevention. a further responsibility of these boards was to deal with doctors who failed to report communicable diseases in wealthy patients. one roman doctor who was arrested for this offence was ordered to serve as resident physician at the local pest-house. outbreaks of the plague placed a severe financial stress upon some municipalities. in milan, extra funding was needed to hire physicians and grave-diggers, to pay for operating a quarantine "pest-house," and to reimburse the infected for two-thirds of the estimated value of their possessions, which were summarily burned. some municipalities set up immigration offices on mountain passes to control the arrival of infected travelers, and others restricted imports, exports, market trading, travel and funerals, although it was unclear how far these costly measures were successful in reducing the toll of disease and mortality. personal hygiene and household management one positive development during the renaissance was the introduction of washable cotton clothing and sheets. this greatly curtailed the spread of insect-borne diseases, particularly among those with sufficient wealth to own several changes of clothing. another innovation was popularization of the bristle toothbrush. this device had been invented by the chinese in the thirteenth century, but did not become popular in england until the late seventeenth century, beginning with the aristocracy. without necessarily knowing why, tudor housewives achieved some sterilization of their dairy equipment by scouring with salt and hot water, and then exposing utensils to bright sunlight. infestation of houses by fleas was also countered by sprinkling appropriate herbs beneath the rush mats that covered their floors. the renaissance saw further occasional attempts to control the quality of food, particularly for the wealthy. cambridge university insisted that the direct supervision of their refectories was important to preserving the health and well-being of their students. one of those promoting hygiene during the enlightenment was the physician james mackenzie, who in 1758 wrote a text on "the history of health and the art of preserving it." the enlightenment saw some improvement of health infra-structure many dwellings for the poorer citizens of europe.were now constructed of brick and boasted glass windows. and samuel johnson (1709-1784) was urging a pro-active response to the prevention of disease:"we must consider how many diseases proceed from our own laziness, intemperance or negligence… and beware of imputing to god, the consequences of luxury, riot and debauchery." the diderot encyclopédie, first published in 1751, included a section on hygiene, which wss defined as: "the things which mankind uses or handles… and their influence on our constitution and organs." gottfried wilhelm leibniz (1646-1716) was perhaps the greatest enthusiast for public health during this era. he strove to establish a pattern of medical training that was oriented towards public health and preventive medicine rather than the treatment of disease. he reminded his colleagues that hippocrates had registered every successful cure, and he urged a similar meticulous recording of outcomes in order to provide a modern preventive medicine data-base. he proposed that standardized questionnaires should be developed to examine eating habits, and that careful mor-the enlightenment tality statistics should be collected so that findings could be correlated with the local climate, air conditions and the nature of the soil. a few other scientists such as hales (who improved the water supply for his village of teddington), and bernouilli (with authored a probability study demonstrating the merits of vaccination) were also interested in public health. but concern about the provision of clean drinking water, adequate treatment of sewage and garbage, and protection against communicable diseases remained the exception rather than the rule, with most countries making a poor showing on indices of population health. francis bacon published studies on the percolation, filtration, distillation and coagulation of water as early as 1627. anton van leeuenhoek described the microscopic animalicules that he had seen in dutch drinking water in 1680, and the french scientist joseph amy patented a water filter in 1746. however, the quality of water in most large cities left much to be desired. philippe de la hire (1640-1718) mapped the area around paris, seeking to improve the water supply to versailles, probably as much to service the palace ornamental fountains as to provide clean drinking water in the town, and he built a massive aqueduct for this purpose (fig. 22.4) . he further suggested that householders should install a sand filter to purify the water collected from the roofs of their dwellings, although he noted that one alternative source of water, from underground aquifers, was rarely polluted. in 1804, paisley, scotland became the first british city to establish a municipal water treatment plant. it used a sand filter that had been developed by robert thom. in 1806, paris also constructed a large water treatment facility on the seine; here, river water was allowed to settle for 12 hours, and was then passed through sponge pre-filters and main filters that contained sand and charcoal. despite these advances, the residents of broad st., in central london, faced a massive outbreak of cholera as late as 1854, because they were drawing water from a shallow well that was located close to a cholera-contaminated cess-pit. too often, the city dwellers of the enlightenment continued to pass sewage into open gullies or cess-pits that were fig. 22.4 ruins of an aqueduct, built by philippe de la hire to improve the water supply to the city of versailles and its royal palace (source: http://en. wikipedia.org/wiki/ canal_de_l'eure) close to wells, and garbage was thrown directly onto the street. however, in 1706, the conseil supérieur of new france ruled that in order to reduce infection, the houses in quebec city must have latrines, and that garbage must be carried to the river st. lawrence, rather than simply thrown out of the door. populatiion health during the enlightenment vital statistics provide simple objective indices of overall population health during the enlightenment. at birth, the average european could expect to live no more than 35 years. a third to a half of the population died before reaching the age of 16 years. those who survived to their mid-teens lived into their 50s or even their early 60s, and at the age of 21 the aristocracy could expect to live a further 43-50 years; this was an improvement over the 25 years of adult survival typical of the fourteenth century. survival prospects were much worse in north america than in europe during the enlightenment. many of the population succumbed to fevers, intestinal diseases, and, in the case of the african slaves, to harsh working conditions. a quarter of european immigrant children did not survive until their first birthday, and half of all marriages ended in the death of one partner before their seventh wedding anniversary. epidemics of beri-beri, smallpox, malaria and yellow fever wreaked havoc among early colonists. two of every three deaths were attributed to typhoid, dysentery or salt poisoning. in an attempt to reduce this terrible toll, newly arrived immigrants were initially isolated in "guest houses." replacement of contaminated water by wine, beer or cider, a reduced consumption of infected clams, and a scattering of the population to areas where there were copious fresh water springs reduced deaths from typhoid and dysentery, but progress in reducing overall mortality was slow. in early canada, dispersal of the population along the major rivers made major epidemics less likely than in the urban settlements of the united states, but isolation, accidents and harsh winters made canadian life expectancy worse than those in either europe or the u.s. only a small fraction of the population lived beyond 40 years, and many of the children suffered from rickets and anaemia. typhus and smallpox were also recurrent problems. the victorian era was marked by growing government responsibility for the health of the public in large european cities. there was a gradual improvement in the quality of housing, and demographics showed a burgeoning birth rate. social reformers also succeeded in abolishing child labour and slavery from western society (chap. 23). in this section, we will discuss the role of boards of health, continued deaths from poisoning, and improvements in housing conditions. major epidemics of influenza, cholera, typhus, typhoid fever and scarlet fever sparked a deep concern about population health in victorian england. in london, england, cholera killed 14,137 people in 1848-49 and 10,738 in 1853 (chap. 24). however, leaders of a new sanitary movement such as edwin chadwick (1800-1890) and thomas southwood smith (1788-1861) began to recognize that ill-health of the individual soon became ill-health of the population. they thus made urgent calls for the provision of clean drinking water, proper removal of refuse and sewage treatment. chadwick and smith sat as commissioners on london's general board of health that regulated the water supply and sewer connections for all new housing in the city, and provided adequate burial grounds for those who died. the quality of london's drinking water was rapidly upgraded, and money was spent on methods of preventing death during childbirth. the public health acts of 1848 and 1875 also established public baths and wash-houses, and by the 1870s, health-conscious municipalities were building public swimming pools. in lower canada (quebec), a physician was appointed as health officer in 1816, with the primary responsibility of monitoring the sick and starving people who were arriving on immigrant ships from europe. by 1823, a strengthened five-member board of health was supervising quarantine arrangements on grosse isle, in the st. lawrence river near to quebec city. nevertheless, the number of immigrants was such that this holding facility was at times overwhelmed, and cholera periodically reached quebec and montreal, killing between 10-15% of the population. in 1847, 5424 people also died of typhus while they were quarantined at grosse isle. a central board of health for both upper and lower canada was created in 1849. compulsory vaccination against smallpox was introduced in the early 1860s. in the united states, organization of sanitary reform began rather later than in canada. the city of new york enacted the metropolitan health bill in 1866, creating a 9-person board of health. immigrants were processed on ellis island, just outside new york city. the original wooden structure was quickly destroyed by a catastrophic fire, but a stone replacement building opened in 1900. many immigrants spent only a few hours in the facility, but those with contagious disease were summarily denied admission to the united states. continued deaths from poisoning many victorians died from eating adulterated or diseased food. one report to the british privy council (1863) estimated that 20% of meat came from diseased cattle. flour was expensive, and bakers frequently adulterated it with chalk (to whiten it) and alum; often, the bakers also kneaded the mixture with their bare feet. an act prohibiting the adulteration of food was passed in 1860, but its enforcement was an option for local authorities, so that it was not very effective. cooking was typically done in tin-lined copper pans; wealthier citizens replaced the pots when the tin had worn away, but the poor could not afford to do this, and in consequence they sometimes developed copper poisoning. other sources of poisoning in the victorian home were leaking gas pipes, lead used in white paint, and arsenic used to colour wallpapers. in the early nineteenth century, the sudden influx of country folk into the major cities of europe created hideous slums: "in big, once handsome houses, thirty or more people of all ages may inhabit a single room." housing gradually improved over the victorian era, as many workers accumulated sufficient funds to purchase modest but well-built homes. enlightened industrialists also constructed model housing estates for their employees. robert owen (1771-1858) organized a model community for his workers at the new lanark mills, in scotland, complete with a nursery school. he envisaged an even more ambitious employee housing project in new harmony, in, but this project failed within two years. the quaker chocolate manufacturer george cadbury (1839-1922) built a model village for his employees around his factory at bournville, near birmingham, and in the u.s. george pullman, the railway carriage czar, built a model town at pullman, il, in 1885. charitable foundations such as the peabody trust began to replace the worst of london's slums with solidly-built if spartan apartments (fig. 22 .5). the first peabody block, at spitalfields, included 57 dwellings for the poor, 9 shops complete with accommodation for the shopkeepers, and on the top floor baths and laundry facilities for a total cost of £22,000. in the united states, building codes were improved during the victorian era, and a national housing association was founded in 1910, under the aegis of the commission on the congestion of population in new york. there were also attempts to persuade philanthropists to build model tenements at low rents; buildings were bought, renovated, and then rented to relocated slum dwellers who were given "friendly instruction" on management of their new households. despite substantial progress in the delivery of public health, there remain a number of continuing challenges in the twenty-first century. current issues include the definitive control of the sales of tobacco and mood-altering drugs, the regulation of automotive emissions and other source of urban air pollution, management of the hiv/aids epidemic, concern over a growing reluctance to accept childhood vaccinations, and the management of infections spread by international air travel. in the edwardian era, cigarette manufacturers had promoted their wares as the cure for various respiratory conditions such as asthma and hay fever. but in 1912, the american physician isaac adler pointed to a growing incidence of lung cancer, and he speculated that the abuse of tobacco and alcohol might be responsible. anti-smoking groups developed in germany following world war i, and a magazine (german tobacco opponents) was published from 1919 to 1935. the nazi regime was opposed to smoking, with hitler declaring it a waste of money. in particular, women who smoked were considered as unsuitable to be german wives and mothers. during world war ii, the axis powers made much propaganda from the fact that hitler, franco and mussolini were non-smokers, whereas churchill, roosevelt and stalin were all heavy users of tobacco. evidence of the toxicity of tobacco steadily accumulated during the modern era. in 1929, fritz linkint dresden demonstrated an increased prevalence of lung cancers in smokers. his research was confirmed in 1939, with a case-control study by franz hermann muller of cologne. during the 1950s, ernst wynder at the sloan-kettering institute in new york and richard peto and bradford hill at oxford university advanced even more compelling evidence that cigarettes were carcinogenic. hill concluded that consuming 35 cigarettes per day increased the odds of dying from lung cancer as much as forty-fold. other damning evidence came from cellular pathology, animal experimentation and the demonstration of toxic chemicals in cigarette smoke. however, for a substantial part of the post-modern era, public health workers had to combat a deliberate campaign by the cigarette manufacturers to confuse and deceive the general public. the manufacturers were well aware of the damning facts by the early 1950s, but their misleading propaganda was able to increase u.s. cigarette sales to a peak of 630 billion units in 1982. as late as 1960, only a third of u.s. doctors considered smoking as "a major cause of cancer," and 43% of physicians were still smoking on a regular basis. beginning in the mid 1970s, there was a dramatic decrease in the social acceptability of cigarette smoking, and growing restrictions were placed on public areas where smoking was permitted. this resulted from demonstrations that passive exposure to cigarette smoke gave rise to small but significant increases in the risks of chronic respiratory disease and asthma in childhood, and carcinoma of the lungs and cardiovascular disease in adults. public polls showed a growing acceptance of public health measures to control smoking in public spaces. cigarette manufactur-ers went to particularly great pains to obfuscate the risks of passive exposure to cigarette smoke, but adverse effects were clearly demonstrated during the 1980s, not only by epidemiological research, but also by the exposure of volunteers to machine-generated cigarette smoke while they exercised in closed chambers. public health workers continue to face many challenges in reducing the sales of tobacco products, as manufacturers doggedly resist measures to reduce consumption through increased taxation, prohibition of sponsorships, and plain packaging. they constantly seek methods of creating new addicts, both through extensive advertising in third world countries and through such tactics as the marketing of electronic cigarettes. as recently as 2015, cigarette smoking still accounted for 11.5% of deaths world-wide. the toll from cigarettes is now compounded by the effects of mood-altering drugs. several countries (including canada) have abandoned attempts to prohibit the marketing of marijuana, with as yet no clear standards of dosages compatible with worker and road safety, and an ever growing segment of the north american population is becoming addicted to powerful opiates, with a high risk of deaths from overdoses. british columbia alone had 914 deaths from opiate overdoses in 2016, despite providing emergency workers with supplies of the antidote naloxone. the modern era saw a dramatic drop in the sulphurdioxide/large particulate smog associated with coal fires in many developed societies, but air pollution problems have continued from coal-fired power station and sautomotive emissions, particularly during thermal inversions. the exposure of cyclists and pedestrians to carbon monoxide was studied during the 1970s. substantial concentrations of carbon monoxide were recorded on congested city streets, particularly if air movement was impeded by tall buildings, but any build-up of carboxyhaemoglobin in the blood stream was reversed quite quickly when the individual moved to a less polluted area. the only adverse clinical effect from carbon monoxide exposure was a somewhat earlier onset of angina if a person with coronary atherosclerosis exercised on a heavily polluted street. chamber experiments by steve horvath in santa barbara, ca, and larry folinsbee in toronto documented acceptable ceilings of exposures to the ozone that was formed by the action of sunlight upon the nitrogen oxides from vehicle and aircraft exhaust. the threshold concentration causing a minor disturbance of respiratory function in healthy exercisers was around 0.75 p.p.m., a level that was exceeded in some north american cities on heavily polluted days. to date, in many cities improved automotive emission controls have done little more than match the increase in vehicle registrations, and places such as paris and beijing have needed to forbid the access of drivers to the centre of cities on alternating days in order to reduce pollution levels. since ozone levels show a marked diurnal cycle, one immediate remedy for the active individual is to exercise at less heavily polluted times of the day (early morning or late at night). the ultimate solution to the problem of automotive exhaust probably lies in the replacement of gasoline-driven by electric or hydrogen-powered vehicles. the hiv/aids epidemic officially began in the u.s. in 1981, when the centers for disease control reported a clustering of cases of pneumocystis pneumonia among homosexual men in los angeles. it was quickly realized that the condition was not limited to homosexual individuals, but was seen also in intravenous drug users, haemophiliacs and others receiving blood transfusions. thus, in august 1982, the cdc coined the new term aids. a year later, luc montagnier and his associates at the pasteur institute in paris discovered the virus responsible for this disease. much effort has since been devoted not only to finding highly effective antiretroviral agents, but also in devising measures to reduce transmission of the disease. particular emphasis has been placed upon the wearing of condoms during sexual intercourse, in providing sterile needles for intravenous drug users through programmes of needle exchange and supervised injection sites, in closer control of blood banks and in ensuring sterility during drug injection treatments of tropical diseases. nevertheless, success in controlling the epidemic has as yet been only partial. in the u.s. the disease had already claimed 575,000 lives by 2006; a further million were living with the disease, and 56,000 fresh cases were diagnosed in that year. in rural africa, the situation remains even worse, with as many as a third of young adults currently infected. during the early part of the post-modern era, successful childhood vaccination campaigns brought the incidence of mumps, measles and rubella to a very low level in most developed countries, and the who set the year 2015 ce for the total elimination of measles and rubella from the european region. however, the percentage of children receiving vaccination has decreased in recent years, with parents weighing the low current risk of infections relative to the supposed dangers of developing meningo-encephalitis and autism. fears that vaccination would cause autism stemmed from a paper published by the british physician andrew wakefield, in 1998. extensive research found no evidence to support his claims, and the british medical journal recently declared that the original article was fraudulent. further, the british general medical council found wakefield had been guilty of serious professional misconduct, and he was struck from the medical register. there have since been small outbreaks of measles consequent upon the decreased proportion of vaccinations in britain and in canada, and unfortunately many of the general public remain convinced that vaccination can cause autism. infectious diseases can now spread very rapidly, due to the ever-growing number of people who engage in global air travel. this problem is well exemplified by an epidemic of sars (severe acute respiratory syndrome). this began in mainland china in november of 2002, and due to delayed reporting by the chinese authorities it spread rapidly around the world. the who issued a global health alert on april 11th 2003. fortunately, application of rigid quarantine measures contained the epidemic, with relatively few deaths in north america, and by july 5th 2003, the who was able to declare that the sars epidemic was over. many of the major epidemics of earlier eras were due largely to poor hygiene-a lack of clean water, poor sewage treatment, and an inadequate control of people who were already infected. although we often assume that these issues have now been resolved, it is important to recognize that in many third world countries supplies of clean water and adequate supplies of food are still lacking, with shortages often exacerbated by ethnic conflicts. the same issues of clean water, waste disposal and burial of the dead could still arise in wealthier countries today if there were to be an earthquake, a typhoon or a tsunami, and emergency services must be prepared to give the highest priority to an early re-establishment of the basic health infrastructure following any natural disaster. issues in the adulteration of food have now been largely overcome in developed society, but the current obesity epidemic underlines that problems still have to be resolved in terms of persuading food processors to avoid tactics designed to persuade consumers to overeat. for those who can afford housing, the modern single-family home is generally well-equiped to optimize the health of those who are living in it. massive tower blocks are less suited to a healthy and active life-style, particularly for families with young children. moreover, ever-increasing minimum specifications for housing, a growing world population and a lack of land is presenting public health agencies with the issue of a growing proportion of homeless individuals in many large cities. globalization is presenting new challenges to public health, not only with the rapid spread of infections, but also with the international enforcement of regulations on issues ranging from emission controls on cars to the quality of foods and medications. the ideal forum for developing appropriate preventive measures would seem the world health organisation, but unfortunately (as with many international bodies) its effectiveness is often limited by political considerations, including threats from some nations to slash funding unless criticism of their practices is shelved. 1. are the infrastructure constraints of an earlier era still compromising public health in third world countries? questions for discussion child against measles, mumps and rubella? what will be the likely new challenges to public health agencies over the next 20 years? public health foundations: concepts and practices cigarette smoking: health effects and challenges for tobacco control plague and the poor in renaissance florence principles of water resources bathing in public in the roman world mission and method: the early nineteenth century french public health movement history of hygiene asian medical systems: a comparative study hygiene in the early medical tradition public health victorian medicine and popular culture private choices and public health. the aids epidemic in an economic perspective health, civilization and the state; a history of public health from ancient to modern times the nazi war on cancer housing in urban britain environmental policy and public health: air pollution, global climate change and wilderness a history of public health shephard rj. the risks of passive smoking on the mode of communication of cholera the new public health the establishment of a board of health for new york city in 1866 further reading some early societies had an infrastructure that provided clean water and the removal of sewage, but since this was usually available only to wealthy citizens, its impact upon the course of epidemics was limited. major cities such as london did not build a comprehensive infrastructure until the middle of the victorian era, when appropriate initiatives were taken by newly formed boards of public health. although the traditional concerns of public health have now been largely met in developed societies, new challenges are constantly arising. these include the control of tobacco products and mood-altering drugs, the reduction of automotive emissions and other forms of urban pollution, management of the hiv/aids epidemic, overcoming a growing reluctance to vaccinate infants, and countering the rapid spread of infections by air travel. key: cord-259727-u2zj7zf6 authors: wallar, l. e.; mcewen, s. a.; sargeant, j. m.; mercer, n. j.; garland, s. e.; papadopoulos, a. title: development of a tiered framework for public health capacity in canada date: 2016-07-31 journal: public health doi: 10.1016/j.puhe.2016.03.009 sha: doc_id: 259727 cord_uid: u2zj7zf6 • select sars reports were qualitatively analyzed for usage of “capacity”/“capacities”. • public health capacity can be sub-divided into 17 individual capacity components. • these components can be organized into five tiers to build a capacity framework. • this framework can be used to guide capacity assessment and building efforts. in the early 2000s, successive canadian public health crises revealed that public health systems were ill-equipped to meet unexpected, increased population health demands. in 2003, the severe acute respiratory syndrome (sars) pandemic created a panicked state of preparation in anticipation of a high mortality rate and broad geographical spread. although this was not realized, large gaps in capacity to meet potential emergency health demands were revealed. 1 after sars, the first and only comprehensive and objective review of the canadian and ontario public health systems was conducted. it strongly emphasized the need for enhanced public health capacity and a strong public health workforce to prevent the occurrence of future crises. over time, these efforts have been hampered by a muddied understanding of what public health capacity actually means. 2e4 the objective of this study was to regain a clear understanding of the components of public health capacity, and how they relate to a stronger public health system. in this study, twelve publicly available canadian or ontario sars reports published between 2003 and 2006 were identified using a key informant (executive director of the association of local public health agencies (1998e2004)), and were accessed from internet websites between october 2012 and january 2014 (n ¼ 12) using the names of the reports, or the reports' commissioners or committee chairs as key words. for a complete listing of these reports, see supplementary data in appendix a. manifest content analysis was used to analyze the use of the terms "capacity" and "capacities" related to public health. 5 tables of contents, chapter headings, executive summaries, recommendations and terms that were unrelated to public health (e.g. bed capacity) were excluded. the remaining terms were coded by report name and type of capacity by lew. for example, epidemiological capacity was coded as "epidemiological". all coding was independently reviewed by seg. disagreements between reviewers related to the addition, deletion and naming of codings (n ¼ 90) were discussed and consensus was achieved. similar codes were deductively organized by lew into families that represented separate components of public health capacity. families and their codes were reviewed by seg and consensus was achieved through critical discussion. these families were then organized by lew and ap into a tiered public health capacity framework where capacity within each tier builds upon the capacities within the preceding tiers, and moves from the individual to the systems level. here, we present this framework of public health capacity that identifies individual components and suggests how they relate to and support one another for the purpose of enhancing overall capacity in public health systems. seventeen components of public health capacity were identified and organized into five tiers, namely: human resources; foundation components; program components; integrative components; and enhanced public health (fig. 1 ). this framework arranges the components of public health capacity from the individual to the systems level. human resources form the bottom tier of the capacity framework as they provide the necessary manpower, skills and competencies to support the succeeding tiers, and ultimately maintain and improve population health and wellbeing. their critical importance was discussed by all of the reviewed reports. as the national advisory committee on sars and public health noted, "no attempt to improve public health will succeed that does not recognize the fundamental importance of providing and maintaining in every local health agency across canada an adequate staff of highly skilled and motivated public health professionals." 6 the foundation components of public health capacity provide the necessary underlying infrastructure by supporting one another to effectively fulfill the programmatic and integrative public health functions, and maintain the smooth functioning of the public health system. for example, research and k* capacity is supported by partnerships and collaboration between various public health stakeholders on the same tier level. this tier also supports succeeding tiers. for example, epidemiology and surveillance capacity is supported by timely access to quality data and information, collaborative linkages, investigative research, common reporting structures, and modern disease information systems. the program components of public health capacity represent more traditional public health functions that support the integrative capacity components which combine these functions. for example, emergency management is supported by public health laboratories that are equipped to handle high volumes of testing, field epidemiologists, surveillance systems and networks, infection control standards, and training of front line workers. the integrative components of public health capacity include systems-level, complex, and inter-connected public health functions that require the integration of human resources, foundation and program capacity components in order to be effective. emergency management refers to planning and preparedness, detection and response, and control and mitigation of outbreaks, emerging and resurgent public health threats, unforeseen events, epidemics, and health crises. population health management refers to meeting community needs and responding to public health issues and challenges within the local and provincial public health systems. delivery of programs and services is primarily discussed in relation to ontario's public health units although the need for human, physical and financial resources applies to public health organizations as well. governance is related to policy and planning procedures, strategic capacity, leadership and management, performance management, and risk assessment and planning. these complex capacity components require the integration of the lower-tiered capacity components to impact local, provincial and federal public health capacity. as the standing senate committee on social affairs, science and technology noted, "capacity enhancement is a broad term which encompasses a number of areas: surveillance systems; fig. 1 e tiered framework of public health capacity and its components. the components of public health capacity were identified through analysis of the usage of public health-related "capacity" or "capacities" in post-sars reports. these components were organized into five tiers from the individual to the systems level. k* indicates knowledge exchange, management and transfer. bold font indicates the five tiers. emergency preparedness and response; human resources; public health laboratories; information technology; communications and research." 7 public health capacity exists at all societal levels, and is supported by human resources, and foundation, program and integrative components. as each component is enhanced, public health systems are able to more effectively meet public health needs. this study presents a cumulative conceptual framework of public health capacity where each capacity tier builds upon the capacities of the underlying tiers from the individual to the systems level. this organization is consistent with the united nations development programme's capacity assessment and development framework and lafond, brown and macintyre's health sector capacity framework. 2, 8 by organizing public health capacity components in this way, it emphasizes how individual capacity components relate to and support one another. this is in contrast to other discussions of capacity in public health that have a more singular focus on specific capacities such as epidemiology or health promotion. 9,10 based on this framework, capacitybuilding efforts are predicted to be potentially more impactful when directed at the lower tiers (human resources, foundation) as these tiers support capacity within the above tiers. this framework is intended for a diverse audience including public health professionals, organizations, academia, government, and professional associations who are interested or engaged in assessing and enhancing the types of public health capacities that are present and/or absent within their respective units. we suggest that this framework can be applied by each actor using an iterative, developmental approach according to the following steps: 1) identify the capacity components that individuals, agencies, and systems should possess given their particular mandate; 2) identify the capacity components that individuals, agencies, and systems possess, and examine how these components relate to the other capacity components in the framework; 3) identify the components that individuals, agencies, and systems do not currently possess in relation to the ideal state; and 4) examine the potential for building these capacities internally or externally via strategic partnerships with other actors who already possess these desired capacities. this conceptual framework provides a common structure of public health capacity components that can be utilized by any actor to better coordinate and target capacity-building efforts to specific components identified using the framework. this framework has some limitations. it is descriptive in nature rather than prescriptive with respect to how each component should be enhanced in current public health systems. it is incumbent on each user of this framework to decide how best to modify and apply it to meet their particular needs. the framework is based on government and governmentcommissioned sars reports that reviewed the canadian and ontario public health systems with an emphasis on community public health outbreaks and emergencies. certain components such as maternal and child health were not addressed in these reports and are therefore not included in this framework. lastly, this framework has not been validated using any real-world applications or scenarios. as this framework is implemented, it will be important to collect and receive feedback on its utility and applicability. as public health continues to meet new and existing challenges, enhancing public health capacity with a renewed focus on where individual capacity components exist within the system, and how these can be effectively leveraged through strategic partnerships will strengthen the ability of public health systems to maintain and improve population health into the future. final report: spring of fear. toronto: ministry of health and long-term care mapping capacity in the health sector: a conceptual framework the development and pilot testing of a rapid assessment tool to improve local public health system capacity in australia four approaches to capacity building in health: consequences for measurement and accountability rethinking validity and reliability in content analysis learning from sars: renewal of public health in canada e a report of the national advisory committee on sars and public health. ottawa: health canada standing senate committee on social affairs, science and technology. reforming health protection and promotion in canada: time to act. ottawa: government of canada united nations development programme bureau for development policy. capacity assessment and development in a systems and strategic management context development policy assessment of epidemiologic capacity in state and territorial health departmentseunited states assessing public health capacity to support community-based heart health promotion: the canadian heart health initiative, ontario project (chhiop) not required (no human participants or animals were used to conduct this research). none. key: cord-010513-7p07efxo authors: daniels, norman title: resource allocation and priority setting date: 2015-08-31 journal: public health ethics: cases spanning the globe doi: 10.1007/978-3-319-23847-0_3 sha: doc_id: 10513 cord_uid: 7p07efxo there has been much discussion of resource allocation in medical systems, in the united states and elsewhere. in large part, the discussion is driven by rising costs and the resulting budget pressures felt by publicly funded systems and by both public and private components of mixed health systems. in some publicly funded systems, resource allocation is a pressing issue because resources expended on one disease or person cannot be spent on another disease or person. some of the same concern arises in mixed medical systems with multiple funding sources. risks matters, not just the aggregate impact. resource allocation in public health thus focuses on deciding what risks to reduce-which depends in part on their seriousness as population factors and who faces them-and how to reduce risks. the cases in this chapter that discuss resource allocation force us to contemplate decisions about priorities in public health as opposed to the more frequently discussed medical issues about health care priorities. later we suggest that making decisions about these issues should be part of a deliberative process that emphasizes transparency, stakeholder participation , and clear, relevant reasoning. collectively, these resource allocation cases bring out several important points. separately, they raise other central issues. it is worth noting these general issues before commenting on the more specifi c problems raised by each case. the fi rst point the cases collectively make is that effi ciency has ethical and not just economic importance (daniels et al. 1996 ) . if one health system is more effi cient than another, it can meet more health needs per dollar spent than the less effi cient one. if we want systems to meet more health needs, and we should, then we prefer more effi cient health systems. specifi cally, if we think we have obligations to meet more health needs, or if we think meeting more "does more good," and we ought to do as much good as we can with the resources we have, then we have an ethical basis for seeking more effi cient health systems. the economic pursuit of effi ciency should not, then, be dismissed as something that has no ethical rationale. a second point the cases collectively make is that effi ciency is not the only goal of health policy , for we have concerns about how health benefi ts are distributed as well as how they add up. health policy is not only concerned with improving population health as a whole, but also with aiming to distribute that health fairly (daniels 2008 ) . that means many resource allocation decisions involve competing health policy goals. the point about competing goals is illustrated by a problem often encountered in policy decisions: should we always favor getting the best outcome from the use of a resource, or should we give people "fair" chances to get a benefi t if it is at least signifi cant (brock 1988 ) ? for example, during an i nfl uenza pandemic, should we allocate ventilators to those with the best chance of survival, or should we give signifi cant but lesser chances to a broader group? reasonable people often disagree about when the difference in expected benefi ts means we should favor best outcomes over fair chances, or even about what counts as a fair chance. hence, a third point emerges from the cases taken collectively: reasonable people often disagree about the choice, and it is not possible to simply dismiss one side as irrational or insensitive to evidence and argument (daniels and sabin 2008 ) . indeed, reasonable people will disagree about how much priority to give to the sickest (or worst off) patients. they may think we have to weigh the seriousness of an illness against the potential benefi t that we know how to deliver, they may disagree about how to trade off those considerations, or they may disagree about when modest benefi ts to larger numbers of people outweigh greater benefi ts delivered to fewer people. together these "unsolved rationing" problems-the best outcome versus fair chances problem (when to prefer best outcomes to fair chances), the priorities problem (how much priority to give to those who are worst off), and the aggregation problem (when do modest benefi ts to more people outweigh significant benefi ts to fewer people)-mean that there is pervasive ethical disagreement underlying many resou rce allocation problems (daniels 1993 ) . there are other common sources of disagreement. one of the most common sources of controversy in resource allocation decisions arises when a particular intervention is seen as the last chance to extend life by some-a necessity if we are to act compassionately-and when it is seen primarily as an unproven intervention by others that we have no obligation to provide it. denials of such interventions in last-chance cases have been considered the "third rail" of resource allocation decisions (daniels and sabin 2008 ) . here we have two competing public value s-compassion and stewardship-and most public offi cials would prefer to be seen by the public as committed to saving lives rather than as ha rd-nosed stewards of collective resources. the cases taken collectively bring out one fi nal point: our main analytic tools for aiding resource allocation decision making are limited in several ways, particularly by insensitivity to various ethical issues, especially issues of distribution. in short, these tools may take the fi rst point, about the importance of effi ciency , seriously, yet fail to help us with the second and third lessons the cases collectively bring out, that we are also interested in distributing effi ciently produced health fairly, and that reasonable people disagree about how to do that. to see this, consider two widely used tools: comparative effectiveness research (cer) , which has been given prominence as a r esearch focus in the patient protection and affordable care act of 2010 , and cost-effectiveness analysis (cea) . both help to answer policy-making questions. for example, a typical use of cer compares the effectiveness of two interventions (drugs, procedures, or even two methods of delivery), and policy makers may want to know if a new technology is more effective than older technologies. of course, they may also want to know if the new technology provides additional effectiveness at a reasonable cost , which points to a shortcoming of much cer in the united state s, where considerations of cost are generally avoided. similarly, if there is only one effective treatment for a condition, cer tells us nothing useful. it also tells us nothing about whether a more effective intervention is worth its extra cost. and, cer cannot help us compare intervention outcomes across different disease conditions, since it uses no measure of health that permits a comparison of effectiveness. indeed, decision makers face many resource allocation questions that cannot be answered by cer, even if cer can help avoid wasteful investments in interventions that do not work or that offer no improvement ov er others. in germany, however, cer is combined with an economic analysis that takes cost into account and that allows the calculation of " effi ciency frontiers " for different classes of drugs (caro et al. 2010 ) . presumably, this method could be extended to different classes of public health interventions if they are grouped appropriately. to calculate an effi ciency frontier, the effect of each drug in a class in producing some health outcome is plotted against its cost , and the curve is the effi ciency frontier for that class of drugs. it is then possible to calculate if a new intervention in that drug class improves effectiveness at a price more or less effi cient than what is projected from the existing efficiency frontier. this use of cer allows german decision makers to negotiate the price of treatments with manufacturers, rejecting payments that yield ineffi cient improvements. german policy makers can then cover every effective intervention sold at a price that makes it reasonably effi cient. still, because german use of cer cannot make comparisons across diseases, it allows vast differences in effi ciency across conditions. cea aims for greater scope than cer. it deploys a common unit for measuring health outcomes , either a disability-adjusted life year (daly) or a quality-adjusted life year (qaly) . this unit purports to combine duration with quality, permitting us to compare health states across a range of disease conditions. with this measure of health effects, we can construct a ratio (the incremental cost-effectiveness ratio, or ic er) of the change in costs that results from the new intervention with the change in health effects (as measured by qalys or dalys). we can then calculate the cost per qaly (or dal y) and arrive at an effi ciency measure for a range of interventions that apply to different condi tions. critics have noted p roblematic ethical assumptions in the construction of the health-adjusted life-year measures and in the use of cea (nord 1999 ; brock 2004 ) . to see some of these problems, consider the following table: rationing problem cea fairness priorities no priority to worst off some priority to worst off aggregation any agg regation is ok some aggregations ok best outcomes/fair ch ances best outcome s fair chances cea systematically departs from judgments many people will make about what is fair. the priorities problem asks how much priority we should give to people who are worse off. by constructing a unit of health effectiveness , such as the qaly, cea assumes this unit has the same value , regardless of who gets it or wherever it goes in a life ("a qaly is a qaly" is the slogan). but intuitively, many people think that a unit of health is worth more if someone who is relatively worse off (sicker) gets it rather than someone who is better off (less sick) (brock 2002 ) . at the same time, people generally do not think we should give complete priority to those who are worse off. we may be able to do little for them, so giving them priority means we would have to forego doing more good for others. few would defend creating a bottomless pit out of those unfortunate enough to be the worst off. similarly, cea assumes that we should aggregate even small benefi ts. then, if enough people get small benefi ts, it outweighs giving large benefi ts to a few. but intuitively, most people think some benefi ts are trivial goods that should not be aggregated to outweigh larger benefi ts to a few (kamm 1993 ) . curing many people's colds, for example, does not outwei gh saving a single life. finally, cea favors putting resources where we get a best outcome, whereas people intuitively favor giving people a fair (if not equal) chance at a benefi t. locating an hiv/aids treatment clinic in an urban area may save more lives than placing a clinic in a rural area, but in doing so, we may deny many people a fair chance at a signifi cant benefi t (daniels 2004 ) . in all three of these examples of rationing problems, cea favors a maximizing strategy, whereas people making judgments about fairness are generally willing to sacrifi ce some aggregate population health to treat people fairly. in each example, whether it is giving some priority to those who are worse off, viewing some benefi ts as not worth aggregating, or giving people fair chances at some benefi t, fairness deviates from the health maximization that cea favors. yet we lack agreement on principle s that tell us how to trade off goals of maximization and fairness in these cases. people disagree about what trades they are willing to make, and this ethical disagreement is pervasive. determining priorities primarily by seeing whether an intervention achieves some cost/qaly standard is adopting a health maximization approach. this approach departs from widely held judgments about fairness, even where people differ in these judgments. thus, the national institute of clinical and health excellence (nice) in the united kingdom has had to modify its more rigid practice of approving new interventions only if they met a cost/ qaly standard in the face of recommendations from its citizens council. this council, intended to refl ect representative social and ethical judgments among british citizens, has proposed relaxing nice's threshold in various cases where judgments about fairness differed from concerns about health maximization. the judgments of the citizens council in this regard agree with what the social science literature suggests are widely held views in a range of cultures and contexts (dolan et al. 2005 ; menzel et al. 1999 ; nord 1999 ; ubel et al. 1999 ubel et al. , 2001 . there are, of course, those who criticize departures from the nice threshold of the sort that the citizens council recommended. compromising the maximization of health that cea promotes may be seen as a moral error, perhaps the result of elevating the rescue of an "identifi ed" victim (say, a cancer patient whose life might be extended modestly by a new drug) ove r benefi ts to "statistical" lives (using the resources to provide greater benefi ts to others). the reasonable disagreement about how to proceed suggests that we should view cea as an input into a discussion about reso urce allocation, not as an algorithm for making decisions. this "aid to decision making" role was proposed by the public health service in its recommendations about the use of cea (gold et al. 1996 ) . in short, controversial ethical positions are embedded in cea, and using cea uncritically commits one to these views, even though many disagree with them. we have already noted that the effi ciency of a health system has ethical consequences. but what should we count as effi ciency ? should we use our resources to generate more revenues for a unit of the health system-say, a hospital? doing so would defi ne effi ciency the way most businesses do: other things being equal, an allocation that produces a greater return on investment is a more effi cient use of stockholder or owner resources. alternatively, we might narrow the range of effects to health effects on the covered population . then we have greater effi ciency when an allocation produces more positive health effects in that population than an alternative allocation. the case guzmán brings from colombia raises this issue forcefully. should hospitals, or a specifi c health plan, allocate resources favoring services (certain treatment s) that raise more revenues than an alternative allocation (certain preventive measures)? perhaps the gains from the treatments will involve fewer population health gains over time than those obtained by the preventive or health promotional measures, even if they show their improvement more quickly and so look better sooner. which plan should the policy maker adopt? this issue examines our purpose in designing a health system. is it to meet the health needs of a population or is it to provide a good return on investment for those who invest in health services? we might think that this question is easier to answer in a system where health care delivery is seen largely as a public undertaking aimed at improving population health. in such a system, it might seem that there is only one purpose behind the health care system. return on investment for the taxpayer funding such a system should be measured by how effi ciently the system improves population health. in systems where resources are owned privately (and there are many of these), however, it seems we must consider at least two goals. even if the private sector must in part seek to improve population health , which may be a requirement of state-imposed health care regulation or, in some people's opinions, a social responsibility of corporations, private health-care organizations still must deliver a reasonable return on investment for owners. thus, policy makers within private health-care organizations have a dual task. balancing return on investment with improvement in populatio n health thus becomes the central issue in the colombian case study. the chilean case written by gómez and luco raises a similar issue, but this case focuses on measurable differences in the cost effectiveness of certain services and in the severity of two conditions. if we consider only cost effectiveness, we view effi ciency in one way-the best health outcomes in the aggregate for the population for an investment in health. if we take severity of condition into account, we might view this as an equity demand-in which case, we have an effi ciency-equity confl ict and must make a trade-off. or, we might think of effi ciency as a ranking of needs by severity of condition. in the latter, the resource allocation case turns on how we defi ne effi ciency. specifi cally, the chilean category of guaranteed health interventions could include cataract surgery (the leading cause of blindness in the chilean population), but not multiple sclerosis (ms) treatment s, which might be viewed as maximizing effi ciency in a standard sense. or, the guaranteed health interventions scheme could include the less cost-effective treatment of ms but not cataract surgery, since ms is viewed as a more severe condition (because it can be life threatening and lead to premature death), even if it is far less prevalent than cataracts. if this were the case, the more effi cient system, in this nonstandard view, would rank treating more severe conditions as more effi cient than treating less severe conditions. if budget limitations mean only one should be included in the guaranteed health interventions program, either m s or cataract surgery, which should it be? the cataract surgery intervention delivers a signifi cant benefi t in terms of qalys to a larger part of the population than does the intervention package for ms, but the greater severity of premature death seems to be an important reason for favoring ms. if this reason is given priority over cost effectiveness and over the standard view of effi ciency , then are less effective treatments for more severe conditions supposed to have priority over more effective and cost-effective treatments for less severe conditions? if so, what kind of a health system does that produce if all needs can not be met given resource limits? alternatively, do we want a system that always we ighs cost effectiveness more highly than the severity of a condition that some people have? that too seems problem atic. suppose we think improving population health is a worthwhile and defensible goal of a health system, we favor improving population health over increasing revenues for the private sector (in the guzmán case), and we also favor giving priority to cost effectiveness over severity of a condition (in the gómez and luco case). a confl ict still remains between health maximization in the aggregate and concerns about equity , as illustrated in the blacksher and goold case (and arguably in the case about triage in pand emics by smith and viens). in the case that blacksher and goold describe, the task is to decide whether to reallocate resources from a program focused on maternal-child health and reduction of b lack-white in fant mortality dis parities to a program that may get more health per dollar spent through other interventions. infant mortality among blacks and whites has declined rapidly in the united state s; and in absolute terms, the decline has been more rapid for blacks. still, the ratio of black infant mortality to white infant mortality has increased. because the public health department is in a highly segregated city, this shift in program focus might seem to require viewing the remaining bl ackwhite health d isparities as morally a cceptable (especially given the high rate of improvement that past programs gave to black infant mortality rates). when should we view health disparities as morally acceptable? when should we weigh reducing health disparities as more important than some aggregate gains in health that we know how to produce in a population ? if public health has two goals-improving population health and distributing that health fairly-how should we weigh the goals when they confl ict? one important feature of the blacksher and goold case, namely the opinions within the community whose inequalities are at issue, is really a feature to which nearly all cases warrant attending. people affected by a policy ought to have some infl uence in determining that policy. some people might believe this is what democracy requires. a diffi culty this view of democracy faces, however, is that those who speak for the community may not appropriately represent the community affected by the decision. nevertheless, the opinions of a broader range of stakeh olders may improve deliberation (depending on how those opinions are managed). it may also improve the acceptance of the decisions, which arguably enhances the legitimacy of the decision-making process . resistance to including a broader range of stakeholder s in decision making about health priorities may come from a concern that they bring with them "partiality." this resistance may come from the view that greater impartiality leads to better deliberation. arguably, this concern about partiality ignores the positive gains that partiality often brings to deliberation, especially if we know how to manage such deliberation so that we minimize the risk s that partiality sometimes brings. we need such management skills in any case since partiality is unavoidable in most contexts. rather than banning what cannot be eliminated, managing partiality in deliberations is the best way to improve decision making in contexts of reasonable disagreement. the confl ict between improving population health and treating people fairly can arise in other contexts. arguably, the problem raised by smith and viens about the principle that should govern triage in pande mics can be viewed as a confl ict between health maximization, in this case, saving the most lives, versus recognizing the claims that the sickest people have on us for assistance. ordinarily, health systems give some priority to those who are sickest, but should that priority disappear in favor of saving lives when scarce resources, such as ventilators, are allocated in pandemic conditions? if we allocate our ventilators to the sickest patients, we may save fewer lives than if we allocate them to those whose lives we can better expect to save. even if we think we should give priority to those worst off, do we ordinarily think that concern for them should govern triage policy in pandemics? if we believe saving the most lives trumps concerns about helping those who are sickest in pandemics, can we justify why the priority we give to the sickest should be revised in pandemics? suppose we have an acceptable way of measuring the burden of disease in a population , and according to this measure, mental illness is not given the priority it ought to have. that is, it contributes more to the burden of disease than is normally recognized in standard health systems, which provide too few services to meet mental health needs. this is the problem upon which rentmeester et al.'s case focuses. specifi cally, some mental health conditions require signifi cant resources for what medicaid terms as "behavioral management," which is seen as a social support service not a medical treatment . as a result, these services, to the extent they are provided, fall to state-funded social service budgets. the services place a burden on state fi nances that would be diminished if they were instead included in medicaid bud gets (50 % of which are fi nanced by each state). arguably, the stigma that attaches to mental health issues is one important reason for this underprovision of social supports for people with mental health issues. in nebraska, the political opposition to expanded medicaid coverage through the affordable care act ad ds to the burden on state budgets and the potential under-servicing of these mental-health induced needs. it takes resources to meet public health needs. suppose we can increase the resources to meet some of those needs by accepting a pu blic-private partnership that improves a compromised private partner's image? should we meet health n eeds at this price? that is the issue posed by the hernández-aguado case from spain . specifi cally, should public health authorities put their stamp of approval, in the form of their logo, on fl u epidemic notices printed on soft drink labels? the inclusion of the logo is a requirement of the private entities that are willing to donate space on the labels of their products. obviously, this provides a form of public support for soft drinks that arguably contribute to obesity in a population and thus to the prevalence of noncommunicable diseases associated with obesity. but in view of the low budgets available for fl u warnings, is this a price worth paying? what would the decision maker have to know about the effects of such labels to decide this case, or is the decision something that can be made independently of the specifi c payoffs of implementing the warning system? is there a way to consider the cost and assess whether the outcome of the warning is worth this price? is this simply an effi ciency calculation about the cost effectiveness of reducing a disease burden in this way? one fi nal crosscutting issue lurks behind all the cases in the resource allocation chapter (perhaps all the cases in the volume)-namely, the nature of the decisionmaking process that addresses the issues they raise. public health decisions about resource allocation-judging from the cases on that topic in this volume-face reasonable ethical disagreement. that is because the tradeoffs involved in the two main goals of public health policy -improving population health and distributing health fairly-are trade-offs about which people often reasonably disagree. how can public health decisions be made in real time, given these ethical disagreements, in ways that enhance their legitimacy and are arguably fair to all parties? one approach to the problem is to construct a fair process for making those decisions and to rely on the outcomes of such a process. people will judge the outcomes of a fair process to be fair (daniels and sabin 2008 ) . what conditions should such a decisionmaking process meet if it is to be considered fair? four conditions are arguably necessary (even if some may think they are not suffi cient and want to add others): (1) the decisions and the rationales for them should be made public. (2) they should be based on reasons all think are relevant. (3) they should be revisable in light of new evidence and arguments. and (4) , these conditions should be enforced so that the public can see that they obtain. some explanation is needed for these conditions. the publicity condition is widely embraced, even if it is fairly strong. it calls for the grounds for decisions-not just the content of the decisions-to be transparent. people have a right to know why decisions that affect their health are made the way they are. moreover, making the reasoning for such decisions public is a way of exposing them to scrutiny so errors in reasoning or evidence can be detected and decisions improved. even though we may not be able to be explicit in advance about all criteria we use to decide such cases, that is, we may work out our reasons through deliberation, we can explain on what we base our decisions. and that gives people affected by our decisions the knowledge they have a right to possess. the search for reasons that all consider relevant to making a reasonable public health decision about resource allocation can narrow disagreement considerably. even if people can agree on what reasons they think are relevant-in the spirit of fi nding mutually justifi able grounds for their decisions-they may not agree about the weight they give these reasons. one way to test the relevance of such reasons is to subject them to scrutiny by an appropriate range of stakeholder s. what counts as appropriate may vary with the case. who should be heard in deliberations is itself worthy of deliberation. stakeholders raise different arguments that should be heard, and including their voices improves buy-in to decisions. since stakeholders may not in many instances be elected representatives, we may be skeptical about whether the democratic process is improved by including them, but, if the deliberation is well managed, the quality of the discussion may improve greatly. the revisability condition , requiring that decisions be modifi able in light of new evidence and argument, is also widely embraced and not considered controversial. decisions are made on the basis of evidence and arguments, and better evidence and arguments may emerge that require revisiting some decisions. some decisions can then be modifi ed, though it may be too late for others, and our consolation is that we made the best choices we could, given the evidence and arguments. the intent of the enforcement condition is to ensure that the other, more substantive, conditions are met. sometimes enforcement is a matter of state regulation . sometimes it can be the result of vol untary conformance with a process. since ethical disagreements abound in resource allocation decisions , we need a process that enhances legitimacy. but can we claim that a decision-making process that is fair yields fair outcomes? one view is that we may ultimately become persuaded by a good argument that fairness requires a different decision than one that emerged from a fair process. we can in this way defeat the fairness we might ordinarily attribute to the outcome of a fair process. does the prospect of defeating the fairness of a decision emerging from a fair process mean that we should not attribute fairness to the outcomes? alternatively, we can admit that the fai rness that comes from a deliberation is only "defeasible" fairness, but it is the fairest conclusion we ca n reach at the time. during the 1990s, many latin american countries began reforming their health systems according to a neoliberal development model that emphasizes free markets (homedes and ugalde 2005 ; stocker et al. 1999 ) . approved in 1993, health reform in colombia was supposed to overcome problems such as low coverage, inequality in access and use of health care services, and ineffi ciency in the allocation and distribution of resources. but the reform also hoped to encourage more focus on illness prevention and health promotion and more community participation in health decision-making processes. the reformers advocated predominantly for neoliberal value s like effi ciency, free choice, universality, and quality. although they were also committed to the communitarian values of solidarity , equity , and social participation . the colombian health reform was one of the fi rst examples of implementing managed competition in the developing world (plaza et al. 2001 ) . to stimulate competition among insurers and health service providers, both public and private, health reformers applied the theory of managed competition (enthoven 1993 ) . according to this theory, competition achieves effi ciency and reduces cost , making health care services responsive to consumer needs (londoño and frenk 1997 ) . hospitals become responsive when they are able to sell services and become fi nancially sustainable. to achieve sustainability, supply subsidies (direct transfers from the state to hospitals) had to replace demand subsidies (transfers directed to the poor through a subsided s ecurity plan). the colombian reform established a general social security system in health that featured two insurance plans: (1) the contributory plan, fi nanced by mandatory contributions (formal employees and employers from the public and private sectors). (2) the subsidized plan, funded by resources from the contributory plan and from taxes and other sources, which covered people unable to pay (vargas et al. 2010 ) . the actors of the system are the insurance companies, the health service providers, and the state regulatory organizations. insurance companies contract with health service providers, and the regulatory organizations control compliance with the defi ned basic health packages. to optimize resources, the reform placed controls on medical practitioners and established explicit priority criteria based on clinical guidelines that defi ned benefi t packages. from 1993, some adjustments to the reform have been introduced, such as the creation, in 2012, of the institute for health technology assessment to provide a n evidence base for health decisions. the institute recommends which medical technologies should be paid with public resources on the basis of which technologies optimally improve the quality and cost effectiveness of medical care. to determine these technologies, it conducts health outcomes research that guides technology development, evaluation, and use (giedion et al. 2012 ) . nevertheless, 20 years later, the promise of reform lies unfulfi lled and many patients still experience high out-of-pocket costs, long wait times, or denial of services. to access health services, frustrated citizens are turning to the legal system as a last resort and, by so doing, congesting the courts (defensoría del pueblo 2012 ). physicians are responding to economic incentives and penalties by restricting hospitalization time and decreasing the use of expensive diagnostic tests and specialist referrals (abadía and oviedo 2009 ) . to further reduce labor costs, service providers have increased the workload of health profession als and the number of patients seen per day, whi le reducing the time spent with each patient (defensoría del pueblo 2007 ). insurance companies often take a long time to pay health service providers, and they also contract their own service network (a process known as vertical integration), so many public hospitals are in serious fi nancial diffi culties. meanwhile, hospital workers frequently disrupt the normal operation of hospitals as they strike to improve work conditions and have their paychecks issued more promptly. should hospitals fail-40 % of the 968 public hospitals in colombia are classifi ed as being at medium or high fi nancial risk -nearly ten million people could be left without health service (ministerio de salud y protección social 2012 ; quintana 2002 ) . add to that, the reforms have increased inequity, as more affl uent patients can more easily access quality health care services than can low-income patients (vargas et al. 2010 ) . the described problems refl ect a complex situation that requires profound structural reform . as one way to address the immediate problems of effi ciency and quality, colombia in 2012 instituted public hospital accreditation. accreditation requires hospital directors to reach goals in service delivery related to fi nancial viability, quality, and effi ciency. hospital boards can now fi re directors who fail to meet these g oals within a specifi ed period (rodríguez 2012 ) . given the imbalances between budgets, service demands, and ongoing costs, hospital directors face enormous challenges and ethical dilemmas in formulating and executing their mana gem ent plans. you are a director of a public hospital that focuses on health promotion and prevention activities, such as general practice, dentistry, clinical laboratory, hospitalization, and emergency care. in developing your management plan, you must make decisions about which services to prioritize . if you prioritize services that represent higher revenues and lower costs as a way of conserving resources, you may have to reduce priority for some services. to guide your decision making, you conducted a retrospective study of service billing in the past 2 years and learned that the clinical laboratory and external medical consultation yielded higher incomes. the lowest yielding programs in the short term-vaccination , educational programs to improve lifestyles , and provision of micronutrient supplements to children and pregnant women-were associated with the best long-term health results. taking seriously your fi duciary responsibilities, you try to guarantee fi nancial sustainability by containing labor costs, restricting consultation times, and shortening hospital stays. your challenge is to do these things without diminishing the quality of patient care. but because you compete with other institutions, you must also assure suffi cient reserves to maintain and update medical equipment that will improve the "sale of services." knowing that every management decision you make will affect the population you serve, you begin to refl ect on the factors affecting your h ospital man agement plan. 1. who are the major stakeholder s in this case and what are their interests, value s, and moral claims? between which of them are there ethical confl ict s or tensions? 2. which of these interests, values, and moral claims should be prioritized? how would you justify your priorities? 3. would you prioritize programs that in the short term brought in needed revenues or those programs that had highest impact long term? 4. how can tensions between the goals of effi ciency, fi nancial viability, and quality be resolved? what weight should be assigned to each goal by the hospital board when evaluating your performance? 5. at least in the short run, the new reforms seem to be prioritizing effi ciency, viability, and quality over equity . should a health system attain the former goals before tackling the problem of equity, or should it insist on equity from the start? 6. can equity in health care be achieved without doing something about wealth inequity and other social determinants of health? 7. should you justify your decisions by emphasizing solidarity with other hospital directors and seeking community support? 8. how could collaborations between public health, communities and the health care system begin to address neoliberal concern s with effi ciency, viability, and quality? the global burden of disease (gbd) compares disease burdens based on epidemiological measures of prevalence, mortality, disability, and associated cost s. the gbd for mental illness amounts to 14 % of the world's total disease burden (world health organization 2005 ). i n the united state s alone, every fi fth child suffers from a mental disorder (perou et al. 2013 ) . although mental illness clearly causes disabilities (prince et al. 2007 ), underservice to those with mental illness is commonplace. lack of access to mental health services counts as the fi rst of many hurdles facing families who have a child with a mental illness. stigma and the lack of parity in health coverage for physical and mental illness are other hurdles for these families. not surprisingly, these hurdles can critically affect the development of children with mental illness. lack of access to mental and behavioral health services for children 5 years and younger especially threatens their development. rapid brain growth occurs in the fi rst 5 years of life, which lays the foundation for cognitive, emotional, and moral development. exposure to chronic stress can prompt the release of hormones in the brain that can have enduring consequences for how the adult brain is organized and how it functions (shonkoff and phillips 2000 ) . because poor health can show up in children as developmental delay, access to mental and behavioral health services is critical. longitudinal studies demonstrate positive and long-acting effects of early childhood interventions, such as environmental enrichment programs, on a range of cognitive and noncognitive skills, social behaviors, academic achievement, and adult job performance (heckman 2008 ) . the esti mated annual rate of return on investment from targeted early childhood development programs is 7 %, and early intervention reduces the predictable need for higher, more costly levels of care in later life (heckman et al. 2010 ) . in the united state s, medicaid is a government-funded program that provides health coverage to people with certain disabilities and to low-income adults and their children. the federal medicaid act (fma) requires states participating in medicaid programs to provide medically necessary treatment to eligible children. under federal medicaid law , states must provide "early and periodic screening , diagnostics, and treatment," also known as epsdt services, to eligible medicaid recipients under age 21 (u.s.c. § 1396d(a)(4)(b)). the defi nition of epsdt includes necessary health care , diagnostic services, treatment, and other measures described in the medical assistance subchapter for the united states code (42 u.s.c. § 1396d (a)) (2012) that correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, regardless of whether such services are covered under the state plan (42 u.s.c. § 1396d (r)(5)) (2013). the medical necessity standard , which is based on clinical standards of care, refers to interventions that may be justifi ed as reasonable, necessary, or appropriate. states must comply with the fma standard to cover all treatments for a medicaideligible child's physical or mental condition, even if service coverage is optional for adults covered by medicaid. fma also bars states from arbitrarily denying or reducing the amount, duration, or scope of a required service to an otherwise eligible recipient solely because of the diagnosis, illness, or condition (nebraska legislature 2012 ). despite the provisions of fma, the u.s. department of health and human services, which oversees the medicaid program, excludes certain behavioral health treatments for children with developmental disabilities and autism (national health law program 2012 ; autism society of nebraska 2012 ). in addition, some states' medicaid contracts allow insurers more freedom than other states to deny payment for services. states also vary in who-the claimant or the insurer-must prove whether coverage provisions are adequate or fall short of federal medicaid legal standards (rosenbaum and teitelbaum 1998 ) . differences among states in approval of payment for specifi c treatments, including mental and behavioral health treatment, illustrate the need for more consistency in medicaid coverage provisions and the lack of parity between mental and physical health coverage. mental health benefi ts must be offered at parity with medical services to newly eligible recipients as part of the 2010 patient protection and affordable care act (aca), and medicaid expansion controversy is clear evidence that parity is a work in progress (mental health america 2013 ; u.s. department of labor 2008 ). because of inadequate coverage for mental and behavioral health services for medicaid-eligible children , some parents have no option other than to surrender their child to the child welfare system so that the child will receive full coverage for necessary mental and behavioral health care services. this results in signifi cant cost-shifting from medicaid to the state's child welfare system. that is, when a state provides federally mandated services to medicaid-eligible children, it receives a fi nancial match from the federal government to pay the cost s. when a state denies federally mandated medicaid services and a family surrenders a child to state custody so the child can receive care, the state pays the expense of the previously denied medicaid costs plus the expense of entitlements the child acquires as a ward of the state. the aca medicaid expansion offers a window of opportunity to increase coverage for behavioral health treatment for children with mental illnesses. although the federal government will bear the primary fi nancial burden of medicaid expansion, some states have elected, for political reasons, not to participate in this expansion. for participating states, aca medicaid expansion will replace state and local mental health services funds with federal medicaid money that will cover a wider range of home and community-based services for mental illness treatment (bazelon center for mental health law 2012 ). public health agencies and leaders often provide input for the medicaid system, helping to develop protocols, criteria, and rules about which treatments are defi ned as medically necessary . such decisions about medical necessity affect clinicians, patients, and families because they determine which treatments get recommended at the clinical level and infl uence which treatments insurers cover. you are the medicaid director of a state with the country's highest percentage of children in the child welfare system. twenty-fi ve percent of children in the state's foster care system are there not because of abuse or neglect, but because of behavioral problems and mental illnesses. as a state offi cial, you are aware that this results in signifi cant cost-shifting from medicaid to the state's child welfare system. recently, the case of 4-year-old sam has come to your attention. sam's family cannot afford mental and behavioral health care for sam, although he is medicaideligible and insured through magiscare (a private company with a state contract to administer medicaid for mental and behavioral health services). sam's parent s are considering surrendering their boy to become a state ward to get him the mental health services he needs. sam, you learn, eats random objects and dirt, throws tantrums, bangs his head on the ground, hits and bites himself and others, and often runs away. recently diagnosed by his physician as having autism, sam was referred to a psychologist who recommended outpatient behavioral therapy. both the physician and the psychologist expect this therapy to be covered through the family's magiscare plan. magiscare denied the psychologist's requests for payment on the grounds that, for children of sam's age, behavioral management is not covered under state law because it is not "medically necessary." magiscare substantiated their denial of payment because sam's behaviors primarily refl ect developmental disabilities related to autism, which are not covered under their contract with the state. when you ask the magiscare executive director about this case, she suggests that sam's parent s could attend therapy sessions to help them cope with their son's behaviors, but she reasserts that behavioral management is not covered for children as young as sam under state law because it is not medically necessary. members of the state legislature and child mental health advocacy groups are trying to expand access to home-based and community-based mental health services. they have asked you to support their efforts. you also consider that your governor, who is your boss, has publically stated his fi rm opposition to aca medicaid expansion, thus denying the state the opportunity to expand coverage for children's mental and behavioral health treatment through the aca. at present, you know that your state is offering limited mental and behavioral health service s and that narrow defi nitions of medical necessity are used to limit access to those services. as the state medicaid director, which steps should you take? 1. who are the main stakeholder s in this case, and what are their primary interests? 2. "passing" the expense of coverage denied by medicaid to other components of public service, such as the child welfare system, has fi scal and social implications. (a) what are some of these implications? (b) how should prevalence, mortality, disability, and cost be factored into thinking about ways to balance short-and long-term risk s and benefi ts to individuals and to the public in this case? 3. suppose a policy advisor warns that expanding behavioral health care for children will strain the medicaid budget and require cuts in services for adults or reduce their eligibility. (a) how should you respond? (b) which considerations or priorities would guide your funding allocations? 4. what role should ethical principle s such as stewardship , public health leadership , and moral courage play in this case? 5. medical necessity implies an acute care model of health service delivery and refl ects a clinical perspective. how well does this idea apply to a public health prevention model of health service delivery? are there better alternatives? 6. parity in insurance coverage for mental health is federally mandated for private insurers, which covers most citizens, but has proven to be an elusive goal for people who do not have private insurance or do not have enough coverage. medicaid is a public ( government funded) insurance program, not a private one. although medicaid benefi ciaries receive coverage for medically necessary mental health services, e ach state defi nes medical necessity uniquely. (a) should a federal mandate defi ne medical necessity for mental and behavioral services? (b) what fi nancial implications would such a mandate have from a state perspective and from an overall perspective? 7. the term principle-policy gap can be used to characterize situations in which most people support health coverage in principle ; but in practice, they are unable to pay for coverage or unwilling to take the political , social, cultural, or fi scal risk s necessary to enable such coverage. what do such gaps tell us about which value s the majority favors, and how might the term principle-policy gap help us understand the dynamics in this case? what roles should public health leaders play in responding to principle-policy gaps? public health systems are usually underfunded in comparison with health care systems. in fact, the organisation for economic co-operation and development (oecd) countries allocate on average only 3 % of their health spending to pub lic health and prevention activities (oecd 2011 ) . this low funding of public health programs hinders the capacity to implement effective public health policies (robert wood johnson foundation 2011 ). population health challenges, such as infl uenza pandemics, are increasingly complex, and tackling them involves urgently executing a wide array of public health measures to prevent disease transmission. in the case of infl uenza pandemics, measures can vary from border quarantine, social distancing, provision of antivirals and vaccine s, and personal hygiene strategies. recommendations often need to be made quickly even when knowledge about the seriousness and potential health and social effects are incomplete. the target for preventive interventions is the entire population. however, resources for intense and sustained health campaigns through mass communications are expensive. in addition, the social determinants of the disease must be understood and considered (crowcroft and rosella 2012 ) . this typically involves the need for policies that engage the health and non-health sectors, such as educational policies and social or economic factors (savoia et al. 2012 ). this complexity, together with decreasing funds and other factors, has contributed to increasing private sector involvement in health care. according to the world health organization (who), a public-private partnership gathers a set of actors for the common goal of improving population health through agreed roles and principle s. this may also be described as public sector programs with private sector participation (who 2013 ). who has described several types of partnerships, including philanthropic, transactional, and transformational. sponsorship is a form of a public-private partnership defi ned as "any form of monetary or in-kind payment or contribution to an event, activity, or individual that directly or indirectly promotes a company's name, brand, products, or services" (kraak et al. 2012 ) . in this sense, sponsorship is a commercial transaction, not type of philanthropy. public-private partnerships have become increasingly common for public health campaigns. some transnational companies and their corporate foundations collaborate with public institutions, such as united nation s agencies and government s, to tackle complex public health problems, such as treatment of diarrhea in developing countries (torjesen 2011 ) , tuberculosis , and malaria (ridley et al. 2001 ) . these collaboration s have been encouraged by international institutions and experts as a way to mobilize resources and expertise, which could complement the public sector. who has also encouraged using public-private partnerships to deliver health services for a range of health problems, including hiv infection, malaria , tuberculosis , trachoma, and vaccine-preventable diseases (buse and walt 2000a , b ) . however, corporations' increasing role in public health has been criticized as jeopardizing the mission of public health and its commitment to population health (hastings 2012 ; ludwig and nestle 2008 ) . some corporations have used tactics that discredit public health actions, such as distorting scientifi c information and using fi nancial tactics and political infl uence to avoid unfavorable regulations (wiist 2011 ) . public health profession als, public health agencies, and governments often must decide whether to collaborate with the private sector to improve population health. these decisions are increasingly frequent as health department budgets shrink and public-private partnerships are seen as a way to secure funds for core public health programs. ethical considerations can help us decide whether and when to form such partnerships. however, the available public health ethics frameworks (e.g., public health leadership society 2002 ; nuffi eld council on bioethics 2007 ; kass 2001 ) do not specifi cally discuss public-private partnerships. only the public health leadership society provides guidance for such collaborations. principle 10 proposes that, "public health institutions and their employees should engage in collaborations and affi liations in ways that build the public's trust and the institution's effectiveness." continued discussion about the ethical implications of private-public partnerships is needed. top health offi cials in an industrialized country have declared a public health emergency due to an infl uenza pandemic. the head of the country's health department receives a call from the president of a multinational company that produces sugary, high-calorie drinks. the company president expresses his concern about the pandemic and wants to collaborate with the government to prevent the spread of fl u. the company offers the health department a considerable amount of space, onethird of each can, on its star product (a soft drink) free of charge, to include messages on fl u prevention . the company insists that the health department logo be included on the can along with the preventive messages. for them, the association between the health department (through the logo) and their product is essential for the collaboration as it would be an acknowledgement by the health department of the company's social responsibility. the head of the health department arranges a meeting with several health authorities and offi cials to consider the offer. on one side, some members of the group support the proposal because of the need to carry out far-reaching public health campaigns to limit the impact of pandemic fl u. at that stage, the incidence of pandemic fl u is increasing quickly and the number of new outbreaks in schools is worrying the health authorities and the population . there have been recent budget cuts to the health department, and some offi cials argue the company's contribution may be the best option to ensure a far-reaching campaign on prevention measures to benefi t the population. they see sponsorship as a form of social responsibility because the company does not have any apparent economic interest in fl u-related activities. they also note that there are no other companies offering a similar collaboration. but other offi cials say the company's soft drink products contribute to the obesity and diabetes epidemic and that the company's use of the health department logo would label it a pro-health industry with the backing of the highest health authority in the country. they also raise concerns about risking the independence of the health department in future regulatory action on sugar-rich beverages. as the hea d of the health department, you must decide if you should collaborate with the company. 1. what considerations should the health department director weigh when deciding whether to collaborate with the beverage company? 2. who are the major stakeholder s the health department should consider, and what value s might each of these stakeholders bring to this decision? 3. in making your decision, what values should be prioritized? 4. what positive or negative impacts would displaying the health department logo on the soft drink cans have on health department operations? 5. how might sponsorship by a company that produces sugary beverages affect public trust in the health department and the institution's effectiveness? 6. would the decision be different if the company produced healthy foods and the department's logo was placed on a healthy product? 7. would community involvement facilitate decision making and the consideration of the ethical questions? what ethical criteria or guidance should be established to accept or reject a future donations or sponsorship of a public health program by a company? preterm births, the leading cause of infant mortality, are increasing annually worldwide (world health organization 2012 ). the united state s shares company with nigeria, india, and brazil among the top ten countri es with the highest numbers of preterm births and ranks 31st among organisation for economic co-operation and development ( in 1900, about 100 infants died per 1000 live births. by 2000, that number fell to 6.89. during the last half of the twentieth century, the rate of black infant mortality dropped dramatically. in 1950, black infant mortality was 43.9 deaths per 1000 live births compared with 26.8 deaths per 1000 live births among whites (mechanic 2002 ) . but by 1998 black infant mortality fell to 13.8 deaths per 1000 live births compared with 6.0 deaths per 1000 live births among whites. as these numbers show, both groups made signifi cant absolute gains, with blacks gaining more in absolute terms-a reduction of 30.1 for blacks and 20.8 for whites. yet, black infant mortality still remained about twice that of whites. these disparities have persisted in the twenty-fi rst century. in 2006, non-hispanic black women experienced the highest rate of infant mortality, with 13.4 infant deaths per 1000 live births, while non-hispanic white women had a considerably lower rate, with 5.6 infant deaths per 1000 live births. citing a 2006 report from the national healthy start association, macdorman and mathews ( 2009 ) report that programmatic efforts to reduce disparities in black-white infant mortality have had some successes at local levels, but eliminating the disparities is diffi cult. the u.s. centers for disease control and prevention and the u.s. department of health and human services have prioritized both the elimination of health disparities and improvement in overall population health. these twin goals-one distributive, the other aggregative-are separate and sometimes confl ict (anand 2004 ) . increases in health disparities often accompany advances in aggregate gains in population health (mechanic 2007 ) . although this case is specifi c to the united state s, the dilemma is not. data show that signifi cant progress on child mortality has been made in many countries but that this overall success is often coupled with increased inequalities between advantaged and disadvantaged groups (chopra et al. 2012 ) . in china and india, for example, disparities in mortality persist between boys and girls younger than 5 years, a function of entrenched gender discrimination (you et al. 2010 ) . these examples raise challenging questions about how ethically to assess such cases and set priorities for the allocation of scarce public health resources. you serve as the director for the local health department in a racially segregated urban city in the midwest with one of the greatest concentrations of african americans in the united states. the city has a long history of civil rights activism that led to protests and marches that ultimately empowered and mobilized black communities and organizations. your health department has a history of prioritizing maternal-child health and the elimination of black-white disparities in infant mortality in its programs, an investment of resources affi rmed by the city residents through the department's community outreach program and planning processes. chronic underfunding of public health, made worse by the economic downturn, has resulted in drastic and unprecedented reductions in the public health budget. in consultation with your staff and community board of health, you have raised the possibility of redirecting resources from maternal-child health into other programs based on a number of practical and ethical considerations. as with national statistics, the city has seen signifi cant declines in black infant mortality, even as blackwhite disparities remain. you note that although the maternal-child health programs are cost-effective, their impact on reducing black-white disparities seems to have stalled. other programs appear to meet targets more consistently. to help support these other programs, you note that allocating resources to more effective programs provides more "health" per dollar, thus meeting the utilitarian demand to maximize overall health, which many view as the primary goal of public health and health policy (powers and faden 2006 ) . in addition, although black-white disparities in infant mortality persist, blacks have made signifi cant gains, declining more than whites in some decades. you note that remaining inequalities could be deemed ethically acceptable by some standard s of equity , such as the "maximin" principle . although this distributive principle is subject to interpretation (van parijs 2003 ) , it is generally understood to require that social and economic inequalities work to benefi t society's least advantaged groups. thus, inequalities (even signifi cant ones) are morally acceptable as long as the least advantaged have signifi cantly benefi ted (powers and faden 2006 ) . the director of community outreach proposes that the health department not make this decision unilaterally, but instead listen to community opinions on these questions of priorities and fairness. he suggests that the health department collaborate with community partners to host a series of public forums. he insists that a topic of such historic and contemporary concern to the community must be subject to public deliberation. despite having a history of supporting community discussions, you are concerned about the cost of community forums, noting that they will drain resources from an already slim budget. the chilean sy stem of guarantees in health-created by law in 2004-aims to establish guaranteed health care interventions in health promotion, disease and injury prevention , diagnosis and treatment , rehabilitation and palliative care (ministerio de salud 2004 ) . the law mandates that public and private insurers provide the resources needed to protect the public against excessive health-related spending and guarantee timely and universal access to authorized interventions based on standard s of care. 1 national health objectives, established by the ministry of health, determine the list of guaranteed interventions. this list, however, is reviewed every 3 years and amended as new scientifi c and health information emerges. as of 2013, the system o f guarantees in health included interventions for 80 health-related conditions (ministerio de salud 2013 ), accounting for almost 60 % of the chilean burden of disease. the system of guarantees in health is a priority system based on acknowledged criteria, namely scientifi c evidence and socially shared value s. for the system to be effective, the criteria must be transparent, publicly accepted, and open to review and modifi cation. the law that created the system of guarantees in health also mandated a procedure for selecting the guaranteed interventions (ministerio de salud 2004 ) . the procedure factors in public opinion research to identify social consensus on health priorities, studies to identify effective interventions that prolong and improve quality of life, and assessments of interventions' cost effectiveness (burrows 2008 ). the procedure determines priorities with an algorithm that includes these factors and information on disease burden and health system capacity (missoni and solimano 2010 ) . after choosing the health interventions, the health ministry elaborates on a package of interventions related to specifi c health conditions and develops clinical guide lines for such interventions. you direct a team within the ministry of health that is responsible for recommending priorities for guaranteed health interventions. the priority ranking system emphasizes the selection of cost-effective interventions for conditions with the greatest burden. however, the health ministry also has authorized including expensive interventions that are less effective or treating health conditions with low prevalence, if that condition or those interventions signifi cantly impact health. because of budget reductions, a number of interventions are under review. your team has been asked to recommend funding interventions for two health conditions-cataract (a common condition with highly effective treatment ) and multiple sclerosis (a less prevalent condition but one with signifi cant health and social impact). cataract, the main cause of blindness, primarily affects people over 40. this health problem has a high impact as measured by quality-adjusted life years (qalys) (ministerio de salud 2007 ) . its surgical treatment is effective for 80-95 % of patients. the package of guaranteed interventions includes diagnostic confi rmation within 180 days after suspected diagnosis and surgical treatment 90 days after confi rmation. in 2013, it was expected that 48,424 cataract surgeries would be performed in chilean public hospitals and 416 in private institutions. multiple sclerosis , an autoimmune infl ammatory disease leading to demyelination in the central nervous system, produces a progressive deterioration of health and quality of life. it represents a minimal disease burden at the population level, mainly due to premature death. in chile, it is estimated that 385 patients are treated for multiple sclerosis each year. the package of guaranteed interventions includes diagnostic confi rmation within 60 days; confi rmed cases must receive treatment within 30 days. treatment includes pharmacological therapy and p hysiotherapy. contingency arrangements. to make the best use of resources and personnel (even in the absence of a pandemic), patients are triaged-evaluated to determine the type and priority of care to be received. while medical information informs the development of triage criteria, ethical considerations about triage goals-whether explicit or implicit-also play a role. for public health emergencies that overwhelm capacity, some propose adjusting critical care triage criteria to emphasize certain public health goals, like saving the most lives possible (christian et al. 2006 ; silva et al. 2010 ) . some contend that utilitarian reasoning should predominate in critical care triage, based on the intuition that, when resources are scarce, allocation decisions should produce the greatest good for the greatest number (charlesworth 1993 ; childress 2004 ) . critics of utilitariani sm reply that it requires coercion or covertness to succeed, because the public will not voluntarily sacrifi ce their lives or their loved ones for the greater good (baker and strosberg 1992 ). utilitarian triage may be unpalatable to the public on the further ground that it quantifi es and judges the value of one life over another, which could disproportionally impact particular population groups (hoffman 2009 ). others therefore would base triage decisions on egalitarian considerations, for instance, by giving everyone an equal chance at obtaining a scarce good, an approach for which historical precedent exists (baker and strosberg 1992 ) . whatever approach is adopted, prior arrangements between policy makers, practitioners, and the public based on thoughtful, transparent deliberation about the most ethical approach to ccu triage usually will improve the legitimacy of d ecisions. those who promote an approach based on fairness and equity need to consider that, during public health emergencies, the goal of saving lives may force a retreat to utilitarian ethics (kirkwood 2010 ; veatch 2005 ) . while not necessarily unethical in itself, a retreat that overturns prior arrangements lays itself open to charges of illegitimacy. variability in the frameworks used to allocate public health resources illustrates the importance of refl ecting upon the value s that undergird policy decisions and individual practices, like critical care triage. appealing spontaneously in the heat of the moment to values that have not been adequately refl ected upon or discussed in a transparent and deliberative manner may lead to undesirable outcomes and accusations of unethical practices. while discussions of ccu triage criteria ultimately concern institutional clinical policy and practice, they refl ect a larger discussion about the overarching public health goals in the face of large-scale, widespread public health emergencies, like pandemics. an outbreak of a novel infl uenza virus has progressed to the point that the world health organization has declared a pandemic. in the pandemic's fi rst wave, hospital capacities were suffi cient to handle the infl ux of pandemic infl uenza patients, whose morbidity and mortality rates mirrored rates for seasonal infl uenza. however, despite a vaccination campaign and other measures, such as ensuring surge capacity, rates of morbidity and mortality associated with the virus have increased drastically during the pandemic's second wave. the resulting increased number of patients needing hospital beds has overwhelmed even the surge capacity of the ccus of a metropolitan city's tertiary care hospitals. to meet this challenge, a teleconference has been scheduled between several members of the hospitals' administration, the ccu directors from each hospital, and public health offi cials involved in leading the jurisdiction's pandemic response. as a public health offi cial who played a central role in developing the pandemic plan for your jurisdiction, you have been included on the call to provide guidance for the pandemic response. during the meeting, a number of ccu directors report that their physicians and nurses are concerned about the type of patients bein g admitted into the ccu. some of the directors see a trend that they suggest is ultimately undermining the effi ciency of the pandemic response. they argue that, as the severity of the pandemic continues to increase, their triage criteria should be modifi ed so as to use ccu resources to save the most lives possible. they worry that admitting those who present with the most need is preventing treatment of those who will benefi t most from ccu admission. "so long as our triage scheme saves the most lives, it is ethically justifiable" a number of them declare. the group takes up the proposal of a ccu director to triage according to sequential organ failure assessment (sofa) scores-which are derived using a tool that determines a patient's organ function and failure rate to predict outcomes (vincent et al. 2000 ) . were the pandemic's severity to increase, the group suggests that, in addition to the ccu director's proposal to use sofa criteria, even more inclusion, exclusion, and priority criteria could be added with the goal of saving as many lives as possible. they've proposed exclusion criteria for ccu admittance that include patients with a poor prognosis, patients with other known health issues, and some mention of age cut-offs, to name a few. others involved in the teleconference question whether this is the right approach to take. they argue that, by aiming to save the most lives possible, those who may benefi t less from ccu admission, like older adults or individuals with disabilities, will be unfairly affected. they say, "we should not just aim to save lives, but rather save lives fairly ." as you and your public health colleagues are leading the pandemic response, the hospital administrators and ccu di rectors look to you for a recommendation or decision about how to proceed. 1. ensuring that the ccu has surge capacity is a common strategy to accommodate an infl ux of patients who have been infected with pandemic infl uenza. (a) does surge capability require alternative critical care triage criteria? (b) if the population's health needs exceed contingency arrangements, should alternative critical care triage criteria be used? (c) how should these decisions be made? (d) what principles, value s, or processes should infl uence these decisions? 2. what considerations might exist during a pandemic that do not exist in everyday critical care and critical care triage that do or do not support the modifi cation of triage criteria? if pandemic critical care triage requires a unique conceptual framework, what principles ought to be valued in such a framework (e.g. need, equality, utility, effi ciency)? 3. would the severity of a pandemic ever warrant the use of a utilitarian scheme for critical care triage, given that the public generally fi nds it unpalatable and carrying out such a plan could require coercion? how could an adverse public reaction to coercive or covert measures be mitigated? 4. in a pandemic, the most seriously ill patients with the lowest probability of being saved might be left untreated because their care would require too many resources with little prospect of recovery. this illustrates a confl ict between the common good and the best interests of individual patients. what other confl icts might arise when triaging in a pandemic? 5. triage can be used to maximize the number of lives saved with available resources. should we aim to maximize the number of lives or, alternatively, the number of life years saved? this can also give rise to questions about the quality of those lives and years lived. is it ever appropriate to make allocation decisions based on quality of life or life years? ethical issues in recipient selection for organ transplantation priority to the worst off in health care resource prioritization ethical issues in the use of cost effectiveness analysis for the prioritization of health care resources the effi ciency frontier approach to economic evaluation of health-care interventions rationing fairly: programmatic considerations how to achieve fair distribution of arts in "3 by 5": fair process and legitimacy in patient selection just health: meeting health needs fairly setting limits fairly: learning to share resources for health benchmarks of fairness for health care reform qaly maximization and people's preferences: a methodological review of the literature cost-effectiveness in health and medicine morality, mortality: death and whom to save from it toward a broader view of values in cost-effectiveness analysis in health care cost value analysis in health care: making sense out of qlays bureaucratic itineraries in colombia: a theoretical and methodological tool to assess managed-care health care systems autonomía médica y su relación con la prestación de los servicios ?option=com_content&view=article&id=1335:la-tutela-y-el-derecho-a-la-salud-2011&cat id=58:libros&itemid=104 . accessed the history and principles of managed competition serie de notas técnicas sobre procesos de priorización de salud: introducción a la serie de priorización explicita en salud why neoliberal health reforms have failed in latin america structured pluralism: towards an innovative model for health system reform in latin america ministerio de salud y protección social, colombia managed competition for the poor or poorly managed competition? lessons from the colombian health reform experience los actores e intermediarios del sistema de salud en colombia gerentes de hospitales públicos y acreditación en salud the exportation of managed care to latin america barriers of access to care in a managed competition model: lessons from colombia nebraska appleseed-cases of denial of behavioral health coverage for children are needed take advantage of new opportunities to expand medicaid under the affordable care act: a guide to improving health coverage and mental health services for low-income people, following the supreme court ruling on the affordable care act schools, skills, and synapses the rate of return to the high/scope perry preschool program medicaid expansion fact sheet lawsuit fi led to protect the rights of nebraska children with autism and development disability nebraska legislature. 2012. floor debate on lb 1063 mental health surveillance among children -united states no health without mental health coverage decision-making in medicaid managed care: key issues in developing managed care contracts phillips, and committee on integrating the science of early childhood development; board on children, youth, and families; institute of medicine; division of behavioral and social sciences and education title 42: public health and welfare. 42 u.s.c.a § 1396d(a)(4)(b) (west 2012) and 42 u.s.c. § 1396d (r)(5) the mental health parity and addiction equity act of mental health: facing the challenges, building solutions global public-private partnerships: part i-a new development in health? global public-private partnerships: part ii-what are the health issues for global governance? the potential effect of temporary immunity as a result of bias associated with healthy users and social determinants on observations of infl uenza vaccine effectiveness; could unmeasured confounding explain observed links between seasonal infl uenza vaccine and pandemic h1n1 infection? why corporate power is a public health priority an ethics framework for public health balancing the benefi ts and risks of public-private partnerships to address the global double burden of malnutrition can the food industry play a constructive role in the obesity epidemic public health: ethical issues principles of the ethical practice of public health. http:// phls.org/cmsuploads/principles-of-the-ethical-practice-of-ph-version-2.2-68496 a role for public-private partnerships in controlling neglected diseases? investing in america's health: a state-by-state look at public health funding and key health facts predictors of knowledge of h1n1 infection and transmission in the u.s. population coca-cola supply chain helps bring diarrhoea treatments to developing world the corporate play book, health and democracy: the snack food and the beverage industry's tactics in context about cdc's offi ce of minority health & health equity (omhhe) understanding the determinants of the complex interplay between cost-effectiveness and equitable impact in maternal and child mortality reduction infant deaths-united states the challenge of infant mortality: have we reached a plateau? disadvantage, inequality, and social policy population health: challenges for science and society oecd health data: infant mortality social justice: the moral foundations of public health and health policy hhs action plan to reduce racial and ethnic health disparities difference principles born too soon: the global action report on preterm birth levels and trends in child mortality priority setting in healt h care: ethical issues m. inés gómez and lorna luco centro de bioética, facultad de medicina clínica alemana-universidad del desarrollo what are some of the ethical, scientifi c, and social considerations that should be weighed in deciding if interventions for both cataract and multiple sclerosis should be covered by the system of guarantees in health? is there an obligation for health systems to cover all health problems affecting a population? are there limits? how should health problems be prioritized and who should have the authority to make these decisions? which criteria should receive the most weight in ranking priorities? how should resources be distributed among health conditions affecting many people versus health conditions affecting few people? how should resources be distributed among procedures that are preventive versus treatments for existing conditions? how does taking a public health perspective versus a clinical medicine perspective affect your thinking about including these two conditions in the system of guarantees in health? what role should transparency play in the selection procedure? references burrows establece un régimen general de garantías en salud estudio carga enfermedad y carga atribuible decreto supremo no. 4. aprueba garantías explícitas en salud del régimen general de garantías en salud towards universal health coverage: the chilean experience , background paper case 6: critical care triage in pandemics smith dalla lana school of public health and the triage and equality: an historical reassessment of utilitarian analyses of triage. kennedy institute of bioethics in a liberal society disaster triage development of a triage protocol for critical care during an infl uenza pandemic allocating ventilators during largescale disasters-problem, planning, and process preparing for disaster: protecting the most vulnerable in emergencies in the name of the greater good? pandemic triage: the ethical challenge mechanical ventilators in us acute care hospitals contextualizing ethics: ventilators, h1n1 and marginalized populations department of health and human services priority setting for pandemic infl uenza: an analysis of national preparedness plans disaster preparedness and triage: justice and the common good scoring systems for assessing organ dysfunction and survival addressing ethical issues in pandemic infl uenza planning: discussion papers the authors thank student chelsea williams for her assistance in assembling the facts of the case. we also thank creighton university's center for health policy & ethics. acknowledgements we thank mr. jonathan whitehead for language editing. open access this chapter is distributed under the terms of the creative commons attribution-noncommercial 2.5 license ( http://creativecommons.org/licenses/by-nc/2.5/ ) which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited. the images or other third party material in this chapter are included in the work's creative commons license, unless indicated otherwise in the credit line; if such material is not included in the work's creative commons license and the respective action is not permitted by statutory regulation, users will need to obtain permission from the license holder to duplicate, adapt or reproduce the material. this case is presented for instructional purposes only. the ideas and opinions expressed are the authors' own. the case is not meant to refl ect the offi cial position, views, or policies of the editors, the editors' host institutions, or the authors' host institutions. infectious diseases such as pandemic infl uenza and severe acute respiratory syndrome (sars) have attuned the attention of policy makers and health practitioners to the importance of protecting and promoting the public's health in the face of increased care needs and extreme resource scarcity. in particular, acute care needs for the critically ill and discussions of treatment priorities have been the subject of much debate in pandemic planning (hick et al. 2007 ; melnychuk and kenny 2006 ; uscher-pines et al. 2006 ). this is not surprising, as it has been estimated that more than 700,000 americans may require mechanical ventilation during a pandemic, far outnumbering available ventilators (rubinson et al. 2010 ; u.s. department of health and human services 2005 ) . additionally, shortages of hospital beds, personnel, and other equipment can be expected during a pandemic, which may limit the ability to meet an expected increase in patient volu me (world health organization 2008 ).prudentially planning for the public's increased care needs during a pandemic requires assessing surge capacity, especially in critical care units (ccu). however, as pandemics increase in severity, they can overwhelm critical care capacity and key: cord-035351-3mv6x0w9 authors: boin, arjen; fahy, lauren a.; ‘t hart, paul title: guardians of public value: how public organizations become and remain institutions date: 2020-11-13 journal: guardians of public value doi: 10.1007/978-3-030-51701-4_1 sha: doc_id: 35351 cord_uid: 3mv6x0w9 it’s an institution—a phrase we have all come across or may have used. we intuitively understand what it means. there is something special, perhaps mythical, about them. we value these institutions. we may even find it hard to imagine a life without some of these institutions. in this chapter, we offer a definition of institutions and introduce our theoretical framework (based on the work of philip selznick). we introduce the case studies in this book and identify patterns of institution building. perhaps mythical, about them. we value these institutions. we may even find it hard to imagine a life without some of these institutions. some public organizations, too, have achieved this special 'institutional' status: organizations that-in the words of philip selznick (1957: 17) , the pioneering scholar of institutions-have become 'infused with value beyond the technical requirements of the task at hand'. institutions embody and safeguard certain values that are important to a society (hendriks 2014) . institutions guard these values against overt attacks and the forces of erosion. the average citizen may never wonder about the critical importance that these public institutions play in their lives. at the same time, academics hardly ever question the importance of institutions. it is simply assumed. this combination of limited public interest and academic conventional wisdom has done little to further research into the way institutions emerge and persevere. in their efforts to protect their institutions, leaders cannot fall back on a full body of academic research findings. such protection is increasingly necessary. government agencies as well as other public sector organizations today face a climate where performance expectations are relentless, transparency and accountability regimes have thickened, and there is little tolerance for failure. critical factors in the broader environment-technology, economic tides, societal beliefs and values, political fault lines and 'rules of the game'-change constantly, sometimes rapidly and deeply. no institution, however powerful and wellregarded, is immune to 'events' and to the churning tides of public opinion. even long-standing institutions face reputational and sometimes existential crises. yet, even in this volatile environment, some public organizations remain deeply valued by the public. they have not just survived challenges and controversies; they have found ways to thrive. they have adapted in the face of crises, preserving their institutional character while meeting newly imposed demands. they have become iconic features of the public landscape. that's why we call them public institutions. this volume is about these public institutions. we have selected twelve organizations that have met selznick's definition for at least a significant part of their lifespan. we examine each of these twelve institutions in some depth to understand their nature, formula and impact. we seek to show what scholars and organizational leaders can learn from them, warts and all. the overarching puzzle that drives the case studies collected here is simple: in this introductory chapter, we explain how in selznick's work and of those that have followed in his footsteps institutions differ from organizations. we then describe the key conceptual and analytical tools that have informed the case studies in this volume, and briefly introduce each of the cases. next, we present a thematic preview of the institutional patterns that emerge when we look across the twelve case studies. we offer these patterns as pointers for classroom discussion, but also as starting points for more empirically informed theorizing about how and why public organizations become institutions (and how they can also 'deinstitutionalize'). finally, we ask a pertinent and perhaps uncomfortable question: can public organizations that effectively and authoritatively guard public value and receive widespread recognition for doing so, continue to flourish in our turbulent and more unforgiving age? when we see one? we use the concept of institution to describe a particular category of organizations. an organization is, in essence, nothing more than an established way of cooperation between two or more individuals (barnard 1938) . what sets an organization apart as an institution is its pursuit of aims that are widely considered to fulfil a societal need, its reliable performance over time, and its exemplary conduct as perceived by societal constituencies. the cases in the book provide powerful illustrations of these institutional characteristics: • the bbc has been producing a judicious and widely respected mix of news and entertainment, has built itself into a global media brand while adapting successfully to major technological (such as satellite and online television) and regulatory changes (introduction of commercial broadcasting). • the scientific centre for particle physics research cern has gained international recognition as the hub in its field, has kept on pushing the boundaries of knowledge, has educated generations of influential researchers and has sparked the public's imagination both through its mammoth underground research facility (the large hadron collider) and its discoveries (the higgs boson particle) as well as through its spinoff technologies (such as the world wide web). • médicins sans frontières (doctors without borders) has been much acclaimed for its fearless commitment to providing medical care to populations caught in complex and devastating conflicts around the world. it has become a beacon of courageous behaviour in very challenging and dangerous circumstances. moreover, it has repeatedly called attention to the follies and excesses of the humanitarian aid industry, and in doing so has become its moral conscience. these examples suggest that there is something special about institutions: they are regarded as more valuable than just any organization. goodsell (2011a: 477) refers to mission mystique, which he defines as an organization's 'aura of positive institutional charisma that is derived from the nature of its mission and how well it is carried out'. aura is, of course, a matter of perception: people must recognize something special in what an organization does and how it performs its tasks. this subjective dimension of institutions makes it challenging for social scientists to arrive at a more systematic way of establishing why and to what extent an organization can be categorized as an institution. but it is a challenge that has to be met. selznick's (1957) classic distinction between organizations and institutions provides a helpful tool in this endeavour. he formulated three criteria that can help us identify the institution in a population of organizations (see fig. 1 .1). selznick's framework can also help us track and interpret institutional trajectories: how an organization takes on institutional characteristics and how an institution may deinstitutionalize. let's have a look at these three criteria. distinct identity and unique competence. an institution has a clearly developed and widely recognized identity that communicates to both its members and the outside world what it seeks to achieve and why, what the dominant practices in the organization are, and how it addresses conflicts that occur in the pursuit of its aims. mark moore (1995)a self-confessed selznickian-speaks about identity in terms of a 'value proposition' and refers to institutional competence as the 'operational capacity' of an organization. an institution's identity and competences are well-suited to meet societal aspirations and expectations. an institution has fostered a strong alignment between the rationale for its existence and the day-to-day strategies and practices it deploys. this alignment is strong reputation, high legitimacy. an institution is trusted and respected, to such a degree that its existence is sometimes taken for granted. employees are proud to work there and intrinsically motivated to contribute to the cause. the institution's external stakeholdersmoore (1995) speaks of an 'authorizing environment'-support the institution through thick and thin by what they say and do. they provide funding, procure its products and services. they trust it to do the right thing in the right manner. they forgive its occasional lapses, to a much greater extent than they would for an organization not endowed with mission mystique. it is hard to imagine that anyone would even propose to abolish it. enduring viability through adaptation. an institution has adaptive capacity, which helps it to stand the test of time. this is not just about changing structures and practices to make the organization more effective or efficient. institutions have the paradoxical ability to change in order to remain the same-changing whatever must be changed to protect the institutional core (ansell et al. 2015 ). an institution can consistently deliver on its mission, working in ways that reaffirm its value proposition and satisfy the evolving expectations and norms of its stakeholders. it does what most public organizations find really hard: adopting and implementing reforms that prove to be effective. an important recent study that provides support for much of what selznick was proposing, albeit cast in slightly different language, is that of charles goodsell (2011a, b) , who examined the organizational history and development of 'mission-driven' public agencies in the united states, including such iconic institutions as nasa and the national forest service. he provides an in-depth, case-oriented study of what life in public institutions looks and feels like. table 1 .1 gives us goodsell's matrix of cultural characteristics and organizational practices that his institutions all shared. it provides a useful elaboration of selznick's institutional characteristics. the combination of selznick's and goodsell's institutional characteristics allow us to make a snapshot of any organization in order to determine whether, or to what extent, it qualifies as an institution. importantly, the three criteria can be applied in a dynamic manner: we can 'shoot' a film of the institution's development by applying the criteria at several points in time. that film would show the ebbs and flows of an organization's goodsell (2011a: 480) institutional status, identifying periods of strong institutionalization but also periods of institutional decline. such a dynamic perspective on institutional development is crucial. institutions are never born as 'institutions', though their architects and foundational leaders may have high hopes for them. they become institutions. they see the light as a small social group, a budding network, a small organization; some develop and gain institutional characteristics. we refer to this as a process of institutionalization (boin and goodin 2007) . but just as an organization can take on institutional characteristics, an institution can also lose institutional characteristics. institutions can deinstitutionalize (oliver 1992; suchman 1995; boin and 't hart 2000; boin 2001 ). its mission can become less relevant, or diluted by mission creep. mission creep refers to the widening of the mission, adopting new ambitions and tasks that distract from the original aims. also, the organizational structure, culture and established practices may lose relevance, hindering rather than helping to achieve the mission. the institution can become ridden with internal conflict, or lose touch with its authorizing environment. institutionalization brings enormous benefits for public organizations. it helps to bind members to a common cause, thus diminishing the transaction costs in the organization. it buttresses against the winds of fashion, as the high level of legitimacy effectively grants a degree of autonomy so that leaders of an institution can chart its course. institutions inspire confidence in those to whom they are accountable and as a result are less scrutinized than other organizations. when an institution is found to have failed or strayed, it is forgiven for more and for longer than organizations that lack their charismatic aura. institutions are, in other words, better prepared to weather the storms of failure, scandal and crisis that any organization faces in its lifetime-provided, as selnick (1957) reminds us, that they remain responsive and adaptive to the environments they work in and from which they derive their public licence to operate (in fact, selznick identified this as the most difficult leadership task). institutions also benefit society. they fulfil certain functions in ways that are appreciated by that society. as the case studies in this book will show, these functions can vary widely. the institutions discussed in this book: • provide fair elections • protect against corruption • offer a trusted source of news • preserve the value of money • create a legal framework that benefits collaboration • preserve cultural traditions • protect the integrity of sports • create conditions for path-breaking research • protect a society against disaster • assist helpless victims of disaster • foster a shared interpretation of complex research findings. a society needs institutions to ensure that we will have fair elections in the future, that we may expect a continued stream of validated news, that we can trust research findings, and be confident that future disasters will not cut the lives of citizens short. but institutions do more than fulfilling useful functions. they guard against the erosion of these functions and protect the values that underlie them. institutions are the guardians of a state's promises; they preserve a society's hopes and ambitions. our fascination with institutions builds on two empirical observations. first, it has been observed that a minority of public organizations live a long life. a majority perishes (a sizeable chunk does not even make it longer than a decade) (lewis 2002) . second, only a handful of those survivors meets the institutional test set forth by selznick. we therefore conclude that public institutions are exceptions or outliers. we want to get to know these outliers. a key challenge for institutional scholars is dealing with the normative connotations that come with the "institution" concept. we generally reserve the term 'institution' for an organization or a cultural practice that is valued-this is, indeed, exactly how we defined the institution. but what is valued by many, may be highly controversial to others. what is valued in one society is anathema in another. an organization revered in a certain era, may today be discussed as an example of malpractice or organized evil. selznick's three criteria do not resolve this normative conundrum. take, for instance, the federal bureau of investigations (fbi). when applied in a broad-brush, across-lifespan fashion, selznick's criteria would have us regard it as an institution. the fbi has a distinct identity: most people (not just americans) have heard of the fbi and will have an idea of what it represents. the fbi has a unique competence and has existed for a long time. at the same time, it is easy to unearth a range of questionable values it espoused and activities it deployed for extended periods of its existence. for example, the latter decades of long-serving and founding director j. edgar hoover were marked by practices that are now widely recognized as questionable if not outright illegal (jeffreys-jones 2007) . so what does this mean for selznick's criteria? what does it mean if organizations with dubious identities and questionable competences qualify as an institution? should we reject these criteria and look for others? should we avoid institutions that today are widely viewed as epitomizing questionable values? we feel that selznick's criteria can still be used, but their use needs to be directed and qualified by situating organizations in a particular window of time and then assessing to what extent the institution embodied, advanced or provided stewardship of values deemed important by the society in which it existed. we must take into consideration that the value sets that stakeholders and the community at large apply to an organization can and do change over time. institutions, in other words, are to be taken as organizations that have become effective and legitimate 'guardians of public value' in a certain time and context. when removed from that time and context, certain institutions or certain epochs in their existences or certain practices in which they engaged may well be considered dangerous or deplorable. the intriguing question is how such morally problematic organizations could maintain high levels of internal and external legitimacy at the time (cf. selznick 1952) . if we suspend judgement, we can learn-even from institutions that in our time and context may look questionable-valuable lessons about their emergence, their value proposition, their governance, their 'formula' for success, their ways of acquiring a public licence to operate, their ways of navigating conflict and tensions, and in some instance, their decline and downfall. an institution tells us something about the society it emerges from and exists in. this is also true for the cases included in this book. the fact that these particular organizations have ended up as specimens of 'guardians of public value' does not mean that we hold them up as being exemplary all of the time and in each respect. most institutions go through periods of mission ambiguity and conflict; they are sometimes at a loss to develop distinctive competence and sustain effective practices, and they may have found it hard at times to adapt to significant changes in their context. each case study will therefore situate the story of the institution in time and space, and treat its institutional (and normative) status as a variable and not as a given. in this book, we study institutions that have done things and done them in ways that were of value to society and were indeed valued by their authorizing environments. moreover, they have not merely 'created public value' (moore 1995) and gained recognition for doing so, but continued to do so for considerable periods of time. they have acted not just as creators of public value, but as its guardians. our aim is to introduce a set of sensitizing concepts in this opening chapter and see if they can help students, researchers and practitioners grasp and interpret the dynamics of institutionalization that have contributed to their lofty reputation and social status. we are obviously not the first to study organizations as institutions. selznick's work inspired a series of detailed studies and theories that explain how organizations become institutions (diiulio 1987; wilson 1989; boin and goodin 2007; boin and christensen 2008; goodsell 2011a, b) as well as accounts of how they become deinstitutionalized (boin and 't hart 2000; alink et al. 2001; collins 2009; mair et al. 2014; ansell et al. 2015) . there is an entire library of institutional study material, both theoretical and empirical, in many different languages and in different disciplines. this research helps to explain why some public organizations (and not others) become-and remain-institutions. more specifically, it helps to answer three big questions that institutional scholars have endeavoured to answer. • how do institutions emerge? what are the drivers of institutionalization? under what conditions does institutionalization happen? do organizational characteristics matter? does it matter in which 'niche' the organization operates? is institutionalization an outcome of leadership? or funding? particular environmental demands? happenstance perhaps? • how do institutions stay strong and relevant? institutions have to perform a balancing act: distinctive (and cherished) competences must be wielded to satisfy societal expectations and perceptions of their performance. but societal expectations and perceptions of public organizations rarely remain fixed over long periods of time. this simple observation means that institutions are always vulnerable to contextual changes. they must, in other words, adapt to remain an institution-they must remain attuned to changes in both their operating environment (e.g. technological innovations, new products and services, competing organizations) as well as their authorizing environment (e.g. political power structures and governing philosophies). to adapt is also to risk alienation from societal expectations and perceptions. becoming an institution may be one thing, remaining an institution is quite another challenge. • what explains their decline and downfall? many long-standing institutions have 'lost it' and declined into oblivion. whether we think of the roman senate or the dutch east india company, it's clear that these were institutions in their time, remained institutions for a long time, and no longer exist. that prompts the question why institutions lose it. do they somehow lose their capacity to adapt to changing expectations? do their leaders succumb to hubris, dragging the institutions away from society? or are these institutions faced with shocks that are so large and sudden that timely adaptation is simply impossible? these three research questions have been studied by different theoretical traditions of institutional analysis that have been extensively described, summarized and compared elsewhere (peters 2011; scott 2013) . to give an impression of the variety in explanations offered by students of institutions, let us just mention four dominant schools here. philip selznick was a pioneer of what is called classic institutionalism. this school focuses on organizations (as pillars of what they called the organizational society), seeking explanations for their emergence, functioning, effects and survival (see f.i. thompson 1967; wilson 1989 ). as we have seen, selznick famously explained how and why institutions differ from 'mere' organizations. this happens when the organization is deeply valued by its employees, stakeholders, political leaders and the public. in explaining the emergence and downfall of these institutions, this approach pays a lot of attention to organizational leaders and the strategies they employ to maintain a relation between their organization and its environment. research in the tradition of new institutionalism shifted attention from the individual organization to a class or type of organizations (meyer and rowan 1977; deephouse and suchman 2008) . where selznick might focus on oxford university as an institution, new institutionalists would focus on the university (sui generis) as an institution. this school has done much to conceptualize the political and social environment in which particular types of organizations do or don't evolve into institutions. the key idea is that organizations assume institutional properties by adhering to an 'ideal-type' that reflects how a society thinks about that type of organization. through processes of 'isomorphism' these organizations are thought to adopt the required characteristics without necessarily changing the way they conduct their core business. while the new institutionalists revived a scholarly interest in institutions, this school of thought has less interest in our core question: why do particular organizations become and remain institutions whereas others flounder and perish? in recent years, a small group of political scientists became interested in the survival chances of public organizations. inspired by the pathbreaking work of herbert kaufman (1976) , david lewis (2002 lewis ( , 2004 built a database of us public agencies to test a theory that predicted 'survivors' would have different birth characteristics than non-survivors. a key assumption is that 'normal' organizations are perennially prone to capture, politicization and restructuring (carpenter 2010) . they can only survive these pressures, or so the theory goes, if they are 'hardwired' against efforts to terminate or co-opt the organization. the premise of this design school has found empirical support: birth characteristics do seem to matter, as they raise survival chances. but they cannot explain which particular organizations will survive and which will perish. subsequent research has shown that design factors can only explain so much. population ecology scholarship, for instance, also seeks to explain why some public organizations survive over time whereas others fold (kaufman 1985; boin et al. 2017; kuipers et al. 2017; van witteloostuijn et al. 2018) . ecological studies are highly focused on structural and environmental factors. these studies offer support for the design school, but also suggest that there are other factors at work at the population level. their studies reliably show that the 'carrying capacity' of a population is probably the most important factor in predicting survival chances. both the design school and the population ecologists tend to deemphasize the potential role of behavioural and cultural factors in explaining institutionalization. precisely those factors emerge in case studies of organizational and entrepreneurial success in both the public and corporate world (lewis 1980; peters and waterman 1982; doig and hargrove 1990; collins 2001; malone and fiske 2013) . also, there are many organizational biographies that describe the genesis, purpose and inner working of public and private institutions, offering in-depth accounts of their performance, legitimacy and endurance (kaufman 1960; boin 2001; wetterberg 2009; carpenter 2010) . these biographies are not designed to draw general lessons or make comparisons. but they make clear that political and organizational leaders can affect the course of institutionalization. we began this project with a set of ideas that may explain why and how some organizations with a public purpose or public relevance end up acquiring mission mystique and become widely viewed as guardians of public value (and thus also why other organizations do not achieve this). first, we don't think institutions materialize by happy circumstancethey have to be created, maintained and protected. that requires a form of leadership, both within the organization and in its authorizing environment. at the same time, we do not believe that, as the design school implies, institutions are 'created by blueprint'. institutions arise from organizations because they have the capacity to adapt and bounce back from the inevitable crisis. this requires a culture that is conducive to experimenting and learning (de geus 1997; goodsell 2011a, b) . second, we are convinced that a public organization cannot do without some minimal level of legitimacy (suchman 1995) . organizations become institutions because they enjoy high levels of legitimacy for long periods of time. while legitimacy is granted (or not) by those whose views count, organizations can actively work to earn that support. they can systematically regain it when it is has been compromised or lost; if these efforts are successful the organization re-institutionalizes. in summary, we see an important relation between leadership and the process of institutionalization. we view institutionalization as a process that is at least partially spontaneous and unplanned. organizations are not designed with a goal in mind to become an institution. but that does not mean that institutionalization simply happens, as a resultant of favourable circumstances or a dose of luck. following selznick, we view institutionalization as an evolutionary process, which can be influenced but not fully controlled by organizational elites (boin and christensen 2008) . leadership is important as it guides, facilitates and shapes the process of becoming an institution. it is also critical for protecting the institution against the 'forces of fragmentation' (kaufman 1960) . we conceptualize leadership as a collective endeavour by organizational elites to fulfil a set of tasks (cf. 't hart and tummers 2019). leadership is not the property of the one individual who happens to occupy the highest rank in the organization. this helps us to escape from simplistic assumptions that institutional success is related to a particular leader (even if that leader stars in the organization's mythology). at the other end of the continuum, we must be careful to relate lapses and pathologies of leadership directly to processes of deinstitutionalization (cf. padilla et al. 2007; helms 2012) . in summary, we follow selznick in assuming that organizational leaders can guide the process of institutionalization in three ways (selznick speaks of three executive tasks). a key challenge for any public organization is that it must deliver on its formal (legal) assignment (or policy goals) while serving societal values and aspirations. if the organization solely seeks to deliver what it is built to deliver, the organization can quickly become redundant upon completion of the mission or shifting policy priorities. organizations become institutions when they are perceived to embody societal ambitions while delivering on formal aims. to combine both is no easy task and will require tough choices-in a world of scarce resources, diverging preferences and bounded rationality, more often than not something will have to give. making these choices amounts to a process of character building, which shapes the identity of the budding institution. leaders can help shape this process, by facilitating experimentation that helps to discover the organization's identity and by making critical decisions (boin and christensen 2008) . leaders also play a key role in communicating a sense of purpose, which keeps the organization aligned, determined and hungry. an organization with a mission needs people (professionals) who fit what the organization is trying to do. selznick made an important point: professionals have to buy into the mission and believe in the underlying values that anchor the institution (cf. kaufman 1960) . this is especially true for public institutions, in which profit and competition cannot be the motivational drivers of the enterprise. leaders of public institutions need to evoke and harness the 'public service motivation' of their employees (perry and hondeghem 2008) . when professionals identify with and are energized by the mission, the management is relieved of the burdensome task of command-and-control duties. a high level of decentralization is then possible, as coordination is achieved through shared values (that functions as a 'software of the mind'). the acid test is employees who proudly talk about their work and institution during birthday parties (cf. dilulio 1994) . institutions, by definition, enjoy a high level of legitimacy. they are valued by their stakeholders and, as often is the case, by society at large. it is a task of institutional leaders to protect and strengthen that relation. in doing so, leaders will face an inherent dilemma that will have to be negotiated time and again. institutions enjoy a high level of legitimacy because they perform a task in an effective, consistent and highly valued way. successful institutions are therefore not inclined to change their practices (which have been proven to work). but societal ambitions and preferences change. however well an institution may perform, they will be confronted with a 'performance deficit'-the gap between societal expectations and perceived performance-sooner or later. if the deficit becomes too wide, an institution faces declining trust and may experience what we have labelled an institutional crisis (boin and 't hart 2000) . continuous adaptation of mission and work practices is therefore necessary. but such adaptation can rock the internal balance-the shared professional pride-that gives rise to its performance. when an institution changes slowly, it may be forced into reform; when it changes too quickly, employees may rebel. it is a leadership task to preserve a sensible balance. this volume brings together case studies of very different organizations that managed to become institutions and have maintained their institutional status in the face of pivotal challenges, controversies and crises. a multidisciplinary cast of subject matter experts, guided by a shared analytical framework, provide educators and students with a rich array of teachable case studies. the starting assumption underlying this volume is that many factors can shape the trajectory of institutionalization. birth characteristics likely matter, as do the circumstances in which the institution saw the light. leadership matters, both within and around the institution. other institutions may cast their shadow. the same is true for historical contingencies. in short, we do not think it makes sense to hew closely to one particular school of thought, entering into a shadow boxing match with other theoretical schools. it is in this vein that we 'instructed' our authors: we gave them the freedom to identify and analyse factors that seemed to matter most in their individual case-leaving the door open for answers that we have not heard before. each chapter describes the story of an institution: its origins and early years; how it coped with change, adversity and crisis; the role of design, choice, chance and learning in these institutional trajectories. each chapter has something to say about institutional leadership, in particular its balancing act of aligning mission, capacity and support in the face of ever-changing environments. we selected cases that we could reasonably expect to have institutional characteristics (for at least a considerable part of their life spans to date). we also set out to include a wide variety of organizations. our cases cover: • governmental and non-profit organizations from a variety of countries and regions. most cases are situated in the western world, but there are also cases from singapore and india. • very old and relatively young organizations, ranging from the swedish national bank (1668) we selected these cases for pedagogical and not for theory-building or hypothesis-testing purposes. we chose this variety of cases to give instructors and students alike a menu for choice. cases were selected to allow readers to compare two or more most-similar cases, most-different cases, or other clusters of like/unlike characteristics. readers should be able to draw on cases to identify patterns or perform plausibility probes on theoretical claims about institutions and institutionalization. moreover, readers should be able to examine the impact of factors such as institutional contexts, organizational capabilities and institution-building leadership strategies. the authors have been selected because they are experts on 'their' institution, not because they subscribe to our analytical framework. each chapter loosely works around the framework set out above and thus actively encourages the reader to interpret the dynamics of each case. the volume offers case histories of the following organizations: the indian electoral commission has stewarded free and honest elections in the most populous and complex democracy on earth. the commission successfully manages more than 1.4 million voting machines, 930,000 voting centres, 1.1 million government and 5.5 million civilian election employees, and more than half a billion voters. the story of its institutional development is one of mandate expansion: institutional leaders using the legal system to enhance the powers it can wield during election time. singapore's corrupt practices investigations bureau was established in 1952 to battle the rife corruption present in all sectors of the public service, where bribes, favours and nepotism were fundamental norms of 'doing business'. the bureau had to earn its stripes fighting corruption among the country's most powerful individuals: both in the police force and in the parliament. through a record of successful actions against corrupt individuals, the agency gradually developed substantial authority to investigate any case in which corruption may be involved. the bureau has been a driving force in making singapore one of the least corrupt nations on earth. the british broadcasting corporation (bbc) is one of great britain's most venerable public institutions. it is also the world's oldest (created in 1922) and largest national public broadcaster (in terms of employees as well as its global reach and authority). through its coverage, the bbc has documented and shaped the transformation of british society. it has maintained a reputation for impartiality and journalistic integrity. it has successfully weathered challenges, incidents and crises and continues to define the standard for quality broadcasting. celebrating its 350-year anniversary in 2018, the swedish riksbanken is the oldest central bank in the world. its independence from government waxed and waned over time, and finally became firmly cemented in 1999. its public authority helped sweden survive the terrible 1992 economic crisis. in response to the global financial crisis that started in 2008, it was the first central bank to adopt negative interest rates to stimulate economic activity. in 2018, it announced that it was considering issuing e-krona, electronic currency (the first central bank to do so). the european court of justice (ecj) is the undisputed guardian of the european union's transnational legal order, issuing landmark rulings and generating jurisprudence at a considerable pace. it was created in 1952 and has the power to invalidate the laws of eu member states when those laws conflict with eu law. the ecj serves as the final arbiter of the growing body of international law that has accompanied the economic and political integration of europe. it always faces the challenge of maintaining its authority and legitimacy when the eu's ideals and institutions come under pressure. the amsterdam concertgebouw orchestra has historically been rated as one of the top symphonic orchestras in the world. founded in 1888, it has had only seven chief conductors. it has found ways to balance the twinned but often conflicting imperatives of artistic excellence and financial viability. it remains dependent on government funding, which in the early 2010s became highly uncertain, triggering a mood of crisis that required astute management. the world anti-doping agency (wada) promotes, coordinates and monitors the fight against performance-enhancing drugs in sports. wada's key activities include scientific research, education, development of anti-doping capacities and monitoring of the world anti-doping code. among the youngest organization in our set of cases, it came into being in 1999 as an independent foundation with a hybrid public-private structure. it is the chief guardian of the world anti-doping code that has more than 600 signatories, including many states as well as international sports foundations. its work has gained global recognition as contributing significantly to key values in sports such as fair play and the protection of athletes' health and well-being. founded in 1954 and based in geneva, the european organization for nuclear research, better known as cern, is a remarkable example of enduring international scientific cooperation in pursuit of one of the most elusive goals ever embraced by any organization anywhere, one that requires sustained and large amounts of public funding. among its key accomplishments are the pioneering of internet technology, the creation of the world wide web, several nobel prize-winning staff members and the 2012 discovery of the higgs boson particle. founded in 1798 during the french occupation, rijkswaterstaat, the directorate-general for public works and water management of the netherlands, has evolved into an iconic institution. its defining accomplishments are in the area of water management-digging canals, building and maintaining dikes, reclaiming vast tracts of land from the sea ('polders'). its planning and engineering feats are essential to the survival of a country where more than 25% of its territory lies below sea level and another 30% is highly exposed to flooding. the institution faced major adaptive challenges when its 'safety-first' paradigm was challenged by the rise of environmentalism. as it strives to transform itself, climate change is presenting another key test of its resilience, ingenuity and collaborative capacity. few humanitarian aid organizations enjoy a global public standing like médecins sans frontières (msf) has. described as the most important humanitarian organization and conscience of the humanitarian world, msf was awarded the nobel peace prize in 1999. it displays a fierce sense of independence. throughout its history msf has often acted controversially, going public with its knowledge about atrocities committed by parties to the violent conflicts in which it operates, as well as explicitly challenging the humanitarian sector's own practices and principles. the intergovernmental panel on climate change (ipcc), founded 1988, is the international body that reviews the latest science and produces assessment reports which inform international negotiations on climate change. it is tasked with establishing a consensus between climate experts and governments, communicating knowledge on climate change to policymakers, negotiators and the public, and for making recommendations on potential courses of action. the ipcc and al gore were co-recipients of the 2007 nobel peace prize. the ipcc has also been criticized at times for its work and is a target of climate sceptics. the ipcc's reputation was damaged when its leadership failed to respond effectively to mistakes found in its 2007 report. since then it has worked to restore confidence. its reports have been very important in the un climate negotiations and strongly influenced the goals of the 2015 paris agreement. within a decade of its inception in 1995 the australian competition and consumer commission (accc) had become a trusted institution in the australian regulatory landscape. the product of a merger, the accc soon carved out and dramatized its mission as a crusader for levelplaying fields and fair play in markets. by successfully taking on some of the biggest corporations in the country in both the courtroom and the court of public opinion soon after coming into existence, the new authority quickly gained notoriety. by asserting its independence from political interference, it gained public credibility in a country that has long held its political class in low esteem. the accc has subsequently conserved its enforcement mission by adapting to challenges in the political and business environments, expanding and redirecting its repertoire for regulatory action, and broadening its consumer and small business constituencies. this book revolves around a central puzzle: why do some public organizations become-and remain-institutions? our relatively small and purposefully skewed set of case studies does not allow us to systematically test hypotheses, nor to generalize insights to larger populations of organization types. that said, what we can do is inductively identify possible patterns and relate them to conventional wisdom in academic theorizing and the world of practice. in interpreting these patterns, we can discern possible scope conditions or social mechanisms that may be at play in bringing about the institutionalization (and deinstitutionalization) of public organizations. more specifically, our cases provide food for thought with regard to four often-mentioned patterns of institutionalization. to help readers interpret the case studies, we will now discuss our observations in more detail. in his study of highly successful corporate organizations, jim collins (2001 collins ( , 2019 found that these organizations had one critical characteristic in common: they have in place what collins refers to as a flywheel. collins is, in essence, talking about what across the social sciences has been called a virtuous cycle: a set of processes that reinforce one another (sitkin 1992; finnemore and sikkink 1998; boin and christensen 2008) . within an institution, the virtuous cycle might look like this (see fig. 1 .2): • the cycle starts with the discovery or invention of an effective, efficient and legitimate way to reconcile organizational aims with societal aspirations. this typically happens through a mix of experimentation and smart copying. • successful practices give rise to the emergence of an internal norm: this is how we do things around here. and legiɵmate pracɵces to perform its societal task condiɵons that enable successful pracɵces become internal norms of 'how we do things around here' internal norms serve as lever to purposefully recruit and socialize highquality, highly moɵvated staff effecɵve and dedicated staff help organizaɵon perform well and insɵll confidence in its authorizing environment organizaɵon is wellfunded and enjoys relaɵvely high autonomy to act, experiment, learn and grow • the internal norm makes it easier to recruit and train the right people, which facilitates cohesion and effectiveness. • effective and dedicated people make the organization look good. this results in enhanced funding, support for the mission and strengthened autonomy. • a strong and legitimate organization performs better, which solidifies the internal norm. our case studies bear witness to this virtuous cycle of institutions. consider the following three examples: the intergovernmental panel on climate change (ipcc) began as an informal collaboration of scientists who worried about climate change. by establishing a network of committed and reputable scientists, they created a platform for policymakers to learn about causes and potential solutions. the ipcc established 'input and output legitimacy of the rigorous and extensive process by which the ipcc's teams of expert authors and peer reviewers carry out their work' (paglia and parker, this volume), which increased its epistemic power and reputation. their reports helped to spread awareness about ongoing climate change, which, in turn, led to increased demand for evidence-based science. the growing interest of policymakers (prompted by growing awareness about the threat) helped to mobilize scientists who recognized a podium for their research. the density of scientific expertise secured privileged access to policymakers, which enhanced the importance of the ipcc. singapore's corrupt practices investigations bureau (cpib) began as a small police unit seeking to root out corruption among colleagues. when it busted a drug ring that was run by the police, the cpib became an independent statutory authority. its autonomy enhanced its investigative powers, which were widely and effectively applied. the success of the cpib came to define singapore's status as a 'clean' state. singapore's enhanced international standing reflected back on the cpib, which saw its autonomy and authority strengthened. decades of successful investigations and prosecutions have embedded the institution in singapore's landscape (and indeed in the esteem of the international community). the cpib's effectiveness and singapore's reputation went hand in hand, reinforcing each other over the decades. the world anti-doping agency (wada) was created to address the protracted doping crisis of the 1990s. its chances of success seemed low. but it soon began to command the respect of its stakeholders, initially by formulating standards that made sense. as governments and sports foundations began to accept the standards, they also legitimated the agency. as the agency gained in stature, it could enlarge its role in the global fight against doping. the enlarged role translated into visible successes, which further strengthened its reputation. quite incredibly, the wada managed to become an undisputed authority in the international field of sports. its role in other sports organizations became entrenched, which further helped the standards to take root. institutionalization does not just happen; virtuous cycles do not simply materialize. this prompts the question if and to what extent the actions of leaders matter when it comes to the institutionalization process. the chapters in this book do not give rise to a new or definite take on this critical question. but they certainly provide powerful illustrations of leaders forging practices, crafting norms and protecting the identity and integrity of their organizations-and they show that this can be done in different leadership configurations and employing different leadership styles. let's look at some examples to illustrate this variety: the institutional history of the amsterdam concertgebouw orchestra cannot be written without recognizing its early and long-serving conductor willem mengelberg. he was the archetypical institution builder, translating the aspirations of the founding regents into an ambitious and appealing musical vision for the orchestra. mengelberg then translated this vision into an unprecedented and uncompromising regime of excellence that produced both classical and contemporary symphonic music, while building an international audience. by placing his orchestra squarely on the map, mengelberg forged a broader authorizing environment for his orchestra, extending well beyond the original group of regents. the european court of justice (ecj) began as a technical tribunal. it was hard to imagine at the time how this small court in luxembourg could become an institution, creating conditions that today make european integration a seemingly one-way road. this did not happen because of one leader. it happened because a group of judges-all appointed sometime in the early 1960s-shared a vision and began to build the ecj in light of that vision. these judges were well-known professionals who moved in the insulated elites that pushed for european integration. without seeking the limelight, they exerted the leadership of true institution builders. the founding commissioner of the australian competition and consumer commission, allan fels, not only brought academic expertise and long regulatory experience to the job, but also a brisk determination to give the new agency the institutional clout its predecessors had often lacked. painstakingly independent and politically neutral, fels used the media to create a powerful platform for the accc's 'naming and shaming' of big corporations that engaged in anticompetitive or manipulative behaviour. in prosecuting and winning high-profile cases, he instilled professional pride in its staff and ensured the accc became a highly visible and impactful crusader for consumers. institution building is more than formulating an evocative mission. professionals must be seduced and coaxed to accomplish the mission (leaders cannot do it by themselves). this can be an arduous job, as the chapters suggest. institutions are not, by definition, happy families (certainly not all the time). a public institution must find ways to harness conflict in ways that make it smarter and stronger (coser 1956 ). the chapters show how institutions do not always suppress conflict, but manage to canalize it. the european organization for nuclear research (cern) did not become a celebrated scientific institution without tension or strife. bringing together the best scientists in the world and have them compete for funds can be a recipe for disaster. cern developed a form of shared leadership, which allowed this international community of super-smart scientists to evolve 'norms and practices of balance-seeking': balance between funding member states and the spending cern administrators. balance between small and large contributors. balance between centralized lab and infrastructure funding and bottom-up funding of the experiments. balance between getting on with current work and preparing the ground for taking on new challenges and realizing future ambitions that are decades away. balance between the scientists' advances in fundamental physics and the engineers' development of the technological tools required to test them. balance between running a tight ship financially and maintaining the ability to respond flexibly to financial setbacks or emerging expenditures. balance between the patience required to do the work necessary to achieve major scientific breakthroughs and the need to be seen to be active, relevant and impactful in the present vital to maintain the institution's global public and political support base. balance between banking on the authority of established scientific leaders and on empowering the innovative irreverence of emerging research talents. (engelen and 't hart, this volume) the governance of the concertgebouw orchestra has been marked by decades of tension between protagonists of its artistic aspirations and business managers seeking to ensure the organization remained financially viable. it describes how mengelberg, the legendary conductor, waged no-holds-barred battles with a succession of business managers and artistic directors who had the temerity of proposing pragmatic rather than 'perfect' options to address pressing financial challenges. it references the painful, unnecessary and politically costly estrangement of maestro bernard haitink from the orchestra during the latter years of his highly successful tenure. but the story also demonstrates, using coser's (1956) words, the positive functions of social conflict: the many conflicts resulted in a change of the governance model, which finally resolved the long-simmering tensions between artistic excellence and financial viability. the birth of médicins sans frontières was rooted in a conflict of values and criticism of the status quo in mainstream humanitarian aid organizations such as the red cross. witnessing severe atrocities among civilians during the nigerian civil war in the late 1960s, doctors were forced to remain silent under the red cross's principle of 'neutrality'. this motivated a group of french doctors to set up msf as a breakaway organization. it set the organization on a path of fierce independence, going public with inconvenient truths and occasionally engaging in very public withdrawals from theatres of conflict where the integrity of its operations was being undermined by conflicting parties. its contrarian ethos also affected msf's internal culture: its policies and strategies took shape though sometimes sharp disagreements about the right thing to do in war-torn areas. organizations become institutions because they somehow maintain high performance over the course of their existence. institutions have survived many cultural, societal and political contexts changes. institutions face constant threats to its engrained and established formula, yet manage to preserve their virtuous cycle. this requires timely, in some cases even preemptive, forms of adaptation to maintain the flywheel. 1 our case studies suggest how institutions manage to accomplish this. institutions monitor the environment for new demands and potential threats; they probe the internal culture for complacency and newly emerging fault lines that have the potential to compromise the institution's integrity and performance. institutions maintain a culture of learning, innovation and contestation-they are 'charged with vitality' (goodsell 2011a) . rijkswaterstaat provides a fascinating case study in this regard. the traditional institution was at first reluctant to acknowledge that its technocratic paradigm of project planning and management had gone past its sell-by date as a result of changes taking place in dutch society during the 1960s. but once its eyes were opened, it went on a learning journey that continues into the present. rijkswaterstaat keeps trying to reconcile the traditional strength of 'go-it-alone civic engineering' with the 'soft skills' and 'collaborative mindset' required to thrive in a post-paternalistic era. the european court of justice is another intriguing example of adaptive capacity. just when the court had found its institutional footing and delivered hallmark rulings that would cement european integration for decades to come, the european project itself came under intense criticism (in the 1970s). around that time, the most influential judges in the court were set to retire. this confluence of events created a dire need to revisit and rethink the way the court functioned. this brings us to what is known as the paradox of success: the capacity to adapt can be undermined by the successes of the institution. the very strength of an institutional formula sows the seeds of the institution's demise. the operative mechanisms here are not only the kind of hubris, complacence and rigidity foreseen by selznick (1957) as chief forces of erosion of institutional integrity. there is something much more mundane at the heart of it: the dedicated adherence to what has been proven to work well makes it seemingly unnecessary to consider alternative ways of working that may be better suited for dealing with evolving contexts and new challenges. figure 1 .3 captures how a virtuous cycle can turn into a vicious cycle of deinstitutionalization, which can be described as follows (masuch 1985; boin and 't hart 2000; ansell and bartenberger 2017) : • successful practices give rise to a strong internal culture ('this is how we do things around here') that makes it hard to suggest or even imagine alternative ways of working. • this is perceived by parts of its authorizing environment as a refusal to acknowledge the need for change. • legitimacy declines as a result; criticism begins to mount. • the institution is at a loss of what to do, falling back on practices that are still assumed to work (but actually exacerbate the problem). • as perceptions of institutional performance continue to decline and institutions demonstrate limited or no willingness to change, conditions for an institutional crisis are created. if allowed to continue, this process of deinstitutionalization can create an existential crisis for an institution. it requires exceptional leadership to guide the institution through such a period. for example, the socalled climategate crisis facing the ipcc , when inaccuracies in its fourth assessment report were revealed, opened up the institution to charges of bias, hidden agendas and politicization of its processes and findings. playing into the hands of 'climate deniers', the crisis put pressure on the ipcc to acknowledge its fallibility, which, in turn, appeared to confirm the criticism put forward by its critics. the ipcc survived the crisis by creating procedures that enhanced the integrity of its findings and conclusions. anti-doping watchdog wada was plunged into an institutional crisis of its own making. wada had failed to detect the brazen, systematic subversion of its norms and its compliance regime by the russian sports federations, peaking at the sochi winter olympics. its initial response to whistleblowers, which came forward from within the russian system, was inept. it also proved unable to orchestrate support for firm sanctions. the organization compounded its problems by gullibly declaring its russian counterpart rusada fully compliant again in 2018, a declaration it had to retract when it transpired that the data on which the decision was based had been tampered with. but the crisis did not undermine the belief that without an institution such as wada there can be no credible anti-doping policy. institutions are conceived in this book as 'societal safeguards'. institutions protect our better angels from the detrimental effects of partisanship, moral panics, opportunism (the temptation of the quick fix) and adventurism (the temptation of the sweeping promise). institutions, in other words, protect us from ourselves. this is especially important in a time when public entities are fragile to the whims of public opinion and the impulses of politicians. some argue that today's institutions experience unique challenges (rosanvallon 2018) . one challenge derives from the rise of what has been called 'monitory democracy' (keane 2018) . in monitory democracies, all forms of authority, all organizations and all power-holders are continuously vetted, interrogated and challenged by a plethora of accountability regimes. if institutions indeed depend on a certain 'mystique' in gaining and maintaining their elevated status, the question arises whether that mystique can survive the withering challenges of hyper-transparency, the relentless thickening of accountability and the growing vagaries of public emotions and political will (hood 2010; bovens et al. 2014; busuioc and lodge 2017) . the dense web of arrangements and rituals of verification and control has made institutional 'mission mystiques' more fickle. operating in today's more polarized social and political climate may make it hard for institutions to claim that they are serving the 'public interest' (mccoy et al. 2018) . institutions can, in other words, rely less and less on their legal mandates, their formal autonomy and their professed commitment to certain fundamental values-to ensure their social licence to operate. institutional legitimacy has become more dependent on whether they actually 'perform' (hitting targets, scoring wins) and how they go about performing (i.e. complying with ever more strongly worded and policed procedural norms of transparency, fairness and propriety). a second challenge is grounded in the shift from the machine age to the network age (castells 1996) . twentieth-century organizing was grounded in hierarchy, specialization and compartmentalization of knowledge, funding, task performance and responsibilities. the dominant ideology of twenty-first-century organizing is one of collaborating across boundaries, pooling of resources, flexible arrangements, shared power and responsibility. in the face of relentless globalization, wicked problems and transboundary crises, public institutions find it hard to position themselves as islands or bulwarks organized around a self-proclaimed mission and accompanying values. today's world is very different from the america of the mid-1950s where selznick wrote his path-breaking book leadership in administration. collaborative approaches to public innovation, societal problemsolving and dealing with wicked issues and creeping crises have become the new normal (emerson and nabatchi 2015) . if they are to remain relevant in a network society, public institutions must be able to act as co-creators in hybrid public-private, intergovernmental and transnational collaborations. the question is how institutions can align or even coalesce their operations, norms and identities with network partners in service of a shared purpose without diluting their own institutional character. in modern society, the concept of a focal organization with a distinct mission, structure, value set, membership and value chain may have to be refreshed. but it would be premature at best to announce the impending death of public institutions and the obsolescence of the kind of institutional analysis performed in this book. the virtuous cycles that these institutions create and maintain are needed perhaps even more than before. networks may be important to make complex service delivery or emergency response work, but they don't have the visibility and established identity that institutions enjoy. citizens of monitorial democracies may have become more transactional and less forgiving in how they assess those organizations and their leaders. by the same token, however, in times of turbulence and confusion, citizens (and markets) look for beacons of hope, protection, direction and order. public institutions may well be our best hope in times of turbulence. public institutions are guarding something that is probably older and weightier than the current interests and priorities of any one group or party in the system, however powerful. whether in times of turbulence of relative stability, the pivotal challenge for institutional leaders remains threefold: to make the case for its raison d'être by claiming guardianship of salient, widely desired public values; to motivate people so that the institution delivers on its licence to operate; and to continuously adapt the organization's make-up, beliefs and practices to remain in tune with the norms and demands of ever-changing times. these are no easy tasks. the chapters in this book provide tales and insights that will hopefully prove useful for future institutional leaders. to facilitate classroom use of each case study we have placed questions for discussion at the end of each chapter. a final note. the manuscript of this volume was closed just weeks before the covid-19 pandemic enveloped and disrupted practically the entire world, thus presenting people, businesses, community organizations, government and international organizations with an unprecedented 'stress test' of their adaptive capacity. it remains to a next group of researchers to investigate whether and how the institutions covered in this book managed to not only survive but productively absorb and adapt to the immense challenges the virus and its many impacts presented. note 1. the kind of consolidating leadership that is required to ensure the institution stay relevant and valuable externally and continues to cohere internally has been captured nicely by frederickson and matkin (2007) in their essay on public leadership as 'gardening'. institutional crises and reforms in policy sectors: the case of asylum policy in europe tackling unruly problems dynamic conservatism: how organizations change to remain the same the functions of the executive. cambridge crafting public institutions: leadership in two prison systems the development of public institutions: reconsidering the role of leadership institutionalizing upstarts: the demons of domestication and the benefits of recalcitrance does organizational adaptation really matter? how mission change affects the survival of u.s. federal independent agencies institutional crises and reforms in policy sectors oxford handbook of public accountability reputation and accountability relationships reputation and power: organizational image and pharmaceutical regulation at the fda the information age: economy, society, and culture good to great: why some companies make the leap and others don't how the mighty fall turning the flywheel the social functions of social conflict the sage handbook of organizational institutionalism the living company governing prisons: a comparative study of correctional management principled agents: the cultural bases of behavior in a federal government bureaucracy leadership and innovation evaluating the productivity of collaborative governance regimes: a performance matrix. public performance & management review international norm dynamics and political change public leadership as gardening mission mystique: strength at the institutional center mission mystique: belief systems in public agencies poor leadership and bad governance understanding good urban governance: essentials, shifts, and values the blame game: spin, bureaucracy, and self-preservation in government the fbi: a history the forest ranger: a study in administrative behavior are government organizations immortal time, chance and organisations power and humility: the future of monitory democracy coming to terms with termination of public organizations the politics of agency termination: confronting the myth of agency immortality presidents and the politics of agency design: political insulation in the united states government bureaucracy public entrepreneurship: toward a theory of bureaucratic political power is the bbc in crisis the human brand: how we relate to people, products, and companies vicous cycles in organizations polarization and the global crisis of democracy: common patterns, dynamics, and pernicious consequences for democratic polities institutionalized organizations: formal structure as myth and ceremony creating public value: strategic management in government the antecedents of deinstitutionalization the toxic triangle: destructive leaders, susceptible followers, and conducive environments motivation in public management: the call of public service the sage handbook of governance search of excellence: lessons from america's best-run companies good governance: democracy beyond elections institutions and organizations: ideas, interests, and identities the organizational weapon: a study of bolshevik strategy and tactics leadership in administration: a sociological interpretation learning through failure: the strategy of small losses managing legitimacy: strategic and institutional approaches understanding public leadership. london: red globe and macmillan explaining the survival of public organizations: applying density dependence theory to a population of us federal agencies money and power: from stockholm's banco 1656 to sveriges riksbank today bureaucracy open access this chapter is licensed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/ by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license and indicate if changes were made.the images or other third party material in this chapter are included in the chapter's creative commons license, unless indicated otherwise in a credit line to the material. if material is not included in the chapter's creative commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. key: cord-258842-vuxzv6eu authors: bennett, b. title: legal rights during pandemics: federalism, rights and public health laws – a view from australia date: 2009-02-26 journal: public health doi: 10.1016/j.puhe.2008.12.019 sha: doc_id: 258842 cord_uid: vuxzv6eu pandemic influenza will cause significant social and economic disruption. legal frameworks can play an important role in clarifying the rights and duties of individuals, communities and governments for times of crisis. in addressing legal frameworks, there is a need for jurisdictional clarity between different levels of government in responding to public health emergencies. public health laws are also informed by our understandings of rights and responsibilities for individuals and communities, and the balancing of public health and public freedoms. consideration of these issues is an essential part of planning for pandemic influenza. s u m m a r y pandemic influenza will cause significant social and economic disruption. legal frameworks can play an important role in clarifying the rights and duties of individuals, communities and governments for times of crisis. in addressing legal frameworks, there is a need for jurisdictional clarity between different levels of government in responding to public health emergencies. public health laws are also informed by our understandings of rights and responsibilities for individuals and communities, and the balancing of public health and public freedoms. consideration of these issues is an essential part of planning for pandemic influenza. ó 2009 the royal society for public health. published by elsevier ltd. all rights reserved. in his book 'blindness', josé saramago tells the story of a city struck by an epidemic of 'white blindness'. this is not the darkness or blackness that most of us associate with blindness. instead, in this blindness, everything is white, as if, according to one man in the early pages of the book, 'i were caught in a mist or had fallen into a milky sea'. 1 those who are blind are placed in quarantine in a disused mental hospital, with food delivered to the main entrance three times daily. inside the hospital, the ugly side of humanity is revealed as the strong take control of the food supplies and assault the women. beyond the hospital walls, the epidemic, initially a trickle of baffling cases, spreads to affect the whole city until, finally, soldiers no longer maintain the quarantine and the blind leave the hospital. the story follows a small band of people as they venture back into the city, led by one woman who still has her sight. through their experiences, we see the chaos of a city where all social infrastructures have broken down and people do their best to survive in their new grim reality. our ability to respond to the social and economic disruption that may be caused by an outbreak of a serious infectious disease may be tested should the world experience another influenza pandemic. following an outbreak in 2004 of a highly pathogenic avian influenza caused by the h5n1 virus, the world health organization noted in 2005 that 'the world has moved closer to a pandemic than at any time since 1968'. 2 more recently, dr margaret chan, director-general of the world health organization, has noted that 'for the first time in history, the world has been watching the conditions that might start an influenza pandemic unfold in real-time'. 3 while human-to-human transmission of the virus has yet to be established, by 19 june 2008, there had been 385 cases of human infection with the h5n1 virus, including 243 deaths, primarily in south east asian countries. the world health assembly has called on its member states to develop national preparedness plans, 4 and the world health organization has provided recommendations 5 and checklists 6 for national plans. while many countries have taken steps to develop preparedness plans for an influenza pandemic, variations between countries and gaps in the plans are still evident. 7 in the uk, a 2005 house of lords science and technology committee report noted that government figures estimated that illness-related absenteeism from work during a pandemic could cut gross domestic product (gdp) by £3-7 billion, while pandemicrelated excess mortality could cut gdp by an additional £1-7 billion (0.37-2.5% mortality). 8 in australia, the impact of pandemic influenza in the absence of an effective vaccine and if containment fails has been estimated at 13,000-44,000 deaths, 57,900-148,000 hospitalizations and 1-7.5 million outpatient visits. 9 at global level, 'even in one of the more conservative scenarios, it has been calculated that the world will face up to 233 outpatient visits, 5.2 million hospital admissions and 7.4 million deaths globally, within a very short period'. 10 the sudden and dramatic increase in demands upon the health system during a pandemic would challenge already-stretched health resources and personnel, highlighting the need for health systems to have in place plans for surge capacity to respond to disasters and health emergencies. 11 in addition, absenteeism in the community more generally could challenge the continuity of critical infrastructures, such as power, telecommunications and water, upon which hospitals rely. 12 while the social disruption arising from pandemic influenza would be considerably less than the total social breakdown portrayed in saramago's story, 'blindness' reminds us of the fragility of our current lives and the speed with which our worlds can be turned upside down. it reminds us of how selfish and uncaring people can be when they are scared and feel threatened, and how quickly order can descend into chaos. it also tells of the courage and strength of the human spirit when faced with danger. this paper talks about the role that law can play in providing some certainty for times of chaos. legal frameworks can clarify the rights and duties of individuals, communities and governments for times of crisis, and public discussions around these issues can themselves help to alleviate community anxiety. in thinking about the legal framework, there are two main issues to be addressed. first, there is a need for an understanding of the role of law in public health at state, national and international levels, and the need for jurisdictional clarity when differing levels of law and government intersect. these legal frameworks are important, for they define the scope of government responses to public health emergencies at local, national and international level. secondly, our understandings of the role of law in responding to pandemics are necessarily informed by relational bonds between individuals in society, and by the meanings of rights and responsibilities for public health laws when dealing with infectious disease. gostin has defined public health law as 'the study of the legal powers and duties of the state to assure the conditions for people to be healthy . and the limitations on the power of the state to constrain the autonomy, privacy, liberty, proprietary, or other legally protected interests of individuals for the protection or promotion of community health'. 13 reynolds points out that 'public health law is a disparate collection of laws and government responses, with its common feature a focus on the population rather than the individual'. 14 while law plays an important part in shaping the role of state action and intervention in the health of individuals and communities, the scope of these state powers is shaped by a range of factors including: the nature and traditions of the legal system in the country in question; cultural understandings of the individual, the community and the state and of the relationships between them; and the wealth or poverty of the country and its people. as magnusson points out, in the context of liberal democracies, debates about the boundaries and meanings of public health law reflect 'competing claims about the boundaries for the legitimate exercise of political and administrative power'. 15 our understandings of law and ethics, and indeed of health itself, are culturally and historically specific, requiring dialogue and cooperation for effective global responses to issues of common concern. the legal framework for public health in australia is made up of a mixture of federal and state legislation, with quarantine powers reserved to the federal government in the australian constitution, 16 and the states having control over other public health matters. the reality is somewhat more complex than this suggests, as the federal government can achieve public health objectives through the use of its other constitutional powers, such as the grants power in section 96 of the constitution which allows the federal government to make financial grants to the states, and the spending power in section 81 which allows the federal government to fund health programs. 17, 19 however, while the federal government can seek to use its other constitutional powers to achieve health-related objectives, it is important to realize that the power under section 51(ix) of the constitution to make laws 'with respect to quarantine' is the only power relating to communicable diseases directly given to the federal government in the constitution, and that this, in turn, shapes australian debates about government responses to public health issues and emergencies. while the absence of comprehensive health-related powers for the federal government in the constitution may seem surprising given our contemporary reliance on a national public health insurance system (medicare), and the general trend in australia away from federalism and towards centralization, 18 it is important to remember that these are more contemporary features of the australian political landscape and were not in existence at the time of federation and the drafting of the constitution in the opening years of the 20th century. 19 australia's geographic location and the fact that it is an island continent have influenced australia's historic approach to quarantine. maglen has argued that while england increasingly relied upon sanitary measures in the 19th century for protection against disease, quarantine remained an important tool against imported disease in the australian colonies of the time. 20 new south wales introduced australia's first quarantine legislation with the quarantine act 1832, and federal quarantine legislation was adopted in 1908. australia's quarantine act 1908 (cth) sets out the powers and procedures for the administration of quarantine in australia. under the act, the scope of quarantine is quite broad and covers a range of measures which aim to prevent or control 'the introduction, establishment or spread of diseases or pests that will or could cause significant damage to human beings, animals, plants, other aspects of the environment or economic activities'. 21 the act defines a quarantinable disease as 'any disease, declared by the governor-general, by proclamation to be a quarantinable disease'. 22 masters of vessels are required to make a notification to a quarantine officer if prescribed symptoms or a prescribed disease is present on board, or if the master 'has reason to believe or suspect' that a quarantinable disease or pest is on board. 23 individuals or vessels can be ordered into quarantine if they have a quarantinable or communicable disease, 24 and there are also powers to subject individuals to quarantine surveillance in certain circumstances. 25 the governor-general can declare, by proclamation, that an epidemic exists or that there is the danger of an epidemic, and while the proclamation exists the minister may give directions and take actions necessary to control, eradicate or remove the danger of the epidemic by way of quarantine or measures incidental to quarantine. 26, 27 the quarantine act 1908 is focused on preventing quarantinable diseases at ports of entry into australia. while there is still benefit in this focus, it is inadequate for a world where international travel is now primarily by aircraft, and passengers can travel from one country to another before they even realize that they are sick. 33 as a canadian report on severe acute respiratory syndrome (sars) noted, 'sars has illustrated that we are constantly a short flight away from serious epidemics'. 28 while previous outbreaks of pandemic influenza have traditionally taken 6-8 months to spread globally, 29 aided by international air travel, pandemic influenza could spread globally within 3 months. 30 this potential for quarantinable diseases to emerge within domestic populations raises questions about the scope and applicability of quarantine laws in these circumstances. however, it has been argued that the broad scope of quarantine under the act, the fact that quarantine powers are not restricted to ports of entry, and the ability for state laws to be over-ridden in emergencies suggests that the federal quarantine power could also have domestic application. 31 domestically, state public health laws are also relevant to the notification and control of communicable diseases. in new south wales, for example, sars and avian influenza in humans are both notifiable diseases under the public health act 1991. 32 state public health laws also contain a range of measures to enable health authorities to restrict the spread of disease, including powers to require medical testing and, in some cases, powers to restrict movement or to specify treatment of individuals who are regarded as posing a risk to public health. a the intersections between federal and state laws are relevant to australia's responses to public health threats. as howse has noted, 'in a public health emergency caused by the spread of an emerging infectious disease, australia could need to rely on a patchwork of legislative measures to assist it to cope'. 34 in australia and elsewhere, cross-jurisdictional and interagency cooperation are essential components in effective emergency responses. 35, 36 at an international level, the international health regulations (ihr) provide a framework for notification and response to infectious diseases. first introduced in 1951 as the international sanitary regulations, and renamed in 1969, the ihr required member states to notify the world health organization of cases of plague, cholera and yellow fever. prior to 1981, smallpox was also on the list of notifiable diseases. however, the ihr became increasingly irrelevant during the 20th century with the re-emergence of old diseases such as tuberculosis, the emergence of new diseases such as sars, and the threat of biological weapons. 37, 38 a revised version of the ihr was adopted in 2005 and took effect from 2007. the ihr (2005) seek to balance public health responses to disease against the needs of international traffic and trade, and rest on the principle that public health responses should not unnecessarily interfere with international traffic and trade. while the ihr (2005) has a list of specified diseases, including sars and smallpox, which must be notified to the world health organization, the ihr (2005) also move beyond the specified-diseases approach and adopt a broader approach with focus on events which could constitute a public health emergency of international concern. using a decision algorithm, countries are required to assess public health events in order to determine whether the event is a public health emergency of international concern. if the event is of international significance, notification to the world health organization is required. the new ihr focus on risks to health, and provide a more flexible and relevant approach to identification of those risks. 39, 40 the ihr (2005) focus on the development, strengthening and maintenance of capacities at national level to respond to public health emergencies of international concern. as outlined above, the legislative frameworks in australia for public health responses to infectious diseases are shaped by australia's federal legal system, and will also be relevant to the responses in other countries with a federal structure. in becoming a signatory to the ihr (2005), the usa submitted a reservation to the ihr on the basis of federalism, noting: 'the government of the united states of america reserves the right to assume obligations under these regulations in a manner consistent with its fundamental principles of federalism. with respect to obligations concerning the development, strengthening and maintenance of the core capacity requirements,.these regulations shall be implemented by the federal government or the state governments, as appropriate and in accordance with our constitution, to the extent that the implementation of these obligations comes under the legal jurisdiction of the federal government. to the extent that such obligations come under the legal jurisdiction of the state governments, the federal government shall bring such obligations with a favourable recommendation to the notice of the appropriate state authorities.' b in australia, the pandemic influenza planning process has taken a whole of government approach, with the planning process involving both federal and state levels of government. in 2007, the national health security act 2007 (cth) was passed. part 2 of the act deals with public health surveillance and has as its objects: provision of a national public health surveillance system to enhance the ability of commonwealth, states and territories in identifying and responding to 'public health events of national significance'; information sharing with the world health organization and 'countries affected by an event relating to public health or an overseas mass casualty'; and 'to support the commonwealth, and the states and territories in giving effect to the international health regulations'. 41 in april 2008, the commonwealth, state and territory governments signed the national health security agreement to support the national health security act and to ensure a coordinated approach between the different levels of government in the event of a public health event of national significance. in 2006, the national pandemic influenza exercise, exercise cumpston 06 enabled the testing and assessment of australia's pandemic preparedness through the use of a comprehensive simulation exercise. 42 quarantine laws and public health laws do give governments some fairly broad powers to declare quarantine and to restrict the movement of individuals. there is a very real sense in which these powers may well be needed in order to ensure an effective public health response to pandemic influenza. however, these laws are also clearly situated within a broader social context. our perceptions of individual liberty and individual rights have undergone considerable evolution since most of our public health laws were originally introduced. today, the public is likely to have high expectations about the preservation of individual liberty and freedom of movement. these expectations underpin the political context for the development and application of public health laws in australia. appropriate responses to these expectations will also play an important role in addressing community unease and potential disobedience to the implementation of response measures. when seeking to clarify public health laws, it is important that we take this broader social context into account. as gostin notes in his definition of public health law outlined above, public health laws are not only about articulating the coercive powers of the state for enforcement of public health measures, but also about the limits of state power and the rights of individuals and communities. the language of human rights is increasingly part of the landscape for health law in australia and a see, for example, public health act 1991 (nsw) s 23. internationally. [43] [44] [45] given the potential for public health laws to impact upon the freedom of individuals, and the need for public health laws to balance the interests of individuals and society, public health laws will ideally have a transparent ethical framework, articulating the principles upon which state intervention will be premised. 46 the world health organization has acknowledged the importance of legal and ethical considerations to pandemic preparedness, noting that public health measures such as quarantine, compulsory vaccination and off-licence use of medicines 'need a legal framework to ensure transparent assessment and justification of the measures that are being considered, and to ensure coherence with international legislation (international health regulations)'. 47 consideration of ethical issues is also essential for, as the world health organization has noted, ethical issues 'are part of the normative framework that is needed to assess the cultural acceptability of measures such as quarantine or selective vaccination of predefined risk groups'. 48 the exercise of state powers in terms of quarantine, isolation and detention during a public health emergency is likely to be particularly controversial in western liberal democracies such as australia. the extent to which the state can and should exercise its powers in this area has become increasingly relevant in public health, as is clear from debates over detention of tuberculosis patients, 49, 50 and from the use of quarantine during the sars crisis. 51 although comparable countries to australia in europe, the usa and canada all have human rights charters or equivalents, which could provide procedural protections and safeguards for citizens in relation to quarantine and detention, australia has yet to develop a bill of rights at the federal level. while australian state and territory governments have begun enacting human rights legislation, 52 there is no comprehensive inclusion of human rights safeguards in the federal quarantine act, which raises issues about the mechanisms for ensuring procedural safeguards in the event of a pandemic. 53 public health measures directed at implementing social distancing, quarantine or travel restrictions will not only infringe on individual liberties that are often taken for granted in western societies, but are also likely to have a profound economic impact. as outlined above, estimates indicate that pandemic influenza will have a significant impact on the global economy. at local level, businesses may be closed or experience a reduction in their cash flow as public health measures are introduced or people stay home voluntarily. in such an environment, the economic cost to individuals and businesses may be significant, which in turn demands consideration of development of support systems and compensation systems for those affected. 54 in the usa, a great deal of work has been done on strengthening the public health laws, both generally and specifically for public health emergencies. the turning point public health statute modernization national collaborative developed the turning point model state public health act. 55 in 2001, the centre for law and the public's health at georgetown and johns hopkins universities prepared a model state emergency health powers act, setting out the powers for a state of public health emergency. the provisions of the earlier model state emergency health powers act were adapted and included in the turning point model act. 56 article v of the turning point model act deals with the powers of public health authorities, including the powers of quarantine and isolation. the model act provides that the principles to be applied in relation to quarantine and isolation include that they should be by the least restrictive means necessary to prevent the spread of disease (s 5-108[b](1)). in addition, there is a provision that: 'the needs of individuals who are isolated or quarantined shall be addressed in a systematic and competent fashion, including but not limited to, providing adequate food, clothing, shelter, means of communication with those in isolation or quarantine and outside these settings, and competent medical care.' (s 5-108[b](6)) article vi of the turning point model act deals with public health emergencies, and contains provisions addressing: planning for a public health emergency; declaring a state of public health emergency; management of property, safe disposal of infectious waste and human remains, and control of healthcare supplies; protection of individuals; immunity from private liability; and payment of just compensation for the use or appropriation of facilities or materials. the turning point model act is intended as a tool to enable governments to assess their existing public health laws. the turning point model act not only sets out the rights of the state in terms of its coercive powers, but also the responsibilities of the state to care for those who are isolated or quarantined. these matters are important if we are to see public health laws as a matrix of both rights and responsibilities. if individual autonomy is to be constrained in the name of public health, we also need to ensure that individual dignity, and ultimately social dignity, is maintained. non-pharmaceutical measures may have a significant community impact. consideration may need to be given to support mechanisms if voluntary, stay-at-home forms of quarantine or isolation are used to limit the spread of influenza in the community. there is also a need to consider the flow-on effects of some of our public health measures. if schools are closed, for example, this may have an immediate impact on the broader workforce in a context, such as the contemporary australian one, where significant numbers of women with children are in the paid workforce. rights and responsibilities are multilayered. they arise at local, national and global levels and at the intersections between these levels. what is clear is that public health rights and responsibilities for infectious disease are global as well as national. if we are to assess the adequacy of our legal frameworks for pandemic preparedness, we also need to assess the adequacy of our laws in terms of their suitability for meeting our international obligations. while developed countries of the world already have sophisticated public health systems, the capacity to meet their obligations under the ihr (2005), and the financial resources to develop national vaccine stockpiles, the developing countries of the world face a very different outlook. 57 as we consider the intersections of law and public health in the context of the shared global risks of an influenza pandemic, it is important to realize that pandemic preparedness must necessarily involve improved international cooperation and the sharing of expertise to assist in capacity building for public health and the regulatory frameworks surrounding it, as well as a renewed dialogue around international obligations to help the world's poorest and least healthy people. 58 legal analysis must be a key part of our planning for pandemic influenza. it is essential that federal and state laws are harmonized so as to ensure their smooth functioning and to eliminate crossjurisdictional differences and uncertainties. public health laws also play a key role in setting out the rights and responsibilities of individuals, communities and governments, providing transparency and accountability to the frameworks for decision-making. in contemporary australian society where there are high expectations of individual rights and freedoms, and of the public health system, public health laws have an important role to play in ensuring that, as far as is possible, the public's health and the public's freedom are both balanced and protected. effective preparedness for pandemics does not end at national borders. pandemic influenza will affect all parts of the globe, leaving no country untouched. as we prepare for the next influenza pandemic, we must remember that global cooperation is also an essential part of effective preparedness. none sought. none declared. avian influenza: assessing the 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organization international monetary fund. the global economic and financial impact of an avian flu pandemic and the role of the imf public health law and regulation centre for public health law. emergency powers and cross-jurisdictional issues regarding outbreaks of communicable diseases managing emerging infectious diseases: is a federal system an impediment to effective laws? centre for public health law. emergency powers and cross-jurisdictional issues regarding outbreaks of communicable diseases assessing crosssectoral and cross-jurisdictional coordination for public health emergency legal preparedness from international sanitary conventions to global health security: the new international health regulations travel in a small world: sars, globalization and public health laws health law's kaleidoscope: health law rights in a global age the new international health regulations: an historic development for international law and public health office of health protection. national pandemic influenza exercise: exercise cumpston 06 report. canberra: australian government, department of health and ageing will international human rights subsume medical ethics? intersections in the unesco universal bioethics declaration health law's kaleidoscope: health law rights in a global age the proliferation of human rights in global health governance world health organization. ethical considerations in developing a public health response to pandemic influenza. geneva: world health organization world health organization. who checklist for influenza pandemic preparedness planning. geneva: world health organization world health organization. who checklist for influenza pandemic preparedness planning. geneva: world health organization detention and the evolving threat of tuberculosis: evidence, ethics and law through the quarantine looking glass: drugresistant tuberculosis, public health governance, law and ethics sars thrusts quarantine into the limelight for discussion, see williams g. the victorian charter of human rights and responsibilities: origins and scope times of pestilence: would a bill of rights assist australian citizens who are quarantined in the event of an avian influenza (bird flu) pandemic? pandemic and public health controls: toward an equitable compensation system public health statute modernization national excellence collaborative. turning point: collaborating for a new century in public health: model state public health act -a tool for assessing public health laws transforming public health law: the turning point model state public health act an exploration of conceptual and temporal fallacies in international health law and promotion of global public health preparedness the duty of states to assist other states in need: ethics, human rights and international law none declared. key: cord-028618-kn87q7nb authors: flinders, matthew title: democracy and the politics of coronavirus: trust, blame and understanding date: 2020-06-23 journal: parliam aff doi: 10.1093/pa/gsaa013 sha: doc_id: 28618 cord_uid: kn87q7nb this article explores the relationship between crises and democracy through a focus on the unfolding coronavirus pandemic. its central argument is that to interpret the current pandemic purely in terms of its epidemiology and public health implications risks overlooking its potentially more significant socio-political consequences. this is because the challenges posed by the coronavirus crisis have themselves become overlaid or layered-upon a pre-existing set of concerns regarding the performance, efficiency and capacity of democratic political structures. the aim of this article is to try and understand and warn against what might be termed a rather odd form of cross-contamination whereby the cynicism, negativity and frustration concerning politicians, political processes and political institutions that existed before the coronavirus outbreak is allowed to direct, define and automatically devalue how democratic structures are subsequently judged in terms of how they responded to the challenge. as such, this article focuses on the link between the coronavirus crisis and the democratic crisis; or, more precisely, the risk that the coronavirus crisis may mutate into and fuel a broader crisis of democracy. keeping democracy healthy during a pandemic has already proved problematic in many countries where politicians have seized upon the crisis in order to claim emergency powers and strengthen their position (hungary, israel, etc.) . at the same time, the victorious claims of countries such as china and singapore have raised potentially far-reaching questions about whether authoritarian regimes handle pandemics more effectively than democratic ones (see, e.g. kleinfeld, 2020) . the fact that this is happening in a global context that already contained an 'autocratization alert' (see v-dem, 2020) , concerns about 'democratic backsliding' (see idea, 2019) and an increase in populist pressures simply underlines this article's emphasis on the need to understand the link-or more specifically the interplay-between the 'new' covid-focused crisis and the pre-existing democratic crisis (on the latter see keane, 2020) . although this article is primarily focussed upon the uk the themes, issues and challenges that it highlights have a far broader international and global relevance. the link between the coronavirus and the crisis of democracy is explored and developed through a focus on three inter-related themes: trust, blame and understanding. the first section focusses on public trust in politics before the pandemic emerged and how the outbreak appears to have affected public attitudes. the interesting element of this discussion is the contrast it offers with the public's trust in scientists and experts and the implications this has in terms of culpability, credit and censure. this brings the discussion to a second focus on the issue of blame in the second section. the simple argument is that if previous pandemics offer insights into the post-crisis politics of coronavirus it is likely that a series of intense and multi-dimensional blame games will rapidly emerge. the main focus of this section is upon the early emergence of potential blame-limitation strategies within the british government's approach. this focus on scapegoats, sacrificial lambs and self-preservation strategies flows into a third and final focus on tolerance and understanding. the aim being to acknowledge the realities of decision-making and governing under pressure in times of crisis and through this develop an argument concerning balance, empathy and proportionate scrutiny. the manner in which a large number of legislative select committees have already announced their intention to launch pandemic-linked inquiries, not to mention demands for wider national and international in-depth reviews, underlines the contemporary relevance of this argument. taken together, a focus on these three topics (trust, blame and understanding) provides a buckle or link through which the relationship(s) between the coronavirus crisis and crisis of democracy can be understood. the aim of this section is to make three relatively straightforward arguments about levels of public trust in elected politicians. the first is that the coronavirus crisis emerged at a time of fundamental concern about the global state of democracy; the second is that the limited data that is currently available suggests the existence of a common crisis-linked 'rallying around the flag' effect; and (third) that this uplift in public confidence and trust may well prove to be short-lived. as a first-step to substantiating these arguments, table 1 provides a precis of the core findings of a number of authoritative and evidence-based reviews on the taken together, the core conclusions suggest that the anxieties that have surrounded democracy for at least half a century have in recent years grown in scale, complexity and intensity. this is linked to the emergence of a clear populist signal, the growth of anti-political sentiment and-critically-the emergence of a clear 'trust gap' between the governors and the governed. within this democratically dubious context the uk held a particularly prominent position due to a combination of generalised and long-standing concerns regarding the nature and limits of a majoritarian power-hoarding democracy plus more specific and related concerns regarding the country's relationship with the european union. the hansard society's 16th audit of political engagement (2019) provides a powerful evidence base for these arguments and its headline findings can be summarised as: • opinions of the system of governing are at their lowest point in the 15-year audit series-worse now than in the aftermath of the mps expenses scandal; • people are pessimistic about the country's problems and their possible solution, with sizable numbers willing to entertain radical political changes; and • core indicators of political engagement remain stable but, beneath the surface, the strongest feelings of powerlessness and disengagement are intensifying. it would at this point be possible to drill-down into each of these points through the provision of evidence-based insights such as: 72% of those surveyed said the system of governing needs 'quite a lot' or 'a great deal' of improvement; asked whether the problem is with the political system or the people running it 2019 was the 14th consecutive year of decline in global freedom drift towards 'division and dysfunction' global phenomenon in which freely elected leaders distance themselves from political norms the largest response group (38%) replied 'both'; 50% of those surveyed believed the main parties and politicians did not care about people like them; 75% thought political parties were too internally divided to serve the best interests of the country; 63% thought britain's system of government is rigged to advantage the rich and the powerful; the number who 'strongly disagree' that political involvement can change the way the uk is run (18%) had hit a 15-year low; as had the 47% who felt they had no influence at all over national decision-making. if this was not bad enough, then the 2019 survey also detected hints of what might be interpreted as an illiberal swing away from the core tenets of liberal democracy. when it came to the public's levels of confidence and trust in different professions, for example, the 'military/armed forces' (74%) and 'judges/courts' (62%) scored far higher than mps (34%) or members of the government (33%). added to this was the fact that only 25% of the public had confidence in mps' handling of brexit (with the government faring only slightly better on 26%). of particular concern was that over half (54%) of those surveyed agreed with the statement that 'britain needs a strong leader willing to break the rules', and 42% thought that many of the country's problems could be dealt with more effectively if the government did not have to worry so much about votes in parliament. the ipsos mori veracity index-published just days before the 2019 general election-found that public trust in politicians had fallen to just 14%, a 5% fall from 2018. professors were, by contrast, highly ranked at 86% but government ministers lowly ranked at 17% which represented a level of distrust far greater than that even suggested by the hansard society's audit of political engagement but which did resonate with the broader data and evidence on the global state of democracy (see table 1 , above). the gap, or more precisely chasm, between public trust in scientists/experts/professors, on the one hand, compared with politicians on the other, is striking and forms a central element of arguments offered later in this article. it is, however, worth noting at this early point that the edelman trust barometer's 'trust and the coronavirus' report of 1 april 2020 that surveyed 10,000 people across ten countries found that: 85% of respondents agreed that 'we need to hear more from the scientists and less from politicians'; 58% were concerned about the politicisation of the crisis ('certain people are making the situation seem worse than it is for political gain'); and that scientists were trusted to tell the truth by 83% of those surveyed, compared to 51% who trusted their prime minister or president. the aim of emphasising these statistics on (dis)trust is simply to underline that the health of democracy was not in good shape when the pandemic emerged and that populists had for some time been fuelling and funnelling public frustration in an attempt to gain power and legitimate the construction of 'strong leader' illiberal democracies (i.e. what the institute for democracy and electoral assistance refer to as 'democratic backsliding'). the obvious risk, and one that has already come into fruition in some countries, is that the pandemic will be used by populists to further dilute or remove democratic safeguards (what daniel levitsky and daniel zilatt refer to in their hopefully not prophetic 2018 book how democracies die as the 'soft handrails' that checks-and-balances provide) as part of the 'autocratization' process that the varieties of democracy project has warned against. the issue of public trust therefore provides the first strand in the link between the coronavirus crisis and crisis of democracy. but what is interesting in this regard is that the immediate impact of the pandemic appears to have been a sharp increase in the popularity of incumbent national leaders (see jennings, 2020) . two elements stand out within this general trend: the first is that the 'boris bounce' was exceptional, rising to 52% by mid-march 2020 (up 16% from his ratings just before the december 2019 general election); the second is that the 'trump jump' fell fairly flat when compared with the spike in public support enjoyed by most leaders. although approval ratings are very different to precise trust-based assessments, they do point to the existence of a social phenomenon that political science has identified for some time and that is certainly related to questions of trust-'the rallying around the flag effect'. this concept was first coined by john mueller in 1970 and relates to the observation that groups tend to unify in times of crisis and at the national level, this is commonly exhibited through support for national leaders. the march 2020 'boris bounce' is essentially the uk's equivalent of a 'rallying around the union jack effect' but it is dissecting and understanding this change in social attitudes that more light can be spread on the emergent politics of coronavirus and in this regard three issues deserve brief comment. the first two issues concern the two main and inter-related variables that are generally offered by scholars to explain this effect. the first of these emphasises the social-psychological dimensions of a crisis and particularly the power of patriotism (for a discussion, see baker and oneal, 2001) . in times of crisis, national leaders are, the theory suggests, viewed as almost the embodiment of national unity fighting the crisis for the public good, which is especially significant when the leader is both head of state and head of government as in the usa. the second theory, that has been explored in the work of hetherington and nelson (2003) amongst others, believes that the rallying effect occurs due to more institutional reasons and particularly due to the opposition's general reluctance to openly attack the government during a clear crisis. a reduction in 'attack politics' by opposition parties leads to less conflict being reported in the media and so, this approach suggests, the public assumes the government must be performing better than normal. the public may not trust their political leaders but they might view them as competent in terms of governing capacity which leads to a third and final point about rallying around flags-it usually does not take long for 'fleeing the flag' to occur. this is a critical point. although most analyses of 'rallying around the flag' effects are concerned with wars, invasions or terrorist attacks with a clear enemy, rather than public health pandemics in which the enemy is a new strain of virus, the overall conclusion is that the 'rally effect' is usually short-lived. the public is fickle and it may be just one or two months before public opinion returns to pre-crisis levels. in the uk, there are already suggestions that the public's support for the government's approach and levels of trust in key ministers was by early april 2020 already waning (see opinium, 2020) . this fall in public support may well reflect the existence of major concerns about unpreparedness and indecision within the government which was underlined in the sudden shift from a focus on 'herd immunity' and basic precautions (notably handwashing) to a policy of legally enforced social distancing and 'lockdown'. from personal protective equipment to the repatriation of citizens, through to the availability of ventilators and questions concerning the police's use of 'lockdown' powers, not to mention mix-ups, muddles and misunderstandings concerning virus-testing and care home policy, a range of issues have combined to produce accusations that the government's response has been little short of 'a disaster' (see jenkins, 2020) . this raises at least two issues that emerge out of this section's focus on trust and serve to refocus attention back on the link between the specific 'covid crisis' and broader 'crisis of democracy'. the first revolves around the issue of blame and warns against the political system going 'mad' in the sense of falling victim to 'multiple-accountabilities disorder' (koppell, 2005) and the scapegoating, scalp-hunting and sacrificial practices that usually come with it. the second (flip-side) issue underlines the need for public understanding in the sense of not only appreciating the realities of crisis management situations but also about the manner in which coronavirus is itself being politicised by different actors. the first of these themes is the focus of the next section. amongst the contemporary chaos, there are three predictions that can be made with relative certainty. the first is that around a year from now there is going to be a baby boom which will reflect what those couples that have enjoyed spending time together have been up to. the second is that the baby boom is likely to be matched by a similarly spectacular increase in divorces (reflecting those couples that did not enjoy spending so much time together). the final confident prediction is that in just a matter of weeks or months the 'covid crisis' will lead to an outbreak of divisive and disruptive political blame games as politicians, policymakers, advisers and experts all seek to avoid carrying the can for those decisions or opinions that inevitably turned-out to be wrong. it is in the context of this core prediction that this sub-section makes three arguments: (i) the analysis of previous pandemics exposes the existence of a powerful socio-political 'negativity bias'; (ii) politicians will try and manage this situation through a mixture of blame-games and self-preservation strategies; and (iii) it is already possible to identify a dominant strategy in the uk context that for the sake of brevity can be labelled 'hugging the experts'. when it comes to considering the link between public trust and blame even the most cursory review of the existing scholarship on how governments have attempted to cope with pandemics in the past reveals a body of work that is primarily framed around the notion of 'policy failure'. this is a critical point. no matter what steps a government might take or how quickly measures are put in place the fact that by its very existence a pandemic brings with it crisis and chaos intermixed with death and suffering ensures that any governmental response will be seen in generally critical terms. the title of greg behrman's 2009 book the invisible people: how the u.s. has slept through the global aids pandemic, the greatest humanitarian catastrophe of our time reflects this point. although it could actually be seen as fairly successful in terms of protecting life, the political reaction to the severe acute respiratory syndrome pandemic at the beginning of the millennium is generally critiqued in terms of either over-reaction or under-reaction (see, e.g. freedman, 2005; hooker and harr aliis, 2009 ). add to this, the manner in which 'what went wrong?' seems to be the dominant lens through which responses to both swine flu and ebola are judged and the link between pandemic control and blame attribution becomes clear (see kamradt-scott, 2018) . but what is also interesting about this seam of scholarship on pandemic crisis management is the manner in which it is infused with discourses not only of political blame and counter-blame, but also with discussions of self-blame, notions of shame and an awareness of the cultural apportionment of blame to specific countries or communities that is generally not discussed within the fields of public administration, executive studies or mainstream public policy (see, e.g. abeysinghe and white, 2011; nerlich and koteyko, 2012) . a link is, however, provided in the work of cáceres and otte in their work on blame apportioning and the emergence of zoonoses (i.e. diseases that can be transmitted from animals to humans) during the last 25 years when they note: [b]lame games take place between infected and non-infected regions, as well as between developed and developing nations. apportioning of blame, more commonly known as finger pointing, is an inherent feature of human beings. this blaming process can be either active or passive depending on the issue(s) and given context(s). evidently, blaming is used to shift responsibilities onto others, it singles out a culprit, finds a scapegoat and pinpoints a target, regrettably however, apportioning blame comes at a cost to those that are blamed. expanding our epidemiological understandings into the realms of blamers and blamed permits a more realistic, emphatic and conscientious look into the unintended consequences of individual and institutional actions, and the extent to which other countries or regions are detrimentally affected by misguided pre-conceptions. (cáceres and otte, 2009, pp. 377-378) this focus on the 'cost' of blame and 'unintended consequences' brings us to a second argument and the suggestion that the politics of the coronavirus pandemic (in the uk and beyond) is already beginning to revolve around the issue of blame (blame-shifters, blame-shiftees, blame-boomerangs, etc.). in this regard, political science offers a rich seam of scholarship on blame avoidance behaviour that arguably dates back to at least machiavelli but has more recently been developed in the work of scholars including r. kent weaver (1986) and christopher hood (2013) . synthesised and simplified down to its core elements, this body of work reveals how politicians are primarily motivated by avoiding blame for failure rather than trying to claim credit for success for the simple reason that the public possess a strong 'negativity bias'. praise will be as fickle as it is short-lived, whereas vitriol will be as strong as it will long-lived. the implication being that politicians will use all sorts of tricks and tactics-agenda-shaping, scapegoating, buck-passing, deflection and secrecy as part of a deeper 'teflon immorality' (see smilansky, 2013) -in order to keep themselves blame free. the relevance of this literature to the link between the coronavirus crisis and the broader crisis of democracy is the manner in which it connects the focus on public trust (discussed above) with the performative and substantive content of governmental policy responses. in this regard, the work of christopher hood on 'the risk game and the blame game' (see table 2 , above) is particularly valuable for at least three reasons: first, it highlights the range of blame-avoidance strategies that politicians can utilise (notably presentational strategies, policy positions and the delegation of responsibility to arm's-length agencies); secondly, it contextualises the use of these strategies through an emphasis on public attitudes; and thirdly, it highlights that blame-shifting can backfire if those to whom responsibility is directed push back (hence the emphasis on blame-reversion, boomerangs and lightning-rods). the key question then becomes how this framework contributes to our understanding of the unfolding politics of coronavirus? working across a very wide and fluid empirical landscape and using a fairly broad analytical brush, the main answer to this question can be summarised as follows. first and foremost (and as the previous section emphasised), public attitudes to politicians, political processes and political institutions were in fairly poor health in most advanced liberal democracies as the pandemic emerged. high levels of political frustration, apathy and anger were identified within large sections of the public and this had led to the emergence of a potentially democratically dangerous level of anti-political sentiment. in contextual terms and with table 2 in mind, public attitudes were arguably leaning more towards the 'vindictive' than the 'sympathetic' vis-à-vis hood's schema and this matters because the literature on pandemics and disease control clearly shows that whether the public is willing to follow government advice is highly dependent on preexisting levels of political trust, hence its common focus on 'crying wolf', metacommunication patterns, 'epidemic intelligence' and 'vaccine hesitation' (see nerlich and koteyko, 2012; mesch and schwirian, 2015) . the lack of pre-existing public trust may well have significant implications in terms of preventing what has been variously labelled 'crisis fatigue' or 'lockdown fatigue' (flinders, 2020) amongst the public and a reluctance to abide by social isolation advice. the fact that in the uk these risks exist in the context of well-documented 'brexit fatigue' underlines the manner in which the coronavirus crisis cannot be studied in isolation and should more accurately be conceived as being layered-upon or interwoven with a complex patchwork of challenges. a second way in which hood's framework helps focus attention on the pandemic-democracy link, in general, and blame, in particular, is through the identification of specific blame-avoidance strategies. in the uk, there has arguably been a very clear strategy at play which has revolved around the adoption of a technocratic, science-based and evidence-led approach that has ensured that no government statement has been made without the explicit caveat about 'following the advice of the experts'. this 'hugging the experts' is possibly even a future blameavoidance tactic in preparation that represents an amalgam of presentational, policy and delegatory elements. the sight of boris johnson or other senior ministers flanked at the daily press conferences by the chief medical officer and chief scientific advisor is without doubt a strategic performative act of blame-sharing and blame-displacement. this is by no means unique to the uk. in some countries, a new public service bargain seems to have emerged whereby the politicians depart the stage to an almost total extent and let the experts become the public face of the crisis. take, for example, anthony fauci, the director of the national institute of allergy and infectious diseases in the usa, fernando simó n, the head of health emergency centre in spain, christian drosten, the head of virology at charité hospital in germany, jérô me salomon, head of the national health authority in france and prof. chris whitty and sir patrick vallance in the uk (the chief medical adviser and government chief scientific adviser, respectively). as jon henley (2020) has illustrated, its 'the experts' that are now the household names. not only does this raise issues about the political selection of expert advice (discussed below) but it also raises questions about the political protections afforded to scientists who become drawn into major debates and may become blame-shiftees or sacrificial lambs when the scrutiny industry kicks-in. and 'kick-in' it will. a third way in which the literature on blame games is relevant to the current coronavirus crisis is due to the manner in which it underlines the aggressive and adversarial nature of public accountability. this is encapsulated in the notion of the 'negativity bias' and simply reflects that manner in which political decisions are generally taken in a low-trust, high-blame environment. put slightly differently, public accountability is generally of the 'gotcha!' variety (which is a particularly problematic paradigm when placed within the contours of hilliard et al. (2020) scholarship on 'the perils of accountability after crisis'). the aim is very rarely to undertake a reasoned, balanced or proportionate review of what happened in order to learn lessons but primarily to apportion blame and demand some form of sacrificial responsibility. this is particularly true in power-hoarding majoritarian democracies like the uk and especially due to the focussing impact of the convention individual ministerial responsibility to parliament. any attempt by ministers to deflect blame therefore risks bouncingback on them in the form of a 'blame boomerang' if the expert, scientist or publicly trusted professor refuses to be scapegoated. the fact that the dark clouds of intense public and parliamentary scrutiny are already visible and hanging over the coronavirus is symptomatic of the potentially pathological politics of accountability that this section is attempting to underline. the world health organisation declared the outbreak to be a pandemic on the 11 march 2020 and by the end of the second week of april 2020, 15 parliamentary committees had public administration and constitutional affairs has announced its intention to call ministers to account on the topic but it has not launched a formal inquiry (yet). already announced inquiries (some multiple inquiries) into various elements of the government's response (see table 3 , below). the number or range of select committee inquiries-or, for that matter, any forms of public accountability process-is not the issue. the point being made relates to the nature and ambitions of those scrutiny processes and whether they themselves become part of the problem with democracy, due to a focus on scalphunting and shallow adversarialism that is devoid from any appreciation of the realities of crisis management, or part of the solution, in terms of promoting a balanced assessment of what went wrong, why and how similar patterns might be avoided in the future. in essence, this is the argument relating to understanding that forms the focus of the next and final section but before engaging with this argument it is necessary to conclude this section with a very brief discussion of three final blame-related insights. the first is that it is likely that the coronavirus crisis will serve to redefine the scholarship on blame-shifting just as it is likely to alter the contours of the debate concerning democracy. the complexity and intricacies of crisis responses will somehow have to be accommodated within models that have generally been constructed around and within the notion of national systems. and yet we can already see the emergence of global blame games wherein specific and primarily american politicians and organisations are attempting to blame china for the crisis (see henderson et al., 2020) ; while china seeks to pass the buck back to the usa in what has become a 'war of words' amidst covid-19 (see the straits times, 2020). donald trump is widely interpreted as trying to scapegoat the world health organisation by withdrawing american funding. european blame games are also beginning as, for example, italy blames the european union for being too slow to help member states (see boffey, 2020) . within the uk cracks and pressure-points are already beginning to appear as tensions grow between departments, ministers, officials, agencies and advisers as the prospect of public scrutiny become ever more immediate. this brings us to a second issue and the 'blame attraction' or 'buck stops here' qualities (see table 2 , above) that come with being a minister. despite the cross-governmental nature of the challenge, in strict constitutional terms, it is the secretary of state for health and the prime minister who are likely to emerge as the 'lightning rods' when it comes to the allocation of blame and as key targets when it comes to demands for a 'sacrificial lamb' to carry-the-can. and yet even here the curiosities of coronavirus may well defeat conventional understandings. on the one hand, the emergence of the health secretary from virus enforced self-isolation on the 2nd april to announce that mistakes had been made and that a u-turn on testing policy was needed that would see capacity increased to 100,000 tests a day by the end of april was a clear attempt to bolster public confidence by taking very clear personal responsibility for the target; on the other hand, the announcement that the prime minister had been taken to hospital and then moved into intensive care potentially insulates him from some element of blame, and may well fuel a second 'rallying around the flag' effect for the government as the media and opposition parties soften their stance. although there is evidence to support this claim, it might be more accurate to identify the existence of a post-hospitalisation surge in support for the prime minister rather than the government. boris johnson was discharged from hospital on the 12 april 2020 and a yougov approval rating poll conducted at the time found a staggering leap in the proportion of the public who thought he was doing 'very well' as prime minister (30%, up from 14% in mid-march), with 36% suggesting he was doing 'fairly well' (up from 32%). boris's teflon-coated qualities and blame-avoidance behaviour have been discussed throughout his political career and he has been known to adopt cunning exit strategies in the past when faced with tricky situations. nevertheless, the notion of 'medical distancing' as a blame avoidance strategy would be extreme even for this most unconventional politician and boris appears to be more popular than ever, possibly to the despair of his opponents. that said, the core argument of this section remains true: the coronavirus crisis is likely to spark a veritable tsunami of complex and aggressive blame games. this creates a strong risk that the structures of democratic governance will themselves fall victim to the painful politico-administrative malady that is generally labelled going 'mad' (i.e. koppell's (2005) 'multiple accountabilities disorder'). this occurs when politicians and their officials are expected to account through so many different accountability channels and to so many scrutiny bodieswhich themselves often demand very different forms of information and are blame-orientated rather than understanding-focussed-that they are distracted from focussing on their core tasks. put slightly differently, mad occurs when senior staffs are expected to spend too much time 'accounting-up' instead of focussing on 'delivering-down' which, in turn, increases the chances that mistakes and errors will be made which would, in turn, simply increase the scrutiny placed upon them. the potential pathologies of highly politicised accountability, as matthew flinders (2011) has demonstrated, means that too much accountability can be as problematic as too little. this leads the discussion to a possibly unexpected focus on understanding as the final strand that connects the coronavirus crisis to the crisis of democracy. democratic politics, as bernard crick sought to explain in his defence of politics (1962), is a rather rough and ready affair. it grates and it grinds, it is frequently cumbersome and generally clunky, it can be inefficient and its basis on the art of compromise can make it difficult to understand for those that are not intricately connected with those processes. it is messy. and yet those characteristics are from crick's perspective not failings but elements of the very beauty of politics; they reflect the simple manner in which politics is charged with somehow generating broadly acceptable decisions and choices in an environment that is increasingly defined by complexity and incompatibility. it would, of course, be possible to make politics smoother and more efficient, to impose clarity and clearer control mechanisms through a uniformity of style and structure. but the cost of such measures would in all likelihood be a decline in the sensitivity of that system to the rights and views of the individuals and communities within it. this matters because at the heart of any understanding of the link between the coronavirus and the crisis of democracy, there has to be a fundamental understanding of the existence of inevitable trade-offs and dilemmas. the existence of these dilemmas is generally far more apparent in times of crisis due to the emphasis that is generally placed on the responsive capacity of the state rather than on the democratic sensitivity of the system. tough decisions will have to be taken quickly, on the basis of imperfect information and without the possibility of extensive consultation and compromise in what might be seen as a capacity/democracy trade-off. understanding the rationale, logic and implications of this shift are critical not just in terms of how it flows through to influence public trust, or how it structures subsequent blame-games but also due to the manner in which it shapes the ideational space-the simple realm of ideas-about how assessments regarding the future of democracy should be made. in order to understand this focus on understanding and demonstrate its centrality to this article's central focus on the nexus between the current covid-19 crisis and broader debates concerning the crisis of democracy, this section adopts a multi-levelled approach. this takes us from a micro-level understanding of politicians as individuals operating in a crisis context; through to a mid-range governmental focus on understanding and gauging 'policy success' as well as 'policy failure'; to a final macro-political focus on the grand narratives and regime battles that coronavirus appears to have unleashed. taken together, what this three-level focus on understanding provides is a fresh and timely analysis of how two very different crises have come to be inter-woven with the risk that one (i.e. covid) will be politicised and utilised in order to inflame the second (i.e. democracy). defending democracy-or more specifically promoting an understanding of its inner beauty, inescapable inadequacies and the inevitable trade-offs that come with any choice of organising society-has therefore been the underlying ambition of this article. this is a point that brings us to begin by reflecting on the scale of the challenge; not in relation to defending democracy but more specifically in relation to the challenges posed by coronavirus. this is a new virus, it can be highly aggressive and it is easily transmitted. with this in mind, it is possible to move across the three levels from the individual, to the system, to the basic notion of democracy. any defence of democratic politics must to some extent seek to defend politicians. although frequently demonised, derided and dismissed as self-serving and self-interested characters, the simple fact is that politicians are at the -end-of-theday humans, as the manner in which several leading politicians have succumbed to coronavirus reflects. notwithstanding clear concerns about patterns of political recruitment and the degree to which the political class reflect the diversity to be found within society, this does not alter the basic point that promotes some understanding of the practical and day-to-day pressures under which politicians generally operate. put slightly differently, 'governing under pressure' is incredibly demanding and an evidence-based debate about the mental health and well-being of politicians was already emerging before the coronavirus crisis emerged (for a review, see flinders et al., 2018 ) . these pressures increase as individuals assume the responsibilities of ministerial office and are particularly pronounced in times of crisis, especially when the source of the crisis is new and therefore no clear knowledge of 'what works' is available. crisis situations by their very nature demand that someone ultimately has to assume control and make decisions under extreme pressure, on the basis of imperfect information and in the full knowledge that they are dealing with matters of 'life and death' for which they will at some point be held to account. in a democracy, it is elected politicians to whom these decisions and situations fall. the public demands clarity ('when will lock-down end?', 'when will a vaccine be found?', 'what is going to happen next?') when politicians are themselves charged with grappling with uncertainty and cannot produce simple answers to complex questions. this may explain their strategy of 'hugging the experts' but as expert opinion itself divides and becomes more contested then so the ability of politicians to look to science for answers, at least in the short-term begins to wane. the micro-level argument is therefore simply one that promotes some understanding of the professional challenges and personal pressures that those who have at least dared to step into the arena and assume the burdens of office are attempting to manage. it would at this point be possible to explore the contemporary relevance of theodore roosevelt's 'it's not the critic who counts' speech of april 1910 but such temptations must be resisted in order to move to a second mid-level focus on understanding institutional change. the simple argument here is that although, as the second section (above) suggested, the response of democratic governments around the world is likely to be seen through interpretations of 'policy failure'-and some mistakes and failures will undoubtedly have occurred-it is also important to understand the scale of what has actually been achieved. in the uk, the whitehall machine and wider-state structures have demonstrated an ambition and agility that although not perfect cannot be denied. the scale of the achievements is worthy of reflection, irrespective of whether it relates to building new hospitals, launching new policies, negotiating new powers, liaising with other governments, co-ordinating a vast network of organisations and suppliers, calming and informing the public, reshaping the economy or building new financial safety nets. interestingly, it is possible to identify a strong 'negativity bias' within academe as well as within society more broadly. to enter the fields of public administration and public policy is generally a fairly depressing experience due to the almost obsessional focus of these fields on failures, catastrophes and disasters. the publication in april 2019 manifesto 'towards positive public administration' by scott douglas, paul t'hart and a large group of leading scholars was an explicit attempt to rebalance the analytical scales and promote an understanding of structural successes, policy achievements and democratic innovations. the mid-level argument is therefore one that seeks to promote some understanding of the structural and institutional accomplishments that have been achieved in the content of a truly exceptional and potentially transformative crisis. democratic politics has not been able to 'make all sad hearts glad' as crick admitted it never could in his defence over half a century ago and to some extent the covid-crisis has shown this, but at the same time its achievements in response to the public health pandemic should not be too easily dismissed. this argument matters because it underpins a far broader macro-political dispute about the global state of democracy and how the coronavirus is already reshaping the debate about regime legitimacy and state capacity. the danger of the 'credit-claiming' behaviour of china in containing the crisis through technologically powered surveillance is that it may engender an 'authoritarian appeal' or 'strong leader' effect that was to some extent already evident in many countries through the drift towards populism (see table 1 , above). 'the new coronavirus pandemic is not only wreaking destruction on public health and the global economy but disrupting democracy and governance worldwide' frances brown et al. (2020) have argued 'it has hit at a time when democracy was already under threat in many places, and it risks exacerbating democratic backsliding and authoritarian consolidation'. the geopolitical consequences of this can already be seen in the 'power grab' behaviour of some national leaders and also in the attempts by international actors to defend democracy. the existence of what dan kelemen (2020) has labelled an 'authoritarian equilibrium' within the european union has raised particular concerns. the decision of the secretary general of the council of europe to publish an open letter to the hungarian prime minister, viktor orbán, on the 24 march 2020 regarding the use of covid-emergency measures, plus the decision to launch a new eu action plan on human rights and democracy the very next day that is explicitly designed 'to defend human rights and democracy all over the world by using all our resources faster and more effectively', captures the sense that a new phase in the long-running tension between authoritarian and democratic regimes may well have started. understanding the dynamic and dialectical relationship between concerns regarding the crisis of democracy and the unfolding coronavirus pandemic is necessary in order to prevent a form of socio-political cross-contamination, whereby the cynicism, negativity and frustration concerning politicians, political processes and political institutions that existed before the coronavirus outbreak is allowed to direct, define and automatically devalue how democratic structures are subsequently judged in terms of how they responded to the challenge. without appreciating (i) the fragility and significance of public trust, (ii) the potentially pathological impacts of blame-games or (iii) understanding the achievements of individuals and institutions working together to address a collective threat, there is a very real risk that the coronavirus crisis will fuel a broader crisis of democracy. the avian influenza pandemic how to win the blame game patriotism or opinion leadership? the nature and origins of the "rally 'round the flag" effect italy critics eu for being slow to help over coronavirus epidemic how will the coronavirus reshape democracy and global governance blame apportioning and the emergence of zoonoses over the last 25 years daring to be a daniel: the pathology of politicized accountability in a monitory democracy coronavirus and the politics of crisis fatigue governing under pressure? the mental wellbeing of politicians sars and regime legitimacy in china the politics of blame: bargaining before an audience coronavirus: meet the scientists who are the new household names, the guardian anatomy of a rally effect: george w. bush and the war on terrorism the perils of accountability after crisis: ambiguity, policy legacies, and value trade-offs' the blame game sars and security: health in the addressing the ills, reviving the promise the british government's response to the coronavirus has been a disaster coronavirus: why boris johnson and other world leaders have become more popular during outbreak what went wrong? the world health organization from swine flu to ebola the new despotism the european union's authoritarian equilibrium do authoritarian or democratic countries handle pandemics the best pathologies of accountability social and political determinants of vaccine hesitancy presidential popularity from truman to johnson crying wolf? biosecurity and metacommunication in the context of the 2009 swine flu pandemic opinium (2020) opinium 'public opinion on coronavirus -1st april towards positive public administration: a manifesto teflon immorality" and the perversity of life us military may have brought coronavirus to wuhan, says china in war of words with us democracy report 2020: autocratization surges -resistance grows the politics of blame avoidance boris johnson approval rating tracker none. none. none. key: cord-283099-nhz3pye2 authors: wang, xue; han, jie; lichtfouse, eric title: unprotected mothers and infants breastfeeding in public amenities during the covid-19 pandemic date: 2020-07-21 journal: environ chem lett doi: 10.1007/s10311-020-01054-1 sha: doc_id: 283099 cord_uid: nhz3pye2 nan the outbreak of the coronavirus disease, named covid-19, has quickly spread at the global scale. on july 11, 2020, there have been a total of 12,286,264 confirmed cases worldwide (who 2020a) . recent studies related to air pollution have reported that the novel coronavirus could survive in the ambient air for several hours and potentially transmit through aerosols, especially in enclosed indoor environments with limited social distancing and poor ventilation (morawska and milton 2020; sharma et al. 2020; who 2020b) . when breastfeeding in public amenities, mothers can wear masks or cloth face coverings to protect themselves from respirable virus carriers in the air, while their infants cannot wear any respiratory protection to avoid direct exposure to the indoor air. with respect to the airborne transmission of covid-19, breastfeeding in public amenities therefore represents a blind spot in the current regulatory guidelines and risk mitigation efforts (cdc 2020; nhc 2020; who 2020c). here we outline the common issues in the current design of lactation facilities and the use of other public amenities by breastfeeding mothers, as a timely reminder on the potential risks to breastfeeding mothers and unprotected infants during the current pandemic ( fig. 1) . breastfeeding is the most effective way to ensure the health and survival of infants. for newborns, breastmilk is the ideal food because it is safe, nutritious and contains antibodies (who 2020d). while the covid-19 has been detected in human breastmilk (groß et al. 2020) , there has been no evidence to date suggesting transmission to infants via breastmilk, but this appears more and more likely because a recent report has evidenced transplacental transmission to the fetus followed by neurological manifestations (vivanti et al. 2020) . the world health organization (who) has recommended mothers with confirmed or suspected covid-19 infection to continue breastfeeding with necessary precautions (who 2020e). in the same vein, the american academy of pediatrics (aap) recommends mothers to consider extending the duration of breastfeeding to supply antibodies to their infants or toddlers during the current pandemic (aap 2020). overall, breastfeeding appears to be a good practice to maintain the health and reduce the risks for infants during the current pandemic, yet there is a need for sufficient lactation rooms in the public space. once a privileged facility, lactation rooms have become more common as a public amenity for lactating mothers and their infants. for instance, the us federal laws require that employers with over 50 employees must provide a placeother than a bathroom-for employees to give breastmilk to infants (ncsl 2020). some states require shopping malls, airports and public service centers to provide areas for breastfeeding (ncsl 2020) . a recent survey shows that only 77% of us airports display information on accesses to lactation rooms . in china, the national health commission requires that baby care rooms with an area no less than 10 m 2 should be provided at transportation hubs, commercial centers, hospitals, tourist attractions and other public places either wider than 10,000 m 2 or with more than 10,000 visitors per day (nhc 2016). the commission also recommends employers to provide lactation rooms under the same conditions. as a result, in september 2018, there were about 286,000 organizations across the country which had provided lactation rooms in their workplace in china (anonymous 2019) . overall, the number of lactation rooms has clearly increased, but their design and location may not be optimized. several issues have been evidenced in recently set-up public amenities for breastfeeding. for instance, many public lactation rooms are located in corners with an inadequate design, often as small, enclosed spaces with windowless walls. this is dangerous for the heath of mothers and babies because enclosed spaces such as schools and beauty salons are known to concentrate air pollutants (de gennaro et al. 2014; rogula-kopiec et al. 2018) . a survey of 105 lactation facilities in us university campuses revealed that over 80% of the designated spaces were structurally enclosed, and only about 40% of those places had in-room control of air temperature (henry-moss et al. 2019). worse, only 8% of the busiest us airport fulfilled the minimum requirements of space and facilities for a public lactation room (haight and ortiz 2014) . in china, while surveys are scarce, many lactation rooms and baby care rooms were found to be inadequate in sizes and ventilation (pmm 2018). for example, a survey of 60 public locations in three major chinese cities disclosed that only 24% of locations provided an adequate area of more than 10 m 2 for baby care (teng 2017) . moreover, 70% of those rooms were located next to public toilets, and only 35% of the rooms had good ventilation. this is a serious health issue because zhu et al. (2001) found severe contamination in indoor air by bacteria in baby care rooms at a hospital, resulting in an overall low compliance rate of 40% versus the national standard. in conclusion, many lactation facilities are inappropriate in terms of location, ventilation, temperature control and health security. mothers may therefore be tempted to find other locations. some mothers opt to breastfeed in public toilets as a secure place shielded from public views and free of intrusion by the opposite sex (sha 2017) . such practice, which is commonly perceived as breastfeeding in public, threatens the unprotected infants because human wastes carry a myriad of pathogens (haight and ortiz 2014; spurles and babineau 2010; datta et al. 2020) . indeed, pathogens could be transmitted not only by airborne transport of respiratory droplets, but also via the fecal-oral route from toilet flushing or poor hygiene. this is very likely because knowlton et al. (2018) found that the atmospheric concentrations of fine particles, below 0.3 μm, and bioaerosols both increased significantly after toilet flushing in hospitals. moreover, those aerosols formed a prolonged and uniform suspension in air with no obvious attenuation within 30 min after toilet flushing. in the same vein, 81% of aerosols and 78% of surfaces of public toilets located in an office building and a hospital contained respiratory or enteric viruses including the adenovirus, the torque teno virus and the norovirus gii (verani et al. 2014 ). overall, breastfeeding in public toilets presents high risk of contamination, which might be aggravated by the fast breathing of infants. infants should be exclusively breastfed for six months and then continue to be fed with breastmilk and complementary food at least until 12 months (aap 2012; who 2020f). for infants within six months of age, the general recommendation is 8-12 times during 24 h, each feeding lasting 10-20 min (cdc 2018; littleton and richardson 2019) . most importantly, infants younger than 12 months have much faster respiratory rates than adults, generally in the range 30-50 breaths per minute compared with 12-18 by adults (fleming et al. 2011) . while being breastfed, the infant's nose and mouth are exposed to the ambient air, and the infant maintains a faster breathing rate for the suckswallow-breath coordination. this suggests that infants are at elevated risks of exposure to airborne pathogens in public amenities during breastfeeding. fig. 1 risk of infants' exposure to airborne pathogens and pollutants in a public lactation room. the number of lactation rooms have increased in the public space, yet many issues remain to be solved, such as inadequate area, location near toilets, poor ventilation and lack of air temperature control the covid-19 episode has also accentuated the risk induced by poor ventilation. indeed, regulators and utility operators have discouraged the use of air conditioning in confined public spaces to prevent the spread of covid-19 by air circulation (cpmi 2020; who 2020g). this creates a dilemma for facilities lacking natural ventilation such as public lactation rooms. furthermore, covid-19 remained viable and infectious in aerosols for three hours at ambient conditions (van doremalen et al. 2020) . higher rates of viral transmission were observed in confined space when persons were in contact with covid-19 infected patients ). in addition, breastfeeding in public toilets or family restrooms increases the risk of fecal-oral transmission of covid-19 (xiao et al. 2020) . high viral loads of covid-19 have been detected in human feces, even in asymptomatic individuals and recovered patients several weeks after their respiratory samples became clear (han et al. 2020; wu et al. 2020; zhang et al. 2020) . direct evidence was provided on june 25, 2020, by the beijing center for disease prevention and control, which announced that two persons became infected after using a public toilet that was later tested positive (li 2020) . this was known as the first confirmed case of covid-19 transmission in public toilet environments in china. overall, the risk of virus transmission to breastfeeding mothers and infants in public amenities is high. what could we suggest to improve their safety? there is actually no viable means of protecting an infant's respiration while being breastfed. to this date, no specific guideline has been published to mitigate such risks during the current pandemic (cdc 2020; nhc 2020). given that many public breastfeeding amenities are small and poorly ventilated, we suggest that, when not in use, doors should be regularly opened to allow natural ventilation, while standard cleaning and disinfection protocols for public spaces are followed (cdc 2020). when breastfeeding in a public facility, mothers should wear respiratory protection to protect themselves and others who may use the same facility concurrently or shortly after. mothers should use the facility alone during the current pandemic to reduce the risk of cross-infection between users. in light of the known risks of fecal-oral transmission of covid-19, breastfeeding in public toilets is not recommended during the current pandemic. instead, mothers should be encouraged to breastfeed in open areas where good ventilation and physical distancing can be achieved. efforts should also be put in improving the design of public lactation rooms, including the provision of adequate areas and emergency ventilation facilities. safety windows should be installed well above the average height of adults with exhaust fans in operation to maintain good ventilation in the room without compromising the privacy of users. more generally, air pollution and the associated health risks should be alleviated both indoors and outdoors using any means (yu 2014 (yu , 2019 feng and zheng 2019; wang et al. 2020) . here, recent results suggest that the use of essential oils, a traditional medicine, may offset the deleterious effect of airborne particulate matter (kfoury et al. 2016) . funding this work was funded by the "young talent support plan" of xi'an jiaotong university. conflict of interest authors declare that they have no conflict of interest in this work. breastfeeding and the use of human milk breastfeeding guidance: post hospital discharge for mothers or infants with suspected or confirmed sars-cov-2 infection unions have set up 286,000 rest and lactation rooms across the country how much and how often to breastfeed reopening guidance for cleaning and disinfecting public spaces, workplaces, businesses, schools, and homes technical guidelines for operation and management of air conditioning and ventilation systems during epidemic period indoor air quality in schools evidence for regional heterogeneous atmospheric particulate matter distribution in china: implications for air pollution control normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: a systematic review of observational studies detection of sars-cov-2 in human breastmilk airports in the united states: are they really breastfeeding friendly viral rna load in mildly symptomatic and asymptomatic children with covid-19 an exploration of lactation facilities and planning in u.s. higher education campuses essential oil components decrease pulmonary and hepatic cells inflammation induced by air pollution particulate matter bioaerosol concentrations generated from toilet flushing in a hospital-based patient care setting the traveling mother: navigating, visualizing and utilizing lactation spaces in us airports solved: beijing couple infected in a public toilet breastfeeding faqs: how much and how often it is time to address airborne transmission of covid-19 ncsl national conference of state legislatures (2020) public laws pp 111-148 and pp guidelines on accelerating the construction of facilities for mothers and infants nhc national health commission of the p.r. china (2020) education handbook on covid-19 how desperate is it to go out and find a clean lactation room air pollution of beauty salons by cosmetics from the analysis of suspensed particulate matter breast-feeding mothers face a policy dilemma: many breast-feed in public toilets environmental chemistry is most relevant to study coronavirus pandemics a qualitative study of attitudes toward public breastfeeding among young canadian men and women the investigation on the space design of the baby care room in public places, a dissertation submitted for the master's degree, south china university of technology van doremalen n, bushmaker t, morris dh et al (2020) aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 viral contamination of aerosol and surfaces through toilet use in health care and other settings transplacental transmission of sars-cov-2 infection unexpected rise of ozone in urban and rural areas, and sulfur dioxide in rural areas during the coronavirus city lockdown in hangzhou, china: implications for air quality who world health organization (2020c) cleaning and disinfection of environmental surfaces in the context of covid-19 who world health organization (2020d) breastfeeding overview who world health organization (2020f) recommendations on breastfeeding who world health organization (2020g) preparedness, prevention and control of covid-19 in prisons and other places of detention prepa redne ss-preve ntion -and-contr ol-of-covid -19-in-priso ns prolonged presence of sars-cov-2 viral rna in faecal samples evidence for gastrointestinal infection of sars-cov-2 water spray geoengineering to clean air pollution for mitigating haze in china's cities fog geoengineering to abate local ozone pollution at ground level by enhancing air moisture detectable sars-cov-2 viral rna in feces of three children during recovery period of covid-19 pneumonia investigation of transmission chain of a cluster covid-19 cases air microbiological pollution and its influencing factors in hospital nursing room key: cord-283553-n06og3cw authors: de coninck, david; d'haenens, leen; matthijs, koen title: nan date: 2020-05-13 journal: public health doi: 10.1016/j.puhe.2020.05.011 sha: doc_id: 283553 cord_uid: n06og3cw nan recently, the coronavirus disease 2019 (covid-19) has been rapidly expanding across the globe. in order to respond to this pandemic, many countries are combining suppression and mitigation activities aimed at delaying major surges of patients and leveling the demand for hospital beds, while protecting the most vulnerable from infection. bedford et al. state that 'national response strategies include varying levels of contact tracing and self-isolation or quarantine; promotion of public health measures, including hand washing, respiratory etiquette, and social distancing; and closing all nonessential establishments' 1 . it is crucial for the public's health that information about these measures is accurately and quickly disseminated throughout the population. currently, legacy news media (e.g. television, radio, newspapers) and social media are the main platforms through which this dissemination takes place 2,3 . however, there are several aspects related to the journalistic infrastructure on the one hand and on the reliance on news media as agents of information on the other that may (in)directly and inadvertently endanger the public's health in several ways. although the corona crisis is the biggest journalistic story in times, that same crisis is also directly crippling media companies. this is a paradoxical situation: news consumption, viewing and reading figures, visits and likes are sky-high 9 , but contrary to what happens in 'normal' times, media turnover is dropping. as non-essential establishments are closed and (mass) events are cancelled, the demand for ads has dropped. consequently, many news outlets are suffering from falling advertisement revenues. this loss may cause structural damage to many traditional news media and may signal a rapid shift to a more digitized media environment. especially the need for local information provision and local connections is greater than ever, but the revenue model for local and 2 regional news provision has completely collapsed as it is heavily dependent on advertising revenues from local small and medium-sized enterprises. the public's reliance on news media coverage to convey accurate information (i.e. more than statistics) increases during times of uncertainty and crisis -especially in the current context with large shares of the population working or locked down in their homes 4 . the social distancing leads to increased anxiety or stress, which in turn has a detrimental impact on the public's physical and mental health over time, as evidenced by longitudinal studies following other health or societal crises 4, 5 . the amount of news media exposure and the content of the news media coverage are related to public anxieties: overly sensationalized coverage (e.g., graphic imagery) is related to higher stress levels 6 . not all media types frame stories the same way, are equally trusted or have an equal impact on fears among the public 7, 8 . given the large presence of fake news and the growing distrust of the public in social media, legacy media remain important platforms for informing the public. the damage that legacy media are currently sustaining threatens journalists' positions, particularly the self-employed journalists and the freelancers, in their ability to accurately report the news. governments must take these problems into account and take measures. we urge policy makers to follow the example of the netherlands, where a subsidy of €11 million has been made available to support local information provision. readers are also invited to donate or to subscribe. governmental support is imperative to sustain and uphold the journalistic infrastructure, maintain integrity and quality in news media, given their importance in the dissemination of information to the public. this, in turn, will have a major impact on public health in the context of the covid-19 crisis. a weakened journalistic infrastructure, during times where people heavily lean on news media to provide them with facts and opinions, bringing expertise and explanations to the table, will potentially lead to increased reporting of 'alternative' or dubious content, which may result in the dissemination of 3 potentially 'dangerous' views that jeopardize public health (e.g., faux covid-19 treatments) 1 . by ensuring that public information media remain strong and properly financed, governments also indirectly make an investment in the public's short-and long-term physical and mental health. policy makers face several challenges as they look ahead to loosening some of the restrictive public health measures that have been installed over the past weeks. some european countries are cautiously looking ahead to what lies beyond the crisis and begin to make plans to lift some of the restrictions: steering legacy media will play a significant role in influencing people's behaviour, for instance on how and when to wear respirator masks. preliminary covid-19 research on representative samples of the flemish (belgian) public teaches us that news media consumptionparticularly on (public) television -is strongly related to support for public health measures. a clear communication strategy by the government will therefore be vital in ensuring that the public is wellinformed about when and how restrictions are lifted in order to avoid another wave of covid-19 10 . minimizing sensationalized coverage, while at the same time actively engaging in debunking fake news, will be necessary to limit public anxiety and stress, and facilitate a 'normalization' of societal life. the authors report no conflict of interest, and no funding was obtained. covid-19: towards controlling of a pandemic social media and emergency preparedness in response to novel coronavirus the novel coronavirus (covid-2019) outbreak: amplification of public health consequences by media exposure. health psychology a dependency model of mass-media effects distress, worry, and functioning following a global health crisis: a national study of americans' responses to ebola media exposure to collective trauma, mental health, and functioning: does it matter what you see? lessons learned from public health mass media campaigns: marketing health in a crowded media world the relationship between media use and public opinion on immigrants and refugees: a belgian perspective nieuwsconsumptie in tijden van covid-19: meer bezoekers, meer likes, meer engagement [news consumption in times of covid-19: more visitors, more likes beware of the second wave of covid-19 key: cord-021847-wea0qpq2 authors: race, jeffrey d.; nichols, carey; blumenthal, susan r. title: chemical, biological, radiological, and nuclear quarantine date: 2015-10-23 journal: ciottone's disaster medicine doi: 10.1016/b978-0-323-28665-7.00082-0 sha: doc_id: 21847 cord_uid: wea0qpq2 nan c h a p t e r 82 chemical, biological, radiological, and nuclear quarantine jeffrey d. race, carey nichols, and susan r. blumenthal although the term quarantine is familiar to most physicians, nurses, and emergency medical services (ems) personnel from their core training, it may mean many different things depending on where, to what level, or from which discipline or perspective someone was trained. the meanings of quarantine and isolation are quite often different between first responders and first receivers (i.e., those who work in hospitals). within each first responder discipline (e.g., emergency medical technician [emt] and paramedic, firefighter, and police officer), there are different roles to play and connections or responsibilities, as determined by position, training, and/or experience. confusion often occurs between the terms isolation and quarantine; many people use the term quarantine to mean either isolation or quarantine. both are public health measures used to control the spread of contagious disease: • isolation is used to separate and restrict the movement of those who are ill with a communicable disease. • quarantine is used to separate and restrict the movement of those who are still well but who may have been exposed to a communicable disease. for the purpose of this chapter we will be using the term quarantine to refer to both isolation and quarantine because we will discuss quarantine in terms of both biological and nonbiological exposures. the quarantine of any population is a troublesome matter for both the society involved and the government agencies overseeing the containment efforts. at a moment's notice a nation must mobilize significant resources to help triage, treat, and contain any communicable and potentially epidemic diseases or exposures. making the decision to identify and then contain individuals certainly cannot be taken lightly and will have both political and logistical repercussions. for the purposes of this chapter the idea of quarantine will include the management of those exposed to chemical, biological, radiological, and nuclear (cbrn) disasters. in particular this chapter will examine and discuss processes to help control the spread of societal hazards, giving particular attention to medical triage and containment. in the event of a terrorist attack or growing natural epidemic, a rapid quarantine effort can certainly help to mitigate the damage. proper deployment and specific targeting will be of critical importance to successfully reduce the overall number of casualties by preventing secondary cases. obtaining data by examining and monitoring exposed individuals can help to predict the clinical trajectory of future cases and also help medical providers rapidly identify any new cases. this information could also be of tremendous significance should the exposure be more occult in nature to help epidemiologists determine the origins of a previously undetected initial event. as with any government-mandated health care policy, quarantines of any variety will certainly raise questions regarding ethics. although restrictive measures discussed in this chapter may be of significant benefit to the afflicted society as a whole, they may meet resistance and raise ethical dilemmas. this may be alleviated by attempting to induce voluntary compliance by always proposing restrictive measures that are proportional to a given threat and providing transparency at all stages of a restrictive quarantine. 1 in the united states in particular, balancing personal liberties with societal benefit rapidly becomes an ethical dilemma without a clear resolution. the word quarantine often carries a stigma and negative connotation-to restrict movement, isolate, and maintain a safe distance from "contaminated" individuals. this becomes especially problematic when a rapid quarantine is clearly the safest option for the nation as a whole following a significant communicable exposure event. the purpose of quarantine is clearly to prevent additional spread of contagious disease or environmental toxins within a specific population. quarantine success demands tailoring preventative measures to specific features of a given exposure. with the overall goal of quarantine being a significant reduction in total casualties, a successful quarantine will look to accomplish the following: • identify what and who has been exposed • determine which exposed people, animals, and/or goods are likely to be contaminated or infected • prevent transmission by managing those who are contaminated or infected • prevent subsequent exposures and contaminations frequently employed measures to accomplish the above goals include the following: • identification of potentially infected or contaminated persons, animals, and goods • initiation of protective measures to prevent further transmission of infectious agents • initiation of protective measures to prevent exposed persons from becoming infected cbrn incidents are those due to weaponized or nonweaponized cbrn materials that have the ability to cause significant harm to life, health, or the environment. traditionally in the united states and canada, nonweaponized materials are referred to as dangerous goods (dg) or hazardous materials (hazmat) and can also include items such as contaminated food, livestock, and crops. the term cbrn includes dg or hazmat plus the same materials weaponized into explosive threats. typically spills or accidental releases or leakages are considered dg or hazmat, whereas intentional spills, releases, or leakages (whether explosive or not) are considered terrorist incidents. 2 although the approach to dealing with the consequences of both types of incidents may be similar, the terrorist incident will involve additional agencies as well as concerns for public and national security and safety. advances in technology and training, years of planning, and billions of dollars spent on that training and equipping response agencies has advanced domestic preparedness for an incident requiring quarantine. this level of training and preparedness has dramatically changed current strategies and tactics in the management of incidents that may require quarantine. countless lives could thus be saved. 3 the popular media have shaped lay public perceptions of quarantine. dramatic portrayals of military personnel in personal protective equipment (ppe) and armored vehicles patrolling city streets create a sense of fear and anxiety. if not managed properly, this anxiety can evolve into panic and chaos. for thousands of years humankind has recognized the need to isolate from the general population persons, animals, and goods that have been exposed to contagious elements. as early as 583 ad, authorities restricted the association of lepers and healthy people, building on the biblical sources in leviticus. 1 history reveals that the use of the term quarantine only recently entered the first responder lexicon despite its having been in practice back to biblical times. 4 in the fourteenth century, europe endured repeated episodes of the plague, with an estimated loss of one third of the population. the plague spread rapidly throughout europe, beginning in the south in 1347, and reaching england, germany, and russia within 3 years. 5 fear, combined with the severe impact of the plague, led to the development of intense measures to attempt to control the spread of the disease-measures we would currently call infection control. some of the more severe measures include the abandonment of the ill in the fields outside reggio, italy, in 1374. by order of viscount bernabo, patients were left in the fields to recover or die on their own. 6 similarly, in the area currently occupied by the modern city of dubrovnik, croatia, the chief physician of the city, jacob of padua, advocated the establishment of an area outside of the city walls for those needing treatment for the "black death." 7 this separation was motivated by an early theory of contagion; however, the efforts were only modestly effective. it was this lack of effectiveness that prompted the great council of the city to develop more aggressive methods to prevent the spread of future epidemics. 6 in 1377 the great council established a four-pillared approach to a trentino, or 30-day isolation period. 6 the four pillars include the following: 1. the exclusion of citizens or visitors from plague-endemic areas from the city of ragusa until they had been in isolation for 30 days 2. the restriction that no person from ragusa could go to the isolation area without remaining there for 30 days 3. that any person who was not assigned by the great council to care for those in quarantine was not permitted to bring food or other items to someone in isolation without having to remain there for 30 days 4. that anyone who did not follow these regulations would be fined and subjected to isolation for 30 days similar laws were introduced in marseilles, venice, pisa, and genoa during the following 80 years, 8, 9 although during this time the period of isolation was extended from 30 to 40 days. this 40-day period was known as a quarantino, which was derived from the italian quaranta or forty. 3, 10 although the rationale for extending the period to 40 days is not known, it has been suggested that the shorter trentino period of 30 days was found to not be long enough to prevent the spread of the plague. 11 others have suggested that the change was related to the 40-day period of the christian observance of lent 4 or the 40-day period associated with many other significant biblical events (the great flood, moses' time on mount sinai, or jesus' time in the desert). 12 still others have suggested that the foundation for the quarantino came from the greek doctrine of "critical days," which stated that contagious disease occurs within 40 days of exposure. 5, 11 regardless of the rationale, the duration embodied within quarantino provides the fundamental concept for our present-day quarantine. the identification of the pathogenic agents of epidemic diseases between the nineteenth and twentieth centuries led to a turning point in the history and development of more modern quarantine. cholera, plague, and yellow fever began to be thought of as individual pathogenic agents to be considered separately in the development of regulations. international regulations were rewritten in 1903 by the eleventh sanitary conference, at which the convention of 184 articles was signed. 13 modern planning, identification, and response to individual pathogenic agents of concern comes out of this historical separation. additionally with the emergence of severe acute respiratory syndrome (sars) in the twenty-first century, traditional measures were once again utilized because a global public health crisis arose as a result of international travel of people and goods. 14 first responders now have tools to rapidly and accurately identify the nature of an incident (e.g., chemical, biological, or radiological). as a result, the strategies and tactics (policies and procedures) have dramatically evolved from those of the past. first responders can rapidly test potential exposures and determine preliminary information on the nature of the offending agent. often these rapid tests are definitive. however, most standard operating procedures call for confirmatory testing and follow-up identification procedures in specialized laboratories in order to increase accuracy and specificity. this strategy allows first responders to rapidly determine whether the incident is of a biological, chemical, or radiological/nuclear etiology and adjust quarantine recommendations accordingly. although the first responder community continues to educate themselves, broad knowledge of signs and symptomatology has become a baseline for education and identification, even without the use of these technologies as a backup. quarantine is technically for those incidents involving biological exposures. however, in modern practice, the term also applies to detention, in holding areas, following exposures and prior to decontamination for chemical and radiological or nuclear events. modern quarantine may be initiated whenever an individual or group is known or suspected to have contracted, or been exposed to, a highly contagious or dangerous disease or a chemical contamination. public health authorities must ensure that there are resources available to provide care for those in quarantine and to implement and maintain the quarantine. it is also imperative that authorities provide for the expeditious provision of health care for those in quarantine, including coordination with the local health care delivery system, heightened surveillance and monitoring, expedited diagnosis and treatment, and preventive treatment (vaccination, prophylactic antibiotics, and ppe). 15, 16 within any potential circumstance in which a modern quarantine might be issued, the primary goal is to reduce disease transmission by increasing the "social distance" between persons (i.e., reducing the number of people each person comes into contact with). 17 to accomplish this there are a wide variety of strategies for disease control that may be implemented individually or in combination with one another. these strategies include shelter-in-place, short-term voluntary home curfew, restrictions on public gatherings and events (including travel and mass transit restrictions), and cordoning off an area with a sanitary barrier. 18 modern quarantine can be effective in some cases even when it is only partial quarantine (i.e., where many or most, but not all, exposed persons are quarantined). 17 this partial or "leaky" quarantine, particularly when combined with a program of vaccination, has been effective in slowing the rate of the spread of disease, including sars and smallpox. 19 distance and duration of exposure are commonly found to be important predictors of transmission. accordingly public health authorities employ modern quarantine procedures that involve limited numbers of exposed persons in small areas. these small areas or zones are designed as "rings" or concentric circles drawn around individual disease cases. 20 only those who fall within the ring of exposure duration or distance would be quarantined along with the individual disease case, with the most intensive disease control activities in the inner ring. implementation of modern quarantine also requires the trust and participation of the public. compliance with quarantine is lowest in areas with little to no experience with quarantine in their recent past. in the united states, obstacles to compliance include difficulties with ppe and preventive measures, issues with compensation for lost income because of missed work, and lack of communication from trusted public officials. 21, 22 the public must be informed about the dangers of contagious diseases subject to quarantine before an outbreak or intentional release of biological agents occurs and throughout an actual event. whereas all aspects of the first responder community provide a rapid response to 911 emergencies when called upon, state and federal governments have enormous resources and jurisdictional laws, rules, and regulations that are utilized to protect and respond to incidents throughout the united states. they also respond in support of first responders, as needed. these federal, state, and local jurisdictional laws govern the specifics of incident command and control in response to a biological incident. the commerce clause of the u.s. constitution provides the authority for utilization of quarantine and isolation by the federal government. the u.s. secretary of health and human services is also authorized to take measures to prevent the entry and spread of communicable diseases from foreign countries into the united states and between states, as stated in section 361 of the public health service act (42 u.s. code } 264). 23 the authority to carry out these functions is delegated to the centers for disease control and prevention (cdc), including the authority to detain, medically examine, and release persons who are suspected of carrying a communicable disease and are arriving into the united states or traveling between states (42 cfr, parts 70 and 71). twenty u.s. quarantine stations are located at ports of entry and land border crossings, enabling the cdc to routinely monitor people at these locations for signs or symptoms of communicable disease. when necessary the cdc can institute public health practices to stop or limit the spread of disease through the use of isolation and quarantine. 21 although isolation and quarantine are well understood as medical functions, they are less well known as "police power" functions. these police power functions come from the right of the state to take actions affecting individuals for the benefit of society and empower the government to detain or constrain people who may be contagious with a communicable disease. federal isolation and quarantine are authorized by executive order of the president and currently exists for the following communicable diseases (this list may be revised by executive order of the president): similar to the federal government, individual states have police power functions to protect the health, safety, and welfare of people within their jurisdiction and to enforce the administration of isolation and quarantine. 21 laws vary between states, and the authority to enforce state law can be at the state or local level, although breaking quarantine is a criminal offense in most states. in the united states, indian tribes also have police power authority to take actions to establish and enforce their own isolation and quarantine laws within tribal lands. 21 who is in charge? in a quarantine situation the federal government has authority over the states and tribal lands and likewise the states have authority over local governments. in addition federal authorities may either assist state and local authorities in infection control operations or request assistance from state and local authorities in enforcing federal isolation and quarantine. it is possible for federal, state, local, and tribal health authorities to each have legal quarantine power over the same incident at the same time. whenever this occurs, however, federal law and authority supersede all others. 24 when a communicable disease that is authorized for quarantine is suspected or identified, the cdc may issue a federal isolation or quarantine order. enforcement of such a public health order may require assistance from police or other law enforcement. the issuing authorities may request domestic law enforcement assistance at any time in the quarantine process. u.s. customs and border protection and the u.s. coast guard are also authorized to assist with the enforcement of federal quarantine orders. 21 failure to follow a federal quarantine order is punishable by fines and imprisonment, although federal law does allow for conditional release from quarantine when possible if the individuals agree to comply with medical monitoring and surveillance. 21 although federal authorities have the capability to declare such events, large-scale isolation and quarantine have not been initiated since the influenza ("spanish flu") pandemic in 1918-1919. 21 state and local authorities respond in a similar manner to federal authorities with regard to the issuance of a quarantine order. assistance with enforcement may be requested from local law-enforcement agencies and from the federal level, when necessary. failure to follow quarantine orders can lead to fines and/or detention, depending on the local or state statutes. first responders will be early on the scene and expected to initiate a response. it is critical that as they arrive, first responders have the capability to properly assess the situation and recognize the signs and indications that a potential cbrn incident has occurred. first responders have to rely on the strength of their training to guide them in their next decisions about the incident. standard operating guidelines and procedures will likely provide the basis for much of these decisions, including a predetermined level of response to suspected or confirmed cbrn incidents, when to initiate a public health response, how to assess the extent of damage and risk, how to determine exposure pathways and the need for mutual aid, and criteria for activating an emergency operations center (eoc) and incident command post (icp). once determinations are made that there is a cbrn incident requiring the activation of an eoc/icp and involving public health, the local resources will continue to operate using the incident command system (ics) and remain in control of the scene for rescue and public safety. the incident commander should coordinate with local and state emergency management officials to request additional resources from state or federal assets in the event that quarantine becomes necessary. first responders may be called upon by the incident commander to assist with provision of needed services throughout the duration of the incident and/or quarantine. scene management for the first responder requires an understanding of quarantine for potentially contaminated or infected persons, establishment of decontamination and triage areas, and isolation of contaminated areas. for each of these items, it is critical that the first responder understands the signs, symptoms, and effects of cbrn substances (weaponized or nonweaponized cbrn materials that can cause significant harm) and is familiar with hazmat management. 1 under control of their respective governor, each state possesses assets that may be deployed to assist in the event of an incident. the national guard civil support teams (csts) are one of the most critical components for quarantine responses. a state's office of emergency services coordinates the request for and deployment of the csts. when an incident exceeds the states' capabilities, they may request federal assets through their federal emergency management agency (fema) regional operations center. agencies and organizations, such as the occupational safety and health administration (osha), environmental protection agency (epa), national fire protection agency (nfpa), and fema, have many different levels of training on this topic, ranging from basic awareness courses up through specialist and advanced formal courses. current guidelines and training emphasize the need to be knowledgeable of all types of haz-mat and their management. recognition is the first line of defense in an incident. recognition not only protects each individual and other first responders, but also enables first responders to initiate the system-wide responses necessary to manage these incidents. most training also emphasizes the adherence to established protocols designed to detect hazardous agents on a minute level by the first arriving units. one aspect of these protocols establishes the criteria for involving the highly advanced capabilities of specialized hazmat and weapons of mass destruction (wmd) teams and state and federal resources, if necessary. recognition that an incident is beyond the management capability of local resources and involves hazmat or wmd would be an initial reason for an incident commander to reach out through an eoc for state or federal resources. this is particularly true when combined with patients exhibiting signs and symptoms of exposure to hazmat or wmd. state resources that may be called upon include agencies such as csts. federal assistance may be requested by the incident commander in coordination with an eoc at the local and state levels through the proper channels. state and federal authorities throughout a state's office of emergency management and department of homeland security (dhs) monitor incidents of significance and of larger magnitudes. this includes fusion centers, which serve as focal points within the state and local environment for the receipt, analysis, gathering, and sharing of threat-related information between the federal government and state, local, tribal, territorial (sltt), and private sector partners. further knowledge of protocols and procedures provides guidance on protection of the scene for the purpose of limitation and/or reduction of further injuries and illness through limiting ongoing or subsequent exposure and contamination. finally first responders' knowledge of their own agency-specific guidelines and those of other related agencies will assist in the speed of implementation of these protocols. it is this knowledge of protocols and procedures that provides a first responder with the ability to take the initial actions toward isolation and quarantine procedures. these actions must be guided by stated policies and procedures and supported by training guidelines and principles. when referring to cbrn incidents, there are continual changes in the management of these incidents based on improvements in education, training, experience, and, most significant of all, technology. best practices have also led to advances in management. however, the united states is a diverse country, and scenarios in different parts of the country have to be managed based on their locale and its related procedures. many different factors, such as weather, population, location, infrastructure, and nature of the incident, come into play in different locations. however, the basic facts of exposure and contamination remain constant. below is a short summary of exposures and contaminations that have relevance to quarantine and isolation. following an exposure or contamination, the greatest concern for the first responder is to limit the number of people already affected or who could potentially be affected. the nature of the agents and the methods of exposure determine the risk level and the actions necessary to mitigate that risk. quarantine and isolation are the most extreme actions for risk mitigation. technically quarantine most closely fits biological exposures due to the method of transmission, incubation, and infection by biological agents. however, quarantine is also used when detaining exposed or contaminated personnel for decontamination following a chemical, radiological, or nuclear exposure (boxes 82-1 to 82-4). there are many biological agents that are pathogenic and can cause harm. rapid identification of potentially infected persons and the biological agents involved increases the effectiveness of methods to control the spread of disease (isolation, quarantine, barrier methods [gloves, filter masks, and eye protection], and hand washing). when quarantine is box 82-1 examples of vaccine-related quarantine measures • unimmunized children exposed to measles are excluded from school until one full incubation period after the last case. children who accept immunization with live virus vaccine within 72 hours of exposure or with immune globulin within 6 days of exposure may return to school. children immunized outside these time frames are excluded from school until a full incubation period from the last exposure of that child has passed. • persons exposed to smallpox without fever or exanthemata may be vaccinated and continue normal activity while being monitored until a vaccine "take" is ensured (discharge from quarantine) or until fever and/or skin lesions appear (isolation required). • immunized domestic and farm animals exposed to rabies are revaccinated and confined for observation if owners are willing and able to restrict the animal's contact with other animals and humans until an incubation period has expired. unimmunized pets have to be quarantined in a controlled facility for 10 days, observed for onset of illness, and, if well, vaccinated before being released from quarantine. necessary it is critical that there is continuity of provision of care and command and control in order to ensure the best possible outcomes. following a chemical exposure, first responders often need to detain exposed people in a quarantine area to isolate them from nonexposed people and areas and to provide rapid decontamination and medical treatment. by treating exposed people according to their clinical syndrome, rather than waiting on the identification of the specific chemical involved, first responders can provide the most rapid, aggressive, and clinically relevant care. 25 this alignment of treatment modalities based on syndromic categories is believed to provide for better outcomes and faster release of exposed persons. radiological and nuclear incidents are often confused with one another. for the purposes of emergency management and disaster medicine, a nuclear incident involves a nuclear detonation, whereas all other radiation incidents are called radiological incidents. 26 although the sources may differ between the two, the exposure requiring isolation, quarantine, decontamination, and treatment is the same for both incidents. with radiological and nuclear exposures, first responders will need to detain exposed people in a quarantine area to provide rapid assessment of injuries. injured people should receive immediate medical treatment and transportation to a hospital facility for additional treatment and appropriate decontamination. the noninjured will be assessed for level of contamination for determination of type of decontamination process (emergency decontamination on site or at hospital or delayed decontamination at home). 27 the actual conditions and stipulations of any quarantine depend on a variety of factors. in particular the type, natural history, contagious period, environmental spread, and specific routes of transmission will all influence the type and variety of restrictive measures that may be necessary. typically these decisions will arise from state or federal public health authorities, but only after careful review of the currently available clinical data. a multidisipinary approach will include physicians, nurses, law enforcement officers, and likely military personnel for adequate containment and restriction enforcement. although the united states has predetermined exposures that do not require additional federal approval to instigate a local quarantine, many jurisdictions require a court order to initiate or enforce movement restrictions or property confiscation. implementing a proper quarantine to separate the unexposed from exposed populations, a variety of measures may be useful. within the quarantine area, unexposed individuals can utilize personal protective measures, including face masks and gloves. removing individuals from a nuclear quarantine area is obviously ideal; however, preventing additional radiation exposure with both personal and regional decontamination methods can help to limit the number of exposures. unexposed individuals within a quarantine zone may benefit from immunization or prophylactic therapies. these prophylactic measures do not have to include the entire at-risk population; however, as evidenced by the 2009 u.s. h1n1 and oseltamivir programs, it may be of benefit to prophylactically treat vulnerable populations, including those with high risk of exposure and immunocompromised individuals, depending on the agent of concern. 28 the decision to offer prophylaxis to some members of the population must be done carefully and with clear dissemination of public information to avoid confusion and unnecessary treatments. for example, the public fear of radiation exposure and misguided rush for iodine tablets following the 2011 fukushima nuclear disaster caused undue stresses and unnecessary treatments even in distant european nations. 29 close, at-home observation remains a viable option, as does the performance of serial examinations on those with known exposure to a contagion or environmental toxin. individuals who develop signs and symptoms may be hesitant to seek care, especially with knowledge that this may lead to isolation. every effort must be made to ensure that a quarantined population is well informed and understands that treatment and social support are readily available during this stressful time. • persons with household and face-to-face contact to pneumonic plague and those exposed through a terrorist act should receive prophylactic antibiotics as quickly as possible and be placed under surveillance for 7 days. if unprotected exposure continues, prophylaxis may need to be extended. those who refuse or cannot receive prophylactic antibiotics must be placed in strict isolation and monitored closely for 7 days. • persons with tuberculosis may be required to remain isolated until antibiotics have effectively sterilized the sputum, at which time isolation ceases, but directly observed therapy continues for the full course of treatment. • a child on a long airplane trip may develop symptoms suspicious of measles. data must be collected on the immunization status and current health status of all travelers. data on the seating arrangements and movements within the plane of the child and other occupants are useful. immunization can be provided to any unimmunized person. if immunization is unavailable or refused, detailed contact information for the next 3 weeks for any susceptible person is collected, as is precautionary information. • in a more complex scenario, the diagnosis of measles is made after the debarkation and airline manifests must be used to find and notify fellow passengers. • travelers with suspected sars provide recent examples. temperature screening at embarkation and debarkation of travelers from areas with reported cases provide an opportunity to detect cases before passengers are dispersed to many destinations. the quarantine officers need data to decide whether to detain any passengers if there is a suspected case. data are collected on the body temperature, current health status, seating arrangements, and movements within the plane of all travelers. detailed travel plans and contact information for all nonfebrile travelers for the next 10 days are obtained in some instances. before being released from quarantine, travelers receive "fever watch" instructions and directions to report to medical care if fever develops. box 82-4 useful resources those who develop evidence of infectivity may qualify for additional restrictive measures, including isolation. however, depending on the type of exposure it may be acceptable to enforce at-home isolation with relief of work duties and other activities that would place a known contagious individual in public spaces. depending on the natural history of the disease, any isolative measures should be lifted as soon as possible once a contagious period has passed to avoid any further public distrust. 1 restricting movement in any capacity will likely displace individuals from their homes, as may already be the case in any large-scale disaster associated with nuclear or airborne toxins. shelter provisions should clearly be provided to those displaced by circumstance, though front-line medical care teams must remain vigilant for signs of communicable exposures. if water sources and other sanity conditions decline, the ease of disease transmission will exponentially increase. as a result disaster response teams should consider ways to quarantine and potentially isolate infectious individuals under even the worst conditions, if at all possible, to help reduce new cases in a refugee shelter situation. events involving highly contagious strains of influenza demonstrate the potential impact of movement restrictions. for example, during the 2009 h1n1 outbreak, the united states and canada instigated voluntary home quarantine of sick individuals and closed public meeting places, including schools and malls, with moderate success. in comparison china enacted a strict quarantine lasting 60 days in many major urban areas, including beijing, with military enforcement to restrict personal movement until the quarantine period was cleared. 30 although differences in governmental policies and ability to rapidly restrict travel and public space usage exist, restricting the movement of individuals in and out of a quarantine zone will be critical to help prevent additional spread of the targeted exposure. in particular, careful screening of major air and seaport passengers will likely become necessary, again depending on the type of contagious material and natural history of the disease. travel restrictions can be especially effective in the early phases of a quarantine to help limit the rapid spread of undetected cases, though sensitive measures are difficult to discern early in a disease process, as evidenced by the questionably ineffective efforts during the 2009 h1n1 outbreak to fever screen airport passengers at airports. 31, 32 restriction of clearly symptomatic individuals from making both local and international travel can be a method to help prevent rapid spread, though as with any restrictive measure this must be carried out in an evidence-based method and tailored to the pathogen at hand. if an exposure is suspected to involve any animals responsible for producing food or other goods, public health officials must also seek to establish livestock quarantines. although this may be difficult in the early stages of a previously unknown or undetected pathogen, many novel diseases are ultimately found to be harbored or spread via animal vectors toward humans. for example, given initial suspicions that the sars pandemic of 2002 and 2003 may have originated in civet cats sold in public markets, china quickly moved to ban the sale or transport of these animals. civet farms were closed until additional information became available, to prevent any further animal-born spread of sars cases. 33 in the present-day, globalized economy, this prospect can be especially difficult, making strict port-of-entry precautions, including freight examination, testing, and quarantine, necessary to combat a given zoonotic exposure. 34 these policies will certainly come with economic consequences and the decision to enact mandatory culling, isolation, or trade restrictions on a specific animal or animal product must not be taken lightly, but instead enacted with clear intentions and clear public information regarding necessity. regardless of the source, in any unfolding epidemic or mass exposure, controlling the movements of populations is challenging but can be of tremendous benefit for preventing additional spread of the contagion. however, inappropriate quarantine is likely to create civil distrust and unrest. in addition a poorly planned quarantine, which unintentionally exposes healthy individuals or animals with the infected or afflicted, can have disastrous consequences and spark further distrust. actions intended for the greater good of a society can be easily perceived as inequitable if poorly understood, and every effort must be made to encourage voluntary compliance and reduce panic with equitable means of population control. trust becomes a vital commodity during times of crisis, and it will become the duty of front-line medical professionals and public health officials to minimize novel cases after an event by providing reasonable yet effective methods of controlling the movements of people and their property following an exposure disaster. as with any significant natural disaster or terrorist attack, management of community assets in the immediate post-event period is critical for effective exposure control. when considering a quarantine or isolation, health care officials must take into account any limitations on existing health care and community assets. it is also possible to instigate voluntary and less-invasive means, such as closure of public schools and transportation, to help alleviate the spread of a concerning pathogen. with this in mind, one can best utilize existing infrastructure for triage and treatment of the exposed, while looking to minimize exposure of healthy individuals by best managing public facilities. following a mass-exposure event, protecting and managing health care assets in a given community is of utmost importance. decontamination (discussed in chapters 83 and 84) will certainly be the initial and primary strain placed on hospitals and emergency departments after a mass-casualty event. once these patients are triaged and decontaminated, proper management and placement within the health care system can help to minimize secondary exposures. in addition to standard hospital policies already in place for infection isolation and environmental decontamination, quarantine measures may include cohorting of patients and health care workers among institutions to reduce the exposure spread to all institutions. should the number of infected or exposed individuals overwhelm the isolation capacity of regional hospitals, setting up separate temporary facilities to care specifically for disaster victims can be an effective means to simultaneously treat and quarantine populations. this strategy does require significant resources and predetermined disaster management plans. measures to protect and maintain the availability of medical care following an exposure are also of utmost importance. basic means, including hand washing and equipment disinfection, gloves and masks, and spatial separation of suspected or confirmed victims, can assist with intrahospital quarantine. effective infection isolation within a care facility can maintain the overall function of that clinic or hospital. it is important to remember that more typical emergencies and community health care demands will continue despite a recent exposure event, and all efforts must be made to maintain normal function while also preventing exposure spread. additional strategies, including measures to avoid patient-to-patient exposures entirely by nonfacility care, can also be effective, and include telephone screening, home visits, and public-place examination clinics. with growing public fears people may seek out unnecessary health care visits, only furthering the risk of contamination. as a result, aggressive public communication and clear reasoning are necessary to help alleviate these fears and prevent unnecessary health care access. in any crisis schools become a source of significant anxiety for parents and students. because of close contact with their peers and family members, school children are a rapid means of spreading infection. an immediate local school closure following an exposure event can be of tremendous benefit to help prevent novel cases and also prevent unnecessary travel and further public exposure to a given pathogen. schools can also be temporarily repurposed as shelters, outbreak clinics, or government rally points for further management after a major disaster. the decision to close individual or entire systems of schools should be based on the nature of the exposure and the need for facility repurposement. simulated influenza pandemic models also suggest that school closures can alleviate strain on local health care assets by reducing new cases in both children and adults. 35 after schools are reopened it is prudent to instruct school officials regarding signs and symptoms of exposure-related illness in order to detect any new cases early and prevent further spread. school events, including sports and social gatherings, should be treated like other mass gatherings after a major disaster with quarantine rules extending to these events as well. isolation measures within schools could help to facilitate ongoing educational concerns; however, the logistics of effective isolation inside of most schools are likely near impossible. it is likely of greater benefit to reopen schools only once a threatening pathogen or exposure has been adequately controlled and new cases have already started to subside. travel management of exposed or infected patients is critical to any adequate quarantine process. unfortunately this will also likely become a major point of social contention, given concerns of government oppression of a specific population. the modern, globalized era has made rapid international travel both easy and affordable, a major risk for ongoing infection spread. in the immediate post-event phase, grounding all air travel to and from areas of concern can help to prevent contagion transmission; however, this will likely be met with significant amounts of public fear as unexposed individuals attempt to rapidly leave the area. as discussed previously, effective quarantine requires the close management of population movement. depending on the variety of disaster exposure, screening methods may be effective to still allow travel while preventing additional spread. the same principles can be applied to roadways, seaports, and other means of public transportation. once a quarantine or travel stoppage is ordered, there will be individuals previously traveling through the area or visiting that cannot leave as previously planned. providing a safe shelter for these travel refugees is not only ethical, but also important to help manage the travel quarantine. if screening methods are effective at ruling out exposure or infection, these individuals can be safely moved back to their home regions. it is also important for neighboring areas to establish their own quarantine and screening practices to help evaluate and manage people leaving from a contaminated area. as mentioned previously, traveler quarantine and isolation has been a recurrent theme throughout human history and is an effective means to prevent introduction of pathogens to a new area. management of private vehicle movements can certainly be a daunting task, but if an infection or environmental exposure is allowed to enter a new geographic region, the ultimate containment process will become exponentially more difficult. as with all forms of quarantine or isolation, clear explanations and equitable treatment of all impacted by the restrictive measures will help to alleviate any growing public distrust. businesses and other places of work that are fundamental level areas of community gathering are capable of expediting the spread of a contagious material. in times of quarantine, many businesses will voluntarily close based on school closures, which can be a helpful means to limit person-to-person interaction. despite this, some daily business will certainly continue, and every effort should be made to encourage worker safety and special precautions should be made to identify and prevent infected individuals from exposing their coworkers. business closures and mandatory sick days can be difficult to enforce, especially in open-market settings with many small business owners operating independently. as evidenced by china's actions to ban the sale or transport of civet cats during the sars pandemic, direct interventions on commerce can help to alleviate further exposure spread during a quarantine. 33 it is also important to note the impact of quarantine measures on local business and commerce. areas highly dependent on tourism and international travel can be dramatically impacted by public fears associated with voluntary or mandatory quarantine. some estimates place beijing at a u.s. $1.4 billion loss with regards to tourism alone as a result of the sars outbreak of 2003. 36 ideally, rapid action and site control can help to minimize the spread of a radiological, nuclear, or biological agent, with hopes to minimize the spread initially and prevent any need for long-term quarantine with significant financial impact. as a quarantine continues, business will suffer from supply shortages and product stagnation-things that must be considered and will certainly account for ongoing financial losses. imposing mandatory embargos and trade restrictions can help both sides of a trade agreement prevent the introduction of hazmat within their borders. an effective quarantine will also look to utilize existing business resources to better understand and control the movement of goods, animals, and individuals to minimize contagion spread. food production and agricultural supply are not only necessary for ongoing exposure dissemination, but also for providing a quarantined population with adequate goods of daily living. many agents of biological terrorism can compromise food production without directly impacting humans, as can effects of nuclear fallout if water supplies are contaminated. initial decontamination and rescue efforts will appropriately focus on humans, but the surrounding livestock exposed to hazardous or contagious materials can also spread disease and radioactive material if their products are not removed from circulation. guidance from public health officials will be critical in the management of agricultural resources, and importing in sufficient supplies during a quarantine is a critical action for effective societal support. plants and other crops may exhibit long-term, though silent, contamination and ultimately require destruction. restricting the movement of livestock in and out of a quarantined area should follow that of humans, with special attention in situations where asymptomatic animals may pass disease to their human counterparts. • balancing civil liberty with quarantine: any quarantine or isolation will fundamentally restrict certain civil liberties. in the health care setting, specific policies regarding patient isolation are at the discretion of the treating facility, but in the public sphere, isolation measures become ethically challenging. as previously emphasized, the principle of utilizing the least restrictive means possible to accomplish public protection must be at the forefront of any quarantine planning. this strategy will ideally optimize voluntary compliance, which in turn will yield an overall higher protection rate than an overly aggressive quarantine with very poor public compliance. as with any public health crisis, every effort should be made to maintain personal privacy, especially regarding infectious status, whenever possible. throughout history, quarantines and restriction of societal rights have been utilized in ethical atrocities, and this must be guarded against with well-defined checks and balances to prevent any unintended consequences of a public health effort. • restricting personal movement and travel capabilities can quickly lead to civil unrest and social stigma. it is important to differentiate and remove any growing blame on infected individuals and redirect focus toward treatment and prevention of further spread. a study of the 2003 sars outbreak quarantine in toronto demonstrated that those entering an enforced quarantine were especially concerned with their ability to maintain work wages, obtain groceries, and continue their prior way of life after the quarantine was lifted. all of these concerns are certainly legitimate and are exacerbated by the intentional interruption of daily routine and removal of routine civil rights. regardless, during times of significant natural disaster, nuclear fallout, or biological terrorism, civil rights may need to be temporarily restricted to help protect the interests of society as a greater whole. the challenge for public officials will be to ensure that this is done in an equitable and reasonable fashion, with allowances and appropriate support for those placed within a quarantine zone, and removal of restricted measures as quickly as the situation permits. • obtaining compliance: whenever rights or activities are restricted by a governing body, a significant amount of civil unrest can result. this can be especially problematic following a major disaster when societal fears and media frenzy have reached maximum levels. utilizing quarantine as a means of greater public defense and disaster response must always take the forefront of any restrictive efforts with careful attention to ensure that it is not being utilized as a punishment or political tool against a specific population. clear public communication forums to reinforce that the goal of any isolation or restriction is to prevent the spread of disease and minimize the overall impact of a natural or terrorist-driven exposure. • unified and consistent statements and stances regarding the best methods for preventing new cases, treating those already exposed, and minimizing civil disruption are critical for the front-line physicians and public health officials. issues of compensation for lost wages, care for family members, and similar concerns of persons subject to quarantine cannot be ignored. as evidenced by the north american influenza pandemics of 2008 and 2009, education and communication with the public are key components to encourage voluntary cooperation. public health officials must ensure that restrictive measures are appropriate and proportional for the targeted exposure, implemented uniformly across all socioecomonic statuses, and followed with highly transparent official communications to maintain public engagement. 1 just as careful planning is required to set up an appropriate and effective quarantine, health policy makers must be equally prudent as they deescalate any restrictive measures. emphasis on resumption of normal routine and the importance of continued monitoring throughout all levels of the health care system can assist in this transition and help to reduce the chances of post-event turmoil. • attention fatigue: constant vigilance is necessary to maintain quarantine, isolation, and infection control measures following a massexposure event. initial disbelief, even if scientifically justified, can lead to a low index of clinical suspicion. this is especially true in the early phase of a major disaster when the exact details and etiology behind a patient's symptoms may be unclear. in the modern era of sophisticated biological weapons and the potential for multiplemodality terrorist events, clinicians cannot allow tunnel vision to prevent them from noticing and differentiating pathology. it is also worth noting that even during a mass-exposure disaster, there will still be more typical medical problems requiring emergency intervention. as a result, front-line physicians and other health care providers must maintain attention to clinical details and prevent diagnostic momentum from building based on recent local events. that being said, erring on the side of caution is likely prudent given an unexplained clinical picture with undifferentiated terrorist or natural exposures and with an accepted number of false positives receiving treatment or isolation for precautionary measures. • conflicting goals: physicians and other medical professionals are already accustomed to placing the needs of their patients first. this becomes especially difficult when a specific diagnosis mandates additional isolative measures. after any anxiety-provoking disaster, there will be a significant number of patients seeking reassurance following the development of suspected symptoms. making decisions that will require treatment can be compounded by additional ethical dilemmas given a patient's entire socioeconomic sphere, in particular if removing a breadwinner from standard duties. it becomes difficult for the front-line physician to protect an entire population from further exposures while also advocating for their individual patients. preexisting relationships with patients and community members can also exacerbate a clinician's ethical dilemma, especially when a particular diagnosis holds isolating repercussions. • this conflict between medical responsibility to individuals and entire populations creates many of the pitfalls surrounding a mass-exposure event. it is especially difficult to maintain professional relationships with patients when trust is questioned following instigation of restrictive measures. clinicians must communicate clearly and provide effective education to their patients, especially regarding prophylaxis and treatment options. in the initial phase of a mass-exposure event, the front-line provider will be faced with difficult decisions, only further compounded by often conflicted goals of individual and community protection. • communication: communication between health care professionals (including first responders) and law enforcement, between the health care professionals and the community, and between governmental authorities and the public require honesty, clarity of message, and frequent updating. trust, consistency, and credibility are essential. professional public information officers (pios) should manage all communication strategies. there are many options for a cbrn incident response, and quarantine is the most extreme of these options. for this reason the criteria for initiating quarantine is clearly delineated in federal, state, and local laws, regulations, and policies. although states may differ regarding their laws on quarantine and emergency response and operations, each state has established laws regarding quarantine. federal laws and regulations outline parameters by which they would supersede state law in support of a local incident. it is incumbent on all disaster medicine providers to know and understand these laws, regulations, and policies, including local and agency-specific procedural guidelines and how they interact with one another. restrictive measures in an influenza pandemic: a qualitative study of public perspectives the chemical, biological, radiological and nuclear strategy of the government of canada ems makes a difference: improved clinical outcomes and downstream healthcare savings. a position statement of the national ems advisory council requires expulsion from camp for everyone with a skin disease or bodily discharge. the bible new american standard some historical comments on quarantine: part one historical sketches of quarantine. philadelphia: tk and pg collins a state of deference: ragusa/dubrovnik in the medieval centuries a short history of quarantine (victor c. vaughan) public health and hygiene: a student's manual. philadelphia: wb saunders some historical comments on quarantine: part two philadelphia: wb saunders foundations of public health: history and development the scientific background of the international sanitary conferences quarantine and isolation: lessons learned from sars, a report to the centers for disease control and prevention the seattle-king county advanced practice center (apc) emergency risk communication branch (ercb), division of emergency operations (deo), office of public health preparedness and response (ophpr) isolation and quarantine: containment strategies for sars isolation and quarantine: containment strategies for sars principles of modern quarantine in: learning from sars: preparing for the next disease outbreak-workshop summary. forum on microbial threats, board on global health, institute of medicine datawatch: attitudes toward the use of quarantine in a public health emergency in four countries. health aff factors influencing compliance with quarantine in toronto during the 2003 sars outbreak legal authorities for isolation and quarantine the public health response to biological and chemical terrorism interim planning guidance for state public health officials. u.s. department of health and human services responding to radiation emergencies. u.s. department of health and human services h1n1 influenza quantitative assessment of preventive behaviors in france during the fukushima nuclear crisis was mandatory quarantine necessary in china for controlling the 2009 h1n1 pandemic? airport arrivals screening during pandemic (h1n1) 2009 influenza in new south wales clinical management of pandemic 2009 influenza a(h1n1) infection management and prevention of sars in china surveillance and control of emerging zoonoses the effects of school closures on influenza outbreaks and pandemics: systematic review of simulation studies the economic impact of sars in beijing key: cord-289175-n95j94ck authors: gostin, lawrence o.; friedman, eric a.; wetter, sarah a. title: responding to covid‐19: how to navigate a public health emergency legally and ethically date: 2020-03-26 journal: hastings cent rep doi: 10.1002/hast.1090 sha: doc_id: 289175 cord_uid: n95j94ck few novel or emerging infectious diseases have posed such vital ethical challenges so quickly and dramatically as the novel coronavirus sars‐cov‐2. the world health organization declared a public health emergency of international concern and recently classified covid‐19 as a worldwide pandemic. as of this writing, the epidemic has not yet peaked in the united states, but community transmission is widespread. president trump declared a national emergency as fifty governors declared state emergencies. in the coming weeks, hospitals will become overrun, stretched to their capacities. when the health system becomes stretched beyond capacity, how can we ethically allocate scarce health goods and services? how can we ensure that marginalized populations can access the care they need? what ethical duties do we owe to vulnerable people separated from their families and communities? and how do we ethically and legally balance public health with civil liberties? f ew novel or emerging infectious diseases have posed such vital ethical challenges so quickly and dramatically as the novel coronavirus sars-cov-2, which causes covid-19. sars-cov-2 is thought to have originated in a wet market in wuhan, china, in early december, making a zoonotic leap from a bat (through an animal intermediary) to a human. it rapidly spread throughout china with highly efficient humanto-human transmission and has now circumnavigated the globe, with a foothold in every continent except antarctica. the world health organization declared a public health emergency of international concern and recently classified covid-19 as a worldwide pandemic. as of this writing, the epidemic peak has not yet been reached in the united states, but community transmission is widespread. president trump declared a national emergency as fifty governors declared state emergencies 1 -a situation unprecedented in modern america. in the coming weeks, hospitals will become overrun, stretched to their capacities. widespread social separation is rapidly becoming the norm, with closures of schools and universities, telecommuting, bans on large gatherings, and millions of people isolated in their homes or makeshift facilities. bans on international travel are already pervasive. domestic travel restrictions are exceedingly rare but now within the realm of possibility. officials are even ordering cordon sanitaires (guarded areas where people may not enter or leave), popularly described as "lockdowns" or mass quarantines. for example, san francisco recently ordered a lockdown, with other cities and states closing gathering places (such as bars, restaurants, and movie theaters) and advising residents to shelter in place. when the health system becomes stretched beyond capacity, how can we ethically allocate scarce health goods and services? how can we ensure that marginalized populations can access the care they need? what ethical duties do we owe to vulnerable people separated from their families and communities? and how do we ethically and legally balance public health with civil liberties? a strained health system: surge response, triage, ethical allocation a surge of individuals exhibiting flu-like symptoms, along with the "worried well," will undoubtedly stress the health system. health facilities do not have the capacity to cope with the expected patient numbers: they lack enough critical care beds, ventilators, essential medicines, and personal protective equipment for health workers. n95 masks, a key tool to prevent respiratory infections, are in short supply. scarcity of health resources not only places covid-19 patients at risk but will also delay care for patients with urgent needs such as for cancer, diabetes, and heart disease-and even affect safe delivery for pregnant women. disruptions to the health system will likely cause more deaths of persons with a variety of urgent health needs than of patients diagnosed with covid-19. 2 in times of crisis and with health systems facing scarcity, hospitals, with guidance from public authorities and professional bodies, must make hard decisions to best ensure optimal health outcomes and fair distribution. how can we avoid the scarcity dilemma? where possible, every effort should be made to avoid the scarcity dilemma altogether. we are already trying to do that through strict physical distancing, which could flatten the epidemic curve and moderate demand on the health system. but since the united states is so late in its mitigation efforts, scarcity is likely to become a reality. what should we do? a world war ii-type mobilization could ramp up the production of personal protective equipment, ventilators, and other essential supplies and equipment that could become scarce. the president should exercise his full authority under the defense production act to mobilize industry to provide urgently needed resources. regions experiencing limited levels of covid-19 could lend equipment, and deploy first responders, to regions where health system capacity is strained. retired health workers or trained health workers not presently practicing could return to service. with ample funding, leadership, and coordination, scarcity can be, if not entirely avoided, then at least mitigated. the president or governors could also call in the military, national guard, or army corps of engineers for assistance with logistics, supply chains, and even building clinics. how can we ethically balance physicians' duties to patients and to the wider community? standards of care ordinarily require physicians to meet the specific medical needs of their patients. but in a crisis, we may have to shift the standard of care to emphasize the needs of the community, 3 while still providing the best possible individual-level care. this concept was encapsulated by the national academy of medicine as "crisis standards of care," defined as the "optimal level of care that can be delivered during a catastrophic event, requiring substantial change in usual health care operations." 4 in jurisdictions with declared public health emergencies, 5 crisis standards of care provide a mechanism for reallocating staff, facilities, and supplies to meet population needs. to free up scarce medical resources, for example, hospitals could postpone nonemergency tests and procedures. in the areas hardest hit so far, like seattle and new york, hospital administrators have been canceling or postponing electiveand even some more serious 6 -surgeries. to avoid harm, health agencies and organizations must plan now to implement crisis standards of care; they should not wait until the disease is widely detected in the community. implementing crisis standards must be part of a systemwide approach in which all stakeholders, including health professionals and the public, participate in transparent decision-making. 7 how can we ethically allocate scarce resources? even with increased production and measures like postponing nonurgent medical procedures, there might still be too few health workers and critical care beds and not enough supplies and equipment. these resources must be allocated ethically. first and foremost is the need to protect health workers delivering care in the midst of the crisis, for without them and their extraordinary efforts, the entire health system would collapse. along with ensuring that health workers are adequately trained in infection control, supplied with protective equipment, and provided vaccines once available, the health system should designate health workers a top priority for receiving scarce resources that are vital for their own protection, care, and treatment. second, beyond health workers, decisions about who is tested or who receives treatment must center on prevention of sars-cov-2 transmission (public health), protection of individuals at highest risk, meeting societal needs, and promoting social justice. protecting public health may mean prioritizing resources for people in confined settings (such as homeless shelters, prisons, and nursing homes), where the virus can spread rapidly from person to person. resources may need to be targeted to areas experiencing localized outbreaks to curb transmission and prevent hospitalizations. groups at highest risks, such as older adults, people with compromised immune systems, and people with underlying conditions (such as heart or lung disease or diabetes) are another priority, as they are most likely to become seriously ill and die. meeting societal necessity means protecting critical services, like public safety, fire protection, and sanitation, as well as producers and suppliers of essential goods and services, like food and medicine, as well as people who carry out critical public health functions. even with mass closures during covid-19, these services must continue, and people working in these areas should be priorities as well. finally, social justice demands that needed supplies and countermeasures are distributed equitably, with steps to ensure that poorer and marginalized populations-segments of the population traditionally left behind, like people with disabilities and people of color-receive a fair distribution of scarce resources. in addition to identifying specific groups that need special care, ethical distribution requires a fair process in deciding. to the extent possible, decision-making about the allocation of scarce resources in response to covid-19 should include the public and be made in advance, and it must be transparent and based on clearly explained rationales that are grounded in scientific evidence related to transmission of the virus, morbidity and mortality, and other relevant considerations, such as those delineated above. fair distribution is not only a national issue. globally, lower-income countries will face much more scarcity than wealthier states and, if covid-19 takes hold, a higher burden of disease. the united states is ethically obligated to assist-even if this means reducing american stockpilesto maximally protect and equally value all human life. 8 vitally needed supplies like personal protective equipment and, when available, vaccines and treatments, must not be hoarded by wealthier countries or the countries where they happen to be manufactured. this is a matter not only of ethics but also of ensuring americans' health. even if we get covid-19 well under control in the united states, new outbreaks here will be all but inevitable unless other countries do so as well. imagine the global political fallout if mil-lions of people died in sub-saharan africa, while availability of an effective vaccine saved those living in north america and europe. access to the health system: protecting the most vulnerable h igh costs, fear of discrimination, and fear of deportation can make covid-19 testing and treatment inaccessible for vulnerable populations, including under-and uninsured persons and immigrants, 9 and this lack of access implicates both health and justice concerns. governments must assure that covid-19 testing and care, and vaccines and treatment once available, are free so that cost does not cause anyone to delay or avoid care. health facilities should be enforcement-free zones for undocumented immigrants, spaces where they will not face any risk of being detained or deported. further, hospitals and health departments must have staff members trained in and responsible for communicating with people who do not speak english or are members of vulnerable populations, like refugees and undocumented immigrants and those with impaired hearing or vision. special measures may be necessary to ensure that vulnerable populations have access to health care and can practice good hygiene. for example, public health agencies should provide supplies of hand sanitizer or hygiene kits to shelters and outreach workers to distribute to people who are homeless for use throughout the day. 10 and authorities could direct or incentivize businesses to permit people who are homeless to use their toilets and washing facilities. a mple evidence shows extreme covid-19 risk in congregate settings such as cruise ships, nursing homes, prisons, churches, shelters, and dorms. in washington state, at least twenty-seven covid-19 deaths are linked to a single nursing home. 11 physical distancing measures, including closing public spaces (schools, childcare, workplaces, mass transit) and canceling public events (holiday celebrations, religious ceremonies, sports events, political rallies), are becoming widespread and could help reduce viral spread if they are implemented smartly, scientifically, and ethically. in this unprecedented period of social separation, loneliness, emotional detachment, and disruptions to social and economic life will produce profound harms. vital cultural practices such as faith-based services, family bonding, and social connectedness are vanishing from public life. we are also witnessing something all too common in disease epidemics-blaming "the other." racial and ethnic discrimination, in this case against people of asian, and especially chinese, descent, may result from the spread of misinformation or sheer ignorance. governments must be prepared to address these harms. protecting the most vulnerable among us. sacrifice is necessary, but it must be part of a fair social compact: people should adhere to advice or even mandates for physical distancing, but governments, in turn, must ensure that their needs are met. for the well-off, with well-stocked pantries and generous telework or paid leave, staying home may be feasible. but for poorer families and individuals, physical distancing can be harmful if they are cut off from sources of income, assistance, and support. once out of work, individuals may not be able to afford necessities like food, housing, and medicine. with many schools closed across the united states, parents without paid family leave will struggle to find childcare and to provide meals that children would normally receive at school. for people who are elderly or with physical or mental disabilities, ordering food online or going to the grocery store can be difficult or impossible. where compliance with physical distancing is directly at odds with meeting basic needs, societal harms are inevitable and must be mitigated. governments must provide wraparound medical care for the under-and uninsured and meet essential needs like medication, food, and water. if schools are closed, leaving low-income children without school breakfasts and lunch, authorities should arrange for children and families to receive food at home. 12 paid sick leave should be afforded to people temporarily out of work due to quarantines, isolation, business closures, or lack of childcare. 13 people with disabilities and their caregivers should receive funding to ensure that their needs are met and to cover extra costs, such as for home delivery of food and other necessities. 14 if americans are doing their part to stay home and prevent covid-19 transmission, government must do its part, too. that is an essential part of the social bargain. further, physical distancing may be very difficult in some places, such as in prisons, detention centers, homeless shelters, and nursing homes. we must protect against disease outbreaks at these sites, including ensuring good medical care, sanitary facilities, and good hygiene (such as ample supplies of soap and hand sanitizer). large-scale and immediate use of compassionate release programs can protect we are all only as safe as the most vulnerable among us-both in the united states and globally. equity and public health go hand and hand. nonviolent prisoners, especially if they are elderly or vulnerable, without compromising public safety. 15 other action will be needed, too, to prevent prisons and jails from becoming hotbeds of infection. such actions might include releasing people with electronic monitoring (allowing for freedom of movement), 16 releasing people who are jailed simply because they cannot pay bail, and reducing arrests and delaying sentencing. 17 those who have underlying medical conditions might be particularly good candidates for these measures. some, like people who are at low risk of reoffending, might simply be released. and the government should enable people who are homeless and currently unsheltered to have safe shelter, whether procuring hotel rooms or developing emergency shelters designed to enable physical distancing. informed and trusted communication. physical distancing policy must go hand in hand with informed and transparent public communication strategies. a trusted source of information must inform the public about known risks, unknown risks, and what steps are being taken to learn more. the public must be assured that their basic needs will be met and that strategies to mitigate harms, such as online instruction for elementary and secondary schools and broadcasting religious services, will be available. the public must be properly informed about good hygiene practices that can help prevent covid-19's spread-and about how they can access hygiene products. isolation, quarantine, cordon sanitaire, and physical distancing g overnments seeking to limit the spread of covid-19 may isolate sick individuals, quarantine exposed individuals, and institute cordon sanitaire. 18 isolation and quarantine were widely used in asia and canada during the sars outbreak, but their effectiveness depends heavily on outbreak stage and viral transmission characteristics, which are not yet fully understood for sars-cov-2. these measures, where known or expected to be effective in reducing viral transmission, can be lawful, but infringements on individual privacy and liberties must be carefully considered. balancing public health and civil liberties. quarantine, isolation, and cordon sanitaire are extreme measures that entail stringent restrictions on freedom of movement, association, and travel and can cause massive economic and social disruption. when balanced against public health interests, a basic rule is that governments should employ the least restrictive means necessary to protect public health. meeting this standard requires that any covid-19 isolation, quarantine, and cordon sanitaire must be based on rigorous scientific assessment of risk and effectiveness. quarantine and isolation for covid-19 should be ordered only if the person is known or highly suspected to have been exposed to the disease, and only for the maximum duration of incubation (fourteen days for covid-19). procedural due process requires that a person has proper notice and an opportunity to challenge a containment order, where feasible. further, individuals subject to isolation, quarantine, or cordon sanitaire orders must be assured a safe and habitable environment. especially in large-scale quarantines, there could be challenges to ensuring safe and hygienic locations, medical and nursing care, necessities like food, water, and clothing, and communications. vulnerable populations must be protected; authorities should identify in advance those who may need extra assistance (such as older people and people with disabilities) and develop plans to meet their needs. above all, containment measures must not be a subterfuge for discrimination. deciding how far governments should go. compulsory orders for quarantine, isolation, and cordon sanitaire bring enormous legal, ethical, and logistical challenges and should be used only as a last resort. self-isolation or self-quarantine are preferable and generally effective. when properly informed, most people will follow their instincts to stay safe and will shelter in place at home. self-isolation has another benefit besides limiting infringement on people's civil liberties: if hospitals become overwhelmed, as in south korea and italy, self-isolation for people with mild symptoms can help make more hospital beds available for sicker patients. where voluntary compliance is not an option, governments may need to enforce containment orders in the interest of public health, but how far should they go? it may be relatively easy to enforce isolation and quarantine orders against individuals who pose a known danger. yet we are witnessing large-scale quarantines imposed without any individualized risk assessment. elderly persons, for example, face such a high risk of death if they contract covid-19 that many nursing homes have gone on "lockdown" mode, forbidding residents to leave or visitors to enter the facility. as described above, these orders must follow rigorous safeguards, including opting for the least restrictive alternative, depending on scientific assessment of risk and effectiveness, ensuring procedural due process, and providing a safe and habitable environment. difficult questions will still arise, though. for example, are complete lockdowns necessary, or may an eighty-year-old without underlying conditions go for a short walk outside while practicing physical distancing? further, monitoring and enforcement through surveillance modes, including thermal scanners, electronic bracelets, and web cameras such as those used during the sars outbreak, 19 implicate privacy interests. enlisting armed police and citizen informers to control large populations in cities like new york or chicago seems so contrary to american values and the rule of law that it is difficult to conceive opting for that route in the days and weeks ahead. but san francisco has already ordered its population to shelter in place for three weeks, with people directed to stay inside and avoid contact with others, though with numerous exceptions. people can leave their homes without government permission, but law enforcement has been asked to ensure compliance. at a time of vast inequities, we are all only as safe as the most vulnerable among us-both in the united states and globally. if poor or disadvantaged members of our community cannot practice physical distancing or access health services, then we will all be at greater risk. conversely, those who are better off should take measures to protect themselves from infection, both for their own health and in order to protect everybody else. equity and public health go hand and hand. we are in uncharted territory, where vital human connections and economic activity are disrupted in ways not seen in generations. if we want to safeguard the public's health while being faithful to our most fundamental values, then we must ensure that our response is effective, ethical, and equitable. presidential powers and response to covid-19 effects of the west africa ebola virus disease on health-care utilization-a systematic review a framework for catastrophic disaster response ethical framework for health care institutions and guidelines for institutional ethics services responding to the novel coronavirus pandemic duty to plan: health care, crisis standards of care, and novel coronavirus sars-cov-2," a discussion paper institute of medicine, committee on guidance for establishing crisis standards of care for use in disaster situations, crisis standards of care: a systems framework for catastrophic disaster response pandemic influenza: public health preparedness for the next global health emergency pandemic influenza: public health preparedness for the next global health emergency covid-19: who is protecting the people with disabilities?-un rights expert," press release pandemic influenza: public health preparedness for the next global health emergency key: cord-258435-lhn34tc4 authors: tracy, c shawn; rea, elizabeth; upshur, ross eg title: public perceptions of quarantine: community-based telephone survey following an infectious disease outbreak date: 2009-12-16 journal: bmc public health doi: 10.1186/1471-2458-9-470 sha: doc_id: 258435 cord_uid: lhn34tc4 background: the use of restrictive measures such as quarantine draws into sharp relief the dynamic interplay between the individual rights of the citizen on the one hand and the collective rights of the community on the other. concerns regarding infectious disease outbreaks (sars, pandemic influenza) have intensified the need to understand public perceptions of quarantine and other social distancing measures. methods: we conducted a telephone survey of the general population in the greater toronto area in ontario, canada. computer-assisted telephone interviewing (cati) technology was used. a final sample of 500 individuals was achieved through standard random-digit dialing. results: our data indicate strong public support for the use of quarantine when required and for serious legal sanctions against those who fail to comply. this support is contingent both on the implementation of legal safeguards to protect against inappropriate use and on the provision of psychosocial supports for those affected. conclusion: to engender strong public support for quarantine and other restrictive measures, government officials and public health policy-makers would do well to implement a comprehensive system of supports and safeguards, to educate and inform frontline public health workers, and to engage the public at large in an open dialogue on the ethical use of restrictive measures during infectious disease outbreaks. long considered an anachronism from a bygone era, quarantine has re-emerged in the 21 st century as an important (albeit controversial) tool in the battle against infectious disease. prior to the 2003 outbreak of severe acute respiratory syndrome (sars), it had been more than 50 years since mass quarantine measures had been invoked in north america [1] . the sars containment measures imposed in canada and asia, and on a lesser scale in the u.s., provoked a heated debate within the public health community regarding the ethics and legality of quarantine [2] [3] [4] [5] [6] [7] . likewise, the sars experience has sparked a renewed research interest in the ethics and effectiveness of quarantine. the findings of two recent retrospective studies of the 1918 spanish flu pandemic strongly suggest that it was non-pharmaceutical inventions such as quarantine and other social distancing measures that were most effective in slowing the rate of spread and minimizing the rate of death [8, 9] . and data from sars-affected regions have pointed to the enduring value and effectiveness of quarantine and other restrictive measures [10, 11] . in contrast, there are those who argue that the use of quarantine during sars was both ineffective and inefficient [6, 7] . the advent of advanced statistical modelling has added a new dimension to this long-running debate [12, 13] . toronto experienced the largest outbreak of sars in north america, with investigation of 2,132 potential cases and identification of 23,103 contacts of sars patients who required quarantine [11] . post-sars investigations have detected myriad adverse effects among those quarantined: significant feelings of uncertainty, anxiety, and isolation [14] ; experience of stigma, fear, and frustration [15] ; symptoms of depression and post-traumatic stress disorder [16] ; and loss of anonymity [17] . despite the long and controversial history of quarantine, little is known about lay perceptions of and attitudes toward its modern-day use. in view of the evidence of potential adverse effects on individual well-being and psychosocial health, and owing to the critical necessity of high compliance in the event of a major infectious disease outbreak, it is increasingly important to understand how quarantine is perceived by the general public. therefore, the objective of the present study was to determine prevailing public attitudes toward the use of quarantine as a means of infectious disease control. the study was conducted in two regions of the greater toronto area (gta), specifically the city of toronto proper and the regional municipality of york located directly to the north of toronto. the gta is among the largest metropolitan areas in north america with a population exceeding 5.5 million [18] . as the urban centre of the gta, the city of toronto is a densely-populated, cosmopolitan city (population estimate: 2,500,000; population density: 3,972/km 2 ; visible minority population: 46%). in contrast, york is a much less-densely populated suburban region comprised of several small cities and towns (population estimate: 900,000; population density: 506.7/km 2 ; visible minority population: 30%). the study sample was stratified to include an equal number of participants from toronto and york. there was no age or gender stratification. all participants provided verbal consent over the telephone prior to the survey interview. research ethics approval was obtained from the university of toronto, toronto public health, and york region public health unit. the survey instrument was developed by toronto public health for use in a telephone survey of the general public following the sars outbreak. the data reported in this paper are derived from a subset of 15 survey items specifically designed to measure public attitudes towards the use of quarantine during infectious disease outbreaks. these items addressed issues ranging from the legality of restrictive measures, the perceived effectiveness of quarantine, and the supports that should be supplied to those affected by quarantine orders. respondents were asked to indicate their level of agreement/disagreement with each item; the response format was a 5-point likert-type design (1 = "strongly disagree"; 2 = "somewhat disagree"; 3 = "neutral"; 4 = "somewhat agree"; and 5 = "strongly agree"). after the response format was explained and before the first survey item was asked, all participants were provided standardized definitions of 'quarantine' ["quarantine means that you must stay in a separate area away from others because you were around someone with a serious illness and so you might have it, too."] and 'infectious disease' ["infectious disease means a sickness that you can catch from another person, like the flu or tuberculosis.]. at the conclusion of the survey, respondents were asked to supply general demographic information. data collection occurred between april 25, 2005 and may 16, 2005 . the survey was administered using computerassisted telephone interviewing (cati) technology. the 15 interviewers received training in advance and worked with the assistance of two project supervisors. potential participants were screened for eligibility at the beginning of each call. inclusion criteria included the following: minimum age of 18 years, primary residence located within the study area during the sars outbreak, english comprehension skills, and ability to provide informed consent. those who did not meet the minimum age criteria were asked if another member of the household aged 18 or above was available to participate in the survey. a final sample of 500 individuals was achieved through standard random-digit dialing. the survey response rate varied slightly by study region. excluding calls to ineligible participants (i.e., did not meet inclusion criteria) and disqualified numbers (e.g., not in service, wrong number, fax/computer/business line), the final response rate was 27% for the city of toronto and 31% for york region. a factor analysis using varimax rotation with kaiser normalization was performed on the data yielding four factors. composite index scores were then computed for each factor by summing the responses on items loading on the respective factors. thus, if a factor comprised five items then individual composite scores for that index could range from 5 to 25. bi-variate and multivariate analyses were performed to investigate the inter-relationships among variables. all analyses were performed using spss 11.0 for windows. no statistical weighting of the data was performed. a total of 500 participants were administered the subset of survey items on quarantine. table 1 presents a summary of the demographic characteristics of this sample. the majority were middle-aged (56%) and female (64%). within this sample, 4% of participants were personally impacted by quarantine during the sars crisis (i.e., either they or someone else in their home was ordered into quarantine). table 2 presents the distribution of responses for each of the 15 likert-type survey items (from "strongly agree" through to "strongly disagree"). in the table, the wording of the individual items is precisely as appeared on the survey instrument; however, for the purposes of presentation, the items are clustered according to the findings of the factor analysis (as described below). as there were no significant differences between respondents from toronto versus york, the overall results are shown. the vast majority of respondents indicated agreement (either "strongly agree" or "somewhat agree") that sufficient justification exists for the use of quarantine during infectious disease outbreaks. similarly, most respondents agreed that public health authorities and government officials should endeavour to lessen the burdens endured by those ordered into quarantine. likewise, there was majority support for the use of various legal sanctions, penalties, and/ or coercive measures in order to maximize compliance with quarantine orders. and, finally, the vast majority of respondents were in favour of safeguards against unwarranted and/or inappropriate use of quarantine. while these high percentages suggest a certain degree of convergence of opinion, it is important to note that the proportion of respondents indicating "strongly agree" versus "somewhat agree" varies significantly across the 15 items, as indicated in table 2 . finally, survey participants were asked to indicate, by way of forced choice, their response to this statement: "breaking or not obeying a quarantine order is most like which of the following [choose 1 only]: (a) parking in a no-parking zone; (b) driving way above the speed limit on a busy street; or (c) physical assault." fully 59% responded that breaking quarantine is most like 'physical assault,' whereas 27% selected 'driving above the speed limit' and 8% chose 'parking in a no-parking zone' (6% did not answer). principal components factor analysis of the survey data yielded an underlying factor structure of four independent factors. based on a subjective analysis of the content of items loading on each individual factor, the four factors were labelled as follows: 'justification,' 'sanctions,' 'burdens,' and 'safeguards' (as shown in table 2 ). four sub-scales were computed by summing scores for the items within each of the factors identified in the factor analysis. in addition, a total composite index was computed by summing scores across the four sub-scales. scores on the four sub-scales and composite scale were submitted to age, gender, and regional analysis. analysis of variance testing revealed a number of statistically significant age and gender differences. on the 'justification' sub-scale, female respondents scored significantly higher than males [f = 11.456 (df = 1), p < .001], thereby indicating greater agreement that the use of quarantine is justified in the context of an infectious disease outbreak. with respect to age, older respondents (>65 yrs) indicated greater agreement that use of quarantine is justified than did the young (18-35 yrs) [f = 4.514 (df = 2), p < .01]. also, older respondents agreed more strongly that the use of sanctions for quarantine absconders is appropriate when compared both with the young and with the middle-aged (36-65 yrs) [f = 4.577 (df = 2), p < .01]. there were no significant differences by region. the quarantine of exposed persons (along with the isolation of infected persons) has been properly described as the most complex and most ethically and legally controversial intervention within the jurisdiction of public health [19] . complexity and controversy notwithstanding, the present data indicate a very high rate of public acceptance of quarantine as a means to control the spread of infectious disease. indeed, the vast majority of respondents indicated strong support for the use of quarantine in an infectious disease outbreak, for legal penalties against absconders, for social supports for those affected, and for public safeguards against potential inappropriate use. data on public attitudes toward quarantine in the wake of sars are scarce. public opinion polls have indicated high levels of acceptance of quarantine among samples of toronto-area residents (97%) and us citizens (93%) [20] . these findings are supported by an observed non-compliance rate of only 0.1% among torontonians requiring quarantine during sars [11] . a qualitative study of factors influencing compliance with quarantine in toronto identified 'protection of the health of the community' as a prominent motivating factor. the authors of the study concluded that "while the overall compliance rate among residents of the gta appears to have been high, the influence of 'civic duty' and social responsibility may not be as significant in other countries and cultures" [21] . comparative data from international studies do lend support to the theory that cultural values and societal norms impact upon quarantine compliance rates. researchers at the harvard school of public health and the u.s. centers for disease control and prevention surveyed residents of hong kong, taiwan, singapore, and the u.s. and found significant regional variability [22] . the proportion of survey respondents favouring the quarantine of persons suspected of having been exposed to a serious contagious disease was as follows: 76% in the u.s., 81% in hong kong, 89% in singapore, and 95% in taiwan. by way of comparison, in the present study, 94% of respondents agreed that quarantine is a good way to stop the spread of infectious disease outbreaks. interestingly, in our study, significantly fewer (58%) agreed that public health officials should be able to detain those who fail to obey quarantine orders. likewise, in the harvard study, the proportions favouring the use of quarantine decrease significantly if people could be arrested for refusing (to a low of only 42% in the u.s. to a high of 70% in taiwan). the authors partially attributed the observed differences to prior experience with infectious disease outbreaks in which quarantine and other restrictive measures were implemented [21] . in view of this inter-region variability, it is not surprising that the global community of public health experts is itself conflicted about the use of quarantine and other restrictive measures that impinge upon the intrinsic rights of individuals. those who favour the consideration of quarantine during infectious disease outbreaks maintain that it is prudent public health policy [23] , whereas those in opposition argue that quarantine is inherently paternalistic and an unnecessary breach of basic human rights [24] . despite the difference of opinion, however, there does appear to be general agreement on this: "ultimately, public health must rely not on force but on persuasion, and not on blind trust but on trust based on transparency, accountability, democracy, and human rights" [24] . with a view to fostering further deliberation and constructive debate, we are proposing a conceptual framework for the ethical use of restrictive measures in public health emergencies (see figure 1 ). building upon previous theoretical work on the justification for public health intervention [25] , our model is designed to reflect the dynamic interplay among theory, empirical evidence, and policy/ practice that is inherent to public health. to that end, we have incorporated the empirical data from the public opinion survey described in this paper. the model explicitly contemplates the four primary functions of public health as regards the use of restrictive measures in infectous disease outbreaks, namely, response, enforcement, support, and oversight. for instance, with respect to the enforcement of quarantine orders, the model illustrates how the specific function of enforcement aligns with the ethical principle of the 'least restrictive means' and is likewise concordant with empirical evidence indicating strong public support for the use of sanctions to promote compliance with quarantine orders (survey data reported here). this conceptual framework for the ethical use of restrictive measures in public health emergencies should be considered provisional and, as such, is open to further testing and refinement. much has been learned from the unexpected arrival of sars in the spring of 2003 [26, 27] . likewise, we continue to learn from historical analyses of the 1918 influenza pandemic, with one recent study providing strong support for the hypothesis that early implementation of public health measures such as quarantine can significantly reduce influenza transmission [9] . given the current threat posed by pandemic influenza, it is incumbent upon the public health community-including ethicists and legal experts-to delineate both the limits to individual liberty and the obligations of public health authorities in the context of an infectious disease outbreak. it is noteworthy that the concept of 'voluntary quarantine' features prominently in many of the current plans for pandemic influenza. as contrasted with the classic quarantine order, which is typically enforceable by law, voluntary household quarantine refers to compliance based on the individual's own free will without legal compulsion. owing to the global threat of pandemic influenza, considerable planning and preparation for infectious disease outbreaks has been undertaken [28] . there remains a pressing need, however, to engage the citizenry more fully in the process of preparedness planning in order to ensure that the plans reflect the common will and that the policies serve the common good [29] . in this regard, the continuing growth in interest and activity in the subfield of public health ethics is certainly welcome and holds greats promise. while we believe the data reported here contribute to the goal of better planning and better preparedness, the present study is limited by its sample of respondents who were drawn only from the greater toronto area. our goal was to assess the attitudes and perceptions of those living in an area significantly impacted by the sars outbreak, but further research is now required to determine the generalizability of the present findings to other geographic regions and other populations. also, our survey was conducted after the conclusion of the outbreak; it is conceivable that public perceptions and attitudes toward the use of restrictive measures could be different during the course of an outbreak. finally, a relatively small proportion of our survey respondents were directly affected by quarantine during sars, which precluded any analysis of differences between those who were directly affected and those who were not. the use of restrictive measures such as quarantine draws into sharp relief the push and pull of opposing forces that characterize the dynamic interplay between the personal autonomy of the citizen on the one hand and the collective rights of the community on the other. as bensimon and upshur [3] have argued, justification for quarantine cannot be founded upon scientific evidence alone; rather, the decision to implement quarantine should be equally an emerging conceptual framework for the ethical use of restrictive measures figure 1 an emerging conceptual framework for the ethical use of restrictive measures. ii. iii. iv. informed by the values, preferences, and practices of the affected communities. the present findings indicate strong public support for the use of quarantine in the context of an infectious disease outbreak and for serious sanctions against those who fail to comply. our data further suggest, however, that public support for quarantine is contingent on the implementation both of legal safeguards to protect against inappropriate use and of psychosocial supports to provide for individuals who are adversely affected. this tension between individual rights and the greater public good is precisely the challenge that infectious disease presents to public health ethics. in order to engender strong public support for the use of quarantine and other restrictive measures, government officials and public health policy-makers would do well to implement a comprehensive system of supports and safeguards, to educate and inform frontline public health workers, and to engage the public at large in an open dialogue on the ethical use of restrictive measures during infectious disease outbreaks. sars epidemic unmasks age-old quarantine conundrum public health vs. civil liberties evidence and effectiveness in decision-making for quarantine public health and ethical considerations in planning for quarantine balancing public health and civil liberties severe acute respiratory syndrome: did quarantine help? is the quarantine act relevant? nonpharmaceutical interventions implemented by u.s. cities during the 1918-1919 influenza pandemic public health interventions and epidemic intensity during the 1918 influenza pandemic evaluation of control measures implemented in the severe acute respiratory syndrome outbreak in beijing public health measures to control the spread of the severe acute respiratory syndrome during the outbreak in toronto when is quarantine a useful control strategy for emerging infectious diseases? impact of quarantine on the 2003 sars outbreak: a retrospective modeling study risk perception and compliance with quarantine during the sars outbreak the psychosocial effects of being quarantined following exposure to sars: a qualitative study of toronto health care workers sars control and psychological effects of quarantine one-year outcomes and health care utilization in survivors of severe acute respiratory syndrome annual demographic estimates: census metropolitan areas, economic regions, and census divsions, age, and sex public health strategies for pandemic influenza: ethics and the law the public's response to severe acute respiratory syndrome in toronto and the united states factors influencing compliance with quarantine in toronto during the 2003 sars outbreak attitudes toward the use of quarantine in a public health emergency in four countries ethical and legal challenges posed by severe acute respiratory syndrome: implications for the control of severe infectious disease threats bioterrorism, public health, and human rights upshur re: principles for the justification of public health intervention public health law and ethics: lessons from sars and quarantine ethics and sars: lessons from toronto stand on guard for thee: ethical considerations in preparedness planning for pandemic influenza upshur r: public engagement on social distancing in a pandemic: a canadian perspective this article is dedicated to the memory of dr. sheela basrur, who served so many so well as medical officer of health for the city of toronto during the sars outbreak, and then later as chief medical officer of health and assistant deputy minister of public health for the province of ontario. the authors declare that they have no competing interests. cst performed the statistical analysis of the survey data, drafted the first version of the manuscript, and contributed to subsequent revisions. er initiated the study, participated in the design of the survey instrument, and contributed to the revising of the manuscript. regu participated in the statistical analysis, contributed to the revising of the manuscript, and will act as guarantor. all authors have read and approved the final version of the manuscript.publish with bio med central and every scientist can read your work free of charge the pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/9/470/pre pub key: cord-198609-jyg9y4g2 authors: noguchi, asahi title: the economic costs of containing a pandemic date: 2020-06-21 journal: nan doi: nan sha: doc_id: 198609 cord_uid: jyg9y4g2 the coronavirus disease (covid-19) has caused one of the most serious social and economic losses to countries around the world since the spanish influenza pandemic of 1918 (during world war i). it has resulted in enormous economic as well as social costs, such as increased deaths from the spread of infection in a region. this is because public regulations imposed by national and local governments to deter the spread of infection inevitably involves a deliberate suppression of the level of economic activity. given this trade-off between economic activity and epidemic prevention, governments should execute public interventions to minimize social and economic losses from the pandemic. a major problem regarding the resultant economic losses is that it unequally impacts certain strata of the society. this raises an important question on how such economic losses should be shared equally across the society. at the same time, there is some antipathy towards economic compensation by means of public debt, which is likely to increase economic burden in the future. however, as paul samuelson once argued, much of the burden, whether due to public debt or otherwise, can only be borne by the present generation, and not by future generations. the coronavirus disease , which has spread to many countries around the world since the beginning of 2020, has inevitably caused great economic loss at a global scale, unlike any pandemic that has occurred since world war ii. it is not simply due to the infectious nature of the disease. the weight of social losses created by the deaths of countless people due to the spread of the infection is enormous in modern society, with the exception of some dictatorships that still exist. on the basis of such modern value judgments, many countries are willing to implement measures such as lockdowns which clearly involve heavy economic losses-in order to save as many lives as possible. the spanish influenza pandemic, which began in 1918 during world war i, resulted in cumulative deaths in the tens of millions throughout the world. in spite of considerable variation, even the smallest of the estimates was large enough to cause a temporary decline in the global population, which had previously been growing by around 13 million people per year (roser [2020] ). even at that time, in some countries and regions, measures similar to the current lockdowns had been implemented. however, the immensely high death toll suggests that such conscious measures to prevent the spread of the disease may have been extremely rare. this might indicate not only the low level of medical knowledge, but also the low value attached to human life during that time. in the covid-19 pandemic, cities across numerous countries faced a rapid spread of infection, and almost without exception, severe restrictions on economic activity were implemented. this was because the only way to prevent further spread of infection was to reduce human contact as much as possible, which implied that economic activity should be kept to a minimum. these stark trade-offs between economic activity and epidemic prevention denote the general characteristics of policies for pandemic deterrence. another characteristic of modern policies for pandemic deterrence is that they often involve some form of economic compensation by governments and local authorities. this kind of public economic compensation basically has two policy objectives. one of these is the provision of financial incentives for leave of absence. if it were not for such financial incentives, people without sufficient savings would have no choice but to leave home and go to work to earn an income. the other is income compensation (similar to insurance) against the decline in corporate and household incomes that would inevitably result from policies to deter the spread of infection. this enables the economic costs of pandemic deterrence to be re-distributed more equitably across society. modern pandemic deterrence policies require huge public expenditures including public economic compensation. the relative size of this public spending could swell to levels not seen since the two world wars of the 20th century, in some cases as high as 30-40% of the gdp. in the case of covid-19, most of the public spending associated with pandemic deterrence policies will probably also be financed by public debt. this is because governments do not want their economies, which have already contracted significantly due to pandemic deterrence policies, to atrophy further by raising taxes on people. nonetheless, concerns about ballooning public debt are sure to grow. there is a clear tendency among some national policy authorities to keep public economic compensation to a minimum, under the pretext of preventing the expansion of the burden in the future. there are 3 many people who outrightly oppose public economic compensation because of the concern that its further expansion would directly increase the burden on themselves. however, there is already a long history of debate and controversy in the economic science on the relationship between public debt and future burdens. while it was abba lerner who sparked the idea (lerner [1948] ), the more general insights were gleaned from his approach and later organized in a textbook by paul samuelson (samuelson [1967] ). their argument conclusively demonstrates the economic truth that much of the economic burden, irrespective of whether the spending is financed by higher taxes or public debt, is ultimately borne by the current generation and not by the future generations. this conclusion is essentially in harmony with respect to the public economic compensation that accompanies pandemic deterrence. in other words, even if the entire economic compensation is financed by public debt, it does not directly lead to a future burden. economic compensation in the form of public debt is not intended to pass the burden on to future generations, but only to redistribute the burden among the current generation. this paper proceeds as follows. section 2 uses the concept of health capital to articulate the trade-offs between economic activity and epidemic prevention that societies should be aware of when trying to contain a pandemic. it also identifies the optimal public intervention path (in terms of minimizing the combined loss from pandemics as a weighted sum of social and economic losses) for national and local governments. section 3 derives the economic losses caused by a pandemic response based on the trade-off relationship between economic activity and epidemic prevention, and subsequently identifies the need to equalize the unequal share of these economic losses across various strata of the society. section 4 argues, mainly relying on samuelson's argument, that the economic burden of pandemic preparedness is essentially borne by the current generation, and that even if the government's economic compensation was based on public debt, it would not be possible to transfer that burden to the future. section 5 concludes that the various considerations made in relation to pandemic preparedness are both necessary and unnecessary, referring to the problems of balancing economic activity with epidemic prevention and sharing economic costs and the problems of increasing future burdens due to fiscal deterioration, respectively. 2 economic analysis of counter-pandemic measures 2-1 trade-off between economic activity and quarantine as noted in section 1, one distinct feature of pandemic preparedness is that it almost always has a trade-off relationship with economic activity. in peacetime when any threat of epidemic or pandemic is undetected, the policy idea of consciously suppressing economic activity to prevent the spread of infection does not exist. it is conceivable that there is some degree of trade-4 off between economic activity and disease prevention even in peacetime, although the society is not aware of it. however, once the epidemic or the pandemic becomes a reality, the situation changes drastically. the society is forced to realize that economic activity must be restricted more severely to strongly deter the spread of infection. in the early stages of infection control, wherein a growing number of infections are being gradually reported overseas, but have not been confirmed inland, governments tend to adopt "bolder measures." these are aimed at strengthening the monitoring the influx of people from abroad, especially from countries and regions where the infection has been confirmed. such measures would have a decidedly negative effect on domestic economic activity, as it would imply restricting foreign tourists and other people entering the country for business purposes. nevertheless, the effect of bolder measures on domestic economic activity is likely to be very limited as long as they are successful. this is because there should be no need to strongly regulate economic activity in the country as long as the infection has not yet spread in the country. however, as soon as it is confirmed that the infection has crossed the border into the country, there is a radical progression in phase. then, the governments are forced to implement some kind of regulation. typically, the governments provided instructions to the general public to refrain from activities, such as public gatherings and events; shut down various educational institutions, stores, and restaurants, where human contact is unavoidable; and transition to staggered attendance in companies. some countries and regions that were severely affected by the pandemic went beyond these directives or solely moral imperatives to implement certain legally enforceable public regulations, in the form of a lockdown, to deter the spread of the disease. restrictions on mobility were imposed, except for the minimum activities necessary for the maintenance of life. inevitably, all economic activities, other than the production and sale of goods and services that were considered to be basic necessities, were in principle suspended. in modern society, where the value of human life is highly respected, it is considered unavoidable to suffer a possible economic loss in order to save as many lives as possible, once faced with increasing human loss due to the spread of infection. the relationship between economic activity and quarantine is illustrated in figure 1 . the vertical axis of this figure shows "income" or "production of goods and services" and the horizontal axis shows "health capital." in general, the income or output of goods and services at any given time is representative of the level of economic activity. in order to deter the spread of infection, it is necessary to ensure certain social environments, such as group avoidance through the promotion of absence from work (or remote work) and ensuring sufficient social distance. health capital comprises precisely these social environments. 2 there is clearly a trade-off between the two, since one must abandon some economic activity in order to secure them. three points are shown on this curve; peacetime, moral imperative, and lockdown. the trade-off between income and health capital does not arise significantly in the vicinity of the peacetime point. this implies that individuals can secure a certain amount of health capital without any significant income loss. an ironic consequence of the covid-19 infection control policies is that the imposition of lockdowns in large cities in developed countries (where economic activity had previously been very high) has resulted in significant improvements in the living conditions in the form of reduced air pollution. some experts point out that these environmental improvements may have some effect of improving people's health. conversely, this means that the vigorous economic activity that had been the norm prior to this pandemic had been worsening people's health through air pollution and other forms of environmental degradation, and the consequent social costs had been universally accepted as the price of economic benefit. such trade-offs between economic activity and health capital, although always existent, are rarely noticed by people in normal times. most people do not feel any emergent need to 2 grossman [1972] was the first to use the concept of health capital in economic analysis, in which health capital is grasped a kind of human capital embodied in the individual. subsequently, however, there has been an emphasis on its public good nature in conjunction with the rise of the concept of "sustainability" in environmental and development economics, which is exemplified by arrow, dasgupta, and mumford secure health capital at the expense of apparent economic loss. however, securing health capital becomes a top priority for the society once a pandemic strikes. this is because the spread of infection in a pandemic would itself cause social losses, such as a rapid increase in the number of deaths due to the pandemic. governments must then implement policies to curb all external activities of people, including economic activities, by means of public requests or legal regulations, in order to curb the spread of the infection. in other words, the trade-offs between economic activity and health capital become more acute with the external environment, as the pandemic leads to a rapid expansion of socially needed health capital. in some cases, societies are forced to restrict all external activities other than the essential economic activities in order to ensure as much health capital as possible. this corresponds to the lockdown point in figure 1 . it means that society has made a public choice to indulge in the minimum income necessary to ensure the maximum health capital. in contrast, the moral imperative point, is a situation in which the governments restrict business operations and individual mobility, not through legal coercion, but solely through some kind of social imperative. the declaration of a state of emergency issued by the japanese government to major cities on april 7, 2020 (that was extended nationwide on april 16) is essentially such a measure. there is no legal regulation of people's behavior, such that health capital secured at that point is lesser than that at the lockdown point. there are also lesser constraints on economic activity and therefore, fewer economic losses. the japanese government's decision to avoid the lockdown was likely due to its concerns about the resultant economic losses, as well as its constitutional restrictions. similarly, sweden decided to not implement lockdowns or mobility restrictions, but instead to limit to lenient regulations, such as requests for population bans, in order to acquire population immunity. in the trade-off between maintaining economic activity and securing health capital for the protection of human life, there is always an implicit value judgment about how each society weights both the economic costs of deterring the spread of infection and the social costs of the spread. while the value of human life is extremely high in modern society, the economic cost of protecting that value cannot be neglected at all. that is the reason why even the most humanitarian nation will not ban cars, in spite of the fact that car accidents cause deaths around the world. some progressive intellectuals often argue that once the risk to human life becomes apparent, it should be addressed at any economic cost. therefore, as regards covid-19 disease control, all governments that do not impose lockdowns would be subject to criticism for their "disregard for human life." however, if even a small island nation with no confirmed cases of infection was forced to impose lockdown (unless risk of infection is absolutely zero), the islanders would be indignant at such interfering measure that is sure to disturb their daily living. strong public regulation is needed in the first place because the spread of the infection would be left unaddressed and the death toll would increase without it. even if a government does not take any action against a pandemic because it is wary of economic loss, it is possible that the infection eventually subsides, and the number of deaths decreases as the population gains immunity. however, the cumulative death toll would be enormous, as it once was with the spanish influenza. in contrast, if the government responds in some manner to a pandemic, it can certainly reduce the cumulative death toll, albeit with economic losses. however, the effect of the public intervention, i.e., the reduction in cumulative deaths, depends not only on the intensity of the intervention, such as whether it is requested or enforced, but also on the phase of the infection. in other words, the nature and intensity of public interventions needed to deter the spread of infection clearly depends largely on the phase in which they are undertaken. this is evident by recalling the countries and regions, such as taiwan perhaps, the same can be said of the diminishing phase of the infection, after the peak of its spread has passed. the governments that have implemented lockdowns will endure the economic losses from restricting economic activity while they are doing it. however, if the additional social losses that would result from relaxing the regulations (i.e., the additional increase in cumulative deaths) were small enough, the governments would prefer to immediately relax the regulations and normalize economic activity. when this situation will occur is determined by health system measures, such as the establishment of effective countermeasures to prevent the spread of infection, the emergence of effective new drugs, and the acquisition of population immunity. if, as a result of such an improved epidemiological situation, the strength or weakness of public regulation to deter the spread of infection becomes 8 almost indiscriminate against social losses, it would mean that the economy was once again in a situation where it should return to the peacetime point in figure 1 . therefore, the social losses caused by the spread of an epidemic can be expressed as follows: sl = (p, i ). (1) this equation implies that the social loss caused by the pandemic sl is the maximum social loss msl minus the social gain of the public intervention sg that is a function of two variables: the phase of the infection at the time of the intervention p and the intensity of the public intervention i. hereafter, we will refer to this equation (1) as the social loss function of an epidemic or pandemic. in general, social loss from the spread of an epidemic refers to all disadvantages other than the economic loss suffered due to the infection, the foremost of which is the loss of human life itself. if the social losses from a pandemic are represented by the cumulative number of deaths, then the value can be derived from the epidemic curve of the infection. this is because the cumulative number of deaths from a pandemic is merely the integral value of the newly infected, as illustrated in the epidemic curve, multiplied by the mortality rate. suppose that the epidemic curve of an infectious disease is mountain-shaped, as in a normal distribution. moreover, suppose that there are four phases (p=1 to p=4) ranging from the beginning of the spread of the infection to its convergence. the intensity of public interventions to deter the spread of infection should also be represented by i=0 (no intervention), i=1 (weak intervention), and i=2 (strong intervention). figure 2 shows the epidemic curve in the absence of any public intervention in all phases, and the phase categories from 1 to 4. the integral of this epidemic curve, i.e., the area of the mountain-shaped curve, represents the cumulative number of deaths in the absence of any public intervention in all the phases. that is the msl in equation (1), which denotes the maximum social loss. the shape of the epidemic curve will inevitably change if the government intervenes. however, the degree of change also depends on the phase of the infection. figure 3 shows that, during the initial phase of the infection (p=1), the epidemic curve does not depend on the intensity of the public intervention. that is, if the intensity of the intervention in each phase is expressed as ip, then the peak in i1=1 is the same as that in i1=2. thus, even if taiwan and hong kong were to implement lockdown in the early stages, the effect would not be much different from that of the border measures alone. however, the situation changes drastically at p=2, i.e., during the expanding phase of the infection. as figure 4 shows, the shape of the epidemic curve is very different between a weak and a strong government intervention, i.e., between i2=1 and i2=2. hence, the government needs to put in place stronger behavioral regulations, such as lockdowns, to curb the cumulative death toll from the infection. a similar dilemma could arise even during the phase where the spread of the infection has finally been deterred. figure 5 depicts how the government's strong interventions in one stage led to a decline in new infections. if, however, the government does not bear the weight of the economic losses and weakens its intervention prematurely (i3=1), then the spread of the infection may occur again. in such cases, it is likely that governments will be able to safely loosen the restrictions on people's behavior only after a phase, such as p=4, where the intensity of public intervention will no longer be a major determinant of the epidemic curve. from the above consideration, apart from the social loss sl calculated at a point of public intervention with a certain intensity in a certain phase, the total social loss across all phases of infection tsl can be obtained as follows: tsl = . (2) 2-3 optimal public intervention path as described above, governments generally choose the intensity of public interventions that is optimal for each phase, based on the assumption that the type of public interventions they undertake to deter the spread of infection will affect social losses represented by the cumulative number of deaths. here, "optimal" does not necessarily mean minimizing social losses per se. in order to reduce social losses, more public intervention is needed to secure higher health capital, which entails greater economic loss in the form of further income loss. this is exactly the tradeoff between economic activity and quarantine. what the government is trying to minimize is some combined measure of the economic and social loss. it can be expressed as follows: this combined pandemic loss cpl is the weighted sum of the economic loss el and social loss sl of this pandemic. 3 the coefficient î» is a parameter for converting the social loss (specifically, the loss of human life) to economic loss. the value represents each society's value judgment of human life. from equation (1), it is clear that the combined pandemic loss cpl is minimized at the point that the government determine the intensity of its intervention i so as to make the increment of economic loss (î�el/î�i) equal to incremental value of social gain (î»î�sg/î�i), i.e., the value of the resulting reduction in the number of deaths. at first glance, it may seem unethical to replace human life with an economic measure. however, our society has been constantly making certain implicit value judgments about the economic value of human life. the evidence of this is that economic activity is never halted, even though many lives are lost each year to asthma, which is due to the air pollution resulting from economic activity. nevertheless, the economic value of human life is extremely high in many modern democratic societies; the degree to which this is the case is roughly proportional to the material wealth from economic growth. this is illustrated by the fact that many developed countries have suppressed economic activity to a minimum, albeit temporarily, to contain the pandemic. if there is a dictatorship that does not recognize any value in the lives of its citizens, what choice will that government make in the event of a pandemic? in that case, the conversion rate î» for replacing human life with economic loss would be zero, and the total loss of the pandemic would be the economic loss itself. the best option for such a government would be to do nothing to deter the spread of the infection that would curtail economic activity, but to continue to let the infection continue as shown in figure 2 . in ordinary democracies where the economic value of human life is high, choices about the nature and strength of public intervention are made after considering the economic losses resulting from the intervention in comparison to the social losses. however, as noted above, the choice depends on the phase on the epidemic curve where the public intervention takes place. public interventions at an early stage on the epidemic curve, such as those in taiwan and hong kong, can minimize pandemic losses without strong public interventions. the intervention path would be, for example, ( ). it means that weak public interventions continue during the spread of the infection, but zero public interventions are used after it starts to shrink. the total combined loss resulting from the infection is the sum of the economic losses and the value of human losses borne at phase 1 and 2 only. in contrast, the optimal path when public intervention is used from the stage where the infection has already spread (p=2) would be, for example, ( ). here, the initial phase of the infection was left unattended, which forced strong public intervention in the spread phase. even then, however, the degree of public intervention can be progressively relaxed as the infection lessens. this is because easing the behavioral restrictions did not increase the cumulative death toll much; the value of the additional human lives that would have been saved by strong restrictions fell short of the additional economic loss that would have been caused by them. thus, when public intervention is applied at a stage when the infection has already spread, the cumulative economic and human losses are large, and consequently, the total losses of a pandemic are very high. even so, this is certainly the optimal choice, in the sense that it minimizes the total combined loss of the pandemic since the time of public intervention. as discussed in the previous section, governments minimize the combined value of the social and economic losses, by determining the path of public interventions for each phase of the epidemic curve, always taking into account the effect of their interventions on curbing the spread of infection and the extent to which they will result in economic losses. in this case, the social loss is the cumulative death toll from the pandemic; the economic loss is the difference between the average income in peacetime (before the pandemic occurred) and the lower income brought about by economic regulation due to the public intervention. figure 6 shows the magnitude of the economic costs incurred when the government locks down in the event of a pandemic. in a lockdown, any human activity that involves external contact is regulated, leaving only the minimum economic activity necessary to maintain people's livelihoods. therefore, the income that is being brought in at that time can be considered the minimum required income in that economy. in other words, the economic cost of lockdown is the difference between the average income in peacetime and the minimum required income in the economy. 4 realistically, if an economy growing at an average rate of 2% per year were to shift to zero growth due to the lockdown, the lost income (2%) would be considered the economic cost of the lockdown. the path by which the decline in income and its growth rate come about will be dealt case-by-case. if the government halts business operations or firms' productive activities through legal regulation, the economic impact would appear to be a reduction in the supply of goods and services due to government regulation. in contrast, if the government asks people to avoid eating out, and people abstain from doing so in response, there should be a decrease in supply through the decrease in demand for food service. thus, if the government merely calls for voluntary restraint, most of the income decline will be the result of demand shocks. however, the stronger the government regulation, the stronger will be the supply shock. importantly, all these consequences, whether they are demand shocks or supply shocks, unfold as a decline in people's current income, which constitutes the economic cost of pandemic preparedness, shown in figure 6 . in this sense, the question of whether the onset of decline is a demand or a supply shock is not so essential. the more pertinent question is about whose income it will reduce. the government's counter-pandemic measures reduced the income of individuals and firms basically through reducing the supply of goods and services, whether directly or indirectly. in short, those who reduced the supply of goods and services faced income losses. in contrast, the individuals and firms that did not reduce the supply of goods and services did not have to contend with reduced incomes. this means that the economic costs of securing the health capital needed to prevent the spread of infection are being passed on in an extremely unequal manner among the members of society. thus, the government's counter-pandemic measures usually place a significant burden on some members of the society, in the form of loss of income, as the supply of goods and services shrinks. the distribution of that burden is extremely uneven with respect to industrial and health capital income (production of goods and services) figure 6 economic cost of a lockdown peacetime point peacetime income lockdown point the minimum required income economic cost of a lockdown employment conditions, because it depends on how government regulation affects firm and household incomes through demand and supply shocks. hence, many governments that have dealt with pandemics have simultaneously offered some form of financial assistance, such as compensation for lost work or fixed benefits for companies and individuals who bear a particularly heavy burden. while the policy objectives of such public support are not always clear, the following benefits are generally expected. the first is livelihood compensation for economically deprived households that have lost their income. this is primarily a measure aimed at low-income people, such as those with little to no savings. the second is the provision of economic incentives for leaves or absence from work. this becomes especially important when government measures remain a moral imperative rather than a legal regulation. in the absence of absenteeism or fixed benefits, there will always be people who are willing to go to work (instead of staying home) for financial reasons. the trend is particularly strong among low-income people who have no savings. in this sense, the government's support measures are not just focused on livelihood compensation, but also serve as an economic incentive to keep people at home, instead of permitting them to go out to work. another important role of the government's economic support is to enable the social sharing of the economic costs incurred due to the counter-pandemic measures. as noted above, the economic costs of preventing the spread of infection (or securing the necessary health capital for epidemic prevention) fall very unequally on certain members of the society. it is transferred to those who have reduced the supply of goods and services as a result of demand and supply shocks. they thereby lost the claims on goods and services from the present to the future. however, those who have not reduced the supply of goods and services have also suffered economic welfare losses. this is because they have been forced to cut back on consumption due to the government's counter-pandemic measures, even though their incomes may not have reduced. since they were inhibited to consume goods and services to the optimum level, their economic welfare has clearly declined. since their incomes were not reduced, however, they necessarily increased their savings, which would result in their future claims on goods and services. in this regard, the economic welfare losses they have suffered might be almost negligible in comparison to the losses of those who have reduced their incomes. in view of the above, the government's economic support should, in principle, be paid according to the share of the economic burden of fighting the pandemic (i.e., how much one's income is reduced by it). the government would be using its own funds to compensate for the damages based on an insurance-like principle, as argued by hayashi [2020] . a major problem with this compensation policy is that it takes a long time to calculate the value of damages. if the government intervenes to combat the pandemic, many people will face an immediate reduction in their income. however, the manner in which the burden is 15 ultimately passed on to the members of society can only be determined after the entire infection passes. for this reason, the government may be reluctant to provide financial support, which would result in low-income individuals with little to no savings pushed to further financial trouble. it is not that difficult to solve these problems. hayashi [2020] suggests that the government should provide unsecured bridge loans to households until the final compensation amount is finalized by the government. alternatively, as many countries have already done, the funds can be distributed uniformly for the time being and adjusted afterwards through taxation. in that case, the government would make a distinction between those whose incomes have been significantly reduced by the government's counter-pandemic measures and those whose incomes have not been reduced, and subsequently give preferential tax treatment to the former. 4 real and fictitious future burdens the financial size of the public compensation could pile up to an amount not seen since wartime spending in world war ii. most of the public spending, at least for the time being, will be funded by public debt, and not by tax increases. this is because not many governments have the political capital to dare to raise taxes in the midst of the growing economic hardship. therefore, few mass media outlets and pundits have already begun to express concern over the future expansion of the budget deficit. since the expansion of the budget deficit due to public support from the government is inevitable, such concerns will probably become more prevalent among the general public. this is because many people tend to assume that a larger government budget deficit means a larger future burden. government policies that deter the spread of infection may reduce not just people's current incomes, but also their future incomes. if the supply of capital goods is cut off due to the cessation of corporate production activities, capital investment by corporations and governments would become impossible, and capital formation in a country will stagnate. moreover, if the accumulation and renewal of the capital stock is thus stalled, it will inevitably lead to stagnation of production and income in the future. in addition, the expansion of leave of absence and furloughs that was implemented to deter the spread of infection will, if prolonged, lead to a degradation of human capital embodied in people's labor. its probability becomes even stronger if dismissal of workers by companies increases. furthermore, corporate bankruptcy due to a contraction of economic activity would imply a loss of management capital. altogether, these shall result in a contraction of production and income in the future, rather than in the present. however, these are all future costs that the society has no choice but to accept to deter 16 the spread of the infection. they are never future burdens created by public support through government debt. on the contrary, if sufficient government support for businesses and households can effectively prevent the expansion of corporate bankruptcies and unemployment, the future burden created by the deterrence of the spread of the infection will certainly be reduced, at least to that extent. the future burden of deficit financing more generally, there are cases in which government support measures using deficit financing will lead to future burdens. it is a situation where deficit financing tightens capital markets, which in turn raises interest rates and crowds out private investment. there, to be sure, deficit financing, irrespective of how it is produced, usually stagnates capital formation and shrinks production and income in the future. however, in a situation where such a crowding-out mechanism does not arise, deficit financing, by itself, will not lead to a burden on future generations. the economist who articulated this logic most clearly was paul samuelson, one of the leading economists of the 20th century, who discussed in detail the problem of future generations' burden of government deficit financing. 5 samuelson first presents the conclusion of this issue as follows: the main ways that one generation can put a burden on a later generation is by using up currently the nation's stock of capital goods, or by failing to add the usual investment increment to the stock of capital. (samuelson [1967] p.346) the meaning of this brief statement is explained in more detail in a summary at the end of the chapter. the public debt does not burden the shoulders of a nation as if each citizen were made to carry rocks on his back. to the degree that we now follow policies of reduced capital formation which will pass on to posterity less capital goods, we can directly affect the production possibilities open to them. to the degree that we borrow from abroad for some transitory consumption purpose and pledge posterity to pay back the interest and principal on such external debt, we do place upon that posterity a net burden, which will be a subtraction from what they can later produce. to the degree that we bequeath to posterity an internal debt but no change in capital stock beyond what would anyway have been given them, there may be various internal transfer effects as one group in the community receives a larger share of the goods then produced at the expense of another group. (samuelson [1967] p.353) this explanation by samuelson can be generalized as the proposition that government debt is not a burden on future generations unless it reduces their future consumption possibilities. conversely, government debt is a future generational burden only if it reduces the future consumption possibilities of people. this may be called the "lerner-samuelson proposition on the future generational burden of government deficit financing," since it was abba lerner who laid the foundation for this reasoning. lerner pointed out that whether public debt will be a burden for future generations depends on whether the national debt issued to finance the budget deficit will be absorbed domestically or abroad. 6 in the case of internal debt, even if future generations are taxed in order to redeem government bonds, they will still receive the payments, and their consumption possibilities as a whole will not necessarily decline. 7 in contrast, in the case of external debt, while the current generation does not have to cut spending, the future generations will have to truncate theirs (through government tax collection) to repay the debt to other citizens, and the consumption possibilities of future generations will necessarily be reduced by that amount. 8 thus, external public debt will necessarily be a burden for future generations. while lerner's argument implies that future generational burden will necessarily arise as long as the public debt is external, it does not imply that it will not arise in principle in the case of internal debt. as samuelson points out, even if all of the public debt is internal, the future possibilities of production and consumption will decrease if the renewal and accumulation of the capital stock is inhibited by the debt. generally, deficit-financing policies undertaken in a full employment economy are more likely to result in tighter capital markets, higher interest rates, and a crowding out of private investment. therefore, future generational 6 it should be noted that "generation" in the discussion of lerner and samuelson means "all people living at a certain point in time", which is different from the usual generational concept of "all people born at a certain point in time." 7 lerner says of this, "very few economists need to be reminded that if our children or grandchildren repay some of the national debt these payments will be made to our children or grandchildren and to nobody else. taking them altogether they will no more be impoverished by making the repayments than they will be enriched by receiving them." (lerner [1948] p.256) burdens will certainly arise, even if the debts are internal. the above consideration leads to a more precise version of the lerner-samuelson proposition that public debt will not be a burden on future generations if it is absorbed domestically and does not reduce the domestic capital stock, subsequently implying that there is no reduction in future consumption possibilities. this proposition holds strictly true in a ricardian economy, wherein people behave as if they equate current tax increases with future tax increases due to bond issues. in this case, people's saving and spending behavior will not change whether government spending is financed by higher taxes or by bond issues. therefore, more fiscal deficits mean neither higher interest rates nor greater external debts. even in non-ricardian economies, the lerner-samuelson proposition holds, at least approximately, in an underemployment economy where unemployment due to lack of demand exists. as traditional keynesian models (such as the is-lm model) show, if the government implements a deficit fiscal policy, there will be some increase in interest rates and crowding out of private investment. however, the degree of crowding out will be contained because income and savings will increase due to the demand-led growth induced by fiscal spending. in short, public debt does not necessarily imply a future generational burden. whether or not the burden arises depends entirely on the economic situation. as samuelson points out, the impact of the buildup of public debt as internal debt appears not so much as an expansion of the future burden itself, but rather as an income transfer between different strata of society. government bonds as public debt are nothing more than assets for bondholders and a right to acquire goods and services in the future. thus, as long as government-issued bonds continue to be absorbed in the country, private sector assets will continue to grow. the economic conditions in the country will decide the macroeconomic effect of the expansion of private assets. in a ricardian economy, this private sector asset signifies future tax increases, therefore would be completely offset by public debt. thus, deficit financing would be macroeconomically neutral. this means that, as robert barro once argued, government debt cannot be the net wealth of the private sector (barro [1974] ). however, in the non-ricardian economy on which traditional keynesian economics has been premised, the economic expansionary effect of deficit-financing government spending is usually greater than tax-financing government spending. the most obvious difference between the two arises in the domestic distribution of purchasing power. the holders of government bonds in the private sector should have relatively greater access to goods and services than those without them. this purchasing power effect does not depend on whether the economy is ricardian or non-ricardian, but on the decision of each economic agent about whether to cut their spending and buy the government-issued bonds that created the debt. it is merely the result of the intertemporal consumption choices of each economic agent-whether to cut current spending to obtain future goods and services or simply to desire current goods and services. the important message in samuelson's argument on the future burden of deficit financing is the economic truth that most of the burden created by government spending, whether it is financed by bond issues or tax increases, will ultimately be borne by the current generation, and not by the future generations. samuelson uses the example of wartime costs to illustrate this. it is worth considering why this is so by following the context of the supplementary argument in chapter 19 of economics that "all debt came from world war ii" (samuelson [1967] p.356). war usually requires artillery and ammunition, and the government spending for it is funded by either higher taxes or public debt. suppose that all the costs were covered by bonds rather than taxes. even then, the burden on future generations will not arise if all the public debt is absorbed domestically and does not result in the crowding out of private investment. to confirm this, consider an economy in which there is no capital stock at all, and therefore no investment; people devote all their income from time to time to consumption. it is, so to speak, an economy that is based solely on hunting and gathering. in this consumptiononly, investment-free economy, it is self-evident that no matter how much manpower is used in the production of artillery and ammunition, it will not result in a burden for future generations. while future generations could produce artillery and ammunition, they cannot bring it to the present unless they possess a time machine. thus, in this case, the burden of producing artillery and ammunition would eventually be borne entirely by the current generation in the form of a reduction in its consumption. this is because there are always constraints on production resources, such as labor. as more human resources are allocated in the production of artillery and ammunition, the production of consumer goods must be reduced. in conclusion, whether wartime costs are financed by higher taxes or public debt is merely a question of how that burden will be shared within the current generation. if it is financed by a tax increase, then the taxpayer who has reduced their disposable income will bear the cost through reduced consumption. in contrast, if it is financed by public bonds, the cost is borne by those who voluntarily reduce consumption and purchase the bonds. however, this strong conclusion that all fiscal burdens are borne not by future generations but by the present generation is derived from the assumption that there is no foreign sector or capital stock; thus, it is by no means universally true. there will always be future burdens when public bonds are absorbed overseas. even if they are absorbed internally, there will be future burdens if they reduce domestic investment and capital stock. regardless of the burden on future generations, if there are individuals who must reduce their consumption due to the government's policy, it is clearly a burden for that generation of people. in this sense, the burden of the government's policy is considered to be borne by the current generation rather than future generations. the same conclusion holds for the government's counter-pandemic measures. as shown in the previous section, imposing public regulations to prevent the spread of infection necessarily reduces the very level of economic activity, through a reduction in demand or supply. in a lockdown, the difference between the income in peacetime and in lockdown is precisely that economic loss ( figure 5 ). thus, public regulations to prevent the spread of the infection affects the economy in the form of demand and supply shocks, shrinking the overall production of goods and services. however, the extent of the impact will vary depending on the circumstances in which each firm and household is located. while some areas will be devastated (such as the entertainment industry or the food and beverage industry), others will rather expand supply (such as the mask-making industry). the economic burden thus created will be entirely borne by the present generation, whether or not it is financially supported by public debt (exactly as it is in the case of the burden of war expenditures). this is because it is the current generation of people who are reducing the production and consumption of goods and services through the imposed counter-pandemic measures. the amount of public debt that piles up at that time will not deter private investment as unemployment expands due to falling demand and interest rates continue to fall. thus, future production and consumption possibilities are not depressed by the bond itself. rather, these possibilities would be better than they would be without it if the government's economic support measures successfully prevented the expansion of corporate bankruptcies and unemployment. apparently, these measures should be deficit-financed, and not involve tax, since they must be implemented without reducing people's disposable income. in a wartime economy, people are sometimes forced to severely cut back on their consumption. in japan, during world war ii, moral slogans such as "luxury is the enemy" and "we don't want it, not until we win" were imposed on the people by the government. it comes from the economic principle that there is no free lunch; everything involves trade-offs. therefore, to obtain the artillery and ammunition needed to carry out the war, the current generation has no choice but to reduce consumption and divert the productive resources (that were used to produce consumer goods) to the production of artillery and ammunition. the resulting decline in consumption is a burden on the current generation. meanwhile, in an economy under pandemic preparedness (such as lockdowns), the greatest burden for the current generation will come in the form of a decline in income. the present generation is subsequently involuntarily forced to produce non-income-generating leisure instead of producing artillery and ammunition. people would prefer to earn income by engaging in economic activities and enjoy consumption of goods and services from that income, rather than such excessive leisure. it is the current generation's income and consumption that is lost in this situation resulting in the economic burden of the counter-pandemic measures. when a society is faced with a pandemic, the preliminary decisions involve the measures to be used and the extent to which they will be imposed to deter the spread of the disease. our goal is to minimize the losses that the society suffers. while the goal, in itself, is quite simple, the decision is far from simple. this is because the stronger the policy to prevent the spread of the disease, the greater the economic losses are likely to be. this is the trade-off between economic activity and epidemic prevention. it is precisely because of this trade-off that we continue to struggle with the decision to impose lockdowns once an infection has spread, and the duration for which it should continue. in fact, if the lockdown does not result in any economic loss, the society will happily continue to comply. this trade-off between economic activity and epidemic prevention signifies that our decisions regarding pandemic deterrence are nothing less than judgments about our priorities. the extent to which a given quarantine policy is effective in deterring infection is a purely empirical epidemiological question that has nothing to do with value judgments. however, no matter how epidemiologically effective the policy may be, there is no immediate justification for its implementation if it involves an economic loss that results in income reduction. in order to implement the policy, a social consensus based on the exact value judgment is necessary; the benefits of reducing the social losses are sure to exceed the economic losses caused by it. another issue we must consider regarding the economic costs of pandemic deterrence is how it will ultimately be shared by the society. we see that the economic burden of policies to prevent the spread of infection falls on each class of the society in a very unequal way. it varies across industries, and it depends on an individual's employment category. some people have lost their jobs and income entirely because of the policies; others have been able to maintain their existing income and enjoy their extra leisure time. preventing the spread of infection is an obvious public good that benefits all members of the society, and yet, the cost is unequally shared. therefore, governments should provide some form of financial support, such as absenteeism and fixed benefits, along with its policies to deter the spread of infection. the biggest obstacle to such public support measures is a very universal concern that they will lead to a deterioration of government finances. the existence of such apprehensions may, in some cases, distort judgments about what and how far to go to deter the spread of the infection itself. it is plausible that some nations may lift the lockdown to avoid the expansion of public assistance, even though there remains a significant risk of the spread of the infection. however, as samuelson have argued, since many of the government's policies can only be carried out using current rather than future labor resources, much of the burden will eventually have to be borne by the current generation. even if public bonds are issued to implement these measures, it does not mean that the burden will be passed on to the future generations. the extent of public debt merely changes the distribution of goods and services in the future according to the current saving and spending behavior of each economic agent. this applies to the public assistance provided as part of the counter-pandemic measures. the current generation is already bearing the heavy burden of shrinking incomes and consumption. even if all public support was provided by issuing public bonds, thereby expanding government debt, the burden of the current generation could not be passed on to future generations. therefore, there is no basis for the notion that government economic support should be withheld as much as possible in order to avoid leaving a burden for future generations. however, the above considerations about the future burden of deficit financing do not at all deny that the accumulation of public debt has any effect on the economy as a whole. generally, if the economy were non-ricardian, then an increase in public debt would act as a greater expansion of people's spending because it would mean an increase in private assets as a future claim to goods and services. therefore, at some stage, governments and central banks may have to carry out macroeconomic tightening (using fiscal and monetary policies) to contain price increases due to the expansion of private spending. this suggests that the failure of governments and central banks to make such macroeconomic adjustments could lead to economic disruptions, such as fiscal collapse and soaring inflation. economists of the keynesian position have been consistently emphasizing that government fiscal deficits are not generally evil, but rather that deficit financing during recessions is necessary for the stabilization of the macroeconomy. however, they did not deny the need for fiscal discipline in the sense of long-run fiscal equilibrium through the business cycle. this is because it is difficult even for keynesians to deny, in principle, the possibility of macroeconomic turmoil that would occur if there were no fiscal discipline. 9 nevertheless, the claims made by some media outlets that the expansion of public support will lead to immediate fiscal collapse and hyperinflation can be considered a product of 9 however, there is a position on the part of some keynesians that denies even the need for fiscal equilibrium in the long-run sense. for example, modern money theory (mmt), proposed in mid-1990s by warren mosler, randall wray, and others, maintains that there is no inherent government fiscal constraint in an economy with a sovereign currency. they termed the rigid fiscal equilibrium doctrine as "deficit hawks," the cyclical deficit doctrine (on which the traditional keynesians have relied) as "deficit doves," and their own position (that government finances do not even need to be balanced through the business cycle) as "deficit owls." (mitchell, wray, and watts [2019] p.333-4) 23 mere sensationalism. there is almost no chance that the excessive demand supported by deficit financing will make it difficult for governments and central banks to control inflation in a situation where many companies are facing a business downturn due to reduced consumer demand as a result of counter-pandemic measures. rather, as christopher sims has suggested as a policy implication of the fiscal theory of price level (ftpl), the evils of being too captive to fiscal discipline are far greater in a demand-deficient, low interest rate economy than they would be otherwise (sims [2016] ). there have been countless examples in history of countries falling into financial ruin due to excessive public debt (reinhart and rogoff [2009] ). however, fiscal collapse has only occurred in very exceptional circumstances in developed countries with adequate tax collection capacity. conversely, there are many examples that show noticeable "debt tolerance" in these countries. the united kingdom had a public debt of 250% of gdp after the end of the world war ii with no signs of fiscal collapse. japan had experienced a sustained deterioration in public finances caused by the prolonged economic stagnation since the 1990s, which caused government bond rates to continue to fall, rather than rise. in short, it is highly unlikely, at least in the developed world, that a transient increase in budget deficits due to an increase in public support will lead to immediate fiscal collapse or hyperinflation. thus, in terms of pandemic preparedness, it is clearly not about what we should consider, but about what we should not. health capital are government bonds net wealth? urgent proposal for the government corona emergency economic measures: government should be devoted to life insurance on the concept of health capital and the demand for health income, employment and public policy, essays in honour of alvin hanson this time is different: eight centuries of financial folly the global impact of the largest influenza pandemic in history economics: an introductory analysis fiscal policy, monetary policy and central bank independence key: cord-019057-3j2fl358 authors: afolabi, michael olusegun title: pandemic influenza: a comparative ethical approach date: 2018-08-28 journal: public health disasters: a global ethical framework doi: 10.1007/978-3-319-92765-7_3 sha: doc_id: 19057 cord_uid: 3j2fl358 community-networks such as families and schools may foster and propagate some types of public health disasters. for such disasters, a communitarian-oriented ethical lens offers useful perspectives into the underlying relational nexus that favors the spread of infection. this chapter compares two traditional bioethical lenses—the communitarian and care ethics framework—vis-à-vis their capacities to engage the moral quandaries elicited by pandemic influenza. it argues that these quandaries preclude the analytical lens of ethical prisms that are individual-oriented but warrant a people-oriented approach. adopting this dual approach offers both a contrastive and a complementary way of rethinking the underlying socioethical tensions elicited by pandemic influenza in particular and other public health disasters generally. contemporary healthcare constitutes an instinctual and institutional response to the multifaceted cycles of health, illness, and disease. 1 hence, the problems of diseases including infectious ones affect all and sundry irrespective of current "sick status". pandemic influenza is one such incident that afflicts all sectors of the society. 2 it also raises questions and issues related to utility and equity, ensuring the protection of vulnerable individuals and groups in society, the need to exercise public health powers with respect for human rights 3 as well as the just allocation of human and material resources. 4 attending to these issues, however, juggles many kinds of personal, social, political, and professional interests against one another; thus, reflecting the traditional public health dilemma of fine-tuning individual against collective good. 5 since the restrictive approach of individualism-driven moral lenses 6 is unsuitable for people-centered quandaries, it seems pertinent to employ a people-centric moral lens to engage them. in this vein, the ethical prism of communitarianism and ethics of care seem apt. by examining and contrasting the core fabric of the communitarian and care ethics frameworks vis-à-vis the attendant dilemmas of pandemic influenza; this chapter attempts to tease out a broader ethical path towards engaging the challenges of pandemic influenza. to properly set the conceptual foreground essential to articulating the ethical features of pandemic influenza, however, it is important to elaborate the associated biological, social, and global dynamics. these parameters, as macphail recently argues, are exigent in the explication and engagement of pandemic or infectious disease outbreaks. 7 there have been some speculations as to the origins of the influenza virus. it has been hypothesized that the virus originated from wild waterfowls and has only slowly evolved through multiple animal species including humans. 8 but what is known about the disease caused by the virus-influenza-is that it is a febrile illness of the upper and lower respiratory tract, characterized by a sudden onset of fever, cough, myalgia, and malaise. pneumonia is a principal serious complication 9 and local symptoms include sniffles, nasal discharge, dry cough, and sore throat. 10 pandemic influenza outbreaks describe the rapid spread of influenza infection. whereas there is some conceptual controversy about the description and definition of pandemics, 11 they generally refer to the dissemination of new infective diseases to which immunity has not been developed in a widespread manner across a significant part of the world. 12 they could break out in nations with a large geographical size (such as china, india, and the united states) or when the number of affected nations are many. the pandemic nature of influenza is historically underscored by the 1918-1919 incident that killed an estimated 20 million to 50 million people. 13 pandemic influenza is generally characterized by an alteration in the viral subtype (due to antigenic shift), higher mortality rates among younger groups, several waves of the particular pandemic, increased capacity of spread, and geographic variation in the impact of the outbreak. 14 specifically, influenza pandemics occur when an influenza virus mutates or when multiple strains combine, or re-assort to produce strains to which there is no current immunity. 15 novel outbreaks of the influenza virus occur either in large nations or across selected nations in close proximity. contemporary society experiences an increased development of new serotypes of several kinds of respiratory viruses because of the evolutionary potential afforded by the human population explosion and the great global increase in human mobility. 16 in a manner of speaking, it seems that phds such as pandemic influenza outbreaks have evolved to become recurring features of the human experience. some insights into the biological features and processes that create pandemic outbreaks support this idea. influenza viruses belong to the orthomyxoviruses family. this comprises seven genera including influenza virus a, b, c, and d. 17 although both the genus influenzavirus a and b affect humans and cause pandemics, 18 influenza a has been the principal culprit in known outbreaks to the extent that four major pandemics have resulted from it (1918-1919, 1957, 1968, and 2009) . 19 however, genetic reassortment and exchange of influenza viruses between humans and animals generate antigenic shift, which periodically introduces new viruses to the human population. this, in addition to mutation and selection, produces antigenic drift that accounts for the year-to-year variations in influenza a subtypes. 20 wild ducks, for instance, serve as the primary host for various influenza type a viruses that occasionally spread to other host species and cause outbreaks in such animals as fowl, swine, and horses. such outbreaks often lead to new human pandemics 21 due to novel viruses infecting immunologically naïve people. 22 a critical aspect of the emergence of novel virus strains is genetic variation and combination that occur at the hemagglutinin (ha) antigens (of which there are 16) and neuraminidase (na) enzymes (of which there are nine) 23 between and amongst human and animal influenza viruses. the subtypes of the ha and na surface proteins forms the basis for the classification of outbreaks. 24 for example, the 1918 through 1919 virus was h1n1, the 1957 through 1963 virus was h2n2, the 1968 through 1970 outbreak was caused by h3n2, 25 the 1996 virus was h5n1, 26 and the 2009 outbreak was caused by h1n1; 27 while the most recent virus seen in eastern china in 2013 was h7n9. 28 all of these traditional and new influenza viruses cause pandemics of differing proportions but more are projected to occur. 29 this projection is well supported by the scientific community. however, it is not known when any will occur or whether it will be caused by the h5n1 avian-derived influenza virus, newer subtypes like h7n9, or completely novel subtypes. virologists like webster and govorkova argue that given the number of cases of h5n1 influenza that have occurred in humans (more than 251) with a mortality or death rate of more than 50%, it would be prudent to develop robust plans for dealing with such pandemic influenza and its (expected) new variations. 30 such plans, however, necessarily demand attention to the associated ethical dynamics. regardless of the specific subtype of human or animal-derived influenza outbreaks, the public health challenges and the moral quandaries are essentially the same. a critical biological feature of influenza lies in its mode and pattern of transmission. this revolves around its capacity to evolve and become airborne-transmissible between and amongst human beings. 31 the influenza virus transmits from person to person primarily in droplets released by sneezing and coughing. some of the inhaled virus lands in the lower respiratory tract, the primary site of disease 21 marion russier et al., "molecular requirements for a pandemic influenza virus: an acid-stable hemagglutinin protein," proceedings of the national academy of sciences 113, no. 6 (2016) . pp. 1636 pp. -1639 anna v cauldwell et al., "viral determinants of influenza a virus host range," journal of general virology 95, no. 6 (2014). pp. 1193-1195. 23 couch. p.; shah. p. 94. 24 cauldwell et al. p. 1193 . 25 miller et al. pp. 2595 -2597 shah. p. 89. 27 rebekah h borse et al., "effects of vaccine program against pandemic influenza a (h1n1) virus, united states, 2009 -2010 ," emerging infectious diseases 19, no. 3 (2013 . pp. 439-441. 28 cauldwell et al. p. 1204. 29 macphail. p. 9. 30 robert g webster and elena a govorkova, "h5n1 influenza-continuing evolution and spread," new england journal of medicine 355, no. 21 (2006) . pp. 2174-2175. 31 russier et al. pp. 1636 -1637 being the tracheobronchial tree, and sometimes the nasopharynx. 32 largely because breathing is an essential biological need of human beings and partly because human-human associations are an inevitable part of reality, this biological feature of influenza viruses makes everyone vulnerable and susceptible to infection. specifically, crowds of people facilitate viral transmission by enabling sharp upticks in the rate of transmission. the virus also circulates for longer periods in infected persons. 33 the biological features of influenza and its mode of transmission elicit some observations. one, pandemic influenza is not a single disease for which a single and specific therapeutic intervention that will be effective all the time can be developed. in other words, while there is a general approach to engaging this public health disaster, specific interventions will usually vary by each outbreak. this gives an existential and evolutionary advantage to the influenza virus over human communities. it also engenders a disaster dynamic in the sense that every outbreak becomes "sudden" and potentially associated with large human casualties. secondly, it shows the common vulnerability to which the local and global human community are subject vis-à-vis the ease of spread of the viral infection. thirdly, the biological features of pandemic influenza demonstrate how a collective response (human material, scientific etc.) is key to engaging its social and other attendant consequences. the importance of this last remark will become clearer against the backdrop of the social and global features of pandemic influenza outbreaks, a. theme addressed in the next section of this chapter. an influenza pandemic has the potential to cause more deaths and illnesses than any other public health threat. 34 pandemic influenza a h1n1 were reported. 37 also, the h5n1 outbreak recorded a death rate of 59%, 38 and the recent h7n9 outbreak caused 251 human infections and 67 deaths. 39 in the united states, the estimated potential threat of pandemic influenza is 1.9 million deaths, 90 million sick people, and nearly 10 million hospitalizations, with almost 1.5 million requiring intensive-care units. 40 global estimates are higher. for instance, the 1918 "spanish flu" caused an estimated 20-50 million global deaths. 41 it has been projected that a recurrence of the 1918 influenza strain would probably result in the death of 51-81 million individuals. 42 these data show that substantial numbers of deaths are an inevitable consequence and feature of pandemic influenza. however, death itself often brings about certain social consequence including the death of some of the most gifted members of the society. sir william osler, one of the pioneers of scientific medicine, died of complications arising from influenza in 1919. influenza was cited by the german war general, erich von ludendorff, as a significant reason for why the initial gains of their last offensive faltered and ultimately failed during world war 1. 43 from a biological perspective, influenza exploits naïve immune systems which tend to over-respond to the influenza virus. as such, young and promising adults constitute a large part of vulnerable victims. in this regard, potential contributions to societies are nipped in the bud, young widows and widowers emerge as well as a lot of orphans. for instance, 21,000 children were orphaned due to the 1918 outbreak in new york city. 44 influenza also spread within households soon before or after the onset of symptoms in primary infected patients. 45 another associated social feature of pandemic influenza is the closure of schools with an attendant truncation of learning and educational opportunities, depending on the length of the outbreak. while some of these social features are local and exert localized effects, human beings as social animals with the aid of the increased means of locomotion transmit some of the local features into a global experience. the 1957 pandemic of influenza which occurred during a time of much less globalization spread to the united states within 4-5 months of its detection in china while the 1968 pandemic spread to the u.s. from hong kong within 2-3 months. 47 it is estimated that the burden of the next influenza pandemic will be overwhelmingly focused in the developing world. 48 however, the epidemiological notion well-known to public health experts that infectious diseases can predicate outbreaks in neighboring places and nations 49 implies that even so-called developed societies cannot be spared as long as the current interpenetration of people across the globe remains. the 2009 influenza outbreak, for instance, spread to 85 countries and caused a total of 39, 620 cases of infection. 50 in short, in a globalized world, infectious diseases travel in nodes of human, material, and animal networks. 51 data from sporadic studies suggest that influenza may be fairly prevalent in africa, albeit sub-clinically. it may, therefore, have a considerable impact on morbidity and mortality on the continent 52 should a combination of factors create a virus that is viable enough to cause a pandemic. this will have far-reaching consequences for the continent due to the material and human resource constraints, lack of preparedness plans as well as the very limited bio-therapeutic capacities that are currently available to produce vaccines. it may likewise create the dispersal of a virus novel to other continents that have experienced typical outbreaks. geographical location plays a major role in public health, 53 and disasters including health disasters are unique in that each affected region of the world has different social, economic, and health backgrounds. 54 as such, while there is a global spread, the nature of each local context and how it responds shapes pandemic influenza in some key ways. first, the nature of the "disseminating" nation influences how infection spreads elsewhere. for example, china's slow reaction to the 2003 sars outbreak as well as its limiting of access to patients and other relevant information 47 hhs, "hhs pandemic influenza plan." p. b6. 48 86, no. 9 (1996) . p. 1208 54 eric k noji, "public health issues in disasters," critical care medicine 33, no. 1 (2005) . p. s29. seemed to have deepened the global intensity of that crisis. 55 in other words, how a local public health disaster is handled shapes the local severity and how it spreads elsewhere. on the other hand, well-handled local health crises positively influence the possible impacts on contiguous nations. in this vein, radest notes that canada's rapid and coordinated response to the sars outbreak significantly limited its spread and impact in the united states. 56 the above examples echo the interconnectivity of the modern world and show how a course of action in one place, however passive, may significantly influence the course of events in another for good or bad. it supports the idea that contemporary health in the twenty-first century is now inevitably and inherently global with respect to infectious diseases. 57 at the heart of these remarks, however, is the possibility of utilizing different networks of human interconnectivity to actively foster the global good. in other words, learning about how people connect and relate at different levels (individually, communally, institutionally et cetera) and learning about the chief actors and players in such a relationship nexus may provide a powerful tool for driving global public health agenda. yet, integral to such a process is how responses to pandemic influenza are framed and implemented locally as well as their attendant limitations. this theme is addressed in the next section. the human instinct for self-preservation has, at the social plane, always resulted in some institutional responses to diseases, whether rudimentary, barely adequate, or sophisticated. in the context of phds, responses are shaped by the nature of the specific disaster, where it is taking place, and what human, material, pecuniary and technological resources are available to deal with the given emergency situation. for instance, the united states prioritizes building a system that ensures stable and economically viable vaccines to engage influenza outbreaks. 58 countries that lack the same kind of resource will clearly prioritize other approaches. however, the general approaches to pandemic influenza are therapeutic and non-therapeutic in nature. this section briefly examines them. pandemic influenza outbreaks, like most diseases, have elicited some biopharmaceutical responses geared towards mitigating its disastrous effects. due to the changing biological and social dynamics associated with the outbreak, social as well as scientific responses are always evolving to keep up. nevertheless, the therapeutic measures fashioned to combat pandemic influenza fall into two groups. these are preventive measures involving the use of anti-viral drugs as well as vaccination. in the past, drugs like rimantadine and amantadine were used as prophylaxis against influenza a. 59 but drug resistance has increasingly been observed to these m2-ion channel-blocking agents. 60 today, drugs of choice are mainly tamiflu (oseltamivir) and relenza (zanamivir). black et al. noted that early anti-viral intervention during the 2009 pandemic helped reduce the doubling time in the early stages of the outbreak. 61 the linkage between antiviral use and reduction in clinical severity and influenza infectiousness is generally supported in the extant literature. 62 hence, treatment of clinical cases with anti-viral agents constitutes the first-line of engagement for pandemic influenza and these drugs are employed to control or contain pandemic outbreaks long enough for vaccines to be made. 63 yet, drugs like oseltamivir and zanamivir, usually neuraminidase inhibitors, can only help reduce transmission if given within a day of the onset of symptoms. 64 on the contrary, delay in symptoms diagnosis, as well as intervention, favors infection dissemination. nevertheless, antiviral agents for influenza offer some protection to families and households once infection has been detected. in clinical trials, antiviral treatments have been shown to be efficacious in preventing infection, hence, slowing down transmission as well as limiting the severity of the disease. 65 but the effectiveness of neuraminidase such as oral oseltamivir and inhaled zanamivir at reducing mortality is uncertain. 66 in addition, there is some evidence of side-effects. for instance, in adults as in children, oseltamivir increases the risk of nausea and vomiting. also, treatment trials with oseltamivir or zanamivir do not settle the question of whether the complications of influenza (such as pneumonia) are reduced. 67 resistance to these anti-viral drugs has also been reported, even in people who have never been previously treated with them. 68 ultimately, the success of antiviral prophylaxis critically depends on the identification of index cases in households, pre-schools, schools, and other institutional settings. 69 this clearly highlights the importance of personal, social, and institutional cooperation in relation to dealing with the associated challenges. on the other hand, vaccination as one of the most effective and cost-saving strategies for ameliorating infectious diseases 70 offers a protective approach to limiting and/or curtailing the social and economic consequences of pandemic influenza. two types of vaccines are generally used. trivalent inactivated vaccine and live attenuated influenza virus vaccine, both of which contain the predicted antigenic variants of influenza a(h3n2), a(h1n1), and b viruses. 71 borse et al. estimated that 2009 vaccination program against influenza prevented 700,000-1,500,000 clinical cases, 4000-10,000 hospitalizations, and 200-500 deaths. they also reported that the national health effects of vaccination were greatly influenced by the timing of vaccine administration and the effectiveness of the vaccine. 72 similarly, ferguson et al. estimated that during a global outbreak, vaccination at the rate of 1% of the population per day would need to begin within 2 months of the initial outbreak. but this is not feasible under current vaccine technologies. 73 this pragmatic challenge would, however, create a biological and social climate in which infection may flourish in a logarithmic manner. the recurring antigenic variation in influenza viruses which leads to the frequent emergence of new infectious strains 74 increases the likelihood of continuous outbreaks. this and the capacity of the influenza virus to acquire amino acid changes in its viral proteins 75 implies that each outbreak will demand novel vaccines. this often delays the possible response time, again creating a window where infection can readily spread, locally and globally. for instance, it will take at least 4 months from identification of a candidate vaccine strain until production of the very first vaccine 76 during an outbreak. this biological fact makes it difficult to stockpile influenza vaccines ahead of outbreaks and, by consequence, limits the preparedness efforts geared towards confronting the public health challenges and moral quandaries. it is important to note that vaccines have some limitations. for instance, they are not entirely safe public health interventions, especially when specifics are examined. 77 this fact has increasingly come to light in relation to vaccines against pandemic influenza. besides sore arm and redness at the injection site as well as red eyes which have been reported in earlier vaccine trials, 78 there has been some association between increased incidence of narcolepsy in children and the use of the aso3-adjuvanted vaccine for pandemic h1n1 influenza in scandinavian countries. 79 in addition, anecdotal reports of fetal deaths occurring shortly after vaccination emerged in 2009 and raised public health concerns about vaccine safety. 80 another shortcoming associated with vaccination generally is vaccine failure, 81 which often creates a false sense of protection in recipients while allowing the continued spread of infection. 82 in relation to pandemic influenza specifically, vaccine failure was recently reported by manjusa et al. in people of 65 years and above as well as those who have been vaccinated against seasonal influenza. 83 this is quite troubling partly because vaccine failure vis-à-vis pandemic influenza vaccines has been little studied, and partly because there are countries like the united states where seasonal flu vaccine shots are almost the norm. another dimension to vaccine failure relates to the variation of influenza virus clades. nelson et al. recently reported that nigeria, côte d'ivoire, and cameroon exhibit more variable patterns of influenza virus seasonality, hence, there is a possibility of variants evolving locally within west africa. this, they further argue, undermines the assumption that a vaccine matched to globally dominant lineages will necessarily protect against these local lineages. 84 this notion further raises the question of whether the immune system of populations living in tropical african 76 hhs, "hhs pandemic influenza plan." p. b12. 77 environments would react similarly to a vaccine developed mainly for populations restricted to certain geographical areas of the world. 85 on this note, in the possible event that someone originally from any of these nations were present in a pandemic influenza scenario outside african shore, the likelihood of their benefiting from vaccination seems slim. hence, a significant offshoot of vaccine failure in relation to pandemic influenza (especially if newer studies show more negative results) will be the reluctance of people to receive vaccines for seasonal flu and those developed for pandemic influenza outbreaks. these have unsettling public health and moral consequences. one way of engaging the limits of influenza vaccines involve creating a vaccine type that is capable of eliciting cross-protective peptides/epitopes that would be effective against different variants. but this is very difficult. 86 besides the scientific technicalities, producing vaccines for pandemic influenza is not a cheap venture. for example, meltzer, cox, and fukuda estimated in 1999 that it would cost the united states about $166.5 billion to contain pandemic influenza. 87 whereas the economic burden of influenza in lower-and middle-income countries involves direct costs to the health service and households and indirect costs due to a loss in human productivity, 88 these countries also have limited financial capacities to pursue pandemic influenza vaccination as a public health tool. the impacts of the ensuing disease burden from such a constraint will not be locally confined, as it will ultimately seep into the trans-national and global terrains. in summary, the major and, perhaps, insurmountable constraint to vaccination as a tool for engaging pandemic influenza lies in the logistic challenge of producing a pandemic vaccine from scratch, conducting pre-clinical testing as well as generating billions of doses within a very short time for global distribution, 89 which may, however, not work across all nations. but considering the limitations associated with antiviral drugs as well as vaccines in relation to combating pandemic influenza, some form of non-therapeutic approach is necessary, at least as some adjunct to mitigate the overall impact of pandemic influenza on the local and global human community. the next section addresses this theme. 85 yazdanbakhsh and kremsner. p. e1000182. 86 the non-pharmaceutical and non-therapeutic approaches to pandemic influenza revolve around measures such as case isolation, school or workplace closure, restrictions on travel, 90 quarantine as well as contact tracing. for instance, school closure is a non-pharmaceutical intervention often suggested for mitigating influenza pandemics. the logic behind this lies in the notion that children are important vectors of transmission, more infectious, and susceptible to most influenza strains than adults. it is also tied to the idea that high a contact rate in schools fosters transmission of infection. this approach, according to cauchemez and colleagues, may bring about an estimated 40% reduction in peak attack rates. however, this reduction will be hindered if children are not adequately isolated or if the policy is not well implemented. 91 whereas school closure may only bring about a small reduction in cumulative attack rates, it can foster a substantial reduction in peak attack rates. 92 closure of schools may, however, increase anxiety and create a crisis, as was observed in france during the 1957 outbreak. 93 closure of workplaces is another non-pharmaceutical intervention for pandemic influenza. it may be warranted by the degree of the outbreak in which businesses shut down at their own discretion, and for their own safety, as was seen during the 1918-1919 outbreak. 94 however, it may also be warranted by government policy. either way, business closure incurs huge economic costs, pecuniary, and other consequences for the different people tied to and/or dependent on the affected businesses or their services and goods. different forms of quarantine measures are also used to mitigate the spread of infection during an influenza pandemic. for instance, isolation and quarantine of infected patients allow some containment of infection which consequently slows down viral transmission. 95 ultimately, quarantine contributes towards reducing the overall costs and impact of an outbreak. some medical experts see household quarantine as the most effective social distance measure, provided the level of compliance is good. 96 yet, quarantine-at least on a general note-does not always work. for example, maritime quarantine was one of the measures employed in west africa to engage the 1918 influenza outbreak as well as interning the ill. however, historians like heaton and falola note that these approaches yielded meager success in relation to quelling the spread and virulence of the pandemic. 97 measures such as cancellation of non-essential public gatherings and restrictions on long-distance travel might help to decrease influenza transmission rates as well as overall morbidity, their effectiveness has not been quantified. 98 the nature of pandemic influenza, the therapeutic and non-therapeutic approaches, and the associated limitations generate some moral concerns. the next section discusses this. ethical issues arise during outbreaks of pandemic influenza. some of these are directly tied to the nature of the virus, some in relation to human responses, some to the social responses, and others to how different human beings respond differently to the several challenges elicited by the pandemic. bioethicists have underscored the critical need to reflect on the ethical issues raised by the specter of pandemic influenza outbreaks. 99 however, what may and what may not be feasible to do will never be clear enough if these ethical quandaries are not clearly explicated. hence, this section seeks to clarify the moral quandaries elicited by pandemic influenza and show the core connecting strands that resonate amongst them. generally, contexts of uncertainty are tied to the evolving nature of knowledge. tannert et al. opine that uncertainty occurs because the more the human community gains insights into the mysteries of nature, the more they realize the limits of their knowledge about how things are. these limitations, they note, make it impossible to foresee all the associated future effects and implications of situations and decisions with certitude. 100 in relation to medicine, jean daly notes that the art of medicine seeks to abolish uncertainty. 101 regardless of the good intentions and telos of medicine, the stark reality is that this task has hardly been achieved. contexts. james marcum contends that uncertainty is largely a part of medicine because of the variability of the underlying biology. 102 uncertainty is not new in the realm of science. 103 however, in the context of public health disasters uncertainty has a strong pragmatic dimension which can influence courses of actions and decisions in multiple unfavorable ways. for example, it occurs during pandemic influenza outbreaks and generates many concerns. in this vein, borse et al. note that the public health community cannot accurately predict the arrival of a pandemic. 104 indeed, a great deal of uncertainty occurs in relation to estimating the potential impact of a pandemic such as influenza. 105 this scenario stifles preparedness efforts, especially in resource-constrained countries where there are often competing social needs to be met with limited budgets. however, the two main uncertainty issues embedded in pandemic influenza involve the nature of the virus and the types of responses available to engage outbreaks. on the one hand, the influenza virus undergoes constant variation in its antigens, creating new infectious strains. 106 the virus also acquires amino acid changes in its proteins. these scenarios increase the likelihood of pandemic outbreaks. however, the question of when, where, and of what magnitude the outbreak will be is never clear-cut. worst-case scenario analysis based on the 1918-20 pandemic provides no insight into the probability of an influenza pandemic in the next 1, 5, or 10 years 107 and how serious such an outbreak might be. this scientific uncertainty or paucity of precise knowledge ignites some social uncertainty and may prompt moral inertia in relation to the level of preparedness and the ability to mitigate the various possible ramifications of an outbreak, when it does occur. this backdrop of uncertainty creates at least three possibilities: over-preparedness, ample preparedness, and under-preparedness. assuming the level of risks remains constant, over-preparing for a pandemic will undoubtedly involve the committing and expenditure of more human and material resources to an outbreak. this will create a sense of waste (to decision and policy makers) after the incident and may affect the resources that will be committed to future outbreaks. the right amount of preparation will help curtail an outbreak while under-preparedness will barely help curtail an outbreak. however, if the level of risk increases, over-preparing may help curtail a pandemic whereas what was hitherto ample preparedness as well as what was hitherto not enough will enable the full range of the effects of a pandemic outbreak to be felt. " ibid.5, no. 5 (1999) . p. 669. 106 kuby. p. 392. 107 murray et al. pp. 221-2215. in other words, the changing nature of the virus demands a constant readjustment of the level of preparedness without a reliable frame of reference with the attendant possibility of some inevitable social harm. not surprisingly, scholars like peter doshi argue that there is a need for evidence-based ways to address hypothetical scenarios of non-zero probability such as the notion that novel influenza pathogens acquire increased virulence during successive "waves" of infection. 108 the scientific uncertainty associated with health disasters such as pandemic influenza may, however, tempt government officials to attempt some form of a cover-up, hence, raising trust issues. for instance, during the 1911 cholera outbreak in naples, italian officials paid newspapers and reporters not to report the outbreak. chinese officials tried to keep the 2003 sars outbreak a secret. saudi officials, likewise, tried to silence the virologist who discovered the coronavirus in 2012 and ultimately forced him to resign from his position. 109 incidents like these have the tendency to dissuade social cooperation during public health emergencies like influenza and have the potential to weaken the overall success of public health interventions. on the other hand, there is a lot of uncertainty surrounding the therapeutic and non-therapeutic approaches adopted vis-à-vis pandemic influenza. it is uncertain, for example, if neuraminidase antiviral drugs really cut down mortality when implemented as the first line of defense. 110 this may create some sense of hesitation in relation to using them. secondly, it is uncertain who and who will not develop some of the associated side-effects. these factors, at a pragmatic level and for less rich nations, may dis-incentivize prioritization of funds for antiviral drugs. uncertainty likewise plays out in the context of influenza vaccines. for instance, only a small amount of any vaccine can be stockpiled 111 because the scientific and public health community can hardly be sure of the efficacy of any given vaccine prior to an outbreak. this is due to possible vaccine failure which will make a new outbreak not amenable to the biological effects of hitherto effective vaccines. hence, vaccines are generally not produced until the new virus strain causing a pandemic is isolated. 112 also, there is uncertainty over who will be at highest risk of infection and complications. 113 this creates a dilemma of some sorts with the potential that a class of the people who need vaccines may not get enough, while another class of people who will benefit less from vaccination gets too much. another kind of uncertainty is linked with possible side-effects of vaccines. while some incidence of narcolepsy was reported in children after the use of aso3-adjuvanted h1n1 influenza vaccine in scandinavian countries, 114 and there have been anecdotal reports of fetal deaths 108 doshi. p. 535. 109 shah. pp. 108-111. 110 hhs, "hhs pandemic influenza plan." p. s5-6. 112 kotalik. p. 427. 113 emanuel and wertheimer. p. 854. 114 dauvilliers et al. pp. 2486 -2490 occurring shortly after the 2009 vaccination 115 ; it is not clear if these safety issues are one-off events or may recur for other pandemic vaccines. responding to influenza vaccine safety signals during a pandemic constitutes a scientific and public health policy issue since decision-makers must balance the immediate consequences of disease against uncertain risks. 116 one of the consequences of the therapeutic uncertainties associated with pandemic influenza is the validity of administering potentially ineffective antiviral drugs with side-effects or vaccines that may cause harm to people. another is the validity of withholding such drugs and vaccines because it may not be useful for some class of people, or because some people may experience certain degrees of side-effects. these issues raise concerns about human rights and whether or not they may be violated through these courses of actions, or by any other course of action associated with handling a pandemic influenza outbreak. the 1948 universal declaration of human rights and the 1966 international covenant on economic, social and cultural rights documents enunciate the rights of "everyone to the enjoyment of the highest attainable standard of physical and mental health". 117 hence, it is perhaps more than ever taken for granted that there are rights-related obligations that society, as well as healthcare providers, owe patients 118 as well as those that may potentially fall sick. since everybody is theoretically a potential victim of ill-health depending on time, placek and social or physiological circumstances, individuals can appeal to a rights-based rhetoric to garner positive action from government and healthcare professionals in relation their health. the morality of such a claim stems partly from governments' moral obligation to their citizens and partly from the fiduciary obligations that health professionals have towards fostering the health of patients (and potential patients) in a fashion that preserves their rights as human beings. many moral concerns related to human rights come to the fore in the context of pandemic influenza outbreaks. the first is related to the limited number of vaccines that can be available for each outbreak (due to reasons outlined in the preceding section) and the best sharing formula to use. whatever adopted formula in a given place or situation, some people who may benefit could be excluded. for instance, 115 pandemic influenza often generates a high number of sick people over a large geographic area who will need care at the same time. while this "need" begins at the local plane, it may evolve to be regional and/or global depending on the extent and severity of an outbreak. hence, the human and material resources of healthcare will be rapidly depleted and overwhelmed. 119 since the needs of everyone cannot be met under such a scenario, there is usually some need to ration available resources. in fact, vaccines are hardly enough during pandemics, and rationing is generally considered as the ethical option. 120 yet, the contemporary interconnection between health, the right to health and human rights 121 implies that withholding vaccines from some people who might be potential victims of a pandemic outbreak may be a human rights violation. on the other hand, administering antiviral drugs to non-vaccinated at-risk people helps reduce the severity of illness. 122 during disaster scenarios, the goal remains saving lives but a pandemic scenario in which 25-50% of the population can fall sick within a very short time 123 often demands some type of prioritization of resources. this is partly because keeping some sets of people alive, especially health workers will ultimately help society keep more people alive during a public health disaster. for instance, the traditional view is that prioritizing the vaccination of front-line healthcare workers can help reduce staff absenteeism as well as help prevent them from becoming vectors of viral infection. this is often justified by the logic that a phd situation such as pandemic influenza often makes health professionals work outside their normal scope of practice, put in extra hours, cover for ill workers, accept great risks 124 as well as incur other situational unexpected responsibilities and supererogatory duties. although adults aged 65 years or older, pregnant women, and people of any age with underlying medical conditions are at high risk of pandemic influenza and its associated complications, the notion that death is more tragic in children and young adults as opposed to elderly persons, perhaps, because younger persons have not had the chance to live and develop through all stages of life and accomplish their dreams has made some ethicists argue for the prioritization of vaccines to younger people. 125 yet, if persons are inherently born with human rights and do not have to earn rights, such an idea tends to revamp the rights to health of some class of people at the expense of others. indeed, notions such as this echo the idea that mainstream bioethical issues tend to be far-flung from the values of ordinary people and often 119 irrelevant to the decisions they experience in their encounter with healthcare. 126 in other words, an empirical approach which takes into consideration what people would want when faced with this thorny dilemma rather than an armchair speculation ought to influence the criteria for rationing vaccines. one of the non-therapeutic responses to pandemic influenza is the isolation and quarantine of infected patients. 127 whereas a visibly infected and sick person may have just a little objection to quarantine (after all, such a state mirrors the ambulatory limitations that most disease states naturally impose on people), it is often problematic for other categories of people. in this vein, isolation and quarantine raise concerns about the acceptability of confining people and preventing them from engaging in some of the social activities they otherwise would have loved. whereas restriction of movement is ethically problematic, 128 it is equally problematic to allow person a who may be infectious to roam free, thereby potentially infecting other persons who may also (without the imposition of some restriction) further spread infection. it is clear from the foregoing that pandemic influenza challenges and raises some moral concerns regarding the rights of people, 129 preempting the need to balance them against what is the optimal good of the society. but embedded in these reservations is the demand for autonomous living, broadly conceived. whereas this has been associated with western contexts, concerns about rights violations in relation to quarantine measures are not confined to the west. sambala and manderson recently commented about how ghanaians and malawians perceive public health interventions including quarantine as being intrusive. 130 but this perception seems to run contrary to the cultural norm of most african people. in relation to this strand of thought, shah notes that during epidemics, the traditional attitude of the acholi people of uganda involves working together to isolate the sick, mark homes of the sick with long elephant grass, warn outsiders not to visit affected villages, and refraining from potentially infection-transmitting practices including sexual intercourse. 131 this suggests at least two things. one, in traditional african societies there may be some fairly general consensus about the need to adopt mutual and social cooperation for the overall benefits of the society in engaging collective threats. secondly, it shows how the global village has increasingly penetrated and fragmented societies that were once non-individualized in orientation. but it seems that societies have been affected differently by the globalizing current of individualistic logic. for instance, macphail whereas europeans and americans generally view quarantine during influenza as almost worthless, asians such as hong kongers, expect it as the norm during health disasters, and demand it. 132 this probably shows how strong an influence the communal-oriented confucian idea still exerts in that country. in the context of pandemic influenza outbreaks, over-emphasizing individualism and the attendant call for autonomy (even when such does not cohere with social interests) overlooks communal values and the relational nature of social interactions. 133 it likewise ignores the complex nature of pandemic influenza and how it plays out in an equally complex web of this global age and how people more or less are susceptible to the harms of public health disasters regardless of their proximity. it has also contributed, as lachman argues, to a reduction in the fear of infectious diseases by increasing the emphasis on patients' rights, giving rise to a dangerous complacency that may do great damage to the goals of public health. 134 one of the ways to address the attendant dangers inherent in this almost pervasive trend is recognizing the vulnerabilities even to far-flung harm that is fast becoming an integral aspect of contemporary life. vulnerability-in different forms and facets-plays out in pandemic influenza, as in other public health disasters. traditionally, belonging to the human community or occupying specific facets of life constitutes sources of vulnerability. but the state of being susceptible to harm by the actions and activities of other people or by parts of nature such as viral organisms is also a potential source. in addition, the state of vulnerability may ensue from a range of social, economic, and political conditions. 135 in the context of pandemic influenza, the naturalistic, socioeconomic, epistemic, political, and biological dimensions of vulnerability arise. on the one hand, humans located in pandemic-prone cities or countries and other human beings linked to the global community by technological means of transportation (such as air travel) or non-technological ones (such as migrating birds) are generally vulnerable to influenza outbreaks. the likelihood of a novel strain of influenza outbreak occurring in a country such as china (for instance, jiangcun in guangzhou) where large numbers of people, birds, and swine mingle freely in certain markets is very high 136 ; hence, making the local population and consequently the people of such a nation more vulnerable. 132 macphail, the viral network: a pathography of the h1n1 influenza pandemic. pp. 95-95. 133 bennett and carney. p. 7. 134 peter j lachmann, "public health and bioethics," the journal of medicine and philosophy 23, no. 3 (1998) . p. 298. 135 henk ten have, "vulnerability as the antidote to neoliberalism in bioethics," revista redbioética/unesco 1, no. 9 (2014). p. 88. 136 on the other hand, the strength of health systems reflected by availability of experts, economic and technical resources will vary the extent of pandemic-related vulnerability which different societies will experience. in addition, it is widely believed within the scientific community that influenza pandemics can hardly be halted, but they can be delayed. 137 therefore, the "ignorance gap" that occurs during pandemic influenza outbreaks creates a context in which some of the preparatory strategies will inevitably fail (due to no fault of anyone), thereby leaving some people less protected. in relation to the socioeconomic dynamics, it is estimated that most influenza pandemic-associated deaths occur in poor countries or in societies with scarce health resources which are already stretched by extant health priorities and challenges. 138 farmer and campos underscore the need for bioethics to engage the growing problem posed by the gap between rich and poor nations, and how such a course of action reflects social justice. 139 politically, communist nations such as china present unique dimensions to the vulnerabilities of pandemic flu as they may control critical information traffic and access to patients, thereby deepening the crisis situation, 140 or misrepresenting it, and thereby subjecting the rest of the connected world to avoidable risks. the biological make-up of human beings both make them vulnerable to becoming infected with influenza virus as well as make them good vectors of dissemination. for instance, the virus has a surface molecule that enables it to attach firmly to cells in the mucous membranes of the respiratory tract, preventing it from being swept out by the ciliated epithelial cells. 141 but breathing is a normal aspect of human existence, and the oxygenation of the human blood and other oxygendependent biochemical processes of the human body rely on it. yet, the combination of these factors facilitates the ready transfer and exchange of the influenza viruses amongst people, especially when they are in close proximity. 142 the foregoing shows how susceptibility and vulnerability to infection during pandemic influenza reflect a combination of factors. 143 how these combine in specific localities and regions will, therefore, determine the extent of an outbreak. it is also clear that some amount of control can be exerted on minimizing some of these factors. for instance, the use of face mask (to limit infection acquisition and spread), transparency (to combat political bottlenecks), and monetary aid (to help poor nations) will exert some preventive effects on infection transmission, hence, limiting the overall burdens and severity of an outbreak. since everyone may not receive the same level of healthcare for various reasons during a public health disaster (depending on time, place, and category of persons such as adults, the aged, or children), questions about justice and what is just in the context of a pandemic outbreak arise. pandemic outbreaks exacerbate extant inequalities to the extent that certain groups of people face disproportionate risks and impacts of disease. 144 this obviously seems unfair, especially if pre-pandemic actions that would have ameliorated the situation were not done. for instance, school closure in certain districts may interrupt educational opportunities or growth of some children, and business closures will lead to financial losses. since such restrictions may not apply to every region of the nation, these measures may seem unfair to those affected, knowing that other children continue to have access to education, and other people continue to run their businesses. if this characterizes the feelings of some of the people affected by these restrictions, then it is reasonable that some form of compensation may be required to foster optimal compliance to the public health measures that are to implemented. indeed, bioethicists like michael selgelid and søren holm make explicit arguments for some form of compensation to people who suffer financial and other losses due to compliance with public health directives issued during influenza outbreaks. 145 although compensation may not be a problem in more affluent nations where other educational stimulus and business tax breaks may help alleviate any temporary pandemic-associated losses, poorer countries will find it hard to compensate people for any such losses. rationing also raises issues about justice in terms of how vaccines (if available) will be shared during an influenza pandemic. given the limited amount of supply available globally, and locally in a developed economy like the us, distributing the limited supply will require determining priority groups. 146 for people not to feel a sense of being left out during local vaccine administration, it is better to have debated and developed a preparedness plan with the consensus of the local populace. resolving vaccine distribution on a global scale will, however, involve very complex sets of factors. for instance, will countries who supply most of the technical and financial resources to develop such an influenza vaccine demand that the needs of her people be prioritized as opposed to the needs of nations that have contributed little or not at all? even if such a question were not explicitly raised, will it be fair to distribute vaccines equally if every country or affected region has not made significantly even contributions? these are unsettling questions that are bereft of simple answers. some ideas stand out when all the ethical issues generated by pandemic influenza are closely examined. four of these ideas demand attention. the first is the need to help people. secondly, the nexus of relationship that exists between people 144 henk ten have, vulnerability: challenging bioethics (routledge, 2016). pp. 70-71. 145 michael j selgelid, "promoting justice, trust, compliance, and health: the case for compensation," the american journal of bioethics 9, no. 11 (2009 146 emanuel and wertheimer. p. 854. and the influenza virus and the changing nature of what is known as well as what can be done to help people under such constraints will limit the help some people may ultimately get during an outbreak. thirdly, the threat of an outbreak presents different risks which vary by context, time, and place. lastly, regardless of the different situational dynamics that pandemic influenza presents locally, regionally, and globally; its threat will affect everyone to varying degrees. since nations theoretically care about their people, it is only reasonable that a people-centered approach offers a useful way to engage the moral quandaries elicited by pandemic influenza outbreaks. the subject matter of diseases is human populations. 147 in fact, the preoccupation of medicine remains the amelioration of the distress of people technically referred to as patients. if a people-centric approach constitutes a viable way of engaging the ethical issues embedded in pandemic influenza scenarios, one way to glean a sufficiently nuanced angle on such an approach will involve turning to ethical lenses that are, in principle, people-oriented. two principal examples of such ethical prisms are communitarianism and ethics of care. this section briefly explains each of these moral lenses, and how each may help engage the ethical issues generated by pandemic influenza. the communitarian moral lens adopts a people or community-centric perspective to moral issues. applied to public health, it offers a population-centered approach which best reflects the philosophy of public health in terms of its commitment to doing the most for the greatest number of people in a society or within a social context. bioethicists like stephen holland regard the communitarian lens as useful since it aims at realizing collective interests. this same idea offers a strong justificatory argument for adopting it in relation to public health interventions. 148 communitarianism pays attention to the social sphere, institutions, and interrelationships in relation to moral judgments that will inform public health policy and practice. its ethos provides an alternative to the dominant atomistic lens of individualism which operates via the logic of self-protection 149 and the unbridled 147 macphail, the viral network: a pathography of the h1n1 influenza pandemic. p. 196. 148 stephen holland, public health ethics (polity press, 2007) . pp. 51-55. 149 pursuance of self-interests. it holds that the social nature of life and institutional and social relationships should inform moral thinking, and by implication, the process of determining appropriate courses of actions should lie within the social space. 150 to be sure, the communitarian notion appeals to the historical traditions of communities or people who share customs, ideals, and values 151 ; and thus prioritizes common threads of thought and practices within specific communities as a strong moral basis for justifying decisions that pit different individual and social interests against one another. there is an important phenomenological aspect of communitarianism. for people raised within the traditional family structure-father, mother, children, and relatives-the family unit constitutes a micro-community which generally socializes the child into a community-oriented way of reasoning. while the strength of such an orientation is expressed in different measures by different individuals, it also provides the cognitive platform for balancing and pursuing personal interests in a feedback loop with the collective interests of other family members. yet, the ultimate measure of what level of community-oriented reasoning an individual retains in adult life will depend on their education, social experiences, whatever meanings they draw from these, and how these parameters are brought to bear in the context of specific decisions and choices. this reality partly explains the multiple versions and interpretations of communitarianism, which tends to mar its conceptual and theoretical coherence. 152 it also partly explains why community values are not generally shared by all. 153 communitarians advance three different types of claims: descriptive claims which stress the social nature of people; normative claims which celebrate the value of community and solidarity, and a meta-ethical claim which emphasizes the idea that political principles should mirror "shared understandings'. 154 two of these dynamics-the normative as well as the metaethical-are important in relation to engaging the ethical issues elicited by pandemic influenza. the significance of the meta-ethical dimension of communitarianism is its capacity to help drive and ground public health policies. this is especially so considering the reality that community and living together in today's fragmented and individualistic world is generally seen ever less as a necessity and assumes the dimensions of a choice as the default state. 155 hence, these two facets will be examined in relation to their possible 150 insights and pragmatic importance vis-à-vis engaging the quandaries associated with influenza outbreaks. healthcare focuses on helping sick people regain optimal health and healthy people maintain good health. pellegrino and thomasma remark that medicine seeks to foster social flourishing as well as the medical good of society. 156 if this is true, and if the end of the communitarian moral lens is to ensure the survival of the society by promoting the interests of people over the selfish interests of individuals, then how can this approach help engage issues of uncertainty, vulnerability, human rights and justice? this can come through appropriate educational policies and approaches carried out prior to and during influenza outbreaks. it is not known when and in whom influenza therapeutic interventions such as antiviral drugs and vaccines may cause side-effects. it is also not known when an outbreak will occur or the attendant magnitude. since public health disasters are classless in terms of who will and who may not be affected, the scenario of uncertainty affects every segment of people in the local communities and nation. hence, health workers, government officials, the rich, the poor, the educated and illiterates and other possible stratification of society are potential victims. a communitarian ethos is useful in at least two ways in relation to dealing with the uncertainties associated with pandemic influenza. generally, it can-with the right pre-disaster public education-help ensure that people understand the unavoidable scientific and knowledge-related gaps in preparedness policies and specific plans put together to engage a specific outbreak. this will help avoid or minimize blame, since scapegoating during disease outbreaks causes different shades of disruption and target important actors including health workers. 157 in fact, the better educated the public is about the challenges of stockpiling vaccines, the more cooperative they will likely be to the vaccine-supply challenges that arise during an outbreak. a communitarian ethos may also help engage the real and possible harms that may ensue due to the therapeutic uncertainties associated with pandemic influenza. these harms arise from the uncertain nature of what is knowable about a pandemic virus before it strikes as well as the biological limits of the therapeutic arsenals often produced within a very narrow time window. this is also generally tied to the reality that new health interventions including drugs and vaccines come with the possibility of some adverse events, which may be linked to the chemical/biological/physical components of the product, to genetic susceptibilities in certain individuals, or to 156 edmund d pellegrino; david c. thomasma, "the good of patients and the good of society: striking a moral balance," in public health policy and ethics, ed. michael boylan (springer, 2006) . pp. 17-25. 157 shah. p. 125. environmental triggers. 158 keeping the public aware of this fact before and during an outbreak as well as emphasizing that accepting these risks (though uncomfortable at the individual plane) will serve to ensure the society overcome a pandemic should help garner some level of support critical to ensure proper compliance. since people are born with inherent human rights and do not have to earn them, it is hard to justify trumping the rights of some for the sake of public health. this is especially so if the people whose rights may be inhibited or violated do not consent to the process. to avert this, a discursive approach involving inclusive deliberations is essential. in this vein, the communitarian lens can help foster dialogue as well as call for the need to reward people for the sacrifices they may or will bear on behalf of the community and the society. for instance, guaranteeing that some compensation will be paid for financial losses incurred through workplace closure as well as apt public education about the nature, purposes, and conditions of quarantine facilities will help convince people that such temporary rights-related inconveniences are for the benefits of the overall society. in relation to vulnerability and justice, the communitarian lens can help clarify the different kinds of social, biological, and natural vulnerabilities that face different people in different contexts. for example, it can offer a way of making the important distinction between general vulnerability that people will experience as human beings, vulnerability based on age, and occupational vulnerability seen in health professionals. based on these distinctions, it can help underscore how context-specific cooperation will help ensure the overall success of the countermeasures adopted to engage a given pandemic. critical to this, however, is the moral currency of trust. trust shapes how the public evaluates risks and benefits. it also influences the acceptance of prescribed public measures to mitigate present or perceived risks. 159 effective risk and crisis communication depend on public trust in the government during a pandemic. as such, a higher level of trust will influence a more positive level of social compliance. van der weerd and colleagues corroborated this in their empirical study of the 2009 pandemic in the netherlands. 160 in addition to trust, transparency in terms of how priorities will be made in terms of the allocation of vaccines as well as antiviral agents, and decisions pertaining to school and/or workplace closures is important. even in western climes, public health experts have sometimes pointed out the paucity of transparency in ethical reasoning and the scanty explicit ethical justification for pandemic-related policies. 161 obviously, an atmosphere of trust and transparency will be conducive to 158 discussing and addressing issues related to local justice. this is especially relevant in relation to less wealthy nations or countries with weak institutions. for instance, it will be hard to garner cooperation in hitherto abandoned communities by appealing to communitarian ethos without addressing extant disparities in the social fabric as well as the healthcare system. if human beings are located in particular communities but are willy-nilly part of a global community, 162 how well the vulnerability and justice-related issues are locally addressed will influence the extent of their regional and global dynamics. this echoes the notion that badly managed local issues associated with pandemic influenza will pose more challenges and burdens at the regional and global levels. since every nation lacks an equal capacity to deal with the local burdens of pandemic influenza, it is necessary for wealthier nations to rally around poorer ones. indeed, the transcontinental nature of health disasters including pandemic influenza and sars underscores the urgent need to strengthen how the global community deals with emerging infectious diseases, and how novel visions of global solidarity and cooperation will be key in such an endeavor. 163 this constitutes a preventive stance and falls well within the traditional agenda of public health. this approach is also a reasonable economic and health security choice as it will statistically cut down the possibility of global and transnational infection dissemination. while the communitarian ethos as argued above offers some insights into how to flexibly engage the moral dilemmas generated by influenza outbreaks, its application in non-community-oriented contexts potentially raises some difficulty at the institutional and individual planes. such possible difficulties, however, call for a global but locally nuanced moral framework. that theme, however, will be addressed in chap. 6. for now, the rest of this chapter will explore another people-centric moral lens, care ethics, in relation to resolving the quandaries of pandemic influenza. in addition to the communitarian lens, the ethics of care perspective (eoc) constitutes a people-centric method of attempting to resolve ethical issues. whereas it sometimes arrives at the same conclusions reached by traditional bioethical approaches, 164 employing it as a complimentary approach to the moral quandaries generated by pandemic influenza should yield additional nuances and insights visà-vis resolving the associated moral concerns. care ethics emphasizes varying degrees of care within relational contexts ranging from the personal sphere to the realm of moral strangers. hence, it is an other and people-centric moral lens. it has 162 henk ten have, global bioethics: an introduction (routledge, 2016). p. 113. 163 peter a singer et al., "ethics and sars: lessons from toronto," british medical journal 327, no. 7427 (2003) . pp. 1342-1343. 164 edwards, "is there a distinctive care ethics?" p. 185. been applied to diverse relational contexts including everyday lives, professional practices, social and public policies, as well as international relations. 165 for scholars like steven edwards, ethics of care uses a distinct ontological commitment to realize its outcomes as well as justify its stance. 166 it is an attempt to re-conceptualize and renegotiate the moral landscape in order to give room for a plurality of values. 167 some have argued that the removal of friendship with its altruistic emotional sequelae and the subversion of virtue ethics from the sphere of morality were some key factors that warranted the moral change which birthed the ethics of care framework. 168 while eoc is also linked with gender-based morality which undergirded campaigns for equal employment opportunities between the sexes, legal rights, reforms of family life and sexual standards, and better education 169 ; scholars like noddings have pointed out that it is broader and deeper than feminist ethics. 170 to be sure, one of its major impetus is the call for the expression of higher capabilities. 171 care ethics also encapsulates a spectrum of ideas. for kittay, care constitutes an "achievement term" such that caring occurs only when specific acts of care have been carried out. 172 in this vein, intentionality would not qualify as part of the baggage of care rhetoric. this obviously has some pragmatic appeal. most people, for instance, would only appreciate care if it helps contribute towards relieving their current distress. yet, caring may also constitute a general attitude and an orientation which may provide appropriate background conditions for shaping responses to others' needs and states of distresses. also, one may care but situational constraints may limit how a caring impulse may translate into pragmatic ends. therefore, that someone simply "lacked opportunity" to show care as apostle paul writes in his epistle to the philippians does not necessarily indicate the absence of care. 173 hence, caring cannot be reduced only to materialistic terms. one way to distinguish the general caring orientation from specific acts of care is to refer to each as "caring about" and "caring for" respectively. 174 care ethics locates morality within the ambiance of family, friends, and colleagues, and ultimately towards the public sphere. 175 it rejects the independent and atomistic notion of the self and champions an inter-dependent and inter-related view. 176 this approach grants eoc a psychological gestalt to which people brought up in caring relationships, at least in the early phases of their lives, can readily identify with. it thus partly appeals to kohlberg's theory of moral development. here, the emphasis is put on the foundational roles of trust and its place in fostering a deepened sense of reciprocity within a social context of inequality. 177 not surprisingly, some ethicists describe caring as the primary virtue which offers a general account of right versus wrong actions as well as political justice. 178 whereas the informal social contract idea underlies inter-personal and stateindividual relationships, 179 the care ethical lens may be applied to the personal sphere as well as social institutions 180 due to its multiple ways of situating relationality. 181 indeed, eoc focuses on attentiveness and sensitivity to the needs of others 182 and offers a moral compass for teasing out delicate boundaries between obligation-based ethics and responsibility-based ethics. as such, it seeks to transcend the depersonalized realm of asking "what obligations do i have to mr. x" to the humane realm of asking "how can i help mr. x" in scenarios of moral crises. 183 since caring embodies an activity, a set of activities or a labor of care from one person to the other, it presupposes that the capacity for receiving care 184 will be present in the recipient(s) of care. public health disasters including pandemic influenza with their myriad of ethical and pragmatic challenges create a spectrum of needs and contextual dependencies which some people will have to meet, directly and indirectly. it thus creates different types of carer versus cared-for relationships between and amongst victims, atrisk people, health workers, and government officials. since it is a foundational nexus like these that underlie the caring ethic, it will be insightful to examine how the ethics of care moral lens may help resolve the moral dilemmas elicited during pandemic influenza outbreaks. 175 osuji. p. 58. 176 whereas tirima recently argued that ethics of care is irrelevant to addressing the moral imperatives in disaster scenarios because it only builds off on relationships and, therefore, requires some proximity between the caring moral agent and the cared-for victim, 185 such a stance is flawed for at least three important reasons. firstly, care ethics can, through relevant public policy, 186 positively influence how victims of disasters are cared for. secondly, contexts of duty exist between some of the players and victims of disasters which form the basis of a relationship of caring. for instance, healthcare professionals incur fiduciary duties to at-risk people, victims of a public health disaster as well as the general populace that may potentially be infected and infect others. thirdly, if the care ethical prism emphasizes how individuals may offer help "in scenarios of moral crises, 187 then it should be relevant in health scenarios where different kinds of conflicting moral emergencies occur. the application of care ethics to specific disaster contexts such as influenza outbreaks, however, requires elaboration. specifically, this needs some explication with reference to issues of uncertainty, vulnerability, human rights and justice. whereas the dilemma of uncertainty that arises during pandemic influenza affects everyone, it will affect different sets of people differently. for instance, the biological uncertainties associated with an influenza outbreak are not known to the same extent by public health experts, health workers, the literate, and illiterate members of the society. caring about the potential practical consequences that may result from the attendant "ignorance" gap should, therefore, involve sharing as much useful information as possible between and amongst the different rungs of people. the relational context, in this regard, may be situated and realized through professional associations, institutional contexts, public announcements through media outlets and patienthealth professional interactions. kunin et al. recently reported on how primary care physicians helped pass on important pandemic-related information to out-patients during the 2009 pandemic in israel. this, they concluded, helped enhance the success of the national pre-pandemic preparedness plans. 188 indeed, during public health disasters, the speed at which information is needed by policymakers may be faster than is usually possible through traditional mechanisms of research dissemination. this scenario makes information sharing a norm; even possibly those provided by preliminary research findings. 189 humans instinctively show care to other humans in need. while this caring instinct has been socially modified and conditioned in some parts of the world where individualistic tendencies run rife, some communal-oriented cultures give room for a freer expression of the instinct of care. the instinct of care may, however, be counterproductive in the context of phds. for instance, during pandemic influenza, sick and dying patients remain active carriers of infection, 190 as such, will infect susceptible friends and relations who feel obligated to show care in relation to helping them. in other words, "unbridled" caring may increase the vulnerabilities elicited during pandemic influenza. yet, the care ethics moral lens may help modify and re-direct the caring impulse in a more socially useful way during a pandemic. the other-centric nature of the eoc lens implies that people should care not only about themselves but about others, perhaps, even moral strangers. how person a will care during a public health disaster will, however, differ from how b will choose to act in a manner that reflects care, depending on their levels of knowledge, resources available to them as well as their social and spatial location. in other words, how a healthcare worker will care professionally in the hospital context and supererogatorily in the non-hospital context will differ from how a lay member of the society can show care in a pandemic situation. however, appealing to the eoc may help facilitate the selflessness needed. if someone cares that their society survives an influenza outbreak, then they should be willing to play roles that will help bring about that goal. this will facilitate compliance with therapeutic measures such as vaccines and antiviral drugs as well as non-pharmaceutical measures such as contact tracing, quarantine, and workplace closure. collective adherence to these measures will help cut down the susceptibility and vulnerability of individuals, groups of people, and the society to the impact of influenza outbreaks. by enabling the willingness of people to subject themselves to the public health restrictions required to contain pandemic influenza and accept the potential risks and side-effects associated with vaccines and antiviral agents, the eoc approach may indirectly eliminate or downplay the human rights-related quandaries engendered by pandemic influenza. noddings has argued that attentiveness and responsiveness are exigent to rights, flowing from one person to the other. 191 if this is true, then the eoc may help individuals adjust the emphasis they place on articulating their rights contextually during an influenza pandemic for the sake of the collective good. finally, an appeal to the care ethical lens may help address the moral quandaries associated with local justice. although some versions of care ethics hold the posi-189 ns crowcroft, lc rosella, and bn pakes, "the ethics of sharing preliminary research findings during public health emergencies: a case study from the 2009 influenza pandemic," eurosurveillance 19, no. 24 (2014). pp. 1-3. 190 shah. p. 87. 191 noddings. p. 72. tion that it is not possible to integrate and apply justice to care, 192 such a limitation hardly applies to the context of a public health disaster such as pandemic influenza. for instance, the different conflicting priorities that arise during influenza outbreaks such as rationing of limited resources will be easier if some people are at least willing to forgo their interests for others. in non-familial carer and cared-for relationships involving at-risk government representatives and at-risk members of the society and familial relationships involving parents and children living in the same house, an appeal to a care ethical lens may help drive the moral sensitivity to the needs of others, enabling some vaccine-eligible persons (under the standard rationing criteria) to forgo their ration, preferring rather that other at-risk people (for example, ordinary people and younger family members) have them. this kind of selflessness approximates some form of humanitarian act in that person a decides to overlook their interests for others "without expecting rewards". 193 however, because human beings naturally seek their own personal interests, there may be some difficulty in achieving this other-centric goal in as many people as possible in a public health disaster situation. this implies that the care ethical lens may have some limitations in relation to sufficiently engaging the ethical dilemmas raised by pandemic influenza in particular and other types of public health disasters, in general. that theme will, however, be addressed in chap. 6. during disasters, there is the utilitarian goal of doing the most good for as many people as possible with minimal harm. 194 a people-oriented moral lens, this chapter argues, may be apt in accomplishing such an agenda. the chapter explored the strengths of the communitarian and care ethics moral lenses in relation to engaging the moral quandaries elicited during pandemic influenza outbreaks. because it is difficult to engage pandemic outbreaks with little prior preparation, 195 these moral lenses become important since they can help people develop an other-centric orientation and sensitivity to the needs of others. to systematically drive the importance of a people-centered approach to pandemic influenza, this chapter explicated the biological make-up of the influenza virus as well as the social and global features of the associated pandemic. this helped underscore the local, regional, and global seriousness of pandemic influenza as a distinct type of public health disaster. the chapter went on to show how an 192 barnes et al. p. 5. 193 195 vawter, gervais, and garrett. p. 6535. understanding of the social and biological dynamics of influenza has shaped the therapeutic and non-therapeutic approaches to engaging outbreaks. it also articulated some of the attendant limitations of pandemic influenza countermeasures including vaccines and anti-viral drugs. this chapter has also highlighted the ethical quandaries generated by influenza outbreaks. these are issues related to epistemic and social uncertainty, biological, social, geographical and political vulnerabilities, potential violations of human rights through some of the therapeutic and non-therapeutic countermeasures, as well as issues of local and global justice. against this conceptual background, the chapter pointed out how helping people is a central concern in pandemic influenza, and how the thorny ethical issues constitute difficulties encountered in accomplishing this goal. on that note, it showed how people-centered lenses such as communitarianism and ethics of care may be useful in engaging the associated practical and moral challenges. to clarify the importance of each of these approaches, the chapter elaborated each of these ethical lenses, and showed how each may help orient different players in the context of a pandemic influenza towards acquiring a sense of community and an other-centric sensitivity which will be essential to resolving the moral dilemmas as well as realizing the critical public health objective central to such a public health disaster. however, partly because there are limited grounds for deciding what the limits of practical reasoning will be ab initio, 196 and partly because of the complexities and nuances that are associated with the global dimensions of the issues at stake in pandemic influenza situations, these ethical lenses may suffer some limitations. whereas this chapter has examined none of such limits, they will be engaged in chap. 6 where the relational-ased global ethical framework will be formulated. biological features of novel avian 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influenza in africa public health ethics: an update on an emerging field biological features of novel avian influenza a (h7n9) virus key: cord-261524-nqukwoqz authors: al-mohaithef, mohammed; javed, nargis begum; elkhalifa, ahmed me; tahash, mohammed; chandramohan, sriram; hazazi, ahmed; elhadi, fatima elsheikh mohammed title: evaluation of public health education and workforce needs in the kingdom of saudi arabia date: 2020-03-17 journal: j epidemiol glob health doi: 10.2991/jegh.k.191123.001 sha: doc_id: 261524 cord_uid: nqukwoqz background: an efficient public health workforce is necessary for improving and maintaining the health of population and such a workforce can be prepared through proper educational programs and trainings. objectives: the present study aims to investigate the needs in the public health education programs, as well as need and availability of competent public health workforce in labour market of saudi arabia. methods: a descriptive, cross-sectional survey was administered in two phases in the college of health sciences at the saudi electronic university (seu). the first phase was carried out between september 2015 and december 2015, which involved interview with administrative heads of four health-related organizations. the second phase was performed in september 2017 and june 2018 after starting an undergraduate course in public health at the university. a total of 41 faculty and 408 students from different branches of seu participated in the online survey. results: according to administrative head of public health-related organization, there is a shortage of qualified workforce in public health. all the four organizations need workforce with the master degree in sub-speciality epidemiology. about 97.5% students agreed there is a shortage of public health speciality in these organizations. about 92.7% faculty had an opinion that there is a requirement to set-up educational programs in public health. to overcome the shortage of competent workforce, two organizations showed interest in updating their employees’ skill through bridging courses. the students perceiving bachelor course in public health showed interest to accomplish master’s degree in epidemiology (38.5%), public health education and promotion (36.5%) and infection control (35.5%). conclusion: there is a shortage of expertise in the public health organizations and there is a need for development of more public health schools in the kingdom of saudi arabia. the establishment of public health courses especially in the field of epidemiology at undergraduate and graduate level will help in the development of efficient and competent public health workforce. 'health human resources' is defined by the world health organization (who) as 'all people engaged in actions whose primary intent is to enhance health' [1] . this includes all people who contribute to a functional health system: those who provide health care directly and those (like public health professionals) who address the underlying health determinants, and others who support the overall effort in other ways [2] . efficient public health services are key in minimizing diseases and increasing the standard of living. public health is both multidisciplinary and interdisciplinary, as professional from different disciplines contribute their knowledge and skills for improving health [3] . there is a strong linkage between the health workforce and public health education as public health require intellectually rich and challenging workforce [4] . the initiative in public health traces back to 1872, when american public health association was formed. the first independent school of public health (sph) began in 1916 in the united states (us) [5] . the school was funded privately major by the rockfeller philanthropies, which in early 20th century helped to define public health profession [6, 7] . the london school of hygiene and tropical medicine, the first sph in the united kingdom (uk) was founded in 1924 with support of rockfeller philanthropies [8] . however, for much of the 19th century, there was no concept of organized public health. in 1960, the hill-rhodes bill helped to renew interest in the public health in us [5] . at this time there was evolution in teaching methods also, with greater emphasis to problem-based learning especially in medical schools [9] . in 2008, the american association of colleges and universities surveyed their membership and found that 167 institutions offered undergraduate majors, minors or concentrations in public health in us [10] . frenk et al. [9] in 2010 estimated that there are about 450 schools of public health worldwide irrespective of departments and courses. according to european association of schools of public health, over 80 institutions in european region qualify as sph [11] . in 2011, uk had 30 universities offering postgraduate qualification in public health [12] , 36 universities offering masters in different disciplines of public health such as nutrition, policy, the environment, research, management, nursing or communicable disease prevention [13] , and the universities' central application service shows more than 100 degrees that have a public health component [14] . in the kingdom of saudi arabia (ksa), a royal decree from king abdulaziz established the first public health department in mecca in 1925, for providing free healthcare to the population and hajj pilgrims [15] . the monitoring of healthcare services were done through series of hospitals and dispensaries. the second milestone achieved in the public health service in ksa was establishment of ministry of health (moh) in 1950 under another decree. the moh responsibility was to manage, plan health policies, supervise and monitor health services in private sector [16] . in ksa until 1980s, the main objective of moh was to provide treatment for existing health problems for which expatriates were hired [16, 17] . however, after the who general assembly in 1978, in accordance to alma-ata declaration, the saudi moh began to develop preventive health service by adopting primary health care (phc) as one of its key health strategies [18] . the phc focused on eight elements which included health education to prevent and control diseases, supply of safe water and basic sanitation, promotion of food supply and appropriate nutrition, maternal and child healthcare, immunization of children against major communicable diseases, appropriate treatment and providing of essential drugs [19] . in saudi arabia, pilgrims from over 160 countries gather to perform hajj every year and in this period the risk of public health problems related to infectious diseases increase [20, 21] . the saudi government has taken a number of steps to improve the management of public health during hajj but still outbreaks occur [22] . in 2009 there was a pandemic h1n1 influenza, the data analyses from europe and the usa regarding the transmission dynamics of the virus estimated the basic reproduction number (r 0 ) of the virus to be 1.2-1.7, with higher estimates in japan r 0 2.3; (95% ci: 2.0-2.6) and in new zealand r 0 1.96; (95% ci: 1.80-2.5) [23] . the saudi government was concerned that pilgrims suffering with or at risk of h1n1 influenza could result in increased basic reproduction number and secondary attack rates of h1n1 influenza during hajj. therefore, the saudi government collaborated with who to plan strategies to control the 2009 h1n1 influenza pandemic from spreading during the hajj season [24] . according to saudi ministry of education (moe) annual report 2018 [25] , only 14 (46.7%) out of 30 universities provide bachelor courses in different disciplines of public health and five universities (16.67%) offers master's degree in public health. among the private universities and colleges, only four (13.3%) institutions provide bachelor course in public health and one (3.3%) offers a master's degree in public health. however, since 2015 public health education shows an approximate increase of 3% and 6% in bachelor courses in public and private institutions respectively. the progress rate shows that it would take a long time to fulfil the need of competent public health workforce of the country. although some government and private institutions are offering courses related to public health in ksa, there continues to be challenges in producing competent public health professionals. one challenge is the lack of a standardized public health curriculum offered in all universities and educational institutions in the ksa. this is achievable through accreditation of educational institutions, which will lead to promote common standards in the course and training programs required for preparing competent public health workforce. another challenge is to provide an appropriate and suitable practical exposure to the students so that they are able to justify the current trend of diseases [26] . currently saudi arabia is experiencing outbreak of novel corona virus middle east respiratory syndrome (mers) caused by merscoronavirus (mers-cov) along with epidemiological and demographical transition, highlighting the importance of public health service and need of a competent public health workforce [26, 27] . moreover, the large size of the country and scattered population poses challenges to the health care service delivery, which include health facility planning and distribution of workforce. as public health is associated with the prevention and control of the diseases, it requires the local workforce for effective and efficient administration and management of public health programs. the government is working on strengthening the health care system, through eight elements of phc approach. 'vision 2030' is a long term plans in the ksa for strengthening the public sectors in the country that includes health, education, infrastructure, recreation and tourism thereby improving the economy of the country. the coordination between public health educational institutions and public health service organizations would help to achieve vision 2030 goal of developing a sustainable public healthcare service in the ksa. the ksa is facing outbreak of several infectious diseases and going through an epidemiological and demographical transition so there is a need for competent public health work force. only few studies are conducted related to public health education and workforce needs in which most of the studies are not comprehensive and would be prejudiced to generalize the results. so a comprehensive study was designed, using a mixed method tools to assess the existing public health courses in the country and to investigate the needs in the public health education programs to strengthen the current courses. further, the study focuses on the need and availability of competent public health workforce to overcome the new challenges. in this descriptive cross-sectional research study, an exploratory mixed-method approach (qualitative and quantitative tools) was used to obtain information about public health education and workforce needs. data were collected and analysed sequentially. the design begins with collection and analysis of qualitative data in the first phase, in order to develop strength, weakness, opportunities and threats (swot) model to identify the existing gaps in capacities. based on the exploratory result from the first phase, the researchers conducted the second quantitative phase. a baseline data on existing educational institutions that offer public health education in the ksa was obtained from moe website and university website. as the study took long time to complete, the details of the educational institutions providing public health education was reviewed using 2018 annual report prepared by moe to update the data collected at the baseline. the data was collected through two phases. it was conducted between september 2015 and december 2015. a face-to-face semi-structured interviews and meetings with the heads of four national public health administrations were carried out. all these heads belonged to different organizations were interviewed to perceive the paucity and needs of the organizations. the organizations were selected conveniently, and the interview focused on the qualifications held by the current employees of the organization, organization demands regarding qualifications and sub-specialty of public health and their perspective to support training programs for current employees. the different health organization administrative head selected for interview were ministry of municipal and rural affairs, saudi food and drug authority, ministry of environment, water and agriculture, and moh. it was done in september 2017 and june 2018 among faculty members and students of college of health science, seu. the study participants for the second phase were selected from different university branches in five major cities across saudi arabia. a random sample (n = 500) students and (n = 50) faculty members were contacted to participate in the study. however, 408 students (81.6% response rate) and 41 faculty members (82% response rate) returned the survey with complete response. an electronic capture of survey data is an efficient tool to collect information from large number of study participants. the results obtained from the thematic analysis of first phase of the study provided the base for preparing the questionnaire for the collection of quantitative data in the second phase. a web-based questionnaire was designed to gather the students and faculty member responses in this phase. the faculty member questionnaire included six questions related to demographics (table 1 ) and four close-ended questions related to need of public health educational programs in saudi arabia, their knowledge on the types of public health programs offered, and challenges in implementing these programs in other institutions (table 2) . similarly, a structured questionnaire survey was done among students after enrolling in an undergraduate course in public health at the seu to gather their opinions about public health education and workforce needs. all students were included except who refuse to participate in the study. the questionnaire contained six questions related to demographic profile (table 3 ); five close-ended questions related to information about public health speciality and source of information, where public health specialists work, shortage in sub-specialty of public health, sub-specialty of their preference and if the participant was a staff member of a healthcare organization, whether they receive support from their organization for completing their educational studies. the last question was an open-end question about whether there is a need for public health specialty in the moh and other public health organizations (table 4 ). the study protocol was reviewed and approved by deanship of scientific research at seu. an informed consent was obtained from all study participants, and they were instructed to participate or withdraw from the study at any stage voluntarily. anonymized data were used for analysis and interpretation. data was analysed descriptively using the statistical software program ibm statistical package for the social sciences (spss) version 23 (chicago inc., usa). the qualitative data obtained from the interview of administrative heads was used to develop swot model to identify the existing gaps in capacities, developing core messages needed; and estimated the capacity building needs for a comprehensive public health workforce program in the ksa. descriptive statistics (frequencies and percentages) were used to describe the main features of quantitative data and chi-square test was used to assess the association between the demographic variables of students and their responses. p-value <0.05 was considered statistically significant. other health related specialties can perform the tasks of a public health professional 9 22 .0 there is no needs for public health graduates in the saudi labor market 3 7.3 the qualitative data obtained in first phase from the administrative head of public health organizations, showed that the employees presently possess an associate degree or bachelor degree in disciplines not related to public health (table 5) . moreover, it also found a shortage of competent workforce and a need of employees with bachelor (25%) or master degrees (100%) in public health. the quantitative data obtained in second phase showed student perceptions of 97.5% agreement with the need of public health specialty in the public health organizations (table 4 ). according to 92.7% faculty member, there is a need to set up educational program in public health in the ksa (table 3 ). the qualitative data obtained in first phase showed that all the four public health organizations (100%) had demand for employees with epidemiology as sub-specialty. the other sub-specialty, which (25) update their knowledge, and skills through bridging course in the specialty of public health to attain competency ( table 5 ). the quantitative data obtained in second phase showed the faculty member's perspective about public health courses with sub-specialty needed to be set up in educational institutions to create competent workforce in public health were epidemiology (70.7%), environmental health (58.5%), public health education and promotion (56.1%), food safety (53.7%) and infection control (53.7%) should ( table 3) . the students showed interest in perceiving the public health in sub-specialty epidemiology (38.5%), public health education and promotion (36.5%) and infection control (35.5%) and this finding shows availability of competent workforce in future (table 4 ). in swot analysis, the main strength of the organizations related to public health was found to be the willingness and commitment of ministries and other stakeholders to develop public health workforce programs. the weaknesses of the organizations found were shortage of resources and capacity to carry out public health workforce programs. the main opportunity for the organizations are the availability of global public health agency for partnership, but the lack of long-term commitment from the partner is the threat associated with it ( figure 2 ). health authorities and specialists were the main response for source of information among male students (59%) than female students (30.8%) (p = 0.0001). the male students had more knowledge about the different work areas of public health specialist as 74.5% of male students responded for other work area than the four main area of work compared with 52.4% female students (p = 0.023). a significantly higher percentage of male students (46%) preferred to pursue sub-specialty environmental or occupational health as compared with 35.6% female students (p = 0.037) ( table 6) . no significant association was found in the responses of students pursuing bachelor degree and master degree for all the variables (p > 0.05) ( table 7) . the association between student employment status and their response revealed that the majority of employed students (56.9%) source of information was health authorities and specialist as compared with 26.7% among unemployed students (p = 0.0001). moreover, friends and family members as source of information was significantly higher among the unemployed students (38.8%) compared with 19.1% among employed students (p = 0.0001) ( table 8) . a significantly higher percentage of employed students (65.4%) responded that there is a need of public health specialty for development of new public health professionals than unemployed students (54.1%) (p < 0.0001). the employed students had more knowledge about the different work areas of public health specialist as 62.6% of employed students responded for other work area than the four main area of work compared with 50.3% unemployed students (p = 0.030) ( table 8 ). food safety, health surveillance, nutrition and community health were more preferred as sub-specialty by the unemployed students (50.9%) than by the employed students (p = 0.036) ( table 8) . are in demand in these organizations are food safety (50%), public health general track (50%), infection control (50%) and environmental health (25%) ( table 5 ). the quantitative data obtained in second phase showed the student's perception about three subspecialties in high demand as epidemiology (57.4%), infection control (56.4%) and public health education and promotion (47.8%). the sub-specialty public health general track, food safety and environmental health, which are in demand in public health-related organizations, received lesser response from students 33.3%, 38% and 41.2% respectively (table 4 ). the qualitative data obtained in first phase put forward that administrative heads of public health organizations are planning to restrict the new recruitment to public health specialty to overcome competent workforce shortage. two organizations (50%) showed interest in supporting their existing experienced workforce to the present study results showed that the health workers in saudi arabia health organizations have an associate degree or a bachelor degree in other than public health as qualifications. this reflects the lack of appropriate qualifications, skills and experience to deal with challenges that arise in the public health field. a movement toward defining criteria for professional competence has evolved recently because it was a common practice in the past to recruit or promote an individual within public health agencies based on outdated concepts of professional qualification eligibility, seniority or sometimes due to the political interference without paying attention to the adequacy of their knowledge, attitudes and skills in public health [2] . in the present study, all the public health-related organizations (100%) reported a need of specialized health workers with a qualification of at least master degree in public health sub-speciality epidemiology. this assessment of the educational needs of local public health organizations is an important step toward development of appropriate programs at the academic level to improve core competencies for public health professionals. most of the western countries demand master of public health degree, or its equivalent that is master of science in public health or master of health sciences, as professional entry-level qualification for public health [28] . master of science in public health is programmed with emphasize to develop academically thought-provoking, student-centered learning, problem-solving and acquisition of skill necessary to practice public health. therefore, recruitment of highly qualified employees and focus on continuing education for updating recent development will be sufficient for valuable and competent work [28] . the public health college and medical colleges must work together in an integrated model. this will help to generate the best possible healthcare workforce, develop innovative tools and approaches through research and eventually achieve the maximum potential for improving the public health. public health in the middle eastern countries is facing challenges both at the recruitment and retention of appropriate skills and expertise, in terms of both quality and quantity [29] . the present study found the same opinions from the administrative heads of the various health organizations. there is an overarching need to improve the ways to address health determinants; which requires cadres of professionals appropriately trained in public health measures [28] . the knowledge obtained from the swot analysis about the strengths and the opportunities can be utilized by the organization to develop the required workforce in public health-related departments. moreover, the knowledge about the weaknesses will help the organization to improve the competency level of the workforce and the threats associated with the organization will guide the organization to prepare for adverse conditions in advance. as per saudi moe annual report 2018, <50% government universities are providing bachelor courses in public health and <20% is providing master course [25] . the government of ksa is working hard on strengthening the health care system, through eight elements of phc approach. to achieve vision 2030 goal of developing a sustainable public healthcare services in the ksa, more public and private educational institutions should develop public health courses at undergraduate and graduate level, so that competent public healthcare workforce is produced. the sub-specialty on high demand by organizations was epidemiology. as the ksa is at its initial phase of developing public health services, emphasis is placed on the need for epidemiological skills. the workforce with specialty in epidemiology have skills to enable priority settings, service planning and evaluation of outcomes, have ability to develop and implement health improvement programs, surveillance of non-communicable disease and competent in proving advice on arrange of public health issues to local organizations and the public [8] . at present, only three government universities and one private university is providing master course in epidemiology along with hospital administration. only few institutions about 16.7% provide master course in public health with focus mainly on health administration. therefore, approximately 92.7% of health science faculty members and 97.5% of students had the opinion that there is a need to establish educational programs in saudi universities related to public health. according to the 65.4% employed students, there is a need of public health specialty especially for the development of new public health departments. in the present study, 50% of the public health related organizations showed interest in bridging course for their experienced employees. this finding is supported by 60.6% of the students working in health organizations who reported organization cares for their public health studies ( figure 3 ). this reflects the organizations in public health need their employees to be up-graded to stand the competency required in the field. this gives a positive signal for the academic institutions to introduce more post-graduate courses in the public health as the demand for this course is increasing. the online courses can be considered as promising new development for continuing education and bridging courses. the development programs as training programs in epidemiology and public health interventions network and online courses should be viewed as a component of, or adjunct to, internal capacity development, but not as a replacement for it [28] . the demand for competent public health workforce will further increase as the government is focusing on enlarging the network of health services at phc level to reach all the corners of the country [27] . moreover, the government project of the custodian of the two holy mosques has planned to create around 2000 highly developed phc center and also to upgrade the existing phc center with wellequipped buildings, skilled and competent workforce, this will result in high demand of public health courses in the ksa [15] . according to the demand of organizations, students and faculty members, mph program needs to focus on disciplinary areas such as epidemiology, infection control, food safety, and environmental and occupational health sciences. the mph degree program development needs to emphasize on student centered learning, problem resolving and gaining of skills necessary to the practice of public health. the lack of resemblance between the taught and required could affect in public health workers being ill-prepared for the requirements of the real world [30] . therefore, educational institutions should spread the health education by engaging the whole of society through community outreach programs. the study from hawai'i also assessed the needs for public health education in their state and reported lack of awareness about the mph and ms programs in university of hawai'i [31] . a study from nepal reported there is a need for trained public health professionals in nepal and educational institutions requires development of effective graduate programs [32] . the accreditation of the public health schools is an essential step toward the improvement and standardization of teaching programs as well as the establishment of competencies [33] . the affiliations of sph to the local government will probably improve the balance between the needs of government and the autonomy of academic schools [33] . the public health schools should focus on research process of public health such as planning, evaluation, surveillance, investigation, and problem and pathway analyses. building of wellorganized public health educational institution requires structuring strong research and development skills among students, practitioners and faculty equally. the accreditation of sph with local government will likely promote targeted research with appropriate funding. moreover, students who participated in this study had limited information about the place of work and public health-related organizations demand of sub-specialty in the ksa. the students report convened by welcome trust highlighted that the health improvement can be achieved only when people are fully engaged in their own health and the health service is focused toward the promotion of good health and prevention of illness [34] . the youth should be updated about the scope of public health and encouraged to take admission in various public health courses, as it will elevate their general awareness of issues that affect individuals, families and communities. this will be a complementary social gain to promote health literacy, and development of a more active civil society in the health field. the efforts and activities in public health in the ksa need more attention. only few universities are providing master course in public health education, which shows that the local educational institutions are not keeping up with the demand for maintaining and improving the public health workforce. the work of public health professionals is important because public health initiatives affect people every day in every part of the world. there is a shortage of expertise in the public health organizations and there is a need for development of more public health schools in the ksa. the establishment of public health courses especially in the field of epidemiology at undergraduate and graduate level will help in the development of efficient and competent public health workforce. the world health report 2006: working together for health. geneva: world health organization global public health: ecological foundations. chapter 8: comparative organization and function of public health systems multidisciplinarity, interdisciplinarity and transdisciplinarity in health research, services, education and policy: 1. definitions, objectives, and evidence of effectiveness dual perceptions of hrd: issues for policy: sme's, other constituencies and the contested definitions of human resource development disease and discovery: a history of the johns hopkins school of hygiene and public health professional education for public health in the united states who will keep the public healthy? educating public health professionals for the 21st century. institute of medicine of the national academy of sciences the evolution of public health education and training in the united kingdom health professionals for a new century: transforming education to strengthen health systems in an interdependent world liberal education and public health: surveying the landscape dedicated to strengthening the role of public health by improving education and training of public health professionals for both practice and research figure 3 | sub-specialty in public health committee of inquiry into the future development of the public health function. public health in england. the report of the committee of inquiry into the future development of the public health func tion choose your future explore your options, apply to university, and more health care system in saudi arabia: an overview organization of the saudi health system essential medicines and health products information portal a world health organization resource [online database quality of primary health care in saudi arabia: a comprehensive review principles and practice of primary health care mecca bound: the challenges ahead viral respiratory infections at the hajj: comparison between uk and saudi pilgrims health risks at the hajj mathematical modelling of the pandemic h1n1 establishment of public health security in saudi arabia for the 2009 hajj in response to pandemic influenza a h1n1 saudi arabia ministry of education report public health education in saudi arabia: needs and challenges regional office for the eastern mediterranean. country cooperation strategy for who and saudi arabia 2012-2016. world health organization. regional office for the eastern mediterranean the imperative of public health education: a global perspective public health in the middle east and north africa: meeting the challenges of the twenty first century competencies required from public health professionals by health based organizations and the role of academia how can the university of hawai'i meet needs for public health education? results of a students' needs assessment assessment of graduate public health education in nepal and perceived needs of faculty and students public health education in europe: old and new challenges report of the public health sciences working group convened by the wellcome trust: public health sciences: challenges and opportunities the authors declare they have no conflicts of interest. mam contributed in data curation, investigation, project administration, software and supervision. nbj contributed in formal analysis. mam and nbj contributed in resources and writing (original draft). amee, mt, sc, ah and feme contributed in validation and visualization. all authors contributed in methodology and writing (review and editing). key: cord-316063-9bg2dm8e authors: morgan, marcus title: why meaning-making matters: the case of the uk government’s covid-19 response date: 2020-10-15 journal: am j cult sociol doi: 10.1057/s41290-020-00121-y sha: doc_id: 316063 cord_uid: 9bg2dm8e through analysis of the uk government’s management of the covid-19 outbreak, this paper offers an empirical demonstration of the principle of culture’s relative autonomy. it does so by showing how the outcome of meaning-making struggles had impacts on political legitimacy, public behaviour, and control over the spread of the virus. ultimately, these impacts contributed to the avoidable deaths of tens of thousands of uk citizens. dividing the crisis into phases within a secular ritual passage or ‘social drama’, it shows how each phase was defined by struggles between the government and other actors to code the unfolding events in an appropriate moral way, to cast actors in their proper roles, and to plot them together in a storied fashion under a suitable narrative genre. taken together, these processes constituted a conflictual effort to define the meaning of what was occurring. the paper also offers more specific contributions to cultural sociology by showing why social performance theory needs to consider the effects of casting non-human actors in social dramas, how metaphor forms a powerful tool of political action through simplifying and shaping complex realities, and how casting can shift responsibility and redefine the meaning of emotionally charged events such as human death. 'any important disease, whose physical etiology is not understood, and for which treatment is ineffectual, tends to be awash in significance' (sontag 1978) . this paper demonstrates the real-life impacts of meaning work through an analysis of the sense-making struggles that took place around the uk government's response to the covid-19 crisis. it argues that events fell roughly into three periods, understood as a succession of phases in a secular ritual passage or 'social drama' (turner 1969 (turner , 1980 fig. 1) . these phases were defined by changes in the moral coding of events, modifications in the casting of actors involved, and alterations in the dominant narrative genre within which events were to be understood. this dynamic chronology therefore constituted a conflictual effort to define the meaning of what was going on. it will show how the outcome of these struggles over meaning-making ultimately impacted not only government legitimacy but also the avoidable deaths of tens of thousands of uk citizens. during the first period (early january to mid-march), the viral threat was identified, but little was done to counter it. events were narrated in a low mimetic mode that cast the virus as an object of routine and mundane political management. banal measures, such as handwashing, were recommended to control the disease, and the prime minister instructed the public that 'they should, as far as possible, go about business as usual' (quoted in calvert et al. 2020, may 24) . british social structure remained intact, and the virus was presented as one amongst a number of problems to be dealt with. this response allowed the virus to spread unobstructed throughout the population. as this period progressed, however, and especially from early march onwards, polarisation grew, government legitimacy declined, narrative inflation took place, and the viral antagonist increasingly became cast as a mortal enemy. pressure-much of it from outside government-eventually succeeded in forcing a ritual breach to occur, and a crisis to be declared in order to deal with the deadly 'invader'. though changes in the government's conception of the virus were underway from early to mid-march, significant practical measures of redressive action only arrived on 23rd march when lockdown came into effect and the uk properly entered its second, liminal period. during this period, routine social life was suspended, antistructure became the norm, and significant measures to control the spread of the disease finally, and belatedly, arrived. government legitimacy rose during this period and focussed ritual expressions of communitas occurred in which social solidarity was expressed with those working on the 'frontline' in fighting the virus. as we shall see, these secular rituals did not, however, magically resolve various significant social cleavages within british society, and in many ways ended up dramatising these latent divides in more vivid light. this second period was narrated in the high mimetic mode of tragedy that drew upon the highly polarised, and occasionally even apocalyptic, language of warfare. one important episode in this period-boris johnson's illness-even reached into the lofty genre of romance and legend, in which the pm-as-hero was cast as possessing preternatural powers of agency in his personal capacity to fight off the virus. the government also attempted to recast, or interpellate, a range of other actors from both within and beyond the government during this middle period, with varying degrees of success. attempts, for instance, were made at redistributing responsibility by recasting senior medical and scientific advisors as ultimately accountable for the government's policy decisions, and the general public as liable for following them. nhs staff and other frontline workers were recast as 'heroes' and eulogised in that role in ways that profoundly reframed the meaning of their mounting deaths. attempts at co-opting external actors to play along with one's intended direction are, however, inevitably unpredictable and the paper will explore phases in the uk's c-19 social drama the failures of these casting efforts, showing how at various junctures uninvited actors inconveniently pushed their way onto the public stage in ways that threatened to undercut the government's intended drama. the third and final ritual phase was announced on 10th may, came into effect from the beginning of june, and is ongoing. turner makes clear that 'social dramas, especially under conditions of major social change, might not complete [their] course ' (1988, p. 35) . this period has so far been characterised by ambiguity and incompleteness. attempts at narrative deflation have been uneasily combined with the inflated moral coding that prevailed during the previous phase, and strong elements of liminality have also remained. it will be shown how the government's ability to successfully narrativize this period has been thrown into jeopardy by contradictions in government actors' own public performances, typified by revelations of a major political scandal involving the pm's top advisor. the effect of these failures is evidenced by a stark decline in government legitimacy during this period, and widespread confusion over government rules and guidance around covid-19. since covid-19 has spread throughout the globe, and different nation-states have responded in different ways, with differing health outcomes, the pandemic therefore presents social science with a large-n dataset that can be used for comparative purposes. this means that a large number of different cases can be observed empirically, without the need to imagine speculative counterfactuals. placed within this international comparative context, it is hard to escape the conclusion that whichever way you measure it, and especially in light of the uk's relatively advanced warning of the virus, the uk's response has been woeful, resulting in tens of thousands of avoidable deaths (aljayyoussi and cross 2020) . a primary contention of this paper is that this abysmal public health outcome was in part an effect of the efforts to fix meaning around the virus by the politicians who directed the response. different constructions of the virus's meaning by powerful political players became quite literally a matter of life and death for many. the paper therefore wishes to illustrate the real-life (and more to the point, realdeath) causal impacts of culture, identifying, with some degree of specificity, 'just how culture makes a difference' (alexander and smith 2003, p. 14) . it intends to show how cultural analysis is not condemned to producing vague descriptions of social life that skirt around the edges of specifying explanatory mechanisms. despite what some of its critics may claim, cultural analysis need not remain stuck on some destabilising merry-go-round of ever-undercutting hermeneutic circles but is instead able to come good on dilthey's (1972 dilthey's ( [1900 , 2002) original goals for interpretive enquiry. these goals never intended to banish explanation from the human sciences, but instead aimed to reconstruct meanings in such a way as to build explanations appropriate to the human sciences. in order to effectively render meaningful 'forms of life', narrative reconstructions ought to rely upon, and take seriously, the categories used by social participants themselves (tsilipakos 2020; winch 1958, pp. 40-65) , though this does not mean they need not remain inside such categories in offering their explanations. the case of covid-19 reveals how struggles over sense-making-such as fixing the genre under which events are understood, or the effective casting of human and non-human actors-can affect whether or not populations find themselves exposed to mortal risk. culture, in other words, is revealed in this paper to act as a mechanism through which the sovereign power to 'expose to death'-what mbembe (2003) has called necropolitics-is able to function. methodologically, these explanatory pathways are traced through an historical reconstruction of dominant meanings that were projected-with variable degrees of success and contention-from centres of power. the paper shows how these meanings shaped interpretation, behaviour, policy, public legitimacy, and ultimately the spread of infection and death rates. to do this, it draws its empirical data from transcripts of the government's daily press conferences, recorded media appearances of politicians and scientists, press briefings, investigative tv, newspaper journalism and media reports that provided the 'first rough draft of history', social media posts, open letters, and newspaper front-page headlines. the information sources are limited, and a full picture would require declassification of internal downing street communications that ought to become the focus of any future public enquiry. nevertheless, to unpick the public messaging itself, and the responses it received, no such data are required. it will also use political polls as imperfect proxies for measuring government legitimacy at various moments. another limitation in the data has been the difficulty of accurately tracking the variation in infection rates at different periods, which is itself a consequence of the lack of a systematic testing system. rather than a comprehensive overview of events, it focuses in on shifts in messaging and symbolic action, moments where sudden change can be detected. it will tell two stories: one of a national public health catastrophe, in which over 57,600 deaths have so far been registered in the uk where c19 was mentioned on the death certificate; another of a public relations exercise, in which casting, narrative, and performance were deployed in an effort to shield the government from responsibility, with the frequent effect of exacerbating the crisis. it will therefore focus on efforts to contain two types of contagion: one viral, the other symbolic, and examine the dangers of treating public policy around matters of life and death as a matter of political communications; of managing a public health crisis as though it were a public relations one. given the openness and complexity of social systems, unlike stage dramas, the genesis and termination of social dramas, as well as the identification of the relevant parties involved, is a matter to be determined, and justified, by social analysts themselves. the events described below unfolded within other, more panoramic social dramas, and themselves contained many smaller, more focussed social dramas. in presenting my own narrative, i am conscious that i am both adding another layer to the storytelling and smuggling in my own account of the appropriate analytic forms and categories through which to understand these extraordinary events. a physical virus, and the substantive suffering involved in the death it causes, might seem to somehow spontaneously contain its own interpretation. this paper intends to demonstrate how nothing could be further from the truth. as we shall see, the meaning of the virus, the performance roles of those who acted to control it, and the significance of the death it caused, were all subject to highly contested meaning work. certain conventional understandings of a pandemic's meaning, derived from historical and popular artistic representations (wald 2008) , no doubt influenced the interpretation of c19, as did even more generalised and generic narrative forms. nevertheless, the crisis also offers a stark example of an 'unsettled time' (swidler 1986) , in which the field of meaning was thrown open for interpretation and struggles to define its symbolic significance ensued. the control that directors exert over conventional stage plays allows them to construct a 'relatively contrived illusion' involving 'the maintenance of a single definition of the situation' (goffman 1959, p. 246) . in contrast, real-life social dramas are obliged to work with highly contingent and often radically uncontrollable actors and conditions. rarely do preformed, coherent, and consensually coordinated 'performance teams' exist at the outset of a social drama (goffman 1959, p. 104; morgan and baert 2015, pp. 36-37) , and this is one feature that renders social dramas more akin to improvisational theatre than the conventional stage play that the dramaturgical tradition has typically used as its referent. as all experienced improv actors know, audience participation-which might be thought of as an implicit casting of the audience into an intended projection of meaning-always operates within a 'horizon of risk' (white 2013, pp. 73-94) . this risk derives from the fact that audience members do not always play ball. stubborn inductees have their own ways of answering the question of 'what is it that's going on here?' (goffman 1974, p. 8) , which rarely align perfectly with the intentions of those directing the show. to increase the likelihood of conformity, one influential manual suggests that audience 'volunteers must be treated with love and generosity' (johnstone 1981, p. 14) , a matter that will be shown to be important later on in this paper. other clues as to how external actors can be successfully enlisted into a particular drama come from the radical tradition of social theory. althusser famously explored how states, and their varied institutions, effectively maintain social control through ideological processes that help reproduce social subjects as beings who tend to naturally identify themselves with those institutions. those experiencing the effects of ideology, whether capitalist or otherwise (althusser 2014, pp. 227-228) , come to see themselves as spontaneously at one with certain categories and ways of thinking and acting. when this occurs, such subjects have, in his parlance, become 'interpellated as subjects' (ibid., pp. 267). 'interpellation' refers here to the process of being hailed and-identifying yourself as the subject who is being addressed-turning around to acknowledge that the call was indeed meant for you (ibid., p. 164, p. 191 ). althusser's account rests upon an elevation of the theoretician of ideologiekritik as capable of penetrating illusion in a context in which mere mortals are assigned no such powers. more importantly though, in spite of his favoured use of the term 'subject', once althusser is done with her, this figure has very little of what we would conventionally identify as 'subjectivity' left. these problems, alongside various others, provoked a particularly vociferous critic of structural marxism to dismiss interpellation as a 'grotesque notion' (thompson 1978, p. 148) . nevertheless, even flawed concepts have their uses when adapted or applied in contexts other than those for which they were designed, and i intend to both adapt and resituated althusser's concept here. i intend to adapt it by offering far greater agency to subjects in refusing to be interpellated in the roles assigned to them, 1 and to resituate it by transplanting it into the wider field of social drama, where it comes to be seen as similar to the attempts at audience participation or 'casting' introduced above. this latter term is useful in allowing us to speak sensibly of how the virus itself was cast in a particular dramatic role at different periods within the drama, since a virus can hardly be said to be interpellated given its incapacity to subjectively recognise itself in its assigned role. whereas most of the studies following the performance turn in cultural sociology, as well as turner's own account, have assumed that the characters that populate social dramas are human agents, in these events, the virus itself became cast as an antagonist with varying powers of agency assigned to it at different phases in the drama. recognising this, need not entail hyperbolic post-humanist claims concerning nonhuman 'actants' (latour 1996, pp. 373-379; cf. morgan 2016, pp. 38-42) , but simply implies an acknowledgment that objects other than human beings serve functional roles in storytelling processes. however, whilst useful for capturing the ability of an actor to resist enrolment, and also for the capacity of non-human entities to become enlisted in a story, the relatively neutral term 'casting' proves inadequate for capturing the power relations involved in many of the ways that actors are often dragooned into their roles. the power of the government's intended casting of the scientists who advised them, for instance, was shored up by the status of many of those scientists as employees of that same government. such power relations did not, however, automatically determine casting outcomes, and as well as identifying conformity, the paper will also review those moments in which scientists rebelled against their assigned roles and blew the whistle on the government's mishandling of the crisis. role casting is only effective to the extent that actors conform to a broader storyline and a more focussed script, which are by definition extended through time. the same is true of the moral coding of objects and events as good or evil: coding's efficacy, which may be thought of as the organisation of events and objects in conceptual space, is only realised once a diachronic movement is introduced to plot these objects and events in evolving narrative time (alexander 2006, pp. 60-62) . getting at this dynamism, ricoeur describes a story as 'a sequence of actions and experiences of a certain number of characters, whether real or imaginary … represented in situations which change … [and to] which they react' (ricoeur 2016, p. 239) . english studies scholars have looked at the way in which popular stories of communicable disease are shared across different outbreaks and circulate within populations very much like diseases themselves do. it has been shown how these stories can then go on to influence responses to outbreaks, both by authorities and by those affected by the disease (wald 2008) . sociologists have examined the role of personal narratives in making sense of the lived experience of pandemics (e.g. davis and lohm 2020), and historians have also applied dramaturgical models to show how epidemics are constructed through narratives that share particular motifs and metaphors (e.g. rosenberg 1989 rosenberg , 1992 . tracking similar lines to van gennep's and turner's tripartite account of the ritual passage explored here, rosenberg, for instance, identifies how epidemics 'follow a plot line of increasing and revelatory tension, move to a crisis of individual and collective character, then drift toward closure ' (1989, p. 2) . salmon (2017, p. 6 ) is correct to point out that narrative has often functioned 'as a technology of communications, control, and power', even if he incorrectly characterises this development as a relatively recent phenomenon. his account also tends to neglect that what plummer (2019) calls 'narrative power' can be used to challenge as well as legitimate authority (e.g. polletta 2006; alexander 2011; olsen 2014) . whilst dominant powers tend to have greater access to, and control over, 'means of symbolic production', alternative stories can and do get voiced in the public sphere, and authorities are often forced to adapt their own stories in response (davis 2002) . whilst the covid-19 outbreak is ripe for sociological analysis of the various speech genres deployed at different phases of its management (bakhtin 1986) , the aspect of genre theory relied upon most here will instead be that concerned with narrative genres (barthes 1977) , both in their ability to account for a mechanism of the exercise of power, and their affording the possibility of a 'structural hermeneutics', which enables 'the construction of models that can be applied across cases and contexts but at the same time provid[ing] a tool for interrogating particularities' (alexander and smith 2003, pp. 25-26) . adapting northrop frye's (1957) classic aristotelian statement on literary criticism, smith (2005) has shown how locating one's narrative in the appropriate archetypal genre can help politicians justify exceptional policy and mobilise dramatic forms of social action. this is because narrative genre helps organise both the cognitive and emotional response to events. for social narratives to be effective, politicians must not only plot them in an appropriate way, but, citizen-audiences must of course be willing to read and experience them in that same way. plotting events in one genre rather than another expands or contracts the possibilities for action that we might expect from both protagonists and antagonists, encouraging certain beliefs about their character whilst discouraging others. the focus here will be on what turner calls the 'star groupers' of the public sphere, those 'main protagonists … who develop to an art the rhetoric of persuasion, who know how and when to apply the pressure and force, and who are most sensitive to factors of legitimacy ' (1980, p. 152) . this group therefore excludes individuals who circulate stories in private discussions during pandemics (davis and lohm 2020) , the content of which may be used to index the efficacy of the star groupers' own interventions, but who nevertheless fail to define a situation in any significant way for broader social groups. politicians form the most prominent element of this star group and though their interventions are far from infallible, and though their public utterances may be characteristically carefree with it comes to meeting truth conditions, they are typically hyper-aware of the felicity conditions that need to be met for their performative acts and utterances to come off effectively in front of enfranchised public audiences. other contributors to this symbolic public sphere included journalists, scientists, doctors, nurses, and organised or disorganised members of the public who in open letters, tweets, television appearances, and op-eds tried to impose their own narrativization of the events and attempted to cast various actors, including the virus itself, in ways that often diverged from the government's own efforts at fixing meaning. smith's (2005) focus is on the way that governments drum up support for the extreme act of war, with all its attendant human sacrifice. given that war is typically considered in realpolitik terms of the clash of instrumental powers, material competition, or violence, it provides an excellent test case for a cultural sociological approach to explanation, since the proposed hypothesis is considered improbable within conventional social science (popper 1963, p. 77) . theories of 'perpetual war' notwithstanding (keen 2006) , taken as a discrete event, war is an extraordinary occurrence that in most contemporary societies requires justificatory work for governments to avoid becoming enveloped in a 'legitimation crisis' (habermas 1988) . to motivate a population to engage in exceptional acts such as war, politicians must plot real-life events in a convincing sequence that is usually characterised by a highly charged apocalyptic struggle between protagonists, coded as absolutely good, and antagonists, coded as absolutely evil. the consequence of this struggle must be presented as the fate of a society's highest ideals. whether or not base and material motivations-imperial expansion, resource extraction, military-industrial complexes, etc.-are in fact driving states to wage war, in national democratic contexts, and international contexts governed by conventions and treaties, war narratives must be pitched in such a way that evil forces come to be seen as threatening what a society holds most dear. in such scenarios, it must come to be seen that without war liberty or justice, for instance, will be banished; with war they will be protected or extended. stories must be told in such a way that blood sacrifice is considered an acceptable price for a society to pay in order to protect its most treasured ideals. drawing directly upon aristotle (1996) , frye (1957) describes five 'fictional modes' on the basis of the hero's role vis-a-vis the audience. (1) the dramatic mode most removed from the mundane is the mythic, in which the hero 'is superior in kind both to other men and to the environment of other men'. such a hero therefore occupies the realm of the divine. (2) slightly closer to earth, in the romantic mode, the hero is 'superior in degree to other men and to his environment' (ibid., p. 33). such a hero therefore 'moves in a world in which the ordinary laws of nature are slightly suspended: prodigies of courage and endurance, unnatural to us, are natural to him' (ibid.). the romantic hero is the protagonist we find not in myth, but in legend. (3) touching down to earth, the hero of the high mimetic mode is 'superior in degree to other men but not to his natural environment ' (ibid., pp. 33-34) . such a hero is therefore bound by the same mundane constraints as others but is more capable than most in his ability to bend and overcome them. frye associates this mode with great leaders, and it is the hero we find in the genre of tragedy that preoccupies aristotle's poetics. in using this term 'mimetic', aristotle draws upon plato's notion of art as mimêsis, or imitation, of life. aristotle stressed that in tragedy, there must be both a closeness and a distance between life and its imitation in order for art to achieve a 'purification of … emotions' (katharsis), especially those of 'pity and fear', and it is from this emotional purging that the audience's pleasure in dramatic tragedy was derived (aristotle 1996, pp. 10-12) . the closeness to real life allows the audience to identify with, and be moved by the characters, whilst the distance from real life allows them to rest assured that it is not them who are undergoing ill. ricoeur introduces another function of art's mimetic distance from reality in his observation that storytelling 'refers to reality not in order to copy it' in any direct sense, 'but in order to prescribe a new reading' (ricoeur 2016, p. 255) . in this sense, a good tragedy is never entirely realist, but always involves a certain stylisation. it is 'a kind of metaphor of reality', that imitates reality 'in accordance with its magnified essential features' (ibid.). (4) firmly rooted in the world of the everyday is the low mimetic hero. such a protagonist is 'superior neither to other men nor to his environment'. in realist fiction in the low mimetic mode, we are moved by such a hero precisely because they are one of us; in low mimetic comedy, we are amused by them because we recognise their flaws in the worst aspects of ourselves. (5) finally, we find a hero who is 'inferior in power or intelligence to ourselves' (frye 1957, p. 34) in the ironic fictional mode. here, the protagonist-hardly any longer a hero, and certainly not in the modern sense of that term-is a frustrated, pathetic, or absurd figure, and readers of such literature can rest assured of their superiority in being capable and conscious in ways that this protagonist is not. as we move down this hierarchy of narrative modes, it is important to point out that the powers of the hero to act on the world around them-to manage or resolve a crisis, for instance-are progressively diminished. smith (2005, pp. 21-22) adds three additional dimensions to frye's generic schema. first, as narrativization moves away from the ironic and towards the mythic mode (a process he calls 'narrative inflation'), heroes' motivations become less base, and more ideal. second, it is not only the protagonist's perceived powers to act that are expanded, but also those of the antagonist. as acts of good and evil become more momentous and dramatic, moral polarisation between the hero and the enemy is therefore also increased, and the antagonistic characters take on an increasingly emblematic appearance. finally, as we move up the narrative hierarchy, the 'issues' at stake also grow in significance and gravity, 'the future of kingdoms and even the world may be at stake and transcendental themes relating to the need for salvation and redemption become increasingly significant'. a key insight of cultural pragmatics is that culture structures both enable and constrain action, which is one way of establishing culture's relative autonomy. whilst agency is key, e.g. in attaching particular real-life events to generic narrative forms, at the same time, culture structures inhibit agency, blocking various possibilities as they open up others. i will try to show how at different points in the uk's c19 crisis, culture workers exerted agency in attaching events to different generic narratives, which both facilitated various forms of action, but simultaneously foreclosed others. once, for instance, the antagonist-virus was successfully narrativized in high mimetic terms as an 'unprecedented', even 'devilish', threat to society, this opened the door to interventionist state action, at the same time as it closed the door to inaction in the face of a morally inflated threat. where smith (2005, pp. 232-233, n4) chooses to neglect the significance frye places on the use of metaphor, this article will address metaphor directly, showing how the dynamics of the real wars that smith analyses offered important narratological functions when used as symbolic metaphors for fighting disease, for as bruner (1990, pp. 59-60) points out, 'narrative is not just plot structure or dramatism … "historicity" or diachronicity. it is also a way of using language [that] relies upon the power of tropes -upon metaphor, metonymy, synecdoche, implicature, and the rest'. it will also try to show how literary theories of narrative genre can complement, and be interwoven with, anthropological theories of ritual process and social drama, the utility of which has already been demonstrated elsewhere (e.g. jacobs 1996) . social drama itself is, after all, a kind of narrative, a story composed of a 'sequence of social interactions of a conflictive, competitive, or agonistic type' (turner 1988, p. 33) . ritual, and the contemporary pseudo-rituals we find in social dramas, are also processes that when successful are, like good tragedies, able to 'achieve genuine cathartic effects' (turner 1974, p. 56) . elsewhere, turner (1980, p. 153 ) makes clear that 'there is an interdependent, perhaps dialectic, relationship between social dramas and genres of cultural performance in perhaps all societies. life, after all, is as much an imitation of art as the reverse … genres … serve as paradigms which inform the action of important political leaders … giving them style, direction, and sometimes compelling them subliminally to follow in major public crises a certain course of action, thus emplotting their lives'. turner's (1969) account of the ritual process drew upon van gennep's (2004) model of rites of passage and his own ethnographies of traditional, tightly integrated and non-differentiated societies such as that which he found amongst the ndembu of zambia. however, he later adapted his concepts to fit complex, non-traditional societies too. modernising turner's approach a step further, cultural pragmatics has emphasised the difficulties-though not impossibilities-of achieving the kinds of ritualistic 'fusion' that were common in more simple societies, due to the highly contingent, reflexive, and 'de-fused' nature of the modern world (alexander 2004; morgan 2020) . this argument mirrors others that we find in literary theory. whether or not one accepts the 'cambridge thesis' concerning the origins of theatre in ritual (cornford 1914; cf. schechner 1988, pp . 1-6), frye's description of the high mimetic mode of greek tragedy emphasised its integrated unity of focus, in which the hero becomes the 'cynosure' of the audience (1957, p. 58) , just like the totem forms the centre of attention for rites of worship in certain indigenous societies. recall that in tragedy, mimesis works in such a way that the fictional hero is also cast as higher in powers than the mortals that he or she imitates in ordinary life, just as for durkheim 'the images of totemic beings are more sacred than the beings themselves' (durkheim 1995, p. 134) . in this respect, unlike the low mimetic mode, which involves fictional forms that 'deal with an intensely individualized society' the 'centripetal gaze' of the higher mimetic modes seem to share something with ritual, for it 'seems to have something about it of the court gazing upon its sovereign, the court-room gazing upon the orator, or the audience gazing upon the actor' (frye 1957, pp. 58-59) . as we work up the narrative ladder to the realm of myth, we are quite explicitly dealing with the sacred realm of the gods. lukács's theory of the novel reveals something similar in its tracking the decline of both epic poetry and dramatic tragedy, which he tells us emerged from the 'integrated civilisation' of the ancient greek world (1971, pp. 29-39) , and the rise of the novel, as a modern attempt to recapture some of this unity in a socially fragmented, and individually alienated, contemporary setting (ibid., pp. 56-93). the novel, for lukács, was an expression of our striving for something more universal in the tensions it exhibits between the way the world is and our idealistic motivations to overcome reality's constraints. for cultural pragmatics, the pseudo-ritual process in contemporary societies is similarly strained between on the one hand, disenchanted conditions of de-fusion and differentiation, and on the other, a striving for re-enchantment, shared meanings, and collective solidarities. under such conditions, culture can still bind social groups together, but it does not come about with such ease and spontaneity. participation cannot be assumed, and the different 'elements of performance' need to be actively brought together and made to work in synchrony. fusion therefore relies upon the artistic skill of actors and directors in successfully orchestrating social performance. in what follows, this paper will describe efforts at such orchestration, and the ways in which such efforts were routinely undermined, both by the inartistic skills of their authors, and the refusal of actors to be interpellated. it will show how conceiving the handling of the uk's covid-19 outbreak as progressing through the stages of a secular ritual process sheds light on how crises are triggered, how they are elevated to dramatic heights, and how they are lowered back down again. this section will describe how the uk government ignored various alarming warnings that suggested the immediate necessity of initiating a social drama around the virus. instead, throughout the first three months of the year, the government chose to narrativize the outbreak in 'low mimetic' terms which disallowed the possibility of an effective response being taken to control its spread and prepare the health service for the severe outbreak that was brewing. 'low mimetic' narrativization barred recognition of the virus as a tragic threat, and therefore prohibited extraordinary action being taken to avert it. ritual breach into an anti-structural state was, in other words, foreclosed, and the everyday routines and structures of british society remained intact, allowing the deadly virus to disperse throughout the population and eventually kill an extraordinary number of uk citizens in the weeks and months ahead. this section will describe how all this was enabled under the banner of 'herd immunity'. it will describe how such symbolic labels were connected to the narratives through which the public were being encouraged to understand the meaning of the virus and show how these culture structures did not only exist at the level of ideas but were also communicated in concrete acts of political performance. finally, this section will show how these sense-making efforts from above proved ultimately ineffective in imposing their intended meanings, as public institutions and individuals took matters into their own hands, rebelled against the government's laissez faire approach and began taking their own prohibitive measures towards the viral threat. these actions 'from below' led to narrative inflation, paving the way for the belated casting of the virus as a tragic threat that was to define phase ii of the national drama. january, 2020 began with china reporting its first death from the novel coronavirus in wuhan, and concluded with the uk leaving the european union. the latter event was marked by prime minister johnson delivering a public address in which he declared that 'the dawn breaks and the curtain goes up on a new act in our great national drama'. similarly to 1918, when woodrow wilson was so distracted by wwi that he failed to recognise the emerging threat posed by the so-called 'spanish flu', the uk government were later criticised for being too involved in their promise to deliver brexit, and deal with other domestic issues such as severe winter flooding, to adequately acknowledge the far more momentous drama that was looming on the horizon. the day prior to johnson's use of theatrical metaphor, the who had declared that covid-19 constituted a public health emergency of international concern, advising governments of 'all countries' to take immediate action, readying themselves 'to contain any introduction of the virus and its spread through active surveillance, early detection, isolation and case management, contact tracing and prevention' (who 2020a, b) . the who's announcement, and many subsequent warnings, could have provoked the government into initiating a social drama around the virus much earlier, as occurred in many comparable nations. this would have involved acknowledging a 'breach' and coding the virus not merely in mundane technical terms, but in extraordinary moral terms, as a threat to cherished values, such as life and livelihood. such coding could have spurred public legitimacy for the rapid declaration of a 'crisis' that would demand radical redressive measures. if this had occurred in good time, the deadly scale of the crisis might have been 'sealed off quickly within a limited area of social interaction' (turner 1974, p. 38 ) as occurred in for instance, in new zealand. rather than conjecturing about counterfactuals though, this section will describe what in fact happened: how throughout january, february, and into early march, the uk government narrativized the covid-19 outbreak in 'low mimetic' terms which prohibited a timely breach, prevented dire coding, and barred the possibility of consequential action being taken to avert it. smith talks about how '[c]risis situations involve a genre guess made from a few events and then ongoing efforts to check this as things develop' (smith 2005, p. 31) . in some ways, the periodic revisions that the uk government made in its generic narrativization of the developing covid-19 situation are accurately described by this notion of a 'genre guess'. in other ways, however, the phrase does not quite fit. this is because politicians were not simply guessing at what genre most accurately fit the unfolding events, but instead-in a context in which other imperatives, such as economic and political motivations shaped decision-making-they were attempting to actively impose their chosen narrative, to which they hoped the reallife events themselves might be made to conform. contagious disease has long been narrativized in the literature and film in apocalyptic terms, and in the book of revelation, plague is indeed one of the four horseman of the apocalypse. this would seem to suggest that if politicians were simply guessing what genre to place events under, conventionally, a deadly pandemic would scream out for narrativization in an apocalyptic, or at least a high mimetic, narrative mode. this was not, however, forthcoming, until a large degree of damage had already been done. instead, the government decided upon low mimesis, a narrative mode that 'takes life exactly as it finds it' (frye 1957, p. 41) , and which whilst involving the resolution of some weak level of binary conflict lacks the dramatic potency of tragedy, let alone the apocalyptic contradictions of good and evil necessary for acts of war. smith describes how the weak character polarisation of the low mimetic mode leads it to 'understand crises as fixable through prudence ' (2005, p. 25) , and in this case, the virus was initially cast as a mundane hazard to be overcome by prosaic forms of individualised action, rather than the coordinated and enforced measures that were to be belatedly introduced in the second period. the uk health secretary was first alerted to covid-19 on 3rd january and on 21st january, neil ferguson provided a report to cobra showing how the infectivity rate was certainly higher than seasonal flu and could be higher than the spanish flu (calvert et al. 2020, april 19) . on 23rd january, the uk department of health's first press release on the new virus described its risk to the public as 'very low' (dhsc 2020). a different narrative genre had clearly taken hold amongst political leaders in china, who the next day placed wuhan, which contains over 11 million inhabitants, into complete lockdown. soon the whole of the surrounding hubai province was placed under the same measures. if this event was registered at all in the uk's official communications, it might be detected in the modifier 'very' having been removed when the chief medical officer, chris whitty, issued a government press release reiterating that 'we all agree that the risk to the uk public remains low' (whitty 2020a). the same phrasing was repeated by the health secretary on 24th january (reuters 2020) , and again in various government communications on 27th january (e.g. hancock 2020a). on 3rd february, johnson made a speech in greenwich that played on familiar themes of british exceptionalism in order to justify keeping the country open for trade. in it, he argued that other nations' overreactions to coronavirus threatened the global market economy, and explained that he intended the uk, which he compared to superman, to buck this trend: 'there is a risk that new diseases such as coronavirus will trigger a panic and a desire for market segregation that go beyond what is medically rational to the point of doing real and unnecessary economic damage, then at that moment humanity needs some government somewhere that is willing at least to make the case powerfully for freedom of exchange, some country ready to take off its clark kent spectacles and leap into the phone booth and emerge with its cloak flowing as the supercharged champion of the right of the populations of the earth to buy and sell freely among each other … i can tell you in all humility that the uk is ready for that role'. (gov.uk 2020e) on 10th february, a slight shift appears to have taken place, with the secretary of state declaring that 'the incidence and transmission of novel coronavirus constitutes a serious and imminent threat to public health' (gov.uk 2020a). nevertheless, mandatory screening was still not taking place at borders-in fact only 273 out of the 18.1 million people arriving in the uk in the three months prior to the lockdown were quarantined (grieirson 2020)-and as late as 20th february, downing street was continuing to reassure the public that 'the risk to individuals remains low' (rawlinson et al. 2020 ). on 12th february, an exeter university study warned that 45 million people in the uk could become infected if the virus was left to spread. on 14th february, johnson was apparently so relaxed about the developing situation that he took a holiday for almost a fortnight in the kent countryside with his new fiancé, during which time he seems to have finalised his divorce, and aides were told to 'keep their briefing papers short' (calvert et al. 2020, april 19) . richard horton, editor of the lancet was later to point out that 'we knew in the last week of january that this was coming, the message from china was absolutely clear … we wasted february when we could have acted' (in evans 2020). later in february, studies emerged that showed that a large percentage of those infected were asymptomatic, and on 2nd march, another alarm bell was sounded after two consensus statements were reported to sage, alerting them to the high likelihood of 'sustained transmission of covid-19 in the uk at present', and warning them that without more 'stringent measures' an estimated 80% of the population would become infected, and that their 'best estimate of the infection fatality rate is in the range of 0.5-1%' (spi-m-o 2020). this translated into an almost unthinkable death toll of between 250,000 and 530,000 british citizens. however, this warning was apparently insufficient to budge the government from its low mimetic reading of events, which they continued to project for two further weeks. that same day johnson's final words in a video address to the nation were strangely edited out of the version that was published on the government's social media accounts. he stated: 'i wish to stress that, at the moment, it's very important that people consider that they should, as far as possible, go about business as usual' (in calvert et al. 2020, may 24) . the day following this sage meeting, johnson held his first press conference, televised to the nation. flanked by the scientific authorities of chris whitty and the chief scientific advisor, patrick vallance. this opening scene would be an opportunity to set the tone for the ensuing drama and define the characteristics of its narrative genre. whitty's relaying of the 80% infection rate might have provoked some gesture towards 'narrative inflation', the process 'through which ramping up … of threats is achieved' (smith 2005, p. 29) . however, any increase in the 'weighting' (alexander 2012, pp. 35-39) offered to the coding of the virus as a significant threat was quickly undone by whitty's reassurance that 'the proportion of the population who get infected is likely to be lower than that and probably a lot lower than that … even for the highest risk group, the great majority of people will survive this … if you're talking about the low-risk groups, the rate of mortality is well below 1 per cent' (in menendez 2020). the general performance that day was coherent, and johnson reassured the gathered journalists that this was 'overwhelmingly a disease that is moderate in its effects' (in calvert et al. 2020, may 24) . if these efforts at retaining a deflated narrative had failed to achieve their end, and any of the assembled journalists risked leaving the conference with the impression that the story to be reported was anything more than routine political management, johnson's memorable subsequent intervention left no room for doubt. 'i was at a hospital the other night where i think there were actually a few coronavirus patients and i shook hands with everybody', he declared, offering the relaxed advice that 'we should basically just go about our normal daily lives', and that 'the best thing you can do is wash your hands with soap and hot water while singing happy birthday twice' (in crace 2020). frye uses 'domestic tragedy' as another term for the low mimetic mode, and it would be difficult to contrive a more mundane and domestic proposal than washing one's hands with soap and water. a concerned downing street source was later quoted in the sunday times telling them: 'the handshake-you can't minimise how important that is' (in calvert et al. 2020, may 24) , and a sage member was quoted in the guardian saying that at this point it became clear that a gap had emerged between 'the scientific advice and political messaging. "the prime minister was going around shaking people's hands to demonstrate that there wasn't a problem. there was a disconnect at that point. we were all slightly incredulous that that was happening"' ). on 28th february, the first death of a british national occurred on the quarantined diamond princess cruise ship, and the sunday times reported that around the same time dominic cummings (johnson's chief advisor, and former director of the successful vote leave campaign) had 'outlined the government's strategy' for the uk's national response to the virus 'at a private engagement', quoting those present as claiming that it was 'herd immunity, protect the economy, and if that means some pensioners die, too bad' (shipman and wheeler 2020) . given the subsequent prominence of this 'herd immunity' term-and given the government's later denials that it was ever informing their strategy-it is worth briefly reviewing its presence in the uk's response, and how neatly it fit with their initial low mimetic narrativization of events. it's not possible stopping everyone in the population getting it. and it's also, actually, not desirable, because you want some immunity in the population -prof. patrick vallance, chief scientific advisor to the government, 12th march, 2020. following cummings's reported private outlining of a herd immunity strategy, it wasn't until early march that the idea was launched into the public sphere and became subject to the mechanisms of civil discourse. its most (in)famous airing was johnson's memorable reference to the concept on itv on the 5th march, the same day that confirmed infections exceeded 100 and the first covid death on uk soil occurred. asked by the presenter whether the plan was 'to spread this out so it doesn't all happen at once and overwhelm the nhs', johnson revealed that 'one of the theories is that perhaps you could take it on the chin, take it all in one go and allow the disease, as it were, to move through the population, without taking as many draconian measures' (this morning 2020). actions, of course, speak louder than words, and johnson put this 'theory' into performative practice by shaking the presenter's hand (who had intentionally kept it by his side to see if johnson would offer his own) on entering the studio. when asked about this during the interview, johnson responded 'i've been going around hospitals as you can imagine and always shake hands. people make their own decisions' (in ng 2020; mason 2020d). background representations (low-mimetic generic narrativizations of the virus) were being converted into concrete scripts (mast 2013, p. 10) , which were then being made to walk-and-talk on the public stage provided by a daytime tv show. performance, in other words, was being creatively deployed to communicate the government's intended meanings for the virus. johnson's symbolic actions (burke 1966) continued to accord with the 'theory' he had shared with the nation when two days later he was photographed at a six nations rugby match at twickenham, with tens of thousands of fans in attendance, after which he retweeted a video of himself again shaking hands with the england team (england rugby 2020). it was later revealed by the times that johnson had failed to attend any of the five crisis response cobra meetings that took place in january and february (calvert et al. 2020, april 19) , 2 and which are typically chaired by the pm at times of national crisis (a. walker 2020; walker 2020a, b). on a bbc broadcast on 11th march, david halpern, a behavioural psychologist and sage member who leads whitehall's behavioural insights team-commonly known as the 'nudge unit'-first offered the public a label to attach the 'theory' that johnson had both verbally explained and then performatively acted out. halpern's unit draws upon 'nudge theory', used by many liberal democratic governments as a way of 'nudging' citizens towards 'better' choices (such as handwashing during the c19 outbreak) in a way that avoids legislative intervention. whilst it raises its own civil liberties issues, it is a mode of applied behavioural psychology that lends itself well to civil libertarian modes of government. on the bbc news that day, halpern described a strategy of 'cocooning' vulnerable groups, for a period of time during which the virus could spread, so that 'by the time they come out of their cocooning, herd immunity [could have] been achieved in the rest of the population' (in easton 2020). the idea was to avoid a second, possibly worse, outbreak in the autumn or winter if too few had developed immunity by then. two days later, on the bbc's most popular radio news broadcast, the today programme, patrick vallance reiterated that 'our aim is to … not suppress it completely; also, because the vast majority of people get a mild illness, to build up some kind of herd immunity so more people are immune to this disease and we reduce the transmission' (in stewart and busby 2020) . later that day he told sky news that 60% of the population (approximately 40 million people) would need to become infected in order to reach herd immunity, accepting that this would involve 'an increasing number of people dying' (vallance 2020) . it is worth noting how death is presented here in regrettable but hardly highdramatic tones. frye associates low mimetic drama with pathos (1957, p. 38) , and pathos allows death to be framed as regrettable, though not something that actors have a great deal of agency to control. as boltanski (1999) has argued, feelings of pity for those that suffer or die might move us, but they rarely evoke action towards ending the causes of that death or suffering. death was being framed here as unfortunate, but ultimately unavoidable. the dominant signification of a 'herd' is livestock, and whatever the technical meaning, the popular semantic implication was that human health was being managed equivalently to cattle. this risked evoking eugenicist connotations that are clearly distasteful to many. lawrence freedman (2020) wrote that the term 'lent itself to accusations that the government was preparing to let the disease rip through the community as part of a cold-blooded experiment in social engineering'. moreover, the science was not clear that long-term antibody resistance was viable, an assumption that was based upon the idea that this new virus would operate in a similar way to influenza . although new influenza viruses keep mutating, they are somewhat predictable in that individuals are known to develop immunity through vaccination or exposure. less is known, by contrast, about how the human immune response to c19 functions, and how long it lasts, so deciding not to suppress or track it involved far higher levels of risk. on 13th march, two other sage members confirmed that herd immunity was the only available option. prof john edmunds told chanel 4 news that there were two approaches to stopping a virus: 'you can stamp out every case in the world', but, 'we haven't managed to do that … when the genie is out of the bottle, the virus is all around the world and spreading, the only other way that the epidemic is going to come to a stop is achieving herd immunity'. prof graham medley, interviewed for the bbc, stated that 'we're going to have to generate what we call "herd immunity", so that's the situation where the majority of the population are immune to the infection, and the only way of developing that in the absence of a vaccine, is for the majority of the population to become infected' (on newsnight 2020). however, it was not only the scientists' references to the idea, or johnson's conspicuous actions in accordance with that idea, but also wider policy decisions during this period that offered an overall unity to the government's initial narrativization. all three of these elements were working performatively in concert with the others. on 10th march, the same day that nadine dories, a health minister, tested positive for the disease, the government claimed that there was no scientific basis for suspending sporting events or other large gatherings. many looked on in disbelief as the cheltenham horse racing festival-an event that was cancelled in 2001 due to the foot-andmouth-disease outbreak (a virus that can in only very rare conditions infect humans)took place unabated. one-quarter of a million racing enthusiasts attended from 10th to 13th march. local cases 'increased several-fold' soon afterwards (tucker and goldberg 2020; sabbagh et al. 2020) . most attendees travelled to cheltenham from other areas of the country, where they of course returned following the event, an unknown number carrying the pathogen with them. two horse-racing fans who had attended cheltenham died with c19 symptoms on the same day at the end of that month (calvert et al. 2020, may 24) . on 11th march-the same day that the director general of the who formally declared a 'pandemic' and expressed that the organisation was 'deeply concerned by …. the alarming levels of inaction' exhibited by some governments (who 2020b)-approximately 3000 atletico madrid fans flew from madrid-a coronavirus hotpot, which was itself already under partial lockdown-into liverpool to attend the champions league tie (proctor 2020) . this was at a time when atletico madrid had been forced to close its home ground due to the virus (dispatches 2020). liverpool soon becomes another uk infection hotspot (nuki 2020) . giant stereophonics gigs were held in glasgow (11th march), manchester (13th march), and cardiff (14th march)-in arenas with a combined capacity of over 40,000-producing memorable images of tightly packed fans. all these areas subsequently experienced spikes in cases, but for the time being, this large-scale imagery served to provide manifest symbols of the government's narrative that there was little high drama in this outbreak, no need for ritual to redress it, and that life should continue as normal. contrast heightens dramatic effect and the sense of doing nothing during this period was exaggerated by news that comparable countries were actively intervening to halt the virus's spread. this was a pandemic, not a local epidemic, and the british story was merely a subplot in a global drama. the domestic audience had access to a global media to inform their judgement of how convincing the government's narrative was. east asian nations had demonstrated the efficacy of mass testing, contact tracing, and stockpiling protective equipment, and equivalent european governments were projecting divergent stories that refused to countenance the enormous death toll associated with a 'herd immunity' strategy. italy, denmark, ireland, norway, and spain had all entered lockdown in early march. germany had heeded the successful south korean experience, carrying out comprehensive testing and contact tracing. by 12th march, france had announced school closures, and banned large public gatherings. 3 on 13th march, the behavioural advisors to sage put the case that public trust in the government's response would be lost 'if measures witnessed in other countries are not adopted in the uk' (quoted in freedman 2020). much of the public and many private institutions clearly felt the dominant national narrative was not changing quickly enough and legitimacy in the government's story appears to have diminished around mid-march. 4 polling published on 14th march revealed that 41% felt that the government was underreacting to the situation, and only 36% trusted what johnson said on the subject (helm 2020) . internal government polling showed that a majority was now in favour of cancelling large sporting events (freedman 2020) . preceding government instructions to do so, the premier league, the football league, and the women's super league all suspended their fixtures indefinitely on 13th march, in spite of the enormous financial cost of these moves (macinnes 2020). financial services professionals were told to work from home after outbreaks appeared in their offices (clarke 2020; reuters 2020) , anxious parents kept their children away from school (murphy 2020), employees began simply refusing to show up to work, and universities began cancelling face-to-face teaching from 13th march, advising students who could do so, to return home as soon as possible (bbc 2020f) . large sectors of the public were refusing to act out their roles in the low mimetic narrative in which they had been cast. after lockdown finally arrived, the telegraph quoted a cabinet member claiming that they 'didn't want to go down this route in the first place-public and media pressure pushed the lockdown' (rayner et al. 2020) . leadership and agency were emerging from below, and the government risked being inadvertently cast as a follower, rather than a leader. on 14th march, a who scientist criticised the 'herd immunity' approach on radio 4′s today programme, emphasising the need to escape the notion that events should simply run their course, and instead pleading the importance of becoming actors in the unexpected drama: 'we can talk theories, but at the moment we are really facing a situation where we have got to look at action' (in financial times 2020; also cockroft 2020). that same day, an open letter, signed by over 500 scientists was published, pressing the government to recognise its capacity to resist the enveloping disaster: 'the growth can be slowed down dramatically, and thousands of lives can be spared … "herd immunity" at this point does not seem a viable option … additional and more restrictive measures should be taken immediately, as it [sic.] is already happening in other countries across the world' (open letter 2020a). another open letter signed by almost 700 behavioural scientists had been published the day previously, likewise, highlighting the country's 'unique window' for action. this letter took aim at the assumption that 'behavioural fatigue' could justify failing to implement lockdown, arguing that 'essential behaviour changes that are presently required (e.g. handwashing) will receive far greater uptake the more urgent the situation is perceived to be. "carrying on as normal" … undercuts that urgency' (open letter 2020b). all these interventions were united in their linking narrative inflation with an increase in perceived agency over unfolding events. on 12th march, a highly significant sage meeting took place in which the development of the virus in italy-which the uk was tracking in terms of case and death rates-was put under focus, and the extraordinary consequences of sticking to a 'herd immunity' approach were apparently acknowledged. in turner's typology, this moment at last marked recognition amongst those in power that the viral breach had developed into a crisis (turner 1980, p. 150) . in aristotle's language, this was the moment of 'recognition', the moment of 'change from ignorance to knowledge' (aristotle 1996, pp. 18-19) . dominic cummings was present at this meeting and was reported by the sunday times to have suddenly realised that 'he had helped set a course for catastrophe', resulting in what the newspaper described as a 'domoscene conversion" (shipman and wheeler 2020) . that same day, johnson, in a much more sombre mood, and seemingly uncomfortable with having to share the bad news, made a striking announcement that signalled a radical break from his previous public communications. he stated that 'this is the worst public health crisis in a generation… it is going to spread further, and i must level with you, i must level with the british public: many more families are going to lose loved ones before their time' . he announced that the government would be moving from its 'contain' to its 'delay' stage (gov.ac.uk 2020b). acting against who advice to 'test, test, test' it was also announced that testing those with symptoms and the minimal efforts that had taken place to contact trace would be abandoned. additional advice was offered, but it was modest, and still merely advice-those exhibiting symptoms should stay at home for 7 days, over 70s were advised not to go on cruise ships, and schools should not take their pupils on trips abroad . levels of human agency, in other words, remained low: though recognition had occurred, and a crisis had been inaugurated, a reversal in action and an initiation of redress was yet to come. that saturday, 14th march, the cabinet met and agreed to escalate the response. an attendee reported that the 'mood in the room was astonishing. you could tell that something very significant had shifted' (in shipman and wheeler 2020). that same day, denials began of what had, a few days earlier, appeared transparent. the department of health issued a statement that 'herd immunity is not part of our action plan, but is a natural by-product of an epidemic' (ghosh 2020) , and the health secretary wrote an article for the sunday telegraph claiming that '[h]erd immunity is not our goal or policy; it's a scientific concept; our policy is to protect lives' (hancock 2020b) . 5 even though the uk epidemic was doubling every three to four days at this point, it was nine more days until lockdown-a policy that jarred with johnson's libertarian impulses-was enacted. this decision to delay had demonstrably fatal consequences for many, as the government's own advisors identified (mason 2020b) . modelling from imperial and oxford universities (in calvert et al. 2020, may 24) suggests that if lockdown had commenced on 3rd march, when the initial dire warnings concerning 'mitigation' were presented to sage, infections would have needed to be brought down from around 14,000. by saturday 14th march, when the decision to change approach arrived, around 200,000 people were infected. by the time lockdown was enforced on 23rd march, infections were estimated to be around 1.5 million. another piece of research for channel 4 suggests that locking down on 12 march would have led to 13,000 fewer deaths, and on 16th march, 8,000 fewer (dispatches 2020) . the starkest estimate, however, has come from the epidemiologist and mathematical biologist neil ferguson, a former sage member who heads the imperial college covid-19 response team that has advised the government throughout the crisis. on 10th june, ferguson told a house of commons science committee that if the government had locked down a week earlier, 'we would have reduced the final death toll by at least a half' (stewart and sample 2020) . 5 further evidence of the brazen nature of these denials comes from the following: the italian health minister reported that johnson had phoned the italian pm on 13th march, telling him explicitly that herd immunity was the strategy (dispatches 2020); an author of a paper widely credited with influencing the government's change of approach (ferguson et al. 2020 ) explained at its launch that 'we were expecting a degree of herd immunity to build up … we now realize it's not possible to cope with that in the current health system, and it may not be acceptable in terms of the numbers' (in conn et al. 2020) ; interviewed on 25th march on bbc breakfast, the former health secretary stated that the government changed 'from a herd immunity approach to a suppression approach about ten days ago'. this section will describe how the government's belated recognition that they had made a catastrophic miscalculation led to narrative inflation to a high mimetic mode. most of this new narrativization took place within the genre of tragedy, which aristotle describes as 'an imitation of action that is serious, complete, and of a certain magnitude ' (1996, p. 10) . a central motif of this inflation was the increasing use of militaristic metaphors, which lent themselves to moral polarisation by magnifying the threat presented by the virus to the level of a belligerent invader. this legitimated the need for the extraordinary state intervention required to enter the liminal lockdown phase on 23rd march. it also provided a thematic frame for ritual activity by recasting those who were charged with directly tackling the virus into the role of national 'heroes', apparently willing to risk sacrificing their lives for the health of the nation. at the same time, the government attempted to recast the scientists as more responsible for government policy than the government itself. this narrative inflation reached its peak with johnson's admission into hospital with the virus, a moment that moved the story from the tragic genre of drama, to the even higher romantic genre of legend, imbuing johnson with superhuman powers to fight off the viral antagonist. the end of this section will describe how relatively soon after johnson's release from hospital, signs of narrative deflation emerged, paving the way for a slow and incomplete return to an ambiguous low mimetic mode, characterised by anticipations of both partial reintegration and schism. on 19th march, dominic cummings met with the government's communications director, the general election campaign director, the election's social media strategist, a pr boss, and various figures from the vote leave campaign, to devise the government's main slogan to define the second high mimetic period of the covid drama (hope and dixon 2020; shipman and wheeler 2020). this group had been involved in the famously effective 'take back control' mantra for the 2016 brexit referendum, and the tory's similarly successful 'get brexit done' slogan for the 2019 general election. the new slogan they created to form the centrepiece of the messaging for the lockdown period was 'stay home. protect the nhs. save lives.', and it was released on friday 20th march, two days before lockdown was officially enforced. in announcing lockdown on 23rd march, johnson emphasised the final element of the slogan: 'i must give the british people a very simple instruction: you must stay at home'. this announcement constituted what aristotle called peripeteia, or reversal, the moment in a plot in which 'there is a change to the opposite in the actions being performed ' (1996, p. 18) . in turner's schema, this reversal in actions initiated the most important period of a social drama, that of redress, in which various mechanisms-such as closure of businesses and public buildings, but most centrally an unambiguous order to the public to 'stay home'-were brought into operation to resolve the crisis and bring the recently elevated viral antagonist to heel. the tripartite slogan was repeated over and over again in speeches and government messaging on television, the radio, billboards, and across social media, including being plastered on the front of the lecterns from which the daily press conferences were held (fig. 4) . on the second day of lockdown (24th march), for the first time in british history, an sms with the slogan was sent to every uk mobile phone, and later that week, a letter from the prime minister containing the slogan was sent to every household in the uk. its appearance was typically surrounded in 'emergency' red and yellow chevrons, signifying the seriousness and urgency of the instruction. emphasising the inflation of agency intended by the slogan, hope and dixon (2020) quote a senior downing street source as explaining that it 'was built around the concept of emergency so people could appreciate how stark times were. we needed action'. the action called for, however, was not action from the government, but from the public, and as will be explored below, this contributed to an attempt at shifting responsibility that was to define this high mimetic lockdown period. ironically enough, other than for those few engaged in essential services, the action called for was also a kind of inaction: 'stay home' was how this invisible antagonist was to be fought. like the casting that takes place in situated performances, and the narrative genres that social dramas yoke themselves to, metaphors are another method of meaningmaking, and the metaphor of war was increasingly used by the government and media in discussions of how the virus would be 'fought'. all this 'war talk' (roy 2003, pp. 1-7) served the purpose of narrative inflation, justifying the extraordinary state powers required to enter lockdown. the war alluded to most frequently was that war that currently holds pride of place in the fractured british conscience collective. this was of course wwii, and the fact that the 75th anniversary of ve day fell within the crisis no doubt primed the receptiveness with which this allusion was met. turner has pointed out that 'the culture of any society at any moment is more like the debris, or "fall-out," of past ideological systems, than it is itself a system, a coherent whole ' (1974, p. 14) , and the collective memory of wwii-a war which the vast majority of living people in the uk never experienced first-hand-has become an established culture structure within the british nationalist mythopoeia, capable of conjuring formidable feelings associated with overcoming adversity, and just victory over evil. sometimes sentimental, sometimes jingoistic, this reference is typically backward-looking 6 or even melancholic (freud 1917, pp. 243-258; gilroy 2005, pp. 88-89) and follows the same route of binary polarisation demanded by genre inflation. as gilroy has put it, the imaginative invocation of wwii allows brits to 'know who we are as well as who we were, and then become certain that we are still good while our uncivilised enemies are irredeemably evil' (ibid.). in the c19 'war', non-human agency featured in the form of the 'invisible enemy' being cast as the antagonistic virus itself. the following words/phrases are all taken from newspaper front-page headlines referring to c19 during the period under study: 'the blitz', 'army', 'victory, 'bulldog spirit' (accompanied by an image of churchill giving the victory sign), 'betrayal', 'battle', 'war footing'. the top five ministers of the government have repeatedly been referred to as the 'war cabinet', words like 'threat', 'battle', 'fight', 'invisible enemy', were used repeatedly in the press conferences, during which johnson also described the nhs as 'unconquerable' (12th april). once lockdown was imposed, these martial binaries were used to identify 'traitors' flouting its rules (the mirror 2020). however, the war imagery was not always bellicose: the hospitals built to deliver extra icu capacity were called 'field hospitals', volunteers producing ppe were described as working on the 'home front' (blackall 2020) , and during an extraordinary televised speech to the nation, the queen alluded to vera lynn's famous wwii song 'we'll meet again'. some of the metaphors, whilst not quite subliminal, were less explicit, so that even if they were not always consciously recognised, they nevertheless retained their power to strike the 'symbolic imagination in more or less the same way' (baudrillard 2002, p. 41 n1) . references, for instance, to the sites where infections were understood to have originated as 'epicentres', or the routine description of those staff dealing directly with infected patients as 'frontline' seemed to operate in this way. war did not only feature in language, but also in ceremonial actions that became the focus of media attention and public celebration or censure. a veteran wwii british army officer, captain tom moore, walked 100 laps around his 25-m garden in the run up to his 100th birthday to raise money for the nhs during lockdown. moore, who completed his circumambulations using a walking frame and adorned with his war medals, provided an immaculately preformed icon for the broader sense of wartime spirit the government was working to evoke. he went on to record a version of lynn's 'we'll meet again' to raise further money for charity, and johnson sent him a recorded birthday greeting from downing street, referencing the 'heroic efforts' he had made to complete his 'mission', later recommending him for a knighthood. more contrived attempts at military ceremony were not so successful, such as the health secretary's announcement on 16th april that a lapel badge would be provided to care workers, describing it as 'a badge of honour in a very real sense, allowing social care staff to proudly and publicly identify themselves' (in wood 2020). in a situation in which deaths were mounting amongst these workers, ersatz medals were perceived by many as an insulting substitute for adequate ppe provision, and the scheme was widely ridiculed (woods 2020) . successful wars are typically good for political fortune, but unsuccessful ones can spell ruin for a government's authority. deploying these affective metaphors as ciphers through which to understand the virus therefore simultaneously opened up political risk, since references to the same civil code could be used to critique, as well as to defend government policy. one consultant cardiologist who contracted the disease but could not access testing complained that 'there is policy of surrender' (in boseley 2020a). an epidemiologist suggested that if we were at war, the government needed to do better, in 'commissioning, or commandeering supplies, and delivering those supplies under fire … appoint a commander and give them powers to requisition equipment and laboratory space … make a battle plan on who should be tested first' (hunter 2020) . critics pointed out that the government's newfound martial courage was effectively locking the stable door after the horse had bolted, recasting them from war heroes to appeasers. as one critical website put it, johnson was 'not churchill. he's chamberlin' (www.appea semen t.org). of course, there is nothing particularly new about politicians and the media using war metaphors ('trade wars', 'war on drugs', 'war on poverty', etc.). they are perhaps the most frequently used metaphors of all, and their ubiquity means we often fail to detect them. their popularity is no doubt due to their readily understandable nature, and their tried-and-tested ability to trigger emotions and summon symbolic boundaries between us (the allies) and them (the enemies) (lamont and molnár 2002) . moreover, these metaphors have a long association with illness and disease in particular (sontag 1978) , entering our consciousness from a young age (sick children are frequently told to 'be a brave soldier'). nerlich (2020) suggests that war metaphors are 'the go-to metaphors used in almost all reporting on infectious diseases' in particular, where pathogens are said to 'invade' cells, 'colonise' their host, and our natural 'defences' are said to become 'compromised', 'conquered', or 'overwhelmed'. one explanation for this strong association might be that infectious diseases operate on a microscopic scale, invisible to the naked eye. metaphors provide a vivid visual imagery that allows us to assimilate and structure our understanding of these invisible but highly consequential forces, to make sense of how they operate, but most importantly, what they mean, since ' [m] etaphor is, at its simplest, a way of proceeding from the known to the unknown' (turner 1974, p. 25) . nevertheless, such metaphors do not arise spontaneously, and there was nothing inevitable about the truculent imagery that was attached to the c19 events. the doctor in camus's la peste notes that a plague is similar to other human evils in that it 'helps men to rise above themselves' (camus 2002 (camus [1946 , p. 96). given the extraordinary outpouring of community solidarity in response to the covid threat, metaphors of cooperation and mutual support might just as easily have been adopted. despite historical associations and factoring in the mores that shape and socialise our decision-making, the choice of war metaphors must ultimately be considered just that: a choice. it should also be noted that just as tying real-life events to generic narratives simplifies a complex reality, metaphors likewise tend to conceal whilst they simultaneously reveal. this is because 'metaphor selects, emphasizes, suppresses, and organizes features of the principal subject by implying statements about it that normally apply to the subsidiary subject' (turner 1974, p. 30) . whilst rhetorically effective, metaphor can at the same time therefore curtail and distort our comprehension of the principal subject. wars, for instance, are fought via top-secret strategies laid out by the commanders of sovereign nation-states. pandemics are not. containing and eliminating viral outbreaks requires cooperation, transparency, and maximal sharing of information. rendering pandemics symbolically as if they were wars allows national governments to avoid transparency, to suspend normal democratic accountabilities, and to ignore the experiences and advice proffered by other nation-states, or by global health organisations. nevertheless, in spite of all these reductions and misrepresentations-and perhaps in fact because of them-metaphor remains a potent symbolic resource. the choice to use warfare as the primary figurative representation of fighting the covid threat had the important effect of inflating the sense of danger, and therefore expanding the powers available to the government to control it. a cultural intervention, in other words, enabled a public health intervention. in war-whether real of metaphorical-as in tragedy, heroes come to the fore, and the following section will explore the role that the figure of the hero played in meaning-meaning during this phase of the crisis. in ancient greece, heroes were considered somewhere between the gods and the mortals, and their memories were often kept alive via ritual forms of worship, including offerings and sacrifices that took place around their burial mounds or shrines (farnell 1921) . heroes were of course also the main protagonists of greek drama in the high mimetic mode; they were the 'somebody doing something' (frye 1957, p. 33) , typically presented as struggling against adversity, often driven by higher moral motives. the great greek tragedies frequently centred around, or concluded with, the hero's death, even if those deaths were rarely represented directly to the audience (pache 2009 ). very soon into the covid-19 outbreak, nhs and other key workers-many of whom had previously been referred to in derogatory terms as 'low-skilled', 'inefficient', 'greedy', and 'selfish' (e.g. mckinstry 2011)-were recast as honourable 'heroes' throughout the british media and in speeches and press briefings issued by the government. this section will discuss how this recasting enabled a reframing of the meaning of these workers' deaths. rosenberg notes how epidemics tend to take 'on the quality of pageant, mobilizing communities to act out proprietary rituals that incorporate and reaffirm fundamental social values and modes of understanding' (rosenberg 1989, p. 2) . various secular rituals sprung up around the newly cast heroic healthcare workers in the uk, included children drawing rainbows, often accompanied by slogans of thanks to nhs staff, and sticking them in their windows to be seen by passers-by. there was also a minute's silence held on 28th april for what the bbc described as 'fallen key workers' (bbc 2020a). the choice of a minute's silence, and the description of those that had died as 'fallen' is lifted directly from war commemoration, and in ritualised memories of war, death is dramatised as heroic, but casualties are nevertheless considered inevitable. as one nhs worker bluntly put it 'calling us heroes makes it ok when we die' (panorama 2020) . similar metaphorical work was at play in the us, where trump usefully spelled out what british leaders intimated. in an off-script section of a speech delivered in pennsylvania, trump observed that 'healthcare warriors' were 'running into death just like soldiers run into bullets', adding-as if savouring the moral aesthetic-that 'it's an incredible thing to see, it's a beautiful things to see'. it scarcely needs stating that no healthcare worker entered their career on the understanding that they may be required to sacrifice their lives. durkheim (1995) discusses how intensely emotional interactions focused around sacred objects arise in response to symbolic threats to a community, their functional purpose being to reconfirm collective bonds at moments when their solidity is waning or placed in danger. this approach to ritual spawned an influential paradigm in british anthropology (e.g. radcliffe-brown 1965), but one that in its focus on collective solidarity, weighed too heavily towards the explanation of ritual's functional role in maintaining stasis rather than triggering change, or at least limited its conception of change to immanent systemic causation. turner (1969) , by contrast, whose ethnographies of the ndembu exposed extraordinary levels of conflict amongst these village communities, placed more emphasis on ritual's-and eventually social drama's-role in not only reconfirming but also transforming social structure. in this sense, turner is perhaps best conceived as a conflict theorist, who developed the metaphor of social drama to explain how conflicts resolved themselves through socially patterned processes. nevertheless, although turner's preoccupation is with the management of outbursts of social conflict, he nonetheless studied such phenomena to gain deeper insights into the ongoing 'deep structures' that are revealed through analysing the surface ruptures (1974, p. 34) . the rituals that took place during the uk c19 outbreak were both triggered as responses to a collective threat, but nevertheless expressed social division as much as solidarity, and anticipated change as much as conservation. the most prominent ritual that arose, for instance, was one initiated by annemarie plas, who imported the practice of regularly clapping for healthcare workers that she had seen take place in her home-country, the netherlands. successful cultural practices tend to 'reproduce themselves' (wagner-pacific and schwartz 1991, p. 413) , and the ceremony was rapidly and widely adopted in the uk, with hundreds of thousands of participants clapping key workers from their windows, balconies, or doorsteps during lockdown, celebrating and consolidating their heroic status in the national imaginary. durkheim had observed the importance of periodically repeating rituals 'to renew their effects ' (1995, p. 420) , and 8 pm on thursday evenings quickly establishing itself as the time in which the rite would be enacted. during the structureless, liminoid days of lockdown, the ritual also provided a way of connecting with neighbours in a collective expression of shared sentiment. reminiscent of prison protests, participants who were not necessarily able to see one another in person, could nevertheless hear each other in cacophonous waves of sound that spread an audible 'bond of communitas' across residential centres (turner 1969, p. 105) . collective participation, however, did not miraculously resolve the contradictions that underlay this ritual. for many on the political left of british society, the nhs has been a sacred object of veneration since its postwar foundation, and its staff have been consecrated as folk heroes by those who have relied upon their care. participation in such public reconfirmations of sentiment were therefore unsurprising when expressed from these quarters. what was surprising was the public participation of some quite unlikely sectors of british society. johnson, for instance, had on multiple occasions backed private provision of healthcare, and in 2002 attacked the idea of sacralising the nhs in a speech in which he called for its 'reform', stating: 'i don't see why it should be sacrilegious to say that the nhs is failing … it's all very well to treat the nhs as a religion but it's legitimate for some of us to point out that insofar as it is a religion it is letting down its adherents very very badly' (in bartlett 2019 ). yet johnson made sure he was filmed every thursday evening engaging in the clapping sacrament. other tory mps who had voted through legislation defunding the nhs for almost a decade when the virus hit had also been filmed cheering in the house of commons after successfully voting down an amendment that would have given nhs nurses a pay rise. they too, however, advertised their enthusiastic participation in the clapping ritual on social media with hash tags such as #youareheroes (e.g. helen whately 2020). even within the c19 crisis, on 18th may, tory mps backed an immigration bill denying so-called 'low-skilled' workers-which included many of the 'heroes' they had been clapping-being granted uk work visas. the same month it was revealed that the £60,000 provided to families of bereaved nhs workers would not be extended to families of care home workers or hospital cleaners who had lost loved ones. the daily mail, who had dedicated various front pages in 2016 to attacking junior doctors striking over unsafe working conditions (12th february; 25th, 28th april; 31st august; 3rd september), and in 2014 had felt it necessary in another front-page headline to inform the public that '4 in 5 nurses on nhs wards are foreign' (dec 17th 2014), similarly joined in the public thanksgiving, boasting of the £1million it had raised via a charity for what it described as the 'nhs heroes' in its 29th april front-page headline. one way of explaining this apparent ritual convergence is that the nhs has successfully been raised to a sacred status within the british civil sphere, and its positive coding has been established as a 'common-sense' across the mainstream political spectrum (gramsci 1971, p. 326 f5). as a result, politicians who care about their careers must be seen to be protecting and supporting it. this is especially so at a time of national crisis in which healthcare workers were narrativized as primarily responsible for fending off the collective threat. another element of an explanation might come from narrative inflation having meant that the virus was successfully coded as the primary antagonistic enemy, and as any war-mongering leader knows, external threats can temporarily and precariously galvanise internal solidarities. finally, griswold (1987) recognises that successful cultural expressions allow their consumers to project diverse meanings upon them, whilst simultaneously retaining some overall coherence. the same is evidently true of cultural practices: those that enjoy widespread participation in complex societies with deep political divides need to function somewhat like rorschach inkblot tests, allowing varied participants to read their own meanings into them, whilst maintaining some broader sense of formal unity. getting at the same thing from a different angle, laclau (1996) might have described the functional role of such practices as akin to 'empty signifiers'-signifiers without firm signifiedswhich in their openness to resignification become focussed sites for political struggles over meaning. in the case of the thursday #clap4carers, participants often creatively moderated the rite in order to emphasise the particular meaning it held for them. an ex-mining union leader and labour mp, for instance, was filmed banging a saucepan, chanting 'pay them properly; give them ppe'. as wagner-pacific and schwartz (1991, p. 417) point out, rituals 'do not resolve historical controversies; they only articulate them, making their memory public and dramatic'. this insight was on display most clearly on the event of the uk's final #clapforcarers, on 28th may, for which a group of healthcare workers gathered outside the downing street gates. as the pm emerged to clap from the steps of no. 10, the group turned their back on him, holding a sign reading 'doctors, not martyrs', and stood in silence for 237 s, one second for each of their colleagues who had died from the disease. 7 the narrative inflation brought about through the use of these war metaphors functioned both to excuse the death of healthcare workers and to increase legitimacy for the interventionist policies that the government had belatedly chosen to deliver. another function, though, was to distribute responsibility for dealing with the crisis away from elected officials. although wars are directed by generals, they are fought by troops, and johnson made clear that it was the british public who were being called up for national service: 'in this fight we can be in no doubt that each and every one of us is directly enlisted. each and every one of us is now obliged to join together, to halt the spread of this disease' (johnson, 23rd march) . thanking others for their role in delivering an outcome implicitly casts these flattered inductees into some degree of responsibility if that outcome turns out to be wanting. here, as in the casting of nhs workers as 'heroes', interpellation can be seen most clearly in the use of gratitude and adulation as a mechanism of power. if we recall the improv advice that 'volunteers must be treated with love and generosity' (johnstone 1981, p . 14), we can see how thanks and praise increases the likelihood that an actor will recognise themselves in their assigned role, and that casting will be effective. when faced with criticism, government statements would be issued defending their own actions in the same breath as thanking the public for theirs. for instance, in response to whether the government had any regrets concerning their handling of the crisis, one downing street spokesperson insisted: 'we have taken the right steps at the right time to combat it, guided by the best scientific advice. we are so grateful for the response of the public, who have helped us to slow the spread of the virus' (in conn et al. 2020) . unlike cruder versions of scapegoating, the implicit-and indeed structuralcorollary of the idea that it was the public's responsibility for winning the war was that it was also, at least in part, the public's responsibility if the war was lost. politicians can typically rely upon the mass media to amplify deviance, and such reports often tend not so much to inform the public of actual news, as to provide them with periodic reminders of society's moral boundaries (erikson 1966) . just as convenient 'folk heroes' had been discovered in figures such as captain tom moore, 'folk devils' were quickly identified too (cohen 1972) . this more sinister element of the framing borrowed from another dramatic genre-the 'open conflict of good and evil' (frye 1957, p. 290) found in the medieval morality play. 8 pulling against any superficial galvanising force found in the ritual processes described above, this allowed for identification of 'enemies within', and the coding of these figures as morally corrupt. news reports focussed on the public's flouting of the lockdown rules (e.g. goorwich 2020; bbc 2020b; osborne 2020), encouraging transgressions to be reported to authorities (e.g. higham 2020). sun bathers in public parks, for instance, were attacked by the government and the media for undermining the fight against collective suffering and paraded in the media as public examples of one of 'the shapes that the devil can assume' (cohen 1972, p. 10) . asked on bbc radio 4 why people were ignoring the government advice, the health secretary responded, 'well i don't know, because it's very selfish' (mason 2020a) . as we shall see, these assertions came back to haunt the government when it was discovered that their senior advisor had himself spectacularly breached the rules. on 9th may, just prior to the second major shift in genre, johnson tweeted 'thanks to you, the plan is working, let's keep going' (fig. 2 ). this 'keep going' refrain was repeated in various other social media posts from johnson's personal and official accounts. beyond shifting responsibility onto the public's shoulders, a climate of 'free-floating responsibility' (bauman 1989, pp. 161-163; cohen 2000, p. 88 ) was established in other ways too. the health secretary shifted responsibility to nhs medical staff for over-using ppe (stewart and campbell 2020) , 'huge global demand' was held responsible for ppe shortages (lay and wright 2020) , 'chinese culture' was responsible for creating the virus (liu 2020), but most consistently and explicitly, scientists were held responsible for the overall strategy of the response. turner (1969, pp. 166-203) discusses how liminal periods allow for changes in traditional status and role distinctions, which is in part how ritual processes are able to deliver social transformation. the 'following the science' mantra allowed mps who had been elected to bear responsibility for public decision-making to shift this responsibility by recasting themselves as simply servants to science. interviewed on sky news about the alarming levels of infection in care homes following revelations that 1,500 elderly hospital patients had been transferred into care homes and the community without being tested, the work and pensions secretary said 'if the science was wrong, the advice at the time was wrong, i'm not surprised if people will then think we then made a wrong decision' (in merrick 2020). hume (1985, pp. 507-521) famously argued that you cannot derive an 'ought' from an 'is', and it is clear that prescriptive policy cannot be read directly off descriptive science. to turn science into policy, interpretation and decisionmaking must intervene, and interpretation is a fundamentally cultural matter (taylor 1971; geertz 1977) , just as political decision-making is a fundamentally normative matter. during the outbreak, significant-and for many, deadly-lags took place between evidence appearing and evidence being acted upon, suggesting that it was not scientific calculations, but political and economic ones-themselves deeply embedded in the normative worldview of those politicians making them-that were leading the response. different 'sciences' were also played off against one another. 'behavioural science', for example, was used as a justification for ignoring measures that epidemiological science might have suggested necessary. in early march, johnson had chaired his first cobra meeting of the crisis, in which he was presented with the shocking 500,000 deaths scenario, following which, many members of the medical science team were shocked that tougher restrictions were not immediately introduced (dispatches 2020). chris whitty justified delaying such measures on the basis that 'if we go too early people will understandably get fatigued' (in cohen 2020), and hancock later delivered the same line adding that 'social science and the behavioural science are a very important part of the scientific advice that we rely on' (in conn et al. 2020) . however, the behavioural scientists advising the government strongly rejected this notion of 'fatigue' (ibid.), as did other independent behavioural scientists (open letter 2020b), placing a question mark over its origins as part of the government's strategy. 'guided by the science' was usually shorthand for the fact that they were relying on the scientific advisory group for emergencies (sage), a body charged with providing impartial scientific advice to the government. the daily press conferences were staged in such a way that there was almost always a scientist from this group, or usually two, on a podium by the mp or pm who was fielding the questions. at first, the composition of sage was kept secret, but its membership was later revealed by the guardian newspaper. anthony costello, a doctor and ex-director of the who, critiqued the group not only for drawing upon too narrow a range of expertise, but also for the fact that 13 of its 23 members were directly employed by the government (costello 2020) . it was soon revealed that the top government advisor, dominic cummings, was also sitting in on sage meetings, alongside another younger political protégé of his . costello (2020) argued that this vastly reduced the likelihood of free disagreement. sir david king, the former chief scientific advisor, was 'shocked' by the revelation that political advisors had attended, stating that 'if you are giving science advice, your advice should be free of any political bias' (in carrell et al. 2020 ). vallance had claimed on 13th march that 'i speak scientific truth to power' (sky news 2020), yet available evidence does not seem to bear this claim out. minutes from a sage subcommittee meeting on 3rd march (spi-b 2020) stated that they had reached 'agreement that government should advise against greetings such as shaking hands and hugging' (in payne and cookson 2020; mason 2020d ). vallance then stood by johnson's side in the press conference that same day whilst he boasted of being 'at a hospital where there were a few coronavirus patients and i shook hands with everybody … i think the scientific evidence is, well, i'll hand over to the experts', johnson said, gesturing towards vallance. vallance failed to correct the pm, simply advising, 'wash your hands'. rifts had apparently developed between the government and the scientists when on 19th march, johnson had-in the absence of any scientific evidence-claimed that they could 'turn the tide' of the virus within 12 weeks, a statement that had apparently 'appalled' the experts (shipman and wheeler 2020). prof. neil ferguson (the lead author of the imperial paper that it was claimed provoked the government's shift in approach) made clear that 'it was the politicians, not the scientists, who decided on policies to pursue' (in conn et al. 2020) . another key sage member, prof graham medley, claimed that although the scientists advised the government, action was ultimately 'a political decision', agreeing with the interpretation that johnson and hancock have sometimes been 'passing the buck' onto the scientists (in con et al. 2020). the former examples in this section showed the role of flattery in the exercise of interpellative power in shifting the responsibilities inherent in democratic office onto the shoulders of the public or healthcare workers. these latter examples, by contrast, show the role of office itself in moving the locus of responsibility from elected and democratically accountable officials to unelected and unaccountable experts. the claim of simply 'following the science' allowed mps to cast themselves in what bauman, drawing upon milgram, called an 'agentic state', a heteronomous condition in which actors present themselves as simply 'carrying out another person's wishes ' (1989, p. 162) . on 10th march, nadine dorries, a health minister, tested positive for covid-19. on 25th march-two days after lockdown had come into effect-so too did heir to the throne, prince charles. on 27th march, prime minister johnson also tested positive, alongside the health secretary, matt hancock. chris whitty, the chief medical officer, also started experiencing symptoms the same day. on 5th april, johnson was admitted to hospital where he would spend seven nights, three of them on an intensive care ward where he was not intubated but was given oxygen treatment. three days later, dominic cummings also developed symptoms. the fact that the virus had penetrated the inner sanctums of the symbolic 'centres' (geertz 1977) of british society, infecting almost all the top officials charged with controlling it, naturally generated enormous media attention. this fuelled genre inflation further, to the point that the suspense story of johnson's 'fight for life'-as the 7th april front pages of both the daily mirror and daily star described it-was eventually elevated to the romantic mode. the romantic mode presents the hero as superior not in kind but in degree to other mortals, and 'the ordinary laws of nature [as] slightly suspended', so that 'prodigies of courage and endurance, unnatural to us, are natural to him' (frye 1957, p. 34 ). on 8th april, the daily mail and the daily express both ran with a front-page headline lifted from a speech made by foreign secretary dominic raab asserting that 'boris is a fighter… he'll pull through'. raab, who was deputising for johnson, had declared the day earlier that 'i am confident he will pull through because if there is one thing i know about this prime minister, he is a fighter'. 9 heads of foreign states echoed raab's claims, narendra modi asserted that 'you are a fighter, and you will overcome this', and donald trump reassured everyone that 'he's very strong, resolute. doesn't quit, doesn't give up'. on 9th april, the sun, pointed to various political elections johnson had won, editorialising that he 'has overcome the odds before and can do so again' (dunn and dathan 2020) . there was, of course, nothing automatic about this construction of meaning, and it is worth comparing it with the initial agentless narrativization of the uk's response to the virus described above, and even the predominant tragic narrative of this period. in the former mode, death was a regrettable inevitability for which pathos was the dominant 'structure of feeling' (williams 1977, pp. 128-135) ; in the latter, the disease might be challenged on a policy front, but death could hardly be warded off through individual force of will. frye describes how the romantic mode is characterised not only by 'the suspension of natural law' but also 'the individualizing of the hero's exploits ' (1957, p. 36) , and this new spotlighting of johnson as capable of somehow fighting the virus by sheer strength and courage, cast a shadow over the agency of the nhs staff who were treating him. it also implied that others who had died from the virus were simply not resolute enough in their 'battle'. sontag describes how this notion of a patient beating disease through individual effort is a common theme especially for cancer patients, and emphasises the added turmoil it can cause for the sufferer. 'widely believed psychological theories of disease assign to the ill the ultimate responsibility both for falling ill and for getting well' (1978), she wrote. interestingly, the responsibility for falling ill-given johnson's previous handshaking gambles-was rarely assigned to him, but the responsibility for getting well certainly was. smith's (2005, p. 20) claim that heroes' motivations become more ideal as narrative inflation takes hold is also borne out in this example. on 4th may, the sun's front page reported on an exclusive interview with the headline 'baby gave me will to live', in which johnson-who has refused to publicly disclose how many children he in fact has-described how 'the fear of never seeing his unborn son gave him the strength to beat coronavirus' (wooding 2020) . another theme of the narrativization of these events was that of democratisation: the notion that key public figures contracting the virus indicated its acting as a great social leveller. a downing street source claimed that the 'stay home' slogan's 'success was to communicate a message that "we are all in this together"' (in hope and dixon 2020). in the daily press conference on 27th march (the day of johnson's diagnosis), cabinet office minister michael gove suggested that the 'fact that both the prime minister and the health secretary have contracted the virus is a reminder that the virus does not discriminate'. on 28th march, the mirror's front-page headline ran 'virus at heart of govt. nobody's safe'. on 17th april, the telegraph's front page was a full spread reading 'all in, all together', calling on readers to stay at home. again, there was nothing inherent in the events that necessarily determined these meanings-when iran's deputy health minister had contracted the virus, it was widely reported in the uk press as signalling the incompetence of the iranian government in managing the outbreak. the government's reading of events quickly found themselves subject to dispute. on bbc's newsnight on 9th april 2020, for instance, the presenter began the show with a segment that quickly went viral on social media: 'they tell us that coronavirus is a great leveller. it's not. it's much much harder if you're poor…. those working on the frontline right now, bus drivers and shelf-stackers, nurses, care home workers, hospital staff and shopkeepers are disproportionately the lower paid members of our workforce. they are more likely to catch the disease because they are more exposed'. she added that 'you do not survive the illness through fortitude and strength of character, whatever the prime minister's colleagues will tell us … this is a myth that needs debunking'. the presenter's views were backed up by evidence. the crisis has been experienced in radically different ways depending upon one's housing, employment, and income situation. the wealthier have been more likely to be able to work from home, enjoy household and garden space, and the ifs has shown that richer households have actually increased wealth during lockdown through spending less on luxuries; an effect that has not been seen for poorer households (crawford et al. 2020 ). there has also been a starkly disproportionate number of bame deaths from c19 in the uk (pareek et al. 2020) . even johnson's particular episode was a poor emblem for social levelling: he was tested when others in his condition and age group had no access to testing, and a source in the hospital even claimed that since he had not required a ventilator, he 'was taking up an icu bed when he didn't need it' (in harding et al. 2020) . once he was released from hospital, the travel restriction that applied to everyone else apparently did not apply to him, and he spent his recovery in a grace-and favour 16th century manor house outside of london, with an indoor pool, surrounded by 600 acres of land. perhaps contrary to what might be expected, the episode of johnson's illness coincided with the second largest increase in support for the government's handling of the crisis during the outbreak (yougov 2020a, b; opinium 2020; fig. 3 ). legitimacy was high throughout this middle period of redress, partly because government opinium and yougov polling on public perception of the government's handling of the crisis actions appeared to be conforming to their projected definition of the situation, which itself coincided with dominant public answers to the question of 'what is it that's going on here?'. this specific uptick in legitimacy in a prevailing climate of high legitimacy can in part be explained through the romantic narrative around johnson's illness, and the consequent recalibration of the level of agency available for dealing not only with johnson's personal health, but with the public health crisis more broadly. jacobs and smith (1997, p. 68) identify how within civil societies, romantic narratives 'encourage maximal participation, solidarity, and trust in a common political culture' promoting the assumption of 'powerful and overarching collective identities'. tying groups together in collective projects, driven by shared sentiments and generative of communal identities are processes that are likely to overshadow the more mundane dissensus that might rise to the surface of political life under less elevated narrative genres. as with civil ceremony and ritual, the dramatisation of external threats can serve to temporarily increase internal solidarities, but such solidarities are fragile and time-bound, and cannot be assumed to hold under altered narrativizations. as incoherencies emerged between the government's definition of the situation and their public performances, as their casting of the primary antagonistic threat shifted, and as the narrative pitch was wound down again, dissensus would soon reappear, and with it, legitimacy would soon fall. in johnson's first speech on emerging from hospital, after claiming that the government's response had been a 'success' (exactly one week before britain's death toll became the second highest in the world), he referred to the virus in criminal terms, as a 'physical assailant, an unexpected and invisible mugger', claiming that 'we have begun to wrestle it to the floor' (28th april). 10 in evoking this 'mugger' imagery, a deflation of tone was inaugurated. the signification of the virus as an unpleasant threat remained, but it was no longer the grand foreign invader that had animated the military metaphor. the virus was being recast in the government's projection as once again a more mundane antagonist that could be-indeed was being-wrestled to the floor. the object of struggle was once again becoming more localised and domesticated, and the powers of action ascribed to the virus-with the structural correlate being also those powers necessary to tackle it-were losing their extraordinary force. johnson's particular emphasis on this mugger as 'unexpected' was latched onto, provoking some angry public responses. on social media, a clip from a popular channel 4 tv programme, gogglebox, in which participants are filmed reacting to tv broadcasts, went viral. responding to 10 much of johnson's political charisma is built upon his figurative and-to his admirers-entertaining, use of language. during the crisis, flattening the infection curve became 'squashing the sombrero', avoiding an infection peak was travelling through a 'vast alpine tunnel', and johnson referred to the regional lockdowns as 'whack-a-mole'. this often-clownish use of imagery has alienated as much as it has entertained though, as occurred in his reported use of the phrase 'operation last gasp' during a meeting to source extra hospital ventilators (blanchard 2020 ). johnson's 'unexpected mugger' comment, one viewer asks rhetorically, 'it wasn't really that unexpected though, was it?', another reacts that 'we saw this coming over the hill from china, so i don't think it was that much of a surprise'. 'if we're going to use that simile, that's like a mugger skipping down the street, doing a little dance number, and a twirl, singing "i'm going to mug yooou!"', says another viewer in the clip, with his sofa companion adding, 'that's like saying jack the ripper was unexpected after he'd killed his fifth prostitute'. these viewers were undoubtedly correct in their assessments. c19 was unprecedented in all sorts of ways, but its arrival-or the arrival of something similarwas certainly not unexpected. since 2008, the government's own national risk register had ranked pandemic influenza as one of the highest national risks to the uk, stating that 'experts agree that there is a high probability of another influenza pandemic occurring', and that 'one half of the uk population may become infected and between 50,000 and 750,000 additional deaths' (cabinet office 2008, p. 13 ). an updated version of the same register in 2017 put pandemic influenza in both the highest risk category, and the most likely civil societal risk to take place (cabinet office 2017). the newer report stated that 'emergency responders have personal protective equipment for severe pandemics and infectious diseases' and that there are 'protocols in place for infection control both before and during an incident ' (ibid., p. 35) . in 2016, however, a secret government simulation had been carried out for a hypothetical influenza pandemic, codenamed exercise cygnus, which had instead shown that the nhs would collapse under lack of resources including inadequate levels of ppe (nuki and gardner 2020) . although c19 is not an influenza virus, the ppe required is identical, and that the government were supposed to have been stockpiling this equipment in accordance with their own risk assessment. they failed to do so. stock went out of date without being replaced during the austerity years (malik 2020) , and fell in value by 40% (£325million) . at the end of 2019, there were also 43,000 nursing vacancies in the nhs (gallagher 2019) . no protective gowns at all were included in the government's stockpile when covid hit, even though the government's own advisors had recommended stockpiling in 2019 (panorama 2020) . nor did the government buy any visors, swabs, or body bags (bbc 2020c). even in the absence of this stockpile, however, there was still time to source what was necessary and build up ventilator capacity. on 7th february, the european centre for disease control had issued clear guidance about the levels of necessary protective equipment required (ecdc 2020) meaning that if the uk had acted then, they could have sourced what was needed. british companies who made ppe had written to the government offering their services but received no response (bbc 2020d), so many of these companies actually began exporting their products to foreign governments, such as the usa (panorama 2020) . the uk failed to join two rounds of eu schemes to bulk-buy ppe, and one to buy ventilators, claiming that that they had missed the invitation emails (boffey and booth 2020; mason and o'carroll 2020) . johnson had promised that 'we'll give them [nhs staff] all the support that they need; we'll make sure that they have all the preparations, all the kit that they need for us to get through it' (this morning 2020) but images of nhs staff re-using disposable gear, wearing old swimming goggles, 'dinner lady' aprons instead of the recommended long-sleeved gowns, and making protective head gear from bin-liners and plastic shopping bags quickly surfaced (e.g. staton et al. 2020) . families of nhs workers and volunteers dug out old sewing machines and began making scrubs for their loved ones, and members of the public with 3d printers began producing masks (blackall 2020; itv 2020) . the government then explicitly ordered coroners not to investigate lack of adequate ppe in the inquests into nhs workers' deaths (booth 2020). most alarmingly perhaps, on 18th march (i.e. following the government's decision to inflate the narrative and introduce far more interventionist social isolation measures), a press release from public health england announced that as of '19th march, 2020, covid-19 is no longer considered to be a high consequence infectious disease (hcid) in the uk ' (gov.uk 2020c) . this was an extraordinary decision to make at the height of the deadliest viral outbreak in living memory, especially four days prior to lockdown coming into effect, and at a period where deaths were mounting exponentially (calvert et al. 2020, april 19) . the classification had direct implications for ppe guidance-for a hcid, medical workers should be supplied with an appropriate long-sleeved gown, a respirator mask, and a visor-and it appears that this downgrading was the government attempting to protect itself from litigation, conscious of inadequate ppe supplies (bbc 2020c). on 5th may, even on the official figures released by the government-which have almost certainly vastly underestimated the real death toll (giles 2020)-british deaths from the virus became the highest in europe, and the second highest in the world, with a higher proportion of deaths than the country with the worst overall death toll in the world. only five days after these ignominious rankings however, narrative de-escalation began translating into policy. this final section describes the third phase of the government's response to the virus, which entailed a winding down of the drama back to an ambiguous low mimetic mode. this involved a significant and much-criticised shift in the government's official slogan, and a change in its policy towards the easing of lockdown restrictions and the encouragement of a return to work. at the level of meaning, where the antagonistic threat had previously been focussed purely on the virus itself, the threat was now broadened to also include the consequences of over-responding to the virus through a 'long period of enforced inactivity'. this section will describe how public approval dropped markedly during this period, arguing that this resulted in large part from generic and performative incoherence. the final subsection describes the most spectacular instance of this performative incoherence by recounting the story of how the architect of the 'stay home' slogan found himself caught in the act of failing to stay home whilst infected by the virus. on 5th may, the telegraph reported a senior adviser to the prime minister as claiming to have 'a phase two messaging plan pretty much ready to go. … we are going to remove "stay at home" because that is not going to be the main focus of things. it is about moving people onto the second part of the journey' (in hope describing what i have chosen to define as the third phase of the response, as 'phase two' or the 'second part of the journey', was a presentation later repeated by johnson, and one that conveniently removes the government's failure to act during the initial period from view. on 10th may, johnson released a speech from downing street in which he announced a loosening of lockdown restrictions, including requesting those who could not work from home to return to their workplaces, the removal of any limitations on outdoor exercise, and the announcement that certain school classes could return from 1st june (gov.uk 2020d). though not entirely coherent, this announcement appeared to signal the beginning of the end of the liminal period of redress, and a movement back towards structural reintegration. in his speech, johnson introduced the new tripartite slogan that would define this third period: 'stay alert. control the virus. save lives.'. the shift in the design of the slogans was also notable (fig. 4) . whereas the old one had been surrounded by red chevrons, the new slogan was surrounded by green ones; the semiotics of the message was clear-the country was shifting from 'stop' to 'go'. the new messaging was immediately criticised as confusing and incoherent (bush 2020; tolhurst 2020; sheridan 2020; a. walker 2020; walker 2020b) , and the devolved scottish, welsh, and northern irish governments all refused to shift from the original slogan. public health communications during a deadly viral outbreak need to be clear and comprehensible and this new slogan was evidently not (mendick 2020) , since it was unclear what the public were being asked to 'stay alert' to. polling showed that whilst 91% of the public understood the old slogan, only 30% understood the new one (yougov 2020b). this was arguably not a communications error, as many pr experts were quick to claim (hickman 2020), but instead an extension of the free-floating responsibility theme mentioned above, achieved through a successful communication of an intentionally incoherent message. the purpose, in other words, was arguably to encourage a loosening of restrictions whilst passing responsibility for the possible consequences of that loosening further onto individuals. evidence for this reading comes from the multiple times during johnson's address that he thanks the public-it was 'thanks to your effort' that the death rate was coming down, and 'thanks to you' that thousands of lives were saved (gov.uk 2020d; johnson 2020). the speech included a clear pivot to recasting the antagonistic threat from being not only the disease itself, but also the consequences of radical responses to the disease: 'there are millions of people who are both fearful of the disease, and at the same time fearful of what this long period of enforced inactivity will do to their livelihoods and their mental and physical wellbeing … this campaign against the virus has come at colossal cost to our way of life' (ibid.). this recasting of the virus introduced an ambiguity that had not previously been present over what exactly it was that the public should be 'fearful' of. after all, johnson continued to describe the virus in the morally polarised terms of high mimetic tragedy as a 'vicious threat', and even used the apocalyptic and religious imagery of 'sacred-evil' (alexander 2012, pp. 56-59) at one point, referring to 'this devilish illness' (gov.uk 2020d). these proclamations, however, were contradicted by the broadening out of the metaphors used to describe the antagonist (from 'foreign invader' to 'mugger'), the ambiguity as to what the primary threat in fact was (was it the virus, or the 'cost to our way of life' incurred by controlling the spread of the virus?), and by the rolling back of the restrictions that had previously been in place. in spite of the continuing refrain that the new plans were 'driven by the science' (gov.uk 2020d), the shift again appears to have been led by politics. the top scientific advisors were never asked to sign off on the slogan , and prof. john dury, who sits on the behavioural subcommittee of sage typically tasked with devising public communications during emergencies asked 'who is advising on the current messaging? unfortunately, it's not us', criticising the 'stay alert' messaging as 'too vague' (in ibid.). later in may, another prominent sage advisor, prof. john edmunds, issued a warning that 'with relatively high incidents, and relaxing the measures, and with an untested track and trace system, i think we are taking some risk here' (in boseley 2020b). the day following johnson's announcement of the lockdown loosening, teachers unions spoke out against sending classes back on 1st june, and a petition asking for parents to retain the right to keep their children at home gathered 390,000 signatures (lovett 2020) . on 15th may, the daily mail front-page headline attacked 'militant unions' for standing in the way of teachers wishing to return to work, and in continuity with the sacrificial-heroic coding of the previous period declared 'let our teachers be heroes'. four days later, the guardian reported that 1,500 primary schools were intending on defying the government's orders to open at the beginning of june (weale et al. 2020) . three days after johnson's lockdown loosening speech, polls indicated a 9-point plunge in public approval of the government's handling of the crisis, with disapproval (42%) for the first time during the crisis exceeding approval (39%) (opinium 2020a ; fig. 3) . a repeat poll on 21st may showed this disapproval with the handling of the crisis growing, as well as johnson's personal approval rating being overtaken by the opposition leader (opinium 2020b) . the same polling found that 47% of the public believed that the government were underreacting to covid-19, compared to 34% who believed they were reacting proportionally, and that 43% of parents felt anxious sending their primary-aged children back to school, compared to 20% who felt relieved; 53% felt anxious sending their secondary school children back, with only 13% reporting relief (ibid.). it is important to ask why it was, during this third period in which the government attempted to move the country back towards structural reintegration, that public legitimacy fell below the levels seen even at the end of the initial period when institutions and individuals were leading the government towards lockdown (fig. 3) . one important factor was a lack of both generic and performative coherence. in terms of genre, whilst many successful dramas are based upon blending (tragicomic, romantic-comedy, etc.), and whilst genres can be shifted from one mode to another, genre constraint nevertheless exists, since genres are indeed generic and therefore do not exhibit unlimited plasticity or boundless synthetic potential. this genre constraint might be thought of as one of the ways in which the relative 'autonomy of culture' functions. the ambiguities described above-in narrativizing what the real threat was (was it still the virus? was it now the effects of countering the virus?), at what level of gravity this threat should be understood, what powers of agency existed to fight the virus, and indeed what the new messaging condensed in the revised slogans in fact meant-flouted generic rules leading to broad confusion as to the kind of story the government was trying to tell. during the initial low mimetic period, a growing proportion of the public may not have found the government's narrative genre convincing, but there was at least coherent projection to disagree with. no such coherence reigned during this third period. on the performative level, in the first period johnson had acted in accordance with low mimesis by shaking hands and allowing sporting events to go ahead, communicating that it was 'business as usual' (calvert et al. 2020, may 24) . in this third period, johnson was mixing the rhetoric of one genre (the high mimetic claims that this was a 'devilish disease ' [gov.uk 2020d] ), with the actions of another (the low mimetic loosening of lockdown restrictions so as to 'reopen society ' [ibid.] ). such incoherence threatened the possibility of widespread fusion, and less of the public seemed prepared to suspend their disbelief and go along with the confused narrative they were being told. such contradictions between word and deed reached their most spectacular apogee in an episode revealed near the end of may. this episode, which occupies the focus of the following and final subsection, further eroded the dramatic force of the government's intended projection, damaging legitimacy even further. on 22nd may, a joint investigation by the guardian and the mirror revealed that dominic cummings had breached the lockdown rules he had helped write after being spotted at the end of march on the grounds of his parent's home in durham, a county in the north of england, 264 miles away from his london home (crerar and armstrong 2020; weaver 2020) . his presence in durham would have violated lockdown rules if he had been feeling well, but the transgression was considered particularly serious since both cummings and his wife had written about their coronavirus illnesses during this period, omitting to mention their extensive trip (wakefield 2020) . at the height of the lockdown, and exhibiting symptoms, they had apparently travelled the majority of the length of the country from the most infected zone to an area with a relatively low infection rate at the time. by this point, the official advice had been tattooed into the public's consciousness by the extraordinary communications campaign cummings himself had designed: stay home, and if you showed symptoms, you should self-isolate for seven days. the next day, a government minister, grant shapps, made clear that although the cummings family had made the cross-country trip, he had 'stayed put' once there (bland 2020) . the following day, however, a member of the public reported spotting the cummings family at barnard castle, 45 min from cummings's parents' home (weaver and dodd 2020) . rather than apologise for the incident, the government chose to double-down, using an appeal to the higher moral motive of love for one's child, as the alibi. downing street issued the following statement on the day the story broke: 'owing to his wife being infected with suspected coronavirus and the high likelihood that he would himself become unwell, it was essential for dominic cummings to ensure his young child could be properly cared for' (in stewart and weaver 2020) . the public had by this point spent weeks restricting their movements. thousands who had contracted the virus had been confronted with the same childcare issues but nevertheless conformed to the lockdown instructions. for many others adhering to the lockdown rules had meant foregoing saying goodbye to dying loved ones and being unable to conduct funeral ceremonies. many scientists, and even tory mps were furious with the official response, and began joining calls from the opposition benches for cummings to resign or be sacked. the following day, a remarkably similar chorus of messages in support of cummings appeared on cabinet ministers' social media accounts. an instance of this came from the health secretary tweeting that 'it was entirely right for dom cummings to find childcare for his toddler, when both he and his wife were getting ill'. on 3rd april, whilst cummings was away in durham, that same health secretary had presided over the daily press conference, behind a podium with the inconspicuous words 'stay at home' emblazoned upon it and stated that 'we cannot relax our discipline now. if we do, people will die', warning that 'this advice is not a request, it is an instruction' (bbc 2020e). the government's narrative risked appearing as though it had been devised only to apply to the public and not to the government itself, a case of 'do as we say, not as we do', which undermined the earlier 'we're all in it together' framing of the outbreak. since the media seemed unprepared to let the story die, the following day johnson held a press conference claiming that cummings had 'acted responsibly, legally and with integrity', again deploying the higher moral motive argument in claiming that 'any parent would understand'. many parents did not understand though, and the headlines that day were the worst since johnson's premiership began. the mirror had headshots of cummings and johnson, with 'a cheat & a coward' splashed across their front page. even the daily mail-typically unwavering in its automatic support for the government-ask incredulously of the pair, 'what planet are they on?'. prof. stephen reicher, a member of the sage behavioural subcommittee, tweeted that 'in a few short minutes tonight, boris johnson has trashed the advice we have given on how to build trust and secure adherence to the measures necessary to control covid-19′. dr adam kucharski, of sage's modelling subcommittee, tweeted that for the contact tracing measures 'to work, we need public adherence to isolation/quarantine to be very high. but i fear it's now going to be far more difficult to achieve this'. as the pressure mounted, it was announced that cummings would give his own press conference the following day (25th may) from the downing street rose garden, an unprecedented move for a senior advisor, which the bbc described as an 'extraordinary piece of political theatre'. in a gesture that no doubt did little to help generate sympathy and diffuse the impression of arrogance, cummings kept the audience waiting for half an hour, pushing back the day's tv scheduling. when he finally emerged, remorse was nowhere to be seen: 'i believe in all the circumstances i behaved reasonably and legally'. to a journalist's question of whether he regretted his actions, he responded 'no, i don't regret what i did'. to a question about whether he had considered resigning, the answer again was 'no'. precedent had been set by the scottish chief medical officer and the author of the imperial paper, both resigning from their roles for far less serious transgressions of the government's rules. cummings justified his journey due to the 'exceptional circumstances' around his childcare, but tens of thousands of people had found themselves in far worse circumstances, and nevertheless kept to the rules. he also confirmed his trip to the scenic town of barnard castle, which, entirely coincidently, had fallen on his wife's birthday. he claimed he had made the journey to test his eyesight, which had apparently been damaged by the disease, to see if he was fit to drive back to london. this decision to operate machinery for an hour and a half in lieu of an eye-test would have been odd if it had only meant putting himself at risk, but having done so with his family in the car, in the same defence in which he claimed that his overall actions were driven by the higher moral motives of love for his child, tried the credulity of many observers. after it was revealed that cummings's wife also held a driving licence, a reader wrote to the guardian suggesting that the reason her licence had not been used to drive the family home was probably that the dog had eaten it (guardian letters 2020). a poll published in the daily mail the following day revealed that whilst 8% believed cummings's eye-test story, 78% took it to be false (hussain 2020) . the same poll suggested that 59% of tory voters thought he came across as arrogant, and a staggering 80% of conservative voters believe he had broken lockdown rules. 70% agreed with the statement that johnson's government believes 'it's one rule for them and another rule for everyone else', with 65% predicting it was less likely that others would now follow the lockdown rules. a yougov poll the same day revealed that 52% of leave voters believed cummings should resign, contradicting claims that the scandal had been artificially concocted by disgruntled remainers as revenge on the man they believed manipulated the referendum result. as the scandal deepened, 44 tory mps called for cummings to resign or be sacked (mason 2020c ). johnson's approval ratings plunged 20 percentage points in the four days following the revelations to their lowest levels ever (from 19% to 1%), and government approval dropped 16 percentage points (from 14% to 2%) in a single day (savanta 2020) . once again, an explanation for this precipitous fall in legitimacy can be found in word and deed failing to align. the high mimetic narrativization of events, in which the 'stay home' message was communicated not as 'a request', but as an emergency 'instruction' (bbc 2020e), was suddenly being presented as open to interpretation. the government appeared to be saying that if one's motives were high enough, one could flout the rules, the importance of which they had spent weeks establishing. for public performance to be effective, narratives need to be acted out in accordance with the 'genre constraints' described above, since 'no matter how intrinsically effective [they are], collective representations do not speak themselves' (alexander 2004, p. 530) . government actions had failed to conform with the genre under which they were narrativizing the crisis, revealing a de-fused performance that wreaked havoc on the coherence of their drama. drawing upon a range of tools for cultural analysis-including narrativization and its link to genre, ritual process and social drama, casting and interpellation, scripting and performance-this paper has tried to specify the ways in which shifts in meaning-making resulted in changes in the political fortune of powerful actors, alterations in public behaviour, and ultimately in life and death outcomes for tens of thousands of uk citizens. it has mapped out specific turning points at which cultural changes in the management of the crisis can be shown to have had often dire impacts on health outcomes. in other words, it has tried to demonstrate why meaning-making matters, and why sociologists ought to pay attention to it. precisely because these mechanisms of sense-making can be shown to impact spheres of social life beyond the cultural, their functioning should be of interest not only to cultural analysts, but also to those concerned with public health and administration more broadly. the lesson, in other words, is that viral threats cannot be treated merely from a medical science perspective of the most technically efficacious ways to halt the spread of a disease, or even from a narrowly political perspective of how to represent, govern, legislate, and manage an organised polity in the midst of an outbreak. nor should we stop short at the important point of underlying the social origins of covid-19 (horton 2020). cultural processes should also be recognised as lying at the heart of both public health and statecraft, since culture composes the media through which these other practices are necessarily transacted. as well as demonstrating culture's relative autonomy and offering an empirical illustration of the potential of the strong program in cultural analysis, this paper has also made a series of other contributions to cultural sociology. for instance, in showing the effects of casting the virus as a sometimes more, sometimes less, threatening antagonist, it has demonstrated how social performance theory needs to take more seriously the way in which non-human actors become inducted into social dramas. by analysing the ritual behaviour that took place around the sacralised nhs, it has shown ritual's role in rendering social conflicts and divisions to public audiences, as much as its more familiar role in affirming consensus and social cohesion. in showing how metaphor simplified a complex reality, redefined the form and gravity of the crisis, and reshaped the meaning of healthcare workers' deaths so as to shift responsibility away from the government, it has revealed mechanisms through which culture (in the form of figurative expression) is able to directly impinge on political process. in showing how flattery can operate as a kind of hailing, it has shown how expressions of praise and gratitude can function as a mode of interpellative power, similarly capable of shifting responsibilities. finally, in charting the progression of the crisis through the stages of a secular ritual process, it has not only shown how anthropological theories of ritual can be productively interwoven with literary theories of narrative to provide hermeneutic forms of explanation, but has also shed light on the meaning work that lies behind how crises are triggered, how they are elevated to dramatic heights, and how they are lowered back down again. though the focus here has been on the diachronic evolution of a single case, future research in this vein would benefit from taking a comparative multi-case approach. this would enable tracing the impact of meaning-making processes synchronically across national contexts, showing how differences in governmental sense-making shaped divergent public health policies in ways that resulted in differences in behaviour, and infection and death rates. studying the c19 pandemic in this way is particularly promising for the further demonstration of culture's relative autonomy in that unlike in many other cases of sociological interest, one of the key variables to be monitored is the behaviour of an indifferent pathogen, rather than that of reflexive human beings, capable of their own internalising, interpreting, and performing processes. this ability to bypass what giddens (1987) called the 'double hermeneutic', in other words, bolsters the possibility of specifying more direct mechanisms of the causal impacts of culture. turner's fourfold schema of the passage of a social drama concludes with either 'reintegration', typically involving some change in the social structure into which that reintegration takes place, or else schismogenesis-the initiation of a permanent 'breach between contesting parties ' (1980, p. 151) . reintegration might be said to have occurred if and when the virus has become an accepted part of everyday life in the uk and considered something like seasonal flu, perhaps through the development of more successful means of treating its symptoms, and the emergence of a shared consensus on reading it in low mimetic quotidian terms. alternatively, a conclusion signalling schism might arise if and when the virus is somehow overcome and separated from the field of view as a present threat, perhaps through a successful vaccination programme leading to a critical mass of immunity within the population. another event around which schism may arise is the ritual management of political sanction-through ballot or public enquiry-for the government's failure to shift from a low mimetic to a tragic narrativization of events early enough and maintain its coherent projection in both rhetoric and action for long enough, or in response to some mismanaged future second wave. a complete manifestation of any these outcomes is clearly not yet present, though aspects of all remain latent and virtual possibilities. another conclusive possibility is also worth noting. turner emphasises that 'during attempts to redress conflict', '[n]ew norms and rules may have been generated… old rules will have fallen into disrepute and have been abrogated ' (1974, p. 42) . if this social drama follows the pattern of many others before it, the social disruption brought about by the anti-structural lockdown period of redress may lead to a makeover of social relations. though lockdown experiences have been highly variable, a recent poll revealed that only 9% of the uk public want things to return to normal after lockdown ends (yougov 2020a). sanguine voices have speculated that the war metaphors that gave figurative expression to the height of the redressive period might be mobilised towards demands for a more egalitarian social dispensation in the uk, such as occurred following wwii (bakewell 2020) . turner saw the interim liminal or liminoid periods in social life as a wellspring of social 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in the production of this article. key: cord-293893-ibca88xu authors: xie, tian; wei, yao-yao; chen, wei-fan; huang, hai-nan title: parallel evolution and response decision method for public sentiment based on system dynamics date: 2020-05-23 journal: eur j oper res doi: 10.1016/j.ejor.2020.05.025 sha: doc_id: 293893 cord_uid: ibca88xu abstract governments face difficulties in policy making in many areas such as health, food safety, and large-scale projects where public perceptions can be misplaced. for example, the adoption of the mmr vaccine has been opposed due to the publicity indicating an erroneous link between the vaccine and autism. this research proposes the “parallel evolution and response decision framework for public sentiments” as a real-time decision-making method to simulate and control the public sentiment evolution mechanisms. this framework is based on the theories of parallel control and management (pcm) and system dynamics (sd) and includes four iterative steps: namely, sd modelling, simulating, optimizing, and controlling. a concrete case of an anti-nuclear mass incident that sparked public sentiment in china is introduced as a study sample to test the effectiveness of the proposed method. in addition, the results indicate the effects by adjusting the key control variables of response strategies. these variables include response time, response capacity, and transparency of the government regarding public sentiment. furthermore, the advantages and disadvantages of the proposed method will be analyzed to determine how it can be used by policy makers in predicting public opinion and offering effective response strategies. social networking services (sns) such as microblog and wechat have become the most prominent carriers and tools for disseminating public sentiment. public sentiment reflects the ideas, attitudes, opinions and emotions that people express on certain noticed issues. positive public sentiment is often a necessary prerequisite for political action, and vice versa; negative public sentiment may become a major obstacle for a correct decision (burstein, 2010) . in this situation, public sentiment plays an increasingly important role in policy making processes in many areas such as public health, food safety, and large-scale projects where public perceptions can be misplaced (jiang, lin, & qiang, 2016) . typical examples include incidents like "the adoption of the mmr vaccine has been opposed due to the publicity indicating an erroneous link between the vaccine and autism" (godlee, 2011) , "china's milk powder industry had seriously declined due to the public sentiment of the sanlu milk powder incident" (chen, 2009) , "5g mobile phone masts have been vandalised caused by a false link with the coronavirus", and "nuclear fuel processing project has been cancelled because of an anti-nuclear public sentiment in guangdong province of china" (weiwei li; . lacking relevant popular science knowledge, most people never say 'yes' to any large-scale project or product involved in a public sentiment. in addition, as long as the projects are planned or "fears" are turned into "crisis," negative public sentiment will be sparked immediately (xiong, liu, & cheng, 2017; lee and chun 2016) . worse yet, if public sentiment is not guided and controlled in time, its effects will spread from the virtual network to the physical world and cause further secondary disasters, such as mass incidents. the interdisciplinary online-offline effects which make the situation more complex and uncertain, acutely threaten social stability and national economic development. there have been significant studies of public sentiment triggered by different incidents. in the public health areas, several epidemiologic studies found that mmr vaccine was not associated with an increased risk of autism even among high-risk children whose older siblings had autism. despite strong evidence of its safety, some parents are still hesitant to accept mmr vaccination of their children due to the fake scientific report and news (destefano & shimabukuro, 2019) . to characterise and evaluate the dissemination of information to the community during a suspected tb outbreak, a model of effective information dissemination in a crisis was developed through a study of information dissemination during the incident (duggan, 2004) . in the food safety area, lyu identified and compared the crisis communication strategies that organizations used to respond to a congenetic melamine-tainted milk crisis and public opinion in two chinese societies (i.e., mainland china and taiwan) and found that sanlu (a mainland china-based organization) and kingcar (a taiwan-based organization) demonstrated inverse pattern of the strategy adoption (lyu, 2012) . in the large-scale project area, jeong used situational communication crisis communication theory and attribution theory to explain the public's responses to a corporation that caused an oil spill accident (jeong, 2009 ). sun investigated nuclear power in china from the perspectives of electricity preference and social perceptions and assessed the public willingness-to-pay (wtp) to prevent a local nuclear power plant. research results indicate that the chinese pay most attention to the development of nuclear energy when they are worried about nuclear accidents (sun, zhu, & meng, 2016) . following the anti-nuclear event in jiangmen in guangdong province, china, li analyzed the causes and characteristics of nuclear public sentiment in depth and presented some relevant measures for preventing negative public sentiment in the era of new media (weiwei li; . above all, most relevant studies include some significant ideas for our purposes. however, existing research methods are mainly qualitative rather than quantitative and post-mortem analysis rather than real-time decision-making. two bottlenecks, a lack of prior knowledge and the dynamic of public sentiment evolution, have caused this situation. on the one hand, the original events (large-scale projects, major incidents or scandals) which trigger the relevant public sentiments occur with low frequency, and the triggered public sentiments are diverse and non-duplicated. thus, the key parameters (such as "posting rate of microblog") of prior knowledge (such as decision models and data) for describing or predicting the scenarios of public sentiment systems are difficult to obtain in time. on the other hand, interdisciplinary and dynamic original events lead to the features of feedback, nonlinearity and instability of the relevant public sentiment systems. this also means that the key parameters of the decision models are adjusted over time. therefore, it is more difficult for policy makers to build a quantitative evolutionary model and make an effective response decision based only on previous decision methods. 1.2 insightful lessons from the perspectives of system dynamics (sd) and parallel control and management (pcm). 1.2.1 lesson from the perspective of sd modelling. the sd research method focuses on system structure and simultaneously takes selectivity (decision-making processes based on information), self-discipline (multi-feedback processes) and non-linearity (time delay) into account (torres, kunc, and o'brien 2017; rashwan, abo-hamad, and arisha 2015) . it is a perspective and set of conceptual tools that helps us to learn about the structure and dynamics of complex systems. additionally, the rigorous modeling method of sd enables us to build formal computer simulations of complex systems and use them to design more effective policies and organizations (john sterman, 2000) . several scholars have used sd models to study the diffusion mechanism of different complex systems, which are helpful for us to develop insightful lessons. the sd methodology is used to develop some increasingly complex models to investigate the process of innovation diffusion and enhance insight in the problem structure and increase understanding of the complexity and the dynamics caused by the influencing elements (maier, 1998) . a diffusion model is employed to extend commonly used epidemic models in the study on analyzing dynamics of intra-organizational innovation implementation processes. the sd modelling and simulation results of this study provides structural explanations and offers insights into why, given various intra-organizational networks, management policies can make different results on whether and how innovations are adopted in an organization (wunderlich, größler, zimmermann, & vennix, 2014) . furthermore, by applying system dynamics, yu proposed a simulation model to study the public sentiment diffusion mechanism in dangerous chemical pollution water emergencies and discover effective response strategies (yu le-an et al. 2015) . his research shows that the sd modelling methods are useful for describing, understanding and simulating the complex public sentiment diffusion systems and for making relevant optimization policies. more importantly, compared with decision-making theories based on large amounts of historical data, sd has the advantage of being able to predict the future based only on system structure. therefore, when one lacks historical data, most complex social systems can be described and analysed using sd method (morgan, howick, & belton, 2017 ). public sentiment system is no exception. to solve the first bottleneck (lack of prior knowledge), the structure of the public sentiment system can also be represented by multi-feedback relationships, and its system functions can be achieved and controlled by sd method. moreover, by now many mature statistical technologies, such as regression analysis, are available to help decision-makers obtain key parameters and build sd simulation models to respond to possible disasters and social crises. 1.2.2 lesson from the perspective of pcm theory. with the advent and development of cloud computing and the internet of things (iot), the capacities of perception, computing, storage, transmitting and analysing have been greatly improved. in this era of new information and communication technology (ict), artificial society and pcm theory have been proposed by the chinese academy of sciences and the national university of defense technology to provide an available decision-making paradigm to respond to the dynamically evolutionary scenarios of interdisciplinary disasters and social crises. this theory uses multi-agents modelling and simulation technology to build an artificial social system equivalent to the real system. by simulation computing in the artificial system, decision-makers are able to recognize the evolutionary mechanisms of disaster scenarios. moreover, by comparatively analysing the artificial and the real systems, the simulation model of the artificial system is modified to parallel the actual situation in real time. lastly, with the knowledge obtained from the simulation results, the evolutionary processes of disasters can be controlled and optimized by making the appropriate decisions in time (f. wang, 2010) . inspired by pcm theory, the public sentiment system, a type of crisis system, can be considered a real system carrying public attitudes and opinions. thus, the second bottleneck (dynamic of public sentiment evolution) may be resolved based on both pcm theory and sd method. after building and running the artificial sd simulation system parallel with the public sentiment system, evolutionary scenarios can be predicted and effective response policies can be provided by decision-makers. therefore, a novel decision-making method "parallel evolution and response decision framework for public sentiment (perdfps)" based on the theories of pcm and sd is proposed as a specific contribution of this paper. this method is structure-dependent rather than data-dependent and can be implemented in real-time, which makes it helpful to simulate, analyze and guide the evolution processes of dynamic public sentiment in the case of lack of historical knowledge on less-frequently occurring original events. the paper is organized as follows for achieving the contribution. section 2 proposes the perdfps framework. and section "3 methodology" is developed to abstract and present the perdfps methodology with a roadmap (table 1) helping decision makers effectively use the novel method. furthermore, the section "4 empirical research" shows a whole case study to deduce the principle and verify the effectiveness of the perdfps method using the anti-nuclear mass incident in jiangmen, china. lastly, theoretical discussions, the limitations and future studies are presented in section 5. dynamics. pcm theory holds that social mass incidents are essentially unpredictable. however, one can now build artificial societies parallel to real-world societies and deduce their evolution in a computational experimental environment. in addition, with dynamic and real-time data, decision-makers are able to perceive coming disaster scenarios and response demand using artificial simulation models and create effective and timely coping strategies, policies and response solutions to control the real situations (f. wang, 2010) . therefore, the "parallel evolution and response decision framework for public sentiment (perdfps)" is proposed as a guideline for achieving this function. moreover, within this framework (fig. 1) , according to the "scenario-response"-based emergency management paradigm (bañuls, turoff, & roxanne, 2013) , the public sentiment system (pss) can be divided into two subsystems: the real scenario system (rss) and the simulation decision-making system (sds). as the source of real-time information, real scenarios are the basis for decision-making as well as the targets of public sentiment control. the original events, sentiment disseminators and sentiment regulators are the essential elements of the real scenario system. the original events (such as public health emergencies, food safety scandals and large-scale projects) may easily trigger relevant public sentiment. public sentiment disseminators include the media, netizens, and others. the media triggers and influences the processes of public sentiment propagation through reporting and directing the news. in addition, netizens use social networks to express and communicate their own opinions, which results in the continued diffusion and evolution of public sentiments. because the collective behaviours of the netizens comprehensively reflect their attitudes towards source events, their support or opposition are essential factors for the government in making an efficient response decision. generally, the government response departments dealing with the emergencies or large-scale projects assume the greatest responsibilities as public sentiment regulators. by taking measures such as holding lectures and seminars, press conferences on the events, and by releasing positive news, they supervise, guide and even control the development of the public sentiments. based on pcm theory, the simulation decision-making system is a closed-loop functional circuit consisting of four steps: sd modelling, simulating, decision-making and parallel controlling. in the first step, using real-time perception (which includes the processes of information collecting, analysing and abstracting), the characteristic elements of the public sentiment system, including source events, sentiment disseminators and sentiment regulators, can be extracted from real scenarios. based on the sd method, the causal loop diagram model is suitable for describing the relationships between the elements of public sentiment systems. in addition, after setting the parameters and calculating rules, the stock flow diagram model, which is based on the qualitative causal loop diagram model, can be built to describe the dynamic system structure and simulate its functional mechanism quantitatively. in the second step, simulation results of public sentiment diffusion and evolution at a future time can be obtained by importing real-time status data perceived from real scenarios into the stock flow diagram model and running it. next, to keep simulation models consistently parallel with real scenarios, decision-makers should dynamically adjust the parameters and structures of the stock flow diagram models by observing and analysing the running effect of models and the real-time status of the scenarios. in this way, the validity and reliability of the simulation results of the sd stock flow diagram model can be gradually improved. in the last step, given a reliable sd model, different response strategies or policies can be tested, verified and optimized in the simulated environment. roadmap is useful for decision makers to know when and how to use a modelling and simulation method for dealing with practical problems (davis, eisenhardt, & bingham, 2007) . for implementing the perdfnps method, we develop a roadmap that describes the principles and steps shown in table 1 ( thompson, howick, & belton, 2016) . no matter how the perdfnps method is carried out, the steps do not occur in neat sequence. specifically, the steps of sd modelling and parallel controlling constitute an iterative process for cultivating a rational decision model. table 1 roadmap for implementing the perdfnps method. step description  identify the type of the decision problem: the sentiment triggered by a periodic heated topic with enough investigable historical data or by an unconventional heated topic?  selecting the relevant decision methods, data-dependent or structuredependent?  reality hypotheses of the model: the simulation results of the model are consistent with the real scenarios.  validity hypotheses of the response strategies: testable relationships between the response strategies and the controllable degree of public sentiments.  analysis of real scenario system from perspectives of structure.  causal loop diagram modelling: abstracting the elements and the causal relationships between them from the scenario system; defining the circular causality loops of relevant modules of system.  stock flow diagram modelling: selecting levels, selecting rates and describing their determinants; selection of parameter values. simulating 3.4 parallel controlling  reality testing: contrasting the simulation results to verify the reality hypotheses of the model.  model improving: to achieve the rationality and consistency of the model.  response strategies setting.  response strategies testing: simulation and discussion of strategy effects for verifying the proposed validity hypotheses. 3.1 identify the decision problem. as a structure-dependent decision-making method, the perdfnps framework is applicable for response to the public sentiments without enough historical data. therefore, in the implementation stage, the decision makers must firstly determine what type of decision problem it is: is there enough historical data for building a model for this event? or is the perdfnps method suitable for the decision problem? if public sentiment is triggered by a periodic heated topic with enough investigable historical data, the decision-making model can be constructed based on the data-dependent statistical methods. for example, the training data used for cultivating the model of its public sentiment system for the presidential election every four years, can be obtained from the social network services including twitter, facebook (h. wang, can, kazemzadeh, bar, & narayanan, 2012) . conversely, if the public sentiment is triggered by an unconventional or non-periodic heated topic such as a nuclear-related event without sufficient investigable historical data, the sd simulation model can be cultivated to describe and solve these kinds of problems based on the structure-dependent perdfnps methods. two kinds of hypotheses are proposed for the perdfnps method according to the requirements of simulation reality and decision validity. (1) dynamic simulation reality hypotheses: hypothesis 1, the simulation results of the cultivated sd model are rational and consistent with the real scenarios. the rationality of the cultivated sd model and the consistency between its simulation results and the real evolution trends of the public sentiment are essential to achieve scenario rehearsal and response effectively in the decision-making processes (thompson et al., 2016) . thus, we firstly present hypothesis 1. then, we begin to cultivate our sd model and verify the hypothesis for a specific case through comparison between the real scenarios and the simulation results (section 4.3). of course, the rational initial general sd model is very important because it determines the efficiency for reality improvement of the descendant models. the best method for verifying the dynamic reality of a simulation model is testing the consistency between its simulation results and the real evolution trends in a real-time case. however, it is difficult to achieve this process in our empirical research. therefore, the special hypothesis 2 for the subsequent section of empirical research is proposed. hypothesis 2, information of the past scenario of the public sentiment, is unknown but can be gradually revealed through evolutionary process. the goals of the empirical research are to verify whether a reliable simulation model that parallels the real public sentiment scenario can be developed and whether the response strategies based on the validity hypotheses can be optimized. for comparing the simulation results with the real-time scenarios, we assume that the data of the scenario is unknown but will be gradually revealed through evolutionary process in the experiment. the public sentiment event is considered a real-time scenario to verify the rationality and consistency of the parallel simulation models to be cultivated. hypothesis 1 and 2 can be validated by reality testing (section 3.4). (2) decision validity hypotheses the public sentiment system is a complex social network system. the various decision response behaviours of government drive the evolutions and diffusions of public sentiments and ultimately decide the results of the original events through affecting the attitudes of people. therefore, four testable decision validity hypotheses are proposed to explore the effective response strategies for guiding the evolution of the public sentiment with the perdfps method. firstly, the government's response measures, including social stability risk assessment, answering questions from the public, giving lectures on the original event-related knowledge and so on, is significant for guiding the evolution processes of the public sentiment events. higher degree of government response results in a more controllable public attitude to the public sentiment event (zhang, qi, ma, & fang, 2010) . the amount of times the government responds to an event can reflect the degree of government response. therefore, the relevant hypothesis 3 is proposed as follows. hypothesis 3 is that, firstly, the more times the government responds, the more controllable the public attitude to the public sentiment event is. secondly, response time represents the time-delay in the government response processes. another important factor is controlling the evolution processes of the public sentiment events. a timely response means higher response speed which leads to a lower heat rate and a higher controllable degree of public sentiment (yu le-an, li ling, wu jia-qian, 2015) . similarly, hypothesis 4 is proposed as follows. hypothesis 4 is that a higher response speed (or short response time) of government leads to a higher controllable degree of public sentiment. furthermore, the degree of information transparency and the degree of popularity of original event-related knowledge also make significant influences to the evolution trends of the public sentiment event. the degree of information transparency represents the disclosure degree of the original event-related information, and the degree of popularity of original event-related knowledge reflects how the knowledge related to safety and risk was popularized locally. scholars analyzed the response processes of public sentiment events and believed that these two factors are positively related to the controllable degree of large scale project-related public sentiment (weiwei li; . hypotheses 5 and 6 are proposed as follows. hypothesis 5 details that a higher degree of information transparency leads to a higher controllable degree of public sentiment. hypothesis 6 is that a higher degree of popularity of original event-related knowledge leads to a higher controllable degree of public sentiment. (1) analysis of real scenario system from perspectives of structure. the sd approach emphasizes how causal relationships among system structures can influence the functions, behaviours and evolution processes of a system. analysis of the boundary and structure of a and regulations, and holding a press conference) to guide the development of original events and control the diffusion of triggered public sentiments in a timely manner. furthermore, the netizen module: original events may affect social and economic benefits, damage the ecological environment and even directly threaten our life safety. therefore, they quickly garner attention from people and trigger various public opinions or sentiments. there are both advantages and disadvantages for various people, and thus netizens are divided into three groups: opponents, supporters and neutrals. these groups express their own opinions and sentiments online and this kind of behaviour turns original events into controversial issues. in addition, the main attitudes of netizens influence and even decide the response behaviours of the relevant media and government departments, as they reflect public opinion. (2) causal loop diagram modelling the sd approach describes a system as a series of simple processes with positive and negative circular causality loops (forrester & senge, 1980; sterman 2000) . the feedback function of a positive loop is self-reinforcing and amplifying; the feedback function of a negative loop is dampening. the public sentiment systems evolve continually under the influence of the interactions between the feedbacks. based on the structure and mechanism of real scenario public sentiment system of a concrete case, the qualitative causal relationships and the circular causality loops of relevant modules can be defined. the concrete examples of this process are shown in section 4.2.1. (3) stock and flow diagram modelling causal loop diagrams aid in visualizing a system's structure and behavior, and analyzing the system qualitatively. to perform a more detailed quantitative analysis, a causal loop diagram is transformed into a stock and flow diagram. a stock and flow model helps in studying and analyzing the system in a quantitative way; such models are usually built and simulated using computer software such as vensim (rahmandada & sterman, 2012; martinez-moyano, 2012) . a stock is the term for any entity that accumulates or depletes over time. a flow is the rate of change in a stock. the key step to build the stock and flow diagram is converting the system description into level and rate equations (torres et al., 2017) . usually, the parameters and initial conditions of the equations can be estimated using statistical methods, expert opinion, market research data or other relevant sources of information (j sterman, 2001) . in a decision-making process for a non-duplicated public sentiment triggered by a major public health incident or a large-scale project, because the decision makers lack prior data and knowledge, the parameters of the initial equations of the 1-general sd model can be referenced from the developed models of historical cases which are similar with the current event in type, system structure and situation. by analyzing and refitting the real-time data gradually collected from the real scenarios, the parameters are modified and the equations are improved. to achieve the target of public sentiment simulation and control, the variables of the stock and flow model are classified into two categories, including state and control variables. the latter is classified into two subcategories, including parallel cultivating control and decision-making control variables. each kind of variable has relevant functions in the model. according to the literature (rahmandada & sterman, 2012) , the variables of the constructed sd model should meet the minimum and preferred reporting requirements for research reproducibility, communication and transparency. appendix 1 shows an example of a constructed and defined sd model of all variables and their equations. model library scenario 0 simulaiton decisionmaking system non-duplicated source events trigger diverse public sentiments and lead to a lack of prior knowledge (the parameters to describe or calculate the key variables) in order to make an effective response decision. in addition, even if we obtain some experience from the public sentiment triggered by a similar original event, due to their various spaces, locations and social environments, the evolution processes of the public sentiments are too different to build a simulation and decision model in one step using the most traditional methods. thus, in this paper, we use pcm theory to cultivate the sd simulation models dynamically and to keep the models parallel with real public sentiment systems in order to obtain accurate simulation results and reliable response solutions (f. wang, 2010) . the parallel controlling principles are shown in figure 2 . (1) 1-generation sd model constructing. the parallel simulation decision-making system enters into the emergence response state immediately after "scenario 0" of a new original event occurs. at this point, decision-makers should decide whether this event has ever occurred using a semantic searching and matching in an existing model library (wu et al., 2017) . if there is a public sentiment scenario very similar to the current scenario through the perspectives of event type and system structure, the relevant simulation model of the scenario is chosen as the initial model "1-generation sd model." however, there are usually no extremely similar scenarios for a non-duplicated public sentiment event. in that situation, the parameters of the initial equations of the 1-generation sd model can refer to the developed models of historical cases which are similar with the current event in type, system structure and situation. regarding the historical cases, it is very difficult to find the most similar one in an emergency situation. we can still improve and cultivate our models iteratively by adjusting them in parallel with the real-time scenarios even if the selected historical case is not identical to the current public sentiment event. of course, the more similar a selected historical case is, the less iteration there will be, so the improved decision-making model will be obtained quickly. (2) reality testing. we can validate hypothesis 1 and 2 by rationality and consistency testing. the rationality and consistency between the models and real public sentiment systems should be discussed by (wooldridge, 2006) . (3) model improving. by analyzing and refitting real-time data gradually collected from real scenarios, the parameters are modified and the equations are improved. in the entire parallel controlling process, the real time information from the various stages of the real scenarios (from scenario 0 to scenario n) should be collected, integrated, and analyzed at a specific time-interval, "△t". at the same time, modifying processes such as parameter refitting and data updating can be used to continually improve the simulation models from "1-generation sd model" to "n-generation sd model," ensuring that simulation results are consistent with the real scenario in the parallel evolution processes. regarding the parameter fitting into the model cultivating process, we constructed the 1-generation sd model and the other n-generation sd models in different ways. take the case shown in the empirical part of this paper as an example. on the one hand, most of the equations of the 1-generation sd model based on the literatures (tian, 2011), (weiwei li; , (zhang, 2012) and (yu le-an, li ling, wu jia-qian, 2015) are obtained using parameter fitting with the data of 36 similar cases such as the "sanlu milk powder incident" from "people.com." on the other hand, for the n-general models, we do not have to fit the parameters to improve the equations. only real-time data needs to be collected to draw the curves of the key state variables such as "increment of posts" and "increment of news" during the time-interval (△t = 24 hours). after contrasting the simulation results of the n-generation model and the scenario n, the parameters of the equations are adjusted and the model is improved to approach the real scenario in an iterative and parallel way. when an n-general model and its simulation results are consistent with the real scenarios, it means that the model has passed reality testing and has become a cultivated model. optimal strategy can be obtained by adjusting the control variables. as shown in the stock and flow diagram model (fig. 6) , the interactions between these system variables drive the evolutions and diffusions of public sentiments and decide the final results of the original events, as seen through the attitudes of people. in the end, when the entire emergency response process ends, the latest parameters and structure of the simulation model are recorded and archived in the model library for the next similar public sentiment. some advanced sd software tools, such as vensim, stella and anylogic, are available to help decision-makers construct, run and analyse the sd simulation models of the public sentiment systems and to create the optimized response policies and solutions in a graphic and visual way (rahmandada & sterman, 2012) . according to the evolutionary cycle and system boundary of the specific public sentiment system, and after setting the main calculating parameters such as simulation step size and run time, the simulation process can be implemented. to propose suitable response solutions, the relevant decision analysing process should include two aspects: (1) response strategies setting. the control variables can be tentatively set by the decision makers to represent different response strategies. however, most of the variables, especially state variables, are uncontrollable from the perspective of government. next, taking the public sentiment of anti-nuclear mass incident as an example (section 4) and according to the "validity hypotheses of the response strategies" table 4 . the r0 strategy is the baseline strategy extracted from this real case; the other response strategies, including a1~a4, b1~b4, c1~c4, d1~d4 and e, are set with different specific values of the key control variables, respectively. (2) response strategies testing. the effects of different strategies can then be tested by reviewing the simulation results with the cultivated n-general sd model. policy-makers would be able to control the system state variables and create an effective and optimized response strategy to guide the public sentiments by adjusting or resetting the values of the four key controllable variables in the sd simulation models. some practical measures, such as enhancing the credibility and degree of information transparency of government, are available to improve the control performances of public sentiments. however, increasing these variable values always brings higher response times or costs. thus, balanced considerations should be included in the decision-making processes. 4.1 case analysis (including "indentify the decision problem" and "research hypotheses") in this section, the anti-nuclear mass incident sparked by a nuclear fuel processing base project near jiangmen city in guangdong province is taken as a case study to verify the feasibility and validity of the perdfps method proposed in section 3 above. the announcement of the result of the social stability risk assessment of the nuclear project is considered the source event of the media module of this public sentiment system. in addition, by choosing and analyzing the increment data of baidu news and xinlang blog posts (fig. 3) during july 5-19, 2013, and the relevant government response measures (table 2 ), the key parameters of the initial stock flow diagram model and the initial data of the simulation process of public sentiment evolution can be extracted gradually. due to the actual evolution cycle of public sentiment lasting only 15 days, it is too short to prepare enough data and develop a reasonable simulation trend. the simulation model is thus set for running 12 hours per day. therefore, the simulation cycle is translated or expanded from 15 days to 240 hours. the main data used in this paper is collected from references and websites (weiwei li; cnsa, 2015) . moreover, some variables or parameters of the model should be adjusted according to the demand of the actual simulation experiment. for example, some unstructured behaviour data, such as government response behaviours, should be ranked into the qualified and controllable variables quantity of government response or increment of government response. note that the data shown in figure 8 are considered unknown information at the beginning of the simulation experiment and will be revealed gradually during the simulation processes. in fact, this primary data is used to verify the reality and validity of our parallel simulation model by describing the real scenarios and comparing them with the artificial ones. therefore, the decision problem of this case is structure-dependent and can be described and solved with the perdfnps method based on the 6 hypotheses proposed in section 3. the jiangmen government released the report of the social stability risk assessment of the nuclear project. the deputy general manager answered questions from the public. 8 th three lectures on nuclear knowledge are given by the jiangmen government. 9 th professor zhou participates in the propaganda lectures on nuclear knowledge, telling the public that the project is safe. 12 th announcement of the determination of the nuclear project is delayed for ten days. the nuclear project is terminated by the government. 4.2 1-genernal sd modelling. plans by the china national nuclear corporation (cnnc) to build a nuclear fuel-processing base near public sentiment in that city. taking this anti-nuclear mass incident as a concrete case, we can analyze the boundary, structure and evolution mechanism of the public sentiment system of this event and build a relevant qualitative causal loop diagram model. this model is divided into three main modules: the media module, the netizen module and the government module. (1) the causal loop diagram of the media module is a positive feedback loop r1 (fig. 4) . once the nuclear event does occur, the relevant news is released on an ongoing basis. in addition, as the event evolves, the quantity of news and the participation degree of media both increase. at the same time, due to media influence, the increased participation degree of media always leads to a higher rate of public sentiment and results in more news increments. the evolution processes of the nuclear public sentiment system are driven by a multi-feedback mechanism, which leads to some delays in the propagation and response processes. thus, the nuclear public sentiment system should be described as a number of nonlinear and multi-feedback relationships, such as the exponential dependence relationship between interactive system variables such as increment of government response, increment of posts and news increment. taking the incident of "anti-nuclear public sentiment in jiangmen city, guangdong province" as an example, and according to the main causal loops in section 3.1, the sd stock flow diagram model of the nuclear public sentiment system is shown in figure 7 . (1) stock flow diagram model of the media module. because the source event doesn't last long, the variable increase rate of news can be defined as a lookup or fitted function and described directly according to the captured short-term history data. the variable quantity of news is influenced by the variable heat rate of public sentiment, which is constrained by the variables participation degree of government, participation degree of media and participation degree of netizens. referring to the evolution mechanism of public sentiment (yu le-an, li ling, wu jia-qian 2015; zhang 2012), the functional relationships of the variables can be defined respectively as the formulas (1-4). in these formulas, we assume that there is no delay in the transmission processes of baidu news, and the variable type of source event is boolean (its value equals 1 if the source event is trigged). (2) stock flow diagram model of the netizen module. the posting reaction of the netizens after receiving news information causes a time-delay effect and the variable increment of posts is also influenced by the variable heat rate of public sentiment. the variable increase rate of posts can be defined as a lookup or fitted function and described directly according to the captured short-term history data. the function of increment of posts is then constructed as a formula (5). referring to the evolution mechanism of public sentiment ( figure 8 . at the beginning of the simulation, we lack sufficient data to fit certain parameters of the 1-generation model. the variables "increase rate of posts" and "increase rate of news" are defined temporarily as formulas (22) and (29) (in the appendix) by collecting and polynomial fitting the 240 hours of data (from july 15 th to august 3 rd ) of the similar public sentiment triggered by the changsheng vaccine event from ef.zhiweidata.com (figure 8 -①), because these two events have the similar "happening, developing, declining, and extinction" life cycle. 2) 1-generation model testing and improving. in the parallel iteration processes, the time-interval for improving the models is set as "△t = 24 hours." we constructed the improved n-generation formulas based on the "minimum sum of squared errors" algorithm with the real data during n△t, and we tested the reality of the model based on "goodness-of-fit formula" with the real data during (n+1)△t. considering the scenario during the 48 th hour as scenario 1 (testing period of 1-generation model t testing-1 = 2△t), assume that the real scenario evolves under the combined influences of the media, netizens, and government. after importing the initial data of the first hour of this case and simulating it for 48 steps (hours), the evolutionary trends of the variables "increment of posts" and "increment of news" can be drawn into figure 8 -②. the simulated time series (orange curves) are both obviously too steep to match the real situations (blue curves). the model reality is tested by calculating the goodness-of-fits ( , gof∈ (-∞, 1] ) between the real time series and the simulated time series of the key state variables. in this formula, y is the observed posts/news increment value, y * is the simulated value (wooldridge, 2006) . we use "gof dp " and "gof dn " to indicate the gof of the "increment of posts" and "increment of news" by the day respectively. after programming and calculating, gof dp and gof dn are -1276.29 and -24726.47 respectively. therefore, the simulation results show that the "1-generation model" is very different from scenario 1 during t testing-1 . to ensure that the simulation results are consistent with real scenarios, we developed a "minimum sum of squared errors" algorithm to improve the models. with this algorithm, each polynomial coefficient of (n-1)-generation "increase rate of posts" and "increase rate of news" formulas is traversed within a certain range, and the sum of squared errors between the observed real value series and the simulated value series is calculated for different coefficient combinations through multiple iterations. then, the optimal coefficient combination with the minimum sum of squared errors is selected to be the polynomial coefficients of the "increase rate of posts" and "increase rate of news" formulas of the n-generation model. after inputting the 48 hours of scenario-1 data, the 2-generation variables "increase rate of posts" and "increase rate of news" are defined as formulas (23) and (30) in the appendix (also shown in figure 8 -②). 3) 2-generation model testing and improving. considering the testing period of the 2-generation model as t testing-2 = 72h (3△t), the real scenario continues to evolve from scenario 1 to scenario 2 for 24 h(△t ). after simulating for 72h, the calculated gof values and drawn evolutionary trend curves (figure 8 -③) of the variables "increment of posts" and "increment of news" both show that the 2-generation model is much better than 1-generation model. however, gof dp and gof dn are still as low as -1.13 and -219.34 respectively, which means the 2-generation model cannot simulate the real scenario 2 during t testing-2 or help us to predict the evolutionary trend of the public sentiment. therefore, after calculating the "minimum sum of squared errors" between the observed 72 hours of scenario-1 data and the simulated value series, the optimal coefficient combination is selected as the polynomial coefficients of "increase rate of posts" and "increase rate of news" formulas of the 3-generation model shown in figure 8 -③. similarly, models are tested and improved from 3-generation to 7-generation after a set number of parallel iterations. the variables "increase rate of posts" are defined as formulas from (24) to (28) and the variables "increase rate of news" are defined from (31) to (35) in the appendix. the simulated trend curves are becoming more and more similar to the real curves, and the gof dp and gof dn of the models are increasing in the iteration processes (figure 8-④~⑧) . finally, the cultivated 7-generation model is obtained with high gof values (gof dp =0.87 and gof dn =0.89). although the simulated curves are still smoother than the real scenarios, the overall public sentiment trend is consistent with the real scenarios as shown in the stock flow diagram model (fig. 7) , the interactions among these system variables drive the evolution and diffusion of public sentiments and ultimately decide the results of the nuclear project by affecting the attitudes of the public. however, most of the variables, especially state variables, are uncontrollable from the perspective of government. next, we chose the four controllable variables, degree of popularity of nuclear knowledge, to explore the effective response strategies for guiding the evolution of the public sentiment in this event. the series of different response strategies is shown in in this table, "times of government response" represents how many times the government responds to public sentiment in an event. its initial value is 7 (times), because in this case, 7 measures were taken to respond to the nuclear-related public sentiment event by the government. we tentatively adjusted its value from 1 to 70 to present the different strategies a1-a4. the number of "response time of government response" represents the time-delay in the government response processes. its initial value is set to 2 (hours). we tentatively adjusted its value from 0.5 to 6 to represent the different strategies b1-b4. the "degree of information transparency" values represent the disclosure degree of the nuclear project-related information. its initial value is set to 0.5. we tentatively adjusted it from 0.1 to 0.9 to represent the different strategies c1-c4. the "degree of popularity of nuclear knowledge" value represents how the knowledge related to nuclear safety was popularized locally. its initial value is set at 50. the variables "degree of information transparency" and "degree of popularity of nuclear knowledge" are considered relative rather than absolute because they are hard to exactly quantify. furthermore, our research focuses on reality testing (how the evolutionary trends of the public sentiment are simulated by the parallel cultivated sd model) and response strategies testing (how the evolutionary trends of public sentiment are influenced by different strategies). this consideration is reasonable. we can simulate the public sentiment scenarios and test the effectiveness of the improved response strategies by increasing or reducing their initial values. 2) simulation and discussion of strategy effects (response strategies testing) after running the cultivated "7-generation model" with different values of control variables for 300 hours, the results indicate the corresponding effects of different strategies a1~d4 on public attitude to the nuclear project, respectively, and find the most appropriate response strategy for guiding nuclear public sentiment. the effects of the four controllable variables on public attitudes are shown in the in the two right-most columns of table 3 . (1) the separate effects of the four control variables on public attitudes compared with the baseline scenario r0, the percentages of support posts under the control of strategies a3 and a4, respectively, rose to 7.37% and 21.36%. this means that the approval rating of the nuclear project will rise only by greatly increasing the "times of government response." it is reasonable because the government is one of the project sponsors. enhancing the measures of response and disposal by means of open information, popular science propaganda, and so on is helpful for increasing the approval rating and guiding public sentiment in the right direction. this result also indicates that hypothesis 3 is tenable in this case. usually, the project approval rating increases as response speed or information transparency increases. however, the simulation results of the eight strategies from b1 to c4 show that the adjustments to the variables "response time of government" and "degree of information transparency" cause no obvious change in the public opinion. therefore, these two variables are not the most important and hypothesis 4, 5 is not entirely tenable in this case. the percentages of support posts under the control of strategies d1 and d2 are, respectively, reduced to 2.63% and 3.73% from 5.56%; in addition, the percentages of support posts under the control of strategies d3 and d4 rise to 9.22% and 20.2% respectively. this simulated result obviously indicates that a lower "degree of popularity of nuclear knowledge" by the public leads to a lower approval rating of nuclear projects. as the project was supported by government-owned corporations, this result also indicates that a higher "degree of popularity of nuclear knowledge" leads to a higher controllable degree of nuclear project-related public sentiment. professor zhou also publicly declared that "the whole nuclear fuel processing in the jiangmen base project does not relate to the nuclear fission reactions" (weiwei li; . however, due to the high threshold of nuclear technologies, it is very difficult for most people to quickly and effectively understand the safety of nuclear energy and accept nuclear projects. the blind worries regarding crises stemming from nuclear projects are one of the main reasons for triggering and spreading negative public sentiment and ultimately terminates potential projects. therefore, spreading long-term and effective popular science propaganda about nuclear safety is necessary and important for the government to accumulate and improve the local degree of popularity of nuclear knowledge and ensure project success. hypothesis 6 is therefore tenable. above all, adjusting the key control variables appropriately leads to completely different public attitudes and event results of the jiangmen anti-nuclear mass incident. in the response processes, a higher approval rating of the nuclear project can be achieved using response strategies with higher degrees of response strength, response speed, information transparency and popularity of nuclear knowledge. the variable "popularity of nuclear knowledge" has the most remarkable effects on public attitudes than the other three variables. the approval rates ahead the disapproval rates leading to the project establishment only by appropriate increase (about six times as the initial value) of the "degree of popularity of nuclear knowledge." these conclusions also indicate that only adjusting three other intermediate control variables, such as the "times of response" even up to ten times as the initial value, is still not enough to reduce the people's unreasonable fears and change the event result. the control variable "degree of popularity of nuclear knowledge" plays a decisive role in the evolution process of the public sentiment. however, it is not easy to increase the degree of popularity of nuclear knowledge in a short period of time. as an advance control variable, this indicator must be improved by education and advocacy activities for months or even years before the nuclear related public sentiment event actually occurs. (2) the effects of the flexible combination strategies on public attitudes additionally, some flexible combination strategies adjust two or more control variable values at the same time, such as strategy e with the higher "times of government response" and "degree of popularity of nuclear knowledge." these strategies are better than the strategies adjusting only one control variable value once for guiding the public sentiment. therefore, the evolution trend of the variable "quantity of support posts" impacted by the combination strategy e is compared with the trends impacted by the strategies r0, a4 and d4 respectively in figure 10 . the comparison shows that the quantity of support posts increases significantly with the strategy a4 (much more times of government response) or the strategy d4 (much higher degree of popularity of nuclear knowledge). however, it can be seen in table 3 that the percentages of support posts are still lower than percentages of support posts with the two single strategies separately in the end of simulation. however, the comparison also shows that the quantity of support posts increases much more significantly and rapidly using strategy e rather than a4 or d4. it can also be shown in figure 12 that strategy e leads to a higher percentage of support posts than percentage of opposite posts, which presents a reversed public sentiment simulation result that the approval rating is higher than disapproval rating for this nuclear-related project. therefore, the government is able to guide and control the evolution and development of public sentiments more effectively in such a scenario by using the combination strategies. taking the anti-nuclear mass incident as a case study, the parallel simulation models of public sentiment regarding the incident are constructed and improved into the final realistic model gradually and iteratively, and the 18 different strategies for responding to real scenarios are simulated with the improved model to discover the effects of the control variables on public sentiments and provide relevant policy implications. the empirical research verifies the effectiveness of the perdfps framework and shows that the methods proposed in this paper can be very useful in providing decision support for guiding and controlling public sentiments during future nuclear energy developments. traditional sd and pcm are integrated into the perdfps framework to solve the unconventional and unrepeatable public sentiment decision-making problems without any sufficient historical data in this paper. the novel approach cultivates the models to simulate real scenarios with real-time data rather than historical data in a parallel way. compared with the data-dependent "predictresponse" decision-making methods, the structure-dependent "scenarioresponse" perdfps framework has more advantages. first, the parallel evolution and response mechanisms of the public sentiment are both considered in the iterative model-improving processes to achieve the consistency between the simulation results and the real scenarios. second, in the case of a lack of historical data, the decision-making model can be constructed and cultivated gradually in the parallel-improving processes if the initial structure of the public sentiment system is describable. moreover, the effects of various response strategies can be simulated and optimized by adjusting the key control variables of the cultivated model. it would be helpful for the government to enact better policies or decisions in future public sentiment events. the parallel interactions between the real scenarios and simulation models will be truly achieved and the decision effectiveness of the perdfps framework will be completely verified in the practical evolution and response processes of the public sentiments. however, due to the limited conditions (most original events such as nuclear-related large-scale project occur rarely), it is impossible to develop a simulation experiment according to a real-time scenario of a nuclear public sentiment in this paper. this research aims to propose the basic parallel decision-making framework to help governments guide and control public sentiment. thus, the empirical research component of this paper uses the historic case of the jiangmen anti-nuclear mass incident to demonstrate and discuss the principle and effectiveness of the perdfps framework. meanwhile, in order to carry out concise empirical research, details are not completely considered as the key variables of the multi-generational parallel simulation models. therefore, in the next step, more elements, features, and other details of public sentiment systems, such as opinion leaders and their impacts on the public sentiment, should be designed and simulated to make decision-making models more realistic and effective in practical response processes. furthermore, due to the similarity of the system structures, the novel approach can be used in the public sentiment events not only in the nuclear related field but also in many other fields, such as food safety and healthcare. once events break out, the public sentiment systems can be constructed rapidly using little initial data and improved on iteratively and dynamically with real-time data. using this framework, decision makers are able to describe, rehearse and make the proper decisions to guide or control the evolution trends of the public sentiment effectively. therefore, in future studies, the perdfps framework and the relevant sd models can be extended to some other social heat incidents with similar public sentiment system structures such as "vaccination scandals" and "food-safety scandals." the percentage of support posts drops to 6% and the percentage of the opposite posts rises to 38%. the curves shown in figure 9 are consistent with the real nuclear project case that was eventually cancelled. therefore, the cultivated 7-generation model can simulate and match the evolutionary real scenarios very well. meanwhile, the simulation results also indicate that the dynamic reality hypotheses proposed in section 3.2 are tenable. references anton collaborative scenario modeling in emergency management through cross-impact public opinion, public policy, and democracy. handbook of politics: state and society in global perspective sham or shame: rethinking the china's milk powder scandal from a legal perspective emergency management typical case study report developing theory through simulation methods the mmr vaccine and autism constructing a model of effective information dissemination in a crisis tests for building confidence in system dynamics models wakefield's article linking mmr vaccine and autism was fraudulent public-opinion sentiment analysis for large hydro projects public's responses to an oil spill accident: a test of the attribution theory and situational crisis communication theory reading others' comments and public opinion poll 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public opinion baesd on system dynamics supporting strategy using system dynamics parallel control and management for intelligent transportation systems : concepts , architectures , and applications a system for real-time twitter sentiment analysis of 2012 u.s. presidential election cycle the prevention and resolution of the nuclear public opinion from the anti-nuclear demonstrations of jiangmen introductory econometrics -a modern approach an efficient wikipedia semantic matching approach to text document classification managerial influence on the diffusion of innovations within intra-organizational networks modeling and predicting opinion formation with trust propagation in online social networks emergency policy exploration for network public opinion crisis in water pollution accident by hazardous chemical leakage based on systematic dynamics research on the mechanism of public opinion on internet for unexpected emergency research on the mechanism of public opinion on internet for abnormal emergency based on the system dynamics modeling the paper is supported by national natural science foundation of china (no. 71974090); young the following etable 1 is developed to clearly explain all the variables defined in our models. the variables of the sd model are classified into two categories including state and control variables. and the latter is classified into two subcategories including parallel cultivating control and decision-making control variables. each kind of variables has relevant functions in the model. ② the parallel control variables including "increase rate of posts" and "increase rate of news" are used to cultivate the n-general sd model. the key state variable "increment of posts" is directly decided by the real-time state variables "heat rate of public sentiment", "reaction time of netizens" and the parallel control variable "increase rate of posts". as shown in the rewritten section 4.3, the variable "increase rate of posts" of the initial 1-genernal sd model (△t=60 hours) is defined temporarily as the formula (22) by collecting and fitting the 216 hours of data (from july 17 to august 3, 2018) of similar public sentiment triggered by a similar event from ef.zhiweidata.com. and the formula (22) is finally adjusted into the formula (24) for the cultivated 3-general model (△t=180 hours) after parallel iterative cultivating.③ the decision-making control variables including "times of government response", "response time of government", "degree of information transparency" and "degree of popularity of nuclear knowledge" are controllable from the perspective of government. these variables can be tentatively set by the decision makers to represent different response strategies. and then the effects of different strategies can be tested by reviewing the simulation result with the cultivated n-general sd model and the optimal strategy can be obtained by adjusting the control variables. key: cord-343530-3fnfs2e5 authors: leung, t.y.; sharma, piyush; adithipyangkul, pattarin; hosie, peter title: gender equity and public health outcomes: the covid-19 experience date: 2020-05-21 journal: j bus res doi: 10.1016/j.jbusres.2020.05.031 sha: doc_id: 343530 cord_uid: 3fnfs2e5 this paper extends the growing research on the impact of gender equity on public health outcomes using the ongoing covid-19 pandemic as its research setting. specifically, it introduces a conceptual model incorporating the impact of gender equity and human development on women’s representation in legislature and public health expenditure, and their combined impact with human environment (population density, aging population and urban population) on important public health outcomes in the covid-19 context, including the total number of tests, diagnosed, active and critical cases, and deaths. data from 210 countries shows support for many of the hypothesized relationships in the conceptual model. the results provide useful insights about the factors that influence the representation of women in political systems around the world and its impact on public health outcomes. the authors also discuss implications for public health policy-makers to ensure efficient and effective delivery of public health services in future. the unprecedented devastation caused by the ongoing covid-19 pandemic has aroused public attention on the need for a proper public health policy (herper, 2020; king, 2020) , especially due to the disproportionately large number of infected cases and deaths in the developed countries, led by the united states, followed by spain, italy, france, germany, the united kingdom and others (worldometers, 2020) . as the debates continue to fix the responsibility for the birth and spread of this deadly virus and the lack of readiness to handle its disastrous impact (patterson, 2020; qato, 2020; smakaj, 2020) , public health experts seem to mainly view it through the lens of medicine, epidemiology, and health science disciplines. however, public health is an interdisciplinary subject that involves social sciences, public policy, public education, economics, and management (jambroes et al., 2014; tulchinsky & varavikova, 2014) . hence, a failure to have a proper public health policy may not only lead to a huge loss of human lives; it can also shatter the economy, expose the incompetence of the public bodies including the governments and political leaders, and weaken the confidence of the general public (united nation, 2020) . in this context, gender equity is recognized as an important factor to influence the quality of public healthcare systems and their outcomes (who, 2017) . although women are underrepresented in leadership positions in healthcare, their significance in other leadership positions cannot be underestimated, as evident from the growing numbers of women ceos, politicians, and heads of governments (mayer & oosthuizen, 2020) . women leaders are strong advocates for immunization programs, education and equal employment opportunities (beaman, duflo, pande, & topalova, 2012) . women senators lobbied for the breast and cervical cancer mortality prevention act in the us (lee et al., 2014) . gender equity also has positive effects on firm performance and governance (post & byron, 2015) . this paper extends the growing research on the impact of gender equity by exploring its impact on public health outcomes using the ongoing covid-19 pandemic as its research setting. the authors begin with an extensive review of the relevant literature to develop a conceptual model and specific hypotheses about the impact of gender equity and human development on women's representation in legislature and public health expenditure, and the combined impact of public health expenditure along with human environment (population density, aging population and urban population) on important public health outcomes in the covid-19 context, including the total number of tests, diagnosed, active and critical cases, and deaths. the authors use the data from 210 countries to find support for many hypotheses. the results provide useful insights about the factors that influence the representation of women in political systems around the world and its impact on public health outcomes. the authors also discuss implications for public health policy-makers to ensure efficient and effective delivery of public health services in future. public health winslow (1920; p. 30) defines public health as "the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health". in other words, public health is not just about medical science of epidemiology, diagnosis, and cure, and it is also linked to social science, which includes politics, management, welfare, and public policy. past research shows significant psychological and cognitive differences in personality, values, and concerns between women and men. for example, women tend to be more cautious (lundeberg, fox, & punćochaŕ, 1994) , risk-averse (agnew, anderson, gerlach, & szykman, 2008; byrnes, miller, & schafer, 1999) , and fatalistic (pandey & jain, 2017 ) than men. women put more emphasis on risk attributes (e.g., possibility of loss) in investment decisions than men (olsen & cox, 2001) and perceive more risk in traffic and environmental hazards (dejoy, 1992; fllyn, sloic, & mertz, 1994) . besides being risk averse, women are also loss averse (brooks & zank, 2005) . in addition, there is a difference in risk-taking behavior between female and make leaders for the decisions making for themselves and their groups. ertac and gurdal (2012) show male leaders take more risk for the decisions made for their own and the groups than male non-leaders. on the contrary, female leaders take less risk on behalf of a group which is lower than that taken individually. these differences in overconfidence and risk aversion levels between females and males make females to be more cautious and take less risk in making decisions. hence, the authors hypothesize as follows: h1. gender equity has a positive effect on, a) representation of women in legislature, and b) public health expenditure. past research shows that public health outcomes are influenced by indicators of human development, such as education (ross & wu, 1995) , employment, income disparity etc. because these variables impact the access to public health infrastructure and general health of populations. human development is related to health condition. education level and economic condition are factors influencing health status. the well-educated are less likely to have economic hardship. they also have a greater sense of healthiness and healthier behaviors such as less/no smoking, more physical exercise, and medical check-ups to improve their health. the wealthier people with higher income have greater purchasing power for healthier lifestyle (healthy food, better nutrition, more protected medical insurance). ross and wu (1995) find education level has positive effect on health through work and economic condition, social-psychological resources, and health lifestyle. hence, . human development has a positive effect on, a) representation of women in legislature, and b) public health expenditure. representation of women in legislature has a positive effect on public health expenditure. at the time of writing this paper, more than 4.2 million cases of covid-19 have been diagnosed worldwide, with about two-third of these cases still active and about 290,000 deaths (worldometers, 2020) . most recent studies examine these outcomes from a medical or therapeutic perspective (e.g., murthy, gomersall, & fowler, 2020) despite much debate in media on the role of public policy makers, politicians, and general public in the spread of this virus. past research shows a positive link between public health expenditure and its outcomes (kim & lane, 2013) , such as infant mortality and life expectancy rates (nixon & ulmann, 2006 h4. public health expenditure has a positive effect on the total number of covid-19 a) tests, b) diagnosed, c) active, and d) critical cases, and e) a negative effect on the number of deaths. human environment, which consists of elements such as population density, urbanization, and age structure, is a major factor influencing public health. world health organization reports the negative impact of high population density and urbanization on mental and physical health (who, 2020a, b) . rapid urbanization in most countries in the last few decades has led to inadequate housing, congested public transport, poor hygiene, and high pollution level (air, water, and noise), which results in physical and mental health problems (who, 2020b) . in fact, infectious diseases and epidemics (e.g., tuberculosis, pneumonia) are also more likely to happen in densely populated and urban areas (who, 2020a, b). as higher population density is expected to lead to more active transport, more perceived stress and smoking, it has negative effects on mortality (beenackers, groeniger, kamphuis, & van lenthe, 2018) and health conditions (greiner, li, kawachi, hunt, & ahluwalia, 2004) . similarly, age structure of a population affects the social (e.g., social protection), economic (e.g., labor force), and health (e.g., healthcare for elderly) systems and policies of a country. the functioning of the immune system declines with age, which influences the physical strength of the elderly to respond to infection. there is a negative relationship between physical health condition and age (ma et al., 2009; sun et al., 2011) . hence, as follows: between the predictor and outcome variables helps eliminate any concerns about endogeneity or reverse causality (mertens, pugliese, & recker, 2017) . moreover, all the measures are either indices or ratios, to avoid confounds due to any other between-country differences. the authors use path analysis with smartpls 3.0 to test all the hypotheses because they have a relatively small sample (n=210) of secondary data with many ratios and other artifacts that may not be normally distributed and their conceptual model is quite complex with many construct and relationships (hair, risher, sarstedt, & ringle, 2019) . all the vif (variance inflation factor) values are less than the recommended cut-off value of three, hence multicollinearity is not a concern (hair et al., 2019). next, r-square values are high for many outcome variables (e.g., number of tests = 0.13, diagnosed cases = 0.28, and deaths = 0.45), hence the model explains a significant proportion of variance in these variables. high values of the blindfolding-based cross-validated redundancy measure q 2 also confirm the predictive accuracy of the pls path model (hair et al., 2019) . finally, a low srmr (0.054) and high nfi (0.86) also show a good model-fit in view of the many missing values in the dataset. table 2 shows the correlations and descriptive statistics for all the variables and table 3 reports health experts argue that women should be involved in all stages of public health management, including planning, decision-making, and emergency response systems, moreover, the lack of any significant impact of public health expenditure on the number of tests or deaths may indicate possible mismanagement of public health systems due to unclear policies and priorities in many countries during this crisis, which has already led to calls for improvement in future (patterson, 2020; qato, 2020) . both aging population and urban population have significant positive effects on the number of tests but only urban population has a positive effect on the number of deaths, which is not surprising as these two population segments have been the worst hit by the covid-19 outbreak so far (keil, connolly, & ali, 2020) . interestingly, population density has no impact on the number of tests or deaths, which suggests some biases in the way these tests are being conducted and the deaths are being reported (kwiatkowski & nadolny, 2020) . there is growing evidence that the covid-19 crisis impacts men and women in different ways, including healthcare workers, patients, their family members and the society at large; and therefore, the measures to address this crisis and its outcomes should take these gender differences into account (linde & gonzalez, 2020; papp, & hersh, 2020) . for example, women tend to be more vulnerable at home and in the workplace, due to which they are more likely to suffer the economic impact of covid-19 crisis (linde & gonzalez, 2020) . moreover, women comprise 70% of the global healthcare workforce and their experiences during the covid-19 pandemic are significantly different to those of their male counterparts, especially due to the unique risks and vulnerabilities faced by women due to "deep-rooted inequalities and traditional gender roles" (papp & hersh, 2020) . therefore, public health agencies and policy makers need to look at the covid-19 pandemic through a gender lens in order to identify and implement the most effective policy responses. all the issues identified in this paper, such as under-representation of women in leadership positions, possible mismanagement of public health systems and inconsistent or incorrect reporting of the public health outcomes in this context, need to be addressed not only for a quick economic recovery in the aftermath of this covid-19 crisis but to also prevent and manage such disasters in future. clearly, covid-19 has revealed the vulnerabilities of the modern civilization and economic systems, wherein the so-called developed countries account for most of the diagnosed cases and deaths, although it is still early days and we need to wait to see its impact on the less developed countries in asia, africa and latin america, before we can make a full assessment and recommendations, especially about the role of gender equity in managing this crisis. who chooses annuities? an experimental investigation of the role of gender, framing, and defaults female leadership raises aspirations and educational attainment for girls: a policy experiment in india urban population density and mortality in a compact dutch city: 23-year follow-up of the dutch globe study loss averse behavior gender differences in risk taking: a meta-analysis an examination of gender differences in traffic accident risk perception deciding to decide: gender, leadership and risk-taking in groups gender, race, and perception of environmental 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programme human development reports everyone included: social impact of covid-19 the untilled fields of public health strengthening preparedness for health emergencies; implementation of international health regulations (ihr, 2005), world health organization statement by dr zsuzsanna jakab, who regional director for europe, for international women's day, world health organization population density -a growing concern, health situation and trend assessment urban health. world health organization world bank open data note: total number of countries for each characteristics is subject to availability of data. key: cord-294789-07hto8qn authors: schoch-spana, monica; brunson, emily k.; long, rex; ruth, alexandra; ravi, sanjana j.; trotochaud, marc; borio, luciana; brewer, janesse; buccina, joseph; connell, nancy; hall, laura lee; kass, nancy; kirkland, anna; koonin, lisa; larson, heidi; lu, brooke fisher; omer, saad b.; orenstein, walter a.; poland, gregory a.; privor-dumm, lois; quinn, sandra crouse; salmon, daniel; white, alexandre title: the public’s role in covid-19 vaccination: human-centered recommendations to enhance pandemic vaccine awareness, access, and acceptance in the united states date: 2020-10-29 journal: vaccine doi: 10.1016/j.vaccine.2020.10.059 sha: doc_id: 294789 cord_uid: 07hto8qn given the social and economic upheavals caused by the covid-19 pandemic, political leaders, health officials, and members of the public are eager for solutions. one of the most promising, if they can be successfully developed, is vaccines. while the technological development of such countermeasures is currently underway, a key social gap remains. past experience in routine and crisis contexts demonstrates that uptake of vaccines is more complicated than simply making the technology available. vaccine uptake, and especially the widespread acceptance of vaccines, is a social endeavor that requires consideration of human factors. to provide a starting place for this critical component of a future covid-19 vaccination campaign in the united states, the 23-person working group on readying populations for covid-19 vaccines was formed. one outcome of this group is a synthesis of the major challenges and opportunities associated with a future covid-19 vaccination campaign and empirically-informed recommendations to advance public understanding of, access to, and acceptance of vaccines that protect against sars-cov-2. while not inclusive of all possible steps than could or should be done to facilitate covid-19 vaccination, the working group believes that the recommendations provided are essential for a successful vaccination program. since its first appearance in the united states in february 2020, the novel coronavirus (sars-cov-2) has infected over 7.6 million americans and killed over 213,000 (as of october 10, 2020) [1] . responses to the virus, including closing venues where person-to-person spread was likely, and requiring the use of masks and physical distancing measures when social contact could not be avoided, have reduced virus spread. at the same time, these protective actions have radically transformed social life and disrupted national and household economies [2] . as the health crisis continues to linger and a sense of pandemic fatigue starts to take hold, political leaders, health officials, and the general public are seeking solutions [3] . one of the most promising, if successfully developed and deployed, is vaccines. this technology could provide individual and population-level immunity, and through these the eventual conditions for the resumption of routine social and economic activities [3] . to facilitate the development and dissemination of such vaccines, the us government has committed over 10 billion dollars (via operation warp speed) with the aim of delivering 300 million doses of a safe, effective vaccine by january 2021 [4] . while this timeline is likely overly optimisticvaccine development, especially against a class of pathogens for which no licensed vaccine currently exists, typically takes 10-15 years [5] -progress is being made. as of october 10, 2020, 92 vaccines are in preclinical evaluation, 43 are in phase i and ii safety trials, 11 have entered phase iii efficacy trials, and five vaccines have been approved for limited use: two in china, two in the united arab emirates, and one in russia [6] . despite these promising developments, operation warp speed manifests a key social gap. the program rests upon the compelling yet unfounded premise that 'if we build it, they will come.' past experience in routine and crisis contexts demonstrates that, for a variety of reasons, not all segments of the public will accept medical countermeasures including vaccines [7] [8] . a recent poll in the us suggests this is already the case for sars-cov-2 (covid19) vaccines. about half of us adults (51%) reported they definitely or probably would accept the vaccine, while 49% said they would not [9] . in the same poll, only 32% of black americans indicated they would definitely/probably accept the vaccine compared to 52% of white americans. a human factor-centered vaccination campaign is needed to address these issues, but this campaign must be effectively planned and implemented. if poorly designed and executed, a covid-19 vaccination campaign could undermine increasingly tenuous beliefs in vaccines and the public health authorities that recommend them. at the same time, the broad impacts of a successful vaccination program would be considerable. immediate benefits would include interrupted disease transmission; fewer cases, hospitalizations, deaths, and chronic sequelae; and the beginning of reinstated social and commercial exchanges. longer term effects would include improved institutional capabilities to foster vaccine confidence among diverse communities, enhanced public understanding regarding vaccination's value to society, and heightened public trust in government, science, and public health. the purpose of this article, which is based on a report on the same topic [10] , is to outline the major challenges and opportunities associated with a future covid-19 vaccination campaign and to provide empirically-informed recommendations to advance public understanding of, access to, and acceptance of vaccines that protect against sars-cov-2. with the current lag time in vaccine availability, vaccination planners and implementers in the us and around the world have the opportunity to exercise foresight and take proactive steps to overcome potential hurdles to vaccine uptake and maximize public acceptance. these steps, however, must be taken now before this critical window of opportunity closes. the research and recommendations presented in this paper are a product of the 23-person working group on readying populations for covid-19 vaccine (table 1) . this group was convened in april 2020 by principal investigators from the johns hopkins center for health security and the texas state university department of anthropology with support from the national science foundation-funded converge initiative [11] . the purpose of the working group was to develop and disseminate recommendations informed by design thinking and evidence from social, behavioral, and communication sciences, that would support realistic planning for a us covid-19 vaccination campaign. members of the working group-listed as authors on this paper-included national figures in public health and social science with research, policy, and practice expertise in vaccinology, vaccine hesitancy/confidence, health disparities, infectious disease, bioethics, epidemiology, bioinformatics, public health law, pandemic mitigation, public health preparedness, mass vaccination campaigns, community engagement, and crisis and emergency risk communication. a combination of literature reviews on vaccination, pandemic planning, and health crisis communication; an assessment of current news and social media trends regarding covid-19 vaccines; and key informant interviews with each working group member focusing on their respective expertise formed the basis of the research presented in this article. this research was refined, and the recommendations were developed, through an iterative process involving the development of draft reports by a core working group, feedback from the entire working group via email and comments provided during a virtual meeting on may 21, 2020, and subsequent rounds of revisions and feedback (including a second virtual meeting on june 12, 2020). the final report from the working group, which forms the basis of the recommendations and best practices below, was finalized on july 9, 2020. envisioned largely as a biotechnology and logistics challenge, covid-19 vaccination also poses complex human factors challenges. such challenges have been observed during past emergencies. in 2010, for instance, many americans rejected the h1n1 vaccine due to safety concerns [12] , despite the fact that the vaccine only involved a strain change (i.e., it was not a new technology) and was fully tested before release. the h1n1 vaccine also amplified perceptions of bias. in los angeles, for example, distrust in public health-resulting from both prior experimentation on blacks (e.g. the tuskegee syphilis study) and long-term discrimination of blacks in health care settings [13] [14] [15] -led local faith-based leaders, radio personalities, and other community representatives to advise black community members to avoid vaccination [16] . even though the los angeles county health department actively sought to address these concerns, these suspicions coupled with a lack of convenient access to h1n1 vaccines ultimately resulted in many blacks in this community remaining unvaccinated [16] . despite the existence and importance of such challenges, funding for research on human factors related to vaccine acceptance is not commensurate with its significance for vaccination success [17] [18] . this type of inquiry-practical research of a social and behavioral nature on a medical technology-generally falls between the priorities of the national institutes of health ([nih] which rarely funds social science research) and the national science foundation (which does not fund applied public health research). funding from other sources including the centers for disease control and prevention (cdc) and private foundations has also historically been limited. in addition, the existing funding infrastructure is not outfitted for rapid response research during dynamic crises like sars-cov-2. while initiatives are underway to develop communities of practitioners and a supportive infrastructure for disaster science in the us, including professional networks, streamlined institutional review board processes, and joint responder-researcher training [19] [20] , more progress is needed especially in regards to rapid funding opportunities. in the case of sars-cov-2 vaccination, for instance, while an nih funding opportunity award that could support research on human factors related to vaccine acceptance was made possible in june 2020, the earliest project start date is september 2021, a full nine months after operation warp speed plans for covid-19 vaccines to become available [21] . to ensure a successful covid-19 vaccination campaign, it is necessary for sponsors to invest in time-critical investigations on human factors related to vaccine acceptance, and for public health authorities and other stakeholders to act on the social and behavioral findings of this research. such efforts include:  reconfiguring existing research investments to include social, behavioral, and communication science. one possibility for this is to set aside a small portion of the operation warp speed budget for research on human factors related to vaccine acceptance. such an approach has been used with great success in the past with other cutting-edge scientific initiatives such as the human genome project and manned space flight [22] [23] [24] .  embeding rapid social, behavioral, and communication science within the covid-19 response, helping to deliver timely data and empirically based advice. by including social scientists in planning and implementation efforts, their people-centered methodologies and specialized knowledge can be integrated in a timely manner to maximize critical insights [25] [26] [27] [28] [29] .  transforming the vaccine research enterprise by involving communities as active partners not passive subjects. traditional "one-sided, top down" approaches to community engagement are not always effective. community partnerships during the west africa ebola outbreak, for example, were necessary to overcome issues of trust and produce needed behavioral changes [30] [31] .  applying human-centered design principles (aka "design thinking") to the planning and implementation of the covid-19 vaccination program. user-focused approaches can result in more usable, acceptable, and effective interventions compared with traditional expert-driven methods [32] [33] . such an approach has been very successful in promoting hpv vaccination [34] . vaccines typically require years of development and testing before licensure. nonetheless, us political leaders have publicly promised to accelerate covid-19 vaccine development at "an unprecedented pace," with the aim of delivering 300 million doses of a safe and effective vaccine by january 2021 [35] . although the use of new technologies can potentially accelerate vaccine production, public expectations around vaccine availability may not align with the practical realities of vaccine development, licensure, manufacture, and distribution. by failing to deliver sars-cov-2 vaccines as promised, the us government could frustrate pandemic-weary communities, siphon away trust, and suffer a major loss of institutional legitimacy. this situation is further complicated by public perceptions of the risks and benefits of sars-cov-2 vaccines. recent polling suggests that increasing numbers of americans plan to reject covid-19 vaccines, even if they are available and affordable [9, 36] . a review of news reports, blogs, and other social media suggests a variety of potential causes for this result, including nonchalance about the disease and concern about vaccine safety. public perception, however, is a moving target. new developments, for example, an emergency use authorization (eua)-a power granted to the food and drug administration (fda) to make unlicensed drugs, vaccines, or other therapeutics available during a public health emergency, provided sufficient evidence that the countermeasure in question "may be effective"-for covid-19 vaccines, could engender additional uncertainties around vaccine safety due to the public's lack of familiarity with this complex regulatory mechanism. whatever the public's beliefs about vaccine benefits, risks, and supply, they cannot be separated from the current cultural milieu. in the us this is currently characterized by division, partisanship, and eroding public trust in government institutions-including the biomedical and public health agencies tasked with overseeing vaccine development, licensure, and distribution. in relation to the latter, for example, the intellectual independence of the fda has come under scrutiny for its ability to objectively assess vaccine safety and efficacy amid immense political pressure to quickly approve a sars-cov-2 vaccine [37] . this complicated social environment poses a distinct and unprecedented complication to all vaccine promotion efforts in the us. amid this increasingly complex social landscape, there are several measures that us public health and healthcare practitioners, political leaders and policymakers, and communication experts can implement to prime the general public for sars-cov-2 vaccines including:  tempering expectations of vaccines as a "quick fix." because covid-19 vaccines will not immediately be available to everyone who wants them, and time will be needed to develop immunity (especially given the likelihood of two-dose regimens), communicators must prepare the public to continue implementing a mix of protective actions and harm reduction strategies.  forecasting a range of vaccine possibilities: from best case to worst case scenarios regarding vaccine supply and effectiveness. from a position of openness and transparency, public health communicators should address inevitable roadblocks and bottlenecks at every stage of vaccine testing, licensure, distribution, and administration, and convey to the public how this could affect vaccine availability. in addition, it will be necessary to reframe the dialogue about the value of vaccines, given that future sars-cov-2 vaccines may be not be the public's hoped for silver bullet. a vaccine, for example, may prevent the most severe disease but not prevent sars-cov-2 infection. in this scenario, vaccination could keep hospitals from being overwhelmed, prevent declines into frailty after severe bouts of disease, and avert medical bankruptcies that may arise with the longer-term impacts of covid-19, but not provide the community immunity necessary to halt the spread of sars-cov-2.  persisting in transparency around vaccine safety systems and actively work to protect their integrity. health authorities should focus existing vaccine safety infrastructure on the use of sars-cov-2 vaccines. in this vein, health authorities should develop a robust system for post-licensure surveillance, including ascertaining background rates of anticipated adverse events prior to vaccine rollout to enable comparison with post-rollout incidence of adverse events. independent oversight of vaccine safety, as occurred during the 2009-10 h1n1 pandemic, should also be used [38] .  early on, seeking the counsel and input of communities of color that may have historic reticence towards public health. vaccine promotion efforts should engage these communities early and as frequently as possible. as partners in the task, they must also empathize with legitimate concerns around vaccine safety, medical experimentation, and inequalities in health care [13] [14] , while also identifying and sharing salient information that can help assuage unwarranted worry. a profusion of true and false information, which the who recently referred to as an "infodemic" [39] , is now circulating around covid-19. in this crowded information landscape, the veracity of information can be difficult to determine and key messages can be lost. in the us, public discourse on the pandemic currently incorporates a panoply of topics including science, public health, social disruptions, political divisions, and economic fallout [40] , each of which can be a vehicle for misinformation-information that differs from expert consensus at the time it is shared [41] . while many reasons exist for this flood of misinformation, including the widespread public adoption of social media platforms as a tool for information seeking, the uncertain nature around covid-19 as a novel infectious disease, and the presence of disinformation campaigns aimed at deflecting blame and pushing false narratives around the global covid-19 response [42] [43] [44] , no easy solutions exist to stem the tide [45] [46] . regarding covid-19 vaccination specifically, while the first vaccine is minimally months away from materializing, the topic has already commanded immense public attention and generated its own pool of misinformation [47] [48] . this ranges from rumors questioning vaccine safety to more complicated narratives suggesting that future covid-19 vaccines were created alongside the virus and that major organizations are planning to use a covid-19 vaccination campaign for financial gain [49] [50] . while not the sole factor in determining behavior adoption, effective communication is necessary to address these issues and build public confidence in covid-19 vaccination [51] . such communication will require addressing the enduring problem of how to best engage, exchange information, and empower audiences who have diverse beliefs and life circumstances. past communication experience with vaccines has shown the importance of engaging with key audiences to understand their concerns, values, attitudes, perceptions, and beliefs [52] [53] [54] [55] , and using this understanding to develop messages that resonate [56] [57] . messages that do not do this are often ineffective and, worse, can move audiences further away from the desired behaviors [58] . given the diverse nature of social identities in the us, covid-19 vaccination communications will need to be tailored to meet the needs of specific audiences including essential workers, parents, groups with high comorbidity rates, and communities of color.  investing in qualitative research to identify specific community concerns and hopes in relation to covid-19 vaccination. qualitative research can provide insight into "how" and "why" participants feel, think, or behave a particular way [60] [61] . such insight, in turn, is the basis for developing more meaningful, trusted, and influential communication strategies [62] . the current climate of racial, political, and economic division in the us has created a charged environment that necessitates both a fair vaccination campaign and widespread, public recognition of its fairness. an initial test of this will be how limited, initial doses of vaccines are allocated. in past public health emergencies, including the 2009-10 h1n1 pandemic, allocation strategies have been used to prioritize delivery of medical countermeasures to specific groups like critical health care workers and those who are at particular risk [64] . pervasive racial biases in the us healthcare system, including lack of insurance and a lesser quality of care for non-white, rural, and low-income populations [67] [68] [69] . such disparities have long-term consequences. black populations in the us, for example, experience increased morbidity and mortality compared to their white peers, sometimes in ways that cannot be accounted for by access to health care and income [70] . public health authorities will need to anticipate and mitigate public discourse regarding vaccine allocation and distribution along with prejudicial ideas about social worth, explaining that vaccinating individuals residing in the us, regardless of social or legal status, is critical to the public's health as a whole. finally, politicization of the pandemic-both real and perceived-may prime expectations of a partisan-based vaccine allocation and distribution rather than an equitable one. some americans, for instance, perceive the use of masks as a slight against president trump by his detractors [71] . likewise trump has signaled his preference for having a vaccine available prior to the 2020 election (a projection not in keeping with expert assessments), prompting concerns about whether he could turn a potential but inadequately tested vaccine into a campaign tool [37] . such polarized views of covid-19 raise concerns about whether vaccine allocation and distribution can and will be judged as fair by the majority of americans. people will judge a covid-19 vaccination campaign's integrity not simply on biomedical merits, but on matters of fairness and equity-that is, have people received their just portion of health services, and has disease prevention, ultimately, been fairly distributed? past experience suggests the following steps may contribute to a fair process:  the us government taking steps to make the vaccine available at no cost to all americans and publicly pledge that everyone who wants covid-19 vaccines will get covid vaccines. removing cost as a barrier is among the most significant ways to assure that all individuals benefit from the life-preserving benefits of sars-cov-2 vaccines, and that the public can have the utmost confidence that public health needs and not economics will determine access. in the time that exists before vaccines are produced it is critical that safe and accessible vaccination sites are identified. this process will require ramping up the use of sites that are already available and accessible, but are used less frequently for vaccination efforts. community pharmacies, for example, are widespread and have been mobilized for past vaccination efforts [72] . to fully utilize pharmacies in covid-19 vaccination efforts, however, it will be necessary to address state-level policies that may currently preclude pharmacists from administering these vaccines without standing orders from physicians. other nontraditional, potential vaccination settings that should be considered include grocery stores, senior citizen centers, workplaces, and schools [73] [74] [75] [76] [77] . in some cases, it also may be acceptable and feasible to deliver vaccination via home visits by community health nurses when vaccination is bundled with delivery of other preventive health services; this approach has received a strong recommendation in the past from the community preventive services task force [78] . for marginalized populations, including racial and ethnic minorities, additional consideration must be given to what constitutes a "safe" vaccination site. during the 2009-10 h1n1 pandemic, for example, mistrust and fear among marginalized communities posed a challenge. latino farmworkers were at greater risk for h1n1-related morbidity and mortality. however, reports of bullying and harassment within and outside of local healthcare settings led many members of this population to be fearful and hesitate to seek out h1n1 vaccination [79] . while national patterns may exist, assessments of what constitutes safe vaccination sites for marginalized populations should be conducted at local levels. once vaccination sites are identified, it will be essential for public health authorities to disseminate up-to-date, comprehensible, and trustworthy information about vaccination opportunities. much of this communication work will be done by local and state health departments, which may be challenging in light of budget cuts and strained local public health infrastructure. an additional complication will be the likely complex covid-19 vaccination environment, characterized by multiple manufacturers, multiple vaccine doses, and differently timed follow-up doses. making vaccines widely accessible is a complex endeavor. past experience suggests that this is possible with proactive, thoughtful coordination and clear communication like the following:  utilizing nontraditional vaccination sites like schools, pharmacies, places of worship, workplaces, grocery stores, health departments, mass vaccination clinics, senior centers, home visits, and others. utilizing these sites, as well as clinical sites that already serve vulnerable or underserved populations (e.g., free/low cost community health care clinics, std clinics, substance use treatment centers) will be important to improve uptake in populations that outreach efforts have failed in the past.  preparing, in advance, all necessary educational materials and training that may be needed for those tasked with vaccination at nontraditional sites. training may include information on how to look up immunization records in state immunization registries, how to safely store vaccines, and how to safely recommend vaccines for targeted populations, keeping in mind any contraindications.  anticipating hesitancy among marginalized populations who may be fearful or wary of seeking vaccination at sites that have historically caused mistrust, and plan to either expand sites to better serve these populations or engage these populations early to earn and build trust. this may require using novel sites to better serve marginalized populations (e.g., places of worship, schools, culturally specific community centers or senior centers, mobile clinics). these nontraditional settings will also require those administering vaccines to be culturally competent. vaccination sites should not be heavily policed or send any signals that they may be somehow unsafe for vulnerable persons.  fostering collaboration among interagency and nongovernment partners to make vaccination available alongside provision of other safety net services. bundling services that address individuals' broader needs during the pandemic (e.g., food security, rent assistance, workforce development) could be a way to build trust, streamline vaccine provision, and enhance more convenient access for community members. the protracted covid-19 pandemic has placed multiple stresses on the american people: the threat of illness and death, the isolating effects of physical distancing measures, and the uncertainties and hardships associated with disrupted economic and schooling activities. the public's patience is understandably wearing thin. operation warp speed is taking revolutionary steps to develop sars-cov-2 vaccines as swiftly as possible and, along the way, to inspire hope that relief from the pandemic's multiple burdens is coming. despite vaccination's promise of release from the confines of the pandemic, some members of the us public-including those most at risk of covid-19's impacts-are already reluctant to embrace this public health measure [9] . likewise, current protests against nonpharmaceutical interventions to the sars-cov-2 crisis, including criticisms about government over-reach, encroachment on individual freedoms, and a clash of personal values, have the potential to further erode public trust in future sars-cov-2 vaccines. under these circumstances, bold measures are necessary to instill public trust and to change the reality and the perception that covid-19 vaccination is a top-down program administered without regard to public sentiment, concerns, or priorities. one potential solution to these issues is the formation of public oversight committees at state and, in large metropolitan areas like new york and los angeles, local levels. governance structures that incorporate public oversight and community involvement have the potential to inspire greater public confidence in, and a sense of ownership over, public health interventions. such "ownership" can fortify the intent to vaccinate and strengthen distribution systems to reach throughout communities, thus helping to assure the fitting and fair use of a public good. this type of community engagement entails the collaboration of affected and at-risk populations with policymakers and practitioners in the generation, implementation, and evaluation of measures to safeguard public health and safety [80] [81] [82] . an accountability mechanism and metrics will be necessary to ensure that allocation is fair, target groups receive vaccine, and underserved populations that have been disproportionately affected during the pandemic are justly attended. while vaccines represent a promising solution to the covid-19 pandemic, the development of vaccines is only part of the answer. widespread acceptance of vaccines is also needed. this acceptance, in turn, requires more than just making safe and effective vaccines available. it is a complex social endeavor that necessitates deep engagement around the human element, and requires the efforts of us policymakers; federal, state, and local public health officials; private funders; professional and community organizations; university researchers; and nontraditional partners. while the content provided in this article is not all-inclusive of what can, or should, be done to support widespread acceptance of covid-19 vaccines, the recommendations and best practices outlined here are important for such a vaccination program to be successful. as experts in a wide variety of vaccination-related topics, we fear that unless these critical steps are taken, any future covid-19 vaccination campaign will be less than hoped for. a worst-case scenario would involve an inability to stop the ravages of the disease and its cascading social and economic effects; further erosion of public trust in government, public health, and vaccine science; and potential threat to other life-preserving and live-enhancing vaccination efforts. that said, a successful covid-19 vaccination endeavor promises an alternative future: a return to a sense of normalcy, major innovations in vaccine research and operations, and the investment of us society as a whole in making vaccines a public good in which all can share and derive value. establish public oversight committees to review and report on systems affecting public understanding, access to, and acceptance of covid-19 vaccines usg should sponsor a national panel entity (e.g., nasem) to review, synt best practices for engaging communi allocation, deployment, and commun achieve equity, solidarity, and good h each state (and the most populous cit committee that is demographically re incorporates diverse sectors of societ and faith communities. abbreviations: hcd = human centered design; nih = national institutes of health; nsf = national science foundation; cdc = centers for disease control and prevention; activ = accelerating covidcenters for disease control and prevention. coronavirus disease 2019 cases in the us the evidence and tradeoffs for a 'stay-at-home' pandemic response: a multidisciplinary review examining medical, psychological, economic and political impact of 'stay-at-home' implementation in america post-abc poll finds. the washington post department of health & human services. fact sheet: explaining operation warp speed the college of physicians of philadelphia. vaccine development, testing, and regulation coronavirus vaccine tracker. the new york times group on vaccine hesitancy. vaccine hesitancy: definition, scope and determinants understanding 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vaccinations administered in nontraditional settings centers for disease control and prevention. national and state-level place of flu vaccination among vaccinated adults in the united states flu season polio: an american story increasing appropriate vaccination: home visits to increase vaccination rates stigma, health disparities, and the 2009 h1n1 influenza pandemic: how to protect latino farmworkers in future health emergencies community engagement, organization, and development for public health practice community participation for transformative action on women's, children's and adolescents' health on behalf of the working group on community engagement in health emergency planning. community engagement: leadership tool for catastrophic health events key: cord-254304-6o50m9si authors: fusco, floriana; marsilio, marta; guglielmetti, chiara title: co-production in health policy and management: a comprehensive bibliometric review date: 2020-06-05 journal: bmc health serv res doi: 10.1186/s12913-020-05241-2 sha: doc_id: 254304 cord_uid: 6o50m9si background: due to an increasingly elderly population, a higher incidence of chronic diseases and higher expectations regarding public service provision, healthcare services are under increasing strain to cut costs while maintaining quality. the importance of promoting systems of co-produced health between stakeholders has gained considerable traction both in the literature and in public sector policy debates. this study provides a comprehensive map of the extant literature and identifies the main themes and future research needs. methods: a quantitative bibliometric analysis was carried out consisting of a performance analysis, science mapping, and a scientific collaboration analysis. web of science (wos) was chosen to extract the dataset; the search was refined by language, i.e. english, and type of publication, i.e. journal academic articles and reviews. no time limitation was selected. results: the dataset is made up of 295 papers ranging from 1994 to may 2019. the analysis highlighted an annual percentage growth rate in the topic of co-production of about 25%. the articles retrieved are split between 1225 authors and 148 sources. this fragmentation was confirmed by the collaboration analysis, which revealed very few long-lasting collaborations. the scientific production is geographically polarised within the eu and anglo-saxon countries, with the united kingdom playing a central role. the intellectual structure consists of three main areas: public administration and management, service management and knowledge translation literature. the co-word analysis confirms the relatively low scientific maturity of co-production applied to health services. it shows few well-developed and central terms, which refer to traditional areas of co-production (e.g. public health, social care), and some emerging themes related to social and health phenomena (e.g. the elderly and chronic diseases), the use of technologies, and the recent patient-centred approach to care (patient involvement/engagement). conclusions: the field is still far from being mature. empirical practices, especially regarding co-delivery and co-management as well as the evaluation of their real impacts on providers and on patients are lacking and should be more widely investigated. co-production in public services has become the leitmotif of public policy reform [1] [2] [3] . it is considered a potential solution to the current and future challenges in the public sector, given that the expected benefits concern the improvement of the services provided, a greater economic and financial sustainability of the system, the more efficient use of resources, and the possibility of increasing the satisfaction level of citizens [4, 5] . despite this growing interest, co-production is still a nebulous concept, a "woolly-word" in the field of public policy [ [6] :640], a "quite heterogeneous umbrella concept" [ [7] :1094], with a wide range of definitions [8] . in 1996, ostrom [[9] :1073] defined it as "the processes through which inputs, used to provide a good or a service, are contributed by individuals who are not in the same organization". this definition was subsequently interpreted in different ways, considering only the involvement of the users [6] or of any individual or entity external to the organisation [10] . there is some agreement that it covers the practices in which state actors (i.e. government agents serving in a professional capacity) and lay actors (i.e. members of the public, serving voluntarily as citizens or users) work together in any phase of the public service cycle (i.e. commissioning, design, delivery, and assessment) [11, 12] . co-production implies that citizens are not merely recipients of services, but can act as co-producers in the design and the delivery of public services [3] . of the various contexts of application, the literature seems to agree that the health sector is a reference point where the concepts of co-production can be analysed and put into practice [5, [13] [14] [15] [16] [17] [18] . it is a sector where resources are being reduced and where there are increasing concerns about long-term economic sustainability. on the other hand, there are expectations of higher quality as well as a growing demand caused above all by an aging population and the rise in chronic diseases. this is forcing healthcare policymakers and managers to reduce healthcare costs (e.g. by reducing the length of hospital stays and readmission rates), and at the same time, improve the quality of the service and, more generally, the patients' quality of life [19] . patient engagement has become imperative in delivering high quality healthcare services [20] . this more active role of patients has transformed public service production: patients are asked to participate actively and act as consumer producers, next to and in interaction with healthcare professionals and other decision-makers in healthcare, such as policy makers [21, 22] . the pressure to create co-produced health services is increasing, and the debate is wide open on the nature of co-production, on how healthcare practices change in order to manage effective partnerships between clients and professionals and on the impacts of trying to optimise health outcomes. despite the growing interest and the consequent increase in the number of publications on co-production in the healthcare sector [16] , there is a lack of studies that provide a comprehensive picture of the structure and the development of this field. some co-production qualitative literature reviews have already been carried out. only one specifically targeted the healthcare sector [16] ; others have investigated the broader context of public services [5, 7] . all of them have focused on specific research questions (such as the aims, drivers/barriers and outcomes), but do not provide an overall and comprehensive picture of the healthcare co-production research field. this paper aims to fill this gap with a quantitative bibliometric analysis on co-production in the healthcare sector. a quantitative review enhances the understanding of this research field and further informs the scientific debate on this topic. specifically, using the main procedures of the bibliometric method (performance analysis, scientific collaboration analysis and science mapping), the work aims to i) quantify the research field and describe its main outputs and evolution; ii) analyse the collaboration practices and map the social structure of the field; iii) define the intellectual structure and understand the main conceptualizations and theoretical approaches; iv) identify the most investigated themes and propose future avenues for research. bibliometric analysis has been increasingly used both in social sciences [e.g. [23] [24] [25] [26] ]; and with specific reference to the health field [e.g. [27] [28] [29] ], and medical science [e.g. [30, 31] ]. it is based on the statistical measurement of science, scientists, or scientific activity and it is, therefore, considered a more objective and reproducible method with which to develop a review process compared to other techniques [32, 33] . the process of data collection and data analysis is detailed below. data were retrieved from the web of science (wos), and specifically from the science citation index expanded (sci expanded) and the social science citation index (ssci) [34, 35] . the search criteria were "co-production and health* or coproduction and health*" in the string "topic" (that is title, abstract and keywords). the search did not include correlated words, such as engagement, involvement and co-creation, given that these are different concepts from co-production, although strictly linked to it [6] . the query was launched on 10 may 2019 and resulted in the retrieval of 555 documents. the search was then refined by language (english) and document type (article and review) [36] . although coproduction first appeared in the 1970s, it has begun to receive particular attention in recent years. no limitation time was selected in order to gather the evolution over time since its first appearance in literature. the filtering stage produced 500 documents. to avoid including papers that were not related to the topic, i.e. not containing the concept of co-production (as defined above), and/or not referring to the health field, the collection was screened in terms of titles and abstracts. the excluded papers focused on microbiology, biochemistry, pharmacology, environmental science and ecology. this phase was first carried out by one author, and then checked by two other authors and any discrepancies in the evaluation were discussed. this screening thus reduced the risk of including unrelated articles or, conversely, excluding pertinent ones. the final sample is made up of 295 documents (see additional file 1). figure 1 summarizes the research design. bibliometric techniques are based on the analysis of bibliographic attributesalso called "metadata" -of a document, such as authors, citations, collaboration, keywords, in order to have insights into a scientific field's structure, social networks and relevant themes [35, 37] . in the present study, the bibliometric analysis was carried out using bibliometrix, a free open source software application, supported by the r environment, which provides a set of tools for quantitative research in bibliometrics and scientometrics [37] . on the basis of the final sample retrieved by wos in bibtex format, data were loaded and converted into r dataframe in bibliometrix, in order to develop three main level of analysis: i) performance analysis; ii) collaboration analysis; and iii) science mapping. a performance analysis highlights the sample characteristics and measures its main performances by quantifying the research field (the number of published documents, the number of received citations), identifying the most important (most cited, most productive, etc) actors, and evaluating groups of scientific actors (countries, universities, departments, researchers) and the impact of their activity [38] [39] [40] [41] . at this stage, a citation analysis was also performed. a citation analysis is based on the hypothesis that authors cite documents considered most important in the development of their research. frequently cited studies are expected to have a greater influence on the research field than those less frequently cited [42, 43] . to ensure the accuracy of the data, the references were checked to ensure that they were written in the same way in all the documents. a scientific collaboration analysis was then carried out in order to highlight the most relevant relations between the actors (i.e. authors and countries) [44] [45] [46] [47] . scientific collaboration analysis is widely used in different strands of research [e.g. [48, 49] ] in order to identify the social structure of the field. this is achieved via a social network analysis where the network's nodes are the authors, their institution or country to which the institutions belong, and the edges (links) are established according to the nodes who co-authored an article. the science mapping was performed through a cocitation analysis and co-word analysis. science mapping "is a spatial representation of how disciplines, fields, specialities, and individual papers or authors are related to one another" [ [40] :147]. the co-citation analysis was used to capture the intellectual structure of the field. co-citation is defined as the frequency with which two documents are cited together in the literature and it assumes that documents are co-cited if they are conceptually close [50] [51] [52] . given that it is a dynamic approach, it is often considered to be preferable to bibliographic coupling, which occurs when two documents have at least one reference in common. its validity as a tool for exploring the intellectual structure of a scientific field has been stated in numerous studies [e.g. [50, 53] ], and it is increasingly being used in all disciplines, including in the management field [e.g. [23, 36, 54] ]. in the clustering derived from this analysis, the network nodes represent cited documents, whose size depends on the number of citations. the edges represent the co-citation relationship and their weights depend on the number of times that two documents have been cited jointly [50] [51] [52] . in this bibliometric analysis, a minimum degree of co-citation (equal to 2) has been set and a threshold of 50 network nodes has been considered. these settings ensure the clarity of the network, without compromising the validity of the results that did not have relevant deviations by increasing the size of the network. a co-word analysis is based on the idea that the cooccurrence of key terms (i.e. abstract, title or keywords) describes the content of the documents [55] . this technique identifies and visualises clusters that represent semantic or conceptual groups of different topics treated in the research field. using the approach developed by cobo et al. [40, 41] , the thematic clusters are visualised in a "strategic diagram" or map. moreover, the authors read the abstracts or full-text of papers when necessary to add relevant information to the results of the quantitative bibliometric analysis (e.g. in "performance analysis" to add the methodological approach and main content of most cited papers and references; in "co-citation analysis" to know the main contents of most important nodes and discuss the clusters). in the additional file 2 the data (i.e. papers of the sample) and metadata (e.g. authors, citations, etc.) used in each analysis' stage are detailed. the articles of the sample have been published from 1994 to 2019 (table 1) . this research field is fairly recent with an annual scientific growth rate of nearly 25%. as shown in fig. 2 , the biggest increase has occurred in the last 4 years (about 80% of documents sourced); in 2018 the number of publications was more than double compared to 2015, and more than quadruple compared to 2014. authorship is very fragmented, with 1225 authors and a collaboration index (i.e. a co-authors per article index calculated only using the multi-authored article set) of 4.37. there is an average of 4.15 authors per document; only a few documents were written by one single author (19 articles, 6.4%). there is an average of 0.24 documents per author, and only 26 (2.1%) of authors have published more than three works, and 149 (12.2%) that have published more than two works. the most productive authors (additional file 3) tend to be academics in medicine and nursing, with a lower incidence in psychology, social informatics and management. the articles in the dataset were published in 148 journals, only 24 of which (16.2%) have published more than three articles and 46 (31%) more than two articles, with a mean of 1.9 article per journal. the most productive journals represent approximately 80% of the total number of documents retrieved; they belong to different areas of researchincluding medicine, management, business, social science -with nearly all in health fields according to wos categories ( table 2 ). the top two journals cover the health field (i.e bmj open) and the public sector (i.e public management review). the geographical distribution of papersbased on all authors' affiliations -is concentrated in anglo-saxon countries (uk, usa, australia, canada and ireland) and in other european countries (netherlands, sweden, denmark, italy, finland and norway) (fig. 3 ). the uk is the most productive country, where patient involvement in clinical practices has been a priority since the 1990s and new forms of organisation and delivery of healthcare services have been promoted by the nhs since the early 2000s [13, [56] [57] [58] . table 3 shows the top 10 manuscripts per total citation, the first of which was published in 2006, when the scientific interest in the topic really began to take hold. the article with the highest number of total citations is the work by mccoll-kennedy et al. in 2012 [59] , followed by the one written in 2015 by voorberg et al. [5] ) and by carayon in 2006 [60] ). the ranking changes slightly if annual citations are considered, i.e. the average number of citations received per year. these top 10 ranked articles consist of four conceptual papers, two reviews and four empirical papers. interestingly, the empirical studies tend to try to develop theoretical or conceptual models/findings from the results: three adopt qualitative methods (i.e. the papers by mccoll-kennedy et al. [59] ; gillard et al. [61] ; mort et al. [62] ) and one quantitative method (i.e. the work by trummer et al. [63] ). in these top ten papers, there is no homogeneity regarding the clinical field on which the study sample focused. furthermore, one of the two reviews [5] is qualitative, i.e. a structured systematic review, the other uses a mixed method [64] . four of the papers were published in health journals, followed by three in public administration and management and one in business, ergonomics and environmental sciences journals. it is not possible to identify reference theories for all ten papers, but four explicitly fit into the public management and administration literature, i.e. the works by osborne et al. [6] , by batalden et al. [65] , 2016; vooberg et al. [5] and dunston et al. [14] ); the work of mccoll-kennedy et al. [59] refers to service management theories and the work of gillard et al. [61] refers to gittell's theory on relational coordination. two studies focus specifically on the co-production of knowledge [61, 64] . the top ten cited references (table 4 ) are mainly coproduction seminal works in the field of public services. only two works, those by dunston et al. [14] and by batalden et al. [65] refer specifically to the health sector. the most cited works are the conceptual framework developed by bovaird in 2007 [66] , which is considered a milestone on co-production topic in public management, and the seminal work by ostrom et al. in 1996 [9] . this analysis provides an overview of the scientific collaboration and research communities, with reference to different aggregation levels [47] . in this study, countries and authors were considered as units of analysis. the first analysis focused on cross-country collaboration (fig. 4) . the network has its central and most important node in the uk (betweenness centrality = 287.030); the other top nodes are the usa, australia, canada and the netherlands. the results are not totally surprising given the scientific production of each country highlighted in the performance analysis. however, further comments can be made regarding the multiple-country collaboration ratio of the top ten countries per publications i.e. the ratio between the number of multi-country collaborations and the total number of papers attributed based on the affiliation of the corresponding author ( table 5 ). the uk has the highest number of cross-country collaborations (20 multi-country collaborations), yet the uk's multicountry publication (mcp) rate is only 13.9%, much lower than the ratios of australia (40%), usa (25%) and italy (22.2%). in order to understand any long-lasting collaborations among authors, the co-authorship network (fig. 5 ) excluded one-shot collaborations (min.edge = 2). only 66 out of 1225 authors, appeared to have collaborated with the same research group more than once, and they are clustered into twelve groups (see additional file 4). the clusters are characterised by differences in the disciplinary and professional background of the authors, geographical affiliation and research focus of the coauthors' work. group 1 is the biggest and densest. it is made up of an academic cross-national network between australian, new zealand and northern european authors with a research focus on patient co-production in mental health. group 2 is a cross national authors' network in europe (i.e. italy, finland, denmark, the netherlands, romania), focused on public health and policy. group 3 is composed of an interdisciplinary group of psychology, primary care and social informatics researchers, all with uk affiliation and focused on coproduction in assisted-living technologies. group 4 is geographically limited to the uk, it includes both academics and practitioners and it is characterised by the research interest on patient co-production in mental health. . groups 5 and 6 share the same focus on public health and policy, but they have a different country's affiliation. group 5 is composed by australian affiliation authors, group 6 by uk affiliation authors. groups 7 focuses on knowledge translation and is made up academic authors with uk affiliation. the same geographical characteristic can be found in group 8, but the scientific focus is on health safety issues. group 9 is made up of primary care and nursing academics, with uk affiliation, specialised in dementia, comorbidity, integrated care and continuity of care for older people with complex health needs. group 10 refers to australian academics and practitioners with an interest in research and evaluation in mental health. group 11 is composed by academics with an australian university affiliation and a focus on service development and citizen participation in rural health. group 12 is made up of authors affiliated with universities in the uk in the field of co-production in medical education. the intellectual structure of the field: co-citation analysis intellectual structure is defined as "the examined scientific domain's research traditions, their disciplinary composition, influential research topics and the pattern of their interrelationships. these publications are the foundations upon which current research is being carried out and contain fundamental theories, breakthrough early works and methodological canons of the field" [ [35] :438]. intellectual structure is investigated through a cocitation analysis which verifies the presence and frequency of the co-citations in a dataset and identifies which clusters of citations are conceptually related and how relevant they are [50, 53] . the co-citation analysis ( fig. 6 and additional file 5) was carried out with a minimum degree of co-citation equal to 2 and a threshold of 50 network nodes. this was designed on the basis of the number of papers and the fragmentation of the field as well as to ensure the the findings show a network whose most central and important nodes are represented by "bovaird t 2007-1" 1 (betweenness centrality = 103.337) [66] and "ostrom e 1996" (betweenness centrality = 170.150) [9] , that are also the two most cited documents in the database (see also the above table 4 ). the study by bovaird [66] was one of the first to report a conceptual framework of coproduction. co-production is described as a "revolutionary concept in public service" [ [66] :846] and the framework maps the various interactions that can be established among public providers, service users and their communities. it identifies the various stages where co-production can take place: planning, design, commissioning, management, delivery, monitoring, and evaluation. bovaird also provides some case studies that give insights into the benefits and challenges of coproduction. using an institutional-economic approach, ostrom [9] analyses co-production as a way to overcome the divide identified between "a market-based logic of development and the traditional theories of public administration" [ [9] :1073]. her two case studies suggest that co-production into polycentric and synergic systems between government agencies and citizens is crucial in order to reach higher levels of welfare in developing countries. the co-citation analysis revealed three main clusters. a: "public administration and management". this is the largest group (33 works) with the densest ties and the most top nodes in the entire network. seminal and early contributions are represented by "parks rb 1981" [67] , "whitaker gp 1980" [68] and "ostrom e 1996" [9] . the cluster includes some political science and economics studies [e.g. [9, 67] ] and a predominance of public administration and management works [e.g. [66, 69] ]. these studies consider co-production as a tool of public policy aimed at improving the efficiency and effectiveness of public services. "coproduction is one way that synergy between what a government does and what citizens do can occur." [[9] :1079]. the prevailing approach is top-down, strongly focused on the public service provider. co-production is seen as something "to be consciously built into public services" [ [70] :s35] and thus the discussion is centred on "the ways in which service user participation can be 'added into' the process of service planning and production" [ [70] :s34]. three types of possible co-producers are identified in the public service regime (clients, citizens and volunteers) and differences with co-production in the private sector are discussed [4, 71] . the papers in this cluster detail the conceptualization of co-production in the public sector, analyse its pros and cons, as well as how its implementation can be incentivised and managed. seven of these specifically investigate the health sector, seen as a key area for the implementation of co-production practices [e.g. [14, 65, 72] ]. co-production is seen as a promising tool for dealing with challenges in the sector such as increasing and changing demands with a simultaneous decrease in resources [14] . the number of elderly people, with multifaceted needs and high expectations, as well as the rates of chronic diseases are growing [1, 73] . this puts the onus on healthcare systems to contain costs without detracting from the high quality of care. rising hospitalization costs are forcing healthcare administrators to reduce the length of hospital stays and the readmission rate, making it necessary to build relational models in which the patient feels part of the healthcare team and willing and able to continue self-care after discharge. co-production can help to ensure both the improvement in the service and sustainability in the system [14] , taking into account possible limitations and challenges [72] . b: "service management". this consists of eight documents from the service management and marketing literature. in this cluster there is little crossover with other disciplines. in terms of service management, these works focus on the (co-)creation of value for/with the customers/users. the internal top nodes are represented by "vargo sl 2008-2" [74] , "vargo stephen 2008" [75] , and "bendapudi n 2003" [76] . from this perspective, organisations consider customers as an important resource, quasi-employees, who carry out part of the service delivery. this concept of customer participation then leads to a service-dominant (s-d) approach where service is the common denominator in exchange, and within its delivery, the customer is a co-creator of value both for the firm and her/himself [75, 77, 78] . from this perspective, some studies refer to a specific topic, such as customer behaviours, practices and psychological implications [e.g. 76, 59] . given these theoretical assumptions, scholars point out that service management and a marketing perspective have much to offer the analysis and interpretation of a "critically important and intellectually healthcare is considered a fertile field for empirical research, given that "no other service sector affects the quality of life more than health care. no other service commands more resources or is more challenged as it faces the future" [ [79] : 121]. in line with the focus of this cluster on service management rather than on the public domain, the studies refer to private healthcare organisations [59, 79, 80] . the visual representation of the co-citation network shows the presence of numerous ties and bridges-nodes (connecting nodes between two clusters), that are "osborne sp 2013-1" [70] , "osborne sp 2013-2" [81] ; "hardyman w 2015" [82] between the two clusters. in fact, there has recently been a crossover between public management and service management in studies that discuss how the public management literature can benefit from the service paradigm, for example in the development of a public service-dominant approach [70, 81, 83] or the work on the co-creation of public value [84] . c: "co-production of knowledge". this cluster has fewer internal and external ties. the cluster focuses on the coproduction of knowledge in its specific meaning of knowledge translation between researchers and decisionmakers (clinicians, managers, policy-makers, etc.) "for the purpose of engaging in a mutually beneficial research project or program of research to support decisionmaking" [[85]:11]. the user's or patient's perspective is, therefore, almost neglected, with the partial exception of "greenhalgh t 2016-1" [86] , who focus on communityacademic partnerships. the top nodes are represented by "gagliardi ar 2016-1" [85] and "graham id 2006" [87] , which are both literature reviews as well as most of the other works in cluster. moreover, unlike the other clusters, six out of the nine studies are specifically on the health sector. a co-word analysis of author keywords (min. frequency = 3; number of words = 300) helps to define a map of the main themes of the field. in order to avoid deviant results, the dataset was screened before being submitted to analysis by the software. generic keywords inserted in the search query were eliminated (i.e. coproduction; co-production; health); ii) the spelling of keywords was harmonized (e.g., plural or singular; american or english style; with hyphen or without hyphen). using the visualization technique proposed by cobo et al. [40, 41] , a strategic thematic map was developed, plotting the themes into four quadrants (clusters of keywords) according to their centrality and density rank values along two axes. the centrality measures the degree of interaction of a network with other networks and is considered "as a measure of the importance of a theme in the development of the entire research field analysed." [[40] :150]. the density measures the internal strength of the network and identifies the degree of development of a theme. the size of the cluster is given by the number of occurrences of the keywords that it contains and therefore by the number of linked papers. the label chosen by the software corresponds to the predominant keyword (fig. 7) . for each quadrant, clusters with a higher number of related papers are discussed. motor themes (first quadrant): these are well developed themes that are key to the structure of the research field, and are characterized by high centrality and high density. there were few "motor" themes -"public health", "social care" and "codesign" -and they are at the axis of the fourth quadrant. social care mainly refers to the coproduction and personalisation of community health and the delivery of well-being services [88] . the focus is above all on the weakest segments of the community or on integration difficulties [89, 90] . confirming the evidence on collaboration among authors, "public health" is one of the most explored fields, both in terms of the co-production of knowledge [91, 92] and service design and/or delivery [93, 94] . "co-design" is a specific phase of co-production referring to activities that involve "the experience of users and their communities" into the creation, planning, or arrangements of public services [ [12] :772]. examples of co-design in our dataset were related to the improvement of hospital services [17] , public health [95] , integrated care [96] , and assistive technology [97] . niche themes (second quadrant): these are well developed and very specialised themes, but marginal in the overall field. "knowledge translation" appears to be a most recurrent theme in this quadrant. its internal specialization and external marginality were evident also in the intellectual structure (i.e. cluster "co-production of knowledge"), where it was scarcely connected with other clusters. knowledge translation concerns the partnership between researchers and practitioners-decision makers aimed at reducing the gap between research and practice [98, 99] . the concept of "empowerment" is strictly related to co-production [20] , and relates to patient self-confidence and the understanding of their role. some authors considered empowerment as a determinant of co-production, given that co-production requires "that a degree of confidence exists for any patient to feel sufficiently empowered to actively engage." [[58] :551]. others argue that it is engagement and co-production that boost empowerment because they increase confidence and give users a sense of influence or control [100] . the theme "quality improvement" focuses on the improvement of health services, which is achieved primarily through coproduction and personalisation of patient care [101, 102] . the "nursing" cluster highlights the recognition of the importance of the role of nurses in health service delivery, thanks to their closeness to endusers and the role played by patients (experts by experience) in improving nursing education and training [103] . peripheral themes (third quadrant): this comprises both emerging and declining themes, characterised by low density (under developed) and centrality (marginal). this quadrant includes care for the elderly, who are a critical and weak group in the population in terms of chronicity and comorbidity and therefore with greater health and social care needs [104] . in this context, there are frequent examples of co-production through technology (e.g. telecare or telehealth), which facilitate the monitoring of the patient's health conditions, the possibility of providing services at home, and the involvement of patients and caregivers in the process of care [105] . transversal and general, basic themes (fourth quadrant): these are themes with a high centrality and low density, which are important for the coproduction field, but are still not well developed. they mostly concern umbrella themes, such as "user involvement", "patient engagement", which the most recent psychological and organizational literature prefers to the term "empowerment". the term "cocreation" is now very widespread, but not very focused. this quadrant includes papers, whose intellectual structure mainly refers to the managerial field, both public and service, with a strong focus on the patient as the key-actor in the process. two main themes refer to the most relevant health disciplines where co-production has been widely applied. the first is "mental health", both with reference to co-production of knowledge [61] and services [106] . several articles investigate the recovery college model, which as an alternative to the traditional clinical model aims to treat and reduce symptoms; it is inspired by the broader principles of mental wellbeing, recovery and co-production [107] . indeed, in these colleges, the training courses, whose participants are not only patients, but also caregivers and staff, are co-designed and co-delivered by medical personnel and experts by experience, whose contribution is recognized as having a strong impact on the effectiveness of the model [107, 108] . the second area is "primary care" which covers studies referring to the management of long-term conditions, where co-production and self-management become necessary both for health providers and patients and their caregivers [109, 110] . moreover, the presence of "evaluation" as a theme highlights that it is considered central for the overall understanding of the co-production practices. several papers have reported the potential of the co-delivery of healthcare services, e.g., peer support groups, nurse-family partnerships [106, [111] [112] [113] . nevertheless, evidence of a clear link to correlate co-production to greater benefits for those involved is, at best, weak [7] . when explored, the impact is measured through subjective methods, such as satisfaction questionnaires or interviews with patients, staff or caregivers [108, 114] . this bibliometric analysis provides a comprehensive picture of the structure and the development of coproduction in the healthcare sector. although there have been some valuable qualitative reviews [16] , to the best of our knowledge this is the first study to use a quantitative approach and cover the most recent published literature. the analysis shows that academic interest in co-production has increased considerably with an annual growth rate of nearly 25%: publications increased four-fold between 2014 and 2018 (almost 300 articles were included in the current analysis, compared to 65 in a previous review). despite this fast-growing interest in co-production in healthcare, the field is still very fragmented. the 295 articles retrieved are split between 1225 authors and 148 sources, of which only 12.2% of authors and 31% of journals have published more than two works. the top authors mainly belong to the area of medicine and nursing, with a lower incidence of other specialisations (psychology, social informatics and management). this fragmentation is also highlighted by the collaboration analysis, which shows very few long-lasting collaborations. authors collaborate frequently (with an average of 4.15 authors per document), but generally only once. the field appears to be concentrated in the eu and anglo-saxon countries, with an absolutely central role of the united kingdom, as shown by the performance analysis as well as the collaboration analysis. although the uk has the highest productivity rate, the collaborations are mostly with other authors located in the uk. the proliferation of co-production research in these countries could be justified by the fact that they were early adopters of patient involvement clinical practices and there is also a strong commitment to co-production by the government and the nhs, in order to cut costs and improve the efficiency of public services [1, 13, 56, 57] . the intellectual structure of health co-production consists of two main subfields (clusters), i.e. public management and service management perspectives. public services have rarely featured in service management research, which is surprising given the discipline's long intellectual history in the concepts of co-production, value-in-exchange and value-in-use. the co-citation analysis revealed a recent but growing crossflow between the two disciplines. in particular, public management academics have investigated how a service-dominant approach [70, 82] and value co-creation [84] can effectively be applied to explain the dynamics of co-production in public sector. the thematic map developed through the co-word analysis helps to identify the most consolidated themes and to provide evidence on the emerging ones. the analysis found few well-developed and central terms and these tended to refer to traditional areas of coproduction (e.g. public health, social care). this confirms the relative low scientific maturity of co-production applied to health services. on the other hand, the analysis revealed some emerging themes related to social and health phenomena (e.g. the elderly and chronic diseases), the use of technologies, and the recent patient-centred approach to care (patient involvement / engagement). the bibliometric method adopted in this study was very useful for investigating and providing a comprehensive picture of co-production in the health field, especially due to the various techniques used (performance analysis, collaboration analysis and science mapping). nonetheless, the paper has some limitations, mostly concerning the methodological issues adopted. only using "co-production" as keyword in the search clearly produced a smaller dataset than might otherwise have been possible; yet it meant that this concept could be analysed in its narrow meaning in combination with related and similar concepts. although a bibliometric method is objective and reproducible, it also implies a less detailed understanding than qualitative techniques. for example, the citation and co-citation analyses show the most cited references, but do not reveal the reason for the citation. again, the conceptual map highlights the main themes, but does not allow for an in-depth analysis of the contents of each paper. the results help to identify avenues for future research. while the branch of knowledge co-production and service co-design (hence the user's participation in the research phase) seems to be more developed in terms of empirical evidence, the research on co-delivery and co-management still seems to be in an embryonic and more theoretical stage. specifically, little has been produced on how the organisation of health services should change or adapt in order to consider the patient as a partner in designing, monitoring, delivering and evaluating a work practice. even less investigated is the theme of the impact of co-production on providers and on patients. the few theoretical studies and even fewer empirical studies on this topic adopt predominantly a mono-dimensional and a mono-stakeholder approach. specifically, psychological-social impacts are assessed, above all in terms of patient satisfaction. besides, even the medical research on home therapy practiceswhich represent a form of "co-production"tends to focus only on the economic and clinical impacts [115] [116] [117] . at present, the presence and the description of co-produced practices is 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neutral with regard to jurisdictional claims in published maps and institutional affiliations we would thank the developers of the software "bibliometrix" for their support and the reviewers for their valuable suggestions. supplementary information accompanies this paper at https://doi.org/10. 1186/s12913-020-05241-2. authors' contributions all the authors have made substantial contribution to the manuscript. in particular, mm and cg conceived the study; ff performed the statistical and data analysis and wrote the first draft of the paper; mm and cg critically reviewed the manuscript to reach the current version. all authors read and approved the final manuscript. no funding was obtained for this study. all data generated or analysed during this study are included in this published article (and its supplementary information files).ethics approval and consent to participate not applicable. not applicable. the author declares that he has no competing interests.received: 4 july 2019 accepted: 19 april 2020 key: cord-287304-h6wj7m8u authors: keil, roger; ali, harris title: governing the sick city: urban governance in the age of emerging infectious disease date: 2007-12-07 journal: antipode doi: 10.1111/j.1467-8330.2007.00555.x sha: doc_id: 287304 cord_uid: h6wj7m8u abstract: based on a case study of the 2003 severe acute respiratory syndrome (sars) outbreak in toronto, canada, this article suggests that we may have to rethink our common perception of what urban governance entails. rather than operating solely in the conceptual proximity of social cohesion and economic competitiveness, urban governance may soon prove to be more centrally concerned with questions of widespread disease, life and death and the construction of new internal boundaries and regulations just at the time that globalization seems to suggest the breakdown of some traditional scalar incisions such as national boundaries in a post‐westphalian environment. we argue that urban governance must face the new (or reemerging) challenge of dealing with infectious disease in the context of the “new normal” and that global health governance may be better off by taking the possibilities that rest in metropolitan governance more seriously. avian flu has begun to capture the imagination of world publics in recent years as the h5n1 virus spread from its perceived origin in east and southeast asia to turkey and potentially to western europe (davis 2005) . newspapers and television corporations have discovered the pandemic as a topic of interest. governments, businesses, and civic organizations at all scales have drawn up preparedness plans. this newfound interest in the threat from emerging infectious disease has a recent precedent. in the spring of 2003 many parts of the world experienced an outbreak of severe acute respiratory syndrome (sars). 1 in many ways, the sars outbreak is now being read as a stage rehearsal for what many public health experts believe will be a much larger epidemic once the h5n1 virus, which has so far only spread from infected birds to humans, mutates and leads to direct human-to-human infection. sars, a previously unknown disease, is much different from h5n1 but the way it was handled by health authorities around the globe can potentially teach us some lessons about future pandemic preparedness. this article looks at the urban governance aspect of these urban governance in the age of emerging infectious disease 847 lessons. we rely on the rich and productive output in urban governance studies but will argue that this literature has had a particular blind spot: the relationship of urban governance restructuring to emerging infectious disease (eid). urban governance must be prepared to deal with infectious disease. at the same time, global health governance overall may be improved by realizing the possibilities that rest in metropolitan governance. a new "post-westphalian" constellation of post-national state power (fidler 2004 ) poses previously unknown demands on the governance of urban regions in the area of infectious disease control. while there has been much attention in recent years on the significance of global city regions in the new world economy (brenner and keil 2006) and while the governance and regulation of these regions has captured the imagination of academics and policymakers alike (buck et al 2005; harding 2005; heinelt and kübler 2005; kantor and savitch 2005; scott 2001) , little has been said specifically about the growing pressures posed by the potential threat of infectious disease through the global network on urban governance. rather than operating solely in between the often contradictory challenges of social cohesion and economic competitiveness, urban governance may soon have to be more centrally concerned with questions of widespread disease, life and death (agamben 1998) and the construction of new internal boundaries and regulations just at the time that globalization seems to suggest the breakdown of some traditional scalar incisions such as national boundaries. in making connections between the traditional discussion of public service provision between competitiveness and cohesion and the more dramatic and urgent questions about disease and health, life and death, we also consult work that has-in a foucauldian mannermore directly engaged with issues of (bio)power and governmentality (osborne and rose 1999; rose 1999) . 2 for the area of urban planning and governance a more or less critical literature has begun to explore the spaces that cities have to maneuver in the rather open field of infectious disease preparedness planning and public health since the onset of the "new normal" after the attacks of 9/11 malizia 2006; matthew and macdonald 2006) . some work has explored the historical precedents of variations in how cities have fought infectious disease in order "to help us plan for the battles against disease that will be part of our future" (leavitt 2003:192) . howard markel has put forward the observation that "[n]othing less than a cooperative partnership of nations, healthcare professionals, researchers, public health specialists, concerned corporations, philanthropies, and individuals will suffice to safeguard the world against the many public health problems we face today" (2004:211-212) . still, we believe more specific work needs to be done clarifying and determining the role municipal institutions of health governance can play in the global system of health governance. it is possible to view the sars outbreak of 2003 as a direct consequence of increased connectivity due to globalization in general and advances in transportation technologies in particular (brockmann, hufnagel and geisel 2005; guimera et al 2005) . in order to understand the effects of connectivity in the global city system on the health of people in these cities, it is necessary to develop new and innovative ways of thinking about what is connected in what ways in that system . there is a strong and growing consensus in the literature on globalization and health/disease that realities in a post-westphalian world need a rethinking of governance structures on a variety of scales between the global and the local (ali and keil forthcoming; fidler 2004; gandy 2005b; harris and seid 2004a; knobler et al 2004; lee 2002; markel 2004; mclean et al 2005; whiteford and manderson 2000) . in this article, we ask what the consequences of the connectivity for health governance will be. although public health policy delivery has always been an intensely local process, the "westphalian" state system had defined health policies in national containers ordered and segmented among others by world health organization guidelines but mostly under the sovereign jurisdiction of nation-states. public health was national health and health policy was national health policy under this regime. who interventions had to occur in the framework of national sovereignties, whose concern was with both popular health and economic welfare-not necessarily in this order (fidler 2004; heymann 2005; heymann interview, geneva 27 september 2005) . when sars hit major metropolitan regions in asia and north america the need to rethink both global and sub-national health governance was exposed. the reliance on the hierarchical and hermetic system of nationally based health policy was put to the test as the who attempted to carve out a novel activist role in protecting global health beyond national interests and as sub-national governments, economic and civil society players moved to react to a localized global health crisis with coordinated action of their own (abraham 2004; fidler 2004) . at both ends of the redefinition of international health governance-the local and the global-an "institutional void" (hajer 2003 ) existed which could not be filled automatically by traditional, national health governance institutions and their international affiliates. we posit that urban governance will increasingly have to deal with questions of vulnerability and risk related to eids. vulnerability to eids is perhaps more pronounced in urban areas, where the majority of us live. urbanization increases the statistical odds that microbes are being spread (pennington 2003) . the aggregation of human populations into highdensity urban "islands" has important effects in providing the host reservoirs for maintaining infection chains (haggett 1994) . accelerated land use changes in and around urban areas have heightened the vulnerability of urban populations to infectious disease (patz et al 2004) . vulnerability is a notion which in close proximity to other "essentializing" western discourses such as tropicality and development (bankoff 2001) . it refers to a state outside of the west. yet, the notion of vulnerability has taken on renewed significance after september 11, particularly in the usa, as the "sense of security of many american citizens" was punctured (simon 2004:41) . it has particular relevance to the case of sars which shattered the local public health and hospital systems of toronto, hong kong and singapore and the public perception of their safety. these cities' "globality" means that an infectious disease cannot be contained by a purely exclusive "local" strategy of public health. most vulnerability reduction policies tend to be largely limited to making safety modifications to key buildings and critical infrastructures, but the sars case illustrates that the human/cultural dimension must also be considered in the effective management of disease outbreaks in the contemporary global city. thus, isolation and quarantine did appear effective in fighting the outbreak, but what more could be done to prepare such containment strategies in case of future outbreaks in the global city? it is clear that we need to better understand the interactions of local modes of healthcare regulation in a globalized urban environment and the specific dimensions of urban vulnerability to public health threats in the global city setting (d'cunha 2003 (d'cunha , 2004 . global cities are usually considered a specific category of urban centres. they often have more to do with each other than with their immediate hinterlands and regions, and they tend to be more like other global cities than like other cities in their national networks (for an overview of the literature, see brenner and keil 2006) . as the case of sars demonstrated, global cities are not just switching stations for flows of capital and labour allegedly ordered in a tight network of privilege and command functions. they also are transfer stations of various and contradictory dynamics of the globalized economy. among them are city-country relations, connections between the developed and the developing world, even human-animal interrelations (brenner and keil 2006; sassen 2002; taylor 2004) . the sars virus is said to have travelled to toronto from hong kong through a chain of connectivities-or to use another term, an actor network-that includes the civet cat, live ("wet") animal markets, cross-border commuters across the spectrum of the labour market, hotels, transnational travellers, airports, healthcare workers, hospitals, etc. contributing factors were faulty or badly maintained aeration and plumbing systems in high-rise buildings, air travel in hermetically closed airplanes, hospital systems, diasporic relations among relatives, and so forth. at each link of this rather disparate chain, sub-connectivities are present, which we have called the capillaries of the global system: family relationships, small and parochial religious communities, more or less isolated (and even criminalized) food-handling practices, hospital hygiene codes, etc, all sub-realities of a larger global network of relationships. these subrealities are often not accounted for in descriptions of global cityness although they seem to be central to our understanding of certain consequences of globalization, such as the spread of eids. they are not just the micro versions of larger macro processes constituted elsewhere: they are co-constitutive of the global realities themselves. insofar as they belong to the larger processes of metabolism, these sub-realities are part of the ecological substrate of the global city system. we argue that it is exactly the dialectics of fixed infrastructures, built environments, institutional arrangements, reliable legal constructs, functioning hospitals (and their governance arrangements) of global cities on one hand and the unfixed, mobile, constantly re-articulated flows of people, non-human organisms, information and things that move through them, on the other. 3 recognizing this dialectic also implies the critique of functionalistic and technological images of global connectivity in fixed network nodes. we rather postulate the topological, agency-founded co-constitution of such nodes gandy 2005a; smith 2003) . urban governance has become a standard phrase in urban political studies. following jon pierre, urban governance can be defined as "the pursuit of collective goals through an inclusive strategy of resource mobilization" (2005:449). as the focus of urban scholars has moved from "the comparative study of constitutions and city charters" to decision-making processes that involve state, market and civil society actors in all areas (gissendanner 2003:663) , a broad spectrum of urban governance research has now been produced with case studies, comparisons and further theoretical developments (see, for example, brenner 2004; elwood 2004; harding 2005, forthcoming; heinelt and kübler 2005; kantor and savitch 2005; kaufmann, léautier and mastruzzi 2005; pierre 2005; sellers 2005) . north-america-centred work on urban regimes, which continues to produce excellent case and comparative studies (for a recent summary of this literature see stone 2005 ) is complemented by a strong european-centred body of work of mostly comparative nature (brenner 2004; buck et al 2005; legales 2002) . in some of the literature, the shift to governance has been discussed in relation to the globalization and neoliberalization of cities, processes which in many cases have been seen as causative of this shift (brenner and theodore 2002) , while other authors have emphasized the role governance has itself played in facilitating these processes in turn. the comparative literature on urban governance restructuring has various intersections with the rescaling of the "political pathology" of infectious disease containment (fidler 2004) as the global and neoliberal contexts of current restructuring at the urban scale have been the focus of much theoretical and conceptual work. of these intersections, the new focus of metropolitanization deserves our specific attention. brenner's central concern, for example, is with the ways in which "urban governance has served as a major catalyst, medium, and arena of state rescaling processes" (2004:174). new collective action at the city-regional level in the many traditional (e.g. economic development and social welfare) and emerging (e.g. environmental, (multi-)cultural) policy fields can be discerned in metropolitan areas around the world. public policymaking increasingly occurs at the metropolitan level as municipal and regional elites deliberately nurture this scale as the basis for international competition (boudreau et al forthcoming; brenner 2004 ). yet, there is also an emerging political space at the metropolitan scale, where collective action and claims for local democracy unfold. metropolitanization can mean an internal reconstitution of the political sphere and its articulation with civil society: "there is a diversification of local responsibilities and activities, from the production of local services to, among other things, a proactive role in economic development" (boudreau et al forthcoming) . among these responsibilities and activities may also be health governance at the urban scale. there is ample scholarship on the historical relationship between municipal government and disease both historically and on recent developments, such as the reemergence of tb, the role of urban poverty and diversity vis-à-vis disease or the ravages of aids (see, for example, craddock 2000; gandy and zumla 2003; raphael 2004; shah 1997 ). yet despite an increased interest in the relationship of globalization and disease (mcmurray and smith 2001), there has not been much attention on the specific urban governance aspects of eids in a world characterized by globalizing and global cities. we will argue accordingly that in the face of new threats to the health of urban dwellers caused both by increased technological, economic, cultural and ecological connectivity (globalization) and healthcare restructuring (neoliberalization), we need a renewed focus on the city as a place of potential or real disease and inversely as a place of health. an exception to the dearth of work conceptualizing health and disease as part of the overall governance of world cities has been the research of victor rodwin and michael gusmano (2002) on public health infrastructure 4 in new york, london, paris and tokyo. while not explicitly locating their work in the governance literature, rodwin and gusmano (2002:445) have noted: "urban health evokes contrasting images: the city as a center of disease, poor health, and enduring poverty versus the city as a cradle of historical public health interventions, innovative medical cures, and healthy lifestyles for the well-to-do". studying "urban health, particularly the evolution and current organization of public health infrastructure and the health status and quality of life in these cities" and the "important links between local, subnational, and central or federal authorities" (ibid:446) sounds familiar to students of urban governance. rodwin and gusmano have shown the impact of global cityness on localized health governance mechanisms and systems. in their work on new york, london, paris, and tokyo, rodwin and gusmano (2002:446) have examined the impacts of "world cities-their health system and neighborhood characteristics-on two outcomes: the use of health services and health status". they found, not surprisingly perhaps, great diversity in which health is factored into the overall global city formation in these four leading global urban centres. their ongoing studies on various aspects of the public health system in these cities reveal the connections between common structural inequalities and social problems in global cities with their health systems. this work fills a void in the research on global cities generally and specifically adds to our understanding of the impact of globally induced social inequality-ie global city formation-on health. it also has the added benefit of being able to help us differentiate between the various health governance systems in cities as diverse as london, paris, new york and tokyo both in their centres and peripheries. rodwin and gusmano have identified four distinct "onerous health risks", which global cities such as toronto, hong kong and singapore confront: the re-emergence of infectious diseases; rising inequalities among social groups; barriers in access to quality healthcare by ethnic minorities and/or the poor; and terrorism and bioterrorism (2002:449). all four themes stretch the notion of the city as a defined territorialized place. they point to cities as sites of topological relations that articulate activities and dynamics at various scales (amin and thrift 2002) . they define, to a large degree, the agenda of global city health governance. yet, as much as rodwin and gusmano's own research sheds light on the place-related aspects of health, it does not itself deal with the network-related aspects of health which is the aspect emphasized in the current article. we suggest adding two important dimensions of the analysis which we believe increase our understanding of the role of urban health governance in the fight against eids. first, the governance of cities today is unimaginable without the modern constitution of the "bacteriological city" at its base (gandy 2005a, forthcoming) , which created managerial processes of a technological, engineering and scientific nature to guarantee public health and to lay the foundation of an economic development and demographic growth ostensibly unencumbered by the incalculable onset of disease outbreaks, which had wrecked urban populations and their economies until the twentieth century in europe and north america. it is on the basis of this century-old history that we now need to rethink urban health governance. a historical process of purification separated the modern city from its natural environments through a set of infrastructures and mechanized metabolic processes such as water and sewer infrastructure, garbage collection and processing, etc (kaika 2004 ). the "bacteriological city" as matthew gandy (2004 gandy ( , 2005a has called the city of the twentieth century, was based on an entirely human-centred purified science, which "othered" animals, externalized disease and-in extreme caseseliminated "less-than-human" humans through technical ingenuity and government biopolitics (foucault 1999) . the bacteriological city kept the germs in check and allowed for new types of socially cohesive urban relations to take shape: "the emerging 'bacteriological city' involved a medley of different social, political, economic and environmental goals set within the context of a movement away from fragmentary and laissez-faire approaches to urban governance" (gandy 2004:367) . this rationalization of urban governance via technologically reliable networks was based on a universalist interest in public health advances. the currently popular "neoorganicist" view of the city, of which the materialist notion of the cyborg city is a critical extension, puts a new spin on the tradition of the bacteriological city. it has been strongly associated with a transhumanist view of our urban reality, in which, as bruce braun observes, "'barely human' others (iraquis, rwandans, muslims), and 'almost human' companions (monkeys, dogs and cats), are discussed alongside accounts of 'inter-species' exchange (bird flu, sars) in which the boundaries of the human are suddenly porous and mobile" (2004:269). such mixing clearly has consequences for governance as the carefully guarded distinctions between people and germs, materialized in the modern bacteriological city, are now being challenged unexpectedly. as a consequence, we now need to figure out collectively where to draw the kinds of regulative boundaries, which we humans may need to survive the imagined or real onslaught of the germs. and such defensiveness is most likely tied up with the regulation of bodies-human and nonhuman-that carry or are suspected to carry the disease. technically, while not necessarily ethically, the sacrifice of millions of ducks or cattle as a reactive of preventative public health measure, is the same kind of measure as airport screening for foot and mouth disease and sars and quarantine of suspected bodies in cities. braun challenges us to think that it is: possible to understand cities, for example as "posthuman" assemblages in ways that both vastly expand our understanding of the actors shaping the urban experience, and that confound our usual understandings of the space and time of urban life . . . writing the sars virus into a "posthuman" toronto explodes the time-space of the city, folding people and animals in china and thailand into bodies on queen street, and revealing time to be multiple and rhythmic-the time of circulation of people and capital but also molecules (2004:273). lastly, disease and health have important impacts on the rearrangement of the governance of public/private space. hospitals, quarantine, cultural spaces are fundamentally reassessed and their place in the order of public and private everyday lives and official geographies is recalibrated: what is acceptable in terms of use of space by various bodies in cities? our argument is that while purification and biopolitics were the characteristics associated with the hygienic city of the last century, we have now entered a phase in which the potential reemergence of infectious disease at a mass scale forces us to rethink the relationship of our built environments, our institutional arrangements and our practices as urban dwellers. this has to do as much with the changing nature of cities as basing points of the global economy-to use quite a conventional concept from global cities theory-as with the kinds of reemerging diseases we now have to deal with. second, it is necessary to extend our view beyond the national institutional level when looking at the governance of eids in cities, as extra-national organizations such as the atlanta centers for disease control (cdc) and supra-national organizations such as the world health organization (who) exert significant influence on urban health governance in any country, sometimes not even mediated through national policy or institutions (fidler 2004; heymann 2005) . in a global perspective maarten hajer has noted a particular "institutional void": [m]ore than before, solutions for pressing problems cannot be found within the boundaries of sovereign polities. as established institutional arrangements often lack the power to deliver the required or requested policy results on their own, they take part in transnational, polycentric networks of governance in which power is dispersed. the weakening of the state here goes hand in hand with the international growth of civil society, the emergence of new citizen-actors and new forms of mobilization (2003:175). municipal public health policy emerges in a context of larger-scale dynamics over which it has little control. global cities and city-states such as toronto, hong kong and even singapore are burdened with responsibilities due to their rising integration into world city networks on one hand and continued lack of self-determined decision-making powers for their complex jurisdictions on the other. in addition, cities like toronto are tied into an increasingly diverse global network of diaspora and migrant cultures at the base of their hybrid globality (goonewardena and kipfer 2005) . the connection between the globalizing political economy and the cultural and demographic changes it brings with it are crucial to understanding the everyday practices and socio-cultural interactions that characterize today's world and more specifically the everydayness of global cities. toronto-like other cities in the global city network and elsewhere-has taken on far-reaching responsibilities for the settlement of immigrants. this has become a central concern of metropolitan governance now. as in past waves of immigration, cities have become the actual border points for new immigrants. it is important to remember, as nicholas king has reminded us, that under these circumstances, "researchers and public health officials would do well to think in transnational as well as international terms. this means focusing less on the transgression of borders by individuals, and more on the formation of transnational connections between spaces and populations once thought to be disconnected or insulated from one another" (2003:53). of course, urban governance is just a fraction of an overall system of health governance, which in the words of fidler (2003) now has to deal with sars as the "first post-westphalian pathogen". 5 fidler also reminds us that as sars represents new problems for public health and creates the need to develop diagnostics, treatments and vaccines in the context of globalization, it breaks down both the sub-national and international framework in which public health has been governed for more than 100 years. in particular, the sars outbreak posed a threat to commonly held views of national sovereignty which allowed nationstates to deal-vertically-with their own health systems internally while negotiating (ideally) at par-horizontally-with other nationstates internationally. the experience with sars points to an interesting dialectics: the existing system is both corroded and withstands the onslaught of the virus. speaking about the us, fidler states, "federalism constructs political borders between federal and state governments. germs no more recognize these borders than they recognize international borders. federalism does not, however, disappear as an influence on public health governance simply because germs do not recognize the boundaries it creates" (2003:486). fidler's "political pathology" is pivotal for the understanding of the parameters of health governance today. he carefully charts the landscape of international and now global health governance since the nineteenth century, when the first international sanitary regulations were drawn up among the great powers of the world. 6 these efforts eventually led to the creation of a world health agency, the who, which has operated on a set of tenuous global regulations such as the international health regulations, which have recently undergone redrafting to reflect the specific challenges posed by the fight against sars (fidler 2004) . the weakness of fidler's otherwise sharp analysis is that it focuses only on one direction of the rescaling of international health governance towards the global level. in answering the question "how to manage borderless bugs in a borderless world", fidler concentrates on the role of new global institutions as well as new non-state actors in the health field. both, he correctly states, narrow the traditional sovereign spaces of health policymaking, even of large states such as china which-begrudgingly-ceded some of its authority to the who during the sars crisis after initially lying to the world about the severity of the disease in its provinces and in the nation's capital. the who emerged as a stronger and more recognized player from the sars crisis and established, for the first time and if only briefly, a global community of eid management (fidler 2004:126; heymann 2005; preiser 2005 ). fidler does not engage with other forms of the rescaling of the westphalian state system such as the one brenner has defined as "metropolitanization" (brenner 2004) . we have been arguing throughout this article that this metropolitan scale of governance deserves more attention in the regulation of an urban-based global reality. in fact, as the former director general of the who underlined, "who officials every day deal with local communities and officials, around the world" (brundtland, email interview 1 november 2005). although, in the past, cities have often been directly blamed or linked to disease (gandy 2003:18) , this pattern was supposed to have been superseded by the modernity of the cities themselves. until not too long ago, cities in the west were considered free of catastrophic disease of the traditional epidemic kind. thomas osborne and nikolas rose noted only as recently as 1999 that we could observe a shift from a focus on disease to a focus on health in the governance of cities: the city has long been imagined in terms of sickness and health. but in recent decades a new image of the healthy city has emerged: the city as a network of living practices of well-being . . . the very idea of disease in the city has been transformed. it is no longer imagined in epidemic form-the invasion of the urban milieu by cholera or typhus putting its inhabitants at risk of infection. rather, disease and ill health more generally, is imagined in terms of activities (diet and coronary heart disease . . .) and relationships (unsafe sex and hiv . . .). we no longer have the sick on the one side of a division, the healthy on the other-we are all, actually or potentially, sick, and health is not a state to be striven for only when one falls ill, it is something to be maintained by what we do at every moment of our everyday lives (1999:752-753). recent developments in the wake of sars but also scenarios following a potential outbreak of an epidemic of either a new flu strain or a human form of the avian flu have belied the disappearance of epidemic disease from the urban experience as expressed in this quote. not only is it not true for most cities in the world where people keep being threatened by infectious disease pandemics of all kinds, it is also not true for western cities anymore as sars has shown in utmost clarity. we do agree with osborne and rose, though, when they point out that the governmentality that regulates disease has shifted from the collective to the individual. 7 this is a major biopolitical shift which is mostly played out on the level of urban governance. this interpretation coincides with other work on the changing nature of public health (petersen and lupton 1996) , which argues that health and disease have been recast as individual responsibilities rather than social ones in the contemporary period [see also sanford and ali (2005) for an elaboration of this argument with respect to sars]. it is exactly this-neoliberalgovernmentality of individualized notions of health and sickness which existed when sars arrived. it is in this framework that we have to understand the new thinking and agency around infectious disease in the city. it adds to the general shift in the current city from traditional notions of control in favour of a more clearly orchestrated mix of state and market interventions. public health governance in the age of sars has-at least potentially-moved to a bundle of strategies that fit well into the overall securitization of urban society which includes "enhanced forms of social control through a mix of architectural, ideological and intelligence-gathering processes" (gandy 2005a:33) . in addition to these developments towards a new governmentality of public health, the sars crisis occurred in a very specific environment, which had been created by the events that followed the attacks on washington and new york city on september 11, 2001. shortly after september 11, 2001, american vice president dick cheney was reflecting on what he called a "new normalcy", a notion that was used widely at the time to legitimize changes to long-held understandings of the social and legal makeup of american society (lawyers committee for human rights 2003). legal scholars and practitioners as well as political pundits and activists of all stripes pondered the meaning of the "new normal" and pointed to the deterioration of basic human and civil rights in the aftermath of the september 11 and subsequent war-related events. "living" in the "new normal" became an object of serious study (simon 2004) . a legal study examined such changes in the areas of "government openness; personal privacy; immigration; security-related detention; and the effect of us actions on human rights standards around the world" (ibid). while admitting to the necessity of some government action in the wake of 9/11, the report notes "dramatic changes in the relationship between the us government and the people it serves" and voices many grave concerns about the deterioration of civic and individual liberties. beyond its immediate denotation with respect to the changing times after 9/11, the term has since thrived as a powerful (if somewhat clichéd) metaphor that has been bandied about in all kinds of contexts. and despite the clearly problematic context in which "the new normal" was introduced into the political and vernacular vocabulary-or perhaps precisely because of the implications of this context-the term found a wide use in toronto's sars outbreak of 2003. during the crisis politics of the day, particularly in the healthcare system itself and among the politicians involved, "the new normal" quickly became the buzzword for an overall state of emergency that gave policy actors and decisionmakers license to make unprecedented changes and to call for reform of major threads of the social fabric, particularly in the area of public health. the "new normal" became the umbrella term for a situation in which thousands were put into quarantine (or if they resisted into isolation), and nurses-many of whom were infected themselves-were missing from understaffed hospitals, at a time when the overall system of healthcare delivery was admittedly about to "snap" (boyle 2003) . one of the main users of the concept was the ultra-conservative minister of health for ontario, tony clement, who, for a moment, surfed on the popular wave of the giuliani-brand "roll-up-your-sleeve" and "openshirt-collar" politics of emergency, which swept him into the public spotlight in the spring of 2003. clement became the public face of a social crisis which had repercussions for much more than health policy per se, and touched on issues involving labour relations, "race" relations, multiculturalism and much more. the "new normal" soon became the yardstick for all these types of issues. for instance, in a dispute with nurses about the lack of full-time positions and the potential change to the funding formula, clement said on 6 may 2003: "in the 'new normal' those kinds of things would have to be reviewed through the prism of infection control". 8 around the same time, clement's ministry issued a "backgrounder" in which the "new normal" was "characterized by high standards of practice that reflect a heightened awareness of emerging infectious diseases including sars" and where there is mention of a "'new normal' environment", in which healthcare workers are meant to operate. 9 one set of directions for the faculty of medicine at the university of toronto dated 2 june 2003, stated self-reflexively: the term "new normal" has already become a bit hackneyed in the face of a second wave of sars in toronto. nonetheless, it is a useful term to encapsulate the change in thinking that may be necessary if we are to achieve longer-term containment of sars and any similar illnesses that may come at us in the future (http://www. library.utoronto.ca/medicine/sars/sarsupdate.pdf; emphasis in the original). at other scales, a toronto family doctor, for example, used the term in a "sars diary" she published in a professional journal and concludes, after relating her ordeals of operating under conditions of quarantine: "i guess this is the new normal i've been hearing about" (greiver 2003 ). yet another voice was the director of the reputed american centers for disease control in atlanta, julie geberding, who referred to diseases like sars and monkeypox as the "new normal" while addressing a meeting of the american medical association in chicago in 2003. 10 the connection of the "new normal" to state protocol in its dealing with citizens in an anti-terrorist effort is neither surprising nor unintended by those who make the link. the very notion of the "new normal" signifies the intrusion of unusual measures in our everyday lives, in which leaders have to be cut slack in making decisions about political rule, when regular law and understandings of rights become irregular or non-normal. the invocation of legitimized state violence-be it in anti-terrorist war or in imposing quarantine on groups within an urban community-through the concept "new normal" is itself becoming an accepted part of what we consider tolerable. the "new normal" changed both the horizon of expectation, which citizens, users of the healthcare system, travellers, etc may have had and the potential range of action for governments in dealing with the crisis. it has led, at a remarkable rate, to a lowering of democratic potential in the making and practice of policy, in this case health. the rights of both patients and healthcare workers were considerably cut back during the toronto sars crisis. this is true precisely because the crisis transformed a group of previously relatively obscure public health officials and politicians into a group of well-known leadership personalities-donald low, marcia taylor, doris greenspun, colin d'cunha, sheila basrur, tony clement, james young-who took care of democracy while it was dormant in the shadow of the "new normal". this "decisionism with a populist face" was an interesting development not in tune with the zeitgeist of moving from government to governance. it was, however, very much in line with the notion of "performativity", 11 as sars and the crisis it brought to urban society, was "performed" by more or less media savvy actors, who were always only minutes ahead of the general public and the press as the epidemic progressed and ultimately subsided. at the other end of the spectrum of agents "performing" the sars crisis was the ill-fated and pompous appearance of toronto mayor mel lastman on cnn at the occasion of the who's travel advisory against toronto. lastman, ignorant of the context of global health governance in which "his" city found itself and apparently unfamiliar with the who, spouted out venom against the un organization which, in his eyes, unduly interfered with toronto's self-governance. 12 these actors/agents were put on stage by the arrival of the virus and they played "crisis" and invented a new mode of governance as they went along. while they were by no means unprepared for the epidemic, public officials joined regular citizens in performing a disease that no one yet knew. through the ways citizens and experts in toronto (and singapore and hong kong and elsewhere) performed the disease, the world learned about sars. it seems that the "institutional void" hajer (2003) sees emerging in this context was filled, at least on an ad-hoc basis, by rapid policy change in an emergency situation created by the potentially catastrophic threat posed by sars. the ideological precepts of the "new normal" enabled the state to reassert itself as an active participant in public life after neoliberal reforms in ontario had stripped its involvement in many areas of public welfare to the bare minimum and to reinsert itself with some legitimacy in a policy community which had learned to not trust a government that had de-funded public institutions such as healthcare and education at an unprecedented scale (keil 2002) . this kept the ontario government "in the game" at a critical time-at least until such measures were challenged by the general public, healthcare workers' associations, patients and their relatives and the press. 13 the loss of clear boundaries for jurisdictions is, of course, a direct outgrowth of global city formation and the growing incapacity of the (local) state in particular to deal with crises visited upon an urban region by its growing internationalization (friedmann [1986 (friedmann [ ] 1995 . the growing challenge presented by global city formation to the fiscal and institutional capacity of the local state is exacerbated by the processes invoked by hajer but also by the ongoing re-scaling of political spaces in a rapidly changing world. specifically with respect to global cities, it has been noted that conceptually and pragmatically the business of municipal politics as well as the conduct of everyday life has been both de-localized in profound ways through economic and cultural globalizations, and re-localized through the idiosyncracies of topologies, which bring together the myriad social connectivities in the microcosms of the world's urban centres (smith 2003) . urban health governance is embedded in a larger system of urban governance with its vertical and horizontal ties to other levels of government and into civil society and the private sector. urban governance in toronto had been characterized by the city's forced amalgamation in 1997, which initially changed the landscape of public policy significantly towards a more competitive, coercive and stratified environment. this coincided with fundamental changes to municipal politics and internal governance processes as the city has been trying to establish a sense of harmonized "good government" and civic engagement after amalgamation. the outcome of these processes was contradictory: on the one hand hardcore neoliberal reforms were rolled out and downloaded by the tory provincial government between 1995 and 2003 and often followed through by a conservative and boosterist mayor mel lastman who was unapologetically the spokesperson of an aggressive business lobby and particularly the development industry; on the other hand, progressive politicians at the municipal level with the support of a continuously active social and environmental movement sector, the public sector unions and an electorate which had not forgiven the tories for their attack on toronto political traditions. the result of these contradictions was that urban governance in toronto at the time of the sars outbreak was split as continued reform in the municipal administration, and certain "forgotten" policy areas such as food, homelessness the environment-and public healthcompeted with neoliberal development mantra of a business elite which began to use the newly amalgamated city as their strategic terrain for interurban competition. inside the municipal administration, departmental restructuring and harmonization had led to insecurity, at least temporarily, as to the procedures and substance of urban policy when political cultures of suburban jurisdictions were melded with the downtown's more progressive, democratic traditions, which had led to more sustained rights claims of more diverse populations. this progressive city/conservative suburb split in the geography of toronto's urban governance was challenged by the new immigration and settlement patterns, which made suburbs more diverse than the inner city and the inner city potentially less dynamic politically than the multiculturally invigorated suburbs. during the time of the sars outbreak, this shift complicated matters significantly as the crisis was played out in geographic and social areas of the city-scarborough and north york-which remained largely terrae incognitae to the old toronto elite. the sars crisis intersected with business as usual in urban governance in as far as it was recast quickly from a health crisis to an economic crisis once the worst of the outbreak was over. the worry among toronto politicians and business people over lost business in tourism and entertainment fell in line with the usual propensity of urban officials and civic leaders to heave their city above its competitors in economic development, cultural creation and tourist attraction. in this sense, the sars crisis interfered with the strategic goals of the governing regime of toronto and the governing institutions that had created their success. the peculiar balance of social, economic, environmental and state interests in elite and popular circles that made up the governing coalition of the urban region was threatened by sars, which was contextualized in a series of setbacks for the region's economic progress and civic self-esteem, the loss of the bid for the 2008 olympic games to beijing in particular. the question was how these changes contextualized health governance in a time of crisis. the institute on governance defines health governance in canada as follows: in canada, the governance of healthcare is built on intergovernmental cooperation, reflecting a formal division of powers regarding healthcare as outlined in the canadian constitution and the charter of rights and freedoms. in addition, governance of healthcare also takes place outside the governmental sphere. this complexity requires organizations, sectors, regions, first nations communities and governments to forge capacities to govern (http://www.iog.ca/ knowledge areas.asp?pageid=23, accessed 1 november 2005). the institute proceeds to define the most pressing healthcare challenges in canada as follows: • critically assessing the alignment of health governance structures and processes with best practices. • reframing the understanding of governance as expanded beyond an individual institution to include mutual accountabilities among providers. • building ways for health providers to share information and work in a complementary way. • strengthening boards of directors, particularly in hospital governance. • building stronger relationships between voluntary sector organizations and government and between the various levels of government, including first nations (ibid). while clearly open to the complexity and multi-scalarity of health governance, this list of priorities is also characterized by a glaring absence of any reference to the role of cities in health governance. this absence is two-fold. there is, on one hand, the traditional obscurity that municipal politics suffers in the canadian state architecture (keil and young forthcoming); on the other hand, there is a more general eclipse at work here which disregards or even dismisses the role of urban governance in the management of societal matters in a post-westphalian world. we believe, though, that urban public health authorities and their associates in local hospitals, urban non-state actors in the health field as well as workers in urban medical settings have played an important role in the detection, identification, monitoring and fight against eids in particular (interviews july to december 2005: toronto public health official, associate medical officer of health-toronto, university hospital network official, microbiologist-in-chief-toronto hospital, ontario nursing association official, public safety and emergency preparedness canada official). they have provided the core responsibilities of public health-assessment, policy development, assurance-often without support and sometimes in conflict with and in contradistinction to higher level health authorities (rodwin and gusmano 2002:446 fn). one analysis revealed about the ontario situation during sars: the province of ontario was ill-prepared to deal with an infectious disease threat on such a scale. in canada, the provision of healthcare, including public health, is a provincial responsibility. however, the financial and operational responsibility for public health had increasingly been shifted to municipalities such that, at the time of the sars outbreak, funding was shared equally between the two levels of government. this funding shift created a decentralised public-health system, with the province's 37 public-health units operating quite independently of each other (lim et al 2004:697, emphasis added) . sanford and ali (2005) have documented aspects of "new public health hegemony" in the response to sars in toronto. they specifically argue that there has been a mix of old and new measures at various scales that was pervasive and that overall a new hegemony around new epidemiological techniques, risk management, morality and security took shape. extending this work to the specific context of urban governance, a number of preliminary observations can now be made in order to characterize the urban health governance challenges identified in toronto during and after the sars outbreaks of 2003. the urban health governance system experienced a very specific set of pressures, which spoke to the kinds of fundamental decisions that have to be made by urban-scaled and municipal authorities in a moment of epidemic disease. affonso, andrews and jeffs (2004:573-574) have perceptively identified three sets of paradoxes that led to three sets of dilemmas in the governance of the sars outbreak. these paradoxes/dilemmas were, first, that healthcare workers became sources of transmission and active sustainers of the sars case matrix (leading to the dilemma to be forced to decide whose safety gets priority: patients or caregivers?). second, hospitals were sources of sars infection in the community, breaking down the boundaries of medical care and community in threatening ways (leading to the question of how far do providers of healthcare have to go to provide safe spaces?). third, a culturally and ethnically diverse city may be particularly vulnerable to infectious diseases (prompting the question about the relationship of civil liberties and disease control). in terms of urban governance, these three couples of paradoxes and dilemmas denote spatio-institutional uncertainties of a new kind, which challenge traditional modes of integration and regulation of economic institutions (labour markets/work places), specialized functional spaces (hospitals), public institutions (public health agencies), codified private behaviours (patient versus citizen rights), etc. in an urban governance model, questions need to be directed at the particular ways through which state action (public health, security, etc), private sector involvement (providers of masks, medical equipment, drugs, etc.) and civic organizations (ethnic initiatives against racism, protection of workers' rights, etc) and individual civil rights claims (patients, quarantined individuals, travellers, etc) are coordinated by whom, at what scale and with what procedural democratic means. affonso, andrews and jeffs (2004) make a number of incisive and plausible recommendations as to how to improve health governance in future outbreaks of the kind endured in 2003 which centre around patient safety and workforce safety, spatial profiling and risk assessment, as well as community mobilization (2004: 574-577) . it is important to note in the context of the question of urban governance before us that each of these intended measures would have a tangible impact on the day-to-day business of governing cities through democratic political rather than managerial-administrative processes at the municipal level. the core dilemmas these processes would face in the reality of current canadian municipalism is first the lack of autonomy local agencies have in the face of an unreformed federalism, which sees cities (and their institutions) as mere units of the administrative state (of the province and canada) and not as political decision-makers on their own terms; and second the tremendous weakening of lower state and governance structures-often despite rhetorical statements to the contrary on the effect of devolution and subsidiarity-in the face of the globalization and neoliberalization of the canadian state, including the increasing porosity towards supra-national institutions such as the who. we have some evidence on how the local state institutions in toronto themselves saw the crisis and what lessons they suggested to draw from it. the former provincial medical officer of health, colin d'cunha 15 (2004) , detailed the various lessons learned from the outbreak, mostly through the lens of health reporting. the provincial scale is extremely important in the canadian system where municipalities are dependent on upper level policy frameworks and financing without much autonomy for local agencies and institutions. urban governance is severely constricted and clearly defined by this situation. while the municipal state may also be the most politicized of the three levels of government, it remains under the tight supervision of the province in particular and while state expenditures have risen consistently since the 1950s in the federal and provincial governments, municipal funds have not kept pace with the demands placed on them through decades of downloading and devolution (villeneuve and séguin, 2000) . d'cunha, whose provincial agency was responsible for 37 local health units in ontario, notes in particular that the reportable disease information system in place when sars hit, had been introduced in the 1980s. a new system of reporting, the integrated public health information system (iphis), although available since early in the century, was only to be implemented in the spring of 2003 and was further delayed through sars. the provincial level system of surveillance was tied in with the global public health intelligence network (gphin). the provincial health protection and promotion act (hppa) makes mandatory disease reporting and control. it was amended after the sars crisis to empower the province to facilitate isolation of infected individuals (d'cunha 2004) . d'cunha's office was also left in dire straits in the wake of serious de-funding of public health institutions at the provincial level under a tory government after 1995. the provincial health authority appeared very much like an empty shell which had coordinating functions of local authorities but could not muster the resources to do a good job giving direction and provide credible leadership to municipal and regional agencies (interview, associate medical officer of health-toronto, october 2005) . in the context of this legal and institutional framework, local-scale health agencies do their work. 16 sheila basrur, the former municipal officer of health, and co-authors have noted that the main roles of toronto public health during the outbreak were case investigation and management, identification and quarantine of contacts, disease surveillance and reporting, health risk assessment and infection control advice to health institutions and other community settings (basrur et al 2004:22) . the sars crisis posed a significant stress on the already severely compromised public health system of toronto as other public health services were cut or reduced to "essential services only" (ibid:23-24). the kinds of measures under the responsibility of the municipal public health hegemony reflect the temporally layered and overlapping traditions stemming from the "bacteriological city", updated and redefined through more recent developments. the point to note in this respect is the often confusing unevenness in measures from various periods, phases, and moments of urban governance, which were haphazardly re-grouped into a recombinant mix of place-specific sets of trials and errors. while the coercive and enabling qualities of an existing municipal public health system were tested daily with unexpected twists in the proliferation of the disease, a new administrative reality emerged in the shadow of the successes and failures of an iterative policy process. cases of temporal unevenness were, for example, the deployment of quarantine and isolation orders for the first time in 50 years (with no living administrative memory of and hence no experiential knowledge with such measures in the system) and the much younger (but failing) 14-year-old provincially authorized surveillance system (which had not kept pace with both technological advances and procedural necessities that had occurred since its inception) (basrur et al 2004) . the unevenness here related in both cases to the fact that two measures at two ends of a developmental scale in public health measures-the rather traditional and rather blunt tool of the quarantine, and the biopolitical, yet informationalized surveillancewere potentially at odds with the constituencies and clienteles they were meant to protect (and whose general rights sensibilities were a far cry from the mid-twentieth century) 17 and, in the case of the failed surveillance, certainly not up to the challenge that the sars outbreak posed. one influential way to understand the local state is to see it as a sphere of influence of both the state and civil society (kirby 1993; magnusson 1996) . civil society is dramatically redefined in the context of the "new normal". in the immediate crisis in the spring of 2003, it became rapidly clear that the "new normal" was not just a rewriting of a few hospital protocols and ministry directives. in true fashion of creating a new "governmentality" through new "technologies of power" in the foucauldian sense (osborne and rose 1999), the "new normal" became a new standard of societal interaction overall, accepted and even disseminated by the "normalized" everyday actions of urban residents, and the yardstick of urban governance. as we are writing this, toronto is going through emergency preparedness week, which calls on everyone to do their part in putting obstacles in the way of harm. the event organizers are clear that they expect citizens to do their part when taking in exhibits under "the theme 'what are your reasons for being prepared?' the city's exhibits will help toronto residents increase their awareness of emergency-preparedness issues and answer this question for themselves. residents will have the chance to speak with representatives from the city's co-ordinated emergency response teams, view emergency equipment, and pick up important personal emergency preparedness literature" (http://www.toronto.ca/wes/ techservices/oem/index.htm, accessed 8 may 2007). while civic duty is part of the overall deal, awareness of the possible pitfalls of running a society on an emergency mindset are also part of the public debate. gro harlem brundtland's powerful statement that "with globalization, a single microbial sea washes all of human kind" (quoted in harris and seid 2004b:13) stands as a starting point of our considerations here. like brundtland, who was the director general of the who during the sars crisis, "hundreds of thousands of men and women around the world devote their working lives and intellectual creativity to protecting our health" (markel 2004:210) . that they do this in a wide variety of institutions-state and non-state; private sector and civil society basedand that they are crossing boundaries of disciplines and professional practice all the time, is an important insight: the crisis of the nation-statebased system does not lead to a simple replacement of the international by an elusive global system of health governance. instead, it is the conviction that undergirds this article that certain re-territorializations are key to the reworking of health governance globally. leading science journalist laurie garrett wrote in her prescient betrayal of public trust (2000:567) that "[s]afety . . . is as much a local as international issue. in public health terms every city is a 'sister city' with every other metropolis on earth". particularly "metropolitanization" is of great consequence as urban areas have been in the centre of re-emerging diseases such as sars and tb. on the basis of evidence from the 2003 sars outbreak in toronto, canada, we have argued in this article that more attention needs to be paid to the changing relationships of urban governance and (re-)emerging infectious disease. towards that end, we specifically looked at two dimensions of urban governance during the sars crisis. first, the way the legacy of the "bacteriological city" was reinterpreted in the sars crisis; second, the way in which the local health governance was embedded in a "post-westphalian" order of health governance. through reading these two dimensions against one another, we have discussed how urban governance-under potentially lasting conditions of the "new normal"-must face the new (or reemerging) challenge of dealing with infectious disease and that global health governance may be better off by taking the possibilities that lie in metropolitan governance more seriously. the toronto case study has revealed a rich casebook of evidence on how state institutions at various scales from the global to the localin constant interaction with civil society and economic actors-have shaped a new modus operandi in how to deal with infectious disease threats in a globalizing environment. not only have cities played a major role as sites and conduits of disease, they have also picked up their share of participating in new forms of governance that brings the (local) state back in. having said that, however, we also showed that both concepts-city and state-are becoming perforated as the "institutional void" around emerging infectious disease corrodes firm boundaries between jurisdictional responsibilities of territorial states and city regions. while sars pricked the skin of the global city system and showed the relative permeability of the westphalian nationstate order by germs, it reconfirmed a certain rigidity of borders (both external and internal) for human mobility. as global health governance made airports biopolitical switching stations and public health officials reverted to quarantine and other measures of sequestration, the state reaffirmed its power in no uncertain terms. as in the early days of the bacteriological city, when municipal administrations created a physical and social infrastructure of hygiene in the struggle against epidemics, urban governance gets assigned new responsibilities ranging from flu preparedness to surveillance once again. but the city is not what it used to be. in an age of heightened urban unboundedness our image of cities is recast "as nodes that gather flow and juxtapose diversity, as places of overlapping-but not necessarily connected-relational networks, as perforated entities with connections that stretch far back in time and space and resulting from all of this, as spatial formations of continuously changing composition, character and reach" (amin 2004:34) . the new politics of place that amin sees on the horizon in this new world of perforated urban spaces now also has to take into account the politics of infectious disease we have discussed in this article. endnotes 1 sars is caused by a coronavirus, which is assumed to have moved through zoonotic infection from civet cats in southern china to rural and urban human populations there, and subsequently to urban populations in several large, globalizing cities around the world, with beijing, guangzhou, hong kong, singapore and toronto among the ones that were affected most. in the canadian metropolis toronto sars claimed 44 lives in two consecutive outbreaks, as 213 people were confirmed infected cases, and thousands were quarantined. the economic fallout of the outbreak was tremendous as entire economic sectors-tourism, film, etc-suffered huge losses from which they have just begun to recover two years later (abraham 2004; fidler 2004; mclean et al 2005) . 2 we have discussed these connections in greater detail in where we have brought foucault's work to bear on an analysis of racialization of the sars outbreak in toronto; see also sarasin (forthcoming) on this subject. 3 this dialectics is different from but related to the one that gandy refers to when he points out the "devastating disparities between the mobility of capital and labour that condemn much of humanity to economic serfdom" which exist in the shadow of the "connections, networks and flows" which some see as characteristic of our current society (gandy 2005a:32-33) . 4 defined as "the capacity of local officials to perform the core functions of public health": assessment, policy development, assurance (rodwin and gusmano 2002:446 fn) 5 "'westphalian' refers to the governance framework that defined international public health activities from the mid-nineteenth century" based on the political logic of sovereign nation-states that had come into existence after the 30 years war (fidler 2003:485-486) . 6 we are grateful to one of the reviewers who correctly pointed out that concentrations of disease in pre-industrial port cities had already led to internationally agreed-upon practices of disease control such as quarantine. we have reviewed this history in ali and keil (forthcoming). 7 in canada, the healthcare system has long been seen as a major area of neoliberalization. we have seen the privatization of healthcare delivery that has potentially damaging effects on the model of social solidarity which underlies that country's medicare system. at the demand end of the neoliberalization and privatization of healthcare, individuals are now more likely to be held responsible for their health and to pay for services needed to address health issues. there is a large critical literature on this in the public domain, of which these are good examples: "canada needs a public health care system" (canadian dimension 30 august 2005) and gindin et al (2005) . http://www.health.gov.on.ca/english/providers/program/pubhealth/sars/docs/new normal/dir bg077 051803.pdf, accessed 25 february 2004). such measures were, for example, publicized widely on the website of the university health network, http://www.uhn.ca/home/sars/. 10 cdc director warns sars, monkeypox are the "new normal", reported on wane-tv, http://www.wane.com/global/story.asp?s=1326536, accessed 25 february 2004. she also was paraphrased as saying that "world travel has become common" that "anti-terrorism efforts have helped public health officials prepare for the infectious disease threat" and called "sars a very sobering reminder of the global community people share". geberding made similar comments on cbs television's early show on 17 june 2003, http://www.cbsnews.com/stories/2003/06/17/ earlyshow/health/health news/main558986.shtml, accessed 25 february 2004. 11 "performativity" is inspired by the definition of "performance/name of action" proposed by bruno latour (1999:308) , meaning that an "actor does not yet have an essence. it is defined only as a list of effects-or performances-in a laboratory. only later does one deduce from these performances a competence, that is, a substance that explains why the actor behaves as it does". 12 mayor lastman was interviewed on cnn by aaron brown on 24 april 2003 and displayed stunning ignorance of the who, its purpose and powers (the globe and mail 2003:a8). 13 a similar chain of events occurred when the ontario government, after making much noise about privatizing electricity supply and provision, stepped into the blackout crisis of 14 august 2003. after having lost all credibility earlier that year in questions of electricity, the ensuing crisis mode allowed premier ernie eves to appear on newspaper front pages as a strong leader who gets things done and problems under control. 14 this section is based on boudreau et al (forthcoming), keil (2002) , keil and boudreau (2005) , keil and young (forthcoming) , kipfer and keil (2002) . our research in toronto benefited greatly from interviews with the following experts: bannerji a, toronto, 8 march 2005; booth c, toronto, 17 january 2005; finkelstein m, toronto, 28 october 2005; gardam m, toronto, 4 november 2005; low d, toronto, 11 november 2005; macdonald v, toronto, 16 september 2005; young j, toronto, 9 december 2005. 15 d'cunha was removed from the position he held during the crisis because many considered his performance during the crisis as incompetent and insufficient. he was replaced on 16 february 2004 by sheila basrur. 16 for a comparative chinese perspective, see hongyi (2004). 17 it must be noted, however, that canadians on the whole are less civil liberties conscious than most americans. collective necessity and public security often trumps concerns over individual freedoms in canada. whether it was the war measures act during the october crisis of the 1970s when tanks rolled in montreal or in current public opinion about stricter security measures in the "war on terrorism", canadian pollsters have consistently found strong support for "stability and security" (clark 2005) . twenty-first century plague: the story of sars the urban geography of sars: paradoxes and dilemmas in toronto's health care homo sacer: sovereign power and bare life global cities and the spread of infectious disease: the case of severe acute respiratory syndrome (sars) in toronto ) pandemics, place, and planning: learning from sars 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infections diseases of globalization: socioeconomic transitions and health governing cities: notes on the spatialisation of virtue unhealthy landscapes: policy recommendations on land use change and infectious disease emergence too much fuss? hugh pennington on the sars virus the new public health: health and self in the age of risk. thousand oaks: sage pierre j (2005) comparative urban governance: uncovering complex causalities presentation at conference "invisible enemies the world cities project: rationale, organization, and design for comparison of megacity health systems powers of freedom: reframing political thought the new public health hegemony: response to severe acute respiratory syndrome (sars) in toronto re-placing the nation: an agenda for comparative urban politics public health and urban development: the plague in surat world city topologies looking back to look forward: reflections on urban regime analysis world city network: a global urban analysis power and decision-making in the city: political perspectives global health policy, local realities: the fallacy of the level playing field this research has been generously supported by a social sciences and humanities research council canada (sshrc) standard grant. we gratefully acknowledge the research assistance of claire major and sarah sanford. key: cord-351411-q9kqjvvf authors: moghadas, seyed m; haworth-brockman, margaret; isfeld-kiely, harpa; kettner, joel title: improving public health policy through infection transmission modelling: guidelines for creating a community of practice date: 2015 journal: can j infect dis med microbiol doi: nan sha: doc_id: 351411 cord_uid: q9kqjvvf background: despite significant research efforts in canada, real application of modelling in public health decision making and practice has not yet met its full potential. there is still room to better address the diversity of the canadian population and ensure that research outcomes are translated for use within their relevant contexts. objectives: to strengthen connections to public health practice and to broaden its scope, the pandemic influenza outbreak research modelling team partnered with the national collaborating centre for infectious diseases to hold a national workshop. its objectives were to: understand areas where modelling terms, methods and results are unclear; share information on how modelling can best be used in informing policy and improving practice, particularly regarding the ways to integrate a focus on health equity considerations; and sustain and advance collaborative work in the development and application of modelling in public health. method: the use of mathematical modelling in public health decision making for infectious diseases workshop brought together research modellers, public health professionals, policymakers and other experts from across the country. invited presentations set the context for topical discussions in three sessions. a final session generated reflections and recommendations for new opportunities and tasks. conclusions: gaps in content and research include the lack of standard frameworks and a glossary for infectious disease modelling. consistency in terminology, clear articulation of model parameters and assumptions, and sustained collaboration will help to bridge the divide between research and practice. l'amélioration des politiques de santé publique par la modélisation de la transmission des infections : des directives pour créer une communauté de pratique historique : malgré l'ampleur des recherches au canada, la mise en oeuvre de la modélisation n'a pas encore atteint son plein potentiel en santé publique dans la prise de décision et la pratique. il y a matière à mieux intégrer la diversité de la population canadienne et d'utiliser les résultats de la recherche dans les contextes pertinents. objectifs : pour renforcer les liens avec l'exercice de la santé publique et en élargir la portée, l'équipe de pandemic influenza outbreak research modelling s'est associée au centre de collaboration nationale des maladies infectieuses pour organiser un atelier national. cet atelier visait à déterminer les secteurs où la terminologie, les méthodo-logies et les résultats de la modélisation manquent de clarté, à transmettre de l'information sur l'utilisation optimale de la modélisation pour étayer les politiques et améliorer la pratique, notamment en accordant plus d'importance aux questions d'équité en santé, et à maintenir et faire progresser la collaboration pour élaborer et mettre en oeuvre la modélisation en santé publique. méthodologie : l'atelier sur l'utilisation de la modélisation mathématique dans la prise de décision relative aux maladies infectieuses en santé publique a réuni des chercheurs modélisateurs, des professionnels de la santé publique, des décideurs et d'autres experts du pays. les conférenciers ont mis en contexte les discussions dans le cadre de trois séances. une dernière séance a suscité des réflexions et des recommandations sur les futures tâches et possibilités. conclusions : les lacunes en matière de contenu et de recherche incluent l'absence de cadres standardisés et de glossaire de la modélisation des maladies infectieuses. une terminologie uniforme, la formulation claire des paramètres et des hypothèses de modélisation ainsi qu'une collaboration soutenue contribueront à corriger l'écart entre la recherche et la pratique. seyed m moghadas phd 1 , margaret haworth-brockman msc 2 , harpa isfeld-kiely ma 2 , joel kettner md 2 research defines a mathematical model as a framework "representing some aspects of reality at a sufficient level of detail to inform a clinical or policy question" (1). mathematical, computational and statistical models and techniques have been applied in the canadian public health system, especially after the 2003 severe acute respiratory syndrome (sars) epidemic, but it is unclear to what degree their outcomes have been used to shape policy and improve practice. furthermore, the diversity of the canadian population has not been adequately addressed in public health models, and research outcomes are often not translated for use within their relevant contexts. to improve the applicability and impact of models in public health, it is necessary to understand areas where modelling results are unclear, the value of a common language between modelling and public health, and how to sustain and enhance the application of modelling in public health. established during the early stages of the 2009 h1n1 pandemic in canada, the pandemic influenza outbreak research modelling (pan-inform) team has a mandate to develop innovative modelling frameworks and knowledge translation methods that inform public health by linking theory, policy and practice. aligned with its mandate, on october 6 and 7, 2014, pan-inform held its fourth biannual workshop (2) (3) (4) cohosted by the national collaborating centre for infectious diseases. this workshop brought together public health this open-access article is distributed under the terms of the creative commons attribution non-commercial license (cc by-nc) (http:// creativecommons.org/licenses/by-nc/4.0/), which permits reuse, distribution and reproduction of the article, provided that the original work is properly cited and the reuse is restricted to noncommercial purposes. for commercial reuse, contact support@pulsus.com practitioners and leading research modellers (a list of attendees is available at <http://pan-inform.yorku.ca/events/pan-inform-workshop-2014/ participants.html>) to enhance cross-discipline communications by providing a forum for knowledge to flow freely in a 'jargon-free' setting. the expected outcome was to identify the infrastructure, expertise and resources necessary to establish a 'communities of practice' (cop) network. the cop concept, initially developed by jean lave and etienne wenger, refers to groups of people who share a concern, a set of problems or a passion about something they do, and learn how to do it better by interacting regularly (5) (6) (7) (8) . the proposed cop, as a new initiative to be catalyzed from this workshop, would offer new approaches to addressing problems at different levels of health care and population health and enable the development of strategic plans to move evidence to action. an important role for this cop is to develop a common language that can be used in understanding the outcomes of health research and disease modelling. the workshop objectives were to: understand areas where modelling terms, methods and results are unclear; share information on how modelling can best be used in informing policy and improving practice, particularly regarding the ways to integrate a focus on health equity considerations; and sustain and advance collaborative work in the development and application of modelling in public health. the two-day event unfolded in four sessions. the first two, "modelling in public health: opportunities and challenges" and "mathematical modelling in public health practice", helped to set the context regarding scientific methods and research applications, particularly for the evaluation of research uptake and provided public health perspectives on the utility of modelling in decision making. the third session, "muddling through modelling: communication, common language and health equity", spurred discussion regarding the need for common language between researchers and knowledge users, to improve the use of modelling study results. this included foundational issues regarding access to data and the involvement of indigenous and other community representation. in the final session, "developing our network and communities of practice", participants reflected on earlier presentations and discussions to clarify what is needed to continue collaboration and knowledge exchange that can increase the value of research modelling in public health. the presentations and discussions that ensued created compelling arguments that the most prominent and observable outcomes can be achieved when communication barriers between disciplines are eliminated. the present report discusses key presentations and discussions that took place, and summarizes the outcomes and action plans that emerged from the workshop. setting the context: opportunities and challenges for modelling in public health sessions 1 and 2 of the workshop began with a presentation regarding the development of infectious diseases modelling in canada. before the 2003 sars epidemic, modelling activities were largely driven by research interests of individuals or small groups, with a significant emphasis on the theoretical aspects of exploring complex mathematical phenomena. for the most part, these activities were carried out in isolation, with minimal communication and engagement with public health professionals and policymakers (2) . during and following the sars epidemic, various groups of disease modellers were formed to engage with, and develop models for application to public and population health in more specific contexts. despite the importance and relevance of these initiatives, knowledge translation remained a challenge that the pan-inform was established in part to address (9). the canadian institutes of health research supported the establishment of pan-inform to address the limited knowledge exchange between modelling researchers and those who could potentially make use of models to inform health policy and improve practice. since its inception, pan-inform has undertaken several national initiatives for knowledge brokering, including the evaluation of canada's response to the spring and winter waves of the novel h1n1 pandemic, identification of strategies for protecting vulnerable populations from emerging infectious diseases, and development of approaches that can enrich existing links with aboriginal health organizations and foster multijurisdictional collaborative efforts in canada (2) (3) (4) . in canada, public health decision making occurs within orders of government at all levels. situations are often very complex for a number of reasons including the availability and adequacy of health resources; inconsistent or absent evidence regarding the effectiveness and cost effectiveness of intervention strategies; pressure from the public, media and government under which public health must operate; other competing public health services; and ethical considerations to balance the protection of community health against individuals' rights and freedoms. other pertinent challenges include the lack of data to estimate potential outcomes of a public health program, paralysis resulting from having too much information on occasion, differing opinions and short timelines. in this context, as one presenter put it, there are three questions decision makers face: what is the benefit of the public health program or intervention; who will benefit from the program and; is the program cost-effective? often, the evidence to answer these questions is not available in a timely manner. ideally, one would address these questions by investigating the effects experimentally. however, controlled trials may not be feasible or ethical, and can also be time consuming, laborious, expensive or inconclusive. models provide a useful tool to overcome these challenges and systematically evaluate possible effects by using existing data and knowledge, generating quantitative outcomes and mapping out interdependencies that may be key factors for determining policy needs. given these capabilities, models can be used to identify key uncertainties in the parameters and generate qualitative predictions, such as the effect of behavioural changes on the trends and distribution of an infection in the population. indeed, the overarching goal of modelling is to support evidence-based public health policy. to enhance the utility of models, communication and collaboration between modellers and public health leaders must take place early in a decision making process. models are more valuable when end users are engaged in formulating the questions because models are built so that they truly reflect a public health question. end users who understand a model are likely to be better able to assess the results. during the construction and validation of a model, the relevance and importance of input parameters must be understood, and the sources for their values and ranges, uncertainty about the parameters, and sensitivity of the model outcomes with respect to parameter variation and original model assumptions, must be determined. new knowledge generated by a model should address the target question and be translated and disseminated for uptake and action appropriate to the context. furthermore, when data are limited, it is essential to quantify any uncertainty in parameterization, because different sets of parameters may fit equally well. ideally, the process to improve the model structure and its outcomes is iterative. the value of direct conversations between modellers and public health leaders, in particular with regard to the availability and access to data and other critical information that are essential for model inputs of real-time scenarios (10) , was exemplified in the use of modelling and the implementation of model recommendations for antiviral use and vaccination in canada's response to the 2009 h1n1 pandemic (11, 12) . table 1 summarizes key issues presented and discussed for modelling in public health during the workshop. the international society for pharmacoeconomics and outcome research guidelines highlight the importance of a common language for drafting a health decision question and addressing it through a modelling framework. the guidelines for transparency and validation state: every model should have non-technical documentation that is freely accessible to any interested reader. at a minimum, it should describe in nontechnical terms, the type of model and intended applications; funding sources; structure of the model; inputs, outputs, other components that determine the model's function and their relationships; data sources, validation methods and results; and limitations (1). good communication flows to and from knowledge producers and users, and requires a common language to build effective partnerships and understanding of the groups' respective concerns. there are a number of challenges to developing a common language: determining a common lexicon; understanding priorities and contributions, which may shift depending on the political climate or population health status; asking the right questions that are appropriate to the given context; knowing the right audience; and being able to communicate findings to others outside the research community. the lack of such common language may have been an impediment to addressing key parameters in 'determinants of health' and 'health equity'. in the canadian context, one needs to take into account differential health status and population structure of first nations, inuit and métis people, population-level patterns of abuse, poverty and historical trauma, challenges regarding access to health services in rural and remote areas, and limits in identifying "vulnerable" populations in available datasets with no real markers. building partnerships and an iterative exchange allows for goals and facts to be clearly identified, and outcomes to be assessed for their value to inform decisions about the potential benefits and risks of policy development and program delivery. effective partnerships require willingness and commitment, alignment of values, mechanisms to engage early and continuously, and plans to regularly review goals, objectives, roles, and responsibilities and outcomes. a recent review of literature highlights the inconsistency in definitions and interpretations of epidemiological terms in several modelling studies and the need for common language to sustain and enhance the application of models in public health (13) . the review found that disparate outcomes and interpretations for policy decisions may arise from inconsistent use of terms in model structures, even when the assumptions and input parameters are identical. discrepancies in how terms are used for modelling are generally associated with two main reasons. first, it is often assumed that the particular terms are well defined or well understood. for example, 'infectiousness' and 'infectious' were found to be used interchangeably; the former describes a characteristic of the disease and/or how readily the disease is transmitted, while the latter describes a patient state (13) . second, definitions of some terms have drifted over time as understanding of the mechanisms of disease processes and control has evolved. for example, the way terms such as 'prevention', 'protection' and 'reduced susceptibility' are used related to communicable disease may lead to different results depending how they are used in modelling. developing a common modelling has an important place in public health policy and practice. the utilization of modelling has been far less that its potential in the canadian context create a national infrastructure or network in canada to develop useful and applicable models based on realistic assumptions and quality data closer working relationships collaboration, engagement and exchange between modellers, and policymakers are needed to facilitate iterative processes that optimize the value and understanding of models and their results identify partners at the provincial level within acute care, emergency services and public health divisions. formalize exchange processes for regular communication and education applying health equity and other lenses limited attention has been paid to using health equity or sex and gender analyses. the availability of aboriginal-specific information has been inconsistent at best modellers and users can be called on to create model frameworks and ask questions that will provide better information about where there are inequities and inequalities. involve the people who understand equity issues data quality and access access to good-quality, population level data is essential to validate a model and its outcomes. such data may not necessarily be available or accessible in a timely fashion during an emerging infectious disease evaluate data quality and the type of information provided by surveillance for its potential to be used for research modelling. engage with provinces to determine the nature and availability of data required for modelling standardization of approaches to develop useful models, three aspects of the modelling will need to be standardized: what (ie, frameworks that are context specific and take into account the population demographic and geographic characteristics); who (ie, involvement of policymakers, knowledge users and modellers with relevant expertise), and how (ie, develop an iterative process from the formulation of health policy questions to the dissemination of model outcomes) a communities of practice network can be tasked with the standardization of this process to ensure that synergies exist when models are formulated to inform clinical or health policy decisions roles and responsibilities clarification on the roles of health agencies and jurisdictions are needed to engage partners from academic institutes, government health organizations and health industries national collaborating centre for infectious diseases will lead the initiative to forge the linkages and develop appropriate channels and effective methods of communication between the involved partners capacity some jurisdictions lack modelling capacity. there is also a lack of information about which modellers are available to work with public health and their expertise a centralized list or network could contribute to greater capacity for public health jurisdictions. develop opportunities for public health personnel to learn more about models and their value language will help to reduce possible variation in study results produced by different research communities. this will in turn decrease misinterpretation of the outcomes by allowing for comparisons of scientific evidence from multiple disciplines involving health research, and helping knowledge users and policymakers to better understand research outcomes and their applicability to policy and practice. there are other factors responsible for variation in model findings, including different strategies or approaches and assumptions, different population demographic variables, and the objectives for evaluating policy effectiveness that can vary from one situation to another. the latter can be exemplified in two recent studies on the effectiveness of school closure during pandemic influenza outbreaks. when assessing the effect of school closure strategies in reducing community attack rates, halder et al (14) found that due to the difficulty in determining the true degree of epidemic spread and its severity in the early stages of an outbreak, a strategy of individual school closures would be more effective than simultaneous closures across a region. the outcomes are drawn from an agent-based simulation model of albany, a small community in western australia with a popula tion of approximately 30,000 individuals. in contrast, to evaluate the impact of local reactive school closures on critical care provision in the united kingdom population setting, house et al (15) concluded that school closures should be coordinated in time (simultaneous) and location (all schools within a school district) to become an effective strategy to reduce infection transmission and, consequently, relieve capacity pressures of hospital intensive care unit admissions. the population demographics and the objectives for closing schools are distinctly different between the two studies, suggesting that different modelling approaches are required for measuring the effectiveness of school closures. understanding scenario-specific outcomes and their applications requires a critical evaluation to address the following questions: • is the methodology appropriate for the specific population setting? • do the assumptions and parameters address the reality of demographic and geographic characteristics? • can the outcomes be compared with other studies and validated with observed data? • how generalizable are the outcomes to address different scenarios or population settings? a consensus emerged during the workshop regarding the need to develop a common language for modelling to enhance its application in a public health context and promote bidirectional communication ( table 2 ). to address this need, the fourth session of the workshop provided an opportunity for participants to discuss the establishment and potential impact of a community of practice. during the final discussion session, a number of important issues related to the development of a cop network were discussed, including its structure and governance, leadership and research capacity, memberships and partnerships, strategic plans for sustainability and resources, and the impact and uptake of outcomes (table 3) . the october 2014 national workshop propelled new discussion on the value of mathematical models in public health planning and the need for greater cohesion and collaboration among stakeholders. the workshop concluded with a consensus among participants that there is work to be done and a willingness to continue to work together. the creation of a common lexicon is a tangible, initial task that should be undertaken as an immediate response to the workshop discussions. we expect that through sustained cross-disciplinary dialogues, a cop will initially produce a 'book of terminology' that describes current usage and proposes common terminology (community standards) in different areas, including medical and infectious diseases epidemiology, public health and disease modelling. this reference book can then be updated regularly when new terms need clarification for shared understanding and agreement in use. furthermore, in times of uncertainty, the virtual cop network will provide opportunities to access, analyze, synthesize and utilize reliable information and databases in a timely fashion, and drive a broad consensus around plausible alternatives and integrated courses of action. it is also true, however, that ongoing discussions between modellers and public health personnel will help to clarify language use and break down perceived barriers. ispor-smdm modeling good research practices task force. modeling good research practices-overview: a report of the ispor-smdm modeling good research practices task force-1 managing public health crises: the role of models in pandemic preparedness canada in the face of the 2009 h1n1 pandemic indigenous populations health protection: a canadian perspective the development, design, testing, refinement, simulation and application of an evaluation framework for communities of practice and social-professional networks communities of practice: an opportunity for interagency working communities of practice: learning, meaning and identity pandemic influenza outbreak research modelling team (pan-inform), fisman d. modelling an influenza pandemic: a guide for the perplexed pandemic influenza: modelling and public health perspectives available at <www.cihr-irsc.gc. ca/e/43717.html> (accessed on annex e. the use of antiviral drugs during a pandemic review of terms used in modelling influenza infection developing guidelines for school closure interventions to be used during a future influenza pandemic modelling the impact of local reactive school closures on critical care provision during an influenza pandemic modelling for public health (mod4ph) <www.linkedin.com/ groups? within a number of weeks after the workshop, a new virtual community of practice, created by national collaborating centre for infectious diseases through linkedin, called mod4ph (modelling for public health) (16) key: cord-349790-dezauioa authors: johnson, stephanie; parker, michael title: ethical challenges in pathogen sequencing: a systematic scoping review date: 2020-06-03 journal: wellcome open res doi: 10.12688/wellcomeopenres.15806.1 sha: doc_id: 349790 cord_uid: dezauioa background: going forward, the routine implementation of genomic surveillance activities and outbreak investigation is to be expected. we sought to systematically identify the emerging ethical challenges; and to systematically assess the gaps in ethical frameworks or thinking and identify where further work is needed to solve practical challenges. methods: we systematically searched indexed academic literature from pubmed, google scholar, and web of science from 2000 to april 2019 for peer-reviewed articles that substantively engaged in discussion of ethical issues in the use of pathogen genome sequencing technologies for diagnostic, surveillance and outbreak investigation. results: 28 articles were identified; nine united states, five united kingdom, five the netherlands, three canada, two switzerland, one australia, two south africa, and one italy. eight articles were specifically about the use of sequencing in hiv. eleven were not specific to a particular disease. results were organized into four themes: tensions between public and private interests; difficulties with translation from research to clinical and public health practice; the importance of community trust and support; equity and global partnerships; and the importance of context. conclusion: while pathogen sequencing has the potential to be transformative for public health, there are a number of key ethical issues that must be addressed, particularly around the conditions of use for pathogen sequence data. ethical standards should be informed by public values, and further empirical work investigating stakeholders’ views are required. development in the field should also be under-pinned by a strong commitment to values of justice, in particular global health equity. genetic information derived from pathogens is an increasingly essential input for infectious disease control, public health and research 1 . although routine sequencing of pathogens was, until recently, unthinkable, the centers for disease control (cdc), food and drug administration (fda), state, and global public health laboratories now routinely sequence more than 200 foodborne bacterial isolates a day and more than 6,000 influenza virus genomes a year 2,3 . in the united kingdom, public health england now engages in routine clinical genomic diagnostics and drug sensitivity testing for mycobacterium tuberculosis 4 . in the research setting, phylogenetic analysis (the study of evolutionary relationships among pathogens) is being used to track and understand factors associated with the spread of infections such as hiv 5 and to monitor the global spread of drug-resistant infections 6 . mobile genomic sequencing technology is also being applied to disease outbreak investigation, most publicly in the case of the ebola outbreak in west africa 7-9 . going forward, the routine implementation of genomic surveillance activities and outbreak investigation is to be expected. while the technical developments of sequencing technology are being implemented at a rapid pace, the non-technical aspects of implementing this technology are still being broadly discussed between the different stakeholders involved 1 . the successful implementation of this rapidly developing technology will, for example, require sharing of samples and metadata, interdisciplinary global collaborative partnerships, and will need to offer useful evidence for public health decision-making. importantly, the successful and appropriate response to these challenges will also require the systematic identification, analysis and addressing of a number of complex ethical, legal and social issues. a number of factors will contribute to the types of ethical issues that arise in different instances. these are likely to include characteristics of the disease, the environmental, political and geographical context, existing laws and policies, public attitudes, and cultural differences 10 . in the work reported in this paper, taking these and other ethical issues as our focus, we sought to systematically examine the available literature to: identify the emerging ethical challenges and proposed solutions; and to systematically assess the gaps in ethical frameworks or thinking and identify where further work is needed to solve practical challenges. scoping reviews seek to identify literature relevant to a research objective and may include a variety of research formats and conceptual literature [11] [12] [13] . this study sought to review published literature on ethical aspects of pathogen sequencing. inclusion criteria for the study encompassed a broad range of article types, including empirical studies, news articles, opinion pieces, features, editorials, reports of practice, and theoretical articles. we systematically searched indexed academic literature from pubmed, google scholar, and web of science from 2000 to april 2019 for peer-reviewed articles that substantively engaged in discussion of ethical issues in the use of pathogen genome sequencing technologies for diagnostic, surveillance and outbreak investigation. the search was then updated in january 2020. the initial search strategies were developed through an iterative process and used a combination of controlled vocabulary (mesh terms) and free text words. an example medline search strategy is provided in table 1 . reference lists of included articles were searched for relevant articles and further database searchers were conducted using the names of researchers commonly publishing in this field. finally, we also reviewed relevant international research and clinical practice guidance for relevant guidelines e.g. website of the world health organization. we sought to maximize the literature included in the review by reviewing guidelines, frameworks, commentaries and original research reviews related to pathogen sequencing. we also included studies on molecular typing where enough accuracy could be included to include transmission tracking, as this was thought to provide useful insights into the ethical challenges pathogen sequencing technologies may pose. we excluded studies considering genomics outside of infectious disease or focusing on host response studies as these were not deemed relevant or specific enough to the topic under investigation. duplicates were removed. sj undertook title and abstract screening to remove obviously irrelevant studies, borderline cases were discussed with mp and a decision reached by consensus. data was then abstracted by sj and cross-checked for accuracy by mp. names of study authors, institutions, journals of publication and results were non-blinded. analysis sj initially inductively analysed all studies, recording the aims and main findings in microsoft excel 2016 (16.0.4699.1000), and developing descriptive codes to chart the broad themes describing the literature base. similar findings were then grouped according to topic area and a preliminary list of themes was developed in collaboration with mp. both authors engaged in iterative discussions about organization of findings, after which the final themes were decided. sj subsequently re-examined each study and extracted data using a standard format (design, results and recommendations). the search produced 466 articles after duplicates were removed. all articles were initially screened by title and abstract and thirty-nine full text articles were assessed for eligibility. twenty eight articles were included in the final analysis; three ethical guidelines or frameworks 14-17 ; seven empirical research studies 1,18-23 ; eight reviews of the ethics 2,17-21 ; and ten publications that contained a section on the ethical aspects of pathogen sequencing 24-33 . the literature largely originated from the us and other high-income countries (hics, country determined by lead author institution): nine from the united states (us), five from the united kingdom (uk), five from the netherlands, three from canada, two from switzerland, one from australia, and one from italy. only two publications, by the same author, originated from the global south (south africa). eight articles were specifically about the use of sequencing in hiv 14, 15, 17, 20, 22, 28, 34, 35 . eleven were not specific to a particular disease. table 2 presents a summary of studies. results were organized into four themes: tensions between public and private interests; difficulties with translation from research to clinical and public health practice; the importance of community trust and support; equity and global partnerships; and the importance of context. when considering the implications of collecting, using and sharing pathogen genome sequence data, the interests and rights of individuals were universally acknowledged. in particular, the literature pointed to the importance of considering and/or protecting individual rights to autonomy 19,21,32,36 , and to privacy 18,21,22,28 . many pointed out that the potential of sequencing techniques to detect the origin and routes of transmission of an outbreak may result in negative consequences for the individuals involved 25 . consequences may include stigmatization, penalties, economic risks, problems with interpersonal relationships (e.g. inadvertent disclosure of infidelity), emotional distress and the capacity for discrimination 19, 21, 22, 24, 25, 27, 30, 32, [37] [38] [39] . there was also concern that sequencing could lead to serious legal consequences, particularly with regards to the criminalization of hiv transmission 14, 15, 17, 22, 24, 28, 34, 35 . it was also acknowledged that individuals may have an interest in avoiding the use of information about them for purposes they do not endorse, such as to support anti-gay sentiment or as part of a criminal investigation 20, 24 . somewere concerned about forced testing either of certain groups such as gay men 28 or healthcare workers 19,21,38-40 . there was acknowledgment of individual professional interests of researchersand practitioners to ownership and use of data 1, 16, 32 . sequencing was also seen to carry risks for communities and groups. many authors noted that certain groups can be placed at risk through characterization as high risk or likely to transmit virus (hiv), including geographically defined groups, sexual or gender minorities, or those defined by ethnicity, nationality, or migration status 14 . similarly, data regarding transmission patterns of multidrug-resistant tuberculosis (tb) could be used for discrimination based on ethnicity, and possible challenges to immigration 20 . institutions could be subject to increasing numbers of legal claims, or companies could suffer reputational or economic damage 39 . it was also noted that some communities may be particularly at risk of being exploited by research, especially during emergency outbreak situations 14,32 . on the other hand, it was acknowledged that widespread availability and use of sequence data contributes important benefits to the clinical and research communities 17 . in particular, the rapid sharing of data can help identify etiological factors, predict disease spread, evaluate existing and novel treatments, symptomatic care and preventive measures, and guide the deployment of there was strong support for the permissibility of conducting sequencing studies, as long as potential risks were thoughtfully mitigated 14,18,19,21,22 . in one empirical study, patients and healthcare workers were asked if the benefits of hiv molecular epidemiology outweigh the risks; all said yes 22 . threequarters of respondents answered with an unqualified, yes, and one quarter gave a positive answer with qualifications, such as 'it's very necessary, just as long as parameters are set in place and they're kept', or 'with proper protections in place, the benefits outweigh the risks' 22 . in another study, expert delphi panelists held that the protection of the public was of overriding importance, but that most of the potential harms could be managed 19 . there were differences across the literature in the priority afforded to different conditions of use, and to the types of risk or amount of risk deemed acceptable. it was broadly agreed that any research should have a favourable risk benefit ratio 14,20 , and that maximizing the utility of data must be weighed against concerns over interests of individuals and that policies on data collection and release should seek to align the interests of different parties 36 . there was, however, disagreement as to whether privacy concerns or public interest should take precedence 24,25,31 and some noted that the balance between the public health benefit and personal privacy risk for individuals whose genetic data (personal or pathogen) are included is difficult to delineate, since neither the true benefit nor the actual risk to participants has been adequately defined 27,35 . below we set out the key recommendations from the literature on the conditions of use for pathogen sequence data. box 1 summarises recommendations from the literature for future research focus and study design. it was clear that the release of information of relevance to public health should not be delayed by publication timelines or concerns over academic ownership of data 16,26,32 . recommendations to address such conflicts of interests included: that medical journals should update their policies to support pre-publication sharing of pathogen sequence data related to outbreaks 16 ; publication disclaimers prohibiting use of sequence data for publication without permission 16,32 ; acknowledgment of data sharing contributions and the inclusion of such criteria to the assessment of academic research credit 1 ; establishment of governance structures and dispute resolution mechanisms that can mediate where disagreements arise 16 . much of the literature suggested that traditional methods of de-identification or anonymization of data are insufficient to meet their purpose in the context of pathogen sequencing 2,14,17,23,28,33,39 . existing approaches to minimize the risk of privacy loss to participants are based on de-identification of data by removal of a predefined set of identifiers 17 . however, this has three key limitations in the context of pathogen genomics. first, sharing of corresponding sample metadata (minimally time and place of collection, ideally with demographic, laboratory, and clinical data) is essential to enhance the interpretation and the value of genomic data 16 , therefore removal of key identifiers such as geographic location may severely limit the utility of genomic data 39 . second, removing predefined identifiers may be ineffective at protecting privacy and confidentiality 17,19,22,39 . for example, one study demonstrated how sample collection dates associated with microbiological testing at a large tertiary hospital were highly correlated with patient admission date (protected health information), meaning data is re-identifiable 23 . small study populations may also mean that individuals who are part of a transmission chain may be able to identify others during the course of routine contact tracing (e.g. sexual partners) 17 . third, anonymization of data does little to mitigate potential risk to communities and groups 14,17,39 . perhaps a consequence there was clear support for re-visioning of existing privacy standards, and for privacy policies specific to the context of sequencing studies. there was debate in the literature around the importance of consent to the use of sequence data and associated meta-data in epidemiological investigation. in the research setting, coltart et al. 14 state that research participants and patients whose samples are being used for phylogenetic analysis should ideally have consented to such use, but suggest that when using data from previous studies, where only broad consent for hiv-related research might have been obtained, waivers of specific consent are allowable when samples are no longer linked to identifiers, or when broad consent for sample collection for research and storage in future studies was given 14 . in the public health and clinical setting, an australian study reported that one of the key differences amongst participants in a modified delphi social and behavioural research into conceptual and normative aspects should be backed up by empirical research 35 . 5. new inter-disciplinary collaborations including microbiologists, engineers and bioethicists 30 . 6. as real-time and other intervention strategies that build on hiv phylogenetic information continue to emerge, it will be critical to address questions of efficacy for cluster growth interventions to ensure that the benefits outweigh potential risks. implementation science research may also inform best practices for discussing the meaning and limitations of sequence data and cluster membership with community members and help to identify acceptable and evidence-based approaches that impose the least risk to persons within specific contexts. these might involve partnerships with providers for non-intrusive patient follow-up related to clusters, more detailed consent procedures for future follow-up related to hiv test results or partner services referrals, and specific guidelines and education to mitigate criminalization risks 28 . 7. communication methods that increase the understanding of phylogenetic studies need to be designed and evaluated. these must emphasise potential harms, thoughtful mitigation of harms to risk groups, processes for monitoring risk, and clear protection procedures to minimise risks 14 . 8. collaboration between stakeholders is necessary, with an active exchange of experiences and best practices. the first step, should be sought in creating awareness and consensus within sectors on the causal factors of barriers to sharing of sequence data 1 . ethical conduct of studies 9. need to pre-define exceptional circumstances where un-validated techniques might be used in emergency situations 27 . 10. to ensure scientific validity, researchers and their associates should be competent to implement the proposed study design. in order to maximize scientific validity, the researchers should ensure that they have all necessary resources, that the community accepts the protocol and that a competent and independent research ethics committee (rec) or institutional review board (irb) reviews and approves the protocol 35 . 11. the scientific objectives of research should guide the choice of participants and determine the inclusion criteria and appropriate recruitment strategies. it is unethical to use privilege, convenience and/or vulnerability as criteria for selecting participants. exclusion of certain population sub-groups or communities in a research study without appropriate scientific justification is also considered unethical 35 . 12. risk mitigation strategies must also provide for redress mechanisms in cases of abuse or misuse of phylogenetic data. these strategies might require the establishment of ties with local legal services, organisations working to protect people with hiv, and criminalised or stigmatised populations, to ensure that they have access to the means to protect their rights 14 . study included the necessity for consent before testing and data-linkage. no panelists agreed with the statement "under no conditions should a study be conducted without prior consent", although only ten of thirty agreed that consent is not required under any conditions 21 . in a dutch study, outbreak managers thought intervention without seeking explicit consent of all individuals involved is justified when there is at least be a substantial public health threat, realistic expectation that deploying the techniques will help to mitigate the outbreak, and that source and contact tracing would most likely not be successful without the use of molecular typing techniques 21 . there was a strong commitment to rapid and open data-sharing, particularly in emergency or outbreak situations 16,27,32 and in such conditions for incentives and safeguards to encourage rapid and unrestricted access to data release 16,27,32 . the world health organization (who) recommended that in emergency outbreak situations "the first set of sequences providing crucial information on the pathogen, genotype, lineage, and strain(s) causing the outbreak should be generated and shared as rapidly as possible. sharing of corresponding anonymised sample metadata (minimally time and place of collection, ideally with demographic, laboratory, and clinical data) is essential to enhance the interpretation and the value of genomic data" 16 . however, access to data gathered as part of clinical care was seen as ethically more contentious as "publicly accessible databases are not an appropriate storage location for the level of metadata required to enable clinical and epidemiological analysis for the purposes of providing patient and population care" 39 . suggestions were made for a tiered approach to data release, whereby a separate database governed by appropriate public health authorities would collate and store metadata in a location to which access to data could be limited to users with a legitimate clinical or public health need to use it, and data that cannot be released into public domains but is needed by authorised healthcare and public health professionals for service delivery remains within a suitable secured access database 39 . a public survey on tb explored questions related to database access and the potential benefits and risks associated with it. most felt that medical professionals and the research community should have access to such a database; and a significant proportion thought that other agencies, such as the police (10%) and immigration officials (13%), should also have access to the genomic database. experts, however, were clear that they felt transmission data should not be used in litigation; this was partially because it was deemed too unreliable 24,27 and also because of the potential for 'abuse' of data 14,15,24 . overall, there was broad support for further work in defining the conditions for collection use and storage of data and samples 2,27,30,32,37 and for policy and legal clarity to aid the ethical implementation of these technologies. this will require more work to carefully assess and understand risks 39 ; research to decide how much individual privacy might be risk in the name of public health 31 ; consideration of alternative strategies required to mitigate this risk, such as suppression of data in the public domain where it may cause serious harm; and adjustments to communication plans 14 . effective phylogenetic work often occurs at the interface between research and public health practice because the same data can be used for both purposes 14 . in this regard, pathogen sequencing was described as 'straddling the boundary between research and clinical use' 27 . the hybrid nature of sequencing activities imposes important ethical challenges. clinical implementation of metagenomics sequencing (un-targeted testing) has the potential to detect unexpected or incidental findings that may include infections with hepatitis or hiv 39 . incidental findings of a different type may occur if non-germline samples (such as faecal samples) are contaminated with germline cells, which could potentially reveal predictive information about developing inherited disease 39 . furthermore, informed consent for phylogenetic studies that are difficult complex and difficult to understand, and in which the benefits and risk may not be fully determined, may also be difficult to achieve 35 . mutenherwa suggests that where sequence data are generated for routine clinical management, its subsequent use for research and surveillance may be underestimated by patients 20 . others suggested that the right to withdraw from research activities-a key indicator of voluntary participation in research-was overlooked by expert stakeholders 20 . understanding and interpreting phylogenetic data requires significant expertise 25,27 and presents a challenge to established professional boundaries. expertise in phylogenetic studies creates new obligations for researchers, such as deciding whether or not to participate in forensic investigations and potential prosecutions of individuals 24 , and to consider the down-stream uses and misuses of data 14 . the routine implementation of pathogen sequencing studies may create new responsibilities for clinical microbiologists (related to public health) 2 , and require major changes in culture such that diagnostic interpretation, therapeutic management decisions and antimicrobial treatment regimes are delegated to physicians instead of microbiologists 31 . many noted that there are important reasons to ensure that the public and individuals understand the uses of data collected as part of a sequencing studies, and the potential risks. first, this was seen to have some intrinsic value in that it supports patient autonomy and truth telling is a respected moral virtue 14,15,19,21 . second, truth-telling was seen to be important because it may lead to better outcomes in research and public health practice. this is both because this was deemed to promote trust in research and therefore lead to increased participation, and because it promotes disclosure, which is helpful from a public health perspective. third, promoting understanding of uses and risks of data was also seen as a way of avoiding harm and exploitation of vulnerable individuals and communities, by enhancing understanding of risks that may be specific to that them. in some cases, this was balanced by a number of practical challenges to telling people the truth, such as: risk of fear mongering 19 ; information needed for legal proceedings in public interest 14 ; and the fact that it may be difficult to adequately inform the public and/or ensure full understanding 20 . none-the-less, there was a clear recommendation in the literature to raise public awareness and understanding of these techniques 19,22,30 , and for early and meaningful community engagement 15,22,32,34 prior to conducting sequencing studies. this was seen as particularly important when working with vulnerable groups or when the risks of participation are high. the notion of justice appeared to be a widely recognized ethical principle in the field 1 . stakeholders pointed to the importance of equitable access to data 27 , and to benefit-sharing obligations 16,26 . this included an ethical imperative that outbreak related research and countermeasures, such as diagnostics and vaccines, should be accessible to all affected countries 26 , and towards reciprocal arrangements such that countries that participate in sequencing activities should derive some corresponding local benefit 27 . collaboration between researchers from africa and hics was raised as an important ethical consideration 20 . in one empirical study, interviewees were concerned that african researchers were not meaningfully engaged in the scientific research process in health research in general and phylogenetic research in particular, and that for equitable and mutually beneficial collaborative research partnerships to be realized, local researchers were encouraged to take leading and active roles throughout the research process 20 . this type of collaborative research practice was supported elsewhere in the literature 14,27,37 . for some, this was to enhance equity as well as to help maximize the utility of data and lead to better public health outcomes. it was argued that local researchers were more likely to understand their health care and research systems and study results were more likely to be easily translated into policy 20 , and that context specific responses to particular outbreaks were likely to be required. recommendations were made to conduct studies exploring the nature of existing collaborative partnerships between researchers from low-and middle-income countries (lmics) and hics to explore team composition and distribution of roles, including contribution to intellectual property 20 . outbreak related research and countermeasures, such as diagnostics and vaccines, must be accessible to all affected countries not only as a legal obligation, but also as an ethical imperative 26 . it was also noted that global and interdisciplinary partnerships are a necessary component of an effective genomic informed response to infectious disease. this was because of the vast range of stakeholders and varying interests involved in control of infectious disease outbreaks, and because issues may resist simple resolution and span multiple jurisdictions 27 . for example, conflict may result from governments wishing to keep an outbreak quiet and/or from the tension between lmics with few resources for generating and using data and the researchers or response teams from better-resourced settings 1,37 . ownership of samples and data was seen as an important barrier to global cooperation. the nagoya protocol (np), for example, was developed to facilitate access to genetic resources and the fair and equitable sharing of benefits arising from their utilization 1 . nevertheless, despite the importance of reinforcing sovereignty rights of states over genetic resources in their territory, uncertainties about intellectual property rights and the resulting disputes hamper access to samples 1,32 . ribeiro et al. 1 explain that: "the real or perceived possibilities for the commercial valorization of microbial genetic resources (mgr) has enforced their appropriation for further use in research, innovation and product development. the problem for public health surveillance occurs when such appropriation is triggered at initial (upstream) phases of the research and innovation cycle, such as sampling and sequencing of microorganisms, instead of later stages, such as the actual product development (in this case drugs, diagnostics and vaccines). as such, stakeholders are reluctant to share their (intangible) assets even in early phases of the innovation process, decreasing the scope of innovation efforts due to the lack of access to upstream research inputs." the same authors suggest that standardized and simplified sharing agreements 26 , and collaboration between stakeholders with an active exchange of experiences and best practices 1 are required. in general, recommendations were made for a global approach to ethics, policy and legal frameworks 16,27,29,32,37 . for example, it was suggested global data sharing arrangements should include "a global data governance or ethical framework, supplemented by local memoranda of understanding that take into account the local context" 29 ; or to investigate how the global alliance for genomics and health (ga4gh) framework for responsible data-sharing could be adapted for digital pathogen surveillance 27 . lastly, it was clear that the types of ethical issues likely to arise are in part dependent upon the contexts in which studies are conducted, as well as the nature of the pathogen under study. chiefly, information that may impact on interpersonal relationships was viewed as particularly sensitive and therefore, worthy of additional ethical reflection. examples included: sexually transmitted infections 14,20 ; consent requirements to use isolates collected from dead neonates for the purposes of epidemiological research 19 ; and disclosure of family members as the source of infection 38 . it was suggested that the balance of risks to patients and public health benefits is likely to be affected by the characteristics of the pathogen, in terms of likely morbidity and mortality: infectivity; treatability and drug resistance 39 . stakeholders also suggested that the ethical permissibility of sharing data about, particularly with regards to the source of transmission, may be different in professional contexts, where healthcare providers or companies are seen to carry a responsibility to control risk, as opposed to outside of professional contexts where protecting individuals from 'naming and shaming' may be of greater concern 21 . it was also noted that the legal and regulatory structures in which studies are conducted may also influence the implementation and ethics of conducting pathogen sequencing studies. in particular, use of phylogenetic analyses in criminal convictions was raised as an ethical risk 14,17,24 . although quality assessment of all included materials is desirable in systematic reviews, it was not possible in this case due to the inclusion of a diverse range of research formats and literature, such as commentaries and ethics guidelines. a second limitation of this review is that a large proportion of the literature included related to phylogenetic and hiv specifically (8 out of 28), meaning that the issues relevant to this context may be over-represented. this review highlights that while pathogen sequencing has the potential to be transformative for public health and clinical practice and to bring about important health benefits, there are a number of key ethical issues that must be addressed. in particular, there was clear support in the literature for innovative and critical thinking around the conditions of use for pathogen sequence data. this includes context specific standards of practice for consent, data collection, use and sharing. these practices should be informed by public values, and further empirical work investigating stakeholders' views are required. this should include experts in pathogen sequencing, patients and the general public, as well as end users such as public health professionals and clinicians. lastly, it is both a scientific and an ethical imperative that development in the field is under-pinned by a strong commitment to values of justice, in particular global health equity. all data underlying the results are available as part of the article and no additional source data are required. this manuscript presents the results of a scoping review of the literature on the topic of the ethical issues in the use of pathogen genome sequencing technologies. the authors make excellent use of the scoping review methodology which they implemented clearly (good use of tables!) and rigorously. there are minor formatting issues and typos: p. 4 under theme 1: somewere concerned about forced testing either of certain groups such as gay men 28 or healthcare workers 19,21,38-40 . there was acknowledgment of individual professional interests of researchersand practitioners to ownership and use of data. p. 9 under theme 3: 'that may be specific to that them' the main substantial issue is the substantial focus of the manuscript on the hiv context (8 articles out of 28) which the authors acknowledge. hiv is a particularly stigmatized, serious condition, with lifelong consequences for patients which is not the case for many other communicable diseases. the problem is that in the past few months, covid-19 has been a game changer in the field. covid-19 is both much more contagious but less stigmatizing and, for most people, less dangerous than hiv. considering that the last update to this scoping review was made in january 2020, none of the covid-19 emerging literature was considered. the result, which is not the fault of the authors, is that the article will only have a limited relevance to the current global pandemic. given the importance of covid to the field and beyond, it could be worth it for the author to take the time to update their research accounting for very recent developments before publishing. otherwise, the publication maybe perceived as already outdated and not garner much attention from readers. a second issue of the manuscript is that while it acknowledges the tension and blurry demarcation between the research and the public health context, it doesn't really provide any solution in this regard. for example, in the context of pathogen genome sequencing for outbreak surveillance during a public health emergency, informed consent is often not required. however, the lack of consent can create issue later for data sharing with the research community. such a scenario is not really discussed in the manuscript. similarly, the impact of the public health vs. research situation on the potential requirement for ethics review is not discussed. perhaps this was not touched upon in the literature, but it is certainly a preoccupation of researchers in the covid context. is the study design appropriate and is the work technically sound? yes are all the source data underlying the results available to ensure full reproducibility? yes are the conclusions drawn adequately supported by the results? yes in the paper in the review appear to be appropriate and informative. some additional concepts that weren't included, possibly because the article presents a review of already published ideas, are the following: the potential for civil legal consequences from publication of genomic data. the article discusses at a few different points the potential for criminal prosecution, but publication of data could also open up participants of a study to civil penalties as well. how ownership rights over microorganisms affect infectious disease control and innovation: a rootcause analysis of barriers to data sharing as experienced by key stakeholders pubmed abstract | publisher full text | free full text societal implications of the internet of pathogens reviewer expertise: ethical, legal and social issues of genomic research, medical law, bioethics. reviewer report 06 july 2020 https://doi.org/10.21956/wellcomeopenres.17333.r39365 © 2020 armstrong g. this is an open access peer review report distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. office of advanced molecular detection, national center for emerging and zoonotic infectious diseases, centers for disease control and prevention, atlanta, ga, usa the article is generally well written, although it would be stronger if it had a more concise, more focused set of recommendations for readers to act on. the focus of the paper is mostly on the use of microbial genomic data for research but also touches a little on the issues around public health use of the data. this reviewer is not an expert in ethics; that said, the ethical concepts brought out ○ the potential for violation of a privacy when cases are rare. for example, early in an outbreak, as is highlighted in the article, there is an urgency to making sequence data from the pathogen in question public. however, it's common early in an outbreak for the media to discover and publish the names of early cases. in that situation (which is relatively common), there's a risk that sequence data made public could be linked to a specific person. ○ one concern that is often under-appreciated is that, under certain circumstances, a researcher or public health agency might be legally compelled to release the identity of someone. in general, public health laws are quite strong in shielding public health data, but that may not be the case with research data. if there is uncertainty about whether such data are protected, any participants in research should be notified. ○ gh4ge is mentioned in the manuscript, but there's no mention of pha4ge ( https://pha4ge.github.io/), which is much more applicable here. ○ issues around the nagoya protocol are addressed, but the tension between gisaid and insdc is not. gisaid provides protections for intellectual property rights that the insdc members do not, and such protections are key for participation of lmics. however, where public funds are used to obtain data, there is a strong argument that the data should be made publicly available (i.e., through insdc) without restriction as long as privacy and confidentiality are not placed at risk. the tension between the two models has been particularly strong with the advent of covid-19, and the very assertive push by gisaid to prevent researchers from submitting to insdc or from citing it. ○ some (minor) specific issues that need to be addressed: i would remove the reference to microsoft excel. there's a strong argument for including information about statistical software, but which spreadsheet is used is not particularly relevant.○ "theme 1: …": there are typos in the first paragraph.○ box 1, item 5: this is not a complete, declarative sentence like the others.○ reference 29 appears to be the incorrect reference. also, the quote from it (pages 9-10) appears to be a quote from a separate document (that should be cited separately, if still available). is the study design appropriate and is the work technically sound? if applicable, is the statistical analysis and its interpretation appropriate? are all the source data underlying the results available to ensure full reproducibility?no source data required competing interests: no competing interests were disclosed.reviewer expertise: pathogen genomics to support public health.i confirm that i have read this submission and believe that i have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. key: cord-031017-xjnbmah5 authors: van goethem, n.; struelens, m. j.; de keersmaecker, s. c. j.; roosens, n. h. c.; robert, a.; quoilin, s.; van oyen, h.; devleesschauwer, b. title: perceived utility and feasibility of pathogen genomics for public health practice: a survey among public health professionals working in the field of infectious diseases, belgium, 2019 date: 2020-08-31 journal: bmc public health doi: 10.1186/s12889-020-09428-4 sha: doc_id: 31017 cord_uid: xjnbmah5 background: pathogen genomics is increasingly being translated from the research setting into the activities of public health professionals operating at different levels. this survey aims to appraise the literacy level and gather the opinions of public health experts and allied professionals working in the field of infectious diseases in belgium concerning the implementation of next-generation sequencing (ngs) in public health practice. methods: in may 2019, belgian public health and healthcare professionals were invited to complete an online survey containing eight main topics including background questions, general attitude towards pathogen genomics for public health practice and main concerns, genomic literacy, current and planned ngs activities, place of ngs in diagnostic microbiology pathways, data sharing obstacles, end-user requirements, and key drivers for the implementation of ngs. descriptive statistics were used to report on the frequency distribution of multiple choice responses whereas thematic analysis was used to analyze free text responses. a multivariable logistic regression model was constructed to identify important predictors for a positive attitude towards the implementation of pathogen genomics in public health practice. results: 146 out of the 753 invited public health professionals completed the survey. 63% of respondents indicated that public health agencies should be using genomics to understand and control infectious diseases. having a high level of expertise in the field of pathogen genomics was the strongest predictor of a positive attitude (or = 4.04, 95% ci = 1.11 – 17.23). a significantly higher proportion of data providers indicated to have followed training in the field of pathogen genomics compared to data end-users (p < 0.001). overall, 79% of participants expressed interest in receiving further training. main concerns were related to the cost of sequencing technologies, data sharing, data integration, interdisciplinary working, and bioinformatics expertise. conclusions: belgian health professionals expressed favorable views about implementation of pathogen genomics in their work activities related to infectious disease surveillance and control. they expressed the need for suitable training initiatives to strengthen their competences in the field. their perception of the utility and feasibility of pathogen genomics for public health purposes will be a key driver for its further implementation. sequence information from viruses, bacteria, and other infectious organisms can be used to identify a pathogen and its specific characteristics, and compare its genetic relatedness to other pathogens [1] . advances in sequencing technologies, especially the shift to next-generation sequencing (ngs), have made it possible to analyze pathogen genomes in much greater detail. compared to sanger sequencing, ngs technologies allow a faster and cheaper way to sequence larger lengths of nucleotides. as such, ngs makes microbial pathogen whole-genome sequencing (wgs) accessible in high throughput within a matter of days [1] . during the last decade, ngs has expanded beyond the research settings and is being rapidly applied into routine practice for public health and food safety [1] [2] [3] [4] [5] [6] . in public health, integrating pathogen genomics with epidemiology provides many opportunities for improving the population-level risk assessment and management of infectious diseases [1] [2] [3] [4] [5] [6] [7] [8] . the main applications of wgs include (1) retrospective (or near real-time) comparisons of pathogens' relatedness to test epidemiological transmission hypotheses of suspected outbreaks (i.e. outbreak investigations); (2) wgs-based prospective surveillance by monitoring of cases generating alerts when clusters of pathogens with similar genomes are identified in a limited geographical area or time period or when virulent clones emerge (outbreak detection by control-oriented surveillance); and (3) cross-sectional genomic epidemiology surveys to monitor long-term changes in epidemiology over larger geographic and population scales to inform prevention strategies (strategy-oriented surveillance) [9] . the main added value of implementing wgs during surveillance activities or outbreak investigations is inherent in the higher resolution of the wgs output itself, leading to an increased sensitivity and specificity to identify transmission clusters compared to conventional subtyping methods [6] . as such, there are numerous success stories of outbreak investigations applying wgs that were able to identify to the source of infection and implement targeted control measures to stop further spread, saving resources at the health protection and local authority level [10] [11] [12] [13] [14] [15] [16] [17] . other concrete examples of the utility of wgs for national surveillance and local infection control include the guidance of vaccination strategies [18] [19] [20] [21] and antibiotic stewardship [22, 23] . besides transforming the public health approach to infectious diseases monitoring, analysis of pathogen genomics can advance the accuracy of infection diagnostics and guide the treatment of individual patients [4, [24] [25] [26] [27] [28] [29] . for several pathogens, ngs is able to replace current time-consuming and/or laborintensive conventional methods with a single, all-in-one diagnostic test [30] [31] [32] [33] . public health professionals play a key role in protecting the population against communicable disease threats. this requires them to give effective responses in a limited time frame, supported by adequate information resulting from applying the most appropriate tools adapted to the specific public health threat scenario. infectious disease surveillance systems build upon the cooperation between: clinicians, who are at the frontline through identification of infected patients; microbiologists, who are involved in testing specimens; molecular biologists, who study organisms at the molecular level; bioinformaticians, who develop computational approaches/algorithms to analyze genomic data; epidemiologists, who use the data to understand patterns in disease occurrence at the population level; infection control practitioners, who are responsible for local prevention and control of infectious diseases in the community; hospital hygienists, who are involved in the prevention and control of healthcare-associated infections; food safety inspectors, who monitor food products; etc. the activities of these public health experts operating at different levels in the information cycle will be impacted by the introduction of pathogen genomics as they are all connected to each other. this ranges from microbiologists adapting their laboratory workflows to epidemiologists rethinking their current data analysis approaches. typically, new laboratory technologies are adopted by data providers first, while data end-users might not be familiar enough with the new methods to effectively translate the output data into public health actions. expertise with pathogen genomics and its applications for public health practice might also differ between those in charge of national surveillance of infectious diseases and those involved in local infection control and patient management, as well as between different fields (i.e. human, animal, food, and the environment) within the one health spectrum [34, 35] . differences in perceptions and needs between these different profiles should be taken into account before we can build a strategy that engages all the stakeholders in an effective collaboration. the key to success in translating pathogen genomics into public health practice is to demonstrate an added value by better addressing the needs and expectations of the whole range of public health experts. an effective exchange of expertise across disciplines (e.g., clinicians, microbiologists, epidemiologists, and bioinformaticians) is key for enabling the smooth implementation of ngs into routine public health activities. if such coordination of joint efforts cannot be accomplished, the technology shift, which is currently ongoing, might not realize its full potential [5, 8] . previous surveys in the field of public health genomics focused on: human genomics [36] [37] [38] ; specific aspects such as proficiency testing [39] , the design of wgs clinical reports [39] or data sharing [40] ; or specific target groups such as national microbiology focal points [41] or food safety laboratories [42] . in this study, by organizing an online survey, we aimed to perform a wide landscape analysis of all potentially involved stakeholders in order to appraise the level of genomic literacy and to gather the opinions of public health experts and allied professionals working in the field of infectious diseases in belgium concerning the implementation of ngs in routine public health activities, in terms of its utility, feasibility, implementation, and translation into actionable results for public health decision making. an electronic questionnaire survey (see additional file 1) was developed for this study using limesurvey (version 2.71.1) [43] for the collection of relevant information from public health professionals working in the field of infectious diseases in belgium. for the purposes of this study, a 'public health professional in the field of infectious diseases' was defined as a person with professional expertise in the field of infectious diseases and who directly or indirectly contributes to the population-level management of infectious diseases. to provide a complete picture of all involved stakeholders, the survey aimed to reach different subgroups based on professional qualification (i.e. microbiologists, molecular biologists, bioinformaticians, epidemiologists, clinicians, clinical biologists, infection control practitioners, and hospital hygienists), employing institution (i.e. governmental, private, hospital, and university), health field (i.e. human, animal, food, and environment), expertise in pathogens (i.e. bacteria, viruses, parasites, fungi, and yeasts), and level of action (i.e. national surveillance and local infection control). to identify all actors in the field of public health activities for infectious diseases, an overview was made of existing surveillance systems (i.e. data sources) in belgium (see additional file 2). the set of questions was compiled based on the literature, including several review articles [1-3, 5, 7, 24-26, 44, 45] . existing items from previous survey questionnaires [27, [36] [37] [38] [39] [40] [41] [42] 46] ) were used and adapted when relevant. most of the existing questionnaires from which some questions were adapted to be used for this survey were not validated, except for chow-white et al. 2017 as mentioned in the respective publication [37] . the construction of the survey was discussed during several feedback rounds within a multidisciplinary team including epidemiologists, microbiologists, and molecular biologists. as a result, the survey instrument was vetted by subject matter experts. the questionnaire eventually contained eight main topics comprising background questions, general attitude towards pathogen genomics for public health practice and main concerns, genomic literacy, current and planned ngs activities, place of ngs in the diagnostic hierarchy of microbiology, data sharing obstacles, end-user requirements, and key drivers for the implementation of ngs. based on a filter question where participants indicated their level of familiarity with pathogen genomics, the respondents were redirected to different sets of questions with different levels of technicity and detail. the filter question gave access to a reduced version of the questionnaire for those participants judging themselves as not at all familiar with pathogen genomics. the responses were mainly collected as single/multiple options from a set of pre-defined answers, but also included the optional entry of free text. these qualitative open questions were included to add context to the quantitative responses. the survey tool was pre-tested by three researchers not directly involved in the development phase to ensure the acceptability and clarity of the questionnaire. participants were contacted individually by an email invitation containing a personal token to complete the survey. no monetary or other incentive was offered. the participant information statement at the beginning of the survey informed the respondents about the objective and design of the study and their rights before participation to the survey, and explained that responses are anonymized and will be kept confidential. the approval from an ethical committee was not considered necessary due to national regulations (legislation 4 april 2014), as this study was not medical in nature and as participants were not subject to any actions and/or rules of conduct. the survey was available online during a two months' period during which three reminders were sent to those who had not yet responded. the first invitations were sent on the 6th of may 2019 and the survey remained active until the 1st of july 2019. participants were invited to send any questions, feedback or comments for the survey to the organizers. only completed questionnaires were used for analysis. descriptive statistics were reported by analyzing categorical response frequencies. differences in viewpoints between the stakeholders were described using subgroup analyses and compared using a fisher's exact test. subgroups were compiled on the basis of the level of action (national vs. local), the position in the information cycle (data providers vs. data end-users), and the level of expertise in the field of pathogen genomics. the level of action was considered national when the main affiliation of the respondent concerned a national institute involved in national public health activities, whereas the local level included professionals who mainly operate at the community, hospital, or university level. subgroups based on the position in the information cycle were defined as data providers, defined here as experts in wet and dry lab procedures and (potentially) generating ngs data (including microbiologists, molecular biologists, clinical biologists, and bioinformaticians), and data endusers defined here as using ngs data to improve their activities and implementing infection control measures (including epidemiologists, local infection control practitioners, hospital hygienists, and clinicians). the level of expertise was categorized as high, middle or low, and was based on respondents' self-reported familiarity with pathogen genomics, training level, and current use of ngs. multiple logistic regression was performed to identify predictors of a positive attitude towards the implementation of pathogen genomics from a public health perspective. enthusiasm about public health agencies using genomics to understand and control infectious diseases was defined directly through a question with multiple options, each containing a clear statement (see additional file 1). for the purpose of this analysis, the question asking about their enthusiasm originally consisting of multiple categories was collapsed into two levels: very enthusiastic versus all others. the following predictor variables were initially tested in the model: level of action; position in the information cycle; level of expertise; current use of ngs; institution; age group; years of professional experience; and position in their institution. model building involved a univariate analysis to select variables to be included in the multivariable model based on a χ2-test (cut-off, p = 0.25), and variable selection from the multivariable model using backward stepwise regression based on the akaike information criterion (aic). adjusted odds ratios (ors) and 95% confidence intervals (cis) were calculated. quantitative analyses were performed using r software (r studio version 1.0.153) [47] . answers to open-ended survey questions were summarized and analyzed using nvivo qualitative data analysis software (nvivo version 12) [48] . this was done by identifying themes (codes) within the data, which were derived both deductively and inductively. following the thematic analysis framework, the text was compared and contrasted with the identified codes. the qualitative findings were summarized as a mind map linking the identified major and minor themes and a word cloud visualizing the word frequency from the qualitative responses. simultaneously, quotes were selected for the sake of illustration. out of the 753 invited participants, 465 did not respond at all, 142 partially filled in the survey, and a total of 146 participants delivered a completed survey which represents an overall survey response rate of 19% (fig. 1 ). from these, 135 participants continued after the filter question and delivered answers to all questions (116 subject were redirected to a technical version of the survey and 19 subjects to a basic version, based on the filter question). the data from the 11 participants who preferred to quit after the filter question were only used to describe the background characteristics of the study population. the 142 subjects who partially filled in the survey were dropped completely from the analysis. full responses to all questions as they appeared in the questionnaire are provided as an appendix to this report (see additional file 3). background characteristics of the 146 participants are presented in table 1 . the majority of respondents had their main affiliation in the public sector (53%), followed by hospitals (including university hospitals) (36%), private sector (8%), and university (3%). the public sector was primarily represented by sciensano (belgian institute for health), comprising 42% of all survey participants (61/146). 53% of the respondents indicated that they had more than 10 years of professional experience within the field of infectious diseases. the reported roles of respondents within their institutions included: microbiologists/molecular biologists/bioinformaticians/clinical biologists (45%); epidemiologists (21%); clinicians (13%); hospital hygienists/infection control practitioners (10%); and policy makers (3%). the 146 survey respondents were asked to describe their level of familiarity with sequencing technologies and pathogen genomics using following classification: 'very -i am involved in the generation and/or use of ngs data' (22%), 'somewhat -i have a general sense of the applications of ngs' (58%), or 'not at all -i don't know anything about ngs and its applications' (21%). of those participants answering 'very familiar', most of them (88%; 28/32) indicated that they mainly used ngs in the context of wgs. of those 'not at all familiar', 11 preferred to quit the survey and 19 continued the survey to answer some general questions, leaving a total of 135 participants for the remainder of the survey (fig. 1) . subgroup analysis showed differences in familiarity with pathogen genomics between data providers and endusers (fig. 2 ). data providers indicated significantly more frequently that they were 'very familiar' compared to data end-users (p < 0.001). the majority of respondents (63%; 85/135) indicated that they were very enthusiastic (i.e. 'we should be using genomics now') about public health agencies using genomics to understand and control infectious diseases, 30% (40/135) did not have an opinion or did not know enough of the topic to be able to give an opinion, and 7% (10/135) indicated that they did not see clear applications and/or an added value for public health. subgroup analysis pointed out differences in enthusiasm according to the level of expertise in the field of pathogen genomics ( fig. 3 ). important predictors, as identified by the best fitting model, of a positive attitude related to the implementation of pathogen genomics from a public health perspective were the level of expertise, the level of action, and the position in the information cycle ( table 2 ). participants classified as having a high level of expertise based on their self-reported familiarity with the topic, their training level, and/or the current use of ngs were significantly more likely to be enthusiastic about the implementation of pathogen genomics in a public health context compared to their peers with a low expertise (adjusted or = 4.04, 95% ci = 1.11 -17.23). further, public health professionals operating at the national level were more often 'very enthusiastic' about the implementation of pathogen genomics (71%) compared to those at the local level (53%). similarly, data providers were more often 'very enthusiastic' (76%) compared to data end-users (50%). a large majority of respondents considered the following public health activities as likely to be most impacted by pathogen genomics in the next five years: identifying an outbreak (clusters of related isolates) (78%; 105/135), nosocomial and food/waterborne outbreak investigations (76%; 103/135), and monitoring the spread of antimicrobial resistance (71%; 96/135). in contrast, only 44% (60/ 135) of respondents thought that pathogen genomics would have a major impact on making a diagnosis and selecting an appropriate treatment (individual patient management). other public health activities that will benefit from the implementation of pathogen genomics mentioned by the participants are presented in table 3 . the most frequent concerns among participants being 'very' or 'somewhat' familiar with ngs technologies and pathogen genomics (n=116) regarding feasibility of its routine use for public health purposes, were the cost of sequencing technologies and the existing barriers to timely and open sharing of pathogen sequence data and accompanying metadata ( table 4 ). all participants exclusively working with respiratory infections (e.g. influenza) and/or vaccine-preventable diseases (e.g. measles) (n=7) were very concerned about the cost, whereas this was only true for 38% of participants exclusively working with invasive bacterial diseases (e.g. neisseria meningitidis), food-and waterborne diseases (e.g. salmonella), and/or healthcareassociated infections (e.g. clostridium difficile) (n=21). further, other concerns shared by a large proportion of the participants were interdisciplinary cooperation, integration of pathogen sequence data with contextual data, access to bioinformatics expertise, and availability of typing schemes and databases. participants indicating to be 'not at all' familiar with pathogen genomics were mainly concerned about the cost of the sequencing technologies (see full responses in additional file 3). other concerns provided by the participants as free text are presented in table 3 . two-thirds of the participants (88/135) indicated that they had followed training in the fields of genomics/genetics/ molecular biology/bioinformatics. there were marked differences by position in the information cycle: 56% (38/ 68) of data end-users indicated that they had never followed any training in the field, whereas this was stated by only 13% (9/67) of data providers (p < 0.001). further breakdown of training experience by professional category is shown in fig. 4 . the main reasons for not taking a training/course in this field (yet) were the lack of available and/or suitable trainings (40%; 19/47) and the lack of time (30%; 14/47). other reasons indicated as free text are presented in table 3 . the vast majority of participants (79%, 106/135) indicated that they felt the need and/or would be interested in following (additional) courses/training/workshops covering a topic related to pathogen genomics. overall, 36% (42/116) participants being 'very' or 'somewhat' familiar with ngs technologies and pathogen genomics indicated that they are currently using or generating ngs data for at least one pathogen. differences between professional groups are presented in fig. 5 . among the microbiologists, those from a national reference centre (nrc) were more likely to be currently using ngs (12/18, i.e. 67%) compared to those from other laboratories (1/7, i.e. 14%), however this difference was not significant (p=0.71). from the public health professionals exclusively involved in human infectious disease activities, 30% (21/70) were currently using ngs technologies, whereas this was the case for 44% (11/25) of those exclusively involved in the food, animal or environmental sector (p=0.23). looking forward, 44% (51/116) of participants indicated that they were planning to use or generate ngs data for any (additional) pathogen(s) within three years. details on the specified pathogens can be found in the appendix (see additional file 3). reasons provided by participants indicating that they did not plan to implement pathogen genomics were mainly related to the cost and the lack of expertise. participants being 'very' or 'somewhat' familiar with ngs technologies and pathogen genomics (n=116) were asked to assign a score from 1 to 5 to the different criteria based on their increasing relative importance to decide whether or not ngs should be implemented for a particular pathogen (fig. 6 ). clinical and/or public health significance of the pathogen were scored as the most important drivers. the different subgroups scored the different criteria similarly (see additional file 3). comments provided by the participants to provide context to their scores are presented in table 3 . centralization of sequencing and bioinformatics at nrcs organized per pathogen or per group of pathogens was most often (34%; 40/116) selected by respondents being 'very' or 'somewhat' familiar with pathogen genomics as the preferred wgs provision model in the belgian context. excluding participants working at nrcs slightly lowered this proportion to 29 out of 98 (i.e., 30%). there were no marked differences according to the level of action of the participants (fig. 7) . illustrative quotes for the need for centralization are presented in table 3 . public health activities, other than those provided within the survey, that will benefit from the implementation of pathogen genomics environmental monitoring "drinking water quality" "air quality, home environmental quality" metagenomics "metagenomics for patients with no identified cause of illness using conventional methods" "identification and characterization of new strains" "insights in dysbiosis" "microbiome analysis" other "discovery of a causal relation between a pathogen and a clinical disease (e.g. cancer)" "vaccine development" "phage therapy" "early diagnostics of diseases due to slow growing pathogens" "international tracking" "monitoring of antiviral resistance" concerns, other than those provided within the survey, related to the implementation of pathogen genomics for public health practice contextual data "harmonization of epidemiological datamost of the epidemiological data is very 'messy' or inconsistent, which makes systematic integration and surveillance unfeasible" "data collection is already limited so newer technologies will not automatically improve this process but be redundant if the basics are not met" "how to interpret the result at clinical level" "[…] they need to have a basic understanding (education) it order to understand and see cost/benefit of the whole picture" "appropriate training of personnel for execution and interpretation" "interpretation across sectors" "multidisciplinary knowledge" ethics "[…] healthcare workers integrity concerns" "in the hiv field, the phylogenetic analyses of virus permit to have an hindsight in paths of transmissionit is a very tricky topic in ethical and potentially legal aspects" other "does the identification prove that the pathogen poses a risk?" "the fear that some actors in the field will try to abuse their power and monopolize this new technologyto be really valuable to patient management and public health it is required to offer access to all laboratories" "high inter-laboratory variability" "[…] standardization and facilities for data sharing need to be improved" "the perceived utility and feasibility of pathogen genomics by public health practitioners is the biggest bottleneck of allall the other concerns listed above can be tackled given the drive within the field to solve them in the first place" reasons, other than those provided within the survey, for not taking a training/course in the field of pathogen genomics "lack of training adapted to public health needs" "not applicable for a clinician" "not my priority" "not relevant for my practice" "depends on the evolution in phenotypic typing" "[…] the main driver the pressure by ecdc rather than a real need for public health […] the first and main driver should be clinical significance: improve quality of care for the patient" "for bacteria, ngs will never fully replace classical methods for resistance testing, but would offer important complementary data" "cost-effectiveness (e.g. replacing multiple tests): not particularly true for viruses, but obvious for bacteria" centralization "[…] should be overall coordinated and controlled by the federal public health authority" "[…] in any scenario it will be important that sequence data are brought together in one databank for surveillance purposes" table 3 . major themes identified within the qualitative data are utility (applications), feasibility (including capacity building, multi-disciplinary working, contextual data, costs, data sharing, ethics, timeliness, wet and dry lab), one health context, and routine implementation (including organization and translation into action). a mind map linking the identified major and minor themes is presented in fig. 8 . a full list of identified themes and the coded text is available in the appendix (see additional file 4), as well as a word cloud constructed based on the free text responses (see additional file 5). this survey sought the opinion of belgian public health professionals working in the field of infectious diseases concerning the implementation of pathogen genomics in public health activities. to successfully translate pathogen genomics into public health practice, the needs and expectations of the different stakeholders should be taken into account. other questionnaire surveys related to knowledge and attitudes towards public health "the bureaucracy involved in the transmission of data" "the structure of public health in belgium will not help sharing data" "the required technical infrastructure" priority to publication "it is really a pity that priority to publication is an obstacle in the scientific world as it functions now" one health "a better collaboration between the veterinary and human side might increase the use of ngs on the veterinary side" "monitoring the emergence and spread of zoonotic pathogens has been impacted negatively, by the introduction of wgs at the human side only" genomics in specific health expert categories have been published [27, 36-39, 41, 42, 46, 49] . however, to the best of our knowledge this survey is the first that aimed to perform a wide landscape analysis of all potentially involved stakeholders. therefore, a strength of the current study is that it took into account a wide range of stakeholders with diverse backgrounds (epidemiologists, microbiologists, bioinformaticians, clinicians, infection control practitioners, etc.), health domains (human, food, environmental, etc.), pathogen expertise (bacteria, viruses, parasites, fungi, etc.), activity sectors (public, private, university, hospital, etc.), work positions (employee and lower/middle/high management), and degree of familiarity with genomics. besides seeking the general attitude of the participants towards the implementation of pathogen genomics in their professional activities and investigating the current and future use, this explorative study was able to touch upon multiple key topics, such as genomic literacy, data sharing obstacles, place of ngs in the diagnostic hierarchy of microbiology, and enduser requirements. familiarity with sequencing technologies and pathogen genomics varied between the different professional groups, with data providers being more familiar than data end-users. as shown before, one of the largest barriers to acceptability from the public health unit is the capacity to understand and use the data [50] . possibly, there is a positive association between genomic literacy criteria could be assigned a score from 1 to 5, or participants could indicate the 'i don't know' option. the boxplots show the median score and the interquartile range (grey boxes). the following criteria were included (top to bottom): clinical and/or public health significance, priority with respect to preventing the spread of antimicrobial resistance, local/national/international policy surveillance priorities or obligations, importance of prevention and control programs (e.g. vaccination), utility of wgs for diagnostics and/or treatment decisions (individual patient care), utility of increased resolution to infer relatedness that would not be obtained via conventional methods, availability of high-quality/complete/standardized epidemiological and/or clinical data to provide context to the wgs results, possibility to link genomic data from different sources (food-animalhuman-environment), cost-effectiveness (e.g. replacing multiple tests), time-saving compared to conventional testing methods, impact on outcomes for patients and populations (translation into actionable results), availability of wgs typing schemes and reference databases (e.g. for antimicrobial resistance), availability of validated (quality-controlled) wgs workflows (both wet and dry laboratory), availability of expertise to generate, analyze and interpret wgs data, and availability of the appropriate infrastructure (sequence technology, high-performance computing, data storage, etc.). having a high level of expertise, was the strongest predictor for a positive attitude, as was also shown in other surveys [51] [52] [53] . epidemiologists and infection control practitioners should be informed about the benefits and limitations of ngs technologies in order to contribute in identifying tangible field application in public health, allowing the use of wgs output to appropriately guide public health actions [38, 51] . another important challenge related to the interpretation of wgs data is the capacity to interpret signals, and thereby separating noise from public health events that require specific actions. consequently, integrating genomics into infection control and surveillance is critically linked to human resource development [8, 24] . in the survey, the main reasons stated for not training in the field of genomics were lack of time or access to suitable trainings "…adapted to public health needs". however, the participants of this survey generally expressed a positive attitude towards following (additional) training courses, or workshops in pathogen genomics. educational workshops should be applied to a public health context and bring together the expertise of microbiologists, molecular experts, bioinformaticians, epidemiologists, infection control practitioners, and clinicians. the development of a new discipline called 'genomic epidemiology' integrating information on epidemiological and pathogen sequence characteristics by public health microbiologists, epidemiologists, and risk managers was recommended in the expert opinion on wgs for public health surveillance by the european centre for disease prevention and control (ecdc) in 2016 [8] . ecdc has initiated public health genomics training workshops that bring together experts with epidemiology, microbiology and pathogen genomics backgrounds from european union (eu) member states with interest in implementing the technology in surveillance and outbreak investigations. besides, the zoonotic origin of many clinically relevant pathogens and antimicrobial resistance determinants stresses the importance of a cross-sectoral one health approach. the implementation of wgs should be synchronized and integrated between the human health and veterinary sectors [9] allowing a better monitoring of the emergence and spread of zoonotic pathogens and antimicrobial resistance-related threats. lack of financial resources was often indicated as a principal reason for not using or planning to use wgs by the respondents of this survey, which was also reported by the european surveys conducted by ecdc [41] and the european food safety authority (efsa) fig. 8 mind map linking the major and minor themes identified in the qualitative responses, belgium, 2019. codes were identified within the data deductively (i.e. themes that are expected and have been chosen in advance) and inductively (i.e. themes that are derived through analysis). during the thematic analysis the qualitative data from the survey was compared and contrasted with the identified codes. as such, the derived codes were assigned to the relevant text. next, the codes (plain boxes) were merged into categories (colored boxes). the following categories were identified: routine implementation (orange), one-health context (yellow), and feasibility (blue) [42] . operational costs will be influenced by the processes used in current laboratory practice and differs between viruses and bacteria. whereas drug susceptibility testing and epidemiological typing are commonly performed for bacteria, this is often not the case for viruses detected in the routine laboratory [54] . therefore, cost-effectiveness of ngs for many bacteria potentially follows from the replacement of conventional characterization methods, whereas for viruses ngs is considered as a tool providing additional complementary information without replacement of the existing methods. further, an important consideration is the added value of ngs for routine diagnostics. as long as ngs is more expensive than the conventional methods and when there is no direct benefit for the individual patient, it will not be used in routine. then the fields of application for surveillance purposes should be clearly defined to be able to justify the additional financial resources needed to perform wgs beside the diagnostic activities. to translate pathogen sequence data into truly useful and actionable information, it needs to be integrated with other types of information (i.e. clinical and epidemiological data). in belgium, most data end-users were concerned about the challenges encountered with the integration of pathogen sequence data with clinical and epidemiological data. indeed, the public health usability of any kind of lab results, including wgs data, is highly dependent on the cross-linkage with contextual epidemiological and clinical information [8, 55, 56] . data integration is often hampered by the incomplete and/or unstandardized nature of the contextual data [57] . the ongoing digitalization of health data such as laboratory and clinical records may represent an opportunity to review and upgrade traditional data collection processes for communicable disease surveillance. according to world health organization's (who) 2016 guidance on managing ethical issues in outbreaks [58] , rapid data sharing is crucial during an unfolding health emergency. this suggests that pathogen sequence data should be rapidly and openly shared at the start of an outbreak, in many cases before scientific publication. however, many barriers for data sharing remain including authorship/attribution for publications, results dissemination, ethical considerations, data ownership, database access agreements, etc. [59] . in our survey, practical barriers (lack of data standardization, poor data quality, missing metadata, etc.) seemed to be the major obstacles in belgium for sharing pathogen sequence data and associated metadata for public health purposes. participants mainly mentioned the lack of a central database and clear guidelines. this reflects a lack of information on the effective data sharing through eu-wide genomic surveillance and cross-border outbreak analysis systems managed by ecdc and efsa in support of the member states [9, 60, 61] . finally, 27% of participants considered the priority to publication as a major bottleneck for sharing pathogen sequence data. publication priority is linked to the importance of guaranteeing reputational returns to research efforts [40, 62] . the challenge here is to find a balanced arrangement that allows data sharing in real time and the acknowledgement of research work by giving to researchers who have been involved in data generation the possibility to use and publish their own results in priority. as the use of ngs shifts from research to routine laboratory practices, this data sharing barrier will slowly be alleviated. regarding expertise and availability of personnel, wet and dry lab experts were more concerned about the analysis of pathogen sequence data than the sequencing itself. as was mentioned in a review article of aarestrup et al. and documented in a recent european survey by revez et al., the most important limiting factor in many countries is the lack of access to bioinformatics expertise, especially when used as part of frontline diagnostics [44] or national public health reference laboratory service [41] . another point of discussion is the potential impact of ngs on the diagnostic microbiology pathway. traditionally, frontline clinical laboratories perform standard identification, antimicrobial susceptible testing and occasionally typing. isolates may then be referred to reference laboratories based on the need (e.g. diagnostic confirmation) or for surveillance purposes. these reference laboratories perform confirmation testing and advanced characterization. ngs was first implemented at the level of academic or reference laboratories, because of the need for investments, operational costs, and requirements for expertise [24] while having limited added value for individual patient care. samples must be multiplexed (batching) for cost-effectiveness, which is easier to achieve in large reference laboratories with high volume of sample throughput [26, 45] . however, processing delays may be present when samples are shipped to a reference center. these processing delays may result in longer turnaround times rendering this centralized approach inappropriate to support a fast response when needed. the reduced costs of sequencing facilitated the introduction of ngs technology to frontline clinical laboratories. this shift towards a decentralized use may reduce turnaround times, empower hospital-based microbiology, and strengthen local infection control efforts [24] . this decentralized capacity will allow the inclusion of these data in the surveillance network coordinated by the epidemiologists what will compensate the reduced referral of isolates to reference centers. consequently, the implementation of ngs in routine labs is an important driver to reconsider the future role of nrcs. molecular typing for public health surveillance is undergoing a stepwise transition to ngs [41] . current and future ngs activities represented in this national survey were mainly in the context of food-and waterborne outbreak detections and investigations, reflecting the priority for these diseases across europe and beyond [63, 64] . several criteria should be considered in the process of integrating wgs in a routine laboratory setting [11] in order to know in which situations and for which pathogens it is worthwhile to use ngs. identifying a set of key drivers that cover all aspects related to the implementation of ngs (utility and feasibility) can help to guide prioritization of pathogens and to efficiently allocate resources. clinical and/or public health significance of the pathogen was scored as the most important driver during the implementation of pathogen genomics in routine public health activities, followed by availability of expertise to generate, analyze and interpret wgs data, and priority of the pathogen with respect to preventing the spread of antimicrobial resistance. qualitative responses revealed the opinion of several participants that the assessment of the added value of new technologies for individual patient care is paramount. if pathogen genomics is routinely used to guide patient management (diagnosis and/or treatment options), the pathogen sequence data gathered for diagnostic purposes can be accumulated for public health activities [65] . if there is no added value for routine diagnosis, the cost of wgs will have to be covered by limited public health budgets. as a limitation, the relatively low response rate induced a potential volunteer bias as those public health experts being more interested and/or experienced in the field could be more likely to participate in the survey. yet, 21% of the participants indicated that they were 'not at all' familiar with sequencing technologies and pathogen genomics. further, we noticed a possible underrepresentation of the food, animal and environmental field in comparison to the human field, as well as a low number of bioinformaticians in the survey. in addition, public health professionals from the belgian institute for health (sciensano) might be overrepresented. the majority of microbiologists participating in the survey are based in a nrc, emphasizing surveillance activities and hence less weight to routine diagnostics. given this potential imbalance, it is important to take into account the distribution of profiles within the study population while interpreting the results. however, it is difficult to ascertain the true underlying distribution of the different professional groups within the target population. another limitation of the study is that the specific terminology used in the questions may not have been uniformly understood or consistently interpreted by stakeholders with different professional backgrounds [39] . public health professionals working in the field of infectious diseases in belgium were in general enthusiastic about public health agencies implementing pathogen genomics for the surveillance and control of infectious diseases. however, introducing genomic methods into public health practice is inevitably linked to the decrease in cost, the introduction in routine activities of frontline clinical labs, the identification of field applications in public health, and the necessary development of new competencies. the results of the survey confirm the need to increase genomic literacy by offering dedicated training opportunities among public health professionals, especially for the data end-users including epidemiologists, clinicians, and infection control practitioners, enabling them to critically assess the utility and feasibility of implementing pathogen genomics in their work activities. as such, those at the forefront (i.e. end-users) may act as "honest brokers" responsible for evaluating the added value of genomic application. in the end, the main driver for the advancement of pathogen genomics in public health practice depends on the added value of this information for the different clinical and public health needs. further, inter-disciplinary (between epidemiologists, microbiologists and bioinformaticians) and intersectoral (one health context) collaboration should be improved in the future to pool expertise and to ensure an integrated and cohesive system for the management of infectious diseases. in terms of feasibility, respondents in this survey were mainly concerned, like their peers in similar european surveys, about data integration, data sharing, and the cost of sequencing technologies. overall, this survey helps to better understand the perceived utility and feasibility of pathogen genomics according to public health professionals and can inform further guidance to facilitate its implementation in belgium. future challenges can be anticipated by performing a similar survey among public health experts based in a country that already progressed further in the process of implementing pathogen genomics within their public health surveillance system. supplementary information accompanies this paper at https://doi.org/10. 1186/s12889-020-09428-4. additional file 1. "questionnaire". description of data: "list of questions included in the online survey". additional file 2. "selection of target groups for the survey". description of data: "an overview of existing surveillance systems to identify all public health professionals who (would potentially) generate or use ngs data for the surveillance of infectious diseases based in different institutes and organizations in belgium." additional file 3. 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information in food safety and animal health decision-making significance of whole genome sequencing for surveillance, source attribution and microbial risk assessment of foodborne pathogens towards an integrated food safety surveillance system: a simulation study to explore the potential of combining genomic and epidemiological metadata guidance for managing ethical issues in infectious disease outbreaks. world health organization world health organization. who r&d blueprint meeting on pathogen genetic sequence data (gsd) sharing in the context of public health emergencies european centre for disease prevention and control and european food safety authority. multi-country outbreak of listeria monocytogenes clonal complex 8 infections linked to consumption of cold-smoked fish products -4 european centre for disease prevention and control and european food safety authority. collection and analysis of whole genome sequencing data from food-borne pathogens and other relevant microorganisms isolated from human, animal, food, feed and food/feed environmental samples in the joint ecdc-efsa molecular typing database data sharing in genomics -re-shaping scientific practice impact of food and water-borne diseases on european population health world health organization. who estimates of the global burden of foodborne diseases real-time analysis and visualization of pathogen sequence data publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we would like to thank all study participants who took the time to complete the survey and provided valuable insights to reach to objectives of our study. these include the scientists from the belgian institute for health (sciensano) and the federal agency for the safety of the food chain (fasfc) working in infectious disease departments; physicians and infection control practitioners of the regional infectious disease control teams from the three regions in belgium; microbiologists from national reference centers (nrcs) and from sentinel laboratories; members from the belgian society of infection specialists and clinical microbiologists (bvikm), the belgian antibiotic policy coordination committee (bapcoc), the belgian infection control society (bics), and the belgian society for food microbiology (bsfm); clinicians, clinical biologists and hospital hygienists participating in sentinel surveillance networks; and public health experts within the ministry of health. we also would like to thank jérome ambroise, jimmy van den eynden, and boudewijn catry for pre-testing the survey, and vera cantaert, yves dupont, chloé wyndham-thomas, and karl mertens for their contributions in recruiting participants. this research was supported by the .be ready project financed by sciensano. the raw data analyzed during the current study are available from the corresponding author on reasonable request. the first page of the questionnaire explained the purpose of the research, the measures taken to protect respondents' confidentiality and the voluntary nature of participation. questionnaire respondents were asked to tick 'agree' at the start of the questionnaire to indicate that they consented to take part in the study and were willing to complete an anonymized questionnaire. ethics approval was deemed unnecessary according to national regulations (law of 4 april 2014; http://www.ejustice.just.fgov.be/mopdf/2014/05/16_1. pdf#page97), as participation was anonymous and no medical data were processed. not applicable. the authors declare that they have no competing interests. key: cord-263667-5g51n27e authors: steele, james harlan title: veterinary public health: past success, new opportunities date: 2008-09-15 journal: preventive veterinary medicine doi: 10.1016/j.prevetmed.2008.02.014 sha: doc_id: 263667 cord_uid: 5g51n27e abstract animal diseases are known to be the origin of many human diseases, and there are many examples from ancient civilizations of plagues that arose from animals, domesticated and wild. records of attempts to control zoonoses are almost as old. the early focus on food-borne illness evolved into veterinary medicine's support of public health efforts. key historical events, disease outbreaks, and individuals responsible for their control are reviewed and serve as a foundation for understanding the current and future efforts in veterinary public health. animal medicine and veterinary public health have been intertwined since humans first began ministrations to their families and animals. in the united states, the veterinary medical profession has effectively eliminated those major problems of animal health that had serious public health ramifications. these lessons and experiences can serve as a model for other countries. our past must also be a reminder that the battle for human and animal health is ongoing. new agents emerge to threaten human and animal populations. with knowledge of the past, coupled with new technologies and techniques, we must be vigilant and carry on. farmer keeping animals in his midst. the people who domesticated the animals were thus the first to be victims. those early humans then developed resistance to some zoonotic diseases that had emerged (diamond, 1997) . the relation of animal diseases to human disease was observed in the ancient civilizations of babylon, the nile valley, and china and noted by leviticus in the old testament, and later by hippocrates in greece, and virgil and galen in rome. millions of people across europe during the middle ages suffered from plague carried by rat fleas. the invasion of europe by rinderpest in the 18th century disrupted commerce and government so much that the papal authority created a medical commission to advise the vatican on what measures should be taken to control the animal plague/rinderpest . the movement of animal diseases into the americas is believed to have been in the support of the settlements founded by columbus in santo domingo in 1493. these livestock were the foundation animals for spanish colonies in the americas. in the next century, de soto, the spanish explorer of florida and the southeast, brought cattle, horses, and swine, as well as dogs that thrived. farther north, the virginia colonists brought animals to roanoke island, but none survived, neither humans nor animals. later the jamestown colonists imported domestic animals that survived and became valuable foundation stock, but no zoonotic diseases are recorded in any of these earliest settlements. not until 1753 was rabies the first zoonosis recorded in the us colonies, and later as an epizootic in both the colonies and the federation of states in the late 18th century (smithcors, 1975a,b) . in 1798, the newly founded medical repository editors were the first to inquire about emerging diseases in the united states and territories. they asked for information on human diseases, diseases among domestic animals, accounts of insects, the condition of the vegetation, and even the state of the atmosphere. they hoped to put the facts together as an annual report on the status of health in the united states. surgeon general luther terry (1963) of the us public health service (usphs) in his address at the american veterinary medical association (avma) centennial called this report the first reference to veterinary medicine in support of public health. a few years after this report, benjamin rush called for the establishment of veterinary medical education at the university of pennsylvania. the united states sanitary commission, organized during the civil war by public-spirited women, was concerned largely with sanitary conditions, including food hygiene. they were the first to call attention to the putrid meat and later embalmed beef sent to the army. the commission was to be a forerunner of public health in the years following the civil war (furman, 1973) . by the 1870s, there was interest in developing a national health service. yellow fever epidemics were frightening as they spread up the mississippi river from new orleans. the possibility that yellow fever involved animals brought professor john gamgee, a famous veterinarian, from england to investigate the epidemic. he recognized the seasonal occurrencethat cold weather stopped the epidemic -and even suggested river traffic be limited to the colder months. however, he failed to associate the effect of cold weather with the decline of the numbers of mosquito populations, the vector of yellow fever (furman, 1973) . the us board of health came into being largely because of the yellow fever epidemic and the morbidity and mortality that it caused. by the time of the board's inception in 1879, malaria was widespread in the south, and tuberculosis was a recognized disease. typhoid fever and enteric diseases were also common. in addition, animal diseases were present, especially the spread of glanders and anthrax following the civil war (furman, 1973) . in 1879 the president of the us board of health, dr. j.l. cabell, asked james law, professor of veterinary medicine at cornell university, to advise the board on how they should supervise the diseases and movements of domestic animals. law's report (1880) was the first comprehensive recognition of the effects of zoonotic diseases upon public health published in the united states (steele, 2000) . the organization of public health in the post civil war period has been reviewed by miles (1969) , former historian of the national institutes of health (nih). his report discusses the struggle between public health and agricultural interests in the decade leading up to the inauguration of the bureau of animal industry in 1884. the interest of the bureau was to protect animal health, and later to provide a meat inspection service for public health, international trade, and subsequently interstate commerce. the relation of animal diseases to the public health and their prevention by frank s. billings (1884) was the first book to review the problems and the state of bacteriology as well as parasitology in the 1880s. although the book is limited to trichinosis, hog-cholera, tuberculosis, anthrax, texas fever, rabies, and glanders, his knowledge of these diseases is remarkable for the time. billings gained this knowledge through education in berlin, where he learned about the history of animal diseases in the greco-roman period and the latin origin of ''veterinarians,'' which he says first appeared in the 4th century writings of vegetii. he also traveled extensively in europe, where he observed veterinary activities. billings makes a strong plea for the development of veterinary public health to control the animal diseases that affect man. he stated that this could be accomplished only by having trained veterinarians who were scientifically educated. he was one of the veterinarians who was active in the early years of the american public health association (apha), during which discussions of trichinosis, tuberculosis and other animal diseases took place at the early annual meetings. a true visionary of veterinary public health, billings pointed out that milk from diseased cows is dangerous. he appealed to the government to set up laboratories to use the new science of bacteriology to find the cause of illness of milk origin. food hygiene came into being only with the new science of bacteriology (billings, 1884) . the frightful toll of milk borne disease is reviewed by stenn (1980) . in his report, he cites the shocking figure of 400 deaths per 1000 births in new york city in 1880. spoiled milk accounted for the deaths of thousands of children in the early 1900s, and in many other cities. the records of 1908, cited by stenn, list many milk borne outbreaks of typhoid fever and diphtheria. he goes on to state that 16% of the milk cans sampled contained tubercle bacilli, and in cities, 50% of the milk had tubercle bacilli. in 1905 a milk borne typhoid epidemic occurred in washington, dc, that caused president theodore roosevelt to order the usphs to investigate the local supply. surgeon general walter wyman ordered his staff to examine not only the washington milk problem but to examine the national milk problem. the 1908 report milk and its relation to public health by milton rosenau, issued by the usphs, brought reform to the dairy industry and support for the bureau of animal industry program to control bovine tuberculosis (myers and steele, 1969) . pasteur took milk safety even further, changing science and veterinary medicine by creating a new concept of the origin of disease. no longer would the myth of spontaneous origin of disease guide society, although there were as many objections to scientific advances then as now. the 1984 centennial celebration of the rabies vaccine revealed in pasteur a man of many accomplishments. he was a chemist who discovered the cause of fermentation and applied it to the beer and wine industries, a process that led to milk pasteurization. he was an artist who was known to the impressionists of the 19th century as the man who prepared better paint colors. he was also a genius who gave public health the science and vaccines to combat 19th century diseases and prepare for the 20th century's emerging problems (koprowski and plotkin, 1985) . although the concept of pasteurization of beer and wine brought fame to pasteur, the application to milk was less known, and it was accepted no more readily than the concept of evolution. it was asserted that all kinds of illness and changes in well being would ensue from pasteurization. the eradication of bovine tuberculosis and brucellosis (bang's disease) insured a safe milk supply and protected the health of farmers, dairymen, veterinarians and the handlers of milk and milk products. the case for pasteurized milk and milk products is conclusive. in the late 20th century, a new array of milk borne zoonoses is of concern to public health and veterinarians. some date back to the 19th century, such as salmonella. the salmonella were identified in 1885 by one of the most distinguished public servants of the veterinary profession, dr. daniel salmon. as the first chief of the bureau of animal industry (bai) from 1884 to 1905, he assembled and trained a great staff. this included theobald smith, v.a. moore and e.c. schroeder, who solved the epidemiology of texas fever caused by babesia bigemina, which is carried by the tick boophilus annulatus. salmon was the leading proponent of veterinary public health in the 1890s. he asked for, and received from congress, authority for a federal meat inspection service in 1890 to meet the demands of foreign commerce. however, his national program was circumvented by local interests citing states' rights; therefore, the meat inspection act of 1890 was ineffective nationally. salmon sought support from the apha and the american medical association for these early veterinary efforts to protect public health. unfortunately, these agencies did not support him (schwabe, 1984a) . the federal meat inspection service act of 1906 came about only after sinclair (1906) exposed the filthy conditions of the chicago stockyards. salmon was blamed for the local hygiene failure over which he had no authority and was removed from office. however, he is remembered today by the usda's salmon award for leadership. in 1906, the bai initiated tuberculin testing of dairy cattle in the district of columbia, a demonstration that revealed an infection rate of almost 19%. this was the beginning of a successful tuberculosis control campaign that led to its eradication under john r. mohler, bai director from 1917 to 1943. the late jay arthur myers memorialized the near eradication of bovine tuberculosis in his 1940 book, entitled ''man's greatest victory over tuberculosis'' (myers, 1940) . at the start of the 20th century, pathologists were greatly interested in comparative medicine. they were led by karl f. meyer, a swiss veterinarian who was to become one of the leaders and outstanding scientists of the 20th century. he was among the early public health scientists to delve into virology as professor of pathology at the university of pennsylvania (penn), and in 1913 he may have been among the first to recover a virus causing equine encephalitis. as director of the pennsylvania livestock sanitary board laboratory, he published on glanders, anthrax, anaplasmosis, sporotrichosis, paratuberculosis, septicemia, and many other diseases of animals. in 1914 he left the university of pennsylvania to accept a position at the university of california's newly established tropical medical center. the following year, he accepted an appointment to the george williams hooper foundation for medical research at the university of california medical center. he remained there the rest of his life and become a legend. his lectures introduced medical students to the biologically active world, including the zoonoses, plant life, the atmosphere and all that is called the environment today. at the hooper foundation, meyer researched a wide spectrum of animal diseases of public health importance. after being active in the investigation of human influenza in 1918-1920, he went to the field to define the epidemiology of malaria, dysentery, and even dental diseases. his study of the bacterial causes of abortion in animals resulted in bringing together brucella abortus, brucella melitensis, and brucella suis in a new genus honoring david bruce. another important event was his report on clostridium botulinum in nature. botulism became a national concern in the 1920s when california canned fruit and vegetables were found to contain botulinum toxin. the industry asked meyer to resolve the problems and underwrote a laboratory to maintain surveillance. thereafter, meyer was active in food safety, but he was also concerned with humane animal care in which he maintained an interest all his life. in 1933, meyer and his long time lab associate bernice eddie began their series of psittacosis reports in birds. these reports eventually led to control 30 years later with tetracycline-impregnated seed. the same antibiotic is now used to prevent ornithosis in domestic fowl (meyer, 1976) . one of meyer's most memorable lectures was in 1931 when he called attention to the importance of the animal kingdom as a reservoir of diseases that endanger the health and welfare of people throughout the world (meyer, 1930) . in 1954, he first reviewed the state of the animal reservoir of diseases, by then referred to as zoonotic diseases, before the world health organization (who) general assembly. he repeated the same theme before the who expert committees for the zoonoses, plague, food hygiene and for the pan american health organization (paho) until his 90th year. meyer's work on plague was reported in the special supplement of the journal of infectious diseases to commemorate his 90th birthday. this was underwritten by max stern, president of hartz mountain, which supported the psittacosis control investigations at the hooper foundation (steele, 1974) . meyer died in san francisco on may 19, 1974, less than a month before his 90th birthday. larry altman (1974) , the medical editor of the new york times, wrote a lengthy obituary from which the following excerpt is taken. it also appears on the fore page of the journal of infectious diseases (supplement), may 1974: ''dr. karl fredrich meyer was regarded as the most versatile microbe hunter since louis pasteur and a giant in public health [. . .] . public health leaders yesterday called his contributions to medicine 'monumental.' his scientific work had such broad implications that it touched on virtually all fields of medicine.'' the obituary was placed in the congressional record that same month. in 1980, albert sabin (1980) wrote a biographical memoir of meyer for the national academy of science, of which meyer was a member from l940 to 1974. sabin explains that as a youth in basel, switzerland, pictures of the black death so fascinated meyer that he became an outdoor scientist instead of following in the aristocratic business world in which he grew up. he told friends that in choosing to become a veterinarian he could ''be a universal man and study all diseases in all species.'' the 1930s were memorable for public health growth and scientific advances. the viral etiology of influenza was uncovered by richard shope and thomas francis at the rockefeller institute. the use of egg embryos was a new method of growing viruses that would lead to the chick-embryo rabies vaccine and other viral vaccines. the development of the strain 19 brucella vaccine and the stern anthrax vaccine in south africa were important to the control of brucellosis and anthrax worldwide. earlier investigation of toxoids by gaston ramon, a french military veterinarian, led to the discovery of tetanus toxoid for both horses and humans. discovery of the sulfa drugs and penicillin gave the clinician medication he had not dreamt of, a prelude to great advances in medicine. to be a veterinary student in the late 1930s was both exciting and slightly dangerous. the brucellosis epidemic among veterinarians -both students and clinicians -raised epidemiological questions as to how brucellosis was spread. in 1938 michigan state college experienced an epidemic among veterinary students and others in the bacteriology building (holland, 1940) . up to then the disease was thought to be caused by direct exposure or ingestion of milk borne brucella, and airborne brucella was not given much consideration. the episode at michigan state college would change that oversight. as a student in the brucellosis testing laboratory, i heard discussion of the means of spread being water borne and back siphonage. professor i.f. huddleson, whose research laboratory was the focus of this investigation, disagreed with the state investigators, who were public health scientists and engineers focusing on the water borne theory. these investigators suggested contaminated glassware was not being autoclaved properly, and in turn, viable brucella was getting into the water system (newitt et al., 1939) . the discussion of the epidemic, which affected most of the people in the building, along with other public health interests of dean ward giltner, professor h.j. stafseth, professor i.f. huddleson and dr. w.t.s. thorp of the michigan state university college of veterinary medicine, led me to think about a career in public health. dr. stafseth encouraged many students to consider public health as a career (stalheim and steele, 2005) . when he learned of my interest, he and dean giltner worked out a program to make me eligible for a usphs fellowship. i was excused from senior clinics to pursue the fellowship. my assignment was an internship at the michigan health department. there i observed and learned from health department veterinarians, pathologists and bacteriologists how to remove and examine an animal brain for rabies and to inoculate mice to further confirm the diagnosis. vaccinia were grown on the belly of a calf that had been shaved, scrubbed and disinfected. after harvesting the scabs, the vaccinia would be tested for contaminants. it was a lengthy procedure. the same high standards were maintained for the pertussis/whooping cough vaccine, equine antiserum for tetanus and rabbit pneumococcal antiserum. it was a learning period that would serve me well. dean giltner and c.c. young, the director of the michigan public health laboratories, put together my fellowship application to the usphs and harvard school of public health. approval came the week before graduation, and my bride-to-be aina oberg and i were elated. we were married the evening after graduation, with many of the faculty and classmates in attendance two days later i took the michigan examination to practice veterinary medicine. the summer of 1941 was spent as an intern at the petoskey animal hospital. there i learned about swimmer's itch-a common affliction of man and pets caused by an avian schistosome. i was exposed to the parasite while swimming in inland lakes. at harvard it became my thesis subject. later it was the first subject i reported on at the avma convention in chicago (1942) with dean giltner in the audience. 1 at harvard, there was talk of war. president conant addressed the incoming class with the admonition there would be important world changes during their student years. the school of public health's dean cecil drinker, the faculty, and the students were stimulating. i was the only veterinarian, which attracted some attention, and the medical school librarian was delighted to know there was a veterinarian around. she showed me a remote section of the library that contained many old books on veterinary medicine-harvard had a veterinary faculty from 1880 to 1910. we students were delighted with our newly found classmates, and many of us would remain lifetime friends. to me, the academic work was not demanding except for statistics, which took much time. after all, in those days, we used hand-cranked machines for tabulations. my wife, aina, first worked at the harvard co-op and then with the british american ambulance volunteers. she enjoyed the students and compliments and being invited to fundraisers for the volunteers. then tragedy struck. a sudden collapse with fever hospitalized her. the diagnosis was advanced tracheal-bronchial tuberculosis that would confine her to sanitariums and hospitals for the next 7 years, from january 1942 to april 1949. after innumerable surgeries, the newly discovered streptomycin saved her life after months of treatment. eventually, we established a home and family with two sons, jay and david, in atlanta, georgia, for 20 years. there aina died from the complications of arrested pulmonary tuberculosis in 1969. the new year (1942) brought unforeseen problems, mainly medical bills, even though student health expenses were covered to a lesser extent. i sought work at the angel memorial animal hospital, where i knew some of the staff. when dean drinker heard of my after-school work plans, he called me into his office and told me to concern myself with school and taking care of my wife. a check signed by dean drinker awaited me in his secretary's office, a practice that continued until graduation. the drinker society still honors his contributions at the harvard school of public health, which we support. as graduation neared, many of us knew we were going into uniformed service job opportunities. i was deferred by the lansing michigan draft board, but i volunteered for the army veterinary corps and the navy special services, an epidemiology unit. both declined my services, and in the meantime, i found no positions of interest. i wanted to do epidemiology of the animal diseases affecting human health, but all the positions i was interested in required a medical degree. finally i brought my dilemma to dean drinker's attention. shortly thereafter, he asked me to his office to talk over my future. i was upset that it seemed i must have a medical degree to be an epidemiologist. should i get an md? dr. drinker and his wife, also a physician, heard me out. their reply was to list my attributes: good student, industrious, good appearance, good speaker, and creative ambitions. that said, they followed with memorable advice: ''jim, fly under one flag.'' before leaving harvard, i met kf meyer who was lecturing at the school of public health. some days later, i learned he had asked about me because he anticipated some research contracts with the us army epidemiology board and would need staff. i was elated when he offered me a position, and aina and i left boston with high expectations. some days later we arrived in chicago, only to find out a week later that meyer had not received the contract and had no funds to support the research position. i was depressed: no job and a sick wife. a few days later i visited the usphs chicago regional offices to seek their help in finding work. i appeared unannounced and asked a secretary to see the director. while waiting, a medical officer appeared and asked if he could help. i explained that i was a usphs fellow they had supported in getting an mph, and my objective was to find a position where i could investigate the epidemiology of animal diseases that affect the public health. dr. henry holle, the medical officer, listened and replied he never heard about such a situation. so he took me to see the medical director, mark ziegler, a tall, soft-spoken, southern gentleman. the availability of a young mph graduate led them to call washington. a week later after a review of my qualifications and evidence of my education, i was offered an internship as a civilian sanitarian in the ohio department of health. there i would spend the next year, july 1942-october 1943. the challenges were milk sanitation problems, food borne diseases, diarrhea, typhoid, rabies and the ohio river flood, a great learning experience. in september 1943, the us army offered me a commission as a veterinary officer which i planned to tentatively accept. within days, medical director frank meriwether told me since the usphs had given me a fellowship, they should have a first call to commission me. i received a commission as a sanitarian on november 1, 1943. afterward, i spent a short tour of duty in the midwest region with senior sanitarian william h. haskell, an authority on pasteurization methods and practice. he was one of the civil service veterinarians brought in by the usph milk specialists early in 1924. in 1943, other newly recruited veterinarians raymond helvig, ray fagan, and ted price were also commissioned as sanitarians. they were the only veterinarians in the usphs except for a veterinarian who was an animal control officer in world war i in 1918 and two parasitologists willard wright and maurice hall at the nih in the 1930s. from chicago, i was ordered to report to washington, dc, for orientation. there i learned of my assignment to puerto rico and the virgin islands where i was to be responsible for coordinating milk and food sanitation and evaluating any zoonotic diseases in areas that had been isolated by the war. brucellosis and bovine tuberculosis were widespread. the diagnosis of venezuelan equine encephalitis and bat rabies in trinidad caused some concern in the islands but did not spread beyond trinidad. rabies was indigenous in the dominican republic and cuba in the 1940s. in march 1945, the pan american sanitary bureau asked the usphs san juan, puerto rico, office to do an assessment of the post-war veterinary public health problems in the dominican republic and haiti, neither of which had a functional veterinary service. i was directed to make a report on their problems. in the dominican republic, there were no reported diseases, but bovine tuberculosis, brucellosis and mastitis were known. no veterinary laboratory support existed, and the abattoirs kept no records. rabies had been reported in dogs, and possibly in horses, and some years later there was an epizootic of equine encephalitis. president trujillo kept some racing horses near ciudad trujillo (santo domingo), and i was asked to examine them. these old horses were brought to the dominican republic before the war in 1939-1940. all were broken down and hardly fit to run. regardless, the dominican republic officials thought i could repair their ailments. when i told them i could not, they complained that i was not cooperative to the u.s. embassy, who then told me to be cooperative. later i visited the trainer, who told me, ''we will do what we can.'' thereafter, i was anxious to leave and went to haiti within a few days. port-au-prince was a rundown but hospitable capital. the country had been ravaged by tropical fevers for decades; malaria and filariasis were widespread. animal diseases were mainly fever and parasites, but an epizootic of anthrax in the early 1940s was still present in 1945: the disease was sporadic in the countryside. to my amazement, the dead animals were salvaged regardless of what they died from. there were no veterinarians in the government or in practice. still, the abattoir in port-au-prince was an elegant open iron structure. the cattle were immobilized by pithing, in which a small blade severs the spinal cord after which they are bled and eviscerated. the procedure was done rapidly, usually late at night, and the meat was distributed early the next day. however, a serious shortage of animal products existed, and few shops had any meat for sale. all in all, my stay at port-au-prince and the rural areas was a distressing experience. some weeks later i was in washington for further assignment as the war wound down. while there, i visited the pan american sanitary bureau to discuss my report with surgeon general hugh s. cumming who served the pan american sanitary bureau for a decade, after retiring from the usphs. at our meeting, i emphasized the need for a veterinary public health program to help in updating the animal health, preventing zoonotic diseases, and enhancing food safety. dr. cumming suggested i discuss the need for a veterinary public health program with his medical staff, where the proposal was enthusiastically accepted. the veterinary public health program was initiated with dr. aurelio malaga alba, a peruvian military veterinarian, as a consultant. dr. fred soper, the post-war director of the reorganized paho appointed dr. ben blood to organize a veterinary public health program in june 1949. he carried on until 1960 and was followed by the outstanding public health veterinarian dr. pedro acha. the temporary duty in dc left my future uncertain. i was to be assigned to kansas city to prepare for the problems that might evolve with the invasion of japan. i took leave to spend some weeks with my hospitalized wife whose health was failing. the end of the war in europe and the pacific shortly thereafter changed my reassignment. i returned to dc to meet with assistant surgeon general joe mountin, whom i met earlier in puerto rico. dr. joe dean, his deputy, had arranged the interview. after a few inquiries about my wife's health, dr. mountin came to the point: ''what are you veterinarians going to do for the public health now that the war is over?'' the follow-up to that interview is in the appendix of ''the 50th anniversary of the veterinary medical corps officers of the u.s. public health service.'' after the approval of a veterinary public health section in the states relation division in december 1945, i spent some months at the national institutes of health. i also worked to establish liaisons with the usda, bai, federal agencies, congressional interests, state relations, the avma and apha. in september 1947 after surgeon general parran's approval of the veterinary medical officer cadre, dr. mountin felt my washington activities were successful. he told me i was to be assigned to the newly created communicable diseases center, formerly the malaria control in war areas. there the veterinary public health program was established as a division, but it was a challenge to integrate. the new director of the centers for disease control (cdc) was dr. r.a. vonderlehr, previously chief of the puerto rico regional office, who i served under. he gave excellent support as did his deputy, dr. justin andrews, who succeeded dr. vonderlehr a year later. rabies was a national problem after the war. there was a great movement of people as war industries and encampments closed, and as a result, pets were lost or abandoned. the incidence of human rabies was the highest ever recorded, and unfortunately, human vaccine therapy was not always effective. canine rabies vaccine protection was short, with the vaccines being given every 6 months. therefore, rabies became the lead program of the veterinary public health division. to head the activity, dr. ernest tierkel, a university of pennsylvania graduate who had completed his mph at columbia school of public health in 1947, was recruited. he, dr. robert kissling and martha eidson along with a staff of animal handlers became the nucleus of the national rabies program at the rockefeller rabies investigation center in montgomery alabama (steele and tierkel, 1949) . the center was transferred to the cdc for $1.00. they successfully demonstrated the effectiveness of a new chicken embryo rabies vaccine in the laboratory (tierkel et al., 1953) and in epidemic situations in memphis, tennessee (tierkel et al., 1950) . dr. mountin had learned from the public health authorities of indiana, michigan and others that brucellosis in man was of concern. they went so far as to say that as the sanitariums lost tuberculosis patients, brucellosis patients would take their place. the indiana health department was to be a brucellosis project site under dr. sam damen, the director of laboratories. the goal was to determine what action the health agencies should take. the federal bovine brucellosis control program was active in all states, so it became apparent that if the health authorities gave their support, the federal state brucella control program could eliminate the animal source of the human disease. late we brought the problem to the attention of dr. herman bunderson, chicago's dynamic health officer who remembered the struggle to eradicate bovine tuberculosis in the chicago milk shed, which included dairy herds in six midwestern states. in 1928, he had required all milk coming into chicago to be from tb-free herds regardless of whether the milk was to be pasteurized. he recognized the brucella problem and shortly thereafter instituted the same standards for the elimination of bovine brucellosis in the 1950s. the brucella eradication program was supported by the usphs milk code, which required that all grade a milk be from disease-free herds (us public health service, 1943) . the chicago brucella control program was soon adopted by big city health authorities, which gave impetus to the joint state federal brucella programs. as a result of these efforts, human brucellosis declined rapidly in the midwest from a high of thousands of human infections to hundreds in less than a decade. thereafter most of the human cases were of occupational origin, in travelers or in people using raw milk in rural areas. in the 1950s there was a scare of brucellosis at dugway proving grounds, a military research center in western utah. dr. herbert stoenner investigated the alleged contaminated area and found the problem to be a rodent disease caused by brucella neotoma. this organism does not cause disease in man or domestic animals, but will cause antibody formation in cattle (stoenner and lackman, 1965) . after world war ii, there was great interest in the application of atomic energy for civilian use. professor s.f. gould (1953) at wayne state medical school initiated studies on the use of irradiation to destroy trichinella. he persuaded the american medical association to host a trichinosis symposium in 1953 in which the cdc participated. the evidence was conclusive that gamma radiation was effective at low doses (gould et al., 1954) . this was the beginning of my interest in promoting food irradiation, but it was not until 1985 that irradiation for commercial use was approved by federal agencies. the zimmerman human tissue survey 1966-1970 revealed the lowest rate of trichinosis ever (zimmerman et al., 1973) . modern pig raising, the prohibition of garbage feeding of swine, and consumer education are all contributing factors in the decline of the disease in pigs and humans (steele, 1982) . trichinosis has continued to decline in the states except in wild animals especially bears. other veterinary public health studies of parasitic diseases involved creeping eruption, also known as cutaneous larva migrans. this condition is due to the common dog hookworm larva ancylostoma caninum entering the skin and causing intense itching. this disease was common in the southeast states among persons exposed to damp, sandy soil; children playing in sandboxes; bathers at the beach, and utility men (cypess, 1982b) . toxocariasis or visceral larva migrans is another parasite due to the dog, and sometimes the cat, roundworm larva migrating in the body of a foreign host, human beings (cypess, 1982a) . dr. peter schantz confirmed these findings as a world health problem. toxoplasmosis was recognized as a human infection, and the domestic cat is recognized as a common source of human infection. infection is more likely to be caused by consumption of raw or undercooked meat. irradiation is effective in destroying this oocyst in meat (gould et al., 1953) . in the early 1950s, a large equine encephalitis epizootic in central california required the assignment of all cdc veterinary officers. later another equine encephalitis epizootic occurred in new jersey in 1959. since then there have been only occasional epizootics of the equine encephalitides. although the principal reservoir is birds, there is also survival of the virus in mosquito eggs that over winter. the cdc-fort collins laboratory has been at the forefront of these investigations. the most recent mosquito born disease is the introduction of west nile virus into north america in 1999. wild birds and common city birds are the reservoirs, and the culex mosquito is involved in the transmission. horses may show clinical signs. control of the vector mosquito breaks the transmission cycle. plague, primarily a disease of rodents, is sporadic in the united states. the appearance of plague in domestic and feral cats and squirrels has brought the ancient scourge to households in the western states (poland and barnes, 1979) . however, dogs were never identified as carriers of the disease to man. an unusual epidemic of anthrax caused alarm in animal and human public health circles in the 1950s. the anthrax was introduced by contaminated bone meal used in animal feed to improve lactation in sows. a radio announcer in cincinnati raised the question if cows' milk could be a vehicle for anthrax to be carried to humans. a search of literature found that milk was never a vehicle or cause of human or animal anthrax disease because the high fever of the disease stops lactation (steele and helvig, 1953) . salmonellosis was a recognized public health problem early in the 1920s as well as during world war ii and afterwards among the civilian populations (galton et al., 1964) . after the war, investigators demonstrated it was widely disseminated. dr. phil edwards led the way at the university of kentucky and later at the cdc. mildred galton, chief of the veterinary public health laboratory contributed with her unusual ability to find evidence that others had overlooked. she demonstrated salmonella in many animals. her studies of transported pigs revealed how stress caused latently infected pigs to become shedders. the same reaction was found in other species. her work on raw eggs and meats led to the pasteurization of egg slurry used in baked or cooked products. she was among the first to find salmonella in raw milk 50 years ago, and her work on the frequent presence of salmonella in poultry led to the federal poultry inspection program in the late 1950s (steele and galton, 1967) . thirty years before weil described leptospirosis in humans in 1880, animal leptospirosis was identified as its own problem. a record of an 1898 canine epidemic in stuttgart, germany, exists, but the etiologic agents were not determined. 30 years after the canine epidemic, it was discovered that microorganisms morphologically identical caused the disease in both dogs and humans. leptospirosis proved confusing to all health professionals partly because ''isolated serovars were given names denoting the clinical signs observed in the patients from whom they were isolated'' (torten, 1979) . therefore, it was thought that serovar grippotyphosa would cause signs similar to catarrhal fever, and serovar icterohemorrhagia would cause hemorrhagic jaundice. it was not recognized that both serotypes are capable of causing both signs (torten, 1979) . in the us, there were numerous outbreaks among animal handlers, veterinarians and swimmers as well as people whose occupation exposed them to contaminated waste water in the 1950-1970 period. leptospirosis is now recognized as a problem associated with disasters such as flooding and earthquakes. there is wide agreement that vaccination of cattle and dogs has reduced environmental contamination (stoenner et al., 1956) . galton (1966) edited the ''leptospiral serotype distribution list '' through 1966, and sulzer (1975) carried it up to 1973. they were truly dedicated in keeping these records. listeriosis was first recorded in 1926 in sheep, and the first reported human case was in denmark in 1929 (bomer et al., 1979) . prevention of listeriosis is still not possible with the knowledge available, as there are no immunizing agents of proven worth. killed bacterins have been disappointing, and living attenuated vaccines have not been evaluated properly nor have they shown promise in limited experiments. good physical hygiene is essential to prevention (bomer et al., 1979) . groups at high risk of infection are pregnant women, neonates, diabetics, alcohol dependents, persons with neoplastic disease, or those being treated with corticosteroids or antimetabolites. among animals, ewes are at the highest risk late in the first pregnancy. sheep in late pregnancy should not be fed ensilage of doubtful quality nor be exposed to severe cold or inclement weather and crowding (bomer et al., 1979) . improved measures for preventing and controlling human listeriosis depend on increasing awareness of its diverse clinical manifestations and an increasing index of suspicion. because l. monocytogenes, the causative agent of listeriosis, is sensitive to most antibiotics, their early administration, once the diagnosis has been established, significantly decreases mortality. cortisone and its derivatives may, however, cause asymptomatic listeria infections to become overt (bomer et al., 1979) . after the end of the war in europe, the breakdown of food hygiene there allowed salvaged food to spread zoonotic diseases. at the same time there were numerous cases of listeriosis reported in france that caused abortion, stillbirths and reproductive tract disease (seeliger, 1961) . the disease remains prevalent in western europe to the extent that all midwives and obstetricians alert their patients to report symptoms. since 2000 there has been a steady decline of reported cases. food borne listeriosis elsewhere was virtually forgotten until 1981 when an outbreak occurred in the maritime provinces of canada and was associated with consumption of contaminated coleslaw (schleck et al., 1983) . then 2 years later, a major outbreak in massachusetts between june and august of 1983 was epidemiologically linked to consumption of a particular brand of pasteurized whole and 2% milk (fleming et al., 1985) . although questions have been raised about the adequacy of the epidemiologic study (ryser and marth, 1991) , no other food has emerged as the vehicle that transmitted l. monocytogenes in this outbreak. in 1985 mexican-style cheese made in a factory near los angeles was definitively linked to a large outbreak listeriosis (linnan et al., 1988) . this was followed in 1987 by the linking of consumption of vacherin mont d'or, a variety of cheese, to an outbreak of listeriosis in the canton of vaud in switzerland (bille et al., 1988) . in recent years, food borne outbreaks continue to be reported in north america and europe. during the 1990s, many more human cases and deaths were reported in the united states. the vehicles reported as contaminated were cold cuts, canned meats and frankfurter sausages. worldwide, listeriosis is a problem mostly in the temperate zones. another emerging zoonotic food borne disease is escherichia coli o157:h7, the enterohemorrhagic strains as well as those characterized by cytotoxins. these e. coli and others of human origin are major causes of the human enteric disease. however, they are less causative in food producing animals that may be infected but show few or no clinical signs. pasteurization of milk is effective in the control of e. coli spread. irradiation has proven effective for pasteurization of food of animal origin for the protection of the public health. recently improved inspection and hygiene have reduced reported human diseases, even though toxic e. coli is wide spread among cattle. the same can be said for newly identified emerging food borne zoonotic diseases. cryptosporidia parvum is a coccidian protozoa found worldwide. giardia are found in numerous animals, and during the late 20th century, the flagellate protozoan was identified worldwide as a water borne disease of humans and animals. old problems new to the states are taenia saginata and t. solium, largely found in immigrant workers. the tapeworm cysts found in meat, beef and pork are easily destroyed by irradiation, a technology that slowly is being accepted in the southern countries where tapeworm disease is recognized as both an economic as well as a public health problem. the acceptance of veterinary public health internationally by the paho has been previously discussed. the inauguration of veterinary public health as a national program in the usphs in 1945 stimulated interest worldwide, especially in the newly created international agencies. the united nations health office organizing committee chaired by surgeon general tom parran met in new york in june 1946 to further public health worldwide. the public health service officers and personnel were asked by the surgeon general's chief of staff, g.l. dunnahoo, to suggest topics. veterinary public health was new, but a few weeks before the organizing group was to meet, i was directed to make a veterinary public health presentation and answer questions at the surgeon general's staff meeting. after the meeting, i asked dr. dunnahoo if he would be interested in a recommendation for a veterinary public health program for the who organizing committee. he urged me to give him a memo recommending a veterinary public health activity. that may 7, 1946, i wrote a memo paraphrased as follows: ''regarding our conversation and your encouragement, i propose that in the organization of the united nation's health office there be a veterinary public health (vph) program. the vph program would be concerned with animal diseases transmissible to man. the vph would carry on liaisons with veterinary activities in the agriculture agencies and collect information on animal health.'' some months later i asked how the vph recommendation was received. dr. dunnahoo said there were no objections or discussion: the vph item was accepted and placed in the records. years later i learned an american veterinarian, martin m. kaplan, was recruited by an english physician with whom kaplan worked with in the united nations relief and rehabilitation administration (unrra) in greece. in 1948 kaplan came to the newly established who in geneva, switzerland. he developed a vph program in the communicable disease division that is a model for a public health program in the developing world. during the next 20 years, he organized the expert committee meetings and technical reports. the first was in l950 (who, 1951) to review tuberculosis, which was a major disease problem in humans and animals at the end of world war ii. an american tuberculosis authority, dr. franklin top, a us army consultant, had reported that 30% of the human cases in occupied germany were caused by mycobacteria tuberculosis bovis. the problem was referred to the who expert zoonoses committee by the who expert tuberculosis committee. there was no consensus on what recommendation to make. the danish veterinarian dr. plum spoke for the classical tuberculin test and identification. the french urged the use of bacille calmette-guã©rin (bcg) vaccinations. the success of bovine tuberculosis eradication in the united states was recommended as the ideal method. eventually the committee recommended test and removal, with the caveat for developing countries to try other methods, including the bcg vaccination, which had no success in field trials. a number of other diseases were reviewed with the recommendation for control. there was a consensus on the following: q fever, anthrax, psittacosis, and hydatidosis. another issue was to settle on a definition of veterinary public health. a current definition of public health is summarized as diseases that are naturally transmitted between animals and man. the following year, 1950, who called together a panel of rabies experts, including e.s. tierkel of the cdc (who, 1950). tierkel and others who followed from the cdc, namely george baer, keith sikes, jerry winkler and currently charles rupprecht, contributed to rabies control and prevention. the first of the who expert committees on the zoonoses was followed by zoonoses study groups in 1958, which meyer chaired in stockholm (who, 1959) . he was most effective in leading the committee, and in his closing remarks he passed the leadership to james steele. at the next meeting of the who zoonoses expert committee in geneva in 1965, i was the chairman (who, 1967) . the next meeting in 1974 was chaired by calvin schwabe (who, 1979) , professor of epidemiology at the university of california school of veterinary medicine and the school of human medicine. schwabe (1984b) summarizes the who veterinary public health in his monumental third edition of veterinary medicine and human health: ''the final objective of veterinary medicine does not lie in the animal species that the veterinarian commonly treats. it lies very definitely in man, and above all in humanity.' ' we in veterinary public health recognize the contributions of acha and szyfres (1980) for their invaluable book, zoonoses and communicable diseases common to man and animals in spanish and english. it has been the foundation of veterinary public health epidemiology and surveillance in the spanish speaking countries of the americas. at this time, dr. george beran is to be recognized as one of the consultants to paho and who, and for his work in the philippines. he has carried on in admirable style for more than 50 years in teaching, research, health promotion and consulting, and as author and editor. he has updated the chemical rubber company (crc) handbook of zoonoses series (beran, 1994) and the paho zoonoses reports, and hopefully will continue to do so. he is a historian of veterinary public health. in closing we pay tribute to the american veterinarians who demonstrated and promoted veterinary public health in the united states. most of these early pioneers 60 years ago were recruited by the cdc and assigned to states that had zoonotic disease problems, mainly rabies. among the early cdc recruits assigned to a state was ernest wine. he was sent to pennsylvania, where he remained for 30 years, rising to the position of state epidemiologist. oscar sussman went to arizona, and later the new jersey health department recruited him, where he built an outstanding program. martin baum served colorado for many years after leaving the cdc. john mason served in new mexico. art wolff did excellent service in michigan before returning to washington, where he became a leader at the usphs in environmental health as a radiation authority and assistant surgeon general. herbert stoenner went to utah and raymond fagan to indiana as described earlier. monroe holmes followed stoenner to utah, and john scrugs went to indiana when fagan went to the harvard school of public health. john winn, francis abimanti, don mason, and lauri luoto were among the early investigators of q fever in california. stoenner, in addition to his investigation of brucellosis and leptospirosis, was also a leader in q fever studies. don mason, john richardson, and paul arnstein worked on the control of psittacosis in k.f. meyer's laboratory at ucsf. dick parke, joe held and robert huffaker kept the cdc office responsive to many inquires and provided service to the states. james glosser closed his career at the cdc in 1971. his work coordinating the venezuelan equine encephalitis epizootic and epidemic with the u.s. department of agriculture veterinary services earned him the united states department of agriculture's outstanding service award. the veterinarians service to public health in the 20th century resulted in better health in all humans and animals. what are the 21st century challenges? animal medicine and veterinary public health have been intertwined since humans first began ministrations to their families and animals. dr. william foege, former director of the communicable disease center and professor at emory school of public health and now consultant to the bill gates foundation center, expressed this more forcefully in saying that we cannot have good public health unless we have good animal health. we can invert that and say we cannot have good animal health unless we have good public health. in the united states, the veterinary medical profession has carried on effectively in eliminating those major problems of animal health that had serious public health ramifications, namely bovine tuberculosis and brucellosis. in recent years the advances in rabies immunization have eliminated the disease from our pets, and humans have benefitted. the new human cases that occur are mainly the result of bat exposure. looking beyond that, we can see there is a sizable list of parasitic diseases, namely trichinosis and tapeworms, that have been brought under control in the united states. however, tapeworms are now being introduced by the recruitment of workers from mexico, central america and south america. these problems affect society in the united states, but it is apparent that we have an obligation to share our knowledge with our neighbors of the americas as well as africa and asia. all of these countries face the same problems the united states, solved in the past century. now as we move into the 21st century, the technology for controlling these diseases is available. these proven effective procedures in the united states can be used worldwide. some challenges exist, however, for methods that control bovine tuberculosis. there is a continuous demand for vaccines to prevent tuberculosis in animals, but there is little evidence there is any value in routine vaccination. these procedures are quite costly, and the best examples are in europe in the past 50 years. after world war ii, tuberculosis was a major problem in central europe especially in germany, eastern europe, what is now russia, and western europe. there has been an uncalled-for degree of confidence in the tuberculosis vaccine, bcg, but with constant pressure from the world health organization, the world animal health organization (oie), the food and agricultural organization and united states agencies and consultants, the use of vaccines has been put aside. the old test and removal strategies have proven to be the most successful. to introduce that method into mexico, central america, south america and asia is difficult at this time because they are hopeful that a good vaccine will be developed. unfortunately we have lived with that hope for 100 years. the major problem that remains is to compensate farmers for diseased animals that are removed. the neighboring countries of mexico, central america and south america have the opportunity to further their own disease control by employing the proven techniques used in the united states, canada and europe. the control of brucellosis in the developing world is a much bigger problem than tuberculosis. in 1960 veterinary epidemiologist george baer described the human disease in mexico and said that most rural people who had reached the age of 40 had evidence of past infection with brucellosis. the same can be said for the countries of latin america where goats have a high rate of b. melitensis infections. to control b. melitensis is a difficult task and is a matter of the governments facing up to the issue. a new vaccine developed in the united states, the rb 51 rough strain, had been researched for 50 years or more before the united states department of agriculture veterinarians were able to find a solution to producing an effective vaccine for cattle. the vaccines have not proven valuable for goats and sheep. the control of widespread brucellosis in north africa and the middle east across asia has been given little attention. the who, through their consultancies and expert committees on rabies, has spread the knowledge of dog vaccination throughout the world. we can say with some degree of pride that the technology developed by veterinarians at the communicable disease center and carried to other parts of the world by authorities such as the late ernie tierkel and others who worked with him and george baer have made a great contribution to the world scene. we do see the light at the end of the tunnel for worldwide control of canine rabies. other efficient rabies vaccines have been developed in south america and europe. looking at the parasitic infections of the world, there is certainly a great deal of interest in control of trichinosis, which has been fostered through scientific congresses every few years. the world wide results are favorable today with a drastic reduction in north america and europe. unfortunately new problems have arisen in connection with the disease in wild animals, especially those found in the arctic zones of the world. taenia saginata and t. solium are receiving more attention as we face worldwide problems with the measurements of disease. in the americas the problem has been carried from one country to another by human carriers and then spread to animals. new foci have been established in north america, where there have been meetings to plan for initiating a worldwide control program. in my own way of thinking, the control of t. saginata is a measurement of good hygiene and good waste control in any country where it is present. dr. peter schantz has advocated world control of tapeworm and hydatid disease with the goal of eradication. many other new problems arising in zoonotic and parasitic diseases are constantly coming to our attention. the continuous migration of workers seeking better opportunities in industrialized countries also carries the risk of infections being brought with them. the surgeon general has spoken for the globalization of public health. the veterinary public health program of the cdc has been active in globalization of veterinary public health, namely in the control of rabies, parasitic diseases and food borne diseases. many of the veterinary officers have served on who expert zoonosis committees have carried out detailed missions for who. the cdc program has been supportive of paho veterinary activities with assignments of veterinary officers to mexico, panama, peru, argentina, and most recently david ashford and hugh mainzer to brazil for foot and mouth disease control and other problems. the number of emerging diseases increased in the latter part of the 20th century. infectious disease scientists have found that acquired immune deficiency syndrome (aids) is a disease that makes people more susceptible to zoonotic diseases, including bovine tuberculosis and related mycobacterial infections, toxoplasmosis, cryptosporidiosis, food borne salmonella and enteric infections including campylobacter, listeria and yersinia. it is possible that other zoonotic diseases that are dormant or infrequent may emerge in individuals with aids, human immunodeficiency virus infection, or other immune-compromised conditions. related latent or nonpathogenic viral diseases have been described in tropical cats of africa including lions as well as domesticated cats. in australia and malaysia new diseases which also affect humans have been reported in horses and swine. these diseases are caused by the morbilliviruses, a measles-like virus that causes canine distemper and rinderpest. another virus that killed the wild felids in the cairo zoo has not been identified. could this be another form of distemper? some of the emerging viral diseases that have a rodent or unknown animal host have caused fatal, devastating diseases in humans in africa and south america, namely lassa fever and south american hemorrhagic diseases in argentina and bolivia. in africa, ebola virus hemorrhagic fever and marburg hemorrhagic fever virus infection, linked to monkey disease, caused disease in medical personnel, handlers and people who had only casual exposure. an incident that surprised us many years ago was the deaths of workers in middle east abattoirs caused by crimean hemorrhagic fever carried by ectoparasites. one example of developing, emerging, or relatively unknown diseases is severe acute respiratory syndrome (sars), a disease that erupted a few years ago in china and was carried to many parts of the world. recently information has suggested that bats are a natural reservoir of a sars like coronavirus. even though sars may have been an occasional emerging disease that disappeared as rapidly as it appeared, there may have been other infections from bats that have been around the world for millenia. naturally, an infection that has been given much attention now is where we stand with the influenza virus. are wild birds the true reservoir? apparently, birds are the reservoir based on the information we have gathered showing that wild birds transmitted the virus to avian domestic flocks. all this new information is challenging. the emerging diseases of the world are reasonably covered in the table of the last chapter of merck veterinary manual's ninth edition zoonosis section, 2005. in addition to infectious diseases, we have a new class of diseases that are caused by prionsproteinaceous infectious parties that transfer diseases without any dna or rna. transmissible diseases are not the same as infectious diseases which are characterized by replication of dna or rna. this is certainly a bewildering situation especially when we read that saliva may be a means of transfer. immediately veterinarians think of rabies which is transmitted by saliva. is it possible the prion of the diseased brain can be secreted through nerve fibers that innervate the salivary gland? the prions are of great and continuing concern as a cause of concern as new types of diseases. our associates in chemistry, physics, and physiology may offer clues to other neurological diseases. one last subject i want to mention is humaneness. it is important that we abide by sensible, humane policies, but humaneness can be carried to such an extreme that it destroys values that we hold so high for protecting our pets, farm animals, and the wild animals around us. periodically we all read about overpopulations in different areas. society calls for conservative measures for population control that applies to all pets, wild animals and domestic animals. in a broader sense, it has applications to the human race. we are aware of the collapse of earlier civilizations that have overpopulated their given area or were destroyed by natural events such as starvation. so i say all veterinarians, especially those in public health, have a responsibility in developing humane regulations for animal population control and public guidance. in the united states, 80-90% of veterinarians treat our animal associates or pets for various diseases. it is important that veterinarians have a broad, basic knowledge of public health issues and are alert for new public health issues that can be resolved with tender loving care, new antibiotics, and new procedures. the 76,000 or more veterinarians in the avma in the united states are key to the control of zoonotic diseases by public health agencies. the health of our animal population is tied to the emotional and mental well being of those humans who are close to animals in their lives. animals are vital companions to those homebound, and animal health becomes a family concern. an area i have stressed is the need for basic veterinary science. we see in current publications that most research is based on support from nih. at the avma meeting in july 2000, the speaker us senator hatch of utah spoke highly of the public health activities of veterinary medicine. he went on to say that there may be a nih veterinary institute in the future. it behooves us all that the agricultural interest in public health be recognized as an important issue to the american public. i think highly of the importance of animal health in providing good public health. public health should not be guided by economic interest but by the welfare of all society. i go back to my earlier statement that animal health and public health are of great importance to all, and we must have good animal health to have good public health. good public health provides a means for good animal health. as we look to the future, we have to have open minds and think in terms that anything can occur in biology. i would like to quote my dean from michigan state, ward giltner, who said the only thing about biology we can accept that remains a firm truth is there always is new information that provides exceptions. looking at it broadly, all infectious things in nature, and prions which may cause disease are always looking for a new host. i like to say they are seeking social security, as most of the world is. carry on in the 21st century. i wish i could continue to be a part of it, but it seems time has a way of saying, ''you have been here. you have enjoyed it.'' i especially enjoy the recognition of 60 years of public health service, i am elated. to the audience, especially to the teachers of public health science, thank you. carry on. dr. steele does not have a financial or personal relationship with other people or organisations that could inappropriately influence or bias the paper entitled ''veterinary public health: past success, new opportunities.'' zoonoses and communicable diseases common to man and animals. pan american health organization viral scientist dies-public health giant handbook of zoonoses section a: bacterial, rickettsial, chlamydial and mycotic. section b: viral, second ed epidemic food-borne listeriosis in western switzerland. ii. epidemio1ogy the relation of animal diseases to the public health and their prevention listeriosis visceral larva migrans cutaneous larva migrans guns, germs, and steel: the fates of human societies pasteurized milk as a vehicle of infection in an outbreak of listeriosis a profile of the us public health service 1798-1948. pub. no. nih-73-369. us department of health, education and welfare. us government printing office leptospiral serotype distribution lists (through 1966). veterinary public health laboratory. us department of health, education, and welfare public health service the world problem of salmonellosis prevention of trichinosis by gamma irradiation of pork as a public health measure control of trichinosis by gamma irradiation of pork undulant fever outbreak at michigan state college. mich world's debt to pasteur report on diseases of domestic animals epidemic listeriosis associated with mexican-style cheese the animal kingdom-a reservoir of disease history of medical research and public health: an oral interview history of the bureau of animal industry, appendix man's greatest victory over tuberculosis. c.c. thomas attempts to control tuberculosis among cattle water borne outbreak of brucella melitensis infection plague milk and its relation to public health karl friedrich meyer 1884-1974: a biographical memoir epidemic listeriosis: evidence for transmission by food food safety veterinary medicine and human health listeriosis the jungle. double, page & company the veterinarian in america 1625-1975 the socioeconomic responsibilities of veterinary medicine biographical notes on the occasion of karl f. meyer's 90th birthday trichinosis zoonoses 1879-1883: an update of james law's report on diseases of animals epidemiology of food borne salmonellosis present status of anthrax rabies: problems and control. a nationwide program nurture turned to poison a new species of brucella isolated from the desert wood rat neotoma lepida (thomas) the epizootiology of bovine leptospirosis in washington leptospiral serotype distribution lists (1966 to 1973). veterinary public health laboratory. us department of health, education, and welfare public health service a century's progress in public health effective control of an outbreak of rabies in memphis and shelby county a brief survey and progress report of controlled comparative experiments in canine rabies immunization leptospirosis milk ordinance and code. public health bulletin no. 220. department of the treasury joint who/fao expert group on rabies. who technical report series no. 28. who joint who/fao expert group on zoonoses: bovine tuberculosis, q fever, anthrax who, 1959. joint who/fao expert committee on zoonoses, report on the 2nd session. who technical report series no. 169. who, geneva. who, 1967. joint who/fao expert committee on zoonoses trichiniasis in the u.s. population, 1966-70. prevalence and epidemiologic factors the symposium at which this paper was presented was sponsored by bayer animal health. the author also wishes to acknowledge and thank dr. cynthia hoobler for assistance with the preparation of this paper. key: cord-314443-qeuvymu8 authors: banai, reza title: pandemic and the planning of resilient cities and regions date: 2020-09-15 journal: cities doi: 10.1016/j.cities.2020.102929 sha: doc_id: 314443 cord_uid: qeuvymu8 the emergence of the coronavirus pandemic motivated this paper, which revisits the nexus of public health and the city, itself a main source of a pandemic which similarly threatens the lives and properties of the world population gradually one glacier at a time: climate change. we argue that pandemics expose both the vulnerability and resilience of the urban system expansively, from rooftop to the region, but also serve as change agents for the planning of resilient cities and regions globally. the discussion of the urban system and the pandemic is comparative, with the recent coronavirus and climate change, a persistent, long-lasting pandemic. the historical and critical review and synthesis of the durable concepts of the urban system at the kernel of the theories and practices of urbanism is highlighted by place matters, cyberspace, density, access, and the city-region. we note the implications for reconfiguring the resilient urban system of the future effectively with pandemic as change agent and the comprehensive plan and its regulatory zoning ordinance as implementation tool. public health and city planning have common disciplinary purposes. city planning's professional identity is defined as a guardian of "public interest." standard city planning enabling act (scpea, u.s. department of commerce 1928) is even more specific, defining municipal planning's promotion of "health, safety, and general welfare" of the population. public health is about identification, control, and prevention of disease. the common references to parks and open spaces with a physiological metaphor-the "lungs" of the city-connotes the nexus of public health and the city explicitly. city planning's focus is the physical layout of the city in a manner that promotes health and prevents the occurrence of diseases in the first place. concomitantly, city and regional planning and design theories, concepts, regulations, and practices emerge historically in response to public health crises, including pandemics, pollution with rapid industrialization, congestion with urbanization, and loss of green space in cities. the origin of modern city planning is aligned with sanitary, housing, and social reforms since the mid-nineteenth century and around the turn of the twentieth century-movements dealing with inadequate sanitation-itself a pandemic response-and limited access to air and sunlight in crowded tenement housing and dilapidated slums. the coronavirus pandemic has at least temporarily significantly reconfigured city life-the relation of work and residence, and leisure, use of public space, safety and security of transportation, both public and private-and posed fundamental equity of access to resources. a smart planning scenario could not have anticipated and illustrated the wide-ranging, impactful socio-spatial dimensions of the coronavirus pandemic in entirety this vividly, let alone applied standard urban planning tools-the comprehensive plan and zoning regulations-proactively (banai, 2013a; kelly, 2010) . it turns out, planning's tool set are disproportionately limited piecemeal or disjointed compared to the magnitude and wide-ranging scope of the better known, durable pandemic of climate change. however, the global experience of the coronavirus pandemic also informs and suggests what kind of planning is commensurate with the dimensions of the challenges posed by climate change. it turns out, pandemics expose the vulnerability and resilience of the urban system, ironically with durable concepts of urbanism, highlighted from the rooftop to the region. the paper is organized by a discussion of durable concepts of urbanism, with implications for reconfiguring the urban system, aided by invoking urban planning's standard tool-the comprehensive plan. the paper concludes with a discussion of planning resilient urban form of the future in the era of climate change. oxford dictionary defines pandemic with its greek origin in midseventeenth century, pandēmos, all (pan) people (demos) "prevalent over a whole country or the world." arguably, climate change, which is prevalent globally, fits that definition, just as coronavirus does. a question is immediately raised: which pandemic is more costly-coronavirus or climate change? hint: one pandemic is a one-hundred-year event, compared to the other, with an incubation period that started with the industrial revolution in 1600s. however, the two pandemics have a similar pattern of spread: exponential. measured by loss of human life, unemployment, underemployment, social isolation, public expenditures, reduction in gross domestic product, and supply-chain interruption, the costs of coronavirus are immense. however, compare the cost of climate change. green house gas (ghg) traps pollutants in cities. combine tailpipe and smokestack pollution from vehicles, buildings, factories, and heat islands in cities, and there is recipe for respiratory illness, including asthma and cardiovascular disease, consequential for the children, the elderly, and populations predisposed with genetic chronic health conditions. parenthetically, people with respiratory and cardiovascular illness and diabetics, which are also linked to urban form-induced obesity as well as poor diet, have a lower chance of surviving the other pandemic: coronavirus. furthermore, consider the costs of entire islands inundated due to sea-level rise, or so-called king (or high) tides that infiltrate coastal cities' groundwater table with sea salt, threatening drinking water or causing frequent surficial flooding depositing sewage into rivers and lakes (chicago), and disrupting traffic in city streets (miami). add the mitigation costs of levee, dike, and sea-wall construction in coastal cities globally, like new york city, new orleans, amsterdam, venice, and london. include droughts that threaten agriculture, causing food insecurity that subsequently threatens employment and national security (even a source of failing states), and induces population migration in search of survival. this is not an exhaustive itemized costs brought about by the silent pandemic of climate change gradually taking its toll on the built and natural environments. the evidence of climate change pandemic and its consequences for cities and regions is compelling. the itemized list in the comparison of pandemics of climate change vs. coronavirus is tentative with respect to consequences of coronavirus. the juxtaposition of the two pandemics, however, is instructive. ironically, one pandemic has a positive impact on the other (see fig. 1 ). images in the media show clearer skylines and iconic, ground-level landmarks, such as the eiffel tower, to be more visible than usual due to quarantines in otherwise congested, polluted, populated, heated-up cities. there are even the images of venice's canals and waterways looking clearer than ever, as the coronavirus quarantine leaves them undisturbed. u.s. environmental legislation has ensured public health of the city with clean air and clean water for the past half-century, abating ghgs-carbon dioxide, sulfur dioxide, nitrate dioxide. similarly, clean water legislation regulated the disposal of cities' waste into rivers, the sources of drinking water and aquatic life. ohio's cuyahoga river was once so polluted that it caught fire, but owing to the clean water act, it's now home to marine life. however, the images of clean waterways and clear skylines during the coronavirus epidemic suggests next steps toward further management of waterways and air pollution in cities. we hope for a vaccine that will cure the coronavirus, but no such thing can solve the pandemic of climate change. it takes more than a shot in the arm. surreal images of cities known for their population density, air pollution, and traffic during the pandemic appeared in the media-skyline visibility but with empty streets, deserted downtowns, blighted parking lots surrounding commercial retail stores, empty office buildings, locked college and university gates, and desolate public parks. in the pre-coronavirus era, empty stores and parking lots and desolate public spaces were regarded as indicators of intolerable blight, justification for urban revitalization. ironically, among the vestiges of blight and sprawl is the drive-in movie theatre, revived because of the pandemic as a safer alternative than the big-box movie theatre. and the impact of social isolation on mental health is also recognized. how could cities and regions sustain the public health benefits of cleaner air and water with a resilient urban form and a smaller ecological footprint post-coronavirus? the coronavirus pandemic, despite its devastatingly inimical tolls on humans, sheds light on the architecture of urbanism, revealing strengths and vulnerabilities of the urban system. the pandemic has in effect enabled a social experiment with controls that are usually possible only in the closed system of a laboratory, not in the open system of a society; however, this experiment calls for a rethinking the urban system with expansive concepts of resilience in planning cities and regions. we note the implications for the comprehensive plan in the face of climate change. the literature on the importance of place, and the related discussion of place-making in urban studies abound. much of the discourse of the new urbanism which emerged in the 1980s is about civic places, which disappeared in the private, subdivided spaces of suburbia (katz, 1994) . the american dream of a house, a yard, and car excluded community, as hayden (2003) argued (see also calthorpe, 1993; mcharg, 1969 mcharg, / 1995 . the mainly residential suburbs bereft of civic spaces could not accommodate a social place for the teenage population without the car, with the exception of vacant lots and buildings under construction. suburbia segregated commercial-residential-public land use, in contradistinction to the historic american main street with fine-grained, mixed land use, and an accessible park. the comprehensive (master) design plans of new urbanism aimed to remedy this shortcoming with integrated land use and pedestrian-friendly access, with enhanced public realm elements, which occupy prominent landmark locations with water feature and articulated surficial materials of the sidewalks anchored by gazebos and pocket parks, heeding the pedestrian as well as vehicular circulation. when the pandemic limited or prohibited access to the public realm, its significance became even more apparent, albeit with an eerie sense of a public realm that is no longer a public domain. the longing for the city's public realm, temporarily off-limits during the pandemic, was expressed through the building balcony, which architecturally transitions between public and private space. the balcony substituted for an inaccessible public realm-from the street, the town square, the park, the waterfront, the cemetery, to places for religious gatherings, church, synagogue, mosque-places that functioned, albeit with some adaptation, aided in cyberspace, and occasionally in defiance of any imposition of control (see also oldenburg's (1991 oldenburg's ( /1999 ) notion of the necessity of "the third place" where essential human interaction occurs beyond work and home; see also calthorpe & fulton's, 2001 , page 37 elaboration). the limit of the experience of physical place via cyberspace is readily revealed if reminded by lynch's (1960) cognitive mapping of the five elements that makes the city legible or imageable, and the sense of place attributes including ambience, sound, smell, topography (steepness of roads) and the like. if eclipsed in dense theoretical academic writing, commercial and social media alike exemplified the significance, actual experience of and the longing for the city's public realm, particularly during a pandemic. the vitality of the city is determined by place. where else? vitality is among the five "performance dimensions" of good city form, defined by lynch (1984, page 118) as "… the degree to which the form of the settlement supports the vital functions, the biological requirements and capabilities of human beings-above all, how it protects the survival of the species." (see also banai & rapino, 2009.) where better to observe the function (or dysfunction) of the settlement form but in the city's public realm, particularly in a pandemic. it is not just the pandemic of an infectious disease that is consequential for the vitality of the city's public realm. climate change's extreme weather pattern with heavy rain events threatens city's vital public realm element with street flooding. the point-and non-pointsource pollution during intense rain events threatens city's water bodies. the comprehensive plan can increase cities' resilience by rezoning blighted, abandoned industrial and commercial properties as green open space buffers that absorb or slow surficial runoff that creates hot spots of pollutants in cities' rivers, creeks, and streams. a dominant element of the public realm is the suburban arterial street. the wide arterial street is enhanced if "shared" equitably accommodating movement of pedestrians and vehicles. the long-term comprehensive plan is a tool to accomplish this aim, by physical design alterations that "calm" traffic and thereby increase public safety. integration of green space in the arterial street in the form of medians or embankments enhances pedestrian safety while abating runoff during the intense rain events that characterize climate change. telecommunications technology and cyberspace substitutes for risky in-person communication in physical space during an easily transmittable pandemic. communication theorists widely touted the benefits of interaction at a distance even pre-coronavirus. among others, webber (1964) argued the case for "community without propinquity." the coronavirus effectively revived and reminded us of the merits of the arguments for and against more widespread online communication. arguments in favor of communities of place rather than communities of interest in cyberspace (calthorpe & fulton, 2001) , however, suggest plausibility with the experience of communication during pandemic and the longing for interaction in physical space of place and neighborhood, and the (physical) public realm, even in defiance of state control. economic and urban theorists up the ante by privileging the benefits of interaction with economies of agglomeration in physical space necessary for efficient business transaction (see also lynch 1984) . notwithstanding the facility of communication in cyberspace, still an urban form of the future-the aerotropolis-is defined by a physical space that accommodates agglomeration of firms and business transactions in a central location akin to the city's central business district (cbd) (kasarda, 2006 , kasarda, 2011 , kasarda and lindsay 2011 . the pandemic showed us the inequity of access due to lack of broadband technology-the digital divide-so the comprehensive plan is an ideal tool for enhancing city's resilience by a planning infrastructure that not only includes water, sewer, and roads, but also broadband service (see also kelly, 2010) . we learned from the pandemic how vital functions are interrupted-education, from pre-school to college; health care; and access to jobs and services. broadband access is not a luxury but a necessity when in-person access is interrupted or not an option. parenthetically, a similar logic holds in planning transit-supportive or transit-oriented developments. the urban form, with its land-use mix and proximity to the centrally located retail and office services are desirable features because of walkability, regardless of the availability of transit (calthorpe, 1993; calthorpe & fulton, 2001 ). the environment-behavior nexus was investigated more than half a century ago by the then-burgeoning subfield of environmental psychology. these well-known laboratory experiments revealed how rats develop abnormal behavior when subjected to crowding. concomitantly, the classic environmental-behavior studies informed how urban form likely impacts the physical and mental health of the urbanists. even obesity (body-mass index) is linked to urban form (walkability), elucidated in the contrast of compact vs. urban sprawl (e.g., frumkin et al., 2004; ewing et al., 2011) . commentators, backed by empirical evidence, touted the public health benefits of cities that promoted walkability with multi-modal regional mobility, thereby abating obesity, and which contained places of work as well as residence and leisure, thereby minimizing stressful commuting to work. (ewing et al., 2011; frumkin et al., 2004) . the urban-studies literature has given considerable attention to density. density figures prominently in urban studies since the feasibility of a vital element of urban form-public transit-is contingent on population density's minimum threshold. however, even predating the laboratory experiments of the environmental psychologists, an english thinker (howard, 1898 (howard, /1902 around the turn of the century proposed and later constructed a garden city that meant to address the health, safety, and general welfare of industrial city residents exposed to all the negative consequences of industrialization, crowding, congestion, pollution, sprawl, and lack of parks and open green space. arguably, the small, low-density garden city land use in balance with the natural environment is a more resilient model of urbanism than the compact, high-density new york city in the face of epidemic guidelines that call for social distancing and low population density of the public realm. durable concepts of urbanism originate prominently in the contrast of two prominent thinkers, one english and the other french. the french modernist architect-urbanist le corbusier (1934 corbusier ( /1967 ) touted his tower-in-the-park skyscraper concept of contemporary city as a better solution to the rapid urbanization of population and congestion spurred by industrialization. the contemporary city accommodated 100 times the population of the garden city with only 30,000 that his english predecessor, howard (1898 howard ( /1902 had proposed in skyscrapers (legates & stout, 1998) . the "popular response" to plan voisin, a later version of the contemporary city proposed for central paris in 1925, was "outrage" (legates & stout, 1998; see also birch, 2009 ). however, corbusier's concept of a dense, modern urbanism with the iconic skyscraper endures globally in cities, famously in the iconic new york city (see lang, 1994) . the pandemic cast a negative image of urban density, and its corollary, public transportation, as hotspots of the coronavirus (new yok city, los angeles, and compact spanish, italian, and english cities). density figures prominently in contemporary accounts of new urbanism since density correlates with walkablity in the "transit metropolis" (cervero, 1998) . even before the coronavirus pandemic, the dense high-rise buildings-particularly for public housing in neighborhoods disconnected from the rest of the city-connoted the image of the vulnerability of their impoverished, isolated, low-income residents. the destruction of st louis's pruitt igoe-designed by a renown modernist architect-demonstrated the unsustainability of the high-rise public housing project. in contrast, modern high-rise buildings could densely accommodate residents in resort towns with a premium view and rent. their residents could weather the lock-down, shelter in place guidelines during the pandemic. however, public housing, following federal guidelines like hope vi and choice neighborhood, is now lowrise with a front porch that resembles houses in older american city neighborhoods before the suburbanization of businesses and population spurred by post-war national interstate highway system. however, density is still a hard sell in popular discussions of realestate markets. low-density single family rather than multi-family housing is politically palatable to politicians who count votes with rooftops, even though compact land development is arguably environmentally more sustainable particularly in the face of climate change and demographic shift (immigration) that increase demand for housing and ancillary urban services-water, sewer, and road. in urban-studies literature, discussions of density and how higher thresholds are tolerated, particularly by urbanites accustomed to low-density suburban sprawl, extend to the justification of trade-offs, i.e. how density is plausibly compensated with other factors, (urban) design features that enhance aesthetics of place, and (land-use) diversity that improve proximity of housing to jobs, services, and amenities like parks and open space-so-called 3ds (for impact on travel, see cervero & kockelman, 1996) . density correlates with demography. in the context of the pandemic, still other factors must be added to the 3ds in deference to public health: demography, disaggregated by racial composition, ethnicity, age, and income. the correlations among the factors are instructive. at risk are residents characterized by compact living and commuting, transit-dependent population, or workplace-residence separation exacerbated by the digital divide. for the purposes of public health during the epidemic, the aforementioned factors require optimization simultaneously. the comprehensive city plan is a logical tool for that optimization. let us posit the concept of access inclusively with lynch (1984) as a dimension of the performance of urban form, not merely by modes of travel to work or services, but also availability of resources. perlman and o'meara (2007) remind us that the urban poor are likely located in "ecologically fragile areas of cities," without adequate water and sewers. coronavirus-prevention guidelines include frequent handwashing. how could these hygiene standards be met when there is no access to running water in poor settlements of the global north and south? the navajo settlement is but one example in the u.s. (see also www.digdeep.org). war-stricken regions of the world whose populations are victimized by global power play, such as libya, yemen, syria, turkey, and afghanistan, and refugees in greek islands, are among other examples. once again, pandemics-be they climate change or the coronavirus-reveal the vulnerability of the population in urban, periurban, and rural areas with global inequity of access to the resources fundamental to human survival. the coronavirus pandemic had a positive effect too, with the u.n. directorate's declaration to halt ongoing wars globally, particularly in the middle eastern countries most heavily impacted. the impact of military conflicts on the global population and environment is rarely discussed in the literature of climate change. the advocacy planning argument of the 1960s and 1970s that posed the limit of comprehensive master plans and stressed the necessity of the "plural plan" responsive to the underrepresented, marginalized, disenfranchised, colonized population revives the discussions of the equity of access to resources with environmental justice in the twenty-first century, particularly in the face of pandemics (see davidoff, 1965) . the wealth of nations is created in cities, jacobs (1984) reminds us. global environmental sustainability starts with urban environmental sustainability (perlman & sheehan, 2007) . cities provide economies of agglomeration, and of scale with efficiencies of resource utilization. however, the idea of abating pressure on resources concentrated in urban centers, like london and new york, and striking a balance of nature and development by spreading population to the larger region did not stop in england with howard's concept of the garden city, noted above. the garden city idea influenced a group of regionalists, or de-centralists with english connections in new york. a multidisciplinary team, journalist (howard) , socio-cultural critic (mumford), social reformer (bauer), economist (chase), biologist (geddes), sociologist (perry), forester-naturalist (mackaye), a developer (bing), and several architects (ackerman, whitaker, wright and stein) formed the regional plan association of america (rpaa, 1920s; see also banai, 1993 banai, , 2013b ). an exemplary feature of this regional planning is its multi-scale scope: from neighborhood to the region. it turns out, the "neighborhood unit" (perry, 1929) is an enduring concept manifested in new urbanism that emerged in 1980s. cities 106 (2020) 102929 the economist member of the regional plan association of america (rpaa 1920s), stuart chase, considered the bigger picture of the efficiency of the urban and regional economy as a problem, stated thus: "the regional planning of communities would wipe out uneconomical national marketing, wipe out city congestion and terminal wastes, balance the power load, take the bulk of coal off the railroads, eliminate the duplication of milk and other deliveries, short circuit such uneconomic practices as hauling pacific apples to new york customers by encouraging local orchards, develop local forest areas and check the haulage of western timber to eastern mills, locate mills near cotton fields, shoe factories near hide producing areas, steel mills within striking distance of ore beds, food manufacturing plants in small giant power units, near farming belts." (quoted in hall, 1996, pp. 151-152) for further discussions of local vs. global, economic vs. ecologic tensions in urban development, see korten's (1996) political-economic critique of capital markets, deemed as exacerbating ecological systems, shuman's (1998) "replacing imports" in self-reliant local communities in a global age, and roseland and soots' (2007) "strengthening local economies." the break in the global supply chain during the coronavirus pandemic made the dire consequences abundantly clear, particularly for the health-care sector with loss of life. how "uneconomical," chase might ask, is the practice of offshoring industrial and manufacturing production and sending the finished products, in whole or part, back to the country of origin by air, sea, river, rail, and road? parenthetically, airline tickets now relay magnitude of carbon footprint in trans-atlantic passenger flights. for a sustainability assessment of a futuristic concept of urban form anchored by a "globally networked economy's airport"-the aerotropolis-see banai (2017) . air transportation's contribution to global climate change remains awaiting the development of technologies that economically sequester atmospheric carbon. the idea of the city and the region as a unit is at the kernel of how the u.s. census defines the metropolitan region, metropolitan statistical area (msa) determined by commuting (see banai & wakolbinger, 2011) . parenthetically, this very commuting among inner city and suburban municipalities aids in the transmission of coronavirus, from high-density urban to low-density rural counties. young (2020) quotes the governor of new york, "many people in the new york city metro area live and work across three states' borders, so just as they coordinated shutting down various businesses [during coronavirus], it makes sense to eventually together bring people back." the holistic concept of the metropolitan region that highlights the functional links among urban and regional economies also reveals the strengths and limits of the urban system, and thereby informs the comprehensive city plan's objectives of enhancing sustainability and resilience of the built and natural environments of climate change. human activity's gradual degradation of the natural environment has a long history that has only intensified since the onset of the industrial revolution, with exponential growth in carbon emission due to burning of fossil fuel-coal, oil and natural gas-sources of ghs. a poplar idiom is aptly invoked. the planet earth's holding capacity, like the proverbial camel, is finite, continually burdened with harmful human activity, diminishing gradually by each melting glacier, like straw on a camel's back. (formally, economists use the term "margin," or "last unit" to explain concepts, as in the cost of producing one more unit of a product, the marginal cost of production.) the precise tipping point, or better stated, breaking point for the planet earth beyond any recovery, is in debate. the signs are visible in the built and natural environments, with droughts, fires, floods threatening food security, national security, employment security, rising poverty, inequality, and global diaspora (brown, 2009 (brown, , 2011 . wackernagel and rees (1996) measure ecological footprint by amount of land needed to sustain human needs for production of food and disposal of waste. land is a finite resource. by that definition, wackernagel and rees (1996) illustrate that if everyone lived like people in the netherlands, then two additional planet earths would be needed. parenthetically, the netherlands example is ironic, given the compact dutch urban form integrated with nature and exemplary sustainability practices (see beatley 2014) . furthermore, amsterdam's schiphol airport is regarded as a model for the "aerotropolis," a futuristic concept of urban form (kasarda and lindsay 2011) . there is no literature on the public heath aspects of the aerotropolis; however, comparing it to the exemplary amsterdam metropolitan region that contains the airport (schiphol) offers some clues. the region is characterized by the historic structures, integrated urban development and nature, compact, mixed-land use with multi-modal regional mobility architype of european cities (see beatley, 2009 ). european countries with net zero are the ideal of how we should live next. however, pacala and socolow (2004) offer a variety of existing technological solutions that limit carbon emission over the next fifty years(see also calthorpe, 2011) . the limit is achieved by a combination of alternative sources, from renewable energy (solar, wind, hydro) to conservation to nuclear power. interestingly, in spain, a country hit hard by one pandemic (coronavirus), the road to recovery is through solutions to the other pandemic-climate change-such as pledging to outlaw fossil fuel-coal, oil, natural gas-toward 100% renewable sources of energy. the pandemic has a global reach, by definition. the method of the approach and presentation of this paper is comparative by juxtaposing the pandemics of climate change and coronavirus, and through a historical and critical review and synthesis of the durable concepts of the urban system at the kernel of the theories and practices of urbanism expansively, from rooftop to the region, highlighted by place matters, cyberspace, density, access, and the city-region. the urban system connotes a holistic approach, with a synthesis of concepts of the urban system elements that are heretofore regarded individually particularly in dealing with resilience. the holistic notion of the urban system thus sheds new light on the resilience of system parts when regarded as a whole. we have juxtaposed the recent coronavirus pandemic with climate change, a persistent, long-lasting pandemic which threatens civilization, not merely urbanization (brown, 2009 (brown, , 2011 . pandemics expose the vulnerability and resilience of the urban system ironically with durable concepts of urbanism, from rooftop to the region. the recent pandemic has posed the dilemma of physical vs. virtual space. the accounts of this distinction appear with durable concepts of place and space in urban studies, which shed light on recent pandemic-related discussion. cyberspace and physical space are related concepts. the distinction made between "community of place" vs. "community of interest" is revisited in urban studies, particularly with the concepts of placemaking. there are limits and possibilities in both cyberspace and physical spaces. the critical role of access is also posed in both spaces, with respect to efficiency and justice. one space asserts the dilemma of a "digital divide," whereas the other asserts the dilemma of public vs. private transportation with equity and efficiency. place density is also a durable, controversially held concept of urbanism. we have highlighted discussion of density dating from first decades of the twentieth century, relating to the challenges of public health. the recent pandemic posed anew the challenge of public health with urban density. pandemics, while exposing the vulnerabilities of the urban system, are also a driver of positive change in planning resilient urban form of the future. reconfiguring the urban system in the era of climate change is compelling with the majority of world population living in cities and regions. at the outset of the paper (pages 1-2), we pose the kind of planning that is commensurate with the dimensions of the challenges posed by the pandemic needed for resilient cities. we argue the case for comprehensive planning, and provide specific interventions toward resilience, with place matters, cyberspace, density, access, and the cityregion. the logic of the long-term comprehensive plan is compelling given the interrelated elements of the urban system. the argument is that resilience of the whole is dependent upon the resilience of the individual parts. the paper thus provides specific areas of how the parts are addressed with elements of the urban general or comprehensive plan. for brevity , the discussion of the application of comprehensive planning as a mode to enhance resilient cities is limited. the comprehensive plan with a legal backing is long-term oriented, with parts that account for key physical elements that prepare the urban and regional system to confront the challenges of climate change. the comprehensive plans rarely include physical elements that enhance the urban and regional resilience proactively in the face of climate change. we have identified how the urban system is reconfigured, from the infrastructure of the public realm (the street, town square, park, and open space) to place density with a human-scale, telecommunication, regarded at par with essential infrastructure of water, sewer, and road, to integrated urban and regional economies that enhance efficient, sustainable local production and distribution of resources. further studies fruitfully build on our comparative, evaluative framework of pandemics as drivers of change toward resilient cities of the future. social theory and the region: from the regional planning association of america to the restructuring of socio-spatial theory, with policy implications plan vs project dilemma in urban and regional studies revisited: a progress review of urban and regional studies the metropolitan region: from concepts to indicators of urban sustainability the aerotropolis: urban sustainability perspectives from the regional city urban theory since a theory of good city form (1981): a progress review a measure of regional influence with the analytic network process planning for 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cuomo says the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. key: cord-308821-j4vylbhy authors: martin, r. title: the role of law in pandemic influenza preparedness in europe date: 2009-03-04 journal: public health doi: 10.1016/j.puhe.2009.01.002 sha: doc_id: 308821 cord_uid: j4vylbhy the european union (eu) is composed of 27 states with widely varying histories, economies, cultures, legal systems, medical systems and approaches to the balance between public good and private right. the individual nation states within europe are signatories to the international health regulations 2005, but the capacity of states to undertake measures to control communicable disease is constrained by their obligations to comply with eu law. some but not all states are signatories to the schengen agreement that provides further constraints on disease control measures. the porous nature of borders between eu states, and of their borders with other non-eu states, limits the extent to which states are able to protect their populations in a disease pandemic. this paper considers the role that public health laws can play in the control of pandemic disease in europe. the 27 states of the european union (eu) form a political and economic community with supranational and intergovernmental responsibilities, and constitute a single market that seeks to guarantee the freedom of movement of people, goods, services and capital between member states. the emergence or re-emergence of diseases such as severe acute respiratory syndrome (sars) and tuberculosis highlighted the need for eu-level health policy, and led to the community action programme 2003-2008 in the field of public health. this programme is now the cornerstone of community public health strategy, focusing on health information and on the community's capacity to react to health threats. in the context of disease control, the executive arm of the eu, the european commission (ec), has responsibility for the co-ordination of epidemiological surveillance of disease between member states and for regulating matters such as case definitions, disease notification and development of disease networks across europe. the ec is assisted by the european centre for disease control (ecdc), which issues protocols on matters of disease reporting and communication of disease information between states and to the ec. the ec and ecdc can only recommend appropriate disease control measures to states. neither is responsible for the management of disease protection and control in individual states. public health powers in relation to disease lie with national governments. it is member states, not the eu, which are signatories to the revised international health regulations (ihr) 2005, although the ihr recognize the role of 'regional economic integration organizations' such as the eu. a thus, if the world health organization (who) were to recommend under the ihr measures falling within eu legislation, such as restrictions on the movement of goods or the processing of personal data, b the eu would need to act collectively, at the initiative of the ec, as member states would be unable to take unilateral action. otherwise, ihr responsibilities lie with individual states. in 2007, a report on pandemic influenza preparedness in the eu 1 noted that substantial progress had been made in preparing for a possible pandemic influenza, but it remained the case that disease control operated at national level. despite encouragement from the eu towards harmonization of approaches, european national plans vary widely in the strategies they have adopted and the public health powers they propose for implementation of those strategies. harmonization of legislative responses to infectious diseases, based upon sound evidence, will be necessary if collaborative efforts in support of infectious disease control are to be effective. to assist in drawing together national responses to pandemic disease, the phlawflu project c was funded to develop public health law expertise across europe, 2 and to examine the legal underpinning of pandemic disease preparedness across the eu and five further european states. d this paper examines obstacles to european commonality of legal responses to communicable disease. there is no doubt that law is an important tool in containment of communicable and non-communicable disease. in the context of pandemic influenza, it is considered that social measures authorized by law will be at least as important as medical interventions. 3 evidence from the 1918 influenza pandemic suggests that compulsory home isolation and quarantine were not particularly effective disease control measures because of the difficulty in diagnosing mild cases. nor were such measures likely to be feasible beyond the initial cases. 4 however, compulsory interventions such as school closures, closure of public places and restriction of mass gatherings, along with disease surveillance and hygiene improvement, have proved effective both in influenza outbreaks and in the sars epidemic. 5 international and eu instruments require states to undertake such measures, many of which will require a legal underpinning. the requirement of compliance with the revised ihr and the globalization of disease information and exchange have prompted many states to revise their public health laws. other states, which had no public health legislation, have now enshrined public health laws in legislative form. these initiatives were long overdue. across europe, as elsewhere, national public health laws tended to be old, based on flawed science, and to predate contemporary understandings and protection of human rights. 6, 7 the allocation of responsibility for public health practice and the role of the state in regulating private behaviours have very different histories across europe. 8 not surprisingly, states have adopted very different positions on the issue of the extent to which constraints can be placed upon individuals for the public benefit. earlier research on european national public health laws in relation to tuberculosis 9 enabled the identification of four different 'families' of public health legislative models in europe. these were: authoritarian (the enforcement of a high number of compulsory control measures); moderate (the enforcement of predominantly compulsory control measures without recourse to prevention powers such as compulsory vaccination or population screening); preventive (where compulsory provisions were oriented towards preventive measures, including screening, medical examination and/or vaccination, rather than compulsory treatment or detention); and the laissez faire model, where few or no compulsory measures existed. a further complication to a comparison of national legal approaches to disease control is the range of different legal systems in europe. while the majority of european states have a civil law legal system based on the french or german systems, some states operate common law systems, e the former soviet states have vestiges of soviet law, and the legal systems of the scandinavian states recognize civil law overlain with some common law. whereas the definitive public health law of some states can be found in statutory form, other states also include the binding decisions of courts. some national legal systems recognize customary law, local edicts or administrative orders as having legal authority. it cannot be assumed that because a particular power does not lie within public health legislation, that power does not exist. determination of the full range of public health legal powers across european states is a technical and difficult task. following the eu working paper on community influenza pandemic preparedness and response planning in 2004, 10 european states have published national preparedness plans. as with the range of approaches to law, there is a wide range of approaches to pandemic preparedness planning across europe. coker and mounier-jack examined 21 european national plans against a who checklist and found considerable gaps and inconsistencies among preparedness plans, with implications for health in both individual states and for europe as a whole. the authors noted that 'the eu has a critical function in protecting its citizens from public health threats. the role of the eu will be essential to ensure improved sharing of knowledge on pandemic response among eu members, to support the effective provision of services, and to coordinate the response at a community level'. 11 few plans address the extent to which proposed interventions are authorized by their national laws. indeed, few state plans acknowledge the need for legal authorization for their proposed measures, and there is often a lack of clarity about the legality of measures. f while there is some commonality across european states in the measures considered appropriate in an epidemic, the formulation of those measures differs from state to state, reflecting the culture and social priorities of individual states. across europe, states have proposed disease reporting networks, social distancing powers, restriction on travel and trade, closure of premises and facilities, and measures regulating the provision of goods and services. however, the extent and scope of these powers vary widely. while most states contemplate powers of isolation and quarantine, some states also propose quarantining flight crews, and authorize compulsory vaccination, compulsory administration of prophylaxis, and compulsory medical treatment. most states authorize the closure of schools and leisure facilities in a pandemic, but some states would also close diplomatic and consular representation, restrict trade union activity or prohibit visitors to inpatients in hospitals. there is variation in the extent to which states will be prepared to requisition persons and property. many states have passed, or are in the process of passing, new legislation to support their preparedness planning. in england and wales, for example, the health and social care act 2008 has introduced into the public health act 1984 new powers of isolation outside a hospital, powers of quarantine, powers to require the wearing of protective equipment, powers to require people to attend counselling or disease risk training, and the power to require individuals to provide health information. it also provides for the application of compulsory power orders to groups of persons as well as to individuals, provides new border control measures and imposes new obligations to monitor health risk. states that had taken a liberal approach to intrusion on individual liberties for the benefit of the public health have, in the face of the threat of a pandemic, passed laws providing considerable public health powers. french public health law had previously c the phlawflu project has received funding from the eu in the framework of the public health programme. d croatia, turkey, iceland, liechtenstein and norway. e including the countries of the uk, ireland, malta and cyprus. f the spanish preparedness plan, for example, expresses concern regarding the legality of proposals for isolation, restriction of movement and the proposal to make compulsory the administration of antivirals to staff in contact with patients, noting that 'the legal services of the ministry of health will need to study the legal aspects relative to compulsory vaccination and isolation and the restriction of movement according to the constitutional act 3/1996 of 14 april of special public health measures in public health, articles 2 and 3'. focused on preventive measures and provided few compulsory powers for disease control. 9 the new french public health code now authorizes isolation and quarantine, obliges individuals to submit to temperature checks, and provides powers to close facilities such as schools, restrict use of public transport, requisition health personnel including students and retired persons, and regulate distribution of medicines. school buildings will be used as centres for vaccination and for accommodation of vulnerable persons. the new code withdraws employment rights such as the right not to work in a situation of danger. employees and public servants in france currently have the right to withdraw from their workplace if they reasonably believe that their work situation presents a grave and imminent danger to life and health, provided that they have alerted their employer to the danger and provided that their leaving does not create a new risk for others. under the new code, which only applies in the particular case of pandemic influenza, this right of withdrawal will not apply in circumstances where the employer has taken all foreseeable measures to reduce the risk of exposure to disease. the formulation of public health measures across europe reflects cultural values and priorities. french law, for example, proposes the possible closure of schools in an epidemic, but the new french public health code, recognizing the importance of education in france, provides very specific measures to protect the right to education of its children. the code acknowledges the need for school closures because children are more susceptible to the influenza virus than adults. however, the code requires that during a school closure, every effort must be made to continue educational provision via the internet, radio and television, and sets out detailed provisions on ways in which education might be continued throughout the pandemic. the difficulty of predicting what legal powers will be needed to exercise effective disease control has led some states to include in their public health legislation a power to make emergency regulations to provide powers that were not foreseen or which would not be appropriate outside an emergency. the health and social care act 2008 for england and wales, for example, proposes that where there is sufficient urgency, a legal instrument may be made without following normal parliamentary procedures. 12 the regulation will then cease to have effect after 28 days, unless it has been ratified by a resolution of each of the houses of parliament. the new french code allows that in the case of a grave threat calling for urgent measures, particularly in the case of an epidemic, the minister responsible for health can, by means of an arête, dictate in the interest of public health measures that are proportionate to the risk and appropriate to the time and place, in order to prevent or to limit the consequences of possible threats to the health of the population. in addition to emergency powers specifically addressed to pandemic disease, many european g and other h states have also introduced or updated separate emergency powers legislation to address unexpected threats, to authorize measures that would not normally be acceptable, or to provide powers as a last resort in the face of emergencies where existing legislation is insufficient. other states have constitutional provisions authorizing emergency powers. i it has until now been the case that for the purpose of legislation, emergencies have been conceptualized as aberrations, normally involving an aspect of violence such as war, rebellion or a violent natural disaster. european emergency powers have generally been limited to a 'state of siege' (france), armed rebellion (hungary), or industrial and natural disasters such as earthquakes or the forest fires in greece. they have not been considered a tool for disease control. in the uk, the civil contingencies act 2004 has replaced the 1920 emergency powers act j in relation to temporary special legislation to respond to serious emergencies. the emergency powers act had provided power to make emergency regulations, following a royal proclamation of a state of emergency, in case of an interference with the supply or distribution of food, water, fuel, light or the means of locomotion that deprived the community, or part of it, of the 'essentials of life'. the civil contingencies act expands the domain of emergency powers so that an emergency is widely defined to include 'an event or situation which threatens serious damage to human welfare', which could potentially include a public health threat such as a serious disease outbreak. while no regulations have been passed to date, there is clearly scope for a heavy-handed response in the event of a public health threat. the civil contingencies bill in its original form underwent prelegislative scrutiny by a joint committee which noted that the bill: ' in the wrong hands, [the bill] could be used to undermine or even remove legislation underpinning the british constitution and infringe human rights. our democracy and civil liberties could be in danger if the government does not take account of our recommended improvements'. 13 the bill was revised and the government agreed to remove a clause that would have prevented emergency regulations from being subject to judicial review with the consequence that the regulations could not be suspended or struck down by a court if they were challenged on human rights grounds. the committee recommended that certain acts of parliament of major constitutional significance should be exempted from a power to modify or disapply legislation, but this remains in the final legislation. the committee also proposed that those powers set out in part 2 of the bill should be subject to a 'sunset clause' and expire every 5 years from royal assent unless renewed by parliament. this was rejected by the government as inappropriate, because the bill contained enabling powers that were intended to deal with a problem that was 'not short-term'. this suggests that a new approach is being taken to the meaning of 'emergency'. under earlier emergency powers legislation, an emergency was determined by a royal proclamation, but under the civil contingencies act, a state of emergency is to be announced, without initial reference to parliament, by the secretary of state or a senior minister. public health emergency planning in the uk appears to acknowledge that the civil contingencies act will have a more general role in the control of disease, although how these plans relate to new powers under the public health act 1984 remains to be seen. a senior spokesperson from the english department of health told the author that the department does not intend to use emergency powers contained in the civil contingencies act for pandemic influenza. powers, contained in the health and social care act 2008 should provide all the necessary legal powers to contain and control disease. however, it is clear from government documents on pandemic planning that there is every expectation that civil contingencies act powers will be used should the need arise. 14, 15 the finnish national preparedness plan for pandemic influenza 16 recommended amending finland's 1991 emergency powers act so that a major epidemic can be classified as a state of emergency as defined in the act. previously, an emergency was defined to include an armed attack against finland, a serious violation of the territorial integrity of finland, a threat of war, a serious threat to the livelihood of the population or the economy by interrupted import of indispensable fuels and other energy, or a catastrophe. finland's communicable disease act of 2005 already contains quite intrusive powers including the power to administer compulsory mass vaccination by the defence forces, compulsory medical treatment, isolation from the workplace, and disease reporting that discloses personal information. the concern with use of emergency powers for disease control is that disease control ceases to be a matter of health protection, and becomes an issue of foreign and national security, with the risk of being hijacked by the agendas of security policy and politics. 17 ,l this has become even more pronounced with the merging of responses to naturally occurring infectious disease and bioterrorism within emergency powers legislation. the who and european commission have both established committees with responsibility for public health as a security issue. m it is questionable whether the suspension of separation of powers and potentially of civil rights and liberties is justified in the name of public health, and arguable that recognition of human rights is essential for dealing effectively with an epidemic. draconian quarantine measures can be counterproductive, and may even encourage people to avoid seeking medical treatment. emergency powers exercised for public health reasons treat citizens as the enemy, and reinforce the philosophy of original public health legislation which classified diseased persons as a public health nuisance to be removed and excluded from society for the benefit of the well. 18 hong kong, which has had recent experience of epidemic disease, considered but rejected expanding its emergency regulations ordinance to cover pandemic influenza, concluding that public health powers were sufficient and appropriate to disease control even during a pandemic. n hong kong has instead amended its quarantine and prevention of disease ordinance in the light of its sars experience. 19 emergency powers and human rights all council of europe member states are party to the european convention for the protection of human rights and fundamental freedoms, and any person whose convention rights have been violated by a state party can take a case to the european court of human rights. in the uk, the human rights act 1998 brings provisions of the convention into uk domestic law and enables human rights actions to be brought in a domestic court. rights with particular relevance to public health powers include article 2 (right to life), article 3 (an absolute right to freedom from torture and inhumane and degrading treatment), article 5 (a qualified right to liberty) and article 8 (a qualified right to private and family life). in enhorn v sweden, 20 a human immunodeficiency virus (hiv)-positive man detained by swedish public health authorities on public health grounds successfully challenged his detention on the grounds that it breached articles 5 and 8 of the convention. the european court of human rights held that any detention must comply with the principle of proportionality, there must be an absence of arbitrariness, detention must be a last resort measure, and any detention must have as its objective not only protection of the healthy but also care of the ill. 21 there has been little judicial challenge in british courts of the exercise of emergency powers. in relation to the english emergency powers act and the emergency powers (defence) act, the courts have played a minimal role, striking down only a handful of emergency measures as ultra vires, usually well after the emergency. more recently, in a case where the british parliament had sanctioned the indefinite detention of any person not a british citizen and certified as a 'suspected terrorist', and where the government had derogated from both the european convention and the international covenant on civil and political rights (iccpr) on the grounds that there was a 'public emergency', the house of lords rejected the government's assertion that the derogation was consistent with the european convention. although the majority of judges declined to question whether there was a public emergency on the grounds that the existence of such an emergency was largely a matter for the government to determine, they concluded that imprisonment of non-citizens alone was neither proportional, given the equal threat from citizens, nor necessary, and questioned the irrationality of singling out a minority (non-citizens) for special burdens, when members of the majority could present an equal risk. 22 lord hoffmann was prepared to consider the notion of an emergency and he found it to be a threat to the 'organised life of the community', which would include not merely a threat to the physical safety of the nation, but also to its fundamental values: 'the real threat to the life of the nation, in the sense of a people living in accordance with its traditional laws and political values, comes not from terrorism but from laws such as these.' 23 the decision suggests a judicial role in overseeing government powers in emergencies. the concept of a 'public emergency' is considered under article 15 of the european convention for the protection of human rights and fundamental freedoms as 'a situation of exceptional and imminent danger or crisis affecting the general public, as distinct from particular groups, and constituting a threat to the organised life of the community which composes the state in question.' o article 15 allows that states might derogate from some of their obligations under the convention 'in time of war or other public emergency threatening the life of the nation', but not from article 2 (right to life) or article 3 (prohibition of torture and inhuman or degrading treatment). the former european commission of human rights, which in 1961 defined a public emergency to consist of a 'threat to the organised life of the community', 24 was called upon to determine the criteria of a public emergency threatening the life of the nation in a case in which the greek government sought to justify derogation of rights on grounds of a public emergency. 25 the commission held that the emergency must be actual or imminent; it must affect the whole nation; the continuance of the organised life of the community must be threatened; and the crisis or danger must be exceptional, in that the normal exceptions permitted by the convention for the maintenance of public safety, health and order are inadequate. derogations may only last for as long as, and only be exercised to the extent required by, the demands of the circumstances. they must not limit the subject's rights of access to court protected in article 6 of the convention, nor the right of a remedy protected in article 13. in circumstances where a state wishes to exercise emergency powers which might contravene human rights, the state is required to make a formal derogation under article 15 of the european convention indicating the rights and the territory to which the derogation applies, 26 and to keep the secretary general of the council of europe informed of the measures taken, the justifications, and the cessation of operation of emergency powers. 27 similar requirements can be found in the iccpr. 28 if european states are to abide by their commitments under the convention, it seems that use of emergency powers will be subject to human rights examination. states will not then be able to exercise their powers in an arbitrary way, and will not be able to respond in a manner that is not proportional to the risk. despite these safeguards, the use of emergency powers legislation for serious ongoing disease outbreaks is questionable. an influenza epidemic could, on a worst case scenario, last for years, which would potentially allow the operation of emergency powers that derogate from human rights protections for a considerable period of time. there is a danger that laws made in the form of emergency regulations might, if in force for long enough, become embedded in the legal system and so constitute a permanent assault on liberties which had previously been achieved, as might be suggested of terrorism legislation in the uk. 29 emergency powers in the context of disease, based as they are on responses to war and catastrophes, tend to operate in such a way that persons affected with disease are characterized as the enemy. they propose that in public health emergencies, there must be a trade-off between the protection of civil rights and effective public health interventions. however, the ideals of democracy, individual rights, legitimacy, accountability and the rule of law suggest that even in times of acute danger, government should be limited in the activities that it can pursue and the powers that it can exercise. as gostin points out in the context of the us model state emergency health powers act, 30 this is not to say that individual rights should always trump public health, but that individual rights should never be infringed 'unnecessarily, arbitrarily or brutally'. 31 nevertheless, there has been significant criticism of the us legislation, and concern that measures proposed in the act are sufficiently dangerous as to 'undermine.constitutional values'. 32 while emergency powers might provide short-term solutions to serious threats, they could also do long-term harm to public trust in public health services, and encourage health behaviours which are counterproductive to the public health. in many countries, including the usa, 33 there are signs that public health and national security are increasingly conflated. the ihr are framed around the assumption that disease is a security issue. 34 however, the danger of subsuming disease control within foreign and national security is that the focus is on security rather than on health. wider national and international interests may not always coincide with public health. global public health may not always coincide with the security concerns of individual states, particularly more powerful states. mcinnes and lee note that policy responses to the sars epidemic elicited a 'garrison mentality' whereby strict border controls and control of movement of persons became central to disease containment, with consequences for the movement of persons, goods and services. 35 it has been widely argued that the promotion and protection of human rights is inextricably linked to the promotion and protection of public health, and that lack of respect for the rights and dignity of persons or groups of persons can increase their vulnerability to disease contagion. 36, 37 the importance of human rights to health has been acknowledged in the revised ihr article 3, which requires that the ihr be implemented with full respect for the dignity, human rights and fundamental freedoms of persons. as mann argues, '.the human rights framework is indispensable both for analyzing the central societal issues which must be confronted and for guiding the direction of societal transformation needed to promote and protect health.' 38 states have a significant number of non-medical tools at their disposal in a disease pandemic, and public health law reform has been undertaken with pandemic influenza in mind. public health legislation around the world now authorizes a wide range of social distancing powers and compulsory screening, examination and treatment measures. in addition, much public health legislation provides for the possibility of some limited emergency measures. nevertheless, some european states have proposed the use of emergency powers legislation to provide exceptional powers in the case of a pandemic; powers which will inevitably constrain the rights of individuals. the evidence base for the need for such exceptional powers has yet to be established, and in the absence of such evidence, there is concern that too heavy a hand will result in long-term harm to public trust in the exercise of population-based disease prevention strategies. early responses to public health threats as reflected in 19th century public health legislation were premised on building fortresses to protect the healthy (and generally wealthy) from those suffering from disease, rather than on care and protection of the population. public health legal powers tend to focus on containment and exclusion, representing 'the community response to social and economic pressures and the wide spread fear of death and disease' 39 rather than on positive public health outcomes. immigrant populations have long been targeted as carriers of disease, and in relation to diseases such as drug-resistant tuberculosis, increasing incidence in the western world is often attributed to persons entering from states with high tuberculosis rates. 40 much contemporary public health policy has rejected the 'fortress' approach to disease control in favour of seeing the public health mandate as imposing duties upon all members of a society or population, 18 or indeed duties of global health protection. the evidence base for border control as a public health, as distinct from a security, measure is limited, especially in a pandemic. 5 in relation to other diseases such as hiv and tuberculosis, border screening has proved to be unreliable and has shown little benefit for the health of the population. 41 compulsory border screening and refusal of entry to affected persons are contemplated by many states in their pandemic influenza preparedness plans, p and the revised ihr 2005 contemplate that who might recommend refusal of entry of suspect and affected persons and refusal of entry of unaffected persons to affected areas, 42 subject to the ethical consideration of respect, to the extent possible, for the individual right to freedom of movement. 43 article 19 of the ihr requires all signatory states to establish points of entry with surveillance and border control capacities. a consequence of having no internal eu borders is that the eu needs a strong common external border. under the 2004 eu free p for example, bulgaria, denmark, greece and latvia. movement directive, 44 member states may deny entry of eu citizens and their family members if they are considered to be a threat to public health, but only if this is proportionate and meets strict material and procedural safeguards. most eu member states q have signed the schengen convention, eliminating border controls between participating countries and creating an external frontier. the convention called for a common visa policy, harmonization of policies to deter illegal migration, and an automated schengen information system to coordinate actions in relation to individuals who had been denied entry. the 1997 amsterdam treaty incorporated the schengen convention into eu treaties, and set out a plan to integrate policies on visas, asylum, immigration and external border controls into community procedures and into the community legal framework. this has resulted in what is for all intents and purposes an eu external border, with much social and economic activity operating at regional rather than national level. however opt-out r and opt-in s possibilities make it difficult to define an administrative space that falls within the frontier, and there is no overarching political control. 45 rather, decisions are made by means of a complexity of intergovernmental and supranational institutions, and there remains considerable sovereign power in relation to many issues of border and public health relevance. the schengen agreement includes consent to share information about people, via the schengen information system. this means that a person cannot 'disappear' simply by moving from one participant country to another. a country is permitted by article 2.2 of the schengen agreement to reinstate border controls for a short period if it is deemed to be in the interest of national security. any schengen country can impose temporary or permanent border controls if it believes itself to be unprotected by other members. under this provision, portugal restricted border entry during the 2004 european football championship, as did france for the ceremonies marking the 60th anniversary of d-day, and again shortly after the london terrorism bombings of july 2005. with foot-and-mouth disease having been confirmed in france, the netherlands and britain, norway, in particular, put its border officers on high alert to prevent spread of the disease into the country. other nordic countries have also increased spot checks on entries into the region, irrespective of their new borderless status, in an attempt to contain foot-and-mouth disease. under the schengen borders code, third-country nationals may be refused entry if considered a threat to public health. one issue that arises from the lack of border controls within europe is the disparity in levels of disease preparedness across europe. in 2004, 10 new member states joined the eu, eight of which are former communist countries in central and eastern europe (slovenia, hungary, czech republic, poland, lithuania, latvia and estonia). these states are characterized by a history of underfunding of health and surveillance systems, unreliability of access to drugs, continuing increase in diseases such as drug-resistant tuberculosis and hiv/acquired immunodeficiency syndrome, and inadequate public health responses to disease. 46 since these states have entered into the eu, citizens can cross borders into other, better-resourced states. in the context of a pandemic, this could mean an influx of persons who are possible disease carriers from poor states with a frail public health system and with insufficient medicines, to other eu states, putting citizens at risk and draining health resources in those states. this creates difficult choices for host countries in terms of the assistance they offer. should they fail to offer healthcare services to mobile populations, these populations will put state population health at risk. should they offer healthcare services to mobile populations, this will strain resources and drain services from home populations. in their comparative study of european national preparedness plans, 11 mounier-jack and coker found that 15 eu states intended to take at least one measure to restrict travel to and from the state during a pandemic, and 13 of these states recommended border restrictions on entry and departure. one state proposed drafting new laws to give stronger border control powers. other states, however, conceded that by phase 6 of a pandemic, 47 while there might be political grounds for restrictions on travel, there would be little public health benefit. the possibility of border closure was an issue examined in exercise common ground, a pandemic influenza exercise for the european union, conducted by the uk's health protection agency over a 2-day period in november 2005. 48 this was the second of two eu exercises commissioned by the ec to evaluate the ability and capabilities of member states to respond to a health-related crisis, in this case an influenza pandemic. concern was expressed when switzerland indicated that it might consider the closure of its borders, given the location of drug manufacturers in switzerland. france's border closure proposals contained exceptions for pharmaceutical and vaccine materials and workers. the feasibility of instituting border controls within europe in a pandemic was then examined at an eu pandemic influenza workshop in august 2007. 49 it was concluded that while border closure might be a useful early containment strategy, at a pandemic stage, it would be impractical to enforce border controls within europe because of the porous nature of european borders and because of the need for cross-border traffic of goods. any prolonged border control would disrupt critical supply chains, and there was a risk that the consequent disruption of border controls within europe would result in greater harm than benefit. 50 screening at borders for diseases such as tuberculosis and hiv is common practice in many states, but has been much criticized on grounds of evidence and ethics. 41 a systematic review looking at the effectiveness of physical interventions such as screening in relation to respiratory viruses concluded that '(g)lobal and highly resource intensive measures such as screening at entry ports.lacked proper evaluation'. 51 there is also limited evidence regarding the efficacy of screening international passengers on departure or arrival in a flu pandemic, except possibly in the early phase. while control and screening measures may have worked in the days of slow travel, it is now the case that travel times are likely to be shorter than incubation periods, such that port screening will be ineffective in disease identification. nevertheless, the mounier-jack and coker study found that eight eu states proposed entry screening in their pandemic preparedness plans. 11 some european states indicated in exercise common ground that they intend to undertake border screening regardless of the evidence base, on the grounds that such measures provide reassurance to the public, and because the surveillance information might prove useful. the ihr 2005 authorize states to require information from travellers about their travels, and to undertake a non-invasive medical examination which is the least intrusive to achieve the public health objective. 52 entry may be refused where the traveller refuses to co-operate. 53 article 31 of the ihr provides that invasive medical examination, t vaccination or other prophylaxis shall not be required as a condition of entry except in limited circumstances, such as to determine whether a public health risk exists, or in relation to persons seeking temporary or permanent residence. in these circumstances, if a traveller refuses to comply, entry may be refused or be made subject to the least invasive procedure to achieve the public health objective. article 23 stipulates that such measures be undertaken within the confines of express informed consent and national and international safety guidelines, and article 32 requires that in implementing measures, travellers are to be treated with dignity and respect, and with recognition of gender, sociocultural, ethnic or religious concerns. within the eu, border measures are a matter of community competence that require state co-ordination. where eu member states intend to adopt border measures for the control of communicable diseases, they must inform and, where possible, consult other member states and the commission in advance. the exercise common ground report and the eu pandemic influenza workshop concluded that there was variability in the extent to which member states, european economic area states (including all eu countries plus iceland, norway and liechtenstein) and switzerland have included an international dimension in their pandemic influenza plans. rather, they have focused on national, domestic issues. it is necessary to consider an international dimension because: 'in a community like the eu, free of internal borders and with many common activities and free movement of people and goods, any countermeasures taken in one member state will be bound to affect at least some if not all, other member states'. 54 the reports noted that states also needed to address issues surrounding expatriates, travel restrictions, restriction of emigration, issues of contact persons and the potential for social disorder. there was a lack of clarity around community law on implementation of travel restrictions, and some confusion regarding the extent to which issues of freedom of mobility needed to be handled differently according to an individual's nationality. to be practical and costeffective, border measures would require policy coordination between countries of arrival and departure, and consensus between neighbouring states to avoid disruption. however, as mounier-jack and coker note, 11 few countries address the issue of collaboration with neighbouring states on matters of travel restrictions in their plans: ' there is clearly a need for countries within a european region to be informed and to inform others of their respective strategies in order to ensure that policies are consistent where necessary, or pose as few challenges as possible to public health protection where differences or inconsistencies exist. there may also be a need to ensure that european response mechanisms work together in harmony if public health interventions are to be similar in different countries'. national generic plans in europe have addressed issues of border control rather inadequately. questions have been raised about mobile populations and their implications for healthcare resources, but the issues remain unresolved. there appears to be political reluctance in the context of a united europe to invoke exemptions from internal market rules of free movement of goods and persons on grounds that neighbouring states are failing to address public health threats, and while there is concern about the consequent risk to populations, most states have taken the pragmatic view that any border control should take place at europe's external borders and not within europe. the variation in public health resources and in public health legal powers across eu states, in a context of free borders, is a concern for europe-wide pandemic disease strategies. it is not impossible that states with the strongest national public health powers, which permit, for example, compulsory vaccination or detention, will find some citizens moving states to avoid imposition of these powers. ideally, states within the eu will work together to achieve some commonality of pandemic disease policy and some commonality in their public health legal frameworks. much has been done to develop common policy approaches to preparation for an influenza pandemic across europe. however, article 152 of the european treaty, which states the eu objective of a high level of health protection and requires the european community to work with nation states to deal with health threats, does not allow for a policy of harmonization of state laws. the most that can be hoped for is some convergence of legal powers resulting from discussion and negotiation between states. the differing histories, politics, culture and legal systems of this group of highly divergent states does not bode well for agreement across europe on the appropriate legal response to disease threats. in an attempt to identify the extent to which there is variation in public health legal powers and the consequences of such variation for public health in europe, the phlawflu project is examining the role of national laws in the control of and protection against pandemic human influenza across europe. 2 the objective of the project is to provide an evolving critical study of national laws supporting and constraining defined issues of communicable disease control across europe, and to provide a resource to support public health law reform and public health policy making in europe. the project methodology includes workshops bringing together public health policy makers from 32 european states to examine legal responses to disease scenarios. it is to be hoped that some common legal responses emerge from these exercises, and given the absence of attention paid to public health laws in europe in recent years, that much can be learned by all states on ways in which to use law as a tool in pandemic disease control. meanwhile, europe is in a complex place in relation to its public health approach to pandemic disease. in times of economic strength and freedom from threats of war and disease, the commonality of eu states comes to the fore, and states are ready and willing to engage in joint enterprise. where states are at threat, however, they tend to turn inward on themselves, and political and cultural differences emerge. in times of threat, states which have traditionally been strong on public intervention in private rights are unwilling to accede to the approaches of more liberal states. traditionally, liberal states are reluctant to impose draconian measures, but at the same time may be unwilling to carry the public health burden of citizens from poorer states. the revised ihr have done much to focus public health law reform measures and to ensure some minimum commonality of content, but it is clear that some states, in accordance with their legal culture, are prepared to undertake more intrusive interventions than others. for all these concerns, it is clear that public health laws will be a mainstay of pandemic disease strategies, both in relation to the eu and in relation to nation states within europe. public health laws will be essential in providing powers to enable actions to be taken to control disease spread, but also to constrain states from taking actions that might reassure short-term security concerns but that have potentially harmful long-term public health consequences. of course, such issues are not unique to europe, but the nature of europe as a continent and as a legal entity creates particular complications for the ways in which law might best be used to create a coordinated european pandemic disease strategy. one unexpected benefit of the pandemic threat has been the renewed interest in exploring the role of law as a communicable disease tool, and in the examination of the range of public health legal approaches across europe. globally, a greater understanding of the role of public health law as a tool for managing and minimizing the spread of communicable disease will be a lasting and invaluable legacy of governance efforts in relation to pandemic influenza. none sought. none declared. european centre for disease prevention and control. technical report: pandemic influenza preparedness in the eu. status report as of autumn european public health law network website. available at: www.ephln.org social measures may control pandemic flu better than drugs and vaccine report on the influenza epidemic in nsw in 1919 world health organization writing group. nonpharmaceutical interventions for pandemic influenza, national and community measures the exercise of public health powers in an era of human rights: the particular problem of tuberculosis 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ordinance the exercise of public health powers in cases of infectious disease: human rights implications a v secretary of state for the home department a v secretary of state for the home department greek case, 12 yb 1, opinion of the commission russian federation. ecthr judgment of 24 european commission for democracy through law (venice commission) the interface between public emergency powers and international law the law of exception: a typology of emergency powers drafted by the centre for law and the public's health at georgetown and johns hopkins universities the model state emergency health powers act bioterrorism, public health and civil liberties public-private health law: multiple directions in public health global public health security health, security and foreign policy public health strategies for pandemic influenza: ethics and the law health and human rights: a reader human rights and the new public health human mobility and population health increasing drug resistant tuberculosis in the uk compulsory screening of immigrants for tuberculosis and hiv world health organization. ethical considerations in developing a public health response to pandemic influenza directive 2004/58/ec of the european parliament and of the council of 29 mapping schengenland: denaturalizing the border health-care system frailties and public health control of communicable disease on the european union's new eastern border world health organization pandemic phases exercise common ground: a pandemic influenza exercise of the european union department of health and cabinet office. pandemic influenza -sharing of evidence and response policies across the eu. london: department of health workshops 11 and 12 facilitated by dr miguel betancourt cravioto and dr daniel reynders physical interventions to interrupt or reduce the spread of respiratory diseases: a systematic review specifications attached to the invitation to tender document, sanco/c3/ 2004/05, quoted in health protection agency, exercise common ground, a pandemic influenza exercise for the european union, final report. london: health protection agency none declared. key: cord-332313-9m2iozj3 authors: yang, hyeonchae; jung, woo-sung title: structural efficiency to manipulate public research institution networks date: 2016-01-13 journal: technol forecast soc change doi: 10.1016/j.techfore.2015.12.012 sha: doc_id: 332313 cord_uid: 9m2iozj3 with the rising use of network analysis in the public sector, researchers have recently begun paying more attention to the management of entities from a network perspective. however, guiding elements in a network is difficult because of their complex and dynamic states. in a bid to address the issues involved in achieving network-wide outcomes, our work here sheds new light on quantifying structural efficiency to control inter-organizational networks maintained by public research institutions. in doing so, we draw attention to the set of subordinates suitable as change initiators to influence the entire research profiles of subordinates from three major public research institutions: the government-funded research institutes (gris) in korea, the max-planck-gesellschaft (mpg) in germany, and the national laboratories (nls) in the united states. building networks on research similarities in portfolios, we investigate these networks with respect to their structural efficiency and topological properties. according to our estimation, only less than 30% of nodes are sufficient to initiate a cascade of changes throughout the network across institutions. the subunits that drive the network exhibit an inclination neither toward retaining a large number of connections nor toward having a long academic history. our findings suggest that this structural efficiency indicator helps assess structural development or improvement plans for networks inside a multiunit public research institution. public research more inclines to distribute its findings than commercialize in contrast to industrial research (geffen and judd, 2004) . in general, institutes conducting public research are largely government funded and target the public domain (bozeman, 1987) . because of their national orientation and stable funding source, public research institutes do cutting-edge research at least one academic field through long-term plans (greater than three years) (bozeman, 1987) . a public research institution often develops as an association of research institutes rather than a single organization. research entities with a public research institution enjoy institutional autonomy in choice of subjects notwithstanding the fact that they are under the same umbrella of governance. naturally, research organizations have different characteristics depending on national circumstances. some public research institutions, such as the max planck gesellschaft (mpg) in germany, are faithful to pure research (philipps, 2013) , while others have significance within a particular national context: part of the national laboratories (nls) in the united states (us) addresses defense-related technologies (jaffe and lerner, 2001) , and the government-funded research institutes (gris) in korea attempt to assist in the country's economic development by promoting indigenous public research (mazzoleni and nelson, 2005; arnold, 1988; lee, 2013) . with recent advances in our understanding of network, it is possible to apply novel network knowledge to manage public research institutions in response to internal and external changes. for example, entities in national innovation systems (freeman, 2004) or the triple helix models (phillips, 2014; leydesdorff, 2003) can be external factors affecting research of public research institutions. the notion of national innovation systems provides a framework to explain underlying incentive structures for technological development at a national level and international differences in competence from a network perspective of public and private organizations (patel and pavitt, 1994) . the triple helix model considers coevolving academic, industry, and government which provokes techno-economic developments of a country (leydesdorff et al., 2013) . in these systems, public research institutes provide fiscal and technical assistance to other organizations. kondo (kondo, 2011) pointed out that public research institutes dedicated to transferring technologies to industry by means of consulting, licensing, and spinning off. by doing so, they contribute to promoting integration and coordination within the system (provan and milward, 1995) . in order to formulate policies and procedures to steer the entire system, system organizers are able to guide public research institutes properly. in this context, control of those key agencies is important to achieving desirable outcomes. moreover, there is a growing need for an efficient implementation throughout public research institutions composed of multiple sub-organizations in order to deal with internal controls (yang and jung, 2014) . for example, most public research institutions have undergone transformations in recent years due to modernization, imperatives for efficiency, and the promotion of collaboration with the industry (buenstorf, 2009; cohen et al., 2002; simpson, 2004; senker, 2001) . in unfavorable economic conditions, declining government funding causes the restructuring of research areas (malakoff, 2013; izsak et al., 2013) or the government demands more practical outputs from them, such as conducting applied research and setting standards (oecd, 2011) . in an attempt to harness technology for socio-economic development, governments often prioritize future research through foresight activities (priedhorsky and hill, 2006) and accordingly assign new academic missions to public research institutions. in particular, developing countries have lately been paying more attention to the technology-driven development model under government supervision (arnold, 1988) . at that time, controlling every entity enables the institution to fully guide those internal changes but entails great expense. from 1935 to 1945, public research institutions engaged in national strategic areas, including exploration of mineral resources, industrial development, and military research and development (r&d) (oecd, 2011) . after the termination of world war ii, the establishment of public research institutions grew in an effort to advance military technology in many countries. moreover, at that time, public research institutions extended almost all areas with which governments were associated, such as economic and social issues. they continued growing until the 1960s. in the 1970s and 1980s, many countries expressed doubts on their contributions to innovation. however, as deepening the understanding of national innovation systems or the triple helix models, public research institutions started to be seen in a new light. in these models, public research institutions have played an indispensable role in preventing systemic failures, which reduce the overall efficiency of r&d (lundvall, 2007; sharif, 2006) due to their relations with external collaborators (klijn and koppenjan, 2000; mcguire, 2002) . still, the importance of public research institutions are emphasized in particular for scientific innovation (cabanelas et al., 2014) . in this regard, a network approach is necessary to efficiently implement transformations throughout sub-organizations, and the academic interest also grows for the effective operation of the network (cabanelas et al., 2014; jiang, 2014) . there is, however, a lack of empirical research on managing public research institutions through a network system. hence, in this paper, we conceptualize three major public research institutionsthe mpg, nls in the us, and gris in koreaas networks, identify the sub-organizational network structure of each, and examine its structural efficiency. a collaborative research network is one of the most prevalent inter-organizational configurations (shapiro, 2015) . however, we deem that topical similarity between research institutes is suitable to represent a relation between them in research interests. most transformations involve changes in research areas, and changes in organizational research topics frequently occur when governments prioritize specific research fields or delegate new roles to institute (wang and hicks, 2013) . prior studies emphasized the importance of similarity in knowledge content among entities to effectively manage inter-organizational networks as well (tsai, 2001; hansen, 2002) . for these reasons, a network here is formed by pairs of subunits having the most similar research profiles. with the addition of temporal dynamics to inter-organizational relations, a chain of networks over time allows the description of the structural evolution of public research institutions. based on revealed networks, we determined the structural efficiency with which network-wide actions can influence entities for finite time periods. no matter the measure puts in place, all members of network need to adopt it to achieve collective actions. in the early stages of change implementation, network organizers select initiators to change among entities. as the change initiators propagate control actions to the remainder of entities, a public research network can be steered in the desired direction like a car. we can derive a minimum number of suitable initiators from a theory of "structural controllability" (yuan et al., 2013) . in the theory, change initiators refers to injection points of external energy used to steer the network, which are theoretically selected depending on network structure. in this process, structural efficiency is obtained by calculating the share of change initiators in the network: the lower the efficiency value, the smaller the number of entities the network manager is required to handle. therefore, by comparing efficiencies with structural properties over time, we can estimate network characteristics specific to institutions. in this study, we divided institutional research portfolios into six time periods based on scientific output over eighteen years (1995) (1996) (1997) (1998) (1999) (2000) (2001) (2002) (2003) (2004) (2005) (2006) (2007) (2008) (2009) (2010) (2011) (2012) , and estimated structural efficiencies of research similarity networks. considering structural efficiency, we can observe that networks in all three research institutions can be managed with less than 30% of sub-organizations, and the values reflect the changes that have occurred in research institutions. each research institution has some suborganizations consistently selected as suitable change initiators over a period of time. our results primarily highlighted young subordinates as appropriate change initiators, which means that information blockades in network might occur unless the selected units are properly managed. moreover, the estimated changes initiators tend to have a lower connectivity in network than the rest of nodes. we expect that our work has implications for decision-making bodies and network managers seeking to an efficient way to influence their intention on a network of public research institutes. the remainder of this paper is structured as follows: in section 2, we briefly describe the impact of structure on network effectiveness associated with public research institutions based on past research. section 3 is devoted to an explanation of data sources, network construction processes, and the calculation of structural controllability in a network. we discuss the results of our experiments in sections 4 and 5, and offer our conclusions in section 6. methods for utilization and development of networks have grown in an attempt to address complex problems that require collective effort. when the purpose of the network is to deliver public services, independent organizations are generally involved in the process, and interdependency between participants facilitates the formation of links (kickert et al., 1997) . by exchanging knowledge through a network, public research organizations attain a higher level of performance, at the same time, create a greater ability to innovate (morillo et al., 2013) . goldsmith and eggers (2004) claimed that using a vehicle for networks is favorable to organizations that require flexibility, rapidly changing technology, and diverse skills because actors can exchange goals, information, and resources while interacting with each other. resources usually refer to units of transposable value, such as money, materials, and customers, and information signifies exchangeable units between agencies, such as reports, discussions, and meetings. with regard to exchanged goods between organizations, van de ven (van de ven, 1976 ) underlined the importance of information and resources as "the basic elements of activity in organized forms of behavior." in research systems, organizations can take advantage of network participation to have a greater possibility of funding, to broaden their research spectrum, or to reduce the risk of failure (beaver, 2001) . therefore, networks are beneficial because they can pool resources, permit the mutual exploration of opportunities, and create new knowledge (priedhorsky and hill, 2006) . however, strategies are needed to coordinate interactions while managing networks because different actors have different goals and preferences concerning a given problem (kickert et al., 1997; o'mahony and ferraro, 2007) . the capability of network management is also necessary to promote innovations (pittaway et al., 2004) , but there remain questions as to how to manage such organizational interactions as beaver (beaver, 2001) pointed out. orchestrating activities seems unnecessary because of interactions between autonomous organizations, but addressing conflicts keeps agencies cooperative in effort to achieve the goal of the network, thereby facilitating the effective allocation and efficient utilization of network resources. furthermore, a network sometimes needs to be intentionally formed to boost management by governing parties which would be either an external organization or network participant(s) (provan and kenis, 2007) . public research institutions can be said to be governed by external organizations, considering that different entities are in charge of their administration in general, such as ministries, research councils, and other steering bodies. both the mpg and korean gris are apparently steered by a single entity. the fundamental management policy of the nls in the us also originates in a federal agency, although several laboratories are operated by contract partners. by frequently repeating interactions among actors, networks produce certain outcomes. the performance of a network is evaluated according to whether the network effectively attains its goal. the outcome varies depending on governing strategies, and the course of attainment can be enhanced by taking advantage of structural properties of the network (kickert et al., 1997; goldsmith and eggers, 2004) . provan and milward (2001) argued that the assessment of network effectiveness should involve consideration not only of beneficiaries, but also of administrative entities and the participants of the network. nevertheless, the literature on networks has paid more attention to the evaluation of their effectiveness by treating networks as a whole, such that the common goal is primarily involved in network-level accomplishment (provan and milward, 1995; möller and rajala, 2007) . there remain difficulties in determining network effectiveness. the problem primarily resides in the impossibility of quantifying the exact network outcome (provan and lemaire, 2012) . as agranoff (2006) claimed, networks are not always directly related to policy adjustments because some interactions are forged by voluntary information exchange or educational service. in the public research institution, researchers engaged in specialized fields have the opportunity to share ideas across administrative boundaries given that they have the goal and intend to generate public knowledge. outcomes of research networks can be approximated by proxy variables, such as patent and paper citations, innovation counts, new product sales, and productivity growth (council, 1997) . furthermore, such networks also indirectly affect subsequent movements and policies. thus, network efficiency needs to be measured for various types of networks, by considering factors beyond collaborations. in order to increase network effectiveness, structural efficiency in networks is important: since all entities are connected, damage to one part can cause the collapse of the entire system through a cascade of failures. in this regard, considerable research on networks has focused on deliberately building efficiently manageable networks (cabanelas et al., 2014; kickert et al., 1997; van de ven, 1976; provan and kenis, 2007) . certain network structures can affect innovation performance by catalyzing knowledge exchange (valero, 2015) . enemark et al. (2014) argued the importance of the network structure to collective actions via experimental tests that demonstrated structural variations in a network can either improve or degrade network outcomes. however, there is ambiguity in appropriate network structures to achieve effective control. pittaway et al. (2004) suggested that longitudinal network dynamics need to be taken into account when designing network topologies. a network is required to change its members or structures in order to adapt to environmental changes. much of the literature on networks emphasized that instability is an opportunity for transformation (hicklin, 2004) . although the capability of flexible response is one of the strongest features within a network model, such network dynamics challenge for effectively managing networks. with regard to network size, it is widely known that the greater number of actors involved, the more difficult it becomes for the network to achieve collective cooperation (kickert et al., 1997) . increasing the number of participants results in more complex network governance because the number of potential interactions also exponentially escalates. however, prior research found that research networks evolved to be more centralized as growing the network (ferligoj et al., 2015; hanaki et al., 2010) . the growing patterns of research networks imply that adding an entity does not always increase complexity of network management. theorists rather claimed that the introduction of a new node would improve efficiency to control networks (klijn and koppenjan, 2000) . centralization captures the extent of inequality with which important nodes are distributed across the network, and is often measured in terms of freeman's centralities (freeman et al., 1979) . a degree (the number of connections) centralized network is known to readily coordinate across agencies and closely monitor services (provan and milward, 1995) . in complex networks, a minority of nodes, referred to as hubs, dominates connections while the majority is connected with a small number of points (barabási and albert, 1999) . research revealed that complex networks were robust against random attacks (albert et al., 2000) . hubs in research networks were not only empirically impressive in their performance (echols and tsai, 2005; dhanarag and parkhe, 2006) , but also easy to access new knowledge developed by other entities (tsai, 2001) . hanaki, nakajima and ogura (hanaki et al., 2010) also found r&d collaboration networks evolved toward more centralized structures because organizations prefer to collaborate with reliable partners based on referrals obtained from former partners. however, a high degree of integration is not always desirable. provan and lemaire (2012) proposed that connective intensity between organizations should be appropriately controlled for effective network structure. cabanelas et al. (2014) also found research networks producing high performance featured nodes with low degree centrality. no matter the types of networks that develop out of interactions, the goal achievement is possible only when the relevant information spreads throughout the network to encourage actors to conform. in recent years for public research institutions, the controllability of organizational portfolios has been seen as constitutive of dynamic capabilities, which means the "ability to integrate, build, and reconfigure internal and external competencies to address rapidly changing environments" (teece et al., 1997; floricel and ibanescu, 2008) . in this sense, estimating efforts to control entities of public research institutions is related to assessing the feasibility of research reorganization over networks. at the same time, the number of key points in information flow within a network affects burden on the network administration. although earlier work emphasized that selectively activating critical actors is more effective to integration than full activation, the system must secure the capability to exercise influence across agencies (kickert et al., 1997; provan and lemaire, 2012) . furthermore, the efficiency with which network structure can be manipulated would be a suitable criterion to evaluate the built structure. this section is devoted to describing methods of network construction based on collected bibliographies and analytical methods. we describe a quantification method for structural efficiency given structure to control the whole network, and explain structural properties to explore their relation with structural efficiency. in the process of efficiency calculation, we extract suitable organizations to initiate transformation. this investigation was conducted in the r ver. 3.1.2 environment (r core team, 2015) , and used the following add-on packages for convenience: ggplot2 (wickham, 2009 ) and igraph (csardi and nepusz, 2006) . we identified research portfolios based on scientific output, and gathered bibliographic data regarding nls, mpg, and gris from the thomson reuters web of knowledge. academic output over eighteen years (1995) (1996) (1997) (1998) (1999) (2000) (2001) (2002) (2003) (2004) (2005) (2006) (2007) (2008) (2009) (2010) (2011) (2012) was compiled according to institutional names and abbreviations of authors' affiliations. we only used affiliations in english for this study. subordinate research institutes listed in official websites were considered, and their portfolios were tracked using at least twenty papers for each. all disciplines, which are the constituent elements of a portfolio, need to be identified using the same classification system for ease of institutional comparison. we utilize the university of california-san diego's (ucsd) map of science (borner et al., 2012) as a journal-level classification system. the map classified documents into 554 subdisciplines belonging to 13 disciplines on the basis of journal titles. naturally, a research portfolio has two levels of classification: discipline and sub-discipline. particularly, a discipline refers to the aggregate level of sub-disciplines in the hierarchical structure in this study. fig. 1 shows an example of disciplinary mapping using sci2 (sci2 team, 2009) in order to analyze the thematic evolution of network over time, we split the portfolios into time intervals. with regard to an adequate duration of assessment period to represent scientific output being measured, abramo et al. (2012) claimed that a three-year period is adequate to assess scientific outputs. by accepting their recommendations, we observed the development of institutional portfolios for six consecutive time slices. as a well-known analytical method, a complex network is suitable for exploring dynamic topology changes (strogatz, 2001) . here, an inter-organizational network is formed between subordinate institutes building similar research profiles. representing sub-organizations, nodes are connected by a link when two sub-organization have similar research portfolios. in order to measure similarities, we used "inverse frequency factors" for weighting system and "second-order cosine similarities" (garcía et al., 2012) . the inverse frequency factor borrows from a term discrimination method for text retrieval (salton and yang, 1973; salton and buckley, 1988) . the factors weight each subdiscipline in the research portfolio. the weight of sub-discipline m for research institute i is determined by w m;i ¼ f m;i â logð n nm þ where f denotes the number of articles; and ð n nm þ implies the inverse frequency factor to file out prevalent research (jones, 1972) . the logarithmic frequency factor is calculated inversely from the ratio number of subunits n m that publish their achievements in sub-discipline m to the total number n of research institutes. as a result, the set of weights generates a 554 sub-disciplines-by-institute matrix. the similarities between two institutional research portfolios primarily take the cosine measure (salton and mcgill, 1986; baeza-yates and ribeiro-neto, 1999) . for the purpose of improving the accuracy of similarity, we applied second-order approaches to the sub-disciplineby-institute matrix. colliander and ahlgren (2012) explained that first-order approaches directly reflect the similarity between only two profiles, whereas second-order similarities determine those between two given portfolios and other institutional portfolios. a large number of studies have confirmed the superior performance of the secondorder approach as well (ahlgren and colliander, 2009; thijs et al., 2012) . moreover, to render easier structural analysis and network visualization, we strip weak similarities from the research similarity matrix. using the maximum spanning tree (mst) algorithm (kruskal, 1956) , we extracted tree like-structures. the mst algorithm ensures that all institutes are connected with maximal similarity, which implies that the institutes are connected through the most relevant links. therefore, a linked pair of institutes indicates greater potential for common intellectual foundations. among various well-known algorithms to detect mst, the backbone of thematic networks is derived by prim's algorithm (prim, 1957) . in order that the network structure can efficiently elicit the desired response from its elements, a certain amount of energy needs to be injected into the network to change the behavior of actors. thus, the selection of several agencies to initiate changes depending on network structure is inevitable. at the same time, it is important to minimize the number of injection points due to management cost. studies on complex networks consider that nodes can dynamically make decisions or can dynamically change their states by responding to information received through links between nodes. as individual actors, nodes on research networks can be researchers or research institutions, and the nodal states can be represented by individual research interests or disciplinary composition. here, we estimate the capability that controls the behavior of such nodes in complex networks with the minimum involvement of intervention adopting the notion of structural controllability. in recent years, a number of studies have focused on driving networks to a predefined state by combining control theory and network science (liu et al., 2011; wang et al., 2012; lombardi and hörnquist, 2007; gu et al., 2014) . according to network controllability, if a network system is controllable by imposing external signals on a subset of its nodes, called driver nodes, the system can be effectively driven from any initial state to the desired final state in finite time (kalman, 1963; lin, 1974) . thus, network controllability depends on the number and the placement of the control inputs. for this reason, structural efficiency refers to the share of the driver nodes. in this study, agencies found using structural controllability are key locations to steer the entire inter-organizational research network. we applied the structural controllability for undirected networks, introduced by yuan et al. (2013) , to matrix representation of our temporal msts. each temporal matrix g(a) was considered a linear timeinvariant model _ xðtþ ¼ axðtþ, where the vector x ∈ ℝ n represents the state of the nodes at time t, a∈ ℝ n×n denotes the research similarity matrix of mst, such that the value a i,j is the portfolio similarity between institutes i and j (a ij = a ji ). the controlled network g(a, b) corresponds to adding m controllers using ordinary differential equations _ xðtþ ¼ axðtþ þ buðtþ, where vector u(t)∈ ℝ m is the controller and b ∈ ℝ n×m is a control matrix. the problem of finding the driver nodes of the system is solved by the exact controllability theory following the popov-belevitch-hautus (pbh) rank condition (hautus, 1969) . to ensure complete control, the control matrix b should satisfy rank[λ m i n − a, b]=n, where i n is the identity matrix of dimension n, and λ m denotes the maximum geometric multiplicity μ(λ l ) (=n-rank(λ l i n − a)) for the distinct eigenvalues λ l of a. therefore, from a theoretical perspective, changes initiated from the drivers are likely to affect the entire structure. hence, driver institutes are crucial to the functioning of networks for public research institutes. in this paper, we regard the share of drivers in all agencies as an efficiency indicator in that the number of drivers is important for efficient control. network properties have been utilized by a considerable amount of literature in the area to better understand structural features of networks (newman, 2003; albert and barabasi, 2002; woo-young and park, 2012) . in order to understand the relation between efficiency and the inter-organizational research network, we extracted major features across institutions based on some structural properties, such as network size and connectivity. the number of participants represents network size associated with network volume. centrality is one of the most studied indicators in network analysis, and measure the influence of a node in a network using degree centrality (freeman et al., 1979; borgatti et al., 2009; freeman, 1978) . we examine the degree feature of driver nodes. as a nodal attribute, we assign research experience in time periods to nodes to characterize driver nodes. this section contains the major results of our investigation of the structural features of the inter-organizational networks. to form our desired skeletal network, we extracted pairs of academically close institutes based on portfolio similarities among their participants using the construction algorithm of the maximum spanning tree (mst). the results obtained from the backbone networks are related to structural controllability. in order to address the evolution of inter-organizational research, we assessed the structural features of temporal msts. figs. 2-4 show tree-like structures of institutions over time. each node represents a sub-organization, and its size is proportional to the total number of documents published. the colors filling the nodes were determined by the discipline in which the institute was found to be most productive. the portfolio similarities between pairs of linked institutes represented the weight on the network, and these weights affected the width of links as well. the descriptive statistics of portfolio similarity summarize and describe the distribution of the skeletal relationships between subordinates, as listed in table 1 . for all institutions, we found that the distributions were biased toward high similarities between research portfolios. for the nls networks in the us, the overall greater averages and smaller standard deviations of portfolio similarities than the other two institutions indicated that most research units were seen as connected, with the smallest difference in their research areas. on the other hand, in case of the gris, the lowest values of average similarity signified that each unit had a distinct research portfolio. the largest standard deviation and the low values of kurtosis for most time periods also showed that their research similarities were the most widely distributed. in order to represent the dynamic characteristics of msts, their structural properties are listed in table 2 . the number of nodes n increased and, accordingly, the number of links increased to n − 1 following the definition of an mst in the context of a connected network. in spite of sparsity of the network, nodes having a relatively large number of links could be found in some institutions, in particular the oak ridge national laboratory (ornl) within the nls, which was connected to approximately a quarter of the other organizations for four time periods, and the korea research institute of standards and science (kriss) and the korea institute of science and technology (kist), which appeared as a maximally connected node in each half of the dataset. however, there was stiff competition among institutes with the maximum number of connections in the mpg. we noted that network density (2/n) could be obtained from the number of nodes, and the transitivity always reduced to zero because mst rules out cycles. we calculated a periodical change of structural efficiency, and then examined the relations between network efficiency and structural properties. following this, we investigated the features of estimated driver nodes in terms of degree and period of appearance. note that although the number of driver nodes is theoretically fixed in a network, there can be multiple sets of drivers (jia and barabasi, 2013) . we randomly selected a set where multiple driver sets existed. as an indicator of network efficiency obtained from structural controllability, fig. 5 denotes the share of driver nodes over time. according to the graph in the figure, the proportion of drivers varied, but institutions did not have to consider all their agencies for network-wide transformation. less than 30% of nodes were selected as suitable points at which to inject external information in all three institutions because the maximum value of structural efficiency in the entire datasets was about 30% at the second period (1998) (1999) (2000) in the gris. in particular, the nls could be influenced with a relatively small share of drivers among the institutions at all times, which the exception of the period 2004-2006, whereas in the gris, the largest portion of nodes mostly needed to initiate changes. the efficiency fluctuation of the mpg was more stable than other two institutions over time periods. an understating of drivers enables administrators to take preemptive action to prevent information isolation, like the knowledge of the relation between the share of drivers and network efficiency can help plan structural development. the total number of driver appearances for the entire period corresponded to 13, 25, and 53 for the nls, the gris, and mpg, respectively but 6, 15, and 31 agencies were selected as drivers. this was an evidence for the existence of memory in the drivers. moreover, figs. 6 and 7 capture some features of the drivers. fig. 6 compares the average number of links between drivers and the entire nodes over different periods. despite the common knowledge that nodes possessing large connectivity are influential, our results showed that drivers with low connectivity tended to determine collective agreement on the network. fig. 7 shows the average durations of appearance by institutional drivers. we see that the driver nodes were the ones newly entered to the network based on the average durations. of the institutions, the research units of the nls showed a wide difference between drivers and non-drivers. public research has contributed to major innovations by improving competitiveness among existing industries and developing new ones. as prominent contributors to public research, governments have implemented a variety of support policies and programs for higher efficiency and excellence. among the actors involved in public research, public research institutions aim to disseminate their knowledge, by providing various functions: priority-driven research to address national and academic agendas or blue skies research engaging large-scale research facilities to complement university research (pot and reale, 2000) . to maintain such diversity, public research institutions seek to coordinate elements with varying specializations and missions in adapting to dynamic technological environments. as a part of the effort, institutions occasionally attempt to restructure research portfolios or modify organizational placements in relation with other research units. in order to assess the development of public research institutions, we examined structural evolution derived from research similarities in the context of networked organizations in this paper. more precisely, this study focused on public research institutions composed of several specialized research units, and extracted a network from similarities between sub-organizational research portfolios over eighteen years. a pair of connected agencies would be most influenced by the same type of exertion on a specific research area. in addition, suborganizations connected to each other can be potential partners to collaborate because they share similar academic backgrounds. for example, the similarity networks of the gris give implications for inter-disciplinary research groups operated by the research council. in the research group, researchers working at different gris seek a solution together to technological difficulties and research similarities can indicate proper gris to resolve the difficulties. moreover, offering the advantage of predictable network controllability, network modeling helps to understand the system's entire dynamics, which could be guided in finite time by controlling the initiators (liu et al., 2011) . as a result of the modeling, we can measure the efficiency of the network, where network efficiency implied the proportion of elements required as initiators to change the states of the entire agencies. the lower the proportion, the greater the network efficiency because the initiators are injection points for external information. we also revealed the structural properties of estimated initiators. our research here is different from other studies concerning network effectiveness in that it quantitatively estimated the effort required to control an entire inter-organizational network based on its structure. naturally, if we send control signals to every single node, the network is operated with high controllability but involves significant cost. thus, by employing the concept of structural controllability, we can theoretically detect the initial spreaders of information that need to be properly treated. otherwise, they would have produced barriers to the exertion of authority; in extreme cases, the information blockades could have caused network failure (klijn and koppenjan, 2000) . however, handling these elements incurs extra cost, because of which it is important to build networks with the minimum possible number of initiators to reduce enforcement costs incurred for complete control (egerstedt, 2011) . common structural features of estimated initiators can direct network management of public research institutions. we generated results to provide a clear idea of how structural efficiency of research network is related to structural properties, such as size and nodal degree. previous work on network governance structures has provided recommendations on how to build and design inter-organizational networks for innovation acceleration. for example, related to the number of participants, it is natural to expect that the share of drivers would also increase owing to a higher risk of insularity in information due to increasing structural complexity. however, our findings suggest not necessarily complying with the idea. each of the institutions considered by us was different in size from others: the mpg was the largest-scale organization, whereas the nls formed the smallest group in terms of number. however, according to our results, the size of the network did not seem to meaningfully affect table 2 network properties of inter-organizational network. time span 1995-1997 1998-2000 2001-2003 2004-2006 2007-2009 2010-2012 the proportion of drivers in public research institutions. despite being a medium-sized institution, the networks of the gris were more likely to be inefficient than those of the mpg and the nls. we think this was because an institution more experienced with managing such a union has built more effective structures. even we found that the gris took advantage of the structural reorganization of the network because additions improved their network efficiency. in this regard, kickert et al. (1997) claimed that the introduction of new actors can be a strategy to accomplish a mutual adjustment, since the new institute would cause structural changes within the network. proposition 1. a subset of nodes positioned in structurally important locations will have ability to steer a whole network of public research institution. our findings indicated that control actions applied to only less than half of the research units can lead to changes of an entire system, and the units repeatedly appear over time. we suspect the reason that public research institutions are designed to be a cost effective and resilient, as do their infrastructure networks. however, as national research structures can be affected by government policies (hossain et al., 2011) , the network efficiency also changes over time. the drastic fluctuation in the share of drivers would be related to changes in the relevant institution's strategy or operation. for example, the gris underwent a restructuring to remove redundancy, and began operating under the research councils after 1999. we can capture drastic changes at the same time in our results because their structural efficiency significantly increased between the second and third periods between 1998 and 2003. the results would imply that the organizational rearrangements in the gris worked well. besides, the research subjects of the nls were revamped in the 2001-2006 period due to several events, i.e. the september 11 attacks and the outbreak of the severe acute respiratory syndrome (sars). since the terrorist attacks of september 11, 2001, the nls have made greater efforts to reinforce national security by working on nuclear weapons or intelligent detection of potentially dangerous events. moreover, a sudden epidemic of sars accelerated multidisciplinary research in the nls on vaccines, therapeutics, bioinformatics, or bioterrorism. we also find that the structural efficiency of the nls were severely affected during the readjustment period. these changes in portfolio composition would cause temporary disarray in the structure of the networks. on the other hand, the property of stable fluctuations in the mpg would be attributable to internal transitions for scientific advances rather than external impact. the mpg makes an expansion of research topics by mostly spinning off units because each unit has its own research area. proposition 2. variations in structural efficiency of research networks will reflect structural changes in research composition. another difference between past research and our work here is that degree centralization is not invariably recommendable. policy makers and network scientists have hitherto paid attention to highly connected institutes because hubs are regarded as network facilitators. however, our findings indicated that most key elements were apt to have low degrees. our study focused on revealing the injection points to infuse their nearest neighbors with energy regardless of the amount of energy required, and the nodes impart directions to connected neighbors at a time rather than exuding control forces over their adjacencies simultaneously. obviously, the energy-entering hub can effectively reach agencies within its orbit, but there is a diffusion range. thus, our observations suggest that network-wide influence was dependent upon nodes with a low connectivity. in this context, a network with moderately distributed focal points can be more effective to influence all organizations than a thoroughly concentrated one. furthermore, emergent sub-organizations show a tendency to have greater effect on structural efficiency than sub-organizations with a long research experience. we suspect that this is why a new research institute is often derived from a larger unit in public research institutions, holds low research similarity with other units than its parent, and takes position at the border, beyond any energy ranges. another possible is that that a newly-established research institute has unstable research portfolios, as braam and van den besselaar (2014) pointed out. the instability that a new research institute has in its research areas can increase uncertainty about the consequences of network-wide changes. therefore, network managers may have the need to monitor the degree of acceptance of a network-wide action especially among emerging sub-organizations. this result is also consistent with recent observations, whereby driver nodes in real-world networks tend to be reluctant to link with high-degree nodes (liu et al., 2011) . proposition 3. other things being equal, a possibility to control the whole research network will increase when control actions work properly at nodes with a low connectivity and a short research history. we consider the differences in network effectiveness between existing studies and our findings originate from: whether the complete functioning of all elements was considered. previous studies regarding the maximization of network effectiveness implicitly presupposed the complete performance of all entities a priori despite conflicts between participants, but at least network managers need to ensure complete operation of their network. for the full functioning of a network, all elements are required to be within the sphere of influence of the network manager for network-wide control. we deal with a possibility to manage the network behavior in public research institutions by quantifying the effort required to implement maneuvers. in order to avoid control blockades, we showed the importance of the elements, inter alia, with low connectivity and brief experience in academia. this study provided theoretical results for structural controllability assuming some ideal situations, such as that measures were implemented on network skeleton without redundant connectivity, sufficient resources were provided to change the network, all institutes respected the administrator's intention, and there were no conflicts between a pair of connected institutes. the success or failure of such measures can be determined once the processes are completely implemented because a network's dynamic nature in inter-organizational network raises difficulties in coordination. nevertheless, estimating the completion of network-wide objectives is still critical to network planning and design. our theoretical calculations here can assist decision making for structural improvement plans. moreover, the common features of the selected initiators are sufficient to suggest elements significant to attaining a synchronized response across and institutional network to reorganize research portfolio. public research institutions continue to gain prominence in the development national agendas of science and technology. institutions have their own strategies according to their values and interests in research trends to a greater or lesser extent. governments and research councils significantly affect these institutes through polices, programs, funding, and financial support in an effort to better coordinate their research agencies (rammer, 2006) . therefore, guiding the subunits of these institutes in a network is important to efficiently deliver managerial control. in doing so, administrators should be concerned with improving network structure to enhance its outcomes. however, manipulating network structure is difficult because of complex and dynamic states of the sub-organizations. in this study, we quantified network structural efficiency to maneuver a set of spontaneous elements into network-wide goals by using the theory of structural controllability (yuan et al., 2013) , and tracked the efficiency of networks of these public research institutions: the gris in korea, the nls in the us, and the mpg. for the relevant calculations, we extracted a hidden network structure from each institution based on similarities between the profiles of their subordinate organizations. the results of structural efficiency enabled the assessment of the operational strategies of each institution for eighteen years. the elements selected by structural controllability implied suitable points to inject external energy for governing networks. revealing the injection points was important to prevent information blockages that hinder collective action. apparently, the greater number of injection points required, the lesser the efficiency of network due to the increased burden of management. our findings indicate that structural efficiencies reflect changes in research interests of an institution. in this sense, research institutions have the necessity to track the structural controllability to assess their structural changes, such as portfolio adjustments on all of sub-organizations. the structural controllability can also provide the suitable spots for an intervention by a network manager (ministries, research councils, or steering bodies) as driver nodes with regard to structural changes. according to our results, the proper intervention points tend to be with a low connectivity as well as young suborganizations. in spite of these implications for managing strategies of interorganizational networks, this study has shortcomings that limit the generalizability of our findings. scientific articles represent only part of an institute's capacity for research. major scientific outputs are classified into two types: scientific articles and patents. depending on the major research types, some institutes concentrate on patents instead of publications. as a result, research portfolios derived from richer data sources than were used would more precisely depict institutional research capacity. another limitation of this study is that network properties other than those considered here, such as network density, clustering coefficient, and betweenness centrality, might affect structural efficiency like. furthermore, our findings raised several questions that suggest directions for future research. these include exploring the range of drivers' influence on structural efficiency, determining the optimal network structure to steer, and investigating diverse network properties with other types of players in innovation systems, e.g., academia and industries. what is the appropriate length of the publication period over which to assess research performance? inside collaborative networks: ten lessons for public managers document-document similarity approaches and science mapping: experimental comparison of five approaches statistical mechanics of complex networks error and attack tolerance of complex networks science and technology development in taiwan and south korea modern information retrieval emergence of scaling in random networks reflections on scientific collaboration (and its study): past, present, and future network analysis in the social sciences design and update of a classification system: the ucsd map of science all organizations 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systems-analytical concept and development tool as budgets tighten, washington talks of shaking up doe labs the roles of research at universities and public labs in economic catch-up. columbia university, initiative for policy dialogue, working paper managing networks: propositions on what managers do and why they do it rise of strategic nets -new modes of value creation do networking centres perform better? an exploratory analysis in psychiatry and gastroenterology/ hepatology in spain the structure and function of complex networks public research institutions: mapping sector trends the emergence of governance in an open source community national innovation systems: why they are important, and how they might be measured and compared mission statements and self-descriptions of german extra-university research institutes: a qualitative content analysis triple helix and the circle of innovation networking and innovation: a systematic review of the evidence convergence and differentiation in institutional change among european public research systems: the decreasing role of public research institutes identifying strategic technology directions in a national laboratory setting: a case study shortest connection networks and some generalizations modes of network governance: structure, management, and effectiveness core concepts and key ideas for understanding public sector organizational networks: using research to inform scholarship and practice a preliminary theory of interorganizational network effectiveness: a comparative study of four community mental health systems do networks really work? a framework for evaluating public-sector organizational networks r: a language and environment for statistical computing trends in innovation policy: an international comparison term-weighting approaches in automatic text retrieval introduction to modern information retrieval on the specification of term values in automatic indexing science of science (sci2) tool changing organisation of public-sector research in europe-implications for benchmarking human resources in rtd establishing 'green regionalism': environmental technology generation across east asia and beyond emergence and development of the national innovation systems concept after the reforms: how have public science research organisations changed? r&d manag exploring complex networks dynamic capabilities and strategic management do second-order similarities provide added-value in a hybrid approach knowledge transfer in intraorganizational networks: effects of network position and absorptive capacity on business unit innovation and performance effective leadership in public organizations: the impact of organizational structure in asian countries on the nature, formation, and maintenance of relations among organizations detecting structural change in university research systems: a case study of british research policy optimizing controllability of complex networks by minimum structural perturbations the network structure of the korean blogosphere a strategic management approach for korean public research institutes based on bibliometric investigation exact controllability of complex networks hyeonchae yang is a ph.d. candidate of the graduate program for technology and innovation management at pohang university of science and technology the authors are grateful to the editors of the journal and the reviewers for their support and work throughout the process. this work is supported by mid-career researcher program through the national research foundation of korea (nrf) grant funded by the ministry of science, ict and future planning (2013r1a2a2a04017095). key: cord-345811-f0yt2a32 authors: parmet, wendy e.; robbins, anthony title: public health literacy for lawyers date: 2007-01-24 journal: j law med ethics doi: 10.1111/j.1748-720x.2003.tb00136.x sha: doc_id: 345811 cord_uid: f0yt2a32 nan lic health advocacy institute, with support from the centers for disease control and prevention, assembled experts froni legal education, public health practice and education, the judiciary, foundations, and the publishing industry to consider what changes would have to occur in legal education so that law graduates would be "literate" in public health and how those changes could come about.b in this article we build upon the intense discussions of the 25 conference participants. we make the case for introducing public health into the core law school curriculum and suggest the content that would be needed to achieve public health literacy among law students. we also argue that public health's focus on populations, aided by the tools of epidemiology, provides a valuable prism for understanding the relationship of individuals and groups and the ways that laws can and ought to affect them. we conclude by urging the development of a body of scholarship and analysis that brings the insights of public health to bear on legal questions. law schools might introduce public health to their students in several ways. most comprehensively, law students can enroll in a j.d./m.p.h. program, and receive the training given public health graduate students for a masters degree in public health. while such programs are increasingly common,7 they are obviously intended for students already committed to careers at the intersection of law and public health. thus jd/mph programs do not reach the vast majority of law students. a larger number of law students can i x exposed to public health in upper level electives that focus on public health law or a particular topic closely related to public health, such as aids law or food and clnig lawn undoubtedly, the content and the extent of exposure to public health principles and methocls will vary widely depending on the particular topic of the class. through these courses, law schools can provide :i limited number of students with in-depth exposure to one or more public health problems and the legal tools and doctrines most relevant to those topics. law faculty and public health professionals at a 2002 workshop' dedicated to developing a curriculum on bioterrorisin concluded, for example, that a hasic understanding of public health powers woulcl be an essential part of any course on bioterrorism. most law students, however, will never get ;i mph or take a public health oriented elective in law school. if they are to be introduced to public health in the course of their legal training, it will have to be within existing, core law school courses, the courses that are generrilly required of first year students or taken almost universally by upper level students. at the public health literacy conference, the lawyers present identified several such courses-tom, constitutional law, environmental law, and administrative law-as prime candickites for the inclusion of public health. attendees also recognized that the integration of public health into such courses would be d#icult to achieve given legal education's traditional reluctance to embrace significant reforms. nevertheless, attentlees agreed that it was important to pursue the effort. what public health knowledge or set of skills should all law students acquire? if these could be identified, educators from law and public health could explore how to incorporate then1 in core law courses. successful integration of public health into standard law school courses would introduce students to: law's public health context w public health powers w public health inethocls public health's population perspective two criteria must be met, according to the public health literacy conference attendees, if law professors are to adopt public health components in core courses. first, the integmtion must not be too hard to accomplish. materials must be available, and support, in tenns of tine, money, wining, and academic respect, must be forthconling.'o second, faculty must believe that the inclusion of such nuterials will not only be good for public health, but that it will also enhance their students' legal skills and pertiaps legal analysis itself. the reminder of this article seeks to adclress these concerns by exploring more fully the four components of a public health education for lawyers identified above-md examines how to empower law students to be literate in public health, law schools must help them to recognize public health issues and be familiar with the lessons from the law's prior encounters with public health. for over a hundred years, legal scholars have stressed the importance of introducing lawyers to the social, economic, and political context in which the law operates. they have also counseled the value of interclisciplinary analysis. in 7he path of the luw, for example, justice oliver holmes scolded the legal profession for its belief that law exists apart from the world in which it operates. he argued that lawyers should be trained to understand "the social advantage on which the rule they lay clown must be justified.,."" following in holmes' footsteps in the early twentieth centuly, the legal realists asserted the inipomnce of the facts, out there in the world, to legal analysis. in their "revolt against fonnalism," legal realists suessecl the value of the social sciences and empirical analysis to legal decision making.12 in subsequent decades, legal scholars from a wide spectrum of perspectives and disciplines stressed the need for interdisciplinary work and social context in order to achieve a rich understanding of the law. scholars and jurists from the conservative "law and economics" school, for example, have focused on understanding the economic context in which the law operates. first, they proclaimed the value of applying economic reasoning to legal decision ~naking.'~ then they recast the analytic tool, useful to explain societal decisions, as an assertion that economic valuation is largely sufficient to comprehend human inotives. from a very different side of the political spectrum, femini~t,'~ critical race,15 and disability scholars16 have asserted the importance of teaching law students ahout the g e n d e d , racial, and disability context of legal issues. each group advocates for the inclusion of its issues and disciplines-milyses that shed light on a spectnini of legal issues. repeatedly, we are reminded in rather different ways that law students cannot fully appreciate the meaning or impact of the law unless they understand how it affects different people and reflects critical social phenomena." similarly, we recommend the inclusion of public health analysis and the public health context in which the law operates. public health teaches us that the health or well being of indivicluals is influenced by forces that operate at the population level, beyond an individual's own conm1.'8 risks to health, and the health problems they create, have had a profound influence not only on the lives of individuals, but also shape societies and the structure of our law." to understand not only public health, but the law, students should grasp the public health context in which key legal docuines have developed. students will then recogmze public health issues when they arise, placing them in a fuller and familiar context of similar issues they have studied. they will appreciate more fully the reasons for and implications of the particular doctrines they are mastering. examples from three different areas of the law may serve to demonstrate what we mean by public health context. the first example comes from fourteenth amendment law. virtually every law student studies the infamous case of lochneru. new york, in which the supreme court struck down a state law setting maximum hours for bakeshop workers.2o many scholars have viewed lochneras one of the pivotal cases in constitutional law. indeed, many legal theorists regularly cite it when they deride judicial decisions.2' to cry "lochner" is to question the legitimacy of a constitutional decision. lochner, like most important supreme court cases, was about many things and many themes can be dissected the rise of the labor movement;t2 the supreme court majority's antipathy to progressive labor legi~lation;~~ and the struggle between courts and legislature^.^^ legal scholars, however, seldom discuss the public health context, although the statute at issue was presented by the state of new york as a public health measure and bakeshop workers did experience numerous diseases, including a high prevalence of infectious tubercul~sis.~~ in fact, justice peckhani, writing for the majority of the supreme court, recognized that the statute would have been constitutional if it were indeed, truly, a public health measure.26 thus, one of the key questions implicit in lochnerwas the meaning of public health and whether worker protection issues could be seen as a valid concern for public health.27 examined in this manner, lochner provides an interesting insight into the contested nature of public health and the government's role in protecting it. the provision of this context to lochnermay not change a student's ultimate opinion about whether the case was correctly decided, but it may shed new light on the decision. this expanded analysis of lochner would prepare students to understand the ways in which struggles over the scope of public health have helped to weave the fabric of our law. a second example also offers itself from constitutional law, this time relating to the commerce clause doctrine. as numerous commentators have noted, in l~$ezu. united stares, the supreme court r e v d its analysis of congressional power under the commerce clause, making it more difficult for congress to enact regulatory legislation.a this constriction of congressional power appeared to derive, in part, from the court's concern for safeguarding the traditional police powers of the states.29 underlying that concern was the assumption that police powers constitute a relatively static set of powers, aimed at protecting the public's health and safety, and that these powers have traditionally been the exclusive province of the states. an understanding of public health history, however, makes problematic the notion that public health powers have been or can be the exclusive domain of the statesm real world public health context intrudes. an analysis of public health problems in the modern global environment-from sars3' to the question of youth violence32 at issue in lopez--raises doubt about the ability of states acting alone to protect the public from such hazards. this analysis does not demonstrate that the supreme court was wrong in lopez-. certainly the coun confronted interpretative and federalism problems beyond the scope of public health, but a discussion of the way in which health problems cross state and even national boarders suggests that lopez' impact may be other than what the court thought. at least, if the court believed that it was protecting the police power and thereby the ability of states to safeguard the health and welfare of their populations, it may well have announced a constitutional rule that will result in exactly the opposite outcome, less protection for the health of a pop~lation?~ this may not prove to be so. but only by providmg students with the public health context behind the case can they huy assess the court's reasoning, speculate on the case's impact, and understand how constitutional doctrines may affect the lives of populations. a final example offered here-although many others can be given--comes from the famous tort case of stubbs v. city of rochester?" the case concerned an outbreak of typhoid fever in rochester, new york. the city offered two different water supplies, one for drinking and one for firefighting. the plaintiffs argued that sewage, known to be in the firefighting water system, contaminated the drinking water supply, causing the plaintiff to conmct typhoid fever. the issue before the court was whether the plaintiff had sufficiently proven that the defendant's negligence caused the typhoid. interestingly, sfubbsconstitutes an early example of a court finding epidemiological evidence sufficient to satisfy the plaintiff's burden of causation.35 thus the case provides an obvious opportunity to introduce students to basic concepts of epidemiology and to observe how methods for studying disease in populations have changed over the years. this would be useful to students, indeed essential, because tort litigation about product liability and toxic exposures has made epidemiology and public health science central to much civil litigation today, as we discuss later in this ankle.$ but the context of the case goes beyond an analysis of evidentiary issues. the development of clean, municipal drinking supplies is undoubtedly one of the great public health victories of all time.37 students reading the case should understand that cities did not always supply clean water for drinking and that prior to the introduction of clean water, concenmtion of populations in cities led to extremely high rates of death (especially among children) from diseases such as typhoid fever and cholera.b dr. john snow's study that linked cholem rates in london neighborhoods to the source of people's drinking water persuaded him to remove the handle from the contanlinated broad street pump, and incidentally helped give rise to the modern science of epidemiology.'g before the science of bacteriology learned to identify pathogenic microorganisms in the late 19th century, municipal authorities, acting on the lessons learned from epidemiology, had achieved a dramatic decrease in deaths from water-borne diseases by protecting drinking water supplies from human wastesa thus .seen in context, sttibbs is not simply about how we can infer individual causation based upon population data, a subject that future ton lawyers would be well advised to master."' stubbs is also a tale from public health's long struggle to use the forces of science and society to protect populations from infectious disease. whether or not the defenclant caused mr. stubbs' typhoid, there can be no doubt that the health of the public benefits from the provision of safe drinking water. but that insight will not be recognized by students who do not know (as many of our students likely do not), that only 120 years ago, deaths from water-borne diseases were common in this country and that it took concerted public efforts to prevent preniatiire death. a second goal is for students to appreciate key legal doctrines that relate to public health, particularly the array of powers government uses to protect the population's health and the restraints the law places upon those powers."2 all law students cannot be expected to study public health law as preparation for becoming public health lawyers. nevertheless, they should understand the basic contours of how the government, acting through law, organizes to protect and promote the public health and the tensions and challenges created by the exercise of those powers. governments have always taken an interest in the health of their population. from the beginning, concerns about how to protect the population and prevent disease and injury have helped define the role of g~vernment.~) in the united states, activities by the states to promote public health came to form the core of what is known as the "police power."44 to be literate in public health, and indeed, to ix effective lawyers, law students should be acquainted with the idea of the police power, the limitations applied or suggested to restrain it, and ways that states exercise it. an introduction to the police power will provide students two critical legal strengths: an appreciation of the legal tools available to help carry out public health actions and.a deeper understanding of the law's role in promoting the health of the population. by delving into the police power, students will see first that government activities to promote and protect the population's health have historic roots. they are not an unusual contemporary phenomenon. second, such activities create difficult challenges for our legal system. public health colleagues withwt legal training, although they must use the police power, often lack this depth of understanding. a basic introduction to public health powers would also expose students to the complex role that the federal government plays in matters of public health. it is commonplace to assert that public health lies in the province of the states:s a carefill reading of history, however, demonstrates a critical and expanding federal role in the protection of public health, reflecting threats that exceed the capacity of states. (sonie threats exceed the capacity of national governments as well, such as biotemrism and global epide~nics.)~~ what tools are available for the federal government to ;issure protection of the public heal& the spending power and the commerce clause are most obvious. what doctrinal limitations constrain efforts to protect the health of the public? teaching these issues in their public health context, as we noted above, will enrich the students' understanding of the doctrines and facilitate the students' ability to use the law creatively. the stucly of public health powers can also provide an opportunity to explore the ways that law can be used to advance public goals. law schools usually emphasize private law and individual rights!' our public law courses-~~~s t i t~i t i o~l law, adnlinistrative law, and criminal law-ften highlight the legal rights of individuals and the lhnits of government action. far less discussion time is devoted to the use of the law as a positive instrument, to how governments can act, and the rationales for their action.@ to many lawyers, those questions appear to be outside of the law itself, within the domain of policy or politics. public health law in the core law school curriculum can provide a context for students to understand the broad range and durability of the powers different levels of government wield to protect the public. (such topics already appear in the syllabi of nlany courses in health and environmental law.) in other words, by looking at public health powers, students can become better able to appreciate and use the law positively to advance the public good. no discussion of public health powers would be complete without a consideration of the role that law plays in limiting those powers.@ a broad array of legal doarines, from the substantive due process doctrine developed under the 14th amendment of the constitution,so to doarines relating to judicial review of administrative agencies, evolved appreciably in the context of public health likewise, some of the earliest equal protection cases challenged actions taken by public health authorities who exercised their powers in a disainlinatory manner?* even today problems may arise when public health agencies use their authority in an unduly coercive or dwnnuna tory manner. lawyers have avenues available to restrain those actions. these topics can engage law students and help them appreciate that law is both a vital engine for public health, and also a critical mediating forre. . . . puellc health mixhod% law students can learn the basic scientific methods that public health employs and in doing so develop a broader acquaintance with quantitative and empirical techniques that are critical to the contemporary practice of law. the public health, conference noted that "public health draws on all the scientific knowledge that informs our understanding of how humans interact with their environments and manifest disease and injuries."s3 epidemiology, which studies the incidence, prevalence, distribution, and etiology of disease, is the core discipline of public health. epidemiologists rely upon a variety of experimental and observational studies, statistical and analytic methods. lawyers cannot be expected to become epidemiologists. to understand the public health issues, however, they should have a basic grasp of the quantitative and scientific methods on which epidemiology rests. at minimum, lawyers should understand the types of studies that epidemiologists rely upon,% possess a familiarity with the concepts of rates, incidence, and prevalence; be aware of the distinctions between association and causation; and recognize that there are many ways that epidemiologists infer causation from a s s~c i a t i o n .~~ lawyers might also receive a basic introduction to scientific reasoning,% the ways in which scientific consensus is developed,s7 and the distinctions between legal and scientific notions of "causation" and "truth."% (ironically, most scientists themselves simply do science, remaining unfamiliar with studies of science and scientific methods.") the suggestion that lawyers should be better informed about statistics and science is neither new nor exclusive to proponents for public health literacy. critics of the legal system's use, misuse, or abuse of science and scientists have long lambasted lawyers for their ignorance about what science is and how it works. @' a 1993 supreme court decision, dauben v. merrell dow pbumacmticak, lnc.,61 and its progeny have made the debate central to tort litigation in the united states.6z in daubert, the supreme court reconsidered the standards for admission of expert evidence. rejecting the earlier fty@ nile as incompatible with the federal rules of evidence, the court instead required federal judges to act as gatekeepers and determine whether the proffered evidence was "reliable," which the court claimed, required a determination of whether the evidence was based on a scientifically valid methodology.& in daubertitself, two justices questioned the wisdom of asking federal trial judges to take on the role of deciding what is good science and what is not, describing the task as akin to asking them to become "amateur ~cientists."~~ since daubert, however, in federal coum and many state coum, that is just what has happened.& because expert witnesses may offer opinions about causation that qijantwative and sceniwic reas0ni"ln are thought to be useful to the finder of factjury or j u d g e a trial judge is now required to act as a "gatekeeper" and decide which expert testimony to admit. the daubert process-pretrial hearings on the admissibility of expert testimony-now donlinates product liability and toxic tort cases6' recently, the data quality act68 has extended a daubert-like process into federal agencies, providing an opportunity to challenge the science used in setting agency policy and in regulatory decision making. this means that every lawyer working with or in government agencies will need to understand science and quantitative reasoning as never before. all these procedures hinge on how lawyers understand and portray science, an important reason why an introduction of public health and scientific decision making is necessary in the core cumculum law school. lawyers employing the daubertprocess have spawned a vimal industry designed to inform judges and lawyers about the "abc's" of epidemiology, the scientific method, and statistics.@ these legal pundits on science have expanded on the court's suggestions in daubert, creating a check-list approach to assessing whether scientific testimony is relevant and reliable, confusing-often deliberately-the legal concept of causation with how scientists reach conclusions about little or none of this lawyers' rendition of science has been subjected to scholarly scrutiny by scientists, and legal practitioners and judges, largely uneducated about science and quantitative methods, have wandered far from scientific practice." the need for a better understanding of science among lawyers is now plainly evident. justice breyer, in his influential critique of the regulatory process and administrative law, has called for a more rigorous understanding of quantitative analysis, including cost-benefit analysis, in determining regulatory standards." the national academy of sciences has a committee of scientists and lawyers reviewing these issues.73 in light of daubert, lawyers must be better informed about how scientists assess causality, how they value evidence, and the application of epidenuology, toxicology, animal and clinical studies. thus, there is an urgent need to develop cumculum within law schools that teaches law students to understand quantitative science. and what better way than around public health issues, that are already deeply embedded in the law? it would meet the broader goal of ensuring that lawyers are competent consumers of epidemiological and statistical analyses and that lawyers can work collaboratively and intelligently with public health professionals, medical expew, regulators, and the plethora of other professionals who rely upon quantitative and empirical tools. lawyers should be able to think critically about populations and what it means to focus on them, as opposed to individuals. this approach to legal problems contrasts with the law's usual focus on individuals. drawing on the traditions of anglo-american liberalism, our jurisprudence posits individuals as mini-sovereigns, each replete with her or his own endogenous set of preferences and from this premise, the goal of law becomes regulation of the interaction of those mini-sovereigns; to protect their rights and property; and, for those who subscribe to utilitarian or neo-classical economic theories, to maximize their aggregate utility or wealth.75 law schools, with their typical emphasis on competition ancl non-collaborative work, reinforce the individualism evident in the doctrines this foundational individualism manifests itself in and deeply influences many fields of law. a few bwad-brushed examples may demonstrate the point. the field of health law itself, as john v. jacobi observed, concerns itself with "bilateral disputes over health finance, medical injury, and patient's rights...'" what is missing, he argues, are the "tools or the perspective" to address issues that affect populations.78 american constitutional law, too, is famously devoted to analysis and consideration of the rights and interests of individuakn thus the question of whether a woman can have an abortion is framed as a conflict between a woman's right to privacy versus the rights of the individual fetus.8o the law of race discrimination, which was once understood as recognizing and responding to group harms:' focuses significantly on the needs and interests of individuals, rather than groups!* although the supreme court's recent decision to uphold race-conscious decision making by universities signals some recognition of the importance of group perspectives,b3 it remains me that state policies that disparately disadvantage suspect classes are not held to violate the constitution even if' the disadvantage to the group is clear and obviously foreseeable.& only when the state, anthropomorphized as if it were also an individual, intentionally aims at disadvantaging one or more people on the basis of their membership in a suspect class, is the constitution found to be offended.us even tort law, the field of common law most focused on population-based concerns, remains heavily influenced by individualism. as scholars have noted, traditional tort law, prior to the so-called 1ws "torts revolution," assumed that "individualism outranks concerns for others."& these tenets remain ensconced in the field, for example, in the noduty rule that many states continue to affirm!' perhaps the single most influential critique of traditional tort law emerges from scholars and judges who believe that the primary goal of tort law should be the maximization of economic efficiency.w while this position postulates the the dominating individualism of american law has come under sustained critique in recent decades from: fenunist scholars who postulate the importance of relationships;w critical race scholars who point out the need to understand the position of identity groups;" ancl communitarians who stress the primacy of nevertheless, these critics, remain just that: critics of the prevailing regime. their influence is occasionally evident in case law, but they have largely failed to alter the status quo. perhaps even more impoitantly, as david ortiz has noted, in many subtle but fundamental ways these critics share many of the individualistic premises of the jurisprudence they critique9~-ofien reifying groups or communities, treating them as if they were, in essence, individuals. what the critics,of individualism in the law seldom offer is a serious or sustained examination of groups (other than identity groups), which includes an analysis of them and their interests and their relationships to the individuals who fonn them. this, of course, is precisely what public health and its scientific foundations do. as jacobi writes, "[plublic health is a discipline dedicated to the scientific examination of the conditions affecting the health of populations."94 public health's prinlary sciences-epidemioiogy and biostatistics-focus on populations as populationsb and apply empirical, statistical, and analytical methods to understand how to define them, determine what affects them, and what distinguishes them from other populations, and how they relate to the individuals who comprise them. by comparing populations, epidemiologists have garnered ,insights useful to legal analysis. geoffrey rose explains that how populations are selected affects what can be learned.* for example, if we try to understand the causes of coronary artery disease by comparing people in a particular population who have heart attacks with those who don't, we may identlfy a risk factor, such as exercise, the presence of which differs between the groups. however, unless the population as a whole is compared with other populations, we may easily miss causes of the disease to which everyone in the population was exposed. only by many comparisons of many populations with different rates of disease, can be begin to idenufy all of the factors contributing to disease? ' rose's insights raises several points relevant for legal analysis.* first, he demonstrates how a focus on individuals-usually the symptomatic p a t i e n w a n at times obscure our understanding of what is happening to the larger group. thus the health damage done to the population by asymptomatic or untreated individuals with mildly elevated blood pressure is far greater than the sum of damage done to symptomatic individuals and those found by doctors to the journal of law, medicine & etbics have hypertension, for the latter group is much smaller. can changes in the environment affect the prevalence and distribution of hypertension in the population? only by comparing groups can scientists predict how individuals are likely to respond to elements of their social and physical environments. this is relevant to a number of legal issues. for example, in understanding the nature and impact of discrimination, we may recognize that the phenomenon at a population or social level cannot be well understood simply by looking to discrete cases of discriminatory behavior. indeed, epidemiological studies that have associated the relationship between discrimination in a population and the health status of minorities suggest precisely that point.93 epidemiology also teaches that the risks individuals face are significantly affected by their environment. for example, an individual with a low genetic predisposition to a disease may still be at a higher risk of that disease than an individual with a high genetic predisposition if the former is exposed to a more dangerous social and physical environment, where the incidence of the disease is tugher. from this we learn that even if our goal is to change an individual's risk factors, environmental or population-based interventions may be more successful than those policies that seek to change individual risk factors. epidemiology's analysis of the relationship between individuals and social risk also has relevance for a wide range of legal issues. for example, debates about whether government should enact apparently paternalistic laws, such as those requiring motorcycle helmet laws, often presume that individuals can make independent choices and that they can control the probabilities of their being affected by different risks.'" rose's work questions that assumption and provides legal decision makers with a different perspective for analyzing so-called paternalistic laws. on the one hand, a seat belt law niay not actually be paternalistic, if we recognize that inciivicluals cannot in fact control the risks to which they are exposed. on the other hand, such laws may be inefficient ways of reducing highway deaths if in fact they focus on altering individual rather than population behavior. as beauchamp and steinbock argue, "[tlhe population perspective constnicts a new story about how highway injuries occur in likewise, a population-based perspective may alter the way we understand relatively new issues, such as the legal responsibility of the food industry for the growing obesity epidernic.lo2 the traditional individualism of american law (and culture) would suggest that in the absence of misrepresentation or the sale of an exceptionally dangerous product, the food industry should not be viewed as responsible for the pr0b1em.l~~ individuals should be regarded as free and responsible for their own eating and exercising habits as well as the weight gain that ensues.""' a population-based perspective, however, questions whether individuals should be viewed as personally responsible for their own weight. after all, the prevalence of obesity is increasing both across the broad u.s. population and across varied sub-populations.iw likewise, the health damage stretches across the population, harming individuals who do not consider themselves in need of weight control or who do not meet the official definition of obesity (bmi greater than 30). in fact, more health damage is likely occurring in the part of the population not identsed as overweight than in the overweight population.'06 this suggests that causes must be understood at a broad, population level. something is happening to make millions and millions of people make "choices" that lead to their gaining weight. epidemiologists, therefore, are looking to fundamental environmental changes, including the marketing and distribution of food, as well as the way our built environment affects our activity levels.'07 these deeper causes may suggest legal causation should be seen as residing in those parties (corporate and governmental) that perpetuate the obesity-causing environment, or it may suggest a role for affirmative government interventions to alter the environment.im while adoption of a populationbased perspective does not provide a single or simple determinative analysis of where and how the law should assign responsibility and intervene in the case of obesity, it does suggest a different set of remedies and approaches than would be offered by a more individualistic, marketbased approach, which might focus solely on remedying market failures by giving individuals more information on how to make healthy choices. importantly, epidemiology also teaches us that populations differ and that it is critically important to define and compare them. thus in thinking about obesity, or any other issue, we need to take care to consider what constitutes the population at issue. lawyers, however, often use terms like "the public good" or "majority" without defining the group or assessing how one group differs from others. this lack of precision may inappropriately privilege majorities (as may occur when courts uphold drug testing for school children on the unproven assumption that it is in the public interest),iw or it may devalue their interests by simply not treating them with sufficient rigor and import. a population-based perspective would not necessarily lead a judge either to uphold or bar a drug search, but it would demand that the "public" cited in defense of the search would be carefully delineated and the relationship between it and the search would be articulated. ultimately, a population-based perspective offers valuable lessons about the complexity of the relationship between individuals and populations. the history of public health is replete with examples in which individual interests have conflicted with either real or purported interests of particular publics.110 however, public health also teaches us that not only are individual interests interwoven with public conditions,"l but that recognition and protection of individual interests may also at times be the most efficient ways to secure a common good. early in the aids epidemic, it was noted that societies that respected individual rights were often the same ones which achieved individual behaviors most protective of tlie whole population."* (wealth and security, it should be said, often predate individual rights and explain tlie ability of people to lean and change behavior.) these perspectives from public health are important to understancling laws (statutory, regulatory, and common law) that purport to serve the common good. in almost all such cases, a lawyer's understanding of the population perspective will add to and enrich the legal analysis. whether drafting an administrative regulation to control air pollution levels or litigating a class action employment case, a lawyer's ability to take populations seriously and recognize the dynamic and multivariate relationship they have to individuals will improve the analysis. the true integration of piiblic health into legal education will not be easy to achieve. law schools have for the most part been quite reluctant to embrace change."' pressures from bar examiners iindoubtedly exacerbate that recalcitran~e."~ in addition, curricular changes require an investment of faculty time, that they may well be unwilling to make without sufficient institutional scippo~t."~ the most critical factor, however, may ix the existence, or lack thereof, of :in engaging :incl intellectu:rlly stimulating body of scholarship using the insights of public health to address a range of legal issues. attendees at tlie public health literacy for lawyers conference agreed that public health will not be integrated into the core legal curriculum unless and until a hotly of legal scholarship demonstrates its relationship to law and its power to enhance legal analysis. if such ;i body exists, then there is reason to hope that law professors will take note. neo-classical economics, for example, became part of legal education only after scholars, such as ronald coase116 and richard posnerl" produced scholarship that displayed the ability of neo-classical economics to provide a coherent, iinsed, descriptive, ancl nomtive analysis of a wide-range of legal problems. the breadth and apparent elegance of their approach helped to stimulate excitement and debate among legal scholars, spurring additional scholarship on the role of economic reasoning in the a s a result, even critics of the distributional consequences of law and econonucs came to see econoniic analysis of tlie law :is a perspective and skill that their students "ought" to know. to permeate legal education with population-based legal analysis, a similar scholarly revolution investigating the utility of incorporating concepts from public health science is needed. perhaps it has already begun. in recent years, there has been a renewed interest in public health law (including this secondjlmesyniposiiim). book-length expositions of the field have been and seven1 major conferences have been held. in addition, issues such as bioterrorism has spurred considerable scholarly delxtte.'" but few scholars have consciously attempted to explore the broader utility of population-based analysis for law and jurisprudence. perhaps, one by one, cases and courses iiiust be reexamined to assess the value of population-based legal analysis. to reach a wider audience, and to entice a critical mass of scholars to join the debate and bring it to their students, more and in-depth scholarship is certainly needed. as we noted at the start, public health's focus on populations, resting on the science of epidemiology, provides a valuable prism for understanding the relationship of individuals and groups and the ways that laws can and ought to affect the~ii.'~' in addition, analyses of morbidity and mortality, and health measures, may well provide an important complement or even alternative to wealth maximization as a measure for determining utility for a population.'22 grounded in observation ancl association, rather than on a singular deductive construct, public health science is unlikely to offer the kind of elegant, unified theory for human behavior spelled out in neo-classical economics, a theory that reminds us of h.l. mencken's suggestion that "for every problem, there is one solution which is simple, neat and wrong." nevertheless, public health can provide an alternative way of looking at old legal issues. for example, it may help lawyers analyze key issues, such as what constitutes the public good, and what are the proper roles and powers of government, where current answers are not wholly satisfactory. in order for public health to play this role, more scholars must join the field. they must explore and debate what it means to consider legal issues through the prism of public health. we expect that once they take up that baton, they will find that it leads them down interesting and as yet unpredictable paths. we hope they will join us on that journey. references see, e.g., guide to comintinity preuentimseryices, at <http://www.thecoi~iiiinityguide.org> (last visited october 8, 2003) (showing legal interventions as among the most effective proven interventions for community health). in recognition of this, the centers for disease control and prevention established a public health law program in 1w. see centers for disease control and prevention, hcblic heulth luw progrum, at <http://www.plippo.cdc.gov/od/ phlp/almiit.asp> (last visited october 8, 2003) . a. robbins and p. freeman, "public although we dmw from the discussions at the april conference, the views and errors here are solely are own. a list of jd/mph programs appears at cdc, public health program, public health practice program ofice, training and education in public health law, at <www, phppo.cdc.gov/od/phlp/education.asp> (last visited october 8, 2003) . for a discussion of the growth of combined degree programs in generdl, see l.r. crane, "interdisciplinary combined-degree and graduate law degree programs: history and trends," john marshall law 3. 4. rw~uu, 33 (1999): 47-80. 8. goodman, supra note 5, at 298-301. see university of the pacific, mcgeorge school of law, capital center, bioterrorism, national security & public health law initiative: models for teaching, at <http:// www. mcgeorge.edu/government-law-and-policy/ bioterrorism/models-for-teaching.htm> (last visited october 8, 2003) . the public health advocacy institute, intends, as part of its public health literacy for lawyers project, to produce model materials for one or more core law school courses. m. minow, "education for co-existence," arizona why justice is good for our health: the social determinants of health inequalities uniuersity of chicago law review lochner the rise and fall of the constitutionalization of public health judicial power and reform politics: 7he anatomy of lochner v the role of new federalism and public health united states v. lopez judicial review under the commerce clause inside the federalism cases: concern about the federal courts parmet supra note 22 judicial review of fda authority to regulate tobacco products as "drugs 356 (1886) (city violated the fourteenth amendment when in the name of public health public health literacy for luwpts: selecting the content, paper presented at public health litmcy forluwym how science works epidemiology, justice, and the probability of causation burden of proof: judging science and protecting public health in (and out od the courtroom a fish out of water: scientisrs in court shattuck lecture -evaluating the health risks of breast implants: the interplay of medical science, the law, and public opinion galileo'sreuenge: junk science in the courtroom see also kuinho tire co complex litigation at the millennium: upsetting the balance between adverse interests; the impact of the supreine court's trilogy on expert testimony in toxic tort litigation is science different for lawyers 73. the science, technology and law panel created by the policy division of the national research council was established to "bring the science and engineering community and the legal community together law, politics, and the claims of community rights talk: xbe impoverishment 01 atoinism the the0 y of hgtilation of civil government: two treatises feminist perspectives and the ideological impact of legal education on the profession thinking beyond my own interpretation: reflections on collaborative and cooperative learning theory in the law school book review -lawrence 0. gostin's seton half law review groups and the equal protection the failure of gender equality: an essay in constitutional dissonance individual rights and class discrimination: the fallacy of an individualized determination of disability 2411, 2003 (striking down admissions program for state university in which applicants were given specific admissions points based upon their race) holding that state policy that foreseeably disadvantaged women did not violate the constitution) holding that police exam that disparately excludes african american applicants from police force does not violate the constitution unless the defendant city intended to discriminate) scientific policymaking and the tom revolution: the revenge of the ordinary observer prima facie torts, combination, and non-feasance at 214 (attributing the nile to an ideology of individualism). the most iduential scholar/judge advocating this view has been judge richard posner science, reason, csr ton law hateful speech, loving communities: why our notion of "ajust balance philosophy and the human sciences: philosophical p a p , wl spheres of justice: a oefense of pluralism and 83 stanford law jacobi, supra note 77 7he strategy of premniim medicine integrating law and social epidemiology twenty-five states have repealed mandatory helmet laws for motorcycle riders over twenty-one years of age since the highway safety act of 1976 removed the department of transportation's authority to condition federal highway hnding on helmet-use laws. national highway safety administration ) (noting that obesity has become an epidemic in the united states and listing associated liealth problems). the public health advocacy institute using the absurdity of regulating the marketing of fast food because of its impact o n obesity as a justification for denying the state the right to regulate the marketing of tobacco) macdonald's ing that consumers could not bring a claim against macdonald's holding it responsible for their weight, as their decision to eat there was their own free choice 2003) (holdmade by the center for consumer freedom, an industrysupported group that objects to legal liability for the food industry the gorge yourself environment public health service, ofice of the surgeon general, 7he surgeon general's call to action to prevent and decrease ooenoeight and obesity the ideal population policy would be a substantial and general weight reduction environmental conuibu-' tions to the obesity epidemic for a discussion of the relative merits and demerits of tort litigation and regulatory approaches to public health, see the relationship between student illicit drug use and school drug-testing policies medicine and public health, ethics and human rights the problem of social cost the firm, the market, and the law 7he economic structure of tort law the ecoiiomics oflustice economic analysis of laui the inefficient common law is wealth ;i value problem-solving behavior and theories of tort liability public health pmcfice bioterrorisni, public health and civil liberties public health law in the age of terrorism: rethinking individual rights and common goods see text accompanying note 6 supra. 122. this is not to say that any of these measures can or should be the sole way of judging welfare maximization, but they do provide an interesting alternative to the economist's tendency to reduce all issues to questions of wealth key: cord-334353-nc2jhemz authors: murphy, thérèse; whitty, noel title: is human rights prepared? risk, rights and public health emergencies date: 2009-05-08 journal: med law rev doi: 10.1093/medlaw/fwp007 sha: doc_id: 334353 cord_uid: nc2jhemz nan public health security is . . . the activities required, both proactive and reactive, to minimize vulnerability to acute public health events that endanger the collective health of national populations. global public health security widens this definition to include acute public health events that endanger the collective health of populations living across geographical regions and international boundaries . . . .[g]lobal health security, or lack of it, may also have an impact on economic or political stability, trade, tourism, access to goods and services and, if they occur repeatedly, on demographic stability. 3 the other term that requires some explanation is 'public health emergency legal preparedness'. stated shortly, this is all about having the right laws in place and then using them in the right way in a time of public health emergency. 4 in other words, it is about both legal preparedness for, and response to, public health emergencies -it is both proactive and reactive. more generally, it can be said to be an essential part of both public and global public health security, and a subset of public health emergency preparedness. having identified these basics, we move to the purpose of this article. the aim is to present a human rights lawyer's perspective on both public health emergency preparedness and, more generally, the turn towards securing public health through securitisation. we develop this perspective by asking the following question: is human rights prepared for public health emergency preparedness? we are not confident that it is. in what follows, we explain why we take this view and we also sketch out a preliminary agenda designed to encourage greater human rights preparedness. we focus in particular on the importance of thinking through how risk and its relationship to rights is being framed, and also how this relationship ought to be framed. one response to public health emergency preparedness might go as follows: even if there is an abundance of new terms, there is nothing new about the link between health and security. the detailed version 3 ibid., at 1. 4 220 medical law review [2009] of this response would run as follows: focusing first on national security, the effect of disease on military strength and preparedness is, without doubt, an age-old concern. infectious diseases can also be a source of indirect harm to national security given their potential to cause 'political and economic damage in countries in which a state has vital security, foreign policy, and trade interests'. 5 turning next to economic security, it is clear that here too there is a longstanding link to health. the first international health regulations (1969) and their predecessors, the international sanitary regulations (1951) , were explicit about this link: they aimed to 'ensure the maximum security against the international spread of diseases with a minimum interference with world traffic'. 6 finally, a third, more general, link between health and security arises from the fact that infectious diseases can 'erode governance capacities' and undermine 'a population's confidence and trust in the political leadership and system'. 7 clearly, then, there are longstanding connections between health and security. but that does not mean that the contemporary linkage between health and security is nothing new. to explain why we think there is something new in play, and to provide background for our argument in the latter parts of the article, this section sketches a history of the relationship between security and health. in particular, drawing on recent developments in international law and policy, it aims to show that health has come to be 'looked at through a new lens'. 8 we begin in 1994, the year in which the united nations development programme (undp) called for attention to be directed towards the achievement of 'human security', 'an idea . . . likely to revolutionize society in the 21st century'. 9 for undp, traditional concepts of security were, on the one hand, too focused on protecting states from 'external aggression, or as protection of national interests in foreign policy or as global security from the threat of nuclear holocaust' and, on the other, not focused enough on 'the legitimate concerns of ordinary people who sought security in their daily lives'. 10 undp saw 'human security' as a way to address this imbalance. it argued that human security could help to protect people from both chronic threats (such as hunger) and sudden, harmful disruptions of their daily lives. 11 six years later, in 2000, another less-than-conventional definition of security emerged. this time it came from a more surprising source: the un security council, which held a session in january 2000 on peace, security and hiv/aids, focusing in particular on the impact of aids in africa. 12 the security council's conjunction of peace, security and hiv/aids was novel. so too was its depiction of security and its explicit reference to the pioneering nature of its own position: it emphasised that by discussing hiv/aids as a security threat, it was 'exploring a brand-new definition of world security' and establishing 'a precedent for security council concern and action on a broader security agenda'. 13 11 september 2001 (or 9/11) is the next crucial date in this short history. as lucia zedner has explained, '[t]he events of that day alter the landscape of security irrevocably'. 14 very shortly thereafter, anthrax letters, sent using the us postal service, affected 22 people, of whom five died. as a core component of its response to the events of 2001, the united states committed to a range of legislative and regulatory activity designed to improve the preparedness of its public health law. for example, within weeks of september 11, the centers for disease control and prevention (cdc) had commissioned a draft model state emergency health powers act and, as of 2009, the united states is scheduled to have its first national health security strategy, designed to augment the extant strategies covering, respectively, the national security of the united states and homeland security. 15 strongly worded rhetoric on health and security has run alongside these reforms. typically, this rhetoric invokes the importance of experienced an outbreak of plague, causing 56 reported deaths; and second, a cholera epidemic killed up to 50,000 of the approximately 700,000 refugees who had fled to the democratic republic of the congo to escape the crisis in rwanda: see, respectively, dt dennis, 'plague in india ' (1994) the united states is only one among numerous jurisdictions pursuing public health emergency preparedness. put bluntly, 'vulnerability is universal '. 17 in 2003, another global health security concern emerged: severe acute respiratory syndrome (sars), a new and serious infectious disease. sars began to spread internationally in february 2003, approximately two months after the global outbreak alert and response network (goarn)-a multi-partner network of agencies and technical institutions established by who 18 -had detected a confirmed influenza outbreak in the guangdong province of china. on 12 march 2003, who issued its first global alert about the new infectious disease. three days later, it issued a second alert, naming the disease, offering guidance to health professionals and public health authorities, and alerting international travellers to the spread of the disease. within four months, however, transmission of sars had been interrupted in all affected countries and, on 5 july 2003, who announced that the outbreak had been contained. in total, 8,098 cases of sars were recorded in 26 countries, with 774 documented deaths (hospital staff were most affected). there were also serious financial implications due to disruption of travel, tourism, trade and production; who's estimate is that the outbreak cost us $12.3 billion in the asian countries affected. 19 the sars outbreak and its containment produced a range of responses. 20 china, for example, was criticised for its delay in reporting 16 cases and an initial lack of cooperation with who. who was criticised by canada for its unilateral issuance of travel advice to persons proposing to travel to toronto, the city outside asia worst affected by the outbreak. 21 meanwhile, in canada, delays and wrangling between the ontario government and the federal government over funding to provide compensation for individuals may have undermined the quarantine scheme by leaving people with financial incentives to break quarantine. 22 as part of quarantine and isolation measures, some jurisdictions, including canada, adopted policies involving heavy limitations on individual rights. 23 who has said that these control schemes were responsible for the interruption of transmission of the disease within four months of the announcement of the outbreak, but the use of measures that severely restricted individual freedoms was deeply controversial. the year 2003 is, however, notable for more than the sars outbreak and its containment. it was also the year in which the commission on human security, co-chaired by sadako ogata and amartya sen, issued its final report. 24 the commission labelled illness, disability and avoidable death as 'critical pervasive threats' to human security; more generally, it harnessed the language of security to highlight the ongoing neglect of social and economic rights. one year on, in 2004, 'comprehensive collective security'-described as a 'new and broader understanding' of international security-provided the overall vision behind the report of the un secretary general's high-level panel on threats, challenges and change. 25 the panel prescribed an improvement in public health systems, arguing that: ur best defence against this danger lies in strengthening public health' and he seemed to indicate that he supported an expanded role for the security council in the event of an 'overwhelming outbreak of infectious disease that threatens international peace and security'. 29 a few months later, in may 2005, the world health assembly, the highest decision-making body of who, adopted a revised set of international health regulations (ihr (2005)). 30 these regulations were welcomed by the then director general of who as a 'major step forward for international health'. 31 they took effect in june 2007, 32 binding who member states on an opt-out basis. 33 they contain 66 articles, organised across ten parts, and a total of nine annexes, and, crucially, they are significantly different from their predecessors, the international health regulations (1969). the new regulations take what has been described as an '"all risks" approach', 34 encompassing any emergency with repercussions for international health security, including 26 ibid., at para 47. 27 ibid., at para 19. 28 ibid., at para xx. 29 outbreaks of emerging and epidemic-prone diseases, outbreaks of food borne disease, natural disasters, and the accidental or deliberate release of pathogens, or chemical or radio-nuclear materials. 35 their purpose is to: prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade. 36 to give effect to this, they place obligations on member states with respect to surveillance and response capacities; states are also obliged to notify who of events within their territories that may constitute a 'public health emergency of international concern'. 37 but what of human rights? do they feature in the new ihr? put shortly, the answer is yes. article 3(1) contains the first reference to human rights: it states that the implementation of the ihr is to be 'with full respect for the dignity, human rights and fundamental freedoms of persons'. thereafter, human rights crop up in a number of articles. article 42, for example, provides that all health measures must be applied in a transparent and non-discriminatory way. informed consent and information privacy feature in several articles, including article 23 which provides that states parties must not apply health measures such as vaccination, medical examination or isolation to international travellers without 'prior express informed consent', save in circumstances where there is 'evidence of an imminent public health risk'. 38 article 45(1) provides that states parties must treat personal health information in a confidential manner 'as required by national law'. more generally, the new ihr feature requirements concerning any limitations on rights that are familiar from international human rights law. so, for example, who recommendations to states parties, and health measures implemented by states parties in response to identifiable risks, must be 'no more invasive or intrusive to persons than reasonably available alternatives that would achieve the appropriate level of health 35 see article 1 for definitions of the terms 'public health risk' and 'public health emergency of international concern'. 36 article 2. article 3(4), however, emphasises that states parties have 'the sovereign right to legislate and to implement legislation in pursuance of their health policies', noting that in so doing they should uphold the ihr. 37 see, respectively, articles 5, 13 and annex 1, and article 6 and annex 2. 38 if there is such evidence, then international travellers may be advised or compelled to submit to control measures such as vaccination, quarantine and isolation. protection'. 39 the ihr also give who a new power to use information about disease outbreaks provided by unofficial sources (for example, non-governmental organisations or individual scientists). 40 significantly, who has described this new power as a 'revolutionary departure from previous international conventions and regulations'. 41 so, how should a human rights lawyer respond to the panoply of new linkages between health and security and, more specifically, the increasing focus on public health emergency preparedness? in this section of the article, we outline two possible responses. we use broad strokes, not close detail: the aim is to provide a sense of the most likely human rights responses and to flag up why, in our view, they point to a need for greater human rights preparedness. the first possible human rights response to public health emergency preparedness is to embrace it, even acclaim it. this response will see public health being brought 'in from the cold'-its profile raised and increased resources directed towards it-as a result of the new linkage between health and security. preparedness, it will suggest, is a 'win-win'. specifically, investment in countering biothreats offers not just the possibility of protection against bioterrorism, but also enhanced public health given that 'the more research in weaponized diseases that takes place, the more innovations for disease prevention will be found'. 42 investment in hospitals, it will argue, should also receive a boost as a result of the new focus on preparedness: after all, 'if a bioweapon is released and people get sick, they will go to hospital first'. 43 faced with historical evidence of abuse committed in the name of public health, and of a traditionally hands-off response by the judiciary when faced with challenges to public health measures, 44 this first response is likely to counter-claim that human rights have been explicitly built-in as part of the ihr. it may also argue that states parties 39 article 43(1) re states parties; see also articles 23 and 31. as regards who recommendations, see article 17. 40 see articles 9, 10 and 11. who is required to seek official verification from the state concerned before taking action. it can share the information with other states if the affected state does not cooperate with verification and control efforts, 'when justified by the magnitude of the public health risk'. 41 above n 2, at xv. 42 jackson, above n 16, at 8. 43 ibid., at 17. 44 this first response will probably also argue that the overall response to hiv/aids shows that the linkage between health and human rights is now both accepted and embedded as best practice. the ascent of human rights in the popular imagination and in national, and international, legal and political orders might also be invoked. and, linked to this, it is likely that emphasis will be placed not just on the emergence of a 'right to human security' but also the fact that, today, neither states nor private actors (such as pharmaceutical companies) can afford to ignore human rights. putting that another way, this first response will point out that, today, rights are a potential risk for states and private actors. we think that this first response will also make claims focused on 'what works'. two particular claims spring to mind. the first addresses international co-operation: it will counter the argument that state sovereignty is an insurmountable obstacle to co-operation with evidence from the sars outbreak in 2003-in particular, who's unilateral issuance of a travel advisory and, relatedly, the fact that canada was 'a model of transparency in its reporting and public information, of determination in its contact tracing'. 46 in short, and in the words of the then executive director of communicable diseases at who, the argument will be that: the outbreak of sars in 2003 and its successful global containment are testimony to a new way of working internationally for the public good. 47 there is another possible version of the 'what works' argument, which focuses on drawing-out the rights potential of the language of security. it will run as follows: if, as seems to be the case in the counter-terrorism context, security and human rights are increasingly represented as in 45 conflict, with rights struggling to maintain popular confidence, why not use security-specifically, a right to security-as a way to bolster human rights? this argument will then go on to emphasise that states' obligations vis-à -vis positive rights (that is, economic, social and cultural rights) could also be bolstered by emphasising the importance of human security. there is though a second, very different, human rights response to public health emergency preparedness and the wider securitisation of health. as we see it, its defining stance will range from anxiety to outright opposition, and it absolutely will not share the optimism of the first response. for instance, faced with the latter's claims on 'win-win', its position is likely to be that preparedness distorts public health priorities, with negative consequences everywhere, but especially in developing states. securitisation, it will argue, compromises the public's health as it clambers after public health as security. moreover, even if one accepts the skewing of attention towards preparedness, isn't it the case-it will argue-that the preparedness project is out of balance? why does investment in neglected diseases continue to lose out so heavily in terms of funding? and, if hospital 'surge capacity' is a core issue, why hasn't there been more investment in public hospitals? claims of a new, co-operative world order will also be met with incredulity. co-operation on preparedness is essential and is embedded in the ihr, but it is also incredibly fragile, as was made clear in 2006 -07 when indonesia temporarily stopped sharing samples of the human avian influenza virus with who. 48 the cessation was prompted by the indonesian government's anger at what it saw as the commercial exploitation of developing countries. the catalyst for this was the announcement by an australian pharmaceutical company that it had developed a vaccine and could manufacture enough to protect the australian public within six months. the company was one of a number that had received indonesian samples from who. indonesia pulled out of sample-sharing with who, insisting that who change the rules to stop commercial abuse of poorer countries. it also allegedly entered into an arrangement with a us-based pharmaceutical company to provide samples in return for affordable access to any vaccine that might be developed. it is very likely that this second grouping of human rights advocateslet us call them linkage-sceptics-will also take a very different stance on the contemporary standing of human rights. it is true, the sceptics will agree, that human rights are built into the ihr. ultimately, however, article 3 of the ihr reserves the sovereign right of states parties to legislate for the public good, upholding the purpose of the ihr and sound science. moreover, the human rights provisions in the ihr have 'little to say about protection of livelihoods and food security, or potential health impacts that might result from the distortion of public health priorities towards global surveillance'. 49 the linkage-sceptic is also likely to point to a problem arising from a less obvious source: the health and human rights movement itself. this movement encompasses two different approaches to public health and human rights, one that forthrightly acknowledges the potential tension between public health necessity and human rights, and another that rejects the assumption of such a tension and instead sees the pursuit of public health and human rights as inextricably linked. one consequence of this has been vigorous intra-movement debate about the extent and inevitability of conflicts and trade-offs between public health and liberty. 50 this debate is both inevitable and deeply useful, but there is a problem in that, in an 'age of preparedness', robust debate amongst rights advocates about the pros and cons of trade-offs could be read in a way that puts rights at risk. threats to human rights-and indeed, human rights as a threat-are nothing new. the hype, or 'myth', of rights is a claim that is familiar from empirical socio-legal work on rights. problems with rights have also been emphasised by rights-sceptics. 51 the point though is that, lately, a new link between human rights and risk has emerged, largely as a result of post 9/11 rhetoric about life in a 'time of crisis'. its position, in crude terms, is that exceptional times mandate exceptional measures to deal with risk. as liora lazarus and benjamin goold have pointed out, 'the idea that certain human rights can be "turned off" when necessary' has acquired remarkable power; it is now widely regarded as a 'thoroughly reasonable reaction to the dangers allegedly faced by democratic societies'. 52 and, as they go on to emphasise: the exceptionalism argument has become pivotal, so much so that liberals and human rights organisations must either rebut claims 49 in this environment, human rights advocates debating the relationship between public health and human rights need to be extremely careful. 54 the ascent of post 9/11 exceptionalism is also reason to be deeply wary of upbeat, optimistic assessments concerning the relationship between security and human rights. for the linkage-sceptic, the hope that has been invested in the idea of a 'right to security' is misplaced, not least because this right could take shape as an argument against human rights. think, for example, of the claim that human rights are no more than a tool used and abused by 'minorities', especially 'dangerous, violent minorities'. this tends to be accompanied by another claim: namely, it is the right to security of 'law-abiding, decent people' to live safe and secure from crime and violence that has been neglected and needs shoring up. 55 moreover, these claims do not crop up only in the context of terrorism. as jonathan montgomery has pointed out, in the uk, discussions on the criminalisation of disease transmission have been fed by metaphors of disease carriers 'as markedly different from "normal" members of society', encouraging 'people to think of the transmission of disease as the province of evil criminals, not people like them'. specifically: those being prosecuted are [now] demonized less for their disease status than as sexual predators, and coverage shows a strong racial overtone. . . . aids is no longer presented as a gay plague but an african one. even more clearly the protection of victims from aggressors has emerged as the rationale for criminalization, obscuring public health issues. the innocence of the victims and the evil of the aggressor are stressed. 56 in our view, the sceptic's argument makes a great deal of sense. put bluntly, amidst the new 'rights revolution', which is characterised by a 53 ibid. med.l.rev. defensiveness in human rights advocacy and, its correlate, an anti-rights sentiment that queries the legitimacy of rights in a time of alleged crisis, there are no guarantees that the securitisation of public health, the right to security or human security will be good for human rights. 57 moreover, we know from history that, in the past, terrible abuses have been committed in the name of public health. 58 we have a potential problem, however, because in addition to agreeing with the sceptic's argument, we also agree with at least some of the optimist's argument. in particular, we cannot see how being 'against security' is a viable stance. in what follows, we try to address our split reaction by thinking through how human rights could engage more effectively with security. in this section, we focus on moving towards human rights preparedness in the 'age of preparedness'. in particular, we focus on risk, an increasingly common thread in contemporary debates about security. we ask: how does the identification and management of public health risks, tied explicitly in the ihr to the use of scientific principles and evidence, fit with human rights? we argue that, in order to answer this, human rights advocates need to direct greater critical attention towards prevailing interpretations of the relationship between risk and rights. 59 we propose two frames of enquiry: first, risk within rights and, secondly, rights as risk. thinking through these frames is, we suggest, an essential foil to the now-conventional mode of thinking about risk and rights which fixates on risk versus rights. as its name suggests, the first frame-risk within rights-emphasises risk as a component of human rights law. it emphasises, in particular, that the prevention of (future) harm can be interpreted within the existing framework of human rights. 60 risk-emerges from a now-dominant feature of contemporary governance: the assessment and management of risk. governments and organisations (whether national or international, and public, private or public-private in character) are expected to identify and prioritise the range of risks (financial, legal, political, reputational, regulatory, etc.) to which they are exposed. the particular point we want to draw out from this is that managing risk means managing the risk of rights. moreover, this risk is not limited to legal risk, that is, ( potential) claims and litigation for violation of human rights obligations. rather, because human rights are more than human rights law, rights as risk also encompasses the potential for human rights consciousness (as manifested, for example, in a public campaign) to disrupt the interests and overall standing of governments and organisations. a. risk within rights in many respects, 'risk' is not new ground for human rights lawyers. the terminology of risk was not widely used in the past, but analysing how threats to public health could be dealt with in a manner compatible with the normative frameworks of human rights instruments is an exercise that should be familiar to human rights lawyers. international instruments, including the 1950 european convention on human rights (echr) and the 1966 international covenant on civil and political rights (iccpr), enable states parties to derogate from certain human rights in the event of public emergencies that threaten 'the life of the nation'. 61 at other times, limitations on non-absolute rights are permitted, provided certain conditions are met. for example, interference with article 8 echr on the right to privacy is justified if it is legally prescribed, serves a legitimate purpose and can be proved to be 'necessary in a democratic society'. for the european court of human rights, the principle of proportionality is a key component of the latter 'democratic necessity' test. 62 more broadly, although the intensity of review in individual contexts (for example, interference with the right to liberty or privacy), and the exact legal terminology and method used, will differ, common judicial approaches towards questions of justification must recognize that liberty is part of our communal interests, along with public health . . . .' 61 as regards the iccpr, see also the 1984 siracusa principles on the limitation and derogation provisions in the iccpr. see, also, the 'intervention ladder' proposed by the nuffield council on bioethics in its recent report on public health, above n 23. 62 or necessity can be found across jurisdictions. 63 it is simply not correct therefore to claim that human rights law fails to deal with risk, or that a choice always has to be made between risk and rights. it is possible to identify-through the structure and interpretive principles of human rights instruments-the means to mediate the relationship between risk and rights. putting that another way, the framework of human rights law can, and already does, address issues of risk. until very recently, however, the identification of a 'risk within rights' approach did not register either among human rights lawyers or in the public imagination more generally. one explanation for this is that, for understandable reasons, lawyers did not pay much attention to the meaning, and role, of risk. 64 it was not a focus of critical concern (even though it was present in 'everyday' legal contexts-for example, identifying risk factors and making predictive judgements in relation to detention, imprisonment, mental health, child protection, asylum or deportation). instead, it was for the most part accepted as an uncontroversial component of the expert, scientific evidence put forward in support of one's legal arguments. 65 but a change has taken place due to the new societal emphasis on (in)security and public protection. significantly, in some jurisdictions, the new post 9/11 national security context has generated strong demand for greater prioritisation of risk 66 -even if this comes at the expense of established human rights norms. 67 the risk and rights relationship, in other words, is being framed as risk or rights-and rights seem to be at a substantial disadvantage. there is though a new critical counter-terrorism scholarship which is fighting this dangerous turn. in our view, its arguments need to be read very closely by those working on public health emergency preparedness, not least because of the effect that a 'risk or rights' approach 63 could have on the interpretation, and use, of the ihr and the design, interpretation and use of national preparedness measures. three insights from critical counter-terrorism scholarship merit particular attention. first, it should not be assumed that the human rights argument has been won: the reasons why human rights need to be protected have to be explained again and again, without fail. arguments, especially official ones, which insist that human rights norms have no place in times of emergency mean that counter-argument needs to be seen as constant requirement. 68 secondly, defending human rights in an era of heightened security-consciousness entails not just closer engagement with the contemporary politics of security, but also recognition of the value of security. 69 and, thirdly, a human rights spotlight on the language and practices of risk assessment and management is essential in order to evaluate the legitimacy of responses to public health threats. in thinking about risk within rights in the context of public health emergency preparedness, these points suggest a range of strategies. for example, the use of coercive measures-such as quarantine-requires particularly strong justification. these measures infringe liberty and privacy rights and, if mistakes are made, healthy individuals are put at serious risk of infection. the threat of quarantine can lead individuals to delay seeking diagnosis and treatment. it can also provoke or compound discrimination and stigmatisation of particular individuals and groups. and, as lucia zedner has pointed out, the use of risk categories to target certain groups can create a further problem: at one level, it makes perfect sense to target security measures at those deemed most to threaten. yet an inherent danger of selectivity is that precisely because it imposes restrictions only on targeted sections of the population, it is less likely to invoke the natural political resistance generated by burdens that affect us all. med.l.rev. critical counter-terrorism scholarship should also be seen as relevant in developing an account of risk-based evidence and its relationship to human rights. some public health commentators, discussing coercive measures, have begun to advocate a direct linkage between risk expertise and human rights standards: an approach, which might enable the formulation of a body of public health ethics acceptable to human rights jurisprudence is to introduce into the language of ethics and rights the notion of evidence-based assessment of risk. 71 this approach, they argue, could help to bring consistency and coherence to the 'balancing [of ] the common public health good with individual rights'. 72 for this to be true, critical counter-terrorism scholarship suggests that two particular problems will need to be addressed: the first concerns the terminology of balance; the second concerns the nature and role of risk-based evidence in legal processes. the metaphor of balance-which is now widely used in debates about appropriate legal responses to the risk of terrorism-has the potential to undermine human rights. as andrew ashworth has argued, the imagery of balancing assumes a 'hydraulic relationship between human rights safeguards and the promotion of security': specifically, 'as one goes up the other must go down, and vice versa'. 73 balancing, unlike proportionality, 'involves a broad brush, and sometimes opaque, analysis aimed at a resolution of the interests at stake and the rights involved'. it uses a 'utilitarian analysis of the rights and public interest goals in question, giving no significantly greater weight to rights than to security measures'. 74 proportionality, in contrast, is more protective of human rights: specifically, under the proportionality approach, there is a presumption that rights restrict public interest goals. rights outweigh goals that are not legitimate and, where goals are legitimate, any measures giving effect to them must be suitable, the least restrictive possible, and proportionate between the effects of the measures and the objectives to be achieved. 75 71 coker and others, above n 59, at 612. 72 ibid., at 613 (emphasis added). the second issue is risk-based evidence. a striking feature of contemporary security debates, in the terrorism and public health fields, is the increased reliance on risk-based evidence and expertise. human rights scholars have argued that, if risk evidence is to be used to justify limitations on rights, the evidence of threats to security must be disclosed and scrutinised according to identifiable legal norms. 76 clearly, where there is litigation, it is the judges' approaches to risk that will be crucial. historically, many types of expert evidence pertaining to public or national security were viewed as non-justiciable. and, where judicial intervention did occur, the actual level of scrutiny was often minimal and deferential to government assertions and experts. 77 today, however, what we have labelled as 'risk within rights' is beginning to be openly articulated by the judiciary in security contexts. specifically, in some jurisdictions, in response to concerns about the nature, and direction, of recent antiterrorism legislation and practice-including preventative detention, surveillance and deportation of suspected individuals-judges have started to engage openly, and more critically, with the relationship between risk and human rights. 78 this is a welcome development. but a wider and deeper engagement will be needed in order to dislodge the zero-sum representation of risk and human rights, and among other things this will require an exploration of the tendency to think of risk as an expert, rational or scientific knowledge, and human rights as a value-based legal knowledge. 79 we shift now to the complex terrain of 'rights as risk'. as noted earlier, the prompt for this second frame is that risk management has become a pre-eminent concern for governments and organisations (whether public, private or public -private in character)-to quote michael power, we are in the midst of 'the risk management of everything'. 80 in this section, we focus on organisational risk, emphasising that this includes management of the risk of rights, and we consider what this might mean for the project of human rights preparedness. 81 as we explain below, we take the view that a human rights engagement with 'rights as risk' is both necessary and undeniably complex. organisational risk is an umbrella term covering the possible risks affecting an organisation (including, for example, government departments, regulatory bodies and pharmaceutical companies). the organisational risks that have to be managed vary widely and are generally classed as reputational, financial, legal, political and operational in nature. the regulatory space in which the organisation operates will be a key factor. influences, demands and obligations can be exerted from numerous directions-for example, from international institutions, governments, state regulatory bodies, courts, professional associations, corporations, shareholders, trades union, litigants, ngos, the public and the media. 82 human rights are a particularly complex organisational risk. they encompass, but are not limited to, legal risk: that is, ( potential) claims and litigation for human rights law violations. rather, because human rights are more than human rights law, rights as an organisational risk are also about the capacity of human rights consciousness (as manifested, for example, in community group protests) to adversely affect the interests of the organisation. furthermore, for an organisation, risks exist in both engaging with, and rejecting, human rights. michael likosky, discussing the imperative of governments and private companies to manage human rights risks in joint projects, emphasises that organisations' risk-mitigation strategies will vary. for example: do they address the underlying human rights problem itself, making a project more respectful of human rights? do they discredit the ngo or community group campaign? do they negotiate with one ngo but not with another? do they assuage the concerns 80 in the public health emergency field, a wide range of influences, demands and obligations have the capacity to lead to the construction of rights as a risk. indeed, the cross-sector and cross-jurisdiction nature of public health emergencies (especially those of 'international concern') creates an especially complex governance landscape: distinct histories, cultures and agendas will be colliding in times of crisis when immediate responses are expected. in what follows, we outline a range of reasons why, from an organisational risk perspective, rights are likely to seen as a risk in the field of public health emergency preparedness. one obvious source of risk is the mounting number of human rights instruments and, as a result of increased litigation and the migration of legal arguments, the worldwide expansion of human rights-referencing case law. 84 the campaign to expand corporate liability for human rights violations is another source: although corporate opposition to new legally binding duties persists, this campaign has encouraged companies to commit to improved self-regulation. 85 another source is the human rights demands found within the conditional loan agreements between international organisations (such as the world bank) and recipient governments, or within the contractual and public procurement rules relating to the providers of public goods and services. 86 global health governance is also characterised by an increasingly influential role for hybrid and non-state actors, including ngos (such as médecins sans frontières), public-private partnerships (such as the global alliance for vaccines and immunisation (gavi)), and private foundations (such as the gates foundation). indeed, in evidence to a uk parliamentary committee, david fidler stated that: increasingly, the gates foundation is the first place people will pick up the phone to call; not the who. in fact, someone told me -and i do not know if this is true -that bill gates is now going to fly to indonesia to help intervene in that controversy over virus sharing. something has changed here. 87 in federal states, the legal relationship between federal and local government may constitute rights as a risk in the public health emergency field. on the one hand, a strong states' rights tradition can hamper, or be used as an excuse by, federal government in developing particular national preparedness measures. on the other hand, however, where federal government seeks aggressively to assert its power and interfere with protected human rights, a tradition of strong states' rights could be a bulwark against such abuse. 88 the levels of public trust in a particular national culture will also influence rights as risk perspectives. 89 lesley jacobs, in a study of the divergent uses of quarantine in hong kong, shanghai and toronto during the sars crisis, attributes the more extensive use of quarantine in toronto to the particular legal consciousness of senior public health officials: 'health security was weighed much more heavily than rights concerns . . . whereas in hong kong and shanghai there was much more of an even balance'. 90 but, even though there was dissent in toronto, courts and human rights bodies were not used to raise concerns about rights violations. one federal public health official has speculated that: the belief that the decisions about sars by senior public officials, provided that they had a legal basis, would be made fairly was so deeply ingrained among the public that there was little need to question or scrutinize those decisions. 91 jacobs's explanation for the non-use of courts is that legal avenues of redress might not be seen as appropriate 'where the health security of the community is at stake'. 92 from an organisational risk perspective, this phenomenon could be used as a reason to dismiss rights as a risk and, more specifically, to downgrade the need for rights protection in 87 house of lords select committee, above n 45, at 381. 88 medical law review [2009] preparedness planning and implementation. this, however, would be counter-productive. as james childress and ruth gaare bernheim have argued, 'public justification, deliberation, and other relationshipbuilding activities may be more important for biopreparedness than state power because they maintain and nurture civic ideals, cooperation, and trust'. 93 moreover, childress and gaare bernheim's argument can be extended to encompass the role of the private sector in sustaining public trust during an emergency. to give just one example: an employer's policy on matters such as job security has a very real capacity either to aid or to hinder the extent of voluntary compliance with quarantine requirements. but it is not just national cultures that merit attention in thinking about rights as risk: organisational cultures also 'shape how human rights are framed, interpreted and institutionalised'. 94 article 3(1) of the ihr states that implementation of the regulations is to be 'with full respect for the dignity, human rights and fundamental freedoms of persons'. the extent of internalisation of human rights within who is, therefore, crucial. little, however, is known about this as the organization has not been the focus of human rights or, indeed, regulation scholarship. 95 but it is obvious that the range of internal staff responses will play a significant role in the design, implementation and monitoring of any human rights-based policies. we can also speculate that any internal divisions on human rights will both increase who's own exposure to organisational risk and affect the handling of the specific human rights matter in question. consider, for example, galit sarfaty's study of interpretations of human rights at the world bank. comparing world bank investment projects relating to hiv/aids prevention in russia and saint lucia, sarfaty speculates on the reasons why different framings of the human rights dimension were adopted in each case: one reason may be that the project team was dominated by staff who prefer a cost-benefit analysis to a legal approach, and who concluded that funds would be better spent on other preventative projects. she also highlights two different core approaches to human rights among world bank staff: she labels the first 'instrumental' and the second 'intrinsic'. staff who adopt an intrinsic framework draw on either moral or legal imperatives and, overall, they see human rights in normative terms as an end in themselves. the instrumentalists, in contrast, see rights as a means to an end, using a functionalist, economics-driven rationale to determine whether, and how, human rights have value in any given case. we believe that thinking about 'rights as risk' should be a key aspect of human rights preparedness. human rights advocates need to recognise the growing significance of organisational risk and, in particular, the ways in which organisational culture intertwines with risk and rights. in addition, human rights needs to reflect on the emergence, from within its ranks, of the 'human rights risk strategist'. likosky, discussing public -private partnership infrastructure projects in different countries, highlights how governments and other organisations may aim to 'advance human rights interests for their own ethical or strategic reasons', and may therefore enter into negotiations and alliances with certain ngos. 97 human rights 'risk consultants', drawn from legal and other backgrounds, may also be employed by governments and organisations, to offer expertise on particular projects and human rights campaigns. looking specifically at the public health emergency context, it can be argued that who's new power under the ihr to use information about disease outbreaks provided by unofficial sources gives governments an added incentive to work with ngos and this, in turn, gives ngos increased influence. the end result is likely to be a mixture of human rights agendas, including-and this is the key point-human rights advocates adopting instrumentalist strategies and language (for example, urging the need to avoid 'business risk') in order to promote human rights protection. there is a lot for human rights advocates to address here. one question that needs to be asked is: are human rights risk strategists at work in public health preparedness projects and, if so, in what ways? are they, for example, picking up on the argument made by francis that it is not merely questions of justice within pandemic planning that demand attention but also the justice of pandemic planning: the triage choices in pandemic planning for the distribution of vaccines and antivirals are open, coordinated, and institutionally adopted. perhaps this is one reason why they have drawn so much attention. . . . no doubt there are other explanations, too, for the apparent assumption that devoting resources to pandemic planning is just. . . . nonetheless, there are serious questions of justice to be asked about the allocation of extensive resources to pandemic threats. 98 and, as they go on to point out, questions concerning the 'justice of' and 'justice within' pandemic planning are not unrelated. put shortly, if basic health care infrastructure is in a state of neglect or unavailable, if health professionals are in short supply or are not trusted by the population, and if there is inequality in access to primary care, then global surveillance, surge capacity and, more generally, preventing and coping with a pandemic will be all the more difficult. 'pandemic myopia', in other words, is a seriously flawed approach to pandemic planning 99 -which is surely something that human rights advocates (whether they see themselves as 'risk strategists' or not) need to be arguing as strongly and clearly as possible. there are other, broader questions too. these stem from the fact that rights as risk is not home-ground for human rights advocacy. put bluntly, it smacks of bad faith, of working on 'their' terms, not on 'ours'. being 'at the table', if that course is chosen, is not likely to be at all easy in practice. the counter-argument to this is that human rights advocacy has always been complex. 100 think, for example, of the diversity of human rights advocates (such as the us christian right at the united nations using human rights to argue against rights to sexual and reproductive health). 101 and it cannot be denied that human rights 'victories' have sometimes had unexpected, negative consequences: on occasion, they have been used by governments as a basis from which to claim that action has been taken and no further governmental action is required. it can also be argued that if deeper engagement with human rights by governments and other organisations (even if primarily through the lens of risk management) is a significant contemporary dynamic, then human rights advocates have little choice but to respond in some fashion. and it should not be forgotten that risk-based indicators and compliance strategies have also been growing areas of interest within human rights work. 102 lastly, there is, of course, the possibility that an organisation that starts out with an instrumentalist mindset towards human rights might ultimately internalise them to beneficial effect. overall, then, human rights advocates should not-and probably cannot-avoid engaging with rights as risk. one of the conclusions in the report of a recent uk parliamentary committee on infectious diseases and global health governance is that who needs additional funding 'if it is to be able to respond effectively to threats on behalf of the international community'. 103 this statement is a reminder of the importance, and the fragility, of public health emergency preparedness. it is likely that it will also be read, at least by some, as a rebuke to individuals, like us, who set out to critique preparedness when it is currently so precarious in practice. critiquing public health emergency preparedness is undeniably hard. who, in the end, would choose to be 'against preparedness'-especially when one considers the extreme human costs of recent public health emergencies? we are not against it, however. our argument throughout has been that critique is essential to preparedness and that, to date, critique from a human rights perspective has been in short supply. we have suggested a preliminary agenda to address the human rights gap, focusing in particular on the frames 'risk within rights' and 'rights as risk', and we assigned the name 'human rights preparedness' to the project as a whole. we concluded by turning inwards, emphasising that this project carries risks for human rights itself. specifically, critiquing preparedness could well involve self-critique as human rights advocacy works towards a more differentiated analysis of how security should be engaged and what it means to do human rights today. putting that another way, human rights preparedness-and, in particular, engagement with 'rights as risk'-is likely to be human rights without a safety net. human rights, terrorism and risk: the role of politicians and judges civil liberties law: the human rights act era see the discussion of uk and canadian national security cases in t poole regulation and administrative constitutionalism designs on nature: science and democracy in europe and the united states risk and human rights: ending slopping out in a scottish prison legal knowledges of risk' in law commission of canada risk, rights and public health emergencies infrastructure and human rights (cup a common law of human rights? transnational judicial conversations on constitutional rights the un human rights norms for corporations: the private implications of public international law between light and shadow: the world bank, the international monetary fund and international human rights law the new corporate accountability: corporate social responsibility and the law (cup risk, rights and public health emergencies pandemic planning and distributive justice in health care on the need to take account of social justice in pandemic planning, especially the needs and interests of the most disadvantaged, see the bellagio statement of principles globalizing family values: the christian right in international politics risk, rights and public health emergencies key: cord-339376-2dczotbh authors: everts, jonathan title: announcing swine flu and the interpretation of pandemic anxiety date: 2012-07-19 journal: antipode doi: 10.1111/j.1467-8330.2012.01021.x sha: doc_id: 339376 cord_uid: 2dczotbh this paper discusses the ways in which 2009 novel swine‐origin influenza a (h1n1) was announced and resonated with current pandemic anxieties. in particular, the us centers for disease control and prevention (cdc) are used as a lens through which recent pandemic anxieties can be analysed and understood. this entails a closer look at the securitisation of public health and the challenges and struggles this may have caused within public health agencies. in that light, cdc' formal entanglement with global health security and its announcement of the h1n1 pandemic are interpreted, followed by an ethnographically informed focus on various people who were engaged in the h1n1 emergency response and their practices and practical struggles in the face of pandemic anxiety. as it stands, the influenza a h1n1 2009 pandemic ("swine flu") is believed to have caused up to 25,000 deaths worldwide between early 2009 and august 2010, when the world health organization (who) announced the end of the pandemic. though the pandemic of the virus has been real and caused many tragedies, observers criticised the attention it received from politicians, global health agencies and experts. critics warned especially of the potential to exploit pandemic threats for fear-mongering and profit-making (gostin 2009; sparke 2009 ), overshadowing at the same time other long-term global health problems, often related to social inequalities (craddock and giles-vernick 2010; davies 2010) . with hindsight, the event of swine flu appears as a small event in respect to anticipated severity and death rates. nevertheless, public health officials and experts stressed their moral obligation to abide to the "precautionary principle" to prevent as much harm as possible even if that means taking some extreme measures, spreading anxiety and playing into the hands of the pharma industry (caduff 2010; gallaher 2009; michaelis, doerr and cinatl 2009) . however, swine flu was a global event, not just from an epidemiological perspective. it was exceptionally widely covered by the news media, inciting a broad range of responses by state and non-state actors, occupying the attention of millions of people for a greater part of 2009. responses included mass distribution of antiviral drugs, production and stockpiling of vaccines, mass slaughtering of pigs in egypt, quarantine for slightly feverish air passengers in china, restrictions and cancellations of flights to mexico, and asian import bans on pork products from the usa. each individual reaction contributed to swine flu as a global event of anxiety through intensifying and amplifying the sense of urgency in the face of this new infectious disease. due to the early emergence of novel h1n1 in north america, the us centers for disease control and prevention (cdc) were at the forefront of h1n1 emergency response. scientists working for cdc were among the first to identify the new microbe and to carry out substantial virological and epidemiological research (special issue of clinical infectious diseases 1 january 2011, supplement 1; dawood et al 2009). they informed the public, politicians, who and other public health agencies worldwide. put simply, the way the world initially learned about h1n1 was significantly shaped by cdc. from a social science perspective, its central role qualifies cdc as a powerful lens through which we can seek to understand h1n1's sudden rise to prominence and the ways it was dealt with. investigating cdc's h1n1 response may also shed light on the implications of a change in public health discourse, a change that made "emerging infectious diseases" a key concern for public health, the kernel of a new age of "pandemic anxiety" (ingram 2008) . for the purpose of this paper, i will employ the perspective of "anxiety as social practice" (jackson and everts 2010) . building upon schatzki's (2002) practice theory, the phenomenon of anxiety can be opened up to a much broader analysis since anxieties "are embodied and social, practical and practised" and like "other social practices, they are routinised, collective and conventional in character" (jackson and everts 2010:2801) . here, of particular interest is how anxieties become "institutionalised" and worked through within organisations (jackson and everts 2010:2799) . certain events engender anxieties specific to an organisation, overlapping with general concerns in respect to the event. events important to an organisation can threaten its meaning of existence, its legitimacy and its credibility. in the case of emerging diseases, pandemics pose a threat and challenge to public health agencies, creating anxieties over its reputation and expertise. although these latter anxieties are derived from pandemic anxiety, they are significant in their own right, shedding light on general anxieties pertaining to that specific organisation and its area of expertise. in the following, cdc's ways to work through the h1n1 pandemic are first contextualised within the emerging global health security regime and second analysed from a practice-based and ethnographic perspective. research conducted within cdc in early 2011, involving expert interviews, informal conversations and observation, provides the background for the findings presented. the aim is to use cdc as a lens through which we can, partially at least, understand the ways in which pandemic anxieties work. this entails a closer look at the securitisation of public health and the challenges and struggles this may have caused within public health agencies such as cdc. in the next section, a brief account of the securitisation of public health discourse is provided. then, cdc's formal entanglement with global health security and its announcement of the h1n1 pandemic are presented. this is followed by shifting the perspective onto various people who were engaged in the emergency response and their practices and practical struggles in the face of pandemic anxiety. scholars from the social sciences have identified significant changes in public health discourse since the early 1990s (collier, lakoff and rabinow 2004; davies 2010; elbe 2010; fidler 2004; king 2004) . the analytical kernel of this changing discourse is perhaps best captured by the term "securitisation" (fidler and gostin 2008:143) . here, securitisation refers to the observation that much of public health discourse has become organised around concerns over security rather than, say, humanitarianism or welfare. following elbe (2010:4) , we can distinguish analytically at least between four types of security relevant to the emerging "health-security nexus": national security, biosecurity, human security, and public health security. in terms of national security, king (2004; see also king 2002b) demonstrates how the discursive production of scales allowed us american scientists, public health agencies and journalists to reframe the international problem of emerging infectious diseases as a threat to american national security. by employing scale politics, eminent scientists in the field of virology, microbiology and epidemiology were able to provide answers to uncertainties arising from globalisation. by making emerging infectious disease the key challenge, enhanced laboratory practice and disease surveillance appeared as effective and nationally manageable countermeasures against the adverse effects of globalisation. this particular discursive strategy was effectively conveyed to politicians and journalists at the 1989 conference on "emerging viruses: the evolution of viruses and viral disease", chaired by eminent virologist stephen s. morse from rockefeller university. also highly influential was the publication of the report emerging infections: microbial threats to health in the united states (1992), presenting the views of a committee convened by the national academy of science's institute of medicine in 1991. the report became the blueprint for rapidly evolving literature and strategy plans on how to tackle the problem of emerging infectious diseases (king 2004:68-69) . public awareness was achieved through the media and journalist writers, since "the concept of emerging diseases offered journalists a powerful scalar resource for characterizing individual outbreaks as incidents of global significance" (king 2004:70) . both scientists and journalists added bioterrorism to the problem of emerging diseases (king 2002a (king , 2003 , emphasising once more the importance of emerging viruses to national security. from there it is only a small step to biosecurity, another security framework increasingly important to public health. for collier, lakoff and rabinow (2004) , growing concerns over bioterrorism and uncertainties in relation to new research possibilities culminating in the human genome project, provide the context of the "emerging biosecurity apparatus". the apparatus has as its main aim to "make life safe" through "attempts to monitor, regulate and/or halt the movements of various forms of life" (bingham, enticott and hinchliffe 2008:1528) . this entails a problematic justification for repressive internal politics as much as for new forms of imperial politics. as braun (2007:22) argues, biosecurity is "a set of political technologies that seek to govern biological disorder in the name of a particular community, through acts that are extraterritorial" (emphasis in the original). both emphasis on national security and biosecurity are deeply entwined and brought together through the terminology of global health security. in discussing pandemic anxieties, ingram (2008:75-76) identifies three main facets of global health security discourse: the emergence of the global as the definitive context for infectious disease; a tendency to locate causes, origins, and responsibility elsewhere and with others; and the emergence of global health security as a guise for the consolidation of hegemonic interests. notably, global health security discourse advances at the expense of other discursive formations, in particular that of human security and humanitarianism. following lakoff (2010) , we can juxtapose global health security and humanitarian biomedicine as two competing public health regimes. "humanitarian biomedicine" refers to the ongoing effort to mitigate existing health problems prevalent especially among poorer nations. in contrast, "global health security" focuses on "emerging infectious diseases"-diseases that have not occurred yet, for which one must be prepared, and which are more relevant to richer countries. "whereas global health security develops prophylaxis against potential threats at home, humanitarian biomedicine invests resources to mitigate present suffering in other places" (lakoff 2010:60) . similarly, davies (2010) argues: while the securitization attempt has meant that particular infectious diseases have reached the realm of high politics, a great number of communicable diseasesparticularly those that are most likely to remain in poor, low-income countries-are not receiving the same level of attention despite the fact that some of these diseases contribute to a greater number of deaths per year (davies 2010:135 ). in the same vein, farmer (1999:56) argued a decade earlier in respect to tuberculosis that "the degree to which this disease is seen as a threat varies with the degree to which the powerful-or, at least, the non-poor-are deemed to be 'at risk'". this particular mode of non-poor pandemic anxiety is deeply worrying in the view of critical scholars since the rich have powers to enforce various kinds of borders, through violence if necessary. as, for instance, price-smith (2009:31) argues, fear and anxiety generated by infectious disease are often most visible in "vicious persecution of minorities or of other polities" and "may even lead to the oppression of the people by a governmental apparatus of coercion in order to maintain the ideology of order and the 'interests' or the state". the 2009 h1n1 pandemic and pandemic threats such as severe acute respiratory syndrome (sars) and hpai h5n1 (avian flu) gave evidence to the various impacts of securitisation discourse. in discussing the canadian response to sars, keil and ali claim that "racism, infection, globalized urbanization are reshuffled into a new political frame of reference" since "racism, linked specifically to infectious disease and the bodies allegedly carrying it, structures biopolitical space of the sars crisis and requires that it be understood from the point of view of affected communities: east asians and those who were identified as such" (keil and ali 2006:30; emphasis in the original). the egyptian response to h5n1 showed another securitisation bias towards large-scale "modern" economies. the cull affected mainly rooftop and backyard poultry but restocking was in favour of large companies . securitisation also leads to more hierarchical "chains of command" and the centralisation of decision-making, as became apparent by the uk's response to h1n1 (chambers, barker and rouse 2012) . looking at public health discourse in the usa, we cannot neatly distinguish historically between a pre-securitisation phase and the current securitised one (fearnley 2010; french 2009; wald 2008 ). however, the 1989 "emerging viruses" conference and the 1992 "emerging infections" report seem to signify the beginning of an acceleration of a specific interweaving of public health and security discourse. from a cdc perspective, the tipping point was the anthrax scare that followed the 9/11 attacks. since then, cdc experienced a "culture shift", as my respondents phrased it. although us security politics were already attuned to the perceived threat of bioterrorism (king 2003) , anthrax gave the immediate impetus for changing the make-up of us public health organisations. and this was by no means only a discursive shift. since 2001, cdc was gradually reformed from a scientific branch of the federal government into an intelligence service supplementing national security and defence politics. this change was achieved through a great influx of retired military personnel who began work for cdc in various divisions. some became advisor to the director, which brought further changes to the organisational and spatial structure. cdc in pre-2001 years resembled a very large research institute or university, openly accessible to virtually everyone. however it has become more than ever a hierarchically organised agency with command structures, which resemble those of military departments; and cdc campuses are now fenced off and only accessible through security check points. within this emerging new organisational structure, two big pandemic anxieties were worked through before h1n1. while sars occupied cdc's attention in 2003, it was really h5n1 in 2005-2006 which had lasting effects on cdc's organisational structure and preparedness planning. from the research as much as the communications point of view, cdc looked good during h1n1 in 2009 (see below). as an explanation for this, some of my interviewees pointed repeatedly to the response structures that were built under the impression of h5n1: regarding h1n1, the awareness was already there and somehow we could tap into it. for h5n1, we did a lot of pandemic influenza planning and in every [us] state we had a conference about what needs to be done. and a year later, (with h1n1), we were able to turn that on. so, all the planning efforts paid off. preparedness planning also involved frequent exercises, which simulated cdc's emergency response in case of a new pandemic. when h1n1 began, "it was just like an exercise" as one epidemiologist put it and another stated, "we all flipped into exercise mode". swine flu was treated like a possible h5n1 pandemic. from an epidemiological and medical point of view, concerns are still in order over h5n1 developing into an easily spreading human-to-human infection with mortality rates over 60%. such a devastating prospect justifies augmented surveillance of emerging viruses and provides an important context for the rapid detection of novel h1n1 and subsequent response. however it was not only exercises that primed, cdc experts for the next pandemic. according to cdc epidemiologists, various cases of novel influenza a (h1n1) were investigated in the years before the actual outbreak in 2009. the background to this was the position statement by the council of state and territorial epidemiologists (cste) that made all novel influenza a viruses nationally reportable in 2007 (cste 2007) . in particular, the position statement from cste requires that "state and territorial epidemiologists in conjunction with public health laboratories will report to cdc all human infections with influenza a viruses that are different from currently circulating human influenza h1 and h3 viruses", including viruses "that are subtyped as non-human in origin and those that are unsubtypable with standard methods and reagents" (cste 2007) . this step was justified on two grounds. first, any novel influenza a virus could "signal the beginning of an influenza pandemic" and, in turn, "rapid detection and reporting" would "facilitate prompt detection and characterization" and "accelerate the implementation of effective public health responses". second, the usa had formally accepted the revised international health regulations 2005 (who 2008) in 2006. the new regulations demand its member states to notify the who on various events detected by national surveillance systems, among them cases of "human influenza caused by a new subtype" which are deemed-among others (smallpox, polio, sars)-as "unusual or unexpected and may have serious public health impact" (who 2008:43) . since the position statement of the cste was issued (9 july 2007), a team of cdc epidemiologists investigated all reported cases of novel influenza a viruses in the usa. these investigations became routine. most of the time, children contracted a (h1n1), suffered from flu symptoms and recovered. field investigations could confirm in most cases that children had been to a country fair or farm where they were exposed to live animals, especially pigs (cf shinde et al 2009) . that was also the assumption that accompanied the investigations of the very first cases, a boy and a girl aged 10 and 9, respectively, of novel h1n1 in southern california in mid april 2009 despite "rumours" within cdc about what was happening in mexico. the mexican general directorate of epidemiology (dge) reported during 1 march to 30 april a total of 1918 suspected influenza cases, including 97 confirmed cases and a total of 84 deaths. suspected and probable cases were reported from all 31 states and from the federal district of mexico and were identified in all age groups. nevertheless, to cdc experts, the mexican events seemed to be locally isolated, possibly caused by an influenza b virus. at first sight, the cases in california had no connection to mexico and the investigating team did not fear any significant further spread. only when a case in texas was reported on 22 april just a few days after the two cases in california did cdc epidemiologists begin to consider the likelihood of a connection to the events across the border. laboratory testing on the behalf of cdc confirmed on 21 april 2009 the presence of the novel virus 2009 swine influenza a (h1n1) (cdc 2009a; first posted as a morbidity and mortality weekly report early release on the website on 21 april). cdc acknowledged the "epidemiological characteristics" of novel h1n1 and recommended monitoring of public health practices "in anticipation of a possible pandemic" (cdc 2009a) . the connection to what was happening in mexico was officially recognised by cdc on 30 april 2009: "patients were infected with the same strain" (cdc 2009b). significantly, this acknowledgement came 5 days after director general of who, margaret chan, "declared this event a public health emergency of international concern". 1 swine flu was by then already addressed on a global scale, following the guidelines of the recently revised international health regulations. 2 from a cdc perspective, who did not wait for three subsequent generations of infections and thus made its announcement too early. cdc experts took another 2 weeks of research before calling h1n1 the "greatest pandemic threat since the emergence of influenza a (h3n2) virus in 1968" (dawood et al 2009). announcing swine flu met certain criteria that justified the choice of terminology. a new pathogen had been identified, its spread verified by connecting cases in different places and its origins classified as a new and as of yet unknown combination of viral genotypes that resulted from previous microbial traffic between birds, pigs and humans. however, before the actual work that led to detecting h1n1 took place, pandemic anxiety and institutionalised heightened concerns had already worked their way through to cdc experts via global and national public health security recommendations and regulations and the announcements made by respective representatives. from this perspective, institutionalised pandemic anxiety pressed public health organisations to announce swine flu as significant global event as soon as possible. judging from the resources and work put into h1n1 emergency response, organisations such as cdc had to play along. however, shifting the focus on the people whose work was critical in turning novel h1n1 from an unknown viral agent into the global event of swine flu, we find a more complex and less straightforward process. in particular, the pressure on a public health agency such as cdc arises from multiple directions and dealing successfully with those pressures involves a host of creative strategies. in the following, both pressures on and strategies by cdc experts during h1n1 will be analysed to provide a more nuanced account of the entanglement of pandemic anxieties and expert practice. the change in perspective is mirrored in a change of language. in the vein of ethnographic writing, the voices of both the author of this paper and the respondents at cdc are foregrounded, allowing for a deeper and more personal account. since recording of interviews was not possible, quotes are taken from fieldnotes and conversation protocols written down after conversations took place. accuracy was one of the terms that i heard frequently during my stay at cdc. it was specifically used in the sense of accurate data or "i need to make sure my data is accurate". as a scientific branch within the us government, to obtain, gather and provide accurate data presents a legal as much as a moral obligation for cdc. that was reflected in personal conversations i had through comments such as: "we speak with the voice of the us government. we need to make sure everything is 100% right"; "we are just like who or the red cross, people trust us, the cdc doesn't lie." however, frequent use of the term accuracy suggests that the term signals not only an obligation but also a key challenge. even at times with rapid data-processing technology, the process of gathering, managing and interpreting data is a time-and resource-consuming affair. hence, at first, i thought the term accuracy was being used as an indicator for the problem of lacking time and other resources. but that was only part of the explanation. the "white house theory" makes a good entrance route for clarifying the accuracy anxiety. in one group discussion, it was pointed out that "there is this theory, the white house could come in any time, asking for information, 'how bad is it'." based on this common assumption, everybody within cdc knows that information and data have to be ready at hand. this is especially the case when the emergency operations center (eoc) becomes activated as happened during h1n1. during emergency response, "time is compressed . . . everything is happening faster", as one of my respondents phrased it. another person i talked to, who was not a regular member of the eoc team, explained: "they don't want to be caught off guard, they want to show they take everything seriously, that they go all guns at all events." this was backed up by similar comments that stated that there was "certainly the anxiety [at the eoc] to look foolish" and that "being blamed for not doing . . . enough is probably one of the worst fears of the eoc." during the h1n1 response, time compression became a challenge for all involved in data gathering, processing and visualization. epidemiologists were the first ones to experience exceptional pressure: "the struggle really is to stay updated. there's not any other system with this time schedule. and we get the pressure from hhs [united states department of health and human services] and washington. and especially with h1n1 we had that." in effect, the pressure was not only to provide data as quickly as possible. it was furthermore to provide high resolution data: "it was the first time really cared in that detail, there were new demands for data on a more detailed level. you see, by and large, people are not interested in flu, it just happens, they think. and suddenly, they wanted all this detailed information." one of the most pressing needs for assessing the h1n1 situation became acquiring data of influenza-like illnesses (ilis) throughout the united states. this, it was hoped, would yield important insights into the spread of the disease, its demographics and the localities most in need of mitigation measures. because of the federal character of the usa, ili data are gathered in aggregate numbers on the state level and shared on a weekly basis. if cdc wants more detailed information (down to the day and county level), they need to call up the states individually. thus, the emergency response team during h1n1 had to call up all the states to get the latest data. in processing and visualising these data, a number of divisions were crucial. one of them produces maps based on those data. from my conversations with cdc cartographers it appears that during h1n1, requests for maps were scheduled within a 30-min time frame. the demand for new, timely and detailed data and the visualisation thereof thus progresses through the various branches within the organisation, making time compression an issue for hundreds of experts involved in emergency response. time compression has a bearing on people's work experience during emergency response. they need to cope with constant demands for new products, which have to be ready within minutes rather than hours. but this does not seem to be the key concern of those involved in emergency response. in the case of epidemiological maps, for instance, they were able to produce maps at very short notice within minutes thanks to thoroughly developed templates and software. the problem however lies within the time allocated for checking the data for possible flaws, "to make sure my data is accurate". working within emergency temporality, the real challenge lies in providing accurate information as fast as possible. as indicated by the above quotes about cdc's obligation, there is no allowance for communicating any faulty information. people working within cdc are well aware of the consequences that even slightly incorrect data can have. thus, within their obligation to provide information that is "100 percent right", cdc experts feel the need to resist all demands for timely data until they have carried out at least a few routine checks for data accuracy. this leads to elongated duration between demands for new data and their presentation. that little extra time-indicating the resistance of cdc scientists in presenting unchecked data-forms the core of a principle conflict between those who pass along the pressure for new information generated by "the white house" and the experts and scientists who provide this information. from an epidemiologist's point of view, those representing the governmental side within emergency response do not recognise the vital importance of the time lag between the demand for data and dissemination: "it feels as if they think we're withholding data or information." indeed, talking to other people at cdc, comments were made that suggested that reluctance from cdc experts in providing data as quickly as possible is frowned upon. during h1n1, this general suspicion was apparently augmented by a lack of reported severe cases within the usa. once the connection to h1n1 cases in mexico became apparent, swine flu appeared as a deadly new disease. but from the epidemiologists' point of view, "as long as you don't know how many people got sick, the population denominator, you cannot say whether the mortality rate is high or not". although cdc sent an already established team to mexico that began counting cases and creating statistics, "the question from white house was, why were there virtually no reported cases in the us". according to cdc epidemiologists, hospitalisation rates in the usa were monitored closely but at no time was the threshold passed that would have led to an automated alert message. therefore, epidemiologists "felt put under microscope"; why did they not get any alerts despite all the sophisticated surveillance and report systems? did they overlook the cases? in my view, this moment represents the point when cdc scientists were at their weakest position. increasingly, their role as rightfully proclaiming scientific truths became more and more questioned. however, they were able to turn their perceived weakness into a powerful resource. since routine surveillance data appeared insufficient, money for thorough case studies research was successfully acquired. among the very first field investigations was the survey of the entire student population and faculty of the university of delaware, altogether around 20,000 people. taken together, infections were confirmed in 10% of the survey population, no deaths. in terms of the feared severity of the disease, the findings from this and very similar studies brought hope. if this had been a re-run of the infamous 1918-1919 pandemic, the delaware study would have revealed around 20 deaths; especially since young adults were the age group hit hardest by h1n1. the information from this case study and others was published by the new england journal of medicine on 7 may 2009 (dawood et al 2009). with hindsight, the publication of this paper at a very early stage of the pandemic was described by some of the authors as the most successful move during the unfolding pandemic, to communicate the very first findings and inform the public. as one of the authors said, they were able to "do a lot of really good work" during the beginning of h1n1. it seemed as if there was "no time to do it" but they "cranked the scientific work out, despite how horrible things were". only 2 weeks after the first call informing them about the first cases in california, they had their article accepted by the new england journal of medicine. the article is mainly concerned with epidemiological core concerns (demographics, symptoms, severity, hospitalisation rates, nucleotide sequencing). though being very cautious in the interpretation of their findings, the authors state in their discussion section that to date they are not encountering a disease in the usa that would justify exaggerated concern since "most confirmed cases of s-oiv infection have been characterized by self-limited, uncomplicated febrile respiratory illness and symptoms similar to those of seasonal influenza" (dawood et al 2009:7) . this is confirmed by comments made by others at cdc about their relief and receding worry already a few weeks after the first occurrence of swine flu, in particular after case studies showed the limited numbers of serious complications due to the novel virus. however, work for cdc epidemiologists and all other divisions involved in the response did not stop there. from then on, important decisions had to be made, including the definition of risk groups and distribution of antivirals and development of vaccine. nevertheless, the critical moment had passed; cdc experts had successfully demonstrated their ability to generate relevant knowledge and information within a very limited timeframe. nevertheless, pressure on cdc experts did not ease and arose from other directions. on 6 may 2009, a 33-year-old pregnant woman died from complications due to h1n1; one of the very first deaths from swine flu in the usa. this tragic case illustrated that h1n1 had the power to kill despite the generally mild symptoms it generated in most patients. from the news media point of view, the ability to kill young women and children made swine flu even more hideous-and more compelling. thus, another challenge to cdc arose from the way swine flu appeared in the headlines of the news media and the stance cdc was trying to convey. within cdc, risk communication has become an important area of concern since the early 2000s. as one of the eminent cdc risk theorists stresses, we can identify certain patterns in which the "media behaves in a crisis": the media, those are only humans as everyone else. first they look at their own safety and are concerned. but once they figure out, it's not that bad for me, they begin to look for the sensation in the event. we were fortunate enough that we never had an outbreak of hemorrhagic fever (ebola) in the usa. at the same time, you notice how the media are fascinated by threats that are grotesque but distant. and it creates scares. but i know if we had an outbreak of ebola here, the whole tenor would be different. so the more distant, the more the media compounds something, the more real the threat, the more they will look for reassurance. however, the trouble with swine flu was that it was not a distant or rare and grotesque disease but it was there and widespread. thus, following the pattern identified by cdc's risk communication expert, we would expect a more responsible and reassuring media approach. but since swine flu was already pronounced to be in general mild in early may, sensationalism still became an issue for cdc scientists and communication experts. from the scientists' point of view, when in a response situation, the challenge is to strike a balance between informing the public on the one hand and to "resist the media who call all the time and ask what's new" on the other: they want quick and accurate information. but we cannot be irresponsible. we need to make sure our data is accurate, our data is valid. and then we can craft a message. and that means that even if the cnn wants to know every hour what is happening, that's too frequent, and then the information is sloppy. that would be irresponsible, especially since the health of people is at stake here. once again, the struggle seems to be over the speed of information and the accuracy of data. however, there is another aspect that becomes more prominent within cdc's engagement with the media. again from a scientist's point of view, the media appears sensationalist. although they provide the media with a lot of detailed information, what actually makes it into the news seems to be driven by sensationalism: you never really know what the press is interested in. you can give them all this information and all they would talk about is this one boy . . . who died shortly after vaccination. and of course, every single death is a tragedy but we are worried about the major changes. the media is all sensational, they have the family and the one death and that's their product and they sell it like a product. from this point of view, cdc scientists try to strike a balance between using the media as an important tool for conveying urgent information to the public but to be reassuring at the same time: "we think about it, whether something causes alarm or brings reassurance. and we try to convey reassurance. we want to bring out the scientifically most accurate data, turn it into a digestible format and reassure. the government should not be alarmist. it has to be reassurance." just as scientists are anxious to strike a balance between information and reassurance, cdc communication experts take the same approach: "we were very careful in striking the balance; we did not want people to have no concern and as well we did not want to be the cause for concern." but how can such a balance be achieved? what i deduce from my conversations with experts, the communication strategy is complex and works on many levels but one aspect came up repeatedly and is possibly the main technique harnessed for striking the balance between raising awareness and conveying reassurance: we're not just gathering data and display the data itself. we do much more than that. we put the data into context; demographics, population characteristics, infrastructure . . . c 2012 the author. antipode c 2012 antipode foundation ltd. i remember when we had this map with the deaths of children. that was not reassuring. people only see the number, and children dying. so we try and craft a language around it and to put it into context. putting data into context is an important strategy for cdc experts dealing with the media. from a communication expert's point of view, "we've done a pretty neat job [with h1n1]-we had done enough in showing what it is and what it does". similarly, scientists were pleased how cdc handled the media and expressed that "the agency did a great job in controlling the media during h1n1". following lakoff (2010) in his analysis of the revised international health regulations (ihr), making many different disease events reportable to who was one of the key innovations in establishing a global disease surveillance system. the new ihr was developed over concerns that nation states would try to hide outbreaks from the international public over fears they could have negative effects on trade and tourism. credibility to these concerns was lent by the way the chinese government initially handled the sars crisis. part of the new strategy epitomised by the altered ihr was to integrate the media into global public health surveillance by adding media reports as one source of relevant information over disease outbreaks to the established reporting by health authorities. but even though it seems as if global health security and news media had forged a successful alliance, my examples from cdc's struggle with the media during swine flu suggests that this alliance is contested in practice. particularly interesting is that from a cdc perspective, there is almost a race between the media and cdc of who knows first: "the media knows it at the same time as we do and we need to gear up for response as fast as we can". in order to stay ahead of the game and to have sufficient time to "gear up" before the first media calls get in, cdc experts developed other tactics of early detection that do not rely on the media: so what we do, for example, we get the data from the pharmacies about over-thecounter drugs such as tamiflu and absenteeism from school and prescriptions from doctors and the ili data. so that is real-time data and it is by place too. so say we have a huge rise in tamiflu sales and you see it on the graph, your line is going up and then you look at absenteeism, and the graph is going up as well and so on, you start to think, well, maybe something's going on here. it's not conclusive but you have some evidence that something is happening. so you go to your flu experts and tell them, there is a cluster, maybe this is a new breakout. and maybe it's not. that's what you need to find out then. . . . the aggregate tells you more than a single information. . . . you need to track the key indicators. . . . you only need four or five indicators but you'll be months ahead if something is happening. this mode of surveillance is entirely decoupled from the media and is designed to even outrun more traditional ways of detecting new diseases such as routine laboratory investigations. crucially, each data source does not tell much on its own. only "data fusion"-the aggregate information-can provide enough evidence for concern. another way of getting real-time information was installed through a 24-hour toll-free hotline. people can call there about anything and any topic. as one communication expert told me, "for cdc, this information is a canary in the coalmine". interestingly, concerned people who call cdc for information become themselves informants and a crucial role in cdc's early warning systems. this is also true for the cdc website and services provided through social media feeds. within cdc, a web metrics report is created daily. the report includes the most popular pages and how people did come to that site and it is understood as a part of cdc's surveillance. according to an analyst, "h1n1 had some really interesting metrics". they had 8 million page views in one day. the highest traffic ever seen before was half a million. from these data, growing awareness and concern could be deduced. but not only this, the analysis of traffic to the website also reveals the locations of those viewing the website: "you can show where people were concerned. [during h1n1] we had this huge pipeline to our website from china and japan so we knew these are the next affected regions. same thing with h5n1 when we got a lot of traffic from european countries to our website." to make the most out of cdc's website popularity, visitors are also asked to complete a short questionnaire: we have this section on our site "tell us what you think". we get a lot of information from that. we get actually more feedback than we can analyze but we try to read all of it. during h1n1, we did an eight months survey of 3,000 people . . . we have a four question survey on our website, it takes maximum five minutes. it asks about what was the reason for you recent visit, who you are, why are you coming. from that information, cdc is able, among other things, to define target groups for their communication strategy. this strategy relies on a more and more diversified approach. while the importance of "traditional" tools from leaflets to print media is still recognised, online tools and the social media become increasingly significant: right now we prepare information for twitter . . . during h1n1, we gained almost one million followers in the first week. since then it's grown only around 30%, so that was a teachable moment. other tools are popular too, widgets, or badges. the email updates were very popular during h1n1. once again, the information sought by others through twitter, email updates or website surfing is turned into a source of real-time information about what, where and what kind of people are concerned. cdc communication experts use this information to tailor and craft messages for specific target groups. according to cdc risk experts, the public needs advice that comes in "manageable bites". instead of asking too much (eg staying at home and taking weeks off of work etc), "you need to do it in baby steps". for h1n1, the most important message was vaccination: as a public health agency, our default message is, go and get vaccinated. our focus was early on to inform the risk groups well, those people who were at the highest risk in terms of death and disease rate. and that was pregnant women. early on we knew this was our main target group and we could craft our messages carefully for this group. to do that, we worked with our partner groups (physicians, nurse groups and so on) and we got the people together for discussing our communication strategy. we took mainly what the media was already saying and crafted messages that would say you shouldn't be around sick people and the obstetricians backed that up and made clear that the vaccine is safe. and if you split the vaccination rate by groups, you can see how effective we were: the vaccination rate for pregnant women was 70 to 80%. this shows we got the message through. so we were quickly able to adverse events early on and to monitor in real-time what the effects were. sometimes, the cdc communication team had to be even more active then "just" disseminating what they had: with h1n1, we had a misinformation quest. there was this anti-vaccine blog that was recommending not to take the vaccine, mainly saying it wasn't effective. so we were able to address this and funnel specific information there. it's hard to tell whether it worked or not. maybe the supply was more of a problem than the vaccination rate and i think the rate was pretty high, especially among the targeted risk groups. and yes, the blog in question toned down their language. i mean, they didn't stop what they were doing but they were less general and more informative. once again, cdc's strategy was successful by its own standards. they provided information to the public via many different channels and vaccination rates showed that they "got the message through". regarding cdc's response to h1n1, former cdc director david j. sencer commented: perhaps the primary lesson learned from this pandemic will be that while decision-making is always risky, that risk can be minimized through effective communications . . . [o] n balance, the response has been a success and so far, the ultimate test of management has been met: no one has been fired (sencer 2011:s6-s7). on the grand scale of nations and supranational organisations, pandemic anxieties are met with securitisation efforts, entailing practices that install or enforce centralised chains of command, emphasise territorial borders and advocate restrictions of movement. on the scale of public health agencies such as cdc, pandemic anxieties resonate with other, "institutionalised" anxieties. in the case of h1n1, at least three anxieties at cdc were crucial: anxieties over the quality or "accuracy" of data; anxieties over how to deal with the media and striking a balance between raising awareness and not being alarmist; and anxieties over staying informed and being the first ones to know. these anxieties are neither new nor foreign to pre-securitised public health. nevertheless, pandemic anxiety certainly augments these "institutionalised" anxieties and makes them more pressing issues. they need to be worked through by employing various strategies and practices. the sense of urgency engendered by pandemic anxiety creates time compression for those involved in emergency response. over fears that speed threatens to compromise the validity of scientific data, resistance to constant calls for new data becomes a vital strategy. by putting the data into context, public health and communication experts try to "get the message through" without creating panic or giving the media reason for alarmist reporting. staying informed and the need to be the first ones to know is achieved through ever more sophisticated surveillance systems. at times, the new systems turn around the relationship between those who seek information and those who provide information: by registering for any cdc alert service or calling the hotline, cdc gets crucial information about emerging health-related worries and its whereabouts in real time. the latter practice of creating more sophisticated surveillance systems feeds back into general pandemic anxiety. the more early detection tools are installed, the more instances of worrying information will be gathered. this in turn contributes to calls for constant vigilance that are met with further securitisation efforts. it is difficult to say whether this is necessarily a "vicious cycle". taking the view from within cdc, securitisation has brought about changes for better and worse. being more attuned to the need for real-time data and the need to be constantly aware of emerging threats is certainly nothing that troubles public health experts and scientists as such. as one respondent phrased it: "preparing for the worst is a good thing to do and nothing that should be incriminated . . . [it]'s part of the job, always foreshadowing what could happen but without being sensational . . . [the problem is], in the ensuing discussion, hindsight seems to be more important than good decision-making." however, as we have more and better technologies at hand that help us to become aware of harmful emerging ecologies such as the changing territories of new infectious diseases, it is very likely that the chain of pandemic anxiety events proliferates and intensifies. promoting a critical understanding of how pandemic anxieties work can help in evaluating their importance. historically, slower modes of detection meant that awareness of the emerging threat was perhaps closely related to actual fatalities. nowadays, we are already aware of the potential threat before we have seen what course it will take. under these circumstances, pandemic anxieties are more and more likely to be based on anticipating the characteristics of the new pathogen rather than actual disease and deaths. thus, the new powers derived from rapid detection technologies need to be critically appraised since we have not yet developed a pragmatic culture of living with constant emergency. who.int/en/what-we-do/health-topics/diseases-and-conditions/influenza/pandemicinfluenza/about-pandemic-phases, accessed 7 july 2010). biosecurity: spaces, practices, and boundaries biopolitics and the molecularization of life public prophylaxis: pandemic influenza, pharmaceutical prevention and participatory governance swine influenza a (h1n1) infection in two children-southern california outbreak of swine-origin influenza a (h1n1) virus infection-mexico reflections on the uk's approach to the 2009 swine flu pandemic: conflicts between national government and the local management of the public health response biosecurity: towards an anthropology of the contemporary london: earthscan cste (council of state and territorial epidemiologists) (2007) national reporting for initial detections of novel influenza a viruses. council of state and territorial epidemiologists position statement 07 cambridge: polity dawood f, jain s, finelli l et al; novel swine-origin influenza a (h1n1) virus investigation team (2009) emergence of a novel swine-origin influenza a (h1n1) virus in humans toward the medicalization of insecurity. cambridge: polity farmer p (1999) infections and inequalities. the modern plagues biosecurity in the global age: biological weapons, public health, and the rule of law towards a sane and rational approach to management of influenza h1n1 2009 influenza a (h1n1) and pandemic preparedness under the rule of international law securing life: the emerging practices of biosecurity aldershot: ashgate institute of medicine (1992) emerging infections: microbial threats to health in the united states anxiety as social practice c 2012 the author. antipode c 2012 antipode foundation ltd multiculturalism, racism and infectious disease in the global city: the experience of the 2003 sars outbreak in toronto dangerous fragments security, disease, commerce: ideologies of post-colonial global health the influence of anxiety: september 11, bioterrorism, and american public health the scale politics of emerging diseases two regimes of global health novel swine-origin influenza a virus in humans: another pandemic knocking at the door the site of the social: a philosophical account of the constitution of social life and change swine-origin influenza triple-reassortant swine influenza a (h1) in humans in the united states from global flu to global health swine flu c 2012 the author. antipode c 2012 antipode foundation ltd many thanks to the people at cdc who were kind enough to show me around and answer my questions; the editor rachel pain for her motivation and patience; and the four anonymous reviewers for their insightful comments. the research was made possible by generous support from dfg (german research foundation). key: cord-352546-w3catjj3 authors: degeling, chris; johnson, jane; kerridge, ian; wilson, andrew; ward, michael; stewart, cameron; gilbert, gwendolyn title: implementing a one health approach to emerging infectious disease: reflections on the socio-political, ethical and legal dimensions date: 2015-12-29 journal: bmc public health doi: 10.1186/s12889-015-2617-1 sha: doc_id: 352546 cord_uid: w3catjj3 background: ‘one health’ represents a call for health researchers and practitioners at the human, animal and environmental interfaces to work together to mitigate the risks of emerging and re-emerging infectious diseases (eids). a one health approach emphasizing inter-disciplinary co-operation is increasingly seen as necessary for effective eid control and prevention. there are, however, socio-political, ethical and legal challenges, which must be met by such a one health approach. discussion: based on the philosophical review and critical analysis of scholarship around the theory and practice of one health it is clear that eid events are not simply about pathogens jumping species barriers; they are comprised of complex and contingent sets of relations that involve socioeconomic and socio-political drivers and consequences with the latter extending beyond the impact of the disease. therefore, the effectiveness of policies based on one health depends on their implementation and alignment with or modification of public values. summary: despite its strong motivating rationale, implementing a one health approach in an integrated and considered manner can be challenging, especially in the face of a perceived crisis. the effective control and prevention of eids therefore requires: (i) social science research to improve understanding of how eid threats and responses play out; (ii) the development of an analytic framework that catalogues case experiences with eids, reflects their dynamic nature and promotes inter-sectoral collaboration and knowledge synthesis; (iii) genuine public engagement processes that promote transparency, education and capture people’s preferences; (iv) a set of practical principles and values that integrate ethics into decision-making procedures, against which policies and public health responses can be assessed; (v) integration of the analytic framework and the statement of principles and values outlined above; and (vi) a focus on genuine reform rather than rhetoric. the recent ebolavirus (ebov) outbreak in west africa and continuing human infections with a novel h7n9 influenza a virus in mainland china are salient reminders of how human and nonhuman health are inextricably linked. nonhuman animals are the source of 70 % of emerging and re-emerging infectious disease (eid) threats to human health [1] , and more than half of all established human pathogens [2] . the threats posed by eids are dynamic. eids are caused by pathogens that can change their behaviour over timeeither through genetic modification or through changes in the patterns and pathways of transmission [3] . social, economic and political systems can either promote or inhibit pathogen transfer, and the incidence and pathogenicity of the disease [4] . while a lack of data makes quantitation difficult, eids and zoonoses account for a significant proportion of the global disease burden [5] . eids and emergence of zoonotic pathogens, including human immunodeficiency virus (hiv), are direct causes of an estimated 15 million deaths worldwide each year [6] . a one health approach is increasingly considered to be the most effective way of managing eid threats [7, 8] because it represents an acknowledgement of certain facts about the nature of disease, which are then deployed to structure the response. one health is grounded in a recognition that human, animal and environmental health are interdependent [9] , that animal species provide a shared reservoir for pathogen exchange and spread, and that many eids are driven by varied and dynamic human-animal interactions [9, 10] . the response one health offers is to deconstruct the disciplinary silos [11] which have separated biomedical and social sciences devoted to the study of human disease from those devoted to nonhuman disease and ecological concerns [12, 13] . inter-disciplinary research is called for and required, as is interventionist practice at local, national and international levels involving: policymakers, planners, regulators, physicians, veterinarians, ecologists, public and animal health officials, environmental health officers, microbiologists, and other allied natural and social scientists [10, 14] . although principally associated with eid prevention and control, one health is also relevant to prevention and control of endemic and zoonotic animal diseases, as well as securing food safety [15, 16] . considering the magnitude and complexity of global issues surrounding infectious disease and food security, the one health approach has the potential to provide the creative, effective and sustainable solutions required. despite its strong motivating rationale, implementing a one health approach can be challenging. dealing with eids in an integrated and considered manner can be highly problematic, especially in the face of a perceived crisis. in this paper we examine the socio-political, ethical and legal considerations implied by a one health approach to eids. first we describe how a one health approach could galvanise and enhance current capacity in eid prevention and control. making reference to case examples, we then identify and characterise sociopolitical, ethical and legal concerns that have the potential to limit the effectiveness of one health interventions. finally, we draw on this data to provide guidance as to how these concerns and issues might be addressed, and point to remaining challenges to the likely success of the one health approach to eid control and prevention. in order to explore the broader implications of a one health approach we employed philosophical and qualitative methods to map existing and potential scientific, ethical and political responses to eids in australia and our region. the overarching philosophical approach is that of developing sustained arguments that critically analyse the existing literature and reconceptualise or refine key concepts. this conceptual information is often observed in exemplars and paradigm cases. in particular we focused on materials pertaining to the social, political and ethical consequences of responses to the risks posed to human health and wellbeing by hendra virus [hev], nipah virus [niv] and rabies virus [rbv] in australasia, and compared them with international responses to canonical examples of pandemic and food borne zoonoses severe acute respiratory syndrome (sars) [17] and bovine spongiform encephalitis/variant creutzfeldt jacob disease (bse/vcjd), respectively. a synopsis of the characteristics and burdens of these diseases and the pathogens that cause them are outlined in boxes 1 and 2. because our aim was to generate inductive insights and develop a robust set of argumentsrather than a comprehensive catalogue of every case example or publicationthe sample evolved iteratively from searches of textual sources such as publicly available international (e.g. who) and government reports; academic databases (e.g. pubmed); online/print news services (factiva); organizational newsfeeds (centers for disease control); and the websites of major one health collaborations [18] . materials in the sample were read and qualitatively reviewed through an iterative process of testing, revising and refining our definitions, principles and theoretical generalisations [19, 20] against the emerging conceptual map and feedback from the research team. led by the first author, this cycle of searching, mapping and critical analysis continued until a period where new textual materials were not providing substantive new insights and the team was confident that a position of conceptual saturation had been achieved. in what follows we draw on these analyses and reflections to describe the content, context and nature of the challenges that need to be faced for the effective implementation of a one health approach to eid control and prevention. findings eid prevention and control strategies require a one health approach one health is a holistic approach that emphasizes, but is not restricted to, the need to understand and regulate the environmental context (human-animalecosystem interface) of disease emergence and expression [21] . eids are characterized by their complexity and uncertainty as to their causes, consequences and likely solutions [22] . in broad terms, the occurrence and cross-species transmissibility of many emerging pathogens, like ebolavirus (ebov) and h7n9, arise from human activities such as changes in land use, growth in global trade and travel and intensification of animal husbandry practices [23] [24] [25] . the speed with which our understanding of the biology and epidemiology of h7n9 has developed demonstrates how much our ability to respond to new eid threats has improved over the last few decades. yet despite advances in immunobiology and genomics that have contributed to diagnostics, therapeutics, and vaccine development, the threat of eids to human health and community wellbeing persists. part of the reason why eid threats remain in spite of scientific advances, are that eid events are not simply about pathogens jumping species barriers. the threats posed by eids are comprised of complex and contingent sets of relations that involve socioeconomic and sociopolitical drivers and consequences, with the latter extending beyond the impact of the disease. the social, cultural and economic impacts of zoonoses are significant. the examples contained in tables 1 and 2 demonstrate the difficult balance between the human health risks and socioeconomic and cultural costs of eid control [26, 27] . policy decisions should be based on sound evidencebut it is often the case in dealing with eids that the evidence required is absent or fluid. eid events are often dynamic situations that are characterised by uncertainty. as events unfold new evidence is created. consequently decisions made on the basis of present data can be seen as wrong in the future, as more evidence and a better understanding emerges. official reviews of canonical eid events such sars [17] and bse/vcjd [28] share two key findings: (i) that actions to reduce risk should not be predicated on scientific certainty; and (ii) that policies to deal with the risks and effects of an eid need to be founded on widely held values, so that people understand, in advance, the kinds of choices that will have to be made. this suggests that the one health approach needs more than inter-sectoral collaboration and robust health legislation, as the unique nature of eids critically limits the effectiveness of scientific, top-down and technocratic approaches to governance [29] . hendra virus infection is endemic among at least two species of flying fox in australia and causes rare, but catastrophic, human infection [85] . loss of habitat has led to increasingly intense incursions of flying foxes into populated rural and peri-urban areas and promoted the 'spill-over' of hendra virus into horses and then to people [86] . hundreds of people have been directly exposed to hendra virus, with seven confirmed human infections and four deaths since 1994. with over one hundred dead horses and persistent risk, the emergence of hendra has had significant impact on equine and tourist industries in north eastern australia, diverted major research resources and caused significant distress and controversy in the broader community [31, 87] . nipah virus, a close relative of hendra, is endemic in east asian flying fox populations. in 1999, after a program of deforestation and agricultural development in eastern malaysia it spread to pigs then humans and other animals, causing respiratory disease and severe encephalitis [88] . it subsequently was reported in india and bangladesh. humans can be infected directly from bats, by ingestion of contaminated food and from other humans. among 522 confirmed human cases, the overall mortality was greater than 50 % [89] . nipah control programs devastated malaysia's pig industry and caused high unemployment and dislocation of rural populations, at a cost of more than us$1 billion to the national economy [90] . nipah virus has been identified by who as a likely cause of future pandemics. rabies virus infects the central nervous systems of people, wildlife and domestic mammals. the disease is transmitted by bites from infected animals and once it becomes symptomatic, it is virtually always fatal. 55,000 people die and 7.5 million receive post exposure prophylaxis annually, costing $124 billion [91] . rabies is endemic in much of south east asia but its range is expanding. focusing on australia, the continent is free from rabies, but the current expansion of the disease in indonesia [92] is a genuine threat to northern regions. although likely controllable in domestic dog populations [93] , if rabies were to become endemic amongst wild or feral animals in this setting, current modelling indicates it would be almost impossible to eradicate [94] . table 2 significant historical (i.e. effectively eradicated) eids severe acute respiratory syndrome (sars) is a human respiratory infection, caused by a coronavirus isolated from chinese horseshoe bats [95] . it was first reported in asia in 2003 and, within a few months, spread to thirty seven countries in the americas, europe and asia. it affected more than 8000 people and caused 774 deaths, before being successfully eliminated by concerted international efforts. the outbreak and fear that another pandemic could occur are estimated to have cost canadian and east asian economies us$200 billion [27] . bovine spongiform encephalitis/variant creutzfeldt jacob disease (bse/ vcjd) is a rare but fatal human neurodegenerative condition, caused by consumption of bovine products contaminated with the prions that cause bse. since vcjd was first identified in 1996, 175 cases have been reported in the uk and forty nine elsewhere. the world bank estimates that the direct costs of vcjd/bse to date exceed more than us $11 billion. infected herds and the control measure imposed to prevent further infections devastated agricultural communities. the impacts of the emergence of a new zoonotic disease amongst the british public were far broader than agriculture, including the cessation of uk plasma production because of potential iatrogenic infection. with an estimated one in 4000 uk residents carrying vcjd, the burdens will continue well into this century [96] . the success of one health depends on more than scientific knowledge and technical achievement because some of the issues that arise in addressing eid risks are socalled 'wicked problems' [30] . when a new eid threat emerges there are rarely ready-made solutions and health policymakers and practitioners are often forced to make tragic choices that may contravene widely held values. considerations must include the need to protect public health and the wider social, economic and environmental impacts of proposed interventions. economic and political interests can complicate the decisionmakers' motives and decision-maker uncertainty is compounded by policy decisions becoming entangled in political, ethical and legal considerations [31] [32] [33] . as events surrounding the ebov outbreak in west africa illustrate, the importance placed on a specific eid threat at any one time also depends on who is setting the agenda [34] . therefore to be successfully implemented, the one health approach must address a range of socio-political, ethical and legal challenges that arise as a consequence of the spread of infection within and between species. most of these challenges are not unique to one health, but are shared by any approach to addressing eids. however these challenges frequently go unrecognized. in the following section we will clarify the nature of these issues so they can be addressed later in the paper. (1)socio-political challenges a focus on individualism, perceptions, short term solutions, populism and avoiding controversy are features of political life, which can prove challenging for eid policy and work against developing effective strategies for addressing eids. policy responses to eid events such as nipah and hendra virus infections (outlined in box 1) tend to focus on necessary and proximal causes (what individuals do to put themselves at direct risk from an infectious pathogen) because the science about other aspects of eids is often complex, uncertain and lacking a clear narrative. compounding this, our moral psychologies have evolved to respond to direct harmsnot indirect distal causal stories. many people in liberal democracies believe that they are entitled to rights and freedoms that cannot be sacrificed merely for the marginal gains of others. as the discourse surrounding climate change and other wicked problems illustrates, this promotes technological solutions because they do not require substantive changes in human behaviours and underlying values systems. [35] the net result is that the policy focus for eid prevention and control tends to remain on individual behaviours rather than the structural drivers of emergence and transmissiona case example being the focus on vaccine development and the husbandry practices of horse owners in response to the zoonotic risks of hendra virus [31, 36] .. the political impetus for action in response to many eids is not necessarily scientific evidence but societal perceptions. indeed, in the face of scientific uncertainty and ethical ambiguity, ideological perspectives and short-term political considerations often supplant efforts to devise effective long-term interventions [28, 37] . political imperatives to avoid, or at least minimise, public concern whilst dealing with eids can also prove challenging. in the case of bse, powerful interests dominated early government responses, leading policymakers to make decisions that avoided public controversy, but had major economic consequences. as the crisis unfolded, expertise became politicized leading to conflict between agencies and policy inconsistency between health communication strategies and the measures being taken to minimize the risks to human health [38] . even when the link between bse and vcjd became clear, existing feed bans were poorly enforced and risk communication was dominated by fear of public panic [39] ; even as the decision was made to remove all potential sources of human infection from the uk food supply, messages were confused and policy implementation impeded by poor co-ordination between agencies [28] . a common but problematic response to eid threats has been to invoke the precautionary principle. roughly speaking, the precautionary principle can be applied in situations where human activities create a scientifically plausible, but uncertain, risk of significant harm. in response the principle advocates that actions ought to be taken to avoid or reduce the harm, and that these actions need to be proportionate to the seriousness of the potential harm. in other word, in the absence of evidence take a conservative approach. however applying the precautionary principle to eids in an attempt to protect the public can result in what, in retrospect, amounts to an excessive response. this occurred with attempts to control nipah infection, where significant damage was inflicted on industry, livelihoods and the economy. similarly, experience with highly pathogenic avian influenza (hpai) h5n1 in china and se-asia showed that overzealous policy responses can destroy livelihoods and threaten food supplies [40, 41] . in vietnam alone, almost 40 million birds were culled in 2004 in an attempt to eradicate hpai. although many birds were owned by large commercial operations, others were kept by 'backyard' farmers and villagers. mass culling of poultry appears decisive, but places excessive burdens on vulnerable populations, is ineffective in the context of extensive 'backyard' poultry farming and can, in fact, promote the spread of disease [42] . a similar scenario is currently playing out with rabies control in bali. unfortunately, the precautionary principle and analytic tools and concepts appealed to in this domain, fail to deliver what is required at times of eid outbreaks since they do not advance public engagement or help resolve disagreements in times of uncertainty [43, 44] . philosophical critiques of the precautionary principle applied to eids have also shown its limitations, including that defining criteria by which to judge a threat as plausible and a response proportionate, often will only substitute one uncertainty for two others [45] . (2)ethical challenges the effectiveness of an eid control policy will depend on the context of its implementation and particularly its alignment with stakeholder and public values [17, 46] . in modern liberal democracies at least some consensus over what is in the public interest and an understanding of the values which support it, is therefore required for the successful implementation of eid responses. yet this is precisely what has been lacking in outbreaks where fracture lines, differences and value conflicts have become apparent. when the stakes are high, evidence and the implications of actions are uncertain, the situation is complex and resources may be limited but where decisions need to be made, differences are exposed. such differences could be around beliefs about how to deal with ecological and environmental issues, which may conflict with the importance people attach to public goods, protection of individual autonomy and animal welfare [47]. these conditions of crisis and division are conducive to undesirable consequences including public fear, mistrust, misinformation and non-compliance with public health directives. for example in canada during the sars crisis, leaders were unprepared for the range of ethical conflicts that arose, including those over: individual freedom versus the common good; healthcare workers' safety versus their duty to care for the sick; and economic costs versus the need for containment [48] . as indicated in box 2, both the outbreak itself and fear that another outbreak could occur had significant economic consequences. any approach which hopes to successfully respond to eid threats, including a one health approach, needs to address the ethical concerns articulated above. to this end, potentially conflicting values and logic must be negotiated to realise effective, sustainable and just solutions. prioritisation and resource allocation require political processes based on fundamental ethical questions about what is valuable, what is to be protected and, ultimately, what is dispensable. to be effective, public policy must be consistent with the values of citizens to whom it is applied, otherwise it can become mired in controversy about whose values should prevail [31, 37, 49] . therefore, one of the first and most important tasks of policy work is to establish how the public interest is best defined. (3)legal challenges the legal environment in which eid policy is made and in which responses to outbreaks occur, presents its own set of challenges. the law surrounding eid responses in most jurisdictions is diffuse, complicated and often subject to re-interpretation on the basis of whose interests are given primacy at the time decisions are made. moreover, in many countries different approaches by state/provincial and local authorities, overlaid by federal/national powers, complicate regulation so much that 'hard law' is often replaced by resort to 'soft law' of executive and administrative powers and international instruments, such as the international health regulations (ihr) [50] . this may add complexity and confusion to the eid regulatory structures, rather than facilitating public health responses to a new threat. such confusion provides a salient reminder that even in 'global law' approaches to eids, the sovereign state remains the institution responsible for regulation and control [51] . public health law responses to eids tend to be oriented towards controlling cross-border pathogen transfer and community outbreaks rather than the underlying deficiencies and structural conditions from which the threats emerge. other laws, such as environmental law, may be more useful in addressing structural conditions for emergence. changes in land use and agricultural intensification in developing societies are major drivers of eid. however, the cost of laws that restrict development may be greater global health inequities, with consequential effects for health outcomes. in order to clarify eidrelated legal tensions between economic development and health security, a more explicit recognition is needed of who are the primary beneficiaries and who bears the costs of a one health approach to eids [52] . legal clarity around the frameworks designed to protect populations from eids is critical to providing an enabling infrastructure to co-ordinate and support the one health-based work of policymakers, development planners, human and animal health-workers and biosecurity agencies. the health of humans, animals, and ecosystems are interconnected. a one health approach promises a better understanding of how to prevent and control eids at the human-animal-ecosystem interface. however the socio-political, ethical and legal challenges of eids illustrated above highlight how responses to infectious disease threats are intrinsically value laden. when a new infectious pathogen such as hendra or nipah virus first appears, or a known threat such as rabies or ebola encroaches on a new setting, there is limited scientific evidence or past experience to guide decisions or determine whether a planned response will be proportionate. vastly different interpretations of eid events and their likely outcomes might be supported by the available data. policymakers and practitioners therefore have little guidance as to what they should do when faced with a nascent infectious disease threat, only what they can do. as others [52] [53] [54] have cogently argued, they must therefore ask themselves: whose health is being prioritized; which public and which good are we seeking to protect? notwithstanding recognition of a need for complementary work on values-based questions that inevitably surround eid risks and eid control, the adoption of the one health approach, so far, has not included development of a comprehensive, ethically-informed policy and implementation framework; this has limited its practical utility [9, 55] . despite rhetorical and some financial support for one health as the guiding ethos by which to address interconnected human, animal and environmental health issues, its impact will be minimal unless implications of uncertainty on, and potential conflicts between, human values and political processes are recognised and articulated. any attempt to address these ethical and normative dimensions must take into account the dynamic nature of eid risk management. a policy that seems reasonable today may be inappropriate tomorrow, in light of new evidence. and when situations are uncertain, decision-makers inevitably fall back on their values. therefore, a solid framework based on shared values is needed to support decision-making surrounding eids when "evidence" isor may beunreliable, and rapidly changing or fluid. what is needed to guide a one health approach to eids? to successfully meet the challenges described above, particularly the necessity to align eid policy with public values, a one health approach needs to engage in the following. (i) social science and economic research to help catalogue and describe the drivers, mechanisms and social and political configurations through which eids become threats to human, animal and ecological health [56, 57] . the complex connections between individual social needs and the local socioeconomic context of affected or at-risk communities, need to be understood and addressed by policymaking processes. this should ensure that manifest injustice, livelihood-based decisions and other social and cultural factors do not undermine the effectiveness of favoured control measures. without adequate knowledge of specific local arrangements, there is a danger that insufficiently nuanced or unified approaches to eids will actually undermine the heterogeneous relationships and contingent practices that make health possible in circumstances of structural disadvantage [56, 58] . the social sciences are analytically broader and more policy focussed than the natural sciences. whereas the natural sciences tend to frame infectious disease threats narrowly as matters of biological integrity and security, such that barrier technologies and hygiene practices dominate the logic of interventions [59] , social science approaches go beyond this. building social scientific evidence for use in conjunction with natural scientific evidence about eids aligns with the growing realization that eid emergence is as much about the social and economic configuration of capital flow as it is about the biological features of host-pathogen interactions. current approaches to the economic and structural drivers of eid emergence still presume that state and market neoliberalism is part of the natural order, even as evidence is mounting that these systems of development are central to the problem [60, 61] . moreover, the current emphasis on microbiology and focus on newer molecular techniques to characterise pathogens, is drawing attention away from developing better understandings of the environmental, economic and social drivers of eids. while this is understandable given the desire for vaccines and drugs to solve eids, if one health researchers and practitioners broaden their approach to causality to include upstream, social and economic systemic causes, questions and issues that have been traditionally bracketed or thought best avoided will become central to the cross-sectoral collaboration implied by one health. framework (ohaf) needs to be pursued. such a framework would catalogue case-based experiences and reflect the particular dynamics of specific eids, and promote inter-sectoral collaboration and knowledge synthesis, including integration of information about social, cultural and economic impacts, control measures and uncertainty [62, 63] . the framework would serve as a prompt to ensure that minority perspectives are represented and all relevant concerns are considered. an ohaf could provide a rubric for comparisons between outbreaks. this would allow the inherent complexities of economic and societal responses to eids to be compared, to inform policy processes. it is vital for discussions about eid prevention and control to have this kind of sound empirical foundation, because uncertainty and media coverage have the potential to drive bad policy. development of an ohaf could be facilitated by adopting well established and methodically rigorous processes such as framework analysis, produced by the national centre for social research (uk) [19] , or multi-criteria decision analysis [mcda] developed within the field of decision science [64] . in the first instance framework analysis would allow for systematic incorporation of the perspectives and contributions of different scholarly disciplines and expert stakeholders. framework analysis facilitates movement between different datasets, thematic areas, theoretical resources, and levels of abstraction without loss of conceptual clarity [65] . the framework method is used to organize and manage research and interpretation through the process of summarization, which is codified into a robust and flexible matrix that allows the policymaker/researcher to analyze data both by case and theme. it is commonly used in areas such as health research, policy development and program evaluation. equally, mcda methods offer an alternative and potentially complementary approach to ohaf development. comprised of a suite of analytic strategies, mcda have been shown to be valuable tools for prioritization and decision-making in animal and human health [64] . mcda provides a framework to compare policy alternatives with diverse and often intangible impacts, which can be particularly useful in determining and justifying the prioritization and mobilization of limited research and public health resources [66, 67] . (iii)genuine processes of public engagement across the developed and developing world are also essential to a successful one health approach. these processes are not so much about engaging in deliberative democracy for policy decision-making, as about defining the principles and values that should guide decision-making. this means procedural inclusiveness alone is not enough to ensure transparency and reflexivity, to capture people's preferences and to effectively communicate with the public [68] . the successful implementation of the one health approach to eids will depend on public trust and cooperation. public support for unpalatable measures is more likely if citizens understand the issues, and policy implementation reflects community values and preferences. to this end, citizens' juries have been employed in the uk, australia, the us and elsewhere [69] [70] [71] [72] to explore similar issues and identify citizens' preferences. they represent informed public opinion better than other social research methods (e.g. surveys or focus groups) because they give participants factual information, bring them into a structured and constructive dialogue with experts, provide them with time to reflect and deliberate, and allow them to represent their views directly to policymakers. to be successful, one health needs to be about more than disease prevention and control. the dynamic, unpredictable effects and risks to peoples' lives of eids necessitate a public health and biosecurity infrastructure equipped to address the ethical problems that arise. eid management must therefore be based on normative principles as well as local knowledge, operational experience and disease-specific scientific and economic evidence. this means that governments and policy-makers need to explain and justify the values that underlie decision-making and engage the public in discussions about ethical choices, so that when difficult decisions arise in the face of uncertainty, they will be accepted as fair and essential for the public good [47] . this necessitates that the guiding values and likely ethical choices need to be articulated in a formal statement in advance, as in the heat of emerging health threat, decision makers will be under pressure from many sources to 'do something quickly'. (v)integration of an ohaf and spv with the ihr and relevant national health and biosecurity legislation is essential so that policymakers and practitioners can dynamically test their decision-making. our response should of course be based on the best scientific evidence, but eids are not just scientific issues, they also have significant social, ethical and animal rights dimensions. experiences of infectious disease threats such as bse/vcjd and sars indicate that there have been problems combining evidence and human values at both local and policy levels [28, 73] . the communicability of diseases between species raises social, ethical and legal issues that have not been clearly elucidated or adequately addressed. our response to nonhuman animal disease is not determined solely by bio-scientific knowledge; the way people and animals live with and amongst each other is also shaped by social norms, economic imperatives and human values. in matters of public health it is no longer sufficient to ask what works and what is the strength of the evidence; we also need to ask ethical questions about how we should seek to live, and what is the right thing to do [74] [75] [76] . consensus about the best approaches to eid control and prevention are not always possible, however an agreed set of guiding principles and values can be a means to ensure dialogue, if not always agreement. the development of an ohaf and spv will also promote clearer communication about public risk. significant eid threats have major implications for distribution of scarce resources, access to and regulation of health services and maintenance of social order. as described above it is also clear that policy and legal responses to eid threats are often highly politicised and compromised by failure to communicate clearly with the public. policymakers responsible for responding to disasters such as eids typically find that there is a dissonance between transparency that may appear alarmist versus withholding information to avoid panic. regardless of advice, people will make their own decisions based on their interpretation of available information, from formal and informal channels. so public communication, before and during a public health emergency, is frequently as important as political decisions and regulatory changes [39, 77] . this means that, to be effective, a one health approachlike any eid policymust deal with scientific uncertainty, whilst addressing the socio-political, ethical and legal dimensions of effective health communication and intervention strategies [3] . by exposing decision-making processes to reveal the scientific and normative uncertainties and ethical complexities, the introduction of an ohaf and a spv into one health theory and practice may incorporate iterative deliberation and learning into eid policy processes. (vi)finally, one health must be about genuine reform rather than merely rhetoric. a one health approach rests on the assumption that the cross-sectoral integration of expertise, research methodologies and public health infrastructure will inevitably improve capacity for disease-risk prediction and effective intervention. however, calls for increased intersectoral co-operation by public health practitioners, clinicians, scientists and policy-makers are not a new phenomenon. for example in the 1990s advocates of "new public health" called for health authorities to turn their attention to the social, economic and environmental factors that affect healthrequiring the realignment and policy integration of health departments with other government agencies [78, 79] . unfortunately in this case as others, attempts at promoting inter-sectoral approaches rarely move beyond rhetoriceven when driven by the best intentions and supported by substantial resources [80] [81] [82] . the problem is that arguments that promote the need for greater co-operation between sectors tend to focus on the likely benefits of collaboration rather than what reform would entailthat is, what needs to be done organisationally and politically to achieve the desired outcomes [83] . established 'sectors'whether orientated towards human or animal health, agriculture or the environmenthave genealogies, traditions and rationalities of "what we are here for" that have been shaped by social, political and administrative processes [11] . as institutions, they are philosophically and structurally resistant to change that diverts resources and re-orients practices away from their own sectoral priorities [83] . in essence, they have their own constituencies to serve. as a consequence, establishment and implementation of mechanisms that enhance information-sharing, collaboration and inter-sectoral co-operation, such as working groups and interdepartmental committees, have rarely delivered the outcomes promised in the past. responses to bse/vcjd in the uk [28] , hpai in south east asia [11] , and recent case studies of one health programs in uganda [84] , suggest that more work is needed to coordinate implementation and overcome sectoral interests. the complexity of the problems posed by eids mean that organising effective control and prevention programs will require genuine cross-sectoral integration and, potentially, re-sectoring of some institutional and professional responsibilities [62] . and as the recent ebolavirus disease outbreak illustrates, there must also be sustained social and political willingness to achieve control. if one health is genuinely the way forward, as we believe it is, then we should do more than talk about its potential benefits. without genuine cross-sectoral reform and a radical broadening of the scope of its inquiry into how specific social, cultural and spatial configurations promote the risks of eid emergence, one health is in danger of becoming merely a rhetorical strategy to avoid conflict between its core disciplines, whereby practitioners, researchers and policymakers will espouse the methodological and moral case for interdisciplinary collaboration yet remain in their silos [11] . even if these barriers are overcome the one health approach will only succeed if it explicitly acknowledges local contingent and contextual dimensions of disease risk and disease expression and the political impacts of scientific uncertainty, while also seeking to accommodate the values and preferences of 'at risk' and affected individuals. further, we suggest that decision making around eids requires an ethical framework that reflects the values of affected and 'at risk' communities, privileges justice, takes account of human flourishing, protects animal health and welfare and is developed in consultation with relevant stakeholders and the public. eid risk management is a major global public health issue to which one health represents a promising approach, but its potential benefits have not been fully realised [53, 55] . despite recognition that the social and cultural dimensions are critical to the success of one health, social scientists are yet to play a central or substantive role in shaping research programs and interventions [12, 13] . at the same time as the literature on the ethics of pandemic responses and preparedness continues to grow, the one health approach to eids has received little formal ethical consideration. even the most ethically attuned existing frameworks for biosecurity and infection prevention and control provide only general operational principles that do not guide actions in times of uncertainty. if one health is to be meaningful − let alone successful − more attention must be paid to how these different types of knowledge are brought together and brought to public attention. effective responses to eids are likely to be delayed or precluded unless all the socio-political, ethical and legal 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incidents between new directions in conservation medicine: applied cases of ecological health henipaviruses: unanswered questions of lethal zoonoses the nipah virus outbreak and the effect on the pig industry in malaysia the cost of canine rabies on four continents review of rabies epidemiology and control in south, south east and east asia: past, present and prospects for elimination development of a novel rabies simulation model for application in a non-endemic environment australian veterinary emergency plan (ausvetplan) review of bats and sars an update on the assessment and management of the risk of transmission of variant creutzfeldt-jakob disease by blood and plasma products the work was funded by nhmrc grant #1083079 and seed funding from the marie bashir institute for infectious disease and biosecurity and the school of public health at the university of sydney. the funding source has had no involvement in how the paper was interpreted or written. the authors declare that they have no competing interests.authors' contributions cd led the conceptualization, review, critical analysis and drafting of the article. jj, gg, ik, aw, mw, and cs all made significant contributions to the critical analysis and drafting of the paper. jj and cd led the final preparation of the paper for submission. all authors read and approved the final manuscript.• we accept pre-submission inquiries • our selector tool helps you to find the most relevant journal submit your next manuscript to biomed central and we will help you at every step: key: cord-303165-ikepr2p2 authors: tulchinsky, theodore h.; varavikova, elena a. title: expanding the concept of public health date: 2014-10-10 journal: the new public health doi: 10.1016/b978-0-12-415766-8.00002-1 sha: doc_id: 303165 cord_uid: ikepr2p2 ancient societies recognized the needs of sanitation, food safety, workers’ health, and medical care to protect against disease and to promote well-being and civic prosperity. new energies and knowledge since the eighteenth century produced landmark discoveries such as prevention of scurvy and vaccination against smallpox. the biological germ theory and competing miasma theory each proved effective in sanitation, and immunization in control of infectious diseases. non-communicable diseases as the leading causes of mortality have responded to innovative preventive care of health risk factors, smoking, hypertension, obesity, physical inactivity, unhealthful diets, and diabetes mellitus. health promotion proved effective to modern public health in tackling disease origins, individual behavior, and social and economic conditions. the global burden of infectious and non-communicable diseases, aging and chronic illness faces rising costs and still inadequate prevention. the evolution of concepts of public health will have to address these new challenges of population health. the development of public health from its ancient and recent roots, especially in the past several centuries, is a continuing process, with evolutionary and sometimes dramatic leaps forward, and important continuing and new challenges for personal and population health and well-being. everything in the new public health is about preventing avoidable disease, injuries, disabilities, and death while promoting and maximizing a healthy environment and optimal conditions for current and future generations. thus, the new public health addresses overall health policy, resource allocation, as well as the organization, management, and provision of medical care and of health systems in general within a framework of overall social policy and in a community, state, national, transnational, and global context. the study of history (see chapter 1) helps us to understand the process of change, to define where we came from and where we are going. it is vital to recognize and understand change in order to deal with radical transformations in direction that occur as a result of changing demography and epidemiology, new science, evolving best practices in public health and clinical medicine, and above all inequalities in health resulting from societal system failures and social and economic factors. health needs will continue to develop in the context of environmental, demographic and societal adjustments, with knowledge gained from social and physical sciences, practice, and economics. for the coming generations, this is about not only the quality of life, but the survival of society itself. over the past century there have been many definitions of public health and health for all. mostly they represent visions and ideals of societal and global aspirations. this chapter examines the very base of the new public health, which encompasses the classic issues of public health with recognition of the advances made in health promotion and the management of health care systems as integral components of societal efforts to improve the health of populations and of individuals. what follows in succeeding chapters will address the major concepts leading to modern and comprehensive elements of public health. inevitably, concepts of public health continue to evolve and to develop both as a philosophy and as a structured discipline. as a professional field, public health requires specialists trained with knowledge and appreciation of its evolution, scientific advances, concepts, and best practices, old and modern. it demands sophisticated professional and managerial skills, the ability to address a problem, reasoning to define the issues, and to advocate, initiate, develop, and implement new and revised programs. it calls for profoundly humanistic values and a sense of responsibility towards protecting and improving the health of communities and every individual. in the twenty-first century, this set of values was well expressed in the human development index agreed to by 160 nations (box 2.1). public health is a multidimensional field and therefore multidisciplinary in its workforce and organizational needs. it is based on scientific advances and application of best practices as they evolve, and includes many concepts, including holistic health, first established in ancient times. the discussion will return to the diversity of public health throughout this chapter and book many times. in previous centuries, public health was seen primarily as a discipline which studies and implements measures for control of communicable diseases, primarily by sanitation and vaccination. the sanitary revolution, which preceded the development of modern bacteriology, made an enormous contribution to improved health, but many other societal factors including improved nutrition, education, and housing were no less important for population health. maternal and child health, occupational health, and many other aspects of a growing public health network of activities played important roles, as have the physical and social environment and personal habits of living in determining health status. in recent decades recognition of the importance of women's health and health inequalities associated with many high-risk groups in the population have seen both successes and failures in addressing their challenges. male health issues have received less attention, apart from issues associated with specific diseases, or those of healthy military personnel. the scope of public health has changed along with growth of the medical, social, and public health sciences, public expectations, and practical experience. taken together, these have all contributed to changes in the concepts and causes of disease. health systems that fail to adjust to changes in fundamental concepts of public health suffer from immense inequity and burdens of preventable disease, disability, and death. this chapter examines expanding concepts of public health, leading to the development of a new public health. public health has evolved as a multidisciplinary field that includes the use of basic and applied science, education, social sciences, economics, management, and communication skills to promote the welfare of the individual and the community. it is greater than the sum of its component elements and includes the art and politics of the funding and coordination of the wide diversity of community and individual health services. the concept of the interdependence of health in body and in mind has ancient origins. they continue to be fundamental to individuals and societies, and part of the fundamental rights of all humans to have knowledge of healthful lifestyles and to have access to those measures of good health that society alone is able to provide, such as immunization programs, food and drug safety and quality standards, environmental and occupational health, and universal access to high-quality primary and specialty medical and other vital health services. this holistic view of balance and equilibrium may be a renaissance of classical greek and biblical traditions, applied with the broad new knowledge and experience of public health and medical care of the nineteenth, twentieth, and the early years of the twenty-first centuries as change continues to challenge our capacity to adapt. the competing nineteenth-century germ and miasma theories of biological and environmental causation of illness each contributed to the development of sanitation, hygiene, immunization, and understanding of the biological and social determinants of disease and health. they come together in the twenty-first century encompassed in a holistic new public health addressing individual and population health needs. medicine and public health professionals both engage in organization and in direct care services. these all necessitate an understanding of the issues that are included in the new public health, how they evolved, interact, are put together in organizations, and are financed and operated in various parts of the world in order to understand changes going on before our eyes. great success has been achieved in reducing the burden of disease with tools and concepts currently at our disposal. the idea that this is an entitlement for everyone was articulated in the health for all concept of alma-ata in 1978. the health promotion movement emerged in the 1970s and showed dramatically effective results in managing the new human immunodeficiency virus (hiv) pandemic and in tackling smoking and other risk factors for non-communicable diseases (ncds). a health in all policy concept emerged in 2006 promoting the concept that health should be a basic component of all public and private policies to achieve the full potential of public health and eliminate inequalities associated with social and economic conditions. profound changes are taking place in the world population, and public health is crucial to respond accordingly: mass migration to the cities, fewer children, extended life expectancy, and the increase in the population of older people who are subject to more chronic diseases and disabilities in a changing physical, social, and economic climate. health systems are challenged with continuing development of new medical technologies and related reforms in clinical practice, while experiencing strong influences of pharmaceuticals and the medicalization of health, with prevention and health promotion less central in priorities and resource allocation. globalization of health has many meanings: international trade, improving global communications, and economic changes with increasing flows of goods, services, and people. ecological and climate change bring droughts, hurricanes, arctic meltdown, and rising sea levels. globalization also has political effects, with water and food shortages, terrorism, and economic distress affecting billions of people. in terms of health, disease can spread from one part of the world to others, as in pandemics or in a quiet spread such as that of west nile fever moving from its original middle eastern natural habitat to the americas and europe, or severe acute respiratory syndrome (sars), which spread with lightning speed from chinese villages to metropolitan cities such as toronto, canada. it can also mean that the ncds characteristic of the industrialized countries are now recognized as the leading causes of death in low-and middle-income countries, associated with diet, activity levels, and smoking, which are themselves pandemic risk factors. the potential for global action in health can also be dramatic. the eradication of smallpox was a stunning victory for public health. the campaign to eradicate poliomyelitis is succeeding even though the end-stage is fraught with setbacks, and measles elimination has turned out to be more of a challenge than was anticipated a decade ago, with resurgence in countries thought to have it under control. global health policies have also made the achievements of public-private partnerships of great importance, particularly in vaccination and acquired immunodeficiency syndrome (aids) control programs. there have been failures as well, with very limited progress in human resources development of the public health workforce in low-income countries. the new public health is necessarily comprehensive in scope and it will continue to evolve as new technologies and scientific discoveries -biological, genetic, and sociological -reveal more methods of disease control and health promotion. it relates to or encompasses all community and individual activities directed towards improving the environment for health, reducing factors that contribute to the burden of disease, and fostering those factors that relate directly to improved health. its programs range broadly from immunization, health promotion, and child care, to food labeling and fortification, as well as to the assurance of well-managed, accessible health care services. a strong public health system should have adequate preparedness for natural and human-made disasters, as seen in the recent tsunamis, hurricanes, biological or other attacks by terrorists, wars, conflicts, and genocidal terrorism (box 2.2) . the concepts of health promotion and disease prevention are essential and fundamental elements of the new public health. parallel scientific advances in molecular biology, genetics and pharmacogenomics, imaging, information technology, computerization, biotechnology, and nanotechnology hold great promise for improving the productivity of the health care system. advances in technology with more effective and less expensive drug and vaccine development, with improved safety and effectiveness, and fewer adverse reactions, will over time greatly increase efficiency in prevention and treatment modalities. the new public health is important as a conceptual base for training and practice of public health. it links classical topics of public health with adaptation in the organization and financing of personal health services. it involves a changed paradigm of public health to incorporate new advances in political, economic, and social sciences. failure at the political level to appreciate the role of public health in disease control holds back many societies in economic and social development. at the same time, organized public health systems need to work to reduce inequities between and inside countries to ensure equal access to care. it also demands special attention through health promotion activities of all kinds at national and local societal levels to provide access for groups with special risks and needs to medical and community health care with the currently available and newly developing knowledge and technologies. the great gap between available capabilities to prevent and treat disease and actually reaching all in need is still the the mission of the nph is to maximize human health and well-being for individuals and communities, nationally and globally. the methods with which the nph works to achieve this are in keeping with recognized international best practices and scientific advances: 1. societal commitment and sustained efforts to maximize quality of life and health, economic growth with equity for all (health for all and health in all). collaboration between international, national, state, and local health authorities working with public and private sectors to promote health awareness and activities essential for population health. 3. health promotion of knowledge, attitudes, and practices, including legislation and regulation to protect, maintain, and advance individual and community health. 4. universal access to services for prevention and treatment of illness and disability, and promotion of maximum rehabilitation. 5. environmental, biological, occupational, social, and economic factors that endanger health and human life, addressing: (a) physical and mental illness, diseases and infirmity, trauma and injuries (b) local and global sanitation and environmental ecology (c) healthful nutrition and food security including availability, quality, safety, access, and affordability of food products (d) disasters, natural and human-made, including war, terrorism, and genocide (e) population groups at special risk and with specific health needs. 6. promoting links between health protection and personal health services through health policies and health systems management, recognizing economic and quality standards of medical, hospital, and other professional care in health of individuals and populations. 7. training of professional public health workforces and education of all health workers in the principles of ethical best practices of public health and health systems. 8. research and promotion of current best practices: wide application of current international best practices and standards. 9. mobilizing the best available evidence from local and international scientific and epidemiological studies and best practices recognized as contributing to the overall goal. 10. maintaining and promoting equity for individual and community rights to health with high professional and ethical standards. source of great international and internal national inequities. these inequities exist not only between developed and developing countries, but also within transition countries, mid-level developing countries, and those newly emerging with rapid economic development. the historical experience of public health will help to develop the applications of existing and new knowledge and societal commitment to social solidarity in implementation of the new discoveries for every member of the society, despite socioeconomic, ethnic, or other differences. political will and leadership in health, adequate financing, and organization systems in the health setting are crucial to furthering health as an objective with defined targets, supported by well-trained staff for planning, management, and monitoring the population health and functioning of health systems. political leadership and professional support are both indispensable in a world of limited resources, with high public expectations and the growing possibilities of effectiveness of public health programs. well-developed information and knowledge management systems are required to provide the feedback and information needed for good management. it includes responsibilities and coordination at all levels of government. non-governmental organizations (ngos) and participation of a well-informed media and strong professional and consumer organizations also have significant roles in furthering population health. no less important are clear designations of responsibilities of the individual for his or her own health, and of the provider of care for humane, high-quality professional care. the complexities and interacting factors are suggested in figure 2 .1, with the classic host-agent-environment triad. many changes have signaled a need for transformation towards the new public health. religion, although still a major political and policy-making force in many countries, is no longer the central organizing power in most societies. organized societies have evolved from large extended families and tribes to rural societies, cities, regions, and national governments. with the growth of industrialized urban communities, rapid transport, and extensive trade and commerce in multinational economic systems, the health of individuals and communities has become more than just a personal, family, and/or local problem. an individual is not only a citizen of the village, city, or country in which he or she lives, but a citizen of a "global village". the agricultural revolutions and international explorations of the fifteenth to seventeenth centuries that increased food supply and diversity were followed only much later by knowledge of nutrition as a public health issue. the scientific revolution of the seventeenth to nineteenth centuries provided the basics to describe and analyze the spread of disease and the poisonous effects of the industrial revolution, including crowded living conditions and pollution of the environment with serious ecological damage. in the latter part of the twentieth century, a new agricultural "green revolution" had a great impact in reducing human deprivation internationally, yet the full benefits of healthier societies are yet to be realized in the large populations living in abject poverty in sub-saharan africa, south-east asia, and other parts of the world. global water shortages can be addressed with new methods of irrigation, water conservation and the application of genetic sciences to food production, and issues of economics and food security are of great importance to a still growing world population with limited supplies. further, food production capacity can and must be enlarged to meet current food insecurity, rising expectations of developing nations, and population growth. the sciences of agriculture-related fields, including genetic sciences and practical technology, will be vital to human progress in the coming decades. these and other societal changes discussed in chapter 1 have enabled public health to expand its potential and horizons, while developing its pragmatic and scientific base. organized public health in the twentieth century proved effective in reducing the burden of infectious diseases and has contributed to improved quality of life and longevity by many years. in the last half-century, chronic diseases have become the primary causes of morbidity and mortality in the developed countries and increasingly in developing countries. growing scientific and epidemiological knowledge increases the capacity to deal with these diseases. many aspects of public health can only be influenced by the behavior of and risks to the health of individuals. these require interventions that are more complex and relate to societal, environmental, and community standards and expectations as much as to personal lifestyle. the dividing line between communicable and non-communicable diseases changes over time. scientific advances have shown the causation of chronic conditions by infectious agents and their prevention by curing the infection, as in helicobacter pylori and peptic ulcers, and in prevention of cancer of the liver and cervix by immunization for hepatitis b and human papillomavirus (hpv), respectively. chronic diseases have come to the center stage in the "epidemiological transition", as infectious diseases came under increasing control. this, in part, has created a need for reform in the funding and management of health systems due to rapidly rising costs, aging of the population, the rise of obesity and diabetes and other chronic conditions, mushrooming therapeutic technology, and expanding capacity to deal with public health emergencies. reform is also needed in international assistance to help less developed nations build the essential infrastructure to sustain public health in the struggle to combat aids, malaria, tuberculosis (tb), and the major causes of preventable infant, childhood, and motherhood-related deaths. the nearly universal recognition of the rights of people to have access to health care of acceptable quality by international standards is a challenge of political will and leadership backed up by adequate staffing with public health-trained staff and organizations. the challenges of the current global economic crisis are impacting social and health systems around the world. the interconnectedness of managing health systems is part of the new public health. setting the priorities and allocating resources to address these challenges requires public health training and orientation of the professionals and institutions participating in the policy, management, and economics of health systems. conversely, those who manage such institutions are recognizing the need for a wide background in public health training in order to fulfill their responsibilities effectively. concepts such as objectives, targets, priorities, cost-effectiveness, and evaluation have become part of the new public health agenda. an understanding of how these concepts evolved will help the future health provider or manager to cope with the complexities of mixing science, humanity, and effective management of resources to achieve higher standards of health, and to cope with new issues as they develop in the broad scope of the new public health for the twenty-first century, in what breslow called the "third public health era" of long and healthy quality of life (box 2.3). health can be defined from many perspectives, ranging from statistics on mortality, life expectancy, and morbidity rates to idealized versions of human and societal perfection, as in the world health organization's (who's) founding charter. the first public health era -the control of communicable diseases. second public health era -the rise and fall of chronic diseases. third public health era -the development of long and high-quality life. preamble to the constitution of the who, as adopted by the international health conference in new york in 1946 and signed by the representatives of 61 states, entered into force on 7 april 1948, with the widely cited definition: "health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity". this definition is still important conceptually as an ideal accepted as fundamental to public policy over the years. a more operational definition of health is a state of equilibrium of the person with the biological, physical, and social environment, with the object of maximum functional capability. health is thus seen as a state characterized by anatomical, physiological, and psychological integrity, and an optimal functional capability in the family, work, and societal roles (including coping with associated stresses), a feeling of well-being, and freedom from risk of disease and premature death. deviances in health are referred to as unhealthy and constitute a disease nomenclature. there are many interrelated factors in disease and in their management through what is now called risk reduction. in 1878, claude bernard described the phenomenon of adaptation and adjustment of the internal milieu of the living organism to physiological processes. this concept is fundamental to medicine. it is also central to public health because understanding the spectrum of events and factors between health and disease is basic to the identification of contributory factors affecting the balance towards health, and to seeking the points of potential intervention to reverse the imbalance. as described in chapter 1, from the time of hippocrates and galen, diseases were thought to be due to humors and miasma or emanations from the environment. this was termed the miasma theory, and while without a direct scientific explanation, it was acted upon in the early to mid-nineteenth century and promoted by leading public health theorists including florence nightingale, with practical and successful measures to improve sanitation, housing, and social conditions, and having important results in improving health conditions. the competing germ theory developed by pioneering nineteenthcentury epidemiologists (panum, snow, and budd), scientists (pasteur, cohn, and koch), and practitioners (lister and semmelweiss) led to the science of bacteriology and a revolution in practical public health measures. the combined application of the germ (agent-host-environment) and miasma theories (social and sanitary environment) has been the basis of classic public health, with enormous benefits in the control of infectious and other diseases or harmful conditions. the revolutionary changes occurring since the 1960s have brought about a decline in cardiovascular and cancer mortality, and conceptual changes such as health for all and health in all to bring health issues to all policies at both governmental and individual levels. the concepts of public health advanced with the 1974 marc lalonde health field concept (new perspectives on the health of canadians, 1974) , stating that health was the result of the physical and social environment, lifestyle and personal habits, genetics, as well as organization and provision of medical care. the lalonde report was a key concept leading to ideas advanced at the alma-ata conference on primary care held in 1978 and more explicitly in the development of the basis for health promotion as articulated in the ottawa charter of 1986 on health promotion. this marked the beginning of a whole new aspect of public health, which proved itself in addressing with considerable success the epidemic of hiv and cardiovascular diseases. in the usa, the surgeon general's reports of 1964 on smoking and health, and of 1979 defining health targets as national policy promoted the incorporation of "management by objectives" from the business world applied to the health sector (see chapter 12). this led to healthy people usa 2000 and later versions, and the united nations (un) millennium development goals (mdgs), aimed primarily at the middle-and low-income countries (box 2.4). the identification of infectious causes of cancers of the liver and cervix established a new paradigm in epidemiology, and genetic epidemiology has important potential for public health and clinical medicine. in the basic host-agent-environment paradigm, a harmful agent comes through a sympathetic environment into contact with a susceptible host, causing a specific disease. this idea dominated public health thinking until the midtwentieth century. the host is the person who has or is at risk for a specific disease. the agent is the organism or direct cause of the disease. the environment includes the external factors which influence the host, his or her susceptibility to the agent, and the vector which transmits or carries the agent to the host from the environment. this explains the causation and transmission of many diseases. this paradigm (figure 2. 2), in effect, joins together the contagion and miasma theories of disease causation. a specific agent, a method of transmission, and a susceptible host are involved in an interaction, which are central to the infectivity or severity of the disease. the environment can provide the carrier or vector of an infective (or toxic) agent, and it also contributes factors to host susceptibility; for example, unemployment, poverty, or low education level. the expanded host-agent-environment paradigm widens the definition of each of the three components ( figure 2 .3), in relation to both acute infectious and chronic noninfectious disease epidemiology. in the latter half of the twentieth century, this expanded host-agent-environment paradigm took on added importance in dealing with the complex of factors related to chronic diseases, now the leading causes of disease and premature mortality in the developed world, and increasingly in developing countries. interventions to change host, environmental, or agent factors are the essence of public health. in infectious disease control, the biological agent may be removed by pasteurization of food products or filtration and disinfection (chlorination) of water supplies to prevent transmission of waterborne disease. the host may be altered by immunization to provide immunity to a specific infective organism. the environment may be changed to prevent transmission by destroying the vector or its reservoir of the disease. a combination of these interventions can be used against a specific risk factor, toxic or nutritional deficiency, infectious organism, or disease process. vaccine-preventable diseases may require both routine and special activities to boost herd immunity to protect the individual and the community. for other infectious diseases for which there is no vaccine (e.g., malaria), control involves a broad range of activities including case finding and treatment to improve the individual's health and to reduce the reservoir of the disease in the population, and other measures such as bed nets to reduce exposure of the host to vector mosquitoes, as well as vector control to reduce the mosquito population. tb control requires not only case finding and treatment, but understanding the contributory factors of social conditions, diseases with tb as a secondary condition (substance abuse and aids), agent resistance to treatment, and the inability of patients or carriers to complete treatment without supervision. sexually transmitted infections (stis) which are not controllable by vaccines require a combination of personal behavior change, health education, medical care, and skilled epidemiology. with non-infectious diseases, intervention is even more complex, involving human behavior factors and a wide range of legal, administrative, and educational issues. there may be multiple risk factors, which have a compounding effect in disease causation, and they may be harder to alter than infectious diseases factors. for example, smoking in and of itself is a risk factor for lung cancer, but exposure to asbestos fibers has a compounding effect. preventing exposure to the compounding variables may be easier than smoking cessation. reducing trauma morbidity and mortality is equally problematic. the identification of a single specific cause of a disease is of great scientific and practical value in modern public health, enabling such direct interventions as the use of vaccines or antibiotics to protect or treat individuals from infection by a causative organism, toxin, deficiency condition, or social factor. the cumulative effects of several contributing or risk factors in disease causation are also of great significance in many disease processes, in relation to infectious diseases such as nutritional status as for chronic diseases such as the cardiovascular group. the health of an individual is affected by risk factors intrinsic to that person as well as by external factors. intrinsic factors include the biological ones that the individual inherits and those life habits he or she acquires, such as smoking, overeating, or engaging in other high-risk behaviors. external factors affecting individual health include the environment, the socioeconomic and psychological state of the person, the family, and the society in which he or she lives. education, culture, and religion are also contributory factors to individual and community health. there are factors that relate to health of the individual in which the society or the community can play a direct role. one of these is provision of medical care. another is to ensure that the environment and community services include safety factors that reduce the chance of injury and disease, or include protective measures; for example, fluoridation of a community water supply to improve dental health, and seat-belt or helmet laws to reduce motor vehicle injury and death. these modifying factors may affect the response of the individual or the spread of an epidemic (see chapter 3). an epidemic may also include chronic disease, because common risk factors may cause an excess of cases in a susceptible population group, in comparison to the situation before the risk factor appeared, or in comparison to a group not exposed to the risk factor. these include rapid changes or "epidemics" in such conditions as type 2 diabetes, asthma, cardiovascular diseases, trauma, and other non-infectious disorders. disease is a dynamic process, not only of causation, but also of incubation or gradual development, severity, and the effects of interventions intended to modify outcome. knowledge of the natural history of disease is fundamental to understanding where and with what means intervention can have the greatest chance for successful interruption or change in the disease process for the patient, family, or community. the natural history of a disease is the course of that disease from beginning to end. this includes the factors that relate to its initiation; its clinical course leading up to resolution, cure, continuation, or long-term sequelae (further stages or complications of a disease); and environmental or intrinsic (genetic or lifestyle) factors and their effects at all stages of the disease. the effects of intervention at any stage of the disease are part of the disease process (figure 2 .4). as discussed above, disease occurs in an individual when agent, host, and environment interact to create adverse conditions of health. the agent may be an infectious organism, a chemical exposure, a genetic defect, or a deficiency condition. a form of individual or social behavior, such as reckless driving or risky sexual behavior, may lead to injury or disease. the host may be immune or susceptible as a result of many contributing social and environmental factors. the environment includes the vector, which may be a malaria-bearing mosquito, a contaminated needle shared by drug users, lead-contaminated paint, or an abusive family situation. assuming a natural state of "wellness" -i.e., optimal health or a sense of well-being, function, and absence of disease -a disease process may begin with the onset of a disease, infectious or non-infectious, following a somewhat characteristic pattern of "incubation" described by clinicians and epidemiologists. preclinical or predisposing events may be detected by a clinical history, with determination of risk including possible exposure or presence of other risk factors. interventions, before and during the process, are intended to affect the later course of the disease. the clinical course of a disease, or its laboratory or radiological findings, may be altered by medical or public health intervention, leading to the resolution or continuation of the disease with fewer or less severe secondary sequelae. thus, the intervention becomes part of the natural history of the disease. the natural history of an infectious disease in a population will be affected by the extent of prior vaccination or previous exposure in the community. diseases particular to children are often so because the adult population is immune from previous exposure or vaccinations. measles and diphtheria, primarily childhood diseases, now affect adults to a large extent because they are less protected by naturally acquired immunity or are vulnerable when their immunity wanes naturally or as a result of inadequate vaccination in childhood. in chronic disease management, high costs to the patient and the health system accrue where preventive services or management are inadequate, not yet available, or inaccessible or where there is a failure to apply the necessary interventions. the progress of diabetes to severe complications such as cardiovascular, renal, and ocular disease is delayed or reduced by good management of the condition, with a combination of smoking cessation, diet, exercise, and medications with good medical supervision. the patient with advanced chronic obstructive pulmonary disease or congestive heart failure may be managed well and remain stable with smoking avoidance, careful management of medications, immunizations against influenza and pneumonia, and other prevention-oriented care needs. where these are not applied or if they fail, the patient may require long and expensive medical and hospital care. failure to provide adequate supportive care will show up in ways that are more costly to the health system and will prove more life-threatening to the patient. the goal is to avoid where possible the necessity for tertiary care, substituting tertiary prevention, i.e., supportive rehabilitation to maximum personal function and maintaining a stable functional status. as in an individual, the phenomenon of a disease in a population may follow a course in which many factors interplay, and where interventions affect the natural course of the disease. the epidemiological patterns of an infectious disease can be assessed in their occurrence in the population or their mortality rates, just as they can for individual cases. the classic mid-nineteenth-century description of measles in the faroe islands by panum showed the transmission and the epidemic nature of the disease as well as the protective effect of acquired immunity (see chapter 1). similar, more recent breakthroughs in medical, epidemiological, biological, and social sciences have produced enormous benefit for humankind as discussed throughout this text, with some examples. these include the eradication of smallpox and in the coming years, poliomyelitis, measles, leprosy, and other dreaded diseases known for millennia; the near-elimination of rheumatic heart disease and peptic ulcers in the industrialized countries; vast reduction in mortality from stroke and coronary heart disease (chd); and vaccines (against hepatitis b and hpv) for the prevention of cancers. these and other great achievements of the twentieth and early part of the twenty-first centuries hold great promise for humankind in the coming decades, but great challenges lie ahead as well. the biggest challenge is to bring the benefits of known public health capacity to the poorest population of each country and the poorest populations globally. in developed countries a major challenge is to renew efforts of public health capacity to bear on prevention of chronic conditions such as diabetes and obesity, considered to be at pandemic proportions; and the individual and societal effects of mental diseases. in public health today, fears of a pandemic of avian influenza are based on transmission of avian or other animal-borne (zoonotic) prions or viruses to humans and then their adaptation permitting human-to-human spread. with large numbers of people living in close contact with many animals (wild and domestic fowl), such as in china and south-east asia, and rapid transportation around the world, the potential for global spread of disease is almost without historical precedent. indeed, many human infectious diseases are zoonotic in origin and transferred from natural wildlife reservoirs to humans either directly or via domestic or other wild animals, such as from birds to chickens to humans in avian influenza. monitoring or immunization of domestic animals requires a combination of multidisciplinary zoonotic disease management strategies, public education and awareness, and veterinary public health monitoring and control. rift valley fever, equine encephalitis, and more recently sars and avian influenza associated with bird-borne viral disease which can affect humans, each show the terrible dangers of pandemic diseases. ebola virus is probably sustained between outbreaks among fruit bats, or as recently suggested wild or domestic pigs, and may become a major threat to public health as human case fatality rates decline, meaning that patients and carriers, or genetic drift of the virus with possible airborne transmission, may spread this deadly disease more widely than in the past (see chapter 4). the health of populations, like the health of individuals, depends on societal factors no less than on genetics, personal risk factors, and medical services. social inequalities in health have been understood and documented in public health over the centuries. the chadwick and shattuck reports of 1840-1850 documented the relationship of poverty and bad sanitation, housing, and working conditions with high mortality, and ushered in the idea of social epidemiology. political and social ideologies thought that the welfare state, including universal health care systems of one type or another, would eliminate social and geographic differences in health status and this is in large part true. from the introduction of compulsory health insurance in germany in the 1880s to the failed attempt in the usa at national health insurance in 1995 (see chapters 1, 10 and 13) and the more recent achievements of us president obama in 2010-2011, social reforms to deal with inequalities in health have focused on improving access to medical and hospital care. almost all industrialized countries have developed such systems, and the contribution of these programs to improve health status has been an important part of social progress, especially since world war ii. but even in societies with universal access to health care, people of lower socioeconomic status (ses) suffer higher rates of morbidity and mortality from a wide variety of diseases. the black report (douglas black) in the uk in the early 1980s pointed out that the class v population (unskilled laborers) had twice the total and specific mortality rates of the class i population (professional and business) for virtually all disease categories, ranging from infant mortality to death from cancer. the report was shocking because all britons have had access to the comprehensive national health service (nhs) since its inception in 1948, with access to a complete range of services at no cost at time of service, close relations to their general practitioners, and good access to specialty services. these findings initiated reappraisals of the social factors that had previously been regarded as the academic interests of medical sociologists and anthropologists and marginal to medical care. more recent studies and reviews of regional, ethnic, and socioeconomic differentials in patterns of health care access, morbidity, and mortality indicate that health inequities are present in all societies including the uk, the usa, and others, even with universal health insurance or services. the ottawa charter on health promotion in 1986 placed a new paradigm before the world health community that recognized social and political factors as no less important ion health that traditional medical and sanitary public health measures. these concepts helped the world health community to cope with new problems such as hiv/aidsfor which there was neither a medical cure nor a vaccine to prevent the disease. its control came to depend in the initial decades almost entirely on education and change in lifestyles, until the advent of the antiretroviral drugs in the 1990s. there is still no viable vaccine. although the epidemiology of cardiovascular disease shows the direct relationship of the now classic risk factors of stress, smoking, poor diet, and physical inactivity, differences in mortality from cardiovascular disease between different classes among british civil servants are not entirely explainable by these factors. the differences are also affected by social and economic issues that may relate to the psychological needs of the individual, such as the degree of control people have over their own lives. blue-collar workers have less control over their lives, their working life in particular, than their white-collar counterparts, and have higher rates of chd mortality than higher social classes. other work shows the effects of migration, unemployment, drastic social and political change, and binge drinking, along with protective effects of healthy lifestyle, religiosity, and family support systems in cardiovascular diseases. social conditions affect disease distribution in all societies. in the usa and western europe, tb has re-emerged as a significant public health problem in urban areas partly because of high-risk population groups, owing to poverty and alienation from society, as in the cases of homelessness, drug abuse, and hiv infection. in countries of eastern europe and the former soviet union, the recent rise in tb incidence has resulted from various social and economic factors in the early 1990s, including the large-scale release of prisoners. in both cases, diagnosis and prescription of medication are inadequate, and the community at large becomes at risk because of the development of antibioticresistant strains of tubercle bacillus readily spread by inadequately treated carriers, acting as human vectors. studies of ses and health are applicable and valuable in many settings. in alameda county, california, differences in mortality between black and white population groups in terms of survival from cancer became insignificant when controlled for social class. a 30-year follow-up study of the county population reported that low-income families in california are more likely than those on a higher income to have physical and mental problems that interfere with daily life, contributing to further impoverishment. studies of the association between indicators of ses and recent screening in the usa, australia, finland, and elsewhere showed that lower ses women use less preventive care such as papanicolaou (pap) smears for cervical cancer than women of higher ses, despite having greater risk for cervical cancer. many factors in ses inequalities are involved, including transportation and access to primary care, differences in health insurance coverage, educational levels, poverty, high-risk behaviors, social and emotional distress, feeling a lack of control over one's own life, employment, occupation, and inadequate family or community social support systems. many barriers exist owing to difficulties in access and the lack of availability of free or low-cost medical care, and the absence or limitations of health insurance is a further factor in the socioeconomic gradient. the recognition that health and disease are influenced by many factors, including social inequalities, plays a fundamental role in the new public health paradigm. health care systems need to take into account economic, social, physical, and psychological factors that otherwise will limit the effectiveness of even the best medical care. the health system includes access to competent and responsible primary care as well as by the wider health system, including health promotion, specific prevention and population-based health protection. the paradigm of the host-agent-environment triad (figures 2.2 and 2. 3) is profoundly affected by the wider context. the sociopolitical environment and organized efforts at intervention affect the epidemiological and clinical course of disease of the individual. medical care is essential, as is public health, but the persistent health inequities seen in most regions and countries require societal attention. success or failure in improving the conditions of life for the poor, and other vulnerable "risk groups", affect national or regional health status and health system performance. the health system is meant to reduce the occurrence or bad outcome of disease, either directly by primary prevention or treatment as secondary prevention or by maximum rehabilitation as tertiary prevention, or equally important indirectly by reducing community or individual risk factors. the the effects of social conditions on health can be partly offset by interventions intended to promote healthful conditions; for example, improved sanitation, or through good-quality primary and secondary health services, used efficiently and effectively made available to all. the approaches to preventing disease or its complications may require physical changes in the environment, such as removal of the broad street pump handle to stop the cholera epidemic in london, or altering diets as in goldberger's work on pellagra. some of the great successes of public health have been and continue to be low technology. examples, among many others, include insecticide-impregnated bednets and other vector control measures, oral rehydration solutions, treatment and cure of peptic ulcers, exercise and diet to reduce obesity, hand washing in hospitals (and other health facilities), community health workers, and condoms and circumcision for the prevention of stis, including hiv and cancer of the cervix. the societal context in terms of employment, social security, female education, recreation, family income, cost of living, housing, and homelessness is relevant to the health status of a population. income distribution in a wealthy country may leave a wide gap between the upper and lower socioeconomic groups, which affects health status. the media have great power to sway public perception of health issues by choosing what to publish and the context in which to present information to society. modern media may influence an individual's tendency to overestimate the risk of some health issues while underestimating the risk of others, ultimately influencing health choices, such as occurred with public concern regarding false claims of an association between the measles-mumps-rubella (mmr) vaccine and autism in the uk (see the wakefield effect, chapter 4). the new public health has an intrinsic responsibility for advocacy of improved societal conditions in its mission to promote optimal community health. an ultimate goal of public health is to improve health and to prevent widespread disease occurrence in the population and in an individual. the methods of achieving this are wide and varied. when an objective has been defined in "social justice is a matter of life and death. it affects the way people live, their consequent chance of illness, and their risk of premature death. we watch in wonder as life expectancy and good health continue to increase in parts of the world and in alarm as they fail to improve in others. a girl born today can expect to live for more than 80 years if she is born in some countries -but less than 45 years if she is born in others. within countries there are dramatic differences in health that are closely linked with degrees of social disadvantage. differences of this magnitude, within and between countries, simply should never happen. these inequities in health, avoidable health inequalities arise because of the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. the conditions in which people live and die are, in turn, shaped by political, social, and economic forces. social and economic policies have a determining impact on whether a child can grow and develop to its full potential and live a flourishing life, or whether its life will be blighted. increasingly the nature of the health problems rich and poor countries have to solve are converging. the development of a society, rich or poor, can be judged by the quality of its population's health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantage as a result of ill-health." preventing disease, the next step is to identify suitable and feasible methods of achieving it, or a strategy with tactical objectives. this determines the method of operation, course of action, and resources needed to carry it out. the methods of public health are categorized as health promotion, and primary, secondary, and tertiary prevention (box 2.6). health promotion is the process of enabling people and communities to increase control over factors that influence their health, and thereby to improve their health (adapted from the ottawa charter of health promotion, 1986; box 2.7). health promotion is a guiding concept involving activities intended to enhance individual and community health and well-being (box 2.8). it seeks to increase involvement and control by the individual and the community in their own health. it acts to improve health and social welfare, and to reduce specific determinants of diseases and risk factors that adversely affect the health, well-being, and productive capacities of an individual or society, setting targets based on the size of the problem but also the feasibility of successful intervention, in a cost-effective way. this can be through direct contact with the patient or risk group, or act indirectly through changes in the environment, legislation, or public policy. control of aids relies on an array of interventions that promote change in sexual behavior and other contributory risks such as sharing of needles among drug users, screening of blood supply, safe hygienic practices in health care settings, and education of groups at risk such as teenagers, sex workers, migrant workers, and many others. control of aids is also a clinical problem in that patients need antiretroviral therapy (art), but this becomes a management and policy issue for making these drugs available and at an affordable price for the poor countries most affected. this is an example of the challenge and effectiveness of health promotion and the new public health. health promotion is a key element of the new public health and is applicable in the community, the clinic or hospital, and in all other service settings. some health promotion activities are government legislative and box 2.6 modes of prevention l health promotion -fostering national, community, and individual knowledge, attitudes, practices, policies, and standards conducive to good health; promoting legislative, social, or environmental conditions; promoting knowledge and practices for self-care that reduce individual and community risk; and creating a healthful environment. it is directed toward action on the determinants of health. l health protection -activities of official health departments or other agencies empowered to supervise and regulate food hygiene, community and recreational water safety, environmental sanitation, occupational health, drug safety, road safety, emergency preparedness, and many other activities to eliminate or reduce as much as possible risks of adverse consequences to health. l primary prevention -preventing a disease from occurring, e.g., vaccination to prevent infectious diseases, advice to stop smoking to prevent lung cancer. l secondary prevention -making an early diagnosis and giving prompt and effective treatment to stop progress or shorten the duration and prevent complications from an already existing disease process, e.g., screening for hypertension or cancer of cervix and colorectal cancer for early case finding, early care and better outcomes. l tertiary prevention -stopping progress of an already occurring disease, and preventing complications, e.g., in managing diabetes and hypertension to prevent complications; restoring and maintaining optimal function once the disease process has stabilized, e.g., promoting functional rehabilitation after stroke and myocardial infarction with long-term follow-up care. health promotion (hp) is the process of enabling people to increase control over, and to improve their health. hp represents a comprehensive social and political process, and not only embraces actions directed at strengthening the skills and capabilities of individuals. hp also undertakes action directed towards changing social, environmental, and economic conditions so as to alleviate their impact on public and individual health. health promotion is the process of enabling people to increase control over the determinants of health and thereby improve their health. participation is essential to sustain health promotion action. the ottawa charter identifies three basic strategies for health promotion. these are advocacy for health to create the essential conditions for health indicated above; enabling all people to achieve their full health potential; and mediating between the different interests in society in the pursuit of health. these strategies are supported by five priority action areas as outlined in the ottawa charter for health promotion: regulatory interventions such as mandating the use of seat belts in cars, requiring that children be immunized to attend school, declaring that certain basic foods must have essential minerals and vitamins added to prevent nutritional deficiency disorders in vulnerable population groups, and mandating that all newborns should be given prophylactic vitamin k to prevent hemorrhagic disease of the newborn. setting food and drug standards and raising taxes on cigarettes and alcohol to reduce their consumption are also part of health promotion. promoting a healthy lifestyle is a major known obesity-preventive activity. health promotion is provided by organizations and people with varied professional backgrounds working towards common goals of improvement in the health and quality of individual and community life. initiatives may come from government with dedicated allocation of funds to address specific health issues, from donors, or from advocacy or community groups or individuals to promote a specific or general cause in health. raising awareness to inform and motivate people about their own health and lifestyle factors that might put them at risk requires teaching young people about the dangers of sexually transmitted diseases, smoking, and alcohol abuse to reduce risks associated with their social behavior. it might include disseminating information on healthy nutrition; for example, the need for folic acid supplements for women of childbearing age and multiple vitamins for elderly, as well as the elements of a healthy diet, compliance with immunization recommendations, compliance with screening programs, and many others. community and peer group attitudes and standards affect individual behavior. health promotion endeavors to create a climate of knowledge, attitudes, beliefs, and practices that are associated with better health outcomes. international conferences following on from the ottawa charter were held in adelaide in 1988 , sundsvall in 1991 , jakarta in 1999 , mexico in 2000 , bangkok in 2005 , and nairobi in 2009 . the principles of health promotion have been reiterated and have influenced public policy regarding public health as well as the private sector. health promotion has a track record of proven success in numerous public health issues where a biomedical solution was not available. the hiv/aids pandemic from the 1980s until the late 1990s had no medical treatment and control measures relied on screening, education, lifestyle changes, and supportive care. health promotion brought forward multiple interventions, from condom use and distribution, to needle exchanges for intravenous drug users, to male circumcision in high-prevalence african countries. medical treatment was severely limited until art was developed. the success of art also depends on a strong element of health promotion in widening the access to treatment and the success of medications to reduce transmission, most remarkably in reducing maternal-fetal transmission (see chapter 4). similarly, in the battle against cardiovascular diseases, health promotion was an instrumental factor in raising public awareness of the importance of management of hypertension and smoking reduction, dietary restraint, and physical exercise. the success of massive reductions in stroke and chd mortality is as much the result of health promotion as of improved medical care (see chapter 5). the character of public health carries with it a "good cop, bad cop" dichotomy. the "good cop" is persuasive and educational trying to convince people to do the right thing in looking after their own health: diet, exercise, smoking cessation, and others. on the other side, the "bad cop" role is regulatory and punitive. public health has a serious responsibility and role in the enforcement of laws and regulation to protect the public health. some of these are restrictive box 2.8 elements of health promotion 1. address the population as a whole in health-related issues, in everyday life as well as people at risk for specific diseases. 2. direct action to risk factors or causes of illness or death. 3. undertake activist approach to seek out and remedy risk factors in the community that adversely affect health. 4. promote factors that contribute to a better condition of health of the population. 5. initiate actions against health hazards, including communication, education, legislation, fiscal measures, organizational change, community development, and spontaneous local activities. 6. involve public participation in defining problems and deciding on action. 7. advocate relevant environmental, health, and social policy. 8. encourage health professional participation in health education and health advocacy. 9. advocate for health based on human rights and solidarity. 10. invest in sustainable policies, actions, and infrastructure to address the determinants of health. 11. build capacity for policy development, leadership, health promotion practice, knowledge transfer and research, and health literacy. 12. regulate and legislate to ensure a high level of protection from harm and enable equal opportunity for health and well-being for all people. 13. partner and build alliances with public, private, nongovernmental, and international organizations and civil society to create sustainable actions. 14. make the promotion of health central to the global development agenda. of individual rights that may damage other people or are requirements based on strong evidence of benefits to population health. readily accepted are food and drug standards, such as pasteurization of milk, and iodization of salt; requirements to drive on the right-hand side of the road (except in some countries such as the uk), to wear seat belts and for motorcyclists to wear safety helmets; and not smoking in public places. enforcement of these and similar statutory or regulatory requirements is vital in a civil society to protect the public from health hazards and to protect people from harm and exploitation by unscrupulous manufacturers and marketing. cigarette advertising and sponsorship of sports events by tobacco companies are banned in most upper income countries. the use of transfats in food manufacturing and baking is now banned and salt reduction is being promoted and even mandated in many us local authorities to reduce cardiovascular disease. advertising of unhealthy snack foods on children's television programs and during child-watching hours is commonly restricted. banning high-sugar soda drink distribution in schools is a successful intervention to reduce the current child obesity epidemic. melamine use in milk powders and baby formulas, which caused widespread illness and death of infants in china, is now banned and a punishable offence for manufacture or distribution in china and worldwide. examples of this aspect of public health are mentioned throughout this text, especially in chapters 8 and 9 on nutrition, and environmental and occupational health, respectively. the regulatory enforcement function of public health is sometimes controversial and portrayed as interference with individual liberty. fluoridation of community water supplies is an example where aggressive lobby groups opposing this safe and effective public health measure are still common. this is discussed in chapter 7. equally important is the public health policy issue of resource allocation and taxation for health purposes. taxation is an unpopular measure that governments must employ and enforce in order to do the public's business. the debate over the patient protection and affordable care act 2010 (ppaca or "obamacare"), discussed elsewhere in this and other chapters, shows how bitter the arguments can become, yet the goal of equality of access to health care cannot be denied as a public good, demonstrably contributing to the health of the nation. primary prevention refers to those activities that are undertaken to prevent disease or injury from occurring at all. primary prevention works with both the individual and the community. it may be directed at the host to increase resistance to the agent (such as in immunization or cessation of smoking), or at environmental activities to reduce conditions favorable to the vector for a biological agent, such as mosquito vectors of malaria or dengue fever. landmark examples include the treatment and prevention of scurvy among sailors based on james lind's findings in a classic clinical epidemiological study in 1747, and john snow's removal of the handle from the broad street pump to stop a cholera epidemic in london in 1854 (see chapter 1). primary prevention includes elements of health protection such as ensuring water, food and drug, and workplace safety; chlorination of drinking water to prevent transmission of waterborne enteric diseases; pasteurization of milk to prevent gastrointestinal diseases; mandating wearing seat belts in motor vehicles to prevent serious injury and death in road crashes; and reducing the availability of firearms to reduce injury and death from intentional, accidental, or random violence. it also includes direct measures to prevent diseases, such as immunization to prevent polio, tetanus, pertussis, and diphtheria. health promotion and health protection blend together as a group of activities that reduce risk factors and diseases through many forms of intervention such as changing smoking legislation or preventing birth defects by fortification of flour with folic acid. prevention of hiv transmission by needle exchange for intravenous drug users, promoting condom usage, and promoting male circumcision in africa, and the distribution of condoms and clean needles for hivpositive drug users are recent examples of primary prevention associated with health promotion programs. primary prevention also includes activities within the health system that can lead to better health. this may mean, for example, setting standards and to reduce hospital infections, and ensuring that doctors not only are informed of appropriate immunization practices and modern prenatal care or screening programs for cancer of the cervix, colon, and breast, but also are aware of their vital role in preventing cardiovascular and other non-communicable diseases. in this role, the health care provider serves as a teacher and guide, as well as a diagnostician and therapist. like health promotion, primary prevention does not depend on health care providers alone; health promotion works to increase individual and community consciousness of self-care, mainly by raising awareness and information levels and empowering the individual and the community to improve self-care, to reduce risk factors, and to live healthier lifestyles. secondary prevention is early diagnosis and management to prevent complications from a disease. public health interventions to prevent the spread of disease include the identification of sources of the disease and the implementation of steps to stop it, as shown in snow's closure of the broad street pump. secondary prevention includes steps to isolate cases and treat or immunize contacts so as to prevent further cases of meningitis or measles, for example, in outbreaks. for current epidemics such as hiv/aids, primary prevention is largely based on education, abstinence from any and certainly risky sexual behavior, circumcision, and treatment of patients in order to improve their health and to reduce the risk of spread of hiv. for high-risk groups such as intravenous drug users, needleexchange programs reduce the risk of spread of hiv, and hepatitis b and c. distribution of condoms to teenagers, military personnel, truck drivers, and commercial sex workers helps to prevent the spread of stis and aids in schools and colleges, as well as among the military. the promotion of circumcision is shown to be effective in reducing the transmission of hiv and of hpv (the causative organism for cancer of the cervix). all health care providers have a role in secondary prevention; for example, in preventing strokes by early identification and adequate care of hypertension. the child who has an untreated streptococcal infection of the throat may develop complications which are serious and potentially life-threatening, including rheumatic fever, rheumatic valvular heart disease, and glomerulonephritis. a patient found to have elevated blood pressure should be advised about continuing management by appropriate diet and weight loss if obese, regular physical exercise, and long-term medication with regular follow-up by a health provider in order to reduce the risk of stroke and other complications. in the case of injury, competent emergency care, safe transportation, and good trauma care may reduce the chance of death and/or permanent handicap. screening and high-quality care in the community prevent complications of diabetes, including heart, kidney, eye, and peripheral vascular disease. they can also prevent hospitalizations, amputations, and strokes, thus lengthening and improving the quality of life. health care systems need to be actively engaged in secondary prevention, not only as individual doctors' services, but also as organized systems of care. public health also has a strong interest in promoting highquality care in secondary and tertiary care hospital centers in such areas of treatment as acute myocardial infarction, stroke, and injury in order to prevent irreversible damage. measures include quality of care reviews to promote adequate longterm postmyocardial infarction care with aspirin and betablockers or other medication to prevent or delay recurrence and second or third myocardial infarctions. the role of highquality transportation and care in emergency facilities of hospitals in public health is vital to prevent long-term damage and disability; thus, cardiac care systems including publicly available defibrillators, catheterization, the use of stents, and bypass procedures are important elements of health care policy and resource allocation, which should be accessible not only in capital cities but also to regional populations. tertiary prevention involves activities directed at the host or patient, but also at the social and physical environment in order to promote rehabilitation, restoration, and maintenance of maximum function after the disease and its complications have stabilized. the person who has undergone a cerebrovascular accident or trauma will reach a stage where active rehabilitation can help to restore lost functions and prevent recurrence or further complications. the public health system has a direct role in the promotion of disability-friendly legislation and standards of building, housing, and support services for chronically ill, handicapped, and elderly people. this role also involves working with many governmental social and educational departments, but also with advocacy groups, ngos, and families. it may also include the promotion of disability-friendly workplaces and social service centers. treatment for conditions such as myocardial infarction or a fractured hip now includes early rehabilitation in order to promote early and maximum recovery with restoration to optimal function. the provision of a wheelchair, walkers, modifications to the home such as special toilet facilities, doors, and ramps, along with transportation services for paraplegics are often the most vital factors in rehabilitation. public health agencies work with groups in the community concerned with promoting help for specific categories of risk group, disease, or disability to reduce discrimination. community action is often needed to eliminate financial, physical, or social barriers, promote community awareness, and finance special equipment or other needs of these groups. close follow-up and management of chronic disease, physical and mental, require home care and ensuring an appropriate medical regimen including drugs, diet, exercise, and support services. the follow-up of chronically ill people to supervise the taking of medications, monitor changes, and support them in maximizing their independent capacity in activities of daily living is an essential element of the new public health. public health uses a population approach to achieve many of its objectives. this requires defining the population, including trends of change in the age and gender distribution of the population, fertility and birth rates, spread of disease and disability, mortality, marriage and migration, and socioeconomic factors. the reduction of infectious disease as the major cause of mortality, increased longevity coupled with declining fertility rates, resulted in changes in the age composition, or a demographic transition. demographic changes, such as fertility and mortality patterns, are important factors in changing the age distribution of the population, resulting in a greater proportion of people surviving to older ages. declining infant mortality, increasing educational levels of women, the availability of birth control, and other social and economic factors lead to changes in fertility patterns and the demographic transition -an aging of the population -with important effects on health service needs. the age and gender distribution of a population affects and is affected by patterns of disease. change in epidemiological patterns, or an epidemiological shift, is a change in predominant patterns of morbidity and mortality. the transition of infectious diseases becoming less prominent as causes of morbidity and mortality and being replaced by chronic and non-infectious diseases has occurred in both developed and developing countries. the decline in mortality from chronic diseases, such as cardiovascular disease, represents a new stage of epidemiological transition, creating an aging population with higher standards of health but also long-term community support and care needs. monitoring and responding to these changes are fundamental responsibilities of public health, and a readiness to react to new, local, or generalized changes in epidemiological patterns is vital to the new public health. societies are not totally homogeneous in ethnic composition, levels of affluence, or other social markers. on one hand, a society classified as developing may have substantial numbers of people with incomes that promote overnutrition and obesity, so that disease patterns may include increasing prevalence of diseases of excesses, such as diabetes. on the other hand, affluent societies include population groups with disease patterns of poverty, including poor nutrition and low birth-weight babies. a further stage of epidemiological transition has been occurring in the industrialized countries since the 1960s, with dramatic reductions in mortality from chd, stroke and, to a lesser extent, trauma. the interpretation of this epidemiological transition is still not perfectly clear. how it occurred in the industrialized western countries but not in those of the former soviet union is a question whose answer is vital to the future of health in russia and some countries of eastern europe. developing countries must also prepare to cope with increasing epidemics of non-infectious diseases, and all countries face renewed challenges from infectious diseases with antibiotic resistance or newly appearing infectious agents posing major public health threats. demographic change in a country may reflect social and political decisions and health system priorities from decades before. russia's rapid population decline since the 1990s, china's gender imbalance with a shortage of millions of young women, egypt's rapid population growth outstripping economic capacity, and many other examples indicate the severity and societal importance of capacity to analyze and formulate public health and social policies to address such fundamental sociopolitical issues. aging of the population is now the norm in most developed countries as a result of low birth and declining mortality rates. this change in the age distribution of a population has many associated social and economic issues as to the future of social welfare with a declining age cohort to provide the workforce. the aging population requires pension and health care support which make demands of social security systems that will depend on economic growth with a declining workforce. in times of economic stress, as in europe, this situation is made more difficult by longstanding short working weeks, early pension ages, and high social benefits. however, this results in unemployment among young people in particular and social conflict. the interaction of increasing life expectancy and a declining workforce is a fundamental problem in the high-income countries. this imbalance may be resolved in part through productivity gains and switching of primary production to countries with large still underutilized workforces, while employment in the developed countries will depend on service industries including health and the economic growth generated by higher technology and intellectual property and service industries. the challenge of keeping populations and individuals healthy is reflected in modern health services. each component of a health service may have developed with different historical emphases, operating independently as a separate service under different administrative auspices and funding systems, competing for limited health care resources. in this situation, preventive community care receives less attention and resources than more costly treatment services. figure 2 .5 suggests a set of health services in an interactive relationship to serve a community or defined population, but the emphasis should be on the interdependence of these services with one other and with the comprehensive network in order to achieve effective use of resources and a balanced set of services for the patient, the client or patient population, and the community. clinical medicine and public health each play major roles in primary, secondary, and tertiary prevention. each may function separately in their roles in the community, but optimal success lies in their integrated efforts. allocation of resources should promote management and planning practices to assist this integration. there is a functional interdependence of all elements of health care serving a definable population. the patient should be the central figure in the continuum or complex of services available. effectiveness in use of resources means that providing the service most appropriate for meeting the individual's or group's needs at a point in time are those that should be applied. this is the central concept in currently developing innovations in health care delivery in the usa with organizations using terms such as patient centered medical home, accountable care organizations (acos), and population health management systems, which are being promoted in the obamacare health reforms now in process (see chapter 10) (shortell et al., 2010) . separate organization and financing of services place barriers to appropriate provision of services for both the community and the individual patient. the interdependence of services is a challenge in health care organizations for the future. where there is competition for limited resources, pressures for tertiary services often receive priority over programs to prevent children from dying of preventable diseases. public health must be seen in the context of all health care and must play an influential role in promoting prevention at all levels. clinical services need public health in order to provide prevention and community health services that reduce the burden of disease, disability, and dependence on the institutional setting. health was traditionally thought of as a state of absence of disease, pain, or disability, but has gradually been expanded to include physical, mental, and societal well-being. in 1920, c. e. a. winslow, professor of public health at yale university, defined public health as follows: "public health is the science and art of (1) preventing disease, (2) prolonging life, and (3) winslow's far-reaching definition remains a valid framework but is unfulfilled when clinical medicine and public health have financing and management barriers between them. in many countries, isolation from the financing and provision of medical and nursing care services left public health with the task of meeting the health needs of the indigent and underserved population groups with inadequate resources and recognition. health insurance organizations for medical and hospital care have in recent years been more open to incorporating evidence-based preventive care, but the organization of public health has lacked the same level of attention. in some countries, the limitations have been conceptual in that public health was defined primarily in terms of control of infectious, environmental, and occupational diseases. a more recent and widely used definition is: "public health is the science and art of preventing disease, prolonging life, and promoting health through the organized efforts of society." this definition, coined in 1988 in the public health in england report by sir donald acheson, reflects the broad focus of modern public health. terms such as social hygiene, preventive medicine, community medicine, and social medicine have been used to denote public health practice over the past century. preventive medicine is the application of preventive measures by clinical practitioners combining some elements of public health with clinical practice relating to individual patients. preventive medicine defines medical or clinical personal preventive care, with stress on risk groups in the community and national efforts for health promotion. the focus is on the health of defined populations to promote health and well-being using evidence-based guidelines for cost-effective preventive measures. measures emphasized include screening and follow-up of chronic illnesses, and immunization programs; for example, influenza and pneumococcal pneumonia vaccines are used by people who are vulnerable because of their age, chronic diseases, or risk of exposure, such as medical and nursing personnel and those providing other personal clinical services. clinical medicine also deals in the area of prevention in the management of patients with hypertension or diabetes, and in doing so prevents the serious complications of these diseases. social medicine is also primarily a medical specialty which looks at illness in an individual in the family and social context, but lacks the environmental and regulatory and organized health promotion functions of public health. community health implies a local form of health intervention, whereas public health more clearly implies a global approach, which includes action at the international, national, state, and local levels. some issues in health can be dealt with at the individual, family, or community level; others require global strategies and intervention programs with regional, national, or international collaboration and leadership. the social medicine movement originated to address the harsh conditions of the working population during the industrial revolution in mid-nineteenth-century europe. an eminent pioneer in cellular pathology, rudolph virchow provided leadership in social medicine powered by the revolutionary movements of 1848, and subsequent social democrat political movements. their concern focused on harsh living and health conditions among the urban poor working class and neglectful political norms of the time. social medicine also developed as an academic discipline and advocacy orientation by providing statistical evidence showing, as in various governmental reports in the mid-nineteenth century, that poverty among the working class was associated with short life expectancy and that social conditions were key factors in the health of populations and individuals. this movement provided the basis for departments in medical faculties and public health education throughout the world stressing the close relationship between political priorities and health status. this continued in the twentieth century and in the usa found expression in pioneering work since the 1940s at montefiore hospital in new york and with victor sidel, founding leader of the community health center movement the usa from the 1960s. in the twenty-first century this movement continues to emphasize relationships between politics, society, disease, and medicine, and forms of medical practice derived from it, as enunciated by prominent advocates such as harvardbased paul farmer in haiti, russia and rwanda, and in the uk by martin mckee and others (nolte and mckee, 2008) . similar concepts are current in the usa under headings such as family medicine, preventive medicine, and social medicine. this movement has also influenced sir michael marmot and others in the world health commission of health inequalities of 2008, with a strong influence on the un initiative to promote mdgs, whose first objective is poverty reduction (commission on inequalities report 2010). application of the idea of poverty reduction as a method of reducing health inequalities has been successful recently in a large field trial in brazil showing greater reduction in child mortality where cash bonuses were awarded by municipalities for the poor families than that observed in other similar communities (rasella, 2013). in the usa, this movement is supported by increased health insurance coverage for the working poor, with funding for preventive care and incentives for community health centers in the obamacare plan of 2010 for implementation in the coming years to provide care for uninsured and underserved populations, particularly in urban and rural poverty areas. the political aspect of social medicine is the formulation of and support for national initiatives to widen health care coverage to the 16 percent of the us population who are still uninsured, and to protect those who are arbitrarily excluded owing to previous illnesses, caps on coverage allowed, and other exploitative measures taken by private insurance that frequently deny americans access to the high levels of health care available in the country. the ethical base of public health in europe evolved in the context of its successes in the nineteenth and early twentieth centuries along with ideas of social progress. but the twentieth century was also replete with extremism and wide-scale abuse of human rights, with mass executions, deportations, and starvation as official policy in fascist and stalinist regimes. eugenics, a pseudoscience popularized in the early decades of the twentieth century, promoted social policies meant to improve the hereditary qualities of a race by methods such as sterilization of mentally handicapped people. the "social and racial hygiene" of the eugenics movements led to the medicalization of sterilization in the usa and other countries. this was adopted and extended in nazi germany to a policy of murder, first of the mentally and physically handicapped and then of "racial inferiors". these eugenics theories were widely accepted in the medical community in germany, then used by the nazi regime to justify medically supervised killing of hundreds of thousands of helpless, incapacitated individuals. this practice was linked to wider genocide and the holocaust, with the brutalization and industrialized murder of over 6 million jews and 6 million other people, and corrupt medical experimentation on prisoners. following world war ii, the ethics of medical experimentation (and public health) were codified in the nuremberg code and universal declaration of human rights based on lessons learned from these and other atrocities inflicted on civilian populations (see chapter 15). threats of genocide, ethnic cleansing, and terrorism are still present on the world stage, often justified by current warped versions of racial hygienic theories. genocidal incitement and actual genocide and terrorism have recurred in the last decades of the twentieth century and into the twenty-first century in the former yugoslav republics, africa (rwanda and darfur), south asia, and elsewhere. terrorism against civilians has become a worldwide phenomenon with threats of biological and chemical agents, and potentially with nuclear capacity. asymmetrical warfare of insurgencies which use innocent civilians for cover, as with other forms of warfare, carries with it grave dangers to public health, human rights, and international stability, as seen in the twenty-first century in south sudan, darfur, dr congo, chechnya, iraq, afghanistan, and pakistan. in 1961, kerr white and colleagues defined medical ecology as population-based research providing the foundation for management of health care quality. this concept stresses a population approach, including those not attending and those using health services. this concept was based on previous work on quality of care, randomized clinical trials, medical audit, and structure-process-outcome research. it also addressed health care quality and management. these themes influenced medical research by stressing the population from which clinical cases emerge as well as public health research with clinical outcome measures, themes that recur in the development of health services research and, later, evidence-based medicine. this led to the development of the agency for health care policy and research and development in the us department of health and human services and evidence-based practice centers to synthesize fundamental knowledge for the development of information for decision-making tools such as clinical guidelines, algorithms, or pathways. clinical guidelines and recommended best practices have become part of the new public health to promote quality of patient care and public health programming. these can include recommended standards; for example, follow-up care of the postmyocardial infarction patient, an internationally recommended immunization schedule, recommended dietary intake or food fortification standards, and mandatory vitamin k and eye care for all newborns and many others (see chapter 15). community-oriented primary care (copc) is an approach to primary health care that links community epidemiology and appropriate primary care, using proactive responses to the priority needs identified. copc, originally pioneered in south africa and israel by sidney and emily kark and colleagues in the 1950s and 1960s, stresses medical services in the community which need to be adapted to the needs of the population as defined by epidemiological analysis. copc involves community outreach and education, as well as clinical preventive and treatment services. copc focuses on community epidemiology and an active problem-solving approach. this differs from national or larger scale planning that sometimes loses sight of the local nature of health problems or risk factors. copc combines clinical and epidemiological skills, defines needed interventions, and promotes community involvement and access to health care. it is based on linkages between the different elements of a comprehensive basket of services along with attention to the social and physical environment. a multidisciplinary team and outreach services are important for the program, and community development is part of the process. in the usa, the copc concept has influenced health care planning for poor areas, especially provision of federally funded community health centers in attempts to provide health care for the underserved since the 1960s. in more recent years, copc has gained wider acceptance in the usa, where it is associated with family physician training and community health planning based on the risk approach and "managed care" systems. indeed, the three approaches are mutually complementary (box 2.9). as the emphasis on health care reform in the late 1990s moved towards managed care, the principles of copc were and will continue to be important in promoting health and primary prevention in all its modalities, as well as tertiary prevention with followup and maintenance of the health of the chronically ill. copc stresses that all aspects of health care have moved towards prevention based on measurable health issues in the community. through either formal or informal linkages between health services, the elements of copc are part of the daily work of health care providers and community services systems. the us institute of medicine issued the report on primary care in 1995, defining primary care as "the provision of integrated, accessible health care services by clinicians who are accountable for addressing the majority of personal health care needs, developing a sustained partnership with patients and practicing in the context of the family and the community". this formulation was criticized by the american public health association (apha) as lacking a public health perspective and failing to take into account both the individual and the community health approaches. copc tries to bridge this gap between the perspectives of primary care and public health. the community, whether local, regional, or national, is the site of action for many public health interventions. moreover, understanding the characteristics of the community is vital to a successful community-oriented approach. by the 1980s, new patterns of public health began to emerge, including all measures used to improve the health of the community, and at the same time working to protect and promote the health of the individual. the range of activities to achieve these general goals is very wide, including individual patient care systems and the community-wide activities that affect the health and well-being of the individual. these include the financing and management of health systems, evaluation of the health status of the population, and measures to improve the quality of health care. they place reliance on health promotion activities to change environmental risk factors for disease and death. they promote integrative and multisectoral approaches and the international health teamwork required for global progress in health. the definition of health in the charter of the who as a complete state of physical, mental, and social well-being had a ring of utopianism and irrelevance to states struggling to provide even minimal care in severely adverse political, economic, social, and environmental conditions (box 2.10). in 1977, a more modest goal was set for attainment of a level of health compatible with maximum feasible social and economic productivity. one needs to recognize that health and disease are on a dynamic continuum that affects everyone. the mission for public health is to use a wide range of methods to prevent disease and premature death, and improve quality of life for the benefit of individuals and the community. the world health organization defines health as "a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity" (who constitution, 1948) . in 1978 at the alma-ata conference on primary health care, the who related health to "social and economic productivity in setting as a target the attainment by all the people of the world of a level of health that will permit them to lead a socially and economically productive life". three general programs of work for the periods 1984-1989, 1990-1995, and 1996-2001 were formulated as the basis of national and international activity to promote health. in 1995, the who, recognizing changing world conditions of demography, epidemiology, environment, and political and economic status, addressed the unmet needs of developing countries and health management needs in the industrialized countries, calling for international commitment to "attain targets that will make significant progress towards improving equity and ensuring sustainable health development". the 1999 object of the who is restated as "the attainment by all peoples of the highest possible level of health" as defined in the who constitution, by a wide range of functions in promoting technical cooperation, assisting governments, and providing technical assistance, international cooperation, and standards. in the 1960s, most industrialized countries were concentrating energies and financing in health care on providing access to medical and hospital services through national insurance schemes. developing countries were often spending scarce resources trying to emulate this trend. the who was concentrating on categorical programs, such as eradication of smallpox and malaria, as well as the expanded program of immunization and similar specific efforts. at the same time, there was a growing concern that developing countries were placing too much emphasis and expenditure on curative services and not enough on prevention and primary care. the world health assembly (wha) in 1977 endorsed the primary care approach under the banner of "health for all by the year 2000" (hfa 2000) . this was a landmark decision and has had important practical results. the who and the united nations children's fund (unicef) sponsored a seminal conference held in alma-ata, in the ussr ( kazakhstan), in 1978, which was convened to refocus health policy on primary care. the alma-ata declaration stated that health is a basic human right, and that governments are responsible to assure that right for their citizens and to develop appropriate strategies to fulfill this promise. this proposition has come to be increasingly accepted in the international community. the conference stressed the right and duty of people to participate in the planning and implementation of their health care. it advocated the use of scientifically, socially, and economically sound technology. joint action through intersectoral cooperation was also emphasized. the alma-ata declaration focused on primary health care as the appropriate method of assuming adequate access to health care for all (box 2.11). many countries have gradually come to accept the notion of placing priority on primary care, resisting the temptation to spend high percentages of health care resources on high-tech and costly medicine. spreading these same resources into highly costeffective primary care, such as immunization and nutrition programs, provides greater benefit to individuals and to society as a whole. alma-ata provided a new sense of direction for health policy, applicable to developing countries and in a different way than the approaches of the developed countries. during the 1980s, the health for all concept influenced national health policies in the developing countries with signs of progress in immunization coverage, for example, but the initiative was diluted as an unintended consequence by more categorical programs such as eradication of poliomyelitis. for example, developing countries have accepted immunization and diarrheal disease control as high-priority issues and achieved remarkable success in raising immunization coverage from some 10 percent to over 75 percent in just a decade. developed countries addressed these principles in different ways. in these countries, the concept of primary health care led directly to important conceptual developments in health. national health targets and guidelines are now common in many countries and are integral parts of box 2.11 declaration of alma-ata, 1978: a summary of primary health care (phc) 1. reaffirms that health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity, and is a fundamental human right. existing gross inequalities in the health status of the people, particularly between developed and developing countries as well as within countries, are of common concern to all countries. 3. governments have a responsibility for the health of their people. the people have the right and duty to participate in planning and implementation of their health care. 4. a main social target is the attainment, by all peoples of the world by the year 2000, of a level of health that will permit them to lead a socially and economically productive life. 5. phc is essential health care based on practical, scientifically sound, and socially acceptable methods and technology. 6. it is the first level of contact of individuals, the family, and the national health system bringing health care as close as possible to where people live and work, as the first element of a continuing health care process. 7. phc evolves from the conditions and characteristics of the country and its communities, based on the application of social, biomedical, and health services research and public health experience. 8. phc addresses the main health problems in the community, providing promotive, preventive, curative, and rehabilitative services accordingly. 9. phc includes the following: (a) education concerning prevailing health problems and methods of preventing and controlling them (b) promotion of food supply and proper nutrition (c) adequate supply of safe water and basic sanitation (d) maternal and child health care, including family planning (e) immunization against the major infectious diseases (f) prevention of locally endemic diseases (g) appropriate treatment of common diseases and injuries (h) the provision of essential drugs (i) relies on all health workers … to work as a health team. 10. all governments should formulate national health policies, strategies and plans, mobilize political will and resources, used rationally, to ensure phc for all people. national health planning. reforms of the nhs -for example, as discussed in chapter 13, remuneration increases for family physicians and encouraging group practice with public health nursing support -have become widespread in the uk. leading health maintenance organizations, such as kaiser permanente in the usa and district health systems in canada, have emphasized integrated approaches to health care for registered or geographically defined populations (see chapters 11-13). this approach is becoming common in the usa in acos, which will be fostered by the 2010 obamacare legislation (ppaca). this systematic approach to individual and community health is an integral part of the new public health. the interactions among community public health, personal health services, and health-related behavior, including their management, are the essence of the new public health. how the health system is organized and managed affects the health of the individual and the population, as does the quality of providers. health information systems with epidemiological, economic, and sociodemographic analysis are vital to monitor health status and allow for changing priorities and management. well-qualified personnel are essential to provide services, manage the system, and carry out relevant research and health policy analysis. diffusion of data, health information, and responsibility helps to provide a responsive and comprehensive approach to meet the health needs of the individual and community. the physical, social, economic, and political environments are all important determinants of the health status of the population and the individual. joint action (intersectoral cooperation) between public and non-governmental or community-based organizations is needed to achieve the well-being of the individual in a healthy society. in the 1980s and 1990s, these ideas contributed to an evolving new public health, spurred on by epidemiological changes, health economics, the development of managed care linking health systems, and prepayment. knowledge and self-care skills, as well as community action to reduce health risks, are no less important in this than the roles of medical practitioners and institutional care. all are parts of a coherent holistic approach to health. the concept of selective primary care, articulated in 1979 by walsh and warren, addresses the needs of developing countries to select those interventions on a broad scale that would have the greatest positive impact on health, taking into account limited resources such as money, facilities, and human resources. the term selective primary care is meant to define national priorities that are based not on the greatest causes of morbidity or mortality, but on common conditions of epidemiological importance for which there are effective and simple preventive measures. throughout health planning, there is an implicit or explicit selection of priorities for allocation of resources. even in primary care, selection of targets is a part of the process of resource allocation. in modern public health, this process is more explicit. a country with limited resources and a high birth rate will emphasize maternal and child health before investing in geriatric care. this concept has become part of the microeconomics of health care and technology assessment, discussed in chapters 11 and 15, respectively, and is used widely in setting priorities and resource allocation. in developing countries, cost-effective primary care interventions have been articulated by many international organizations, including iodization of salt, use of oral rehydration therapy (ort) for diarrheal diseases, vitamin a supplementation for all children, expanded programs of immunization, and others that have the potential for saving hundreds of thousands of lives yearly at low cost. in developed countries, health promotions targeted to reduce accidents and risk factors such as smoking, high-fat diets, and lack of exercise for cardiovascular diseases are low-cost public health interventions that save lives and reduce the use of hospital care. targeting specific diseases is essential for efforts to control tb or eradicate polio, but at the same time, development of a comprehensive primary care infrastructure is equally or even more important than the single-disease approach. some disease entities such as hiv/aids attract donor funding more readily than basic infrastructure services such as immunization, and this can sometimes be detrimental to addressing the overall health needs of the population and other neglected but also important diseases. the risk approach selects population groups on the basis of risk and helps to determine interventional priorities to reduce morbidity and mortality. the measure of health risk is taken as a proxy for need, so that the risk approach provides something for all, but more for those in need, in proportion to that need. in epidemiological terms, these are people with higher relative risk or attributed risk. some groups in the general population are at higher risk than others for specific conditions. the expanded programme on immunization (epi), control of diarrhoeal diseases (cdd), and acute respiratory disease (ard) programs of the who are risk approaches to tackling fundamental public health problems of children in developing countries. public health places considerable emphasis on maternal and child health because these are vulnerable periods in life for specific health problems. pregnancy care is based on a basic level of care for all, with continuous assessment of risk factors that require a higher intensity of follow-up. prenatal care helps to identify factors that increase the risk for the pregnant woman or her fetus/newborn. efforts directed towards these special risk groups have the potential to reduce morbidity and mortality. high-risk case identification, assessment, and management are vital to a successful maternal care program. similarly, routine infant care is designed not only to promote the health of infants, but also to find the earliest possible indications of deviation and the need for further assessment and intervention to prevent a worsening of the condition. low birth-weight babies are at greater risk for many short-and long-term hazards and should be given special treatment. all babies are routinely screened for birth defects or congenital conditions such as hypothyroidism, phenylketonuria, and other metabolic and hematological diseases. screening must be followed by investigating and treating those found to have a clinical deficiency. this is an important element of infant care because infancy itself is a risk factor. as will be discussed in chapters 6 and 7 and others, epidemiology has come to focus on the risk approach with screening based on known genetic, social, nutritional, environmental, occupational, behavioral, or other factors contributing to the risk for disease. the risk approach has the advantage of specificity and is often used to initiate new programs directed at special categories of need. this approach can lead to narrow and somewhat rigid programs that may be difficult to integrate into a more general or comprehensive approach, but until universal programs can be achieved, selective targeted approaches are justifiable. indeed, even with universal health coverage, it is still important to address the health needs or issues of groups at special risk. working to achieve defined targets means making difficult choices. the supply and utilization of some services will limit availability for other services. there is an interaction, sometimes positive, sometimes negative, between competing needs and the health status of a population. public health identifies needs by measuring and comparing the incidence or prevalence of the condition in a defined population with that in other comparable population groups and defines targets to reduce or eliminate the risk of disease. it determines ways of intervening in the natural epidemiology of the disease, and develops a program to reduce or even eliminate the disease. it also assesses the outcomes in terms of reduced morbidity and mortality, as well as the economic justification in cost-effectiveness analysis to establish its value in health priorities. because of the interdependence of health services, as well as the total financial burden of health care, it is essential to look at the costs of providing health care, and how resources should be allocated to achieve the best results possible. health economics has become a fundamental methodology in policy determination. the costs of health care, the supply of services, the needs for health care or other health-promoting interventions, and effective means of using resources to meet goals are fundamental in the new public health. it is possible to err widely in health planning if one set of factors is overemphasized or underemphasized. excessive supply of one service diminishes the availability of resources for other needed investments in health. if diseases are not prevented or their sequelae not well managed, patients must use costly health care services and are unable to perform their normal social functions such as learning at school or performing at work. lack of investment in health promotion and primary prevention creates a larger reliance on institutional care, driving health costs upwards, and restricting flexibility in meeting patients' needs. the interaction of supply and demand for health services is an important determinant of the political economy of health care. health and its place in national priorities are determined by the social-political philosophy and resource allocation of a government. the case for action, or the justification for a public health intervention, is a complex of epidemiological, economic, and public policy factors (table 2 .1). each disease or group of diseases requires its own case for action. the justification for public health intervention requires sufficient evidence of the incidence and prevalence of the disease (see chapter 3). evidence-based public health takes into account the effectiveness and safety of an intervention; risk factors; safe means at hand to intervene; the human, social, and economic cost of the disease; political factors; and a policy decision as to the priority of the problem. this often depends on subjective factors, such as the guiding philosophy of the health system and the way it allocates resources. some interventions are so well established that no new justification is required to make the case, and the only question is how to do it most effectively. for example, infant vaccination is a cost-effective and cost-beneficial program for the protection of the individual child and the population as a whole. whether provided as a public service or as a clinical preventive measure by a private medical practitioner, it is in the interest of public health that all children be immunized. an outbreak of diarrheal disease in a kindergarten presents an obvious case for action, and a public health system must respond on an emergency basis, with selection of the most suitable mode of intervention. the considerations in developing a case for action are outlined above. need is based on clinical and epidemiological evidence, but also on the importance of an intervention in the eyes of the public. the technology available, its effectiveness and safety, and accumulated experience are important in the equation, as are the acceptability and affordability of appropriate interventions. the precedents for use of an intervention are also important. on epidemiological evidence, if the preventive practice has been seen to provide reduction in risk for the individual and for the population, then there is good reason to implement it. the costs, risks and benefits must be examined as part of the justification to help in the selection of health priorities. health systems research examines the efficiency of health care and promotes improved efficiency and effective use of resources. this is a vital function in determining how best to use resources and meet current health needs. past emphasis on hospital care at the expense of less development of primary care and prevention is still a common issue, particularly in former soviet and developing countries, where a high percentage of total health expenditure goes to acute hospital care with long length of stay, with smaller allocation to preventive and community health care. the result of this imbalance is high mortality from preventable diseases. new drugs, vaccines, and medical equipment are continually becoming available, and each new addition needs to be examined among the national health priorities. sometimes, owing to cost, a country cannot afford to add a new vaccine to the routine. however, when there is good evidence for efficacy and safety of new vaccines, drugs, diagnostic methods or other innovations, it could be applied for those at greatest risk. although there are ethical issues involved, it may be necessary to advise parents or family members to purchase the vaccine independently. clearly, recommending individual purchase of a vaccine is counter to the principle of equity and solidarity, benefiting middleclass families, and providing a poor basis of data for evaluation of the vaccine and its target disease. on the other hand, failure to advise parents of potential benefits to their children creates other ethical problems, but may increase public pressure and insurance system acceptance of new methods, e.g., varicella and hpv vaccines. mass screening programs involving complete physical examinations have not been found to be cost-effective or to significantly reduce disease. in the 1950s and 1960s, routine general health examinations were promoted as an effective method of finding disease early. since the late 1970s, a selective and specific approach to screening has become widely accepted. this involves defining risk categories for specific diseases and bearing in mind the potential for remedial action. early case finding of colon cancer by routine fecal blood testing and colonoscopy has been found to be effective, and pap smear testing to discover cancer of the cervix is timed according to risk category. screening for colorectal cancer is essential for modern health programs and has been adopted by most industrialized countries. outreach programs by visits, telephones, emails or other modern methods of communication are important to contact non-attenders to promote utilization, and have been shown to increase compliance with proven effective measures. these programs are important for screening, follow-up, and maintenance of treatment for hypertension, diabetes, and other conditions requiring long-term management. screening technology is changing and often the subject of intense debate as such programs are costly and their cost-effectiveness is an important matter for policy making: screening for lung cancer is becoming a feasible and effective matter for high-risk groups, whereas breast cancer screening frequency is now in dispute; while nanotechnology and bioengineering promises new methods for cancer screening. the factor of contribution to quality of life should be considered. a vaccine for varicella is justified partly for the prevention of deaths or illness from chickenpox. a stronger the right to health public expectation and social norms argument is often based on the fact that this is a disease that causes moderate illness in children for up to 2 weeks and may require parents to stay home with the child, resulting in economic loss to the parent and society. the fact that this vaccination prevents the occurrence of herpes zoster or shingles later in life may also be a justification. widespread adoption of hepatitis b vaccine is justified on the grounds that it prevents cancer of the liver, liver cirrhosis, and hepatic failure in a high percentage of the population affected. how many cases of a disease are enough to justify an intervention? one or several cases of some diseases, such as poliomyelitis, may be considered an epidemic in that each case constitutes or is an indicator of a wider threat. a single case of polio suggests that another 1000 persons are infected but have not developed a recognized clinical condition. such a case constitutes a public health emergency, and forceful organization to meet a crisis is needed. current standards are such that even one case of measles imported into a population free of the disease may cause a large outbreak, as occurred in the uk, france, and israel during 2007 through 2013, by contacts on an aircraft, at family gatherings, or even in medical settings. a measles epidemic indicates a failure of public health policy and practice. screening for some cancers, such as cervix and colon, is cost effective. screening of all newborns for congenital disorders is important because each case discovered early and treated effectively saves a lifetime of care for serious disability. assessing a public health intervention to prevent the disease or reduce its impact requires measurement of the disease in the population and its economic impact. there is no simple formula to justify a particular intervention, but the cost-benefit approach is now commonly required to make such a case for action. sometimes public opinion and political leadership may oppose the views of the professional community, or may impose limitations of policy or funds that prevent its implementation. conversely, professional groups may press for additional resources that compete for limited resources available to provide other needed health activities. both the professionals of the health system and the general public need full access to health-related information to take part in such debates in a constructive way. to maintain progress, a system must examine new technologies and justify their adoption or rejection (see chapter 15). the association between health and political issues was emphasized by european innovators such as rudolf virchow (and in great britain by edwin chadwick; see chapter 1) in the mid-nineteenth century, when the conditions of the working population were such that epidemic diseases were rife and mortality was high, especially in the crowded slums of the industrial revolution. the same observations led bismarck in germany to introduce early forms of social insurance for the health of workers and their families in the 1880s, and to britain's 1911 national health insurance, also for workers and families. the role of government in providing universal access to health care was a struggle in individual countries during the twentieth century and lasting into the second decade of the twenty-first century (e.g. president obama's affordable health care act of 2010). as the concept of public health has evolved, and the cost effectiveness of medical care has improved through scientific and technological advances, societies have identified health as a legitimate area of activity for collective bargaining and government. with this process, the need to manage health care resources has become more clearly defined as a public responsibility. in industrialized countries, each with very different political make-up, national responsibility for universal access to health has become part of the social ethos. with that, the financing and managing of health services have developed into part of a broad concept of public health, and economics, planning, and management have come to be part of the new public health (discussed in chapters 10-13). social, ethical, and political philosophies have profound effects on policy decisions including allocation of public monies and resources. investment in public health is now recognized as an integral part of socioeconomic development. governments are major suppliers of funds and leadership in health infrastructure development, provision of health services, and health payment systems. they also play a central role in the development of health promotion and regulation of the environment, food, and drugs essential for community health. in liberal social democracies, the individual is deemed to have a right to health care. the state accepts responsibility to ensure availability, accessibility, and quality of care. in many developed countries, government has also taken responsibility to arrange funding and services that are equitably accessible and of high quality. health care financing may involve taxation, allocation, or special mandatory requirements on employers to pay for health insurance. services may be provided by a state-financed and -regulated service or through ngos and/or private service mechanisms. these systems allocate between 6 percent and 14 percent of gross national product (gnp) to health services, with some governments funding over 80 percent of health expenditure; for example, canada and the uk. in communist states, the state organizes all aspects of health care with the philosophy that every citizen is entitled to equity in access to health services. the state health system manages research, staff training, and service delivery, even if operational aspects are decentralized to local health authorities. this model applied primarily to the soviet model of health services. these systems, except for cuba, placed financing of health low on the national priority, with funding less than 4 percent of gnp. in the shift to market economies in the 1990s, some former socialist countries, such as russia, are struggling with poor health status and a difficult shift from a strongly centralized health system to a decentralized system with diffusion of powers and responsibilities. promotion of market concepts in former soviet countries has reduced access to care and created a serious dilemma for their governments. former colonial countries, independent since the 1950s and 1960s, largely carried on the governmental health structures established in the colonial times. most developing countries have given health a relatively low place in budgetary allotment, with expenditures under 3 percent of gnp. since the 1980s, there has been a trend in developing countries towards decentralization of health services and greater roles for ngos, and the development of health insurance. some countries, influenced by medical concepts of their former colonial master countries, fostered the development of specialty medicine in the major centers with little emphasis on the rural majority population. soviet influence in many ex-colonial countries promoted state-operated systems. the who promoted primary care, but the allocations favored city-based specialty care. israel, as an ex-colony, adapted british ideas of public health together with central european sick funds and maternal and child health as major streams of development until the mid-1990s. a growing new conservatism in the 1980s and 1990s in the industrialized countries is a restatement of old values in which market economics and individualistic social values are placed above concepts of the "common good" of liberalism and socialism in its various forms. in the more extreme forms of this concept, the individual is responsible for his or her own health, including payment, and has a choice of health care providers that will respond with high-quality personalized care. market forces, meaning competition in financing and provision of health services with rationing of services, based on fees or private insurance and willingness and ability to pay, have become part of the ideology of the new conservatism. it is assumed that the patient (i.e., the consumer) will select the best service for his or her need, while the provider best able to meet consumer expectations will thrive. in its purest form, the state has no role in providing or financing of health services except those directly related to community protection and promotion of a healthful environment without interfering with individual choices. the state ensures that there are sufficient health care providers and allows market forces to determine the prices and distribution of services with minimal regulation. the usa retains this orientation in a highly modified form, with 86 percent of the population covered by some form of private or public insurance systems (see chapters 10 and 13). modified market forces in health care are part of health reforms in many countries as they seek not only to ensure quality health care for all but also to constrain costs. a free market in health care is costly and ultimately inefficient because it encourages inflation of provider incomes or budgets and increasing utilization of highly technical services. further, even in the most free market societies, the economy of health care is highly influenced by many factors outside the control of the consumer and provider. the total national health expenditure in the usa rose rapidly until reaching over 17.7 percent of gross domestic product (gdp) in 2011, the highest of any country, despite serious deficiencies for those without any or with very inadequate health insurance (in total more than 30 percent of the population). this figure compares to some 11.2 percent of gdp in canada, which has universal health insurance under public administration. following the 1994 defeat of president clinton's national health program, the conservative congress and the business community took steps to expand managed care in order to control costs, resulting in a revolution in health care in the usa (see chapters 11 and 13). in the 2011-2019 decade health expenditure in the usa is expected to rise to 19.6 percent of gdp, partly owing to increased population coverage with implementation of the ppaca (obamacare). reforms are being implemented in many "socialized" health systems. these may be through incentives to promote achievement of performance indicators, such as full immunization coverage. others are using control of supply, such as hospital beds or licensed physicians, as methods of reducing overutilization of services that generates increasing costs. market mechanisms in health are aimed not only at the individual but also at the provider. incentive payment systems must work to protect the patient's legitimate needs, and conversely incentives that might reduce quality of care should be avoided. fee-for-service promotes high rates of services such as surgery. increasing private practice and user fees can adversely affect middle-and low-income groups, as well as employers, by raising the costs of health insurance. managed care systems, with restraints on fee-for-service medical practice, have emerged as a positive response to the market approach. incentive systems in payments for services may be altered by government or insurance agencies in order to promote rational use of services, such as reduction of hospital stays. the free market approach is affecting planning of health insurance systems in previously highly centralized health systems in developing countries as well as the redevelopment of health systems in former soviet countries. despite political differences, reform of health systems has become a common factor in virtually all health systems since the 1990s, as each government searches for costeffectiveness, quality of care, and universality of coverage. the new paradigm of health care reform sees the convergence of different systems to common principles. national responsibility for health goals and health promotion leads to national financing of health care with regional and managed care systems. most developed countries have long since adopted national health insurance or service systems. some governments may, as in the usa, insure only the highest risk groups such as the elderly and the poor, leaving the working and middle classes to seek private insurers. the nature and direction of health care reform affecting coverage of the population are of central importance in the new public health because of its effects on allocation of resources and on the health of the population. the effects of the economic crisis in the usa are being felt worldwide. while the downturn has largely occurred in wealthier nations, the poor in low-income countries will be among those affected. past economic downturns have been followed by substantial drops in foreign aid to developing countries. as public health gained from sanitary and other control measures for infectious diseases, along with mother and child care, nutrition, and environmental and occupational health, it also gained strength and applicability from advances in the social and behavioral sciences. social darwinism, a political philosophy that assumed "survival of the fittest" and no intervention of the sate to alleviate this assumption, was popular in the early nineteenth century but became unacceptable in industrialized countries, which adopted social policies to alleviate the worst conditions of poverty, unemployment, poor education, and other societal ills. the political approach to focusing on health and poverty is associated with jeremy bentham in britain in the late eighteenth century, who promoted social and political reform and "the greatest good for the greatest number", or utilitarianism. rudolf virchow, an eminent pathologist and a leader in recognizing ill-health and poverty as cause and effect, called for political action to create better conditions for the poor and working-class population. the struggle for a social contract was promoted by pioneer reformists such as edwin chadwick (general report on the sanitary condition of the labouring population of great britain, 1842), who later became the first head of the board of health in britain, and lemuel shattuck (report of a general plan for the promotion of public and personal health, 1850) . shattuck was the organizer and first president of the american statistical association. the social sciences have become fundamental to public health, with a range of disciplines including vital statistics and demography (seventeenth century), economics and politics (nineteenth century), sociology (twentieth century), history, anthropology, and others, which provide collectively important elements of epidemiology of crucial significance for survey methods and qualitative research (see chapter 3). these advances contributed greatly to the development of methods of studying diseases and risk factors in a population and are still highly relevant to addressing inequalities in health. individuals in good health are better able to study and learn, and be more productive in their work. improvements in the standard of living have long been known to contribute to improved public health; however, the converse has not always been recognized. investment in health care was not considered a high priority in many countries where economic considerations directed investment to the "productive" sectors such as manufacturing and large-scale infrastructure projects, such as hydroelectric dams. whether health is a contributor to economic development or a drain on societies' resources has been a fundamental debate between socially and market-oriented advocates. classic economic theory, both free enterprise and communist, has tended to regard health as a drain on economies, distracting investment needed for economic growth. as a result, in many countries health has been given low priority in budgetary allocation, even when the major source of financing is governmental. this belief among economists and banking institutions prevented loans for health development on the grounds that such funds should focus on creating jobs and better incomes, before investing in health infrastructure. consequently, the development of health care has been hampered. a socially oriented approach sees investment in health as necessary for the protection and development of "human capital", just as investment in education is needed for the long-term benefit of the economy of a country. in 1993, the world bank's world development report: investing in health articulated a new approach to economics in which health, along with education and social development, is seen as an essential precondition for and contributor to economic development. while many in the health field have long recognized the importance of health for social and economic improvement, its adoption by leading international development banking may mark a turning point for investment in developing nations, so that health may be a contender for increased development loans. the concept of an essential package of services discussed in that report establishes priorities in low-and middle-income countries for efficient use of resources based on the burden of disease and cost-effectiveness analysis of services. it includes both preventive and curative services targeted to specific health problems. it also recommends support for comprehensive primary care, such as for children, and infrastructure development including maternity and hospital care, medical and nursing outreach services, and community action to improve sanitation and safe water supplies. reorientation of government spending on health is increasingly being adopted, as in the uk, to improve equity in access for the poor and other neglected sectors or regions of society with added funding for relatively deprived areas to improve primary care services. differential capitation funding as a form of affirmative action to provide for highneeds populations is a useful concept in public health terms to address the inequities still prevalent in many countries. as medical care has gradually become more involved in prevention, and as it has moved into the era of managed care, the gap between public health and clinical medicine has narrowed. as noted above, many countries are engaged in reforms in their health care systems. the motivation is largely derived from the need for cost containment, but also to extend health care coverage to underserved parts of the population. countries without universal health care still have serious inequities in distribution of or access to services, and may seek reform to reduce those inequities, perhaps under political pressures to improve the provision of services. incentives for reform are needed to address regional inequities, and preserving or developing universal access and quality of care, but also on inequities in health between the rich and the poor countries and within even the wealthy countries. in some settings, a health system may fail to keep pace with developments in prevention and in clinical medicine. some countries have overdeveloped medical and hospital care, neglecting important initiatives to reduce the risk of disease. the process of reform requires setting standards to measure health status and the balance of services to optimize health. a health service can set a target of immunizing 95 percent of infants with a national immunization schedule, but requires a system to monitor performance and incentives for changes. a health system may also have failed to adapt to changing needs of the population through lack, or misuse, of health information and monitoring systems. as a result, the system may err seriously in its allocation of resources, with excessive emphasis on hospital care and insufficient attention to primary and preventive care. all health services should have mechanisms for correctly gathering and analyzing needed data for monitoring the incidence of disease and other health indicators, such as hospital utilization, ambulatory care, and preventive care patterns. for example, the uk's nhs periodically undertakes a restructuring process of parts of the system to improve the efficiency of service. this involves organizational changes and decentralization with regional allocation of resources (see chapter 13). health systems are under pressures of changing demographic and epidemiological patterns as well as public expectations, rising costs of new technology, financing, and organizational change. new problems must be continually addressed with selection of priority issues and the most effective methods chosen. reforms may create unanticipated problems, such as professional or public dissatisfaction, which must be evaluated, monitored, and addressed as part of the evolution of public health. literacy, freedom of the press, and increasing public concern for social and health issues have contributed to the development of public health. the british medical community lobbied for restrictions on the sale of gin in the 1780s in order to reduce the damage that it caused to the working class. in the late eighteenth and the nineteenth centuries, reforms in society and sanitation were largely the result of strongly organized advocacy groups influencing public opinion through the press. such pressure stimulated governments to act in regulating the working conditions of mines and factories. abolition of the slave trade and its suppression by the british navy in the early nineteenth century resulted from successful advocacy groups and their effects on public opinion through the press. vaccination against smallpox was promoted by privately organized citizen groups, until later taken up by local and national government authorities. advocacy consists of activities of individuals or groups publicly pleading for, supporting, espousing, or recommending a cause or course of action. the advocacy role of reform movements in the nineteenth century was the basis of the development of modern organized public health. campaigns ranged from the reform of mental hospitals, nutrition for sailors to prevent scurvy and beriberi, and labor laws to improve working conditions for women and children in particular, to the promotion of universal education and improved living conditions for the working population. reforms on these and other issues resulted from the stirring of the public consciousness by advocacy groups and the public media, all of which generated political decisions in parliaments (box 2.12). such reforms were in large part motivated by fear of revolution throughout europe in the mid-nineteenth century and the early part of the twentieth century. trade unions, and before them medieval guilds, fought to improve hours, safety, and conditions of work, as well as social and health benefits for their members. in the usa, collective bargaining through trade unions achieved wage increases and widespread coverage of the working population under voluntary health insurance. unions and some industries pioneered prepaid group practice, the predecessor of health maintenance organizations and managed care or the more recent acos (see chapters 10 and 13). through raising public consciousness on many issues, advocacy groups pressure governments to enact legislation to restrict smoking in public places, prohibit tobacco advertising, and mandate the use of bicycle helmets. advocacy groups play an important role in advancing health based on disease groups, such as cancer, multiple sclerosis, and thalassemia, or advancing health issues, such as the organizations promoting breastfeeding, environmental improvement, or smoking reduction. some organizations finance services or facilities not usually provided within insured health programs. such organizations, which can number in the hundreds in a country, advocate the importance of their special concern and play an important role in innovation and meeting community health needs. advocacy groups, including trade unions, professional groups, women's groups, self-help groups, and many others, focus on specific issues and have made major contributions to advancing the new public health. the history of public health is replete with pioneers whose discoveries led to strong opposition and sometimes violent rejection by conservative elements and vested interests in medical, public, or political circles. opposition to jennerian vaccination, the rejection of semmelweiss by colleagues in vienna, and the contemporary opposition to the work of great pioneers in public health such as pasteur, florence nightingale, and many others may deter or delay implementation of other innovators and new breakthroughs in preventing disease. although opposition to jenner's vaccination lasted well into the late nineteenth century in some areas, its supporters gradually gained ascendancy, ultimately leading to the global eradication of smallpox. these and other pioneers led the way to improved health, often after bitter controversy on topics later accepted and which, in retrospect, seem to be obvious. advocacy has sometimes had the support of the medical profession but elicited a slow response from public authorities. david marine of the cleveland clinic and david cowie, professor of pediatrics at the university of michigan, proposed the prevention of goiter by iodization of salt. marine carried out a series of studies in fish, and then in a controlled clinical trial among schoolgirls in 1917-1919, with startlingly positive results in reducing the prevalence of goiter. cowie campaigned for the iodization of salt, with support from the medical profession. in 1924, he convinced a private manufacturer to produce morton's iodized salt, which rapidly became popular throughout north america. similarly, iodized salt came to be used in many parts of europe, mostly without governmental support or legislation. iodine-deficiency disorders (idds) remain a widespread condition, estimated to have affected 2 billion people worldwide in 2013. the target of international eradication of idds by 2000 was set at the world summit for children in 1990, and the who called for universal iodization of salt in 1994. by 2008, nearly 70 percent of households in developing countries consumed adequately iodized salt. china and nigeria, have had great success in recent years with mandatory salt fortification in increasing iodization rates, in china from 39 percent to 95 percent in 10 years. but the problem is not yet gone and even in europe there is inadequate standardization of iodine levels and population follow-up despite decades of work on the problem. professional organizations have contributed to promoting causes such as children's and women's health, and environmental and occupational health. the american academy of pediatrics has contributed to establishing and promoting high standards of care for infants and children in the usa, and to child health internationally. hospital accreditation has been used for decades in the usa, canada, and more recently in australia and the uk. it has helped to raise standards of health facilities and care by carrying out systematic peer review of hospitals, nursing homes, primary care facilities, and mental hospitals, as well as ambulatory care centers and public health agencies (see chapter 15). public health needs to be aware of negative advocacy, sometimes based on professional conservatism or economic self-interest. professional organizations can also serve as advocates of the status quo in the face of change. opposition by the american medical association (ama) and the health insurance industry to national health insurance in the usa has been strong and successful for many decades. the passage of the ppaca has been achieved despite widespread political and public opposition, yet was sustained in the us supreme court and is gaining widening popular support as the added value to millions of formerly uninsured americans becomes clear. in some cases, the vested interest of one profession may block the legitimate development of others, such as when ophthalmologists lobbied successfully against the development of optometry, now widely accepted as a legitimate profession. political activism for reform in nineteenth-century britain led to banning and suppressing the slave trade, improvements in working conditions for miners and factory workers, and other major political reforms. in keeping with this tradition, samuel plimsoll (1824-1898), british member of parliament elected for derby in 1868, conducted a solo campaign for the safety of seamen. his book, our seamen, described ships sent to sea so heavily laden with coal and iron that their decks were awash. seriously overloaded ships, deliberately sent to sea by unscrupulous owners, frequently capsized, drowning many crew members, with the owners collecting inflated insurance fees. overloading was the major cause of wrecks and thousands of deaths in the british shipping industry. plimsoll pleaded for mandatory load-line certificate markers to be issued to each ship to prevent any ships putting to sea when the marker was not clearly visible. powerful shipping interests fought him every inch of the way, but he succeeded in having a royal commission established, leading to an act of parliament mandating the "plimsoll line", the safe carrying capacity of cargo ships. this regulation was adopted by the us bureau of shipping as the load line act in 1929 and is now standard practice worldwide. jenner's discovery of vaccination with cowpox to prevent smallpox was adopted rapidly and widely. however, intense opposition by organized groups of antivaccinationists, often led by those opposed to government intervention in health issues and supported by doctors with lucrative variolation practices, delayed the implementation of smallpox vaccination for many decades. ultimately, smallpox was eradicated in 1972, owing to a global campaign initiated by the who. opposition to legislated restrictions on private ownership of assault weapons and handguns is intense in the usa, led by well-organized, well-funded, and politically powerful lobby groups, despite the amount of morbidity and mortality due to gun-associated violent acts (see chapter 5). fluoridation of drinking water is the most effective public health measure for preventing dental caries, but it is still widely opposed, and in some places the legislation has been rescinded even after implementation, by wellorganized antifluoridation campaigns. opposition to fluoridation of community water supplies is widespread, and effective lobbying internationally has slowed but has not stopped progress (see chapter 6). despite the life-saving value of immunization, opposition still exists in 2013 and harms public health protection. opposition has slowed progress in poliomyelitis eradication; for example, radical islamists killed polio workers in northern nigeria in 2012, one of the last three countries with endemic poliomyelitis. resistance to immunization in the 1980s has resulted in the recurrence of pertussis and diphtheria and a very large epidemic of measles across western europe, including the uk, with further spread to the western hemisphere in 2010-2013 (see chapter 4). progress may be blocked where all decisions are made in closed discussions, not subject to open scrutiny and debate. public health personnel working in the civil service of organized systems of government may not be at liberty to promote public health causes. however, professional organizations may then serve as forums for the essential professional and public debate needed for progress in the field. professional organizations such as the apha provide effective lobbying for the interests of public health programs and can have an important impact on public policy. in mid-1996, efforts by the secretary of health and human services in the usa brought together leaders of public health with representatives of the ama and academic medical centers to try to find areas of common interest and willingness to promote the health of the population. in europe too, increasing cooperation between public health organizations is stimulating debate on issues of transnational importance across the region, which, for example, has a wide diversity of standards on immunization practices and food policies. public advocacy has played an especially important role in focusing attention on ecological issues (box 2.13). in 1995, greenpeace, an international environmental activist group, fought to prevent the dumping of an oil rig in the north sea and forced a major oil company to find another solution that would be less damaging to the environment. an explosion on an oil rig in the gulf of mexico in 2010 led to enormous ecological and economic damage as well as loss of life. damages levied on the responsible company (british petroleum) amount to some $4.5 billion dollars and several criminal negligence charges are pending. greenpeace also continued its efforts to stop the renewal of testing of atomic bombs by france in the south pacific. international protests led to the cessation of almost all testing of nuclear weapons. international concern over global warming has led to growing efforts to stem the tide of air pollution from fossil fuels, coal-burning electrical production, and other manifestations of carbon dioxide and toxic contamination of the environment. progress is far from certain as newly enriched countries such as china and india follow the rising consumption patterns of western countries. public advocacy and rejection of wanton destruction of the global ecology may be the only way to prod consumers, governments, and corporate entities such as the energy and transportation industries to change direction. the pace of change from fossil fuels is slow but has captured public attention, and private companies are seeking more fuel efficiency in vehicles and electrical power production, mainly though the use of natural gas instead of fuel oil and coal for electricity production or better still by wind and solar energy. the search for "green solutions" to the global warming crisis has become increasingly dynamic, with governments, the private sector, and the general public keenly aware of the importance of the effort and the dangers of failure. in the latter part of the twentieth century and the early twenty-first century, prominent international personalities and entertainers have taken up causes such as the removal of land mines in war-torn countries, illiteracy in disadvantaged advocacy is a function in public health that has been important in promoting advances in the field, and one that sometimes places the advocate in conflict with established patterns and organizations. one of the classic descriptions of this function is in henrik ibsen's play an enemy of the people, in which the hero, a young doctor, thomas stockmann, discovers that the water in his community is contaminated. this knowledge is suppressed by the town's leadership, led by his brother the mayor, because it would adversely affect plans to develop a tourist industry of baths in their small norwegian town in the late nineteenth century. the young doctor is taunted and abused by the townspeople and driven from the town, having been declared an "enemy of the people" and a potential risk. the allegory is a tribute to the man of principle who stands against the hysteria of the crowd. the term also took on a far more sinister and dangerous meaning in george orwell's novel 1984 and in totalitarian regimes of the 1930s to the present time. populations, and funding for antiretroviral drugs for african countries to reduce maternal-fetal transmission of hiv and to provide care for the large numbers of cases of aids devastating many countries of sub-saharan africa. rotary international has played a key role in polio eradication efforts globally. the public-private consortium global alliance for vaccines and immunization (gavi) has been instrumental in promoting immunization in recent years, with participation by the who, unicef, the world bank, the gates foundation, vaccine manufacturers, and others. this has had an important impact on extending immunization to protect and save the lives of millions of children in deprived countries not yet able to provide fundamental prevention programs such as immunization at adequate levels. gavi has brought vaccines to low-income countries around the world, such as rotavirus vaccine, pentavalent vaccine in myanmar, and pneumococcal vaccine for children in 15 countries in sub-saharan africa, including dr congo. the bill & melinda gates foundation pledged us $750 million in 1999 to establish gavi, with us $75 million per year and us $1 billion in 2010 to promote the decade of vaccines. international conferences help to create a worldwide climate of advocacy for health issues. international sanitary conferences in the nineteenth century were convened in response to the cholera epidemics. international conferences continue in the twenty-first century to serve as venues for advocacy on a global scale, bringing forward issues in public health that are beyond the scope of individual nations. the who, unicef, and other international organizations perform this role on a continuing basis (see chapter 16). criticisms of this approach have focused on the lack of similar effort or donors to address ncds, weak public health infrastructure, and that this frees national governments from responsibility to care for their own children. no one can question, however, that this kind of endeavor has saved countless lives and needs the backing of other aid donors and national government participation. consumerism is a movement that promotes the interests of the purchaser of goods or services. in the 1960s, a new form of consumer advocacy emerged from the civil rights and antiwar movement in the usa. concern was focused on the environment, occupational health, and the rights of the consumer. rachel carson stimulated concern by dramatizing the effects of ddt on wildlife and the environment but inadvertently jeopardized anti-malarial efforts in many countries. this period gave rise to environmental advocacy efforts worldwide, and a political movement, the greens, in western europe. ralph nader showed the power of the advocate or "whistle-blower" who publicizes health hazards to stimulate active public debate on a host of issues related to the public well-being. nader, a consumer advocate lawyer, developed a strategy for fighting against business and government activities and products which endangered public health and safety. his 1965 book unsafe at any speed took issue with the us automobile industry for emphasizing profit and style over safety, and led to the enactment of the national traffic and motor safety act of 1966, establishing safety standards for new cars. this was followed by a series of enactments including design and emission standards and seat-belt regulations. nader's work continues to promote consumer interests in a wide variety of fields, including the meat and poultry industries, and coal mining, and promotes greater government regulatory powers regarding pesticide usage, food additives, consumer protection laws, rights to knowledge of contents, and safety standards. consumerism has become an integral part of free market economies, and the educated consumer does influence the quality, content, and price of products. greater awareness of nutrition in health has influenced food manufacturers to improve packaging, content labeling, enrichment with vitamins and minerals, and advertisement to promote those values. low-fat dietary products are available because of an increasingly sophisticated public concerned over dietary factors in cardiovascular diseases. the same process occurred in safe toys and clothing for children, automobile safety features such as mandatory use of car seats for infants, and other innovations that quickly became industry standards in the industrialized world. dangerous practices such as the use of lead paint in toys and melamine contamination of milk products from china capture the public attention quickly and remind public health authorities of the importance of continuous alertness to potential hazards. consumerism can also be exploited by pharmaceutical companies with negative impacts on the health system, especially in the advertising of health products which leads to unnecessary visits to health providers and pressure for approval to obtain the product. the internet has provided people with access to a vast array of information and opinion, and to current literature otherwise unavailable because of the often inadequate library resources of medical and other health professionals. the very freedom of information the internet allows, however, also provides a vehicle for extremist and fringe groups to promote disinformation such as "vaccination causes autism, fluoridation causes cancer", which can cause considerable difficulties for basic public health programs or lead to self-diagnosis of conditions, with often disastrous consequences. advocacy and voluntarism go hand in hand. voluntarism takes many forms, including raising funds for the development of services or operating services needed in the community. it may take the form of fund-raising to build clinics or hospitals in the community, or to provide medical equipment for elderly or handicapped people; or retirees and teenagers working as hospital volunteers to provide services that are not available through paid staff, and to provide a sense of community caring for the sick in the best traditions of religious or municipal concerns. this can also be extended to prevention, as in support for immunization programs, assistance for the handicapped and elderly in transportation, meals-on-wheels, and many other services that may not be included in the "basket of services" provided by the state, health insurance, or public health services. community involvement can take many forms, and so can voluntarism. the pioneering role of women's organizations in promoting literacy, health services, and nutrition in north america during the latter part of the nineteenth and the early twentieth centuries profoundly affected the health of the population. the advocacy function is enhanced when an organization mobilizes voluntary activity and funds to promote changes or needed services, sometimes forcing official health agencies or insurance systems to revise their attitudes and programs to meet these needs. by the early 1970s, canada's system of federally supported provincial health insurance plans covered all of the country. the federal minister of health, marc lalonde, initiated a review of the national health situation, in view of concern over the rapidly increasing costs of health care. this led to articulation of the "health field concept" in 1974, which defined health as a result of four major factors: human biology, environment, behavior, and health care organization (box 2.14). lifestyle and environmental factors were seen as important contributors to the morbidity and mortality in modern societies. this concept gained wide acceptance, promoting new initiatives that emphasized health promotion in response to environmental and lifestyle factors. conversely, reliance primarily on medical care to solve all health problems could be counterproductive. this concept was a fundamental contributor to the idea of health promotion later articulated in the ottawa declaration, discussed below. the health field concept came at a time when many epidemiological studies were identifying risk factors for cardiovascular diseases and cancers that related to personal habits, such as diet, exercise, and smoking. the concept advocated that public policy needed to address individual lifestyle as part of the overall effort to improve health status. as a result, the canadian federal government established health promotion as a new activity. this quickly spread to many other jurisdictions and gained wide acceptance in many industrialized countries. concern was expressed that this concept could become a justification for a "blame the victim" approach, in which those ill with a disease related to personal lifestyles, such as smokers or aids patients, are seen as having chosen to contract the disease. such a patient might then be considered not to be entitled to all benefits of insurance or care that others may receive. the result may be a restrictive approach to care and treatment that would be unethical in the public health tradition and probably illegal in western jurisprudence. this concept was also used to justify withdrawal from federal commitments in cost sharing and escape from facing controversial health reform in the national health insurance program. during the 1960s and 1970s, outspoken critics of health care systems, such as ivan illytch, questioned the value of medical care for the health of the public. this became a widely discussed, somewhat nihilistic, view towards medical care, and was influential in promoting skepticism regarding the value of the biomedical mode of health care, and antagonism towards the medical profession. in 1976, thomas mckeown presented a historicalepidemiological analysis showing that up to the 1950s, medical care had only a limited impact on mortality rates, although improvements in surgery and obstetrics were notable. he showed that crude death rates in england averaged about 30 per 1000 population from 1541 to 1750, declining steeply to 22 per 1000 in 1851, 15 per 1000 in 1901, and 12 per 1000 in 1951, when medical care became truly effective. mckeown concluded that much of the improvement in health status over the past several centuries was due to reduced mortality from infectious diseases. this he related to limitation of family size, increased food supplies, improved nutrition and sanitation, specific preventive and therapeutic measures, and overall gains in quality of life for growing elements of the population. he cautioned against placing excessive reliance for health on medical care, much of which was of unproved effectiveness. this skepticism of the biomedical model of health care was part of wider antiestablishment feelings of the 1960s and 1970s in north america. in 1984, milton roemer pointed out that the advent of vaccines, antibiotics, antihypertensives, and other medications contributed to great improvements in infant and child care, and in the management of infectious diseases, hypertension, diabetes, and other conditions. therapeutic gains continue to arrive from teaching centers around the world. vaccine, pharmaceutical, and diagnostic equipment manufacturers continue to provide important innovations that have major benefits, but also raise the cost of health care. the latter issue is one which has stimulated the search for reforms, and search for lower cost technologies such as in treatment of hepatitis c patients, a huge international public health issue. the value of medical care to public health and vice versa has not always been clear, either to public health personnel or to clinicians. the achievements of modern public health in controlling infectious diseases, and even more so in reducing the mortality and morbidity associated with chronic diseases such as stroke and chd, were in reality a shared achievement between clinical medicine and public health (see chapter 5). preventive medicine has become part of all medical practice, with disease prevention through early diagnosis and health promotion through individual and community-focused activities. risk factor evaluation determines appropriate screening and individual and community-based interventions. medical care is crucial in controlling hypertension and in reducing the complications and mortality from chd. new modalities of treatment are reducing death rates from first time acute myocardial infarctions. better management of diabetes prevents the early onset of complications. at the same time, the contribution of public health to improving outcomes of medical care is equally important. control of the vaccine-preventable diseases, improved nutrition, and preparation for motherhood contribute to improved maternal and infant outcomes. promotions of reduced exposure to risk factors for chronic disease are a task shared by public health and clinical medical services. both clinical medicine and public health contribute to improved health status. they are interdependent and rely on funding systems for recognition as part of the new public health. during the 1950s, many new management concepts emerged in the business community, such as "management by objective", a concept developed by peter drucker at general motors, with variants such as "zero-based budgeting" developed in the us department of defense (see chapter 12). they focused the activities of an organization and its budget on targets, rather than on previous allocation of resources. these concepts were applied in other spheres, but they influenced thinking in health, whose professionals were seeking new ways to approach health planning. the logical application was to define health targets and to promote the efficient use of resources to achieve those targets. this occurred in the usa and soon afterwards in the who european region. in both cases, a wide-scale process of discussion and consensus building was used before reaching definitive targets. this process contributed to the adoption of the targets by many countries in europe as well as by states and many professional and consumer organizations. the usa developed national health objectives in 1979 for the year 1990 and subsequently for the year 2000, with monitoring of progress in their achievement and development of further targets for 2010 and now for 2020. beginning in 1987, state health profiles are prepared by the epidemiology program office of the centers for disease control and prevention based on 18 health indicators recommended by a consensus panel representing public health associations and organizations. the eight mdgs adopted by the un in 2000 include halving extreme poverty, reducing child mortality by twothirds, improving maternal health, halting the spread of hiv/aids, malaria, and other diseases, and providing universal primary education, all by the target date of 2015. the mdgs form a common blueprint agreed to by all countries and the world's leading development institutions. the process has galvanized unprecedented efforts to meet the needs of the world's poorest, yet 2008 reviews of progress indicate that most developing nations will not meet the targets at current rates of progress. the united nations development programme (undp) global partnership for development 2012 report on the mdgs states that if the national development strategies and initiatives are supported by international development partners, the goals can be achieved by 2015. the mdgs were adopted by over 120 nations and provided guidance for national policies and for international aid agencies. the focus was on middle-and low-income countries and their achievements have been considerable but variable (see box 2.15 and chapter 16) . as of july 2012, extreme poverty was falling in every region, the poverty reduction target had been met, the world had met the target of halving the proportion of people without access to improved sources of water, and the world had achieved parity in primary education between girls and boys. further progress will require sustained political commitment to develop the primary care infrastructure: improved reporting and epidemiological monitoring, consultative mechanisms, and consensus by international agencies, national governments, and non-governmental agencies. the achievement of the targets will also require sustained international support and national commitment with all the difficulties of a time of economic recession. nevertheless, defining a target is crucial to the process. there are encouraging signs that national governments are influenced by the general movement to place greater emphasis on resource allocation and planning on primary care to achieve internationally recognized goals and targets. the successful elimination of smallpox, rising immunization coverage in the developing countries, and increasing implementation of salt iodization have shown that such goals are achievable. while the usa has not succeeded in developing universal health care access, it has a strong tradition of public health and health advocacy. federal, state, and local health authorities have worked out cooperative arrangements for financing and supervising public health and other services. with growing recognition in the 1970s that medical services alone would not achieve better health results, health policy leadership in the federal government formulated a new approach, in the form of developing specific health targets for the nation. in 1979, the surgeon general of the usa published the report on health promotion and disease prevention (healthy people). this document set five overall health goals for each of the major age groups for the year 1990, accompanied by 226 specific health objectives. new targets for the year 2000 were developed in three broad areas: to increase healthy lifespans, to reduce health disparities, and to achieve access to preventive health care for all americans. these broad goals are supported by 297 specific targets in 22 health priority areas, each one divided into four major categories: health promotion, health protection, preventive services, and surveillance systems. this set the public health agenda on the basis of measurable indicators that can be assessed year by year. reduce child mortality -progress on child mortality is gaining momentum. the target is to reduce by two-thirds, between 1990 and 2015, the under-5-year-old mortality rate, from 93 children of every 1000 dying to 31 of every 1000. child deaths are falling, but much more needs to be done in order to reach the development goal. revitalizing efforts against pneumonia and diarrhea, while bolstering nutrition, could save millions of children. l mdg5. improve maternal health -maternal mortality has nearly halved since 1990, but levels are far removed from the 2015 target. the targets for improving maternal health include reducing by three-quarters the maternal mortality ratio and achieve universal access to reproductive health. poverty and lack of education perpetuate high adolescent birth rates. inadequate funding for family planning is a major failure in fulfilling commitments to improving women's reproductive health. l mdg6. combat hiv/aids, malaria, tuberculosis, and other diseases -more people than ever are living with hiv owing to fewer aids-related deaths and the continued large number of new infections. in 2011, an estimated 34.2 million were living with hiv, up 17 percent from 2001. this persistent increase reflects the continued large number of new infections along with a significant expansion of access to lifesaving antiretroviral therapy, especially in more recent years. l mdg7. ensure environmental sustainability -the unparalleled success of the montreal protocol shows that action on climate change is within grasp. the 25th anniversary of the montreal protocol on substances that deplete the ozone layer, in 2012, had many achievements to celebrate. most notably, there has been a reduction of over 98 percent in the consumption of ozone-depleting substances. further, because most of these substances are also potent greenhouse gases, the montreal protocol has contributed significantly to the protection of the global climate system. the reductions achieved to date leave hydrochlorofluorocarbons (hcfcs) as the largest group of substances remaining to be phased out. l mdg8. a global partnership for development -core development aid fell in real terms for the first time in more than a decade, as donor countries faced fiscal constraints. in 2011, net aid disbursements amounted to $133.5 billion, representing 0.31 percent of developed countries' combined national income. while constituting an increase in absolute dollars, this was a 2.7 percent drop in real terms over 2010. if debt relief and humanitarian aid are excluded, bilateral aid for development programmes and projects fell by 4.5 percent in real terms. equitable and sustainable funding of health services. 18. developing human resources (educational programs for providers and managers based on the principles of the health for all policy). 19. research and knowledge: health programs based on scientific evidence. 20. mobilizing partners for health (engaging the media/ television/internet). 21. policies and strategies for health for all -national, targeted policies based on health for all. a 2010-2012 review has been commissioned by the european office of the who to assess inequalities in the social determinants of health. while health has improved there are still significant inequalities. factors include variance in local, regional, national, and global economic forces. the european union and the european region of who are both working on health targets for the year 2020. there are competing demands in society for expenditure by the government, and therefore making the best use of resources -money and people -is an important objective. the uk has devolved many of the responsibilities to the constituent countries (england, wales, scotland, and northern ireland) within an overall national framework (box 2.17). of the health consequences of their decisions and to accept responsibility for health. health promotion policy combines diverse but complementary approaches, including legislation, fiscal measures, taxation, and organizational change. it is a coordinated action that leads to health, income, and social policies that foster greater equity. joint action contributes to ensuring safer and healthier goods and services, healthier public services, and cleaner, more enjoyable environments. health promotion policies require the identification of obstacles to the adoption of healthy public policies in non-health sectors, and ways of removing them. built on progress made from the declaration on primary health care at alma-ata, the aim was to make the healthier choice the easier choice for policy makers as well. the logo of the ottawa charter has been maintained by the who as the symbol and logo of health promotion. health promotion represents activities to enhance and embed the concept of building healthy public policy through: l building healthy public policy in all sectors and levels of government and society l enhancing both self help and social support l developing personal skills through information and education for health l enabling, mediating, and advocating healthy public policy in all spheres l creating supportive environments of mutual help and conservation of the natural environment l reorienting health services beyond providing clinical curative services with linkage to broader social, political, economic, and physical environmental components. (adapted from ottawa charter; health and welfare canada and world health organization, 1986) an effective approach to health promotion was developed in australia where, in the state of victoria, revenue from a cigarette tax has been set aside for health promotion purposes. this has the effect of discouraging smoking, and at the same time finances health promotion activities and provides a focus for health advocacy in terms of promoting cessation of cigarette advertising at sports events or on television. it also allows for assistance to community groups and local authorities to develop health promotion activities at the workplace, in schools, and at places of recreation. health activity in the workplace involves reduction of work hazards as well as promotion of a healthy diet and physical fitness, and avoidance of risk factors such as smoking and alcohol abuse. in the australian model, health promotion is not only the persuasion of people to change their life habits; it also involves legislation and enforcement towards environmental changes that promote health. for example, this involves mandatory filtration, chlorination, and fluoridation for community water supplies, vitamin and mineral enrichment of basic foods. primary care alliances of service providers are organized including hospitals, community health services serving a sub-district population for more efficient and comprehensive care. these are at the level of national or state policy, and are vital to a health promotion program and local community action. community-based programs to reduce chronic disease using the concept of community-wide health promotion have developed in a wide variety of settings. such a program to reduce risk factors for cardiovascular disease was pioneered in the north karelia project in finland. this project was initiated as a result of pressures from the affected population of the province, which was aware of the high incidence of mortality from heart disease. finland had the highest rates of chd in the world and in the rural area of north karelia the rate was even higher than the national average. the project was a regional effort involving all levels of society, including official and voluntary organizations, to try to reduce risk factors for chd. after 15 years of follow-up, there was a substantial decline in mortality with a similar decline in a neighboring province taken for comparison, although the decline began earlier in north karelia. in many areas where health promotion has been attempted as a strategy, community-wide activity has developed with participation of ngos or any valid community group as initiators or participants. healthy heart programs have developed widely with health fairs, sponsored by charitable or fraternal societies, schools, or church groups, to provide a focus for leadership in program development. a wider approach to addressing health problems in the community has developed into an international movement of "healthy cities". following deliberations of the health of towns commission chaired by edwin chadwick, the health of towns association was founded in 1844 by southwood smith, a prominent reform leader of the sanitary movement, to advocate change to reduce the terrible living conditions of much of the population of cities in the uk. the association established branches in many cities and promoted sanitary legislation and public awareness of the "sanitary idea" that overcrowding, inadequate sanitation, and absence of safe water and food created the conditions under which epidemic disease could thrive. in the 1980s, iona kickbush, trevor hancock, and others promoted renewal of the idea that local authorities have a responsibility to build health issues into their planning and development processes. this "healthy cities" approach promotes urban community action on a broad front of health promotion issues (table 2. 2). activities include environmental projects (such as recycling of waste products), improved recreational facilities for young people to reduce violence and drug abuse, health fairs to promote health awareness, and screening programs for hypertension, breast cancer, and other diseases. it combines health promotion with consumerism and returns to the tradition of local public health action and advocacy. the municipality, in conjunction with many ngos, develops a consultative process and program development approach to improving the physical and social life of the urban environment and the health of the population. in 1995, the healthy cities movement involved 18 countries with 375 cities in europe, canada, the usa, the uk, south america, israel, and australia, an increase from 18 cities in 1986. the model now extends to small municipalities, often with populations of fewer than 10,000. networks of healthy cities are the backbone of the movement, with more than 1400 member towns and cities across europe. the choice of core themes offers the opportunity to work on priority urban health issues that are relevant to all european cities. topics that are of particular concern to individual cities and/or are challenging and cutting edge for innovative public health action are especially emphasized. healthy cities encourages and supports experimentation with new ideas by developing concepts and implementing them in diverse organizational contexts. a healthy city is a city for all its citizens: inclusive, supportive, sensitive and responsive to their diverse needs and expectations. a healthy city provides conditions and opportunities that encourage, enable and support healthy lifestyles for people of all social groups and ages. a healthy city offers a physical and built environment that encourages, enables and supports health, recreation and well-being, safety, social interaction, accessibility and mobility, a sense of pride and cultural identity and is responsive to the needs of all its citizens. the apha's formulation of the public health role in 1995, entitled the future of public health in america, was presented at the annual meeting in 1996. the apha periodically revises standards and guidelines for organized public health services provided by federal, state, and local governments ( table 2 .4). these reflect the profession of public health as envisioned in the usa where access to medical care is limited for large numbers of the population because of a lack of universal health insurance. public health in the usa has been very innovative in determining risk groups in need of special care and finding direct and indirect methods of meeting those needs. european countries such as finland have called for setting public health into all public policy, which reflects the vital role that local and county governments can play in developing health-oriented policies. these include policies in housing, recreation, regulation of industrial pollution, road safety, promotion of smoke-free environments, bicycle paths, health impact assessment, and many other applications of health principles in public policy. public health involves both direct and indirect approaches. direct measures in public health include immunization of children, modern birth control, and chronic disease case finding -hypertension, diabetes, and cancer. indirect methods used in public health protect the individual by community-wide means, such as raising standards of environmental safety, ensuring a safe water supply, sewage disposal, and improved nutrition (box 2.18). in public health practice, the direct and indirect pproaches are both relevant. to reduce morbidity and mortality from diarrheal diseases requires an adequate supply of safe water and waste disposal, and also education of the individual in hygiene and the mother in use of ort, and rotavirus vaccination of all children. the targets of public health action therefore include the individual, family, community, region, or nation, as well as a functioning and health system adopting current best practices for health care and health protection. the targets for protection in infectious disease control are both the individual and the total group at risk. for vaccine-preventable diseases, immunization protects the individual but also has an indirect effect by reducing the risk even for non-immunized persons. in control of some diseases, individual case finding and management reduce risk of the disease in others and the community. for example, tb requires case finding and adequate care among high-risk groups as a key to community control. in malaria control, case finding and treatment are essential together with environmental action to reduce the vector population, to prevent transmission of the organism by the mosquito to a new host. control of ncds, where there is no vaccine for mass application, depends on the knowledge, attitudes, beliefs, and practices of individuals at risk. in this case, the social context is of importance, as is the quality of care to which the individual has access. control and prevention of noninfectious diseases involve strategies using individual and population-based methods. individual or clinical measures include professional advice on how best to reduce the risk of the disease by early diagnosis and implementation of appropriate therapy. population-based measures involve indirect measures with government action banning cigarette advertising, or direct taxation on cigarettes. mandating food quality standards, such as limiting the fat content of meat, and requiring food labeling laws are part of the control of cardiovascular diseases. the way individuals act is central to the objective of reducing disease, because many non-infectious diseases are dependent on behavioral risk factors of the individual's choosing. changing the behavior of the individual means addressing the way a person sees his or her own needs. this can be influenced by the provision of information, but how someone sees his or her own needs is more complex than that. an individual may define needs differently from the society or the health system. reducing smoking among women may be difficult to achieve if smoking is thought to reduce appetite and food intake, given the social message that "slim is beautiful". reducing smoking among young people is similarly difficult if smoking is seen as fashionable and diseases such as lung cancer seem very remote. recognizing how individuals define needs helps the health system to design programs that influence behavior that is associated with disease. public health has become linked to wider issues as health care systems are reformed to take on both individual and population-based approaches. public health and mainstream medicine have found increasingly common ground in addressing the issues of chronic disease, growing attention to health promotion, and economics-driven health care reform. at the same time, the social ecology approaches have shown success in slowing major causes of disease, including heart disease and aids, and the biomedical sciences have provided major new technology for preventing major health problems, including cancer, heart disease, genetic disorders, and infectious diseases. technological innovations unheard of just a few years ago are now commonplace, in some cases driving up costs of care and in others replacing older and less effective care. at the same time, resistance of important pathogenic microorganisms to antibiotics and pesticides is producing new challenges from diseases once thought to be under control, and newly emerging infectious diseases challenge the entire health community. new generations of antibiotics, antidepressants, antihypertensive medications, and other treatment methods are changing the way many conditions are treated. research and development in the biomedical to improve the quality of public health practice and performance of public health systems sciences are providing means of prevention and treatment that profoundly affect disease patterns where they are effectively applied. the technological and organizational revolutions in health care are accompanied by many ethical, economic, and legal dilemmas. the choices in health care include heart transplantation, an expensive life-saving procedure, which may compete with provision of funds and labor resources for immunizations for poor children or for health promotion to reduce smoking and other risk factors for chronic disease. new means of detecting and treating acute conditions such as myocardial infarction and peptic ulcers are reducing hospital stays, and improving long-term survival and quality of life. imaging technology has been an important development in medicine since the advent of x-rays in the early twentieth century. technology has forged ahead with high-technology instruments and procedures, new medication, genetic engineering, and important low-technology gains such as impregnated bed nets, simplified tests for hiv and tb, and many other "game changers". new technologies that can enable lower cost diagnostic devices, electronic transmission, and distant reading of transmitted imaging all open up possibilities for advanced diagnostic capacities in rural and less developed countries and communities. molecular biology has provided methods of identifying and tracking movement of viruses such as polio and measles from place to place, greatly expanding the potential for appropriate intervention. the choices in resource allocation can be difficult. in part, these add political commitment to improve health, competent professionally trained public health personnel, the public's level of health information, and legal protection, whether through individuals, advocacy, or regulatory approaches for patients' rights. these are factors in a widening methodology of public health. the centers for disease control and prevention (morbidity and mortality weekly report) in 1999 summarized 10 great achievements of public health in the usa, with an extension of the lifespan by over 30 years and improvements in many measures of quality of life. they were updated in a similar summary report in 2011, showing continuous progress, and a global version which was also encouraging in its scope of progress (table 2 .5). these achievements were also seen in all developed countries over the past century and are beginning to be seen in developing countries as well. they reflect a successful application of a broad approach to prevention and health promotion along with improved medical care and growing access to its benefits. in the past several decades alone, major new innovations are leading to greater control of cardiovascular disease, cancer prevention, and many other improvements to health affecting hundreds of millions of people. a similar 2011 report by the cdc shows global progress in the first decade of the twenty-first century, while mdg reports show progress on all eight target topics, although not at uniformly satisfactory rates. these achievements are discussed throughout this text. this successful track record is very much at the center of a new public health involving a wide range of programs and activities, shown to be feasible and benefiting from continuing advances in science and understanding of social and management issues affecting health care systems worldwide. public health issues have received new recognition in recent years because of a number of factors, including a growing understanding among the populace at different levels in different countries that health behavior is a factor in health status and that public health is vital for protection against natural or human-made disasters. the challenges are also increasingly understood: preparation for bioterrorism, avian influenza, rising rates of diabetes and obesity, high mortality rates from cancer, and a wish for prevention to be effective. health systems offer general population benefits that go beyond preventing and treating illness. appropriately designed and managed, they: l provide a vehicle to improve people's lives, protecting them from the vulnerability of sickness, generating a sense of life security, and building common purpose within society l ensure that all population groups are included in the processes and benefits of socioeconomic development l generate the political support needed to sustain them over time. health systems promote health equity when their design and management specifically consider the circumstances and needs of socially disadvantaged and marginalized populations, including women, the poor, and groups who experience stigma and discrimination, enabling social action by these groups and the civil society organizations supporting them. health systems can, when appropriately designed and managed, contribute to achieving the millennium development goals. the mdgs selected by the un in 2000 have eight global targets for the year 2015, including four directly related to public health (discussed above, box 2.15). these are a recognition and a challenge to the international community and public health as a profession and as organized systems. formal education in newly developing schools of public health is increasing in europe, including many countries of eastern europe, and beginning to develop in india and sub-saharan africa. but there is delay in establishing centers of postgraduate education and research in many developing countries which are concentrating their educational resources on training physicians. many physicians from developing nations are moving to the developed countries, which have become dependent on these countries for a significant part of their supply of medical doctors. progress in implementation of the mdgs is mixed in sub-saharan africa, making some progress in immunization, but falling back on other goals. proposals to renew global health targets following the 2015 end-stage of the mdg health goals will need to add a focus on ncds, which account for 60 percent of global deaths, including 8.1 million premature deaths below the age of 60 (undp). economic growth has been hampered by the global recession since 2008, which will affect continued progress with many other factors of changing population dynamics, the economics of prevention versus expensive treatment costs, and the high costs of health care. environmental degradation with high levels of carbon dioxide contamination is a growing concern, with disastrous global warming and consequent effects of drought, flooding, hurricane, and elevated particulate matter-induced asthma and effects on cardiovascular disease. the potential for the development of basic and medical sciences in genetics, nanotechnology, and molecular biology shows enormous promise for health benefits as yet unimagined. at the same time, the effectiveness of health promotion has shown dramatic successes in reducing the toll of aids, reducing smoking, and increasing consciousness of nutrition and physical fitness in the population, and of the tragic effects of poverty and poor education on health status. the ethics of public health issues are complex and changing with awareness that failure to act on strong evidence-based policies is itself ethically problematic. the future of public health is not as a solo professional sector; it is at the heart of health systems, without which societies are open to chronic and infectious diseases that are preventable, affecting the society as a whole in economic and development matters. there is an expanding role of private donors in global health efforts, such as the rotary club and the polio eradication program, gavi with immunization and bed-nets in sub-saharan africa, and bilateral donor countries' help in reducing the toll of aids in sub-saharan africa. the new public health has emerged as a concept to meet a whole new set of conditions, associated with increasing longevity and aging of the population, with the post-world war ii baby-boom generation reaching the over-65 age group facing the growing importance of chronic diseases. inequalities in health exist in and between affluent and developing societies, as well as within countries, even those having advanced health care systems. regional inequalities are seen across the european region in an east-west gradient and globally a north-south divide of extremes of inequality. the global environmental and ecological degradation and pollution of air and water present grave challenges for developed and developing countries worldwide. yet optimism can be derived from proven track records of success in public health measures that have already been implemented. many of the underlying factors are amenable to prevention through social, environmental, or behavioral change and effective use of medical care. the new public health idea has evolved since alma-ata, which articulated the concept of health for all, followed by a trend in the late 1970s to health in all policies and establishing health targets as a basis for health planning. during the late 1980s and early 1990s, the debate on the future of public health in the americas intensified as health professionals looked for new models and approaches to public health research, training, and practice. this debate helped to redefine traditional approaches of social, community, and preventive medicine. the search for the "new" in public health continued with a return to the health for all concept of alma-ata (renewed in 2008) and a growing realization that the health of both the individual and the society involves the management of personal care services and community prevention, with a comprehensive approach taking advantage of advancing technology and experience of best practices globally. the new public health is an extension of the traditional public health. it describes organized efforts of society to develop healthy public policies: to promote health, to prevent disease, and to foster social equity within a framework of sustainable development. a new, revitalized public health must continue to fulfill the traditional functions of sanitation, protection, and related regulatory activities, but in addition to its expanded functions. it is a widened philosophy and practical application of many different methods of addressing health, and preventing disease and avoidable death. it necessarily addresses inequities so that programs need to meet special needs of different groups in the population according to best standards, limited resources, and population needs. it is proactive and advocates interventions within legal and ethical limits to promote health as a value in and of itself and as an economic gain for society as well for its individual members. the new public health is a comprehensive approach to protecting and promoting the health status of the individual and the society, based on a balance of sanitary, environmental, health promotion, personal, and community-oriented preventive services, coordinated with a wide range of curative, rehabilitative, and long-term care services. it evolves with new science, technology, and knowledge of human and systems behavior to maximize health gains for the individual and the population. the new public health requires an organized context of national, regional, and local governmental and non-governmental programs with the object of creating healthful social, nutritional, and physical environmental conditions. the content, quality, organization, and management of component services and programs are all vital to its successful implementation. whether managed in a diffused or centralized structure, the new public health requires a systems approach acting towards achievement of defined objectives and specified targets. the new public health works through many channels to promote better health. these include all levels of government and parallel ministries; groups promoting advocacy, academic, professional, and consumer interests; private and public enterprises; insurance, pharmaceutical, and medical products industries; the farming and food industries; media, entertainment, and sports industries; legislative and law enforcement agencies; and others. the new public health is based on responsibility and accountability for defined populations in which financial systems promote achievement of these targets through effective and efficient management, and cost-effective use of financial, human, and other resources. it requires continuous monitoring of epidemiological, economic, and social aspects of health status as an integral part of the process of management, evaluation, and planning for improved health. the new public health provides a framework for industrialized and developing countries, as well as countries in political-economic transition such as those of the former soviet system. they are at different stages of economic, epidemiological, and sociopolitical development, each attempting to ensure adequate health for its population with limited resources. the challenges are many, and affect all countries with differing balances, but there is a common need to seek better survival and quality of life for their citizens (table 2 .6). the object of public health, like that of clinical medicine, is better health for the individual and for society. public health works to achieve this through indirect methods, such as by improving the environment, or through direct means such as preventive care for mothers and infants or other atrisk groups. clinical care focuses directly on the individual patient, mostly at the time of illness. but the health of the individual depends on the health promotion and social programs of the society, just as the well-being of a society depends on the health of its citizens. the new public health consists of a wide range of programs and activities that link individual and societal health. the "old" public health was concerned largely with the consequences of unhealthy settlements and with safety of food, air, and water. it also targeted the infectious, toxic, and traumatic causes of death, which predominated among young people and were associated with poverty. a summary of the great achievements of public health in the twentieth and in the early twenty-first century in the industrialized world is included in chapter 1 and throughout this text. these achievements are reflective of public health gains throughout the industrialized world and are encourage and leverage national, state, and local partnerships to build a stronger foundation for public health preparedness and investigate health problems and health hazards in the community 3. inform, educate, and empower people about health issues 4. mobilize community partnerships to identify and solve health problems 5. develop policies and plans that support individual and community health efforts 6. enforce laws and regulations that protect health and ensure safety 7 evaluate effectiveness, accessibility, and quality of personal and population-based health services vision, mission and goals guidelines on food fortification with micronutrients. who, geneva. alliance for health policy and systems research 10 essential public health services healthy communities, 2000. model standards for community attainment of the year 2000 national health objectives determinants of adult mortality in russia: estimates from sibling data commission on social determinants and health. closing the gap in a generation: health equity through action on the social determinants of health compression of morbidity in the elderly institute of medicine. who will keep the public healthy? educating public health professionals for the 21st century global alliance for vaccine and immunization (gavi) chronic disease prevention and the new public health the evolution, impact and significance of healthy cities/healthy communities world health organization. ottawa charter for health promotion: an international conference on health promotion behavioral and social sciences and public health at cdc. mmwr health in all policies: seizing opportunities, implementing policies. ministry of social affairs and health new perspectives on the health of canadians: a working document new perspective on the health of canadians: 28 years later the us healthy people initiative: its genesis and its sustainability mortality from cardiovascular and cerebrovascular diseases in europe and other areas of the world: an update strategic review of health inequalities in england post. department of health primary care (extended version): ten key actions could globally ensure a basic human right at almost unnoticeable cost public health in europe: power, politics, and where next health: a vital investment for economic development in eastern europe and central asia. european observatory on health systems and policies. who, european regional office it is not just the broad street pump addressing the epidemiologic transition in the former soviet union: strategies for health systems and public health reform in russia what is the "new public health"? millenium development goals: 2013 progress chart united nations development programme, millennium development goals. eight goals for healthy people 2020 healthy people. the surgeon general's report on health promotion and disease prevention the millennium development goals: a cross-sectoral analysis and principles for goal-setting after selective primary health care: an interim strategy for disease control in developing countries declaration of alma-ata. international conference on primary health care healthy cities networks across the who, european region preamble to the constitution of the world health organization as adopted by the international health conference regional office for europe. health 21 -health for all in the 21st century. who regional office for europe, copenhagen. world health organization, 2012. regional office for europe. who european healthy cities network. available at:. who regional office for europe leading health indicators selected for 2010 incorporate the original 467 objectives in healthy people 2010, which served as a basis for planning public health activities for many state and community health initiatives. for each of the leading health indicators, specific objectives and subobjectives derived from healthy people 2010 are used to monitor progress. the specific objectives set for healthy people 2020 are listed in box 2.16. thirteen new topic areas are listed for 2020, such as older adults, genomics, dementias, and social determinants of health. these provide guidelines for national, state, and local public health agencies as well as insurance providers, primary care services, and health promotion advocates. a key issue will be in reducing regional, ethnic, and socioeconomic health disparities.the process of working towards health targets in the usa has moved down from the federal level of government to the state and local levels. professional organizations, ngos, as well as community and fraternal organizations are also involved. the states are encouraged to prepare their own targets and implementation plans as a condition for federal grants, and many states require county health departments to prepare local profiles and targets.diffusion of this approach encourages state and local initiatives to meet measurable program targets. it also sets a different agenda for local prestige in competitive terms, with less emphasis on the size of the local hospital or other agencies than on having the lowest infant mortality or the least infectious disease among neighboring local authorities. the who european region document "health 21 -health for all in the 21st century" addresses health in the twentyfirst century, with 21 principles and objectives for improving the health of europeans, within and between countries of europe. the health 21 targets include:1. closing the health gap between countries. 2. closing the health gap within countries. 3. a healthy start in life (supportive family policies). 4. health of young people (policies to reduce child abuse, accidents, drug use, and unwanted pregnancies). 5. healthy aging (policies to improve health, self-esteem, and independence before dependence emerges). 6. improving mental health. 7. reducing communicable diseases. 8. reducing non-communicable diseases. 9. reducing injury from violence and accidents. 10. a healthy and safe physical environment. 11. healthier living (fiscal, agricultural, and retail policies that increase the availability of and access to and consumption of vegetables and fruits). 12. reducing harm from alcohol, drugs, and tobacco. 13. a settings approach to health action (homes should be designed and built in a manner conducive to sustainable health and the environment).14. multisectoral responsibility for health.15. an integrated health sector and much stronger emphasis on primary care. 16. managing for quality of care using the european health for all indicators to focus on outcomes and compare the effectiveness of different inputs. the uk national health service (nhs) has semi-autonomous units in england, scotland, wales, and northern ireland. they are funded from the central uk nhs but with autonomy within national guidelines. the nhs has defined national health outcomes for improvements grouped around five domains, each comprised of key indicators aimed at improving health with reducing inequalities. l preventing people from dying prematurely from causes amenable to health care for all ages: l the target diseases include cardiovascular, respiratory, and liver diseases, and cancer (with focus on cancer of breast, lung, and colorectal cancer) l reducing premature death in people with serious mental illnesses l reducing infant mortality, neonatal mortality, still births, and deaths in young children l increasing 5-year survival for children with cancer. health improvement; help people to live healthy lifestyles, healthy choices, reduce health inequalities, protection from major incidents and other threats, while reducing health inequalities. l health care, public health and preventing premature mortality; reduce the numbers of people living with preventable ill-health and people dying prematurely, while reducing the gap between communities.source: uk department of health. available at: https://www.gov.uk/government/organisations/department-of-health/about#our-priorities, https:// www.gov.uk/government/uploads/system/uploads/attachment_data/ file/193619/improving-outcomes-and -supporting-transparency-part-1a.pdf. pdf, and https://www.gov.uk/government/uploads/system/uploads/attach-ment_data/file/127106/121109-nhs-outcomes-framework-2013-14.pdf. pdf [accessed 24 june 2013] . national policy in health ultimately relates to health of the individual. the various concepts outlined in the health field concept, community-oriented primary health care, health targets, and effective management of health systems, can only be effective if the individual and his or her community are knowledgeable participants in seeking solutions. involving the individual in his or her own health status requires raising levels of awareness, knowledge, and action. the methods used to achieve these goals include health counseling, health education, and health promotion (figure 2 .6).health counseling has always been a part of health care between the doctor or nurse and the patient. it raises levels of awareness of health issues of the individual patient. health education has long been part of public health, dealing with promoting consciousness of health issues in selected target population groups. health promotion incorporates the work of health education but takes health issues to the policy level of government and involves all levels of government and ngos in a more comprehensive approach to a healthier environment and personal lifestyles.health counseling, health education, and health promotion are among the most cost-effective interventions for improving the health of the public. while costs of health care are rising rapidly, demands to control cost increases should lead to greater emphasis on prevention, and adoption of health education and promotion as an integral part of modern life. this should be carried out in schools, the workplace, the community, commercial locations (e.g., shopping centers), and recreation centers, and in the political agenda.psychologist abraham maslow described a hierarchy of needs of human beings. every human has basic requirements including physiological needs of safety, water, food, warmth, and shelter. higher levels of needs include recognition, community, and self-fulfillment. these insights supported observations of efficiency studies such as those of elton mayo in the famous hawthorne effect in the 1920s, showing that workers increased productivity when acknowledged by management in the objectives of the organization (see chapter 12). in health terms, these translate into factors that motivate people to positive health activities when all barriers to health care are reduced.modern public health faces the problem of motivating people to change behavior; sometimes this requires legislation, enforcement, and penalties for failure to comply, such as in mandating car seat-belt use. in other circumstances it requires sustained performance by the individual, such as the use of condoms to reduce the risk of sti and/or hiv transmission. over time, this has been developed into a concept known as knowledge, attitudes, beliefs, and practices (kabp), a measurable complex that cumulatively affects health behavior (see chapter 3). there is often a divergence between knowledge and practice; for example, the knowledge of the importance of safe driving, yet not putting this into practice. this concept is sometimes referred to as the "kabp gap". the health belief model has been a basis for health education programs, whereby a person's readiness to take action for health stems from a perceived threat of disease, a recognition of susceptibility to disease and its potential severity, and the value of health. action by an individual may be triggered by concern and by knowledge. barriers to appropriate action may be psychological, financial, or physical, including fear, time loss, and inconvenience. spurring action to avoid risk to health is one of the fundamental goals in modern health care. the health belief model is important in defining any health intervention in that it addresses the emotional, intellectual, and other barriers to taking steps to prevent or treat disease.health awareness at the community and individual levels depends on basic education levels. mothers in developing countries with primary or secondary school education are more successful in infant and child care than less educated women. agricultural and health extension services reaching out to poor and uneducated farm families in north america in the 1920s were able to raise consciousness of safe self-health practices and good nutrition, and when this was supplemented by basic health education in schools, generational differences could be seen in levels of awareness of the importance of balanced nutrition. secondary prevention with diabetics and patients with chd hinges on education and awareness of nutritional and physical activity patterns needed to prevent or delay a subsequent myocardial infarction. the who sponsored the first international conference on health promotion held in ottawa, canada, in 1986 ( figure 2.7) . the resulting ottawa charter defined health promotion and set out five key areas of action: building healthy public policy, creating supportive environments, strengthening community action, developing personal skills, and reorienting health services. the ottawa charter called on all countries to put health on the agenda of policy makers in all sectors and at all levels, directing them to be aware a typical healthy city has a population in the multiple thousands, often multilingual, with an average middleclass income. a healthy cities project builds a coalition of municipal and voluntary groups working together in a continuing effort to improve quality of service, facilities, and living environment. the city is divided into neighborhoods, engaged in a wide range of activities fostered by the project. municipalities have traditionally had a leading role in sanitation, safe water supply, building and zoning laws and regulation, and many other responsibilities in public health (see chapter 10). the healthy cities or communities movement has elevated this to a higher level with policies to promote health in all actions. some examples are listed of municipal, advocacy group, and higher governmental activities for healthier city environments: working with senior levels of government, other departments in the municipalities, religious organizations, private donors, and the ngo sector to innovate and especially to improve conditions in poverty-afflicted areas of cities is a vital role for health-oriented local political leadership. human ecology, a term introduced in the 1920s and revived in the 1970s, attempted to apply theory from plant and animal life to human communities. it evolved as a branch of demography, sociology, and anthropology, addressing the social and cultural contexts of disease, health risks, and human behavior. human ecology addresses the interaction of humans with and adaptation to their social and physical environment.parallel subdisciplines of social, community, and environmental psychology, medical sociology, anthropology, and other social sciences contributed to the development of this academic field with wide applications in health-related issues. this led to the incorporation of qualitative research methods alongside the quantitative research methods traditionally emphasized in public health, providing crucial insights into many public health issues where human behavior is a key risk factor.health education developed as a discipline and function within public health systems in school health, rural nutrition, military medicine, occupational health, and many other aspects of preventive-oriented health care, and is discussed in later chapters of this text. directed at behavior modification through information and raising awareness of consequences of risk behavior, this has become a longstanding and major element of public health practice in recent times, being almost the only effective tool to fight the epidemic of hiv and the rising epidemic of obesity and diabetes.health promotion as an idea evolved, in part, from marc lalonde's health field concepts and from growing realization in the 1970s that access to medical care was necessary but not sufficient to improve the health of a population. the integration of the health behavior model, social ecological approach, environmental enhancement, or social engineering formed the basis of the social ecology approach to defining and addressing health issues (table 2 .3).individual behavior depends on many surrounding factors, while community health also relies on the individual; the two cannot be isolated from one another. the ecological perspective in health promotion works towards changing people's behavior to enhance health. it takes into account factors not related to individual behavior, which are determined by the political, social, and economic environment. it applies broad community, regional, or national approaches that are needed to address severe public health problems, such as controlling hiv infection, tb, malnutrition, stis, cardiovascular disorders, violence and trauma, and cancer. beginning to affect the health situation in countries in transition from the socialist period. countries emerging from developing status are also showing signs of mixed progress in the dual burden of infectious and maternal/child health issues, along with growing exposure to the chronic diseases of developed nations such as cardiovascular diseases, obesity, and diabetes. the new public health synthesizes traditional pub lic health with management of personal services and community action for a holistic approach. evaluation of costeffective public health and medical interventions to reduce the burden of disease also contributes to the need to seek and apply new approaches to health. the new public health will continue to evolve as a framework drawing on new ideas, science, technology, and experiences in public health throughout the world. it must address the growing recognition of social inequality in health, even in developed countries with universal health programs with improved education and social support systems. for a complete bibliography and guidance for student reviews and expected competencies please see companion web site at http://booksite.elsevier.com/9780124157668 bibliography